10. Pelvic masses Flashcards
Pelvic masses are common and can be found in females at what age? (1)
at any age (fetal to postmenopausal).
Pelvic masses may originate from what? (2)
- gynecologic organs (ovary, fallopian tube, cervix, or uterus)
- or from other nongynecologic pelvic organs (bowel, bladder, ureters, skeletal muscle, or bone)
The key objectives when investigating a woman with a pelvic mass are determination of what? (2)
- Their pregnancy status (b-hCG testing)
- Whether the mass is gynecologic versus nongynecologic
Name PREPUBERTAL OVARY DDx of pelvic mass (4)
- Benign simple ovarian cysts (i.e., germinal inclusion cyst, paraovarian cyst)
- Dermoid cysts (benign cystic teratoma)
- Malignant germ cell tumors
- Dysgerminoma
- Yolk sac/endodermal sinus tumors
- Embryonal carcinomaa
- Granulosa cell/Sertoli-Leydiga
- Gonadoblastomas (rare)
Name PREPUBERTAL FALLOPIAN TUBE DDx of pelvic mass (2)
- Peritubular cyst
- Congenital cysts
- Mesonephric
- Paramesonephric
Name PREPUBERTAL UTERUS DDx of pelvic mass (1)
Uterine anomaly (bicornuate uterus, uterus didelphys)
Name PREPUBERTAL NON-GYNECOLOGIC DDx of pelvic mass (3)
- Pelvic kidney
- Distended bladder
- Appendiceal abscess
Name REPRODUCTIVE OVARY DDx of pelvic mass (7)
- Functional ovarian cysts (follicular, corpus luteum, thecal lutein, hemorrhagic)
- Polycystic ovaries
- Endometrioma
- Luteoma of pregnancy
- Benign neoplasm (such as dermoid or fibroma)
- Borderline epithelial ovarian tumors
- Malignant epithelial and germ cell tumors
- Serous
- Mucinous
- Endometrioid
- Clear cell
- Teratoma (solid/cystic)
- Choriocarcinomaa
- Polyembryonic CAa
- Endodermal sinus/yolk sac (rare)
- Granulosa cell /Sertoli-Leydiga
Name REPRODUCTIVE FALLOPIAN DDx of pelvic mass (7)
- Ectopic pregnancy
- Tubo-ovarian abscess
- Hydrosalpinx/ pyosalpinx
- Embryologic remnant cysts
- Mesonephric
- Paramesonephric
- 1° fallopian tube neoplasm
Name REPRODUCTIVE UTERUS DDx of pelvic mass (6)
- Pregnancy
- Adenomyoma
- Leiomyoma (fibroid)
- Hematometra/ pyometra
- Endometrial CA (rare)
- Leiomyosarcoma (rare)
Name REPRODUCTIVE NON-GYNECO DDx of pelvic mass (7)
- Distended bladder
- Appendiceal abscess
- Diverticular disease
- Pelvic kidney
- Redundant sigmoid colon
- 1°CA (rectal, colon, or bladder)
- Metastatic CA (breast, colon, lung)
Name POST-MENOPAUSE OVARY DDx of pelvic mass (4)
Malignant neoplasms
- Epithelial cell tumors
- Cystadenocarcinomas (serous or mucinous)
- Endometrioid
- Clear cell
- Sex cord neoplasms
- Granulosa cell tumora
- Sertoli-Leydig cell tumora
- Metastases (i.e., Krukenberg tumor from GICA)
Benign neoplasms (rare) - thecoma or fibromas
Name POST-MENOPAUSE FALLOPIAN TUBE DDx of pelvic mass (4)
- Tubo-ovarian abscess
- Hydrosalpinx/pyosalpinx
- Embryologic remnant cysts
- Mesonephric
- Paramesonephric
- 1° fallopian tube neoplasm
Name POST-MENOPAUSE UTERUS DDx of pelvic mass (5)
- Endometrial CA
- Leiomyosarcoma (rare)
- Adenomyoma
- Leiomyoma ( broid)
- Hematometra/ pyometra
Name POST-MENOPAUSE NONGYNECOLOGIC DDx of pelvic mass (7)
- Distended bladder
- Appendiceal abscess
- Diverticular disease
- Pelvic kidney
- Redundant sigmoid colon
- 1°CA (rectal, colon, or bladder)
- Metastatic CA (breast, colon, lung)
