Managing Ovarian Masses: The challenge in finding the right balance

Transcription

1 Managing Ovarian Masses: The challenge in finding the right balance Dr. Lisa Allen/Dr. Sari Kives University of Toronto Elsevier Lectureship NASPAG April 20, 2017

2 Objectives At the conclusion of the presentation, attendees will: 1. Understand the importance of appropriate management of adnexal pathology in children and adolescents. 2. Be aware of the evidence to guide surgical management decisions in adnexal pathology in this age group 3. Appreciate how assessment of patient outcomes can guide development of management protocols.

3 Disclosure I have no financial disclosures to declare

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7 How often are you likely to encounter ovarian pathology in children and adolescents, what type and why?

8 Ovarian neoplasms 2.6/100,000 girls per year

9 Benign tumors: 0.34/100,000 age /100,000 at age 12 Malignancies /100,000 < 13 yrs Hermans AJ et al Gynecol Oncol 2016;143:93-97

10 3 years 114 consults for ovarian masses By Ped Gyne Service Tertiary Level Hospital Kirkham Y, Lacy L, Kives S, Allen L JOGC;2011;33(9):

11 41.2% expectant management 58.8% operative procedure Kirkham Y, Lacy L, Kives S, Allen L JOGC;2011;33(9):

12 not operated on non referred cases/100,000 Benign tumors: 0.34/100,000 age /100,000 at age 12 ovarian cysts not referred Malignancies /100,000 < 13 yrs Hermans AJ et al Gynecol Oncol 2016;143:93-97

13 Ovarian cysts 183 visualized ovaries, 108 pts ages 2-9 >9 mm cysts 6% most common 3-5 yr range Adolescents 10 19, 139 ultrasounds, follicular phase >3 cm cysts 12% Quablan HS et al Clin Exp Obstet & Gyn 2000;51-53 Porcu E et al Arch Gynecol Obstet 1994;255:69-72

14 Authors Brown (91, Philadelphia, 1993) Non neoplastic (%) Neoplastic benign (%) Cass (106, Texas, 2001) Rogers (126, Toronto, 2014) Kirkham (67, Toronto, 2011)* De Silva (134, Melbourne, 2004) Cribb (219, New Zealand, 2014) Michelotti (231, Pittsburg, 2010) Hermans (111, Netherlands 2015) Madenci (502, US, 2016) *7% overall malignancy rate (43% expectant management) Neoplastic malignant (%)

15 Hermans AJ et al Gynecol Oncol 2016;143:93-97

16 Histopathology primordial germ cells Others coelomic epithelium sex cords/stromal

17 Pathology # Pts Percent of Total Germ Cell 39.6 Mature Teratoma Struma Ovarii Immature Teratoma Mixed germ cell tumor Retrospective review masses managed surgically PAG & Ped Surg (22 Sx Ped Surg primary surgical service) Malignancy rate Germ cell tumors 18% Epithelial tumors 20% Dysgerminoma Yolk sac tumor Embryonal Epithelial 19.3 Cystadenoma Borderline tumor Sex Cord Stromal 1.5 Juvenile granulosa cell) Other: 37.1 Simple or follicular Paratubal Hemorrhagic Corpus luteum Endometrioid Rogers E, Casadiego G, Lacy J, Gerstle T, Kives S, Allen L. JPAG (3);

18 Hermans AJ et al Gynecol Oncol 2016;143:93-97

19 Why are you going to see them? Symptoms of Ovarian Masses Pain 73% Incidental 8.8% Increased girth 7.9% Precocious puberty 1.8% Nausea and vomiting 3.5% Kirkham Y, Lacy L, Kives S, Allen L JOGC;2011;33(9):

20 What we have learned so far Common at all ages to see ovarian cysts on pelvic imaging High % of ovarian lesions can be managed expectantly Ovarian neoplasm rates increase after childhood Majority of masses that require surgery are benign Proportion of malignancies in surgical series: 5 21% Malignancy rate may be highest % in childhood Borderline ovarian neoplasms start to occur around early adolescence All histologic cell types represented at all ages but proportions vary

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22 Game called: Can you identify the malignancies?

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29 The goal of a prediction rule is to ensure that: Benign cysts/tumors can receive appropriately conservative management (observation, laparoscopy, cystectomy). Malignant tumors can receive appropriately aggressive management (complete resection, avoidance of spillage, delivery of intact capsule, full staging, correct assignment of adjuvant therapy).

