Pelvic Masses Flashcards
Give examples of bowel problems which can cause pelvic masses.
- Constipation.
- Caecal carcinoma.
- Appendix abscess.
- Diverticular abscess.
Give examples of bladder problems that can cause pelvic masses.
- Urinary retention.
* Pelvic kidney.
Retroperitoneal tumour can cause pelvic masses
T
What 3 areas can a gynaecological pelvic mass be from?
- Uterine - body or cervix
- Tubal (+ para-tubal)
- Ovarian
What must you always consider in a female with a pelvic mass?
PREGNANCY !!!!
What is the commonest cause of a uterine mass?
Fibroids
Although unusual, what 2 cancers can present with a uterine mass?
- Endometrial
* Cervical
How does endometrial cancer usually present?
Early with PMB (post-menopausal bleeding)
If cervical cancer presents with a uterine mass, this is a _____ presentation
LATE
If cervical cancer presents with a uterine mass, it will be later presentation. What may also be present at this point?
- Renal failure
- Bleeding
- Pain
What are uterine fibroids also called?
Leiomyomas
What is a leiomyoma?
Benign smooth muscle tumours
What is the malignant version of a leiomyoma?
Leiomyosarcomas
Leiomyosarcomas are common/rare
Rare
How common are uterine fibroids?
VERY common
In what age group are leiomyomas most common?
> 40years.
What is the size of a leiomyoma like?
Usually a few cm, but may be much bigger and multiple.
Fibroids are a common cause of pelvic masses
T
Name the 5 different types of fibroids (based on location).
- Pedunculated
- Intramural
- Intracavitary
- Subserous
- Submucous
How might uterine fibroids present?
ASYMPTOMATIC
OR
- Menorrhagia.
- Pelvic mass.
- Pain/tenderness.
- Pressure symptoms
When is pain/tenderness due to uterine fibroids disproportionate?
Only if there is ‘red degeneration’ e.g. pregnancy, menopause
What ethnic group are at greater risk of uterine fibroids?
Afro-Carribean
If a woman has suspected fibroids, what ix should/may be carried out?
- Hb if heavy bleeding.
- Ultrasound is usually diagnostic – see smooth echogenic mass; often multiple.
- MRI for more precise localisation.
What Ix is diagnostic of uterine fibroids?
US
How may a uterine fibroid appear on US?
Smooth, circular and homogenous
What are the treatment options for fibroids?
- Expectant – if asymptomatic.
- Hysterectomy – traditionally chosen if family is complete.
- Alternatives – myomectomy, uterine artery embolization, hysteroscopic resection.
What happens to fibroids during/after menopause? Why?
They shrink – they’re hormone dependent
Fibroids are ________ dependant
Hormone
Name 4 causes of tubal swellings.
- Ectopic pregnancy
- Hydrosalpinx
- Pyosalpinx
- Paratubal cysts
How does an ectopic pregnancy present?
EMERGENCY +
- IPT
- Empty uterus
- Pain
- Bleeding
Hydrosalpinx are often …
Longstanding/incidental findings
What is pyosalpinx?
- A pus-filled uterine tube, occurring due to infection.
* Patient will be acutely unwell due to inflammation.
Paratubal cysts are usually . . .
Small and incidental (embryological remnants)
What is hydrosalpinx?
When the fallopian tubes fill with serous fluid
Outline the different types of ovarian mass.
Tumours/Neoplastic:
- Benign.
- Malignant.
Not Tumours:
- ‘Functional’ cyst. (due to ovulation).
- Endometriotic cysts.
What are ‘functional’ cysts related to?
Ovulation
What are the 2 types of ‘functional’ cyst?
- Follicular
* Luteal
‘Functional’ cysts are rarely larger than ___ cm
5cm
How can ‘functional’ cysts present?
- Often an asymptomatic/incidental finding.
- There may be menstrual disturbance.
- May bleed or rupture and cause pain (emergency).
How are ‘functional’ cysts managed?
Expectant management – as usually resolve spontaneously
What happens in endometriosis?
Endometrium is the wrong place (e.g. ovaries, pouch of douglas, other).
