Ovarian cysts Diagnosis and Management

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1 Ovarian cysts Diagnosis and Management Mr P K Athanasias MRCOG Consultant Gynaecologist St Anthony s Hospital [email protected]

2 Introduction ovary is an ovum-producing reproductive organ located in the lateral wall of the pelvis Produces hormones which trigger menstruation analogous to testes in male individuals

3 Anatomy Ovaries are located in an area of the pelvic wall called ovarian fossa Lies beneath the external iliac artery and in front of the ureter and the internal iliac artery Held in place by - mesovarium - IP ligament that connects the ovary to the pelvic wall -ovarian ligament that attaches the lower end of the ovary to the uterus

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6 What is a cyst Comes from latin cystis and from ancient greek κύστις which means sac A cyst is a closed sac, having a distinct membrane and division compared to the nearby tissue It may contain air, fluid or solid material Once formed, a cyst could go away on its own or may have to be removed through surgery

7 Incidence Ovarian cysts are common entities and involve all age groups The incidence of ovarian cysts is unclear due to the lack of consistent reporting and a high chance of spontaneous resolution. Most US prevalence data indicate a range among the general population of 3% to 15% Up to 10% of women will have some form of surgery during their lifetime for the presence of an ovarian mass.

8 Symptoms Often asymptomatic Incidental finding during a routine physical examination or imaging for another condition

9 Symptoms When ovarian cysts -Rupture -Twist -Bleed -Increase in size

10 Rupture

11 Torsion

12 Haemorrhagic cyst

13 Large cyst

14 Common symptoms Pain in lower abdomen Bloating Backpain Dyspareunia Urinary frequency Nausea/vomiting Weight loss/loss of appetite

15 Differential diagnosis Paratubal cyst Hydrosalpinx Tubo-ovarian abscess Peritoneal cyst Pseudocyst Appendiceal abcess Diverticular abscess Pelvic kidney

16 Tubal pathology

17 Evaluation Personal and Family history Physical examination -Abdominal palpation -Bimanual examination

18 Diagnosis Trans vaginal scan (TVS)

19 Abdominal ultrasound- when? - Cyst extending outside the pelvis - Intact Hymen - Patients wish

20 Role of CT scan? MRI - When TVS inconclusive - For cancer staging

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22 MRI MRI can be particularly helpful in the assessment of an ovarian mass that is thought to be malignant Better at distinguishing para-ovarian lesions More accurate evaluation of large masses that are difficult to completely visualize with US Can determine the extent of possible malignancy No radiation

23 Management Depends on Severity of sypmtoms Age Malignancy potential Size of the cyst Patients preference

24 Cysts that cause symptoms and affect the patient s everyday activities should be treated Acute severe symptoms from an ovarian cyst require prompt surgical intervention

25 Pre-menopausal women The overall incidence of a symptomatic ovarian cyst in a pre-menopausal female being malignant is: -1:1000 increasing to -3:1000 at the age of 50

26 Management aim Conservative management where possible Use of laparoscopic techniques if appropriate, thus avoiding laparotomy where possible Referral to a gynae oncologist when necessary

27 Benign cysts Dermoid cyst 25% Corpus luteal cyst, functional cyst 17% Serous cystadenoma 14% Mucinous cystadenoma 11% Endometrioma 8% Low malignant potential tumour 3%

28 Functional cysts Physiological Thin walled cysts with up to 50 mm diameter Resolve usually in 2-3 cycles

29 If <50 mm then no follow up recommended by RCOG Repeat TVS in 3 months reasonable option though If diameter mm then yearly follow up with TVS If >70 mm consider surgery or MRI

30 Endometrioma Surgical treatment recommended if more than 3 cm in diameter Cause of subfertility

31 If simple cysts persist Unlikely to be functional Consider surgery OCP won t promote resolution of the cyst

32 Complex cyst Multilocular Thick septae Strong blood flow Solid components Irregular surface Acsites Bilateral lesions Papillary projections

33 Complex cyst

34 If cyst complex Need to rule out malignancy with -requesting tumour markers -arranging additional imaging

35 Malignant tumours Epithelial carcinoma Germ cell tumour Sex cord tumour

36 CA-125 Do not request if cyst appears simple Raised in numerous conditions as: -fibroids -endometriosis -adenomyosis -pelvic infection -pregnancy -IBD

