O&G JC108: Pelvic Mass: Ovarian Cancer And Cysts, Uterine Fibroid, Pelvic Imaging Flashcards
***DDx of Pelvic mass
- Gynaecological
- **Ovarian masses
- **Uterine Fibroid
- **Adenomyosis
- **Pregnancy
- Paraovarian cyst (~ ovarian mass)
- Hydrosalpinx (~ ovarian mass) - GI (e.g. abscess (SpC OG))
- Urological
- Distended ***bladder - Retroperitoneal masses spreading to anterior abdomen
- Pseudocysts (Loculations from adhesions e.g. previous surgery)
Aim:
- Attend to patients who need urgent treatment
—> shock, ***peritoneal signs
- Exclude ovarian cyst complications, pregnancy complications
History taking in Pelvic mass
- Age
- HPI, details
- Onset
- How mass was discovered (for a while / incidental?)
- Duration (long: benign)
- Size
- Site
- ***Change since first noted
- Associated symptoms e.g. distension, pressure symptoms - Associated symptoms (+ve / -ve related)
- Menstrual history, Previous gynae exam (esp. **Cervical smear)
- **Menstrual flow
—> Compare with previous pattern
—> Timing (regularity): duration (sudden change), cycle length (shortened with intermenstrual bleeding?)
—> Amount (heavy, how many pads, flooding sensation, clots >2cm)
—> **Anaemic symptoms
—> DDx: **Fibroid, ***Adenomyosis
-
**Dysmenorrhea
—> Primary (early onset, right after menarche, consider **structural abnormality (e.g. **Imperforate hymen, 2 uterus 1 obstructed —> blood retained in uterus))
—> Secondary (no previous history of dysmenorrhea, associated symptoms: menorrhagia, subfertility, DDx: **Adenomyosis) - ***Associated symptoms (e.g. urinary / bowel symptoms)
—> ∵ Pressure effect (tenesmus), invasion (PR bleeding)
—> DDx: Gynaecological / Non-gynaecological pathologies / Secondary ovarian cancer from bowel primary - ***Constitutional symptoms
- Obstetrics history
- Sexual history + Contraception
- Family history
- Medical / Surgical history
- Drug history + allergy
Physical examination of Pelvic mass
General
1. Vital signs
2. ***Pregnancy test
3. BMI
4. Performance status (esp. cancer)
5. Pallor
6. Lymphadenopathy (+ chest, cardiac examination to see patients fit for surgery)
Abdominal exam
1. Shape
2. Mass: location, size, mobility, regular, consistency etc.
3. Tenderness: peritoneal signs (urgent)
4. Ascites
5. Organomegaly
Pelvic exam (start from lower genital tract)
1. Vulva, Vagina
2. Cervix (speculum)
3. Uterine size
4. **Adnexal mass (size, tenderness, mobility (move with uterus), arising from pelvis)
5. **PoD (nodularity, thickening, tenderness in endometriosis)
+/- Rectal exam
1. Mass (esp. ovarian cancer, rule out ***CRC, assess need for bowel resection if ovarian cancer)
Investigations of Pelvic mass
- Pelvic USG
- Screening tool only!!! Diagnosis should be made ***histologically!!!
Other tests as indicated:
2. CBP for menorrhagia
3. CT / MRI / PET-CT (for suspected ovarian cancer) (**Pelvis + **Abdomen (SpC OG))
4. ***CA125 (Ovarian cancer)
5. CEA (exclude CRC as DDx of pelvic mass)
6. Pre-op workup
Management principles of Pelvic mass
- Review history, P/E
- Review investigation results, diagnosis, +/- previous treatment
- ***Benign / Malignant, Acute / Chronic
- Presence of symptoms / signs
- Patient’s fitness
- Patient’s wishes
- Individualised
Fibroid
- Most common neoplasms of uterus
- 20-40% reproductive age women
- ***Benign smooth muscle tumour
- Usually multiple causing ***asymmetrical enlargement of uterus
- ***Mass effect on myometrium + surface lobularity
Types:
1. Intramural
2. Subserosal (outside uterus, cause pressure symptoms)
3. Submucosal
4. Pedunculated
5. Intraligamentary
6. Parasitic
7. Cervical
Clinical features:
1. Asymptomatic
2. **Menorrhagia (e.g. submucosal fibroid ↑ SA of endometrium)
3. **Abdominal mass
4. Pressure effect (e.g. press on bowel / urethra —> urinary retention / vessels —> DVT)
5. **Anaemia
6. Dysmenorrhea (*rare, if excessive bleeding —> clots retained / fibroid polyp —> try to expel)
- normal submucosa / subserosal fibroid does NOT cause pain!!!
