A 45-year-old woman is found to have an ovarian cyst of 6 cm with a smooth wall, no septae, and no solid component on ultrasound. CA-125 is 28 U/mL. RMI (Risk of Malignancy Index) is calculated as 36. Which of the following is the MOST appropriate management?

• A Immediate laparotomy and frozen section
• B Laparoscopic cystectomy as the RMI is low and features are benign ✓
• C Repeat ultrasound in 6 months and discharge if unchanged
• D CT scan pelvis followed by referral to oncology

Explanation

RMI <25 is low risk, 25–250 is intermediate, and >250 is high risk for ovarian malignancy. An RMI of 36 (intermediate range) with a simple unilocular 6 cm cyst and normal CA-125 in a premenopausal woman is most appropriately managed by laparoscopic cystectomy, which provides both diagnosis and treatment. For high-risk features (RMI >250), referral to a gynaecological oncologist is appropriate. Watchful waiting with repeat imaging is reasonable for very simple cysts <5 cm in premenopausal women, but at 6 cm with intermediate RMI, surgical evaluation is preferred.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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Written and medically reviewed by the StethoPrep medical team.