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Histology of Chocolate Cysts

Article  in  Journal of Gynecologic Surgery · March 1990

DOI: 10.1089/gyn.1990.6.43

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Dan C. Martin
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Martin DC, Berry JD. Histology of Chocolate Cysts. J Gynecol Surg 6(1):43-46,1990

Published Abstract
This study was designed to determine the gross anatomic criteria needed to diagnose
endometrioma. Close observation and histologic examination of chocolate cysts in this patient
study revealed that those with a flattened appearance and red or red and brown mottled ridges
generally were endometriosis and those with a dark uniform base, an intracavitary clot, or a
yellowish rim generally were corpus lutea or albicans. (J GYNECOL SURG 6:43, 1990)
https://www.liebertpub.com/doi/abs/10.1089/gyn.1990.6.43

Published PDF available at:

https://www.liebertpub.com/doi/pdf/10.1089/gyn.1990.6.43

Dan C. Martin, M.D.

201 Wakefield Road
Richmond, VA23221-3258
Messages can be left at Google Voice (901) 761-4787

Also see:
Khare VK, Martin DC, Eltorky M. A comparative study of ovarian and pelvic wall-infiltrating
endometriosis. J Am Assoc Gynecol Laparosc. 1996 Feb;3(2):235-9.
https://www.ncbi.nlm.nih.gov/pubmed/9050632
Khare VK, et al. compared the histology of ovarian endometriomas (OE) with that of pelvic
wall-infiltrating endometriosis (PWIE). All cases of OE showed changes suggestive of type 3
collagen deposition and myofibroblast proliferation. All cases of PWIE showed changes
suggestive of type 1 collagen deposition and extensive smooth muscle metaplasia. The
endometrial glands and stroma of OE tended to be on the inside lining of the chocolate cyst and
did not freely intermix with native ovarian collagen. The lesions of PWIE, however, showed
endometrial glands and stroma mixing freely with the native pelvic wall collagen.
These findings suggest two different mechanisms for the pathogenesis of OE and PWIE and
offer a rationale for using different surgical approaches to the different sites. Ovarian
endometriosis is a lesion within the ovary with a response compatible with recent metastasis,
whereas PWIE appears to be a metaplastic reaction.
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1 Draft
2
3 Histology of Chocolate Cysts
4 Dan C. Martin, M.D., Department of Obstetrics and Gynecology, Baptist Memorial Hospital,
5 University of Tennessee, Memphis, Memphis, Tennessee
6
7 Jane Demos Berry, M.D., Department of Pathology, Baptist Memorial Hospital, University of
8 Tennessee, Memphis, Memphis, Tennessee
9
10 ABSTRACT
11 Due to the histologic diagnosis of corpus lutea in cysts which the author had clinically diagnosed as
12 endometriomas, the charts of 30 patients were reviewed. These 30 patients had a total of 41 chocolate cysts
13 removed using a combination of CO2 laser incision, laser dissection and slow stripping of the cyst wall.
14 These procedures were performed during the routine clinical care of these patients.
15 Close observation and histologic examination of chocolate cysts in this patient study revealed that those with
16 a flattened appearance and red or red and brown mottled ridges generally were endometriosis and those with
17 a dark uniform base, an intracavitary clot, or a yellowish rim generally were corpus lutea or albicans.
18
19 INTRODUCTION
20
21 Since Sampson's 1921 description (1) of chocolate cysts of the ovary, there has been general
22 agreement that it is difficult if not impossible to use the gross appearance to distinguish between
23 endometriomas and the residual of hemorrhagic corpus lutea. (2,3) In spite of this, physicians sometimes
24 make the diagnosis of endometriosis without attention to histology, and patients can come to the office with
25 the understanding that they had an endometrioma removed even though their pathology documents a
26 hemorrhagic corpus luteum. In addition, drainage, vaporization, and coagulation of the endometriomas have
27 been suggested as forms of immediate therapy for chocolate cysts without histologic diagnosis. (4,5)
28
29 Because of a high incidence of hemosiderin-laden macrophages in corpus lutea in what were thought to be
30 endometriomas, this study was retrospectively designed to determine the gross anatomic criteria needed to
31 make the diagnosis of endometrioma.
32
33 MATERIALS AND METHODS
34
35 Thirty patients had 41 chocolate cysts excised using C02 laser incision followed by dissection and stripping of
36 the cyst wall. Semm's stripping techniques (6) were used, with two sets of forceps and a blunt probe employed
37 to develop the specimen (Fig. 1).
38
39 The ovarian cysts were initially opened using superpulse CO2 laser technique using the laser. A
40 relaxing incision was then made around the opening incision and a dissection plane developed
41 using two sets of grasping forceps and a blunt probe. The cyst wall was resected and sent for
42 pathology in all cases.
43
44 The laser incision technique was either superpulse or repeat pulse superimposed on the superpulse with a
45 Sharplan 1100 C02 laser. The superpulse average was 15 to 25 W with a 480 W peak. When the repeat pulse
46 setting was used, this was gated at 0.1 seconds. The spot size of the laparoscopic delivery system has
47 previously been measured at 0.6-1.2 mm. The highest instantaneous peak power density was calculated at
48 150,000 W/cm2 and the lowest average power density was calculated at 1100 W/cm2.
49
