STUDY OF MANAGEMENT OF OVARIAN CYSTS

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Fawzi et al. World Journal of Pharmacy and Pharmaceutical Sciences

STUDY OF MANAGEMENT OF OVARIAN CYSTS

Dr. Maysaa Fawzi Ali*, Dr. Zainab Falih Ali and Dr. Shatha Khayoon Jasim

1,2,3

M.B.CH.B, D.G.O, IRAQ.

Ovarian cyst accidents include cyst rupture, haemorrhage and torsion.

Torsion commonly occurs to the whole adnexa and is not necessarily

associated with an ovarian cyst. Suspected adnexal torsion should

always be managed with early laparoscopy and detorsion of the twisted

tube or ovary. Ovarian cyst rupture and haemorrhage usually occur in

association with physiological (functional) cysts and are generally self-

limiting. Laparoscopy may be necessary in cases where the diagnosis

is in doubt or for haemodynamic compromise.

Clinical features of ovarian cyst accidents are nonspecific. Ultrasound is the first-line

investigation and is diagnostic in the case of haemorrhage. Typical ultrasound findings have

been described for ovarian torsion, including an enlarged oedematous ovary with peripheral

displacement of follicles. Doppler blood flow findings are variable and not diagnostic.

Recurrent cyst rupture or haemorrhage should be prevented by suppression of ovulation,

usually with the combined oral contraceptive. Fixation of the ovary by a variety of techniques

should be considered to prevent recurrent torsion.

Ovarian cyst ‘accident’ is the term used to refer to any of the three classical complications of

ovarian cysts that present to the emergency gynaecology department. These are ovarian cyst

haemorrhage, rupture and torsion. Historically surgery has been employed either by

laparotomy, or more recently laparoscopy, to facilitate diagnosis and operative management

of the cyst. With the advent of high resolution transvaginal ultrasound (TVS), and advances

in other imaging modalities, an accurate diagnosis can often be made without surgical

intervention and conservative management strategies may be employed in many clinical

situations.

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

SJIF Impact Factor 7.632

Volume 10, Issue 10, 2244-2267 Research Article ISSN 2278 – 4357

*Corresponding Author

Dr. Maysaa Fawzi Ali

M.B.CH.B, D.G.O, IRAQ.

Article Received on

21 August 2021,

Revised on 10 Sept. 2021,

Accepted on 30 Sept. 2021

DOI: 10.20959/wjpps202110-19888


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A good history is often very important in establishing a diagnosis in women presenting with

pelvic pain. TVS is an accurate and reliable tool for detecting and characterising ovarian

tumours, in most cases allowing diagnosis not only of the presence of an ovarian cyst but

generally of the type and nature of the lesion, such that appropriate subsequent management

can be directed. A detailed discussion of this can be found elsewhere in this volume.

The availability of transvaginal ultrasound at the point of initial contact for women with

pelvic pain has been demonstrated to be effective at making a diagnosis. In a study of 1000

women attending an acute gynaecology unit where ultrasound was performed at the initial

assessment, 90 of 399 women were clinically suspected to have a significant ovarian cyst

(greater than 5 cm in diameter), and thiswas confirmed in 31% of the cases by using

ultrasound.1 Importantly, the ultrasound assessment was associated with a significant

reduction in the number of women deemed to need admission (from 37% to 19%) and a

decrease in the need for follow-up examinations as well (from 26% to 18%).

AIM

Ovarian masses are very common in pre- and postmenopausal women and are typically an

incidental finding.

Initial assessment

A thorough history should be taken, with specific attention to:

• Risk factors

–– family history of breast, colon, uterine or ovarian cancer, hereditary ovarian cancer

syndrome (BRCA gene mutation/Lynch syndrome)

• Protective factors

–– parity and breastfeeding (50% reduced risk)

–– combined oral contraceptive pill

• Menopause status

• Symptoms, including those of endometriosis or malignancy (persistent abdominal

distension, change in appetite, pelvic pain, urinary urgency).

A careful examination, including an abdominal and vaginal examination, should be

undertaken and the presence of lymphadenopathy assessed.


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Investigations

Box 1

Investigations for suspected ovarian cyst accidents.

A A urinary pregnancy test must always be performed in women of reproductive age with

abdominal pain.

