Cyst found on ultrasound: Imaging Tests for Ovarian Cysts
Imaging Tests for Ovarian Cysts
When you need an ultrasound—and when you don’t
Most ovarian cysts are small sacs, filled with fluid, on your ovaries. These are called “simple” ovarian cysts.
If your healthcare provider finds an unexpected cyst or enlarged ovary during a pelvic exam, you should have a vaginal ultrasound to assess for cancer. However, many women have follow-up ultrasound exams to make sure that cancer doesn’t grow later. Most of the time those extra exams are not needed. Here’s why:
Most ovarian cysts are low-risk and can be ignored.
A simple ovarian cyst often forms as part of the normal menstrual cycle. About one in five women who are past menopause also get them. These cysts are small and usually do not cause symptoms. And they usually do not turn out to be cancerous in women of any age.
Research has shown that if the cyst does not show signs of cancer, cancer is not likely to grow later.
For that reason, it is safe to ignore the cyst after the first vaginal ultrasound, as long as it does not start to cause symptoms, such as pelvic pain.
Ultrasound is safe, but follow-up can have risks.
During an ultrasound, a slender instrument is placed inside the vagina and sound waves are used to create pictures. An ultrasound exam does not expose you to radiation. And it is not costly. So repeating it may seem harmless.
But being called back a few weeks or months after the first ultrasound to check the cyst again may cause anxiety. And by then you may be in a new menstrual cycle. The old cyst may have gone away on its own. But a new cyst may have formed, which can lead to a follow-up ultrasound on the new one.
These rounds of ultrasound can also lead to unnecessary surgery to remove a cyst or ovary. For instance, some doctors take out cysts that do not appear to go away or that look bigger on follow-up tests, even though they would almost never become cancerous.
The risks of this surgery include pain, bleeding, and infection.
The tests can be a waste of money.
If you do not have health insurance, a vaginal ultrasound can be expensive, and an operation to remove an ovarian cyst can cost thousands of dollars. And any money spent on unnecessary tests and procedures is money wasted.
So when should you have a follow-up ultrasound test?
You may need a follow-up ultrasound test, and sometimes surgery, if the first ultrasound shows that you have a large cyst or a cyst that may be cancerous or could develop into cancer. If a cyst has the appearance of cancer, it should be removed right away. A surgeon who specializes in treating ovarian cancer should do the surgery. That type of surgeon is called a gynecologic oncologist.
This report is for you to use when talking with your healthcare provider. It is not a substitute for medical advice and treatment. Use of this report is at your own risk.
© 2016 Consumer Reports. Developed in cooperation with the American College of Radiology.
07/2016
Ovarian cyst – NHS
An ovarian cyst is a fluid-filled sac that develops on an ovary. They’re very common and do not usually cause any symptoms.
Most ovarian cysts occur naturally and go away in a few months without needing any treatment.
The ovaries
The ovaries are 2 almond-shaped organs that are part of the female reproductive system. There’s 1 on each side of the womb (uterus).
The ovaries have 2 main functions:
- to release an egg approximately every 28 days as part of the menstrual cycle
- to release the sex hormones oestrogen and progesterone, which play an important role in reproduction
Ovarian cysts may affect both ovaries at the same time, or they may only affect 1.
Symptoms of an ovarian cyst
An ovarian cyst usually only causes symptoms if it splits (ruptures), is very large or blocks the blood supply to the ovaries.
In these cases, you may have:
- pelvic pain – this can range from a dull, heavy sensation to a sudden, severe and sharp pain
- pain during sex
- difficulty emptying your bowels
- a frequent need to urinate
- heavy periods, irregular periods or lighter periods than normal
- bloating and a swollen tummy
- feeling very full after only eating a little
- difficulty getting pregnant – although fertility is usually unaffected by ovarian cysts
See a GP if you have symptoms of an ovarian cyst.
If you have sudden, severe pelvic pain you should immediately contact either:
Types of ovarian cyst
The 2 main types of ovarian cyst are:
- functional ovarian cysts – cysts that develop as part of the menstrual cycle and are usually harmless and short-lived; these are the most common type
- pathological ovarian cysts – cysts that form as a result of abnormal cell growth; these are much less common
Ovarian cysts can sometimes also be caused by an underlying condition, such as endometriosis.
The vast majority of ovarian cysts are non-cancerous (benign), although a small number are cancerous (malignant).
Cancerous cysts are more common if you have been through the menopause.
Find out more about the causes of ovarian cysts
Diagnosing ovarian cysts
If a GP thinks you may have an ovarian cyst, you’ll probably be referred for an ultrasound scan, carried out by using a probe placed inside your vagina.
If a cyst is identified during the ultrasound scan, you may need to have this monitored with a repeat ultrasound scan in a few weeks, or a GP may refer you to a doctor who specialises in female reproductive health (gynaecologist).
If there’s any concern that your cyst could be cancerous, the doctor will also arrange blood tests to look for high levels of chemicals that can indicate ovarian cancer.
But having high levels of these chemicals does not necessarily mean you have cancer, as high levels can also be caused by non-cancerous conditions, such as:
Treating ovarian cysts
Whether an ovarian cyst needs to be treated will depend on:
- its size and appearance
- whether you have any symptoms
- whether you have been through the menopause
In most cases, the cyst often disappears after a few months.
A follow-up ultrasound scan may be used to confirm this.
If you are postmenopausal, there is a slightly higher risk of ovarian cancer. Regular ultrasound scans and blood tests are usually recommended over the course of a year to monitor the cyst.
Surgical treatment to remove the cysts may be needed if they’re large, causing symptoms or potentially cancerous.
Ovarian cysts and fertility
Ovarian cysts do not usually prevent you getting pregnant, although they can sometimes make it harder to conceive.
If you need an operation to remove your cysts, your surgeon will aim to preserve your fertility whenever possible.
This may mean removing just the cyst and leaving the ovaries intact, or only removing 1 ovary.
In some cases, surgery to remove both your ovaries may be necessary, in which case you’ll no longer produce any eggs.
Make sure you talk to your surgeon about the potential effects on your fertility before your operation.
Video: ovarian cysts
This video explores the symptoms ovarian cysts can cause, the long-term effects, and the treatment options.
Media last reviewed: 1 April 2021
Media review due: 1 April 2024
Page last reviewed: 10 December 2019
Next review due: 10 December 2022
Ovarian cyst found, what’s next?
Hi Sue,
Sorry if I seemed a bit vague before, it’s just difficult to know how much to tell someone when you don’t want to worry them. Also, every case is different, so what happened to me may not happen to you, but maybe in some way it may help put your mind at ease a little….I hope so anyway.
My case is a bit strange, and to be honest due to a string of circumstances I have been very lucky.
However, the main thing for you is that your case is being dealt with. My tumour was found purely by chance, and initially they didn’t think it was malignant (I was told that I was the wrong age for ovarian cancer at 34!). I had an ultrasound in March this year, in preparation for being referred for IVF treatment. During the ultrasound they found a cyst on my left ovary. I relayed this information to my fertility nurse, who then rang back a couple of days later to say that it wasn’t a cyst, it was a ‘mass’, roughly 3.5cm’s in diameter. I, like you, was asked to come in asap for the blood tests that tested for the CA125 marker (which I believe picks up on most types of ovarian cancer). I had 4 sleepless nights waiting for the results, and was over the moon when thye came back negative. My consultant still had to identify what my ‘mass’ was, they thought it may be a dermoid cyst. However, the IVF clinic we were going to be referred to asked that it should be left if it was a cyst, but should be removed if it was solid.
I had an MRI (I think it was in May or June) which showed my ‘mass’ was solid. They now thought it was a fibroma (although still couldn’t say for sure!) I therefore needed the ‘mass’ removing, along with my left ovary, as it would be impossible to remove just the ‘mass’. My consultant operated after about 6 weeks, so we could get on with our IVF, so I had it removed on 9th August.
About 4 weeks later we got a call from my consultant’s secretary to say that he wanted to see us urgently, and that I should take my husband with me!!!! We saw him the next day and the histology report showed that I had had a malignant tumour on my ovary, specifically a granulosa cell tumour. That was the bad news. Now for the good news (and there can be good news!) – the only treatment is removal (which they had already done), I didn’t need chemo or radiotherapy, they had caught it very early on (bear in mind I didn’t have any symptoms, although my consultant now thinks this may have been why my periods were irregular), and I now need monitoring every few months to make sure it doesn’t come back in the other ovary.
They didn’t suspect this type of tumour because I am the wrong age (34 years old, and this tumour is mainly found in teenage girls and post-menopausal women), and one of the indicators is a high level of oestrogen, which I didn’t have. Also, the test for this type of tumour is apparently very expensive, so they will not test randomly, unless they suspect this type.
This has all seemed a bit surreal to me, as I know that I have had cancer, yet I am no different now than I was before I knew about it. I still have to go to work everyday and do all the household chores, my life hasn’t changed one bit…….other than this being the first thing I think of when I wake up and the last thing I think of when I go to bed. I hope in some way my story may give you a little bit of hope that even if it is cancer it doesn’t always mean all the nasty stuff we associate with this disease. I may not have gone through the pain and suffering, but I still have the worry that it may come back, but more than anything I am grateful it was found, purely by coincidence.
