Ovarian cysts and cyclic hormone replacement therapy: is there an association?

Imaging characterization of adnexal lesions: Do CT findings correlate with US?

OBJECTIVE

To compare contrast-enhanced CT and US agreement in characterizing adnexal lesions in late post-menopausal women.

MATERIALS AND METHODS

This was a HIPAA-compliant IRB-approved retrospective review of the contrast-enhanced CTs of 130 late post-menopausal women (> 55 years). The lesions were classified as simple cystic, minimally complex cystic, complex cystic, solid-cystic, or solid based on CT and US morphology. Findings were analyzed to evaluate agreement between CT and US on adnexal lesion characterization.

RESULTS

One forty-one adnexal lesions were assessed by both contrast-enhanced CT and US. Overall, there was good agreement between CT and US, which agreed on the lesion morphology in 114 (81%) cases with an unweighted kappa value of 0.68 (95% CI 0.56-0.78). By CT, 83 (59%) were classified as simple cystic, of which 73/83 (88%) were confirmed as simple cystic by US. Of the remaining 10 CT simple cysts, 9 were reclassified by US as minimally complex cystic and one as complex cystic. Eight of these lesions were benign based on pathology or follow-up imaging, while two lesions remained indeterminate. By CT, 27 lesions (19%) were classified as minimally complex, while US reclassified 13 (48%) of the lesions (eight to simple cystic and five as complex or solid-cystic). Among the 31 remaining lesions, there were 4 (13%) discordances between CT and US.

CONCLUSION

There is good agreement between CT and US in characterizing adnexal lesion morphology, particularly simple cysts. However, there was significant discordance seen with characterization of minimally complex cysts, indicating that these lesions need US follow-up.

[Epidemiology of presumed benign ovarian tumors]

Ovarian cysts presumed benign can be organic or functional. Their prevalence is estimated between 14 and 18% in postmenopausal women and around 7% in asymptomatic women of childbearing age. Their incidence during pregnancy is between 0.2 and 5% and varies within the term of pregnancy. Ovarian cysts presumed benign have caused nearly 45,000 hospitalizations in France in 2012, bringing the annual risk of hospitalization for a woman residing in France to 1.3‰. Among the risk factors studied in the literature, tamoxifen increases the incidence of ovarian cysts in premenopausal patients and immunosuppressive treatments are associated with a high prevalence of benign ovarian cysts while estrogen contraception reduces the risk of developing functional cysts.

Cytokine response in the postoperative period after surgical treatment of benign adnexal masses: comparison between laparoscopy and laparotomy

BACKGROUND

Cytokines are the main mediators of the inflammation and the response to trauma. The purpose of the present study was the comparative assessment in sera of patients with benign adnexal masses treated by laparoscopy or laparotomy of the following proinflammatory and anti-inflammatory cytokines: interleukin (IL)-1beta, IL-6, IL-8, tumor necrosis factor-alpha (TNF-alpha), and IL-10 in the early postoperative period.

METHODS

A total of 40 patients with benign adnexal masses were studied; 25 of whom underwent laparoscopy and 15, laparotomy. Blood serum concentration of IL-1beta, IL-6, IL-8, TNF-alpha, and IL-10 were measured by commercially available ELISA assays before and 4 h, 24 h, and 48 h after the operation.

RESULTS

Concentrations of IL-6 were significantly increased in both groups at 4 h, 24 h, and 48 h after the surgery; levels of IL-10 showed a significant increase 4 h and 24 h after the operation; an increase in IL-1beta levels was observed only after laparotomy; no significant variations were observed in serum levels of IL-8; the postoperative increase of IL-1beta, IL-6, and IL-10 levels was more pronounced in patients undergoing laparotomy than in those treated laparoscopically; length of the surgical procedure, amount of CO2 used, tumor diameter, age, and body mass index (BMI) of the patients did not influence the postoperative patterns of the studied cytokines.

CONCLUSIONS

Systemic cytokine response after operations for benign adnexal masses depends on the degree of the surgical trauma, and is less pronounced in patients undergoing laparoscopy.

