Dermoid ovarian cyst

Dermoid ovarian cyst refers to benign germinogenic tumors.

The very definition - germinohema explains the origin of the cyst, since germinis is an embryo, in the medical sense - an embryonic layer, a leaf. The dermoid cyst is often referred to as true tumors, since the neoplasm is formed by the mitosis of the cells, unlike the cysts that result from the accumulation or stagnation of the fluid.

According to statistics, the ovarian dermoid cyst is diagnosed in 20% of patients with various types of cysts. The dermoid develops from three embryonic layers - outer, middle and inner (ectoderm, mesoderm and endoderm). The cyst can be determined regardless of age, but most often it is formed in early childhood, very slowly develops and can manifest itself clinically with an increase in the period of hormonal changes - puberty, pregnancy, menopause. Dermoid neoplasms are most often localized in one ovary, are considered benign ovarian tumors (DOJ), but 1.5 to 2% can be malignant in squamous cell carcinoma.

According to the international classifier, the disease is defined as follows:

ICD-10-0. M9084 / 0 - Dermoid cyst.

Causes of dermoid ovarian cyst

The etiology and exact causes of dermoid ovarian cysts are studied to this day, there are several versions united by one generally accepted theoretical and practical basis - embryogenesis abnormality. The explanation of the formation of dermoid as a result of hormonal changes is considered incorrect, rather the hormonal system provokes the acceleration of cyst growth, but is not its original cause.

Indeed, a dermoid cyst may not appear clinically for decades, and is not visible on ultrasound, if it has very small dimensions. During pregnancy, menopause or puberty, the dermoid is more often detected, as it begins to grow. Nevertheless, the cyst has no connection with the menstrual cycle, it has absolutely no effect on it, so the hormonal causes of the ovarian dermoid cyst should not be considered true.

The main version, which can explain the formation of dermoids, is a violation of tissue differentiation during embryogenesis. As a consequence, a small dense tumor with a leg is formed. The cyst is located in the ovary on one side, closer to the uterus (front), has a heterogeneous, complex consistence consisting of such elements: 

• Ectoderm - skin scales, neuroglia (neural tissue) - ganglia, glia, neurocytes.
• Mesoderm - elements of bone, muscle, cartilaginous, fatty, fibrous tissue.
• Endoderma - elements of the tissue of salivary glands, thyroid gland, bronchial and gastrointestinal epithelium.

The walls of the capsule of the cyst are thin, but since they are formed from connective tissue, they are firm, elastic. The dermoid always has a long leg, is mobile and not soldered with the surrounding skin.

Summarizing the causes of the dermoid ovarian cyst, you can describe them as follows:

The etiology of dermoids is of an embryonic nature, when elements of the embryonic leaflets (more often mesenchymal leaves) remain in the ovarian tissue of the ovary. Under the influence of a hormonal, less often traumatic factor, the dermoid cyst may increase and manifest clinically.

[1], [2], [3], [4]

Dermoid ovarian cyst and pregnancy

Dermoid ovarian cyst and pregnancy can not interfere with each other if the neoplasm does not increase, does not get inflamed, and there is no complication in the form of torsion of the cyst leg. The cyst itself has absolutely no effect on the bearing of the fetus and can not have a pathological effect on the mother's body or on the development of the embryo. However, the growing uterus provokes a natural dystopia - the displacement of the internal nearby organs, respectively, the dermoid cyst may be infringed, its leg may be squeezed and twisted. A consequence of this condition is necrosis of the cyst or its rupture. It is for this reason that the best way to avoid surgery during pregnancy is preventive diagnosis six months before conception. During a comprehensive examination of the cyst, if it exists, it is detected, removed, and such treatment does not interfere with the further fertilization of the woman. In the case when the dermoid cyst and pregnancy are already "neighboring", a small size of the tumor is observed, if it starts to increase, it is operated with a laparoscopic method not earlier than the 16th week, so as not to disturb the gestation process and preserve the fetus.