It’s all very scary when they suddenly start doing tests for cancer, but if you actually look at the symptoms for most ‘women’s problems’ it’s very hard to distinguish between any of them……………….heavy bleeding, abdominal pain, tenderness, bloating, most women suffer that every month!!!! I remember not even feeling that concerned about what they had found, until the nurse told me I had to be tested for cancer, I think I went through every emotion and back again then, and was extremely scared and frightened because then you are dealing with the unknown. I have watched close family members suffer with cancer, but nothing prepares you for medical people suspecting you may have it!!!! I know exactly where you are right now, and those few days of waiting and not knowing were the worst………but this is your time now to take stock and decide how you are going to deal with this, no matter what the outcome. And above all try to stay positive.
If you need to know anything else, or just want to chat, let me know.
I have everything crossed for you and hope everything gets sorted soon. And if your hospital doesn’t have a good reputation make sure you are in control of what is happening…………..don’t let them exclude you!!!! If it’s any consolation I don’t like my GP’s surgery…..last time I saw a GP there I cried :'(
Take care and keep me updated on your results, etc,
Yorkie1 xxxx
The characteristic ultrasound features of specific types of ovarian pathology (Review)
Abstract
Characterizing ovarian masses enables patients with malignancy to be appropriately triaged for treatment by subspecialist gynecological oncologists, which has been shown to optimize care and improve survival. Furthermore, correctly classifying benign masses facilitates the selection of patients with ovarian pathology that may either not require intervention, or be suitable for minimal access surgery if intervention is required. However, predicting whether a mass is benign or malignant is not the only clinically relevant information that we need to know before deciding on appropriate treatment.
Knowing the specific histology of a mass is becoming of increasing importance as management options become more tailored to the individual patient. For example predicting a mucinous borderline tumor gives the opportunity for fertility sparing surgery, and will highlight the need for further gastrointestinal assessment. For benign disease, predicting the presence of an endometrioma and possible deeply infiltrating endometriosis is important when considering both who should perform and the extent of surgery. An examiner’s subjective assessment of the morphological and vascular features of a mass using ultrasonography has been shown to be highly effective for predicting whether a mass is benign or malignant. Many masses also have features that enable a reliable diagnosis of the specific pathology of a particular mass to be made. In this narrative review we aim to describe the typical morphological features seen on ultrasound of different adnexal masses and illustrate these by showing representative ultrasound images.
Keywords: ovarian cancer, ovarian neoplasm, ovary, pattern recognition, ultrasonography
1. Introduction
The characterization of ovarian masses and distinguishing between benign and malignant pathology is important both to decrease unnecessary anxiety and enable decisions regarding optimal treatment. Benign pathology may be best treated conservatively or in a general gynecology unit using a minimal access approach. Conversely, suspected malignant masses should be referred to specialized units for further management. Thus prior knowledge of the nature of ovarian masses is essential not only for the patient but in order to organize clinical services in terms of planning, costs and overall management (1).
Transvaginal ultrasonography (TVS) is the most commonly employed imaging modality for the assessment of adnexal masses, and a number of prediction models have been created to maximize its predictive capability. In many countries the risk of malignancy index (RMI) (2) which combines ultrasound features, serum CA125 levels and the menopausal status of the patient is still used to characterize ovarian pathology.
However, more recently logistic regression models and simple rules created by the International Ovarian Tumor Analysis (IOTA) group have been shown to perform better than the RMI (3–7). The most recent systematic review and meta-analysis has concluded that based on currently available evidence, these IOTA rules and models should now be used in clinical practice (3). Notwithstanding these advances, the optimal approach to characterizing ovarian masses remains the subjective interpretation of the ultrasound features of a mass by an expert operator (8–10).
For the purposes of this review, the term ‘pattern recognition’ refers to the subjective evaluation of adnexal masses using grey-scale and power/color Doppler ultrasonography (11,12). In the hands of experienced examiners pattern recognition has a high sensitivity (77–86%) and specificity (94–100%) to diagnose teratomas/dermoid cysts, endometriomas, hydrosalpinges and peritoneal pseudocysts (13). It has however, not been found to be as useful for the diagnosis of fibromas, paraovarian cysts and rare benign tumors, and may have difficulty in differentiating between physiological and other ‘simple’ cysts on the basis of a single scan (sensitivity 8–17%) (13).
These findings suggest that with adequate training and knowledge of the common features associated with particular pathologies, ultrasound examiners should be able to reliably diagnose and differentiate between certain specific types of adnexal pathology. It is important to remember that when evaluating women with an adnexal mass, ultrasound characteristics need to be correlated with the clinical history, as well as signs and symptoms before arriving at a diagnosis. This review describes only the features that may be found using ultrasound that may be used to predict common specific types of adnexal pathology.
2. Physiological, peritoneal and tubal cystic pathology
Follicular cysts
They are usually unilocular and thin walled with anechoic contents (12). They rarely exceed 8–10 cm in diameter and typically spontaneously resolve within 6 weeks (14). Posterior wall hyperechoic enhancement is a feature due to reflection of the ultrasound beam off the posterior wall having travelled through the anechoic window formed by the clear cyst contents (14) ().
Follicular ‘physiological’ cyst. Note the bright white hyperechoic posterior wall enhancement.
Corpus luteum cysts
These are formed following the rupture of a mature Graafian follicle. They are thick walled hyperechoic cysts that typically demonstrate peripheral circumferential blood flow, sometimes known as the ‘ring of fire’ (12). Some cysts may show areas of internal hemorrhage. The cyst contents typically have a spider-web-like appearance () due to a small amount of internal hemorrhage, but can frequently show different features including blood clots within the cyst resembling solid components. Doppler examination may be useful in these circumstances as the blood clot will have no blood flow, although perhaps more useful is the a typical jelly-like ‘wobbling’ movement that can be elicited from the blood clot within the cyst if the vaginal probe is used to gently prod the ovary during the examination (15). In most cases, hemorrhagic cysts resolve within 6–12 weeks without intervention (15).
The cob-web sign, which represents the fibrin strings of a recently formed clot within a hemorrhagic corpus luteum cyst (A), and after clot retraction (B).
Peritoneal pseudocysts
Peritoneal pseudocysts, are collections of peritoneal fluid trapped in adhesions usually caused by previous pelvic surgery, pelvic inflammatory disease or endometriosis. They usually occur in premenopausal women, because of the presence of functional ovaries that release small amounts of fluid into the peritoneal cavity (15–18). They grow gradually and may reach several centimeters in size. They can cause abdominal pain or distension, but in the majority of cases are asymptomatic (15–18).
Pseudocysts appear mainly as multilocular cysts, with a high number of septa that are adherent to the ovarian surface. Septa are most frequently complete and thin (15–18) (). In contrast to septae within true ovarian cysts the septae in pseudocysts generally move and ‘flap’ when the cystic area is prodded by the transvaginal ultrasound probe.
This has been described as the ‘flapping sail sign’ (18). They have an irregular shape, that follows the contours of the pouch of Douglas or pelvic sidewall and surrounding pelvic organs, giving a ‘lumpy’, ‘star-like’ or ‘tubular’ appearance (15–18).
Multilocular peritoneal inclusion cysts.
The ipsilateral ovary is visible in almost all cases (). It can be external to the lesion or entrapped within the cyst (17,18). The cyst contents are generally anechoic, but may show low-level echogenicity (16,18).
A non-septated peritoneal pseudocyst with the ovary seen separately containing an endometrioma and follicles in the cortex. The patient has a clinical history of multiple surgical procedures for endometriosis.
Paraovarian cysts
Paraovarian cysts arise in the broad ligament between the ovary and the fallopian tube. They account for 5–20% of adnexal masses (19,20). The incidence of borderline and malignant paraovarian tumors is low but cases have been reported (20,21). They appear as thin walled unilocular anechoic masses close to but separate from the ovary (). However they can show papillary projections in ~30% of cases (20).
A paraovarian cyst with a normal ovary seen separate to it.
Their mean diameter is usually <5 cm with no evidence of any follicles or significant vascularity. In almost all cases, it is possible to visualize the ipsilateral normal ovary, and to detect movement of the cyst in the opposite direction to the ovary when the area is pushed with the vaginal probe – the ‘split sign’. This may help to differentiate between a paraovarian and ovarian cyst when the ipsilateral ovary is not clearly visible (20).
Tubal pathology
A normal Fallopian tube is rarely visible during an ultrasound examination. Hydrosalpinges have typical diagnostic features on ultrasound with anechoic contents and incomplete septae (15) (). In the case of an acute or chronic inflammatory process the tube may become detectable and some specific characteristics have been described.
Incomplete septum in a hydrosalpinx.
Acute salpingitis typically appears like a pear-shaped unilocular mass with anechoic or low-level content, characterized by thickening of the wall (>5 mm) and the presence of incomplete septae (). In transverse section it often shows the well described ‘cogwheel sign’ appearance (15,22) (). Color or power Doppler examination generally shows significant vascularity in cases of an acute inflammatory process as well as the presence of fluid in the pouch of Douglas (23).
Acute salpingitis demonstrating incomplete septae and thick walls. (A) An example of increased vascularity in an incomplete septum using color Doppler TVS. (B) Another example using power Doppler TVS.
In chronic salpingitis the tube appears as an elongated fluid-filled mass, with incomplete septae, but the thickening of the wall is no longer visible. It is characterized by the typical sonographic ‘beads on a string’ sign, due to 2–3 mm sized hyperechoic structures on the tubal wall, seen on transverse section (15,22–24).
A tubo-ovarian complex represents the involvement of ovarian tissue in the inflammatory process. Normal ovarian parenchyma is visible, but it is usually seen separate from tubal structures (15,22–24) ().
A tubo-ovarian complex. (A) Ultrasound appearances. (B) The same case at laparoscopy.
