Management of Ovarian Cysts
Simple or multiloculated cysts <7cm diameter
There should be no solid components, no apparent growths or
excrescences within the cyst and no excessive free fluid in the Pouch of
Douglas. The CA125 should also be normal.
a) Reproductive age group (12-45 years approximately)
These are of two types:Functional – these are part of the normal
function of the ovary and come and go with menstrual cycles; provided of
course that the patient is not on the oral contraceptive pill and has been
taking the pill consistently daily.
If the patient does not have symptoms (mainly pain), indicating a possible
complication of the cyst such as torsion, bleeding or partial rupture, then the
pelvic ultrasound should be repeated in 4-6 weeks time. If the lesion is a
functional cyst, then it will have disappeared, although there may be a similar
lesion on the other ovary. If this is the case then nothing further needs to be
done and the patient can be reassured.Pathological -
If the lesion is still present then it is not a functional
cyst but rather a pathological tumour. It may be benign, borderline (low
malignant potential) or malignant, and it should be removed surgically.
There is no place for needle aspiration, either laparoscopically or under
image control, as a proportion of these lesions will be malignant and
leakage may condemn the patient to a subsequent unnecessary death from
disseminated ovarian cancer.
b) Non-Reproductive age group (<12 or >45 years approx).
As the ovary has no function in the non-reproductive age group there can be no
functional cysts. Therefore all cysts, regardless of size or simplicity are
pathological and should be surgically removed.Again, there is no place for needle aspiration, either laparoscopically or under
image control, as a proportion of these lesions will be malignant
and leakage may condemn the patient to a subsequent unnecessary death from
disseminated ovarian cancer. I have seen a couple of patients over the years
who have had this done and within 12 months were undergoing major radical cancer
surgery for disseminated ovarian cancer.
2.
Complex Cysts &/or Lesions > 7cm.
All of these tumours are
pathological and should be surgically removed.
Again, there is no place for needle aspiration, either laparoscopically or under
image control, as a significant proportion of these lesions will
be malignant and leakage may condemn the patient to a subsequent unnecessary
premature death from disseminated ovarian cancer.
If uncertain about the nature of the lesion the patient should be referred to a
Specialist Gynaecologist for assessment.
Patients who are suspected of having a possible malignancy should be referred to
a Certified Gynaecological Oncologist (they carry the letters CGO after their
name).
If you are uncertain as to the likelihood of malignancy being present then the
Risk of Malignancy Index (RMI) should be
calculated. This is done as follows:
RMI = U x M x CA125 level
U is scored as 1 or 3 on the basis of the presence or absence
of five ultrasound features. These include
U scores 1 if none or only one of above are present and
U scores 3 if two or more of
these features are present.
M scores 1 for premenopausal, and 3 for postmenopausal. If the patient has had a hysterectomy then she scores 1 if <50 years and 3 if ≤50 years.
If the RMI is >200 then there is a substantial risk of ovarian malignancy and
the patient should be referred to a Certified Gynaecological Oncologist (CGO).
The overall sensitivity of this algorithm for diagnosing borderline, invasive
ovarian, or primary peritoneal cancers is about 87% and the positive predictive
value is about 87% (Bailey et al, Int J Gynecol Cancer 2006, 16
(Suppl. 1), 30-34). The RMI sensitivity increases as does the stage of the
disease.
