Adnexal masses -Ovarian Cysts

Michelle M Fynes
MB BCh BAO (Hons) MD (Research) MRCOG DU DipUS
Subspecialty Accredited Urogynaecologist RCOG (2003) and RANZCOG (2002)
CCST Obstetrics and Gynaecology (2003)
Specialist Complex Peri-partum Childbirth Injury and
Paediatric Adolescent and Forensic Gynaecology
Definition

• Ovarian cyst - collection of fluid, very thin wall, within ovary

• Ovarian follicle >2cm is termed ovarian cyst.
• Range in size from as small as a pea to larger than an orange.
• Most ovarian cysts are functional in nature and benign
• Functional cysts occur in nearly all premenopausal XX, and up to 14.8% postmenopausal XX.
• Pre-menopausal almost all ovarian masses/cysts are benign.

• Incidence symptomatic pre-menopausal ovarian cyst being malignant is approximately

1:1000 and 3:1000 at 50years.
• Ovarian cysts most common in reproductive years.
• Functional cysts 2-3 cm usually resolve 2-3 menstrual cycles
• Symptoms (usually pain) may be caused by increasing size, bleeding, rupture, leak or torsion.
• Surgery may be required if cyst >5cm in diameter.
• 10% of women will surgery during their lifetime for an ovarian mass.
 Classification of Adnexal Masses
Primary malignant
• ovarian Germ cell tumour
• Epithelial carcinoma
• Sex-cord tumour
Benign ovarian
• Functional cysts Secondary malignant ovarian
• Endometriomas • Predominantly breast and gastrointestinal
• Serous cystadenoma carcinoma.
• Mucinous cystadenoma
• Mature teratoma
• Borderline tumour ovary

Benign non-ovarian
• Paratubal cyst
• Hydrosalpinges
• Tubo-ovarian abscess
• Peritoneal pseudocysts
• Appendiceal abscess
• Diverticular abscess
• Pelvic kidney
 Functional ‘Simple’ Ovarian cysts
2.5cm left ovarian cyst

Classification functional cysts

• Follicular cyst
• Corpus luteal cyst

Other
• Cystic Axial CT- Haemorrhagic ovarian
cyst. Anterior blood pool
• Solid/cystic

Two groups
• Pre-menopausal
• Post-menopausal

CT- 30 year old female with an

8.5cm cyst
Management suspected ovarian masses –
Pre-menopausal women

Underlying management rationale to minimise morbidity by:

• Conservative management where possible

• Use laparoscopic techniques where appropriate (avoid laparotomy)
• Referral to a gynaecological oncologist where appropriate.

• 10% are found to be non-ovarian in origin

• Functional or simple cysts <5cm usually resolve 2-3 cycles
• Surgery indicated, persistent symptoms laparoscopy ‘gold standard’
• Laparoscopic management cost-effective earlier discharge
• Mini-laparotomy considered for large cysts
 History and Examination

• Risk factors- ovarian or breast cancer.

• Symptoms suggestive of endometriosis
• Symptoms suggesting possible ovarian malignancy: persistent abdominal distension,
appetite change including increased satiety, pelvic or abdominal pain, increased
urinary urgency and/or frequency.
• Physical examination should include abdominal and vaginal (bimanual) assessment
• Presence or absence of local lymphadenopathy.
• Acute presentation with pain consider cyst accident (torsion, rupture, haemorrhage).
• Sensitivity examination poor in detection
ovarian masses (15–51%). Value in evaluating
• Tenderness, mobility, nodularity and ascites.
 What investigations?

CA-125 assay

• CA-125 not necessary clear US diagnosis simple ovarian cyst

• CA-125 unreliable differentiating benign vs malignant masses
• Premenopausal XX to increase rate false positives and reduced specificity
because CA-125 raised in –
• Fibroids, endometriosis, adenomyosis , PID, pelvic sepsis.
• CA-125 raised < 200 units/ml, further investigation appropriate to exclude/treat
the common differential diagnoses
• In stage III–IV endometriosis likely to be raised >200 or >1000 units/ml
• CA-125 levels if raised, serial monitoring helpful rapidly rising levels likely
associated with malignancy
• CA-125 is a marker epithelial ovarian carcinoma raised 50% of early stage disease.
• CA-125 assay > 200 units/ml, discussion with a gynaecological oncologist