7. Others
DDx: Menorrhagia, Mass, Dysmenorrhea: Adenomyosis
P/E:
1. Pallor
2. **Non-tender (except red degeneration: fibroid grow faster than vessels —> ischaemia of fibroid —> pain)
3. Symmetrical / Asymmetrical / **Irregular (If regular: other DDx: Adenomyosis)
4. **Firm mass (arise from pelvis), **Rubbery (if hard: calcified)
5. ***Mobile mass moved with cervix
6. Special locations: Pedunculated (outside uterus) / Subserosal fibroid / Fibroid polyps (fibroid within endometrial cavity, uterus not enlarged)
(Complications (Felix Lai):
1. **Torsion
2. **Degenerative changes of Fibroids
3. **Infertility
4. Adverse pregnancy outcome
- **Malpresentation
- Miscarriage
- ***Placental abruption
- IUGR
- Preterm labour)
Investigations for Fibroids
USG
- Transvaginal (for small fibroids)
- Transabdominal (for large fibroids)
- Sonohysterogram (for fibroid polyps)
Features on USG:
1. **Well-circumscribed
2. Pseudocapsule from surrounding compressed myometrium
3. **Hypoechoic / ***Heterogeneous echoes
Degenerative changes of Fibroids
- Hyaline
- Myxoid
- Calcific
- Cystic
- ***Haemorrhagic / Red
- ***Sarcomatous (Sarcomatous malformation can be malignant: Leiomyosarcoma)
- Fatty
***Treatment for Fibroid
Asymptomatic: Observation
Symptomatic:
1. ***Transamin
- symptomatic relief
- ***Mirena (IUCD with progestogen)
- symptomatic relief - Surgical removal (**Myomectomy / **Hysterectomy)
- Open / Laparoscopic / Vaginal / Hysteroscopic
-
**Myomectomy: **Intramural / **Subserosal fibroid
—> but chance of **recurrence of fibroid
—> may also cause **adhesions —> difficult for fertility
—> need C-section for pregnancy if full thickness of myometrium resected to prevent **scar rupture
—> ***torrential bleeding —> may still require hysterectomy - **Hysteroscopic resection: **Submucosal fibroid / ***Fibroid polyp
-
**Uterine artery embolisation (UAE), **High-intensity focused ultrasound (HIFU)
- usually for women who had ***no fertility wishes since uterus affected as well
- chance of infection when fibroid undergo necrosis
(SpC Revision:
CI to UAE:
- Evidence of current genitourinary infection and/or malignancy
- Refusal to undergo hysterectomy following peri- or post-UAE complications
- Evidence of pregnancy
- Asymptomatic
- Uterine malignancy was suspected
- Concurrent use of a GnRH agonist
- Evidence of pedunculated submucosal fibroids, dominant pedunculated serosal fibroids (attachment point <50%) (∵ may dislodge into peritoneal cavity after necrosis)
- History of allergic reaction to contrast medium and renal impairment
- Desire of future pregnancy)
Ovarian cyst
Clinical features:
1. Asymptomatic
2. **Abdominal mass
3. Pressure symptoms (e.g. urinary / bowel symptoms, bloating (SpC OG))
4. **Abdominal pain (∵ mass effect / complications e.g. ***torsion, haemorrhage, rupture) —> severe acute pain —> medical emergency!!!
5. Dysmenorrhea (endometriotic cysts i.e. chocolate cysts)
- regular pain associated with menstruation
P/E:
1. Vital signs if in pain
2. Mobility
- **usually separated from uterus
- **less mobile if adhesions, **endometriosis (i.e. endometriotic cysts)
3. Tenderness, Peritoneal signs
4. Consistency (cystic?)
5. Usually **no ascites (except ***Meigs’s syndrome: ascites, pleural effusion)
6. May not be palpable if small / soft
7. Special situations: Complications, Meig’s syndrome
Ovarian cancer
Types (Felix Lai):
Epithelial malignancy (95%)
1. ***Serous tumour (50%) (漿液性)
2. Mucinous tumour (25%) (黏液性)
3. Endometroid tumour (15%)
4. Clear cell (5%)
5. Transitional cell (Brenner) tumour (1%)
6. Mixed epithelial tumour
Non-epithelial malignancy (5%)
1. Germ cell tumour (5%) (Teratoma / Dysgerminoma / Yolk sac / Choriocarcinoma / Embryonal / Polyembryoma / Mixed)
2. Stromal cell tumour (1%) (Theca / Granulosa / Sertoli / Leydig cell tumour)
Clinical features:
1. **Asymptomatic (silence killer)
2. Non-specific: GI upset (epigastric distension, diarrhoea etc.)
3. Abdominal distension (∵ mass / ascites)
4. Abdominal pain
5. Pressure symptoms
6. **Complications: Haemorrhage, Rupture
7. **Constitutional symptoms: LOW, LOA, unexplained fever, malaise, DVT
8. **Metastatic symptoms (e.g. cough, pleural effusion)
Site of metastasis (Felix Lai):
1. Breast
2. Colon
3. Appendix
4. Stomach
5. Pancreas
6. Krukenburg (metastasis from primary stomach tumour)
P/E:
1. General condition
- Fit for cancer treatment?
