What is the recommended management for a patient with recurrent dermoid ovarian cyst?

From the Guidelines

The recommended management for a patient with recurrent dermoid ovarian cyst is surgical excision, typically through laparoscopic cystectomy with preservation of normal ovarian tissue when possible. For patients with recurrent dermoid cysts, complete surgical removal of the cyst is essential to prevent further recurrence. If the patient has completed childbearing or has multiple recurrences, oophorectomy (removal of the affected ovary) may be considered. Surgical approach depends on the size of the cyst, with laparoscopy preferred for cysts less than 10 cm and laparotomy sometimes necessary for larger cysts or when malignancy is suspected. Preoperative evaluation should include pelvic ultrasound and possibly tumor markers like CA-125, AFP, and hCG to rule out malignancy, as suggested by the O-RADS US risk stratification and management system 1. Postoperatively, patients should be monitored with periodic ultrasounds to detect any recurrence. Surgery is recommended even for asymptomatic recurrent dermoid cysts due to potential complications including torsion, rupture, and the rare possibility of malignant transformation (1-2% risk), as noted in the management of dermoid cysts and endometriomas 1. Medical management alone is not effective for dermoid cysts as they are benign germ cell tumors that require physical removal.

Some key points to consider in the management of recurrent dermoid ovarian cysts include:

• The use of the O-RADS US risk stratification and management system to guide management decisions 1
• The importance of preoperative evaluation, including pelvic ultrasound and possibly tumor markers, to rule out malignancy
• The preference for laparoscopic cystectomy for cysts less than 10 cm, with laparotomy sometimes necessary for larger cysts or when malignancy is suspected
• The need for postoperative monitoring with periodic ultrasounds to detect any recurrence
• The consideration of oophorectomy (removal of the affected ovary) for patients who have completed childbearing or have multiple recurrences, as noted in the guidelines for the management of dermoid cysts and endometriomas 1.

Overall, the management of recurrent dermoid ovarian cysts should prioritize surgical excision, with careful consideration of the patient's individual circumstances and the potential risks and benefits of different management approaches, as outlined in the O-RADS US risk stratification and management system 1 and the guidelines for the management of dermoid cysts and endometriomas 1.

From the Research

Recurrence of Dermoid Ovarian Cysts

• The recurrence rate of ovarian dermoid cysts is a significant concern in the management of these cases, with studies indicating varying rates of recurrence depending on the surgical approach used 2, 3.
• A study published in 2022 found that the rates of recurrent surgery were similar among women who underwent laparoscopic cystectomy compared with laparotomy, while the rates of reported ultrasound recurrence were significantly lower in the laparoscopy group compared with the laparotomy group 2.
• Another study from 2014 reported a case of multiple and bilateral ovarian dermoid cysts, highlighting the importance of accurate preoperative diagnostic imaging to detect all dermoid cysts and minimize the risk of recurrence 4.
• The recurrence rate of ovarian dermoid cysts in pediatric and adolescent girls was found to be 10.6%, with only 3% requiring further surgical management 5.
• A comparison of laparoscopy and laparotomy for the treatment of ovarian dermoid cysts found that laparoscopic treatment was associated with a higher incidence of intra-abdominal spillage, but this was not associated with increased morbidity, and the risk of recurrence was significantly higher in the laparoscopy group 3.
• A review of 47 cases of laparoscopic management of ovarian dermoid cysts found that the procedure was safe and effective, with minimal spillage occurring in 42.5% of cases and no cases of chemical peritonitis 6.

Risk Factors for Recurrence

• The risk factors for recurrence of ovarian dermoid cysts are not fully understood, but studies suggest that the surgical approach used may play a role, with laparoscopy potentially being associated with a higher risk of recurrence 2, 3.
• Other factors, such as age, cyst diameter, diagnosis of torsion, intraoperative cyst spillage, estimated blood loss, intraperitoneal adhesions, and postoperative fever, were not found to be associated with recurrence in one study 2.
• Accurate preoperative diagnostic imaging is important to detect all dermoid cysts and minimize the risk of recurrence 4.

Management of Recurrent Dermoid Ovarian Cysts

• The management of recurrent dermoid ovarian cysts typically involves surgical removal of the cyst, either by laparoscopy or laparotomy 2, 3.
• The choice of surgical approach will depend on various factors, including the size and location of the cyst, the patient's overall health, and the surgeon's preference.
• Regular follow-up with ultrasound exams is recommended to monitor for recurrence and detect any new cysts early 2, 5.