Natural Ovarian Cyst Cure and Treatment
Dermoid cyst is the most common noninflammatory space occupying orbital mass in children 11, 45 . It usually appears in the first decade of life as a fairly firm, fixed, subcutaneous mass at the superotemporal orbital rim near the zygomaticofrontal suture (Fig. 8.23). Occasionally, a dermoid cyst may occur deeper in the orbit unattached to bone. Although it sometimes stationary, it does have a tendency to slowly enlarge. It can occasionally rupture, inciting an intense inflammatory reaction. Management is either serial observation or surgical removal of the mass.
Frozen section examination is still useful to establish rule out malignancy and ascertain the status of surgical resection margins. On frozen section, tumour typing is often feasible. Enlarged non-metasta-tic lymph nodes and suspicious in situ or borderline lesions (breast nodules, polyps, ovarian cysts) are often unsuitable for frozen section procedures and require a definitive deferred diagnosis. Routine H and E staining of paraffin-embedded tissue section has to be supplemented by special stains, some of which are still used despite the advent of immunocytochemistry (ICC). Useful stains and methods are
Serous cystadenoma adenofibroma Atypical proliferative serous tumor Intraepithelial low-grade carcinoma Mucinous cystadenoma Atypical proliferative mucinous tumor Intraepithelial carcinoma Endometriosis Endometrioid adenofibroma Atypical proliferative endometrioid tumor and BRAF occur in the development of serous borderline tumors, Ho et al. compared the mutational status of KRAS and BRAF in both SBTs and the adjacent epithelium from cystadenomas, the presumed precursor of SBTs. In that study, three of eight SBTs contained mutant BRAF and four SBTs contained mutant KRAS. All specimens with mutant BRAF harbored wild-type KRAS and vice versa. Thus, seven (88 ) of eight SBTs contained either KRAS or BRAF mutations. The same mutations detected in SBTs were identified in the cystadenoma epithelium adjacent to the serous borderline tumor (SBTs) in six (86 ) of seven informative cases. As compared with SBTs, the cystade-noma epithelium like ovarian surface epithelium lacks cytological...
Serous cystadenocarcinoma is essentially indistinguishable from serous cystadenoma, but shows signs of malignancy. Kamei et al. reported a case of multifocal SCT with atypical cells 22 . One of the seven multiple tumors described showed an increase in the nuclear cytoplasmic ratio, irregular nuclear margins, and perineural invasion. Abe et al. described a case of SCT with invasive growth to the lymph node and adipose tissue 38 . Invasion of the surrounding tissue can result in a distant metastasis 15 . In one case, the
Spontaneous hemorrhage is the most dreaded occurrence in a lymphangioma and may lead to eyelid ecchymosis, subconjunctival hemorrhage, and acute proptosis (Figure 14.6). This may create diagnostic difficulty in a patient with a previously undiagnosed asymptomatic lymphangioma. Acute increase in intraorbital pressure can result in compressive optic neuropathy and vision loss.37,39 In the clinical differential diagnosis of spontaneous orbital hemorrhage, the following possibilities should be considered in addition to lymphangioma trauma, bleeding disorder, orbital varix, and, rarely, cavernous hemangioma. One characteristic feature of lymphangioma is that the proptosis is exacerbated after trauma or upper respiratory tract infection.38,40 Under these circumstances, hemorrhage into the channels of the tumor may lead to the development of chocolate cysts.
Is composed of bloodless ectatic lymph channels. These spaces are lined by a single layer of flat mesothe-lial cells (Figures 14.8 and 14.9). Hemorrhage into these spaces produces chocolate cysts. Lymphoid aggregates, with or without germinal centers, are often seen. Fibrosis is present in lymphangiomas with chronic recurrent hemorrhages.37 Lymphangioma may resemble a cavernous hemangioma or varix microscopically as well as clinically.