In a tubo-ovarian abscess, ovarian tissue is no longer visible; the lesion may be unilocular, solid or multilocular-solid with mixed or ground-glass echogenicity. On the basis of the ultrasound features, these have to be differentiated from endometriomas or hemorrhagic cysts (15,22–24). In practice the clinical features associated with an abscess make the diagnosis relatively straightforward.
3. Ovarian pathology
Serous cystadenomas
These appear as smooth, thin walled, anechoic, fluid-filled structures. They are bilateral in 15% of cases and their mean size is 5–8 cm (25). Some contain fine septations whilst others have areas of haemorrhage appearing as small echogenic areas (25) ().
Serous cystadenoma. (A) Unilocular serous cystadenoma. (B) Multilocular cystadenoma.
Mucinous cystadenomas
Mucinous cysts are classically thin walled, large and unilateral. They consist of internal thin-walled locules containing mucin which appears as fluid with low level echogenicity (25) (). In general neither serous nor mucinous cystadenomas are associated with significant vascularity (25).
Mucinous cystadenomas. (A) Unilocular. (B) Multilocular.
Caspi et al described the presence of variable echogenicity among different tumor locules as an ultrasound feature of multilocular mucinous cystadenomas (26) (), however this has not been confirmed in larger studies to date.
A mucinous cystadenoma with variable echogenicity among the cyst locules.
Cystadenofibromas
Cystadenofibromas represent a relatively rare type of benign epithelial ovarian tumor. They are mainly serous although mucinous subtypes do exist (27). Descriptions of the sonographic features of cystadenofibromas are limited but some specific appearances have been described. They may appear as unilocular-solid, or less frequently, multilocular-solid masses with thin cyst walls and anechoic contents (15,27). The diagnosis may be aided by the presence of hyperechoic solid components with acoustic shadows and low to moderate vascularity (15,27). They are often seen as unilocular-solid lesions with single papillary projections. The key feature to look for then is acoustic shadowing even within these small papillations (15,27). Differentiating between cystadenofibromas and borderline or malignant ovarian masses can be difficult (15,27) ().
Serous cystadenofibromas. (A) Unilocular solid with a papillary projection and acoustic shadows. (B) Multilocular solid. (C) Another example of serous cystadenofibroma with unilocular solid morphology.
Mature teratoma/dermoid cysts
Mature cystic teratomas are benign germ cell tumors. They usually have the highest sensitivity and specificity for a specific diagnosis with ultrasound as they generally have rather typical features (28). They are cystic and unilocular in the majority of cases, with mixed echogenicity representing the different components of fat, bone and fluid (28). Pathognomonic of dermoid cysts is a Rokitansky nodule, a distinct hyperechoic mural nodule representing areas of floating hair in low-density fluid (29,30) (). There are often bright echoes and sharp acoustic shadows associated with hair or even teeth in the cyst.
Ultrasound features of dermoid cysts. (A) Rokitansky nodule with a strong acoustic shadow. (B) Acoustic shadows and bright echoes representing hair in the cyst. (C) Unusual but interesting presentation of a dermoid cyst which has been described as ‘floating balls’ – secondary to hyperechoic intracystic fat balls.
Endometriomas
Ultrasonography is particularly sensitive for accurately diagnosing ‘typical’ endometriomas, most commonly seen in premenopausal women. Typically an endometrioma is a unilocular tumor and has low-level echogenicity representing old blood in the cyst cavity (commonly termed ‘ground glass’). It is this ‘ground glass’ feature that is the most typical feature (28,31–33) ().
Endometriomas may also have atypical features, and frequently debris within the cyst may give the impression that it is a unilocular-solid lesion with solid papillary projections. In postmenopausal women the appearances of an atypical endometrioma should be examined very carefully as there is a significant risk of malignancy in such lesions in this age group (29,32) ().
Atypical endometriomas with solid papillary projections. (A) Multilocular solid endometrioma. (B) Unilocular solid endometrioma.
During pregnancy endometriomas can change their appearance secondary to decidualization. The features may become quite alarming, with solid vascular projections into the cyst cavity. When no pre-existing scan of the ovary is documented it is difficult in these cases not to suspect malignancy (), although papillary projections were a more frequent sonographic feature among malignant lesions than among benign endometrioid cysts (34,35).
Decidualized endometrioma in pregnancy with vascularized papillary projections.
Ovarian fibromas and fibrothecomas
These are benign tumors of stromal origin. Fibromas originate from spindle cells producing collagen and can be associated with ascites or Meig’s syndrome. Fibrothecomas originate from both spindle and theca cells and may produce a small amount of estrogens (36,37).
Their characteristic sonographic appearance is of a round or oval solid tumor, with regular margins. They may have stripy acoustic shadows, but these are present in just a small percentage of cases (15,36,37) (). Fibromas and fibrothecomas can also show cystic areas, due to hemorrhage, edema or necrosis within the stromal tissue (). Doppler findings are variable, but frequently the lesions show little peripheral vascularity (36,37) ().
Typical round regular ovarian fibroma with (A) acoustic shadows and (B) minimal peripheral vascularity on color Doppler.
Ovarian fibroma with cystic changes.
Ovarian stromal tumors (struma ovarii)
Struma ovarii is a rare subtype of mature teratoma characterized by the presence of ectopic thyroid tissue. They account for <5% of mature teratomas (38). Although a preoperative diagnosis is not always possible, they have been described as having a similar appearances to mature teratomas but with increased vascularity in the central part of the mass (39). They are difficult to classify (40), but are of interest morphologically because they have been associated with a sonographic sign called the ‘struma pearl’. These are rounded hyperechogenic structures with smooth surfaces, with increased vascularity on Doppler examination (40) ().
Struma ovarii showing (A) multilocularity and struma pearl formation (arrow) as well as (B) central vascularity (arrow pointing toward the ‘pearl’). (C and D) Laparoscopic features of the same cyst at the time of cystectomy.
Brenner tumors
Brenner tumors also arise from the ovarian stroma but are benign in 99% of cases. Their diagnosis is often an incidental finding in women between the fifth and the seventh decade of life. They are usually small and often coexist with serous or mucinous cystadenomas (). They are more frequently unilateral, mainly within the left ovary (41–43). Brenner tumors are sometimes associated with acoustic shadowing and so may be confused with an ovarian fibroma or pedunculated fibroid from the uterus () (41–43).
Brenner tumors. (A and B) Solid Brenner tumor with marked acoustic shadowing. (C) Brenner tumor with mucinous cystadenoma.
Primary invasive ovarian epithelial cancer
Stage 1 primary invasive ovarian epithelial cancers share similar ultrasound characteristics to borderline tumors, but they differ significantly from the appearances of later stage disease (44) (). They often contain papillary projections and less commonly are purely solid (44).
Primary invasive ovarian epithelial cancers. (A) Stage 1 clear cell carcinoma of the ovary. (B) Unilocular solid early invasive cancer with increased vascularity on color Doppler.
Later stage primary ovarian tumors are usually multilocular with a high proportion of solid tissue and are frequently associated with ascites as well as metastatic disease to the peritoneum, omentum and elsewhere in the abdomen and pelvis (44). They are also significantly vascular with high color scores (3–4) (44) ().
Advanced primary ovarian cancers. (A) Multilocular solid ovarian serous adenocarcinoma with increased vascularity. (B) Peritoneal deposits from late stage primary ovarian cancer in in the pouch of Douglas with ascites.
Borderline tumors
The presence of papillary projections within a cyst has been used as a discriminatory factor for serous borderline tumors (45). However, the potential for misdiagnosis between borderline tumors (BOT), cystadenomas, cystadenofibromas and invasive malignant tumors is significant (45). Doppler assessment of tumor vascularity is not useful in distinguishing between borderline and invasive tumors (45,46). The size and characteristics of the surface of the papillary projections are however thought to be helpful with the angle the projection makes with the cyst wall being significantly different (47) (–). In this review the mean size of papillary projections was 9.6, 15.7, and 35.3 mm in benign, borderline, and malignant tumors, respectively. In benign masses an acute angle was present between the cyst wall and projection in 68% of cases and an obtuse angle in 40% of borderline and 89% when the mass was an invasive malignancy. These observations are of interest, but have not yet been validated in larger prospective studies (47).
Ovarian serous borderline tumors. (A) Papillary projection with irregular surface. (B) Papillary projections in cases of serous BOT with their 3D images.
Mucinous intestinal BOTs. (A) Honeycomb or cribriform sign. (B and C) Intense multilocularity in intestinal type mucinous BOT.
Serous and mucinous endocervical type BOTs are usually unilocular solid tumors with a high number of vascular papillary projections within the cyst. Mucinous intestinal type BOT are more often very large, unilateral, multilocular tumors with a high number of locules encased by thick, hyperechoic tissue with no evidence of solid components (–). They are associated with the ‘honeycomb’ sign formed by tightly interrelated septae within the cyst. Intestinal-type mucinous BOT are generally less vascular than both serous and endocervical BOT (48,49).
Tumors that have metastasized to the ovary
Ovarian metastasis from breast, gastric, and uterine cancers as well as lymphomas appear as solid tumors on ultrasound examination ( and ). In contrast, ovarian metastasis from the colon, rectum and biliary tract, tend to be multilocular-solid or multilocular with anechoic or low-level echogenicity (50) ( and ). The latter group demonstrate, a larger diameter and more frequently the presence of an irregular external surface (50). The detection of papillary projections is rare in metastatic tumors (50) (–). The presence of rich vascularity (color score 3–4) is characteristic of all metastatic tumors (44), but metastatic tumors from the colon, rectum and biliary tract tend to be less vascular compared to those from the stomach, breast, uterus or lymphomas (50).
