OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN I

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1 OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN I Is it raccomended that ovarian cysts in postmenopausal women should be assessed using CA 125 and transvaginal grey scale sonography. Serum CA 125 is raised in over 80% of ovarian cancer cases and, if a cut-off of 30 U/ml is used, the test has a sensivity of 81% and specificity of 75%. Ultrasound is also well established achieving a sensitivity of 89% and specificity of 73% when using a morphology index. There is no routine role yet for Doppler, MRI, CT or PET. (RCOG 2003)

2 OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN II Ovarian cysts are common in postmenopausal women, although the prevalence is lower than in premenopausal women. Of healthy postmenopausal women screened, 21,2 % had abnormal ovarian morphology either simple or complex. The greater use of ultrasound means that an increasing proportion of these cysts will come to the attention of gynaecologists. (RCOG 2003)

3 OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN III It is recommended that a risk of malignancy index should be used to select those women who require primary surgery in a cancer centre by a gynaecological oncologist. (RCOG 2003)

4 OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN CONSERVATIVE MANAGEMENT Simple, unilateral, unilocular and echo-free with no solid parts or papillary formations, less than 5 cm in diameter, have a low risk of malignancy (less than 1%). It is recommended, in presence of a normal serum CA 125 levels, they to be managed conservatively, with a follow-up ultrasound scan, a reasonable interval being four months. (RCOG 2003)

5 OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN SURGICAL MANAGEMENT ASPIRATION Cytological examination of ovarian cyst fluid is poor at distinguishing between benign and malignant tumours, with sensitivity of around 25%. In addition, there is a risk of cyst rupture: aspiration, therefore, has no role in the management of asymptomatic ovarian cysts in postmenopausal women. (RCOG 2003)

6 OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN SURGICAL MANAGEMENT LAPAROSCOPY The laparoscopic approach should be reserved for those women who are not eligible for conservative management but still have a relatively low risk of malignancy. The appropriate laparoscopic treatment should involve oophorectomy (usually bilateral) rathen than cystectomy, with removal of the ovary intact in a bag without cyst rupture into the peritoneal cavity. (RCOG 2003)

7 OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN SURGICAL MANAGEMENT LAPAROSCOPY Women at intermediate risk undergoing laparoscopic oophorectomy should be counselled preoperatively that a full staging laparotomy would be required if evidence of malignancy is revealed. If a malignancy is revealed during laparoscopy or subsequent histology, it is recommended that the woman is referred to a cancer centre as quickly as possible. (RCOG 2003)

8 OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN SURGICAL MANAGEMENT LAPAROTOMY A high risk of malignancy index or clinical suspicion or findings at laparoscopy are likely to require a full laparotomy and staging procedure which should include: Citology : ascites or washing TAH, BSO and infracolic omentectomy Biopsies from adhesion and suspicious areas Appendicectomy Bilateral pelvic and paraortic lymphadenectomy (RCOG 2003)

9 ( RCOG 2003)

10 ( RCOG 2003)

11 (RCOG 2003)

12 Table1. Morphological score Value Wall Septa Vegetations Echogenicity 1 3 mm no septa no vegetations sonolucent* 2 > 3 mm 3 mm low echogenicity 3 > 3 mm 4 irregular, mostly solid 3 mm with echogenic area 5 irregular, non applicable > 3 mm with disomogeneous echogenic areas, solid *or with fine trabecular and jelly like hypoechoic content typical of endohaemorragic corpus luteum. Cut-off value for risk of malignancy 9 (Ferrazzi, 1997)

13 Cisti ovariche semplici in postmenopausa Prevalenza: 6.6% Conway et al % Wolf et al % Aubert et al % Levin et al Incidenza simile di anno in anno Castillo et al Prevalenza non è correlata all età della menopausa Castillo et al. 2003, Wolf et al Diametro medio circa 3 cm, +80% <5 cm Castillo et al. 2003, Wolf et al. 1991, Bailey et al. 1998, Valentin et al. 2002

14 Prevalenza delle cisti ovariche semplici in postmenopausa Prevalenza all esame autoptico del 19.7% 62.7% diametro medio <20 mm 29.4% diametro medio tra 20 e 50 mm 7.8% diametro medio >50 mm Prevalenza simile a quella riportata in molti studi in base all esame US Ecografia è procedura elettiva per identificare le cisti ovariche Dorum et al. 2004

15 Cisti ovariche semplici in postmenopausa 50% Risolve spontaneamente in 2 aa 50% Persiste 65-75% invariate 25-35%: 50% diminuisce di volume 50% aumenta di volume Nei follow-up nessuna paziente ha sviluppato Ca a mesi Castillo et al. 2006, Valentin et al. 2002, Modessit et al. 2003

16 Cisti ovariche semplici in postmenopausa Potenziale rischio di malignità < 1% Castillo et al., Gynecol Oncol 2003 Bailey et al. Gynecol Oncol 1998 Aubert et al. Maturitas 1998 Andolf et al. J Clin Ultrasound 1988 Conway et al. J Ultrasound Med 1998 Levine et al. Radiology 992 Padilla et al. Obstet Gynecol 2000 Bar-Haval et al. Acta Obstet Gynecol Scand 1997 Modesssit et al. Obstet Gynecol 2003 Kroon et al. Obstet Gynecol 1995 Auslender et al. J Clin Ultrasound 1996 Valentin et al. Ultrasound Obstet Gynecol 2002 La piu frequente istologia: cistoadenoma sieroso (>80%)