Serous cystic pancreatic tumours are cystic epithelial neoplasms composed of glycogen-rich, ductular-type epithelial cells that produce a watery fluid similar to serum. Most are benign (serous cystade-nomas), either serous microcystic adenoma or serous oligocystic adenoma. Only very rare cases exhibit signs of malignancy (serous cystadenocarcinoma). A solid variant of serous cystadenoma (solid serous cystadenoma) has been described 1499 but remains to be established as a separate disease entity.
Distinction from cystadenoma may be difficult and relies largely on identification of infiltrative growth into salivary parenchyma or surrounding tissues. Review of multiple sections is often helpful. Low-grade mucoepidermoid carcinoma is typically cystic but, unlike cystadenocarcinoma, usually has a wide variety of cell types and areas that are more solid than cystic. The papillary cystic variant of acinic cell carcinoma has focal acinar differentiation and a greater degree of epithelial proliferation. Epidermoid differentiation in cystadeno-carcinomas is rare.
If a mass is found in the superolateral quadrant of the orbit, dermoid cysts and lacrimal gland masses should be considered. Fifty percent of lacrimal gland tumours are pleomorphic adenomas and the other half are malignant 27, 98, 134 . The malignant category includes predominantly adenoid cystic, carcinoma ex pleomorphic adenoma and mucoepidermoid carcinoma. The lacrimal tumours have few distinguishing imaging features, showing mostly a homogeneous character and moderate contrast enhancement. Poorly defined margins with bone destruction suggest a malignancy, but even the malignant lesions can be relatively well defined. The histology of lacrimal gland tumours is similar to that of salivary gland tumours as discussed in Chap. 5. Papil-lomas and squamous cell carcinomas are the benign and malignant tumours most commonly seen in the lacrimal sac. Their microscopic features are similar to those arising from the mucosa of the nose (see Chap. 2) or in the conjunctiva.
Another undetermined process (14-20). New and Aronow found that blood with a hematocrit of 45 measures 58 HU on CT, rising to 60 to 80 HU after blood clot retraction with the protein component being responsible for the high attenuation (21). This appears to be consistent with the frequent finding of hemorrhagic cysts in the range of 70 to 90 HU (19,20). The importance of hemorrhagic cysts lies in distinguishing them from high attenuation solid renal tumors (Fig. 13) (22). Ultrasound may not be helpful because the contents (blood or debris) that make the cyst high in attenuation may also generate internal echoes indistinguishable from a solid tumor. Generally speaking, cysts
Osteitis pubis is not only a diagnostic problem but also a therapeutic dilemma often requiring a multi-disciplinary approach. Making the diagnosis of osteitis pubis is not particularly difficult when the radiographs corroborate the diagnosis. However, the physician is faced with a difficult diagnostic challenge when an athlete presents with groin pain and nondiagnostic radiographs, especially if the symptoms are chronic. In this particular clinical setting, a referral to a general surgeon to rule out an inguinal hernia, spermatic cord problems, abdominal wall defects, and other urologic conditions is warranted. And, in the female athlete, a gynecologist referral to evaluate for conditions such as ovarian cysts, endometriosis, and pelvic inflammatory disease is appropriate.
Diagnostic considerations The disorder is often accompanied by additional deformities such as dermoid cysts or a microphthalmos. Congenital defects of the first embryonic branchial arch that can result in coloboma include Franceschetti's syndrome (mandibulofacial dysostosis) or Goldenhar's syndrome (oculoauriculovertebral dysplasia). Depending on the extent of the coloboma, desiccation symptoms on the conjunctiva and cornea with incipient ulceration may arise from the lack of regular and uniform moistening of the conjunctiva and cornea.
There is rarely any neurological deficit, unless a dermoid cyst has compressed local nerve roots or meningitis has caused a deficit. MRI scanning reveals the extent of the tract and any associated dysraphic abnormality (Fig. 27.5). Contrast media or probes should not be inserted along the tract. The object of surgery is to excise the tract in its entirety. This involves excising its cutaneous orifice and following this to its termination. This may require opening the dura and excision of the attachment to the filum terminale. Any associated dermoid cyst, either intradural or extradural, should also be excised.
