- Email: [email protected]
Conservative management of post-operative peritoneal cysts associated with endometriosis
International Journal of Gynecology & Obstetrics 60 Ž1998. 151]154
Article
Conservative management of post-operative peritoneal cysts associated with endometriosis K. Takeuchi a,U , S. Kitazawab , S. Kitagaki c , T. Maruo a a
Department of Obstetrics and Gynecology, School of Medicine, Kobe Uni®ersity, Kobe, Japan b Second Department of Pathology, School of Medicine, Kobe Uni®ersity, Kobe, Japan c Department of Obstetrics and Gynecology, Chibune General Hospital, Osaka, Japan
Received 31 July 1997; received in revised form 21 October 1997; accepted 3 November 1997
Abstract Objecti®e: To describe the usefulness of fine-needle aspiration cytology and drainage, followed by long-acting GnRH-agonist therapy in the management of post-operative peritoneal cysts with endometriosis. Methods: In six women who were diagnosed as having post-operative peritoneal cysts with endometriosis, fine-needle aspiration cytology and drainage was performed. Thereafter, four patients were treated with long-acting GnRH-agonists for 6 months. Two patients refused the treatment. Results: In all patients fine-needle aspiration yielded specimens which consisted of a population of mesothelial cells. The mean follow-up time was 4 years Žrange 3.5]5.. The four patients treated with long-acting GnRH-agonists show no evidence of recurrence. In two patients who had no additional treatment, the recurrence of the cyst was noted 2 months and 5 months after the drainage. Conclusion: Combination of fine-needle aspiration cytology and drainage and subsequent long-acting GnRH-agonist therapy can be a useful conservative management of post-operative peritoneal cysts associated with endometriosis. Q 1998 International Federation of Gynecology and Obstetrics Keywords: agonist
U
Post-operative peritoneal cysts; Endometriosis; Fine-needle aspiration cytology; Long-acting GnRH-
Corresponding author. Tel.: q81 078 3417451 ext. 5642; fax: q81 078 3717483; e-mail: [email protected]
0020-7292r98r$19.00 Q 1998 International Federation of Gynecology and Obstetrics PII S0020-7292Ž97.00253-1
152
K. Takeuchi et al. r International Journal of Gynecology & Obstetrics 60 (1998) 151]154
1. Introduction Post-operative peritoneal cysts w1x known as multicystic mesotheliomas w2x or multilocular peritoneal inclusion cysts w3x are infrequent postoperative complications and are characterized by frequent intra-abdominal recurrences that may involve extensively in the pelvis, upper abdomen and retroperitoneum w3x and that can lead to polysurgery. Endometriosis has been reported as a risk factor or an associate operative finding of postoperative peritoneal cysts w3,4x. Groisman et al. w5x suggested that endometriosis may increase the possibility of post-operative peritoneal cyst formation because it causes progressive and severe adhesions around the lesion. The purpose of this article is to discuss the usefulness of fine-needle aspiration ŽFNA. cytology and drainage and GnRH-agonist therapy in the conservative management of post-operative peritoneal cysts associated with endometriosis. 2. Materials and methods The inclusion criteria for FNA cytology and drainage included post-operative peritoneal cysts with a history of endometriosis confirmed by previous operative findings and with normal serum levels of CA 125 Ž- 35 Urml., CEA Ž- 2.5 ngrml. and CA 19-9 Ž- 37 Urml.. The cysts had benign sonographic characteristics, i.e. they were thin-walled, contained no papillations or solid areas and were irregular in shape on magnetic resonance ŽMR. imaging. The mean size of the cysts was 7.5 cm Žrange 5]12.. All patients gave written, informed consent. A transabdominal or transvaginal ultrasound examination was performed on nine patients and MR imaging was performed on all patients. Serum levels of CA 125, CEA and CA 19-9 were measured in all patients. Under transvaginal ultrasonographic guidance, the cyst was aspirated and drained transvaginally using a 21-gauge needle. Direct smears of the aspirate were made and fixed in 95% ethanol and stained by the modified Papanicolaou method.
