Week 6 - E - Pelvic Mass - Uterine (fibroids), Tubule, Ovarian (Tumours (benign/Malignant)& Non-Tumours (Functional&Endometriotic cysts)

Question 1

When considering pelvic masses, have to remember a lot of causes can be non-gynaecological causes eg things learnt from GI block or renal/urological block Listen a couple of these things?

Answer 1

GI

• * Bowel -
  
  • * constipation,
  • * caecal carcinoma,
  • * appendicular abscess,
  • * diverticular abscess
• Urological
  
  • * Urinary retention causing bladder distension
  • * Pelvic kidney

Question 2

Pelvic masses in gynaecology are usually due to a uterine, ovarian or tubal cause What is a non-pathological cause of uterine mass? What is the commonest cause of uterine mass?

Answer 2

A non-pathological cause of a uterine mass would be pregnancy Commonest cause of a uterine mass however would have to fibroids (uterine leimyoma)

Question 3

Name other causes of uterine masses

Answer 3

Endometrial cancer- presents early usually with post menopasual bleeding Cervical cancer - usually presents late (thats why screening is so important) - can be affecting renal function/bleeding/pain

Question 4

What stage of cervical cancer is where there may be a non-functioning kidney or hydronephrosis?

Answer 4

This would be stage IIIb of cervical cancer

Question 5

What are uterine fibroids? They are very common and at which age do they usually occur?

Answer 5

Uterine fibroids (leiomyomas) are benign tumours of the smooth muscle of the uterus usually occurring in those aged above 40

Question 6

What is the cancerous malignant smooth muscle tumour of the myometrium of the uterus that is very rare?

Answer 6

This would be the leimoyosarcoma - it is very rare and has a poor prognosis

Question 7

Fibroids are oestrogen dependent and therefore when do they tend to enlarge?

Answer 7

As they are oestrogen dependent, they tend to enlarge during pregnancy and if on the combined pill

Question 8

Fibroids start as lumps in the wall of the uterus but may grow to bulge Fibroids are generally classified by their location. There are three major types of uterine fibroids.- intramural, submucosal and subserosal State what each of the three mean? (can also get pedunculated fibroids and intracavitary fibroids but less commmon)

Answer 8

Intramural fibroids grow within the muscular uterine wall.

Submuscosal fibroids bulge into the uterine cavity (under the endometrium)

Subserosal fibroids project to the outside of the uterus (under the peritoneum)

Question 9

What is the presentation of uterine fibroids?

Answer 9

May be asymptomatic or May present with menorrhagia Pain/tenderness Also can have pressure symptoms

Question 10

What population are fibroids more common in? Why may it sometimes present with fatigue in women? When are the cases where pain in fibroids is said to be disproportional?

Answer 10

More common in the Afro-Carribean population Sometimes can present with fatigue if the women is anemic due to the blood loss Disproportional pain if red degeneration of the fibroid

Question 11

Red degeneration of the fibroid is when thrombosis of the capsular vessels is followed by venous engorgement and inflammation -leading to abdominal pain and localised peritoneal tenderness When does red degeneration of the fibroid end to occur?

Answer 11

Red degneration of the fibroid tends to occur mainly in pregnancy

Question 12

What are the investigations for uterine fibroids? What is the usual diagnostic test for uterine fibroids? What can be used to access more precise location of the fibroid?

What problems may large fibroids cause for young women?

Answer 12

• INvestigation - haemoglobin if lots of bleeding to check for anaemia in the women
• Usual diagnostic test is ultrasound - smooth echogenic mass
• MRI for more precise location

Uterine fibroids may cause fertility problems - natural IUCD

Question 13

What is the treatment of uterine fibroids?

Answer 13

No treatment required if asymptomatic, but follow-up should be scheduled annually.

If the womens family is complete then traditionally a hysterectomy is carried out

Usually myomectomy is the choice of treatment in subfertile women however

Question 14

What are alternative therapies for uterine fibroids in women who wish to preserve fertility but not undergo surgery? (generally in women where fertility is not an issue - hysterectomy) If the women is a non surgical candidate, what can be doen to shrink the fibroid and reduce the bleeding?