Although SCTs have been classified as microcystic adenomas, recent advances in imaging techniques have revealed more cases of serous oligocystic adenoma 25 . Serous oligocystic adenoma is the second common subtype of SCT, accounting for 7-30 of all SCTs 14, 19, 20, 27, 30, 31 . Synonyms include macrocystic serous cystadenoma, and serous oligocystic and ill-demarcated adenoma 1, 8, 30-33 .
Magnetic resonance imaging findings were compared to physical examination and intraoperative findings. HASTE-sequence MRI was more accurate than physical examination in identifying cystoceles, enteroceles, vault prolapse, and pelvic organ pathology such as uterine fibroids, ure-thral diverticula, ovarian cysts, and Nabothian and Bartholin's gland cysts.5 Comiter et al.6 found that with dynamic MRI, surgical planning was altered in more than 30 of cases, most often because of occult enterocele not appreciated on physical examination.
Duration of pain Gastroenteritis and mesenteric adenitis start gradually and plateau over hours. Appendicitis starts gradually and classically increases in severity until perforation occurs. Urinary calculi, ovarian torsion, and ruptured ovarian cyst are sudden in onset and severe from the outset. Pain of intussusception is intermittent over hours and sometimes days. Functional pain is most frequently chronic.
The most common clinical differential diagnosis of cystic orbital lesions includes dermoid cyst, colobo-matous cyst, teratoma, meningoencephalocele, lymphangioma, acquired inclusion cyst, chronic hematic cyst (cholesterol granuloma), mucocele, subperiosteal hematoma, and parasitic cyst.25 On MRI these lesions appear as well-defined, round to oval lesions with variable signal intensity depending on the composition of their content (Table 10.4).1,2,5,31 Dermoid cyst may have an homogeneous or heterogeneous, isointense to hyperintense signal with respect to the vitreous on Tl-weighted images.5 On T2-weighted images, the cyst may appear isointense or hypointense to the vitreous.5 Dermoid cyst may have a characteristic dumbbell configuration.5,25 The varying intensity pattern of dermoid cyst on nonenhanced MR studies may also be seen in the other cystic orbital lesions. However, fat-fluid level is characteristically seen in dermoid cyst.5 The oily portion of the cyst content appears in the...
Epithelial and Dermoid Cysts The most common developmental cysts occurring in the orbital and periorbital region and having a predilection for the superotemporal quadrant, are the epithelial and dermoid cysts. Dermoid cysts contain one or more epidermal appendages such as hair follicles, sweat glands, and sebaceous glands epithelial cysts contain only stratified squamous cell epithelium. Echographi-cally, epithelial and dermoid cysts appear on B scans as smoothly rounded, echolucent lesions with good sound transmission (Figure 8.2A,B). However, some dermoid cysts show low internal amplitude echoes depending on the number of hair shafts and other appendages within the lesion, which invariably cause partial sound attenuation. On A scan, epithelial cysts are low reflective. Dermoid cysts are medium to low reflective with occasional high reflective spikes that indicate the presence of certain coarse structures such as fine hairs or cartilaginous remnants.4,5 FIGURE 8.2. Cystic lesions...
In 1978, Compagno et al. described microcystic adenomas as composed of innumerable tiny cysts 2 . Serous microcystic adenoma is the most common subtype of SCT, accounting for more than 70 of SCTs 19, 20 . Synonyms include microcystic adenoma, glycogen-rich adenoma, and simply serous cystadenoma 1, 2, 10 .
The term dermoid cyst should be reserved for a cystic neoplasm that originates from the ectoderm and meso-derm endoderm is never found in these cysts 101 . The head and neck area is a common site of occurrence for dermoid cysts, accounting for 34 of cases. These cysts are located in the skin and subcutaneous tissues 113 . The position of these dermoid cysts at the midline and along the lines of embryonic fusion of the facial processes is consistent with their origin by inclusions of ectodermal tissue along lines of closure at junctions of bone, soft tissue, and embryonic membranes 87 . Dermoid cysts in the neck account for 22 of mid-line or near-midline neck lesions 101 . They have been described in the upper neck, near the thyroid cartilage, and as low as the suprasternal notch. They may occur in people of almost any age. More than 50 are detected by the time a person is 6 years old, and approximately one-third are present at birth 87, 101, 113 . The distribution between the sexes is...