Symptoms of dermoid formation in a pregnant woman are not specific, the cyst often develops asymptomatically and does not show painful sensations. Clinic "acute abdomen" can only be if the dermoid began to grow actively, increase, and his leg twisted.

Diagnose the cyst most often on examination during registration for pregnancy. Palpation reveals a painless, mobile, dense tumor, the size and condition of which are refined with the help of ultrasound.

Once again, it should be emphasized that a dermoid cyst of a small size (up to 3 cm) does not affect pregnancy, nor does pregnancy can have a provocative effect on the cyst. Nevertheless, the dermoid must be removed, since there is a risk of malignancy, it is not high - only 1.5-2%, but it is better to neutralize it. The dermoid cyst is most often operated on during labor, performed with caesarean section, or after them. Prognosis of treatment of dermoids, uncomplicated, inflammatory process, suppuration or torsion, favorable.

[5], [6]

Symptoms of dermoid ovarian cyst

The dermoid cyst develops slowly, but constantly, its symptomatology differs little from the clinic of other benign formations, and can be this: 

• The first sensation of aching, transient pain may appear if the cyst has increased to 5 centimeters.

Large cysts - from 10 to 15 centimeters are manifested thus:

• Drawing pains in the lower abdomen.
• Sensation of pressure, raspiraniya in the abdomen.
• A large cyst in astenic women can provoke a visual increase in the abdomen.
• As a result of pressure on the bladder, urination becomes more frequent.
• Pressure on the intestines causes violations of defecation - diarrhea or constipation.
• An inflamed cyst is accompanied by an increase in body temperature, a strong pain in the lower abdomen.
• Torsion of the legs of the cyst provokes the classic clinic of the "acute abdomen", pelvioperitonitis - unbearable, radiating down to the leg, pain, febrile condition, nausea, tachycardia, falling blood pressure, cyanosis.

Thus, the symptoms of the dermoid ovarian cyst depend on the size of the tumor and its location, but most often the dermoid does not cause complaints and does not affect the woman's health, especially when the size is less than 5 centimeters.

Dermoid cyst of the left ovary

Ovaries are a paired organ of the small pelvis and, like all other paired structures, they are asymmetric and can not be of the same size in principle, this is due to the anatomy of the person. It should be acknowledged that the true cause of asymmetry and the difference in the size of the ovaries have so far been little studied, but most likely it is related to the genetic factor and various provision of blood vessels (vascularization).

Statistics say that the dermoid cyst of the left ovary is much less common than in the right ovary, obviously, this is due to the asymmetric arrangement of the organ, which is formed even at the stage of antenatal ontogeny. Uneven position of the ovaries is present at all stages of their fetal development, with the right ovary predominating over the left one, both in the functional sense and in the anatomical (in size).

In addition, the vascularization (blood supply) of the left and right ovary is different: the artery of the left ovary is diverted to the left vein of the kidney, and the ovarian branch of the right ovary is in the lower vena cava. Thus, the left ovary develops somewhat more slowly, and the separation of embryonic leaves into it is possible to a lesser extent than in the right ovary. It must also be taken into account that during puberty, puberty and later, with regular menstrual cycles, the left ovary ovulates less and less intensively, respectively, the hormonal factor that could provoke tumor growth affects it little. A left-sided benign tumor can form in utero and not manifest during the course of life by any sign.

The dermoid cyst of the left ovary is diagnosed at any age - from young to climacteric, most often it has small dimensions - up to 3-4 centimeters and rarely grows up to 5 centimeters. It is treated such a dermoid as well as the cyst of the right ovary, - only in an operative way. The operation is mandatory, since there is a risk of overgrowth of the left-sided cyst with squamous cell carcinoma.

[7], [8]

Dermoid cyst of the right ovary

The dermoid cyst of the right ovary is diagnosed twice as often as the dermoid of the left ovary. The causes of this phenomenon have been little studied, etiologically right-sided cysts can be explained by the features of embryogenesis.

