RANZCOG questions on ovarian cysts Flashcards
A 25 year old woman is undergoing a caesarean section for an abnormal CTG. After delivery of the baby you find an enlarged ovary that is cystic and solid in nature with a few papillary excrescences on the surface. You suspect this could be a borderline tumour.
a. Describe the intra-operative options available to confirm the diagnosis and assess the disease in this setting? (6 marks)
• Ensure patient stable, haemostasis achieved etc before managing
• Inform patient and anaethetist of findings
• Options: Immediate assessment vs delayed (do nothing now and return later for full staging laparotomy). Preferable to do now if situation allows and patient gives verbal consent.
• Options to confirm diagnosis:
o Biopsy, ovarian cystectomy or unilateral salpingo-oophorectomy – preferable to perform oophorectomy (biopsy may upstage disease, cystectomy alone increases rate of recurrence)
o Frozen section for urgent histology if service available
• Assess the disease:
o Explore (inspect/palpate):
Other ovary and biopsy/cystectomy if abnormal
Tubes
Peritoneal surfaces including diaphragm if tolerated and access allows
Palpate liver if tolerated and access allows
Omentum
Biopsy if any suspicious lesions
o Peritoneal washings – although will be contaminated with blood and amniotic fluid/debris so probably not helpful – document on form manner in which taken
• Issues
o If under GA, inadequate consent
o If under regional analgesia possibly inadequate analgesia to perform above
o Likely have used Pfannensteil incision- limited access to upper abdomen
o Washings likely to be contaminated with blood/amniotic fluid and debris
o Frozen section histology difficult to interpret in pregnancy
A 25 year old woman is undergoing a caesarean section for an abnormal CTG. After delivery of the baby you find an enlarged ovary that is cystic and solid in nature with a few papillary excrescences on the surface. You suspect this could be a borderline tumour.
Initial biopsy confirms a serous borderline tumour. How would you counsel the patient about this condition, her treatment and follow up? (9 marks)
• Condition:
o Tumour of low malignant potential. Hasn’t invaded serosa as compared to invasive ovarian cancer
o Tend to be confined to ovary
• Prognosis:
o Good prognosis when staged accurately
o 5 year survival:
Stage 1 99% (majority -75% are stage 1 at diagnosis)
Stage 2 98%
Stage 3 96%
Stage 4 77%
• Treatment:
o Refer to Gynaeoncology MDM
o Needs to complete staging as this determines future management and identifies occult disease
o Staging: unilateral oophorectomy (if not already done), washings, omentectomy, exploration of peritoneal surfaces
o If other ovary is normal macroscopically and on USS do not need to biopsy
o Given age, TAH/BSO is not necessary however consider if patient adamant would like this, or when childbearing complete as this is definitive treatment
o Ongoing management depends on final staging, rarely need chemotherapy unless stage 3 or 4, and even this is controversial
• Followup:
o Prognosis as above
o Recommend annual longterm followup with history, examination, USS +/- tumour markers
o Pregnancy/fertility treatments not contraindicated
o Consider completion surgery with TAH/BSO once family complete (counsel on surgical menopause)
o Recurrence rates:
Cystectomy 25%
Oopherectomy 10%
TAH/BSO <5%
o Very low risk of malignant transformation <1%
You see a 37 year old woman in the Gynaecology Outpatient Clinic. Two months ago she developed acute appendicitis on holiday and had an uncomplicated laparoscopic appendicectomy at a rural hospital. An incidental finding of an 8cm left ovarian cyst was made at the time of surgery and a laparoscopic ovarian cystectomy was performed. Her recovery was uneventful and she attends with a letter from the rural hospital that advised her that she had a borderline ovarian tumour (BOT).
a.
i) After initial history and examination, outline your immediate management plan with regard to her BOT. (4 marks)
ii) Justify each of your management points. (4 marks)
Use a table for your answer in part a.
