Ovarian cysts in Primary Care

When to refer? Physiological/pathological Benign/malignant Surgical approach? Open or keyhole? Do I need to do anything? Conservative or active Mx Learning Points

Incidence? By the age of 65 years, 4% of all women in England and Wales will have been admitted to hospital with a diagnosis of an ovarian cyst Shaw, Souter and Stanton 2003

Advent of TV U/S

1 st published work related to medicine: Transmission ultrasound investigation of the brain

1960s to 2000s Rapid technology advances grey scale still to real time development of Doppler Colour Doppler microchip processing power power Doppler 3D imaging

Aetiology Age related:Functional Simple, haemorrhagic, endometriomas Dermoid Serous Cystadenomas YOUNG WOMEN…… Borderline malignancy or cancer YOUNG OR OLDER WOMEN……

Average Number of New Cases Ovarian cancer Per Year UK 750 cases 0.4 – 8.9 / 100,000 premenopausal women 60 / 100,000 postmenopausal women

Do I need to do anything when an ovarian cyst is diagnosed? Womens anxieties centre on: risk of cancer possible loss of fertility FHx ovarian CA

Asymptomatic vs Symptomatic Benign vs Malignant

Asymptomatic ovarian cysts

Just follow the guidelines……..

Simple cyst

Eg? HaemorrhagicEndometrioma

Can we predict whether a cyst is benign or malignant?

IOTA International Ovarian Tumour Analysis group Timmerman et al Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the IOTA group. Ultrasound Obstet Gynecol 2000; 16: Cyst descriptionCystic Solid Septation Walls Papillary projections Vascular flow B-rules and M-rulessens 95% spec 91%

Endometrioma

Ultrasound images vital

Guess the cyst on CT

Guess the cyst with MRI

RMI index Jacobs, London 1990 CA125 x M x U Postmenopausal women RMI 0f 200sens 78% spec 87% RMI II, RMI III, RMI IV Management of suspected ovarian masses in premenopausal women Greentop Guideline no 62 RCOG/BSGE Joint Guideline Nov 2011 BEWARE LIMITATIONS

How do women present to you?? PainTorsion Rupture Haemorrhage Bloating, abdo girth increase, weight loss Metastatic disease :

How do you get the ultrasound?!!!!

Surgery for: Symptomatic cysts Asymptomatic cysts of questionable aetiology Interventional Radiology for: Really sick people or tissue diagnosis…..

Pre-operative assessment is the most important factor in the management of ovarian cysts Surgical Approach Open vs laparoscopic

Laparoscopy for all benign ovarian cysts

Guess the cyst at operation

Clinical Scenario 1

Use your imaging…….

Screening and Family History of Ovarian CA Number of 1 st degree relatives Associated pathology Genetic testing – BRCA1/2 - HNPCC Screening vs oophorectomy

Conclusions (1) Team approach… Primary care assessment Investigations Imaging Tumour markers Surgical intervention How and when? MDM?

Conclusions (2) Knowledge of management for asymptomatic ovarian cysts Know DHB criteria for access to U/S Be aware of limitations of tumour markers