Thereafter, four cases were managed by longacting GnRH-agonist Ž3.75 mg depot leuprolide acetate . therapy for 6 months. The remaining two patients refused the long-acting GnRH-agonist therapy. All patients underwent clinical and ultrasonographic examination every month. 3. Results From January 1990 to January 1994, six patients met the criteria and consented to undergo FNA cytology. The clinical presentation and treatment of six cases of the post-operative peritoneal cysts are summarized in Table 1. All patients had histories of gynecologic or non-gynecologic operations. Three patients had had multiple operations. Endometriosis had been diagnosed macroscopically andror histologically in all patients. In case 1 danazol had been administered for 6 months after the second operation. In any of the cases no history of post-operative fever was found. None had a history of pelvic inflammatory disease. All patients had regular menstruation and were not using oral contraceptives. The ultrasound showed a large cyst adjacent to the ovary or a large irregular cyst with multiple septations. MR imaging demonstrated that the cysts, which had an irregular shape, had low signal intensity on T1weighted images and high signal intensity on T2weighted images. The FNA cytology and drainage were completed successfully in all cases. All the aspirated cyst fluid specimens were clear, straw-colored. In all patients FNA yielded specimens which consisted of monophorous population of mesothelial cells, lacking cytologic atypia, which were arranged as single cells or in clusters. The background was clear with neither necrotic debris nor abundant inflammatory cells. The mesothelial cells were not arranged in prominent papillary formations; no mitotic figures were found. The mean follow-up time was 4 years Žrange 3.5]6.. In case 3 and 4, who did not have longacting GnRH-agonist therapy because of their rejection, the recurrence of the cyst was noted 2 months and 5 months after the FNA cytology and drainage, respectively. The remaining four
K. Takeuchi et al. r International Journal of Gynecology & Obstetrics 60 (1998) 151]154
patients who had long-acting GnRH-agonist therapy are alive and well without evidence of recurrence. 4. Discussion Post-operative peritoneal cysts occur predominantly in reproductive-aged women w2,3x. Up to 84% of patients have a history of prior abdominal surgery, endometriosis of pelvic inflammatory disease w3,5x. Physiologic peritoneal fluid is believed to be produced by the ovaries rather than by the peritoneal surface. Peritoneal fluid is high in estrogen and the other ovarian hormones and fluctuates with the menstrual cycles, with the largest amount during the luteal phase. If the peritoneum is infected or injured, its absorptive properties diminish and secretion of fluid by the ovary may become trapped in surrounding scarred peritoneum and cause a post-operative peritoneal cyst w6x. Although there have been no well-documented reports of fatal post-operative peritoneal cysts, post-operative recurrences have been reported in up to 50% of patients w3x.
153
With one exception, the cases which we experienced presented with pelvic pain, lumbago or urinary symptoms. All were at risk for pelvic adhesions and all had regular menstruation. To make the differential diagnosis including paraovarian cyst, functional cyst or peritoneal lymphangioma, FNA cytology was performed. When the aspirate contains mesothelial cells singly or in small clusters, lacking cytologic atypia, the diagnosis of post-operative peritoneal cyst was made. Post-operative peritoneal cysts have been mainly treated by surgical resection. Microsurgery to remove adhesions and the cyst lining may prevent recurrence, minimizing the formation of other adhesions w7x. The use of oral contraceptives may prevent reaccumulation by decreasing ovarian secretion w7x, while the effectiveness of GnRH-agonists in the volume reduction of the cyst is reported w8x. These conservative treatments, however, may have only temporary effects. In this study, GnRH-agonist therapy remained to be effective after 6 months of therapy in the patients with post-operative peritoneal cysts with
Table 1 Clinical characteristics and treatment Case No.
Age Žyear.
Gravity and parity
Presentation
Previous Operations
Treatment after drainage
Outcome
1
41
G2P2
Chronic pelvic pain
1. TAH 2. LSO
GnRHa
AFD, 6 years
2
37
G1P0
Urinary symptoms
Myomectomy
GnRHa
AFD, 4 years
3
33
G2P2
Routine examination
Myomectomy
not done
AWD, 4 years
4
40
G1P1
Lumbago
TAH
not done
AWD, 4 years
5
27
G2P2
Chronic pelvic pain
1. splenectomy 2. operation for ileus 3. myomcetomy
GnHRa
AFD, 4 years
6
29
G1P1
Chronic pelvic pain
1. LSO 2. Appendectomy
GnHRa
AFD, 3.5 years
AFD: alive, free of disease; AWD: alive, with disease; CS: cesarean section; GnRHa: gonadotropin releasing hormone agonist; LSO: left sal; RSO: right salpingo-oophorectomy; TAH: total abdominal hysterectomy.