30 Does it matter? What if we do an oophorectomy for a benign lesion?

31 Assessing Gonadal function after Childhood Ovarian Surgery Zhai A et al J Pediatr Surg 2012;47: N=180 Retrospective review, mail survey 45% response rate, 44 oophorectomy, 37 ovarian salvage Dysmenorrhea 27% vs 59% (p=0.04) 7/10 and 2/13 with regular menses pre sx had persistent regular menses after (p=0.013) No difference in age at menarche CONCLUSION: Unilateral oophorectomy does not appear to impair late gonadal function when compared with ovarian salvage Oophorectomy appears to maintain more normal ovarian activity as estimated by menstrual irregularity (definition of irregular menses <28 or >30 days) Oophorectomy may be performed without apparent adverse effect on gonadal activity

32 Assessing Gonadal function after Childhood Ovarian Surgery Zhai A et al J Pediatr Surg 2012;47:

33 Risk of disease in contralateral ovary Decreased ovarian reserve Fertility Earlier Menopause

34 Does it matter? If we do a cystectomy for a malignant lesion?

35 J Pediatr Surg 2004;39(3):

36 Until recently, all patients with ovarian malignant germ cell tumors or stromal tumors received adjuvant chemotherapy (four cycles of PEB; cisplatin, etoposide, bleomycin)

37 J Clin Oncol 2014

38 Half the patients eventually required chemotherapy (which means half did not). All patients who recurred on surveillance had elevated AFP, and recurred within 1-8 mo (median 2). CONCLUSION: As long as meticulous attention is paid to surgical guidelines, and patients are carefully monitored, approximately 50% to 60% of girls can be spared the potential morbidity of chemotherapy with successful outcome. Nearly all patients (11/12) could be salvaged with adjuvant chemotherapy started at recurrence. One patient died, but this patient had chemo-refractory disease, and hence final outcome may not have been different.

39 Germ cell Malignancy Cystectomy

40 Do we need to talk about this Is there a problem?

41 347/458 (76%) cystectomy/partial oophorectomy JPAG /143 (75%) Ovarian Sparing surgery JPAG /51 benign lesions cystectomy (71%) JPAG /59 benign lesions cystectomy (84%) JOGC 2011

42 ISSN: (Print) (Online) Journal homepage: 32/132 ovarian preservation (24%) J Pediatr Surg 2014 Published online: 02 Jun Update on the surgical management of ovarian neoplasm s in children and adolescent s: analysis on 32 cases Claudio Spinelli, Silvia St ram bi, Concet t a Liloia, Alessia Bert occhini & Ant onio Messineo 1/27 cystectomy (4%) Gynecol Endocrinol 2016 To cite this article: Claudio Spinelli, Silvia Strambi, Concetta Liloia, Alessia Bertocchini & Antonio Messineo (2016) Update on the surgical management of ovarian neoplasms in children and adolescents: analysis on 32 cases, Gynecological Endocrinology, 32:10, , DOI: / To link to this article: Submit your article to this journal 1/8 benign epithelial tumors cystectomy (12.5%) Article views: JPAG View related articles View Crossmark data 0/22 cystectomies for mature teratoma (0%) J Pediatr Surg 2014

43 8/8 Oophorectomy for malignancies (100%) JPAG /8 cystectomies for malignancies (63%) JOGC 2011

