From the Guidelines
The best next step in management for this 62-year-old nulligravid woman with an incidentally discovered 5-cm right ovarian cyst is to monitor the cyst with repeat imaging, as the risk of malignancy is low for simple cysts up to 10 cm in diameter, according to the American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Gynecology 1.
Key Considerations
- The patient's age and postmenopausal status do increase the concern for potential ovarian cancer, but the evidence suggests that simple cysts up to 10 cm in diameter are likely to be benign 1.
- The size of the mass (5 cm) is within the range that can be safely monitored without surgical intervention, as recommended by the American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Gynecology 1.
- The absence of symptoms and family history of ovarian or breast cancer are also important factors to consider, and in this case, they support a more conservative approach.
Management Approach
- The patient should undergo repeat imaging in 1 year to assess for stability or decrease in size of the cyst, with consideration of annual follow-up for up to 5 years if the cyst remains stable 1.
- If the cyst enlarges, then management by a gynecologist is suggested, which may include surgical evaluation.
- It is essential to note that the O-RADS US risk stratification and management system provides a framework for managing adnexal masses, and in this case, the patient's cyst would be classified as a simple cyst, which has a low risk of malignancy 1.
Important Evidence
- A recent meta-analysis by Parazzini et al suggested a limited risk of malignancy in anechoic cysts among postmenopausal women of approximately 1.5% 1.
- The study by Bindman et al found that no simple cysts were diagnosed as cancer in women younger than 50 years, and only a single simple cyst was ultimately diagnosed as a malignancy in women over 50 years at 3 years following US 1.
From the Research
Next Steps in Management
The patient is a 62-year-old nulligravid woman with a right adnexal mass. Given her age and the presence of a 5-cm right ovarian cyst, the following steps can be considered:
- Measurement of serum CA 125 levels to assess for potential malignancy 2, 3, 4, 5
- Transvaginal ultrasound to further evaluate the characteristics of the ovarian cyst 2, 4, 5, 6
- Consideration of Doppler ultrasound to assess blood flow to the cyst 2, 4, 5
- Potential referral to a gynecologic oncologist for further evaluation and management
Diagnostic Considerations
The use of CA 125 and transvaginal ultrasound can help in the diagnosis of ovarian cysts, but their accuracy can vary:
- CA 125 has a sensitivity of 85.71% and a specificity of 85.93% in detecting malignant lesions among ovarian cysts 5
- Transvaginal ultrasound has a sensitivity of 71.41% and a specificity of 80% in detecting ovarian cysts 5
- The combination of ultrasound and CA 125 can improve the sensitivity and specificity of diagnosis 2, 5
Management Options
The management of the patient will depend on the results of the diagnostic tests and the patient's overall health status:
- If the cyst is suspected to be malignant, surgical evaluation and potential removal of the cyst may be necessary
- If the cyst is benign, observation or potential removal of the cyst may be considered
- The patient's age and lack of symptoms will also be taken into consideration when determining the best course of management 3