Papillary ovarian cyst is a type of serous tumor of ovarian tissue, having a pronounced capsule, an inner lining formed by papillary epithelial growths, and liquid contents. Papillary ovarian cyst is manifested by a feeling of heaviness and soreness in the lower abdomen, dysuric phenomena, menstrual disorders, infertility, ascites. Some types of tumors of this type can degenerate into adenocarcinoma. Papillary ovarian cyst is diagnosed by vaginal examination, ultrasound, MRI, determination of the marker CA-125, laparoscopy. For reasons of oncological alertness, the presence of a papillary ovarian cyst requires the removal of the affected ovary or uterus with appendages.
General information
Ovarian papillary cyst develops more often in the reproductive age, somewhat less often during menopause and practically does not occur before puberty. The frequency of papillary cysts in gynecology is about 7% of all ovarian tumors and almost 34% of epithelial type tumors. Papillary ovarian cysts are prone to blastomatous degeneration in 50-70% of cases, therefore they are considered as a precancerous disease. The presence of ovarian papillary cyst in 40% of patients is combined with other tumor processes of the reproductive organs – ovarian cyst, uterine fibroids, endometriosis, uterine cancer.
Causes
In the question of the causes of ovarian papillary cysts, modern gynecology has several hypotheses. According to one theory, ovarian papillary cysts, like other tumor formations of ovarian tissue, develop against the background of chronic hyperestrogenism caused by hyperactivity of the hypothalamic-pituitary system. Another theory is based on arguments about “constant ovulation” caused by early menarche, late menopause, a small number of pregnancies, refusal of lactation, etc. According to the theory of genetic predisposition, the presence of ovarian tumors and breast cancer in female family members is important in the development of papillary ovarian cysts.
It is assumed that ovarian cysts can develop from the integumentary epithelium, from vestigial elements surrounding the ovary, or areas of displaced uterine or tubal epithelium. The development of ovarian papillary cysts may be associated with the carrier of HPV or herpes type II, frequent inflammation (endometritis, oophoritis, adnexitis), disturbed menstrual cycle, multiple termination of pregnancy.
Classification
Morphologically, papillary ovarian cyst is characterized by papillary epithelial growths on its inner and sometimes outer surface. According to the localization of papillary growths, papillary ovarian cyst can be inverting (30%), everting (10%) and mixed (60%). Inverting cyst is characterized by individual papillae or massive papillary growths lining only the inner surface of the tumor wall. In an everting cyst, papillary growths cover only the outer surface of the wall. With papillary ovarian cyst of a mixed type, papillae are located both outside and inside the capsule.
In terms of oncological alertness, the histological form of ovarian papillary cyst is extremely important. There are papillary ovarian cysts without signs of malignancy, proliferating (precancerous) and malignant (malignated). Papillary ovarian cyst often has a multicameral structure, an irregularly rounded shape, convex walls, and a short leg. Inside the chambers of the cyst contains a yellowish-brown liquid medium.
The walls of the chambers contain irregularly arranged papillary growths, the number of which can vary, and the shape resembles corals or cauliflower in appearance. Small and multiple papillae give the wall of the cyst a velvety appearance. When epithelial papillae germinate through the wall of the cyst, the parietal peritoneum of the pelvis, the second ovary, the diaphragm and neighboring organs are seeded. Therefore, everting and mixed papillary cysts are considered as potentially malignant and more prone to ovarian cancer.
Papillary ovarian cysts are characterized by bilateral localization with different-time development of tumors and intraligmental growth. Papillary ovarian cysts of large sizes develop extremely rarely.
Symptoms
At an early stage of the disease, the symptoms are not pronounced. The clinic of papillary ovarian cyst manifests with the appearance of sensations of heaviness, soreness in the lower abdomen; pain often radiates to the lower extremities and lower back. Early development of dysuric phenomena, defecation disorders, general weakness is noted. Some women may have menstrual irregularities such as amenorrhea or menorrhagia.
With everting and mixed forms of cysts, ascites of a serous nature develops; the hemorrhagic nature of the ascitic fluid indicates the presence of a malignant cyst. Ascites is accompanied by an increase in the size of the abdomen. The adhesive process in the pelvis often leads to infertility.
When the leg of the ovarian papillary cyst is twisted, formed by stretched ligaments, ovarian artery, lymphatic vessels, nerves, fallopian tube, tumor necrosis occurs, which is clinically accompanied by signs of an acute abdomen. Rupture of the cyst capsule is accompanied by the development of intra-abdominal bleeding, peritonitis.
Diagnostics
Papillary ovarian cyst is recognized by vaginal examination, ultrasound, diagnostic laparoscopy, histological analysis. With a bimanual gynecological examination, a one- or two-sided painless ovoid formation is palpated, pushing the uterus to the pubic joint. The consistency of the cyst is tight-elastic, sometimes uneven. Everting and mixed cysts, covered with papillary outgrowths, have a fine-grained surface. The interlocking arrangement causes limited mobility of papillary ovarian cysts.
In the process of gynecological ultrasound, the size of the cyst, the thickness of the capsule are precisely determined, the presence of chambers and papillary growths is specified. With palpation of the abdomen, as well as with the help of ultrasound of the abdominal cavity, ascites can be detected. Detection of an ovarian tumor requires examination of the cancer marker CA-125. In some cases, CT or MRI of the pelvis is advisable to clarify the diagnosis. The final confirmation of the diagnosis and clarification of the morphological form of ovarian papillary cyst is carried out in the process of diagnostic laparoscopy, intraoperative histological examination.
Treatment
In relation to papillary ovarian cysts, only surgical tactics are indicated. If there are no signs of malignancy, cysts in patients of reproductive age are limited to oophorectomy – removal of the ovary on the affected side. With bilateral cysts, regardless of age, a total oophorectomy is performed.
In premenopause and menopause, as well as with borderline or malignant cysts, supravaginal amputation of the uterus with appendages or pangisterectomy is performed. To clarify the morphological form of the cyst and determine the volume of intervention during surgery, the tumor tissue undergoes urgent histological examination.
Intraoperative detection of ascites, papillae dissemination on the tumor surface and peritoneum does not directly indicate the malignancy of the cyst and cannot serve as a reason for refusing surgery. After removal of the ovarian papillary cyst, the foci of dissemination regress, and ascites does not resume.
Forecast
The timely diagnosis and removal of ovarian papillary cysts practically eliminates the possibility of their recurrence in the form of ovarian cancer. Nevertheless, in order to exclude oncological risks after surgery, patients are subject to the supervision of a gynecologist. If treatment is refused, papillary ovarian cyst can take an unfavorable course with the development of ascites, complications (leg twisting, capsule rupture), malignancy.