- Request notes:
- Ensure cyst was completely excised
- Review images and ensure there was no evidence of intra-peritoneal spread and ensure cyst was on the left ovary
- Review if cyst was ruptured during operation
- Ensure contralateral ovary appeared normal
- The above factors may increase the risk of spread and recurrence - Review pathology
- Review pathology of appendix- mucinous tumours of the ovary, especially if associated with pseudomyoxma peritonei, are often of appendiceal origin
- Review DNA aneuploidy status and if micropapillary tumour- higher risk pointing towards needing completion treatment
- Ensure ovary and appendix have been thoroughly sectioned and reviewed by an experienced pathologist as sections of invasion/atypia may be missed
- Higher risk histology may need further surgery and has a higher risk of recurrence - Tumour markers
- CA125, CA19-9 and CEA- if levels are high then invasive cancer should be suspected - Pelvic USS
- Review current status of both ovaries and if any residual lesions are present
- Consider MRI if lesions are present to review if there are any peritoneal or extra-ovarian lesions - Referral to gynae oncology MDM
- Will enable formal case review by qualified gynae-oncologists, radiologists, oncologists, and pathologists to give opinion on treatment options going forward - Arrange follow-up
Ensure that above are complete and explain the findings to the woman
b. What histological findings are associated with an increased risk of recurrence of a borderline ovarian tumour? (2 marks)
- Higher stage disease
- Invasive implants
- DNA aneuploidy
- Serous tumours with micropapillary features
The woman has not yet had a family but intends to in the future. Assuming that she has no high-risk histological findings;
c. Evaluate her current management considerations to reduce her long-term health risks but enable her to have a family and her future management considerations. (5 marks)
• Counselling for the woman to explain the pathology and implications
o Discuss with the woman what her plans are with regards to further fertility and her feelings about surgery
• Conservative management
o No consensus on which women need restaging or completion surgery, which is why review at the gynae onc MDM with the above information will be helpful
o This is often on a case-by-case approach, which takes into account:
Histological subtype of borderline tumour
Completeness of the primary surgery
Fertility desires of the woman
o There is no evidence that pregnancy or fertility treatment increase the risk of recurrence
• Restaging and fertility-sparing conservative surgery
o Restaging surgery should be considered if any of the above histological findings are present and after discussion with the woman
o Should include: peritoneal washings, omentectomy, and examination of the peritoneum in this woman. If there is no evidence of ongoing disease on the left ovary, this could be spared but in most cases a unilateral salpingo-ophorectomy would be performed and the specimens sent for histology
o Surgery should be done in a gynae-oncology unit
• Completion of surgery once family complete or with more advanced disease
o Completion surgery is a total hysterectomy and bilateral salpingo-ophorectomy, washings, omentectomy, appendicectomy, removal of all visible tumour and this should be performed after her family is complete or if necessary
o Should be done in a gynae-oncology unit and be carefully counselled
• HRT
o There is no data regarding the risk of HRT after a borderline tumour
o Women should be counselled about the risks and benefits and consider using HRT up until the average age of menopause
• Ongoing monitoring
o Risk of recurrence is varied- depends on type of tumour and primary surgery
o Clinical examination and ultrasound are of benefit in the detection of recurrent disease in women who have had conservative management or conservative surgery (ie still have one or both ovaries)
Follow-up every 3 months for the first 2 years, every 6 months for the next 2 years and annually thereafter
o The role of tumour markers in follow-up is uncertain
o She should be advised about the need for earlier review if she develops symptoms
o She should be aware of the risk of peritoneal recurrence, which may not be picked up on routine surveillance and advised to seek medical advice for any symptoms
A 42 year old woman is referred with a 7cm “complex pelvic mass” on ultrasound. There are both solid and cystic areas.
a. Excluding the ovary, list a pathology in the different anatomical structures you would consider in your differential diagnosis. (5 marks)
Tubal – paratubal cyst, hydrosalpinges, tuboovarian abscess Peritoneal – peritoneal pseudocysts Appendix - appendiceal abscess Bowel – diverticular abscess Kidney – pelvic kidney Bladder – bladder cancer Uterus – fibroid, sarcoma, pregnancy Cervix – cervical cancer Ureter – hydroureter
A 42 year old woman is referred with a 7cm “complex pelvic mass” on ultrasound. There are both solid and cystic areas.
Following a detailed history and examination, what investigations might you order to arrive at a specific diagnosis? (4 marks)
Pregnancy test
Full blood count
Imaging - TV and TA USS abdo/pelvis, CT or MRI
Tumour markers – Ca 125, CEA, Ca-19-9, alpha fetoprotein, LDH, HCG
Depending on results of above – consider biopsy of primary lesion or other mass e.g. omental cake/cytology if ascites, barium enema, IVP, CXR
A 42 year old woman is referred with a 7cm “complex pelvic mass” on ultrasound. There are both solid and cystic areas.
Your investigations diagnose the pelvic mass as an ovarian cyst with a lesion on the contralateral ovary.
If this woman is postmenopausal with a CA125 measuring 30u/ml calculate the risk of malignancy index (RMI) (2 marks)
RMI = menopausal status (3 points for postmenopausal), x Ca 125 level (30), x USS features (3 points for 2+ suspicious features – bilateral, solid components)
= 270
A 42 year old woman is referred with a 7cm “complex pelvic mass” on ultrasound. There are both solid and cystic areas.
ii) Interpret your result and explain how this RMI result would affect your management of this woman (4 marks)
High risk (>200) – 75% of malignancy
Referral to gynaeoncology (improves outcomes)
Staging laparotomy – recommend:
Midline laparotomy
Bilateral cystectomy at least, probable TAH/BSO given menopausal status
Inspection and palpation of all peritoneal surfaces and biopsy of suspicious lesions – can consider frozen section if uncertain
Washings
Select or complete LN dissection
Appendectomy if suspected or known mucinious ca
If ovarian cancer confirmed, adjuvant CTX +/- RTX depending on stage
Adnexal mass in pregnancy
A previously well 32 yo nullipara at 8 weeks gestation is incidentally found to have an 7cm right adnexal mass of mixed echogenicity on her dating USS.