Describe: Approach to the Dx of pelvic mass. (Figure)
Describe: Approach to the management of ovarian cysts (Figure)
Name Features of Androgenization (7)
- Prepubertal age:
- Clitoromegaly (> 5 mm wide)
- Hirsutism
- Reproductive age:
- Hirsutism
- Acne and/or seborrhea
- Alopecia
- Deepening of voice
- ↑ Muscle bulk
Name Features of Estrogenization (2)
Prepubertal age:
- Premature menarche
- Precocious puberty (advanced Tanner staging)
Describe Approach to the management of uterine leiomyomas (Figure)
Describe: Symptomatic leiomyomas (2)
- ~ 40%
- Abnormal uterine bleeding (AUB), pressure/ compromise of pelvic organs → ↑ irritative voiding Sx (UTI), ↑ abdo size, acute pelvic pain due to fibroid torsion or degeneration, infertility.
Describe: Asymptomatic leiomyomas (4)
- ~60%
- minimal or no Sx
- fibroid <6 cm or stable size
- not located in submucosa
Name structures
Describe HPI and Hx: Pelvic mass (14)
- Characterize any abdo/pelvic pain (OPQRST)
- Bloating or early satiety
- Review of Sx
- Weight D, energy level
- Skin/hair D
- Acne/hirsutism
- Breast discharge/pain
- Urinary/bowel patterns
- Constitutional Sx
- GI: early satiety
- Abdo fullness
- Medications
- Past surgical Hx
- FHx or personal Hx of breast, ovarian, GI, endometrial CA
Describe menstrual Hx: Pelvic mass (7)
- Menarche
- Cycle length
- Flow duration + heaviness
- Dinmenstrual pattern
- Abnormal Uterine Bleeding
- PMS
- Menstrual pain
Describe Sexual Hx: Pelvic mass (3)
- # Partners
- Method(s) of contraception
- Dyspareunia
Describe OB/GYN Hx: Pelvic mass (6)
- Hx STIs, vaginitis
- Hx vaginal discharge
- Pap smear status
- GTPAL status
- Mode of delivery
- Hx pregnancy complications
Describe focused physical exam for pelvic mass: Breats (4)
- Tanner staging
- Tenderness
- Masses
- Discharge
Describe focused physical exam for pelvic mass: Abdo (3)
- Masses or organomegaly
- Tenderness, guarding, rebound
- Ascites
Describe focused physical exam for pelvic mass: Pelvic +/- bimanual exam (3)
- External : clitoromegaly (> 5 mm wide), Tanner staging
- Speculum: vagina (color, odor, physiologic leukorrhea, rugae,
- discharge), cervix (discharge, color, abnormalities)
-
bimanual:
- Cervix (motion tenderness)
- Uterus (position, size, shape, mobility, symmetry, tenderness, consistency)
- Adnexa (size, shape, mobility, tenderness, consistency, location of mass)
Describe focused physical exam for pelvic mass: Other (3)
- Assess lymph nodes (cervical, supraclavicular, and inguinal)
- DRE
- Rectovaginal exam (assess posterior uterine surface, uterosacral ligaments, parametria, pouch of Douglas, and rectum)
Differentiate characteristics of benign versus malignant ovarian masses
- Patient age
- Location
- Size
- Consistency
- Shape
- Mobility
- Other
Name Diagnostic Imaging of Pelvic Masses (4)
- U/S
- First choice
- Delineates mass qualities (cystic vs. solid, size, location)
- Assesses for ascites
- Safe in pregnancy
- CT
- Suboptimal for assessing the ovary
- Assesses all other organs, lymph nodes
- Assesses retroperitoneum
- MRI
- Identification of soft tissue lesions
- Safe in pregnancy
- Other
- Abdo XR
- IV pyelogram
Describe the management of ovarian masses (4)
- Depends on the age of patient, size of the mass, U/S features, and tumor markers.
