Ovarian cysts in premenopausal women

Question 1

Incidence of malignancy in premenopausal women with an ovarian cyst

Answer 1

1:1000 increasing to 3:1000 at the age of 50

Question 2

Underlying management rationale for premenopausal women

Answer 2

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

Question 3

List types of ovarian masses:

1. Benign ovarian
2. Benign non-ovarian
3. Primary malignant ovarian
4. Secondary malignant ovarian

Answer 3

1. Functional cysts, Endometriomas, Serous cystadenoma
   Mucinous cystadenoma, Mature teratoma
2. Paratubal cyst, Hydrosalpinges, Tubo-ovarian abscess, Peritoneal pseudocysts, Appendiceal abscess
   Diverticular abscess, Pelvic kidney
3. Germ cell tumour, Epithelial carcinoma, Sex-cord tumour
4. Predominantly breast and gastrointestinal carcinoma.

Question 4

History for women with ovarian mass

Answer 4

• Attention to risk factors or protective factors for ovarian malignancy and a family history of ovarian or breast cancer.
• ?Symptoms suggestive of endometriosis
• ?Symptoms suggesting possible ovarian malignancy: persistent abdominal distension, appetite change including increased satiety, pelvic or abdominal pain, increased urinary urgency and/or frequency.

Question 5

Examination for women with ovarian mass

Answer 5

Examination:
- Should include abdominal and vaginal
examination
- Presence or absence of local lymphadenopathy.
- Clinical examination has poor sensitivity in the detection of ovarian masses (15–51%) but its importance lies in the evaluation of mass tenderness, mobility, nodularity and ascites.

Question 6

Role of CA125 in evaluating cysts in premenopausal women

Answer 6

CA-125 is unreliable in differentiating benign from malignant ovarian masses in premenopausal
women because of the increased rate of false positives and reduced specificity. This is as a result of
CA-125 being raised in numerous conditions including fibroids, endometriosis, adenomyosis and
pelvic infection. Consequently a raised serum CA-125 should be interpreted cautiously. However, it
is important to note that only in stage III–IV endometriosis is it likely to be raised to several
hundreds or thousands of units/ml.21 It is also important to note that CA-125 is primarily a marker
for epithelial ovarian carcinoma and is only raised in 50% of early stage disease.22
● A serum CA-125 assay is not necessary when a clear ultrasonographic diagnosis of a simple ovarian cyst has
been made.23–26
● 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 (see Table 1).
● 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.3
● If serum CA-125 assay more than 200 units/ml, discussion with a gynaecological oncologist is recommended.3
Guidelines from the United Kingdom2 and the USA3 recommend that α-FP and hCG should be measured in all
women under 40 with a complex ovarian mass because of the possibility of germ cell tumours. Guidelines
from the USA also recommend measuring LDH in these women.

Question 7

Role of CA125 in evaluating cysts in premenopausal women

Answer 7

CA-125 is unreliable in differentiating benign from malignant ovarian masses in premenopausal
women because of the increased rate of false positives and reduced specificity.

CA-125 is primarily a marker for epithelial ovarian carcinoma and is only raised in 50% of early stage disease.

● A serum CA-125 assay is not necessary when a clear ultrasonographic diagnosis of a simple ovarian cyst has been made.23–26

● 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 8

Non-malignant causes of a raised CA125

Answer 8

Fibroids,
Endometriosis,
Adenomyosis
Pelvic infection

Question 9

Lab investigations for premenopausal women with ovarian cysts

Answer 9

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.

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

Question 10

How to calculate RMI?

Answer 10

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.

Question 11

Sensitivity and specificity of RMI>200 for ovarian ca?

Answer 11

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

Question 12

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

Answer 12

B Rules:

• Unilocular cysts
• Presence of solid components where the largest solid component <7 mm
• Presence of acoustic shadowing
• Smooth multilocular tumour with a largest diameter <100 mm
• No blood flow

M Rules:

• Irregular solid tumour
• Ascites
• At least four papillary structures
• Irregular multilocular solid tumour with largest diameter ≥100 mm
• Very strong blood flow

Question 13

Management of ovarian masses presumed to be benign in non-emergency situations

Answer 13

• 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.
• Ovarian cysts that persist or increase in size are unlikely to be functional and may warrant surgical
  management. Dermoids more likely to grow in size.

Question 14

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

Answer 14

A recent Cochrane review of the effects of the oral contraceptive pill in the treatment of functional
ovarian cysts concluded that there was no earlier resolution in the treatment group compared to
the control group.

However, these trials were small with significant heterogeneity.

Question 15

Surgical approach for the elective management of ovarian masses

Answer 15

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.

Laparoscopic management is cost-effective because of the associated earlier discharge and return to
work.