A Full blood count, urea and electrolytes and possibly liver function and coagulation screen

(depending on the clinical situation) should be taken.

A The white count may be raised in torsion but also with appendicitis, infection and a pelvic

abscess.

A Ca125 should not usually be taken as it is particularly non-specific in the acute setting and

in a woman of reproductive age, being raised with any cause of peritonitis, including

haemorrhage, cyst rupture and infection as well as menstruation, fibroids and endometriosis.

A Urinary infection or calculus should be ruled out by confirming the absence of blood,

nitrites and leucocytes on urine dipstick.

A Triple swabs for infection should be taken if PID is a possible differential diagnosis from

the history and examination.

A Transvaginal ultrasound (TVS) examination (transabdominal in children) should be

arranged preferably at the time of presentation in a dedicated acute gynaecology unit, or as

soon as possible.

A If the adnexae appear normal on TVS then consideration should be given to

transabdominal ultrasound scan to examine the appendix, or CT scan in cases of an acute

abdomen

IMAGING

Ultrasonography

Transvaginal and transabdominal ultrasound views should be obtained.[1,3]

This allows better

differentiation and characterisation of the mass. The only definitive diagnosis of an ovarian

mass is through histology; however, there are typical characteristics of certain structures seen

on an ultrasound. Although ultrasonography is the best mode of imaging we have for

assessment of ovarian pathology, its sensitivity and specificity for the diagnosis of ovarian

cancer is only 86–91% and 68–81% respectively.[3]

The International Ovarian Tumor Analysis (IOTA) Group has developed a list of

characteristics for benign and malignant masses.[1,4,5]

These rules are used in premenopausal


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women; however, similar characteristics are also used in the risk of malignancy index (RMI),

which is discussed later. The IOTA Group rules are defined as benign or B-rules and

malignant or M-rules (Table 1). Any patient with an M-rule should be referred to a

gynaecologist.[4,5]

The presence of ascites has a positive predictive value of 95% for ovarian

cancer.

Sonographic characteristics that have been typically associated with ovarian

malignancy are:

Solid component, often nodular or papillary.

Septations, if present, that are thick (>2 to 3 mm).

Presence of ascites.

Peritoneal masses.

Enlarged lymph nodes.

NB Unilocular cysts with a single (<3mm) thin septum can be considered as simple

Computed tomography and magnetic resonance imaging

Ovarian masses may be seen on computed tomography (CT) and magnetic resonance imaging

(MRI). These are typically incidental findings.

Assessment with ultrasonography is required to further assess the character of the mass.

The use of CT or MRI in the assessment of an ovarian mass does not improve the sensitivity

or specificity obtained through ultrasonography in the detection of ovarian cancer. MRI may

be useful in assessment of large cysts that are difficult to assess on an ultrasound.[1]

Tumour markers

Serum Ca125

Serum Ca125 is a glycoprotein antigen and is the most widely used tumour marker in the

assessment of ovarian masses. In premenopausal women, Ca125 should be measured only if

the ultrasound appearance of a mass raises suspicion of malignancy. It is unreliable in

differentiating malignant from benign, as Ca125 >35 U/ml has a sensitivity and specificity

for ovarian cancer of <80% (potentially as low as 50–60%).[3]

It can also be raised in

conditions such as endometriosis, fibroids, adenomyosis and pelvic infection. If Ca125 is

elevated, consider repeating 4–6 weeks after the initial test.[7]

Rapidly rising levels are more


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likely to be associated with malignancy rather than levels that do not change. Discussion with

a gynaecological oncologist is recommended in patients with a Ca125 >250 U/ml.[1,3]

In postmenopausal women, Ca125 should be measured routinely. Ca125 of >35 U/ml has a

sensitivity of 69–97% and specificity 81–93% for the diagnosis of ovarian cancer.[3]

This

result should then be used in conjunction with ultrasound findings and menopause status in

RMI.

Human epididymis protein 4

Human epididymis protein 4 (HE4) is another tumour marker currently available for the

assessment of ovarian cancer. It has a similar sensitivity as that of Ca125 in comparing

ovarian cancer to healthy controls, but is not elevated in as many common benign

gynaecological conditions. It is used in conjunction with Ca125 in the Risk of Malignancy

Algorithm (ROMA).[8,9]

HE4 can be falsely elevated in patients with impaired renal function,

and can also be elevated in endometrial, primary liver and non-small cell lung cancer.10 The

American, UK and Australian guidelines do not address the usefulness of HE4 or ROMA in

assessing risk for ovarian cancer.

