As ovarian cysts frequently cause predominantly abdominal as opposed to gynaecological symptoms, it is not unusual for them to be encountered by the general surgeon, either during the clinical assessment of such patients, or at laparotomy or laparoscopy. Cysts can also present as a relatively asymptomatic abdominopelvic swelling.

1.Age and fertility;

2.Whether known to be pregnant or not;

3.Operative findings

Appearance of cyst (size, surface, etc.);

Appearance of opposite ovary;

Appearance of abdominal organs (omentum, infradiaphragmatic surfaces, etc.);

4.Availability of gynaecologist;

5.Experience of general surgeon.

Ovarian cysts may be physiological, benign, or malignant. Ovarian epithelial cancer is common with over 4000 deaths per year in England. The 5-year survival rate of 30 per cent has remained unchanged over the last 30 years. The only variety of tumour where the survival has improved remarkably is the germcell type. To date there is no satisfactory screening for ovarian cancer. Over the last 10 years there have been several studies which have shown the protective effect of the combined oral contraceptive pill on ovarian cancer.

With the development of gynaecological oncology as a separate subspecialty, including advances in chemotherapy, and with better communication between surgical and gynaecological colleagues as well as closer liaison with those in other disciplines, it is hoped that the unchanged overall mortality rate from ovarian cancer will decrease and that there will be a reduction in the morbidity caused by inappropriate treatment for both benign and malignant disease, in particular in the younger woman.

There are several main clinical types of ovarian swellings which will be discussed later in the text (Table 1) 406. When presented with an adnexal mass any structure which normally occupies the pelvis must be considered in the differential diagnosis. Table 2 407 outlines the more common and some less likely possibilities. Following clinical examination the investigations described in Table 3 408 may be of value.

If fertilization occurs, the usual regression of the corpus luteal cyst is halted; by around the eighth week of gestation it has doubled in size, occupying at least one-third of the ovary. In early pregnancy the active corpus luteum ensures the continuation of pregnancy (up to 10 weeks) after which it shrinks. As a result the majority of ovarian cysts found incidently on ultrasound in early pregnancy are found to have resolved spontaneously on rescanning. The contents of a ruptured corpus luteal cyst can cause peritoneal irritation giving rise to severe abdominal pain. This usually resolves spontaneously within 24 to 48 h on conservative management. Removal of the corpus luteum in early pregnancy in the human produces abortion in only 10 to 20 per cent of pregnancies. However, the safest time to remove persistent large corpus luteal cysts (>5 cm) in pregnancy is after the 12th week of gestation as they may undergo torsion or haemorrhage in later pregnancy when access is difficult and the risk of premature labour very real. Removal also ensures that ovarian tumours are not neglected. The incidence of malignant ovarian tumours in pregnancy is of the order of one in 12 000 to 50 000 pregnancies.

In a woman who may be pregnant, if a corpus luteal cyst is discovered at laparotomy or laparoscopy, be it ruptured or not, the general advice is that it should not be removed. Not only may the woman miscarry as a result but the unnecessary surgery on the ovary may encourage adhesion formation which may interfere with future fertility.

In the asymptomatic, non-pregnant woman the detection of a simple cyst on ultrasound is usually managed conservatively if it measures less than 5 cm in diameter. These cysts may be non-functional cysts or follicular or corpus luteal cysts. A follow-up ultrasound in approximately 3 months in the majority of cases shows resolution. In those cysts more than 5 cm in diameter there is considerable risk of torsion since a large cyst will become an abdominal organ as the pelvis will be too small to contain it. This 5-cm rule is a very crude method for selecting patients for surgery.

If the cyst is causing symptoms aspiration or cystectomy is necessary. Research is proceeding in colourflow Doppler ultrasound studies of ovarian cysts in an effort to detect potential malignancy in simple-appearing cysts. These studies are being analysed in conjunction with measurement of CA–125 which is an ovarian tumour marker, but results are not yet available.

A simple fluid-filled cyst can be aspirated using a long spinal needle, either transabdominally or transvaginally, with the aid of ultrasound. Aspiration can also be performed at laparoscopy or laparotomy. The fluid should always be sent for cytological examination.

If aspiration is not the preferred procedure or if the cyst is not a simple fluid-filled cyst, cystectomy can be performed. Usually normal ovarian tissue can be distinguished as separate from the cyst. An incision is made through the capsule thickness only, along this line. The cyst is then enucleated with a combination of sharp and blunt dissection. The residual ovary is reconstructed with fine 2/0 chromic catgut to the stroma and a non-absorbable suture to the capsule, e.g. 4/0 nylon. The non-absorbable suture is used to close the capsule to decrease the risk of adhesion formation to the ovary.

