ovarian cyst emam

8/3/2019 Ovarian Cyst Emam

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BYBY

MohammadMohammad EmamEmamProf. OB& GYNProf. OB& GYN

MansouraMansoura Faculty of MedicineFaculty of MedicineMansouraMansoura Integrated FertilityIntegrated Fertility

Center Center (( MIFCMIFC-- Egypt)Egypt)

20102010

UltrasonicUltrasonic- - Guided Ovarian CystGuided Ovarian Cyst Aspiration: When ? Why? Aspiration: When ? Why?


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Hist ory

U.S. guided ovarian cyst aspiration hasevolved with the era of TVS around 1990Then regression of procedure as recurrencerate is high

At 2000 till now, Reviving and revising of procedure re evolved again in far east with

addition of Sclerosing materials.With long protocol for ART, TVS aspiration

of ovarian cyst in many centers have beenindicated.


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The routine use of ultrasound by gynecologistsThe routine use of ultrasound by gynecologistsled to more frequent detection of ovarianled to more frequent detection of ovariancysts.cysts.

Wide spread of interventional TVS cystWide spread of interventional TVS cystaspiration without basic principalaspiration without basic principalamong some general gynecologistsamong some general gynecologists

RationaleRationale


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AimTo highlight ::

The guidelines for thegynecologist regarding U/ S

guided ovarian cyst aspiration.

Mansoura -Egypt experienceregarding this topic


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General principles for managementGeneral principles for managementof ovarian cystsof ovarian cysts (( 55 points):points):Establish the type of cyst.Establish the type of cyst.

Avoiding surgery for functional Avoiding surgery for functionalcyst.cyst.

Exclude malignancy ( U/ S, Exclude malignancy ( U/ S, Doppler andDoppler and tumor markertumor markerlikelike CaCa--125125) .) .


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General principles for managementGeneral principles for management

of ovarian cystsof ovarian cysts (( 55 points)points) ::

Age of patient must be considered Age of patient must be considered

((S

urgery may beS

urgery may be recommended inrecommended in postpostmenopausalmenopausal womenwomen oror inin prepubertalprepubertal ).).

Gynecologists should be aware of theGynecologists should be aware of therole of Interventional ultrasound!!!!?role of Interventional ultrasound!!!!?


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1

Corpu s lu te umCorpu s lu te um

Graaf ianfoll ic le

Graaf ianfoll ic le

P r imaryfoll ic lesP r imaryfoll ic les

Grow t h and D eve lopm e n t of Grow t h and D eve lopm e n t of

Ov

ar ian Foll

icles

Ov

ar ian Foll

icles


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Ovarian CystsOvarian CystsN eoplasticN eoplastic

Epithelial TEpithelial TS ex cord TS ex cord TGerm cell T .Germ cell T .othersothers

(( Metastatic .)Metastatic .)

N on N eoplasticN on N eoplasticP hy si olog ic al

Foll ic ular.Th ec a Lu tei n

P a t holog ic al

Endom et r io tic .

Inflamma t oryP

COS


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D ifference between Benign & MalignantD ifference between Benign & Malignant

BenignBenign Malignant Malignant UnilateralUnilateral BilateralBilateral

CysticCystic Solid component Solid component

UnilocularUnilocular MultilocularMultilocular

Stable over timeStable over time GrowthGrowthNo ascitesNo ascites Ascites Ascites


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TR EAT MEN T Of Non NeoplasticTR EAT MEN T Of Non Neoplastic

P hysiological:P hysiological:SmallSmall -->> Conservative (disappearConservative (disappear

spontaneously)spontaneously)LargeLarge ---->> drainage (may reoccur)drainage (may reoccur)

---->>removal (surgery)removal (surgery)Contraceptive therapyContraceptive therapy

P athologicalP athological According to type According to type


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Ov ar ian Cyst As p ira ti onOv ar ian Cyst As p ira ti onMaybe an alternative forMaybe an alternative for laparotomylaparotomy ororlaparoscopy.laparoscopy.