An HE4 level in isolation is difficult to interpret, and its usefulness in a clinical setting is

being reviewed. HE4 is currently used in the USA for monitoring recurrence or progression

of epithelial ovarian cancer.[3,8]

HE4 is not currently covered by Medicare and costs

approximately.[11]

It is not recommended as a screening test for ovarian cancer.

Other biochemical markers

Alpha-feta protein (AFP), human chorionic gonadotropin (hCG) and lactate dehydrogenase

(LDH) are also recommended in women under 40 years who have a complex mass on

ultrasound, as these can be elevated in germ cell tumours.[1,9]

Carcinoembryonic antigen

(CEA) and cancer antigen 19.9 (Ca19.9) are two other tumour markers that are commonly

ordered for the investigation of an ovarian mass; however, their application to clinical

practice is unclear. The usefulness of these tests is not discussed in the UK and Australian

guidelines. They are non-specific and can be elevated in benign and malignant non-

gynaecological conditions. Ca19.[9]

may be useful in the assessment of mature cystic

teratomas; however, its usefulness in differentiating mature cystic teratomas from ovarian

cancer is unclear.[12,13]

CEA seems to be an independent prognostic factor for mucinous

ovarian cancer.[14]

Further investigation is required.


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Risk of malignancy index

The risk of malignancy index (RMI) is the most widely used risk assessment for ovarian

malignancy. Developed in 1990, it uses serum Ca125, menopausal status and findings on

ultrasound (RMI = ultrasound findings x menopause status x Ca125 U/ml). It is particularly

useful in the assessment of postmenopausal women. Moderate risk is a RMI value between

25–200, and RMI >200 is considered high risk. An RMI >200 has a sensitivity of 87% and

specificity of 97% for ovarian cancer and therefore requires urgent assessment by a

gynaecological oncologist (Table 2).[1,6,15]

Ovarian cyst accidents and pregnancy

It was assumed in the past that ovarian cysts in pregnancy were more likely to undergo

torsion or rupture than in non-pregnant women. One study of women with ovarian torsion

found that 13.7% of the 87 women diagnosed with torsion were pregnant.[9]

A recent

retrospective review of women found to have ovarian cysts greater than 4 cm in diameter

found a torsion rate of 15%. However, in a study of 3000 consecutive pregnant women

Condous et al. found 166 cysts in 161 women, and followed them prospectively through

pregnancy. All cysts were managed expectantly initially and five (3%) underwent torsion.

Other prospective studies show a similarly low torsion rate of 0–6%. In conclusion, therefore,

expectant management of ovarian cysts in pregnancy is generally safe and surgery for a cyst

in pregnancy should only be performed for pain or because there is suspicion of malignancy

on ultrasound assessment, rather than because of a presumed risk of torsion or rupture.

The incidence of rupture in women with ovarian hyperstimulation has been reported to be

high, with one series reporting an incidence of 18% for ovarian torsion in 201 cases of

hyperstimulation (more in the pregnant than non-pregnant group).[14]

This however would

seem a higher prevalence of the disorder than is generally seen in gynaecological practice.

Haemorrhage in multiple cysts in a hyperstimulated ovary may also cause pain in such

women (Fig. 6).

Laparoscopic management of ovarian cysts in pregnancy, with trocar sites decided according

to the uterine size and the cyst location has been reported to be successful in many cases.

Although technically possible, laparoscopic surgery for benign teratoma during pregnancy is

associated with a high (93%) perioperative cyst rupture rate.


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MRI is thought to be a safe and accurate tool for diagnosis of pelvic pathology in pregnancy

and may be more appropriate than a CT scan in cases where ultrasound is inconclusive in a

pregnant woman.

Ovarian cyst accidents in children

Young girls presenting with pelvic pain should be considered to have adnexal torsion as a

differential diagnosis. In a large series of 102 girls treated for ovarian pathology in one

institution,

Fig. 6: TVS showing an enlarged hyperstimulated ovary, with haemorrhage within

several of the multiple follicles.

of those presenting with acute abdominal pain (n¼ 59), 25 (42%) had ovarian torsion. In 14,

the torsion was associated with a mature teratoma and only one (2%) had a malignant tumour.

