ovarian cysts in postmenopausal women

OVARIAN CYSTS
IN POSTMENOPAUSAL WOMEN
I
Is it raccomended that ovarian cysts in postmenopausal women should be
assessed using CA 125 and transvaginal grey scale sonography.
Serum CA 125 is raised in over 80% of ovarian cancer cases and, if a cut-off
of 30 U/ml is used, the test has a sensivity of 81% and specificity of 75%.
Ultrasound is also well established achieving a sensitivity of 89% and
specificity of 73% when using a morphology index.
There is no routine role yet for Doppler, MRI, CT or PET.
(RCOG 2003)
OVARIAN CYSTS
IN POSTMENOPAUSAL WOMEN
II
Ovarian cysts are common in postmenopausal women, although
the prevalence is lower than in premenopausal women.
Of 20.000 healthy postmenopausal women screened, 21,2 %
had abnormal ovarian morphology either simple or complex.
The greater use of ultrasound means that an increasing
proportion of these cysts will come to the attention of
gynaecologists.
(RCOG 2003)
OVARIAN CYSTS
IN POSTMENOPAUSAL WOMEN
III
It is recommended that a “ risk of malignancy index ” should
be used to select those women who require primary surgery
in a cancer centre by a gynaecological oncologist.
(RCOG 2003)
OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN
CONSERVATIVE MANAGEMENT
Simple, unilateral, unilocular and echo-free with no solid parts or
papillary formations, less than 5 cm in diameter, have a low risk
of malignancy (less than 1%).
It is recommended, in presence of a normal serum CA 125 levels,
they to be managed conservatively, with a follow-up ultrasound
scan, a reasonable interval being four months.
(RCOG 2003)
OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN
SURGICAL MANAGEMENT
ASPIRATION
Cytological examination of ovarian cyst fluid is poor at
distinguishing between benign and malignant tumours, with
sensitivity of around 25%. In addition, there is a risk of cyst
rupture: aspiration, therefore, has no role in the management of
asymptomatic ovarian cysts in postmenopausal women.
(RCOG 2003)
OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN
SURGICAL MANAGEMENT
LAPAROSCOPY
The laparoscopic approach should be reserved for those women
who are not eligible for conservative management but still have a
relatively low risk of malignancy.
The appropriate laparoscopic treatment should involve
oophorectomy (usually bilateral) rathen than cystectomy, with
removal of the ovary intact in a bag without cyst rupture into the
peritoneal cavity.
(RCOG 2003)
OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN
SURGICAL MANAGEMENT
LAPAROSCOPY
Women at intermediate risk undergoing laparoscopic oophorectomy
should be counselled preoperatively that a full staging laparotomy
would be required if evidence of malignancy is revealed.
If a malignancy is revealed during laparoscopy or subsequent
histology, it is recommended that the woman is referred to a cancer
centre as quickly as possible.
(RCOG 2003)
OVARIAN CYSTS IN POSTMENOPAUSAL WOMEN
SURGICAL MANAGEMENT
LAPAROTOMY
A high risk of malignancy index or clinical suspicion or findings at
laparoscopy are likely to require a full laparotomy and staging
procedure which should include:
•Citology : ascites or washing
•TAH, BSO and infracolic omentectomy
•Biopsies from adhesion and suspicious areas
•Appendicectomy
•Bilateral pelvic and paraortic lymphadenectomy
(RCOG 2003)
( RCOG 2003)
( RCOG 2003)
(RCOG 2003)
Table1. Morphological
score
Value
Wall
Septa
Vegetations
Echogenicity
1
≤ 3 mm
no septa
no
vegetations
sonolucent*
2
> 3 mm
≤ 3 mm
3
low echogenicity
> 3 mm
4
irregular, mostly
solid
5
irregular, non
applicable
≤ 3 mm
with echogenic area
> 3 mm
with disomogeneous
echogenic areas,
solid
*or with fine trabecular and jelly like hypoechoic content typical of endohaemorragic
corpus luteum.
