Rapidly doubling endometrioma
An endometrioma can double its size within 2 weeksunder special conditions


Authors: C. Tsompos
Authors‘ workplace: Department of Obstetrics and Gynecology, Mesologi County Hospital
Published in: Čes. Gynek.2012, 77, č. 6 s. 594-596

Overview

One unsuccessfully transvaginaly – under ultrasonic guidance – drained cyst, after possible injury may have doubled within 2 weeks its diameter. The probability of being another one cyst else, does not seem to be valid because it would have been diagnosed due to size. If so, it also would have been selected for transvaginal aspiration in last – before 2 weeks – session, and not that one of 4 cm cyst. It was not written down also as a simple diagnosis at before 2 weeks ultrasound. The first consideration of unsuccessful post-aspirational post-injuring cyst diameter doubling within 2 weeks seems to get verified.

Key words:
endometrioma, transvaginal aspiration.

INTRODUCTION

A lot of adnexal [1] masses that would remain undiagnosed before the era of ultrasounds, now are discovered accidentally during transvaginal ultrasound investigation of asymptomatic women. Ultrasound diagnosis [2] in combination with tumor markers, are important in selecting the ideal method of treatment. Some benign are usually treated by follow-up, combined or not with various medications such as contraceptives, GnRH agonists, certainly if they do not cause any symptoms e.g. functional cysts. Other masses could be treated better by aspiration e.g. peritoneal cysts. Other ones are treated operationally e.g. borderline tumors or invasive malignancies. Many benign tumors can be removed laparoscopically, while malignant ones require laparotomy.

CASE

A 45 years [3] old woman was admitted in the Gynecologic Department of Hospital for investigation of feverish underbelly ache lasting one week ago. The fever waves rised at 39 oC, along with simultaneous appearance of the underbelly ache which was constant but bearable at presence. Further clinical and lab investigation revealed explicit pointed sensitivity in the underbelly region. From the patient history resulted a vaginal labor before 10 years, as well as 3 ovary cyst ultrasound guided transvaginal aspiration sessions. Those aspirations were the treatment sessions of polycystic syndrome ovaries held in past times. Last session was performed in an advanced medical centre 2 weeks before admition of patient in our Department. It concerned also a cyst 4 cm diameter at right ovary. That last aspiration session was noted by failure and the attempt was abandoned. The reasons of failure was being impossible to get comprehensible. Despite the insistence of aspirating physician to explain the failed cyst aspiration, it was not got comprehensible whether either cyst access was succeeded, or cyst puncture was performed after probable access, or cyst content drainage was performed after probable puncture. Also, doubt remained whether treatment was followed by sclerotherapy administration with either tetracycline, or 95% alcohol, or methotrexate, or rIL-2, after probable drainage.

Integrated investigation revealed negative pregnancy test, leukocytosis as much as 30 030/mm3>12 400/mm3 and a cystic formation of 7,6 cm longest diameter by transvaginal ultrasound that occupied cul-de-sac shifted lightly right. Detailed cystic formation features were homogeneous constitution, two-room, without compact elements, circumscribed, with neither arterial flow detection, nor vein one, nor peripheral microneoviscularization. Those features orientated to rather a benign cyst. Investigation by tumor markers did not raised any malignancy suspicion. Further imaging investigation by CT and MRI simply confirmed the ultrasonic diagnosis. Exploratory laparotomy revealed a right adnexal endometrioma of dimensions same as that diagnosed by ultrasound. The endometrioma was removed laboriously due to extensive adhesions around it. The pathologic report simply confirmed later the histologic diagnosis of endometrioma.