Breast cancer with metastasis to the ovaries. (A) Lead vessel sign in color Doppler 2D image. (B) Lead vessel sign in power Doppler 2D image. (C) Lead vessel sign in 3D power Doppler image.
Metastatic cancers to the ovary appear as solid tumors. (A) Lymphoma. (B) Gastric adenocarcinoma. (C) Gastric adenocarcinoma with metastasis to the ovary with using power Doppler 2D image.
Colon cancer with metastasis to the ovary.
Pancreatic cancer with metastasis to the ovaries.
The vascularity of metastatic tumors is characterized by the presence of a ‘lead vessel’ – a single large vessel penetrating from the periphery to the central part of the lesion (). Further research is needed to determine the diagnostic performance of this sign (51).
Conclusion
Predicting the specific histopathology of an adnexal mass is important as it may lead to surgery being avoided or being less invasive in some cases whilst ensuring appropriate referral to a gynecological oncology surgeon in the case of malignancy. In general there is an intense focus on excluding malignancy when the characterization of ovarian pathology is considered. However the field has moved on, both in terms of tailoring treatment to individual patients and with what we know about the features of different types of ovarian pathology. In this review we hope we have illustrated some of the pathognomonic features of some of the more commonly found adnexal masses in clinical practice. By improving the specific classification of masses we hope that management decisions in relation to such pathology will become more patient specific and lead to improved outcomes.
Are Simple Cysts Found on Ultrasound Exams Linked to Ovarian Cancer?
A large case-control study found that ultrasonographic appearance of ovarian masses is significantly associated with the risk of ovarian cancer. The presence of simple cysts was not associated with any increased risk, while complex cysts and solid masses are correlated with a higher risk of cancer.
“Increased use of transvaginal pelvic ultrasonography has led to the frequent identification of ovarian masses,” wrote study authors led by Rebecca Smith-Bindman, MD, of the University of California, San Francisco. Simple cysts are the most commonly such masses identified, and in spite of evidence suggesting these are likely not cancer precursors, guidelines and researchers continue to recommend ongoing surveillance. “The recommendations for ongoing surveillance of simple cysts, despite widespread belief that they are almost certainly benign, in part reflects the poor prognosis of malignant ovarian cancer and concern that there is a small but unknown risk of cancer even in masses with the most benign appearances.”
The new study was the first in a large, unselected population to assess ovarian mass appearance and the connection to ovarian cancer risk. It was a nested case-control study of patients enrolled in Kaiser Permanente Washington, a large healthcare system in Washington State, and included a total of 72,093 women who underwent pelvic ultrasonography examinations over a 10-year period. The results were published in JAMA Internal Medicine.
A total of 210 women were subsequently diagnosed with ovarian cancer. In the full cohort, 75.5% of women were younger than 50 years, while 76.7% of those with ovarian cancer were 50 years and older. The diagnosis of ovarian cancer occurred a mean of 3.4 months following the first ultrasonography.
Simple cysts were the most common ovarian finding, occurring in 23.8% of the cohort aged younger than 50 years and in 13.4% of those aged 50 years and older. Among the 15,306 women with a simple cyst, only one woman was subsequently diagnosed with ovarian cancer within 3 years; this results in a likelihood ratio of an ovarian cancer diagnosis after a simple cyst of 0.06 (95% CI, 0.01–0.48).
Among women diagnosed with ovarian cancer, the most common finding was a complex cystic mass; this was found in 31 of 49 women (63.3%) younger than 50 years, and in 90 of 161 women (55.9%) 50 years and older. Finding a complex cystic mass on ultrasonography raised the risk of ovarian cancer significantly in both women younger than 50 years, with a likelihood ratio of 8.20 (95% CI, 4.21–15.90), and in those 50 years and older, with a likelihood ratio of 7.60 (95% CI, 5.00–11.59).
Solid masses occurred in 10.2% of those with ovarian cancer younger than 50 years, and in 7.5% of those 50 years and older. Again, the finding of a solid mass was associated with increased risk of ovarian cancer, with a likelihood ratio of 8.08 (95% CI, 1.86–36.12) in younger women and of 10.08 (95% CI, 3.25–31.21) in older women.
On a multivariable analysis, ultrasonography findings were significant predictors of cancer (C statistic, 0.89), and both complex cysts and solid masses were associated with increased risk. Women with normal ovaries, with simple cysts, and with cysts with low-level echoes were all not associated with any increased risk.
In an accompanying editorial, Deborah Levine, MD, of Beth Israel Deaconess Medical Center in Boston, pointed out several methodological limitations of the study, including an inability to account for patient symptoms, which can guide treatment, and the small number of ultrasounds actually evaluated out of the larger cohort. Still, she agreed that the findings regarding simple cysts are important.
“The results … add to the growing literature that asymptomatic simple cysts may be safely ignored, regardless of size and regardless of patient age,” Levine wrote. “With confident diagnosis of simple cysts, clinicians can be reassured that the likelihood of cancer is similar to that of patients without cysts, and management can be based on patient symptoms rather than on a benign incidental pelvic ultrasonographic finding.”
Ultrasound-Guided Cyst Aspiration Diagnostic Procedure
Ultrasound-Guided Cyst Aspiration
Ultrasound-guided cyst aspiration is a simple procedure
performed by placing an ultrasound probe over the site of a breast
cyst and numbing the area with local anesthesia. The breast
radiologist then places a small needle directly into the cyst and
withdraws fluid.
A technologist and radiologist work together during the cyst
aspiration procedure. The patient lies on their back or are turned
slightly to the side on a padded table. Warm gel is placed on the
breast and ultrasound is used to identify the location of the
cyst(s). The Radiologist inserts a thin needle into the breast to
drain the cyst(s). The patient may feel a pinch and slight pressure
at this time. The fluid from the cyst drains into a syringe and the
cyst collapses. Depending on the appearance of the fluid, it may be
discarded, or sent to the laboratory for analysis. A bandage is
applied over the puncture site. There may be some slight bruising
or swelling. The cyst aspiration procedure takes between 15-30
minutes to complete.
How to Prepare for this Procedure
- You may eat a light breakfast or lunch
- Wear a comfortable bra and top that can be easily removed for
the procedure - Bring a list of all your medications, including frequency and
dosage - Bring a list of all your allergies
- Take your usual medications unless otherwise instructed by your
physician - If you are taking products that can increase your risk of
bleeding, medications like Aspirin, Coumadin, Plavis, Ibuprofen,
Motrin, Naprosyn, vitamin E, ginko biloba, garlic, glucosamine
chondroitin, flaxseed, fish oil, feverfew, ginger, licorice, St.
Johns Wart, Zinc, please notify the nurses in the Breast Health
Center by calling 978.304.8112 at least 3 days ahead of time.
Corpus Luteum Cyst During Pregnancy: Definition, Symptoms, Treatment
What Is a Corpus Luteum Cyst?
A corpus luteum cyst is a type of ovarian cyst (a small, fluid-filled sac). This type of cyst happens because the corpus luteum continues to grow, rather than break down as it normally would if not pregnant. Also called a corpus luteal cyst, it often occurs during pregnancy. These can also appear at other times, primarily during the reproductive years.
Understanding the ovulation process can help explain how and why these cysts develop.
Your ovaries have thousands of follicles, which are little pouches that hold eggs. Once a follicle releases an egg during ovulation, it forms the corpus luteum—a short-lived structure that releases estrogen and progesterone, hormones that ready the uterus for implantation.
If conception occurs, the placenta will take over the function of progesterone production at around 12 weeks gestation. Sometimes, a corpus luteum cyst can develop on the ovary during the first trimester of pregnancy.
Corpus luteam cysts vary in size but are usually between 2 and 6 centimeters. They are usually not a cause for concern. However, these cysts can lead to complications, which are typically unrelated to pregnancy itself.
Having had a corpus luteam cyst in one pregnancy does not necessarily mean you will develop one in another pregnancy. If you do develop cysts in subsequent pregnancies, they may or may not cause pain.
Symptoms
In many cases, women who have a corpus luteal cyst do not experience any pain. In fact, a corpus luteal cyst will typically resolve on its own after a few menstrual cycles without a woman even knowing it was there.
The most common symptom in those who do take notice of a corpus luteam cyst is a slight twinge of one-sided pain or mild tenderness during the menstrual cycle. The pain may be worrisome, especially if you are sexually active and concerned about the possibility of an ectopic or tubal pregnancy. This concern may prompt a visit to a doctor or midwife.
When to Seek Emergency Care
Large corpus luteum cysts have the potential to burst and cause internal bleeding. They can also lead to ovarian torsion, a rare but serious complication in which the ovary twists around surrounding tissues.
Immediate medical attention is needed if any symptoms of these conditions arise, including:
- Sudden, sharp, one-sided pain in the lower abdomen or pelvis
- Shoulder pain
- Fainting or dizziness
Identifying Corpus Luteum Cysts
Corpus luteal cysts are typically diagnosed with a transvaginal ultrasound, also called an internal ultrasound.
Your provider inserts a wand called a transducer into your vagina. The device emits sound waves that produce images of the inside of your body and projects them on to a monitor.
While an ultrasound may be ordered if you have symptoms, cysts are often found during a routine ultrasound for other purposes, both in women who are pregnant and those who are not.
There may be more opportunities to spot a corpus luteal cyst in a woman who’s expecting, simply because they’re usually having routine imaging as part of their prenatal care.
