Ovarian cysts in postmenopausal women Flashcards
How are ovarian cysts diagnosed in postmenopausal women and what initial investigations should be
performed?
In postmenopausal women presenting with acute abdominal pain, the diagnosis of an ovarian cyst
accident should be considered (e.g. torsion, rupture, haemorrhage).
It is recommended that ovarian cysts in postmenopausal women should be initially assessed by measuring serum CA125 and transvaginal ultrasound scan. In order to calculate RMI I.
What is the role of history and clinical examination in postmenopausal women with ovarian cysts?
A thorough medical history should be taken from the woman, with specific attention to risk factors and
symptoms suggestive of ovarian malignancy, and a family history of ovarian, bowel or breast cancer
Appropriate tests should be carried out in any postmenopausal woman who has developed symptoms within the last 12 months that suggest irritable bowel syndrome, particularly in women over 50 years of age or those with a significant family history of ovarian, bowel or breast cancer
A full physical examination ofthe woman is essential and should include body mass index, abdominal
examination to detect ascites and characterise any palpable mass, and vaginal examination
Examination has a poor sensitivity for detection of ovarian masses (15-51%)
What blood tests should be performed in postmenopausal women with ovarian cysts?
CA125 should be the only serum tumour marker used for primary evaluation as it allows the RMI to be calculated. 90% malignant ovarian cysts will have elevated CA125, but up to 50% early stage disease will have negative CA125.
CA125 levels should not be used in isolation to determine if a cystis malignant.While a very high value
may assist in reaching the diagnosis, a normal value does not exclude ovarian cancer due to the
nonspecific nature of the test.
There is currently not enough evidence to support the routine clinical use of other tumour markers,
such as human epididymis protein 4 (HE4), carcinoembryonic antigen (CEA), CDX2, cancer antigen 72-4 (CA72-4), cancer antigen 19-9 (CA19-9), alphafetoprotein (-FP), lactate dehydrogenase (LDH) or
beta-human chorionic gonadotrophin (-hCG), to assess the risk of malignancy in postmenopausal
ovarian cyst
Imaging for postmenopausal cysts
TVUSS and TA USS should be first line imaging investigations
CT, MRI and positron emission tomography (PET)-CT scans are not recommended for the initial
evaluation of ovarian cysts in postmenopausal women
If, from the clinical picture, ultrasonographic findings and tumour markers, malignant disease is
suspected, a CT scan of the abdomen and pelvis should be arranged, with onward referral to a
gynaecological oncology multidisciplinary team
MRI should be used as the second-line imaging modality for the characterisation of indeterminate
ovarian cysts when ultrasound is inconclusive
Do all postmenopausal women with ovarian cysts require surgical evaluation and is there a role for
conservative management?
Cysts <1cm should not be reported as of no clinical significance.
Asymptomatic, simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low risk
of malignancy. In the presence of normal serum CA125 levels, these cysts can be managed
conservatively, with a repeat evaluation in 4–6 months. Itis reasonable to discharge these women from follow-up after 1 year if the cyst remains unchanged or reduces in size, with normal CA125, taking into consideration a woman’s wishes and surgical fitness.
If a woman is symptomatic, further surgical evaluation is necessary
All postmenopausal women with persistent complex adnexal mass needs surgical evaluation.
Do all postmenopausal women with ovarian cysts require surgical evaluation and is there a role for
conservative management?
Asymptomatic, simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low risk
of malignancy. In the presence of normal serum CA125 levels, these cysts can be managed
conservatively, with a repeat evaluation in 4–6 months. Itis reasonable to discharge these women from follow-up after 1 year if the cyst remains unchanged or reduces in size, with normal CA125, taking into consideration a woman’s wishes and surgical fitness.
If a woman is symptomatic, further surgical evaluation is necessary
A woman with a suspicious or persistent complex adnexal mass needs surgical evaluation
Could postmenopausal ovarian cysts be managed by laparoscopy?
Women with a RMI I of less than 200 (i.e. at low risk of malignancy) are suitable for laparoscopic
management.
Laparoscopic management of ovarian cysts in postmenopausal women should be undertaken by a surgeon with suitable experience.
Laparoscopic management of ovarian cysts in postmenopausal women should comprise bilateral salpingo-oophorectomy rather than cystectomy.
Women undergoing laparoscopic salpingo-oophorectomy should be counselled preoperatively that a full staging laparotomy will be required if evidence of malignancy is revealed.
Where possible, the surgical specimen should be removed without intraperitoneal spillage in a
laparoscopic retrieval bag via the umbilical port. This results in less postoperative pain and a quicker retrieval time than when using lateral ports of the same size. Transvaginal extraction of the specimen
is also acceptable, if the surgeon has the available expertise.
When should laparotomy be undertaken?
All ovarian cysts that are suspicious of malignancy in a postmenopausal woman, as indicated by a
RMI I greater than or equal to 200, CT findings, clinical assessment or findings at laparoscopy,
require a full laparotomy and staging procedure.
If a malignancy is revealed during laparoscopy or from subsequent histology, it is recommended that
the woman be referred to a cancer centre for further management.
How to manage:
- Asymptomatic, simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, with RMI <200
Repeat assessment in 4-6 months with CA125 and recalculate RMI
- Resolved: Discharge
- Remains the same: Repeat assessment in 4-6/12 then tailor management to patients wishes if it remains the same
- Change in features: consider intervention
How to manage:
- RMI<200 with any of the following: symptomatic, non-simple features, > 5 cm, multilocular, bilateral
- Consider BSO,
- Providing RMI<200 can be done laparoscopically
- Counsel preoperatively that if cancer found a full staging laparotomy may be required
- Try to remove without spilling via the umbilical port (less pain than port of same size laterally)
How to manage:
- RMI >200
- CT CAP
- Referral to Gynae oncology for MDT review
- MDT review- likely malignant: full staging procedure
- MDT review- unlikely malignant: Pelvic clearance (TAH + BSO + omentectomy + peritoneal cytology) by a suitably trained gynaecologist
Calculation of RMI
CALCULATION OF THE RMI I
The RMI I combines three presurgical features. It is a product of the serum CA125 level
(iu/ml); the menopausal status (M); and an ultrasound score (U) as follows:
RMI = U x M x CA125
• 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
3 = postmenopausal
• Serum CA125 is measured in iu/ml and can vary between zero and hundreds or even
thousands of units.
Incidence of postmenopausal cysts
estimated the incidence to be anywhere between 5% and 17%
History- symptoms of ovarian cyst
persistent abdominal distension,
feeling full and/or loss of appetite,
pelvic or abdominal pain,
increased urinary urgency and/or frequency
What is the Goff symptom index?
- Symptoms: Pelvic/abdominal pain or discomfort, increased abdominal size or bloating, early satiety/difficulty eating
Frequency >12 times per month
Present for <1 year
More sensitive in postmenopausal women
