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Approach to patient with ovarian cysts
A 19-year-old woman presented with left lower abdominal pain and a history of ovarian cysts seen on prior imaging. On examination, she had tenderness in her lower abdomen. Ultrasound showed a new 5 cm hemorrhagic cyst on her left ovary. She underwent a laparoscopic cystectomy which found a hemorrhagic cyst with clots but no torsion. Her postoperative course was uncomplicated. Ovarian cysts are common and most are functional, resolving without treatment. Evaluation involves history, exam, ultrasound and considering tumor markers or laparoscopy if concerned for a neoplasm.
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Approach to patient with ovarian cysts
- 1. Approach to patientwith Ovarian cysts Done by: Yahyia Al-Abri 90440
- 2. Outline • Definition ofovarian cyst • Case scenario • How to approach – History, physical examination , investigation, management. • Functional ovarian cyst • Benign ovarian neoplasm • Mixed ovarian neoplasm • Ovarian cancer
- 3. ovarian cyst • Anovarian cyst is a sac filled with liquid or semiliquid material that arises in an ovary. • These cysts can develop in females at any stage of life, from the neonatal period to postmenopausal • Most ovarian cysts, occur during infancy and adolescence, which are hormonally active periods of development. • Most are functional in nature and resolve without treatment.
- 6. Case • 19 yearsold Omani lady, Unmarried, Presented to the A&E with history of Abdominal left iliac fossa pain started 15 minutes prior coming to the hospital.
- 7.
- 8. History • Most patientswith ovarian cysts are asymptomatic • Pain or discomfort may occur in the lower abdomen sudden, unilateral, sharp pelvic pain Cyst rupture bilateral, dull pelvic pain. Theca-lutein cysts painful and heavy periods and dyspareunia Endometriomas
- 9. History • Associated symptoms –Patients may experience abdominal fullness, bloating and tenesmus. • Irregularity of the menstrual cycle. • Young children may present with precocious puberty (Granulosa-theca cell tumors) and early onset of menarche. pressure on the bladder Micturition may occur frequently polycystic ovarian syndrome infertility, oligomenorrhea,
- 10. Our case Shedescribed the pain as colicky, intermittent, located in left iliac fossa radiates to the suprapubic area. Severe pain Pain better slightly on lying down No h/o of nausea or vomitting No h/o fever No urinary symptoms No PV bleeding. Her LMP was at 07/11/2015 Regular period
- 11. Our case Past medicalhistory: • She has similar episodes of pain since March 2015, several visits to the student clinic and A&E for the same complain • CT abdomen was done(prominent ovaries with cysts likely functional) on 26/3/2015 • Follow up US on 20/9/2015: evidence of large cyst in left adnexa measuring 7.5x6.2 mm in size
- 12. What is yourdifferential diagnosis ? • Ovarian cyst accidents – cyst rupture, – haemorrhage – torsion • Acute PID
- 13. Physical examination • Generalexamination • Abdominal examination • Pelvic examination
- 14. Physical examination • Alarge cyst may be palpable on abdominal examination • Functional cyts • mobile, unilateral, and not associated with ascites. • Tender to palpation
- 15. Physical examination Signs Diagnosis hirsutism,obesity, and acne Polycystic ovarian syndrome hyperpyrexia complications of ovarian cysts, such as ovarian torsion diffusely tender abdomen with rebound tenderness and guarding hemorrhage or peritonitis cachexia and weight loss, lymphadenopathy in the neck, shortness of breath, and signs of pleural effusion. Advanced malignant disease Tachycardia and hypotension. Hemorrhage due to cyst rupture T
- 16. Our case O/E: • vitals:normal • Abdomen: – mild tenderness in the lower abdomen – no guarding ,no rigidity
- 17. Investigation (laboratory) • Nolaboratory tests are diagnostic for ovarian cysts. • Investigations aid in the differential diagnosis – Urinary pregnancy test – CBC ( Anemia + infection) – Urinalysis (UTI and stones) – Endocervical swabs – Cancer antigen 125
- 18. Investigation (radiology ) •Ultrasonography – primary imaging tool for a patient considered to have an ovarian cyst – help to define a cyst’s morphologic characteristics – Follow up exclude ovarian neoplasm/show resolution of a cyst – A normal ovary is 2.5-5 cm long, 1.5-3 cm wide, and 0.6-1.5 cm thick
- 19. Ultrasonography • simple ovariancysts – uniformly thin, rounded wall and a unilocular – hypoechoic or anechoic. – They usually measure 2.5-15 cm in diameter, and posterior acoustic enhancement • Complex cysts – Multilocular ,thickening of the wall, projections into the lumen or on the surface,
- 20. Radiology • CT scanning –more sensitive but less specific than ultrasonography in detecting ovarian cysts. – best in imaging hemorrhagic ovarian cysts or hemoperitoneum due to cyst rupture – to distinguish other intra-abdominal causes • CT scanning should be avoided in pregnancy, – MRI
- 21. Procedure • Diagnostic laparoscopy –To inspect a suggestive adnexal cystic mass. – advantage of decreased morbidity, improved postoperative recovery.
