Ovarian Masses Flashcards
IOTA rules
What are the B rules
What are the M rules
B - for benign
Unilocular cysts
solid components where the largest solid component is <0.7cm
Presence of acoustic shadowing
Smooth multilocular tumor with largest diameter <10cm
no blood flow
M rules Irregular solid tumor Ascites At least 4 papillary structures Irregular multilocular solid tumors with largest diameter >10cm Very good blood flow
Worst features are multilocular and solid elements
What is the rate of cancer if:
No M features and >2 B features
No M and 2 B (or B1 unilocular)
No M 1B (not unilocular)
no M or B
There are more M features then B features
No M features and >2 B features = 0.6% No M and 2 B (or B1 unilocular) = 1.3% No M 1B (not unilocular) =8.3% no M or B =41% There are more M features then B features =87%
What is the RMI cut of for malignancy and associated sensitivity and specificity
RMI > 200 Sensitivity 78% specificity 87%
What is the RMI
U X M X CA125
what is U
What is M
U No features = 0 1 point = 1 feature 2 = 2 or more features multilocular, solid, metastasis ascites, bilateral lesions
M Menopausal status
1 = premenopausal
2 = postmenopausal
Risk factors from family hx for ovarian cancer
Risk factors for malignancy:
Two or more first-degree relatives with ovarian cancer
One with ovarian cancer at any age and one with breast cancer under 50
One relative with ovarian cancer at any age and two with breast cancer under 60
Three or more family members with colon cancer or two with colon cancer and one with stomach, ovarian, endometrial, urinary tract or small bowel cancer in two generations
On individual with both breast and ovarian cancer
Also increased risk if BRCA1, BRCA 2 or mismatch repair genes carrier
How to manage simple cysts
Premenopausal
What are the size cut offs and recommended intervention
Simple cyst less then 50mm
- likely will resolve in 3 menstural cycles, no follow up needed
Simple cyst 50-70mm - annual USS FU
Simple cyst over 70mm - consider MRI or surgical intervention
What is the role of COCs in functional cysts?
The use of the COCP does not promote the earlier resolution of functional cysts in small heterogenous trials, but it does prevent further cyst formation
What other tests in young woman for complex ovarian cysts ?
Is CA125 in the premenopusal woman reliable ??
LDH, ɑ-FP and hCG should be measured due to possibility of germ cell tumours in woman under 40
Ca125 is unreliable in differentiating malignant or benign masses in premenopausal women (higher false positive and decreased specificity)
If Ca125 raised to <200units/ml then further investigation may be required to exclude the other common differential diagnoses
Rapidly rising levels of Ca125 are more likely to be associated with malignancy
If Ca125 raised >200units/ml there should be discussion with gynaeoncology
What size ovarian cyst in the post menopausal woman do you need to investigate?
All cysts in postmenopausal women should be investigated with Ca125 and TV USS
There is not enough evidence to support routine use of other tumour markers
TV USS without colour flow Doppler is the best imaging modality. There is no evidence for CT/MRI/PET-CT scans for initial assessment of ovarianc masses
Postmenopausal woman
RMI <200
Cyst <5cm
If Ca125 is not raised then conservative management with follow up scan in 4-6 months is recommended
Discharge the woman if there is no increase in cyst size after 1 year and there is no rise in Ca125
Postmenopausal woman
RMI >200
What do you do?
This prompts referral for CT and onward referral to gynae oncology MDT for discussion of further management
CT is to evaluate the abdomen for omental masses, LN, hepatic masses, obstructive uropathy, or alternate primary cancer site
MRI can be second-line imaging modality to characterise indeterminate ovarian/adnexal masses if USS is inconclusive
If RMI >200 OR clinical assessment OR CT findings suggests malignancy then full staging and laparotomy is required
If malignancy is revealed during laparoscopy or subsequent histology then referral to a cancer centre is required for further management
What do you operate on the post menopausal cyst ?
What operation?
If the cyst is greater than 5cm OR non-simple features OR multilocular OR bilateral OR if the woman is symptomatic then surgical evaluation is necessary
If the RMI <200 then laparoscopic management is suitable and should comprise bilateral salpingo-oophorectomy rather than cystectomy and specimen should be removed without spillage
There is no role for aspiration of cysts in postmenopausal women
All women should be counselled that if there is suspicion of malignancy (intra-operatively) then a staging laparotomy is required
Management of women with a RMI <200 may be by a general gynaecologist with the appropriate laparoscopic skills
In pregnancy if there is a cyst why wait until after the first trimester?
Almost ALL functional cysts will have resolved by this time
Organogenesis is mostly complete, thus minimizing the risk of drug-induced teratogenesis
Decreased miscarriage risk - the hormonal function of the corpus luteum has been replaced by the placenta, so decreased progesterone secretion after oophorectomy or cystectomy does not result in loss of the pregnancy if not replaced
Spontaneous pregnancy losses due to intrinsic fetal abnormalities are likely to have already occurred and will not be erroneously attributed to the surgery
What are risk factors and protective factors for ovarian cancer ?
risk 7
protective 4
Risk factors • Nulliparous • early menarche • late menopause • infertility • BMI over 30 Genetic syndrome HNPCC or BRCA (average age 50) Age - average dx 60 yo
Protective • OCP • Breastfeeding • Multiparous • TL
How often is the CA125 raised in ovarian cancer ?
Early stage 30-50%
advanced 80%
Better PPV 70-100% in postmenopausal woman sensitivity 69-87% specificity 81-100%