Roe (1965) defined a spontaneous thyroid tumor as a neoplasm that had developed without any influence exerted by internal or external carcinogens. Data on the incidence of spontaneous thyroid tumors in animals are contradictory. McCoy (1909) and Woolley & Wherry (1912) were the first to systematically investigate thyroids of animals. They searched for tumors in 23,000 and 100,000 wild rats, but failed to detect them. In 1917, Bullock and Rhodenburg firstly described nine tumors found in 4,300 rats in 1926, Slye at al detected 12 so-called carcinomas in 51,700 mice. They are seen more often in laboratory rats, but have a predilection for older animals. Many of these tumors are derived from the C-cell component of the thyroid gland. Lindsay et al (1968) coined the term naturally occurring carcinoma of the rats thyroid for these medullary tumors. In the following years, many studies described spontaneous tumors in various rat strains For example, van Dyke (1944) reported on nine...
EPIDERMOID DERMOID CYSTS Dermoid (dermis) - as above, but thicker walled and, in addition, containing hair follicles and glandular tissue. Midline dermoid cysts lying in the posterior fossa often connect to the skin surface through a bony defect. This presents a potential route for infection. When lying in the cerebellopontine angle, epidermoid dermoid cysts often cause trigeminal neuralgia (see page 159). Neurological findings may range from a depressed corneal reflex to multiple cranial nerve palsies. Rupture and release of cholesterol into the subarachnoid space produces a severe and occasionally fatal chemical meningitis. The presence of a suboccipital dimple combined with an attack of infective meningitis should raise the possibility of a posterior fossa dermoid cyst with a cutaneous fistula.
In the last several years, attempts have been made to characterize the clinicopatho-logical features of noninvasive and invasive epithelial ovarian tumors of all histological types in an effort to elucidate their pathogenesis and behavior (2,7-9). These studies identified a subset of low-grade serous tumors originally designated micropapillary serous carcinoma (MPSC) with characteristic histopathological features, low proliferative activity, and an indolent behavior. These tumors contrast dramatically with the conventional type of serous carcinoma, which is a high-grade aggressive neoplasm that has high proliferative activity (2,7,9). The term MPSC was originally proposed to distinguish the noninvasive form of this tumor from the more common noninvasive tumor, termed an atypical proliferative serous tumor, both of which have been included under the rubric of borderline or low-malignant potential (7,9). Subsequent studies have suggested that MPSC is the precursor or in situ lesion of...
The clinicopathological observations described earlier, provide the basis for a proposed model of ovarian carcinogenesis, in which there are two main pathways, corresponding to type I and type II tumors. The tumor types, putative precursor lesions and associated molecular genetic alterations are summarized in Table 1. It should be emphasized that the terms, type I and type II, refer to tumorigenic pathways and are not specific histopathological terms. Type I tumors (low-grade serous carcinoma, mucinous carcinoma, endometrioid carcinoma, malignant Brenner tumor, and clear cell carcinoma) develop in a stepwise fashion from well-recognized precursors, namely borderline tumors, which in turn, develop from cystadenomas adenofibromas (Fig. 1 Table 1) (14). The benign tumors appear to develop from the surface epithelium or inclusion cysts in the case of serous and mucinous tumors and from endometriosis or endometri-omas in the case of endometrioid and clear cell tumors. Type I tumors are...