44 Referral patterns Pediatric Gynecologist Pediatric Surgeon Adult gynecologist

45 no solid components, of which 27 had no positive undergo surgery might have been missed, because Original tumor markers Research (alpha-fetoprotein, b-human chorionic they were more difficult to identify. This means the gonadotropin, and lactate dehydrogenase). The sensitivity was 40.91% (95% and confidence Treatment interval [CI] 29.0 ofdescribed, Adnexal and the malignancy Masses rate may be somewhat real incidence of benign cysts ispossibly higher than Diagnosis 53.7%) and the specificity was 100% (95% CI 81.3 overestimated in our population. in100%). Children In this group, two and laparotomies Adolescents and seven Histologicpatternswereoverall consistent withthe oophorectomies (of which five were the result of torsion) J. might Hermans, have existing literature. The only exception was the higher Ayke MD, been Kirsten avoided B. Kluivers, in case the MD, model PhD, Marc had H. Wijnen, incidence MD, ofphd, granulosa Johan Bulten, cell tumors, MD, PhD, which was 21% of Leon been F. applied Massuger, preoperatively. MD, PhD, and Sjors F. Coppus, MD, PhD all malignancies, whereas in previous studies, sex cord stromal tumors represent 5 8% of all malignancies. 4 Torsion was related to oophorectomy, which was OBJECTIVE: To evaluate the diagnosis and treatment a gynecologic also surgeon found protected in previous against studies. oophorectomy 8,9 Literature on saving decisions Table 4. made Odds in children Ratios of andoophorectomy adolescents with inanpatients benign cases. the ovary, even when it appearsto be necrotic, isavailable since 1993 including long-term follow-up. 10,11 The adnexal mass. With a Benign Ovarian Mass Who (Obstet Gynecol 2015;125:611 5) METHODS: This Underwent was a retrospect Surgicalive Therapy cohort study DOI: /AOG among patients younger than age 18 years who were oophorectomy rate may be significantly lowered when LEVEL OF EVIDENCE: II diagnosed applying this knowledge in clinical daily practice. Variable with or treated for an adnexal OR* mass 95% at CI the OP* Radboud University Medical Center, Nijmegen, the varian masses The criteria in children as defined are uncommon, by Papic withet al 6 to predict Netherlands, Univariate estimates between January 1999 and October an incidence benign masses of neoplastic wereovarian developed masses based estimated.002 atlected 2.6 cases preoperatively per 100,000 as girls well each as year. postoperatively. 1 In on data col- Age, Premenarchal signs and symptoms, laborator 5.31 y results, imaging data, Pain type of surgery including surgeon 0.70 specialt y, and Previous.481 studies the present have found study that wemalignancy performed rates external in validation histologic Palpable diagnosis mass were analyzed. Published 1.44 criteria for ovarian.465 neoplasms Pain+palpable mass of the data in in children a preoperative ranged between setting. 3.7 characterizing a mass benign (Papic et al) were applied Although Papic and 23.5%, Maximum diameter (cm) excluded 2,3 accounting for 1% of all female pediatric to the present data set. infants under the age of 1, we have included cancers. 1,4 Although epithelial ovarian cancer is leading RESULTS: Max diameter One hundred greater eleven patients 2.42were included..085 in the all adult age ovarian groups cancers, as well as it only paraovarian represents cysts and torsed The meanthan age 6ofcm the patients was years, ranging 1.9% of all ovaries. childhood Negative ovarian scores neoplasms. on all 5 Germ of the cell criteria resulted between Laparoscopy 0 and 17 years. Ovarian masses 0.47were malignant tumors and in sex a 100% cord stromal benign tumors rate are in more the present common population, in 28Torsion patients (25.2%). Surgical therapy 2.52was applied in.069 Gynecologic surgeon among whichildren wouldwith haveovarian changed neoplasms policy into and a more sparing 83.1% of the benign masses and in 100% of the malignant Multivariate estimates have a much operation better prognosis. in seven 4 cases. The sensitivity of this model masses. Oophorectomy was performed in 46.4% of the benign Maximum masses. The diameter presence of a gynecologist was the.020the majority howeverofwas the only ovarian 41% masses (CI 29 54%), in children which indicates only factor greater thatthan significantly 6 cm are thus benign. lowered the chance of that there In the isstill past it room was common for improvement practice to of risk models. oophorectomy Torsion in benign masses (odds 3.41 ratio perform 0.14, 95%.035 a single-sided oophorectomy in case of an Focusing on oophorectomy, we found that the confidence Gynecologic interval surgeon ). Papic 0.14 et al s model ovarian had.001 mass or ovarian torsion in children. No presence of a gynecologic surgeon was significantly surgeon wanted to risk the incomplete removal of a sensitivity OR, odds ratio; of 40.91% CI, confidence and a specificit interval. y of 100%. associated with a reduced probability of oophorectomy CONCLUSION: * Odds ratios and The P values malignancy were calculated rate among using patients binary regression a malignancy and torsed ovaries were already considered lost. in Papic benignet al masses 6 report(odds an increased ratio 0.14), rate of a finding that analysis. with adnexal masses in our cohort was one in four Bold indicates data with a significant P value. confirms the results Obstet of others. Gynecol 8,9 Fear 2015;125(3): ovary-sparing procedures in recent years but also for malignancy patients. Most patients with an adnexal mass were point out that too many unnecessary oophorectomies treated surgically, and oophorectomy was performed in

46 What should dictate management? Tumor characteristics Informed patient/family preference NOT: Surgeon specialty Geographic location Low volume vs high volume institution Patient demographics

