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Concept: Ovarian cyst

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INTRODUCTION: Detection of asymptomatic adnexal tumours in postmenopausal women has increased due to wider use of diagnostic ultrasound and imaging quality improvements. Reliable methods to differentiate between benign and malignant tumours are required to avoid delays in treating ovarian cancer and to prevent unnecessary interventions for benign lesions. In the UK, the Royal College of Obstetricians and Gynaecologists has issued guidance for the management of adnexal cysts in postmenopausal women, which is considered standard in routine clinical practice. The protocol utilises the Risk of Malignancy Index to assess the risk of adnexal lesion being malignant. This protocol has a relatively high intervention rate in order to avoid a delay in a cancer diagnosis. The Simple Rules Protocol designed by International Ovarian Tumour Analysis Group reports a low false-positive rate in the diagnosis of ovarian cancer without a loss of sensitivity and therefore has the potential to reduce unnecessary interventions in asymptomatic postmenopausal women with benign cysts. METHODS AND ANALYSIS: 140 postmenopausal women aged 40-80, with incidentally detected adnexal tumours on ultrasound scan will be recruited to this study. They will be randomly allocated, to be assessed and managed according to either of the two protocols under investigation. In both arms of the study the tumours will be classified into three groups: high, intermediate or low risk of malignancy. Women with high risk of malignancy will be referred for management in a tertiary cancer centre, women with low-risk tumours will be managed expectantly, while those with intermediate risk findings have surgery in their local hospital units. Analysis will be on an intention-to-treat basis. ETHICS AND DISSEMINATION: Research ethical approval was granted by the North London Research Ethical Committee 2 (10/H0724/48). Trial results will be published according to the CONSORT statement. TRIAL REGISTRATION NUMBER: Registration at http://www.controlled-trials.com/ISRCTN89034131/. ISRCTN89034131.

Concepts: Cancer, Oncology, Sensitivity and specificity, Hereditary nonpolyposis colorectal cancer, Benign tumor, Ovarian cyst, BRCA2, Hysterectomy

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Ovarian cancer (OC) is associated with non-specific symptoms such as bloating, making accurate diagnosis challenging: only 1 in 3 women with OC presents through primary care referral. National Institute for Health and Care Excellence guidelines recommends sequential testing with CA125 and routine ultrasound in primary care. However, these diagnostic tests have limited sensitivity or specificity. Improving accurate triage in women with vague symptoms is likely to improve mortality by streamlining referral and care pathways. The Refining Ovarian Cancer Test Accuracy Scores (ROCkeTS; HTA 13/13/01) project will derive and validate new tests/risk prediction models that estimate the probability of having OC in women with symptoms. This protocol refers to the prospective study only (phase III).

Concepts: Type I and type II errors, Hereditary nonpolyposis colorectal cancer, Ovarian cyst, BRCA2, Ovarian cancer, Experimental uncertainty analysis, CA-125, Bloating

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Massive enlargement of an ovarian cyst is an uncommon cause of morbidity and a rare cause of mortality due in large to part to noninvasive imaging techniques that usually permit early detection. When an ovarian cyst reaches giant proportions, it produces abdominal enlargement often with a fluid wave resulting in a condition that mimics ascites, called pseudoascites. Despite their impressive appearances, such cysts often are operable for cure. We describe a case of a middle-aged woman who presented 3 years before her death with symptoms from an undiagnosed giant cyst and given a diagnosis of ascites of undetermined etiology. She subsequently died at home unexpectedly, and at autopsy, she was found to have a massively enlarged but otherwise benign mucinous cystadenoma.

Concepts: Disease, Causality, Death, Pathology, Ovarian cyst, Pelvis, Cyst, Autopsy

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To evaluate the histomorphometry and expression of Ki-67 and c-kit in ovarian follicles of pinealectomized or melatonin-treated pinealectomized rats.

Concepts: Ovarian cyst, Ovarian follicle

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Objective: To evaluate results of expectant management of sonographically benign ovarian cysts in selected asymptomatic premenopausal women. Study design: Prospective cohort study comprising premenopausal women diagnosed as having a persistent adnexal cyst. Patients were selected according to complaints (asymptomatic), ultrasound cyst’s appearance (benign) and size (< 8 cm). Patients underwent a follow-up protocol with transvaginal scan at 6 months interval for two years and then annually for at least 3 years. Results: The study comprises 166 women (mean age: 40 years) with 192 masses present at inclusion. Twenty-two women (29 masses) were lost to follow-up. Seventy-four masses (38.7%) resolved spontaneously (median time from diagnosis to resolution: 40 months). Forty-nine masses (25.1%) persisted without changes (median time follow-up time: 88 months, range: 36-192 months). Forty masses (20.9%) were surgically removed (12 cases because of increasing size, four cases because of a second lesion appeared during follow-up, three cases because of changing aspect and increasing size, five cases because of surgery for uterine benign or malignant disease, two case because of changing aspect without increasing size, one patient because of ovarian torsion clinical and 13 cases because of patient's decision with no change on the mass). Histology was benign in all but in two cases (stage Ia mucinous ovarian carcinoma and stage Ia mucinous borderline tumor). During follow-up 40 new masses in 31 women were diagnosed (21 resolved spontaneously, 5 were surgically removed -all benign histology- and 14 are persisting) Conclusions: Expectant management of cysts with benign ultrasound morphology is a management option in selected asymptomatic premenopausal women. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Concepts: Cohort study, Cancer, Oncology, Medical terms, Observational study, Ovarian cyst, Ovarian cancer, Hysterectomy

