Management of ovarian cysts in postmenopausal women

By

El-Said Abdel-Hady, PhD MRCOG,

Mansoura University.

Case study A 54-year-old woman, was referred with

left ovarian cyst 8X8.5 cm discovered on abdominal U/S.

C/o: Left sided loin pain for 2 days.

She is postmenopausal for 2.5 years.

What is your management?

Management

1- How to assess the risk of malignancy in such cysts?

2- Where and by whom should the management be carried out?

3-What are the management options?

How to assess the risk of malignancy?

A-Transvaginal sonography (TVS) & Doppler

B-Transvaginal sonography & CA125

C-MRI

D-CT

E-Positron emission tomography (PET)

B

How to assess the risk of malignancy?

Ovarian cysts in postmenopausal women should be assessed using transvaginal sonography (TVS) and CA125.

There is no routine role yet for Doppler, MRI, CT or positron emission tomography (PET) or MRI spectroscopy.

Grade B, RCOG Guideline No. 34 October 2003.

Suspicious findings on USS

Bilateral ovarian cysts. Cystic/Solid parts. Multilocular ovarian cysts. Presence of intra or extracystic

papillae. Thick wall and Turbid contents. Presence of ascites. Evidence of metastasis.

RISK OF MALIGNANCY INDEX (RMI)Criteria Scoring

System Score

Menopausal status

premenopausal postmenopausal

13

A (1 or 3)

Ultrasonic feature

Multiloculated Solis areas BilateralityAscitesMetastasis

No feature = 0One feature =1> 1 feature =3

B (0,1 or 3)

Serum CA 125 Absolute level C

RISK OF MALIGNANCY

INDEX

Ax B x C

Jacobs et al Br J O bstet Gynaecol 1990 : 97 : 922-9

RISK OF MALIGNANCY INDEX (RMI)

If a cut off value of 200 is used to discriminate benign from malignant ovarian masses,

There is a good correlation, with a sensitivity of 87% and a specificity of 97%.

Jacobs et al Br J O bstet Gynaecol 1990 : 97 : 922-9

Risk Of Malignancy Index (RMI)

RMI Risk of cancer (%)

Low <25 <3

Moderate 25-250 20

High >250 75

The Case study: Transvaginal U/S revealed :

The Cyst was bilocular with no solid areas & no

other U/S abnormalities.

CA125 :35 IU/mL

RMI= 3(PM) x 1(TVS) x 35(CA125) = 75

2- Where and by whom you recommend the management?

A-General gynecologist

B-General gynecologist +

general surgeon

C-Gynecological cancer unit

D- Cancer center

C

Flowchart for the management of ovarian cysts in postmenopausal women

TVS and Serum CA125

Calculate RMI

RMI <25 RMI 25 - 250 RMI >250

Laparoscopy or laparotomy in cancer unit

Can be managed by a general gynecologist

laparotomy in cancer center

RCOG Guideline No. 34 October 2003

Simple unilateral cyst < 5

Serum CA125 < 30

Other cysts

Conservative management Normally Laparoscopy

Repeat TVS + CA125 (for max. of one year at / 4 months

Cyst resolved or reduced in size

No change in cystCyst increased in size or developed suspicious features

Discharge If no changes after one year ( three scans) then discharge

RMI <25Can be managed by a general gynecologist

Calculate RMI&

Manage As aboveRCOG Guideline 2003

RISK OF MALIGNANCY INDEX (RMI)

The RMI scoring system is the method of choice for predicting whether or not an ovarian mass is likely to be malignant.

Women with a risk of malignancy index score >200 should be referred to a centre with experience in ovarian cancer surgery.

National Guideline Clearinghouse 2003.

Management options

According to the RMI: Conservative management. Laparoscopy. Laparotomy.

Conservative management

Simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low risk of malignancy.

It is recommended that, in the presence of a normal serum CA125 levels, they be managed conservatively.

Grade B. RCOG Guideline No. 34 October 2003

LOW RISK:(RMI <25): < 3% risk of cancer

Management in a gynaecology unit.

Conservative management should entail repeat ultrasound scans and serum CA125 measurement every four months for one year.

If the cyst does not fit the above criteria or if the woman requests surgery then laparoscopic oophorectomy is acceptable.

MODERATE RISK: RMI =25-250approximately 20% risk of cancer

Management in a cancer unit. Laparoscopic oophorectomy is

acceptable in selected cases. If a malignancy is discovered

then a full staging procedure should be undertaken in a cancer centre

HIGH RISK: RMI =>250 > 75% risk of cancer

Management in a cancer centre.

Full staging procedure as described above.

What is the role of aspiration in the management of postmenopausal ovarian cysts?

A) Of value and should be used in simple cases.

B) Of no value and should not be tried.

Aspiration has no place

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

Grade B. RCOG Guideline No. 34 October 2003

Laparoscopy

The RMI should be used to select women for laparoscopic surgery, to be undertaken by a qualified surgeon.

The laparoscopic management should involve oophorectomy (usually bilateral) rather than cystectomy.

Laparoscopy

If a malignancy is revealed during laparoscopy or subsequent histology, it is recommended that the woman is referred to a cancer centre for further management.

A rapid referral of ovarian malignancy is recommended and secondary surgery should be performed as quickly as feasible.

Laparoscopy showing ovarian malignancy

Laparotomy All ovarian cysts that are suspicious of

malignancy as indicated by a high RMI, clinical suspicion or laparoscopy are likely to require a full laparotomy and staging procedure.

RCOG Guideline No. 34 October 2003

Laparotomy

This should be performed by an appropriate surgeon, working as part of a multidisciplinary team 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

RCOG guideline No 34.

Thank you