47 What we have learned so far Unilateral Oophorectomy may have implications on future reproductive health for young women Incomplete adherence to staging protocols may result in more young women receiving chemotherapy for germ cell tumors postoperatively For low malignant potential tumors the risk of cystectomy alone increases recurrence rates Rates of epithelial cystadenocarcinoma are very rare in children and adolescents Variable rates of application of ovarian sparing procedures The presence of a knowledgeable surgeon at surgery increases rates of ovarian preservation

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55 Pediatric Preop Risk Stratification Characteristic Oltmann (OR) Papic (OR) Age 1 8 yrs 3.02 ( ) Not stat sign Symptom Mass 4.84 ( ) Symptom Prec Pub Size 5.67 ( ) >8 cm 19.0 ( ) >10 cm 9.60 ( ) Solid ( ) Abnormal Tumor markers Not conclusive ( >999) Oltmann SC et al J Pediatr Surg 2010;45: Papic J et al 2014;49:

56 Pediatric Preop Risk Stratification Benign Malignant p-value PPV NPV Pain 83/113 (73.5%) 12/16 (75%) % 72.15% <=8 years old 17/113 (15%) 5/16 (31.2%) % 95.21% Abnormal Markers 9/49 (18.4%) 9/16 (56.2%) % 94.39% LDH 7/9 (77.7%) 4/9 (44.4%) % 56.23% βhcg 0/9 (0%) 2/9 (22.2%) % 79.74% AFP 2/9 (22.2%) 6/9 (66.7%) % 87.8% CA-125 1/9 (11.1%) 2/9 (22.2%) % 77.98% Complex Cyst 76/113 (67.3%) 16/16 (100%) % 100% 8 cm 60/113 (53.1%) 16/16 (100%) % 100% 10 cm 34/113 (30.1%) 9/16 (56.2%) % 89.78% 8 cm + Complex Cyst 41/113 (36.3%) 16/16 (100%) % 100% Table 2: Comparison of benign vs malignant adnexal masses Pediatric patients adnexal mass cases were stratified based on their pre-operative mass characteristics as identified by either ultrasound imaging, history, or biochemical markers. A Fisher s exact test comparing the two cohorts identifies the significant differences between benign and malignant masses (p 0.05). Using the sensitivity and specificity of these pre-operative characteristics, the positive predictive value (PPV) and negative predictive value (NPV) of these criteria were also calculated. Note: 7/16 malignant cases were 8 10 cm in size Rogers E, Casadiego G, Lacy J, Gerstle T, Kives S, Allen L. JPAG (3);

57 NPV 100% Functional cysts (Hemorrhagic Cysts Follicular Cysts) Pathologic Cysts (Cystadenomas, Paratubal/Paraovarian Cysts, Dermoids < 8 cm, Endometriomas < 8 cm)

58 Management; expectant management or conservative surgery No additional testing is necessary routinely, except serial follow-up ultrasound Expectant: More often Neonate /Postmenarcheal Smaller masses: Up to size of mass (< 9.8cm) No symptoms of: Increased girth Precocious puberty Nausea and vomiting If surgery - cystectomy

59 NPV 100% PPV 37.1% 63/289 22% of masses Overall malignancy rate 8%

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62 TUMOUR MARKERS IN OVARIAN MALIGNANCY AFP HCG INH LDH CA125 Test/Est CEA Dysgerminoma - -/+ - -/+ -/+ - - Yolk sac tumor /+ -/+ - - Immature teratoma -/ Embryonal Ca -/+ -/ Choriocarcinoma Mixed MGCT -/+ -/+ - -/+ -/+ - - Granulosa cell Sertoli-Leydig - - -/ Epithelial /+ - -/+

63 Benign Malignant p-value PPV NPV Pain 83/113 (73.5%) 12/16 (75%) % 72.15% <=8 years old 17/113 (15%) 5/16 (31.2%) % 95.21% Abnormal Markers 9/49 (18.4%) 9/16 (56.2%) % 94.39% LDH 7/9 (77.7%) 4/9 (44.4%) % 56.23% βhcg 0/9 (0%) 2/9 (22.2%) % 79.74% AFP 2/9 (22.2%) 6/9 (66.7%) % 87.8% CA-125 1/9 (11.1%) 2/9 (22.2%) % 77.98% Complex Cyst 76/113 (67.3%) 16/16 (100%) % 100% 8 cm 60/113 (53.1%) 16/16 (100%) % 100% 10 cm 34/113 (30.1%) 9/16 (56.2%) % 89.78% 8 cm + Complex Cyst 41/113 (36.3%) 16/16 (100%) % 100% Table 2: Comparison of benign vs malignant adnexal masses Pediatric patients adnexal mass cases were stratified based on their pre-operative mass characteristics as identified by either ultrasound imaging, history, or biochemical markers. A Fisher s exact test comparing the two cohorts identifies the significant differences between benign and malignant masses (p 0.05). Using the sensitivity and specificity of these pre-operative characteristics, the positive predictive value (PPV) and negative predictive value (NPV) of these criteria were also calculated. Rogers E, Casadiego G, Lacy J, Gerstle T, Kives S, Allen L. JPAG (3);