In practical gynecology, especially in surgery, there are facts that have not yet been confirmed by scientific developments and well-founded theories, facts that say that the right ovary of a woman is more susceptible to various tumor formations and other pathologies. Anatomically, the right and left ovaries differ little from each other, but they are laterally asymmetric and often have different parameters - dimensions. In addition, the right ovary is more intensively supplied with blood, because it has a straight path: the aortic artery. Also, the possible reason that the dermoid cyst of the right ovary is more common is its more active ovulatory activity. According to statistics, the distribution of ovulation between the ovaries is as follows: 

• Right ovary - 68%.
• The left ovary is 20%.
• The remaining percentages cover ovulation evenly distributed between the ovaries.

It is believed that the dermoid cyst can develop very long and grows slowly, literally in millimeters per year. It can not disturb a woman for decades until a certain trigger stage, usually hormonal changes, less often a traumatic event. Obviously, the right ovary, each time performing the function of ovulation, undergoes microtraumas of a functional nature, therefore, is more vulnerable and susceptible to hormonal influence. Perhaps, one of the reasons for this is that the dermoid cyst of the right ovary leads in the diagnostic list of all germicogenic cysts.

Treatment of the right cyst dermoid involves surgery at large neoplasms, when the leg is twisted, an emergency operation is indicated. If the dermoid is detected on a routine examination or when registered for pregnancy, it is small (up to 3 centimeters) and does not bother a woman for six months, it is subject to observation. At the first favorable case (after childbirth), the dermoid cyst should be removed in order to avoid complications - increased education, torsion of the leg or malignancy (overgrowth in the malignant process).

[9], [10]

Diagnosis of dermoid ovarian cyst

Diagnosis of ovarian cysts, especially dermoid, most often occurs with routine gynecological examinations, when registered for pregnancy or for painful symptoms presented by a woman. However, dermoids are asymptomatic, so their detection in 80% is secondary.

Diagnosis of the ovarian dermoid cyst in the first stage consists in examination and two-handed examination. As a rule, the method of examination is vaginal-abdominal, less often recto-abdominal manual examination. Mature dermoid tumor (teratoma) on palpation is felt as an oval, mobile, rather elastic formation that is localized to the side of the uterus or in front of it. Palpation of the dermoid does not cause painful sensations to a woman, except discomfort associated with examination, there are no other unpleasant phenomena. Confirmation of a detected tumor requires more accurate methods, such as ultrasound or puncture. Ultrasound examination is highly informative, the procedure involves the use of a transabdominal or transvaginal sensor. The ultrasound shows the parameters of the dermoid, the thickness of its capsule, the consistence of the cavity (composition), the presence of calcifications, in addition, using ultrasound, it is possible to determine how vigorously the blood supply of the cyst is. If the results of ultrasound do not satisfy the gynecologist, a woman can be assigned a CT scan or an MRI.

With a complicated process - inflammation, suppuration, large tumors, combined cysts, diagnosis of the ovarian dermoid cyst suggests a puncture from the vaginal vault, including a laparoscopic method. In case of suspicion on oncoprocesses, however, in the standard examination also, a blood test for SA - oncomarkers is assigned. Thus, the malignancy of the cyst is confirmed or eliminated, in addition, the differentiation of the dermoid from other neoplasms of a germogenic character is realized.

Diagnosis of the dermoid cyst (mature teratoma) of the ovary: 

• Collection of anamnesis, including hereditary.
• Gynecological complex of studies - examination, palpation.
• Rectovaginal examination is possible, excluding or confirming pressure on nearby organs or tumor growth.
• Ultrasound examination, as a rule, in a transvaginal way.
• If necessary, puncture and cytology of the material obtained.
• If necessary, dopplerography, for differentiation of benign or malignant tumor development.
• Identification of possible tumor markers - CA-125, CA-72.4, CA-19.9.
• Computer or magnetic resonance imaging.
• It is possible to administer an x-ray study of the stomach.
• Cystoscopy, urography is possible.

