Management of Suspected Ovarian Masses in Premenopausal Women

Question 1

incidence of Suspected Ovarian Masses in Premenopausal Women

Answer 1

• Up to 10% of women will have some form of surgery during their lifetime for the presence of an ovarian mass.
• In premenopausal women almost all ovarian masses and cysts are benign.
• The overall incidence of a symptomatic ovarian cyst in premenopausal female being malignant is approximately 1:1000 increasing to 3:1000 at the age of 50.

Question 2

nonovarian origin, in Suspected Ovarian Masses in Premenopausal Women

Answer 2

Ten percent of suspected ovarian masses are ultimately found to be non-ovarian in origin

Question 3

The underlying management rationale is to minimise patient morbidity by:

Answer 3

● conservative management where possible
● use of laparoscopic techniques where appropriate, thus avoiding laparotomy where possible
● referral to a gynaecological oncologist where appropriate.

Question 4

• Functional or simple ovarian cysts (thin-walled cysts without internal structures) which are less than 50 mm MX

Answer 4

Many ovarian masses in the premenopausal woman can be managed conservatively.
- Functional or simple ovarian cysts (thin-walled cysts without internal structures) which are less than 50 mm maximum diameter usually resolve over 2–3 menstrual cycles without the need for intervention.

Question 5

Preoperative differentiation between the benign and the malignant ovarian mass in the premenopausal
woman can be problematic with no test or algorithm being clearly superior in terms of accuracy. Exceptions

Answer 5

Exceptions
are germ cell tumours with elevations of specific tumour markers such as alphafetoprotein (α-FP) and human
chorionic gonadotrophin (hCG).

Question 6

If surgery is indicated, a approach

Answer 6

• If surgery is indicated, a laparoscopic approach is generally considered to be the gold standard for MX of benign ovarian masses.
• Laparoscopic MX is also cost-effective because of associated earlier discharge from hospital.
• Mini-laparotomy may be considered for occasional very large cysts of benign appearance. On rare occasions laparoscopic approach may be specifically contraindicated in an individual patient

Question 7

orderline ovarian tumours

Answer 7

It is important to consider borderline ovarian tumours as histological diagnosis when undertaking any surgery for ovarian masses and, when such histological diagnosis is made or strongly suspected, referral to a gynaecological oncology unit is recommended. Preoperative diagnosis can be difficult with radiological & serum markers being relatively insensitive, especially in their differentiation from stage I ovarian epithelial cancers.

• Although up to 20% of borderline ovarian tumours appear as simple cysts on ultrasonography majority of such tumours will have suspicious ultrasonographic finding.

Question 8

Types of adnexal masses

Answer 8

Benign ovarian 
1 - Functional cysts
2 - Endometriomas
3 - Serous cystadenoma
4 - Mucinous cystadenoma
5 - Mature teratoma

Benign non-ovarian 
1 - Paratubal cyst
2 - Hydrosalpinges
3 - Tubo-ovarian abscess
4 - Peritoneal pseudocysts
5 - Appendiceal abscess
6 - Diverticular abscess
7 - Pelvic kidney

Primary malignant ovarian
1 - Germ cell tumour
2 - Epithelial carcinoma
3 - Sex-cord tumour

Secondary malignant ovarian
1 - Predominantly breast and gastrointestinal carcinoma.

Question 9

What is the role of history and examination in the assessment of women with suspected ovarian masses?

Answer 9

• A thorough medical history should be taken from the woman with specific attention to risk factors or
  protective factors for ovarian malignancy and a family history of ovarian or breast cancer. Symptoms
  suggestive of endometriosis should be specifically considered along with any symptoms suggesting possible ovarian malignancy: persistent abdominal distension, appetite change including increased satiety, pelvic or abdominal pain, increased urinary urgency and/or frequency.
• A careful physical examination of the woman is essential and should include abdominal and vaginal
  examination and the presence or absence of local lymphadenopathy. In the acute presentation with pain the diagnosis of accident to the ovarian cyst should be considered (torsion, rupture, haemorrhage).
• Although clinical examination has poor sensitivity in the detection of ovarian masses (15–51%) its importance
  lies in the evaluation of mass tenderness, mobility, nodularity and ascites.

Question 10

What blood tests should be performed?

Answer 10

• A serum CA-125 assay does not need to be undertaken in all premenopausal women when an ultrasonographic diagnosis of a simple ovarian cyst has been made.21–23
• Lactate dehydrogenase (LDH), α-FP and hCG should be measured in all women under age 40 with a complex ovarian mass because of the possibility of germ cell tumours.

● A serum CA-125 assay is not necessary when a clear ultrasonographic diagnosis of a simple ovarian cyst has
been made.
● If a serum CA-125 assay is raised and less than 200 units/ml, further investigation may be appropriate to
exclude/treat the common differential diagnoses
● When serum CA-125 levels are raised, serial monitoring of CA-125 may be helpful as rapidly rising levels are more likely to be associated with malignancy than high levels which remain static.
● If serum CA-125 assay more than 200 units/ml, discussion with a gynaecological oncologist is recommended.

