Ovarian cyst types and management

1. Dr.Alaa Ibrahim

2. ،‫ﺍﻟﺴﺮﻳﻊ‬ ‫ﻉ‬ ‫ﺍﻟﺪﻛﺘﻮﺭﺓ‬ ‫ﺣﺠﺘﺔ‬

3. COMMON OVARIAN TUMOURS
Infancy -Functional cyst , Germ cell tumor
Pre pubertal - Functional cyst , Germ cell tumor
Adolescent - Functional cyst , Germ cell tumor
Reproductive - Functional cyst - Dermoid
Peri menopausal - Epithelial ovarian tumor-- Functional
cyst
Post Menopausal - Neoplastic ovarian tumor- Functional
cyst
3. Epithelial tumor Epithelial tumor Mets

4. CLINICAL PRESENTATION
• Asymptomatic – accidentally discovered on USG
• Chronic pattern of pain, increasing abdominal
girth over months or weeks.
• Associated with secondary symptoms of
anorexia, nausea, vomiting, urinary frequency.
• Could be associated with primary or secondary
amenorrhea, menstrual irregularities, virilization,
precocious puberty
• Become acutely symptomatic if undergoes
torsion, rupture or haemorrhage. Benign ovarian
neoplasms are indistinguishable clinically from
malignant counterparts

5. COMPLICATIONS
• Torsion
• Intracystic hemorrhage
• Infection
• Rupture
• Pseudomyxoma peritonei
• Malignancy

6. PHYSICAL EXAMINATION
• Abdominal and vaginal examination and the
presence or absence of local lymphadenopathy
• Assess
– Laterality
– Cystic Vs solid
– Mobile Vs fixed
– Smooth Vs irregular
– Ascites
– Cul-de-sac nodules
– Rapid growth rate
‫ﺍﺫﺍ‬ ‫ﺍﻋﺮﻑ‬
unilateral
‫ﺍﻭ‬
bilateral

7. Rule out Cancer
Alleviate symptoms
Prevent cyst accidents

8. Age (risk increases with age)
Nulliparity
Ethnic (American, Northern European)
Family history(only 10% are familial)
Endometrial cancer
Breast Cancer

9. ?Fertility Drugs
Use of Oral Contraceptives .
Tubal Ligation is protective
Hysterectomy is protective but BSO does not
eliminate the risk

10. History: risk factors, symptoms
Physical exam.:
Ultrasound, CT, MRI(not better than US)
Tumour markers
HCG, CBC, RFT, LFT
Laparoscopy/Laparotomy

11. TVS:
can achieve sensitivity of 88% to 100% and
specificity of 62% to 96%.
• Adding doppler does not seem to yield much
improvement in the diagnostic precision, but
increases the confidence with which a correct
diagnosis of benignity or malignancy is made.

12. 1.Solid mass/ or complex mass
2.Cystic Mass(unilocular more likely benign)
3.Size
4.Complex mass can be seen with corpus luteum
or hemorrhagic cyst
5.Doppler flow/Pulsitile index
Pulsitility index of less than 0.4 is indicative of
malignancy (experimental)
6.Associated findings (ascites, omental mass,
endometrial abnormalities and metastasis
‫ﻋﻦ‬ ‫ﻣﻌﻠﻮﻣﺎﺕ‬ ‫ﻳﻨﻄﻴﻨﻲ‬ ‫ﻻﺯﻡ‬ ‫ﺍﺳﻮﻱ‬ ‫ﺍﻟﻠﻲ‬ ‫ﺍﻟﺴﻮﻧﺎﺭ‬

15. OTHER IMAGING MODALITIES
• CT, MRI, PET not recommended in the initial
evaluation
• CT scan: evaluating – LN involvement, –
Omental mets, peritoneal deposits, hepatic
mets, – obstructive uropathy – or a probable
alternate primary site when cancer is
suspected based upon TVS
• MRI : differentiating non adnexal pelvic
masses (like leiomyomata).
‫ﺍﺣﺘﺎﺝ‬ ‫ﺷﻮﻛﺖ‬
CT scan
‫ﻭ‬
MRI
‫ﻓﻮﻙ‬ ‫ﺍﻟﺠﻮﺍﺏ‬ ‫؟؟‬

16. TUMOR MARKERS
CA- 125 Most useful when non-mucinous
epithelial cancers are present Elevated in 80%
of patients with epithelial ovarian Ca but only
in 50% of patients with stage I disease
Increased sensitivity in post menopausal
women esp. when associated with relevant
clinical and USG findings Cut-off of 30 u/ml,
sensitivity of 81% and specificity of 75%
‫ﺍﻟﺴﺮﻳﻊ‬ ‫ﻉ‬ ‫ﺣﺠﺘﺔ‬
‫ﺍﻟﺒﺎﻗﻲ‬ ‫ﻭﺍﻟﻨﺺ‬
Normal

17. Unfortunately can be elevated in
endometriosis.
menses.
Infection.
Fibroids.
liver or renal failure.
Ascites.
breast cancer.
endometrial and cervical cancers and GI
malignancies.

18. HE4 is a precursor to the epididymal secretory
protein E4 and in normal ovarian tissue, there
is minimal gene expression and production of
HE4. • As a single tumor marker, HE4 had the
highest sensitivity for detecting ovarian cancer,
especially Stage I disease.
HE4 levels(>70 pM) were found to be elevated
in over half of the patients with ovarian cancer
with normal serum CA125 levels (>35 U/ml)

19. Age of patient
Size of mass
Ultrasound description of cystic or complex or
solid
Other associated finding i.e, ascites,
pulmonary effusion, lymphadenopathy, other
cancers (cervix, endometrium, breast)

20. Ovarian mass in childhood:
-Simple cyst - Observe and reassess
-Solid or solid cystic MRI and tumor markers
High suspicion of malignancy -Laparotomy
laparoscopy Frozen section Malignant –
oophorectomy and staging
Benign - cystectomy

21. Ovarian mass in reproductive age group
Asymptomatic simple cysts <5cms :
Likely physiological (do not require follow up)
USG cystic -observation every 3-6 months
Complex, solid, suspicious Persistence or
progression then –surgery.
5-7 cms :
Yearly USG >7cm Require further
imaging/surgical intervention.