- Must take into consideration the patient’s age, desire to preserve fertility, and patient preference.
- Any ovarian mass in a postmenopausal woman is considered CA until proven otherwise.
- Any solid ovarian mass in childhood is considered malignant until proven otherwise.
Name: Indications for Specialty Referral with Pelvic Mass (2)
- Persistent masses (> 2 menstrual cycles) in reproductive-aged women
- Any postmenopausal mass
Name lab markers for ovarian masses (4)
- CA-125 Sensitivity > > specificity
- AFP
- LDH
- hCG
Describe this marker: CA-125
- Source
- Normal value
- Levels found in
- Sensitivity
- Source: Glycoprotein produced by fetal coelomic epithelium
- Normal value: < 35 U/mL
- Levels found in:
- Epithelial cell ovarian tumors
- Also elevated in: fibroids, PID endometriosis, cirrhosis, adenomyosis, pregnancy, appendicitis breast/lung/ovarian/colon/fallopian tube CAs, pancreatitis, renal failure, ascites
- Sensitivity:
- ↑ In ~85% of ovarian CAs
- ↑ In ~50% of stage I ovarian CAs
- If postmenopausal with complex adnexal mass and Ca-125 > 200, 96% PPV for ovarian CA
- Testing for CA-125 in premenopausal women not diagnostic on its own because of ↑ # benign causes of its elevation
Describe this marker: AFP
- Source
- Normal value
- Levels found in
- Sensitivity
- Source: Major protein in fetal serum; not detectable after birth
- Normal value: < 5.4 ng/mL
- Levels found in:
- Germ cell tumors (i.e., endodermal sinus)
- Also dermoids, pregnancy, HCC
- Sensitivity
- ↑ In ~85% of germ cell tumors
- ↑ In ~20% of stage I germ cell tumors
Describe this marker: AFP
- Source
- Normal value
- Levels found in
- Sensitivity
- Source: Enzyme found in almost all body tissues
- Normal value: < 250 U/L
- Levels found in: Dysgerminomas
Describe this marker: hCG
- Source
- Normal value
- Levels found in
- Sensitivity
- Source: Normally produced by the placenta
- Normal value: < 5 mIU/mL
- Levels found in:
- Germ cell tumors GTD (i.e., choriocarcinoma)
- Also in pregnancy, marijuana use
- Sensitivity:
- ↑ In ~80% of germ cell tumors
- ↑ In ~20% of stage I germ cell
Name characteristics of masses that are suspected abnormal pregnancy, malignancy, and masses requiring surgical intervention? (regardless of if patient is asymptomatic) (4)
- >5 cm with growth
- Nodular, fixed, solid
- Presence of ascites
- ↑ CA-125
Describe epidemiology: Ovarian Carcinoma—Epithelial (2)
- Approximately 80% of ovarian CAs
- Lifetime incidence 1.5%
Name RFs: Ovarian Carcinoma—Epithelial (5)
- FHx of ovarian CA (5% if one rst-degree relative affected; 7% if two)
- Excess ovulation (low parity, nulliparity, early menarche, late menopause)
- Increasing age
- Lynch II syndrome: familial disposition to endometrial, ovarian, and GU CAs
- Mutations in BRCA1 (chr17q) and BRCA2 (chr13q) tumor suppress or genes which account for familial breast ovarian CA
Name protective factors: Ovarian Carcinoma—Epithelial (3)
- OCP use
- Lactation
- Tubal ligationor salpingectomy
Describe screening: Ovarian Carcinoma—Epithelial (1)
No reliable screening test available
Describe RX: Ovarian Carcinoma—Epithelial (4)
- Surgical debulking
- Chemotherapy.
- Follow progress with serum CA-125 levels.
- If carrier of BRCA1 or BRAC2 can recommend prophylactic bilateral salpingectomy ± oophorectomy when child bearing is complete.