LDH, α-FP, hCG assay

• Guidelines UK/USA α-FP and hCG measured in all XX <40years with a complex
ovarian mass because possibility of germ cell tumours.
• Guidelines USA also recommend measuring LDH
What imaging for suspected ovarian masses?
TVUS ?
• Single most effective way preferable TAS increased sensitivity
• May need both TAS and TVUS for larger masses and extra-ovarian disease
• Colour flow Doppler not shown to improve diagnostic accuracy but TVUS in combination with colour
flow mapping/3D imaging may improve sensitivity, particularly in complex cases.
• ‘Pattern recognition’ of specific ultrasound findings can produce sensitivity and specificity equivalent
to logistic regression models, especially when performed by more experienced clinicians
• This reduces number of ‘unnecessary’ staging laparotomies.

What is the role routine use CT or MRI ?

• CT/MRI no better than TVUS for diagnosis used to evaluate complex lesions
• If suspicious malignancy referral to a gynaecological oncology MDT

What is the best way to estimate the risk of malignancy?

• Risk of Malignancy Index (RMI) most widely used model
• Recent studies specific model of US parameters derived from IOTA Group increased sensitivity and
specificity. RMI I most effective suspected ovarian CA.
• Calculation RMI I – 3 pre-surgical features:
CA-125; menopausal status (M); US score (U). US scored 1 point for-
– Multi-locular cysts
– Solid areas RMI = U x M x CA-125
– Metastases
– Ascites
– Bilateral lesions.
 IOTA - Group ultrasound ‘rules’ to classify masses as
benign (B-rules) or malignant (M-rules)

B-rules
• Uni-locular cysts
• Presence of solid components where the
largest solid component <7 mm
• Presence of acoustic shadowing
• Smooth multi-locular tumour with largest
diameter <100 mm
• No blood flow

M-rules
• Irregular solid tumour
• Ascites
• At least four papillary structures
• Irregular multi-locular solid tumour with
largest diameter ≥100 mm
• Very strong blood flow
Management pre-menopausal ovarian masses
Can asymptomatic women with simple ovarian cysts
be managed expectantly?
• Simple cysts 30mm but < 50 mm diameter
simple generally do not require follow-up very
likely to be physiological almost always resolve
within 3 cycles.
• Simple ovarian cysts of 50–70 mm in diameter
yearly ultrasound follow-up
• Larger simple cysts consider MRI or surgical
intervention.
How should persistent, asymptomatic ovarian cysts
be managed?
• Ovarian cysts that persist or increase in size
unlikely to be functional may warrant surgery.
• Mature cystic teratomas (dermoid cysts) may
grow over time. Risk pain and cyst accidents.
• Pre-operative assessment using RMI 1 or US
IOTA rules
• No evidence-based consensus on size > which
surgery indicated. Most studies use an arbitrary
maximum diameter of 50–60 mm among
inclusion criteria for conservative management.
• COCP use does not promote the resolution of
functional ovarian cysts.
Surgery for pre-menopausal ovarian masses
Is the laparoscopic approach better for the elective
surgical management of ovarian masses?
Less morbidity, shorter recovery time, cost-effective
as earlier discharge and return to work.
Large masses, solid components laparotomy may be
more appropriate.
• Maximum cyst size > which laparotomy
considered is controversial.
• Rupture occurs more often with cysts > 7cm.
• Drainage or removal of large ovarian cysts
requires significant extension of laparoscopic
port incision, advantages reduced.
• Some require mini-laparotomy for
drainage/removal of cyst.
Should an ovarian cyst be aspirated?
• Aspiration of ovarian cysts, either vaginally or
laparoscopic is less effective and associated with
high risk recurrence.
• RCT’s - resolution rates simple ovarian cysts
similar expectant management (46%) versus
ultrasound guided needle aspiration (44.6%)
• Recurrence rates after laparoscopic aspiration
simple cysts - 53% to 84%.
Who should perform laparoscopic surgery for a
presumed benign ovarian cyst?
Decision Factors
• Patient - suitability laparoscopy and her wishes
• Mass - size, complexity, likely nature
• Setting - surgeon’s skills and equipment
Endometriomas
Based on clinical and patient experience,
endometriosis can cause the following symptoms:
• severe dysmenorrhoea, deep dyspareunia
• chronic pelvic pain, ovulation pain
• cyclical or perimenstrual symptoms, such as bowel or
bladder, with or without abnormal bleeding or
Laparoscopic cystectomy for ovarian endometriomas is
• infertility better than drainage and coagulation.
• chronic fatigue • Recurrence and symptoms reduced by excision rather
• dyschezia (pain on defaecation). • than drainage and ablation.
• Subsequent spontaneous pregnancy rates where
previously subfertile are improved with excision.