It should be noted that an important object of research is the dermoid tubercle, which is the first indicator of possible malignancy of the process. It is examined histologically with puncture, laparoscopy.

[11], [12]

Dermoid ovarian cyst on ultrasound

Ultrasound echography is still one of the most informative and safe methods of examination in obstetric and gynecological practice. The procedure is based on the principle of echolocation, when the sensor emits an ultrasonic wave, which in turn is reflected from the dense structure of the organ, and returns again to the sensor. As a result, the exact image of the desired cut, section, appears on the screen. Since ultrasound works mainly in the mode of receiving a wave, not radiation, the method is absolutely safe for the body, including for pregnant women who have indications for examination.

Dermoid ovarian cyst on ultrasound is determined quite accurately, most often the method involves research using a transvaginal sensor. Earlier, the method of examination through the front wall of the peritoneum was used everywhere, and for this it is necessary that the bladder be filled to the maximum. This caused a lot of inconvenience and created obstacles that are absent in the transvaginal mode.

Dermoid ovarian cyst on ultrasound is differentiated from other types of cysts, teratom and is defined as a visible neoplasm with thickened walls from 7 to 14-15 millimeters with echopositive inclusions from 1 to 5 mm. Ultrasound should be performed repeatedly to track the dynamics of changes in the cyst. Mature dermoid teratomas have clear contours during scanning, but each study can provide new information about the contents of the cyst when various hyperechoic elements are visualized. Occasionally, ultrasound determines a tumor with a very dense, almost uniform content, which has rare linear inclusions. It should be recognized that it is the internal structure of the cyst that creates certain difficulties in diagnosis, because it can include only mesenchymal tissues, but it can also consist of endo and ectoderm.

Ultrasound scanning dermoids often needs to be refined with MRI or CT due to the polymorphism of the contents of the cyst.

Echographic signs of ovarian dermoid: 

• By localization of the dermoid cyst on ultrasound is defined as one-sided, bilateral cysts are very rare, only 5-6% of the women surveyed. 
• The magnitude of the dermoid can vary within the limits of 0.2-0.4 - 12-15 centimeters.

It should be noted that small dermoids are poorly screened and in 5-7% of women with cysts up to 2 cm, additional methods of investigation are required.

Ultrasound examination of dermoid formation is carried out in such ways: 

• Using an abdominal sensor with a filled bladder.
• Transvaginal sensor - a more informative way.

With the help of the rectal sensor, if the results of previous transabdominal or transvaginal ultrasonography are unclear, if a virgin is examined, as well as with vaginal entry or infection or stenosis in the elderly (often after gynecological operations).

It should also be noted that a dermoid containing mesodermal elements (bones, teeth elements) is the only germicogenic cyst, which can also be determined by radiography of the abdominal cavity.

[13]

Treatment of dermoid ovarian cyst

The only reliable way to neutralize, remove the mature teratoma (dermoid) is the operation. Treatment of dermoid ovarian cyst by medicinal methods, reflexotherapy, physiotherapy procedures can not be effective because of the structure of the contents of the cyst. Unlike other types of neoplasms, cysts filled with fluid, exudate, dermoids are not able to resolve, because inside they contain bone, fibrous, fat and hair elements.

The technique of surgical intervention is directly related to such factors: 

• Age of the patient.
• The size of the cyst.
• Localization of the neoplasm.
• Degree of neglect of the process.
• The condition of the cyst is inflammation, suppuration.
• Torsion of the legs of the cyst (emergency operation).
• The nature of the dermoid cyst is a benign or malignant neoplasm.

The standard parameters for choosing the method of operation are the following: 

• Young women of reproductive age are shown a cystectomy (removal of the tumor within healthy tissues) or resection of the ovary at the site of cyst formation.
• Women in the climacteric period is prescribed ovariectomy - the removal of either one affected ovarian cyst, less often both. It is also possible to remove the ovary and the fallopian tube - an adnexectomy. 
• When the legs of the dermoid are twisted, the operation is carried out in an emergency.

