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Adnexal masses -Ovarian Cysts Michelle M Fynes MB BCh BAO (Hons) MD (Research) MRCOG DU DipUS

Adnexal masses -Ovarian Cysts

Michelle M Fynes MB BCh BAO (Hons) MD (Research) MRCOG DU DipUS

Subspecialty Accredited Urogynaecologist RCOG (2003) and RANZCOG (2002)

CCST Obstetrics and Gynaecology (2003) Specialist Complex Peri-partum Childbirth Injury and Paediatric Adolescent and Forensic Gynaecology

Definition

Definition • • • Ovarian cyst - collection of fluid, very thin wall, within ovary Ovarian

Ovarian cyst - collection of fluid, very thin wall, within ovary Ovarian follicle >2cm is termed ovarian cyst.

Range in size from as small as a pea to larger than an orange.

Definition • • • Ovarian cyst - collection of fluid, very thin wall, within ovary Ovarian

Most ovarian cysts are functional in nature and benign Functional cysts occur in nearly all premenopausal XX, and up to 14.8% postmenopausal XX. Pre-menopausal almost all ovarian masses/cysts are benign.

Incidence symptomatic pre-menopausal ovarian cyst being malignant is approximately 1:1000 and 3:1000 at 50years.

Ovarian cysts most common in reproductive years. Functional cysts 2-3 cm usually resolve 2-3 menstrual cycles

Symptoms (usually pain) may be caused by increasing size, bleeding, rupture, leak or torsion.

Surgery may be required if cyst >5cm in diameter. 10% of women will surgery during their lifetime for an ovarian mass.

Benign ovarian • Functional cysts • Endometriomas • Serous cystadenoma • Mucinous cystadenoma • Mature teratoma

Benign ovarian

Functional cysts

Endometriomas

Serous cystadenoma

Mucinous cystadenoma

Mature teratoma

Borderline tumour ovary

Benign non-ovarian

Paratubal cyst

Hydrosalpinges

Tubo-ovarian abscess

Peritoneal pseudocysts

Appendiceal abscess

Diverticular abscess

Pelvic kidney

Classification of Adnexal Masses

Primary malignant

ovarian Germ cell tumour

Epithelial carcinoma

Sex-cord tumour

Secondary malignant ovarian

Predominantly breast and gastrointestinal

carcinoma.

Benign ovarian • Functional cysts • Endometriomas • Serous cystadenoma • Mucinous cystadenoma • Mature teratoma
Functional ‘Simple’ Ovarian cysts Classification functional cysts • Follicular cyst • Corpus luteal cyst Other •

Functional ‘Simple’ Ovarian cysts

Functional ‘Simple’ Ovarian cysts Classification functional cysts • Follicular cyst • Corpus luteal cyst Other •

Classification functional cysts

Follicular cyst

Corpus luteal cyst

Other

Cystic

Solid/cystic

Functional ‘Simple’ Ovarian cysts Classification functional cysts • Follicular cyst • Corpus luteal cyst Other •

Two groups

Pre-menopausal

Post-menopausal

Functional ‘Simple’ Ovarian cysts Classification functional cysts • Follicular cyst • Corpus luteal cyst Other •

2.5cm left ovarian cyst

Functional ‘Simple’ Ovarian cysts Classification functional cysts • Follicular cyst • Corpus luteal cyst Other •

Axial CT- Haemorrhagic ovarian cyst. Anterior blood pool

Functional ‘Simple’ Ovarian cysts Classification functional cysts • Follicular cyst • Corpus luteal cyst Other •

CT- 30 year old female with an 8.5cm cyst

Management suspected ovarian masses Pre-menopausal women

Management suspected ovarian masses – Pre-menopausal women Underlying management rationale to minimise morbidity by: • Conservative

Underlying management rationale to minimise morbidity by:

Conservative management where possible

Use laparoscopic techniques where appropriate (avoid laparotomy)

Referral to a gynaecological oncologist where appropriate.

