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Author: Contact Name and Job Title Kate Stewart ST7, David Nunns Consultant
Gynaecological Oncologist, NUH
Version 7
This guideline has been registered with the trust. However, clinical guidelines are guidelines only.
The interpretation and application of clinical guidelines will remain the responsibility of the individual
clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines
after the review date.
Aims and purpose
To guide the clinician (general gynaecologists all grades) on the
assessment, referral and initial management of ultrasound scan
detected ovarian cysts.
Algorithm for the management of ovarian cysts on USS (please see
main text for detail)
Background
Up to 10% of women will have some form of surgery for the presence
of an ovarian mass. In premenopausal women almost all ovarian
masses and cysts are benign and many ovarian masses in this group
can be managed conservatively
The underlying management rationale is to minimise patient morbidity
by:
o conservative management where possible providing necessary
reassurance
o use of laparoscopic techniques where appropriate, thus avoiding
laparotomy
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o referral to a gynaecological oncologist where appropriate.
It should be noted that almost all pelvic ultrasound scan requests
will require a transvaginal scan (TVS). TVS is almost always
superior to transabdominal ultrasound (TAS) for examining the pelvic
organs. However, some women cannot accommodate a vaginal scan
probe and can only have an abdominal scan.
At the present time the routine use of CT and MRI for assessment of
ovarian masses does not improve the sensitivity or specificity obtained
by transvaginal ultrasonography in the detection of ovarian
malignancy and should be reserved as second line investigation after
discussion with a senior colleague. However, if the mass is larger
than the array of the scanning probe or if there are diagnostic
difficulties with the USS then a CT/MRI may be indicated.
It is important to consider borderline ovarian tumours as a histological
diagnosis when undertaking any surgery for ovarian masses and,
when such a histological diagnosis is made or strongly suspected,
discussion with the gynaeoncology team is recommended.
Although up to 20% of borderline ovarian tumours appear as simple
cysts on ultrasonography, the majority of such tumours will have
suspicious ultrasonographic findings.
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1.Tumour markers
Tumours marker (such as Ca125) is used as a part of patient triage
and risk assessment. They are not diagnostic and lack good sensitivity
and specificity.
Measure serum CA125 in all women with suspected ovarian cancer
A serum CA-125 assay does not need to be undertaken in all
premenopausal women when an USS diagnosis of a simple ovarian
cyst has been made.
In women under age of 40 years with suspected ovarian cancer also
measure: levels of alpha fetoprotein (AFP), beta human chorionic
gonadotrophin (beta-hCG) as well as serum CA125, to identify germ
cell tumours.
http://www.iotagroup.org/index.php/educational-material
IOTA Group ultrasound rules to classify masses as benign (B-
rules) or malignant (M-rules)
B-rules M-rules
Cyst criteria apply even if cysts are multiple (cysts completely separate
from each other) or bilateral.
Pre-menopausal cysts Less than 5cm 5 - 7cm more than 7cm
Simple/ No follow up Suggest rescanning in Suggest benign
Haemorrhagic cyst required unless four months. gynaecological team
there is clinicalIf smaller or resolved no review re: surgery
concern. further follow up required. depending on clinical
Findings are If larger or persisting assessment
likely to be suggest further
physiological in gynaecological review.
nature and Ovarian cysts that persist
almost always or increase in size are
resolve within 3 unlikely to be functional
menstrual and may warrant surgical
cycles. management. If
symptomatic, for benign
gynaecological review.
Endometrioma/ Manage on clinical grounds
dermoid No routine rescans indicated as less likely to change in size
Ovarian cysts with any Take CA-125 and calculate RMI. Consider germ cell tumour markers
malignant features (see IOTA (AFP, HCG and LDH). Discuss with the gynaeoncology team.
criteria in above table)
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In this case a CT scan chest abdomen and pelvis would be more
appropriate (patients require a GFR for IV contrast).
The pooled sensitivities and specificities of an RMI I score of 200 in
the detection of ovarian malignancy are sensitivity 78% (95% CI 71-
85%) and specificity 87% (CI 83-91%)
The value is less in premenopausal women where Ca-125 levels may
be raised with benign conditions eg, endometriosis.
RMI score = ultrasound score x menopausal score x CA125 in
U/ml.
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Postmenopausal cysts Less than 3cm 3-5cm More than 5cm
Simple ovarian cysts If the cyst is smallSuggest rescan Suggest benign
with no worrying with CA-125 gynaecological team
features, this is measurement in referral. Calculate
most likely to be a four and eight RMI and discuss if
residual follicle. No
months. appropriate with the
further scan is If no change gynaeoncology team
indicated. demonstrated in
these scans, no
further imaging
indicated unless
clinical concern.
Dermoid cysts No immediate action Suggest Suggest benign
is indicated gynaecological gynaecological team
manage on clinical referral. referral. Calculate
grounds No rescan RMI and discuss if
indicated appropriate with the
gynaecological
oncological team
Ovarian cysts with any Take CA-125 and calculate RMI. Discuss with the gynaeoncology
malignant features (see IOTA team.
criteria in above table) or not
simple
4. Special scenarios
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Traditionally, surgery has involved partial or complete oophorectomy
or salpingo-oophorectomy.
There is evidence to suggest that the clinical appearances of torted
adnexae do not correlate well with the likelihood of residual ovarian
function and recovery and there are good outcome data to support
conservative management with laparoscopic de-torsion in the majority
of cases with little short or long-term associated morbidity even if the
ovary appears dark purple or black.
True cysts can be drained at the time to maximise ovarian
conservation.
Follow up after detorsion should be by scan in Miss Jhambs
emergency gynaecology Thursday afternoon clinic to determine the
presence of any true cysts that may require interval cystectomy.
4.4 Management of cysts in pregnancy
Asymptomatic adnexal masses are frequently diagnosed in
pregnancy, either at the dating scan or at the time of caesarean
section. They are mostly ovarian in origin. Although the overall
incidence of adnexal masses in pregnancy is approximately 4%, the
incidence of complex or simple persistent cysts measuring more than
6 cm is only 0.07%. Three-quarters of these persistent cysts are
complex in nature and the majority of complex cysts are either benign
teratomas or endometriomas.
Ovarian cysts in pregnancy can result in cyst rupture, cyst
haemorrhage, torsion (up to 5%), obstructed labour and fetal
malpresentation
The majority of ovarian cysts in pregnancy are benign and can be
managed conservatively. Ovarian cancer is extremely rare in women
of childbearing age, the overall reported incidence of ovarian cancer in
pregnant women varies from 0.0040.04%, If there is a suspicion of
malignancy or there is a significant cyst complication, such as torsion,
and surgery is planned, this should take place during the second
trimester to minimise the risk of miscarriage.
4.4.1 MRI in pregnancy
MRI is considered safe in pregnancy (without contrast) and can be
helpful in the assessment of an ovarian mass that is thought to be
malignant.
4.4.2 Tumour markers in pregnancy
Effect of pregnancy
CA 125 Raised during pregnancy due to decidual cell
(epithelial cancer) production.
Some researchers have suggested using a cut-off
level of 112 U/ml
BHCG
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(germ cells tumours)
AFP
(germ cells tumours) Serum AFP, betahCG and inhibin levels are all raised
Inhibin due to placental synthesis
(granulosa and
mucinous)
LDH
(malignant germ cell Due to the rarity of this neoplasm, data regarding this
tumours) association is sparse
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complex ovarian tumour that has persisted during the pregnancy
but which has not required earlier operative intervention.
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