In contrast, of those presenting with an abdominal mass (n¼ 23), six (26%) had malignancies.

There was no age difference between those with benign disease (9.9 _ 5.6 years; n¼ 96) and

those with malignant tumours (8.6_ 3.9 years; n ¼ 10). This highlights the need for those

working in acute gynaecology to be conversant with the features of different types of ovarian

pathology using ultrasonography.

Cass performed an extensive review of the pathophysiology, diagnosis and management of

torsion in children in 2005. Torsion is most common in the perimenarchal and early teenage

age group. It commonly occurs in the absence of ovarian pathology, though an unusually long

utero-ovarian pedicle has been described, which may be familial. The overall prevalence of

pathology in association with torsion is similar to adults. Pathology includes simple cysts,

mature teratoma and hydrosalpinx.


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Malignancy is rare in children as it is in the adult population with torsion, with very few cases

in the reported literature.

As with adult patients, traditional management of torsion involved adnexectomy but

laparoscopic detorsion is effective with similarly good outcomes (87–93%) in terms of

ovarian function as in adults. A review of the pathological specimens removed from children

treated with adnexectomy for torsion found viable ovarian tissue in 61% (38% of those

described operatively as ‘black’) and there was no difference in inflammatory markers such

as temperature and white cell count or time to diagnosis between those with without viable

ovarian tissue.

In cases where an ovarian cyst is suspected to be the cause of torsion, ovarian cystectomy

may be best performed as an interval procedure after repeat ultrasound scan at about 6 weeks

to assess whether a residual cyst exists when the oedema and vascularity associated with the

acute torsion have resolved.

Recurrent torsion in the same or contralateral ovary (‘asynchronous bilateral torsion’) is well

reported. In girls who have undergone adnexal torsion with or without preservation of the

ovary, prophylactic oophoropexy (ovariopexy) of the remaining ovary or ovaries should

therefore be seriously considered (as is performed for testicular torsion) to prevent the

potentially catastrophic consequences of recurrent torsion and loss of fertility if

oophorectomy is performed.

Oophoropexy, or surgical stabilisation of the ovarian tissue, is performed by suturing the

ovary (once de-torted laparoscopically) to the back of the uterus or by one of a variety of

other techniques including plication of the ovarian ligament, or fixation of the ovary to the

pelvic side wall. The techniques for oophoropexy are outlined in the Cass review.There

remains some uncertainty as to the long-term outcome with such a procedure especially in

terms of whether the vascular supply of the ovary might possibly be impaired by the

procedure.

Isolated fallopian tube torsion in the presence of a morphologically normal ipsilateral ovary is

also described and is reported to have been managed with salpingectomy.


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Management

There are three main forms of management– conservative, surveillance and surgical

management. Deciding which is the appropriate management is based on assessment of

symptoms, ultrasound findings, menopausal status, RMI (if applicable) and risk factors. An

approach to management is outlined in Figure 1.

Premenopausal women

Asymptomatic women with a simple ovariancyst <5 cm on ultrasound do not require follow-

up. These simple cysts will resolve within three menstrual cycles. For simple cysts of 5–7 cm,

a repeat ultrasound should be obtained, and for cysts of >7 cm surgical intervention should be

considered. If surgery is required, a laparoscopic cystectomy is the operation of choice, as

aspiration can cause recurrence.[16]

Postmenopausal women

Simple unilateral, unilocular ovarian cysts of <5 cm and low risk of malignancy (normal

Ca125) can be managed conservatively as the RMI would be zero and 50% of these will


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resolve spontaneously in 3 months. Cysts of 2–5 cm should be rescanned in 3–4 months.[18–20]

Women with a moderate-to-high risk RMI should be referred to a gynaecologist or

gynaecological oncologist for consideration of surgical management. In addition, any woman

who does not meet the criteria for conservative management should be offered surgical

management. If malignancy is suspected, an oophorectomy is recommended rather than a

cystectomy. This allows removal of the cyst intact and prevention of spillage into the

peritoneal cavity. A bilateral oophorectomy may be offered for postmenopausal women

because the contralateral ovary may also be affected; however, there are no studies that have

assessed malignancy after unilateral versus bilateral oophorectomy.

