The post-menopausal simple ovarian cyst

1. The post-menopausal simple ovarian cyst Management Strategies דר' ישי לוין, בי"ח ליס ליולדות

2. Scope of the problem • Ovarian cancer is the leading cause of death from gynecologic cancer in the United States. • ovarian cancer is the fifth leading cause of all cancer deaths in women; 80% of such cases involve women >50 years • ovarian cancer will develop in approximately 1 in 70 women (1.4%) in their lifetime (and this increases to 4% to 6% if there is a family history (one first-degree relative. דר' ישי לוין, בי"ח ליס ליולדות

3. ההיסטוריה דר' ישי לוין, בי"ח ליס ליולדות

4. The PMPO syndrome (postmenopausal palpable ovary syndrome). • Barber and Graber in 1971, in a now classic editorial, stated that "the palpation of what is interpreted as a normal sized ovary in the premenopausal woman represents an ovarian tumor in the postmenopausal woman." דר' ישי לוין, בי"ח ליס ליולדות

5. J Reprod Med. 1991 Aug;36(8):Miller RC, Nash JD, Weiser EB, Hoskins WJ.The postmenopausal palpable ovary syndrome. A retrospective review with histopathologic correlates. • 20 patients overall. malignancy rate of 15%: PMPO is clinically significant. דר' ישי לוין, בי"ח ליס ליולדות דר' ישי לוין, בי"ח ליס ליולדות

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7. עד כמה הבעיה שכיחה? ? דר' ישי לוין, בי"ח ליס ליולדות

8. Ultrasound Obstet Gynecol. 2003 Sep;22(3):Valentin L, Skoog L, Epstein E.Frequency and type of adnexal lesions in autopsy material from postmenopausal women: ultrasound study with histological correlation. • The study included 104 adnexa from 52 consecutive women with a mean age of 79 • At ultrasound examination, 56% (29/52) of the women had adnexal lesions, cysts being detected in 54% (28/52) and solid lesions in 12% (6/52). • Conclsion: Small (< or = 50 mm) benign adnexal cysts and small benign solid tumors are so common in postmenopausal women that their presence may be regarded as normal. Our results support conservative management of adnexal lesions with benign ultrasound morphology incidentally detected at ultrasound examination in postmenopausal women דר' ישי לוין, בי"ח ליס ליולדות

9. Obstet Gynecol Surv, Volume 57, Number 12 Yinka Oyelese, MD,* Angela S. Kueck, MD,* James F. Barter, MD,† and Ivica Zalud, MD, PhD Asymptomatic Postmenopausal Simple Ovarian Cyst דר' ישי לוין, בי"ח ליס ליולדות

10. Goldstein SR, AJOG December 1996 • Volume 175 • Number 6 • we find there were 16 serous cysts, 1 mucinous cyst, 4 hydrosalpinges, 2 endometriotic cysts, and 3 parovarian cysts. Barber and Graber were accurate. These are not physiologic • Wolf et al: They studied 184 women between 50 and 84 years old with 358 ovaries in situ. A total of 17.3% of women had simple cystic structures ranging from 4 mm to 4.7 cm (although 58% were 1.0 cm in greatest diameter). However, over the 2-year study period some cystic structure was exhibited in 28% of women at some time. Follow-up scans revealed that 53% disappeared, 3% decreased in size, 28% remained unchanged, 11% increased in size, and 6% both increased and decreased in size. דר' ישי לוין, בי"ח ליס ליולדות

11. Natural History of simple cysts • Levine et al: (Follow up of Wolf’s study) Of these cysts, 53% disappeared completely, 3% decreased in size, 28% remained the same, and 11% increased in size. Six patients underwent surgery, and there was one cancer among these. This was in a woman who had developed a complex adnexal mass and abnormal Doppler flow. • Aubert et al : 36 women,simple ovarian cysts. No ascites, <5 cm, unilocular, unilateral, without excrescences, septations, or solid components, CA-125 normal, RI values <=0.4: no change in the cysts in 29 patients (80.5%), and in 4 women (11.1%) the cysts decreased in size; three cysts disappeared altogether • Rodriguez et al: US preoperatively to examine 52 postmenopausal women undergoing pelvic surgery for other indications. Simple adnexal cysts in seven (13%) of these women; pathologic examination revealed no malignancies in any of them. דר' ישי לוין, בי"ח ליס ליולדות

