eMedicine Specialties > Obstetrics and Gynecology > General Gynecology
Ovarian Cysts: Differential Diagnoses & Workup
Updated: Mar 19, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Abdominal Abscess
Ectopic Pregnancy
Other Problems to Be Considered
Diverticular disease
Hydronephrosis
Hydrosalpinx
Paraovarian cyst
Pedunculated leiomyoma
Pelvic kidney
Pelvic lymphocele
Peritoneal cyst
Tubo-ovarian abscess
Workup
Laboratory Studies
- No laboratory tests are diagnostic for ovarian cysts.
- Cancer antigen 125 (CA125) is a protein expressed on the cell membrane of normal ovarian tissue and ovarian carcinomas.
- A serum level of less than 35 U/mL is considered normal. In some laboratories, the upper limit of normal may be lower than this.
- While CA125 values are elevated in 85% of patients with epithelial ovarian carcinomas, overall, the value is elevated in only 50% of patients with stage I cancers confined to the ovary. CA125 levels are also elevated in patients with some benign conditions or other malignancies and in 6% of healthy patients.
- The finding of an elevated CA125 level is most useful when combined with an ultrasonographic investigation while assessing a postmenopausal woman with an ovarian cyst.
- Other tumor marker values may be elevated in patients with neoplastic ovarian cysts. These markers include serum inhibin in granulosa cell tumors, alpha-fetoprotein in endodermal sinus tumors, lactic dehydrogenase in dysgerminomas, and alpha-fetoprotein and beta-hCG in embryonal carcinomas.
Imaging Studies
- Ultrasonography
- This is the primary imaging tool for a patient considered to have an ovarian cyst. Findings can help define morphologic characteristics of ovarian cysts.
- Simple cysts are unilocular and have a uniformly thin wall surrounding a single cavity that contains no internal echoes. These cysts are unlikely to be cancerous. Most commonly, they are functional follicular or luteal cysts or, less commonly, serous cystadenomas or inclusion cysts.
- Complex cysts may have more than one compartment (multilocular), thickening of the wall, projections (papulations) sticking into the lumen or on the surface, or abnormalities within the cyst contents. Malignant cysts usually fall within this category, as do many benign neoplastic cysts.
- Hemorrhagic cysts, endometriomas, and dermoids tend to have characteristic features on sonograms that may help to differentiate them from malignant complex cysts.
- Sonograms may not be helpful for differentiating hydrosalpinx, paraovarian, and tubal cysts from ovarian cysts.
- Endovaginal ultrasonography can help in a detailed morphologic examination of pelvic structures. This requires a handheld probe to be inserted into the vagina. It is relatively noninvasive and is well tolerated in reproductive-aged women and post–reproductive-aged women who are still engaging in intercourse. It does not require a full bladder.
- Transabdominal ultrasonography is better than endovaginal ultrasonography for evaluating large masses and allows assessment of other intra-abdominal structures such as the kidneys, liver, and ascites. It requires a full bladder.
- 3-dimensional ultrasonography may have advantages in the evaluation of ovarian cysts.1,2
- Doppler flow studies
- These studies can help identify blood flow within a cyst wall and adjacent areas, including tumor surface, septa, solid parts within the tumor, and peritumorous ovarian stroma. The principle is that new vessels within tumors have lower resistance to blood flow because they lack developed smooth muscle in the walls. This can be quantitated into a resistive or pulsatility index.
- Estimation of the resistive index has limited clinical value in premenopausal women because of the great overlap of low-resistance flow characteristics in functional tumors and early cancers.
- Determination of the presence or absence of any blood flow within certain cysts may be helpful in diagnosis. For instance, hemorrhagic cysts may contain fine internal septations that characteristically do not demonstrate blood flow on Doppler images.
- MRI
- MRI with gadolinium allows clearer evaluation of lesions deemed indeterminate after performing ultrasonography.
- MRI images have better soft tissue contrast compared to CT scan images, particularly for identifying fat and blood products, and can give a better idea of the organ of origin of gynecologic masses.
- MRI is not necessary in most cases.
- CT scan
- CT scanning is inferior to ultrasonography and MRI for helping define ovarian cysts and pelvic masses.
- CT scan allows examination of the abdominal contents and retroperitoneum in cases of malignant ovarian disease.
Procedures
- Using needle aspiration to obtain fluid for cytologic examination provides inaccurate cytology results, and needle aspiration is an inappropriate method for cyst drainage in most cases.
- Performing diagnostic laparoscopy may sometimes be necessary to inspect a suggestive adnexal cystic mass, but an intraovarian malignancy may be missed.
Histologic Findings
The definitive diagnosis of all ovarian cysts is made based on histological analysis. Each type has characteristic findings.
More on Ovarian Cysts |
| Overview: Ovarian Cysts |
 Differential Diagnoses & Workup: Ovarian Cysts |
| Treatment & Medication: Ovarian Cysts |
| Follow-up: Ovarian Cysts |
| Multimedia: Ovarian Cysts |
| References |
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References
Chan L, Lin WM, Uerpairojkit B, Hartman D, Reece EA, Helm W. Evaluation of adnexal masses using three-dimensional ultrasonographic technology: preliminary report. J Ultrasound Med. May 1997;16(5):349-54. [Medline].
Kupesic S, Plavsic BM. Early ovarian cancer: 3-D power Doppler. Abdom Imaging. Sep-Oct 2006;31(5):613-9. [Medline].
Caruso PA, Marsh MR, Minkowitz S, Karten G. An intense clinicopathologic study of 305 teratomas of the ovary. Cancer. Feb 1971;27(2):343-8. [Medline].