Question 11

What is the role of ultrasound in the assessment of suspected ovarian masses?

Answer 11

A pelvic ultrasound is the single most effective way of evaluating an ovarian mass with transvaginal
ultrasonography being preferable due to its increased sensitivity over transabdominal ultrasound.

Question 12

What is the role of the routine use of computed tomography and magnetic resonance imaging (MRI) in the assessment of suspected ovarian masses?

Answer 12

At the present time the routine use of computed tomography and MRI for assessment of ovarian masses
does not improve the sensitivity or specificity obtained by transvaginal ultrasonography in the detection
of ovarian malignancy.

Question 13

What is the best way to estimate the risk of malignancy?

Answer 13

An estimation of the risk of malignancy is essential in the assessment of an ovarian mass

• Simple models involve using discrete cut-off values such as CA-125, pulsatility index, resistance index.
• Intermediate models include morphology scoring systems and the risk of malignancy index.27,37
• Advanced models include artificial neural networks and multiple logistic regression models – a method for
  determining whether each of a set of independent variables has a unique predictive relationship to a
  dichotomous dependent variable.

Question 14

Which RMI should be used?

Answer 14

A systematic review of diagnostic studies concluded that the RMI I is the most effective for women with
suspected ovarian cancer.
RMI = U x M x CA-125.
● The ultrasound result is scored 1 point for each of the following characteristics: multilocular cysts, solid areas,
metastases, ascites and bilateral lesions. U = 0 (for an ultrasound score of 0), U = 1 (for an ultrasound score of
1), U = 3 (for an ultrasound score of 2–5).
● The menopausal status is scored as 1 = premenopausal and 3 = postmenopausal.
● Postmenopausal can be defined as women who have had no period for more than one year or women over
the age of 50 who have had a hysterectomy.
● Serum CA-125 is measured in IU/ml and can vary between zero to hundreds or even thousands of units.
A recent systematic review36 showed the pooled sensitivities and specificities of an RMI I score of 200 in the detection of ovarian malignancies to be:

Question 15

RMI I sensitivity specificity

Answer 15

RMI I sensitivity 78% (95% CI 71-85%), specificity 87% (95% CI 83-91%)

Question 16

Is there another way to estimate accurately a risk of malignancy in premenopausal women without using
a CA-125?

Answer 16

• There are simple ultrasound rules derived from the IOTA Group. The use of specific ultrasound
  morphological findings without CA-125 has been shown to have high sensitivity, specificity and likelihood ratios.
• If not clearly classifiable from these rules, further investigation by a specialist in gynaecological
  ultrasound is appropriate.

Question 17

IOTA Group ultrasound ‘rules’ to classify masses as benign (B-rules) or malignant (M-rules)

Answer 17

B-rules
1 - Unilocular cysts
2 - Presence of solid components where the largest solid component <7 mm
3 - Presence of acoustic shadowing
4 - Smooth multilocular tumour with a largest diameter <100 mm
5 - No blood flow

M-rules
1 - Irregular solid tumour
2 - Ascites
3 - At least four papillary structures
4 - Irregular multilocular solid tumour with largest diameter ≥100 mm
5 - Very strong blood flow

Question 18

D

Answer 18

Can asymptomatic women with simple ovarian cysts be managed expectantly?
Women with small (less than 50 mm diameter) simple ovarian cysts generally do not require follow-up
as these cysts are very likely to be physiological and almost always resolve within 3 menstrual cycles.
Women with simple ovarian cysts of 50–70 mm in diameter should have yearly ultrasound follow-up and
those with larger simple cysts should be considered for either further imaging (MRI) or surgical
intervention.

Question 19

D

Answer 19

With the widespread use of ultrasound in clinical practice incidental finding of simple ovarian cysts has
become commonplace. In one study 4% of women, with a median age of 26 years, had an ovarian cyst greater
than 30 mm in diameter in their luteal phase.52

Question 20

D

Answer 20

One generally accepted definition of an ovarian cyst is: ‘a fluid-containing structure more than 30
mm in diameter’. Women with simple cystic structures less than 50 mm generally do not require
follow-up as these cysts are very likely to be physiological and almost always resolve within 3
menstrual cycles.53 The Society of Radiologists in Ultrasound published a consensus statement
concluding that asymptomatic simple cysts 30–50 mm in diameter do not require follow-up, cysts
50–70 mm require follow-up, and cysts more than 70 mm in diameter should be considered for
either further imaging (MRI) or surgical intervention due to difficulties in examining the entire cyst
adequately at time of ultrasound.54

Question 21

How should persistent, asymptomatic ovarian cysts be managed?

Answer 21

Ovarian cysts that persist or increase in size are unlikely to be functional and may warrant surgical
management.