Management of ovarian cysts

BACKGROUND

The treatment of an ovarian cyst relies on its nature, and accurate preoperative discrimination of benign and malignant cysts is therefore of crucial importance. This study was undertaken to review the literature concerning the preoperative diagnosis and treatment of ovarian cysts.

METHODS

Articles concerning ovarian cysts from a medline literature search during the period 1985-2003 were included in addition to articles found as references in the initial publications.

RESULTS

Different methods for discriminating between benign and malignant ovarian cysts are discussed. The diagnosis and the treatment are assessed in relation to age, menopausal status, pregnancy, and whether the cyst is presumed to be benign or malignant. In general, expectant management is the choice in premenopausal and pregnant women with non-suspicious cysts and normal levels of CA-125. In postmenopausal women, unilocular, anechoic cysts less than 5 cm in diameter together with a normal CA-125 may be followed up. Operation is recommended in women with cysts larger than 5 cm and/or elevated levels of CA-125. Women with symptoms should be operated regardless of age, menopausal status, or ultrasound findings.

CONCLUSIONS

The preoperative discrimination between benign and malignant ovarian cysts is a challenge. Multimodal methods improve the results of single modalities, but we still need improved preoperative diagnostic tools. Furthermore, these methods should be validated in consecutive patient populations large enough to give a reliable estimate of the method's sensitivity and specificity.

Natural history of sonographically detected simple unilocular adnexal cysts in asymptomatic postmenopausal women

OBJECTIVE

To determine the natural history of simple unilocular adnexal cysts in asymptomatic postmenopausal women.

METHODS

Eight thousand seven hundred ninety-four asymptomatic postmenopausal women underwent transvaginal ultrasound as part of routine gynecological check-up at our institution between January 1995 and June 2002. All patients in whom a simple unilocular adnexal cyst was found out were offered surgical treatment or conservative follow-up with serial transvaginal ultrasound at 6-month intervals. In all these cases, serum CA-125 levels was determined.

RESULTS

Two hundred twenty-three simple adnexal cysts in 215 women were found out (prevalence: 2.5%). Annual incidence did not change significantly. Sixty-six (30.6%) women were lost after initial diagnosis. One hundred and forty-nine patients with 153 cysts were entered ultimately in the study. Forty-five (30%) underwent surgery (34 after initial diagnosis and 11 during follow-up). A total of 49 cysts were removed. The most frequent histological diagnosis was serous cystadenoma (84%). There was a case of a stage IA ovarian carcinoma (2% of the cysts removed, 0.6% of all the cysts included in the study). One hundred and four patients with 104 cysts underwent conservative follow-up throughout the study period. Forty-six (44%) of these cysts resolved spontaneously (74% of them within 2 years). In 14 (30%) of these women, a new cyst was diagnosed when follow-up went on. In 58 patients, cysts persisted during all study period (median follow-up: 48 months, range: 6-90 months), 69.6% of them remained unchanged, 17.2% increased, and 17.2% decreased. Patients in whom cysts resolved spontaneously had a shorter menopausal time (P=0.001) and tend to be younger (P=0.06). No differences were found regarding cysts' features.

CONCLUSION

The risk of malignancy of simple adnexal cysts in asymptomatic postmenopausal women is low. Almost half of them will resolve spontaneously during follow-up. Most of those that persist remain unchanged. Asymptomatic postmenopausal women having simple adnexal cysts can be managed conservatively with a very reasonable degree of reassurance.

Laparoscopic management of suspicious ovarian cysts in elderly, postmenopausal women

OBJECTIVES

To present our experience with laparoscopic treatment of ovarian cysts in elderly, postmenopausal women.

STUDY DESIGN

During the period January 1996 to August 1997, 21 elderly, postmenopausal women were admitted to the Rabin Medical Center for laparoscopy. The indications for the operation were an ovarian cyst that did not meet the criteria of a simple cyst, was larger than 4 cm, had pathological Doppler flow or elevated CA-125 level.

RESULTS

The median age of the patients was 67.19 (range 60-74). Despite the fact that 15 (71.4%) of the patients suffered from chronic disease, all laparoscopies were successfully accomplished. No case of malignancy was found.

CONCLUSIONS

Laparoscopic management of carefully selected ovarian cysts is an appropriate alternative for exploratory laparotomy even in elderly patients with or without underlying diseases.