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Reproduction and Sexual Health > Pelvic Masses > Flashcards

Pelvic Masses Flashcards

1
Q

Give examples of bowel problems which can cause pelvic masses.

A
  • Constipation.
  • Caecal carcinoma.
  • Appendix abscess.
  • Diverticular abscess.
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2
Q

Give examples of bladder problems that can cause pelvic masses.

A
  • Urinary retention.

* Pelvic kidney.

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3
Q

Retroperitoneal tumour can cause pelvic masses

A

T

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4
Q

What 3 areas can a gynaecological pelvic mass be from?

A
  • Uterine - body or cervix
  • Tubal (+ para-tubal)
  • Ovarian
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5
Q

What must you always consider in a female with a pelvic mass?

A

PREGNANCY !!!!

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6
Q

What is the commonest cause of a uterine mass?

A

Fibroids

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7
Q

Although unusual, what 2 cancers can present with a uterine mass?

A
  • Endometrial

* Cervical

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8
Q

How does endometrial cancer usually present?

A

Early with PMB (post-menopausal bleeding)

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9
Q

If cervical cancer presents with a uterine mass, this is a _____ presentation

A

LATE

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10
Q

If cervical cancer presents with a uterine mass, it will be later presentation. What may also be present at this point?

A
  • Renal failure
  • Bleeding
  • Pain
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11
Q

What are uterine fibroids also called?

A

Leiomyomas

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12
Q

What is a leiomyoma?

A

Benign smooth muscle tumours

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13
Q

What is the malignant version of a leiomyoma?

A

Leiomyosarcomas

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14
Q

Leiomyosarcomas are common/rare

A

Rare

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15
Q

How common are uterine fibroids?

A

VERY common

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16
Q

In what age group are leiomyomas most common?

A

> 40years.

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17
Q

What is the size of a leiomyoma like?

A

Usually a few cm, but may be much bigger and multiple.

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18
Q

Fibroids are a common cause of pelvic masses

A

T

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19
Q

Name the 5 different types of fibroids (based on location).

A
  • Pedunculated
  • Intramural
  • Intracavitary
  • Subserous
  • Submucous
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20
Q

How might uterine fibroids present?

A

ASYMPTOMATIC

OR

  • Menorrhagia.
  • Pelvic mass.
  • Pain/tenderness.
  • Pressure symptoms
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21
Q

When is pain/tenderness due to uterine fibroids disproportionate?

A

Only if there is ‘red degeneration’ e.g. pregnancy, menopause

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22
Q

What ethnic group are at greater risk of uterine fibroids?

A

Afro-Carribean

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23
Q

If a woman has suspected fibroids, what ix should/may be carried out?

A
  • Hb if heavy bleeding.
  • Ultrasound is usually diagnostic – see smooth echogenic mass; often multiple.
  • MRI for more precise localisation.
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24
Q

What Ix is diagnostic of uterine fibroids?

A

US

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25
Q

How may a uterine fibroid appear on US?

A

Smooth, circular and homogenous

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26
Q

What are the treatment options for fibroids?

A
  • Expectant – if asymptomatic.
  • Hysterectomy – traditionally chosen if family is complete.
  • Alternatives – myomectomy, uterine artery embolization, hysteroscopic resection.
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27
Q

What happens to fibroids during/after menopause? Why?

A

They shrink – they’re hormone dependent

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28
Q

Fibroids are ________ dependant

A

Hormone

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29
Q

Name 4 causes of tubal swellings.

A
  • Ectopic pregnancy
  • Hydrosalpinx
  • Pyosalpinx
  • Paratubal cysts
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30
Q

How does an ectopic pregnancy present?

A

EMERGENCY +

  • IPT
  • Empty uterus
  • Pain
  • Bleeding
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31
Q

Hydrosalpinx are often …

A

Longstanding/incidental findings

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32
Q

What is pyosalpinx?