22. • The value of ovarian suppression with OCP not prevent
Ovarian cyst but remains common practice.
• Repeat evaluation: physical examination and TVS
• Indications for surgery: change in sonographic
characteristics to a more complex mass and rise in CA
125
indications for surgical management:
• Remember—‘THIN RIM’
• T—Torsion
• H—Haemorrhage
• I—Infection
• N—Necrosis
• R—Rupture
• I—Infarction
• M—Malignant change

23. Ovarian cysts in postmenopausal women:
• Post menopausal gonad atrophies to a size of
1.5 X 1 X 0.5cm on average
• Shouldn’t be palpable on pelvic examination.
• Presence of palpable ovary must alert the
possibility of an underlying malignancy.
• Causes -10% functional 90% neoplastic (either
benign or malignant)
ASSESSMENT
using CA125 and transvaginal grey scale
sonography.

24. Simple, unilateral, unilocular ovarian cysts, less than
5 cm in diameter, have a low risk of malignancy. It is
recommended that, in the presence of a normal
serum CA125 levels, they be managed
conservatively.
• Aspiration is not recommended for the
management of ovarian cysts in postmenopausal
women.
• It is recommended that a ‘risk of malignancy index’
should be used to select women for laparoscopic
surgery.
• It is recommended that laparoscopic management
of ovarian cysts in postmenopausal women should
involve oophorectomy (usually bilateral) rather than
cystectomy.

25. The advantages of laparoscopic surgery are
less post-operative pain, shorter hospital
stay, quicker return to normal activities and
possibly less adhesion formation than after
an open procedure.
However, the consequences of spillage of
cyst contents, incomplete excision of the
cyst wall and an unexpected histological
diagnosis of malignancy are considerable
disadvantages.

26. Functional ovarian cysts
• Follicular cysts
• Corpus luteum cysts
• Theca lutein cysts
• Luteomas of pregnancy By far the most
common clinically detectable enlargements of
the ovary in the reproductive years. All are
benign and usually asymptomatic.

27. Common Epithelial Tumors:
• Serous tumors
• Mucinous tumors
• Endometrioid tumors
• Clear cell tumors
• Brenner tumors
• Mixed epithelial tumors
• Undifferentiated ca.
• Unclassified epithelial tumors

28. Sex cord tumors:
• Granulosa-stromal cell tumors, theca cell
tumors
• Androblastomas
• Gynandroblastomas

29. Germ cell tumors:
• Dysgerminoma
• Endodermal sinus tumor
• Embryonal ca.
• Polyembryoma
• Choriocarcinoma
• Teratoma
• Mixed

30. Small cysts < 5 cm can be monitored by serial
scans, before making a decision as to what the
definitive treatment should be.
As regards treatment choices, the options
include medical therapy or surgery.

31. Medical therapy
consists of medicines such as danazol or GnRH
analogs to suppress the endometriosis; and
while this is very effective in providing
temporary symptom relief , it is not very
effective in treating the cyst, which tends to
remain in spite of the treatment.
The definitive solution is surgical;
this usually consists of operative laparoscopy .
cystoectomy

32. The major problem with chocolate cysts is that
they tend to recur. This is why doctors will
often combine medical suppression with
surgical treatment.

35. Benign cystic Teratoma (Dermoid
Cyst)-
Most common tumor in reproductive age
women 25% of all ovarian neoplasms
80% less than 10cm
15% bilateral
50% asymptomatic
1-2% malignant transformation

36. Complications :
rupture, torsion, infection, hemorrhage, and
malignant transformation, Thyrotoxicosis,
autoimmune hemolytic anemia, and carcinoid
Treatment:
ovarian cystectomy or Oophorectomy(can wait
until after -delivery if pregnant)

39. ‫ﻧﻮﻉ‬ ‫ﻧﻜﻮﻝ‬ ‫ﺷﺸﻮﻓﻮﻥ‬ ‫ﺳﺄﻟﺖ‬
cyst
‫ﻣﻦ‬ ‫ﺟﺎﻱ‬ ،‫ﺟﺎﻱ‬ ‫ﻭﻣﻨﻴﻦ‬
germ cell

41. ‫ﺍﻝ‬ ‫ﺍﺷﻮﻑ‬
cyst
‫ﻋﺒﺎﺭﺓ‬ ‫ﻻﻥ‬ ‫ﺩﺍﻛﻨﺔ‬ ‫ﺳﻮﺩﺍﺀ‬
‫ﻋﻦ‬
fluid

42. ‫ﺍﻟﺼﻮﺭ‬ ‫ﻉ‬ ‫ﺗﺮﻛﺰﻭﻥ‬ ‫ﺷﻲ‬ ‫ﺍﻫﻢ‬ ‫ﻛﺎﻟﺖ‬ ‫ﺍﻟﺪﻛﺘﻮﺭﺓ‬

46. ‫ﺷﻜﻠﻬﺎ‬ ‫ﻳﻜﻮﻥ‬
glandular
‫ﻳﻤﻴﺰﻫﺎ‬ ‫ﺷﻲ‬ ‫ﺍﻫﻢ‬

53. Omental metastasis of ovarian tumor