Use of the combined oral contraceptive pill

Commencing the combined oral contraceptive (COC) pill does not hasten resolution of

functional ovarian cysts, but can be used to prevent formation of cysts.[22,23]

Complications

Rupture and haemorrhage Ovarian cyst rupture and haemorrhage are essentially physiological

events during the ovarian cycle, involving the follicle or corpus luteum. The theca interna and

the corpus luteum are particularly liable to haemorrhage due to their increased vascularity.

Two-thirds of corpus luteum cysts involve the right ovary and rupture occurs most commonly

on days 20 to 26. The commonest cause of unilateral lower abdominal pain in early

pregnancy is a corpus luteal cyst, often seen with haemorrhage within it (Fig. 2). Women

experience follicular rupture at ovulation to varying degrees, with the term mittelschmerz

(‘middle pain’) used to describe the pain in those women who are aware of the midcycle

release of peritoneal fluid associated with rupture of the normal follicle at ovulation. These

events are so common that they may often not present to the gynaecologist as the symptoms

are not severe and settle spontaneously.

Pain from haemorrhage into a cyst probably occurs due to stretching of the ovarian capsule

and pain from ovarian cyst rupture is from peritoneal irritation. Whether a woman presents

for medical input probably depends on the volume of fluid released into the peritoneal cavity

or degree of haemorrhage into the cyst and her sensitivity to this.

There is no definition of when haemorrhage into a cyst or rupture of a cyst is pathological as

opposed to physiological, though if a cystic lesion is less than 25 mm in mean diameter it is

conventional to term this a follicle, and to use the term ‘cyst’ when the lesion is greater than


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25 mm in mean diameter. The normal size range for a corpus luteum is approximately 20 to

30 mm.[44]

Fig. 2: TVS showing bizarre echoes within an ovarian cyst (‘jelly like’ blood clot to the

left of the image and reticular pattern towards the right), diagnostic of a haemorrhagic

ovarian cyst.

Ovarian torsion

Ovarian torsion involves a partial or complete rotation of the ovary onto its supporting

ligaments, cutting off its blood supply. Presenting symptoms usually include sudden onset

lower abdominal pain, nausea and vomiting with a palpable adnexal mass. The primary risk

factor for ovarian torsion is an ovarian mass >5 cm.24–26 Ovarian torsion is primarily a

clinical diagnosis, but ultrasonography may be useful. One study showed a diagnostic

accuracy of ultrasonography as 74.6%, with abnormal ovarian blood flow and presence of

free fluid as the most diagnostic.

Despite this, ultrasonography is not reliable in excluding an ovarian torsion.26 Suspected

ovarian torsion requires urgent gynaecological review. Surgery usually involves laparoscopy

with de-torsion and ovarian conservation, but an oophorectomy may be performed if the

ovary is not viable. Torsion is most commonly associated with benign conditions.[25,27]

Pregnant women with ovarian cysts

Ovarian masses are usually an incidental finding. The majority of these masses are benign

and can be managed expectantly, as at least 50% resolve spontaneously during pregnancy.28

The reported rate of complications with expectant management is <2%.29 If a cyst is


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identified early on a dating ultrasound, a repeat ultrasound at 12–14 weeks should be

performed to check if it has resolved.29 Operative intervention is indicated if malignancy is

suspected, if there is an acute complication (eg torsion) or if the size is likely to cause

obstetric or other problems. The ideal time of operation is after the first trimester, as this

decreases the miscarriage rate and teratogenicity. The risk of ovarian cancer in pregnant

women who are noted to have a cyst on ultrasound is <1%.29,30.

Screening for ovarian cancer

For the general population, there are currently no national or international guidelines for

screening for ovarian cancer. No investigation to date has been shown to have adequate

sensitivity and specificity as a suitable screening test.

A precursor lesion has yet to be identified. In particular, screening with transvaginal

ultrasound has a high false-positive rate because of its inability to differentiate between

malignant and benign masses. Serum Ca125 can be affected in a number of benign conditions

and is elevated in <50% of women with stage 1 ovarian cancer.6 Women with a very strong

family history of breast and ovarian cancer should be referred for genetic counselling.

Women who are carriers of the BRCA1 mutation have a lifetime risk of ovarian cancer as

high as 60%, and BRCA2 as high as 40%.[6]

Key points

• Ultrasonography (transabdominal and transvaginal) is the main form of imaging in the

assessment of ovarian masses.

