Management of Complex, Septated Ovarian Cysts

Initial Diagnostic Approach

The American College of Radiology recommends performing transvaginal ultrasound combined with transabdominal imaging as the primary diagnostic modality, including color or power Doppler evaluation to assess vascularity of any solid components, with key features to document including maximum cyst diameter 1, papillary projections (count if present) 2, and presence of ascites 2, 1

The O-RADS system is used to determine malignancy risk and guide management decisions, with septated cysts lacking solid components or papillary projections having very low malignancy risk and typically managed conservatively with surveillance ultrasound 2, 1
Multilocular cysts with smooth inner walls and septations only (no solid areas or papillary projections) are classified as O-RADS 2 or 3 depending on size and color score, with O-RADS 2 (almost certainly benign, <1% malignancy risk) having a multilocular cyst <10 cm with smooth inner walls, color score 1-3 2
O-RADS 3 (low risk, 1-10% malignancy risk) has a multilocular cyst ≥10 cm with smooth inner walls, or any size with color score 4 2

For O-RADS 2 lesions in premenopausal women, simple or multilocular smooth-walled cysts <5 cm require no additional management, while cysts 5-10 cm require follow-up ultrasound in 8-12 weeks during the proliferative phase to confirm functional nature or reassess for wall abnormalities 1
For O-RADS 2 lesions in postmenopausal women, cysts ≤3 cm require no further management, while cysts >3 cm but <10 cm require follow-up ultrasound at 1 year showing stability or decrease in size, with consideration of annual surveillance up to 5 years if stable 1
For O-RADS 3 lesions, refer to a general gynecologist for management, considering ultrasound specialist evaluation or contrast-enhanced MRI for further characterization of indeterminate features 2
For O-RADS 4 lesions, require gynecologic oncology consultation prior to surgical removal or direct referral for management 2
For O-RADS 5 lesions, direct referral to gynecologic oncologist is mandatory, with initial surgery by a gynecologic oncologist improving outcomes through complete staging and optimal cytoreduction 2

The American College of Radiology recommends transvaginal ultrasound combined with transabdominal approach as the most useful initial modality for evaluation of adnexal masses 3
Color or power Doppler should be included to evaluate vascularity of any solid components, as recommended by the Journal of the American College of Radiology 3

The Ovarian-Adnexal Reporting and Data System (O-RADS) should be used to classify the cyst and determine malignancy risk, with categories including O-RADS 0: Incomplete evaluation, O-RADS 1: Physiologic category, O-RADS 2: Almost certainly benign, O-RADS 3: Low risk of malignancy, O-RADS 4: Intermediate risk of malignancy, and O-RADS 5: High risk of malignancy, as defined by the Radiology society 4

The American College of Radiology recommends referral to a gynecologist if a cyst persists or enlarges at follow-up, as stated in the Praxis Medical Insights guidelines 5, 6
Complex cysts ≥10 cm should be managed by a gynecologist, as recommended by the Praxis Medical Insights guidelines, due to a risk of malignancy of 1-10% 6

The Journal of the American College of Radiology recommends contrast-enhanced MRI for further characterization of indeterminate adnexal masses, as it performs superiorly to both ultrasound and noncontrast MRI 3
Noncontrast MRI may be used when IV contrast is contraindicated, as stated in the Journal of the American College of Radiology guidelines 3
CT is usually not useful for further characterization of indeterminate adnexal masses, and PET/CT cannot reliably differentiate between benign and malignant adnexal lesions, as recommended by the Journal of the American College of Radiology 3

Failing to perform adequate follow-up for complex cysts is a common pitfall, as stated in the Praxis Medical Insights guidelines 5
Not distinguishing between simple and complex cysts, which have different management protocols, is a common pitfall, as recommended by the Praxis Medical Insights guidelines 6