10% are found to be non-ovarian in origin Functional or simple cysts <5cm usually resolve 2-3 cycles

Surgery indicated, persistent symptoms laparoscopy ‘gold standard’

Laparoscopic management cost-effective earlier discharge

Mini-laparotomy considered for large cysts

History and Examination • • Risk factors- ovarian or breast cancer. Symptoms suggestive of endometriosis •

History and Examination

Risk factors- ovarian or breast cancer. Symptoms suggestive of endometriosis

History and Examination • • Risk factors- ovarian or breast cancer. Symptoms suggestive of endometriosis •

Symptoms suggesting possible ovarian malignancy: persistent abdominal distension, appetite change including increased satiety, pelvic or abdominal pain, increased urinary urgency and/or frequency.

Physical examination should include abdominal and vaginal (bimanual) assessment Presence or absence of local lymphadenopathy.

Acute presentation with pain consider cyst accident (torsion, rupture, haemorrhage).

Sensitivity examination poor in detection ovarian masses (1551%). Value in evaluating

Tenderness, mobility, nodularity and ascites.

History and Examination • • Risk factors- ovarian or breast cancer. Symptoms suggestive of endometriosis •
History and Examination • • Risk factors- ovarian or breast cancer. Symptoms suggestive of endometriosis •
CA-125 assay
CA-125 assay

What investigations?

CA-125 not necessary clear US diagnosis simple ovarian cyst

CA-125 unreliable differentiating benign vs malignant masses

Premenopausal XX to increase rate false positives and reduced specificity

because CA-125 raised in Fibroids, endometriosis, adenomyosis , PID, pelvic sepsis.

CA-125 raised < 200 units/ml, further investigation appropriate to exclude/treat

the common differential diagnoses In stage IIIIV endometriosis likely to be raised >200 or >1000 units/ml

CA-125 levels if raised, serial monitoring helpful rapidly rising levels likely

associated with malignancy CA-125 is a marker epithelial ovarian carcinoma raised 50% of early stage disease.

CA-125 assay > 200 units/ml, discussion with a gynaecological oncologist

LDH, α-FP, hCG assay

Guidelines UK/USA α-FP and hCG measured in all XX <40years with a complex ovarian mass because possibility of germ cell tumours.

Guidelines USA also recommend measuring LDH

What imaging for suspected ovarian masses?

TVUS ?

Single most effective way preferable TAS increased sensitivity

May need both TAS and TVUS for larger masses and extra-ovarian disease

Colour flow Doppler not shown to improve diagnostic accuracy but TVUS in combination with colour flow mapping/3D imaging may improve sensitivity, particularly in complex cases.

‘Pattern recognition’ of specific ultrasound findings can produce sensitivity and specificity equivalent

to logistic regression models, especially when performed by more experienced clinicians

This reduces number of ‘unnecessary’ staging laparotomies.

What is the role routine use CT or MRI ?

CT/MRI no better than TVUS for diagnosis used to evaluate complex lesions

If suspicious malignancy referral to a gynaecological oncology MDT

What is the best way to estimate the risk of malignancy?

Risk of Malignancy Index (RMI) most widely used model

Recent studies specific model of US parameters derived from IOTA Group increased sensitivity and specificity. RMI I most effective suspected ovarian CA.

Calculation RMI I 3 pre-surgical features:

CA-125; menopausal status (M); US score (U). US scored 1 point for-

Multi-locular cysts

Solid areas

RMI = U x M x CA-125

Metastases

Ascites

Bilateral lesions.

What imaging for suspected ovarian masses? TVUS ? • Single most effective way preferable TAS increased
What imaging for suspected ovarian masses? TVUS ? • Single most effective way preferable TAS increased
What imaging for suspected ovarian masses? TVUS ? • Single most effective way preferable TAS increased
What imaging for suspected ovarian masses? TVUS ? • Single most effective way preferable TAS increased
What imaging for suspected ovarian masses? TVUS ? • Single most effective way preferable TAS increased
What imaging for suspected ovarian masses? TVUS ? • Single most effective way preferable TAS increased
What imaging for suspected ovarian masses? TVUS ? • Single most effective way preferable TAS increased
IOTA - Group ultrasound ‘rules’ to classify masses as benign (B-rules) or malignant (M-rules) B-rules •

IOTA - Group ultrasound ‘rules’ to classify masses as benign (B-rules) or malignant (M-rules)

IOTA - Group ultrasound ‘rules’ to classify masses as benign (B-rules) or malignant (M-rules) B-rules •

B-rules

Uni-locular cysts

Presence of solid components where the

largest solid component <7 mm Presence of acoustic shadowing

Smooth multi-locular tumour with largest diameter <100 mm

No blood flow

M-rules

Irregular solid tumour

Ascites

At least four papillary structures

Irregular multi-locular solid tumour with

largest diameter ≥100 mm

Very strong blood flow

Management pre-menopausal ovarian masses

Can asymptomatic women with simple ovarian cysts

be managed expectantly?

