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Simple ovarian cyst found in ultrasound. Worried for ovarian cancer

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Radiologist
Practicing since : 2007
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Hi,
I had a simple ovarian cyst that was diagnosed by ultrasound on 9/27/12. I had a follow up exam 2 days ago via ultrasound. Now the cyst is being described as complex. I am loading a report and several images. Please take a look at all the images and report. I am terrified this is ovarian cancer. Back in September (during the time of the first ultrasound), I did have a CA125 test and the result was 13. I know you can not tell me for sure if this is now a cancerous ovarian cyst but please tell me your true thoughts as I know cancerous cysts on ultrasound can have a certain appearance. I have terrible anxiety over this, to the point that I am unable to concentrate on work or anything except this cyst. I have a call in to my doctor to try to schedule surgery to remove this but I'd appreciate your true thoughts on the appearance of this cyst.
Thank you.
XXXXXX
Posted Sat, 11 May 2013 in X-ray, Lab tests and Scans
 
 
Answered by Dr. Ganesh Sanap 10 hours later
Hi, welcome and thanks for writing in.
I have gone through your reports and images of ultrasonography. I would like to know only 2 answers.
1. What was the indication for left oophorectomy?
2. Follow up or recent CA 125 level has been done or not?

Image quality is good to diagnose but we will discuss everything after above answers.

Looking forward for your response.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Simple ovarian cyst found in ultrasound. Worried for ovarian cancer 11 minutes later
Hi,
The left ovary removal was performed in 1992. For some reason, the date in the pathologist report is 2009, not sure why. The left ovary was removed due to mucus cystadenoma (benign) at the approximate age of 16 (I'm now 38). The cyst at that time was literally the size of a basketball. It had twisted the ovary so they removed the cyst and tried to save the ovary but because it remained twisted, they went ahead and removed the ovary in a second surgery.
I have not had a follow up CA125 since September 2012. Please do tell what your thoughts are about this current cyst.
Thanks
XXXXXX
 
 
Answered by Dr. Ganesh Sanap 2 hours later
Hi, welcome back.
On ultrasonography images it looks a complex cyst only. There is no soft tissue within known as mural nodule. Also CA 125 level is within normal limits. Overall I will suggest it is benign lesion. It is not a cancerous condition of ovary.
Also left ovary had benign lesion which also decreases the risk of cancer in contralateral ovary. Decision of operation is solely depends on symptoms and your gynaecologist opinion.

Hope I have answered your query. If you have further concern, please let me know.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Simple ovarian cyst found in ultrasound. Worried for ovarian cancer 21 hours later
Hi,
Thank you for your reply.

I have a few follow up questions. Can you explain what is meant by "it looks like a complex cyst only"?

Also, within the cyst, what is the grey cloudy looking stuff in the cyst? You are saying you do not see soft tissue in the cyst but isn't this grey stuff in the cyst considered soft tissue?

And lastly, I am in menopause since age 19 due to chemotherapy for a bone marrow transplant I had in 1994 (for leukemia, CML). I am concerned at the thickness of the endometrial stripe at 9mm. The ultrasound 6 months ago said the endometrial stripe was 7mm. Isn't this thick for someone in menopause? The radiologist reports says normal uterus but I'm assuming a uterus can look normal even if there is uterine cancer present? I'm concerned about the thickening of the endometrial stripe, could this be due to cancer of uterus?

Thanks again
XXXXXX
 
 
Answered by Dr. Ganesh Sanap 12 hours later
Hi, welcome back.
It looks like a complex cyst means , it is a complex cyst. The grey stuff is one of the artefact of ultrasonography which is difficult to understand for new person. On adjusting the setting it fades. It is usually seen in large cystic structure.
If uterine stripe is 9 mm then it need to evaluated because it is significant in postmenopausal women. You need to consult your gynaecologist for examination and proper advise regarding further investigation like endometrial sampling. It is difficult to say the exact nature 9f endometrium without its sampling.

Hope I have answered your query.

Regards.

Above answer was peer-reviewed by
 
Follow-up: Simple ovarian cyst found in ultrasound. Worried for ovarian cancer 30 minutes later
Hi,
I promise this is my last question. I understand artefacts are difficult to understand for someone without training.

May I ask if this grey cloudy stuff within the cyst are artefacts of ultrasound, what is it within the cyst that makes it complex? I thought the actual grey stuff is what makes the cyst complex.

Thanks again and this is my last question.
 
