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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Transvaginal ultrasound showed complex cyst, CAT scan showed simple cyst. Any suggestion?

Answered by
Dr. Ranjeet Jagdale


Practicing since :2005

Answered : 34 Questions

Posted on Mon, 7 Jan 2013 in X-ray, Lab tests and Scans
Question: Hi,
I was told I had a complex cyst by transvaginal ultrasound in July (that was previously a simple cyst in April) by my regular gynecologist. I was sent to a gynecologist oncologist and had a CAT scan (abdominal and pelvic) and the report said it was a simple cyst. Then 3 weeks later on 9/27/12, I had a second opinion from a different gynecologist oncologist via another transvaginal ultrasound. I was again told it was a simple cyst. I have a disc of many pictures of the cyst but I'd like to see if I can post one to have you take a look and also would like to quickly type in the radiology consultation report. Can you help me? Also attached is the radiology report and one photo of the cyst. To me this photo looks like the cyst has a septation in it. If this is the case, I thought this would be called a complex cyst but I have been told now twice by two different oncologist gynecologists that it's a simple cyst. This photo looks complex to me??
Answered by Dr. Ranjeet Jagdale 59 minutes later
Hi sorry to hear what you must be going through and would do my best to help you.
I have gone through your report and USG image, I dont see any septation within the cyst , however what concerns me is a small nodule in the left upper portion of the cyst which I would like to have a second look at if you could send me some more images of the cyst , that would be helpful.
thank you
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Ranjeet Jagdale 44 minutes later
Thank you for your reply. I've attached 3 more files. The total images taken were 67 images. Please let me know if you would like to see more. Nothing was mentioned about any nodules in the cyst in either the CAT scan done of my pelvis and abdomen and nothing was mentioned about nodules on the 67 images of the ultra sound. Please let me know your thoughts. I'm wondering if the nodule could be debris (perhaps blood or follicular fluid?)?
Please let me know if there are 3 additional uploads as it's hard to view what was actually uploaded.
Thank you.
Answered by Dr. Ranjeet Jagdale 47 minutes later
Hi thank you for posting more images.

The nodule which was seen in the previous image is not seen in any of the images you have sent me now thus it will be just a sectional and artefactual.
I dont see any septa within and the apparent septa which you probably you are thinking as seen in the image Photo Cyst Pic.2 is the wall of the cyst with the surrounding fluid. So it does look like a simple cyst :)
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Ranjeet Jagdale 9 hours later
If I may ask, what you first believed was the nodule, was it the area on the upper section of what I thought was the septa (that you are saying is the wall of the cyst). It looks like a big grey colored area?

In the other photos I loaded (specifically picture labeled cyst pic 2 and cyst pic 3), I see this same grey colored area at the top of the cyst but it appears to be in a different area of the cyst (compared to the picture just labeled "cyst"). Is this what you mean by artefactual, that it is not a fixed nodule but rather debris floating around or something that shows no blood flow to it? I'm just trying to understand how you concluded it was not a nodule.

Thanks so much!
Answered by Dr. Ranjeet Jagdale 16 hours later
Hello there, sorry for a late reply.

In the pictures labeled pic 2 and 3 its definitely artefactual and its due to something called as reverberation artefacts. I was having a doubt in pic 1 but again it seems artefactual because it is not seen in the same position in next pictures and debris usually does not float unless it has fat within, usually it settles down.

The artefact is due to USG technique and when someone actually scans the patient it is much easier to take care of the artefact by just changing the angulation of the probe.