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Intraspinal and extradural cysts in the cervical spine are rare disorders that may cause myelopathy or radiculopathy. A synovial cyst or ganglion derived from the facet joint and that from a ligamentum flavum have been reported. We report a surgical case of degenerative intraspinal cyst, causing cervical myelopathy. MRI of a case revealed cystic lesion at C4-5. Spinal cord was compressed by cyst and symptoms of myelopathy were also observed. The patient with cervical spinal canal stenosis underwent laminoplasty and excision of the cyst. The patient recovered well immediately after the surgery. Literature review showed that 133 patients have been reported, including the present case. Previous reports indicated that most cysts occurred in old patients and at the atlanto-axial or C7-T1 junction, and laminectomy or laminoplasty with excision of the cyst gave good results in most cases.

Concepts: Medical terms, Patient, Surgery, Vertebral column, Ovarian cyst, Spinal stenosis, Cyst, Ganglion cyst

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The aim of this study was to describe a new technique for laparoscopic removal of large ovarian cystic masses. The authors performed a retrospective study during the period January 2008 to December 2009 in the Second Department of Obstetrics and Gynecology of Aretaieion University Hospital; 19 women with large ovarian cysts were included in the study. During the study period, 53 women underwent laparoscopic excision of ovarian cysts. Among them, 19 had very large complex ovarian cysts with a mean diameter of 8.4 cm. The mean age of the patients was 32.1 years. Ultrasound examination revealed findings suggestive of benign disease in all patients. In 8 out of 19 patients CA-125 levels were elevated, ranging from 40.5 to 194.7 IU/mL. A 5-mm suprapubic trocar was directly inserted into the cyst and fluid contents aspirated, so the decompressed cyst could fit in a 5-cm laparoscopic bag. The cyst wall was carefully detached from the healthy ovarian tissue and placed in the bag without any spillage. The remaining cyst wall was removed from the peritoneal cavity with the laparoscopic bag. The mean operative time was 45 minutes. No operative or postoperative complications were noted. There was no conversion to laparotomy. Mean hospital stay was 1 day. Pathology revealed 7 endometriomas, 3 mucinous cystadenomas, 3 serous cystadenomas, 3 serous cysts, and 3 teratomas. Direct trocar insertion within the ovarian cyst followed by aspiration of the fluid contents is a safe and feasible method for the laparoscopic management of large ovarian cysts.

Concepts: Hospital, Surgery, Ovarian cyst, Ovarian cancer, Gynecology, Cyst, Laparoscopic surgery, Endometriosis

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Context: Müllerian inhibiting substance (MIS) is produced in Sertoli cells of fetal testis and causes regression of Müllerian ducts in male embryos. MIS also can induce the cell cycle arrest and apoptosis in Müllerian duct-derived tumors in vivo and in vitro. Objective: Our objective was to investigate the expression of MIS type II receptor (MISR II) and whether MIS can inhibit the proliferation and induce apoptosis in primary cultures of endometrial stromal cells (ESC) of endometriosis. Design and Settings: In vitro experiments were performed in the university research laboratory. Participants: Tissue samples from 12 patients who had undergone evisceration for ovarian endometrial cysts were included in this study. Interventions and Main Outcome Measures: The expression of MISR II in ESC was investigated by immunohistochemistry. The cell viability and apoptosis in ESC treated with MIS was measured by methylthiazoletetrazolium assay and annexin V analysis. The expression of regulatory proteins in ESC treated with MIS was shown by Western blotting. Results: ESC showed specific immunostaining for the MISR II. ESC treated with MIS exhibited 32% growth inhibition (P = 0.0001). The changes in cell cycle distribution after MIS exposure at 72 h demonstrated that S and G(2)M phases were decreased; G(0)G(1) and sub-G(0)G(1) phases were increased. ESC treated with MIS showed 13.72% annexin V-fluorescein isothiocyanate positivity. In the ESCs, which contain defective p16, MIS increased the expression of pocket proteins p107 and p130 and decreased E2F transcription factor 1. Conclusions: The results support a central role for MIS in endometriosis. Although the precise mechanism of MIS-mediated inhibition of ESC growth has not been fully defined, these data suggest that MIS has activity against ESC in vitro and may also be an effective targeted therapy for endometriosis.

