Management of Ovarian Cysts in Postmenopausal Women GT34, Premenopausal GT62

Question 1

Which RMI score is recommended for assessment of postmenopausal cysts?

Answer 1

RMI I score
Threshold 200 (sens 78% spec 87%)
Some use 250 (sens 70% spec 90%)

Question 2

What are the other scoring systems for postmenopausal cysts?

Answer 2

OVA1
Risk of Malignancy Algorithm
(Both require specific assays - ?practical)
IOTA comparable sens and spec

Question 3

What is the management of postmenopausal simple, unilocular, unilateral cyst <5cm diameter?

Answer 3

If normal Ca125
Repeat scan and Ca 125 in 4-6 months
Discharge after 1 year if same/smaller with Ca125 depending on wishes/surgical fitness

Question 4

When can aspiration be considered for postmenopausal cysts?

Answer 4

Symptom control if advanced malignancy and unfit for surgery/further treatment

Question 5

When can postmenopausal cysts be managed laparoscopically?

Answer 5

RMI <200
BSO
Will need staging laparotomy if malignancy found

Question 6

When should laparotomy be performed in postmenopausal cyst management?

Answer 6

RMI >=200
CT findings suggestive of malignancy
Clinical assessment suggests malignancy
Malignant findings at laparoscopy

Question 7

What is the incidence of cysts (>1cm) in postmenopausal women?

Answer 7

5-17%

Question 8

In which other conditions can Ca125 be raised?

Answer 8

PID
Fibroids
Acute events with benign cysts e.g. haemorrhage
Endometriosis
Caucasian > African or Asian
Conditions that cause irritation of peritoneum (e.g. TB, ascites etc)
Primary tumours that metastasise to peritoneum (Breast, pancreas, lung, colon)

Question 9

In how many postmenopausal women with simple cyst features will have benign disease?

Answer 9

95-99%

Question 10

What features on ultrasound indicate a ‘complex’ cyst?

Answer 10

Complete septation (multilocular)
Solid nodules
Papillary projections

Question 11

How is RMI I calculated?

Answer 11

U x M x Ca125

M = pre (1) post (3)

U = 0 - no features
= 1 - 1 feature
= 3 - 2-5 features

Multilocular
Solid areas
Metastases
Ascites
Bilateral

Question 12

What are the %s having cancer with RMI:
<25
25-250
>250
?

Answer 12

<25 - 3%
25-250 - 20%
>250 - 75%

Question 13

What % of women will have some form of surgery in their lifetime for an ovarian mass?

Answer 13

10%

Question 14

What is the incidence of a symptomatic cyst being malignant in premenopausal women and those over 50yo?

Answer 14

1: 1000
3: 1000 at 50

Question 15

What % of suspected ovarian masses turn out to be non-ovarian in origin?

Answer 15

10%

Question 16

What should be measured in all women under age 40 with a complex ovarian mass?

Answer 16

AFP
bHCG
(LDH) - USA guidance
Ca125 (unreliable at diagnosis)

Question 17

What are the ‘B-rules’ by the IOTA group?

Answer 17

• Unilocular cyst
• Presence of soid components within (<7mm)
• Acoustic shadowing
• Smooth multilocular tumour with largest diameter <100mm
• No blood flow

Question 18

What are the ‘M-rules’ by the IOTA group?

Answer 18

• Irregular solid tumour
• Ascites
• > = 4 papillary projections
• Irregular multilocular solid tumour with largest diameter
  ≥100 mm
• Very strong blood flow

Question 19

Which premenopausal women can be managed expectantly?

Answer 19

<50mm in diameter simple cysts
No F/U
Usually resolve within 3 cycles

Question 20

What is the follow up for premenopausal women with a simple cyst 50-70mm in diameter?

Answer 20

Yearly USS

If larger - consider MRI or surgical intervention