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Pelvic Mass Flashcards

1
Q

what are non gynaecological causes of a mass in the pelvis

A
  • bowel: constipation, caecal carcinoma, appendix abscess, diverticular abscess
  • bladder/ urological: urinary retention
  • other: retroperitoneal tumour, ascites (non gynae origin)
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2
Q

what are the three categories of gynae pelvic masses

A

pregnancy
uterine (benign and malignant)
adnexal (benign and malignant)

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3
Q

what are the causes of a uterine mass

A

pregnancy
fibroids- commonest
endometrial cancer (usually presents early as PMB so mass unlikely)
cervical cancer
(would be late presentation so +/- renal failure/ bleeding/ pain)

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4
Q

what are uterine fibroids

A

leiomyomas- benign smooth muscle tumours

usually a few cm but can be bigger and multiple

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5
Q

are uterine fibroid common

A

yes (esp >40s)

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6
Q

what are the types of uterine fibroids

A 
pedunculated 
intracavitary 
intramural 
submucous 
subserous
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7
Q

what is the presentation of uterine fibroids

A 
may be asymptomatic/ incidental finding 
menorrhagia 
pelvic mass
pain/ tenderness 
pressure symptoms
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8
Q

what investigations for suspected fibroids

A

Hb if heavy bleeding
USS usually diagnostic (smooth echogenic mass, often multiple)
MRI for more precise localisation

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9
Q

what is the treatment for fibroids

A 
nothing if asymptomatic 
hysterectomy if family complete 
or: 
-myomectomy 
-uterine artery embolisation 
-hysteroscopic resection
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10
Q

what are the causes of tubal swelling

A

ectopic pregnancy
hydrosalpinx (often longstanding/ incidental)
pyosalpinx (acute/ inflammatory)
paratubal cysts (embryological remnants, usually small and incidental)

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11
Q

is an ectopic pregnany an emergency

A

yes

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12
Q

what are the causes of an ovarian mass

A

tumours - benign or malignant

not tumours- functional cysts, endometriotic cysts

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13
Q

what are functional cysts

A

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

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14
Q

what are endometriotic cysts

A

when endometriosis results in cblood filled (chocolate) cysts on ovaries (endometriomas)

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15
Q

how do endometriotic cysts present

A

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.

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16
Q

what are the types of primary ovarian tumours

A

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
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17
Q

what is meigs syndrome

A

triad of ascites, pleural effusion and benign ovarian fibroma

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18
Q

what might malignant germ cell ovarian tumours produce

A

HCG (false pos IPT) or AFP

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19
Q

what happens if a dermoid cyst produced thyroid tissue

A

can cause thyrotoxicosis

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20
Q

what can a dermoid cysts form

A

Totipotential e.g.

Teeth, sebaceous material, hair

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21
Q

what can granulosa cell tumour secretions cause

A

May produce oestrogens

–> precocious puberty, PMB

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22
Q

what can thecal cell tumour secretions cause

A

produce androgens

–> hirsutism —> virilisation

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23
Q

what cancers spread to the ovaries

A

breast
pancreas
stomach
GI primaries

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24
Q

how can dermoid cysts be diagnosed on imaging

A

contain fat- no fat in ovaries so if see this= germ cell tumour
also might contain calcification= teeth

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25
Q

what are the features of ovarian cancers spreading

A

early tranperitoneal spread(trans-coelomic)
-Deposits on all peritoneal surfaces
-Omental disease/infiltration
=Malignant ascites with protein exudate

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26
Q

how do ovarian cancers present

A 
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.
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27
Q

how many ovarian cancers have genetic cause, and what are they

A 
5%
BRCA1 & 2
Breast & ovarian Ca
HNPCC (Lynch syndrome)
Bowel, endometrial, ovarian ca + many others
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28
Q

what are the risk factors for ovarian cancer

A

Increasing age
Nulliparity
Family history

(OCP protective against it)

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29
Q

what Ix for suspected ovarian cancer

A 
Hx and exam 
Ca125
carcino-embryonic antigen CEA
imaging: 
-USS 
-CT (to assess disease outwith ovary: omental disease, peritoneal disease, lymph involvement)
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30
Q

what else can cause increased Ca125

A 
Endometriosis
Peritonitis/infection
pregnancy
Pancreatitis
Ascites from any cause.e.g. liver disease
Other malignancies gynae/non gynae.
31
Q

how sensitive is Ca125

A

Raised in ≈80% ovarian cancers.

