JC108 (O&G) - Pelvic Mass: Ovarian Cancer & Cysts, Uterine Fibroid, Pelvic Imaging Flashcards
Outline history taking questions for pelvic mass
Mass: Size, site Onset; how the mass was discovered Duration; change since first noted Associated symptoms (e.g. distension, pressure symptoms)
Menstrual history: Timing: duration, cycle length Amount of flow Anaemic symptoms Compare with previous pattern Any Pain/ dysmenorrhea
Others: Previous gyn exam, cervical smear Obstetrical history (affects management) Sexual history, contraception Drug, allergy Family Medical/surgical
Uterine fibroids
- cell of origin
- Presentation, S/S
- Major ddx
Uterine fibroids (leiomyomas) - benign smooth muscle tumor
Symptoms/ signs:
- multiple, asymmetrical uterine enlargement
- Submucosal fibroid increase surface area of endometrium - menorrhagia** (different from ovarian cyst, ovarian cancer)
- mass effect and pressure effect: Abdominal distention, AROU, DVT, change in bowel habit
- Clotting in uterus or fibroid enlarges into polyp, causing dysmenorrhea ** (like ovarian cyst, cf ovarian cancer) when uterus contracts
Top Ddx: adenomyosis
Ddx benign ovarian masses
Physiological/ functional cysts (appear with menstruation)
Endometriomas (endometriotic cyst/ chocolate cyst)
Serous cystadenoma
Mucinous cystadenoma
Mature teratoma
Ddx benign non-ovarian adnexal masses
Benign non-ovarian (ovary next to fallopian tube and mesosalpinx)
Hydrosalpinges (blocked fallopian tube)
Paratubal cyst
Peritoneal pseudocysts
Tubo-ovarian abscess
Appendiceal abscess
Diverticular abscess
Pelvic kidney
Distended bladder
Ddx primary and secondary malignant ovarian masses
Primary
Germ cell tumour
Epithelial carcinoma
Sex-cord tumour
Secondary
Breast
Gastrointestinal (e.g. stomach Krukenberg tumor)
Types of uterine fibroids
Histological features
Types
- Submucosal
- Intramural
- Subserosal
- Pedunculated
- Intraligamentary
- Parasitic
- Cervical
- Intracavitary
Histology: Degenerative changes:
hyaline, myxoid, calcific, cystic, hemorrhagic/red, sarcomatous (may be
malignant – leiomyosarcoma, rare), fatty
Ovarian cyst
- Presentation
- Top ddx
S/S:
- Asymptomatic if small, mobile, separated from uterus, +/- tender
- Mass effect: abdominal distension, pressure symptoms, abdominal pain
- Cyst complications: Torsion, hemorrhage, rupture
- Dysmenorrhea
Top Ddx:
Endometriosis, endometriotic cyst (less mobile, adhesions to uterus)
Ovarian cancer
- Presentation
- Top ddx
S/S: Similar to ovarian cysts and fibroids except no menorrhagia, constitutional and metastatic symptoms:
- Asymptomatic if small
- Mass effect and pressure symptoms: Abdominal distension, abdominal pain, ascites, DVT, AROU, bowel function
- Complications: hemorrhage, rupture
- Constitutional: LoW, LoA, Unexplained fever
- Metastatic symptoms: PR bleed, cough, IO…
2 surgical emergencies a/w ovarian cysts
Torsion: compromises blood supply, but necrosis of ovary is irreversible > treat by de-torsion and cystectomy
Rupture: ovary is highly vascular > severe bleeding and hemoperitoneum
Physical findings:
Pallor
Asymmetrical mass, irregular, in pelvis, firm, non-tender, moves with cervix
Top ddx
Uterine fibroids
Ddx of gynaecological masses: If regular shape mass - adenomyosis if tender - ovarian cysts if fixed - ovarian cancer if peritoneal signs - ovarian cyst with torsion and hemorrhage
Physical findings: Pelvic mass found separated from uterus Tender Mobile Peritoneal signs
Most likely gynaecological mass?
Ovarian cyst with torsion or hemorrhage leading to peritonitis
If less mobile - adhesions with surround structures, endometriosis, stuck to uterus and becomes endometriotic cyst
If ascites - Meig’s syndrome: triad of benign ovarian tumor
+ ascites + pleural effusion
Define Meig’s syndrome
triad of benign ovarian tumor + ascites + pleural effusion,
resolves after tumor resection
Physical findings:
Cachexic, lymphadenopathy, DVT
Pelvic mass is non-tender, fixed, hard, irregular surface
Ascites
Organomegaly
Nodular deposits in Pouch
Stony dull percussion on respiratory exam
Most likely gynaecological mass?
Ovarian cancer
Ascites (shifting dullness due to peritoneal metastasis/ liver metastasis
= stage IV
Nodular deposits in Pouch of Douglas (sign of peritoneal metastasis)
Pleural effusion – stony dull (sign of metastasis)
Outline P/E for pelvic mass
General:
- vital signs, BMI, performance status, pallor, lymphadenopathy
- pregnancy test
Abdominal: Full set
Pelvic:
Vulva, vagina, cervix (speculum)
Uterine size
Adnexal mass: size, tenderness, mobility with uterus, arising from pelvis
Pouch of Douglas: nodularity, thickening, tenderness
Metastasis: Respiratory examination, rectal examination
Uterine fibroid
Describe features of the mass on P/E
Mass:
- Symmetrical/ asymmetrical
- Irregular shape
- Usually non-tender
- Moves with cervix
- Arise from pelvis
- Consistency varies: firm if calcified, rubbery if normal
Special notes:
- If tender»_space;> Red degeneration due to fast fibroid growth under hormonal stimulation, outgrowing vessels and causing ischemia
- Special locations: pedunculated mass - very mobile, subserosal fibroid does not present as a uterine mass
- Pallor»_space;> severe menorrhagia
Radiological features of uterine fibroids
- Well- circumscribed
- pseudocapsule from surrounding compressed myometrium
- Hypoechoic/ heterogeneous echoes
Adnexal mass/ cyst
Treatment options for pre-menopausal women
Simple, functional cysts, asymptomatic, <5cm = close case
Simple, functional cysts, asymptomatic, 5-7cm = observe and repeat ultrasound in 3-6 months for regression
Persistent cyst/ increases in size or >7cm:
- Cystectomy or salpingo- oophorectomy
- Approach: Laparoscopy (small)/ laparotomy (big or suspicious-looking)
Symptomatic mass/ suspect cancer:
- Refer gynecology
- Exclude secondary from colon, stomach, breast…etc
- Staging surgery +/- chemotherapy
