Ovarian tumor like condition, also known as non-redundant cysts, includes chocolate cysts due to endometriosis of the ovary, retention cysts due to functional changes of the ovary, such as follicular cysts, luteal cysts (hematomas), polycystic ovary syndrome, and ovarian hyperstimulation changes due to controlled ovulation in assisted reproductive technology. In addition, flavin cysts associated with trophoblastic diseases are also included in this category. The morphologic changes of ovarian neoplastic lesions, especially chocolate cysts and hemorrhagic luteinizing cysts, are often confused with ovarian superfluous tumors, causing difficulties in the differential diagnosis by ultrasound.
I. Unicompartmental cystic lesions
Cystic masses originating from the adnexa include functional retention cysts of the ovary and vesicular adnexa of the fallopian tube, which are far from the ovary and are fluid-filled vesicles, morphologically similar and usually no more than 5-8 cm in diameter.
Clinical and pathologic features
The follicular cysts are formed when the follicle does not rupture after maturation, or atresia occurs and the fluid is retained in the follicular cavity, which protrudes from the surface of the ovary in the form of a blister, with a thin wall and a smooth interior, and the fluid inside the cyst is clear and transparent, yellowish, often less than 4 cm in diameter, occasionally up to 7 ~ 8 cm. Most of them are absorbed gradually within 4-6 weeks or rupture by themselves.
2, luteal cyst (corpus luteum cyst): cystic corpus luteum persists or grows, or luteal hematoma is absorbed, forming luteal cysts. Diameter generally does not exceed 4cm, occasionally up to 10cm, the cyst fluid is translucent or brown plasma. Luteal cysts can occur in the middle and late menstruation and pregnancy, luteal cysts during menstruation continue to secrete progesterone, often delaying the menstrual cycle, luteal cysts during pregnancy can exist for a longer period of time to mid-pregnancy.
3.Simple cyst: Simple cyst is a general concept and often represents a group of adnexal cysts with similar histological manifestations in clinical practice. When follicular cysts, corpus luteum cysts and adnexal inflammatory microcysts have been diseased for a long time, the pathological manifestations are similar due to cyst wall fibrosis, epithelial atrophy and degeneration, and it is difficult to identify the source; in addition, during the development of female genitalia, cystic changes may occur in various parts, including the tubal vesicular attachment of Mullerian duct origin, round ligament cysts and ovarian crown cysts and broad ligament cysts of mesonephric duct origin, etc., which are generally named according to the site or They are generally named according to their location or are commonly referred to as simple cysts. They often do not have any clinical manifestations.
4, ovarian coronal cyst (parovarian cyst): located in the fallopian tube tract between the two broad ligaments of the fallopian tube and the ovarian hilum, the cyst is formed by the distal blind end of the ovarian coronal enlargement, the ovary is normal, and the fallopian tube is elongated close to the wall of the cyst. The cysts are round or salami-shaped, often about 5 cm in diameter.
Luteal hematoma
The follicular membrane layer ruptures after ovulation, causing hemorrhage and blood retention in the follicular or corpus luteum cavity to form a hematoma. The normal corpus luteum is about 1.5 cm in diameter and later transforms into a white body and naturally subsides during the follicular phase of the next cycle. The corpus luteum hematoma, or hemorrhagic corpus luteum, occurs unilaterally and is usually 4 cm in diameter, occasionally up to 10 cm in diameter, and after the corpus luteum hematoma is absorbed, it forms a luteal cyst. When larger hematomas rupture, intra-abdominal bleeding, abdominal pain, signs of peritoneal irritation and vaginal bleeding may occur, which cannot be easily distinguished from ectopic pregnancy.
C. Polycystic ovary syndrome
Polycystic ovarian syndrome (PCOS), also known as Stein-Leventhal syndrome, is a syndrome caused by derangement of the menstrual regulation mechanism. Patients have a group of symptoms such as sporadic menstruation or amenorrhea, infertility, hirsutism and obesity, and the ovaries are bilaterally enlarged with polycystic changes. The etiology may be related to dysfunction of the hypothalamic-pituitary-ovarian axis, which is the ultimate outcome of persistent ovarian anovulation. The diagnosis rate of this disease is gradually increasing due to the enhanced understanding of the disease.
[Pathology].
The ovaries are enlarged bilaterally, about two to five times the normal size, with smooth, grayish-white, shiny surface and thickened, fibrotic white membranes visible on the cut surface. Microscopically, there were no dominant follicles or signs of ovulation under the envelope, no corpus luteum formation, follicles in various stages of development and atretic follicles, dilated into cysts.