A
  • A pus-filled uterine tube, occurring due to infection.

* Patient will be acutely unwell due to inflammation.

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33
Q

Paratubal cysts are usually . . .

A

Small and incidental (embryological remnants)

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34
Q

What is hydrosalpinx?

A

When the fallopian tubes fill with serous fluid

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35
Q

Outline the different types of ovarian mass.

A

Tumours/Neoplastic:

  • Benign.
  • Malignant.

Not Tumours:

  • ‘Functional’ cyst. (due to ovulation).
  • Endometriotic cysts.
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36
Q

What are ‘functional’ cysts related to?

A

Ovulation

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37
Q

What are the 2 types of ‘functional’ cyst?

A
  • Follicular

* Luteal

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38
Q

‘Functional’ cysts are rarely larger than ___ cm

A

5cm

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39
Q

How can ‘functional’ cysts present?

A
  • Often an asymptomatic/incidental finding.
  • There may be menstrual disturbance.
  • May bleed or rupture and cause pain (emergency).
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40
Q

How are ‘functional’ cysts managed?

A

Expectant management – as usually resolve spontaneously

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41
Q

What happens in endometriosis?

A

Endometrium is the wrong place (e.g. ovaries, pouch of douglas, other).

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42
Q

What can endometriosis cause on the ovaries?

A

Blood-filled cysts on the ovaries endometriomas/’chocolate’ cysts

  • Endometrial cysts
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43
Q

How would someone with an endometriotic cyst present?

A
  • Severe dysmenorrhoea
  • PREMENSTRUAL PAIN.
  • Dyspareunia - painful sex
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44
Q

What are endometrioid cysts associated with?

A

Subfertility

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45
Q

An endometriotic cyst is usually a tender mass with __________

A

Nodularity

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46
Q

Where might tenderness be felt in someone with an ednometriotic cyst?

A

Behind the uterus

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47
Q

Endometriotic cysts are usually asymptomatic until they rupture

A

T

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48
Q

What are the 3 categories of primary ovarian tumour, in terms of where the tumour arises from?

A
  1. Arising from surface epithelium.
  2. Arising from germ cells.
  3. Arising from stroma.
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49
Q

What are the 5 types of primary ovarian tumour which arise from surface epithelium?

A
  • Serous.
  • Mucinous.
  • Endometrioid.
  • Clear cell.
  • Brenner.
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50
Q

What are the i) benign ii) malignant forms of serous/mucinous/endometrioid ovarian tumours referred to as?

A

i) Cystadenoma.

ii) Cystadenocarcinoma.

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51
Q

What is the term ‘germ cells’ referring to?

A

Oocytes

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52
Q

Name the 2 types of germ cell tumour.

A
  • Benign cystic teratoma (dermoid cyst, common).

* Malignant germ cell tumours (v v rare).

53
Q

What is the stroma?

A

The tissue which produces the hormones.

54
Q

What do granulosa cells secrete?

A

Oestrogen

55
Q

What will a tumour, arising from granulosa cells secrete?

A

Oestrogen

56
Q

What do theca/leydig cells secrete?

A

Androgens

57
Q

What will a tumour, arising from theca/leydig cells secrete?

A

Androgens

58
Q

What tumour can arise from stroma?

A

Fibroma – be aware of Meig’s syndrome.

59
Q

What is Meig’ syndrome?

A

The triad of :

  • Benign ovarian tumour
  • Ascites
  • Pleural effusion

It resolves after resection of the tumour

Ovarian fibromas constitute the majority of the benign tumours seen in Meigs syndrome.

60
Q

How might Meig’s syndrome present?

A
  • Pelvic mass (benign ovarian fibroma)
  • Ascites
  • Pleural effusion
61
Q

What is the tumour in Meig’s syndrome?

A

Ovarian Fibroma (benign)

62
Q

Aside from oestrogen and androgens, what else can malignant germ cell tumours produce?

