The Management of Ovarian Cysts in Postmenopausal Women Flashcards
How are ovarian cysts diagnosed in postmenopausal women and what initial investigations should be
performed?
- different presentations and significance of ovarian cysts in postmenopausal women.
- In postmenopausal women presenting with acute abdominal pain, diagnosis of ovarian cyst accident should be considered (e.g. torsion, rupture, haemorrhage).
- It is recommended that ovarian cysts in women should be initially assessed by measuring CA125 level and transvaginal ultrasound scan.
What is the role of history and clinical examination in postmenopausal women with ovarian cysts?
- thorough medical history, with specific attention to risk factors & symptoms suggestive of ovarian malignancy, and a family history of ovarian, bowel or breast cancer.
- Where family history is significant, referral to Regional Cancer Genetics service should be considered.
- 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 BMI, abdominal examination to detect ascites and characterise any palpable mass, and vaginal examination.
What blood tests should be performed in postmenopausal women with ovarian cysts?
CA125
- CA125 should be the only serum tumour marker used for primary evaluation as it allows the Risk of Malignancy Index (RMI) of ovarian cysts in postmenopausal women to be calculated.
- 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 nonspecific nature of the test.
What blood tests should be performed in postmenopausal women with ovarian cysts?
Other tumour markers
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 cysts
What is the role of ultrasound scanning in categorising cysts?
A transvaginal pelvic ultrasound is single most effective way of evaluating ovarian cysts in postmenopausal women.
- Transabdominal ultrasound should not be used in isolation. It should be used to provide supplementary
information to transvaginal ultrasound particularly when an ovarian cyst is large or beyond the field of view of transvaginal ultrasound. - On transvaginal scanning, morphological description and subjective assessment ofthe ultrasound features should be clearly documented to allow calculation of the risk of malignancy.
- Transvaginal ultrasound scans should be performed using multifrequency probes by trained clinicians
with expertise in gynaecological imaging.
What is the role of Doppler and three-dimensional ultrasound studies?
- Colour flow Doppler studies are not essential for routine initial assessment of ovarian cysts in postmenopausal women.
- Spectral and pulse Doppler indices should not be used routinely (resistive index, pulsatility index, peak systolic velocity,time-averaged maximum velocity)to differentiate benign from malignant ovarian cysts, as their use has not been associated with significant improvement in diagnostic accuracy over morphologic assessment by ultrasound scan.
- Three-dimensional ultrasound morphologic assessment does not appear to improve the diagnosis of complex ovarian cysts and its routine use is not recommended in the assessment of postmenopausal
ovarian cysts.
What is the role of computed tomography (CT) scan, magnetic resonance imaging (MRI) and other cross-sectional imaging?
CT, MRI and positron emission tomography (PET)-CT scans are not recommended for the initial evaluation of ovarian cysts in postmenopausal women.
What is the role of computed tomography (CT) scan, magnetic resonance imaging (MRI) and other cross-sectional imaging?
CT scan
- CT should not be used routinely as the primary imaging tool forthe initial assessment of ovarian cysts in postmenopausal women because of its low specificity, its limited assessment of ovarian internal morphology and its use of ionising radiation.
- If, from 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.
What is the role of computed tomography (CT) scan, magnetic resonance imaging (MRI) and other cross-sectional imaging?
PET-CT scan
- Current data do not support routine use of PET-CT scanning in the initial assessment of postmenopausal ovarian cysts. Data suggest there is no clear advantage over transvaginal ultrasonography
What is the role of computed tomography (CT) scan, magnetic resonance imaging (MRI) and other cross-sectional imaging?
MRI
- MRI should not be used routinely as the primary imaging tool for the initial assessment of ovarian cysts in postmenopausal women.
- MRI should be used as the second-line imaging modality for the characterisation of indeterminate ovarian cysts when ultrasound is inconclusive.
Which RMI should be used?
- The ‘RMI I’ is the most utilised, widely available and validated effective triaging system for women with suspected ovarian cancer.
- Although RMI I score with a threshold of 200 (sensitivity 78%, specificity 87%) is recommended to predict the likelihood of ovarian cancer and to plan further management, some centres utilise an equally acceptable threshold of 250 with a lower sensitivity (70%) but higher specificity (90%).
- CT of the abdomen and pelvis should be performed for all postmenopausal women with ovarian cysts who have a RMI I score greaterthan or equalto 200, with onward referralto a gynaecological oncology multidisciplinary team.
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.
- woman with a suspicious or persistent complex adnexal mass needs surgical evaluation.
What is the role of aspiration of ovarian cysts in postmenopausal women?
- Aspiration is notrecommended forthe management of ovarian cysts in postmenopausal women except
for the purposes of symptom control in women with advanced malignancy who are unfit to undergo
surgery or further intervention.
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 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 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.