- 22. Our case • Labsdone in the A&E: - Hb 11.6 WCC 8.7 - U&E Normal - Tumor markers normal • U/S pelvis done: – The right ovary is normal in size and appearance. hyperechoic lesion about 5 cm on left ovary that is new from old scan that can be hemorrhagic complex cyst & can not rue out/in torsion
- 23. Calculation of theRisk Of Malignancy Index (RMI) Risk of Malignancy Index = A x B x C. A cut-off value of 200 discriminate a benign from malignant mass with a Sensitivity of (87%) and a specificity of(97%).
- 24. Functional Cysts -Management • If the RMI is low and the cyst is considered to be functional. – Wait and re-examine the patient after her next menses. – Low-dose contraceptive agents may be given to suppress gonadotropin levels and prevent development of another cyst. • If it is solid, painful, or fixed or has an elevated RMI. – surgical exploration may be necessary. – Laparoscopic cystectomy to allow histologic evaluation may be needed to differentiate between a functional and a neoplastic ovarian cyst.
- 25. Ovarian Cyst Rupture •Conservative in stable patient. • Surgical care – laparoscopy or laparotomy, depending on clinical presentation, amount of blood in the abdomen, patient stability.
- 26. Our case PLAN: • consenttaken for : – Emergency laparoscopy ovarain cystectomy ,+/- salpingectomy +/- salpingo oopherectomy – risk of converted to laparotomy ,risk of veesels ,bowel ,bladder injuries ,risk of thrombosis , risk of infection all explined to the pateint ,pateint`s father and mother • Cross match, NPO • Shift direct from A&E to the OT
- 27. Our case Laproscopic findings: –Left ovarian cystectomy – Post-op Diagnosis: hemorrhagic cyst with clots, No ovarian torsion – Findings: Normal R ovary , pelvis, uterus and upper abdomen • Day 1 Post op: She is complaining of mild pain at surgical site. - Mobilizing. - Voided well. - To be discharged with encouraging oral hydration and analgesia. - Appointment for tracing histopathology after 6 wks - Earlier to A&E if any complains as explained.
- 28. What are thedifferential diagnosis of ovarian mass?
- 29. Specific typePathogenesis Follicular cysts Luteincyst Polycystic ovaries Functional Salpingo-oophoritis Pyogenic oophoritis-puerperal, abortal, or related to an intrauterine device Granulomatous oophoritis Inflammatory EndometriomasMetaplastic Premenarchal years-10% are malignant Menestruating years-15% are malignant Postmenopausal years-50% are malignant Neoplastic
- 31. follicular cysts -Arise whenphysiologic release of the mature ovum fails (follicle fail to rupture). -Follicular growth continues. -Excessive stimulation by FSH. -Lack of the normal preovulatory LH surge. - 3 cm _Rarely grow larger than 10 cm. -Most are asymptomatic. -Larger cysts may cause pelvic discomfort or heaviness. -Thin-walled, unilocular -Usually unilaterally.