Most often, surgical intervention is performed by laparoscopic method, which will be used - laparoscopy or laparotomy, the doctor decides on the state of woman's health. In the post-operation period, treatment of the dermoid ovarian cyst may include therapy with hormone-supporting drugs, and it should also be noted that normal conception is possible only six months after surgery.

Treatment of dermoid in pregnant women is somewhat different: 

• Education of a small size, not prone to rapid increase or suppuration, is subject to observation throughout the pregnancy.
• The rapidly increasing cyst is subject to immediate removal, but not earlier than the 16th week of pregnancy.
• All dermoids, even small ones, should be removed after birth in order to exclude the risk of their malignancy.
• A festering cyst, accompanied by a crushed leg, is removed in any period of pregnancy, as it is about preserving the life of the mother.

Removal of dermoid ovarian cyst

Surgical removal of the ovarian dermoid cyst is considered to be the gold standard for the treatment of DOJ (benign ovarian formations) of a germogenic nature, especially this method is relevant for mature teratomas (dermoids).

When removing cysts, surgeons try to minimize traumatic organ damage and maintain fertility (fertility). Modern surgery has a mass of instrumental, hardware technologies for conducting such operations, thus reducing the inpatient period of treatment, and scarring and scarring through time practically disappear.

Removal of dermoid can be variable, so cysts from 0.5 to 5 centimeters in size, uncomplicated formations, are operated with laparoscopy. As a rule, three small incisions are made, a video camera and surgical instruments are passed through them. The operation lasts no more than an hour, after just 3-5 days a woman can leave the hospital and continue treatment on an outpatient basis.

There are several types of operations, the choice of which depends on the size of the cyst, the age of the woman, the concomitant diseases.

Removal of the dermoid ovarian cyst can be done in such ways: 

1. Kystectomy. This is the removal of the cyst - its capsules and contents within the boundaries of healthy tissues. The ovary remains intact, it does not operate. Typically, a cystectomy is performed with small dermoids, when the formation does not grow into the ovarian tissue of the ovary. A small surgical incision is delayed 203 months later, in half a year the scar is practically invisible, and the ovaries do not change their functionality.
2. Resection (wedge-shaped) part of the ovary, when the dermoid is removed together with the damaged tissue zone. Such an operation is indicated for a dermoid of more than 5-7 centimeters, and an absolute indication is the torsion of the leg. Over time, the function of the operated ovary is restored, during the rehabilitation period the follicular reserve comes from a healthy ovary (compensation).
3. Removal of the ovarian dermoid cyst in conjunction with the ovary is an ovariectomy. This method can be chosen at rupture, necrosis of the cyst, with a twist of the leg, suppuration.

Women of reproductive age, who wish to become pregnant in the future, are more likely to undergo laparoscopy or a wedge resection. To give birth to patients with a high risk of malignant cysts, women of menopausal age show complete removal of the affected ovary.

Emergency operations are carried out at the clinic "acute abdomen", which is typical for torsion, suppuration of the cyst.

Effects of removal of the ovarian dermoid cyst

Like any other operation, the removal of the dermoid ovarian cyst may have a variety of consequences. It is unambiguous to say that laparoscopy or ovariectomy is absolutely safe and not provoking consequences, it is impossible.

The most important task in the treatment of a woman with a cyst is to minimize the risk of developing cancer, as well as maintaining fertility and the normal functioning of the hormonal system.

Young patients of childbearing age are more likely to fear the consequences of surgery, as they tend to endure and give birth to a baby. In fact, the removal of a dermoid, not complicated by suppuration and other variants of inflammation, is not a contraindication to pregnancy. After six months, or better - a year, it is possible to conceive a healthy fetus and quite a happy childbirth, even though one of the ovaries has been removed. Of course, pregnancy is impossible with the removal of two ovaries, as well as after chemotherapy after the treatment of squamous cell carcinoma, which can develop from the dermoid in 1.5-2% of cases.