Laparoscopic ovarian cystectomy is recommended for

endometriomas ≥ 4 cm in diameter before IVF.
• No RCT’s laparoscopic excision with no treatment
before IVF.
• Laparoscopic ovarian cystectomy recommended if
≥4cm to confirm the diagnosis histologically; reduce
the infection; improve access to follicles, and possibly
improve ovarian response and prevent endometriosis
progression.
• Counsel re risks of reduced ovarian function after
surgery and loss of the ovary.

Hart RJ, Hickey M, Maouris P, Buckett W, Garry R.

Excisional surgery versus ablative surgery for ovarian
endometriomata. Cochrane Database Syst Rev
2005;(3):CD004992.
Surgical technique
Removal of cyst/mass?
• Spillage of cyst avoided if possible. Pre and
intraoperative assessment can’t preclude
malignancy.
• Consideration given to use of tissue bag to avoid When should an oophorectomy be performed?
peritoneal spill of contents bearing in mind the
likely preoperative diagnosis. • The possibility of removing an ovary should be discussed
• Chemical peritonitis due to spillage of dermoid cyst with the woman preoperatively.
contents occurs < 0.2% cases. How to remove the mass?
• If inadvertent spillage does occur, peritoneal lavage
using large amount warmed fluid. Cold irrigation • Where possible removal of benign ovarian masses
causes hypothermia, retrieval of contents harder should be via the umbilical port.
due to solidifying fat-rich contents.
• Less postoperative pain, quicker retrieval time than
• RCOG Guideline treatment endometriosis when using lateral ports of the same size.
recommends lesions >3cm histology needed to
confirm diagnosis and exclude rare case malignancy. • Various types of laparoscopic tissue retrieval bags have
been described.
• Potential to upstage a tumour if the suspected
endometrioma is actually a malignant tumour. • Extending accessory ports increases postoperative pain,
incisional hernia, epigastric vessel injury, poor cosmesis.
Adnexal Mass Emergencies
Isolated tubal torsion. (A) Color Doppler image shows a swirling appearance
of the vascular pedicle (arrows) and a dilated right Fallopian tube
(arrowheads) with findings concerning for tubal torsion. (B) Corresponding
laparoscopic intraoperative image demonstrates the torsed Fallopian tube.
Detorsion of the Fallopian tube with fenestration of the dilated end
(fimbriaplasty) was performed as the tube and ovary appeared viable

Paraovarian cyst with torsion. Midsagittal US scan through the bladder (B)
shows an enlarged, heterogeneous ovary (arrowheads) and an adjacent cyst
(C). No flow could be elicited on color Doppler interrogation. On surgery it
proved to be adnexal torsion related to a paraovarian cyst leading to
ipsilateral salpingo-oophorectomy.
Adnexal Mass Emergencies
Ovarian teratoma with torsion. (A) Enhanced axial CT adolescent XX sudden
onset pelvic pain reveals teratoma (arrows) containing fat/calcification.
Adjacent ovary prominent peripheral follicles (arrowheads). Thickened
teratoma wall, surrounding fat is stranded, free pelvic fluid (*). B, bladder; U,
uterus. (B) pathologic specimen; torsion confirmed at surgery.

Bilateral tubo-ovarian abscesses with pyosalpynx. (A) TVUS right adnexa

thick-walled, complex lesion, fluid level consistent with abscess (arrows).
Wall is hyperemic, surrounding soft tissues indistinct/edematous. (B) TVUS
sagittal dilated left Fallopian tube (arrowheads), heterogenous contents,
mucosa thickened consistent with a pyosalpynx. U, uterus.
 Emergencies
Mature ovarian teratoma- XX 16 years abdominal
pain. (A) X-Ray toothlike calcific density (? Teratoma).
(B) TA-US echogenic adnexal mass (arrows) posterior
acoustic shadowing (arrowheads) ? mature teratoma.
Multitude interfaces near field result from mix
fat/hair obscures rest lesion, “tip of the iceberg” sign
is used. (C) CT large amount fatty tissue in mass
(arrows), typical of mature teratoma. B, bladder.