- 32. Corpus luteum cyst (lutein): •Result when a corpus luteum fails to regress following the release of an ovum. • It is the most common pelvic mass encountered within the 1st trimester. • most spontaneously involute at the end of the 2nd trimester. • -Most are asymptomatic and resolve with observation and analgesia but If persist => surgical.
- 33. Hemorrhagic corpus luteumcysts • Results from invasion of ovarian vessels into corpus luteum • They are more likely to cause symptoms and more likely to rupture. • Ruptured hemorrhagic corpus luteum cysts can result in a Hemoperitoneum requiring surgery
- 34. Theca-lutein cysts • hypertrophyof the theca interna cell layer in response to excessive stimulation from hCG. • Present with – hydatidiform mole. – multiple gestation. – choriocarcinoma. – ovulation induction with gonadotropins or clomiphene. • usually bilateral. • may become quite large (>30 cm) • characteristically regress slowly after the gonadotropin level falls.
- 35. luteoma of pregnancy •Prolonged hCG stimulation during pregnancy leading to hyperplasic reaction of ovarian theca cells. • Appear as brown to reddish-brown nodules that may be cystic or solid. • Multifocal and usually bilateral • Can cause maternal virilization in 30% of women and ambiguous genitalia in a female fetus. • regress spontaneously postpartum.
- 37. Benign neoplastic ovariantumors Divided by cell type of origin Epithelial Stromal Germ cell •Mucinous •Serous •Brenner •Fibromas •Granulosa- theca cell tumors •Sertoli-Leydig cell tumors •Benign cystic teratoma
- 38. US/CytologyPRESENTATIONDESCRIPTIONTYPE •Often multilocular •Histologicaly contain Psammomabodies (calcified concentric concretions) 10% bilateral • most common is serous cystadenoma •70 % benign •5-10%borderline malignant •20% to 25% are malignant Serous •Resembles endocervical epithelium •Often multilocular •Often associated with a mucocele of the appendix Huge size, Often filling entire pelvis •may be complicated by pseudomyxoma peritonei •85% benign •20% of epithelial tumors Mucinous •Has a large fibrotic component that encases epithelioid cells that resemble transitional cells of the bladder. •a small, smooth solid ovarian neoplasm. •usually benign •33% are associated with mucinous epithelial elements. Brenner 1- Epithelial ovarian neoplasms
- 40. US/Cytology•PRESENTATION•DESCRIPTIONTYPE Form encapsulated, solid, smooth-surfacedtumor, composed of spindle- shaped cells. • Non-functioning • associated with Meigs syndrome • benignFibroma -solid-yellow appearance -Histologic hallmark of cancer is small groups of cells known as Call-Exner bodies Estrogen-producing feminizing effects (precocious puberty, menorrhagia, postmenopausal bleeding) •Can be associated with endometrial cancer •Inhibin is tumor marker Granulosa-theca cell tumors (benign or malignant) Androgen-producing virilizing effects (hairsutism, deep voice, recession of front hair) Can measure elevated androgens as tumor markers Sertoli-leydig cell tumors (benign or malignant) Sex Cord–Stromal Ovarian Neoplasm
- 41. MCQ • A 4-year-oldgirl is noted to have breast enlargement and vaginal bleeding. On physical examination, she is noted to have a 9-cm pelvic mass. Which of the following is the most likely etiology? • A. Cystic teratoma B. Dysgerminoma C. Endodermal sinus tumor D. Granulosa-theca cell tumors E. Mucinous tumor
- 42. MCQ A. Fitz-Hugh-Curtis syndrome B.Lung cancer C. Meig's syndrome D. Leriche's syndrome F. Liver failure A 47 year old woman is admitted to the gynaecology ward after the discovery of an ovarian mass on an annual gynaecological checkup. On general examination she is found to have a distended abdomen, with possible ascites, and bilateral pleural effusions. Biopsy of the mass reveals a fibroma. Given the signs and symptoms, what is the diagnosis?