IV. Ovarian hyperstimulation syndrome
Ovarian hyperstimulate syndrome (OHSS) is a common medical complication in the process of inducing hyperovulation. In the last 20 years, the development of fertility techniques and the widespread use of ovulation-promoting drugs (including CC, HMG, FSH, HCG and GnRH agonists) have led to an increasing trend of ovarian hyperstimulation syndrome, with the incidence of OHSS ranging from 1% to 14% and severe OHSS ranging from 0.5% to 2% in IVF cycles with assisted reproductive technology. Ultrasound monitoring has positive implications for the diagnosis and prevention of OHSS, and regular ultrasound examinations during the course of treatment can help monitor changes in the condition. Ultrasound-guided drainage of intracystic fluid in the ovary to reduce the amount of estradiol entering the blood circulation and laparotomy to release ascites to relieve pressure symptoms are the main symptomatic treatment measures.
Pathophysiological mechanism
The main pathophysiological changes of OHSS are acute increase in capillary permeability, massive extravasation of body fluid and a series of secondary changes, resulting in ascites, pleural fluid or even diffuse edema, oliguria, enlarged ovaries and impaired liver and kidney function, forming a complex syndrome. the pathogenesis of OHSS has not been elucidated, and it may be a complex process of multifactorial synergistic effects. OHSS may occur only when exogenous gonadotropins promote excessive follicular growth and development, secrete excessive estrogen, promote ovulation after HCG injection and form multiple luteinized cysts.
Clinical manifestations and grading]
Based on clinical manifestations and laboratory tests, OHSS is classified as mild, moderate or severe.
1. Mild: 3~6 days after ovulation or 5~8 days after HCG injection, with lower abdominal discomfort, poor appetite, fatigue, E2 level ≥5500pmol/L (1500pg/ml), early luteal progesterone value ≥96nmol/L, more than 10 follicles, ovarian enlargement up to 5cm in diameter, with or without follicular cysts/luteal cysts.
2, Moderate: significant lower abdominal distension, may have nausea, vomiting, thirst, occasionally with diarrhea; weight gain ≥ 3 kg, increased abdominal circumference; E2 water ≥ 11000 pmol/L (3000 pg/ml), obvious ovarian enlargement, ovarian diameter between 5 ~ 10 cm, ascites < 1.5 liters.
3. Severe: marked increase in ascites, increased abdominal distension and pain, thirst and drinking but little urination, nausea, vomiting, abdominal distention and even inability to eat, fatigue, weakness, cold sweat and even deficiency; diaphragm elevation due to large amount of ascites or thoracic fluid causing respiratory distress and inability to lie down; ovarian diameter ≥ 10 cm, a few up to 15 cm, very few patients can have ovarian torsion and show acute abdominal disease; weight gain ≥ 4.5 kg.
V. Ovarian endometriotic cysts
The presence of endometrial tissue with cyclic growth in pelvic organs other than the normal location of the uterus is called pelvic endometriosis. The ectopic foci in the ovary form cysts due to repeated bleeding and contain dark brown mucousy old blood, resembling chocolate fluid, called chocolate cysts, see Figure 11-2-29. Chocolate cysts can be single or multiple and vary in size, due to the tension of bleeding inside the cysts, the fluid inside the cysts often leak out causing local inflammatory reaction and tissue fibrosis, resulting in fixation of the ovaries and cysts In the pelvic cavity, adhesions with surrounding tissues cannot be moved. On microscopic examination, endometrial epithelium, endometrial glands and endometrial mesenchyme can be seen on the cyst wall of endometriosis lesions, but recurrent bleeding lesions may not have this typical tissue structure, but if there are typical clinical symptoms, a small amount of endometrial mesenchymal cells can also be diagnosed on microscopic examination.
Clinical manifestations
The main clinical symptom is pain in the lower abdomen or lumbosacral region during menstruation, with varying degrees of severity, and the degree of pain is not obviously related to the size of the lesion; ovarian function is affected in 15% of patients, and the menstrual cycle is prolonged; when combined with adenomyosis or uterine fibroids, heavy menstrual flow occurs; due to the combination of pelvic adhesions, tubal obstruction, ovulation disorders, and luteal insufficiency, 40% of patients Infertility occurs in 40% of patients due to the combination of pelvic adhesions, tubal obstruction, ovulation disorders and luteinizing insufficiency. When the ectopic foci form larger cysts, cystic masses can be palpated in the pelvic cavity by double diagnosis and are more fixed.