Treatment of Exophytic Cysts
The recommended treatment approach for exophytic cysts depends critically on the anatomical location and size, with most simple exophytic cysts requiring either observation, aspiration, or surgical excision based on specific criteria.
Ovarian/Adnexal Exophytic Cysts
Premenopausal Patients
- Simple cysts ≤5 cm require no additional management 1
- Cysts >5 cm but <10 cm warrant follow-up ultrasound in 8-12 weeks (preferably during proliferative phase) to confirm functional nature 1
- If the cyst persists, enlarges, or shows wall abnormalities on follow-up, refer to gynecology for management 1
Postmenopausal Patients
- Simple cysts ≤3 cm require no further management 1
- Cysts >3 cm but <10 cm require at least 1-year follow-up demonstrating stability or decrease in size, with consideration of annual follow-up for up to 5 years if stable 1
- If enlargement occurs, refer to gynecology 1
Key caveat: These recommendations apply only to simple cysts (anechoic, thin-walled, no internal echoes or septations). Complex or complicated cysts require tissue diagnosis via ultrasound-guided biopsy or surgical excision 1.
Breast Exophytic Cysts
Simple Cysts (BI-RADS Category 2)
- Asymptomatic simple cysts require only routine screening 1
- Therapeutic aspiration is indicated only if persistent clinical symptoms are present 1
Complicated Cysts (BI-RADS Category 3)
- Options include aspiration OR short-term follow-up with physical examination and ultrasound ±mammography every 6-12 months for 1-2 years 1
- If blood-free fluid is obtained on aspiration and mass resolves, monitor for recurrence 1
- If the cyst increases in size on follow-up, perform tissue biopsy 1
Complex Cysts (BI-RADS Category 4)
- Ultrasound-guided biopsy or surgical excision is warranted 1
Hepatic Exophytic Cysts
Simple Hepatic Cysts
- Giant simple hepatic cysts (>4 liters) causing mass effect symptoms require surgical intervention 2
- Surgical drainage with cyst wall excision is the definitive treatment for symptomatic cases 2
Hydatid Cysts
Treatment is stratified by cyst size and stage 1:
- Cysts <5 cm: Albendazole 400 mg twice daily alone, duration determined by cyst type 1
- Stage 1 simple liver cysts ≥5 cm: PAIR (Puncture, Aspiration, Injection, Re-aspiration) plus albendazole 400 mg twice daily, with praziquantel 20 mg/kg twice daily for 2 weeks pre- and post-procedure 1
- Larger, extrahepatic, or multiple cysts: Surgical intervention indicated 1
- Late stage cysts (WHO type 4 or 5): Careful observation with sequential ultrasound scans 1
Critical warning: Treatment must be performed only in specialist centers due to significant risks of anaphylaxis and cyst dissemination with surgical or percutaneous interventions 1.
Genital Warts (Exophytic)
Cervical Exophytic Warts
- High-grade squamous intraepithelial lesions must be excluded before treatment 1
- Management requires consultation with an expert 1
External Genital Warts
- Surgical removal via tangential excision with scissors/scalpel or curettage, with wounds extending only into upper dermis 1
- Electrosurgery provides simultaneous destruction and hemostasis 1
- Surgery is most beneficial for patients with large number or area of warts 1
Renal Exophytic Cysts
Exophytic renal cysts demonstrate minimal pseudoenhancement on CT compared to intrarenal cysts 3. This imaging characteristic aids in distinguishing them from solid lesions and typically allows conservative management when meeting simple cyst criteria.
Important Pitfalls to Avoid
- Never assume all cysts are benign: Always correlate imaging characteristics with clinical presentation 1
- Avoid incomplete evaluation of large cysts: Cysts approaching 10 cm may require transabdominal ultrasound in addition to transvaginal examination to fully assess wall characteristics 1
- Do not perform aspiration without appropriate follow-up: Recurrent cysts after aspiration require tissue diagnosis 1
- Never treat hydatid cysts outside specialist centers: Risk of fatal anaphylaxis and dissemination is substantial 1