Simple cysts 30mm but < 50 mm diameter simple generally do not require follow-up very

likely to be physiological almost always resolve within 3 cycles.

Simple ovarian cysts of 5070 mm in diameter yearly ultrasound follow-up

Larger simple cysts consider MRI or surgical

intervention.

Management pre-menopausal ovarian masses Can asymptomatic women with simple ovarian cysts be managed expectantly? • Simple

How should persistent, asymptomatic ovarian cysts be managed?

Ovarian cysts that persist or increase in size unlikely to be functional may warrant surgery.

Mature cystic teratomas (dermoid cysts) may

grow over time. Risk pain and cyst accidents.

Pre-operative assessment using RMI 1 or US IOTA rules

No evidence-based consensus on size > which surgery indicated. Most studies use an arbitrary maximum diameter of 5060 mm among inclusion criteria for conservative management.

COCP use does not promote the resolution of functional ovarian cysts.

Management pre-menopausal ovarian masses Can asymptomatic women with simple ovarian cysts be managed expectantly? • Simple

Surgery for pre-menopausal ovarian masses

Is the laparoscopic approach better for the elective surgical management of ovarian masses?

Surgery for pre-menopausal ovarian masses Is the laparoscopic approach better for the elective surgical management of
Surgery for pre-menopausal ovarian masses Is the laparoscopic approach better for the elective surgical management of

Less morbidity, shorter recovery time, cost-effective as earlier discharge and return to work. Large masses, solid components laparotomy may be more appropriate. Maximum cyst size > which laparotomy considered is controversial. Rupture occurs more often with cysts > 7cm.

Drainage or removal of large ovarian cysts

requires significant extension of laparoscopic port incision, advantages reduced.

Some require mini-laparotomy for drainage/removal of cyst.

Surgery for pre-menopausal ovarian masses Is the laparoscopic approach better for the elective surgical management of
Surgery for pre-menopausal ovarian masses Is the laparoscopic approach better for the elective surgical management of

Should an ovarian cyst be aspirated?

Aspiration of ovarian cysts, either vaginally or laparoscopic is less effective and associated with

high risk recurrence.

RCT’s - resolution rates simple ovarian cysts similar expectant management (46%) versus ultrasound guided needle aspiration (44.6%)

Recurrence rates after laparoscopic aspiration simple cysts - 53% to 84%.

Who should perform laparoscopic surgery for a presumed benign ovarian cyst?

Decision Factors Patient - suitability laparoscopy and her wishes Mass - size, complexity, likely nature Setting - surgeon’s skills and equipment

Endometriomas

Based on clinical and patient experience,

endometriosis can cause the following symptoms:

severe dysmenorrhoea, deep dyspareunia

chronic pelvic pain, ovulation pain

cyclical or perimenstrual symptoms, such as bowel or bladder, with or without abnormal bleeding or

infertility

chronic fatigue

dyschezia (pain on defaecation).

Endometriomas Based on clinical and patient experience, endometriosis can cause the following symptoms: • severe dysmenorrhoea,
Endometriomas Based on clinical and patient experience, endometriosis can cause the following symptoms: • severe dysmenorrhoea,
Endometriomas Based on clinical and patient experience, endometriosis can cause the following symptoms: • severe dysmenorrhoea,
Endometriomas Based on clinical and patient experience, endometriosis can cause the following symptoms: • severe dysmenorrhoea,
Endometriomas Based on clinical and patient experience, endometriosis can cause the following symptoms: • severe dysmenorrhoea,

Laparoscopic cystectomy for ovarian endometriomas is better than drainage and coagulation.