154
K. Takeuchi et al. r International Journal of Gynecology & Obstetrics 60 (1998) 151]154
a history of endometriosis. These results support the hypothesis that endometriosis plays a role in the pathogenesis of post-operative peritoneal cysts and that this is a reactive rather than a neoplastic lesion. Although the role of FNA cytology in the diagnosis of ovarian cysts still leaves room for discussion, we believe that it may offer an important diagnostic option for post-operative peritoneal cysts and that GnRH-agonists may have a role in the conservative management of these cysts associated with endometriosis. A larger number of patients and a longer period of follow-up are necessary for the confirmation of our results. References w1x Gussman D, Thickman D, Wheeler JE. Postoperative peritoneal cyst. Obstet Gynecol 1986;68:53s]55s.
w2x Weiss SW, Tavassoli F. Multicystic mesothelioma. Am J Surg Pathol 1988;12:737]746. w3x Ross MJ, Welch WR, Scully RE. Multicystic peritoneal inclusion cysts Žso-called cystic mesothelioma.. Cancer 1989;64:1336]1346. w4x McFadden DE, Clement PB. Peritoneal inclusion cysts with mural mesothelial proliferation: A clinicopathologic analysis of six cases. Am J Surg Pathol 1989;10:844]854. w5x Groisman GM, Kerner H. Multicystic mesothelioma with en dom etriosis. A cta O b stet G yn ecol Scan d 1992;71:642]644. w6x Koninckx PR, Renaer M, Brosens IA. Origin of peritoneal fluid in women: an ovarian exudation product. Br J Obstet Gynaecol. w7x Hoffer FA, Kozakewich H, Colodny A, Goldstein D. Peritoneal inclusion cysts: ovarian fluid in peritoneal adhesions. Radiology 1988;169:189]191. w8x Letterie GS, Yon JL. Use of a long-acting GnRH agonist for benign cystic mesothelioma. Obstet Gynecol 1995;85:901]903.
Article
Conservative management of post-operative peritoneal cysts associated with endometriosis K. Takeuchi a,U , S. Kitazawab , S. Kitagaki c , T. Maruo a a
Department of Obstetrics and Gynecology, School of Medicine, Kobe Uni®ersity, Kobe, Japan b Second Department of Pathology, School of Medicine, Kobe Uni®ersity, Kobe, Japan c Department of Obstetrics and Gynecology, Chibune General Hospital, Osaka, Japan
Received 31 July 1997; received in revised form 21 October 1997; accepted 3 November 1997
Abstract Objecti®e: To describe the usefulness of fine-needle aspiration cytology and drainage, followed by long-acting GnRH-agonist therapy in the management of post-operative peritoneal cysts with endometriosis. Methods: In six women who were diagnosed as having post-operative peritoneal cysts with endometriosis, fine-needle aspiration cytology and drainage was performed. Thereafter, four patients were treated with long-acting GnRH-agonists for 6 months. Two patients refused the treatment. Results: In all patients fine-needle aspiration yielded specimens which consisted of a population of mesothelial cells. The mean follow-up time was 4 years Žrange 3.5]5.. The four patients treated with long-acting GnRH-agonists show no evidence of recurrence. In two patients who had no additional treatment, the recurrence of the cyst was noted 2 months and 5 months after the drainage. Conclusion: Combination of fine-needle aspiration cytology and drainage and subsequent long-acting GnRH-agonist therapy can be a useful conservative management of post-operative peritoneal cysts associated with endometriosis. Q 1998 International Federation of Gynecology and Obstetrics Keywords: agonist
U
Post-operative peritoneal cysts; Endometriosis; Fine-needle aspiration cytology; Long-acting GnRH-
Corresponding author. Tel.: q81 078 3417451 ext. 5642; fax: q81 078 3717483; e-mail: [email protected]
0020-7292r98r$19.00 Q 1998 International Federation of Gynecology and Obstetrics PII S0020-7292Ž97.00253-1
152
K. Takeuchi et al. r International Journal of Gynecology & Obstetrics 60 (1998) 151]154
