Pelvic mass Flashcards
What staging criteria is used for gynaecological tumours?
FIGO staging
FIGO staging is based on clinical staging meaning careful clinical examination is carried out before definitive therapy. True/false?
True
With the exception of the ovary which includes surgical exploration
Anatomical structures of the pelvis?
Anterior compartment - bladder
Middle compartment - uterus
Posterior compartment - bowel
Lateral compartment - adnexae (region adjoining the uterus that contains the ovary and fallopian tube)
Bleeding = what gynaecological cancer?
Uterine (most common is endometrial)
Pain = what gynaecological cancer?
Ovarian
Pressure symptoms = what gynaecological cancers?
Uterine or ovarian
Long term symptoms lasting months/years usually indicates malignancy. True/false?
False
Short term symptoms lasting weeks are usually associated with malignancy.
Long term symptoms lasting months/years usually associated with being benign.
What is a bimanual pelvic examination?
bimanual pelvic examination (BPE) is used to check a woman’s internal pelvic organs.
The health care provider inserts two fingers into the vagina and then places pressure with the other hand to the lower part of the belly.
Uterine cancer features?
Symptom: bleeding
Bimanual examination: midline, lobulated mass, moves with cervical motion and non-tender
Ovarian cancer features?
Symptom: pain
Bimanual examination: lateral, occupying fornices, no movement with cervical motion and can be tender
Features of a benign mass?
Appearance over months/years
Smooth mass, mobile (moveable)
Features of a malignant mass?
Acute appearance (over few weeks)
Cachexia (wasting of body), ascites, craggy mass (uneven mass) and not mobile (not moveable)
Acute masses present with what symptoms and features?
Doubling pain with nausea
Bimanual examination: tender abdomen, rebound, guarding (tensing of abdominal muscles to guard inflamed organs) and exquisite cervical excitation
What is CA-125?
A tumour marker that can be used to detect ovarian cancer if shown in high levels in the blood.
Can CA-125 be high without cancer?
Yes
In pre-menopausal women, what benign conditions can cause raised CA-125?
diverticulitis, endometriosis, liver cirrhosis, pregnancy, and uterine fibroids
Other tumour markers that can be used in women < 40 years old?
Alpha foeto-protein - raised in embryonal carcinoma
HCG - raised in choriocarcinoma
LDH - raised in dysgerminoma
What is the RMI in gynaecology?
Risk of malignancy (RMI) in ovarian tumours
combines 3 pre-surgical features: serum CA125 (CA125), menopausal status (M) and ultrasound score (U).
The RMI is a product of the ultrasound scan score, the menopausal status and the serum CA125 level (IU/ml). RMI = U x M x CA125.
RMI ranges?
RMI score greater than 200: high risk, with referral to specialist gynaecological cancer service, and staging CT advised
RMI score 25-200: intermediate risk, with MRI recommended to further evaluate the lesion
RMI score less than 25: low risk, with repeat clinical assessment advised, with MRI if ultrasound features are borderline 1
What is included in the ultrasound segment of the RMI score?
Ultrasound result is scored 1 point for each of the following characteristics on US:
multilocular cysts (cysts with multiple lines of separation), solid areas, metastases, ascites and bilateral lesions.
RMI = ultrasound score x menopausal status x ca-125 value (U/ml). True/false?
True
Further radiology that can be used for investigation of ovarian cancer?
CT - to assess spread of cancer and operability
MRI - to characterise the ovarian cyst in a better way
Ovarian sex cord-stroma masses?
Granulosa cell
Thecoma
Fibroma
Sertoli cell
Sertoli-Leydig
Steroid
Ovarian germ cell masses?
Dysgerminoma
Yolk sac
Embryonal carcinoma
Choriocarcinoma
Teratoma
Ovarian surface epithelium stroma masses?
