Mrs. J wants to know if you plan to remove the cyst. What do you tell her?
In this case, the cyst is probably incidental to the abdominal pain Mrs. J experienced at presentation. Because most cysts are benign, observation and repeat sonograms are justified unless the patient’s CA-125 level is found to be elevated or the size or complexity of the cyst increases. Mrs. J has a CA-125 level of 12, and her sonographic findings have not changed since the initial exam, so she can be managed with repeat imaging and blood tests in 2 months.
Data point to safety of surveillance
A sonographic study of asymptomatic postmenopausal women found that about 6% had cysts smaller than 5 cm at initial screening.8 Of the 256 women noted to have these simple cysts, 125 resolved spontaneously within 6 weeks. Among the 131 women with persistent unilocular cysts, 45 requested surgery, and no cancers were found. Among the 86 women who elected to be followed with repeat sonograms and CA-125 levels, no cancers were found after a mean follow-up of 18 months.
A more recent study involved 15,106 women age 50 or older who were screened with transvaginal sonography.2 Of these, 2,763 (18%) had unilocular cysts less than 10 cm in size. Seventy percent of the women had resolution of the cysts within 6 weeks, and none of the 220 women with persistent unilocular cysts developed ovarian cancer after a mean follow-up of 6.8 years.
In properly selected patients, risk of cancer was close to nil
An early study9 focused on 61 postmenopausal women with unilateral, cystic adnexal masses, benign-appearing sonograms, and normal CA-125 levels. These women were managed with laparoscopic oophorectomy. All had benign masses.
Another prospective study involved 228 postmenopausal women with a pelvic mass, 53 of whom had pelvic and sonographic exams suggestive of a benign mass and a CA-125 level below 35 U/mL. All 53 had a benign mass.10
Enlarging, complex cysts and elevated CA 125
In a study of 250 women with complex cystic ovarian tumors smaller than 10 cm (89% were <5 cm in size), more than half the cysts resolved spontaneously.8 However, 7 ovarian carcinomas were found. Thus, observation is not recommended for women with these findings. As might be expected, 6 of the 7 women found to have ovarian cancer had progression of cyst size and/or complexity by the 2-month follow-up sonogram.
Another study11 found that, among 226 postmenopausal women followed with sonograms and CA-125 levels after an initial finding of a unilocular ovarian cyst smaller than 5 cm, cyst size increased in only 54 women, all of whom were operated upon. Two malignancies were found, both in women with elevated CA-125 levels. None of the women whose cyst size remained the same had ovarian cancer.
CASE What is the next step?
When you suggest that Mrs. J be followed with another sonogram and CA-125 level in 2 months, she agrees. At that follow-up, no change in the size or internal architecture of the cyst is noted, and the CA 125 is normal. You ask her to return in 6 and 12 months for repeat sonograms and blood tests, all of which are normal.
At this point, surveillance can shift to yearly pelvic exams. Because women are understandably worried about ovarian cancer, they should be counseled about the importance of careful follow-up. Subjecting them to unnecessary surgery is not advised because of the very real risks of complications from anesthesia and surgery in postmenopausal women.
When surgery is warranted for postmenopausal women
Some women may be symptomatic from larger cysts, or they may not be comfortable with, or available for, close follow-up. In these cases, surgery may be warranted. Women with cysts that are increasing in size, or noted to have a change in internal architecture at the time of sonographic assessment, should also have surgery.
Remove the entire ovary
The entire ovary should be removed in postmenopausal women for complete pathologic analysis.
Technique. Grasp the utero-ovarian ligament and pull it medially to expose the infundibulopelvic ligament. I use a 5-mm bipolar cutting forceps to desiccate and divide the ligament, taking care to identify the ureter and make sure it is well away from the area to be desiccated. Then desiccate and divide the mesosalpinx and follow it to the corneal portion of the fallopian tube. Place the ovary in a laparoscopic sac. Many versions of these sacs exist, but for large cysts I prefer the Cook LapSac (Cook Urological, Spencer, Ind), which has sizes as large as 20×28 cm. These sacs are strong and almost impermeable and hence less likely to tear and allow spillage of the cyst contents into the peritoneal cavity. To keep the neck of the sac open, fill it with irrigating fluid. Once the adnexa is placed in the sac, suction the irrigating fluid and bring the neck of the bag out through an 11-mm port. The cyst can then be aspirated and decompressed to allow removal.