HOW ARE OVARIAN CYSTS DIAGNOSED?

At the time of a pelvic exam the doctor may be able to feel a cyst as a soft movable lump next to the uterus. The best way to get an idea of the size and type of cyst that is present is with a vaginal sonogram.

On the sonogram, functional cysts usually appear entirely clear in the middle and the walls of the cyst appear smooth (fig 1). The cyst of endometriosis looks like a circle with speckles (blood) floating within (fig 2). A dermoid cyst may have very white areas, representing the sound waves bouncing off fat or calcium in teeth or bone (fig 3). A hemorrhagic cyst often has thick areas of blood clot within the cyst (fig 4) that can be seen to dissolve when the sonogram is repeated a few weeks later.

Abnormal cysts often will have an overgrowth of cells that stick out from the inside of the cyst wall, making the inside of the cyst appear jagged on the sonogram (fig 5). Still, many of these irregularly shaped cysts are benign, but cancer can also appear this way. Unfortunately, the sonogram cannot make a definite diagnosis of benign vs. malignant cysts. So, if the sonogram is suspicious for cancer, surgery will be needed.

Figure 1: Clear functional cyst

Figure 2: Speckled blood with endometrioma

Figure 3: Fat cells floating at the top of cyst

Figure 4: Blood clot within hemorrhagic cyst

Figure 5: Irregular shape of ovarian cancer

IF YOU HAVE A CYST, SHOULD YOU GET A CA-125 TEST?
The CA-125 blood test was developed in an attempt to detect ovarian cancer at a very early stage. Theoretically, cancer cells should produce unusual bio-chemicals that can be detected in the blood. Unfortunately, the CA-125 test is extremely inaccurate. Other conditions commonly found in younger women such as endometriosis, fibroids, pelvic infections, benign cysts and even pregnancy can lead to falsely abnormal results. Perfectly healthy women can also have an abnormal CA-125 value. Needless to say, getting an abnormal result would scare you (and your doctor) terribly. This fear often leads the patient into unnecessary surgery with all of its attendant risks, expense, and time needed for recovery. Therefore, I feel strongly that the CA-125 test should not be done in women younger than 50 years of age who have an ovarian cyst.

In post-menopausal women who are found to have an ovarian cyst, the CA-125 test is somewhat more accurate. For those women, a normal test is reassuring, while an abnormal test still does not mean that ovarian cancer is present. However, in this situation the cyst needs to be removed in order to be sure that cancer is not present.

A better test to detect ovarian cancer, called proteomics, is on the horizon. This blood test uses a computer to find abnormal proteins in the blood and matches these proteins with those recently discovered to be associated with ovarian cancer. Early studies have been very promising, with detection of even early cancer. Hopefully, the test will be available to the general public by 2005. I am including an abstract about this exciting research:

Use of proteomic patterns in serum to identify ovarian cancer.
Lancet. 2002 Feb 16;359(9306):572-7.
Authors: Petricoin EF, Ardekani AM, Hitt BA, Levine PJ, Fusaro VA, Steinberg SM, Mills GB, Simone C, Fishman DA, Kohn EC, Liotta LA.

BACKGROUND: New technologies for the detection of early-stage ovarian cancer are urgently needed. Pathological changes within an organ might be reflected in proteomic patterns in serum. We developed a bioinformatics tool and used it to identify proteomic patterns in serum that distinguish neoplastic from non-neoplastic disease within the ovary. METHODS: Proteomic spectra were generated by mass spectroscopy (surface-enhanced laser desorption and ionisation). A preliminary "training" set of spectra derived from analysis of serum from 50 unaffected women and 50 patients with ovarian cancer were analysed by an iterative searching algorithm that identified a proteomic pattern that completely discriminated cancer from non-cancer. The discovered pattern was then used to classify an independent set of 116 masked serum samples: 50 from women with ovarian cancer, and 66 from unaffected women or those with non-malignant disorders. FINDINGS: The algorithm identified a cluster pattern that, in the training set, completely segregated cancer from non-cancer. The discriminatory pattern correctly identified all 50 ovarian cancer cases in the masked set, including all 18 stage I cases. Of the 66 cases of non-malignant disease, 63 were recognised as not cancer. This result yielded a sensitivity of 100% (95% CI 93--100), specificity of 95% (87--99), and positive predictive value of 94% (84--99). INTERPRETATION: These findings justify a prospective population-based assessment of proteomic pattern technology as a screening tool for all stages of ovarian cancer in high-risk and general populations.