Pelvic Mass Flashcards
What are common uterine masses?
Pregnancy
Fibroids
Endometrial cancer (presents early with PMB)
Cervical cancer
What is a fibroid?
Leiomyoma
Usually a few cm but can be much bigger and multiple
What are the different forms of fibroids?
Pedunculated Intramural Submucosal Subserosal Intracavitary
What is the presentation of a uterine fibroid?
Asymptomatic or incidental finding Menorrhagia Pelvic mass Pain/ tenderness Pressure symptoms
When is the pain/ tenderness of uterine fibroids disproportionate?
Red degeneration in pregnancy or menopause
What investigation should be performed for suspected fibroids?
Hb if heavy bleeding
USS usually diagnostic (smooth echogenic mass often multiple)
MRI for more precise localisation
What is the treatment for fibroids?
Expectant if asymptomatic Myomectomy Uterine artery embolisation Hysteroscopic resection Hysterectomy if family complete
What are the different causes of tubal swellings?
Ectopic pregnancy (emergency, adnexal mass on USS) Hydrosalpinx (longstanding) Pyosalpinx (acute/ inflammatory) Paratubal cyst (small and incidental)
What are the causes of an ovarian mass?
Tumours/ neoplastic; benign or malignant
Not tumours; functional cysts, endometriotic cysts
What are the two types of functional cysts?
Follicular cysts
Luteal cysts
What size are functional cysts?
<5cm in diameter
Will functional cysts resolve spontaneously?
Yes; often asymptomatic/ incidental finding
What symptoms can functional cysts present with?
Menstrual disturbance
Can bleed/ rupture and cause pain
What is endometriosis?
Endometrial glands and stroma in the wrong place
What will endometriotic cysts look like?
Endometriomas
Chocolate cysts
What is endometriosis associated with?
Severe dysmenorrhoea
Pre-menstrual pain
Dyspareunia
Subfertility
Where are endometriotic cysts typically found?
Tender mass with nodularity behind uterus
What are the primary ovarian tumours that arise from the surface epithelium?
Serous Mucinous Endometrioid Clear cell Brenner
What are the primary ovarian tumours that arise from the germ cells?
Benign cystic teratoma
Malignant germ cell tumour
What are the primary ovarian tumours that arise from the stroma?
Granulosa cell may secrete oestrogen
Theca/ leydig cell may secrete androgens
Fibroma = meig’s syndrome
How can malignant germ cell tumours present?
hCG (false positive IPT) or AFP
How can dermoid cysts present?
Totipotential
Teeth, sebaceous material, hair
Thyroid tissue -> thyrotoxicosis
How can granulosa cell tumours present?
Oestrogens
Precocious puberty or PMB
How can thecal tumours present?
Androgens
Hirsutism
Virilisation
How can meig’s syndrome present?
Fibroma
Ascites
Right sided pleural effusion
Is the ovary a common site for metastatic spread of disease?
Yes
What primary tumours will commonly spread to the ovaries?
Breast
Pancreas
Stomach
GI
How will ovarian cancer present?
Mass Swelling Pressure Early satiety Wt loss Bloating Change of bowel habit SOB/ pleural effusion Leg oedema/ DVT Early transperitoneal spread; deposits on all peritoneal surfaces, omental disease, malignant ascites with protein exudate Insidious symptoms
What genetic syndromes are assoc with ovarian cancer?
BRCA 1 and 2 (breast and ovarian) Lynch syndrome (colorectal, endometrial, ovarian)
What are risk factors for ovarian cancer?
Increasing age
Nulliparity
Family history
OCP is PROTECTIVE
What are the ix for suspected ovarian ca?
History and exam
Tumour markers; ca-125 and CEA
Imaging; USS, CT (omental and peritoneal disease, lymph nodes)
What can cause moderate elevation of Ca-125?
Endometriosis Peritonitis/ infection Pregnancy Pancreatitis Ascites from other causes Other malignancies gynae/ non gynae
What is the main function of doing CEA in ovarian cancer?
Exclude mets from GI primary
Raised esp in mucinous tumours
What are suspicious USS findings for ovarian cancer?
Complex mass with solid and cystic area Multi-loculated Thick septations Assoc ascites Bilateral disease
How is the RMI calculated?
Menopausal status x serum ca 125 x USS score
How is an ovarian cyst treated?
Removal or drainage if likely benign
What is the surgical treatment of an ovarian tumour?
Midline laparotomy to allow thorough assessment of the abdomen and pelvis; a total abdominal hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy; biopsies of any peritoneal deposits; random biopsies of the pelvic and abdominal peritoneum; and retroperitoneal lymph node assessment
When is chemo given in ovarian cancer?
Can be neo adjuvant or adjuvant
Platinum based
What history is important to take in a pelvic mass presentation?
Speed of onset/ duration of symptoms Mass/ swelling/ bloating Pressure symptoms (bladder or bowel) Pain (with periods, between, post coital) Menstrual hx (heaviness, cycle) Cervical smear history Parity and fertility problems Family history Previous gynae problem
What are the acute presentations of a pelvic mass?
Cyst accident; rupture, haemorrhage, torsion
Fibroid degeneration; red, compromised blood supply
How is ascites examined for?
Shifting dullness
Fluid thrill
How should the pelvic mass be described?
Size; cm or weeks gestation Consistency; soft, firm, hard, craggy, indurated, boggy, fluctuant Surface; smooth, irregular Tenderness Mobility Relation to uterus Pouch of douglas
When is an MRI indicated in work up of a pelvic mass?
Fibroids or uterine mass
When is a CT indicated in the work up for a pelvic mass?
Suspected ovarian ca
