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1

Incidence of malignancy in premenopausal women with an ovarian cyst

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

2

Underlying management rationale for premenopausal women

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

3

List types of ovarian masses:
1. Benign ovarian
2. Benign non-ovarian
3. Primary malignant ovarian
4. Secondary malignant ovarian

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.

4

History for women with ovarian mass

- 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.

5

Examination for women with ovarian mass

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.

6

Role of CA125 in evaluating cysts in premenopausal women

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.

7

Role of CA125 in evaluating cysts in premenopausal women

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.

8

Non-malignant causes of a raised CA125

Fibroids,
Endometriosis,
Adenomyosis
Pelvic infection

9

Lab investigations for premenopausal women with ovarian cysts

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

10

How to calculate RMI?

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.

11

Sensitivity and specificity of RMI>200 for ovarian ca?

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

12

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

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

13

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

- 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.

14

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

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.

15

Surgical approach for the elective management of ovarian masses

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 with solid components (for example large dermoid cysts) laparotomy
may be appropriate.

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

16

Should an ovarian cyst be aspirated?

Aspiration of ovarian cysts, either vaginally or laparoscopically, is less effective and is associated with
a high rate of recurrence.