Recurrence and symptoms reduced by excision rather

than drainage and ablation.

Subsequent spontaneous pregnancy rates where previously subfertile are improved with excision.

Laparoscopic ovarian cystectomy is recommended for endometriomas ≥ 4 cm in diameter before IVF.

No RCT’s laparoscopic excision with no treatment before IVF.

Laparoscopic ovarian cystectomy recommended if ≥4cm to confirm the diagnosis histologically; reduce the infection; improve access to follicles, and possibly improve ovarian response and prevent endometriosis

progression.

Counsel re risks of reduced ovarian function after surgery and loss of the ovary.

Hart RJ, Hickey M, Maouris P, Buckett W, Garry R.

Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev

2005;(3):CD004992.

Surgical technique

Removal of cyst/mass?

Spillage of cyst avoided if possible. Pre and

intraoperative assessment can’t preclude

malignancy.

Surgical technique Removal of cyst/mass? • Spillage of cyst avoided if possible. Pre and intraoperative assessment
Surgical technique Removal of cyst/mass? • Spillage of cyst avoided if possible. Pre and intraoperative assessment

Consideration given to use of tissue bag to avoid peritoneal spill of contents bearing in mind the likely preoperative diagnosis.

Chemical peritonitis due to spillage of dermoid cyst contents occurs < 0.2% cases.

When should an oophorectomy be performed?

The possibility of removing an ovary should be discussed with the woman preoperatively.

How to remove the mass?

If inadvertent spillage does occur, peritoneal lavage

using large amount warmed fluid. Cold irrigation causes hypothermia, retrieval of contents harder due to solidifying fat-rich contents.

RCOG Guideline treatment endometriosis recommends lesions >3cm histology needed to confirm diagnosis and exclude rare case malignancy.

Potential to upstage a tumour if the suspected endometrioma is actually a malignant tumour.

Surgical technique Removal of cyst/mass? • Spillage of cyst avoided if possible. Pre and intraoperative assessment

Where possible removal of benign ovarian masses should be via the umbilical port.

Less postoperative pain, quicker retrieval time than when using lateral ports of the same size.

Various types of laparoscopic tissue retrieval bags have been described.

Extending accessory ports increases postoperative pain, incisional hernia, epigastric vessel injury, poor cosmesis.

Surgical technique Removal of cyst/mass? • Spillage of cyst avoided if possible. Pre and intraoperative assessment

Adnexal Mass Emergencies

Isolated tubal torsion. (A) Color Doppler image shows a swirling appearance of the vascular pedicle (arrows) and a dilated right Fallopian tube (arrowheads) with findings concerning for tubal torsion. (B) Corresponding laparoscopic intraoperative image demonstrates the torsed Fallopian tube. Detorsion of the Fallopian tube with fenestration of the dilated end (fimbriaplasty) was performed as the tube and ovary appeared viable

Adnexal Mass Emergencies Isolated tubal torsion. (A) Color Doppler image shows a swirling appearance of the
Adnexal Mass Emergencies Isolated tubal torsion. (A) Color Doppler image shows a swirling appearance of the
Adnexal Mass Emergencies Isolated tubal torsion. (A) Color Doppler image shows a swirling appearance of the

Paraovarian cyst with torsion. Midsagittal US scan through the bladder (B) shows an enlarged, heterogeneous ovary (arrowheads) and an adjacent cyst

(C). No flow could be elicited on color Doppler interrogation. On surgery it

proved to be adnexal torsion related to a paraovarian cyst leading to ipsilateral salpingo-oophorectomy.

Adnexal Mass Emergencies Isolated tubal torsion. (A) Color Doppler image shows a swirling appearance of the
Adnexal Mass Emergencies Ovarian teratoma with torsion. (A) Enhanced axial CT adolescent XX sudden onset pelvic

Adnexal Mass Emergencies

Ovarian teratoma with torsion. (A) Enhanced axial CT adolescent XX sudden onset pelvic pain reveals teratoma (arrows) containing fat/calcification. Adjacent ovary prominent peripheral follicles (arrowheads). Thickened teratoma wall, surrounding fat is stranded, free pelvic fluid (*). B, bladder; U, uterus. (B) pathologic specimen; torsion confirmed at surgery.