 
Answered by Dr. Ganesh Sanap 58 minutes later
Hi, welcome back.
There are some XXXXXXX echoes which makes it complex cyst.
And you can ask as many questions you want . I will try to guide as much as possible. Don't hesitate for that.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Simple ovarian cyst found in ultrasound. Worried for ovarian cancer 14 minutes later
Thank you so much for your kindness. So if my understanding is correct, XXXXXXX echoes means there are some compartments or membranes within the cyst? Did you see the XXXXXXX echoes in the images I provided?

To summarize, the grey cloudy stuff is not soft tissue but rather is artefacts of ultrasound? You also see no solid components within the cyst such as projections or nodules or solid material? But there are XXXXXXX echoes that are just not visible in the photos? That is the part I don't understand, perhaps the XXXXXXX echoes are visible in the photos and I can't see them due to my untrained eye?

Have you seen cysts with this appearance such as mine that actually turn out to be cancerous? Do you still feel this is a benign lesion?
Oh and lastly, do you see any septations within the cyst? Does anything else in the photos look abnormal or alarming?

Thank you once again.
 
 
Answered by Dr. Ganesh Sanap 1 hour later
Hi.
There are few dots in the centre which appear bright , these are XXXXXXX echoes. Septations are membrane which are absent in your case. There are no Septations and no other abnormal finding in cyst.
Such cyst turning to malignancy is very rare. It needs to correlated with CA125 level. I would suggest as you have menopause already, surgical removal is better choice in this case.


Regards.
Above answer was peer-reviewed by
 
Follow-up: Simple ovarian cyst found in ultrasound. Worried for ovarian cancer 1 hour later
Thank you for your response. If I may, I have uploaded one more photo. It is called "IMG_0690 circled".
If you can please look at the photo at the area I circled on the left side, can you tell me what that is? It almost looks like a huge septation.Also, do these bright dots in the center represent soft tissue?

Thank you!
 
 
Answered by Dr. Ganesh Sanap 12 hours later
Hello,
Circled portion is a artefacts only. If you see carefully it is same as surrounding tissue. Also dots are not soft tissue at all. They are XXXXXXX echoes. For your convenience please Google the phrase ovarian cyst with mural nodule. You will clear all you doubts. Visual impression is always easy to understand.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Simple ovarian cyst found in ultrasound. Worried for ovarian cancer 33 hours later
One final question please. Is the cyst wall thick?

Also, the right ovary now measures 3.8 x 3.6 x 4.1 cm. The report 6 months ago says the right ovary measures 3.9 x 2.4 x 3.7 cm. What causes an ovary to increase in size?
 
 
Answered by Dr. Ganesh Sanap 24 minutes later
hi, welcome.
Cyst wall is not thick. Size of ovary is incresed possibly due to cyst or it is just a subjective variation in measurement. It is of not major concern.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Simple ovarian cyst found in ultrasound. Worried for ovarian cancer 47 hours later
Hello once again. One follow up question please. Are the bright white dots/foci (not grey cloudy looking material/artefacts inside cyst) more along the cyst wall or just inside the middle of the cyst? I'm asking because I'm trying to figure out if these are wall foci?
Thanks once again.
XXXXXX
 
 
Answered by Dr. Ganesh Sanap 10 minutes later
Hi, welcome back.
White dots are inside the cyst, not along the cyst wall. The soft issue like image along wall is artefact. It is complex cyst without soft tissue . No doubt about that.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Simple ovarian cyst found in ultrasound. Worried for ovarian cancer 7 days later
Hello,
May I please ask a couple follow ups? I have added two more pictures ("0693-circled" and "0706"). I had a couple of people (gynecologists) tell me the grey cloudy stuff in the cyst is actual debris so that left me confused. Please take a look at those two pictures I just posted, I believe you said those are artefacts of ultrasound and are reverbation artefacts? Does this mean the grey cloudy stuff is not really part of the cyst? If the answer to this is yes, is this definitive or is it possible that it's something that's really inside the cyst?
Thanks again so much.
XXXXXX
 
 
Answered by Dr. Ganesh Sanap 5 hours later
Hi, welcome back.
Lets clear one thing, debris is structure which accumulate from raw material. So you can judge, it should in sink in most dependant part of cyst. In images you are provided grey stuff is not sinking. It is floating in the fluid. They are XXXXXXX echoes.
In previous images grey stuff at periphery and upper part is artefact.
In any case whether it is debris or XXXXXXX echoes, the cyst is not malignant at all. Don't worry about nature of cyst.
Last thing dont hesitate to ask questions. I will try my best to explain as per my knowledge and experience.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Simple ovarian cyst found in ultrasound. Worried for ovarian cancer 4 hours later
Hello again,

I’ve been reading more about the cyst and reading back over the information you have given me. If I understand correctly, my cyst is hypoechoic and has echogenic foci (white dots) throughout the cyst. Could this be a hemorrhagic cyst or mature teratoma, or endometrioma?