So, these cysts are diagnosed more often during pregnancy.
Your doctor or midwife may want you to have a follow-up ultrasound to check on the cyst if you continue to have symptoms. Otherwise, unless treatment is required, no follow-up is typically needed.
Risk Factors
Anyone can get corpus luteal cysts, though they are more likely to develop in women taking medication to induce ovulation, like Clomid (clomiphene). These medications are usually prescribed by a doctor or midwife for women experiencing fertility problems and for those with polycystic ovary syndrome (PCOS).
It’s important to remember that since the corpus luteum is a normal part of the menstrual cycle, the type of functional ovarian cyst associated with them can also develop when you are not pregnant. You can also develop one even if you are not taking, or have never taken, medication to treat infertility.
Treatment
A corpus luteal cyst is usually not harmful. The cysts do not typically cause any complications during pregnancy, especially when they’re discovered during the first trimester. If the cyst is potentially malignant, meaning it could grow or worsen, surgery may be required to avoid the risk of miscarriage.
If the cyst is causing pain, your doctor or midwife may prescribe pelvic rest (no sexual activity) or pain medications. However, in most cases, a corpus luteal cyst will resolve on its own without intervention.
Occasionally, the cyst will rupture. Pain may increase when this happens but subside quickly, and pain medication and rest may be indicated. Less frequently, a corpus luteal cyst can cause the ovary to twist (torsion). This can be very painful and may require surgery to prevent further injury of the ovary.
Can a Corpus Luteum Cyst Be Cancerous?
No. These cysts are what are called functional cysts—sacs that form on the ovary simply due to the normal process of menstruation. Unlike some other ovarian cysts, these do not have the potential to become cancerous.
A Word From Verywell
While it may feel unsettling to learn you have an ovarian cyst, corpus luteum cysts usually do not cause pain or complicate pregnancy or birth. Also, they rarely require any treatment.
90,000 Ovarian cysts. The author of the article: gynecologist Andirzhanova Gulfiya Ildarovna.
03 December 2019
Family Health Magazine
In the ovary, various processes can occur that lead to an increase in its
volume, – both absolutely harmless and
life-threatening.The most common ovarian cysts are benign formations that are
an accumulation of fluid surrounded by a shell.
An ovarian cyst (from the Greek – a bag, a bladder) is a formation in the form of a bladder with
liquid or semi-liquid contents,
arising in the structure of the ovary and increasing its volume several times.
Causes of ovarian cysts
not definitively established. Hormonal disorders can play a role in the mechanism of development of cysts. There are the following types of cysts:
Functional cysts that form as a result of a violation of the monthly cyclical process in the ovary.Follicular cysts result from the absence of ovulation and further
growth of an unruptured follicle. They are
do not exceed 7-8 cm in diameter, have
very thin wall, there are no more
2 months and open up on their own
without serious consequences. Cysts of yellow
bodies arise after ovulation has occurred as a result of the accumulation of fluid
inside the corpus luteum of the ovary and often accompany pregnancy. Cysts of yellow
bodies are also small, but
a thicker wall than follicular.They can contain both clear yellow liquid and blood. Cysts
corpus luteum can exist for
several menstrual cycles or in
during the first 3-4 months of pregnancy,
after which they dissolve on their own.
Corpus luteum cysts sometimes rupture
with bleeding into the abdominal cavity that
may require surgery.
Polycystic ovaries, characterized by the presence of multiple immature follicles 5-10 mm in size.Because of these small cysts, both
ovary increases in size, but not
exceed 5 cm in diameter. Polycystic ovaries are associated with menstrual irregularities and infertility.
In some cases, to recover
ovulation is performed laparoscopic
operation. Endometrioid cysts,
resulting from lesions
ovaries and adjacent organs, endometriosis. As a consequence of the repetitive
small bleeding from foci of endometriosis, blood accumulates in the delimited space and becomes thick
brown fluid, which is why endometrioid cysts are also called
“Chocolate”.Endometrioid cysts
accompanied by pain and infertility,
sometimes spontaneously rupture and, for the most part, require surgical
treatment.
Dermoid cysts, which are a type of true tumors
ovaries. These cysts are the result of the growth of rudimentary cells in the ovary.
due to impaired embryonic tissue differentiation. Dermoid cysts
occur in young women, usually
are small, densely walled and contain grease, tufts of hair and sometimes
teeth, cartilage and bones.Dermoid cysts
have a long stem and are often twisted, causing acute pain and the need for urgent hospitalization.
Dermoid cysts are usually easily diagnosed by ultrasound.
Cystadenomas, which are true ovarian tumors and result from overgrowth
certain ovarian cells. Cystadenomas have a strong membrane and contain
clear liquid or mucus. They can be large and
consist of several chambers.Sometimes in
cystadenomas appear cancer cells.
Symptoms of cystic formations
the ovaries are irregular menstruation and a feeling of heaviness in the lower abdomen. There may be pain in the lower abdomen with
one side, pulling or aching character, may appear or intensify
during intercourse. The pain can become intense, accompanied by nausea, vomiting, spread over the abdomen and give into the rectum during development
complications (torsion or rupture of the cyst). Dermoid cysts are more often subjected to torsion, luteal cysts are ruptured.Follicular cyst rupture may cause short-term pain, but
does not pose a health hazard.
Menstrual irregularities can
manifest as a delay in menstruation
or dysfunctional uterine bleeding.
Abdominal enlargement occurs only
with large cystic tumors.
Often, cysts are asymptomatic and are discovered accidentally during
ultrasound examination (ultrasound) carried out for another reason. Ultrasound has
highest diagnostic value
with ovarian cysts also because
which suggests the type of cyst
before surgery and plan accordingly
treatment.However, not always ultrasonic
the study allows you to distinguish functional cysts from small cystadenomas.
In this case, expectant
tactics within 2 months. If the cyst
more than 2-3 menstrual periods persist
cycles, carry out its laparoscopic
assessment and removal. During the operation, remove
cyst with maximum preservation of healthy ovarian tissue in women of reproductive age.
Wait-and-see tactics are applied
with small (up to 10 cm) cysts, if
Ultrasound no obvious signs of a tumor (dense inclusions).In addition to cysts, tumors that do not contain fluid (solid) can occur in the ovaries. Some of them are accompanied by excess hormone production:
estrogens or androgens, and most
these tumors are malignant. The test for the tumor marker CA-125 can help diagnose malignant tumors, but the most reliable
this test is performed in postmenopausal women. The ovaries may also have
tumors developing from imported
blood of cancer cells of other organs
(for example, stomach).Therefore, when a solid tumor of the ovary is found, an examination is necessary to exclude cancer.
other organs.
Special measures for prevention
ovarian cysts do not apply. It has been found that the use of hormonal contraception reduces the risk of
ovarian cysts. To be on time
to diagnose ovarian pathology, it is necessary to undergo an ultrasound scan once every six months
organs of the small pelvis. Upon detection
for an ultrasound of an ovarian cyst, you need to contact a specialist to resolve the issue
about further tactics and method of treatment.
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90,000 treatment, laparoscopic and robotic operations with rapid rehabilitation
One of the priority areas of work of the EMC Gynecology and Oncogynecology Clinic is the diagnosis and treatment of cysts and tumors of the ovaries (formations), which are often diagnosed in women of reproductive age, as well as after menopause.
Often the terms – cyst, cystoma, ovarian tumor – are practically synonyms for the clinician and mean the presence of an abnormal formation (growth) on the ovary.The fact is that in international classifications there are concepts ADNEXAL MASS, OVARIAN MASS, OVARIAN CYST – they are all interchangeable, each cystic ovarian formation can be called one of three terms.
Ovarian tumor implies the presence of a cyst with a dense component. By itself, a cyst is a “bubble” on the surface or inside the ovary, filled with fluid. Even for modern methods of intrascopy (ultrasound, CT, MRI), and therefore for the oncogynecologist, these formations are distinguished only by the nature of the contents.
There are many classifications according to histology, size, functionality, but the classification according to the degree of malignancy is quite universal and meets the need for information about the disease of both the doctor and the patient.
Types of ovarian cysts
Ovarian cysts and tumors are classified into three types:
Benign formations (cysts) of the ovaries are more common in young women and can be associated with diseases such as endometriosis (when the cells of the endometrium, the inner layer of the uterine wall, grow outside this layer), and can also be the result of menstrual irregularities.
Borderline ovarian tumors are more common in women after 30 years of age. Under a microscope, cysts can be defined as malignant, but they have a clinical course that is more reminiscent of benign formations. Borderline tumors in rare cases cause the spread of metastases (screenings), but often provoke relapses (when after a while the tumor returns to the ovary or appears in another place) – in these cases, repeated operations are necessary. Chemotherapy is not effective in this case.
Malignant tumors of the ovaries (ovarian cancer) in most cases occur in women after menopause. Unfortunately, 80% of patients go to the doctor only with the manifestation of symptoms – at the third or fourth stage of the disease. In these cases, the most radical operations are performed, aimed at removing all tumor nodes from the abdominal cavity, after the operation (in some cases, even before the operation), chemotherapy is performed. Despite the late stage of treatment, 30-40% of patients have a chance of a complete cure.
How are ovarian cysts (formations, tumors) detected?
Some women go to the gynecologist with pain in the lower abdomen. Sometimes these pains are cyclical, in some cases they are permanent. In some cases, cysts and ovarian masses are detected incidentally during prophylactic ultrasound examinations.
What are tumor markers? What are they used for?