Serous
Mucinous
Endometroid
Clear cell
Transitional cell
What are functional (ovarian) cysts and features?
a fluid-filled sac within the ovary
Related to ovulation
Rarely more than 5cm diameter
Usually resolve spontaneously
May cause menstrual disturbance
Consider as a differential in acute abdomen as it may bleed or rupture
Often asymptomatic/incidental
Functional cysts are basically enlarged Graafian follicles or corpeus luteum cysts. true/false?
True
What are endometriotic cysts?
Endometriosis cysts ( endometrioma ) occur when sacs filled with endometrial-like tissue form in the ovaries.
Aka “chocolate cysts”
Difference between endometriosis and endometriotic cysts?
Endometriosis is a condition in which the endometrium is found elsewhere than in the lining of the uterus.
Endometrioma (endometriotic cyst) is an ovarian cyst caused by endometriosis. Nicknamed “chocolate cyst”
Features of endometriotic cysts?
Presents with:
Severe dysmenorrhea/premenstrual pain
Dyspareunia
Associated with sub fertility
Occasionally asymptomatic
Acute abdomen if ruptures
Examination:
Tender mass with modularity
Tenderness behind uterus
What is a dermoid cyst?
A type of tumour that contains a cyst filled with tissues that are normally found in the outer layers of the skin, including sweat and oil glands.
These may also contain elements of hair and teeth.
What is taken into consideration when treating benign ovarian tumours?
Symptoms, fertility and menopausal status
Treatment options for benign ovarian tumours?
CONSERVATIVE
MEDICAL –GnRH analogues, OCP. Can be used for ovarian suppression.
SURGICAL – LAPAROSCOPIC/LAPAROTOMY
OVARIAN CYSTECTOMY
UNILATERAL OOPHERECTOMY
BILATERAL OOPHERECTOMY
PELVIC CLEARANCE
What are borderline ovarian tumours?
Borderline ovarian tumors (BOTs) are abnormal cells or growths that develop in the tissue encapsulating an ovary.
While BOTs are not cancerous, they have the potential to develop into cancer. So removal would be advised
Features of borderline ovarian tumours?
Growth much more controlled than cancer
Unlikely to spread
Even if spread – as implant rather than deeply invasive
Usually a better prognosis compared to ovarian cancer
Young women – unilateral cystectomy/oopherectomy with close follow up
Postmenopausal women – pelvic clearance
What is pelvic clearance?
a major surgical procedure to treat cancer that has spread through the pelvis by removing multiple organs.
Typically, this means removing the lower bowel or rectum and the prostate or vagina. The bladder may also be removed.
How many types of fibroid (leiomyomas) are there?
3
What are the 3 types of fibroids?
Subserosal fibroids: These are the most common type. They grow on the outside of the uterus.
Intramural fibroids: These grow inside the muscular wall of the uterus.
Submucosal fibroids: These grow into the open space inside the uterus.
Submucosal fibroids are usually benign. true/false?
True
SMOOTH MUSCLE TUMOURS
USUALLY, BENIGN
0.5% MALIGNANCY RISK
Treatment options for fibroids?
CONSERVATIVE
MEDICAL MANAGEMENT – HORMONAL Mx for bleeding, GnRH agonists
Surgical management – myomectomy (surgical fibroid removal), hysterectomy (surgical removal of uterus)
Interventional radiology – UTERINE ARTERY EMBOLISATION
Examples of GnRH agonists?
Buserelin
Gonadorelin
Goserelin
Histrelin
Leuprorelin
Nafarelin
Triptorelin
Appearance of uterine fibroids on ultrasound?
Concentritic, solid, hypoechoic (dark grey) masses.
Fibroids are a benign growth of the myometrium
Benign ovarian cyst appearance on ultrasound?
Uniform, smooth rounded dark fluid-filled bubbles on ultrasound.
If ovarian cyst > 5cm and symptomatic there is a chance it would become more serious and should be removed via laparoscopy
Malignant ovarian cancer on ultrasound?
Papillary projections on ultrasound. Diagnostic of epithelial stromal tumour.
Wall projections that are at least 3mm in height perpendicular to wall.
More than 4 projections or projections involving more than 50% of internal cyst wall point to malignancy