What can endometriosis cause on the ovaries?
Blood-filled cysts on the ovaries endometriomas/’chocolate’ cysts
- Endometrial cysts
How would someone with an endometriotic cyst present?
- Severe dysmenorrhoea
- PREMENSTRUAL PAIN.
- Dyspareunia - painful sex
What are endometrioid cysts associated with?
Subfertility
An endometriotic cyst is usually a tender mass with __________
Nodularity
Where might tenderness be felt in someone with an ednometriotic cyst?
Behind the uterus
Endometriotic cysts are usually asymptomatic until they rupture
T
What are the 3 categories of primary ovarian tumour, in terms of where the tumour arises from?
- Arising from surface epithelium.
- Arising from germ cells.
- Arising from stroma.
What are the 5 types of primary ovarian tumour which arise from surface epithelium?
- Serous.
- Mucinous.
- Endometrioid.
- Clear cell.
- Brenner.
What are the i) benign ii) malignant forms of serous/mucinous/endometrioid ovarian tumours referred to as?
i) Cystadenoma.
ii) Cystadenocarcinoma.
What is the term ‘germ cells’ referring to?
Oocytes
Name the 2 types of germ cell tumour.
- Benign cystic teratoma (dermoid cyst, common).
* Malignant germ cell tumours (v v rare).
What is the stroma?
The tissue which produces the hormones.
What do granulosa cells secrete?
Oestrogen
What will a tumour, arising from granulosa cells secrete?
Oestrogen
What do theca/leydig cells secrete?
Androgens
What will a tumour, arising from theca/leydig cells secrete?
Androgens
What tumour can arise from stroma?
Fibroma – be aware of Meig’s syndrome.
What is Meig’ syndrome?
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.
How might Meig’s syndrome present?
- Pelvic mass (benign ovarian fibroma)
- Ascites
- Pleural effusion
What is the tumour in Meig’s syndrome?
Ovarian Fibroma (benign)
Aside from oestrogen and androgens, what else can malignant germ cell tumours produce?
- HCG
* AFP
What can a HCG secreting germ cell tumour cause?
False pregnancy test
What is the other name for a dermoid cyst?
Teratoma
What is special about teratomas?
They are totipotential, so any cell type can be present in the cyst
- Teeth
- Sebaceuos material
- Hair
Why might teratomas be associated with thyrotoxicosis?
There may be some thyroid tissue in the teratoma.
What might a dermoid cyst look like on plain x-ray?
- Rim calcification.
- Calcification - tooth.
- Fat inside - different density.
What might granulosa cell tumours produce?
Oestrogen
What effects, might an oestrogen producing tumour have?
- Precocious puberty (early)
* PMB (post-menstrual bleeding)
What do thecal tumours produce?
Androgens
What might androgen production from thecal tumours lead to?
- Hirsutism - abnormal hair growth of a woman
* Virilisation - male growth patterns of a female
What syndrome is ovarian fibromas associated with?
Meig’s syndrome
Are the fibroma in Meig’s syndrome benign? Why are these still somewhat ‘dangerous’?
Yes - due to risk of pleural effusion
The ovary is a common site of metastatic disease. Cancers from where most often metastasise to the ovary?
- Breast
- Pancreas
- Stomach
- GI tract
What specific symptoms may ovarian cancer present with?
Mass, swelling, pressure
What happens early on in ovarian cancer?
Early transperitoneal spread (trans-coelomic)
Describe the early transperitoneal spread (trans-coelomic) in ovarian cancer.
- Deposits on all peritoneal surfaces.
- Omental disease/infiltration.
- Malignant ascites with protein exudate.
List symptoms which may occur in the rather varied presentation of an ovarian carcinoma.
- 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.
What % of ovarian cancers have a genetic basis?
5%
What should you always ask about in someone who is suspected of having ovarian cancer?
Family history
What are the 2 genetic predispositions of ovarian cancer?
- BRCA1 + 2 mutations breast and ovarian Ca.
* HNPCC (Lynch syndrome) bowel, endometrial, ovarian Ca + many others.
There is no screening proven to detect early disease of ovarian cancer
T :(
Give 3 risk factors for ovarian cancer?