A
  • HCG

* AFP

63
Q

What can a HCG secreting germ cell tumour cause?

A

False pregnancy test

64
Q

What is the other name for a dermoid cyst?

A

Teratoma

65
Q

What is special about teratomas?

A

They are totipotential, so any cell type can be present in the cyst

  • Teeth
  • Sebaceuos material
  • Hair
66
Q

Why might teratomas be associated with thyrotoxicosis?

A

There may be some thyroid tissue in the teratoma.

67
Q

What might a dermoid cyst look like on plain x-ray?

A
  • Rim calcification.
  • Calcification - tooth.
  • Fat inside - different density.
68
Q

What might granulosa cell tumours produce?

A

Oestrogen

69
Q

What effects, might an oestrogen producing tumour have?

A
  • Precocious puberty (early)

* PMB (post-menstrual bleeding)

70
Q

What do thecal tumours produce?

A

Androgens

71
Q

What might androgen production from thecal tumours lead to?

A
  • Hirsutism - abnormal hair growth of a woman

* Virilisation - male growth patterns of a female

72
Q

What syndrome is ovarian fibromas associated with?

A

Meig’s syndrome

73
Q

Are the fibroma in Meig’s syndrome benign? Why are these still somewhat ‘dangerous’?

A

Yes - due to risk of pleural effusion

74
Q

The ovary is a common site of metastatic disease. Cancers from where most often metastasise to the ovary?

A
  • Breast
  • Pancreas
  • Stomach
  • GI tract
75
Q

What specific symptoms may ovarian cancer present with?

A

Mass, swelling, pressure

76
Q

What happens early on in ovarian cancer?

A

Early transperitoneal spread (trans-coelomic)

77
Q

Describe the early transperitoneal spread (trans-coelomic) in ovarian cancer.

A
  • Deposits on all peritoneal surfaces.
  • Omental disease/infiltration.
  • Malignant ascites with protein exudate.
78
Q

List symptoms which may occur in the rather varied presentation of an ovarian carcinoma.

A
  • Heartburn/indigestion
  • Early satiety
  • Weight loss/anorexia.
  • Bloating
  • ‘Pressure’ symptoms (esp bladder)
  • Change of bowel habit
  • SOB/ Pleural effusion
  • Leg oedema or DVT
  • N.B May not be a pelvic mass.
79
Q

What % of ovarian cancers have a genetic basis?

A

5%

80
Q

What should you always ask about in someone who is suspected of having ovarian cancer?

A

Family history

81
Q

What are the 2 genetic predispositions of ovarian cancer?

A
  • BRCA1 + 2 mutations  breast and ovarian Ca.

* HNPCC (Lynch syndrome)  bowel, endometrial, ovarian Ca + many others.

82
Q

There is no screening proven to detect early disease of ovarian cancer

A

T :(

83
Q

Give 3 risk factors for ovarian cancer?

A
  • Increasing age.
  • Nulliparity.
  • Family history.
84
Q

Having never had children before increases your risk of ovarian cancer

A

T

85
Q

What is protective against ovarian cancer?

A

OCP

86
Q

What 3 Ix’s are important in ovarian cancer?

A
  • Hx and examination.
  • Tumour markers.
  • Imaging.
87
Q

What 2 tumour markers are associated with ovarian cancer?

A
  • CA 125

* Carcino-embryonic antigen (CEA).

88
Q

What type of imaging is best for a cyst?

A

US

89
Q

What is CT good for?

A

Assessing disease outwith the ovary, especially omental disease, peritoneal disease and lymph nodes.

90
Q

CA 125 is associated with _______ cancer

A

Ovarian

91
Q

In __% of ovarian cancers, CA 125 is raised

A

80%

92
Q

Does a normal CA 125 exclude ovarian cancer?

A

NO !!!

93
Q

Give examples of when CA 125 is moderately raised.

