GTG 62 premenopausal ovarian cyst management

Question 1

What is the incidence of a malignancy for symptomatic ovarian cysts in premenopausal women?

Answer 1

1 in 1000

Question 2

What is incidence of malignancy for symptomatic ovarian cysts in premenopausal women aged 50?

Answer 2

3 in 1000

Question 3

How should a woman with an incidental finding of a 3cm, asymptomatic, simple ovarian cyst be managed?

Answer 3

Do not perform ca-125 or other tumour markers
Does not require follow up
Offer reassurance that the cyst will resolve within 3 menstrual cycles

Question 4

What proportion of suspected of ovarian masses are non-ovarian in origin?

Answer 4

10%

Question 5

What proportion of borderline ovarian tumours will have suspicious features on ultrasound?

Answer 5

80%

Question 6

Which ovarian cancer is ca-125 primarily a marker for?

Answer 6

Epithelial ovarian carcinoma

Question 7

In a pre-menopausal woman, how should a ca-125 <200 be managed?

Answer 7

Exclude other causes of raised ca-125
Consider serial measurements of ca-125 because rapidly rising levels are more suggestive of ovarian cancer than static high levels

Question 8

In a pre-menopausal woman, how should a ca-125 of >200 units/ml be managed?

Answer 8

Refer to gynaeoncology

Question 9

Which risk of malignancy index is most effective in predicting risk of ovarian cancer?

Answer 9

RMI 1

Question 10

How is RMI calculated?

Answer 10

Ca125 x menopausal status (0= premenopausal, 1 = postmenopausal) x ultrasound findings

Question 11

Which ultrasound findings contribute to the RMI score?

Answer 11

Ultrasound findings (1 point for each)

1) Multilocal cysts
2) Solid areas
3) Bilateral lesions
4) Metastases
5) Ascites

Score = 0 = no features

Score =1 = 1 feature

Score = 3= 2-5 features

Question 12

What is the sensitivity and specificity of an RMI score of 200?

Answer 12

Sensitivity 78%

Specificity 87%

Question 13

What is the sensitivity and specificity of the IOTA ultrasound rules?

Answer 13

Sensitivity 95%

Specificity 91%

Question 14

Describe how cyst loculation on ultrasound is classified by B and M rules ?

Answer 14

Unilocular cyst = B rule

Multilocular, smooth, <100mm = B rule

Multilocular, irregular, >100mm = M rule

Question 15

Describe how blood flow in an ovarian cyst is classified in B and M rules?

Answer 15

No blood flow = B rule

Very strong blood flow = M rule

Question 16

Describe how solid components of an ovarian cyst are classified in B and M rules?

Answer 16

Acoustic shadowing = B rule

Solid components <7mm = B rule

Irregular solid tumour = M rule

> /= 4 papillary projections = M rule

Question 17

Is ascites classified as B or M rule?

Answer 17

M rule – refer to gynaeoncology

Question 18

Which ovarian cysts in premenopausal women do NOT require follow up?

Answer 18

<50mm, unilocular, simple ovarian cyst

Question 19

What feature of a simple ovarian cyst in a premenopausal woman should prompt follow up with ultrasound?

Answer 19

50-70mm require yearly ultrasound

Question 20

What feature of a simple ovarian cyst in a premenopausal woman would indicate the need for MRI?

Answer 20

The cyst is >70mm (MRI or surgical intervention is indicated)

Question 21

What are the two different ways of risk assessing premenopausal ovarian cysts?

Answer 21

RMI 1 (score >200 warrants referral to gynaeonc)

IOTA ultrasound rules – any positive M rules warrant referral to gynaeonc

Question 22

How should asymptomatic, persistent ovarian cysts be managed in premenopausal women?

Answer 22

Risk assess with wither RMI 1 or IOTA ultrasound rules
If increasing in size or persisting after several cycles – consider surgical management
Asymptomatic cysts 5-6cm are arbitarily managed conservatively

Question 23

Does COCP help resolve functional cysts?

Answer 23

No

Question 24

Which operative technique is preferred for ovarian cysts which a suspected to be benign?

Answer 24

Laparoscopy. Laparotomy may be considered for very large ovarian cysts but the cut off is unclear
Aspiration is not recommended due to high risk of recurrence

Question 25

What is the incidence of chemical peritonitis due to spillage of dermoid cyst contents?

Answer 25

0.2%

Question 26

How should ovarian cysts be removed at laparoscopy?

Answer 26

Tissue retrieval bag, via the umbilical port

Question 27

Which biochemical tests should be performed in a woman under the age of 40 presenting with a complex ovarian mass?

Answer 27

LDH AFP HCG, Ca-125