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Essentials - Gynecology > 10. Pelvic masses > Flashcards

10. Pelvic masses Flashcards

1
Q

Pelvic masses are common and can be found in females at what age? (1)

A

at any age (fetal to postmenopausal).

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2
Q

Pelvic masses may originate from what? (2)

A
  • gynecologic organs (ovary, fallopian tube, cervix, or uterus)
  • or from other nongynecologic pelvic organs (bowel, bladder, ureters, skeletal muscle, or bone)
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3
Q

The key objectives when investigating a woman with a pelvic mass are determination of what? (2)

A
  • Their pregnancy status (b-hCG testing)
  • Whether the mass is gynecologic versus nongynecologic
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4
Q

Name PREPUBERTAL OVARY DDx of pelvic mass (4)

A
  1. Benign simple ovarian cysts (i.e., germinal inclusion cyst, paraovarian cyst)
  2. Dermoid cysts (benign cystic teratoma)
  3. Malignant germ cell tumors
    • Dysgerminoma
    • Yolk sac/endodermal sinus tumors
    • Embryonal carcinomaa
    • Granulosa cell/Sertoli-Leydiga
  4. Gonadoblastomas (rare)
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5
Q

Name PREPUBERTAL FALLOPIAN TUBE DDx of pelvic mass (2)

A
  1. Peritubular cyst
  2. Congenital cysts
    • Mesonephric
    • Paramesonephric
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6
Q

Name PREPUBERTAL UTERUS DDx of pelvic mass (1)

A

Uterine anomaly (bicornuate uterus, uterus didelphys)

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7
Q

Name PREPUBERTAL NON-GYNECOLOGIC DDx of pelvic mass (3)

A
  • Pelvic kidney
  • Distended bladder
  • Appendiceal abscess
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8
Q

Name REPRODUCTIVE OVARY DDx of pelvic mass (7)

A
  1. Functional ovarian cysts (follicular, corpus luteum, thecal lutein, hemorrhagic)
  2. Polycystic ovaries
  3. Endometrioma
  4. Luteoma of pregnancy
  5. Benign neoplasm (such as dermoid or fibroma)
  6. Borderline epithelial ovarian tumors
  7. 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
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9
Q

Name REPRODUCTIVE FALLOPIAN DDx of pelvic mass (7)

A
  • Ectopic pregnancy
  • Tubo-ovarian abscess
  • Hydrosalpinx/ pyosalpinx
  • Embryologic remnant cysts
  • Mesonephric
  • Paramesonephric
  • 1° fallopian tube neoplasm
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10
Q

Name REPRODUCTIVE UTERUS DDx of pelvic mass (6)

A
  • Pregnancy
  • Adenomyoma
  • Leiomyoma (fibroid)
  • Hematometra/ pyometra
  • Endometrial CA (rare)
  • Leiomyosarcoma (rare)
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11
Q

Name REPRODUCTIVE NON-GYNECO DDx of pelvic mass (7)

A
  1. Distended bladder
  2. Appendiceal abscess
  3. Diverticular disease
  4. Pelvic kidney
  5. Redundant sigmoid colon
  6. 1°CA (rectal, colon, or bladder)
  7. Metastatic CA (breast, colon, lung)
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12
Q

Name POST-MENOPAUSE OVARY DDx of pelvic mass (4)

A

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

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13
Q

Name POST-MENOPAUSE FALLOPIAN TUBE DDx of pelvic mass (4)

A
  1. Tubo-ovarian abscess
  2. Hydrosalpinx/pyosalpinx
  3. Embryologic remnant cysts
    • Mesonephric
    • Paramesonephric
  4. 1° fallopian tube neoplasm
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14
Q

Name POST-MENOPAUSE UTERUS DDx of pelvic mass (5)

A
  1. Endometrial CA
  2. Leiomyosarcoma (rare)
  3. Adenomyoma
  4. Leiomyoma ( broid)
  5. Hematometra/ pyometra
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15
Q

Name POST-MENOPAUSE NONGYNECOLOGIC DDx of pelvic mass (7)

A
  1. Distended bladder
  2. Appendiceal abscess
  3. Diverticular disease
  4. Pelvic kidney
  5. Redundant sigmoid colon
  6. 1°CA (rectal, colon, or bladder)
  7. Metastatic CA (breast, colon, lung)
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16
Q

Describe: Approach to the Dx of pelvic mass. (Figure)

A
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17
Q

Describe: Approach to the management of ovarian cysts (Figure)

A
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18
Q

Name Features of Androgenization (7)

