Management of ovarian cysts in postmenopausal women

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Management of ovarian cysts in postmenopausal women

  1. 1. Management of ovarian cysts in postmenopausal women By El-Said Abdel-Hady, PhD MRCOG , Mansoura University .
  2. 2. Case study <ul><li>A 54 -year-old woman, was referred with left ovarian cyst 8X8.5 cm discovered on abdominal U/S . </li></ul><ul><li>C/o: Left sided loin pain for 2 days. </li></ul><ul><li>She is postmenopausal for 2.5 years . </li></ul><ul><li>What is your management? </li></ul>
  3. 3. Management <ul><li>1- How to assess the risk of malignancy in such cysts? </li></ul><ul><li>2- Where and by whom should the management be carried out? </li></ul><ul><li>3-What are the management options? </li></ul>
  4. 4. How to assess the risk of malignancy? <ul><li>A-Transvaginal sonography (TVS) & Doppler </li></ul><ul><li>B-Transvaginal sonography & CA125 </li></ul><ul><li>C-MRI </li></ul><ul><li>D-CT </li></ul><ul><li>E-Positron emission tomography (PET) </li></ul>B
  5. 5. How to assess the risk of malignancy? <ul><li>Ovarian cysts in postmenopausal women should be assessed using transvaginal sonography (TVS) and CA125. </li></ul><ul><li>There is no routine role yet for Doppler, MRI, CT or positron emission tomography (PET) or MRI spectroscopy. </li></ul><ul><li>Grade B, RCOG Guideline No. 34 October 2003. </li></ul>
  6. 6. Suspicious findings on USS <ul><li>Bilateral ovarian cysts. </li></ul><ul><li>Cystic/Solid parts. </li></ul><ul><li>Multilocular ovarian cysts. </li></ul><ul><li>Presence of intra or extracystic papillae . </li></ul><ul><li>Thick wall and Turbid contents. </li></ul><ul><li>Presence of ascites. </li></ul><ul><li>Evidence of metastasis. </li></ul>
  7. 7. 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 <ul><li>Ultrasonic feature </li></ul><ul><li>Multiloculated </li></ul><ul><li>Solis areas </li></ul><ul><li>Bilaterality </li></ul><ul><li>Ascites </li></ul><ul><li>Metastasis </li></ul>C Absolute level Serum CA 125 Ax B x C RISK OF MALIGNANCY INDEX
  8. 8. RISK OF MALIGNANCY INDEX (RMI) <ul><li>If a cut off value of 200 is used to discriminate benign from malignant ovarian masses, </li></ul><ul><li>There is a good correlation, with a sensitivity of 87% and a specificity of 97%. </li></ul><ul><li>Jacobs et al Br J O bstet Gynaecol 1990 : 97 : 922-9 </li></ul>
  9. 9. Risk Of Malignancy Index (RMI) <ul><li>RMI Risk of cancer (%) </li></ul><ul><li>Low <25 <3 </li></ul><ul><li>Moderate 25-250 20 </li></ul><ul><li>High >250 75 </li></ul>
  10. 10. The Case study: <ul><li>Transvaginal U/S revealed : </li></ul><ul><li>The Cyst was bilocular with no solid areas & no other U/S abnormalities. </li></ul><ul><li>CA125 : 35 IU/mL </li></ul><ul><li>RMI= 3(PM) x 1(TVS) x 35(CA125) = 75 </li></ul>
  11. 11. 2- Where and by whom you recommend the management? <ul><li>A-General gynecologist </li></ul><ul><li>B-General gynecologist + general surgeon </li></ul><ul><li>C-Gynecological cancer unit </li></ul><ul><li>D- Cancer center </li></ul>C
  12. 12. 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
  13. 13. 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
  14. 14. RISK OF MALIGNANCY INDEX (RMI) <ul><li>The RMI scoring system is the method of choice for predicting whether or not an ovarian mass is likely to be malignant. </li></ul><ul><li>Women with a risk of malignancy index score >200 should be referred to a centre with experience in ovarian cancer surgery. </li></ul><ul><li>National Guideline Clearinghouse 2003. </li></ul>
  15. 15. Management options <ul><li>According to the RMI: </li></ul><ul><li>Conservative management. </li></ul><ul><li>Laparoscopy. </li></ul><ul><li>Laparotomy. </li></ul>
  16. 16. Conservative management <ul><li>Simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low risk of malignancy . </li></ul><ul><li>It is recommended that, in the presence of a normal serum CA125 levels, they be managed conservatively . </li></ul><ul><li>Grade B. RCOG Guideline No. 34 October 2003 </li></ul>
  17. 17. LOW RISK:( RMI <25): < 3% risk of cancer <ul><li>Management in a gynaecology unit . </li></ul><ul><li>Conservative management should entail repeat ultrasound scans and serum CA125 measurement every four months for one year . </li></ul><ul><li>If the cyst does not fit the above criteria or if the woman requests surgery then laparoscopic oophorectomy is acceptable. </li></ul>
  18. 18. MODERATE RISK: RMI =25-250 approximately 20% risk of cancer <ul><li>Management in a cancer unit. </li></ul><ul><li>Laparoscopic oophorectomy is acceptable in selected cases. </li></ul><ul><li>If a malignancy is discovered then a full staging procedure should be undertaken in a cancer centre </li></ul>
  19. 19. HIGH RISK: RMI =>250 > 75% risk of cancer <ul><li>Management in a cancer centre. </li></ul><ul><li>Full staging procedure as described above. </li></ul>
  20. 20. What is the role of aspiration in the management of postmenopausal ovarian cysts? <ul><li>A) Of value and should be used in simple cases. </li></ul><ul><li>B) Of no value and should not be tried. </li></ul>
  21. 21. Aspiration has no place <ul><li>Aspiration is not recommended for the management of ovarian cysts in postmenopausal women. </li></ul><ul><li>Grade B. RCOG Guideline No. 34 October 2003 </li></ul>
  22. 22. Laparoscopy <ul><li>The RMI should be used to select women for laparoscopic surgery, to be undertaken by a qualified surgeon . </li></ul><ul><li>The laparoscopic management should involve oophorectomy (usually bilateral ) rather than cystectomy. </li></ul>
  23. 23. Laparoscopy <ul><li>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 . </li></ul><ul><li>A rapid referral of ovarian malignancy is recommended and secondary surgery should be performed as quickly as feasible. </li></ul>
  24. 24. Laparoscopy showing ovarian malignancy
  25. 25. Laparotomy <ul><li>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 . </li></ul><ul><li>RCOG Guideline No. 34 October 2003 </li></ul>
  26. 26. Laparotomy <ul><li>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: </li></ul><ul><li>Cytology: ascites or washings </li></ul><ul><li>Laparotomy with clear documentation </li></ul><ul><li>Biopsies from adhesions and suspicious areas </li></ul><ul><li>TAH, BSO and infra-colic omentectomy </li></ul>
  27. 27. RCOG guideline No 34.
  28. 28. Thank you

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