Perforated appendicitis complicated with

ovarian abscess - XX 13-years. (A) Longitudinal
US enlarged ovary (delineated by cursors) with a
complex collection contains few gas foci
(arrows). (B) US Transverse thick-walled abscess
peripheral hypervascularity. B bladder; U uterus.
Foreign body- XX 7 years orange vaginal
discharge. Sagittal T2-weighted. Hypo-
intense cylindrical vaginal structure.
Orange crayon vaginoscopy. (B) bladder
Emergencies – Pelvic Pain XX 17 years acute on chronic pelvic
pain- Sagittal US haemorrhagic cyst
(arrowheads) internal lacy or fish-net
Adnexal endometriosis- XX 17 years (A) Transverse US bilateral adnexal appearance, no flow within septations.
endometriomas (arrows) internal low level echoes. (B) No flow within lesions Flow demonstrated in rim normal
appearances similar to haemorrhagic cyst; (C) Coronal T1 (D) T2 MRI images ovarian tissue (arrows).
adnexal lesions (arrows) high signal on T1/ T2, consistent with blood in lesions.
Left is slightly >heterogeneity/complex appearance B bladder U uterus.

XX 18 years acute pelvic pain – TA-US

hemorrhagic ovarian cyst (arrowheads)
with retracting clot. Flow on color
Doppler within the peripheral rim of
normal ovarian tissue (arrows).
Adnexal masses in pregnancy ?
Guideline: The Society of American
Gastrointestinal and Endoscopic
Surgeons (2011):
• Laparoscopy is safe and effective
treatment in gravid patients with
symptomatic ovarian cystic masses.
• Observation for all asymptomatic cystic
lesions if US not concerning for
malignancy and tumor markers normal.
• Observe acceptable cystic lesions <6 cm
Evidence level IV
Risks
• Miscarriage
• Obstetric complications, including LBW,
preterm delivery, use of tocolytics for
preterm labor, low Apgar score, and fetal
anomaly.
• These risks deemed acceptable in case series.
References:
1. Azuar AS. Bouillet-Dejou L et al. Laparoscopy during pregnancy: experience of the French
university hospital of Clermont-Ferrand. Obstetrique & Fertilite. 2009;37(7-8):598-603
2. Bunyavejchevin S, Phupong V. Laparoscopic surgery for presumed benign ovarian tumor
during pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.:
CD005459. DOI: 10.1002/14651858.CD005459.
3. Ko ML. Lai TH. Chen SC. Laparoscopic management of complicated adnexal masses in the first
trimester of pregnancy. Fertility & Sterility. 2009;092(1):283-7, 2009
4. Koo YJ. Lee JE. Lim KT et al. A 10-year experience of laparoscopic surgery for adnexal masses
during pregnancy. Int J Gynaecol & Obstet. 2011;113(1):36-9.
5. Guidelines for diagnosis , treatment and use of laparoscopy for surgical problems during
pregnancy. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES); 2011
Ovarian mass at Caesarean section ?

No studies comparing removal of incidentally found adnexal

masses at caesarean section with later removal . Series by
Hobeika et al 2008 -

• Reviewed histopathology of 43 adnexal masses

incidentally diagnosed and excised during CS –
• Mature cystic teratomas (34.9%)
• Mucinous cystadenomas (16.3%)
• Serous cysts/cystadenomas (14.0%)
• Endometriomas (11.6%)
• Luteomas (7%)
• Paraovarian cysts (4.7%)
• Corpus luteum cyst (2.3%)
• Fibroma (2.3%)
• Inclusion cyst (2.3%)
• Serous-mucinous cyst (2.3%) References:
• Borderline serous cystadenoma (2.3%). 1. Ahram J. Lakoff K. Miller R. Serous cystadenocarcinoma as incidental finding
during a repeat cesarean section. AmJOG. 1985;153(1):78-9.
Lesions rare and mostly benign, but found the case of 2. Ansell J. Bolton L. Spontaneous rupture of an ovarian teratoma discovered
borderline tumor alarming. during an emergency Caesarean section. JOG 2006;26(6):574-5.
3. El-Ghobashy A. Ohadike C. Wilkinson N. Lane G. Campbell JD. Recurrent
urachal mucinous adenocarcinoma presenting as bilateral ovarian tumors on
cesarean delivery. Int J of Gynecol Cancer 2009;19(9):1539-41.
4. Engin-Ustun Y. Ustun Y. Dogan K. Meydanh MM. Ovarian carcinoma as an
incidental finding during cesarean section in a preeclamptic woman: case
report. Eur J Gynaecol Oncol 2007;28(5):423-4.
5. Hobeika EM. Usta IM. Ghazeeri GS. Mehio G. Nassar AH. Histopathology of
adnexal masses incidentally diagnosed during cesarean delivery. EJOG and
Reprod Biol 2008;140(1):124-5.
Post-menopausal ovarian cysts
Incidence ?
20 000 postmenopausal women screened in the Prostate, Lung,
Colon and Ovarian Cancer Screening Trial.
21.2% ovarian morphology abnormal - simple or complex.