37 CA-125 If >200 u/ml refer to oncologist Rapidly rising levels more likely to mean malignancy If <200 u/ml rule out common conditions

38 If woman < 40 y.o. Request AFP and HCG to rule out germ cell tumour In the States LDH is also requested Most units will ask for CA-199 and CEA

39 Estimate risk of malignancy Many models RMI currently recommended by RCOG RMI = U x M x CA-125

40 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. Serum CA-125 is measured in IU/ml

41 Surgery Laparoscopy is the gold standard for cysts presumed to be benign Should be considered for cysts with low malignant potential Requires expertise Requires special equipment

42 Laparoscopy Keyhole surgery Requires surgical expertise Discharge in maximum 24 hours Quick recovery Small scars Less post-operative pain

43 Laparoscopy

44 Laparotomy is recommended for large and likely malignant cysts Spillage of cyst contents should be avoided Option of oophorectomy should be discussed with the woman

45 What about aspiration? Better to avoid Recurrence rate approximately 70% Consider it only with simple cysts and patients with complicated medical history

46 Post-menopausal women A large European screening trial revealed a 21.2% incidence of ovarian cysts among healthy post-menopausal women An ovarian cyst in this age group raises the following issues: -What is the most appropriate management -Where the management should take place

47 Assessment TVS CA-125 Estimate RMI

48 Triaging women using the risk of malignancy index (RMI) Risk RMI Women (%) Risk of cancer (%) Low < < 3 Moderate High >

49 Conservative approach Simple cyst less than 5 cm Unilocular Unilateral No adverse features on U/S Normal CA-125

50 Conservative approach TVS every 4 months for a year If cyst hasn t changed then discharge If patient symptomatic or requests intervention then offer surgery Aspiration is not recommended

51 Laproscopy If RMI <250 Should involve oophorectomy and not cystectomy Avoid spillage of the cyst contents Consider bilateral oophorectomy If malignancy is revealed during Laparoscopy then refer to a cancer centre

52 Laparotomy If RMI > 250 Should involve: -Cytology of peritoneal fluid -Biopsies from adhesions and suspicious areas -TAH+BSO+infracolic omentectomy

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55 Case 1 32 y.o. Nulliparous Regular cycle LIF pain for 3 months Unremarkable PMH

56 Attended GP Surgery Abdominal palpation- NAD Bimanual examination- fullness on LIF + moderate left adnexal tenderness TVS requested Does she need tumour markers?

57 TVS

58 Plan Refer to gynaecologist No need for tumour markers Diagnosis of a mature teratoma For Laparoscopic removal

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60 Dermoid cysts Typical appearance on U/S Request for tumour markers not unreasonable Avoid spillage as might cause chemical peritonitis Operate in a bag Peritoneal lavage if spillage occurs or cyst ruptures pre-operatively

61 Case 2 27 y.o. History of subfertility Regular cycle Long history of dyspareunia/dysmenorrhea RIF pain for 5 months, gradually worse

62 Attended GP surgery Physical examination revealed large right adnexal mass TVS arranged CA-125 requested

63 TVS

64 CA-125 = 77 TVS-endometrioma 11x9x8 cm For Laparoscopy or Laparotomy?

65 Laparoscopy Procedure of choice for endometriomas Detailed pre-op assessment on subfertility patients AMH shown to drop after an ovarian cystectomty Consider the 3 step procedure (Drainage-GnRh analogue-vaporisation or removal of the cyst 3 months later)

66 Conclusion TVS is the imaging of choice for suspected ovarian cysts Do not request tumour markers unless an adnexal mass is diagnosed Young women with acute symptoms need urgent referral and investigations to exclude torsion and subsequent necrosis of the ovary

67 Conclusion When an ovarian cyst is diagnosed we need to answer two questions: - Is it cancer? - Does it require surgery?

68 Conclusion Simple cysts are predominantly benign Can be followed up in the community if <5 cm. Complex cysts need referral to a gynaecologist There is no reliable ovarian cancer screening

69 Conclusion If you have any concerns - do not hesitate to refer the patient - call the gynaecologist for advice

70 Thank you Mr P K Athanasias Consultant Gynaecologist St Anthony s Hospital Clinics: Saturday mornings and alternate Monday evenings Appointments: /9 [email protected]