CLINIOPATHOLOGICAL MEET

1. CASE REVIEW
• Mrs X 56 yrs postmenopausal female
presented to the opd with
Chief Complaints
• c/o pain lower abdomen off and on since one
year
• c/o breathlessness with palpitations x 2-3
months

2. History of presenting complaints
Pt was apparently well a year back when she
presented with c/o pain in the lower abdomen
vague , dull pain, low intensity, not radiating
since 1 year .
• She also had c/o breathlessness on exertion
with palpitations for which she was admitted
at Artemis hospital where she was worked for
the same ECG showed non specific changes
2D ECHO done was with in normal limits.

3. Menstrual history
• Postmenopausal since 10 years
• previous cycles regular
Obstetric History
P4L4A1 all normal vaginal deliveries
Past History not significant

4. Examination
General Physical Examination
• General condition fair
• PR 90/min regular
• B.P. 130/80mmHg
• No Pallor
• No Icterus
• P/A soft
Vague fullness in the lower abdomen
No definate lump could be felt

5. • P/S
cervix looks normal, a small sessile benign
cervical polyp seen vagina healthy
• P/V
Cervix feels firm, uterus retroverted
A large cystic mass palpable in right fornix and
Pouch of Douglas 10x10 cm mobile non tender

6. Investigations
• Blood Group B positive
• Hb 10gm% TLC 7900 Platelet 1,72000
• Blood Sugar Random 118mg%
• Serum creatinine 0.93
• HIV ,HBsAg negative
• Urine routine and Culture Normal
• Chest x ray normal

7. • PAPS Smear
• Transformation Zone Component seen
Mild Cellularity mainly showing parabasal
squamous epithilial cells having reactive
changes in form of increased nuclear size ,
perinuclear halo and vacuolations at places
with moderate acute inflammatory cells
Imp NILM Inflammatory Smear with
reactive changes

8. Ultrasound
Liver is normal in size and parenchymal echotexture.No
focal lesion is seen in the liver.Intrahepatic bile ducts are
not dilated. Hepatic , portal veins and the IVC are normal.
Gall bladder is normal in size and wall thickness . No
calculus or mass is seen. CBD is normal in diameter.
Both kidneys are of normal size shape and echopattern
Renal parenchyma is normal . Corticomedullary
differentiation is normal. Collecting system is normal.
Spleen is of normal size and echopattern .
Pancreas is of normal echopattern with no obvious focal
lesion. No evidence of free fluid seen in abdomen.
Urinary bladder doesnot show any intraluminal pathology .
Uterus is postmenopausal in size and appearance . No
adenexal mass is seen.

9. A large cystic lesion is seen in pelvic cavity measuring
11.06x 9.37 x 8.57cm. Its fluid contents are echofree. A
few thin internal septae seen in the cyst. Multiple
small cystic lobules are seen along the inner wall of
the cyst . Ovaries are not visualized separately .
No pelvic collection seen.
Impression large complex cyst
ECHO Report Normal
CA 125 10.2IU/ml

10. CECT Scan
Liver is normal in size , shape and outline .There is
normal post contrast enhancement Pancreas ,
Spleen and Bilateral Kidneys are normal in position
and outline
There is cystic mass in the pelvic region extending
from midline to right side 11.1 x 7.8x 9.7cm . The
wall is thin with enhancement at some places .No
evidence of any solid element seen with in the cyst
Uterus shows normal enhancement and has been
displaced inferiorly

11. No abnormal calcification seen
No free fluid seen in peritoneal cavity
Bowel loops small and large don’t show any
pathology
No evidence of abnormal mesentry
lymphadenopathy seen
Impression Pelvic Cystic mass right ovarian cyst

12. • After Preanaesthetic Check up and fitness staging Laparotomy
was under taken
• On opening the abdomen peritonial fluid and washings for
cytology for malignant cells were taken from pelvis , paracolic
gutters and upper abdomen and proceeded with exploratory
laparotomy
• Per op uterus with cervix and left ovary normal shape size and
texture
• Right ovarian mass well defined cystic 10cmx10cmx8cm with
smooth margins, mobile with right fallopian tube stretched out
over it

13. • No growth or excrescences seen any where
• No ascites
• Omentum looked normal
• Pouch of douglas normal
• Large and small gut normal
• Upper abdomen normal

14. • Proceeded with total Abdominal
Hysterectomy with bilateral
salphingoopherectomy , omental biopsy
taken
• Right ovarian cyst in OT Cut section showed
multicystic with mucinous material 10 cm x
10 cm

15. Histopathology
Specimen received
• Right Ovarian Cyst
• Uterus with Cervix
• Left Tube and Ovary
• Omental Biopsy
Gross specimen
• Right ovary already cut 8cmx5cmx3cm with stretched fallopian tube over
it measuring 4 cm in length
• Cut surface of ovary shows multiloculated cyst containing gelatinous
material and a solid focus yellowish in colour 1.5 cm in size
• Specimen of uterus ,cervix with left sided tube and ovary measuring
uterus measuring 7x5x2.5 cm tube 6.5cm in length ovary 3x1x0.5cm
• Cut surface shoes endometrial polyp measuring 2.5cm x 1.0cm in cavity
cervical polyp 1.5cmx0.5cm
• Omental biopsy fibrofatty tissue

16. Microscopic Examination
• Sections from right ovarian cyst shows
multiple cystic spaces lined by mucinous
epithelium. Several nest of transitional
epithelium with clear cytoplasm and
longitudinal nuclear groove(coffee bean
appearence) are seen . Few nests show cystic
spaces containing eosinophilic material .
• Histological findings are consistent with mixed
Brenner Mucinous tumour of ovary

17. • Proliferative Endometrium
• Endometrial polyp Adenomyosis uterus
• Chronic non specific cervicities
• Both tubes left ovary and peritonial biopsy are
unremarkable

18. Management of ovarian cysts in
postmenopausal women
RCOG GUIDELINE 2010

19. 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?

20. 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

21. 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 2010.

22. Suspicious findings on USG
 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.

23. RISK OF MALIGNANCY INDEX (RMI)
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
Jacobs et al Br J O bstet Gynaecol 1990 : 97 : 922-9

24. 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

25. Risk Of Malignancy Index (RMI)
RMI Risk of cancer (%)
• Low <25 <3
• Moderate 25-250 20
• High >250 75

26. 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

27. 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

28. 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

29. 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

30. 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 >250
should be referred to a centre with experience in ovarian
cancer surgery.
RCOG 2010.

31. Management options
According to the RMI:
• Conservative management.
• Laparoscopy.
• Laparotomy.

32. 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 2010

33. 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.

34. 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

35. HIGH RISK: RMI =>250
> 75% risk of cancer
• Management in a cancer centre.
• Full staging procedure as described
above.

36. 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.

37. Aspiration has no place
• Aspiration is not recommended for the
management of ovarian cysts in
postmenopausal women.
Grade B. RCOG Guideline No. 34 2010

38. 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.

39. 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.

40. Laparoscopy showing ovarian malignancy

41. 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 2010

42. 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

43. RCOG guideline No 34 2010.

44. Thank you