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Had ovarian cyst that was diagnosed by ultrasound. One ovary got removed. Chances of having cancer in the other?

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Practicing since : 2005
Answered : 34 Questions
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 (6 month follow up). 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. Please note the report says I had my left ovary removed in May 2009. This date is incorrect, my ovary was removed in 1992 around the age of 16 due to benign mucous cystadenoma that was the size of a basketball. The doctor tried to save my ovary but it had become so twisted that it was later removed in a second surgery. I am terrified my current situation on the remaining right ovary 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. Please give me your true opinion on the current photos posted.
Thank you.
Posted Tue, 30 Apr 2013 in X-ray, Lab tests and Scans
Answered by Dr. Ranjeet Jagdale 23 hours later
Hello there, sorry to hear about your problems.From your history and the images provided by you I would like to tell you few things at first so that you know how we approach to such a case.
•     Step 1
If a cystic pelvic mass is present we first confirm whether it is ovarian or non-ovarian in origin ----- your case Ovarian
•     Step 2
Determine if the lesion can be categorized as one of the common, benign ovarian masses (simple cyst, hemorrhagic cyst, endometrioma or mature cystic teratoma), or is indeterminate-------- Your case either it is hemorrhagic cyst or an indeterminate type( though hemorrhagic cyst would have caused you some pain)
•     Step 3
To aid in selecting the proper work-up, the final step is to determine whether a patient falls into a low-risk category or a high-risk category ------ Premenopausal falls into low risk category. I do not know if you have any family history of ovarian or breast malignancy.(if that is there , then you are a High risk patient)
Now Role of Ultrasound is in characterization of ovarian masses especially for distinguishing cystic from complex cystic-solid and solid lesions
Your mass is definitely cystic and has no solid components ,however has some echoes within. I don’t see any septations, calcifications , Vascularized nodularities, papillary projections, or XXXXXXX solid masses in images provided to me, so the lesion is more likely to be benign than malignant.
It has been classified as complex , because of the XXXXXXX echoes.

I would like to suggest few things
1.     You can undertake an MRI because using MRI as an adjunct to sonography a delay in the treatment of potentially malignant ovarian lesions is prevented.
2.     Other things is repeating a CA-125 levels and seeing if there is any increase in those values.
3.     Or you can do a repeat USG in a month after your next menstrual cycle to see for any interval change.

Hope this helps you, please feel free to revert back if you have any queries.

Thank you and good luck.
Above answer was peer-reviewed by
Follow-up: Had ovarian cyst that was diagnosed by ultrasound. One ovary got removed. Chances of having cancer in the other? 23 minutes later
I was hoping you would be the one to reply. I'm not sure if you remember me but you actually looked at my images back in September when the cyst was classified as simple. You were extremely helpful just as you have been today. Thank you for all the information, very helpful.
A couple points, even though I'm 38, I went through menopause at age 19 due to chemotherapy for a bone marrow transplant for leukemia (CML). I do not have history in my family that I'm aware of for breast or ovarian malignancy. Although a few years ago my mom had some breast calcification that was biopsied that was hyperplasia or dysphasia, I'm not sure of the exact name. They removed this small area and she has not had problems since and does go for yearly mammograms.

You mention pain, I do have pain from the cyst. It's not a constant or intolerable pain but there is mild pain on and off. Can you explain what an intermediate cyst is? Is this a benign type or is that a malignant type?

What do you mean by XXXXXXX echoes, are these the bright white spots in the cyst or is it all the grey/cloudy looking areas that are seen in some of the photos? Do XXXXXXX echoes represent some type of solid make up? Sorry, I'm just not sure I understand what XXXXXXX echoes are.

Regarding suggestion #1, are you saying MRI helps to rule out malignancy so that unnecessary treatment is not performed?

And my last question, the report says uterus is normal but I see the endometrial stripe is 9mm. This I think is thick for someone in menopause. Back in September 2012, the thickness was 7mm. If this were due to uterine cancer, would this likely be full blown uterine cancer or More likely hyperplasia?

Thank you again for time and I look forward to your reply.

Answered by Dr. Ranjeet Jagdale 4 hours later
Hello XXXXXX, yes I do remember you now .:)
And thanks for telling me this , I went through those Images which you had sent me earlier, I had them with me.
And there isn’t much change in the appearance of your cyst in now like 6months except for increase in the amount of XXXXXXX echoes and by this I mean increase in amount of tiny bright foci that are seen floating in your cyst. Also there is no mention of fluid within your pelvis , which was there previously.This is the reason why your doctor has labelled it a complex cyst now.
The pain from this kind of cyst is possible. And I had mentioned intermediate type earlier because I didn’t know it was you. If I had known then I would have straight away compared it with the previous images and would have said it does not look much different and is more likely a benign cyst.However the fact that it is persisting for such a long duration I personally feel it should be removed as unlikely it will go on its own , however your gynecologist will be the best person to tell you about the treatment.
We say a cyst intermediate when we don’t have clear cut feature on either side like benign or malignant and would need further investigation to be more confident about the type and nature of the cyst.