64 Benign Malignant p-value PPV NPV Pain 83/113 (73.5%) 12/16 (75%) % 72.15% <=8 years old 17/113 (15%) 5/16 (31.2%) % 95.21% Abnormal Markers 9/49 (18.4%) 9/16 (56.2%) % 94.39% LDH 7/9 (77.7%) 4/9 (44.4%) % 56.23% βhcg 0/9 (0%) 2/9 (22.2%) % 79.74% AFP 2/9 (22.2%) 6/9 (66.7%) % 87.8% CA-125 1/9 (11.1%) 2/9 (22.2%) % 77.98% Complex Cyst 76/113 (67.3%) 16/16 (100%) % 100% 8 cm 60/113 (53.1%) 16/16 (100%) % 100% 10 cm 34/113 (30.1%) 9/16 (56.2%) % 89.78% Oltmann highly associated with malignancy elevated only 54% of malignancies 8 cm + Complex Cyst 41/113 (36.3%) 16/16 (100%) % 100% Table 2: Comparison of benign vs malignant adnexal masses Pediatric patients adnexal mass cases were stratified based on their pre-operative mass characteristics as identified by either ultrasound imaging, history, biochemical markers. A Fisher s exact test comparing the two cohorts In identifies 46% the of malignancies significant differences normal between benign and malignant masses (p 0.05). Using the sensitivity and specificity of these pre-operative characteristics, the positive predictive value (PPV) and negative predictive value (NPV) of these criteria were also calculated. Rogers E, Casadiego G, Lacy J, Gerstle T, Kives S, Allen L. JPAG (3);

65 Madenci A et al J Pediatr Surg 2016;51:

66 Madenci A et al J Pediatr Surg 2016;51:

67 Madenci A et al J Pediatr Surg 2016;51:

68 Madenci A et al J Pediatr Surg 2016;51:

69 OSS 170/429 (40%) 0 2.3% malignancy risk Either OSS or oophorectomy 231/429 (54%) % malignancy risk Oophorectomy 22/429 (5%) malignancy risk Madenci A et al J Pediatr Surg 2016;51:

70 Defining complexity on imaging Lesion Hemorrhagic cyst Mucinous cystadenoma Mature Teratoma Indicators of malignancy Description Various stages of hemorrhage, acute, clot formation, retraction (fibrin strands, retracting thrombus, fluid levels Different densities of fluid (layering of mucin) Fat/Fluid levels, calcifications with posterior echogenic shadowing, fine echogenic bands hyperechoic mural module Solid components > 2cm in size, thick septations, multiple papillary projections,ascites, high doppler content

71 In Press 2017

72 Ovarian Crescent Sign

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74 Do we stage appropriately?

75 Do we stage appropriately? Only 4.5% correctly staged (no under or over staging) * * 90.9% 47.7% 81.8% 90.9% 72.7% 90.9% 1/52 over staging biopsy + (omentum) Madenci et al J Pediatr Surg 2016;51:

76 v Madenci et al J Pediatr Surg 2016;51:

77 Component Tumor Capsule Ascites Peritoneal implants Omentum Lymph nodes Contralateral ovary Findings Visual assessment of capsule integrity incorrect ~20% 23/100 positive cytology 5 upstaged based solely on cytology 0/7 normal areas positive (for malignancy) 18/29 abnormal areas positive 1/23 normal areas positive 7/45 abnormal areas positive 0/18 grossly normal nodes positive 19/46 grossly abnormal nodes positive 0/21 normal-appearing ovaries positive 11/21 abnormal positive

