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