Typical, although rare, effects of removal of the ovarian dermoid cyst: 

• Recurrent development of cysts with incomplete, partial removal of the capsule of the cyst.
• Infertility, including persistent. If resection or ovariectomy was carried out on one ovary, it was restored, but the woman can not conceive, the reason should be looked for in other similar diseases of the pelvic organs, hormonal system, thyroid gland and so on.
• Endometriosis.
• The failure of the hormonal system, which ideally should be restored within a year - either independently, or with the help of hormone replacement therapy.

It should be noted that the maintenance of fertility depends on the volume of remaining healthy ovarian tissue of the ovary. If more than half of the tissue is preserved, conception is possible after 6 months, before this time the ovary restores lost functions. If the resection was carried out on two ovaries, in which 50% of healthy tissue is also left, pregnancy can be performed a year later, provided all medical recommendations are observed. Only 10-13% of patients lose fertility as a result of surgical treatment of the dermoid cyst.

Removal of the dermoid ovarian cyst, the consequences of which, as a rule, do not cause fear, is a mandatory measure that reduces the risk of dermoid development into cancer.

[14], [15], [16]

Laparoscopy of the dermoid ovarian cyst

The gold standard for surgical treatment of mature teratomas, as well as other DOJ (benign ovarian formations) is laparoscopy of the ovarian dermoid cyst.

Previously, such cysts were treated with adnexectomy, hysterectomy (removal with appendages). Currently, surgeons tend to minimize complications and use to low-traumatic, organ-saving methods, including a safe and effective way - laparoscopy. This reduces the possibility of the adhesion process in 2 times, the healing process of the surgical incisions lasts no more than 2 months (usually 4 weeks), in addition, the laparoscopic method allows preserving the genital function of a woman and has one of the main advantages for the patients - it does not provoke cosmetic defects skin of the peritoneum.

Also, the ability to monitor the removal process with a surgical video camera ensures the identification of pathological tissue, thus, healthy ovarian structures of the ovary remain intact.

In older women, in menopausal and later periods, laparoscopy of the ovarian dermoid cyst reduces the risk of thromboembolism, previously quite common in cavitary operations.

According to statistics, 92-95% of all operations for dermoid cysts are carried out with the help of laparoscopy, this speaks not so much of the relevance, popularity of the method, but of its effectiveness and safety.

Laparoscopy is performed with the help of a special apparatus - a laparoscope, in the peritoneum the minimal punctures are made for carrying out through them all the necessary manipulations. The operation is controlled by a miniature video camera, which allows the doctor to see the state of the internal cavity, organs, and control the instrument. The tumor is removed, the capsule is removed, coagulation of the incisions of the ovary tissue is simultaneously carried out, so bleeding is practically absent. Seams on the ovary can be imposed only in the case of cysts of huge sizes - from 10 to 15 centimeters. In addition to the fact that during the operation the dermoid is removed, at the same time, the second ovary is also inspected. After removal of the cyst or excision of part of the ovary, the surgeon flushes the abdominal cavity to neutralize the risk of peritonitis or inflammation. In addition, sanation is needed to completely extract the contents of the cyst - the hair follicle, the fatty dendrite, which can enter the peritoneum during the cyst extraction. Sanitation is carried out with the help of an aspirator (irrigator), the remnants of the contents of the dermoid are removed in the same way as its basic structure. In the future, only control of the haemostatic indices of small surgical punctures (wounds) is needed. The extracted material is necessarily examined histologically.

Recovery after laparoscopy of the ovarian dermoid cyst is not time-consuming. Just a day after the operation a woman can move, get up, the main rehabilitation lasts no more than 2 weeks, and after 1.5-2 months you can start even sports training, but in a gentle option.