• Ca125 can be unreliable in premenopausal women as it can be elevated in a number of

benign conditions; however, it is useful in the assessment of postmenopausal women.

• RMI is used to assess risk of ovarian cancer and is based on menopause status, ultrasound

findings and Ca125 levels.

• Unilateral, simple ovarian cysts that are <5 cm in premenopausal women are likely be

functional cysts and no follow-up is required.

• Ovarian torsion is a clinical diagnosis and requires urgent gynaecological review.

• There is no routine screening for ovarian cancer for the general population.

• If concerned or unsure of management, seeking gynaecological advice is recommended.


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Surgery

Consideration of surgery should be made if the cyst does not meet the criteria for

conservative management. Conservative management may be appropriate in selected cases.

The laparoscopic approach to surgery in presumed benign ovarian masses is preferred to

laparotomy due to lower morbidity and shorter recovery time. The risks, benefits and

potential complications of surgery should be individualised. Large ovarian cysts may still

require laparotomy, although no robust data on size and type of approach to surgery exists.

Complex ovarian cysts (unless thought to be haemorrhagic or corpus luteum).

NB Functional ovarian cysts do not occur in late postmenopausal women.

Postmenopausal simple cysts >5cm. The risk of malignancy is thought to be between 2%

and 9%.

Premenopausal simple cysts >7cm. There is concern regarding accurate assessment of the

cyst wall beyond 7cm. If conservative management is preferred, an MRI of the cyst may

be of value to characterise the cyst wall and exclude complex features.

Symptomatic.

Suspicion of malignancy.

A laparoscopic approach can be used when the risk of malignancy is considered to be low.

Thorough inspection of the peritoneal cavity should be performed and if features suggestive

of malignancy are encountered, a gynaecological oncologist should be consulted regarding

further evaluation and staging.

Spillage of cyst contents should be avoided where possible, this may involve the use of

retrieval bags. Where spillage does occur, extensive peritoneal lavage with warmed fluid

should be performed.

Laparoscopic specimen retrieval should, where possible, be through the umbilical port. This

technique is associated with less postoperative pain, quicker retrieval time, improved

cosmesis and fewer incisional hernias.

Laparoscopic management of ovarian cysts in postmenopausal women should involve

salpingoophorectomy (usually bilateral) rather than cystectomy. Women should be

counselled preoperatively that if features of malignancy are suspected during laparoscopy,


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then the procedure may have to be abandoned with recourse to a laparotomy under the

oncology team at a later date.

Ovarian cystectomy and preservation of ovarian tissue is preferred when surgery is performed

for benign disease in women wishing to retain their fertility. The risk of oophorectomy, for

example to control bleeding, should be mentioned during consent.

SPECIAL SITUATIONS

Suspected endometrioma

Endometriomas can appear complex on ultrasound and can be associated with a raised CA

125. MRI can be useful when the diagnosis is unclear using ultrasound. Malignant

transformation occurs in 1%, with the majority occurring in cysts over 9cm and in women

over 45 years of age, although it is recommended that histology should be obtained from

endometriomas of greater than 30mm diameter.[16]

Endometriomas should be managed within

the spectrum of endometriosis and influenced by symptomatology. Development of solid

elements should raise concern.[5]

Pregnancy

Incidence- 30% in 1st trimester, of which 90% represent corpus luteum of pregnancy and

resolve spontaneously. The majority can be managed conservatively.

Complications

Torsion

Rupture

Haemorrhage

Malignancy (<1%)

Tumour markers tend to be elevated in pregnancy and are of limited use.

Indications for surgery

Complex cyst- with suspicion of malignancy (not obviously a dermoid cyst)

Increasing size

Symptoms suggestive of torsion, rupture or bleeding

MRI may be useful when evaluating suspicious cysts.

If surgery is necessary, this can be most safely performed early in the second trimester. In

experienced hands a laparoscopic approach appears safe.


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An ovarian cyst diagnosed at the time of caesarean section should be removed (cystectomy or

oophorectomy) rather than aspirated, unless it is obviously functional when it should be left

intact. Consultant involvement is recommended.

