management of ovarian cysts in postmenopausal women
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)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