I hope this helps you, tale care
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Ranjeet Jagdale 40 hours later
One last question please. Could what appears as the wall on the right side or what I may have thought was a septation, could that be refraction?
Answered by Dr. Ranjeet Jagdale 2 hours later
Hi XXXXXXX, I can understand that You are worried, but I want to assure you that there is no septa seen in the images provided by you. If you want you can put an arrow on the image as to what you think as the septa and I can explain what that structure is.
Hope this helps, take care
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Ranjeet Jagdale 48 minutes later
Thank you so much for that offer, I really appreciate it. I've loaded a photo ("photo 2 Septa circled") and actually put a circle around what I'm thinking is a septation. If you can explain what you think this may be (refraction, cyst wall) and I guess how a radiologist can really conclude that something is not a septation.
Thank you again!
Answered by Dr. Ranjeet Jagdale 11 minutes later
hello there,

That is the wall of the cyst and not a septa. If you see carefuly at it , it has a smooth curve which a wall of the cystic structure assumes by laws of physics and more than that it looks as a septa to you because of the fluid surrounding the cyst.
There is small amount of fluid around the cyst.
So please dont worry.
I have also seen that you have posted another query on our site but I didnt choose to answer that as thought you might be wanting opinion from some other doctor.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Ranjeet Jagdale 12 minutes later
Yes, right. I just like to get a few opinions. I'm a worrier I guess because of my past history of leukemia. My main concern is when in late April my regular gynecologist did an ultrasound and said I had a simple cyst and then they followed up in early July and they called this cyst as now being complex and it looks like the exact same picture I posted to you from my September 27 ultrasound ordered by a gyno/oncologist. So I guess it is confusing why the gynecologist in July called it complex but follow up by two different gyno/oncologists concluded by radiologist via CAT scan and ultrasound (2nd radiologist for ultrasound) that it was simple. I will assume the latter two doctors are correct. Thank you again for taking a look :-)
Answered by Dr. Ranjeet Jagdale 4 minutes later
You are welcome and always happy to help you. Hope u maintain a better health and take care.
Warm regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Ranjeet Jagdale 3 days later
I promise these will be my last couple of follow up questions. You have been so kind and have been the best so far in explaining.

1. In April 2012, this same cyst appeared as a "normal" looking simple cyst. Meaning, it did not have this adjacent fluid next to it. The same regular gynecologist office did another ultrasound in July and they said the cyst was complex. They thought this cyst wall was a septation (the same one I circled in the prior uploaded photo). The rest of the story is I went to the two oncologists and had a CAT scan and then ultrasound by the 2nd oncologist and they both said simple cyst. My question is, is it considered normal that a cyst could have this adjacent fluid next to it that was not there months prior? And if so, what is this fluid, does it mean the cyst is leaking?

2. From time to time, I have pressure and discomfort from the cyst. Does this mean the cyst is getting worse or bigger when I feel this discomfort?

3. Last question. I uploaded one last photo, called "Cyst 2nd Area Circled". Can you take a look at the area I circled and tell me what that it?

Thanks again for all your help.

Answered by Dr. Ranjeet Jagdale 3 hours later
Hello XXXXXXX, not an issue, you can ask as many questions till you are convinced and satisfied with the answer.

As far as the fluid around the cyst is considered then that fluid in small quantities(as in your case) is considered normal and it occurs in menstruating females and is usually considered due to ovulation. Hence you can see it in one scan and wont be seen in another.
What is important is check the size of the cyst in the interval scan and see if it has increased in size over that period and a cysts which fails to resolve even after few months needs to be closely watched. At present it appears simple but if it has increased in size over the period and if it persists for say 6months then you better consult your gynac doctor and discuss about the treatment options.

Cysts wont leak like that unless it has ruptured and in that case you will have bad pain and size of cyst will come down.

Cyst 2nd Area Circled : That is just the pelvic wall it looks like that because of the fluid next to it. So that is normal structure.

Happy to help you. Take care and regards

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Ranjeet Jagdale 10 hours later
You are saying this fluid is normal in menstruating women and I went through menopause at age 19 due to chemotherapy for a bone marrow transplant.

Do you feel I should be concerned given this fact and again that the fluid was not there in April but appeared in July?

Also, if a simple cyst does get bigger over time, does that mean the cyst is typically cancerous.

Ok, last thing. I promise you I am not crazy but what I did may sound strange. I have put another picture for you to take a look at. This photo is called "Septated Cyst Example". This is a septated cyst I found on the internet and I'm asking you to take a look because to me, it looks very similar to my cyst. I guess I don't understand why my septation is really just the cyst wall but this other septated cyst example is truly a septated cyst. Mine and this example look very similar.

