• Ovarian cysts are typically noted after clinical screening, or as a result of exam for a suspected pelvic mass,or an incidental finding in investigations done for other reasons
• Management of ovarian cysts depends on age, hormonal status and sonographic features
  • The physician’s role in the approach to ovarian masses is largely to exclude cancer

Premenopausal

Significant Pain

• Rapid onset of acute pain may occur with adnexal torsion which must be treated surgically
• Cyst rupture can result in a small amount of intraperitoneal bleeding or hemorrhage which can manifest as generalized abdominal pain or sudden, unilateral, sharp pelvic pain
• If there are findings suggestive of hemoperitoneum, surgical intervention by laparoscopy or laparotomy is required

Clinical and Sonographic Features Suggestive of Malignancy

• Transabdominal and transvaginal ultrasounds are the primary imaging modality to evaluate adnexal masses
• Transabdominal ultrasound provides overall assessment of organ size and anatomy while transvaginal ultrasound has higher image resolution and gives more detailed characterization of pelvic structures and masses
• Malignant masses are irregular, have thick wall or septations, have solid components (eg mural nodules) or at least 4 papillary structures, with increased vascularity and increased pelvic fluid

The following require surgical exploration:

• Ovarian masses that are persistent, bilateral, solid, fixed, irregular and associated with ascites, cul-de-sac nodules and rapid rate of growth
• Large cysts (>8 cm) and those with multiloculations, septae, papillae and increased blood flow

Postmenopausal

• Ovarian cysts in postmenopausal women should be assessed using transvaginal sonography and CA-125
  • CA-125 together with ultrasound findings and menopausal status may be used to determine ovarian cancer risk through the Risk of Malignancy Index (RMI)
  • RMI of 25-200 is moderate risk while RMI of >200 warrants a gynecologic oncology referral
    • A CT scan of the abdomen and pelvis should be done in patients with RMI >200   
  • An alternative to RMI is the International Ovarian Tumor Analysis (IOTA) which has comparable specificity and sensitivity

• The incidence of ovarian cancer increases with age and is mostly a disease of postmenopausal women

Ultrasound (US)

• The ovaries become smaller after menopause
  
  • A postmenopausal ovary that is 2x the size of the contralateral one is suspicious
• A transabdominal ultrasound may be used if the ovarian cyst is large or outside the field of view of a transvaginal ultrasound

Serum CA-125 Measurement

• An antigenic determinant found in both benign and malignant lesions
• Measurement of CA-125 is most useful in risk stratification of postmenopausal women with suspicious pelvic mass observed by US
  
  • In these patients, a CA-125 level >65 U/mL has a positive predictive value of 97%
  • Levels below 35 U/mL are associated with benign conditions; however, sensitivity and specificity vary
  • However, negative serum CA-125 result also does not rule out ovarian cancer
  • Up to 50% of early-stage ovarian cancer and 20-25% of late-stage cancers are found to have normal CA-125
• CA-125 is raised in 80% of patients with serous cystadenocarcinoma of the ovary but is raised in only half the patients with stage I disease
• Serum CA-125 is not recommended as routine screening for ovarian cancer in healthy premenopausal women
  
  • Elevated CA-125 levels have been observed in pregnancy, endometriosis, fibroids, adenomyosis, cystic teratoma and acute or chronic salpingitis
  • May be measured in premenopausal women if ultrasound findings are suspicious for malignancy
• Most important use of serum CA-125 is assessing the effectiveness of surgery and other therapies given to the patient; it also allows monitoring for recurrence of ovarian cancer in histologically known cases
• Other tumor markers include CA-15.3 and CA-19.9

Presurgical

• In addition to history, pelvic exam, ultrasound and serum CA-125, other tumor markers eg alpha fetoprotein, β−human chorionic gonadotropin and carcinoembryogenic antigen are determined preoperatively
  • Women <40 years should check their lactate dehydrogenase (LDH), alpha fetoprotein, and human chorionic gonadotropin levels for potential germ cell tumors
• If any result points to malignancy, abdominal and pelvic computed tomography (CT) are requested
• In patients with CT scan finding showing malignancy, staging laparotomy or chemotherapy is indicated
• In patients with negative CT scan finding, laparoscopy is planned and consent for possible laparotomy is obtained

Surgery

• Patients with multilocular, bilateral cysts >3-5 cm, who are symptomatic, have elevated CA-125, and have suspicious or persistent non-simple cyst on US should be investigated further with surgery
  • Elevated CA-125: >200 U/mL in premenopausal women or >35 U/mL in postmenopausal women

Surgery may be considered if the patient has a strong family history of ovarian, breast, endometrial or colon cancer or if the mass appears to be enlarging

• Cyst rupture
• Torsion

• Consider ovarian cyst rupture, torsion, or hemorrhage in postmenopausal women with acute abdominal pain