Pelvic Mass Flashcards
What are the non-gynaecological causes of a pelvic mass?
Bowel- constipation, caecal carcinoma, appendix abscess, diverticular abscess
Bladder/urological- urinary retention, pelvic kidney
Other- retroperitoneal tumour
What are the gynaecological locations of a pelvic mass?
Uterine- body, cervix
Tubal (& para-tubal)
Ovarian
What are the gynaecological causes of a uterine mass?
Pregnancy
Commonest fibroids
Endometrial cancer- early presentation (PMB), therefore mass unusual
Cervical cancer- also late mass presentation +- renal failure/bleeding/pain
Describe uterine fibroids
Very common, especially >40yo
Usually few cm, but may be bigger + multiple
What are some possible locations/classes of fibroids?
Pedunculated Intracavitary Intramural Subserous Submucous
How may uterine fibroids present?
May be asymptomatic/incidental finding Menhorrhagia Pelvic mass Pain/tenderness (Only disproportionate if red generation e.g. pregnancy, menopause) Pressure symptoms
What Ix should be carried out in suspected fibroids?
Hb if heavy bleeding
US usually diagnostic- smooth echogenic mass (often multiple)
MRI for more precise localisation
How are fibroids treated?
Expectant if asymptomatic
Otherwise hysterectomy if family complete
Alternatives- myomectomy, uterine artery embolisation, hysteroscopic resection
What may cause tubal swellings?
Ectopic pregnancy- may detect adnexal mass on US
Hydrosalpinx- often longstanding/incidental
Pyosalpinx- acute/inflammatory
Paratubal cysts (small/incidental)
Describe functional ovarian cysts
Related to ovulation- follicular and luteal cysts
Rarely >5cm diameter
Usually resolve spontaneously
Often asymptomatic/incidental
Expectant management appropriate
May be menstrual disturbance, bleed, rupture and cause pain
What can cause endometriotic cysts?
Endometriosis
What are endometriotic cysts associated with?
Severe dysmenhorrhoea
Premenstrual pain
Dyspareunia
Subfertility
Describe an endometriotic cyst(s)
Typically tender mass with nodularity and tenderness behind uterus
Occasional asymptomatic until large chocolate cyst, may rupture
Describe primary ovarian tumours arising from surface epithelium
Serous, mucinous, endometrioid, clear cell, Brenner
If benign cystadenoma, malignant cystadenocarcinoma
Describe primary ovarian tumours arising from germ cells
Benign cystic teratoma (dermoid cyst, common)
Malignant germ cell tumours (rare)
Describe primary ovarian tumours arising from stroma
If from granulosa cell may secrete oestrogens
If theca/leydig cell may secrete androgens
Also fibroma (beware Meig’s syndrome)
What are rare stigmata of dermoid ovarian cyst?
Totipotential
Teeth, sebaceous material, hair
Thyroid tissue-> thyrotoxicosis
What are rare stigmata of granulosa cell ovarian tumours?
May produce oestrogens leading to precocious puberty, PMB
What are rare stigmata of thecal tumours?
May produce androgens, leading to hirsutism and virilisation
What are rare stigmata of ovarian fibromas?
Meig’s syndrome benign fibroma but pleural effusion
Where do 2’ ovarian tumours commonly come from?
Breast
Pancreas
Stomach
GIT
How will ovarian cancer usually present?
May be mass, swelling, pressure symptoms
But if early transperitoneal spread- deposits on all peritoneal surfaces, omental disease/infiltration/malignant ascites with protein exudate
What are the clinical features of ovarian cancer with early transperitoneal spread?
Deposits on all peritoneal surfaces
Omental disease/infiltration
Malignant ascites with protein exudate
Usually more insidious symptoms
How can the presentation of ovarian cancer vary?
Heartburn/indigestion Early satiety Weight loss/anorexia. Bloating ‘Pressure’ symptoms (esp bladder) Change of bowel habit SOB/ Pleural effusion Leg oedema or DVT
What genes lead to a predisposition of breast and ovarian cancer?
BRCA1 & 2
What % of ovarian cancers have a genetic basis?
5%
What does HNPCC predispose to?
Bowel, endometrial, ovarian cancer and others
What are the RFs for ovarian cancer?
Age (old>young)
Nulliparity
FHx
(OCP protective)
What tumour markers should be looked for in suspected ovarian cancer?
CA 125
Carcino-embryonic antigen CEA
What imaging should be used Ix of suspected ovarian cancer?
US better for nature of cyst
CT better for assessing disease outwith ovary, especially omental and peritoneal disease, and LNs
In how many ovarian cancers is CA 125 raised?
~80%
What is a moderate raise of CA 125 associated with?
Endometriosis Peritonitis/infection pregnancy Pancreatitis Ascites from any cause e.g. liver disease Other malignancies gynae/non gynae
In what specific type of ovarian cancer is CEA often moderately elevated in?
Mucinous tumours
What is the main function of CEA testing?
Exclude mets from GI primary
What US findings should make you suspicious of ovarian cancer?
Complex mass with solid & cystic area Multi-loculated Thick septations Associated ascites Bilateral disease
What is the risk of malignancy index?
Menopausal status x CA 125 x US score
How are ovarian cysts/mass treated?
Removal or drainage if likely benign
Other ovary/uterus removal with removal/biopsy of omentum
Debulking of tumour and inspection of all peritoneal surfaces
Chemo pre/post surgery
What cyst ‘accidents’ can present as an emergency?
Rupture
Haemorrhage (into cyst)
Torsion
How may fibroid degeneration present as an emergency with acute abdomen?
Usually red degeneration
Compromised blood supply
Seen in pregnancy, peri-menopause
What Ix should be carried out in pelvic mass?
Hb WCC/CRP if suspect inflammatory mass Biochemistry esp serum albumin Tumour markers (CA125, CEA, HCG,AFP) (CXR) Ultrasound TA/TV
What specific imaging could be carried out for fibroids/uterine mass?
MRI
What specific imaging could be carried out for suspected ovarian cancer?
CT
Is tissue aspiration for cytology helpful in pelvic mass investigation?
No
What imaging could be used in a guided tissue biopsy for pelvic mass?
CT/US