Regarding MRI: It can helps you to find the nature of the content and also to rule out malignancy which looks less likely with the fact that cyst has not changed much in over 6 months now.
About your uterine stripe being 9mm , it is on a higher side for a menopausal woman so best will be to go to your gynecologist and if he agrees you can get the endometrial tissue sampling done to look for any malignancy. Just the thickened endometrium does not mean full blown cancer and can be just hyperplasia as you rightly said,but thickening is suspicious and needs to be evaluated. It is normal for a menstruating and ovulating woman to have normal variation in the endometrial thickness.

Thank you and regards, Hope this helps you.
Above answer was peer-reviewed by
Follow-up: Had ovarian cyst that was diagnosed by ultrasound. One ovary got removed. Chances of having cancer in the other? 32 hours later
Thank you so much for being so thorough in answering my questions. This is much appreciated.

I did think of one thing about the endometrial stripe. I have gained some weight in the last 6 months. I've been on Paxil (10 mg) for anxiety and it seems my weight has gone up since I've been on this medication. I know weight gain can cause more estrogen production which in turn can cause thickening of endometrium. At least I have heard this before, not sure if it's true. I will have a biopsy done.

Thank you for comparing the photos from 6 months ago. I did not realize you were able to look at posts that long ago because for some reason, under my log in name, I could not find the conversation I'd had with you 6 months ago.

To make sure I understand everything, you are saying the cyst does not look much different than 6 months ago except more XXXXXXX echos.

Do you see any thickening of cyst wall? The images I've seen of different cysts are confusing to me. Some cysts that are labeled with papillary projections and solid components look very similar to the current photos I posted. If I look at the cyst wall, it looks like small sharp little points protruding into the cyst from the cyst wall. And the grey cloudy areas inside the photos (not visible in all photos) look like photos I've seen of XXXXXXX solid components. I know my eye is completely untrained to look at these. I guess my question is, is it obvious these small sharp protruding points along the cyst wall are not projections and is it obvious the grey cloudy looking stuff inside the cyst is not solid material but rather is artefacts of ultrasound?

I tried to look up what foci are but am unable to find what this means. So you are saying that what classifies my cyst as complex is the XXXXXXX echoes/tiny white foci but foci are not solid components? Are foci then some type of floating debris without vascularity?

I've read many things that say complex cysts less than 5cm are more likely benign. Is this true and if so why is this "magic" measurement of less than 5cm used?

And lastly, if you see the radiologist report from 6 months ago and the one now, it appears my actual ovary measurement size has increased. What causes this? The report says the cyst is about the same size but the size of the ovary has increased. This is confusing, can you explain the significance of this?

I know I've asked alot of questions in this post but you have been a big help to me in understanding this and I think if the remaining questions are answered, I will have better understanding of what I'm looking at within the photos. Do you feel I've posted enough photos to adequately demonstrate the picture of the cyst?

Thank you again very much. :-)

Answered by Dr. Ranjeet Jagdale 1 hour later
Hello again,

I really appreciate you are so well informed about your illness and read so much about it. Nice to know and I feel happy to speak with you as doctor because You make my job easier.

Yes , foci means some kind of floating debris and it does not mean a solid component.
Your cyst wall is thick but it does not have any obvious solid components or papillary projections which should worry me, whatever tiny projections you are saying are a part of a long standing cyst and cannot be classified into features of a malignant cyst.
The size measurement is an arbitrary measurement based on studies over the years and it is generally found that size less than 5cms is more seen in benign cysts, however this is not a strict criteria and a larger cyst can be benign and vice versa.

I don’t see much change in ovarian size and if you see the previous report the largest dimension of the cyst was 3.9cms and now it is 4.1cms that is barely 2mm and this much measurement difference is not significant, however your ovarian size is mildly increased but this is not significant and should not be a cause to worry , however you should consult your gynecologist because a cyst which is present for so long is unlikely to go on its own and better to be removed surgically , though I am not the expert in saying that but a personal opinion.
You can also evaluate yourself for the thickened endometrium with your gynecologist.
Hope this helps you

Take care and Regards XXXXXX

Dr Ranjeet
Above answer was peer-reviewed by
Follow-up: Had ovarian cyst that was diagnosed by ultrasound. One ovary got removed. Chances of having cancer in the other? 37 minutes later
Hello Dr. Ranjeet,

Thank you again and thanks for your patience. Final questions:

Cyst wall - was the cyst wall thick in the first set of photos I showed you 6 months ago?

Ovarian size - I know you said the size is mildly increased and not concerning, but what causes an ovary to increase in size?

And lastly - I did this last time :-) I've loaded 3 photos named "possible projections", "what is this", and "grey cloudy" and circled one thing in each picture. The questions are, are those projections on the possible projections photo? On the what is this photo and the grey cloudy photo, are those artefacts?

I don't know if I've reached my limit on questions but if needed, I will refill.
I will also consult my doctor, my appointment is in 2 weeks and I will ask for surgery.