2. Mobile / Fixed **non-tender mass from pelvis (usually cystic + solid)
3. **Ascites
4. Signs of metastasis
- Lymphadenopathy
- Pleural effusion
- DVT
- Organomegaly
- ***Deposits in PoD
Risk factors (Felix Lai):
1. BRCA1 / BRCA2 mutation
2. Nulliparity
3. HRT
4. Family history of Ovarian / Breast cancer
5. Smoking
Incessant ovulation theory: More ovulatory cycles —> Increase risk (SpC OG)
USG features of Adnexal mass
Ascertain nature of mass (∵ good at looking at water content)
1. Size
2. Bilateral / Unilateral
3. **Cyst content: Cystic / Solid areas in mass or cyst / Internal wall
4. **Septations
5. Ascites
Cyst content
1. **Anechoic (purely water, compare with bladder)
2. **Low level echoes (homogeneous low echogenicty) —> Old blood / Clots (e.g. endometriotic / haemorrhagic cysts)
3. Ground glass appearance (homogeneous dense echoes) —> Mucinous cystadenoma
4. Haemorrhagic / Clots (thread-like fibrin strands)
5. Mixed (heterogeneous echoes as seen in teratoma, mixed with solid growth, capillary-like in malignant condition)
6. Mixed with blood-fluid / fat-fluid level
7. Mixed (abscess)
8. ***Solid components
- Unilocular-solid cyst
- Multilocular cyst
- Multilocular-solid cyst with papillary projection (could be malignant)
- Solid tumour
Types of Adnexal masses
Benign ovarian:
- **Functional / Physiological cyst (occur in menstruation)
- **Endometrioma (chocolate cyst)
- Serous cystadenoma
- Mucinous cystadenoma
- Mature teratoma
Benign non-ovarian (Fallopian tube, Mesosalpinx):
- Paratubal cyst
- **Hydrosalpinges
- **Tubo-ovarian abscess
- Peritoneal pseudocyst
- Appendiceal abscess
- Diverticular abscess
- Pelvic kidney
Primary malignant ovarian
- Germ cell tumour
- ***Epithelial carcinoma
- Sex-cord tumour
Secondary malignant ovarian
- Predominantly breast + GI carcinoma (***Krukenberg tumour)
Benign vs Malignant tumour
USG Indicators of malignancy:
1. Papillary projections (>3mm in height)
2. Solid-cystic masses
3. Strong intramural colour flow (vascularity)
4. Thick septum
***IOTA (International Ovarian Tumour Analysis) simple rules:
Malignant: >= 1 M feature + no B feature
Benign: >=1 B feature + no M feature
Inconclusive: if no / both B / M features present
B rules:
- Unilocular cysts
- Presence of solid components where largest solid component <7mm
- Presence of acoustic shadowing (i.e. pure cystic)
- Smooth multilocular tumour with largest diameter <100mm
- No blood flow
M rules:
- Irregular solid tumour
- Ascites
- >=4 papillary structures
- Irregular multilocular solid tumour with largest diameter >=100mm
- Very strong blood flow
***RMI (Risk of malignancy index):
U x M x CA125
- <25: low risk (<3%)
- 25-250: intermediate risk (20%)
- >250: high risk (75%)
U (USG, 0 point if no USG features, 1 point for each of following characteristics, 3 points if >=2 features):
- multilocular cyst
- evidence of solid areas
- evidence of metastasis
- ascites
- bilateral lesions
M:
- 1 for pre-menopausal women (web)
- 3 for all post-menopausal women
CA125
- Coelomic epithelium related glycoprotein
- Level: depend on Stage + Histology
- Present in most **Serous, **Endometroid, ***Clear cell ovarian carcinomas
- Mucinous tumours express less frequently
- Also found in epithelium of Fallopian tubes, endometrium, uterine cervix
- Usual cut-off: ***35 u/ml
- ***Low specificity (false positive), elevated in any conditions that irritate mesothelium / epithelium
—> ∴ not recommend routine checking if not suspect CA ovary!!!
