Pelvic Mass Flashcards
what are non gynaecological causes of a mass in the pelvis
- bowel: constipation, caecal carcinoma, appendix abscess, diverticular abscess
- bladder/ urological: urinary retention
- other: retroperitoneal tumour, ascites (non gynae origin)
what are the three categories of gynae pelvic masses
pregnancy
uterine (benign and malignant)
adnexal (benign and malignant)
what are the causes of a uterine mass
pregnancy
fibroids- commonest
endometrial cancer (usually presents early as PMB so mass unlikely)
cervical cancer
(would be late presentation so +/- renal failure/ bleeding/ pain)
what are uterine fibroids
leiomyomas- benign smooth muscle tumours
usually a few cm but can be bigger and multiple
are uterine fibroid common
yes (esp >40s)
what are the types of uterine fibroids
pedunculated intracavitary intramural submucous subserous
what is the presentation of uterine fibroids
may be asymptomatic/ incidental finding menorrhagia pelvic mass pain/ tenderness pressure symptoms
what investigations 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
nothing if asymptomatic hysterectomy if family complete or: -myomectomy -uterine artery embolisation -hysteroscopic resection
what are the causes of tubal swelling
ectopic pregnancy
hydrosalpinx (often longstanding/ incidental)
pyosalpinx (acute/ inflammatory)
paratubal cysts (embryological remnants, usually small and incidental)
is an ectopic pregnany an emergency
yes
what are the causes of an ovarian mass
tumours - benign or malignant
not tumours- functional cysts, endometriotic cysts
what are functional cysts
related to ovulation- follicular or luteal cysts
rarely >5cm, usually resolve spontaneously
often asymptomatic/ incidental finding
expectant management
can have menstrual disturbance/ bleed/ rupture and cause pain
what are endometriotic cysts
when endometriosis results in cblood filled (chocolate) cysts on ovaries (endometriomas)
how do endometriotic cysts present
Typically associated with severe dysmenhorrhoea, and premenstrual pain.
Typically associated with dyspareunia
Often associated with subfertility
Typically tender mass with ‘nodularity’ and tenderness behind uterus.
Occasionally asymptomatic until large chocolate cyst, which may rupture.
what are the types of primary ovarian tumours
arising from surface epithelium:
- serous
- mucinous
- endometrioid
- clear cell
- brenner
arising from germ cells:
- benign cystic teratoma (dermoid cyst, common)
- malignant germ cell tumours (VV rare)
- malignant cystic teratoma
- dysgerminoma (usually malignant)
arising from stroma:
- if granula cell may secrete oestrogen
- if theca/ leydig cell may secrete androgens
- fibroma
what is meigs syndrome
triad of ascites, pleural effusion and benign ovarian fibroma
what might malignant germ cell ovarian tumours produce
HCG (false pos IPT) or AFP
what happens if a dermoid cyst produced thyroid tissue
can cause thyrotoxicosis
what can a dermoid cysts form
Totipotential e.g.
Teeth, sebaceous material, hair
what can granulosa cell tumour secretions cause
May produce oestrogens
–> precocious puberty, PMB
what can thecal cell tumour secretions cause
produce androgens
–> hirsutism —> virilisation
what cancers spread to the ovaries
breast
pancreas
stomach
GI primaries
how can dermoid cysts be diagnosed on imaging
contain fat- no fat in ovaries so if see this= germ cell tumour
also might contain calcification= teeth
what are the features of ovarian cancers spreading
early tranperitoneal spread(trans-coelomic)
-Deposits on all peritoneal surfaces
-Omental disease/infiltration
=Malignant ascites with protein exudate
how do ovarian cancers present
May be mass, swelling, pressure symptoms. Usually more insidious symptoms: Heartburn/indigestion Early satiety Weight loss/anorexia. Bloating ‘Pressure’ symptoms (esp bladder) Change of bowel habit SOB/ Pleural effusion Leg oedema or DVT (generalised oedema if low albumin) N.B May not be a pelvic mass.
how many ovarian cancers have genetic cause, and what are they
5% BRCA1 & 2 Breast & ovarian Ca HNPCC (Lynch syndrome) Bowel, endometrial, ovarian ca + many others
what are the risk factors for ovarian cancer
Increasing age
Nulliparity
Family history
(OCP protective against it)
what Ix for suspected ovarian cancer
Hx and exam Ca125 carcino-embryonic antigen CEA imaging: -USS -CT (to assess disease outwith ovary: omental disease, peritoneal disease, lymph involvement)
what else can cause increased Ca125
Endometriosis Peritonitis/infection pregnancy Pancreatitis Ascites from any cause.e.g. liver disease Other malignancies gynae/non gynae.
how sensitive is Ca125
Raised in ≈80% ovarian cancers.