The other main type of physiological cyst occurs as polycystic ovaries. Approximately 20 per cent of asymptomatic women on ultrasound are found to have polycystic ovaries. While polycystic ovarian syndrome is common, it seldom requires urgent surgical intervention.

Symptoms occur notoriously late in the natural history of the disease. They tend to be very vague and localized to the abdomen so that diagnosis is frequently made at laparotomy. The women with ovarian tumours, as a result, often present to the surgeon rather than the gynaecologist. Early symptoms may include abdominal distension and discomfort or pain, dyspepsia, flatulence, weight loss, anorexia, bowel dysfunction, pelvic discomfort with pressure sensation, bladder symptoms, backache, ankle oedema, and thrombophlebitis; occasionally there is postmenopausal bleeding or in younger women menstrual irregularity. Ovarian neoplasia must therefore be considered in the differential diagnosis of these very common symptoms. Torsion or haemorrhage into the tumour may result in an acute or subacute presentation. Not infrequently the patient herself notices a symptomless mass.

In a woman with persistent unexplained gastrointestinal symptoms, particularly in middle age and later, ovarian cancer should be considered early and excluded by vaginal and ultrasound examination.

When ovarian cancer is discovered unexpectedly at laparotomy the appropriate action will depend upon the circumstance (Fig. 1) 1449. A thorough laparotomy should be performed. Some of the common features suggestive of malignancy are ascites; nodularity; irregular surface to the cyst, possibly with adhesions; solid, irregular, or complex cystic/solid appearance on cross-section; multiple peritoneal deposits of tumour tissue including on the under surfaces of the diaphragms; para-aortic lymphadenopathy and omental deposits of tumour. If the surgeon is experienced in ovarian cancer management, proceeding to full surgical staging and therapeutic surgery will usually be possible. For less experienced surgeons, appropriate assistance should be sought and, if available, the need for closure following biopsy to await a planned reoperation can often be avoided. Figure 2 1450 shows a flow chart for the management of ovarian tumours found unexpectedly at laparotomy.

To achieve adequate information for full staging a vertical abdominal incision is required. If the original incision has been transverse, this can be modified by extending the incision and dividing the rectus muscles to allow upper abdominal access.

Standard therapeutic surgery consists of a meticulous staging laparotomy followed by a total abdominal hysterectomy with bilateral salpingo-oophorectomy and infracolic omentectomy combined with removal of all tumour or as much as possible. Careful staging is crucial to future management and includes inspection and palpation of all intra-abdominal structures, collection and cytological examination of ascites, and biopsy of any suspicious lesion. Too often this is incompletely performed and on occasion staging needs to be repeated. The rationale for total hysterectomy and bilateral salpingo-oophorectomy relates to the high incidence of bilateral ovarian tumours, synchronous or asynchronous, which may be metastatic or separate primaries, and the frequent finding of cancer in the uterine cavity particularly with endometrioid ovarian cancers. Omentectomy has been added in recent years as in 8 to 10 per cent of cases the omentum may be the only site of metastases which furthermore may be detected only on histology. It is a low risk procedure and improves staging with consequent alteration in management strategy and accuracy of prognosis.

For advanced disease when complete macroscopic removal of the tumour is not possible, ‘debulking’ surgery is currently accepted practice. The aim is to remove as much tumour as possible, trying to ensure that the largest mass remaining is less than 1.5 cm in diameter, in the hope that this will improve the prospect of successful chemotherapy. This technique is applied much more widely in ovarian cancer management than with other intra-abdominal malignancies. The relatively non-invasive behaviour of many ovarian cancers, even when disseminated, makes debulking procedures technically much more feasible than with other cancers.

CT scanning is the most useful imaging technique for identifying any residual tumour should it be missed at laparotomy, particularly liver metastases and retroperitoneal lymphadenopathy, and serial tumour marker measurement (especially CA–125) may be of assistance in suggesting the presence of residual or recurrent tumour.

There is no role for adjuvant therapy in stage 1A and 1B ovarian tumours. In cases where the disease appears to have been completely removed but there has been tumour outside the ovaries adjuvant therapy may be of value. Second-look surgery is now no longer acceptable as routine practice.

As nearly 90 per cent of ovarian cancers occur over age 45, future childbearing is not often a consideration. However, in younger women and girls the possibility of conserving reproductive potential must be considered.