Concepts: DNA, Cell nucleus, Cancer, Molecular biology, Embryo, Transcription factor, Ovarian cyst, Cell cycle

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A 30 years old nullipara with a diagnosis of papillary thyroid carcinoma with nodal metastases had undergone total thyroidectomy and nodal dissection for the same. In the postoperative work-up for radioiodine-131 ((131)) ablation of the residual tissue, she was found to have on (131)I whole-body scan multifocal uptake in the neck and a solitary focus in the mediastinum. In addition, there was a relatively intense focal uptake in the right pelvis above the urinary bladder. Ultrasonography (USG) of the pelvis demonstrated a 2.3×2.0cm mostly echogenic mass with some sound attenuation in the right ovary. No color uptake to suggest internal vascularity was observed within this mass. Axial plain CT without contrast, undertaken in order to discard iodine interference, demonstrated in the 2.0×1.54cm right ovarian mass cavity with fat attenuation. Magnetic resonance imaging (MRI) of the pelvis with diffusion weighted imaging (DWI) was undertaken to further characterize the right ovarian lesion noninvasively. The axial T1-weighted spin-echo MR image showed a high-signal-intensity mass of the right ovary . On the fat-saturated T2-weighted fast spin-echo MR, the mass demonstrated saturation of the cystic contents with punctate high signal intensity of size 2.0×1.8cm. On diffusion weighted MRI the cystic contents of the lesion showed high signal on DWI, which had low apparent diffusion coefficient (ADC) value, attributable to fat and keratinoid substance. The ADC value of the cystic contents was 0.570×10(-3)mm(2)/s, while the cystic component presented values of 1.77×10(-3)mm(2)/s. The above findings were commensurate with the diagnosis of an ovarian dermoid cyst. Dermoid cysts are cystic teratomta that contain developmentally mature skin, complete with hair follicles and sweat glands and can differentiate into a variety of tissues (e.g. sebum, blood, fat, bone, nails, teeth, eyes, cartilage) including thyroid tissue. The incidence of thyroid tissue in the ovarian dermoids ranges from 11% to 18% though in one series it was 7.3%. Though mostly benign, they may undergo malignant transformation in one of its elements, usually develop squamous cell carcinoma. Malignant transformation of the thyroid tissue is extremely rare, usually being papillary thyroid carcinoma. A struma ovarii is a rare form of mature teratoma that contains mostly thyroid tissue. They can present with intriguing findings on functional scans, an understanding of which is important to obviate errors. Noting the age and nulliparous status of the patient, treatment with (131)I was postponed so that the dermoid cyst could be surgically removed before high dose administration of (131)I, so as to reduce the absorbed radiation dose to the right ovary. In conclusion, it is important to recognize the physiological and pathological aetiologies (unrelated to thyroid) that demonstrates radioiodine uptake and may lead to false positive radioiodine scan in patients of differentiated thyroid carcinoma. They require to be differentiated from uncommon metastatic sites, which also show radioiodine uptake and warrants for radioiodine therapy for disease control. An appreciation is essential for proper management and will obviously prevent administration of inappropriate radioiodine therapy doses.

Concepts: Cancer, Oncology, Magnetic resonance imaging, Ovarian cyst, Squamous cell carcinoma, Cyst, Dermoid cyst, Teratoma

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Ultrasound guided aspiration of ovarian endometrioma had been tried as an alternative therapeutic modality in patients whose desire to avoid surgery or surgical approach is contraindicated since 1991. Cyst puncture can reduce tumor volume and destruct the cyst wall, alleviate sticking circumstances and enhance the chance of recovery. But simple aspiration without other treatments results in high recurrence rate (28.5 % to 100 %). In order to reduce recurrence after aspiration, ultrasound-guided aspiration with instillation of tetracycline, methotrexate, and recombinant interleukin-2 has been combined and proven to be effective with the recurrence rates of 46.9 %, 18.1 %, and 40 % respectively. Noma et al. (2001) reported that conduct of ethanol instillation for more than 10 min particularly for a case with a single endometrial cyst is considered most effective from the standpoint of recurrence (14.9 %). Our goal is to analyze patients with recurrent pelvic cyst who underwent surgical intervention. The research data are based on clinical diagnosis, symptoms and medical intervention classification, and the cyst numbers are defined as forecast project target. The decision tree, methodology of data mining technology, is used to find the meaningful characteristic as well as each other mutually connection. The experimental result can help the clinical faculty doctors to better diagnose and provide treatment reference for future patients.

Concepts: Medicine, Surgery, Physician, Ovarian cyst, Case study, Decision tree, Recurrence relation, Endometriosis