What is the differential diagnosis? (4 marks)
- Ovarian, benign Mature Teratoma Cystadenoma (serous or mucinous) Endometrioma Corpus luteum Theca lutein cyst (more common if high HCG – GTD, twins) Luteoma – suspect if maternal virilisation in pregnancy Functional cysts
- Ovarian, malignant
Germ cell tumour
Epithelial carcinoma
Sex cord tumour - Secondary malignancy – breast or GI tumour
- Benign non ovarian Paratubal cyst Hydrosalpinx Peritoneal pseudocyst Pelvic kidney Subserosal fibroid
Adnexal mass in pregnancy
A previously well 32 yo nullipara at 8 weeks gestation is incidentally found to have an 7cm right adnexal mass of mixed echogenicity on her dating USS.
Outline what investigations you would arrange? (4 marks)
Tertiary level transvaginal ultrasound with colour Doppler to look at characteristics of cyst
Unilocular/multilocular
Mixed echogenicity
Solid components, mural nodules, papillary excrescences, ascites increase suspicion and increase suspicion of malignancy
RMI calculated = ultrasound features x menopause status x Ca-125 >200 (sensitivity for malignancy 78%)
Check viability of pregnancy
Ca-125
Not reliable in pregnancy as can be elevated in pregnancy
Appearance of cyst on ultrasound more important
Other tumour markers
LDH for germ cell tumours (not normally raised in pregnancy)
Consider Ca19-9 and CEA for mucinous tumours
MRI could be considered for staging if malignancy suspected or to help plan surgery
Adnexal mass in pregnancy
A previously well 32 yo nullipara at 8 weeks gestation is incidentally found to have an 7cm right adnexal mass of mixed echogenicity on her dating USS.
Detail your management strategy for this woman including the pros and cons of surgery (7 marks)
Would need serial scanning during first trimester
If cyst was still present and was similar size or larger at the end of first trimester
Would offer surgical management between 14-20 weeks, by either laparoscopy or laparotomy depending on the surgeon’s expertise and cyst size
Most transient ovarian cysts including corpus luteum cysts would have resolved by 14 weeks gestation
If laparoscopy is being done it is suggested to keep the intraperitoneal pressure to 8-12mmHg to avoid reduction in uteroplacental blood flow
Pros
Cysts >5cm in size are more likely to persist in pregnancy and are less likely to be corpus luteum
Also the larger the cyst, the higher the risk of torsion
If the cyst is resected this would mean the she avoids the risk of emergency surgery if she was to present acutely with torsion
Some recommend expectant management if 5-10cm and simple cystic appearance
However if nodules, solid appearance, septations etc needs to be resected, with likely oophorectomy if suspicious for malignancy
If the cyst was to enlarge during the pregnancy could predispose to obstructed labour or malpresentation
The only way to exclude malignancy is to resect the cyst and send it for histology
Cons
If the cyst turned out to be a corpus luteum, she would need progeseterone support if it was removed before 10 weeks gestation to prevent a miscarriage from inadequate progesterone
The cyst may have regressed spontaneously so surgery may have been unnecessary, but serial scanning would show if cyst was persistent
She is not able to have full staging surgery and continue with her pregnancy if a malignancy is suspected. An oophorectomy can be performed but she would need further surgery to complete after pregnancy.
Surgery carries a risk of miscarriage, tubal adhesions of the fimbria to the incision of the ovarian capsule
Risk of oophorectomy if excessive bleeding from ovary during surgery
Risk of venous thromboembolism increased with surgery in pregnancy
If cyst is still present at term if mother requires caesarean section the cyst could be removed at that time, otherwise a laparotomy or laparoscopy should be booked postpartum after another ultrasound to ensure that the cyst is still present.
Adnexal masses in pregnancy
~75% are simple cysts <5cm
70% resolve by 2nd trimester
>8cm – more likely to have complications
Torsion most likely in late 1st trimester or early 2nd trimester
Simple and cystic <6cm 🡪 RMI <1 🡪 can observe
Surgery if
Persist into 2nd trimester
Rapidly enlarging
>8cm
Appear malignant
Surgery optimally at 16-20/40 because physiological cysts regressed and pregnancy now independent of corpus luteum
If discovered late in 3rd trimester, can defer evaluation, management and surgical exploration until postpartum
Feedback: Thorough evaluation, counselling, surveillance and finally decision on whether to operate
a. With respect to the epidemiology of ovarian cancer in Australia and New Zealand:
i) Of 1000 women, approximately how many will develop ovarian cancer in their life? (1 mark)
1.3-1.5/100
13-15/1000
ii) Of these women who develop ovarian cancer, approximately how many will develop cancer because of a genetic predisposition? (1 mark)
10%
iii) What is the strongest risk factor for developing ovarian cancer? (1 mark)
BRAC1 or BRCA 2 mutation
BRCA1: 20-60% lifetime risk for ovarian cancer
BRCA2: 10-20% lifetime risk for ovarian cancer