- 43. Germ cell tumors •Occur at any age. • Make up about 60% of ovarian neoplasms occurring in infants and children. • Most common benign cystic teratoma (dermoid cyst). • 10-15% are bilateral. • Slow growing tumor. • Diagnosed b/w 25-50 yrs of age. • <10 cm in diameter.
- 44. Teratomas Dermoid cysts (teratomas)are one of the most common types of cysts , half are diagnosed in women between 25 and 50 years Composed primarily of ectodermal tissue (sweat & sebaceous glands, hair follicles, and teeth), with some mesodermal and rarely endodermal elements
- 45. A dermoid cyst(mature cystic teratoma) after opening the abdomen.
- 46. Mixed Ovarian Neoplasms •Ovarian tumor in which the neoplastic elements are composed of more than one cell type • More solid than epithelia ovarian tumor • The most common is the cyst-adeno-fibroma. • It is benign but it may predispose to malignant dysgerminoma.
- 47. Benign Ovarian Tumors-Management • Benign epithelial ovarian neoplasms are generally treated by unilateral salpingo- oophorectomy. – cystectomy with preservation of the depending on the neoplasm (cystic teratoma) and age of patient. – Gonadoblastoma, dysgenetic ovaries = bilateral salpingo-oorphrectomy • Appendectomy should also be done in mucinous cystadenoma. Because it is associated with a mucocele of the appendix
- 48. • Dermoid cyst(teratoma) • Granulosa cell tumour • Corpus luteum cyst • Mucinous cystadenoma • Follicular cyst • Serous cystadenoma • If ruptures may cause pseudomyxoma peritonei • The most common type of epithelial cell tumour • May contain skin appendages, hair and teeth
- 49. MCQ A. Follicular cyst B.Teratoma (dermoid cyst) C. Endometrioma D. Ovarian adenocarcinoma E. Ovarian fibroma A 20-year-old female presents with a 3 month history of abdominal pain. Abdominal ultrasound shows a 8cm mass in the right ovary. Histopathological analysis reveals Rokitansky's protuberance. What is the most likely diagnosis?
- 50. Ovarian cancer • Itis the leading cause of death from gynecologic cancer because it is difficult to detect before it disseminates. • Most women with ovarian cancer are in the 5th or 6th decade of life. • Population screening is not feasible because ultrasonography and available tumor markers, lack specificity and sensitivity for early-stage disease.
- 51. Ovarian Cancer- Clinicalfeatures • In early-stage disease, vague abdominal pain or bloating – Other symptoms include dyspareunia, urinary frequency or constipation and menstrual irregularity or Postmenopausal bleeding. • In advanced-stage disease, patients most often present with abdominal pain or swelling (from the tumor itself or from associated ascites). • In bimanual pelvic examination – a solid, irregular, fixed pelvic mass.
- 52. Ovarian Cancer- Management •Depending on the stage of the cancer. • In postmenopausal women they are best treated by a total abdominal hysterectomy and bilateral salpingo-oophorectomy. • In premenopausal women , the contralateral ovary and the uterus can be preserved in some types.
- 53. References • Essentials ofobstetrics and gynecology,HACKER and MOORES. • Medscape • Abduljabbar HS, Bukhari Y. Review of 244 cases of ovarian cysts. Saudi Med J 2015; Vol. 36 (7) • www.ncbi.nlm.nih.gov/pubmed/21991700 • https://www.womenshealth.gov/publications/o ur-publications/fact-sheet/ovarian-cysts.html
Editor's Notes
- #7 Acute diverticulitis Chronic constipation Colon cancer Ectopic pregnancy Inflammatory bowel disease Irritable bowel syndrome Pelvic inflammatory disease Rectal cancer Torsion of ovarian cyst Ulcerative colitis
- #19 However, the following laboratory tests can aid in the differential diagnosis and in the diagnosis of cyst-related complications: Endocervical swabs - Should be obtained to assess for chlamydia and gonorrhea if pelvic inflammatory disease is among the differential diagnoses CA125 should not be drawn in pregnant patients with ovarian cysts or in the acute setting with ovarian cyst accidents, as this marker is raised in peritonitis, hemorrhage, cyst rupture, and infection, as well as in menstruation, fibroids, and endometriosis. The finding of an elevated CA125 level is most useful when combined with an ultrasonographic investigation while assessing a postmenopausal woman with an ovarian cyst.