Tumor markers are specific substances that arise in the biological fluids of patients as a result of the vital activity of cancer cells.The most frequently studied tumor marker in the blood in ovarian formations is CA-125. It is often identified when cysts or ovarian masses are found. Unfortunately, CA-125 lacks specificity. It can increase several times in case of benign processes in the abdominal cavity (uterine fibroids, endometriosis, benign ovarian cysts, colitis, and others), while in half of women with malignant ovarian tumors in the early stages, the level of CA-125 is normal. Therefore, the definition of CA-125 is often not used to resolve the issue of tumor malignancy before surgery, but in combination with ultrasound data, in some cases, it can become a significant diagnostic indicator for a gynecologist.
Does the presence of a cyst always require removal?
Perhaps only functional cysts (cysts that form as a result of the menstrual cycle and did not occur ovulation) deserve observation by a gynecologist in dynamics. Functional cysts should disappear after 1 to 2 menstrual cycles. If this does not happen, the cyst is not functional, but pathological.
Polycystic ovaries (many small cysts along the periphery of the ovary) may be a normal variant, and also be a sign of one of the components of polycystic ovary syndrome.These small cysts also, in most cases, do not require surgical treatment, unless they are combined with infertility or menstrual irregularities.
Polycystic ovaries are actually found in 15-20% of perfectly healthy women and do not require treatment. In other cases, they are included in the clinically significant polycystic ovary syndrome (hyperandrogenism, cycle disorders). All other cysts and ovarian masses are considered pathological and require surgical removal.
What is the purpose of the operation?
It is possible to accurately determine whether a benign cyst or a malignant (borderline) cyst is possible only after the removal of a cyst or an ovary with a cyst during the operation. All preoperative diagnostic techniques (ultrasound, tumor markers, symptom analysis) are approximate and do not give a 100% answer to the question of malignancy.
Some cysts can also cause ovarian torsion, when its blood supply is cut off, the ovary dies, which is an indication for emergency surgery.Some cysts can rupture involuntarily, sometimes leading to significant bleeding (ovarian apoplexy), which usually also requires urgent surgery.
Is it possible to preserve the ovary itself, on which the cyst has arisen, or does it need to be completely removed?
This largely depends on the nature of the cyst, the woman’s age and a number of other factors. Speaking of benign ovarian cysts (endometrioma, cystadenoma, follicular cyst, etc.)) with not very large sizes, it is possible to preserve the ovary and remove only the cyst with a capsule in order to avoid relapse.
If the cyst during the operation looks suspicious from the oncological point of view, it is safer to remove the entire ovary together with the cyst, while immersing it in a plastic bag directly in the abdomen, and then removing it – it is very important not to “break” the cyst in the abdomen, that is, the contents did not enter the patient’s abdominal cavity, as this could provoke problems in the future.
Your gynecologist must warn you about the possible need to remove the entire ovary with a cyst (tumor) and that this decision can be made by the surgeon during the operation, although in most cases the ovary can be preserved.
In some cases, it is required to remove the cyst together with the ovary – in this case, the surgeon sends him for an urgent histological examination, the results of which help to quickly decide on the required amount of surgical intervention directly during the operation.
Are there any chances of pregnancy and childbirth if one of the ovaries is removed?
One ovary can fully perform its functions, including the production of sex hormones, ensuring a normal menstrual cycle, as well as the formation of eggs monthly. If the fallopian tube of the preserved ovary is passable, then the chances of getting pregnant and carrying a child are the same as in women with two ovaries.
Treatment of ovarian cysts
If the cyst (formation) of the ovary is not too large, is less than 7-9 centimeters in diameter and does not raise any special suspicions about its malignancy according to the results of ultrasound, a minimally invasive procedure is performed – ovarian laparoscopy.
It is worth noting that the vast majority of ovarian cysts fall into this category and are treated with laparoscopic surgery, which gives excellent cosmetic results, minimal blood loss during surgery, and quick recovery. If the cyst is too large and cannot be safely removed from the abdominal cavity through the small laparoscopic openings, an abdominal surgery is performed.
If, according to the data of ultrasound or computed tomography (CT) or blood tumor markers, there is a thorough suspicion that the formation is malignant, in this case, an abdominal operation is performed.
For a number of atypical cysts and formations of the ovaries, it is advisable to carry out a laparoscopic operation. In other cases, laparoscopy is used only to diagnose ovarian formation, and then goes into abdominal surgery.
Are there non-operative treatments for ovarian cysts (masses)?
Apart from functional cysts and polycystic ovaries, other types of cysts and formations are treated with surgery. There is a misconception that some hormonal drugs contribute to the resorption of the cyst, but there is no evidence of the effectiveness of this method in the medical literature.
In some cases, the cyst resolves on its own (functional cyst), but this usually occurs spontaneously, and not due to the use of hormonal drugs. The use of hormonal (contraceptive) drugs is really justified only in one case – to prevent the re-formation of functional and other benign ovarian cysts. Moreover, the use of hormonal contraceptives for 5 years or more (in total for a woman’s life) reduces the risk of developing ovarian cancer by 40%.
Which doctor should I contact for ovarian cysts?
If an ovarian cyst is detected according to the results of ultrasound, it is necessary to contact a gynecological surgeon specializing in laparoscopic operations. Even if the cyst turns out to be functional, the gynecologist-endosurgeon will continue to monitor the patient for several months until the cyst resolves on its own. If the cyst is not typical or there is a suspicion of the presence of a borderline or malignant tumor, in this case, you should contact a gynecological oncologist surgeon who will prescribe additional studies and perform laparoscopic or abdominal surgery.
EMC oncogynecological surgeons have the appropriate surgical training, extensive surgical experience in gynecological oncology and related disciplines, the most modern modern equipment, and most importantly – an understanding of the need for complete radical removal of the tumor during surgery.
The main task of the EMC Department of Gynecology and Oncogynecology is to provide surgical and therapeutic medical care for gynecological and gynecological oncology diseases in a short time, as efficiently as possible, painlessly and with minimal side effects.The work is being built in accordance with the standards of evidence-based medicine practiced in the United States and Western Europe.
The team of doctors of the department – surgeons-oncogynecologists, surgeons-gynecologists, urogynecologists, behind whom not only years of practice in the best clinics in Russia, the USA, Europe and Israel, but also powerful theoretical training, which is constantly being improved thanks to the participation of doctors in international congresses and conferences by specialty.
The head of the department is an experienced surgeon-gynecological oncology and obstetrician-gynecologist, certified by the US National Commission (Board Certified) for obstetrics-gynecology and gynecological oncology, and also a certified specialist in obstetrics-gynecology and oncology in Russia, Vladimir Nosov.The EMC clinic is one of the few in Moscow, the level of medical services delivery of which meets international standards.
90,000 Cysts in the head: real and imaginary
Good diagnostic equipment in clinics is necessary, but it can be a cruel joke: surgical operations under these conditions sometimes become redundant.
We continue the series of publications devoted to neurosurgical diseases. The project was prepared jointly with the ICOO for helping children with neurosurgical diseases “He needs you”.We want these “terrible” diagnoses not to put pressure on parents and take away their hope. In our publications, the best specialists and experienced parents will tell you about the ways of healing and overcoming, give recommendations and show that life can continue with any, even such complex, diseases.
The incidence of surgical interventions for indications such as “brain cyst” has not increased because the incidence has increased. There has been an increase in the number of x-rays showing – often quite by accident – cysts in the brain.Or other pathologies described by specialists as cysts, but they are not. And the risk, minimized during such operations, and their good funding led to the fact that cysts are operated when it is necessary and when, to put it mildly, it is inappropriate.
So, let’s figure out what a cyst is, how to distinguish it from a fake cyst, and what kind of cyst requires surgical treatment, together with Dmitry Yuryevich Zinenko, Doctor of Medical Sciences, Head of the Department of Neurosurgery, Scientific Research Clinical Institute of Pediatrics named after Yu.E. Veltischeva.
“Scary” titles
What is a cyst? A cyst (its other name is “liquor cyst”) is a cavity filled with fluid, which has a capsule that isolates it from other liquor-containing spaces.
Most often, parents of children who have retrocerebellar cyst turn to a neurosurgeon for advice. And although this phrase scares and even brings parents to panic, I must say that these words are used by radiologists to describe a variant of the norm.Most often, it is not a cyst at all (that is, not an isolated cavity filled with fluid), and it does not require surgical treatment.
Children under two years of age with a diagnosis of retrocerebellar cyst should be shown to a neurosurgeon to avoid the development of hydrocephalus.
Another variant of the norm – pineal cyst . Probably the most frequent accidental finding on an MRI. No surgical treatment is required.
Epidermoid or dermoid cyst is not a true cyst.It is filled not with liquid, but with skin appendages – follicles, sebaceous glands, hair, cartilaginous tissue, etc. In its structure, it is more like a tumor and requires the same treatment as for a tumor – removal.
Porencephalic cyst usually occurs in the place where part of the brain died as a result of hypoxia or hemorrhage, this place is filled with fluid. By itself, such a cyst does not interfere with development and does not require mandatory surgical treatment.
Pseudocyst – looks like a cyst, but not a cyst, a cavity that is not limited by anything, it has a message with other parts of the skull.Does not require surgical treatment.
The cyst of the transparent septum in the overwhelming majority of cases is a variant of the norm, but, if large, can lead to impaired CSF circulation, which requires surgical treatment.
Surgical treatment is indicated for children whose cerebrospinal fluid cyst rapidly enlarges, causes an increase in intracranial pressure, neurological symptoms or seizures.