Cut-off value for risk of malignancy ≥ 9 (Ferrazzi, 1997)
Cisti ovariche semplici in postmenopausa
• Prevalenza:
–
–
–
–
6.6% Conway et al. 1998
14.8% Wolf et al. 1991
5.7% Aubert et al. 1998
17.4% Levin et al. 1992
• Incidenza simile di anno in anno
Castillo et al. 2003
• Prevalenza non è correlata all’età della menopausa
Castillo et al. 2003, Wolf et al. 1991
• Diametro medio circa 3 cm, +80% <5 cm
Castillo et al. 2003, Wolf et al. 1991, Bailey et al. 1998, Valentin et al. 2002
Prevalenza delle cisti ovariche
semplici in postmenopausa

Prevalenza all’esame autoptico del 19.7%
 62.7% diametro medio <20 mm
 29.4% diametro medio tra 20 e 50 mm
 7.8% diametro medio >50 mm

Prevalenza simile a quella riportata in molti
studi in base all’esame US
Ecografia è procedura elettiva per identificare
le cisti ovariche
Dorum et al. 2004
Cisti ovariche semplici
in postmenopausa
50% Risolve spontaneamente
in 2 aa
50% Persiste
65-75%
invariate
25-35%:
 50% diminuisce di volume
 50% aumenta di volume
Nei follow-up nessuna paziente ha sviluppato Ca a
36-48-75 mesi
Castillo et al. 2006, Valentin et al. 2002, Modessit et al. 2003
Cisti ovariche semplici in postmenopausa
Potenziale rischio di malignità
Castillo et al., Gynecol Oncol 2003
Bailey et al. Gynecol Oncol 1998
Aubert et al. Maturitas 1998
Andolf et al. J Clin Ultrasound 1988
< 1%
Conway et al. J Ultrasound Med 1998
Levine et al. Radiology 992
Padilla et al. Obstet Gynecol 2000
Bar-Haval et al. Acta Obstet Gynecol Scand 1997
Modesssit et al. Obstet Gynecol 2003
Kroon et al. Obstet Gynecol 1995
Auslender et al. J Clin Ultrasound 1996
Valentin et al. Ultrasound Obstet Gynecol 2002
La piu’ frequente istologia: cistoadenoma
sieroso (>80%)
(Castilllo 2004)
(Castillo 2004)
Histologic results from the 211 premenopausal patients treated
by laparoscopy
Table 2.
Number of cysts
Percentage
Serous cyst
72
(34.13%)
Endometriotic cyst
68
(32.23%)
Paraovarian cyst
7
(3.32%)
Hemorrhagic cyst
11
(5.22%)
Cystadenomas
9
(4.27%)
Dermoid cyst
14
(6.64%)
Hydrosalpinx
6
(2.90%)
Primary tubal
carcinoma
1
(0.48%)
Follicular cyst
19
(9.10%)
Lutein cyst
4
(1.90%)
(Stamatellos, Gynecol Surg 2006)
BENIGN CYSTIC TERATOMA
I
• The majority occurs during reproductive years.
• Malignancy complicates 0.17 – 3.0 % of cases.
• The rate of bilateral mature cystic teratomas is
>10%.
• Risk of torsion (3%), acute rupture (1-3%.) or chronic
leakage (1%).
(Commerci 1994)
• Granulomatous chemical peritonitis associated with
the leakage of cystic teratomas is characterized by
multiple small yellow-white implants and dense
adhesions.
(Stern 1981)
BENIGN CYSTIC TERATOMA
II
178 cystic teratomas.
Overall incidence of leakage at cystectomy was not statistically
different between patients undergoing laparotomy (38.7%) and
laparoscopy (42.2%).
There was no difference between cysts that leaked and those that
did not in location, mean diameter at preoperative ultrasound,
diameter as estimated at surgery and presence of adhesions.
Cystectomy by laparotomy is insensitive to surgeon experience as
misured in years; however, laparoscopic experience (20 cases for
year) is highly predictive of success at laparoscopic cystectomy.