Thank you!
Answered by Dr. Ranjeet Jagdale 8 hours later
Hi Good evening XXXXXX,

Yest Cyst wall was of similar thickness as compared with previous USG in September.
To be honest I am not sure as to why there is increase in size though it is a small increase. One explanation could be mild increase in the volume of the cyst for which we need to know the other two dimensions which have not been mentioned in the present report.
Only one image is uploaded saying "projections" but they are not true projections and just artefactual because the way the probe was held . You can see similar on the opposite wall as well but less in quantity.There will be some image which will show that wall clearly.But don't you worry, whatever images you have sent , I have seen them properly and nothing looks suspicious in those images.
Yes its a good idea to discuss with your doctor regarding surgery. I dont think we can classify it as a malignant cyst based on USG findings but yeah it is been there for long enough and should be treated.
Thanks and regards
Above answer was peer-reviewed by
Follow-up: Had ovarian cyst that was diagnosed by ultrasound. One ovary got removed. Chances of having cancer in the other? 1 hour later
I think you have answered everything I needed to know.

I was confused by your last sentence. We can't classify it as malignant based on ultrasound. Am I misunderstanding or are you saying its likely malignant but ultrasound will not confirm that? I'm sorry if I'm reading too much into that sentence or misunderstanding what you are saying. Does this last sentence mean you are leaning toward malignancy?
Answered by Dr. Ranjeet Jagdale 27 minutes later
Hi sorry about the confusion.

I meant we cannot call it malignant based on USG so more like a benign lesion. But like every other test, USG has its own sensitivity and specificity and one cannot be 100% sure that a benign appearing lesion will always turn out to be benign on histopathology, however 9 out of 10 times it does.
All the criteria which have been described for a benign or malignant lesion are based on observations in thousands of patient and there can be overlap of finding.

However based on USG appearance and the stability of your lesion it is highly likely to be benign and unlikely to be a malignant lesion.Having said that even if it is benign why should you keep it inside.So do ask your doctor about the surgical treatment options.
Thanks and take care
Above answer was peer-reviewed by
Follow-up: Had ovarian cyst that was diagnosed by ultrasound. One ovary got removed. Chances of having cancer in the other? 6 hours later
Thank you very much for all your time.

Best and take care :-)
Answered by Dr. Ranjeet Jagdale 1 hour later
You are most welcome and wishing you a very good health :)

Thank you and Take care.
Above answer was peer-reviewed by
Follow-up: Had ovarian cyst that was diagnosed by ultrasound. One ovary got removed. Chances of having cancer in the other? 29 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 cust 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.
Follow-up: Had ovarian cyst that was diagnosed by ultrasound. One ovary got removed. Chances of having cancer in the other? 7 hours later
I decided to go back and look at the CD of all the ultrasound images. I was trying to find a clearer picture of that right upper cyst wall. Please humor me by allowing me to post 4 more photos (they are IMG 0706, 0707, 0708, 0709). Do you see anything more in those photos (projections, nodules, etc) that the other previously posted photos may not have shown? Also, are there a lot of bright foci within the cyst because in image 0707 I almost can't see any.
Thanks yet again :-)
Answered by Dr. Ranjeet Jagdale 2 hours later

The image which you have sent as "what this?" also deos not show any nodule. The area which you have circled is artefactual and not an actual cyst.

So don't you worry. I cannot see any other images that you are saying as 708,709.
Above answer was peer-reviewed by
Follow-up: Had ovarian cyst that was diagnosed by ultrasound. One ovary got removed. Chances of having cancer in the other? 9 minutes later
Ok, thanks. I'm not sure why the images don't all load as they appear to load on my side. Could be I have too many photos.
The ONLY thing I'm unsure of is the last photo I just uploaded (it's called "two circles"). I PROMISE this will be my last image.
What I'd like to know about this specific photo is, the two area's circled, are those grey cloudy areas what you are saying are artefacts and if yes, is it for sure artefact rather than debris or something solid? Seems it would be so difficult to know this for sure.
Thanks :-)
Follow-up: Had ovarian cyst that was diagnosed by ultrasound. One ovary got removed. Chances of having cancer in the other? 2 minutes later
If you don't see the image, let me know and I will delete another to put that one on in its place.
Answered by Dr. Ranjeet Jagdale 1 hour later
Hi , Now I just got 706 image and others are 689 to 698
I don't seen the image with two circles.

I guess you need to delete the previous images or email them to me at YYYY@YYYY .

And whatever images I have received so far from 689-699 and what is this? and image 706, dont show any suspicious nodule or projection
Above answer was peer-reviewed by
Follow-up: Had ovarian cyst that was diagnosed by ultrasound. One ovary got removed. Chances of having cancer in the other? 19 hours later
I sent the photos to your email, they may have gone in your spam folder. They would have come from YYYY@YYYY

Answered by Dr. Ranjeet Jagdale 3 minutes later
Hello , oh ok thanks, I will check and get back to you soon.

Above answer was peer-reviewed by
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