Is a matter of controversy .Is a matter of controversy .High recurrence rate.High recurrence rate.Unreliable cytology .Unreliable cytology .Risk of dissemination of Risk of dissemination of NeoplasticNeoplasticcells.cells.


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Interventional UltrasoundInterventional Ultrasound

for Ovarian Cyst Aspiration ?for Ovarian Cyst Aspiration ?11))Functional ovarian cystsFunctional ovarian cysts22)) P re menopausalP re menopausal ov ov cystscysts

33))Ovarian cyst during second trimesterOvarian cyst during second trimesterof pregnancy .of pregnancy .44))Retention cysts afterRetention cysts after GnRHGnRH analogueanalogue

during long protocol of A.R. T cycle.during long protocol of A.R. T cycle.55) S ome) S ome EndometrioticEndometriotic cystcyst66))Ovarian cysts in fetusesOvarian cysts in fetuses


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11) ) Functi

onal ov

ar ianFun

ctional o

var

ian

cy

stscy

sts

Review of the literature showed that:Review of the literature showed that: Incidence ofIncidence offunctional ovarian cysts isfunctional ovarian cysts is ((aboutabout 4343 % of cysts% of cystsexplored by laparoscopy) .explored by laparoscopy) .

When the criteria by U/ S . and C.A.When the criteria by U/ S . and C.A.125125 is benignis benign((missing a malignancy ismissing a malignancy is 2 2::10001000 only)only)

S o risk benefit ratio show thatS o risk benefit ratio show that: :11)) Aspiration is better than we perform laparoscopy Aspiration is better than we perform laparoscopyfor fear offor fear of 2 2 per thousands malignancy.per thousands malignancy.

22)) Cytology and follow up can minimize this risk .Cytology and follow up can minimize this risk .


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22) ) U/S gu id e dU/S gu id e d o vo v c ysts a s p ira ti onc ysts a s p ira ti onin

Pr

em

enopau

sein

Pr

em

enopau

se

Exclusion of malignancy , with the help ofExclusion of malignancy , with the help ofultrasound , Doppler and Caultrasound , Doppler and Ca- -125125: :

6565%% of surgery can be avoided byof surgery can be avoided byaspiration of simple ovarian cystsaspiration of simple ovarian cystsMissing a malignancyMissing a malignancy 4 4 out ofout of 10001000

Recurrence rate after aspirationRecurrence rate after aspiration2525% .% .querleuquerleu et alet al 20012001, Bonilla et al, Bonilla et al 20002000


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P o st m e nopau s al o v . c ystP o st m e nopau s al o v . c ystRules :Rules :

There is no physiologicalThere is no physiological ov ov. cyst. cystin postmenopausal womenin postmenopausal women

Aspiration is not recommended for Aspiration is not recommended forthe management of ovarian cyststhe management of ovarian cystsin postmenopausal women.in postmenopausal women.RCOG Guidelines(RCOG Guidelines( 20032003) , ) , (B).(B).


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33))Ov ar ian c yst dur ing sec ondOv ar ian c yst dur ing sec ondt r im este r of pr e gnan c yt r im este r of pr e gnan c y

11)) The traditional management is:The traditional management is:laparotomylaparotomy ((betweenbetween 16 16 andand 2020 w).w).

NO intervention if the size less than

NO intervention if the size less than 7 7 cm.cm.

22)) with strict ultrasonic characteristics of benignwith strict ultrasonic characteristics of benigncysts ,cysts ,T A or TV ultrasonic aspiration at the secondT A or TV ultrasonic aspiration at the secondtrimester is very successful.trimester is very successful.

33)) Follow up after deliveryFollow up after delivery ..


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44) ) Rete n ti on c ysts af te r Rete n ti on c ysts af te r GnR HGnR H

analogu e dur ing A.R.T. c yc leanalogu e dur ing A.R.T. c yc le

Controversies regarding management of Controversies regarding management of functional cyst after functional cyst after Gn RhGn Rh analogueanalogueadministration:administration:

Cancel t h e cycle +OCS.Cancel t h e cycle +OCS.