And again, I am sorry for posting and asking you to take a look. I really am a normal person, I just have some health anxiety and am concerned that my cyst changed from April to July with this new fluid and that the very first regular gynecologist was so concerned that the cyst had a septation but then was told it's a simple cyst, it's hard to know what to believe......

Thank you.
Answered by Dr. Ranjeet Jagdale 5 hours later
Hi XXXXXXX, its absolutely fine you are worried about your health and I dont think its crazy.

If you notice carefully the septa here has a sort of triangular base when it comes in contact with the cyst wall but in your case it is just smooth wall and the fluid around your cyst does not have a well defined margin as in this cyst from internet.

even a simple cyst can get bigger with time and not necessarily it has to be malignant

Now that u are saying U are not menstruating , then probably we need to look at what is causing the fluid around the cyst. If I was in your place I would undergo a repeat USG now (so like 4months after July scan) and find out about the size of the cyst and fluid around it.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Ranjeet Jagdale 1 hour later
Thank you for your reply.

In your professional opinion, do you think this cyst is probably cancerous? When I say history, I mean fluid around the cyst given that I am in menopause, does fluid around cyst usually indicative of cancer if there is no menstruation?

So you are saying I should trust that the radiologists looking at both my CAT scan and ultrasound a couple weeks later can definitely differentiate between a septation and cyst wall?

Thank you and above are my last questions.
Answered by Dr. Ranjeet Jagdale 30 hours later
Hello XXXXXXX sorry for a late reply.

There are no radiological features to suggest with certainty that the cyst is cancerous. The appearance of the cyst suggest a benign(non cancerous) nature of the cyst.

Usually fluid around the cyst in small quantities does not mean a cancerous lesion and even though you are menopausal the fact that you have got a big ovarian cyst means that you could have had smaller cysts one of which might would have ruptured which is normal physiological.

Yeah radiologist looking at both CT and USG can definitely differentiate between the two.

And if you haven't had a scan in last 4months than it is better to get one Pelvic USG now so as to know the status of the cyst with respect to its size and fluid around it.
Hopefully it must have regressed.

I hope this answers your queries, If you still have any questions don't worry and ask. I want you to have no more doubts about your cyst and keep worrying about it.

Take care and regards, sorry again for being late in replying to Ur query.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Ranjeet Jagdale 16 hours later
Thank you so much for your reply.

The ultrasound pictures I posted to you were performed on 9/27/12 so it is not quite time yet for another ultrasound.

Is it true that the radiologist looks at the entire series of photos before he or she determines something is just fluid filled?

I think my worry is because the cyst causes increased pressure and mild pain and I keep imagining that the pain and pressure I feel is because the cyst is growing larger. Is this generally the case, that increased pain and pressure usually means a cyst is increasing in size?

And lastly, I think you said in an earlier post that the fluid next to the cyst would very unlikely be related to the cyst possibly "leaking". I have read some on the Internet, when a cyst tries to resolve, could it not leak in the process?

Thank you again for your kindness and patience.

Answered by Dr. Ranjeet Jagdale 10 hours later
Yes Radioologist does look at all the images before giving his/her opinion. The part of the world where I practice, radiologist does the USG and not a technician.

Your cyst is 4cms in maximum dimension and it has been persistent for many months now, I would still recommend you to get a repeat USG done and check the present condition of the cyst and if it is persistent and or increasing in size you should consult your doctor for its removal because it can be a ovarian cystadenoma, which is not cancerous but is a tumor.
if the cyst has not changed or has decreased then you can have yearly follow up.
Simple adnexal cysts up to 10 cm in a patient of any age are highly likely to be benign, with malignancy rates of less than 1%.
And if the fluid around your cyst is because of leak from the cyst, the size of the cyst should have reduced.
You are welcome and I am happy to answer to your queries, I hope I have helped you in best possible way I could.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

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