Indications for conservative management

Asymptomatic

Simple

Less than 10cm

If the cyst has not increased in size at the detailed 20 week scan, no further scan is necessary

until after delivery

Follow up ultrasound scan 6 weeks postpartum

Patients with suspicious adnexal masses detected during pregnancy should be discussed at the

gynaecological oncology multidisciplinary team meeting.

Follow up of borderline tumours

All decisions should be made following discussion at the Gynaecological Oncology MDT.

Robust data relating to the management of borderline tumours is limited at present, which

needs to be conveyed to the patient during management discussions.

If both ovaries are removed

Stage I - no follow up required as prognosis is excellent (5 year survival- 99%).

Stage II-IV- individualised.

If contra-lateral ovary or both remain (following cystectomy)

Stage I - Risk of recurrence is approximately 40%. Six monthly, ultrasound for 2 years, then

annually (with CA 125, if elevated at presentation (25%)). Patients should be offered removal

of remaining ovarian tissue +/- hysterectomy when family complete.

Stage II - IV - individualised

Follow up of ovarian cancers

See Anglia Cancer Network guidelines

Aspiration of ovarian cysts

This should not be performed routinely since:

Neoplastic cysts will recur

Malignant cysts will be upstaged


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Image guided aspiration can be considered if:

Significant medical co-morbidities contraindicating surgery

The cyst is causing significant symptoms

If a cyst is aspirated, fluid should not be sent for cytology as sensitivity and specificity are so

poor as to render the result meaningless.

MATERIALS AND METHODS

• Data Sources and Search terms

We conducted this review using a comprehensive search of MEDLINE, PubMed, EMBASE,

Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled

Trials from January 1, 1995, through January 1, 2017.

• Data Extraction

Two reviewers independently reviewed studies, abstracted data and resolved disagreements

by consensus. Studies were evaluated for quality. A review protocol was followed

throughout.

Signs and symptoms

Most patients with ovarian cysts are asymptomatic, with the cysts being discovered

incidentally during ultrasonography or routine pelvic examination. Some cysts, however, may

be associated with a range of symptoms, sometimes severe[3]

, while malignant ovarian cysts

frequently do not cause symptoms until they reach an advanced stage.

Pain or anxiety may arise in the lower abdomen. Torsion (twisting) or rupture may lead to

more severe pain. Cyst rupture is characterized by sudden, unilateral, sharp pelvic pain. This

can be allied with trauma, exercise, or coitus. Furthermore, cyst rupture can lead to peritoneal

signs, abdominal distention and bleeding that is commonly self-imited.

RESULTS

Different methods for discriminating between benign and malignant ovarian cysts are

discussed. The diagnosis and the treatment are assessed in relation to age, menopausal status,

pregnancy, and whether the cyst is presumed to be benign or malignant.

In general, expectant management is the choice in premenopausal and pregnant women with

non-suspicious cysts and normal levels of CA-125. In postmenopausal women, unilocular,

anechoic cysts less than 5 cm in diameter together with a normal CA-125 may be followed


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up. Operation is recommended in women with cysts larger than 5 cm and/or elevated levels

of CA-125. Women with symptoms should be operated regardless of age, menopausal status,

or ultrasound findings.

Table I. Features of an ovarian cyst.

Numbers of locules

Presence of solid parts (septum and solid papillary proliferations)

The diameter of the cyst/tumor

Presence of cysts/tumors in the contralateral ovary

Fluid in the pouch of Douglas

Table II. Differences between non-suspicious and suspicious ovarian cysts

Non-suspicious ovarian

cyst

Unilocular cysts without solid parts or papillary

proliferations

Suspicious ovarian cyst At least two locules, mixed cystic solid or solid (more

than 80% solid), bilateral tumor

Table III. Management of ovarian cysts in pre- and perimenopausal and pregnant

women (women are considered perimenopausal in this study if less than 1 year after the

menopause).

Suspicious cysts and solid tumors should be removed surgically

Non-suspicious cyst with a diameter

<4 cm: no reason for follow up

4–7 cm: estimation of CA-125 followed by an ultrasound scan 3 months

later

>7 cm: laparoscopy/laparotomy after determination of CA-125

In pregnancy, surgery before 7 and after 24 weeks of gestation should be


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DISCUSSION

1. Investigation for an ovarian mass includes both transvaginal and transabdominal

ultrasound. Simple, anechoic cysts <5 cm in premenopausal women are likely to be benign

and do not require further follow-up. The use of the cancer antigen 125 (Ca125) tumour

marker can be unreliable in premenopausal women given the low sensitivity for ovarian

cancer; however, it is useful in postmenopausal women.

