Pelvic Mass and pathology ovarian tumours Flashcards
What are the non-gynae causes for pelvic mass?
- Bowel
- Bladder/uro
- other
Bowel ω Constipation! ω Caecal carcinoma ω Appendix abscess ω Diverticular abscess
Bladder/Urological.
ω Urinary retention
ω (pelvic kidney)
Other
ω e.g. retroperitoneal tumour.
What are the gynae causes for pelvic mass?
Uterine: body
- Pregnancy
- fibroids (most common)
- endometrial cancer (although usually presents early as PMB)
Uterine: cervix
-also presents late
Tubal (& para-tubal)
Ovarian
What are uterine fibroids?
¥ Leiomyomas - benign smooth muscle tumours
-usually few cm but may be much bigger
Fibroids:
- are they common?
- what is the presentation?
Very common, esp >40yrs
May be asymptomatic/ incidental finding
or
¥ Menhorrhagia
¥ Pelvic mass
¥ Pain/tenderness
-Only disproportionate if ‘red degeneration’ eg. Pregnancy, Menopause
(this is haemorrhage into tumour)
¥ ‘Pressure’ symptoms
What investigations are carried out for fibroids?
¥ Hb if heavy bleeding
¥ Transvaginal Ultrasound usually diagnostic.
ω smooth echogenic mass often multiple.
MRI for more precise localisation
What is the treatment for uterine fibroids?
symptomatic management with a levonorgestrel-releasing intrauterine system is recommended by CKS first-line
other options include tranexamic acid, combined oral contraceptive pill etc
GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
surgery is sometimes needed: myomectomy, hysterscopic endometrial ablation, hysterectomy, uterine artery embolization
What tubal masses exist?
¥ Ectopic pregnancy
ω Emergency +IPT/empty uterus/pain/bleeding
ω May detect adnexal mass on USS
ω Never presents as mass you can feel – it’s too small
¥ Hydrosalpinx
ω Often longstanding/incidental
ω Collection of fluid in tubes
¥ Pyosalpinx
ω Acute/inflammatory
¥ Paratubal Cysts.
ω Usually small & incidental (embryological remnants)
What ovarian masses can arise?
Cysts:
- functional cysts
- endometriotic cysts
Tumours/neoplasm:
- benign
- malignant
What is a functional cyst?
- are they large?
- how are they treated?
- what can they causes clinically?
Common cyst where ovulation doesn’t occur and follicle doesn’t rupture
ω Follicular cysts
ω Luteal cysts.
¥ Rarely >5cm diameter
¥ Usually resolve spontaneously
¥ Expectant management appropriate.
¥ May be menstrual disturbance
¥ May bleed or rupture and cause pain.
¥ Often asymptomatic/incidental finding.
What is endometriosis?
-what sites does this occur in?
¥ Endometriosis = endometrium in wrong place (ovaries/POD/other)
Sites – Ovary (‘chocolate’ cyst- blood filled cyst on the ovary which is a tender mass with nodularity and tenderness behind uterus) – Pouch of Douglas – Peritoneal surfaces, including uterus – Cervix, vulva, vagina – Bladder, bowel etc
fixed, retroverted uterus
What clinical symptoms are found with endometriosis?
Often asymptomatic until a large choc. cyst develops and ruptures.
- chronic pelvic pain
- dysmenorrhoea - pain often starts days before bleeding
- deep dyspareunia
- subfertility
Less common features
- urinary symptoms e.g. dysuria, urgency
- dyschezia (painful bowel movements)
What is the pathogenesis and what is seen on pathology for endometriosis?
Pathogenesis
- Regurgitation
- Metaplasia
- Vascular or lymphatic dissemination
Macroscopic
- Peritoneal spots or nodules
- Fibrous adhesions: from scarring after inflammation
- Chocolate cysts
Microscopic
- Endometrial glands and stroma
- Haemorrhage, inflammation, fibrosis
What is the gold standard investigation for endometriosis?
laparoscopy is the gold-standard investigation
there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are significant the patient should be referred for a definitive diagnosis
What is the management of endometriosis?