1. Introduction Post-operative peritoneal cysts w1x known as multicystic mesotheliomas w2x or multilocular peritoneal inclusion cysts w3x are infrequent postoperative complications and are characterized by frequent intra-abdominal recurrences that may involve extensively in the pelvis, upper abdomen and retroperitoneum w3x and that can lead to polysurgery. Endometriosis has been reported as a risk factor or an associate operative finding of postoperative peritoneal cysts w3,4x. Groisman et al. w5x suggested that endometriosis may increase the possibility of post-operative peritoneal cyst formation because it causes progressive and severe adhesions around the lesion. The purpose of this article is to discuss the usefulness of fine-needle aspiration ŽFNA. cytology and drainage and GnRH-agonist therapy in the conservative management of post-operative peritoneal cysts associated with endometriosis. 2. Materials and methods The inclusion criteria for FNA cytology and drainage included post-operative peritoneal cysts with a history of endometriosis confirmed by previous operative findings and with normal serum levels of CA 125 Ž- 35 Urml., CEA Ž- 2.5 ngrml. and CA 19-9 Ž- 37 Urml.. The cysts had benign sonographic characteristics, i.e. they were thin-walled, contained no papillations or solid areas and were irregular in shape on magnetic resonance ŽMR. imaging. The mean size of the cysts was 7.5 cm Žrange 5]12.. All patients gave written, informed consent. A transabdominal or transvaginal ultrasound examination was performed on nine patients and MR imaging was performed on all patients. Serum levels of CA 125, CEA and CA 19-9 were measured in all patients. Under transvaginal ultrasonographic guidance, the cyst was aspirated and drained transvaginally using a 21-gauge needle. Direct smears of the aspirate were made and fixed in 95% ethanol and stained by the modified Papanicolaou method.
Thereafter, four cases were managed by longacting GnRH-agonist Ž3.75 mg depot leuprolide acetate . therapy for 6 months. The remaining two patients refused the long-acting GnRH-agonist therapy. All patients underwent clinical and ultrasonographic examination every month. 3. Results From January 1990 to January 1994, six patients met the criteria and consented to undergo FNA cytology. The clinical presentation and treatment of six cases of the post-operative peritoneal cysts are summarized in Table 1. All patients had histories of gynecologic or non-gynecologic operations. Three patients had had multiple operations. Endometriosis had been diagnosed macroscopically andror histologically in all patients. In case 1 danazol had been administered for 6 months after the second operation. In any of the cases no history of post-operative fever was found. None had a history of pelvic inflammatory disease. All patients had regular menstruation and were not using oral contraceptives. The ultrasound showed a large cyst adjacent to the ovary or a large irregular cyst with multiple septations. MR imaging demonstrated that the cysts, which had an irregular shape, had low signal intensity on T1weighted images and high signal intensity on T2weighted images. The FNA cytology and drainage were completed successfully in all cases. All the aspirated cyst fluid specimens were clear, straw-colored. In all patients FNA yielded specimens which consisted of monophorous population of mesothelial cells, lacking cytologic atypia, which were arranged as single cells or in clusters. The background was clear with neither necrotic debris nor abundant inflammatory cells. The mesothelial cells were not arranged in prominent papillary formations; no mitotic figures were found. The mean follow-up time was 4 years Žrange 3.5]6.. In case 3 and 4, who did not have longacting GnRH-agonist therapy because of their rejection, the recurrence of the cyst was noted 2 months and 5 months after the FNA cytology and drainage, respectively. The remaining four
K. Takeuchi et al. r International Journal of Gynecology & Obstetrics 60 (1998) 151]154
patients who had long-acting GnRH-agonist therapy are alive and well without evidence of recurrence. 4. Discussion Post-operative peritoneal cysts occur predominantly in reproductive-aged women w2,3x. Up to 84% of patients have a history of prior abdominal surgery, endometriosis of pelvic inflammatory disease w3,5x. Physiologic peritoneal fluid is believed to be produced by the ovaries rather than by the peritoneal surface. Peritoneal fluid is high in estrogen and the other ovarian hormones and fluctuates with the menstrual cycles, with the largest amount during the luteal phase. If the peritoneum is infected or injured, its absorptive properties diminish and secretion of fluid by the ovary may become trapped in surrounding scarred peritoneum and cause a post-operative peritoneal cyst w6x. Although there have been no well-documented reports of fatal post-operative peritoneal cysts, post-operative recurrences have been reported in up to 50% of patients w3x.