Normal level does not exclude cancer

32
Q

what is CEA (carcinoembryonic antigen)

A

May be moderately elevated in ovarian Ca
Esp mucinous tumours
Main function = exclude mets from GI primary.

33
Q

what USS findings are suspicious of ovarian Cancer

A 
Complex mass with solid & cystic area.
Multi-loculated
Thick septations
Associated ascites
Bilateral disease.
34
Q

what does the risk of malignancy index consider

A

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)

35
Q

how is an ovarian cyst/ mass treated

A

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

36
Q

how likely is ovarian cancer to be cured

A

unlikely unless confined to ovary at presentation

37
Q

what questions should you include in a pelvic mass history

A

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

38
Q

what can cause acute presentation of an ovarian mass

A

cysts:
- rupture
- haemorrhage
- torsion

fibroid degeneration:

  • usually red degeneration
  • compromised blood supply
  • seen in pregnancy, peri menopause
39
Q

what should you look for on exam in pelvic mass

A 
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

40
Q

how should you describe a pelvic mass

A 
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.
41
Q

when would you do an MRI

A

fibroids/ uterine mass

42
Q

what tests if you suspect an inflammatory mass

A

WCC/CRP

43
Q

what surgery if you suspect ovarian caner

A

lapartomy (open to assess spread)

44
Q

what is the association in HLRCC

A

fibroids and renal cancer

45
Q

why do you test LFTs in pelvic mass

A

ascites

46
Q

what should you suspect and test in a young person with an ovarian mass

A

germ tumour- LDH, AFP, HCG

47
Q

when would you do a hysteroscopy

A

only if bleeding problem and want to see what is in uterine cavity

48
Q

when do you get shifting dullness and fluid thrill

A

ascites
large volume= thrill
less = shifting

49
Q

what do the RMI levels mean

A

<30 3 in 100 OC
30-200 20 in 100 OC
>200 75 in 100 OC
OC= ovarian cancer

50
Q

why is albumin low in cancer

A

ascites

51
Q

what causes ascites in ovarian cancer

A

increased capillary permeability

52
Q

what lymph nodes do the ovaries drain to

A

lumbar

53
Q

what are the features of a fibroma

A

benign tumour of the stroma tissue of the ovary, white whirled appearance, looks like fibroid

54
Q

are you more likely to have a right or left plerual effusion in meigs syndrome

A

right

55
Q

what is the most common malignant ovarian tumour

A

high grade serous

56
Q

what are the medical treatment options for benign ovarian tumours

A

only for endometriomas

GnRH analogues, OCP

57
Q

what surgical options for benign ovarian tumours

A

ovarian cystectomy
unilateral oophrectomy
bilateral oophrectomy
pelvic clearance (post menopausal only)

58
Q

what are the treatment options for ovarian germ cell tumours

A

fertility sparing

unilateral salpingoophrectomy +/- chemo

59
Q

what is the basis for ovarian cancer Tx

A

chemo and surgery

expect if stage 1A then just surgery

60
Q

what is a krunckenberg tumour

A

secondary ovarian tumour (usually from stomach) that has signet ring on histology

61
Q

how bad are borderline ovarian tumuors

A

can spread transcoelomic

risk of recurrence 5-10%

62
Q

heavy periods, pressure symptoms and pain =?

A

uterine fibroids

63
Q

do mucinous cells ina cyst mean it is benign or malignant

A

benign

64
Q

how do benign ovarian cysts present

A

long history of abdominal bloating
regular menses
smooth mobile midline swelling arising from midline

65
Q

what do fibroids look like on USS, pathology and histology

A

USS- whirly, homogenous, solid mass in utero
pathology- uniform, whirled appearance
histology- smooth muscle spindle cells, no disorientation

66
Q

what do mucinous cysts look like on histology

A 
benign 
mucinous cells 
fluid fills
BM intact 
nuclei in line along bottom
67
Q

in ovarian cancer, what does Ca125 measure

A

peritoneal disease (spread)- also a marker of inflammation

68
Q

what are the risk factors for endometrial cancer

A

age past menopause
nulliparity
obesity

69
Q

how do endometrial polyps present

A

period like bleeding, short history

abdo swelling

70
Q

how might atrophic vaginitis present

A

vaginal spotting
feels dry and irritated
punctate spots on vaginal wall

71
Q

what are the types of endometrial cancer

A

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

72
Q

can a smear be used to diagnose someone with symptoms

A

no

73
Q

what is koilocytosis

A

abnormal nuclei - caused by HPV

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