- drug
- surgical
NSAIDs and other analgesia for symptomatic relief
combined oral contraceptive pill progestogens e.g. medroxyprogesterone acetate
gonadotrophin-releasing hormone (GnRH) analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
intrauterine system (Mirena)
drug therapy unfortunately does not seem to have a significant impact on fertility rates
Surgery:
-some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility
What are the complications of endometriosis?
- Pain
- Cyst formation
- Adhesions
- Infertility
- Ectopic pregnancy
- Malignancy (endometrioid carcinoma)
What primary ovarian tumours exist?
- arising from surface epithelium
- arising from germ cells
- arising from stroma
Arising from surface epithelium (65-70%) (although remember there's no true epithelium in ovary): Ð Serous (most common epithelial type) Ð Mucinous Ð Endometrioid Ð Clear cell Ð Brenner
(for serous/mucinous and endometrioid, if they are benign = cystadenoma, if they are malignant = cystcarcinoma)
Arising from germ cells (15-20%):
Ð Benign cystic teratoma (= dermoid cyst, common 95% germ cell tumours,)
Ð Malignant germ cell tumours (v v rare)
Arising from stroma/sex cords:
Ð If granulosa cell may secrete oestrogens, all are potentially malignant, may be assoc. with oestrogenic manifestations
Ð If theca/leydig cell may secrete androgens.
Ð Also fibroma (beware Meig’s syndrome) this is a benign tumour which may produce oestrogen causing uterine bleeding.
What are the rare stigmata of:
- malignant germ cell tumours
- dermoid cyst
- granulosa cell tumour
- thecal tumours
- fibromas
¥ Malig germ cell tumours
Ð May produce HCG (false pos IPT) or AFP
¥ Dermoid cyst
Ð Totipotential e.g.
Ð Teeth, sebaceous material, hair
Ð Thyroid tissue –>thyrotoxicosis
¥ Granulosa cell tumours
Ð May produce oestrogens
Ð –> precocious puberty, PMB
¥ Thecal tumours.
Ð May produce androgens
Ð –> hirsutism —> virilisation
¥ Fibromas.
Ð Meig’s syndrome benign fibroma but pleural effusion
How are epithelial ovarian tumours subdivided?
benign/borderline/malignant
• Benign
– No Cytological abnormalities, proliferative activity absent or scant
– No stromal invasion
• Borderline
– Cytological abnormalities, proliferative
– No stromal invasion
• Malignant
– Stromal invasion
How are malignant serous carcinomas typed?
Two distinct entities with different precursor lesions
High grade serous carcinoma
- Serous tubal intraepithelial carcinoma (STIC)
- Most cases are essentially tubal in origin
Low grade serous carcinoma
-Serous borderline tumour
Endometrioid and clear cell carcinoma:
- what has this got a strong assoc. with?
- how are endometrioid caricinomas graded?
- are most endometrioid carcinomas low/high grade and late/early stage?
- what syndrome is this assoc. with?
Strong association with endometriosis of the ovary
Endometriod carcinomas graded the same as uterine tumours.
Most endometrioid carcinomas are low grade and early stage.
Association with Lynch syndrome
What is a brennar tumour?
A tumour of transitional type epithelium, usually benign,
borderline and malignant variants are rare
What can dermoid cysts or teratomas contain?
– 95% of germ cell tumours – cystic, containing sebum and hair – ectoderm, mesoderm and endoderm – skin, respiratory epithelium, gut, fat common – can rarely become malignant
What is the most common malignant primitive germ cell tumour?
-who does this affect?
Dysgerminoma, most common malignant primitive germ cell tumour
1-2% of all malignant ovarian tumours
Almost exclusively children and young women, average age 22
What is meigs syndrome
TRIAD
- ascites
- pleural effusion
- benign ovarian tumour (usually fibroma)
Cure by removal tumour
What are the commonest metastatic tumours in the ovary?
Stomach
Colon
Breast
Pancreas
Ectopic pregnancy:
-what is the commonest site?
Implantation of a conceptus outside the endometrial cavity
Commonest site is Fallopian tube
May occur in ovary or peritoneum
Often ruptures
May cause fatal haemorrhage
Consider diagnosis in any female of reproductive age with amenorrhoea and acute hypotension or an acute abdomen.
