Ovarian Cyst and MRI

[amazing1672]

I am 35 years old and have gone through infertility issues for which I have done 4 cycles on Chlomid, 3 cycles on gonadotropins and 3 cycles of IVF with no positive pregnancy ever. I stopped the infertility treatments in Aug 2005. Due to infertility and these treatments I have always had a fear of ovarian cancer.

I have been having non-specific gastric issues for the past 3-4 months and have undergone an upper endoscopy, a barium swallow and ultrasound of the abdomen where no issues were found except for a small hiatal hernia and a little inflammation of the gastric tract. This was all done as I was suffering from abdominal pain in the epigastric area. This pain has gone down considerably over the past couple of months as I have been taking aciphex.

Due to the OVCa symptoms that I have read about though, I also went to my OB/GYN and she suggested we do a trans vaginal U/S. During the U/S they found a well curcumscribed homogeneously hypoechoic lesion measuring 1.9x1.2x1.3 cm and they said it could be a solid lesion or a complex cystic lesion. They also found a degenerating fibroid which I knew I had from the time I was doing my infertility treatments.

They asked me to repeat this U/S in 2 months time. I got the U/S done last week and though  I haven't seen the report yet, the doc's office called and said they found this to be unchanged and have recommended a MRI. I have that scheduled for saturday.

I would like to find out your opinion of this. Are there chances that this is OVca? What will the MRI find that is different than the U/S? Should I ask for a CA 125 test also.

Thanks for your time on this.

[amazing1672]

Thank you so much for your response Dr. Goodman. I got the results of the MRI and it says that at present there is no evidence of malignancy and they have recommended a follow up in 3 months. The mass size is 2x1.5 cm according to the MRI. The issue I am having as you correctly pointed out is - how far to take this evaluation. Should I wait for a few months and see the progression or should I jump the gun and get it out? If I try getting it out now, I am sure laproscopy is the suggested means but because of the small size of the mass, does it mean I will have to get my right ovary out as well? Also, neither the ultrasound nor the MRI is saying what this mass could be - is it an endrometrioma or some other form of benign neoplasm? Is it possible to understand what this is before we go for a lap?
I live in the Boston area and may want to try and set a follow-up with you but will appreciate if you can help answer some of the above questions for me. Thanks.

[Annekathryn Goodman, M.D.]

Hi There,
Thank you for all the information. I would summarize your situation as follows:
You h ave unexplained pain. You have had an extensive evaluation. The only finding has been a small solid nodule on your ovary that has not changed in a few months of observation. You have a history of infertility and you have taken ovulation induction drugs.

You probably do not have cancer but you now have this dilemma. How far to take this evaluation. Your main risk factor for ovarian cancer is having infertility.  I suspect that it will be hard to not do a laparoscopy and remove that nodule.

Birth control pills suppress only cysts that are related to ovulation. The fact that this has not changed suggests it is not related to ovulation. A CA 125 may add information but I would not be surprised if it was elevated.  It can be elevated with fibroids and endometriosis which are two common benign gyn conditions. It is quite possible that you have endometriosis. It is common, it can be related to infertility, and it can cause solid or cystic growths that are unchanging on the ovaries
best wishes

[amazing1672]

I got a pelvic MRI done last night to get a better characterization of the cyst that I mentioned earlier. I also got the reports of my U/S from 9/21. The U/S shows that the ovarian size and the uterus size has remain unchanged and the ovaries are normal in volume. They have termed the cyst as a solid looking hypoechoic lesion 1.8x1.4x1.4 cm with increased vascularity. The fact that it has remain unchanged is concerning for a neoplasm - this is from the report. Hence, they suggested a MRI for better characterization.
Dr. Goodman, I have a few questions on this and will greatly appreciate your response. I am meeting with a GYN/Onco next week as my OB/GYN gave me a choice to meet with one but I would like to understand your opinion on this as well.

Do you think anyone can make a guess on how long this cyst has been there. It was an incidental finding from a U/S but no one knows how long it has been there. If it hasn't really bothered me for so long, shouldn't we try and use BCPs to first see if that can be helpful rather than just going for a removal. I have no lower abdominal pain, no bloating, no pain during intercourse and if it wasn't for the U /S I would never have known this existed. Do you think it is too aggressive to just go for a lap to remove it given its small size. Will you be concerned about the vascularity noticed during the U/S? Can we wait a little longer and then decide on a lap or would you recommend just taking it out? Should I get a CA125?
Thank you.

[amazing1672]

I just got a call from my OB/GYN who told me that the U/S showed a solid mass with increased vascularity. The size is pretty much unchanged and the size of the ovary looks normal. I don't know what this means but she says the MRI should give us more information and she is also going to refer me to a GYN/Oncologist and then proceed with a laproscopy if the GYN/Onco recommends that. She was of the opinion that we should take this out but her comment on the increased vascularity has freaked me out completely. Do I need a CA 125 test. What do you think about the course of action planned?