Adnexal Mass Emergencies Ovarian teratoma with torsion. (A) Enhanced axial CT adolescent XX sudden onset pelvic
Adnexal Mass Emergencies Ovarian teratoma with torsion. (A) Enhanced axial CT adolescent XX sudden onset pelvic

Bilateral tubo-ovarian abscesses with pyosalpynx. (A) TVUS right adnexa thick-walled, complex lesion, fluid level consistent with abscess (arrows). Wall is hyperemic, surrounding soft tissues indistinct/edematous. (B) TVUS sagittal dilated left Fallopian tube (arrowheads), heterogenous contents, mucosa thickened consistent with a pyosalpynx. U, uterus.

Foreign body- XX 7 years orange vaginal discharge. Sagittal T2-weighted. Hypo- intense cylindrical vaginal structure. Orange
Foreign body- XX 7 years orange vaginal discharge. Sagittal T2-weighted. Hypo- intense cylindrical vaginal structure. Orange
Foreign body- XX 7 years orange vaginal discharge. Sagittal T2-weighted. Hypo- intense cylindrical vaginal structure. Orange

Foreign body- XX 7 years orange vaginal discharge. Sagittal T2-weighted. Hypo- intense cylindrical vaginal structure. Orange crayon vaginoscopy. (B) bladder

Emergencies

Mature ovarian teratoma- XX 16 years abdominal pain. (A) X-Ray toothlike calcific density (? Teratoma). (B) TA-US echogenic adnexal mass (arrows) posterior

acoustic shadowing (arrowheads) ? mature teratoma.

Multitude interfaces near field result from mix fat/hair obscures rest lesion, “tip of the iceberg” sign is used. (C) CT large amount fatty tissue in mass (arrows), typical of mature teratoma. B, bladder.

Foreign body- XX 7 years orange vaginal discharge. Sagittal T2-weighted. Hypo- intense cylindrical vaginal structure. Orange

Perforated appendicitis complicated with

ovarian abscess - XX 13-years. (A) Longitudinal US enlarged ovary (delineated by cursors) with a complex collection contains few gas foci (arrows). (B) US Transverse thick-walled abscess peripheral hypervascularity. B bladder; U uterus.

Foreign body- XX 7 years orange vaginal discharge. Sagittal T2-weighted. Hypo- intense cylindrical vaginal structure. Orange
Foreign body- XX 7 years orange vaginal discharge. Sagittal T2-weighted. Hypo- intense cylindrical vaginal structure. Orange

Emergencies Pelvic Pain

Adnexal endometriosis- XX 17 years (A) Transverse US bilateral adnexal endometriomas (arrows) internal low level echoes. (B) No flow within lesions appearances similar to haemorrhagic cyst; (C) Coronal T1 (D) T2 MRI images adnexal lesions (arrows) high signal on T1/ T2, consistent with blood in lesions. Left is slightly >heterogeneity/complex appearance B bladder U uterus.

Emergencies – Pelvic Pain Adnexal endometriosis- XX 17 years (A) Transverse US bilateral adnexal endometriomas (arrows)

XX 17 years acute on chronic pelvic pain- Sagittal US haemorrhagic cyst (arrowheads) internal lacy or fish-net appearance, no flow within septations. Flow demonstrated in rim normal ovarian tissue (arrows).

Emergencies – Pelvic Pain Adnexal endometriosis- XX 17 years (A) Transverse US bilateral adnexal endometriomas (arrows)

XX 18 years acute pelvic pain TA-US hemorrhagic ovarian cyst (arrowheads) with retracting clot. Flow on color Doppler within the peripheral rim of normal ovarian tissue (arrows).

Emergencies – Pelvic Pain Adnexal endometriosis- XX 17 years (A) Transverse US bilateral adnexal endometriomas (arrows)

Adnexal masses in pregnancy ?

Guideline: The Society of American Gastrointestinal and Endoscopic Surgeons (2011):

Risks

Adnexal masses in pregnancy ? Guideline: The Society of American Gastrointestinal and Endoscopic Surgeons (2011): Risks

Laparoscopy is safe and effective

treatment in gravid patients with

symptomatic ovarian cystic masses.