- #22 MRI scans have better soft tissue contrast than do to CT scans, particularly for identifying fat and blood products, and can provide a better idea of the organ of origin for gynecologic masses.
- #23 Performing diagnostic laparoscopy may sometimes be necessary to inspect a suggestive adnexal cystic mass. Laparoscopy offers the advantage of decreased morbidity, improved postoperative recovery, and decreased cost compared with laparotomy.
- #25 All suspesious adenxial mass should be evaluated The RMI has high sensitivity (87%) and specificity (97%).
- #26 Aspiration of the fluid as a diagnostic tool is inappropriate because the false-negative rate for the cytologic examination is high and slow leakage of the fluid disseminates cancer if the cyst is malignant. When the patient is in her late 40s, the chances of an ovarian neoplasm are increased, and observational delays should be undertaken with caution.
- #33 follicular cysts may result from a lack of physiologic release of the ovum due to excessive FSH stimulation or lack of the normal LH surge at midcycle just before ovulation. Hormonal stimulation causes these cysts to continue to grow. Follicular cysts are typically larger than 2.5 cm in diameter and manifest as a discomfort and heaviness. Granulosa cells that line the follicle may also persist, leading to excess estradiol production, which, in turn, leads to decreased frequency of menstruation and menorrhagia
- #36 A hydatidiform mole is a growing mass of tissue inside your womb (uterus) that will not develop into a baby. It is the result of abnormal conception Choriocarcinoma is a fast-growing form of cancer that occurs in a woman's uterus (womb). The abnormal cells start in the tissue that would normally become the placenta. Clomifene (INN) or clomiphene (USAN) is a selective estrogen receptor modulator
- #39 Are believed to be devied to 3 types The most common type it epithelia
- #40 Are believed to be derived from the mesothelia cell lining the peritoneal cavity and the lining surface of the ovary The most common is serous cystoadenoma need surgical excision because of their large size Pseudomyxoma peritonei is a very rare type of cancer that usually begins in your appendix as a small growth
- #42 Meig's syndrome: -Ascites and hydrothorax associate with fibroma. -Ascites caused by transudation of fluid from ovarian fibroid. -Flow of ascites through transdiaphragmatics lymphatics to right plural cavity hydrothorax The functioning characteristics are responsible for a variety of associated presenting signs and symptoms. The granulosa-theca cell tumors promote feminizing signs and symptoms. during infancy and childhood: precocious menarche, precocious thelarche, or premenarchal uterine bleeding. In the reproductive years: menorrhagia (with alternating amenorrhea), endometrial hyperplasia, endometrial cancer, breast tenderness, and fluid retention Sertoli-Leydig cell tumors are responsible for virilizing effects: hirsutism, temporal baldness, deepening of the voice, clitoromegaly, and a defeminizing change in body habitus to a muscular build. Fifteen percent of these tumors produce no obvious endocrinologic effects. Fibromas are not hormonally active, but may cause Meigs’ syndrome. Postmenopausal bleeding.
- #43 d
- #44 C
- #49 The contralateral ovary must be carefully inspected to exclude a bilateral lesion If the patient is young and nulliparous, the ovarian neoplasm is unilocular, and there are no excrescences within the cyst, an ovarian cystectomy with preservation of the ovary may be performed. In an older woman, a total abdominal hysterectomy and bilateral salpingo-oophorectomy may be appropriate, particularly if there is any suspicion of malignancy. Stromal cell neoplasms of the ovary are generally treated by unilateral salpingo-oophorectomy when future pregnancies are a consideration. Ovarian fibromas, even when associated with ascites and a right hydrothorax (Meigs’ syndrome), are almost always benign and might even be treated by resection from the ovary in a young woman. Cystic teratomas (“dermoids”) can be treated by ovarian cystectomy.Because 15% to 20% are bilateral, the contralateral ovary should be carefully evaluated and any cysts resected.
- #51 B