Management of Ovarian Cysts in Postmenopausal Women GT34, Premenopausal GT62 Flashcards
Which RMI score is recommended for assessment of postmenopausal cysts?
RMI I score
Threshold 200 (sens 78% spec 87%)
Some use 250 (sens 70% spec 90%)
What are the other scoring systems for postmenopausal cysts?
OVA1
Risk of Malignancy Algorithm
(Both require specific assays - ?practical)
IOTA comparable sens and spec
What is the management of postmenopausal simple, unilocular, unilateral cyst <5cm diameter?
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
When can aspiration be considered for postmenopausal cysts?
Symptom control if advanced malignancy and unfit for surgery/further treatment
When can postmenopausal cysts be managed laparoscopically?
RMI <200
BSO
Will need staging laparotomy if malignancy found
When should laparotomy be performed in postmenopausal cyst management?
RMI >=200
CT findings suggestive of malignancy
Clinical assessment suggests malignancy
Malignant findings at laparoscopy
What is the incidence of cysts (>1cm) in postmenopausal women?
5-17%
In which other conditions can Ca125 be raised?
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)
In how many postmenopausal women with simple cyst features will have benign disease?
95-99%
What features on ultrasound indicate a ‘complex’ cyst?
Complete septation (multilocular)
Solid nodules
Papillary projections
How is RMI I calculated?
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
What are the %s having cancer with RMI: <25 25-250 >250 ?
<25 - 3%
25-250 - 20%
>250 - 75%
What % of women will have some form of surgery in their lifetime for an ovarian mass?
10%
What is the incidence of a symptomatic cyst being malignant in premenopausal women and those over 50yo?
1: 1000
3: 1000 at 50
What % of suspected ovarian masses turn out to be non-ovarian in origin?
10%
What should be measured in all women under age 40 with a complex ovarian mass?
AFP
bHCG
(LDH) - USA guidance
Ca125 (unreliable at diagnosis)
What are the ‘B-rules’ by the IOTA group?
- Unilocular cyst
- Presence of soid components within (<7mm)
- Acoustic shadowing
- Smooth multilocular tumour with largest diameter <100mm
- No blood flow
What are the ‘M-rules’ by the IOTA group?
- Irregular solid tumour
- Ascites
- > = 4 papillary projections
- Irregular multilocular solid tumour with largest diameter
≥100 mm - Very strong blood flow
Which premenopausal women can be managed expectantly?
<50mm in diameter simple cysts
No F/U
Usually resolve within 3 cycles
What is the follow up for premenopausal women with a simple cyst 50-70mm in diameter?
Yearly USS
If larger - consider MRI or surgical intervention