Ca125 is used in conjunction with ultrasound findings and is used to determine risk of

ovarian cancer through the risk of malignancy index (RMI). Gynaecological oncology

referral is reqired if RMI is >200. Complications of ovarian cysts include cyst rupture and

torsion. Torsion is a gynaecological emergency and requires urgent review.

2. Accurate preoperative discrimination between benign and malignant ovarian cysts remains

difficult despite recent advances in medical imaging.

Reliable prediction of the nature of an ovarian cyst is of crucial importance for treatment.

Preoperative detection of malignancy would allow selective referrals to the appropriate

centers for optimal care, whereas women with benign cysts could be offered more

conservative treatment. The opinion of the affected woman is clearly another important

component when the strategy for management of a unilocular cyst is to be settled. RMI is the

best discriminator between malignant and benign ovarian tumors described in the literature,

but the method has not been subjected to assessment in a randomized trial. However, a

significant problem in previously published data on RMI is the relatively poor performance

of the index in detecting nonepithelial ovarian cancers, borderline ovarian tumors and early-

stage cancers. In a recent study, the RMI was prospectively compared with Tailor’s

regression model, which includes ultrasonographic morphology and transvaginal color


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Doppler imaging of tumor blood flow. The simple RMI performed better than Tailor’s

regression model and better than individual demographic (e.g. age and menopausal status),

ultrasonographic and biochemical parameters. In the future, the incorporation of tumor blood

flow characteristics in risk evaluation models may improve the diagnostic accuracy On the

other hand, used in the daily clinic, pretreatment evaluation should be as simple as possible.

The RMI has proved useful in optimizing referral of patients with malignant tumors to

centralized primary surgery. Women with a RMI below the cut-off level 200, which has

given the best sensitivity and specificity at predicting malignancy, may be operated upon by

laparoscopic surgery if appropriate. Aspiration of cysts should be avoided, but in rare cases in

premenopausal women with several previous abdominal operations and complications, a

symptomatic cyst might be punctured, also as a diagnostic input if the symptoms disappear.

However, in case of malignancy, the woman’s prognosis may have deteriorated to a higher

FIGO stage.

Several studies indicate that oral contraception prescriptions are unlikely to prevent the

development of functional cysts or to hasten their disappearance.

The impact of HRT on ovarian cysts needs further clarification.

The diagnosis of ovarian cancer is still one of the hardest tasks in gynecology, and the search

for optimal diagnostic tools should continue.

Neural network models appear to be encouraging, eventhough at this moment complicated

scoring systems do not perform a better accuracy of the risk assessment for adnexal masses

than the scoring made by the clinicians. The initial reports on proteomic patterns in serum to

identify ovarian cancers seems promising, and in combination with other diagnostic tools

give hope for a more multimodal way of diagnosing ovarian cancer. Hopefully thereby

discrimination between benign and malignant cysts can be improved, to avoid unnecessary

surgery for functional.

REFERENCES

1. Royal College of Obstetricians and Gynaecologists. Management of suspected ovarian

masses in premenopausal women. Green-Top Guideline. No 62. London: RCOG, 2011.

2. National Institute for Health and Clinical Excellence. Ovarian cancer: the recognition and

initial management of ovarian cancer. NICE guidelines 122. London: NICE, 2011.


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3. Myers ER, Bastian LA, Havrilesky LJ, et al. Management of adnexal mass. Evidence Rep

Technol Assess, 2006; 130: 1–145.

4. Timmerman D, Valentin L, Bourne TH, Collins WP, Verrelst H, Vergote I; International

Ovarian Tumor Analysis (IOTA) Group. Terms, definitions and measurements to

describe the sonographic features of adnexal tumors: a consensus opinion from the

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5. Diagnosis and management of ovarian cyst accidents Cecilia Bottomley, MRCOG,

Specialist Registrar in Obstetrics and Gynaecology a,*, Tom Bourne, PhD, FRCOG,

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UK b Imperial College London, Hammersmith Campus, Du Cane Rd, London W12 0HS,

UK

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STUDY OF MANAGEMENT OF OVARIAN CYSTS

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