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13. אמצעי עזר באבחנה. דר' ישי לוין, בי"ח ליס ליולדות

14. Doppler • Malignant ovarian cysts are more vascular than benign cysts because of neovascularization • Malignant neoplasms often have bizarre vasculature that is rich in arteriovenous anastomoses. They are often associated with a low-resistance, high-flow picture, whereas benign tumors usually have normal flow patterns, demonstrating a high-resistance type of flow • Initial studies suggested that malignant ovarian tumors may be differentiated from benign tumors on the basis of transvaginal color Doppler. Kurjak et al. examined 680 pre- and postmenopausal women with ovarian neoplasms and obtained a sensitivity of 96% and a specificity of 99% for distinguishing between benign and malignant neoplasms when using a cutoff of 0.4 for the resistance index for benign tumors דר' ישי לוין, בי"ח ליס ליולדות

15. Doppler – cont’ • More recently, Tekay and Jouppilla have called into question the role of Doppler in differentiating between benign and malignant ovarian masses. They contend that there is significant overlap between the Doppler values for benign and malignant ovarian masses. Blood flow data should be considered indicative of the angiogenic intensity of a tumor, but it cannot serve as a definitive diagnostic marker for cancer • Cystic adnexal masses with a resistive index of greater than 0.4 are highly likely to be benign • The role of Doppler continues to evolve; however, in seasoned hands it has been very useful in the assessment of ovarian masses. דר' ישי לוין, בי"ח ליס ליולדות

16. CA-125 • CA-125 has been shown to be elevated in 80% to 90% of women with epithelial serous ovarian tumors and has proven a useful tool in the detection of recurrent ovarian cancer • Mucinous tumors are less frequently associated with elevated levels of CA-125 . In addition, CA-125 may be raised in a number of other benign and malignant conditions, including endometriosis, fibroids, adenomyosis, pelvic inflammatory disease, tuberculosis, pregnancy, and malignant tumors of the lung, pancreas, colon, and breast. • However, when CA-125 is elevated in association with an abnormal sonographic finding, particularly in a postmenopausal woman, there should be a high index of suspicion for ovarian malignancy. דר' ישי לוין, בי"ח ליס ליולדות

17. סיכום מדדים מרמזים על ממאירות. דר' ישי לוין, בי"ח ליס ליולדות

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19. דר' ישי לוין, בי"ח ליס ליולדות

20. Conclusions • Simple ovarian cysts are much more common in postmenopausal women than previously had been thought. The available studies give prevalence rates between 3.3% and 14.8%. • The available data seem to suggest that the risk of malignancy in simple unilocular cysts measuring less than 5 cm in diameter is extremely small • In addition, these cysts frequently regress spontaneously and rarely grow in size • However, should the cyst persist, increase in size, develop solid components, or be associated with elevated CA-125 levels, prompt surgical removal is indicated דר' ישי לוין, בי"ח ליס ליולדות

21. Conclusions - cont’ • When surgical removal has been chosen, the laparoscopic approach may be associated with considerable benefits • In women at high risk of ovarian cancer, such as those with a strong family history, a genetic predisposition to ovarian cancer, or an elevated CA-125 level, surgical removal may be justified when a simple cyst is discovered in the postmenopausal period דר' ישי לוין, בי"ח ליס ליולדות

22. Conclusions - cont’ • It is certainly appropriate to obtain a CA 125 level from such patients • If the level is elevated (cutoffs) and associated with a mass in the adnexa of a postmenopausal patient, then the mass should be removed. • color flow Doppler is a research tool in need of further study • if the cystic structure is unilateral, unilocular, with no septation or ascites and measures <3 cm (and probably up to 5 cm), follow-up should certainly be conservative. The interval of follow-up is negotiable דר' ישי לוין, בי"ח ליס ליולדות