Ovarian Cysts Found During Regular Checkup

Situation

A woman in her thirties is diagnosed with a cyst of about 4 cm on one of her ovaries during a regular checkup. The gynaecologist suspects that it might be malignant based on the ultrasound images. There seems to be some solid structure inside the cyst. She otherwise exhibits no other symptoms. The doctor recommends seeking a second opinion. Another gynaecologist performs a more in-depth examination through transvaginal ultrasound, and decides that it is a benign endometriomas. By now the cyst has grown to about 6 cm due to menstruation. He recommends "keyhole" surgery (laparoscopic surgery) to remove the cyst.

Incidentally, the woman has an overseas trip scheduled in two weeks. The second gynaecologist suggests that the cyst might burst in flight due to air pressure. Hence although he believes the cyst is benign, he recommends that the cyst be removed as soon as possible so that she could recover in time for the trip.

Options and Risks

Options Risks
Schedule the minimally invasive surgery. There's a chance of spillage of malignant cells if the cyst is cancerous.
Request for a CA-125 test. Wrong conclusions could result from consideration of a single CA-125 reading alone.
Find a gynaecological oncologist for another opinion. Treatments could be delayed.

Poll

What would you choose?

Considerations

Minimally Invasive Surgery

Nowadays minimally invasive surgery1 is often recommended to treat endrometriosis. Perhaps because women of reproductive age have a higher chance2 of endometriosis and lower chance of ovarian carcinoma than postmenopausal women, and OCCC is a relatively uncommon histological type of epithelial ovarian cancer (except in Japan),3 a gynaecologist's differential diagnosis could be "biased" towards the finding that ovarian cysts in a young OCCC patient are likely benign. And statistics would readily support and maintain this bias.

In addition, a gynaecologist might not realize that OCCC patients tend to be younger and their symptoms manifest earlier than patients of other epithelial ovarian types.4 And about one fourth to more than a half of OCCC patients are associated with endometriosis.5,6

Some gynaecological oncologists recommend against using minimally invasive surgery to diagnose, stage, or treat ovarian cancers, and some research showed that minimally invasive surgery could worsen the prognosis of ovarian cancer patients since such a procedure would create an optimal environment for the malignant cells to seed and spread.7,8 If pathological reports indicate that the ovarian cysts once thought to be benign and later ruptured during laparoscopic surgery are malignant, patients should consult a qualified gynaecological oncologist as soon as possible about the need to perform staging laparotomy.

While there might be cases where minimally invasive surgery is a viable procedure for diagnosing and treating ovarian cysts suspected of malignancy, it is still best to be performed by a qualified gynaecological oncologist. For example, he might put forth measures to anticipate breakage of cysts and isolate spillage of tumor cells to avoid contamination of the abdominal cavity. That is, care must be taken to avoid rupturing the cystic masses as it could spread the tumour to other sites.

Note also that "non-surgical techniques to definitively diagnose ovarian cancer currently are not available. Biopsies of ovarian cysts are not recommended."9 And a patient needs to be careful about the permissions granted to the doctor when undergoing surgery. For example, a consent form for an exploratory procedure could grant him the sole discretion to remove her uterus and/or ovaries without the need for further consent.10

CA-125 Test

An elevated level of CA-125 alone in a single reading might not be a reliable indicator of the presence of malignant ovarian tumors. Ovarian cancer patients do not always have elevated CA-125 levels, and abnormal CA-125 levels may be associated with non-cancerous conditions such as infection and menstruation.

"[An abnormal level of CA-125] shows that there is some kind of inflammation in the area of the body surrounded by the hip bones (the pelvis). But it cannot tell the doctor exactly what is causing the inflammation."11

Delay in Treatments

The implications of not treating a benign cyst promptly, i.e., while seeking another opinion from a gynaecological oncologist, should be considerably less severe when compared to the implications of surgery performed by a gynaecologist who thought the cyst was benign but that it later turns out otherwise. For example, a benign ovarian cyst without symptoms usually does not require immediate surgical treatments. Further tests and observations may be warranted. A proper differential diagnosis (e.g., based on the initial size of the cysts and how they change over time, and what they look like) is more critical when symptom-less cysts are first discovered.12 And there is no known study indicating that ovarian cysts are more prone to rupture during flight. It is unlikely that endometriomas would rupture spontaneously.13

For instance, functional cysts could disappear on their own over time. A U.S. clinical professor of obstetrics and gynaecology14 suggests that continual monitoring is preferred over intrusive diagnoses and treatments if all the following are true:

  • The ultrasound images show a simple cyst without any internal structure.
  • The cyst is on only one ovary.15
  • The cyst is less than 4 to 5 inches (10 to 13 cm) in diameter.
  • The cyst occurs in a premenopausal woman.
  • No fluid or nodules are found in the pevlis.
  • There are no major symptoms of pain.

Some doctors might also prescribe contraception pills to suppress ovulation for diagnosis or treatment purposes.16

For a patient diagnosed with endometriosis, alternatives to surgery do exist for managing symptoms while letting the doctor continue to monitor the patient and leaving open the patient's option to have the endometrial tissue surgically removed.17 Surgery should be considered carefully, such as for treating severe pains or infertility where no other remedies are effective.

In general, a qualified gynaecological oncologist should be able to make a better differential diagnosis, judgment, and recommendation, such as interpreting test results,18,19 prescribing further tests, and consulting other specialists. And gynaecological oncologists are also better trained to perform staging, debulking, and other intrusive procedures for ovarian cancer patients. "Gynaecological cancer surgery can be challenging, involving techniques not routinely encountered by generalists. Even in early-stage ovarian cancer, surgery by a specialist gynaecological oncologist is an important prognostic indicator."20,21

In summary, women diagnosed with ovarian cysts where there is a slightest suspicion of malignancy should consult a gynaecological oncologist immediately.22

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