A
  • Prepubertal age:
    • Clitoromegaly (> 5 mm wide)
    • Hirsutism
  • Reproductive age:
    • Hirsutism
    • Acne and/or seborrhea
    • Alopecia
    • Deepening of voice
    • ↑ Muscle bulk
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19
Q

Name Features of Estrogenization (2)

A

Prepubertal age:

  • Premature menarche
  • Precocious puberty (advanced Tanner staging)
20
Q

Describe Approach to the management of uterine leiomyomas (Figure)

A
21
Q

Describe: Symptomatic leiomyomas (2)

A
  • ~ 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.
22
Q

Describe: Asymptomatic leiomyomas (4)

A
  • ~60%
  • minimal or no Sx
  • fibroid <6 cm or stable size
  • not located in submucosa
23
Q

Name structures

A
24
Q

Describe HPI and Hx: Pelvic mass (14)

A
  • 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
25
Q

Describe menstrual Hx: Pelvic mass (7)

A
  • Menarche
  • Cycle length
  • Flow duration + heaviness
  • Dinmenstrual pattern
  • Abnormal Uterine Bleeding
  • PMS
  • Menstrual pain
26
Q

Describe Sexual Hx: Pelvic mass (3)

A
  • # Partners
  • Method(s) of contraception
  • Dyspareunia
27
Q

Describe OB/GYN Hx: Pelvic mass (6)

A
  • Hx STIs, vaginitis
  • Hx vaginal discharge
  • Pap smear status
  • GTPAL status
  • Mode of delivery
  • Hx pregnancy complications
28
Q

Describe focused physical exam for pelvic mass: Breats (4)

A
  • Tanner staging
  • Tenderness
  • Masses
  • Discharge
29
Q

Describe focused physical exam for pelvic mass: Abdo (3)

A
  • Masses or organomegaly
  • Tenderness, guarding, rebound
  • Ascites
30
Q

Describe focused physical exam for pelvic mass: Pelvic +/- bimanual exam (3)

A
  • 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)
31
Q

Describe focused physical exam for pelvic mass: Other (3)

A
  • Assess lymph nodes (cervical, supraclavicular, and inguinal)
  • DRE
  • Rectovaginal exam (assess posterior uterine surface, uterosacral ligaments, parametria, pouch of Douglas, and rectum)
32
Q

Differentiate characteristics of benign versus malignant ovarian masses

  • Patient age
  • Location
  • Size
  • Consistency
  • Shape
  • Mobility
  • Other
A
33
Q

Name Diagnostic Imaging of Pelvic Masses (4)

A
  • 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
34
Q

Describe the management of ovarian masses (4)

A
  • 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.
35
Q

Name: Indications for Specialty Referral with Pelvic Mass (2)

A
  • Persistent masses (> 2 menstrual cycles) in reproductive-aged women
  • Any postmenopausal mass
36
Q

Name lab markers for ovarian masses (4)

A
  • CA-125 Sensitivity > > specificity
  • AFP
  • LDH
  • hCG
37
Q

Describe this marker: CA-125

  • Source
  • Normal value
  • Levels found in
  • Sensitivity
A
  • 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
38
Q

Describe this marker: AFP

  • Source
  • Normal value
  • Levels found in
  • Sensitivity
A
  • 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
39
Q

Describe this marker: AFP

  • Source
  • Normal value
  • Levels found in
  • Sensitivity
A
  • Source: Enzyme found in almost all body tissues
  • Normal value: < 250 U/L
  • Levels found in: Dysgerminomas
40
Q

Describe this marker: hCG

  • Source
  • Normal value
  • Levels found in
  • Sensitivity
A
  • 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
41
Q

Name characteristics of masses that are suspected abnormal pregnancy, malignancy, and masses requiring surgical intervention? (regardless of if patient is asymptomatic) (4)

A
  • >5 cm with growth
  • Nodular, fixed, solid
  • Presence of ascites
  • ↑ CA-125
42
Q

Describe epidemiology: Ovarian Carcinoma—Epithelial (2)

A
  • Approximately 80% of ovarian CAs
  • Lifetime incidence 1.5%
43
Q

Name RFs: Ovarian Carcinoma—Epithelial (5)

A
  • 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
44
Q

Name protective factors: Ovarian Carcinoma—Epithelial (3)

A
  • OCP use
  • Lactation
  • Tubal ligationor salpingectomy
45
Q

Describe screening: Ovarian Carcinoma—Epithelial (1)

A

No reliable screening test available

46
Q

Describe RX: Ovarian Carcinoma—Epithelial (4)

A
  • 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.

Essentials - Gynecology (14 decks)

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