OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN RCOG guidelines, 2003

1. OVARIAN CYSTS
IN
POSTMENOPAUSAL
WOMEN
RCOG guidelines, 2003
Aboubakr Elnashar
Benha university Hospital,
Egypt
aboubakrelnashar

2. Assessment:
1. CA125
Range of normal is different in each lab
Most reliable serum marker for epithelial ovarian
carcinoma {Raised in over 75% of cases}.
Cut-off of 30 u/ml: sensitivity of 81%
specificity of 75%.
Raised in:
Only50% of stage I cases.
Other malignancies
Benign conditions: e.g. benign cysts and
endometriosis.
aboubakrelnashar

3. 2. Transvaginal sonography.
sensitivity of 89%
specificity of 73%
No routine role for:
Doppler, MRI, CT
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4. 3. Risk of malignancy index (RMI)
To select those women who require primary
surgery in a cancer centre by a gynaecological
oncologist.
RMI = U x M x CA125
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5. RMI II score: recommended
more sensitive than the RMI I
specificity of 90%
positive predictive values around 80%.
Simple
cut-off score of 200.
aboubakrelnashar

6. RMI I SCORE
•U = ultrasound score
U= 0 (for US score of 0)
U = 1 (for US score of 1)
U = 3 (for US score of 2–5)
one point for each of the following:
Multilocular cyst
Solid areas
Bilateral
Metastases
Ascites
•M = 3 for all postmenopausal women
•CA125=serum CA125 measurement in u/ml
aboubakrelnashar

7. Management of ovarian cysts
I. Conservative management
Indication:
1. Cyst:
Simple
Unilateral
Unilocular
<5 cm {low risk of malignancy}.
2. CA125:
Normal
aboubakrelnashar

8. II. Surgical management
Indication:
Those women who do not fit the above criteria for
conservative management
Where:
most suitable location
By:
most suitable surgeon
How:
Aspiration is not recommended
aboubakrelnashar

9. 1. Laparoscopy
Oophorectomy (usually bilateral) rather than
cystectomy.
If a malignancy is revealed (during laparoscopy or
subsequent histology):
Referral to a cancer centre for secondary surgery as
quickly as feasible.
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10. 2. Laparotomy
Indication:
suspicion of malignancy as indicated by
1. High RMI
2. Clinical
3. laparoscopy
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11. BY:
An appropriate surgeon, working as part of a
multidisciplinary team in a cancer centre
Through
Extended midline incision
Include:
● cytology: ascites or washings
● laparotomy with clear documentation
● biopsies from adhesions and suspicious areas
● TAH, BSO and infra-colic omentectomy
The laparotomy and staging procedure may include
bilateral selective pelvic and para-aortic
lymphadenectomy.
aboubakrelnashar

12. I. LOW RISK: RMI≤25
<3% risk of cancer
● Where: gynaecology unit.
● Indications:
Simple cysts ≤5 cm
CA125 <30
● Management:
1. Conservative:
US and CA125/4 months for one year.
2. laparoscopic oophorectomy
If the cyst does not fit the above criteria or
if the woman requests surgery
aboubakrelnashar

13. II. MODERATE RISK: RMI: 25-250
20% risk of cancer
● Where: cancer unit.
●Management:
1. Laparoscopic oophorectomy
in selected cases.
2. If a malignancy is discovered:
full staging procedure
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14. III. HIGH RISK: RMI ≥250
>75% risk of cancer
● Where: cancer centre.
● Management: Full staging procedure
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