Observation for all asymptomatic cystic lesions if US not concerning for malignancy and tumor markers normal.

Observe acceptable cystic lesions <6 cm

Evidence level IV

Adnexal masses in pregnancy ? Guideline: The Society of American Gastrointestinal and Endoscopic Surgeons (2011): Risks

Miscarriage

Obstetric complications, including LBW,

preterm delivery, use of tocolytics for preterm labor, low Apgar score, and fetal anomaly. These risks deemed acceptable in case series.

References:

  • 1. Azuar AS. Bouillet-Dejou L et al. Laparoscopy during pregnancy: experience of the French university hospital of Clermont-Ferrand. Obstetrique & Fertilite. 2009;37(7-8):598-603

  • 2. Bunyavejchevin S, Phupong V. Laparoscopic surgery for presumed benign ovarian tumor during pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD005459. DOI: 10.1002/14651858.CD005459.

  • 3. Ko ML. Lai TH. Chen SC. Laparoscopic management of complicated adnexal masses in the first trimester of pregnancy. Fertility & Sterility. 2009;092(1):283-7, 2009

  • 4. Koo YJ. Lee JE. Lim KT et al. A 10-year experience of laparoscopic surgery for adnexal masses during pregnancy. Int J Gynaecol & Obstet. 2011;113(1):36-9.

  • 5. Guidelines for diagnosis , treatment and use of laparoscopy for surgical problems during pregnancy. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES); 2011

Ovarian mass at Caesarean section ?

No studies comparing removal of incidentally found adnexal masses at caesarean section with later removal . Series by Hobeika et al 2008 -

Reviewed histopathology of 43 adnexal masses incidentally diagnosed and excised during CS

Mature cystic teratomas (34.9%)

Mucinous cystadenomas (16.3%)

Serous cysts/cystadenomas (14.0%)

Endometriomas (11.6%)

Luteomas (7%)

Paraovarian cysts (4.7%)

Corpus luteum cyst (2.3%)

Fibroma (2.3%)

Inclusion cyst (2.3%)

Serous-mucinous cyst (2.3%)

Borderline serous cystadenoma (2.3%).

Lesions rare and mostly benign, but found the case of

borderline tumor alarming.

Ovarian mass at Caesarean section ? No studies comparing removal of incidentally found adnexal masses at

References:

  • 1. Ahram J. Lakoff K. Miller R. Serous cystadenocarcinoma as incidental finding during a repeat cesarean section. AmJOG. 1985;153(1):78-9.

  • 2. Ansell J. Bolton L. Spontaneous rupture of an ovarian teratoma discovered during an emergency Caesarean section. JOG 2006;26(6):574-5.

  • 3. El-Ghobashy A. Ohadike C. Wilkinson N. Lane G. Campbell JD. Recurrent urachal mucinous adenocarcinoma presenting as bilateral ovarian tumors on cesarean delivery. Int J of Gynecol Cancer 2009;19(9):1539-41.

  • 4. Engin-Ustun Y. Ustun Y. Dogan K. Meydanh MM. Ovarian carcinoma as an incidental finding during cesarean section in a preeclamptic woman: case report. Eur J Gynaecol Oncol 2007;28(5):423-4.

  • 5. Hobeika EM. Usta IM. Ghazeeri GS. Mehio G. Nassar AH. Histopathology of adnexal masses incidentally diagnosed during cesarean delivery. EJOG and Reprod Biol 2008;140(1):124-5.

Post-menopausal ovarian cysts Incidence ? 20 000 postmenopausal women screened in the Prostate, Lung, Colon and
Post-menopausal ovarian cysts Incidence ? 20 000 postmenopausal women screened in the Prostate, Lung, Colon and

Post-menopausal ovarian cysts

Incidence ?

20 000 postmenopausal women screened in the Prostate, Lung, Colon and Ovarian Cancer Screening Trial.

21.2% ovarian morphology abnormal - simple or complex.