Dermoid cysts of the nose constitute 5.5-12 of those of the head and neck region. More than half are detected in children 6 years old or less, and approximately a third are present at birth. They occur most commonly in the bridge of the nose and always in the midline 33, 63, 88, 254, 278 . Dermoid cysts are lined with mature keratinising squamous epithelium and contain appendages of the skin in the cyst wall, but no endoderm. The lumen is filled with cheesy, yellow-white material. This lesion is differentiated from the very rare sinona-sal teratoma by the limited variety of tissue types and the absence of endodermal components 100 . Epidermal inclusion cysts do not contain adnexa. Dermoid cysts of the nose should also be distinguished from en-cephalocele. We are unaware of hairy polyps occurring in the nose.
Molding of the bone by a well-circumscribed orbital mass is highly suggestive of a congenital lesion (e.g., dermoid cyst, lymphangioma) or a slowly growing benign lesion (e.g., cavernous hemangioma, neuro-fibroma, neurilemoma, benign lacrimal gland tu-mor).1-4 Bone erosion or scalloping is usually seen in a more aggressive inflammatory or neoplastic primary or secondary lesion.1-3,8
The upper aerodigestive tract, including the larynx. A whole spectrum of oncocytic laryngeal lesions has been observed, ranging from focal to diffuse oncocytic metaplasia, papillary cystic hyperplastic lesions to benign and malignant tumours (the latter occur mainly in the sinonasal and palatal region) 44 . On the other hand, it has been suggested that all these lesions, variously called oncocytic cyst (OC), oncocytic papillary cystadenoma, oncocytoma, oncocytic adenomatous hyperplasia, more likely belong to non-neoplastic rather than to true neo-plastic lesions 193, 265, 291 . This opinion has been supported by the various extent of oncocytic metaplasia in the laryngeal minor salivary glands, as well as by the occasional appearance of multiple cystic lesions 84, 111, 230, 387 .
SCTs of the pancreas are uncommon tumors and are usually classified as microcystic adenomas 2, 10 . The serous microcystic adenoma has a characteristic spongy gross appearance as a result of numerous tiny cysts and a central scar 1, 2, 5, 10 . The epithelial cells are rich in glycogen, giving rise to the alternative name of glycogen-rich cystadenoma 2 . In recent years, lesions of the pancreas, including SCTs, have been detected more easily because of the advance in diagnostic imaging methods. Moreover the morphologic spectrum and biologic diversity of SCTs have expanded. Two newly described SCTs, known as serous oligocystic adenoma and solid serous adenoma, have been reported as variants of the more familiar serous microcystic adenoma 1, 8, 11, 12 . SCTs are frequently incidental findings. It is important to distinguish between these subtypes. Due to slow growth, most SCTs do not require resection unless the patient is symptomatic 13, 14 . Malignant transformation of SCTs is...
Plain radiography and sialography are useful for ductal inflammatory disease, but computed tomography (CT), ultra-sonography, CT sialography, and magnetic resonance imaging (MRI) are usually better for evaluation of suspected neoplastic disease. MRI is particularly useful when inflammatory disease is not suspected. It does not have the risks of radiation exposure nor complications with intraductal injection of contrast media, and it is often superior in demonstrating the interface of tumour and surrounding tissues. T1-weighted images of normal parotid have an image signal intermediate between fat and muscle whereas submandibular tissue is closer to muscle in intensity. With advanced age and fatty infiltration, the signal intensity of parotid tissue approaches fat. Most salivary gland tumours are brighter on T2 than T1 images but this difference is minimal in prominently cellular tumours. Lesions with higher water content, such as human immunodeficiency virus related parotid cysts,...
Serous cystadenoma 8441 0 Fig. 10.10 Microcystic serous cystadenoma. A CT scan showing a well demarcated, spongy lesion in the head of the pancreas. B Cut surface showing a typical honeycomb appearance and a (para-)cen-tral stellate scar (arrowhead). Fig. 10.10 Microcystic serous cystadenoma. A CT scan showing a well demarcated, spongy lesion in the head of the pancreas. B Cut surface showing a typical honeycomb appearance and a (para-)cen-tral stellate scar (arrowhead).