(Milad 1999)
Laparoscopic cystectomy is currently considered the
first-line choice for the conservative treatment of
benign ovarian cysts
However the safety of this technique in
term of ovarian damage to the operated
gonad has recently been questioned
Nargund,Human Reprod.1996
In patients previously operated for
endometriotic ovarian cysts, during IVF the
number of both follicles and retrieved
oocytes obtained in the operated gonad
during ovarian hyperstimulation is markedly
reduced when compared to the
controlateral intact ovary
Potential deleterious mechanisms
Amount of ovarian tissue removed during
cystectomy
Damage inflicted to ovarian stroma by
electrosurgical coagulation during hemostasis
Previous presence of the cyst
Somigliana, Fertil. Steril.,2003
37 patients 53 cycles of IVF
control ovary
operated ovary
Basal volume
9.6 ± 6.1
7.4 ± 5.5 cm3
N°follicles
4.4 ± 2.6
1.9 ± 1.4
p<0.007
p<0.001
Mean reduction in follicles retrieval 56% (95% C.I.)
This reduction did not seems to be related to the dimension of the
excise ovarian cyst
Canis , Human Reproduction, 2001
√ 41 Pts : laparoscopic ovarian cystectomy for endometrioma > 3 cm
√ 139 Pts : pelvic endometriosis without ovarian endometrioma
√ 59 Pts: tubal infertility
Ovarian stimulation with CC+Gn or GnRHa + Gn
Number of oocytes and embryos obtained is not significantly
decreased by laparoscopic cystectomy
Does laparoscopic removal of nonendometriotic
benign ovarian cysts affect ovarian reserve?
Seventeen IVF-cycles in women who previously underwent
laparoscopic excision of a monolateral nonendometriotic
benign ovarian cyst.
Basal volumes of the intact and the operate gonads were 5.7
± 3.3 and 3.4 ± 2.3 cm³ respectively (P=0.01), corresponding
to a mean reduction of 39%.
The numbers of dominant follicle were 4.6 ± 2.5 and 2.7 2.4
in the control ovary and in the previous operated ovary,
respectively (P=0.01), corresponding to a mean reduction of
42%.
(Somigliana 2006)
Muzii L. et Al, Fertil.Steril.,77,609,2002
Laparoscopic excision of ovarian cyst using
stripping technique – 42 women
Results
•Recognizable ovarian tissue adjacent to the cyst wall in
36%
•Significant difference between endometriotic and
nonendometriotic cyst (54% vs 6%, p<0.005)
•No specimen showed the normal follicular pattern
observed in healthy ovaries
Indicators of ovarian reserve
•Ovarian volume (Lass 1999)
•Antral follicle count (Bancsi 2002)
•Stromal blood flow (Tarlatzis 2003)
Exacoustos et al.,AmJ.Obstet.Gynecol,191,68,2004
Exacoustos et al.,AmJ.Obstet.Gynecol.,191,68,2004
Exacoustos et al.,Am.J.Obstet.Gynecol.191,68,2004
Ovarian cortex surrounding benign
neoplasms I
Specimens obtained from the area of
maximum distension of the ovarian cortex
overlying benign cyst.
Evaluation of the type and number of follicles
and vascular network
( Maneschi ,1993 )
Ovarian cortex surrounding benign
neoplasms II
Teratomas Cystoadenomas Endometriomas
Normal
morphologic
pattern
Regular
vascular
network
P < 0.01
92%
84%
77%
78%
19%
22%
( Maneschi, 1993)
Ovarian cortex surrounding benign
neoplasms III
• Stretching and thinning the ovarian cortex are
not associated with morphologic alterations
• Endometrioma is often associated with
microscopic endometriosis in surrounding
cortical tissue and with alterations of the
follicular and vascular patterns ( toxic or
inflammatory mechanism ? )
( Maneschi , 1993 )
Conclusions
Laparoscopic excision of ovarian cyst is
associated with a damage of ovarian reserve at
least in a short term follow up
Our results tend to rule out a role for an injury
of ovarian vascularization
The modality to achieve a good hemostasis may
be important
Is the reduction of ovarian reserve a
consequence of surgery or,conversely,the damage
is already present before surgery?