78 What we have learned so far Masses that are simple and less than 8 cm in size can be managed expectantly or with laparoscopic cystectomy Other thresholds 9 cm, 10 cm Expectant management is most often associated with neonates and adolescents, smaller size and lack of features of torsion or precocious puberty The positive predictive value of malignancy using size of 8 cm and complexity on ultrasound is 37% Tumor markers while statistically associated with malignancy are not as predictive Tumor markers may have a role of stratifying the heterogeneous/complex mass MRI can decrease the indeterminate rate of imaging, with more accurate demonstration of benign lesions Algorithms still place >50% of masses in category for either OSS or oophorectomy Very few patients are staged according to COG guidelines Overstaging results in very few positive specimens

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85 Myth busters It is too big to do a cystectomy

86 Is cystectomy viable in the very large ovarian mass? Ovary Size: pre and postop cystectomy pts cm size, mean 14.8 cm Affected Ovary Contralateral Ovary 1 0 Size (cm) Volume (cm3) Reddy J Laufer M Fertil Steril 2009;91:1941

87 Myth busters It is not possible to separate the normal tissue form from the cyst

88 Is cystectomy viable in the very large ovarian mass? Residual ovarian tissue in cystectomy specimens 30 pts (6 16 yrs, median 9.1), 18 l/s, 12 laparotomy, Up to 10 cm size Pathology: follicular cysts, dermoids, mucinous/serous cysadenomas, endometriotic cysts 86.7% no ovarian tissue in the cystectomy specimen 13.3% (2 l/s, 2 laparotomy) tissue found, <1mm only with endometriotic cysts Palmara J Pediatr Surg 2012;47:

89 Is cystectomy viable in the very large ovarian mass? Residual ovarian tissue in oophorectomy specimens 72 ophorectomy specimens for benign disease 76% identifiable ovarian tissue 11% necrotic (torsion) 45% of the overall benign masses (132 case) were > 10 cm at time of surgery Papic J J Pediatr Surg 2014;49:

90 Myth busters There is too much risk from attempting conservative/mis surgery

91 Overall Laparoscopy rate 62% Benign Laparoscopy rate 69% Rogers E, Casadiego G, Lacy J, Gerstle T, Kives S, Allen L. JPAG (3);

92 MIS = small Pfannenstiel

93 Risk of spillage: peritonitis Templeman 2000 (n=14 l/s) Pathology Mature Cystic Teratoma (MCT) Cyst Rupture 92.8% 0% Savasi 2009 (n=23 l/s) MCT 100% 0% Nezhat 1999 (n-470 adults) MCT 66% 0.2% Youset 2016 (n-59) 52.5% MCT 32.2% Epithelial benign 13.% malignant 46% 0% Peritonitis Savasi, Lacy, Gerstle, Stephens, Kives, Allen JPAG 2009;22(6):360-4 Templeman CL et al Hum Reprod 2000;15: Nezhat CR eta al JSLS 1999; Yousef et al JPAG 2016;29:

94 Risk of spillage: recurrence rate Laberge 2006 (n=245) Rogers 2014 (n=66)# Harada 2013 (n=382)# Yousef 2016 (n=59)# Pathology Overall recurrence rate L/S Open Requiring surgery MCT 7.6*% 0%* 4.2 vs 0%* MCT 10.6% 15% 3.8% 3% MCT 4.2% 2.9% 52.5% MCT 32.2% Epithelial benign 13.% malignant 10% 14% 9% # Intraoperative spill not associated with recurrence *stat significant Rogers EM, Allen LM, Kives S JPAG 2014;JPAG:24(4) Yousef et al JPAG 2016;29:

95 What we have learned so far Even extreme large masses can be managed conservatively With cystectomy With MIS/Mini laparotomy approach If benign cyst is drained/ruptured low risk for peritonitis and recurrence Even with Mature Cystic Teratomas

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97 Summary Ovarian cysts are common on routine imaging Rate of ovarian masses likely approximately 9/100,000 Many ovarian cysts will resolve without surgical management (>40%) Only a small proportion of ovarian tumors are malignancies 7% A prediction rule can allow the best balance in conservative vs oncologic management Size (8 10 cm) and complexity/solid are the most conserved in the algorithms MRI can decrease the proportion of indeterminate diagnoses on imaging, enhancing accurate detection of benign masses Tumor markers esp AFP and BHCG may be of value in decision making in complex/heterogenous masses

98 Summary Benign masses should be managed with cystectomy and the least invasive surgical approach Peritonitis and recurrence of benign masses are low and not likely related to less invasive approaches Tumors known or suspected to be malignant require a surgical approach that allows complete intact resection and full staging Overstaging adds little value and increases surgical risk Stage I ovarian germ cell tumors can be treated with surveillance alone, with chemotherapy reserved for recurrence.