Ovarian cyst Flashcards
Define ovarian cyst.
Ovarian cyst is a surgical, imaging, or examination finding of an enlarged, fluid-filled ovary or portion of ovarian tissue.
List the different types of ovarian cysts.
- Phsyiological cysts
- Benign epithelial tumours
- Benign germ cell tumours
- Benign sex cord stromal tumours
How do ovarian cysts present?
- acute pelvic pain
- chronic pelvic pain
- presence of an abdominal mass/adnexal mass
- incidental finding on gynae examination or pelvic USS
Differentials: tumours of adjacent structures (uterus, bladder, bowel) and pregnancy.
How do you diagnose ovarian cysts?
USS - TVUSS is better resolution for pelvic masses, trans-abdominal USS indicated in those who have not been sexually active or in combination with TVUSS to explore large ovarian masses beyond the pelvis.
+/- CT/MRI - if thought to be malignant
Serology - for tumour markers to differentiate benign and malignant neoplasms
Pregnancy test - excluse pregnancy
CRP, WCC - exclude appendicitis or tubo-ovarian abscess etc
What is the management of a simple ovarian cyst?
If incidental finding on US + simple and…
Small (<50mm diameter): Expectant management - likely physiological and will resolve within 3 menstrual cycles; do not follow up
Medium (50-70mm diameter): Follow up - yearly US scan
Large (>70mm diameter): Imaging/Removal - further imaging required i.e. MRI or laparoscopic removal
What is the management of an ovarian cyst in a patient who is symptomatically unwell?
Laparoscopy or laparotomy - urgent surgical exploration required to manage possible ovarian torsion/cyst rupture or haemorrhage + reusus + broad spectrum antibiotics
What is the management of ovarian cyst in a post-menopausal patient with solid/complex ovarian cyst?
Treat as suspicious for malignancy:
-
TVUSS - determine risk of malignancy index (RMI)
- RMI = US features of cyst + menopausal status + Ca125
- Laparotomy
- Gynae oncology review
What are the differentials for a pelvic mass?
- Gynaecological: benign or malignant ovarian cyst; torsion; para-ovarian cyst; ectopic pregnancy; hydrosalpinx; pyosalpinx; tubo-ovarian abscess; tubal malignancy; pregnancy; fibroids; uterine malignancy.
- Gastrointestinal: small or large bowel obstruction; diverticular/appendicular abscess; intussusception; malignancy.
- Urological: hydronephrosis; pelvic kidney; renal/bladder malignancy.
- Other: pelvic lymphocele; peritoneal cyst; psoas muscle abscess; lymphoma; neuroblastoma; aortic aneurism.
List 5 ovarian tumour markers.
Name 3 types of physiological ovarian cysts.
How can you decrease risk of developing these cysts?
- Follicular cyst - most common cyst type
- Corpus luteum cyst
- Theca luteal cyst
Functional cyst development risk is reduced by COCP use.
Describe the pathophysiology of a follicular ovarian cyst. What is the prognosis?
- Pathophysiology: Occurs due to non-rupture of the dominant follicle OR failure of atresia in a non-dominant follicle
- Prognosis: Commonly regress after several menstrual cycles
How do you diagnose a functional/physiological cyst? What size are they usually?
Diagnosed when cyst size is >3cm (normal ovulatory follicles measure up to 2.5cm). Aetiology is largely unknown.
Rarely grow >10cm
Describe the pathophysiology of a corpus luteum cyst. How does it more commonly present?
Pathophysiology: if pregnancy doesn’t occur in a menstrual cycle, the corpus luteum cyst usually breaks down and disappears. If this doesn’t occur, it may fill with blood or fluid and form a corpus luteal cysts.
Presentation: more likely to present with intraperitoneal bleeding than a follicular cyst and may need wash out and ovarian cystectomy if there is significant bleeding
What is the management of functional/physiological ovarian cysts?
Depends on symptoms:
Asymptomatic - reassure + repeat USS to check for resolution or non-enlargement
Symptomatic - laparoscopic cystectomy
What is the pathophysiology of theca luteal cysts? What is the prognosis?
Theca luteal cysts are associated with pregnancy, esp multiple pregnancy. Often bilateral
Prognosis - most resolve spontaneously during pregnancy
What are inflammatory ovarian cysts most commonly associated with?
PID and are most common in young women - can affect the tube, ovary, bowel or develop from other infective causes like appendicitis or dicerticular disease
What is the management of inflammatory ovarian cysts?
- Antibiotics
- Surgical drainage or excision - after the acute infection has resolved due to risk of perioperative systemic infectoin and bleeding from handling acutely inflamed and infected tissue
Which types of inflammatory cysts are known as ‘chocolate cysts’? How do these appear on USS?
Endometriomas - they have altered blood within the ovary making it look like a ‘chocolate cyst’.
USS - ‘ground glass’ appearance
NB: Removal or endometriomas must be balance against damage to the ovarian tissue. Overall medical treatment of endometriosis does not improve fertility but surgical does.
Name a type of benign germ cell tumour of the ovary.
Dermoid cyst aka mature cystic teratomas
Describe some characteristics of a dermoid cyst. How do they present? What is a common complication?
Lined with epithelial tissue and so may contain skin appendages, hair and teeth i.e. differentiated tissue types derived from all three embryonic germ cell layers (mesenchymal, epithelial and
stroma).
Presentation: Usually asymptomatic, bilateral in up to 10%
Complication: torsion is more likely than with other ovarian tumours, risk of malignant transformation (<2%, usually aged >40yrs)
What is the commonest benign ovarian tumour in women <30 years?
Dermoid cyst
When are dermoid cysts usually diagnosed? How?
Median age of diagnosis is 30 years
Pelvic USS but MRI also useful due to high fat content in dermoid cysts.
What is the management of dermoid cysts?
Ovarian cystectomy - spontaneous resolution is unlikely. Especially indicated if symptomatic or if the cyst is >5cm or enlarging. This prevents ovarian torsion .
What cyst appearance makes it suspicious for malignancy?
Multiloculated