NoNo ttttttTV S aspiration of t h e cyst will provide t h eTV S aspiration of t h e cyst will provide t h econtinuation of t h e cycle and may improvecontinuation of t h e cycle and may improveth e follicular recruitment?!th e follicular recruitment?!


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Tr ial s t o m in im ize r ec urr e n ceTr ial s t o m in im ize r ec urr e n ce

GNRH aGNRH aUse of Alternative substances to fluidUse of Alternative substances to fluidaspirated :aspirated :

1.1. MethotrexateMethotrexate. .2.2. SclerosingSclerosing agentsagents (ethanol,

bleomycin ..etc)3. Tetracycline4. Erythromycin


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66))Fet

al Ov

ar ian

cy

stsF

etal O

var

ian

cy

sts

Are usually detected during ultrasonic Are usually detected during ultrasonic

evaluation of pregnancy and followedevaluation of pregnancy and followedafter delivery asafter delivery as neonates.neonates.

5656%% of neonates have been operatedof neonates have been operatedafter birth byafter birth by oophorectomyoophorectomy for forneglected cysts inneglected cysts in uteroutero ..


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InIn uteroutero aspiration of cysts >aspiration of cysts >55cm :cm :

11))May prevent mechanical complicationsMay prevent mechanical complications

22)) The safety and efficiency of thisThe safety and efficiency of this

approach , on the cases reported in theapproach , on the cases reported in theliterature seem encouragingliterature seem encouraging ..

JJ GynecolGynecol ObstetObstet biolbiol ReprodReprod ( ( P aris)P aris) 20002000 Apr ; Apr ; 2929((99):):161161- -99P errotinP errotin F , Roy F , F , Roy F , potinpotin J , Lardy H , J , Lardy H , LansacLansac J , BodyJ , Body G .G .

U/S. gu id e d a s p ira ti on of f et al o v . c ystsU/S. gu id e d a s p ira ti on of f et al o v . c ysts


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Man s oura Exp e r ie n ce (Man s oura Exp e r ie n ce (11))

DD between Functional and non functionalunilocular ovarian cyst, (diameter less than7cm ,unilocular with no intracytoplasmicpapillae)

UCE triad ( Ultrasound ,cytology , and E2)

Accuracy In differentiating is 95%

(Gibreel and GHA N EM ,2003)


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Man s oura Exp e r ie n ce (Man s oura Exp e r ie n ce (22))

Efficacy of ethanolS clerotherapy for nonneoplastic ovarian cysts.

(osman and ghanem) MIFC ,2008


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Man s oura Exp e r ie n ce (3)

The ratio of cyst fluid (E2) to serumE2 as a predictor of the rate ofendometrial shrinkage following cystaspiration in the course of longpituitary down regulation protocol .

Emam etal/2001


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Summary


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ovarian cyst US

Unilocular Multilocular-H omog e nou s

-Th in wall s

-N o ve g et a ti on

- Hete rog e n e ou s

-Th ick wall s

-ve g et a ti on

C.A. 12535

Laparoscopy or laparotomy

Observe 2 months

Stable or 5cm

Observe 6 months Aspiration by U. S .

Cytology

BenignS uspicious


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Con c lu si onCon c lu si on

Following strict criteria to exclude malignancyFollowing strict criteria to exclude malignancy as TVS andas TVS andC.A.C.A. 125125 : Gynecologist can: Gynecologist can :

11)) S elect cases suitable forS elect cases suitable for U/ S . guidedU/ S . guided cystcystaspiration , whichaspiration , which could becould be thethe definitivedefinitivemode of treatment.mode of treatment.

22)) Avoid more invasive procedures like Avoid more invasive procedures likelaparoscopy and laparotomy in many caseslaparoscopy and laparotomy in many casesof ovarian cysts.of ovarian cysts.


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Con c lu si onCon c lu si on

Close follow upClose follow up afterafteraspiration is necessaryaspiration is necessaryto detect recurrence.to detect recurrence.


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ovarian cyst emam

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