Picture. 1. Endometrioma ultrasonic images
Picture. 1. Endometrioma ultrasonic images

DISCUSSION

Enquires were raised upon whether either cyst diameter doubling was become after cyst unsuccessful aspiration and probable puncture within 2 weeks, or it was about another one cyst. Most likely explanation was that of inflammation of cyst after the aspiration attempt. Clinical signs and lab findings were advocating also about inflammation presence. The post-aspiration inflammation can be blamed for the cyst diameter doubling. Other explanation is that a likely cyst puncture caused bleeding accident, as it is described below in bibliography. The hematoma of that bleeding was drained exclusively into cyst interior, and that was what caused the profound cyst diameter. Probably its diameter was underestimated in the first aspiration attempt, something which, also should had been reported. The probability of being another one cyst does not appear to be valid because such a sizable cyst would have been diagnosed and perhaps been selected for aspiration instead that of 4 cm at last session. But the cystic formation of 7,6 cm diameter was not reported as ultrasonic diagnosis by aspirating physician 2 weeks before admition. Hence the two first affairs are logically strengthened. If none affair is valid, then, the sole remaining explanation is that some endocrine mechanism was involved increasing the cyst size.

Mystery also covers the presence of inflammatory environment that frames the case. Even if bibliography justifies an aspiration inflammatory complications rate, however this is not proved. Nothing can exclude one incidental coexisting pelvic inflammatory disease somewhere else. Unique advocating argument in favour of the complication, as more probable cause of inflammation presence is the therapeutic criterion. That is to say, simultaneous cure after cyst operational removal.

The most rapid [4] relapse concerns 6 ovarian cystsin 5 women treated by transvaginal ultrasonic aspiration and were again detected 3 months afteraspiration. The combination of this technique with sclerotherapy by tetracycline administration for non malignant ovarian cysts is recommended for the relapse rates reduction [5]. Also [6]another combination recommended for the relapse rates reduction is the six-month post-aspiration per os contraceptive pills supplying for simple benign cysts > 4 cm (rate of relapse 15%). Repeated [7] endometrioma aspirations is an effective therapeutic choice in patients with endometriosis and can be repeated on average 3,1 ± 2,8 times per patient without any complication. Farthest [8] follow-up end-point of 12 months was required in order to detect 8% of relapses by which the 75% were only selected for second aspiration sessions followed by sclerotherapy using 95% alcohol administration. 7 patients [9]were diagnosed with ovarian bleeding from a total of 3241 women submitted in transvaginal oocyte aspiration. All of 7 women were thin noting body mass index 19-21 kg/m2 and 4 had polycystic ovaries syndrome (PCOS). Ovarian bleeding prevalence in thin women with PCOS were 4.5% with odds ratio fluctuating in 50 [11-250] in combination with the remaining women. The median time for ovarian bleeding operational management fluctuated between 11.4 ± 5 hours, with median hemoglobin decline6,1 ± 1,8 mg/dl and the 85.71% of patients treated by laparoscopic electrocoagulation, showing that although this incidence is rare, thin women with PCOS, have a greater risk. The first adnexal cyst ultrasonic aspiration attempts followed by consecutive methotrexate administration became transabdominally [10].The relapse rate [11] after transvaginal methotrexate administration sclerotherapy was appreciated in the 28.6% after 20 ± 5 months of follow-up from which only the half cases needed repetition of treatment process. Other study [12] of longer-term follow-up revealed a relapse rate of 75%, from which 60% needed further intervention, and a 55.55% of last needed also laparotomy intervention. Another one [13] study concerning certainly benign cysts recorded relapse rate of 22.7% in 6 months.

Although aspirational [14] advances, the aspiration needle can wound the neighboring pelvic bodies and structures leading to serious complications. Most common are bleeding, pelvic structures wounds and pelvic inflammation. Other described complications include adnexal volvulus, endometriosis cysts rupture, anesthetic complications and still vertebral osteomyelitis. The improvement possibility of transvaginal ultrasonic aspiration remains enough great along published guidelines since that technique has huge diversity available. Another [15] study showed that post-aspiration treatment combined with GnRH agonists and rIL-2 administration in drained cyst increases considerably the beneficial effects. Another [16] study showed post-aspiration adhesions formation and a general complication infection [17] rate of 1.3%.

Adress:

Tsompos Constantinos, Consultant A

Department of Obstetrics and Gynekology

Mesologi County Hospital

40B Almyraki street

Mesologi 30200

Etoloakarnania

e-mail: Constantinostsompos@yahoo.com


Sources

1. Callen, WP. Ultrasonography in obstetrics and gynecology: Ultrasound evaluation of the adnexa. 5th Ed. Philadelphia: Saunders Elsevier, 2008, p. 968.