The finding of an ovarian cyst in a postmenopausal

woman raises two questions-

What is the most appropriate

management ?
Post-menopause ovarian cyst - TVUS and CA125
No routine role for Doppler, MRI, CT or PET
US sensitivity 89% and specificity 73%
based on morphology index
CA125 raised > 80% ovarian cancer (> 30 u/ml)
Sensitivity of 81% and specificity of 75%.
Recommended ‘risk of malignancy index’ used to
select those require primary surgery in a cancer
centre by gynaecological oncologist.
Cut-off RMI >250 sensitivity 70% /specificity 90%.
How should it be managed ?
• 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, to be undertaken by a suitably qualified
surgeon.
• It is recommended that laparoscopic management of
ovarian cysts in postmenopausal women should involve
oophorectomy (usually bilateral) rather than cystectomy.
Risk assessment and Management
Where should this management take place?
• Low risk by a general benign gynaecologist
• Intermediate risk a cancer unit
• High risk in a cancer centre.
Low risk: <3% risk of cancer
• Management in a gynaecology unit.
• Simple unilateral locular cysts no solid parts no
papillary formations (2cm-<5 cm)
• CA125 <30 manage conservatively.
• Repeat US and CA125 every 4 months for 1 year.
• > 50% cysts resolve spontaneously by 3 months.
• Cyst does not fit criteria or if surgery requested
then laparoscopic oophorectomy acceptable.
Moderate Risk: 20% risk of cancer
• Management in a cancer unit.
• Laparoscopic oophorectomy selected cases.
• Malignant then a full staging procedure undertaken
in a cancer centre.
High Risk: >75% risk of cancer
• Management in a cancer centre.
• Full staging procedure.
Rapid referral (2 weeks) to cancer centre recommended
for those found to have malignancy or at high risk
Laparotomy
All ovarian cysts suspicious of malignancy in a
postmenopausal woman-
1. High risk of malignancy index
2. Clinical suspicion
3. Findings at laparoscopy
Full laparotomy and staging procedure-
Performed by an appropriate surgeon, working with an
MDT in a cancer centre, through an extended midline
incision, and should include:
 Cytology: ascites or washings
 Laparotomy with clear documentation
 Biopsies from adhesions and suspicious areas
 TAH, BSO and infra-colic omentectomy
Staging may include bilateral selective pelvic
and para-aortic lymphadenectomy.
Ovarian malignancies
References

1. Royal College of Obstetrics and Gynaecologists. Management of Suspected Ovarian Masses in

Premenopausal Women. Green-top Guideline No. 62. London: RCOG; 2011.
2. Royal College of Obstetrics and Gynaecologists. The investigation and management of endometriosis.
Green-top Guideline No. 24. London: RCOG; 2006.
3. National Institute for Health and Clinical Excellence. Ovarian cancer: The recognition and initial
management of ovarian cancer. NICE clinical guideline 122. London: NICE; 2011.
4. American College of Obstetricians and Gynecologists. Management of adnexal masses. ACOG Practice
Bulletin No. 83. Washington DC: ACOG; 2007.
5. Le T, Giede C, Salem S, Lefebvre G, Rosen B, Bentley J, et al; Society of Obstetricians and Gynaecologists
of Canada. Initial evaluation and referral guidelines for management of pelvic/ ovarian masses. J Obstet
Gynaecol Can 2009;31:668–80.