Question 22

Does the use of combined oral contraceptives help in the treatment of functional ovarian cysts?

Answer 22

The use of the combined oral contraceptive pill does not promote the resolution of functional ovarian
cysts.

Question 23

Is the laparoscopic approach better for the elective surgical management of ovarian masses?

Answer 23

The laparoscopic approach for elective surgical management of ovarian masses presumed to be benign
is associated with lower postoperative morbidity and shorter recovery time and is preferred to
laparotomy in suitable patients.7–10
Laparoscopic management is cost-effective because of the associated earlier discharge and return to
work.11
In the presence of large masses with solid components (for example large dermoid cysts) laparotomy
may be appropriate.

Question 24

D

Answer 24

The maximum cyst size above which laparotomy should be considered is controversial. In one trial
comparing mini-laparotomy with laparoscopy for the surgical management of benign ovarian tumours, cyst
rupture occurred more often in the laparoscopy group, but only in a subgroup of women with cysts larger
than 70 mm.9

Question 25

D

Answer 25

Who should perform laparoscopic surgery for a presumed benign ovarian cyst?
Laparoscopic management of presumed benign ovarian cysts should be undertaken by a surgeon with
suitable experience and appropriate equipment, whenever local facilities permit.

Question 26

D

Answer 26

Should an ovarian cyst be aspirated?
Aspiration of ovarian cysts, either vaginally or laparoscopically, is less effective and is associated with
a high rate of recurrence.

Question 27

D

Answer 27

Randomised controlled trials have shown the resolution rates of simple ovarian cysts to be similar
whether expectant management or ultrasound guided needle aspirations were used (46% versus
44.6% respectively).65 The recurrence rates after laparoscopic needle aspiration of simple cysts
range from 53% to as high as 84%

Question 28

D

Answer 28

For highly selected cases, following discussion between the woman and her clinician, transvaginal or
laparoscopic aspiration may be an appropriate intervention.

Question 29

D

Answer 29

Is it important to avoid unplanned rupture of the cyst?
Spillage of cyst contents should be avoided where possible as preoperative and intraoperative
assessment cannot absolutely preclude malignancy.
Consideration should be given to the use of a tissue bag to avoid peritoneal spill of cystic contents
bearing in mind the likely preoperative diagnosis.

Question 30

D

Answer 30

It is preferable to avoid spillage of cyst contents because the apparently benign characteristics of a cyst on
preoperative and intraoperative assessment cannot absolutely preclude malignancy.68
Chemical peritonitis due to spillage of dermoid cyst contents has been reported in different series to occur
in less than 0.2% of cases.69–71 If inadvertent spillage does occur, meticulous peritoneal lavage of the peritoneal
cavity should be performed using large amounts of warmed fluid. Use of cold irrigation fluid may not only
cause hypothermia, but it will also make retrieval of the contents more challenging by solidifying the fat-rich
contents. Any solid content should be removed using an appropriate bag.
The RCOG Green-top Guideline on the investigation and management of endometriosis1 recommends in the
case of endometrioma (greater than 30 mm in diameter) that histology should be obtained to identify
endometriosis and to exclude rare cases of malignancy. Obtaining such histology using the standard surgical
technique will inevitably cause peritoneal spill of cyst contents. There is always the potential to inadvertently
upstage a tumour if the suspected endometrioma is actually a malignant tumour. This is rare: a leading centre
reported no cases of malignancy in 814 women with consecutive endometriomas of greater than 30 mm in
diameter.72As there is no effective preoperative discriminator between an endometrioma and some rare cases
of ovarian cancer such upstaging may be inevitable. Consideration of the possibility of rare underlying
malignancy should be managed on an individual basis through multidisciplinary team meetings.

Question 31

D

Answer 31

When should an oophorectomy be performed?
The possibility of removing an ovary should be discussed with the woman preoperatively.
This discussion should be in the context of it being either an expected or unexpected part of the procedure.
The pros and cons of electively removing an ovary should be discussed, taking into consideration the
woman’s preference and the specific clinical scenario.

Question 32

D

Answer 32

How should an ovarian mass be removed?
Where possible removal of benign ovarian masses should be via the umbilical port. This results in less
postoperative pain and a quicker retrieval time than when using lateral ports of the same size.
Various types of laparoscopic tissue retrieval bags have been described, both specifically designed
products and innovatively used pre-existing equipment. The use of tissue retrieval bags is
commonplace but there is no general consensus for their routine use.
Removing tissue in a tissue retrieval bag via the umbilical port has been investigated in a
randomised73 and a large prospective trial.74 Removal of benign ovarian masses via the umbilical
port should be utilised where possible as this results in less postoperative pain and a quicker
retrieval time. Avoidance of extending accessory ports is beneficial in reducing postoperative pain,
as well as reducing incidence of incisional hernia and incidence of epigastric vessel injury. It also
leads to improved cosmesis.