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- Mon Sep 15, 2008 8:48 am
28 y/o Hashimoto's Thryoiditis Patient with Multiple Lab Abnormalities and Persistant Septated Cyst-- Background:
--% Bioavailable Testosterone = 26.5%
--WBC = 11 (3+ years)
--Swollen lymph nodes in armpits, base of skull and neck (3+ years)
--Absolute CD3 (2326)
--%CD 4 Pos. Lymphs (61.5%)
--HCG <2. Never pregnant.
Visited gyn last year for extreme pelvic pain, back pain, distended abdomen, urinary, and mentrual irregularities (losing period, worsening cystic acne). When the sonagram came back, doctor wanted me to go for immediate laparoscopy to "see what it was." I declined laparoscopy b/c I felt rushed, doctor did not explain what his suspicions were or why laparoscopy was indicated over MRI. I was uncomfortable with the facility with which he was affiliated-- hospital lost my chart on both previous visits, and I was left for HOURS in the ER meanwhile nobody knew I was there waiting for treatment.
One year later, went for annual exam and presented old sonagram report to new gyn. Did a follow-up sonagram, and doctor seemed very concerned about what he saw. Sent me for an in-house blood test immediately after consultation. Images looked bad, doppler evaluation shows poor vascularity. Sent me for an MRI.
Follow up MRI:
--3.2 x 1.9 x 1.7 cm septated cyst in the left ovary, similar to that seen on ultrasound from a year ago.
--1cm Hemorraghic cyst in left ovary.
--Both ovaries demonstrate small follicles.
--No septal enhancement; no osseous abnormality evident.
--Free fluid in pelvis, likely physiologic.
Sounds like they were attempting to rule out ectopic pregnancy, dermoid cyst, and teratoma. Sounds like it also rules out standard functional cyst given septations and persistence of 1 year. Thickness of septations was not noted; but clearly does not contain the type of enhancing calcifications expected of ectop or benign tumor. This sounds really bad considering that all my blood work just came back elevated and my endo wants me to see a hemotologist.
My understanding is that MRI can't make the distinction between benign and malignant septated cysts. Is that correct or a misunderstanding?
Would an MRI report ever directly list the dx / impression as "ovarian cancer"? What language would you expect to find in a report for a patient who has not been previously diagnosed with cancer via biopsy?
Given the history of symptoms, lab abnormalities, urgency of an immediate blood test, and attempts to rule out a variety of normally benign conditions, I'm very scared that this MRI points to ovarian cancer. Can you offer an opinion as to the degree of my risk at this point?
What do I do next? Where do I go?
| Dr. Safaa Mahmoud
- Wed Oct 15, 2008 7:01 pm
An ovarian cyst is a collection of fluid surrounded by a thin wall within the ovary. They affect women of all ages but mainly during their childbearing periods. Small cysts causing no symptoms are usually kept under follow up and some types are expected to disappear in few months.
The majority are benign not harmful (95%). Hemorrhagic cysts occur when a blood vessel rapture into the cyst. Hemorrhagic cysts like other types of ovarian cysts if lasts longer than two or three menstrual cycles, surgical intervention is considered. Some ovarian cysts may rupture and bleed causing pain. In these cases surgery is also of consideration.
MR imaging is very helpful in the differentiation between benign from certain malignant types of ovarian cancer (93% accuracy). However, it can not be used to diagnose or exclude malignancy. These MRI findings are very suggestive of malignancy: necrosis in a solid lesion and vegetations in a cystic lesion. In addition, supplementary findings include ascites and hemorrhage. Laparoscopy and biopsy are the investigations of choice.
Most cysts can be removed with laparoscopic surgery. Laparoscopy provide faster recovery and less scarring than traditional surgery.
Thyroid peroxidase (TPO) antibody is used to detect antibodies agaisnt the thyroid gland conidtions similar to Hashimoto's Thryoiditis. Most people with chronic thyroiditis (70%-90%) are positive for TPOAB test.
Thyroid-stimulating hormone TSH Normal range is 0.4–4.5mIU/L.
High TSH levels may be caused by hypothyroidism.
-Hashimoto's thyroiditis is the most common cause of primary hypothyroidism.
-A pituitary gland tumor is uncommon while inadequate thyroid hormone replacement medicine for a hypothyroid gland is very common.
To me your blood count is not that alarming and during infection or inflammations a similar mild elevation in the WBCs occurs. Lymphocytes constitute 16-45% of white blood cells. Of those lymphocytes, about 50% are T cells, and B cells, and natural killer cells each constitute 25% . Helper T-cells, or absolute CD4+ or T4 count is 500 to 1500 per cubic millimetre of blood (32-68% of lymphocytes).
It is not clear for me from the history given why your physician ordered the test and how he interpreted the results but under any circumstances hematologic consultation is beneficial.
I advise you to follow up with your doctor and to seek endocrinologist consultation.
Hope you find this information useful.
Please keep us updated.
- Fri Nov 07, 2008 11:19 pm
Thank you so much for your time and energy doctor.
Truly, not everyone is willing to devote that kind of effort to help a complete stranger. People like you bring renewed faith. Thank you.
I have had extensive testing because my Hashi's has not responded appropriately to any of my medications over the course of several years. Additionally, I was exposed for some time to very high levels of Aspergillus mold, so I plan to ask the surgeon to check for indications of systemic infection, though I know how slim that possibility is...
I am scheduled for laparoscopy in early December. I will certainly let you know how everything goes.