A more conservative approach to initial surgery is favoured with unilateral oophorectomy only if careful staging suggests early stage disease, even though this may mean an extra laparotomy if the histology of biopsies suggests the tumour to be more than stage 1 and therefore requiring further surgery. Malignant germ-cell tumours occur particularly in this age group and behave differently from epithelial cancers. As the age-specific incidence of germ cell tumours is maximal at 30 years, the possibility of this condition should be given serious consideration in any young woman or girl with an adnexal mass. Germ-cell cancers, formerly carrying a very poor prognosis, are now usually curable (85 per cent) and in most cases this can be achieved with preservation of reproductive capacity. ‘Borderline’ ovarian cancer can occur at any age but is relatively more common in younger women and the management then presents particular difficulties. Borderline ovarian tumours comprise 20 per cent of ovarian malignancies and most cases present under the age of 45. Diagnosis is histological, made regardless of the clinical stage. There is a trend towards increasing conservatism in the use of all therapeutic modalities in younger patients.

Barber HRK. 1981. Malignant disease in pregnancy. In: Coppleson M, ed. Gynaecologic Oncology, 1st edn. Edinburgh: Churchill Livingstone, 1981: 795–806.

Bostwick DG, Tazelarr HD, Ballon SC, Hendrickson MR, Kempson RL. Ovarian epithelial tumours of borderline malignancy. Cancer, 1986; 58: 2052–65.

Bourne T, Campbell S, Steer C, Whitehead MI, Collins WP. Transvaginal colour flow imaging: a possible new screening technique for ovarian cancer. Br Med J, 1989; 299: 1367–70.

Cancer Statistics: Registrations. England and Wales, London: HMSO, 1990.

Csapo AI, Pulkkinen MO, Kaihola HL. The relationship between the timing of luteectomy and the incidence of complete abortions. Am J Obstet Gynecol, 1974; 118: 985.

Disaia PJ, Creasman WT. Cancer in pregnancy. In: Disaia PJ, Creasman WT, eds. Clinical Gynaecologic Oncology. 2nd edn. St Louis: CV Mosby 1984: 428–43.

Fox H, Buckley CH. Pathology for Gynaecologists. London: Edward Arnold, 1982.

Fox H, Langley FA. Tumours of the ovary. London: William Heinmann, 1976.

Green MH, Clark JW, Blayney DW. The epidemiology of ovarian cancer. Semin Oncol, 1984; 11: 209–26.

Griffiths CT. Carcinoma of the ovary: surgical objectives. In: Sharp F, Soutter WP, eds. Ovarian Cancer—The Way Ahead. London: Royal College of Obstetricians and Gynaecologists, 1987: 235–44.

Hacker NF. Feasibility of primary cytoreductive surgery. In: Sharp F, Soutter WP, eds. Ovarian Cancer—The Way Ahead. London: Royal College of Obstetricians and Gynaecologists, 1987: 245–55.

Jacobs I, et al. Multimodal approach to screening for ovarian cancer. Lancet, 1988; i: 268–71.

Jarrell MA, Brumsted JR. Successful treatment of a persistent cyst, developing after ovarian transposition with leuprolide acetate. Obstet Gynecol, 1990; 76: 5:2; 927–8.

Johnson RJ. Noninvasive techniques in detecting ovarian carcinoma. In: Blackledge GD, Chan KK, eds. Management of Ovarian Cancer. London: Butterworth, 1986: 33–45.

Kurjak A, Zalud I, Jurkovic D, Alfirevic Z, Miljan M. Transvaginal colour doppler for the assessment of pelvic circulation. Acta Obstet Gynaecol Scand, 1989; 68: 131–5.

Polson DW, Adams J, Wadsworth J, Franks S. Polycystic ovaries—a common finding in normal women. Lancet, 1988; i: 870–2.

Rustin GJS. Managing malignant ovarian germ cell tumours. Br Med J, 1987; 295: 869–70.

Shepherd JH. Surgical management of ovarian cancer. In: Shepherd JH, Monaghan JM, eds. Clinical Gynaecological Oncology. 2nd edn. Oxford: Blackwell Scientific Publications, 1990: 218–46.

Smith JP, Day TG. Review of ovarian cancer at the University of Texas Systems Cancer Centre, MD Anderson Hospital and Tumour Institute. Am J Obstet Gynecol, 1979; 135: 984.

Standing Medical Advisory Committee, Dept. of Health. Management of ovarian cancer—current clinical practices 1991. London: Department of Health, 1991.

Tobias JS, Griffiths CT. Management of ovarian carcinoma: current concepts and future prospects. N Engl J Med, 1976; 294: 877.

Vessey M, et al. Ovarian neoplasms, functional ovarian cysts, and oral contraceptives. Br Med J, 1987; 294: 1518–20.

Wijnen AJ, Rosenshein MD. Surgery in ovarian cancer. Arch Surg, 1980; 115: 863–8.