Pelvic Masses

Question 1

List some non-gynaecological causes for a pelvic mass.

Answer 1

constipation, caecal carcinoma, appendix abscess, diverticular abscess
urinary retention
retroperitoneal tumour
ascites (non-gynae cause)

Question 2

List some gynaecological causes for a pelvic mass.

Answer 2

pregnancy
uterine: benign & malignant
adnexal masses: benign & malignant

Question 3

A patient presents with a adnexal mass and mentions a FH of breast and prostate cancer. What mutation are you thinking of?

Answer 3

BRCA mutation

Question 4

Tumour markers for germ cell cancers?

Answer 4

LDH, AFP and HCG

Question 5

Tumour markers for serosal masses?

Answer 5

Ca125

Question 6

Which cells produce Ca125?

Answer 6

mesothelial cells

Question 7

What does RMI include?

Answer 7

menopausal status (pre or post)
ultrasound features of ovary 
serum Ca125

Question 8

If patient’s RMI >200, what are their chances of ovarian cancer?

Answer 8

3/4

Question 9

Describe the points system for RMI.

Answer 9

menopausal status: 1 for pre and 3 points for postmenopausal
USS: one feature gets 1 pint and >1 feature gets 3.
Serum 125 is taken by its absolute level

Question 10

What is the formula for RMI?

Answer 10

menopausal status x USS features x Ca125

Question 11

If you wanted to identify the contents of an abdominal cyst, which imaging modality would you use?

Answer 11

MRI - able to identify if contents of cyst are solid, fluid, endometrioma, PCOS and if cancer, shows invasion to surrounding structures.

Question 12

Meig’s syndrome

Answer 12

benign ovarian fibroma associated with ascites ± pleural effusion

Question 13

Functional ovarian cysts - management?

Answer 13

rarely >5cm, usually resolve spontaneously so expectant management is appropriate.
Often asymptomatic but occasionally menstrual disturbance or pain if rupture or bleeds.

Question 14

Patient presents with what you suspect as endometriosis. You perform bimanual exam - what do you expect to feel?

Answer 14

Tender mass with modularity and tenderness behind the uterus.
Might not be tolerated by patient due to severe pain

Question 15

30 y/o nulliparous patient presents with severe period pain which begins before she bleeds and continues through menstruation. She has also recently been having pain during sex.
Diagnosis and treatment?

Answer 15

endometriosis/endometrioma

Medical - GnRH analogues, OCP, NSAIDs for pain

Surgical excision/ablation if she wants to have children and doesn’t want to take OCP.

Question 16

Ovarian tumours of which type arise from surface epithelium? (benign and malignant)

Answer 16

serous
mucinous
endometrioid
brenner 
clear cell

Question 17

Name for benign cystic teratoma?

Answer 17

dermoid cyst

Question 18

Tumours arising from granulosa cell might secrete what?

Answer 18

oestrogen

Question 19

Tumours arsing from theca/leydig cells may secrete what?

Answer 19

androgens

Question 20

Ovaries are a common site of metastatic disease. Which primary tumours often metastasises there?

Answer 20

breast, pancreas, stomach, GI

Question 21

Patient has metastasis of their primary cancer to their ovaries. Histology shows characteristic signet ring cells - where is the primary tumour?

Answer 21

usually stomach

= Kruckenberg tumour

Question 22

40 y/o woman presents with intermenstrual bleeding, painful periods and backache. Abdomen is slightly tender on palpation in centre but main finding is on bimanual palpation when you feel a small mass in the posterior uterus.
Diagnosis and treatment options?

Answer 22

uterine fibroids - leiomyoma

medical - GnRH analogue, Mirena coil, progestins (ullipristal acetate max 3 months use; norethisterone tablets temporary stop to excessive menstrual bleeding)

surgical - laparoscopic myomectomy

Question 23

List some of the presentations of ovarian cancer.

Answer 23

heartburn/indigestion
early satiety
weight loss/anorexia
bloating
'pressure' symptoms (esp. bladder)
change of bowel habit 
SOB/pleural effusion
leg oedema or DVT

Question 24

Does a normal level of Ca125 exclude cancer?

Answer 24

No normal level does not exclude cancer

Question 25

Patient has recently been diagnosed with malignant cystic teratoma. What are the treatment options available?

Answer 25

fertility sparing, unilateral salpingoopherectomy ± chemotherapy

Question 26

In which ovarian cancer subtype is only surgery sufficient as treatment?

Answer 26

stage 1A mucous serous epithelial

Question 27

What is the aim of surgery in ovarian cancer?

Answer 27

total macroscopic debunking of tumour

tumour debunking is one of the most important factors in prognosis

Question 28

What is optimal cytoreduction?

Answer 28

where no visible disease is left behind following laparotomy

Question 29

What is optimal surgical staging?

Answer 29

midline incision to allow palpation of all peritoneal surface.
Assessment of peritoneal cytology, hysterectomy, bilateral removal of ovaries and fallopian tubes and infra-colic omenectomy

Question 30

What should be avoided during surgery in early disease (disease within ovaries)?

Answer 30

capsular rupture during surgery should be avoided

Question 31

Who gets optimal surgical staging?

Answer 31

patients getting surgery in early disease - when it is still confined by ovaries

Question 32

What FIGO staging is disease which has spread beyond the pelvis?

Answer 32

FIGO III and IV

Question 33

What are the 2 options when treating advanced disease surgically?

Answer 33

aggressive cytoreduction - aim to leave no residual disease

cytoreduction - residual deposits are no >1cm diameter

Question 34

Why is a low level of albumin significant for pelvic masses?

Answer 34

low albumin makes you worried about ovarian cancer - protein loss into ascites

Question 35

Difference between fibroma and fibroid?

Answer 35

fibroma is benign tumour of stroma

fibroid is benign tumour of smooth muscle

Question 36

Teenager presents with large 20-30cm ovarian mass.

What are your initial thoughts/diagnosis?

Answer 36

MALIGNANT
germ cell tumour probably
malignant cystic teratoma or dysgerminoma