Epithelial rests found at sutural sites within the orbit can give rise to epithelial cysts. Cysts of the surface epithelium are further divided into simple epithelial cysts (epidermal, conjunctival, respiratory and apocrine gland), and dermoid cysts (epidermal and conjunctival). Epidermal dermoid cyst (dermoid) is by far the most common orbital cystic lesion in children, accounting for over 40 of all orbital lesions of childhood. Other developmental cysts are teratomatous cysts, neural cysts (congenital cystic eye and colobomatous cyst) and those associated with brain and meningeal tissue (encephalo-cele and optic nerve meningocele) 103 . Developmental cysts have to be differentiated from secondary cysts, like mucocele and inflammatory cysts. Mucocele can occur in children with cystic fibrosis. Inflammatory cysts are generally due to parasitic infestations and are more common in tropical areas of the world. Furthermore, non-cystic tumourous lesions with a cystic component (like...
A 20-year-old female presented to her family doctor complaining of abdominal pain. Abdominal US and a CT scan confirmed the finding of a cystic lesion in the pancreatic head, suggestive of cystadenoma. An enucleation of the tumor was performed. The tumor measuring 7 X 7 X 3 cm revealed a well-circumscribed unilocular cyst with a thin fibrous capsule, and the cyst contained dark red material. The inner surface of the cyst wall was covered by papillary tumor cells. Histologically, on the cystic lumen, the oval-shaped tumor cells were arranged around a fibrovascular stalk with a pseudopapillary pattern (fig. 4).
MRI can often provide the specific diagnosis of benign ovarian masses (pedunculated leiomyomas, dermoid cysts and endometriomas, with accuracy 90 ) 5 . Cho et al. 21 applied proton MRS3 to examine 31 patients with adnexal lesions that were subsequently treated surgically. A total of 7 patients had malignant ovarian tumors (3 were metastatic). The remaining 24 patients had benign lesions of various types (cystadenoma, teratoma, endometriosis, ectopic pregnancy, salpingitis with necrosis). The lesions were between 4 and 23 cm (in all cases larger than the localization of the voxel). The resonance at 1.3 ppm attributed to the methylene group in fatty acid chains was observed in 5 of 7 patients with malignant ovarian tumors, in 7 of 11 benign teratomas, and in the case of salpingitis. This resonance at 1.3 ppm was not seen in any of the 6 benign ovarian epithelial tumors. The lipid Their results are summarized in Table 10.2. The authors note the need to avoid contamination of peripheral...
Other benign biliary lesions Biliary cystadenoma. These lesions resemble their intrahepatic counterparts (see chapter on bile duct cystadenoma and cystadenocarcinoma). Cystadeno-mas are seen predominantly among adult females and are usually symptomatic. Some of the tumours may measure up to 20 cm in diameter leading to obstructive jaundice or cholecystitis-like symptoms. More common in the extra-hepatic bile ducts than in the gallbladder, cystadenomas are multiloculated neoplasms that contain mucinous or serous fluid and are lined by columnar epithelium reminiscent of bile duct or foveolar gastric epithelium 404 . Occasionally endocrine cells are present. The cellular subepithelial stroma resembles ovarian stroma and shows immunoreactivity for estrogen and progesterone receptors 2029 . The stroma also shows variable fibrosis. Malignant transformation (cystadenocarcinoma) can occur 404 .
Fore, based only on the precontrast MR characteristics, it is difficult to differentiate the solid (capillary hemangioma, A and C) from the cystic (dermoid cyst, B and D) lesions. fore, based only on the precontrast MR characteristics, it is difficult to differentiate the solid (capillary hemangioma, A and C) from the cystic (dermoid cyst, B and D) lesions.
Lymphangioma is an important vascular tumor of the orbit in children 4,28,50 . It tends to become clinically apparent during the first decade of life. It may case abrupt proptosis following orbital trauma, secondary to hemorrhage into the lymphatic channels within the lesion (Fig. 8.24). Such spontaneous hemorrhages, called chocolate cysts, may require aspiration or surgical evacuation to prevent visual loss from compression of the eye.
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