Pelvic Masses

Question 1

what are the 4 structures in the pelvis and what compartments are they in?

Answer 1

Anterior compartment – bladder
Middle compartment – uterus
Posterior compartment – bowel
Lateral compartment – adnexae (tubes and ovaries)

Question 2

most likely to cause of a pelvic mass?

Answer 2

pregnancy

Question 3

what are the masses that arise from the bladder?

Answer 3

bladder tumours

bladder distension

Question 4

what are the masses which arise from the uterus?

Answer 4

uterine fibroids
adenomyosis
carcinosarcomas
leiomyosarcoma

Question 5

what are the masses which arise from the cervix?

Answer 5

Haematometra/pyometra

Question 6

what are the masses which arise from the ovaries and tubes?

Answer 6

benign or malignant ovarian masses
hydrosalphinx
ectopic pregnancy
tuboovarian abscess

Question 7

what are the masses which arise from the bowel?

Answer 7

bowel tumours
appendiceal mass
hernias
diverticular abscess

Question 8

what investigations should be done when a pelvic mass is found?

Answer 8

tumour markers
USS
MRI (premenopausal) - characterise the ovarian cyst in a better way
CT (postmenopausal) - assess spread of cancer and operability
risk of malignancy index (RMI)

Question 9

what tumour markers do you check?

Answer 9

CA-125 - elevated in ovarian cancer (also in lots of other conditions so not great indicator) 
Carcinoembryonic antigen (CEA) - elevated in mucinous cancers associated with the GI tract or ovary 
If ratio CA-125/CEA <25 then suspect metastatic ovarian masses 

Alpha foeto-protein (AFP) – raised in embryonal carcinoma
HCG – raised in choriocarcinoma
LDH – raised in dysgerminoma

Question 10

what suggests a benign mass on an USS?

Answer 10

Likely benign cyst if uniocular – single compartment, solid component measuring less than 7mm, no increase in vascularity. If multiloculated, largest diameter is less than 10mm

• B1 – unilocular
• B2 – Presence of solid components with largest diameter <7mm
• B3 – presence of acoustic shadows
• B4 – smooth multiocular tumour with largest diameter <100 mm
• B5 – no blood flow

Question 11

what suggests a mass which is likely cancerous?

Answer 11

irregular solid tumour, presence of ascites, 4 or more papillary projections and increased vascularity

• M1 – irregular solid tumour
• M2 – presence of ascites
• M3 – at least 4 papillar structures
• M4 – irregular multilocular solid tumour with largest diameter > 100mm
• M5 – very strong blood flow

Question 12

what is the risk of malignancy index (RMI) for pelvic masses?

Answer 12

More useful indicator of cancer
Score given on – menopausal status, ultrasonic features, serum Ca-125
If RMI>200 then ¾ patients will have ovarian cancer

Question 13

what is the acute presentation of a benign ovarian tumour?

Answer 13

• Torsion/rupture
• Haemorrhage
• Patients will have acute pain with nausea needing morphine for pain relief

Question 14

how are benign ovarian tumours treated?

Answer 14

Conservative

Medical
o GNRH analogues
o OCPills
o Ovarian suppression – can be used for endometriosis

Surgical – laproscopic/laparotomy 
o	Ovarian cystectomy 
o	Unilateral oophorectomy 
o	Bilateral oophorectomy 
o	Pelvic clearance

Question 15

what is a dermoid cyst?

Answer 15

Originate from topipotent cells 
Ovarian teratomas – tissue from ectoderm, mesoderm and endoderm but mainly fat 
Contents can be: 
o	Teeth 
o	Hair 
o	Sebaceous material 
o	Thyroid tissue (thyrotoxicosis)

Question 16

what is a borderline ovarian tumour?

Answer 16

growth is much more controlled than cancer
they are unlikely to spread, if do spread - as implant rather than deeply invasive
better prognosis than ovarian cancer

Question 17

how are borderline ovarian tumours managed?

Answer 17

young women - unilateral cystectomy/ oophectomy with close follow up
post-menopausal - pelvic clearance

Question 18

what is an epithelial ovarian tumour?

Answer 18

• Many different types. Cell of origin not entirely clear – different histological types have different origins and arise through different molecular pathways
• 65-70% of ovarian tumours

Question 19

what are the types of epithelial ovarian tumour?

Answer 19

Serous – malignant serous carcinomas types as low grade or high grade
Mucinous
Endometrioid
Clear cell
Brenner
(subdivided on histopathological examination into benign/borderline/malignant)

Question 20

what are the divisions of a epithelial ovarian tumour?

Answer 20

Benign - No cytological abnormalities, proliferative activity absent or scant and no stromal invasion
Borderline - Cytological abnormalities, proliferative and no stromal invasion
Malignant - Stromal invasion

Question 21

what are the 2 types of serous ovarian carcinoma?

Answer 21

high grade - serous tubal intraepithelial carcinoma (STIC), most cases essentially tubal in origin

low grade - serous borderline tumour

Question 22

what is an endometrioid and clear cell carcinoma epithelial ovarian tumour?

Answer 22

strongly associated with endometriosis
Endometrioid carcinomas graded the same as uterine tumours
Most endometrioid carcinomas are low grade and early stage
Association with lynch syndrome

Question 23

what is a brenner tumour?

Answer 23

tumour of transitional type epithelium, usually benign - borderline and malignant variants are rare

Question 24

where do ovarian cysts arise from?

Answer 24

innate or acquired:

• follicular e.g. polycystic ovaries
• luteal
• endometriotic
• epithelial
• mesothelial

Question 25

what is a follicular cyst?

Answer 25

it’s very common and can occur when ovulation doesn’t occur - polycystic ovaries
follicle doesn’t rupture and grows until it’s a cyst
can be grow to several cm in size
Thin-walled, lined by granulosa cells
Usually resolve over a few months