If teratoma or endometrioma, can’t these types of cysts be cancerous?

I looked at the photo of the cyst on Doppler (I think IMG 0690 circled). I see some blue and red color (Doppler) around the cyst, does this mean the cyst has blood flow?

Also, I don’t understand why in some of the photos, the cyst looks just black in color (which I thought means just fluid filled) with a few of the echogenic foci but none of the grey cloudy (internal echoes/hypoechoic) material is seen in some of the other images. What makes the cyst appear so different depending on the image taken?

And lastly, I understand you feel this is not malignant and you seem confident of this, can’t a cyst appearing like mine (hypoechoic with echogenic foci) be cancerous?

Do you think it's possible that image 0690-circled (attached) is a solid area of the cyst (I've circled what looks like an indentation)?
Thanks
XXXXXX
 
 
Answered by Dr. Ganesh Sanap 7 hours later
Hi welcome back again.
You have picked the perfect point regarding appearance of gray white stuff. If it is true soft tissue within cyst then it should be seen in all images and all directions. It is not a true soft tissue because it is not seen in all images. As cyst is large ultrasonography sound waves has angulation which gives such images.
Haemorrhagic cyst has very prominent echoes seen throughout cyst giving it a hyperechoic appearance. But present cyst is hyperechoic. Teratoma has widely different appearance, no need to consider it in differential diagnosis.
I lastly don't think it's a solid area.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Simple ovarian cyst found in ultrasound. Worried for ovarian cancer 35 minutes later
Hello,
I think I understand your explanation. You are saying because the area I circled is not seen in all images and if were true tissue, we'd see it in all the images. I know I'm asking many questions and I appreciate your patience.

You are saying my cyst is hyperechoic, no hypo?

I'm sure you are tired of looking at my many images, sorry, this is just very frightening.

I found another image online of actual cancer. I've posted it, the file is just called "cancer". This will be the last photo I post.

Do you think my cyst looks similar to that cyst?

Thank you again.
 
 
Answered by Dr. Ganesh Sanap 40 minutes later
Hi,
welcome back.
I am saying cyst is hypoechoic. Sorry for inconvenience , it was my mistake.
I have gone through new image. There is doubt full structure there but I am not convinced about cancer. There are many images online which are not proved. We are also using Internet for reference, but books are final destination.
You Google as ovarian cyst with mural nodule rsna. In this article you will get a good images.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Simple ovarian cyst found in ultrasound. Worried for ovarian cancer 27 hours later
I did google it, thank you.
I'm so sorry, i loaded the wrong picture, The area circled is in image "0690 right wall".
Is this some kind of solid object causing this cyst wall indention or possibly some large papillae/projection?
 
 
Answered by Dr. Ganesh Sanap 1 hour later
Hi, welcome back.
I think we have discussed that image earlier. It is not a soft tissue, papilla or projection . You can see it is extending outside cyst wall with same echogenicity. It is artefactual finding only. Have you seen the images in article of cyst with mural nodule.?

Regards.
Above answer was peer-reviewed by
 
Follow-up: Simple ovarian cyst found in ultrasound. Worried for ovarian cancer 2 days later
Hi,
I am having surgery tomorrow but wanted to ask you one final question. Image 0690 I believe is the one that shows the Doppler. There looks to be some flow in the thickened cyst wall although the radiologist doing the report says Doppler appears normal. I know I've had too many opinions on this but I did upload my CD images to a site and a second radiologist mentions flow to cyst wall that could also be ovarisn tissue but cyst wall flow should also be considered.
In this 0690 image, does this look like flow to cyst wall to you? Thanks again for all your help and once I receive your reply, I'll leave you another 5 star rating. Thanks!
XXXXXX
 
 
Answered by Dr. Ganesh Sanap 24 minutes later
Hi, welcome back again.
First of all best luck for your surgery. I am 100 percent sure there is no role of doppler in evaluation of ovarian cyst with or without soft tissue. That's why I never talked about doppler in previous discussions. You can check that also. I have lot of references for that also. You can ignore that surely.
I am very happy to have such a thorough discussion with you.
Hope for the best.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Simple ovarian cyst found in ultrasound. Worried for ovarian cancer 1 hour later
Hi,
Thanks for your quick reply. I apologize but I'm not sure I understand. Are you saying Doppler flow in cyst wall has no significance at all even if the cyst is complex?
Thanks!
XXXXXX
 
 
Answered by Dr. Ganesh Sanap 50 minutes later
Hello.
I want say same thing. There is no significance in doppler flow in cyst wall for differentiating benign or malignant.

Regards.
Above answer was peer-reviewed by
 
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