UltrasonicUltrasonic- Guided Ovarian Cyst Aspiration: When ? Why?

BY

Mohammad Emam
Prof. OB& GYN
Mansoura Faculty of Medicine
Mansoura Integrated Fertility Center ( MIFC- Egypt) MIFC-

2010

History
U.S. guided ovarian cyst aspiration has evolved with the era of TVS around 1990 Then regression of procedure as recurrence rate 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 been indicated.

Rationale
The routine use of ultrasound by gynecologists led to more frequent detection of ovarian cysts.

Wide spread of interventional TVS cyst aspiration without basic principal among some general gynecologists

Aim
To highlight
:

The guidelines for the gynecologist regarding U/S guided ovarian cyst aspiration.

Mansoura -Egypt experience regarding this topic

General principles for management of ovarian cysts ( 5 points):

Establish the type of cyst. Avoiding surgery for functional cyst. Exclude malignancy ( U/S, Doppler and tumor marker like Ca-125) . Ca-125)

General principles for management of ovarian cysts ( 5 points) :

Age of patient must be considered (Surgery may be recommended in post menopausal women or in prepubertal). prepubertal). Gynecologists should be aware of the role of Interventional ultrasound!!!!?

Epidemiology of Ovarian Cysts?

Many types. Different cause. Many women will have cysts during their childbearing years. Most are asymptomatic. Some types can cause serious health problems. problems.

Growth and Development of Ovarian Follicles

Graafian follicle

Primary follicles Corpus luteum

Ovarian Cysts
Non Neoplastic
Physiological

Follicular.
Theca Lutein

Pathological Endometriotic. Inflammatory PCOS

Neoplastic Epithelial T Sex cord T Germ cell T. others

( Metastatic .)

Difference between Benign & Malignant

Benign
Unilateral Cystic Unilocular Stable over time No ascites

Malignant
Bilateral Solid component Multilocular Growth Ascites

TREATMENT Of Non Neoplastic Physiological:

Small -> Conservative (disappear spontaneously) Large --> drainage (may reoccur) -->

-->removal (surgery) -->

Contraceptive therapy

Pathological
According to type

Ovarian Cyst Aspiration



Maybe an alternative for laparotomy or laparoscopy.

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

Interventional Ultrasound

for Ovarian Cyst Aspiration ?

1)Functional ovarian cysts 2)Pre menopausal ov cysts 3)Ovarian cyst during second trimester of pregnancy . 4)Retention cysts after GnRH analogue during long protocol of A.R.T cycle. 5)Some Endometriotic cyst 6)Ovarian cysts in fetuses

1) Functional ovarian cysts

Review of the literature showed that: Incidence of functional ovarian cysts is (about 43 % of cysts explored by laparoscopy) . When the criteria by U/S. and C.A.125 is benign C.A.125 (missing a malignancy is 2:1000 only) So risk benefit ratio show that: that: 1) Aspiration is better than we perform laparoscopy for fear of 2 per thousands malignancy. 2) Cytology and follow up can minimize this risk .

2) U/S guided ov cysts aspiration in Pre menopause

Exclusion of malignancy , with the help of ultrasound, Doppler and Ca-125: Ca-125:

65% 65% of surgery can be avoided by aspiration of simple ovarian cysts Missing a malignancy 4 out of 1000 Recurrence rate after aspiration 25% 25% .
querleu et al 2001, Bonilla et al 2000 2001,

Postmenopausal ov. cyst

Rules :
There is no physiological ov. cyst ov. in postmenopausal women Aspiration is not recommended for the management of ovarian cysts in postmenopausal women. RCOG Guidelines( 2003), (B). 2003),

3)Ovarian cyst during second trimester of pregnancy

1) The traditional management is:
laparotomy (between 16 and 20 w). NO intervention if the size less than 7 cm.

2) with strict ultrasonic characteristics of benign cysts ,TA or TV ultrasonic aspiration at the second ,TA trimester is very successful. 3) Follow up after delivery

4) Retention cysts after GnRH analogue during A.R.T. cycle

Controversies regarding management of functional cyst after GnRh analogue administration: Cancel the cycle +OCS. No ttt TVS aspiration of the cyst will provide the continuation of the cycle and may improve the follicular recruitment?!

5)Role of u/s- guided Aspiration of u/sEndometriotic Cyst

US -guided aspiration of endometrioma: endometrioma:

Alleviate symptoms till hormonal suppression or surgery is done. Recurrence rate is 66%. 66%. Risk of abscess formation is high.

Trials to minimize recurrence

GNRH a Use of Alternative substances to fluid aspirated :
1. 2.

3. 4.

Methotrexate. Methotrexate. Sclerosing agents (ethanol, bleomycin ..etc) Tetracycline Erythromycin

6)Fetal Ovarian cysts

Are usually detected during ultrasonic evaluation of pregnancy and followed after delivery as neonates. 56% 56% of neonates have been operated after birth by oophorectomy for neglected cysts in utero .

U/S. guided aspiration of fetal ov. cysts

In utero aspiration of cysts > 5cm :

1)May prevent mechanical complications 2) The safety and efficiency of this approach, on the cases reported in the literature seem encouraging .
J Gynecol Obstet biol Reprod (Paris) 2000 Apr ; 29(9):161-9 29( ):161Perrotin F , Roy F , potin J , Lardy H , Lansac J , Body G .

Mansoura Experience (1) (1

DD between Functional and non functional unilocular ovarian cyst, (diameter less than 7cm ,unilocular with no intracytoplasmic papillae)
UCE triad ( Ultrasound ,cytology , and E2) Accuracy In differentiating is 95%

(Gibreel and GHANEM ,2003)

Mansoura Experience(2) Experience(2 Efficacy of ethanol Sclerotherapy for non neoplastic ovarian cysts.
(osman and ghanem) MIFC,2008

Mansoura Experience (3)

The ratio of cyst fluid (E2) to serum E2 as a predictor of the rate of endometrial shrinkage following cyst aspiration in the course of long pituitary down regulation protocol . Emam etal/2001

Summary

ovarian cyst US
Unilocular
-Homogenous -Thin walls -No vegetation

Multilocular

- Heterogeneous
-Thick walls -vegetation

C.A. 125
<35 Observe 2 months
Laparoscopy or laparotomy Stable or <5cm Observe 6 months >5cm

>35

Aspiration by U.S. Cytology

Benign

Suspicious

Conclusion
Following strict criteria to exclude malignancy as TVS and C.A. 125 : Gynecologist can :

1) Select cases suitable for U/S. guided cyst aspiration , which could be the definitive mode of treatment. 2) Avoid more invasive procedures like laparoscopy and laparotomy in many cases of ovarian cysts.

Conclusion

Close follow up after aspiration is necessary to detect recurrence.

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