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18 (Castilllo 2004)

19 (Castillo 2004)

20 Table 2. Histologic results from the 211 premenopausal patients treated by laparoscopy Number of cysts Percentage Serous cyst 72 (34.13%) Endometriotic cyst 68 (32.23%) Paraovarian cyst 7 (3.32%) Hemorrhagic cyst 11 (5.22%) Cystadenomas 9 (4.27%) Dermoid cyst 14 (6.64%) Hydrosalpinx 6 (2.90%) Primary tubal carcinoma 1 (0.48%) Follicular cyst 19 (9.10%) Lutein cyst 4 (1.90%) (Stamatellos, Gynecol Surg 2006)

21 BENIGN CYSTIC TERATOMA I The majority occurs during reproductive years. Malignancy complicates % of cases. The rate of bilateral mature cystic teratomas is >10%. Risk of torsion (3%), acute rupture (1-3%.) or chronic leakage (1%). (Commerci 1994) Granulomatous chemical peritonitis associated with the leakage of cystic teratomas is characterized by multiple small yellow-white implants and dense adhesions. (Stern 1981)

22 BENIGN CYSTIC TERATOMA II 178 cystic teratomas. Overall incidence of leakage at cystectomy was not statistically different between patients undergoing laparotomy (38.7%) and laparoscopy (42.2%). There was no difference between cysts that leaked and those that did not in location, mean diameter at preoperative ultrasound, diameter as estimated at surgery and presence of adhesions. Cystectomy by laparotomy is insensitive to surgeon experience as misured in years; however, laparoscopic experience (20 cases for year) is highly predictive of success at laparoscopic cystectomy. (Milad 1999)

23 Laparoscopic cystectomy is currently considered the first-line choice for the conservative treatment of benign ovarian cysts However the safety of this technique in term of ovarian damage to the operated gonad has recently been questioned

24 Nargund,Human Reprod.1996 In patients previously operated for endometriotic ovarian cysts, during IVF the number of both follicles and retrieved oocytes obtained in the operated gonad during ovarian hyperstimulation is markedly reduced when compared to the controlateral intact ovary

25 Potential deleterious mechanisms Amount of ovarian tissue removed during cystectomy Damage inflicted to ovarian stroma by electrosurgical coagulation during hemostasis Previous presence of the cyst

26 Somigliana, Fertil. Steril., patients 53 cycles of IVF control ovary operated ovary Basal volume 9.6 ± ± 5.5 cm3 p<0.007 N follicles 4.4 ± ± 1.4 p<0.001 Mean reduction in follicles retrieval 56% (95% C.I.) This reduction did not seems to be related to the dimension of the excise ovarian cyst

27 Canis, Human Reproduction, Pts : laparoscopic ovarian cystectomy for endometrioma > 3 cm 139 Pts : pelvic endometriosis without ovarian endometrioma 59 Pts: tubal infertility Ovarian stimulation with CC+Gn or GnRHa + Gn Number of oocytes and embryos obtained is not significantly decreased by laparoscopic cystectomy

28 Does laparoscopic removal of nonendometriotic benign ovarian cysts affect ovarian reserve? Seventeen IVF-cycles in women who previously underwent laparoscopic excision of a monolateral nonendometriotic benign ovarian cyst. Basal volumes of the intact and the operate gonads were 5.7 ± 3.3 and 3.4 ± 2.3 cm³ respectively (P=0.01), corresponding to a mean reduction of 39%. The numbers of dominant follicle were 4.6 ± 2.5 and in the control ovary and in the previous operated ovary, respectively (P=0.01), corresponding to a mean reduction of 42%. (Somigliana 2006)

29 Muzii L. et Al, Fertil.Steril.,77,609,2002 Laparoscopic excision of ovarian cyst using stripping technique 42 women Results Recognizable ovarian tissue adjacent to the cyst wall in 36% Significant difference between endometriotic and nonendometriotic cyst (54% vs 6%, p<0.005) No specimen showed the normal follicular pattern observed in healthy ovaries

30 Indicators of ovarian reserve Ovarian volume (Lass 1999) Antral follicle count (Bancsi 2002) Stromal blood flow (Tarlatzis 2003)

31 Exacoustos et al.,amj.obstet.gynecol,191,68,2004

32 Exacoustos et al.,amj.obstet.gynecol.,191,68,2004

33 Exacoustos et al.,am.j.obstet.gynecol.191,68,2004

34 Ovarian cortex surrounding benign neoplasms I Specimens obtained from the area of maximum distension of the ovarian cortex overlying benign cyst. Evaluation of the type and number of follicles and vascular network ( Maneschi,1993 )

35 Ovarian cortex surrounding benign neoplasms II Teratomas Cystoadenomas Endometriomas Normal morphologic 92% 77% 19% pattern Regular vascular 84% 78% 22% network P < 0.01 ( Maneschi, 1993)

36 Ovarian cortex surrounding benign neoplasms III Stretching and thinning the ovarian cortex are not associated with morphologic alterations Endometrioma is often associated with microscopic endometriosis in surrounding cortical tissue and with alterations of the follicular and vascular patterns ( toxic or inflammatory mechanism? ) ( Maneschi, 1993 )

37 Conclusions Laparoscopic excision of ovarian cyst is associated with a damage of ovarian reserve at least in a short term follow up Our results tend to rule out a role for an injury of ovarian vascularization The modality to achieve a good hemostasis may be important Is the reduction of ovarian reserve a consequence of surgery or,conversely,the damage is already present before surgery?