50 When the cyst wall was densely adherent in the area of the hilus, the wall was resected at a level above
51 the hilus, and the remnant base was coagulated with bipolar electrosurgery. The tissue was submitted
52 to the Department of Pathology for histologic study.
53
54 The written descriptions and photographic slides of the cysts were reviewed and tabulated. As these were
55 reviewed retrospectively, there was no uniform set of descriptions used. However, those specimens at the
56 end of the study were described in better detail than those in the early part of the study.
57
58 RESULTS
59
60 Of the 41 specimens, 25 were histologically confirmed as endometriomas, 5 were not diagnostic, and 11
61 were corpus lutea or corpus albicans. Of the 11 corpus lutea and corpus albicans, 6 had an obvious
62 yellowish appearance and were diagnosed at the time of surgery, whereas 5 had a darker base and were
63 thought to be endometriomas at the completion of surgery. Thus, 15% (6 of 41) of the chocolate cysts
64 were noted to be corpus lutea on examination of the cyst wall in the operating room, and 12% (5 of 41)
65 were diagnosed only on the basis of histology.
66
67 Retrospectively, the appearance most commonly associated with the finding of glands and stroma was a
68 generally flattened white internal lining with irregular raised red or red and brown streaks scattered throughout
69 the internal wall (Fig. 2). Histologically, the brown areas were hemosiderin laden stroma remnants (Fig. 3).
70 The red areas of these, as well as the red areas of endometriomas with only a mottled red appearance (Fig. 4),
71 were polypoid endometrial growth (Fig. 5) or nonspecific hemorrhage on histology. The lining of
72 endometriomas was surrounded by fibrosis and a rim of normal appearing ovary.
73
74 Corpus lutea and corpus albicans had a darker and more uniform base and contained clot within the cyst
75 cavity. The hemosiderin of corpus lutea was irregularly distributed but could accumulate from the
76 surface (Fig. 6) to the base (Fig. 7) of the remnant of luteinized granulosa cells.
77
78 DISCUSSION
79
80 In spite of the general agreement in the literature that the histologic diagnosis of chocolate cysts is not
81 made on the basis of clinical observation, some clinicians have treated these with vaporization or
82 coagulation without histologic studies. (5,7,8) In this study, the author retrospectively reviewed the gross
83 description and photographic slides of the cysts of 30 patients to correlate those with the histologic findings.
84
85 The cyst walls were generally stripped by the method of Semm. (6) However, when the level of the cyst was to
86 the hilum, excessive bleeding occurred when the hilar vessels were torn. Vaporization at this level was not
87 sufficiently precise. Because of this, the base was coagulated using a bipolar coagulator when there appeared to
88 be endometriosis adherent near the hilar vessel area.
89
90 Close observation and histologic examination was used for the proper diagnosis of chocolate cysts in this
91 patient study. Those with a flattened appearance and red or red and brown mottled ridges generally were
92 endometriosis. Those with a dark uniform base, an intracavitary clot, or a yellowish rim generally were
93 generally corpus lutea. These appearances need to be confirmed in a prospective study, or histologic
 94 confirmation will continue to be necessary for a proper diagnosis. The correct diagnosis is needed for patient
95 information, prognosis, and long-term care.
96
97 REFERENCES
98
99 1. Sampson JA. Perforating hemorrhagic (chocolate) cysts of the ovary, their importance and especially their
100 relation to pelvic adenomas of the endometrial type. Arch Surg 1921;3:245.
101
102 2. Novak ER, Woodruff JD. Pelvic endometriosis. In: Novak ER, Woodruff JD, eds. Novak's
103 gynecologic and obstetrical pathology. 7th ed. Philadelphia: WB Saunders Co, 1974:507.
104
105 3. Buttram VC, Ir., Reiter RC. Endometriosis. In: Buttram VC Ir, Reiter RC, eds. Surgical treatment
106 of the infertile female. Baltimore: Williams & Wilkins, 1985:89.
107
108 4. Yuzpe AA, Gomel V, Taylor PJ. Endoscopy in the patient with endometriosis. In: Gomel V, Taylor PJ,
109 Yuzpe AA, Rioux JE, eds. Laparoscopy and hysteroscopy. Chicago: Year Book Medical Publishers,
110 1986:111.
111
112 5. Martin DC, Diamond MP: Operative laparoscopy: Comparison of lasers with other techniques. Curr Prob
113 Obstet Gynecol Fértil 1986;9:564.
114
115 6. Semm K. Course of endoscopic abdominal surgery. In: Semm K, Friedrich EK, eds. Operative manual
116 for endoscopic abdominal surgery. Chicago: Year Book Medical Publishers, 1987:130.
117
118 7. Baggish MS. Intraabdominal laser applications. In: Sanz LE, ed. Gynecologic surgery. Oradell, NJ:
119 Medical Economics Books, 1988:343.
120
121 8. Brosens IA, Braechman P, Puttemans P: Ovarioscopy: A new technique for intraovarian diagnosis in
122 surgery. Abstracts of the 1988 Meeting of The American Fertility Society, p SI 10.
123
124
125 Fig. 1. The stripping technique begins with an initial incision into the endometrioma to drain the fluid and
126 examine the base. A relaxing incision is then made close to the initial incision to facilitate grasping of the
127 cyst wall. The cyst wall is then slowly resected off the ovarian tissue using a combination of traction and
128 probing with the grasping forceps or blunt probe. The specimen is sent for pathologic study. (With
129 permission from Intra-abdominal Laser Surgery, Second Edition, in preparation.)
130