A
  • Endometriosis.
  • Peritonitis/infection.
  • Pregnancy.
  • Pancreatitis.
  • Ascites from any cause e.g. liver disease.
  • Other malignancies – gynae/non-gynae.
94
Q

What is measuring CA 125 useful in?

A

Follow up of ovarian cancer (more than diagnosis)

95
Q

SEROUS ovarian cancers secrete CA125, while mucinous types don’t

A

T

96
Q

What ovarian cancers DONT secrete CA 125?

A

Mucinous

97
Q

What do mucinous ovarian cancers secrete?

A

CEA

98
Q

Mucinous ovarian cancers secrete CEA more than serous ovarian cancers

A

T

99
Q

What is the main use of CEA?

A

To exclude mets from a GI primary.

100
Q

What is the appearance of an ovarian cancer on US?

A

Complex mass with SOLID AND CYSTIC areas

101
Q

How is the ‘risk of malignancy’ index in ovarian cancer calculated?

A

Menopausal Status x Serum CA125 x Ultrasound score

102
Q

What should be done if someones ‘risk of malignancy’ index is high?

A

Refer to gynae cancer team

103
Q

If a cyst/mass is benign, what is the management?

A

Removal or drainage

104
Q

If a mass is benign ….

A

Remove or drain

105
Q

If a mass in not benign …

A
  • Removal of ovaries and uterus with removal/biopsy of omentum.
  • ‘Debulking’ of tumour.
  • Complete examination/inspection of all peritoneal surfaces
106
Q

When is chemo done in a malignant mass?

A

Either pre-surgery or after surgery

107
Q

Cure of an ovarian cancer is unlikely unless?

A

It is confined to ovary at presentation.

108
Q

Bloatedness is a red flag if?

A

New onset in a post-menopausal woman

109
Q

What should you do in a post-menopausal woman who presents with bloatedness?

A
  • Do CA125.

* If CA125 if raised, do an ultrasound

110
Q

What should you do if CA 125 is raised?

A

US !!!

111
Q

A pelvic mass may present as an emergency with what?

A

An acute abdomen

112
Q

What are the 2 groups of causes of acute presentation pelvic masses?

A
  • Cyst ‘accident.’

* Fibrinoid degeneration.

113
Q

Give examples of cyst ‘accidents’.

A
  • Rupture (into pelvic cavity).
  • Haemorrhage (into cyst).
  • Torsion.
114
Q

What is fibroid degeneration usually due to?

A

Red degeneration

115
Q

What happens to blood supply in fibroid degeneration?

A

It is compromised

116
Q

In what women is fibroid degeneration an emergency?

A

In pregnancy and peri-menopause

117
Q

What nodes do lymph from the ovaries drain to?

A

Para-aortic nodes

118
Q

Outline the journey of lymph drainage from the ovaries.

A
  1. Para-aortic nodes
  2. Coeliac nodes
  3. Epicardial
  4. Mediastinal nodes
119
Q

Patients with ovarian cancer can often present with supra-clavicular or axillary nodes

A

T

120
Q

When examing a mass from the pelvis, what should you always test?

A

If you can get below the mass

121
Q

What 2 exams can be done?

A
  • Speculum examination.

* Bimanual examination

122
Q

How is the size of a mass described?

A

cm or ‘weeks gestation.’

123
Q

How can the consistency of a ,ass be described?

A

soft, firm, hard, craggy, indurated, boggy, fluctuant

124
Q

ALWAYS MEASURE ALBUMIN !!! If albumin is low then they are unlikely to have cancer

A

T

125
Q

List the 4 main tumour markers that we can test for.

A
  • CA125
  • CEA
  • HCG
  • AFP
126
Q

What is the main Ix that should always be done for a pelvic mass?

A

US

127
Q

US + MRI for …

A
  • Fibroids

* Uterine mass

128
Q

US + CT for …

A
  • Suspected ovarian cancer
129
Q

What is the best treatment for ovarian cancer?

A

Open surgery (laparotomy)

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