Pelvic Mass Flashcards
What are the non gynaecological causes of pelvic masses?
Bowel
- constipation
- caecal carcinoma
- Appendix abscess
- Diverticular abscess
Bladder/urological
- urinary retention
Other
- retropertoneal tumour
- Ascites
What are the gynaecological causes of pelvic mass?
- Pregnancy
- uterine: benign and malignant
- adnexal masses: benign and malignant
Describe a useful framework for pelvic mass evaulation?
- Symptoms
- Abdominal examination
- Bimanual/examination
- blood tests
- USS (transabdominal and transvaginal)
What symptoms need to be enquired about in evaluation of pelvic mass
Slow/fast growing , pain, pressure symptoms, AUB, incidental
What should be looked for in abdominal examination for pelvic mass?
Masses, tenderness, shifting dullness, fluid thrill, scars
What should be looked for in bimanual palpation in pelvic mass evaulation?
Masses, tenderness, shifting dullness, fluid thrill, scars, cervical excitation, mass movement, adnexal tenderness
What tests should be done in pelvic mass examination?
Blood tests
- FBC, LFT, RFT, CA125, LDH, AFP, HCG
Urine Test
What should be assessed in USS for pelvic mass?
Assess uterus, adnexae
What is RMI?
Risk of malignancy index
If RMI >2– then 3/4 patients will have oc
What is RMI index scored on?
-
Menopausal status
- Premenopausal = 1
- Postmenopausal = 3
-
Ultrasonic features, No feature = 0, 1 feature = 1, >1 feature= 3
- Multiloculates
- Solid areas
- Bilaterally
- Ascites
- Metastasis
-
Serum Ca125
*
What are the further investigations of Pelvic Mass?
Computerised tomography
MRI
Hysteroscopy
Diagnostic laparoscopy
What are primary benign ovarian tumours?
Functional cysts arising from;
surface epithelium, germ cells or stroma
What types of benign ovarian tumours arise from surface epithelium?
- Serous
- Mucinous
- Endometroid
- Brenner
- Clear cell
What types of benign ovarian tumours arise from germ cells?
Benign cystic teratoma (= dermoid cyst, common)
What do benign ovarian tumours arising from stroma secrete?
If granulosa may secrete oestrogens
If theca/leydic gells may secrete androgens
Also Fibroma (beware Meig’s syndrome)
What is Meig’s syndrome?
Benign ovarian fibroma associated with ascites +/- pleural effusion therefore do not assume this is stage 4 cancer
What kinds of functional cysts are there?
Follicular cysts
Luteal cysts
What is the treatment for functional cysts?
Usually resolve spontaenously
Expectant management appropriate
How may functional cysts present?
Asymptomatic/incidental finding
May be menstrual disturbance
May bleed or rupture and cause pain
What does endometriosis cause?
Endometriomas, chocolate cysts
What is endometriosis associated with?
Severe dysmenorrhoea, premenstrual pain, dyspareunia, subfertility
How do endometriotic cysts typically prsent?
Tender mass with ‘nodularity’ and tenderness behind uterus.
Ocassionally aysmptomatic untill large chocolate cyst, which may rupture
What is a dermoid cyst?
A cyst with totipotential
Teeth, sebaceous material, hair, thyroid tissue > thyrotoxicosis
Describe the x-ray appearance of a dermoid cyst?
Rim calcification
Fat inside= different density
Calcification= tooth?
What are the treatment options of benign overian tumours?
- conservative
- medical- only in endometriomas (GnRH analogues, OCP)
- Surgical - laparoscopic/laparotomy
- Ovarian cystectomy
- unilateral oophorectomy
- bilateral oophorectomy
- pelvic clearance
What are the primary malignant ovarian tumours arising from surface epithelium?
- Serous
- Mucinous
- Endometrioid
- Brenner
- Clear cell
What are the primary malignant ovarian tumours arising from germ cells?
- malignant cystic teratoma
- dysgerminoma
What are the primary malignant ovarian tumours arising from stroma?
- If granulosa cell may secrete oestrogens
- If theca/leydigcell may secrete androgens.
- Also fibroma (beware Meig’s syndrome)
How does ovarian cancer present?
Mass, swelling, pressure symptoms
How does ovarian cancer spread?
Early transperitoneal spread (trans-coelomic)
- deposits on mulitple peritoneal surfaces
- omental disease/infiltration*
- malignant ascites with protein exudate*
What is the varied presentation of ovarian cancer?
- 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
Ca125 is raised in __% of ovarian cancers, only __% of stage 1 disease
Ca125 is raised in 80% of ovarian cancers, only 50% of stage 1 disease
When is moderate elevation of CA125 seen?
- Endometriosis
- Peritonitis/infection
- Pregnancy
- Pancreatitis
- Ascites from any cause e.g. liver disease
- Other malignancies gynae/non gynae
What are the treatment options of malignant ovarian cancer?
- Germ cell tumours
- fertility sparing, unilateral salpingoopherectomy +/- chemotherapy
- other cancers (MC, serous, epithelial)
- chemotherapy + surgery; except for stage 1A when only surgery is sufficient
What is the aim of the surgery in ovarian cancer?
Total macroscopic debulking of tumour
What is cytoreduction?
Reduction of cells
Cytoreductive surgery is to remove as many cancerous cells as possible
What is optimal cytoreduction?
Optimal cytoreduction is where no visible disease is left behing following the laparotomy
What is ‘early disease’?
Disease remaining within the ovaries
Describe staging in early disease surgery
Through a midline incision to allow palpation of all peritoneal tissue.
- assessment of peritoneal cytology, hysterectomy, removal of ovaries and fallopian tubes and infracolic omentectomy should be performed
- Aim to exclude disease involving the liver, spleen, peritoneum, retroperitoneal nodes, appendix and diaphragm by close clinical inspection and palpation.
What should be avoided in early disease surgery?
Capsular rupture
What is involved in surgery for advanced disease?
Surgery and chemotherapy
What is ‘advanced disease’?
When the disease has spread beyond the pelvic
FIGO staging III and IV
What are the two ideas when considering surgery for advanced disease?
- aggressive surgical cytoreduction with the aim of leaving no residual disease
- cytoreduction where residual deposits are no more than 1cm in diameter
When is chemotherapy and neoadjuvant treatment given?
Chemotherapy is given prior to the surgical procedure. Neoadjuvant chemotherapy may be given in an attempt to shrink the cancer so that the surgical procedure may not need to be so extensive.
What is the commonest site of metastatic disease?
Ovary
What are the common primaries of metastatic ovarian cancer?
Breast, pancreas, stomach and GI
What is a kruckenberg tumour?
Characteristic signet ring histology (usually metastatic from stomach)
What are uterine fibroids?
Leiomyomas- benign smooth muscle tumours
(Leiomyosarcomas very rare)
What is the common presentation of uterine fibroids?
AUB
Can present with pressure symptoms
What are the different types of uterine fibroids?
- pedunculated
- intravacitary
- subseroids
- submucous
- intramural
What are the treatment options for uterine fibroids?
- conservative
- medical
- GnRH analogues, mirena, progestins
- surgical
- laparoscopic/laparotomy
- myomectomy (hysteroscopic or abdominal)
- subtotal hysterectomy
- total hysterectomy