Normal level does not exclude cancer
what is CEA (carcinoembryonic antigen)
May be moderately elevated in ovarian Ca
Esp mucinous tumours
Main function = exclude mets from GI primary.
what USS findings are suspicious of ovarian Cancer
Complex mass with solid & cystic area. Multi-loculated Thick septations Associated ascites Bilateral disease.
what does the risk of malignancy index consider
menopause status (post higher risk= 3, pre scores 1)
x
serum Ca125 (absolute level)
x
USS score (multiloculated, solid areas, bilaterality, ascites, mets= none 1, 1 feature 1, >1 scores 3)
how is an ovarian cyst/ mass treated
Removal or drainage if likely benign
Otherwise removal of ovaries and uterus with removal/biopsy of omentum, ‘debulking’ of tumour and complete examination/inspection of all peritoneal surfaces.
Chemotherapy may be given pre-surgery or after surgery
how likely is ovarian cancer to be cured
unlikely unless confined to ovary at presentation
what questions should you include in a pelvic mass history
Speed of onset/duration of all symptoms
Mass/swelling/bloatedness
Pressure symptoms (bladder/bowel)
Pain (with periods/between periods/dyspareunia)
Menstrual history (heaviness, cycle, unscheduled)
Cervical smear history
Parity and fertility problems.
Family history.
Previous gynaecological and surgical history.
Ovarian cancer symptoms
what can cause acute presentation of an ovarian mass
cysts:
- rupture
- haemorrhage
- torsion
fibroid degeneration:
- usually red degeneration
- compromised blood supply
- seen in pregnancy, peri menopause
what should you look for on exam in pelvic mass
generally: Anaemia Cachexia Chest examination Breast examination Nodes. Leg/peripheral oedema
abdomen: Scars Distension Ascites -Symmetrical -In flanks -Shifting dullness -Fluid thrill Mass -Is it arising from the pelvis -Can you get below it?
vaginal:
speculum and bimanual
how should you describe a pelvic mass
Size -cms or ‘weeks gestation’ Consistency -e.g. soft, firm, hard, craggy, indurated, boggy, fluctuant Surface -Smooth, irregular, ‘bosselated’ Tenderness Mobility Relation to uterus Pouch of douglas.
when would you do an MRI
fibroids/ uterine mass
what tests if you suspect an inflammatory mass
WCC/CRP
what surgery if you suspect ovarian caner
lapartomy (open to assess spread)
what is the association in HLRCC
fibroids and renal cancer
why do you test LFTs in pelvic mass
ascites
what should you suspect and test in a young person with an ovarian mass
germ tumour- LDH, AFP, HCG
when would you do a hysteroscopy
only if bleeding problem and want to see what is in uterine cavity
when do you get shifting dullness and fluid thrill
ascites
large volume= thrill
less = shifting
what do the RMI levels mean
<30 3 in 100 OC
30-200 20 in 100 OC
>200 75 in 100 OC
OC= ovarian cancer
why is albumin low in cancer
ascites
what causes ascites in ovarian cancer
increased capillary permeability
what lymph nodes do the ovaries drain to
lumbar
what are the features of a fibroma
benign tumour of the stroma tissue of the ovary, white whirled appearance, looks like fibroid
are you more likely to have a right or left plerual effusion in meigs syndrome
right
what is the most common malignant ovarian tumour
high grade serous
what are the medical treatment options for benign ovarian tumours
only for endometriomas
GnRH analogues, OCP
what surgical options for benign ovarian tumours
ovarian cystectomy
unilateral oophrectomy
bilateral oophrectomy
pelvic clearance (post menopausal only)
what are the treatment options for ovarian germ cell tumours
fertility sparing
unilateral salpingoophrectomy +/- chemo
what is the basis for ovarian cancer Tx
chemo and surgery
expect if stage 1A then just surgery
what is a krunckenberg tumour
secondary ovarian tumour (usually from stomach) that has signet ring on histology
how bad are borderline ovarian tumuors
can spread transcoelomic
risk of recurrence 5-10%
heavy periods, pressure symptoms and pain =?
uterine fibroids
do mucinous cells ina cyst mean it is benign or malignant
benign
how do benign ovarian cysts present
long history of abdominal bloating
regular menses
smooth mobile midline swelling arising from midline
what do fibroids look like on USS, pathology and histology
USS- whirly, homogenous, solid mass in utero
pathology- uniform, whirled appearance
histology- smooth muscle spindle cells, no disorientation
what do mucinous cysts look like on histology
benign mucinous cells fluid fills BM intact nuclei in line along bottom
in ovarian cancer, what does Ca125 measure
peritoneal disease (spread)- also a marker of inflammation
what are the risk factors for endometrial cancer
age past menopause
nulliparity
obesity
how do endometrial polyps present
period like bleeding, short history
abdo swelling
how might atrophic vaginitis present
vaginal spotting
feels dry and irritated
punctate spots on vaginal wall
what are the types of endometrial cancer
Adenocarcinomas:
– Endometrioid carcinoma: precursor atypical hyperplasia, most common type, usually due to high oestrogen levels driving the endometrium
– Serous carcinoma: precursor serous intraepithelial carcinoma, atrophic endometrium- older women
can a smear be used to diagnose someone with symptoms
no
what is koilocytosis
abnormal nuclei - caused by HPV