- Increasing age.
- Nulliparity.
- Family history.
Having never had children before increases your risk of ovarian cancer
T
What is protective against ovarian cancer?
OCP
What 3 Ix’s are important in ovarian cancer?
- Hx and examination.
- Tumour markers.
- Imaging.
What 2 tumour markers are associated with ovarian cancer?
- CA 125
* Carcino-embryonic antigen (CEA).
What type of imaging is best for a cyst?
US
What is CT good for?
Assessing disease outwith the ovary, especially omental disease, peritoneal disease and lymph nodes.
CA 125 is associated with _______ cancer
Ovarian
In __% of ovarian cancers, CA 125 is raised
80%
Does a normal CA 125 exclude ovarian cancer?
NO !!!
Give examples of when CA 125 is moderately raised.
- Endometriosis.
- Peritonitis/infection.
- Pregnancy.
- Pancreatitis.
- Ascites from any cause e.g. liver disease.
- Other malignancies – gynae/non-gynae.
What is measuring CA 125 useful in?
Follow up of ovarian cancer (more than diagnosis)
SEROUS ovarian cancers secrete CA125, while mucinous types don’t
T
What ovarian cancers DONT secrete CA 125?
Mucinous
What do mucinous ovarian cancers secrete?
CEA
Mucinous ovarian cancers secrete CEA more than serous ovarian cancers
T
What is the main use of CEA?
To exclude mets from a GI primary.
What is the appearance of an ovarian cancer on US?
Complex mass with SOLID AND CYSTIC areas
How is the ‘risk of malignancy’ index in ovarian cancer calculated?
Menopausal Status x Serum CA125 x Ultrasound score
What should be done if someones ‘risk of malignancy’ index is high?
Refer to gynae cancer team
If a cyst/mass is benign, what is the management?
Removal or drainage
If a mass is benign ….
Remove or drain
If a mass in not benign …
- Removal of ovaries and uterus with removal/biopsy of omentum.
- ‘Debulking’ of tumour.
- Complete examination/inspection of all peritoneal surfaces
When is chemo done in a malignant mass?
Either pre-surgery or after surgery
Cure of an ovarian cancer is unlikely unless?
It is confined to ovary at presentation.
Bloatedness is a red flag if?
New onset in a post-menopausal woman
What should you do in a post-menopausal woman who presents with bloatedness?
- Do CA125.
* If CA125 if raised, do an ultrasound
What should you do if CA 125 is raised?
US !!!
A pelvic mass may present as an emergency with what?
An acute abdomen
What are the 2 groups of causes of acute presentation pelvic masses?
- Cyst ‘accident.’
* Fibrinoid degeneration.
Give examples of cyst ‘accidents’.
- Rupture (into pelvic cavity).
- Haemorrhage (into cyst).
- Torsion.
What is fibroid degeneration usually due to?
Red degeneration
What happens to blood supply in fibroid degeneration?
It is compromised
In what women is fibroid degeneration an emergency?
In pregnancy and peri-menopause
What nodes do lymph from the ovaries drain to?
Para-aortic nodes
Outline the journey of lymph drainage from the ovaries.
- Para-aortic nodes
- Coeliac nodes
- Epicardial
- Mediastinal nodes
Patients with ovarian cancer can often present with supra-clavicular or axillary nodes
T
When examing a mass from the pelvis, what should you always test?
If you can get below the mass
What 2 exams can be done?
- Speculum examination.
* Bimanual examination
How is the size of a mass described?
cm or ‘weeks gestation.’
How can the consistency of a ,ass be described?
soft, firm, hard, craggy, indurated, boggy, fluctuant
ALWAYS MEASURE ALBUMIN !!! If albumin is low then they are unlikely to have cancer
T
List the 4 main tumour markers that we can test for.
- CA125
- CEA
- HCG
- AFP
What is the main Ix that should always be done for a pelvic mass?
US
US + MRI for …
- Fibroids
* Uterine mass
US + CT for …
- Suspected ovarian cancer
What is the best treatment for ovarian cancer?
Open surgery (laparotomy)
