Question: Hi there,

Good Morning,

I am Dr. XXXXXXX Nadeem, working in Insurance Company. I have one Gynecology case. I Need to have your expert opinion on this case.

This is 32-year-old female member, who presented to the hospital with complaint of severe lower abdominal pain.

•     The member is Para 3+0.
•     All her deliveries were normal vaginal deliveries.
•     Her last child birth was in December 2014.
•     Her CA 125 level was high at 152.7 IU/ml.

Trans-vaginal ultrasound of the pelvis (07.05.2015)

•     Uterus is anteverted, showing normal in shape, size and echotexture.
•     Endometrial thickness is 7.6 mm, no focal lesion is seen, IUCD in situ.
•     Both ovaries showed poly cystic ovaries.
•     Left ovary showed exophytic cystic lesion with vascular solid component measuring 46.9 x 27.9 mm, picture suggest neoplastic cyst.
•     Right adnexa near to the right ovary showed thick walled cystic lesion measuring 17.7 x 16.1 mm, picture suggestive of ?ectopic pregnancy or ? corpus luteal cyst.
•     No free fluid seen in the pelvic cavity.

MRI Pelvis (9/5/2015)

•     The left ovary is moderately enlarged in size and show 2 cysts. The first cyst has a well defined wall and shows low SI and TIW1 and high SI on T2WI with wall enhancement after contrast injection, measuring 2.2x2.7cm
•     The second cyst has irregular outline and shows two component, on antero-medial component having intermediate SI and TIWI and high SI on T2WI indicating hyper-acute hemorrhage and second postero-lateral component having high signal intensity on T1-weighted imaging and intermediate signal intensity on T2-weighted imaging indicating sub-acute hemorrhage IC type. The post-contrast images show heterogeneous enhancement, measuring 3.3x4.5.2cm. these MRI criteria suggest Left ovarian hemorrhagic cyst.
•     The uterus is orthotopic with smooth borders. The displays a normal configuration and appropriate development for age. The myometrium shows homogenous signal intensity. The endometrium is thick, measuring 1.5cm. The endometrial cavity has IUCD.
•     The vaginal fornix is normal.
•     The right ovary is normal shape, size and position. No cystic or solid mass could be seen.
•     The adequately distended urinary bladder has smooth outer contour and normal wall thickness.
•     The pelvic inlet appears normal, with normal configuration of the iliac wings and iliopsoas muscles.
•     Imaged bowel structures, especially the cecum and rectum, show no abnormalities with no evidence of wall thickening or mass lesion. The peri-rectal fat and ischio-rectal fossa are unremarkable.
•     The vessels of the lesser pelvis are normal in course and caliber.
•     There are no signs of lymphadenopathy.
•     Conclusion
o     MRI criteria suggesting left ovarian hemorrhagic cyst. However chocolate cyst (endometrioma) should be considered in the DD.
o     Endometrial thickening 1.5cm
o     IUCD without complication.

Treating doctor is requesting for the following procedures in this case as she is suspecting neoplasm.

Laparoscopic ovarian cystectomy + oophorectomy under GA.

Please give us your expert opinion in this case and confirm if the above mentioned treatment plan given by the treating doctor is really helpful and will give benefit to our member.