Pelvic mass Flashcards by Adam Iqbal

What staging criteria is used for gynaecological tumours?

FIGO staging

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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

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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)

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Bleeding = what gynaecological cancer?

Uterine (most common is endometrial)

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Pain = what gynaecological cancer?

Ovarian

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Pressure symptoms = what gynaecological cancers?

Uterine or ovarian

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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.

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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.

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Uterine cancer features?

Symptom: bleeding

Bimanual examination: midline, lobulated mass, moves with cervical motion and non-tender

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Ovarian cancer features?

Symptom: pain

Bimanual examination: lateral, occupying fornices, no movement with cervical motion and can be tender

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Features of a benign mass?

Appearance over months/years

Smooth mass, mobile (moveable)

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Features of a malignant mass?

Acute appearance (over few weeks)

Cachexia (wasting of body), ascites, craggy mass (uneven mass) and not mobile (not moveable)

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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

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What is CA-125?

A tumour marker that can be used to detect ovarian cancer if shown in high levels in the blood.

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Can CA-125 be high without cancer?

Yes

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In pre-menopausal women, what benign conditions can cause raised CA-125?

diverticulitis, endometriosis, liver cirrhosis, pregnancy, and uterine fibroids

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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

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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?

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