131
132 Fig. 2. Internal wall of a chocolate cyst, after washing, demonstrates a mottled appearance with a
133 predominant brown coloration on a white background in this case. (With permission from Laparoscopic
134 Appearance of Endometriosis, Resurge Press, 1990.)
135

136
137 Fig. 3. Histologically, the brown areas are hemosiderin-laden residual of hemorrhage into
138 endometriosis. (With permission from Laparoscopic Appearance of Endometriosis, Resurge Press,
139 1990.)
140

141
142 Fig. 4. A reddish mottled appearance on a white background associated with a chocolate cyst is generally
143 easier to document histologically. The reddish areas are areas of glands and stroma. (From Laparoscopic
144 Appearance of Endometriosis, Resurge Press, 1990)
145
146
147 Fig. 5. A small polypoid area of endometrial glands and stroma is adjacent to an area with
148 hemosiderin. The fibrotic base lies on a thin strip of normal ovary, which is removed in stripping
149 the chocolate cyst. (From Laparoscopic Appearance of Endometriosis, Resurge Press, 1990)
150

151
152 Fig. 6. Hemosiderin associated with a corpus lutea or corpus albicans can accumulate at any layer. In
153 this specimen, the accumulation is on the surface of the hyalinized remnant of the granulosa layer.
154
155
156 FIG. 7. This corpus luteum has the accumulation of hemosiderin at the base of the old granulosa
157 layer.

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