John W. Seeds
History of present illness
A 64-year-old gravida 2, para 2 woman presented to the emergency department for left lower quadrant abdominal pain with a reported intensity of 8 out of 10 on the pain scale and an episodic pattern. The pain has worsened over the last three days. She also reports three days of constipation. She has no vaginal bleeding. She denies any urinary symptoms. She had no problems prior to the onset of the pain. She took acetaminophen without relief.
Her medical history was significant only for well-controlled hypertension. She has no prior surgeries. Her only medication was hydrochlorothiazide.
Physical examination
General appearance:Well-developed, well-nourished woman in moderate distress
Vital signs:
Temperature: 37.1°C Pulse: 84 beats/min
Blood pressure: 130/85 mmHg Respiratory rate: 16 breaths/min BMI: 28 kg/m2
HEENT:Unremarkable Neck:Supple
Cardiovascular:Regular rate and rhythm without murmurs, rubs, or gallops
Lungs:Clear to auscultation bilaterally
Abdomen:Mild distension, left lower quadrant tenderness to direct palpation, no rebound, no adenopathy
Extremities:No clubbing, cyanosis, or edema Neurologic:Nonfocal
Pelvic:
Speculum: Normal appearing vaginal discharge, mild atrophy
Bimanual: No cervical motion tenderness or distinct adnexal masses, uterus small, mobile, anteverted, mild tenderness in region of the left adnexa, generalized fullness consistent with stool
Rectal:Large amounts of stool in vault Laboratory studies:
CBC and WBC: Normal Blood chemistries: Normal
Imaging:
Pelvic ultrasound: Abdominal ultrasound showed right-sided ovarian mass. Vaginal ultrasound showed a 40-mm-average-diameter anechoic cystic mass in the right ovary with sharp margins and no internal septation or other complexity (Fig. 48.1).
Color Doppler: Examination of the ovary showed only minimal vascular activity at the margin of the cyst (Fig. 48.2)
Because of suspicion that her symptoms were from constipa- tion, an enema was administered. She had a large bowel move- ment with complete resolution of all of her symptoms. Repeat pelvic examination was unremarkable.
How would you manage this patient?
The patient has a simple ovarian cyst, with characteristics that make the risk of ovarian cancer tremendously small.
Given the location being contralateral to the pain, it was likely an incidental finding and not the cause of her symp- toms, which were most likely from constipation. To provide further reassurance, a CA125 was drawn, which returned 5 U/mL (normal <35 U/mL). The patient was counseled on bowel regimens to prevent the recurrence of her constipation.
She was counseled that the cyst was unlikely to be a problem, and had likely been present for some time. She had repeat ultrasound examinations in 6 and 12 months, which showed the cyst to be unchanged.
Simple ovarian cysts in the postmenopausal woman
The lifetime risk for ovarian cancer is 1 in 70, with about 15 000 deaths annually from this cancer [1]. Given this con- cern, for years a palpable ovary in a postmenopausal woman was an indication for surgery. Ovarian cancer is particularly concerning given the nonspecific symptoms of early develop- ment and spread. It is often diagnosed at a late stage with poor survival. While 90% diagnosed with stage I disease survive 5 years, only 20% of cases are stage I at diagnosis, and 65–70%
are diagnosed at a late stage with only a 35–55% 5-year survival [1]. However, most adnexal masses in postmenopausal women are benign, such as serous cystadenomas [2,3]. Recent advances have given the ability to better differentiate benign from malignant masses.
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Age is the most powerful risk factor for ovarian cancer with a median age at diagnosis of 63 years. A family history of breast cancer also increases risk. BRCA1 carriers have a 60-fold increase in risk and BRCA2 carriers have a 30-fold increase in risk [1]. Contrary to older thought, early ovarian cancer frequently does have symptoms. Unfortunately, the symptoms are nonspecific, and include increased abdominal size or bloating, abdominal or pelvic pain, or feeling full quickly or difficulty eating. These symptoms are common,
but patients with ovarian cancer tend to have them much more frequently and for longer periods of time [4]. This patient’s symptoms, which were a single episode, likely from constipation, and completely resolved with treatment of her constipation, are not suspicious for ovarian cancer.
Screening for ovarian cancer continues to be widely studied and, to date, there are no effective screening tests. These studies have given significant information about the preva- lence of adnexal masses in postmenopausal women. Bimanual
Fig. 48.2 This view of the cyst with color Doppler show few foci of vascular activity at the margin of the cyst.
Fig. 48.1 These two orthogonal views of the ovary show the cyst to have no internal echos (anechoic or black) and no internal septae or solid components or marginal nodules.
Case 48: A 64-year-old woman with a simple ovarian cyst
examination is poor for detecting adnexal masses, with highly variable sensitivity related to the size of the tumor, examiner experience, and patient habitus.
