Pelvic Mass Flashcards
When is shifting dullness useful?
- with minimal fluid
500ml
Situations when CA125 is elevated?
- endometriosis
- pleural effusion
- uterine fibroids
- ovarian cancer
- pancreatitis
- ASCITES of any cause; liver cirrhosis
- PID
- peritonitis
When is CA125 produced?
- the mesothelial cell on the ovarian surface/ pleural surface/ peritoneum are stimulate
What demographic gr. is predisposed to functional cysts?
- pre-menopausal women
SYmptoms of endometriosis ?
- period-related GI symptoms (painful BOWEL movements)
- period-related urinary symptoms (BLOOD in urine)
- severe DYSMENORHEA
- PMENSTRUAL pain
- dyspareunia and pain AFTER sex
– infertility a.w with one of the above
What is a dermoid cyst?
- d.t totipotent cells= can differentiate into any cells
can have thyrotocxicosis /teeth/
How to manage ovarian benign tumors?
- do not treat unless there are symptoms
- how to preserve fertility
MEDICAL: GnRH analogues, OCP
SURGERY: laparotomy/ laparoscopic
cystecomty
oopherectomy —BCRCA (uni-/b.l)
pelvic clearance
Symptoms of torsion?
Sign seen on transvaginal ultrasound with Doppler flow?
- 20-40 y.o pt with ACUTE abdomen and relevant hx
- SYNCOPAL attacks
- N.V
- lack of blood flow to the ovary
First line management of raised CA125?
USS
What are appendicile tumors a.w?
- ovarian tumors
Recent stroke should be a deterrent for operations? True?
YES
- HIGH morbidity for post-op in those with RECENT CVA
Teenager with LARGE ovarian mass? Likely to be _________
- germ cell tumors
teenager with LARGE malignant mass- REMOVE IT
Common ovarian tumors in post-menopausal women?
- serosal tumors
High-grade
How to manage ovarian cancer in young women?
- FERTILITY SPARING for young women (unilateral salpingoopherectomy +/- chemo)
What is important in early disease?
- conduct a thorough explorative laporotomy (have a feel of the lnear by organs)
What is borderline ovarian tumors?
- less aggressive
can spread
-less invasive (10-20 years)
BOWEL causes of pelvic masses
- constipation
- caecal carcinoma
- appendix abscess
- diverticular abscess
Urological causes of pelvic mass?
- urinary retention
- benign/ malignant growth in bladder
What blood tests should be done for pelvic masses?
- FBC
- U&Es
- LFTs
- RFTs
- CA125
- LDH
- AFP
- HCG
What is RMI?
- aka Risk of Malignancy Index
- score is given based on:
1. menopausal status
2. Ultrasound ovarian features
3. actual Ca125
What does it mean to have an RMI of > 200 ?
- 3 out of 4 pts WILL have OC
If RMI is between 30-200?
0.2% chance
What FURTHER INVESTIGATIONS can be performed after an USS is done for a pelvic mass?
- CT
- MRI
- Hysteroscopy
- Diagnostic laparoscopy
What does the CT scan pick up on?
- useful for retroperitoneal structures (LYMPH nodes)
- useful as a BIRD’S eye view of ALL organs in the pelvis and abdomen
When is the MRI used?
- for FINER details of SOFT tissue masses
can identify components of cyst, endometrioma, PCOS, extent of cancer invasion
Name a germ cell tumor.
benign cystic teratoma
dermoid cyst
Name benign ovarian tumors arising from the STROMA.
FIBROMA
beware of MEIG’s Syndrome
What cells are part of the stroma and how may that affect the hormones released?
- Granulosa cell= secretes Estrogen
- Theca/ leydig cells= secrete androgens
Name primary benign ovarian tumors arising from the surface epithelium.
- serous
- mucinous
- endometroid
- brenner
- clear cell
What is Meig’s Syndrome?
- involves a benign ovarian fibroma a.w ASCITES +/- pleural effusion
What is MEIG $ often confused with?
- a benign ovarian fibroma may be confused with stage 4 Ovarian Cancer
What is the prognosis of functional cysts?
- <5cm
- incidental finding
- resolves spontaneously
What are functional cysts a.w?
ovulation!
Name 2 functional cysts.
- follicular cysts
- luteal cysts
What may functional cysts cause?
- menstrual dist
urbance - may BLEED/ rupture and cause PAIN
How to manage functional cysts?
- Watchful waiting
2. surgery (if potentially cancerous/large/persistent)
What are the signs of endometriotic cysts?
- severe dysmenorrhea
- premenstrual pain
- Dyspareunia
- —occasionally asymptomatic, until its a LARGE chocolate cyst and it ruptures
What are the clinical findings of the endometriotic cysts?
subfertility
- tender mass with NODULARITY and tenderness behind the uterus
- “boggy uterus”
What maybe seen in a dermoid cyst?
- teeth, sebacious material, hair, thyroid tissue
Which surgeries may be performed?
- ovarian cystectomy
- unilateral/B.L oopherectomy
- pelvic clearance
When may surgeries be performed?
- in acute presentation
- –torsion/rupture/ Hemorrhage
Describe the ways in whcih ovarian cancer may present as.
- heartburn
- early SATIETY
- wgt LOSS
- BLOATING
- pressure symptoms (freq. and urgency)
- SOB/ pleural eff.
- leg edema (DVT)
Where ovarian Ca said to spread to?
- early transperitoneal spread
- deposits on MULTIPLE peritoneal surfaces
- —OMENTAL infiltration
- —> MALIGNANT ascites with protein exudates
How is one dx with ovarian cancer?
- non-gynaecologically
- —d.t insidious path
How to manage germ cell tumors?
- Fertility sparing, unilateral salpingoopherectomy +/- chemotherapy
What is the aim of surgery?
- total macroscopic DEBULKING of tumor
v. impotant for prognosis
What is meant by staging via midline incisions in ovarian cancer?
—-done through MIDLINE incisions (allows palpation of ALL peritoneal surface)
What is the AIM of staging via midline incision?
- to exclude disease involving the LIVER, spleen, peritoneum, retroperitoneal nodes, appendix, diaphragm
Define cytoreduction.
- to remove AS many cancerous cells as possible
- –optimal cytoreduction: when there is no VISIBLE disease left behind
What is given PRIOR to the sugrical procedure?
- NEOADJUVANT chemotherapy (to shrink the cancer)
What is supraradical surgery for ovarian cancer?
- removal of supracolic omentum, peritoneal ablation, removal of the SPLEEN +/- large/ small bowel resection
Name sources IIary ovarian tumors.
- BREAST, STOMACH, PANCREAS, GI primaries
What is a kruckenbrug tumor?
- metastasis from the STOMACH
- —-characteristic SIGNET ring on histology
What are borderline ovarian tumors?
- less aggressive
- can spread transcoelomic
- —-risk of recurrence (5-10% in the long run)
Most common symptom of fibroids?
- Abnormal Uterine Bleeding
- —presents with PRESSURE symptoms
Which group of people are leiomyomas seen in?
- ladies >40y.o
- –very COMMON
What pressure symptoms may be seen with Fibroids?
- dyspareunia
- pelvic pain
- constipation
- urinary symptoms
What surgical rx can be done for fibroids?
- laproscopic/ laparotomy
- myomectomy
- subtotal hysterectomy
- total hysterectomy
What medical interventions for fibroids?
- GnRh analogues
- Mirena
- Progestins
