Chocolate cysts, a very nice name, are a nightmare for many women patients. Infertility, dysmenorrhea, heavy menstruation, sexual discomfort, chronic pelvic pain…a series of discomforts that plague beautiful women. But many women still do not pay enough attention to it. Let’s take a look at a case: the patient was 38 years old, with progressive aggravation of primary dysmenorrhea for more than 2 years, requiring fen-phen to relieve during menstruation, accompanied by lower abdominal pain after sexual intercourse. The patient was found to have a pelvic mass of about 7 cm during physical examination in May 2014, and was considered to have an endometriotic cyst, which we usually call a “chocolate cyst”, and was not treated. The postoperative pathology was clear cell adenocarcinoma of the right ovary combined with endometriotic cyst. I am an obstetrician and gynecologist, and I am sorry to see that the patient met with such a change in her youth. For this reason I would like to share this knowledge with you.
What is a chocolate cyst?
”Chocolate cysts” refers to endometriosis lesions occurring on the ovaries, local bleeding during menstruation, so that the ovaries increase in size, forming cysts containing old blood, this old blood is brown, sticky like burnt, like chocolate, so also known as “chocolate cysts “The medical term for this is endometriosis cyst. Endometriosis cyst is a common gynecological disease, the incidence of which accounts for about 15% of women of childbearing age. Although endometriosis is a benign lesion, it has the biological characteristics of a malignant tumor, such as extensive adhesions, distant metastases and easy recurrence. The malignant rate of endometriosis is 0.7% to 1% on average, and some scholars have reported that it is as high as 2.5% and becomes “endometrium-associated ovarian cancer” after malignant transformation. In recent years, with the increasing incidence of endometriosis, the number of cases of endometriosis malignant transformation is also increasing year by year, and the prevention and treatment of endometriosis malignant transformation are also receiving more and more attention.
The ovary is the most frequent organ of endoheterosis and its malignant transformation, and the malignant transformation into ovarian cancer accounts for 76%-85% of all cases, and the main pathological types are ovarian endometrioid adenocarcinoma (11%-33%) and ovarian clear cell carcinoma (33%-53%). Malignant lesions of extra-ovarian endometriosis can be found in the intestine, pelvis, vaginal rectal septum, vagina, and cesarean scar, with adenocarcinoma predominating. Currently, the internationally accepted criteria for the diagnosis of endometriosis malignancy are the three conditions proposed by Sampson:
(1) Cancerous tissue and ectopic endometrium coexist in the same lesion.
(2) Histological correlation between the two.
(3) The presence of other primary tumors was excluded. Scott added to this the diagnostic criterion of microscopic histological evidence of ectopic endometrium migrating to malignancy.
What are the discomforts for women with chocolate cysts?
The clinical presentation of endometriosis-associated ovarian cancer is nonspecific. Early diagnosis is difficult. 43% to 70% of patients have abdominal pain symptoms and 10% to 28% of patients are seen because of the discovery of pelvic masses. In late stage, when the mass is large, it can squeeze the surrounding organs and cause various symptoms, such as difficulty in urination or dyspareunia if it compresses the bladder; constipation or dyspareunia if it compresses the rectum; once it is combined with ascites or metastasis, gastrointestinal symptoms such as abdominal distension, dyspepsia, loss of appetite, belching, etc.; if the abdominal volume is large and squeezes the diaphragm upward or is accompanied by pleural fluid, chest tightness, difficulty in inspiration, panic, etc. can occur. Late stage patients commonly suffer from emaciation, anemia and cachexia, and may also develop swollen lymph nodes in the supraclavicular, axillary and even inguinal areas.
Which patients are prone to malignant transformation?
Patients with the following risk factors for endo-malignant transformation should be monitored and followed up closely to be alert to the occurrence of endo-malignant transformation:
(1) Women of menopausal age >50 years.
(2) The duration of endometriosis is more than 8 years.
(3) Women with high estrogen levels or on estrogen replacement therapy, especially those with obesity.
(4) Those treated with Danazol.
(5) Early menarche, short cycles, late menopause, and low maternal frequency.
(6) Those with a history of exposure to dioxin-contaminated environment should be alerted to the possibility of malignant transformation.
Malignant change has more or less precursors
When the following clinical manifestations occur in patients with endometriosis, the possibility of malignancy should be noted:
(1) Ovarian endometriosis cysts >10 cm in diameter or with a tendency to increase in size.
(2) Recurrence after menopause, change in pain rhythm, progressive dysmenorrhea or persistent abdominal pain.
(3) Imaging reveals solid or papillary structures within the ovarian cyst, or the lesion is rich in blood flow.
(4) High serum CA125 level (>200kU/L).
(5) The contents of the ovarian endometriotic cyst become thin (fewer fine light spots) on ultrasound.
Prevention is the big
At present, there is no clear preventive measure for endometriosis malignancy. The following management plan for patients with endometriosis may help to reduce the occurrence of malignancy:
(1) Surgery should be chosen when the ectopic cyst is ≥4 cm in diameter.
(2) Use puncture and aspiration methods with caution.
(3) The indications for radical surgery should be relaxed in high-risk groups according to age and fertility requirements.
(4) If atypical hyperplasia or endothelial metaplasia is found in conservative surgically resected specimens, they should be followed up closely for a long time.
(5) In post-menopausal patients, radical surgery is the appropriate choice.