If a child has been photographed and a cyst is found, do not panic! After receiving a description of the X-ray image, first of all, pay attention to the conclusion.If the conclusion says: “There are no pathological abnormalities”, most likely you will not need any surgical intervention. Even if you come across the word “cyst” somewhere, most likely, the radiologist needed it to describe the normal state. Just in case, check with him if you need a neurosurgeon’s consultation.
When you need a consultation with a neurosurgeon
Newborns today are almost universally examined using neurosonography (ultrasound examination of the brain).During this examination, infants often have a cyst of one kind or another. If the cyst is large, specialists will most likely recommend an MRI scan. If not, they will watch. Consultation with a neurosurgeon requires a rapidly growing cyst, or a cyst that causes epileptic seizures or other neurological symptoms.
If, at the age of several months, a previously healthy child shows signs of increased intracranial pressure and a cyst is found on examination, surgical treatment is necessary.
When an older child was examined for a traumatic brain injury and a cyst was accidentally found, this is NOT a surgical treatment.
If the examination is scheduled due to delayed speech, developmental delay, then the cyst found is a reason to consult with the surgeon to understand whether this cyst is associated with this symptomatology.
When a school-age child is examined for severe headaches, the cyst found should be discussed with a neurosurgeon.Surgery may help eliminate the cause of these pains.
If a child who is engaged in martial arts or boxing undergoes a mandatory MRI scan (young athletes are supposed to be examined before a competition), during which he accidentally has a cyst, it is necessary to get advice from a neurosurgeon about the possibility of practicing these sports. A cyst without additional symptoms in older children is usually not life-threatening. But it has contraindications for practicing contact traumatic sports, primarily martial arts and boxing, to a lesser extent football and hockey.Such a cyst does not require surgical treatment.
Methods for the treatment of cerebrospinal fluid cyst
The most common indications for surgical treatment of a cyst: grows too fast, causes epileptic seizures, causes neurological deficits, the cyst prevents the child from developing.
The main, safest and most effective method of treating CSF cyst today is fenestration. That is, dissection of the walls of the cyst to communicate between the cyst and other CSF spaces, where normally this accumulated fluid is located.
It is possible to install a stent (catheter) connecting the cavity of the cyst and ventricles. It happens that the operation turns out to be ineffective and forces to apply another method of treatment – bypass surgery.
Bypass surgery (today is practically not used as a primary method of treatment), although it allows you to quickly reduce the size of the cyst, but creates a lifelong dependence on the bypass system. If this method can be avoided, neurosurgeons try to avoid it.
However, in the treatment of young children (up to two years of age), as well as in the treatment of cysts, which were complicated by hemorrhage, shunting operations are inevitable.
In general, cyst surgery has a low risk of complications in the hands of experienced doctors. Such an operation involves hospitalization for only three to four days and several subsequent consultations with a surgeon. Deviations from this rule occur only in 10% of cases.
Most often in such a situation, an endoscopic operation is used, but in some cases an open microsurgical access is more correct. An uninitiated person will not see the difference after the operation, the size of access to the brain cavity will be the same.In this case, it is not so important for the patient what kind of instrument this operation is performed with. It is important to make the patient feel better.
A cyst that interfered with learning
Anastasia Klykova from the Leningrad Region has three children. When Nastya’s own son Fyodor was six years old, two adopted children appeared in their family with a difference of six months. It happened so. At first, Nastya got involved in a correspondence about one abandoned boy with the same congenital disease as her Fedor (intestinal malformation).And … I could not help but take him home.
“Just think,” thought Nastya. “We have been living with one such boy for six years, and we will live with two”. And six months later, the girl Vika appeared at home, surprisingly similar to Nastya herself.
And then Fyodor went to school, and something strange began to happen. It was clear that it was difficult for him to study. He sat under a desk or painted, sitting on the windowsill, but he could not write and read.
After the next parent-teacher meeting, Nastya thought: “A can for everyone” and took Fyodor out of school.I decided to examine him in order to understand whether this was the case. Yes, and a competent psychiatrist advised: first exclude organic causes.
Organic reasons were found: MRI confirmed a cyst in the brain. By itself, a cyst may not be troublesome. Or maybe – cause. It may or may not be the cause of Fedor’s school difficulties. Nastya was faced with the most difficult choice: to have the operation or not.
Correspondence, consultations … Doctors expressed diametrically opposite opinions.
“Therefore, I went to several to understand where our doctor is, to trust him and stop twitching.” Nastya agreed to an operation at the N.N. A.L. Polenova in St. Petersburg.
During the operation, a benign tumor was found in the cyst, which was not visible on the photograph. After a while, many doctors said that it was impossible to wait: a tumor is a direct indication for surgery.
That year, after the operation, Fedor became interested in Roman numerals. And instead of the usual addition-subtraction of Arabic numbers for a second grader, he did the same with Roman ones.“He just liked to see his mother’s bewildered face, who couldn’t check him,” laughs Nastya.
The boy still lives a full life, breeds ants and tadpoles. He visits his grandmother in the summer. What is he doing? Reads “Harry Potter” in the wrong translation and looks for mistakes. And Nastya admits that at that moment it was her adopted children who helped her a lot.
“The thought was clear: if there were no younger ones, I would have lost my mind. And so my attention was dispersed: a garden, a matinee, knee-highs, dresses, bows.It helped not to get stuck. ”
If you need medical help or consultation, an application for remote consultation and hospitalization in specialized hospitals can be submitted here.
Download the memo, it contains a lot of useful information: contacts of doctors, information on treatment, care and rehabilitation.
Illustrations by Oksana Romanova
Exhausted.
90,000 An ultrasound scan revealed an ovarian cyst. What now?! | for expectant mothers
Sometimes an ovarian cyst may not appear in any way, but most often a woman feels pain on certain days of the cycle.Rupture of a cyst, infertility, becoming cancer is usually the most frightening thing.
This article answers the following questions:
- Dangerous and non-dangerous types of cysts;
- Which cysts can develop into cancer?
- How to treat? Do I need to operate?
- How to determine the type of cyst by ultrasound?
Normal
Not Dangerous Cysts
There are two types of ovarian cysts that can be considered normal , they are associated with functional processes.
Follicular cyst – During the first phase, estrogen stimulates the growth of the dominant follicle and it fills with fluid. If the egg does not release on time, the follicle can continue to grow and reach up to 10 cm.
It is these cysts that are found in PCOS, almost always remain small and do not pose a danger.
Cyst of the corpus luteum (luteal) – usually after ovulation, the corpus luteum resolves within two weeks.If this does not happen, then an excess amount of fluid accumulates in it, forming a cyst.
This is also not dangerous, unless the cyst is fed by a blood vessel. It is called hemorrhagic ovarian cyst . It can be associated with long-term pain and deserves more careful monitoring.
Not normal dangerous cysts
These cysts are not associated with natural processes, therefore always require a visit to the doctor .
Endometriomas – cysts filled with old blood. This led to the nickname “ chocolate cysts ” as the liquid inside them looks like chocolate syrup.
These cysts can grow up to 8 cm. They form when pieces of the endometrium attach to the pelvic organs. Directly associated with endometriosis .
Dermoid cysts – also called cystic teratomas. May contain, instead of liquid , pieces of hair, teeth and other tissues of the body.It is still unknown why they are formed.
Cystadenomas – are formed from epithelial cells on the ovarian membrane . These cysts are filled with fluid or gel-like material.
Which cysts can turn into cancer?
All of these cysts are benign. This means that there is a very low probability of that they will become cancerous . For example, less than 2% of dermoid cysts show signs of malignancy.
How to treat? Do I need to operate?
Normal small cysts do not need to be treated , they go away on their own, you will need to do an ultrasound in 2-3 months.
Conservative treatment (hormonal pills)
It has been proven that taking OC for the treatment of simple cysts is as effective as doing nothing, i.e. essentially useless in treatment (Turan 1994, Sanersak 2006).
Operation
Other types of cysts, unfortunately, will most likely require surgical intervention.
How to determine the type of cyst by ultrasound?
Normal cysts : anechoic (black on ultrasound), fluid inside, clear boundaries, rounded.
Non-normal cysts : fuzzy borders, double contour, separation inside, a mixture of anechoic (black) and hyperechoic (light) areas.
Ultrasound successfully predicts the type of cyst in 96-97% of cases.
Various types of ovarian cysts by ultrasound
Various types of ovarian cysts by ultrasound
Endometrioid ovarian cyst
An endometrioid ovarian cyst, or endometrioma, arises from the endometrium, which normally lines the inside of the uterus.The content of the endometrioma is a thick brown liquid, its other name is “chocolate cyst”.
So, an endometrioid cyst was found on your ultrasound scan. What to do? You have probably already come across the fact that each doctor has his own opinion on this matter: one says that it is necessary to remove it, the other advises to observe.
Indeed, there are different approaches to the management of such cysts. Let’s figure it out:
- Surgical operation (laparoscopy) leads to the disappearance of symptoms (pain), removal of the cyst, excluding the possibility of its degeneration into a malignant tumor, torsion, rupture.
- Observation without surgery allows you to preserve the ovarian tissue, i.e. ovarian reserve, which is extremely important for anyone planning a pregnancy. It has been proven that ovulation occurs with the same frequency in an ovary with a cyst as in a healthy one.
- By the way, no medications will remove the endometrioma, so it is useless to take them!
- Who needs surgery? Those who have symptoms (for example, pain) or endometrioma growth (we are afraid of a malignant tumor).