Vaginal ultrasound, while widely available, is highly subjective and sensitivity varies by examiner experience. As a screening test, pelvic ultrasound has found the prevalence of adnexal cysts in the postmenopausal woman to be between 2.5 and 18%. Use as a primary screening test could be harmful as it could lead to unnecessary surgery if any adnexal cyst were considered an indication for surgery, while producing few early diagnoses of ovarian cancer [2]. Given the prevalence of ultrasound detectable adnexal masses in postmenopausal women, they are a frequent incidental finding on imaging studies done for other reasons, as in this patient. It can cause significant anxiety in the patient, and if not carefully managed, can lead to unnecessary intervention.
The ultrasoundfindings found in this patient are typical for a benign cyst [1]. Anechoic cysts with smooth walls, thin or absent septations, less than 10 cm in diameter, and absent solid components have a very low risk for malignancy [2]. The risk of malignancy in a cyst less than 10 cm, unilateral, unilocular, with no solid areas or papillary formations has been found to be 0–1%. Two-thirds of such masses were seen to resolve within 3 months, and the risk of malignancy is less than 0.1%.
CA125 may be helpful in further stratifying risk. While no major society has developed firm recommendations for the evaluation and management of simple cysts in postmenopausal women, many practitioners integrate CA125 into their assess- ment. CA125 is a serum protein elevated with virtually any process that disturbs the peritoneum, including ovarian cancer. While elevation of CA125 may be seen in over 80%
of patients with epithelial ovarian cancer, it has been reported positive in only in 50% of stage I disease [5,6]. The reported sensitivity of CA125 in separating benign from malignant adnexal masses varies from 61 to 90% and the predictive value varies from 35 to 91%. It is rarely elevated in cancers other than epithelial [1]. CA125 appears to perform better in post- menopausal women. Any significant elevation of CA125 in a postmenopausal patient with an adnexal mass is very
suspicious for malignancy and consideration of surgical inter- vention would be appropriate. Given the nonspecific nature of CA125, mild elevations are common, and need to be inter- preted in the context of other clinical information. While some providers would be comfortable enough that the cyst in this patient was benign based on its ultrasound characteristics, use of CA125 provided additional reassurance.
Small asymptomatic simple cysts with thin or absent septa- tions can be managed by observation. While no major society has specific guidelines for frequency of follow-up, repeat ultra- sound at intervals of 6 and then 12 months is reasonable provided the cyst is stable or smaller on follow-up [2]. Some providers will repeat CA125 measurements as well. Aspiration is not recommended because cytology has shown poor sensi- tivity for the diagnosis of malignancy, the cyst will often recur, and if malignant, spillage of contents may increase the risk of spread [6]. Surgery is usually necessary if the patient develops symptoms, the CA125 rises, or new ultrasoundfindings of solid areas, excrescences, or ascites develop [1,2]. In this patient, long-term follow-up confirmed the stability of the benign cyst.
Key teaching points
Simple ovarian cysts are found in up to 18% of
postmenopausal women. The vast majority are resolved or unchanged in one year.
If the cyst is anechoic, has sharp margins, few or no thin internal septa, no marginal nodularity or solid
components, and is less than 10 cm in diameter, the risk of cancer is less than 0.1%.
CA125 may be helpful for differentiating benign from malignant in postmenopausal women. If normal and the cyst is asymptomatic and appears simple on ultrasound, expectant management is appropriate. If elevated, surgery should be considered.
Observation with vaginal ultrasound and serum CA125 at 6 and 12 months is appropriate for the management of postmenopausal women with asymptomatic simple cysts less than 10 cm.
References
1. American College of Obstetricians and Gynecologists. Management of adnexal masses. Practice Bulletin No. 83.Obstet Gynecol2007;109:1233–48. Reaffirmed 2011.
2. Modesitt SC, Pavlik EJ, Ueland FR, et al.
Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter.Obstet Gynecol2003;102:594–9.
3. Castillo G, Alcazar JL, Jurado M.
Natural history of sonographically detected simple unilocular adnexal cysts in asymptomatic postmenopausal women.Gynecol Oncol2004;92(3):
965–9.
4. American College of Obstetricians and Gynecologists. The role of the obstetrician–gynecologist in the early detection of epithelial ovarian cancer.
Committee Opinion No. 477.Obstet Gynecol2011;117:742–6.
5. Greenlee RT, Kessel B, Williams CR, et al. Prevalence, incidence, and natural history of simple ovarian cysts among women>55 years old in a large cancer screening trial.Am J Obstet Gynecol 2010;202(4):373.E1–9.
6. Nardo LG, Kroon ND, Reginald PW.
Persistent unilocular ovarian cysts in a general population of postmenopausal women: Is there a place for expectant management?Obstet Gynecol 2003;102:589–93.