153
With one exception, the cases which we experienced presented with pelvic pain, lumbago or urinary symptoms. All were at risk for pelvic adhesions and all had regular menstruation. To make the differential diagnosis including paraovarian cyst, functional cyst or peritoneal lymphangioma, FNA cytology was performed. When the aspirate contains mesothelial cells singly or in small clusters, lacking cytologic atypia, the diagnosis of post-operative peritoneal cyst was made. Post-operative peritoneal cysts have been mainly treated by surgical resection. Microsurgery to remove adhesions and the cyst lining may prevent recurrence, minimizing the formation of other adhesions w7x. The use of oral contraceptives may prevent reaccumulation by decreasing ovarian secretion w7x, while the effectiveness of GnRH-agonists in the volume reduction of the cyst is reported w8x. These conservative treatments, however, may have only temporary effects. In this study, GnRH-agonist therapy remained to be effective after 6 months of therapy in the patients with post-operative peritoneal cysts with
Table 1 Clinical characteristics and treatment Case No.
Age Žyear.
Gravity and parity
Presentation
Previous Operations
Treatment after drainage
Outcome
1
41
G2P2
Chronic pelvic pain
1. TAH 2. LSO
GnRHa
AFD, 6 years
2
37
G1P0
Urinary symptoms
Myomectomy
GnRHa
AFD, 4 years
3
33
G2P2
Routine examination
Myomectomy
not done
AWD, 4 years
4
40
G1P1
Lumbago
TAH
not done
AWD, 4 years
5
27
G2P2
Chronic pelvic pain
1. splenectomy 2. operation for ileus 3. myomcetomy
GnHRa
AFD, 4 years
6
29
G1P1
Chronic pelvic pain
1. LSO 2. Appendectomy
GnHRa
AFD, 3.5 years
AFD: alive, free of disease; AWD: alive, with disease; CS: cesarean section; GnRHa: gonadotropin releasing hormone agonist; LSO: left sal; RSO: right salpingo-oophorectomy; TAH: total abdominal hysterectomy.
154
K. Takeuchi et al. r International Journal of Gynecology & Obstetrics 60 (1998) 151]154
a history of endometriosis. These results support the hypothesis that endometriosis plays a role in the pathogenesis of post-operative peritoneal cysts and that this is a reactive rather than a neoplastic lesion. Although the role of FNA cytology in the diagnosis of ovarian cysts still leaves room for discussion, we believe that it may offer an important diagnostic option for post-operative peritoneal cysts and that GnRH-agonists may have a role in the conservative management of these cysts associated with endometriosis. A larger number of patients and a longer period of follow-up are necessary for the confirmation of our results. References w1x Gussman D, Thickman D, Wheeler JE. Postoperative peritoneal cyst. Obstet Gynecol 1986;68:53s]55s.
w2x Weiss SW, Tavassoli F. Multicystic mesothelioma. Am J Surg Pathol 1988;12:737]746. w3x Ross MJ, Welch WR, Scully RE. Multicystic peritoneal inclusion cysts Žso-called cystic mesothelioma.. Cancer 1989;64:1336]1346. w4x McFadden DE, Clement PB. Peritoneal inclusion cysts with mural mesothelial proliferation: A clinicopathologic analysis of six cases. Am J Surg Pathol 1989;10:844]854. w5x Groisman GM, Kerner H. Multicystic mesothelioma with en dom etriosis. A cta O b stet G yn ecol Scan d 1992;71:642]644. w6x Koninckx PR, Renaer M, Brosens IA. Origin of peritoneal fluid in women: an ovarian exudation product. Br J Obstet Gynaecol. w7x Hoffer FA, Kozakewich H, Colodny A, Goldstein D. Peritoneal inclusion cysts: ovarian fluid in peritoneal adhesions. Radiology 1988;169:189]191. w8x Letterie GS, Yon JL. Use of a long-acting GnRH agonist for benign cystic mesothelioma. Obstet Gynecol 1995;85:901]903.