Most ovarian cysts resolve, sonographic surveillance recommended [Classics Series]

Classics Series, Landmark Trials in Medicine

1. The majority (>60%) of ovarian abnormalities, even complex, solid or bilateral cysts, resolved with serial ultrasounds.

2. Complex-appearing cysts resolved more quickly than simple-appearing cysts (8.7 weeks vs. 53.0 weeks, to resolution, respectively, p<0.01).

3. The positive predictive value associated with serial ultrasounds is 24.7% compared to 8.1% with a single ultrasound.

Original date of publication: August 2013

Study Rundown: Ovarian cancer is a rare but deadly diagnosis that carries an overall 5-year survival of 44%. Additionally, classic ovarian cancer symptoms are vague and include pelvic pain, abdominal pain and bloating. To improve detection, various screening methods have been investigated. Carcinoma antigen 125 (CA-125) is a marker of epithelial growth in mullerian (fallopian, endometrial, endocervical) and coelemic (pericardial, pleural and peritoneal) cell lines. Assessment of serum CA-125 levels was evaluated as a marker for ovarian cancer but was found to lack specificity for screening. Transvaginal ultrasonography has been purported to have decent sensitivity (80-100%) and specificity (94-99%) to detect ovarian cancer. However, research from the National Ovarian Cancer Early Detection Program, which screened 4526 women at high risk for ovarian cancer, demonstrated a low predictive ability such that all the cancers diagnosed with ultrasound in their study were Stage III (see relevant reading). Yet, many providers still closely rely on ultrasound to guide management of adnexal masses and specifically use sonographic markers to guide their decision to surgically remove the mass. However, as of early 2013, no literature existed on the disposition of ovarian abnormalities detected by ultrasound, such that information such as how long it takes cysts to resolve and whether time-to-resolution varies with cyst characteristics was unknown. In the present study, researchers performed serial ultrasounds to assess the incidence and disposition of ovarian abnormalities and discovered that most ovarian cysts resolve. Additionally, they found that most complex-appearing cysts resolved more quickly than simple cysts. This landmark study demonstrated that change in cyst characteristics over time is a valuable clinical variable. Their findings discourage surgical intervention on the basis of a single ultrasound and encourage sonographic surveillance of ovarian abnormalities with serial ultrasounds (every 6 months for simple cysts and every 6 weeks-every 3 months for complex cysts) either to resolution or, in the instance of increasing cyst size or complexity, surgical removal.

Strengths include large population-based study sample, 25-year study period and individual review of all abnormalities by the principal investigator. Findings were limited by single-institution study in one state such that findings may not apply to populations with other ethnic compositions. Additionally, the screening algorithm was adjusted over the 25-year study period such that screening intervals varied according to current practice recommendations. This population was at elevated risk for ovarian cancer either due to age or family history and thus results may not apply to a low-risk population.

Click here to read study in Obstetrics & Gynecology

Relevant reading: The role of ultrasound evaluation in the detection of early-stage epithelial ovarian cancer.

In-Depth [longitudinal prospective cohort study]:  A total of 39 337 women in the University of Kentucky Ovarian Cancer Screening Program were monitored with 221 576 baseline and interval ultrasounds over 25 years. Asymptomatic women >50 years old or women >25 years old with a family history of ovarian cancer were eligible. Ovarian abnormality was defined as ovarian size >2 standard deviations above normal and the presence of cysts (with deputations, ovulations, solid areas or papillary projections) and/or acrogenic solid structures. When abnormal results were identified, repeat ultrasounds were performed from 6 weeks to 6 months later. For women without abnormalities, serial ultrasounds were performed annually. Time-to-resolution, cyst characteristics and surgical pathology were assessed.

Compared to postmenopausal women, the prevalence of sonographic ovarian abnormalities was higher among premenopausal women (34.9% vs. 17.0%, respectively, p<0.001), as was the prevalence of ovarian cysts (15.3% vs. 8.2% p<0.001). Of women with ovarian abnormalities, 63.2% resolved on subsequent ultrasounds. Complex-appearing cysts resolved more quickly than simple-appearing cysts (median resolution time 8.7 vs. 53.0 weeks, respectively, p<0.01). Over the duration of the study, the positive predictive value of sonographic screening increased from 8.1% at the time of initial ultrasound to 24.7% with serial ultrasounds.

Image: PD

More from this author: HPV triage is optimal management for ASCUS [Classics Series], Risks of trial of labor after cesarean delivery (TOLAC) [Classics Series], Vaginal progesterone for sonographic short cervix decreased preterm birth [Classics Series]

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