- With small endometriomas that do not manifest themselves in any way, surgery is not needed. Even if you are infertile. There is no evidence that removing a cyst improves the chances of conception. Observe your ovaries every six months for an ultrasound scan.
What to do for those who have already had an operation to remove an endometrioma, and it reappears? Reoperation may be more damaging to the ovary than the first. Therefore, it is necessary to think carefully about its expediency.
I know a girl who at the age of 24, on the advice of a gynecologist, removed a small endometrioma.As a result, a few months after the operation, her hot flashes began and her periods stopped. She started having menopause at the age of 25! The ovaries must be protected.
| 17 | Endocrinologist appointment with recommendations Appointment of an endocrinologist with recommendations | st. Vladimirskaya 81-A st. A. Malyshko 39 | |
| 55 | Thyroid ultrasound + Doppler Thyroid ultrasound + color / power Doppler mapping | st. Vladimirskaya 81-A st. M. Maksimovich 10 st. A. Malyshko 39 | |
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how to prepare, how they are doing, what you can eat the day before.
The possibilities of ultrasound examination are very wide. Especially informative is the ultrasound of the abdominal cavity, in which the vital organs of a person are localized – the abdominal aorta, liver, spleen, gallbladder, pancreas, etc.
Thanks to the planned preventive examination, recommended once a year, there is a high probability of diagnosis and prevention of further development of the disease at an early stage.
As a rule, patients agree to this type of research because it is painless and does not pose any health risks. Ultrasound allows you to determine with very high accuracy the size, shape, localization and structure of the abdominal organs, the state of the vessels and ducts.
Focal lesions are easily visualized by ultrasound, such as cancer of the pancreas, liver, tumor metastasis, cysts, abscesses, hematomas, adenomas, calculi.But confirmation of the diagnosis, especially oncopathology, is possible only after histological examination of the tissue. Even small amounts of free fluid (from 100 ml) in the abdominal cavity are diagnosed by ultrasound. What is included in an abdominal ultrasound scan, how to properly prepare for it and how the study is done, we will tell in our article.
Symptoms for which an abdominal ultrasound is indicated
- bitterness in the mouth, hypersalivation
- heaviness in the right hypochondrium
- bursting and pulling pains in the epigastrium after eating
- various types of abdominal pain
- increased gas production
Diseases for which ultrasound is needed BP
Ultrasound is indicated in the presence or suspicion of the following diseases:
- pancreatitis
- hepatitis
- cholecystitis
- liver cirrhosis
- cysts in BP organs kidney and gall bladder stones
- neoplasms of organs BP
Preparation for abdominal ultrasound – detailed recommendations If you are prescribed
Ultrasound of the abdominal cavity preparation is no less important than the study itself, because it directly affects the information content of the procedure.
3 days before the ultrasound: | The evening before the ultrasound scan: | Ultrasound day: |
| Eating a small amount of food every 3-4 hours, about 4-5 times a day. Drinking liquid about one and a half liters daily. | A light dinner is allowed, which must be eaten before 20.00 | If the study is carried out in the morning, breakfast is excluded. |
| Products that increase gas formation are completely excluded from the diet: black bread, baked goods, fruits and vegetables, fatty meat and fish, alcohol, soda, milk, juices, legumes, etc. | Meat and fish products, even dietary ones, should not be included in dinner. | If the study is scheduled after 3 pm, a light breakfast is allowed, which must be eaten before 11 am. |
|
| 2 hours before the ultrasound, take 5-10 tablets of activated charcoal or simethicone (2 capsules or 2 teaspoons of emulsion) |
| Adsorbents can be prescribed if the patient has a tendency to flatulence: activated carbon, enterosgel, espumisan, etc. | If laxatives are poorly tolerated, it is recommended to introduce a Besacodyl suppository into the rectum (see suppositories for constipation). | In case of a tendency to flatulence, a cleansing enema may be prescribed in the morning, before the procedure. |
| Enzyme preparations may be prescribed to improve digestion and prevent gas formation: mezim, festal, pancreatin, creon, etc. | If laxatives are ineffective, a cleansing enema is prescribed 12 hours before the ultrasound scan. | Before an ultrasound scan, do not chew gum, dissolve lozenges, smoke, take antispasmodics. |
Abdominal ultrasound – child preparation
- Babies under 1 year old – it is recommended not to feed for 2-4 hours and not to drink for about 1 hour before the ultrasound.
- Children 1-3 years old – do not feed for 4 hours and do not drink for 1 hour before the ultrasound,
- Children over 3 years of age – preparation before an ultrasound scan is more stringent, you can not eat for about 6-8 hours and drink liquids 1 hour before the study.
When should not ultrasound be done
- After fluoroscopy of the gastrointestinal tract using contrast (irrigoscopy, gastrography).
- After endoscopy of the gastrointestinal tract (fibrogastroduodenoscopy, colonoscopy).
- After laparoscopy and pneumoperitoneum.
In the first and second cases, a delay of 2 days is made, in the last – 3-5 days. Preparation of ultrasound of the abdominal cavity in these cases is the same as described above.
How is ultrasound performed
PD ultrasound, as a rule, includes a mandatory examination of the gallbladder, liver, retroperitoneal space, spleen, pancreas and blood vessels.The rest of the organs are optional for research and are examined according to indications. The standard research protocol includes:
- determination of localization and size of organs
- study of the structure of organs
- determination of free fluid in the abdominal space (more precisely, confirmation of the absence of such)
- exclusion of formations, cysts, calculi, etc.
Description of Procedure
How is an abdominal ultrasound done? The procedure itself takes 15-20 minutes on average.An ultrasound scan is performed by an ultrasound doctor, assisted by a nurse, filling out the study protocol. There are no painful or uncomfortable sensations during the procedure. A special conductive gel is applied to the contact probe.
The examination is carried out in a supine position, if necessary, the doctor may ask you to roll over on your side, as well as hold your breath for a few seconds. With the help of a sensor connected to the monitor of the ultrasound machine, the doctor moves along the skin of the anterior abdominal wall, going down and to the sides.During the procedure, the doctor will name numbers, medical terms that the nurse enters into the protocol. Immediately after the ultrasound, you can eat and lead a normal life without restrictions.
What is included in the examination – the organs under study and the possibilities of ultrasound
- Liver . It is examined first of all. Hepatosis, cirrhosis, cysts, tumors can be diagnosed.
- Gallbladder and ducts . The patency of the ducts, the presence of polyps, stones in the gallbladder, and the condition of the organ wall are assessed.
- Stomach . It is examined at the time of exclusion of formations.
- Pancreas . All shares are assessed if possible. Pancreatitis, swelling and pancreatic necrosis can be detected.
- Spleen . The structure, location and size of the organ are assessed. Neoplasms, cysts, inflammation are excluded.
- Intestine . Most often, only the large intestine is examined. If formations and polyps are found, the patient is sent for a narrow examination.
- Kidney . Localization and relative position, sizes are assessed. Inflammatory changes, conglomerates, tumors and cysts can be found.
- Bladder . The shape, size, condition of the walls, content are evaluated.
- Vessels . The abdominal aorta and large vessels feeding the organs are necessarily assessed. The blood flow and the state of the vascular wall are determined.
- Lymph Nodes .Their size is assessed (an increase is typical for oncopathology).
- Uterus in women and prostate gland in men. These organs are located in the small pelvis, however, they can be examined. Tumors and inflammation can be detected.
Features of ultrasound of the abdominal cavity in children
Ultrasound in infants is of particular interest, since in children from one year of age and older, ultrasound does not actually differ from that in adults. Young children are referred for an abdominal ultrasound scan at:
- the presence of congenital abnormalities;
- pains in the abdomen and fever of unknown origin;
- routine screening, which is mandatory during the neonatal period.
90,245 abdominal injuries;
Ultrasound allows you to assess the state of the digestive and excretory systems, namely: liver, bladder and ureters, kidneys, gallbladder, pancreas, stomach, intestines. The retroperitoneal space, adrenal glands, arteries, veins and nerve plexuses are necessarily examined.
The procedure is carried out according to the same principle as the examination of an adult, but in the presence of one of the parents, who helps to keep the baby.
This study is necessary to exclude (or confirm) congenital pathologies, to confirm the normal state and functioning of organs according to age norms.
Ultrasound can detect :
- congenital organ pathologies
- tumors, cysts and organ polyps
- reactive pancreatitis
- kinks and constrictions of the gallbladder
- hyperplasia, liver cirrhosis and hepatitis
- enlargement of the spleen
- enlargement of regional lymph nodes
- blood flow disorders
Abdominal ultrasound – how to evaluate the study results
As a rule, the ultrasound doctor at the end of the study makes a short summary that the patient can understand, which may sound like “You are doing well” – the most anticipated and reassuring phrase.But there may be another conclusion, for example: “You need to see a gastroenterologist (urologist, etc.) for consultation.” But this should not be scary, any, even the most serious pathologies are treatable, the main thing is not to delay it.
A study protocol is issued, in which there are standard columns describing each organ, as well as a doctor’s conclusion. In the conclusion, all identified pathologies or suspicions of them are indicated. If the patient is healthy, the conclusion will sound something like this: Abdominal organs are normal.
At the A2Med medical center, abdominal examinations are carried out by a doctor of ultrasound diagnostics with extensive experience Ponosova Marina Alekseevna. The examination is carried out on the latest device GE Voluson 3D / 4D
You can sign up for diagnostics by phone. 258-05-07
Medical center “A2Med” is located at Komsomolskiy Ave., 15v (3rd floor)
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