Post-menopausal ovarian cysts Incidence ? 20 000 postmenopausal women screened in the Prostate, Lung, Colon and

The finding of an ovarian cyst in a postmenopausal woman raises two questions-

Post-menopausal ovarian cysts Incidence ? 20 000 postmenopausal women screened in the Prostate, Lung, Colon and

What is the most appropriate management ?

Post-menopause ovarian cyst - TVUS and CA125

No routine role for Doppler, MRI, CT or PET US sensitivity 89% and specificity 73% based on morphology index CA125 raised > 80% ovarian cancer (> 30 u/ml) Sensitivity of 81% and specificity of 75%.

Recommended ‘risk of malignancy index’ used to select those require primary surgery in a cancer centre by gynaecological oncologist. Cut-off RMI >250 sensitivity 70% /specificity 90%.

How should it be managed ?

Aspiration is not recommended for the management of ovarian cysts in postmenopausal women.

It is recommended that a ‘risk of malignancy index’ should be used to select women for laparoscopic surgery, to be undertaken by a suitably qualified surgeon.

It is recommended that laparoscopic management of

ovarian cysts in postmenopausal women should involve

oophorectomy (usually bilateral) rather than cystectomy.

Risk assessment and Management Where should this management take place? • Low risk by a general

Risk assessment and Management

Where should this management take place?

Low risk by a general benign gynaecologist

Intermediate risk a cancer unit

High risk in a cancer centre.

Rapid referral (2 weeks) to cancer centre recommended for those found to have malignancy or at high risk

Low risk: <3% risk of cancer

Management in a gynaecology unit.

Simple unilateral locular cysts no solid parts no papillary formations (2cm-<5 cm)

CA125 <30 manage conservatively.

Repeat US and CA125 every 4 months for 1 year.

> 50% cysts resolve spontaneously by 3 months.

Cyst does not fit criteria or if surgery requested then laparoscopic oophorectomy acceptable.

Moderate Risk: 20% risk of cancer

Management in a cancer unit.

Laparoscopic oophorectomy selected cases.

Malignant then a full staging procedure undertaken in a cancer centre.

High Risk: >75% risk of cancer

Management in a cancer centre.

Full staging procedure.

Laparotomy

All ovarian cysts suspicious of malignancy in a postmenopausal woman-

  • 1. High risk of malignancy index

  • 2. Clinical suspicion

  • 3. Findings at laparoscopy

Full laparotomy and staging procedure-

Performed by an appropriate surgeon, working with an MDT in a cancer centre, through an extended midline incision, and should include:

  • Cytology: ascites or washings

  • Laparotomy with clear documentation

  • Biopsies from adhesions and suspicious areas

  • TAH, BSO and infra-colic omentectomy

Staging may include bilateral selective pelvic

and para-aortic lymphadenectomy.

Ovarian malignancies

Ovarian malignancies
Ovarian malignancies
Ovarian malignancies
Ovarian malignancies
References 1. Royal College of Obstetrics and Gynaecologists. Management of Suspected Ovarian Masses in Premenopausal Women.

References

References 1. Royal College of Obstetrics and Gynaecologists. Management of Suspected Ovarian Masses in Premenopausal Women.
References 1. Royal College of Obstetrics and Gynaecologists. Management of Suspected Ovarian Masses in Premenopausal Women.
  • 1. Royal College of Obstetrics and Gynaecologists. Management of Suspected Ovarian Masses in Premenopausal Women. Green-top Guideline No. 62. London: RCOG; 2011.

  • 2. Royal College of Obstetrics and Gynaecologists. The investigation and management of endometriosis. Green-top Guideline No. 24. London: RCOG; 2006.

  • 3. National Institute for Health and Clinical Excellence. Ovarian cancer: The recognition and initial management of ovarian cancer. NICE clinical guideline 122. London: NICE; 2011.

  • 4. American College of Obstetricians and Gynecologists. Management of adnexal masses. ACOG Practice Bulletin No. 83. Washington DC: ACOG; 2007.

  • 5. Le T, Giede C, Salem S, Lefebvre G, Rosen B, Bentley J, et al; Society of Obstetricians and Gynaecologists of Canada. Initial evaluation and referral guidelines for management of pelvic/ ovarian masses. J Obstet Gynaecol Can 2009;31:66880.