Pelvic Mass Flashcards
what are some non-gynaecological causes of a pelvic mass
Constipation
Caecal carcinoma
Appendic abscess
Diverticular abscess
urinary retention
pelvic kidney
where can gynaecological pelvic masses come from
Uterus - body, cervix
Tubal (and para tubal)
Ovary
what are the causes of uterine pelvic mass
Fibroids
Pregnancy
Endometrial cancer (however usually presents early so pelvic mass unlikely)
Cervical cancer
what are uterine fibroids
Leiomyomas (benign smooth muscle tumours)
v common esp >40 years
what are the different types of fibroids
pedunculate - protrudes outside the muscle intracavitary - inside the uterus intramural - middle of muscle wall submucous -bulge into cavity subserous - under the serosa
how do uterine fibroids present
asymptomatic/incidental finding menorrhagia (V heavy periods) pelvic mass pain/tenderness 'pressure' symptoms
how do you investigate fibroids
Hb if heavy bleeding
US usually diagnostic
MRI for more precise localisation
how do you treat fibroids
expectant (leave it alone)
traditional hysterectomy if family complete
myomectomy
uterine artery embolisation
hysteropoc resection
what are causes of tubal swellings
Ectopic pregnancy
Hydrosalpinx (tube filled with fluid)
Pyosalpinx (tube filled with puss)
Paratubal cysts
causes of ovarian masses
tumours/neoplasm
-benign or malignant
non-tumours
- functional cysts
- endometriotic cysts (endometriosis on the ovary)
what is a functional cyst
cyst related to ovulation
- follicular cysts
- luteal cysts
usually resolve spontaneously
asymptomatic/incidental finding (my be mistral disturbance, bleeding, rupture and pain)
expectant management appropriate
what is an endometriotic cyst
endometriosis (endometrium in wrong place) causes endometrial deposits on the ovary
can cause blood filled cysts on ovaries (chocolate cysts)
how do endometriosic cysts present
severe dysmenorrhoea and premenstrual pain
dyspareunia (painful sex)
subfertility
tender mass with ‘nodularity’ and tenderness behind uterus
occasionally asymptomatic until large chocolate cyst which ruptures
where can primary ovarian tumours arise from
Surface epithelium
Germ Cells
Stroma
what primary ovarian tumours arise from the surface epithelium
serous mucinous endometrioid clear cell Brenner
what primary ovarian tumours arise from germ cells
benign cystic teratoma (dermoid cyst)
malignant germ cell tumours (v rare)
what primary ovarian tumours arise from stroma
fibroma
if theca/leydig cell it secretes androgens
if granuloma cell it secretes oestrogen
what do malignant germ cell tumours produce
HCG causing false positive pregnancy test of AFP
what do dermoid cysts produce
totipotential
produce teeth, sebaceous material, hair
thyroid tissue - thyrotoxicosis
what do granuloma cell tumours produce
oestrogen
leads to precocious puberty, post menopausal bleeding
what syndrome are fibromas related to
Meig’s syndrome - benign fibroma with pleural effusion and ascites
where do secondary (metastatic). ovarian tumours most commonly come from
breast
pancreas
stomach
GI primaries
how does ovarian cancer usually present
mass, swelling or pressure symptoms
early transperitoneal spread - deposits on all peritoneal surfaces
malignant ascites with protein exudate
more insidious symptoms
bloating heart burn weight loss 'pressure' symptoms eg. bladder change of bowel habit SOB/pleural effusion leg oedema or DVT
what genes can predispose to ovarian cancer
BRACA 1 & 2 (breast and ovarian)
HNPCC (Lynch syndrome- bowel, endometrial, ovarian and others)
what are some risk factors for ovarian cancer
increasing age
nulliparity
family history
(OCP is a protective factor)
how do you investigate a suspected ovarian cancer
history and exam
tumour markers
USS - better for imagineer nature of cyst
CT - good for assessing disease outwit ovarian
what tumour markers are measured in ovarian cancer
CA 125
Carcino-embryonic antigen (CEA )
when is CA125 raised
in 80% of ovarian cancers
normal level does not exclude cancer
what things can cause a moderate raise in CA125
endometriosis peritonitis/infection pregnancy pancreatitis ascites other malignancies
when is CEA (carcinoma-embryonic antigen) raised
moderately raised in ovarian cancer
especially in mucinous tumours
what is the main function of CEA tumour marker
excluded mets from GI tumour
how does ovarian cancer present on ultrasound scan
complex mass with solid cystic area
multi-lobulated
thick separations
associated ascites
bilateral disease
how do you calculate the risk of malignancy index for ovarian cancer and what do you do if its high
combine menopausal status with serum CA125 and US score
if elevated refer to gynaecological cancer team
how do you treat benign ovarian cysts
removal or drainage if benign
how do you treat malignant ovarian cysts
delbuluking surgery (removal of ovaries and uterus with removal/biopsy of momentum)
examination of all peritoneal surfaces
chemotherapy given pre-srugery
unlikely to cure
what symptoms to ask in a pelvic mass history
slow/fast growing pain pressure symptoms menstrual history bloating parity and fertility problems family history previous gynae history ovarian cancer symptoms
how do you describe a pelvic mass
size (cms or weeks gestation) consistency (soft, firm, craggy) surface (smooth, irregular) tenderness mobility relation to uterus pouch of Douglas
what investigations are done for a pelvic mass
Hb WCC/CRP Biochem esp serum albumin Tumour markers (CA125, CEA) USS MRI for fibroids/uterine mass CT for suspected ovarian Ca CT/US guided tissue biopsy
treatment option of endometriomas (endometrial cyst on ovary)
GnRH analogues
Oral contraceptive pill
if not surgery
what is Meig’s syndrome
Benign ovarian fibroma associated with ascites +/- pleural effusion
Treatment for germ cell tumours
fertility sparing treatment
unilateral salpingoophrectomy +/- chemotherapy
treatment options for endometrial fibroids
conservative
medical
-GnRH analogues, mirena coil, progestins
surgical
-lapparoscopic myomectomy, subtotal hysterectomy or total hystorectomy