Classification (SpC OG):
Gynaecological:
Physiological:
1. **Menstruation
2. **Pregnancy
Non-physiological:
1. Benign ovarian tumours
2. **Fibroid
3. **Endometriosis
4. Acute PID
Non-gynaecological:
1. ***Liver cirrhosis (ascites)
2. Pancreatitis
3. COPD
4. Kidney problems
5. Flu
- More sensitive + specific in post-menopausal women
- More useful in ***follow up of patients after treatment for proven CA ovary + elevated CA125 level before treatment
—> cancer / treatment monitoring
***Treatment of Adnexal mass / Cysts (pre-menopausal)
Functional ovarian cyst:
- Asymptomatic —> Observation + Repeat USG (3-6 months) —> may regress itself
- Symptomatic: possible complications —> Removal (preserve as much Ovary as possible)
Persistent cyst:
- consider removal to confirm diagnosis (***cystectomy vs salpingo-oophorectomy, laparoscopy vs laparotomy)
Suspect cancer:
- refer oncology, exclude secondary from colon, stomach, breast etc, staging surgery +/- chemotherapy
**Treatment algorithm of **Pre-menopausal adnexal mass
- Asymptomatic
—> <5cm (including functional simple cyst) —> Close case
—> 5-7cm —> Rescan —> Regression —> Close case
—> 5-7cm —> Rescan —> Benign features, remain stable, not want surgery —> Refer integrated clinic for rescan + follow up
—> ***>7cm —> Advise surgical evaluation - ***Symptomatic —> Advise surgical evaluation
- ***IOTA rule as malignant, CA125 >200, Evidence of metastasis —> Advise surgical evaluation
**Treatment algorithm for **Post-menopausal adnexal mass
General principle:
- Simple, unilateral, unilocular cyst <5 cm, normal CA125, unchanged after serial assessment —> **Conservative treatment
- All other cysts —> **BSO (laparotomy / laparoscopy)
Calculate **RMI
—> <200 (low risk)
—> Asymptomatic, Simple cyst, <5 cm, Unilocular, Unilateral (achieve ALL features) —> Low risk: **Conservative
—> Symptomatic, Non-simple features, >5 cm, Multilocular, Bilateral (ANY 1 of features) —> High risk: ***BSO
—> **>=200 (high risk)
—> CT scan
—> High risk of malignancy: **Laparotomy full staging procedure
—> Low risk of malignancy: ***Pelvic clearance (TAHBSO + Omentectomy + Peritoneal cytology)
***Staging operation (Primary laparotomy) (Standard)
1. TAHBSO (Total abdominal hysterectomy bilateral salpingo-oophorectomy)
+
2. Pelvic + Paraaortic lymphadenectomy
+
3. Omentectomy
+
4. Peritoneal washings
+
5. Staging laparotomy (peritoneum, pelvis, paraaortic gutters, omentum biopsy)
(Visual assessment of the upper abdomen, peritoneal surfaces, and large and small bowel mesentery and other abdominal organs, with biopsies of abnormal findings (UpToDate))
**Staging + **Treatment of Ovarian cancer
- Depends on Stage + Fitness + Histology of patients
- Early: Surgery +/- Chemo
- Late: Surgery + Chemo +/- Targeted
SpC OG
Stage 1: Confined to ovaries
Stage 2: Within pelvis
Stage 3: Abdomen / Retroperitoneal LN
Stage 4: Distal spread: Lung / Liver / Supraclavicular LN
Felix Lai:
- Staging: **Surgically staged, **FIGO staging (same as Endometrial cancer)
- Chemo: **Carboplatin + Paclitaxel
- Targeted therapy: Anti-angiogenesis e.g. Bevacizumab, PARP-inhibitor e.g. Olaparib, Niraparib (SpC Revision)
- Surgery:
Early stage:
1. **Staging operation (Primary laparotomy) (Standard)
1. TAHBSO (Total abdominal hysterectomy bilateral salpingo-oophorectomy)
+
2. Pelvic + Paraaortic lymphadenectomy
+
3. Omentectomy
+
4. Peritoneal washings
+
5. Staging laparotomy (peritoneum, pelvis, paraaortic gutters, omentum biopsy)
(Visual assessment of the upper abdomen, peritoneal surfaces, and large and small bowel mesentery and other abdominal organs, with biopsies of abnormal findings (UpToDate))
Late stage: **Debulking surgery / **Neoadjuvant + Debulking surgery
-
**Intraoperative frozen section
- Perform **unilateral salpingo-oophorectomy (USO) in young patients with fertility wish
- Malignant then proceed to standard operation
Prognosis in Ovarian cancer (SpC Revision)
Prognostic factors:
1. Stage
2. Residual tumour after operation
3. Histology
4. Age
5. Performance status
5-year survival:
- Stage 1: 80-90%
- Stage 2: 60-80%
- Stage 3: 40-60%
- Stage 4: 20%
Summary
- Uterine fibroid, Ovarian mass, Cancer are important DDx of pelvic mass
- History, P/E help to suggest a diagnosis
- Pelvic USG is commonly performed
- Management will depend on age, symptom, condition, wish of patient
(ROMA score (SpC OG) (X know))
ROMA vs RMI:
ROMA (Risk of ovarian malignancy algorithm):
- No USG features
- Additional tumour marker HE4
- Mathematic formula
- Classify into high / low risk
- Not standard practice (yet)
