POSTMENOPAUSAL CYST OBSETERIC AND GYNAECOLOGY.pdf

slides presentation post menopausal cyst

1. POSTMENOPAUSAL
CYST
PRESENTER : DR NUR SYUHADA’

2. OUTLINES
1.HISTORY AND PHYSICAL EXAMINATION
2.TUMOR MARKERS
3.ULTRASOUND IMAGING & RMI SCORING
4.MANAGEMENTS

POSTMENOPAUSAL CYST

3. 1. HISTORY

➔Abdominal mass/abdominal pain
Persistent abdominal distension, feeling full
and/or loss of appetite, pelvic or abdominal
pain, increased urinary urgency and/or
frequency
➔Family history
1st degree relative with
bowel/breast/ovarian cancer (BRCA 1 or
BRCA 2 gene)

4. 1. PHYSICAL EXAMINATION

➔Abdominal examination
Palpate for any masses, tenderness, mobility,
nodularity or ascites.
●Irregular mass, solid consistency, fixed,
nodular, or bilateral with presence of ascites,
features of malignancy.
Vaginal examination

BMI > 30

5. TUMOR MARKERS
CEA
-Tumor marker in
colorectal cancer
Ca-19.9
-Exclude bowel and
pancreatic tumor


CA-125
- Sensitivity and specificity
of 78% in postmenopausal
women
- Raised in non-malignant
conditions : PID, fibroid,
acute event in benign cyst

HE4
- Sensitivity (92.3% ) and
specificity (75%) in
postmenopausal group
- Not in routine clinical use

6. What are the imaging
modality that is most
effective of evaluating
postmenopausal cyst?
Tip
TVS
(sensitivity 89%, specificity 73%)

7. Morphological features of a ‘simple cyst’ :
1.Round or oval shape
2.Thin or imperceptible wall
3.Posterior acoustic enhancement
4.Anechoic fluid
5.Absence of septations or nodules.

9. An ovarian cyst is defined as complex in the
presence of one or more features:
- complete septation (i.e. multilocular cyst)
- solid nodules
- papillary projections.

13. SCORING SYSTEMS
RMI SCORE
(RISK OF
MALIGNANCY
INDEX)
IOTA
Classification

14. IOTA CLASSIFICATION

B-rule M-rule

1.Unilocular cyst 1.Irregular solid tumor
2. Presence of solid components where
largest solid components <7mm
2. Ascites
3. Presence of acoustic shadowing 3. At least 4 papillary structures
4. Smooth multilocular tumor with largest
diameter <100mm
4. Irregular multilocular solid tumor with
largest diameter >100mm
5. No blood flow on color Doppler

5. Presence of color Doppler

15. RMI (Risk of Malignancy Index) Score:

RMI = U × M × CA125
U = ultrasound scores
M = menopausal status
( 1 if premenopausal, 3 is
postmenopausal)
Cut off points = 200




ULTRASOUND SCORES:
1.MULTILOCULAR CYST
2.SOLID AREAS
3.METASTASIS
4.ASCITES
5.BILATERAL LESIONS

0 = NO ABNORMALITY
1 = 1 ABNORMALITY
3 = 2 OR MORE ABNORMALITY

16. RMI SCORING
RMI > 250
Risk of cancer
around 75 %
RMI < 25
Risk of cancer < 3 %
RMI 25-250
Risk of cancer
around 20 %

17. CT SCAN
CT imaging is not to detect and characterise
pelvic masses but to evaluate the abdomen
for metastases when a malignant cyst is
suspected
-omental metastases
-peritoneal implants
- pelvic or para-aortic lymph node
enlargement
- hepatic metastases
-obstructive uropathy
-possibly an alternate primary cancer site,
including pancreas or colon

18. How to manage ovarian
cysts in postmenopausal
women

19. CONSERVATIVE
MANAGEMENT
HOW FREQUENT TO MONITOR
-ULTRASOUND AND CA-125,
EVERY 4-6 MONTHS
-IF THE CYST REMAINED
UNCHANGED OR REDUCES IN
SIZE, WITH NORMAL CA-125, IT’S
REASONABLE TO DISCHARGE
AFTER 1 YEAR (AFTER
CONSIDERING PATIENT’S WISH
AND SURGICAL FITNESS)
-Asymptomatic
-Simple, unilateral,
unilocular ovarian cysts,
less than 5 cm in diameter
-Normal serum CA125
levels

RMI SCORE < 25

20. SURGICAL INTERVENTION
RMI < 200 RMI > 200 + CT findings + clinical assessment
LAPAROSCOPIC WITH BILATERAL
SALPINGO-OOPHORECTOMY
Should be counselled preoperatively that a full
staging laparotomy will be required if evidence
of malignancy

LAPAROTOMY AND FULL STAGING
PROCEDURE
- Laparotomy with clear documentation
- Cytology - ascites/wash
- TAH + B/L salpingo-ophorectomy +
omentectomy
- Biopsies from any suspicious areas

22. REFERENCES
-RCOG Green Top guidelines no 34
-ACOG guidelines on management of
adnexal masses
-Radiopedia