Benign presumed ovarian cyst: pathological and ultrasonographic confrontation about 60 cases Wissal Jaafar, Najeh Hsayaoui, Nesrine Souayeh, Hajer Bettaieb, Mohamed Amine Ben Khedija, Hedhili Oueslati, Chaouki Mbarki Ben Arous Regional Hospital- Gynecology and Obstetrics / Tunis Medical University / Tunisia
Introduction: The cysts of the ovary present a gynecological frequent pathology. The improvement of the ultrasound technique transformed the care of this pathology. Sonography allows to identify the functional character of cysts and especially to establish very strong assumption of kindness or wickedness thanks to precise semiological analysis.
Patients and Methods:
Our study was an analytical retrospective study on 60 patients operated for cyst of the ovary during a period of four years from January 2009 till December 2012 in the department of obstetrics gynecology of Ben Arous hospital, Tunisia. We consulted the ultrasound examination data. Only benign ovarian tumors presumed in sonography were included in this study. Results: The average age of patients was 35,7 years [14-60 years]. Past history of infertility was found in 13% of the cases. The mean parity of the patients was 1,6 with extremes from [1-6]. The pelvic pain was the chief complaint 53%: acute pain 35% and pains chronicles 65%. Ultrasound was performed in all patients: abdominal ultrasonography in 41,6%, vaginal ultrasound examination in 58,3%. The average size of ovarian cyst was 7,6 cm [4-15cm]. 80% of cysts had a size between 4 and 10 cm. In our series, the ultrasound assumption of the histological origin was in 16% of cases in favor of functional cysts, and in 84% of cases in favor of the organic origin. All the cysts presumed in ultrasound functional (8 cases) were confirmed by the histological examination. For the presumed cysts organic (52 cases), 96% were confirmed by the histological examination. The sensibility of the ultrasound to detect an organic lesion was 80%. The specificity was 100%, the VPP was 100% and the VPN was 96,1%. For the histological assumption, the best sensibility was registered for dermoid and serous cysts: respectively 100% and 80% for only 40% concerning mucinous cysts. Endometriosis cysts and mucinous cysts presented the best specificities with respectively 100% and 96.4%.
Authors Number Sassone et al 143 (4) Hithmi (5) 134 Ben Tounes (6) 100 Boudhraa et al 100 (7) Mathlouthi et al 77 (8) Our study 60
Sensibility 100
Specificity 95
75 80 66
52 90,12 87
71,4
80
100
-
Discussion: Imaging has two roles in the diagnosis of ovarian cysts: asserting the organic nature of the mass and determining the rather benign or rather malignant nature of the cyst (1) I. The benign and malignant approach by ultrasound: The univariate analysis of the largest study on the subject shows that the ultrasound parameters chosen all help to differentiate the benign from the malignant, but that none can do it alone (2). the characterization of ovarian tumors in ultrasound has a sensitivity that varies from 62 to 100% and a specificity from 73 to 95% (3) see table below. Several studies have been carried out with the aim of identifying which of the characteristics of the cyst is more evocative of the malignant nature of the ovarian tumor. Thus, the following three parameters have been studied: size, endocystic vegetations and septa. 1.Size: Andolf and Grandberg found, among the multilocular cysts, 9% of malig lesions, if the size is less than 5 cm and 32% when it exceeds 5 cm (9), (10). Among the unilocular cysts, a review of the literature found percentages of malignancy respectively 0.3% and 10% if the size is greater than or equal to 5 cm. In our series, 80% of benign tumors were less than 10 cm in size and 90% were unilocular 2. Vegetation: For Dimassi et al, endocystic vegetations show the most predictive ultrasound sign of malignancy with a positive predictive value (PPV) at 86.67% and a negative predictive value (NPV) at 100%. In our series, 96.6% of benign tumors do not have endocystic growths 3. Partition: For Grandberg et al, only 40% of multilocular lesions were related to malignant lesions (10). In our series, 90% of benign tumors are unilocular. II. The histological approach of histological type of the ovarian cyst: Since 2000, the most important study is the one of the IOTA team involving 1066 tumors including 800 benign tumors, the histological diagnosis was evoked on the ultrasound in 84% of cases with a specificity of 94% to 100% and variable sensitivity according to histological type, the most important was for dermoid cysts, pseudocysts and for endometriomas 77% (11)(12). 1. Serous cystadenoma: Unilateral homogeneous anechoic character associated with posterior reinforcement of echoes is in favor of this type (1). According to the IOTA team (12), ultrasound sensitivity is very low 6%. Our results are discordant to these and of the order of 80%. 2. Mucinous cystadenoma: Of all types of tumors, mucinous cysts are the most frequently multilocular (50%). They are also quite large with a large axis of 80mm on average (13). In more than half of the cases there is a classic echogenicity called "low level": a black background (anechoic) strewn with very fine echogenic particles. According to Sokalska A et al, the sensitivity of ultrasound to determine this type is 36%. (1) (40% in our series) 3. Endometriotic cyst: Patel et al. have tried to evaluate the performance of ultrasound in the diagnosis of endometriotic cysts, and found a correlation between ultrasound and histological diagnosis in 95% of cases (14). For Volpi et al, the sensitivity was 82.4% and a specificity of 97.7%, which corresponds to a PPV of 94% and a VPN of 92.8% (15). Our result is consistent with that of the literature. We thus admit the value of ultrasound examination in the diagnosis of endometriomas. In 95% of cases, the presence of these low intensity intracystic echoes is the most useful sign for the diagnosis (14). He is not pathognomonic but specific. For Ardaens, the presence of echogenic punctuations of the wall, witnesses to the correlation of ferric pigments, is pathognomonic (16). 4. Mature teratoma (dermis cyst): They are sometimes very easy to diagnose in their most typical aspects, but their polymorphism often makes the task difficult (the posterior shadow cone, the protuberance of Rokitansky (17), (18)). For a Canadian team, the sensitivity of ultrasound in the presumptive diagnosis of dermoid cysts is 96% (19). For the IOTA series, this sensitivity is 86%. In our series the sensitivity and specificity in the diagnosis of this histological type was 100% and 96
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