Management of ovarian cysts in postmenopausal women
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Management of ovarian cysts in postmenopausal women

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Management of ovarian cysts in postmenopausal women Management of ovarian cysts in postmenopausal women Presentation Transcript

  • 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) Jacobs et al Br J O bstet Gynaecol 1990 : 97 : 922-9 Score Scoring System Criteria A (1 or 3) 1 3 Menopausal status premenopausal postmenopausal B (0,1 or 3) No feature = 0 One feature =1 > 1 feature =3
    • Ultrasonic feature
    • Multiloculated
    • Solis areas
    • Bilaterality
    • Ascites
    • Metastasis
    C Absolute level Serum CA 125 Ax B x C RISK OF MALIGNANCY INDEX
  • 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 cyst Cyst increased in size or developed suspicious features Discharge If no changes after one year ( three scans) then discharge RMI <25 Can be managed by a general gynecologist Calculate RMI& Manage As above RCOG 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 =25-250 approximately 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