In the presence of large masses (>7cm) with solid components (for example large dermoid cysts) laparotomy may be appropriate, as evidence increased risk of spillage at laparoscopy and likelihood of extending port sights to remove tissue, thus negating benefit of laparoscopy.

A systematic review of six randomised controlled trials compared the laparoscopic approach with
laparotomy in a total of 324 women undergoing removal of ovarian cysts. Laparoscopy was
associated with reduced febrile morbidity, less postoperative pain, lower rates of postoperative
complications, earlier discharge from hospital and lower overall cost.

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.

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.

Spillage of dermoid can cause peritonitis- the pelvis should be irrigated with warm water if this occurs

Question 16

Should an ovarian cyst be aspirated?

Answer 16

Aspiration of ovarian cysts, either vaginally or laparoscopically, is less effective and is associated with
a high rate of recurrence (50-80%).

Question 17

For simple premenopausal ovarian cysts, what is the management if

• <5cm
• 5-7cm
• > 7cm

Answer 17

<5cm: No follow up a required as very likely to be physiological and almost always resolve

5-7cm: USS follow up at 1 year

> 7cm: Surgical intervention and/or MRI (cysts >7cm are difficult to fully characterise at USS)

Question 18

What is the risk of chemical peritonitis with spillage of dermoid cyst contents?

Answer 18

0.2%

If there has been spillage of a dermoid, Peritoneal lavage should be performed using large amounts of warmed fluids

RCOG GTG

Question 19

With laparoscopic ovarian cyst removal (benign), which port should the ovarian cyst be removed from?

Answer 19

When possible, via the umbilical port

• Less pain and quicker retrieval time
• Allows for smaller lateral ports
• Reduces incidence of incisional hernia, epigastric vessel injury
• Improved cosmetics

RCOG GTG

Question 20

Management of dermoid cysts.

Answer 20

Calculate RMI I and/or IOTA rules - if elevated refer to gyn oncology.

Generally surgical management - no evidence for what size this should be offered.

• laparoscopy
• consider laparotomy if >7cm due to higher risk of spillage - risks chemical peritonitis and possible upstaging a malignant mass.

Conservative Rx:

• if asymptomatic
• if size <5 or 6 cm
• annual scans +/- tumour markers

Mature cystic teratomas (dermoid cysts) have been shown to grow over time, increasing the risk of pain and ovarian accidents. Surgical management is therefore usually appropriate, with preoperative assessment using RMI 1 or ultrasound rules (IOTA Group).There is no evidence-based consensus on the size above which surgical management should be considered. Most studies have used an arbitrary maximum diameter of 50–60 mm among their inclusion criteria to offer conservative management.

Question 21

Management endometrioma.

Answer 21

Surgical management if ≥3cm, in order to obtain histology due to rare possibility of coinciding malignancy (2-3 x risk for clear cell, endometriod and LGSC ovarian cancers)

• Ideally laparoscopy under suitably qualified endometriosis surgeon
• Careful pre-operative work-up - consider MRI for DIE; tumour markers

Question 22

What is the sensitivity and specificity of the IOTA rules for detecting ovarian cancer?

Answer 22

sensitivity = 95%
specificity = 91%

Question 23

What is the role of MRI in the diagnosis of ovarian cysts?

Answer 23

Not indicated first line test.

Consider if USS findings equivocal to better characterise type and location of adnexal cysts.

Question 24

IOTA explanation of 6 cysts seen on USS

Answer 24

Simple cyst: unilocular, no internal material (anechoic), thin walled and avascular.

Corpus luteum: unilocular with peripheral vascularity (‘ring of fire’), second half of the cycle and associated with a secretory endometrium (unless there is a Mirena insitu). These often appear haemorrhagic.

Haemorrhagic cyst: unilocular, reticular pattern of fine thin intersecting lines (fibrin strands).

Endometrioma: homogeneous low-level internal echoes ‘ground glass’, minimal vascularity, smooth walled. Often bilocular, often bilateral.

Dermoid/teratoma: avascular, usually unilocular but with variable internal structure due to the differentiating cell types, most commonly hair (fine linear dots and dashes) and fluid levels (due to different fluid types). Classically dermoids have shadowing echogenic areas due to calcification.

Invasive malignancy: large irregular solid mass, highly vascular, usually no visible normal ovarian tissue remaining, ascites (defined by IOTA as fluid above the level of the uterine fundus to differentiate from physiological pelvic fluid commonly seen after ovulation).

Question 25

Management of haemorrhagic cyst

Answer 25

Haemorrhagic cysts often resolve spontaneously.

Repeat ultrasound in 3 months can be considered to ensure cyst resolution.

Ideally, this ultrasound should be performed just after a period to prevent confusion with a new corpus luteum.