Clement PB. Anatomy and histology of the ovary. In: Kurman RJ, ed. Blaustein's Pathology of the Female Genital Tract. 4th ed. New York, NY: Springer-Verlag; 1989:438-70.
Dewhurst J, Pryce-Davis J, Helm W. Diagnosis and management of granulosa/theca cell tumours in childhood. Paediatric and Adoloscent Gynaecology. 1985;3(2):131-56.
Evans AT 3rd, Gaffey TA, Malkasian GD Jr, Annegers JF. Clinicopathologic review of 118 granulosa and 82 theca cell tumors. Obstet Gynecol. Feb 1980;55(2):231-8. [Medline].
Farah L, Azziz R. Polycystic Ovary Syndrome. The Female Patient. 1999;24:79-86.
Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer statistics, 2000. CA Cancer J Clin. Jan-Feb 2000;50(1):7-33. [Medline].
Higgins RV, Matkins JF, Marroum MC. Comparison of fine-needle aspiration cytologic findings of ovarian cysts with ovarian histologic findings. Am J Obstet Gynecol. Mar 1999;180(3 Pt 1):550-3. [Medline].
International Federation of Gynecology and Obstetrics. Annual Report on the Results of Treatment in Gynaecological Cancer. J Epidemiol Biostat. 1998;3:1-68.
Jacobs I, Bast RC Jr. The CA 125 tumour-associated antigen: a review of the literature. Hum Reprod. Jan 1989;4(1):1-12. [Medline].
Loyer EM, Whitman GJ, Fenstermacher MJ. Imaging of ovarian carcinoma. Int J Gynecol Cancer. Sep 1999;9(5):351-361. [Medline].
Lu D, Davila RM, Pinto KR, Lu DW. ThinPrep evaluation of fluid samples aspirated from cystic ovarian masses. Diagn Cytopathol. May 2004;30(5):320-4. [Medline].
Maiman M. Laparoscopic removal of the adnexal mass: the case for caution. Clin Obstet Gynecol. Jun 1995;38(2):370-9. [Medline].
Miller BA, Kolonel LN, Bernstein L, et al. Racial/Ethnic Patterns of Cancer in the United States 1988-1992. Bethesda, Md: National Cancer Institute; 1996.
Moran O, Menczer J, Ben-Baruch G, et al. Cytologic examination of ovarian cyst fluid for the distinction between benign and malignant tumors. Obstet Gynecol. Sep 1993;82(3):444-6. [Medline].
Osmers R. Sonographic evaluation of ovarian masses and its therapeutical implications [editorial]. Ultrasound Obstet Gynecol. Oct 1996;8(4):217-22. [Medline].
Peterson WF, Prevost EC, Edmunds FT, et al. Benign cystic teratomas of the ovary; a clinico-statistical study of 1,007 cases with a review of the literature. Am J Obstet Gynecol. Aug 1955;70(2):368-82. [Medline].
Ries LAG, Kosary CL, Hankey BF, et al. Cancer Statistics Review: 1973-1996. Bethesda, Md: National Cancer Institute; 1999.
Roman LD. Small cystic pelvic masses in older women: is surgical removal necessary?. Gynecol Oncol. Apr 1998;69(1):1-2. [Medline].
Schmeler KM, Mayo-Smith WW, Peipert JF, et al. Adnexal masses in pregnancy: surgery compared with observation. Obstet Gynecol. May 2005;105(5 Pt 1):1098-103. [Medline].
Schnorr JA Jr, Miller H, Davis JR, et al. Hyperreactio luteinalis associated with pregnancy: a case report and review of the literature. Am J Perinatol. Feb 1996;13(2):95-7. [Medline].
Simpkins F, Zahurak M, Armstrong D, et al. Ovarian malignancy in breast cancer patients with an adnexal mass. Obstet Gynecol. Mar 2005;105(3):507-13. [Medline].
Steinkampf MP, Hammond KR, Blackwell RE. Hormonal treatment of functional ovarian cysts: a randomized, prospective study. Fertil Steril. Nov 1990;54(5):775-7. [Medline].
Sykes PH, Quinn MA, Rome RM. Ovarian tumors of low malignant potential: a retrospective study of 234 patients. Int J Gynecol Cancer. 1997;7:218-26.
Weiss NS, Homonchuk T, Young JL Jr. Incidence of the histologic types of ovarian cancer: the U.S. Third National Cancer Survey, 1969-1971. Gynecol Oncol. Jun 1977;5(2):161-7. [Medline].
Whittemore AS, Harris R, Itnyre J. Characteristics relating to ovarian cancer risk: collaborative analysis of 12 US case-control studies. II. Invasive epithelial ovarian cancers in white women. Collaborative Ovarian Cancer Group. Am J Epidemiol. Nov 15 1992;136(10):1184-203. [Medline].
Further Reading
Keywords
ovary, benign cyst, graafian follicles, functional cysts, theca-lutein cysts, hyperreactio luteinalis, ovarian hyperstimulation syndrome, serous cystadenoma, mucinous cystadenoma, neoplastic cyst, malignant cyst, granulosa cell tumor, sex cord stromal tumor, germ cell tumor, primordial cell tumor, teratoma, endometrioma, pseudomyxoma peritonei, ovarian tumors, cystadenocarcinoma
gestational trophoblastic neoplasia, hydatidiform mole, choriocarcinoma, polycystic ovary syndrome, polycystic ovarian syndrome, PCOS, ovarian hyperstimulation syndrome, epithelial ovarian cystadenocarcinomas, ovulation induction with gonadotropins, ovulation induction with clomiphene citrate, ovulation induction with letrozole