2. Kalmantis, MR., Daskalakis, G., Rodolakis, A., et al. The role of 3D ultrasound Power Doppler in the investigation of ovary, uterus and breast volumes. Investigation of international bibliography. Proposal in 3D Ultrasonography seminar, Thessaloniki 19-02-2011. Hel Ultras 2011; 8 (2): 77–78.

3. Tsompos, C. Rapid growing endometrioma. Hel Ultra, 2011, 8(4), p. 151–155.

4. Chan, LY., So, WW., Lao, TT. Rapid recurrence of endometrioma after transvaginal ultrasound-guided aspiration. Eur J Obstet Gynecol Reprod Biol, 2003, 15, 109(2), p. 196–198.

5. Kars, B., Buyukbayrak, EE., Karsidag, AY., et al. Comparison of success rates of ‚transvaginal aspiration and tetracycline sclerotherapy‘ versus ‚only aspiration‘ in the management of non-neoplastic ovarian cysts. J Obstet Gynaecol Res, 2012, 38(1), p. 65–69.

6. Koutlaki, N., Nikas, I., Dimitraki, M., et al. Transvaginal aspiration of ovarian cysts: our experience over 121 cases. Minim Invasive Ther Allied Technol, 2011, 20(3), p. 155–159.

7. Zhu, W., Tan, Z., Fu, Z., et al. Repeat transvaginal ultrasound-guided aspiration of ovarian endometrioma in infertile women with endometriosis. Am J Obstet Gynecol, 2011, 204(1), p. 61.

8. Gatta, G., Palato, V., Di Grezia, G., et al. Ultrasound-guided aspiration and ethanol sclerotherapy for treating endometrial cysts. Radiol Med, 2010, 115(8), p. 1330–1339.

9. Liberty, G., Hyman, JH., Eldar-Geva, T., et al. Ovarian hemorrhage after transvaginal ultrasonographically guided oocyte aspiration: a potentially catastrophic and not so rare complication among lean patients with polycystic ovary syndrome. Fertil Steril, 2010, 93(3), p. 874–879.

10. Mesogitis, S., Antsaklis, A., Daskalakis, G., et al. Combined ultrasonographically guided drainage and methotrexate administration for treatment of endometriotic cysts. Lancet, 2000, 355(9210), p. 1160.

11. Agostini, A., De Lapparent, T., Collette, E., et al. In situ methotrexate injection for treatment of recurrent endometriotic cysts. Eur J Obstet Gynecol Reprod Biol, 2007, 130 (1), p. 129–131.

12. Duke, D., Colville, J., Keeling, A., et al. Transvaginal aspiration of ovarian cysts: long-term follow-up. Cardiovasc Intervent Radiol, 2006, 29(3), p. 401–405.

13. Kocak, I., Uzel, A., Aytaç, R. An evaluation of transvaginal ultrasound-guided aspiration of simple adnexal cysts. J Obstet Gynaecol, 1998, 18(5), p. 474–477.

14. El-Shawarby, S., Margara, R., Trew, G., Lavery, S. A review of complications following transvaginal oocyte retrieval for in-vitro fertilization. Hum Fertil (Camb), 2004, 7(2), p. 127–133.

15. Acién, P., Quereda, FJ., Gómez-Torres, MJ., et al. GnRH analogues, transvaginal ultrasound-guided drainage and intracystic injection of recombinant interleukin-2 in the treatment of endometriosis. Gynecol Obstet Incest, 2003, 55(2), p. 96–104.

16. Muzii, L., Marana, R., Caruana, P., et al. Laparoscopic findings after transvaginal ultrasound-guided aspiration of ovarian endometriomas. Hum Reprod, 1995, 10(11), p. 2902–2903.

17. Zanetta, G., Lissoni, A., Dalla Valle, C., et al. Ultrasound-guided aspiration of endometriomas: possible applications and limitations. Fertil Steril, 1995, 64(4), p. 709–713.

Labels
Paediatric gynaecology Gynaecology and obstetrics Reproduction medicine

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Czech Gynaecology

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2012 Issue 6

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