pelvic + ovarian masses Flashcards
what is a functional cyst?
- cyst related to ovulation
- rarely >5cm
- usually resolve spontaneously
- often asymptomatic/incidental finding
when is a functional cyst considered a differential?
- in acute abdomen
- as they can bleed or rupture
how does an endometriotic cyst present?
- severe dysmenorrhea/premenstrual pain
- dyspareunia
- assoc w sub-fertility
- occasionally asympomatic
-> acute abdomen ddx if it ruptures
endometriotic cyst findings on examination?
- tender mass w modularity
- tenderness behind uterus
dermoid cyst is described as totipotential what does this mean?
- cells that can give rise to cells of all types
what kind of contents can be in a dermoid cyst?
- teeth
- sebaceous material
- hair
- thyroid tissue -> thyrotoxicosis
what is the treatment of benign ovarian tumours?
- conservative
- medical - GNRH analogues, OCP
- surgical - laparoscopic/laparotomy
what are some different surgical options for benign ovarian tumours
- ovarian cystectomy
- unilateral oophorectomy
- bilateral oophorectomy
- pelvic clearance
what is the role of GNRH analogues in the treatment of ovarian tumours?
- GnRH is a hormone produced by hypothalamus that stimulates production of FSH and LH
- it is also involved in regulation of proliferation and mets of ovarian cancer
- GnRH acts directly on GnRH receptors on surface of ovarian cancer cells
- GnRH analogues block release of gonadotrophins - therefore suppressing ovarian growth/proliferation
in borderline ovarian tumours in young women what is typical tx?
- unilateral cystectomy/oopherectomy w close follow up
- laparoscopic techniques - avoid laparotomy
in borderline ovarian tumours in postmenopausal women what is typical tx?
- pelvic clearance
what is in the anterior compartment of the pelvis?
- bladder
what is in the middle compartment of the pelvis?
- uterus
what is in the posterior compartment of the pelvis?
- bowel
what is in the lateral compartment of the pelvis?
- adnexae
name some types of tubal masses?
- hydrosalpinx, ectopic px, tuboovarian abscess
what is the top DDx for pelvic masses?
- pregnancy
name some other ddx for pelvic masses other than pregnancy?
- bladder tumours
- bladder distension
- uterine fibroids
- adenomyosis
- carcinosarcoma
- leiomyosarcoma
- cervical cancer - hematometra/pyometra
- ovarian mass - benign or malignant
- tubal mass
- bowel tumour
- appendiceal mass
- hernia
- diverticular abscess
- pelvic kidney
- ascitis
in a women presenting with bleeding as main symptom where is origin?
- uterine
in a women presenting with pain as main symptom where is origin?
- ovarian
in a women presenting with pressure symptoms as main symptom where is origin?
- uterine or ovarian
long term symptoms (months/years) in a women w a pelvic mass what does this usually mean?
- benign aetiology
short term symptoms (weeks) in a women w pelvic mass what does this usually mean?
- acute aetiology
- examples inlcude torsion, rupture, haemorrhage
women presenting w possible pelvic mass, doubling pain with nausea indicates what kind of scenario?
- acute scenario
- seek help immediately!
a midline, lobulated mass, moves w cervical motion, non-tender is situated where?
- uterine origin
lateral, occupying fornices, no movement w cervical motion, can be tender is located where?
- ovarian origin
smooth, mobile mass can suggest what?
- benign mass
cachexia, ascites, craggy mass, not mobile can suggest what kind of pathology?
- malignant
tender abdomen, rebound tenderness, guarding, exquisite cervical excitation can suggest what?
- acute presentation
38 year old women, pelvic mass, long standing menorrhagia
O/E midline mass, 16 weeks size, moves w cervical motion and non-tender on examination?
- uterine fibroids
-> uterine origin due to description of mass…
38 year old women, pelvic mass, pain on RS assoc w dyspareunia and dysmenorrhoea
O/E 6cm mass in right fornix, does not move w cervical motion
- adnexal mass (area next to uterus)
what imaging is recommended for suspected ovarian masses?
- USS
what imaging is recommended for fibroids?
- MRI
what invesitgations is recommended for premenopausal ovarian cysts?
- MRI, tumour markers CA125 and AFP, HCG, LDH
what investigations is recommended for postmenopausal ovarian masses?
- CT and CA125
38 y/o women, pelvic mass, RS pain, dyspareunia, dysmenorrhoea
2 days - more intermittment, more pain, and nauseus
O/E tender in RIF, rebound tenderness, 6cm mass in R fornix, does not move w cervical motion, cervical exciation present
- adnexal mass - acute mass
what benign conditions can CA125 be raised?
- endometriosis
- benign ovarian cysts
- uterine leiomyomata (fibroids)
why is CA125 tumour marker important
- can indicate ovarian cancer
- if >35 IU/ml or above usually recommended US of pelvis
what other tumour markers are important in women <40 when Ix a pelvic mass?
- AFP - raised in embryonal carcinoma
- HCG - raised in choriocarcinoma
- LDH - raised in dysgerminoma
what can a raised AFP indicate?
- embryonal carcinoma
what can a raised HCG indicate?
- choriocarcinoma
what can a raised LDH indicate?
- dysgerminoma
name some malignant features present on USS?
- irregular solid tumour M1
- presence of ascites M2
- at least 4 papillary structures M3
- irregular multilocular-solid tumour w largest tumour > 100mm M4
- very strong blood flow M5
what is RMI?
- risk of malignancy index
- useful to estimate risk of malignancy
- based on CA125, menopausal status, US score
1 point for:
- multi-locular cysts
- solid areas
- metastases
- ascites
- bilateral lesions
how do you calculate RMI?
RMI = U x M x CA-125
what is some benign features on USS?
- unilocular cysts
- presence of solid components where largest solid component < 7mm
- presence of acoustic shadowing
- smooth multi-locular tumour w largest diameter - <100mm
- no blood flow
what is mx for pre-menopausal simple cyst 30-50mm?
- likely physiological, do not require follow up
- almost always resolve within 3 cycles
what is mx for pre-menopausal women w simple ovarian cyst 50-70mm?
- yearly US follow up
what is the mx for pre-menopausal wojmen w larger simple cyst?
- consider MRI or surgical intervention
mx for endometrioma?
- laparoscopic cystecomty
what are the 3 types of fibroids/leiomyomas?
- subserosal
- intramural
- submucosal -> smooth muscle tumours, usually benign
where are intramural fibroids located?
- are located within uterine wall
- become transmural fibroids - when they span from outer serosal surface through uterine wall all the way to endometrium
- assoc w reduced fertility outcomes
where are submucosal fibroids located?
- intramural fibroid where part of fibroid projects into uterine cavity and another part in myometrium
- grow just underneath uterine lining (endometrium) can reduce embryo implantation
where are subserosal fibroids located?
- grow on outside of uterus
- fewer reproductive consequences because of this
- however some can put pressure on abdomen, bladder, or rectum (fullness ie pregnancy symptoms, bloating, pelvic pressure, urinary urgency, or constipation)
suspect metastatic ovarian masses if CA125/CEA is below?
<25
