Pelvic Mass

Question 1

What are the potential non-gynaecological causes of a pelvic mass?

Answer 1

GI:

• Constipation!
• Caecal carcinoma
• Appendix/Diverticular abscess

Bladder/Urological:
- Urinary retention

Other
Retroperitoneal tumour
Ascitis due to liver disease

Question 2

What are the gynaecological causes of a pelvic mass?

Answer 2

• PREGNANCY

UTERINE
Benign or Malignant mass

ADNEXAL MASSES
Benign or Malignant mass

Question 3

How should a pelvic mass be assessed?

Answer 3

• Symptoms
• Abdominal examination
• Bimanual/pelvic examination
• Blood Tests
• USS (Transabdominal and transvaginal)
• Check past Gynae Hx and FHx (Lynch, BRCA, HLRCC*)
• URINE TEST (pregnancy/ectopic)

Question 4

What symptoms and features should be asked about if suspecting a pelvic mass?

Answer 4

Slow/fast growing mass?
pain?
pressure symptoms - frequency, urgency etc
systemic symptoms?

Question 5

What signs should you look for on examination of the abdomen?

Answer 5

Masses
tenderness
shifting dullness/fluid thrill (ascites)
scars

Question 6

What signs should you look for on bimanual palpation of the pelvis?

Answer 6

cervical excitation
mass movement
adnexal tenderness

Question 7

What other tumour markers should be tested alongside CA125?

Answer 7

AFP, BetaHCG

check for non-epithelial ovarian cancers

Question 8

What factors contribute to a patients Risk of Malignancy Index (RMI)?

Answer 8

Menopausal Status (1 point if Pre, 3 if Post)

US Features - multiloculated, solid, ascitis, mets
>1 feature = 3 points

Serum CA125 level

(Multiply 3 together for RMI)

Question 9

What does an RMI >200 indicate?

Answer 9

3 in 4 chance of malignancy

Question 10

What further investigations can be done if there is a high suspicion of malignancy?

Answer 10

CT
MRI
Hysteroscopy
Diagnostic laparoscopy

Question 11

What condition is characterised by a benign ovarian fibroma associated with ascites +/- pleural effusion (usually on RHS not bilateral)?

Answer 11

Meig’s syndrome

do not assume this is stage 4 ovarian cancer

Question 12

Functional cysts are usually associated with ovulation and therefore resolve on their own. TRUE/FALSE?

Answer 12

TRUE

Question 13

How can benign ovarian tumours be treated?

Answer 13

• Conservative
• Medical – (only in endometriomas)
  => GnRH analogues, Oral Contraceptive Pill
• Surgical – Laparoscopic/ Laparotomy
  OVARIAN CYSTECTOMY (just remove cyst/lesion)
  UNILATERAL OOPHERECTOMY (maintains fertility)
  BILATERAL OOPHERECTOMY
  PELVIC CLEARANCE

Question 14

How does ovarian cancer usually spread into the peritoneum?

Answer 14

• trans-coelomic
• Deposits on multiple peritoneal surfaces
• Omental disease/infiltration
• Malignant ascites with protein exudate

Question 15

What can raise CA125 levels apart from ovarian malignancy?

Answer 15

• Endometriosis
• Peritonitis/infection
• pregnancy
• Pancreatitis
• Ascites

Question 16

What is the aim of surgery in ovarian tumours?

Answer 16

Total macroscopic debulking

Complete cytoreduction offers best improvement in survival.

Question 17

Describe the principles of ovarian surgery in early disease.

Answer 17

• midline incision to allow palpation of peritoneal surface
• Assessment of peritoneal cytology, hysterectomy, removal of ovaries and fallopian tubes
• infracolic omentectomy should be performed.
• Capsular rupture should be avoided.

Question 18

What is meant by ‘Supraradical’ surgery for ovarian cancer?

Answer 18

• removal of supracolic omentum
• peritoneal stripping or ablation
• removal of the spleen
  +/- small or large bowel resection

=> carries high mortality/morbidity
=> only offer to suitable women

Question 19

What are the treatment options for fibroids?

Answer 19

Conservative

Medical – GnRH analogues, Mirena, Progestins

Surgical – Laparoscopic/Laparotomy

• Myomectomy (Hysteroscopic or abdominal)
• Subtotal Hysterectomy
• Total hysterectomy