Answer 14

Can try medical therapy Eg GnRH agonist or Progestogens Uterine artery embolization

Question 15

Tubal swellings are the next causes of pelvic masses What are 4 different causes of tubal swellings?

Answer 15

Ectopic pregnancy Hydrosalpinx Pyosalpinx Paratubal cysts

Question 16

What is an ectopic pregnancy?

Answer 16

This is a pregnancy were the fertilized ovum impants outside of the uterus

Question 17

Wat are predispoing factors to an ectopic pegnancy? Where do the majority impannt? What is the clinical presentation?

Answer 17

Anything that slows the ovums passage in the tubal wall eg previous surgery, salpingitis (inflammation), PID - due to chlamydia or gonorrhea Majority implant in tubal site (97%) with most being in the ampulla Clincal presentation - always think of an ectropic pregnancy in a sexually active women with abdominal pain, bleeding or fainting

Question 18

Ectopic pregnancy is an emergency, how may it may diagnosed?

Answer 18

Urine pregnancy test to confirm pregnancy TVUS/TAUS to confirm the location of pregnancy If TVUS is negative for locating pregnancy, then serial blood HCG - HCG levels should double in 48 hours

Question 19

What is the emergency treatment for an ectopic pregnancy? What procedure? Is fallopian tube removed?

Answer 19

Would be

• * Laparatomy if shock from a ruptured ectopic pregnancy - this is because clamping the the bleeding is the only way to relieve the shock
• * Laparascopy is usually carried out if the pregnancy has not ruptured

Salpingectomy is usally carried out if the other fallopian tube is healthy

Salpingotomy if want to preserve fertility and other tube is unhealthy (removes the ectopic pregnnacy but the tube)

Question 20

What can be carried as medical management of an ectopic pregnancy ?

Answer 20

If an ectopic pregnancy is diagnosed early but active monitoring isn’t suitable, treatment with a medicine called methotrexate may be recommended. This works by stopping the pregnancy from growing. It’s given as a single injection into your buttocks.

Question 21

What is a hydrosalpinx?

Answer 21

This is adistally blocked fallopian tue that is now filled with clear or serous fluid

Question 22

The blocked tube may become substantially distended giving the tube a characteristic sausage-like or retort-like shape. The condition is often bilateral and the affected tubes may reach several centimeters in diameter. The blocked tubes cause infertility. What are symptoms of hydrosalpinx? WHat is the major cause of the disease?

Answer 22

Infertility is common Pelvic pain The major cause for distal tubal occlusion is pelvic inflammatory disease (PID), usually as a consequence of an ascending infection by chlamydia or gonorrhea

Question 23

Pyosalpinx is a hydrosalpinx but there is pus in the fallopian tube - usually seen as a acute part of pelvic inflammatory disease What is a paratubal cyst?

Answer 23

It is a usually small and incidental finding on a scan - due to embryological remnants A paratubal cyst is an encapsulated, fluid-filled sac. They’re sometimes referred to as paraovarian cysts. This type of cyst forms near an ovary or fallopian tube, and won’t adhere to any internal organ.

Question 24

Functional cysts and endometrial cysts are not ovarian tumours but can cause an ovarian mass as they are cysts What is a functional ovarian cyst?

Answer 24

A functional ovarian cyst is a cyst that forms during or after a women’s ovulation and is usually harmless It holds a maturing egg. Usually the sac goes away after the egg is released. If an egg is not released, or if the sac closes up after the egg is released, the sac can swell up with fluid.

Question 25

The two types of functional ovarian cyst are follicular or luteal What is the difference between follicular and luteal cysts? What is the usual size of the fucntional ovarian cyst?

Answer 25

Follicular cysts - these cysts form when a sac on the ovary does not release an egga dnt he sac fills with fluid Luteal cysts -this occurs when the sac realeases an egg and then reseals and fills with fluid Usually the functional cysts are about 3cm and rarely are greater than 5cm

Question 26

Most functional ovarian cysts do not cause symptoms and often resolve spontaneously. The larger the cyst is, the more likely it is to cause symptoms. How long do the functional cysts usually take to esolve? What can Symptoms can include if they are large or rupture?

Answer 26

The functional cysts usually take 2-3 menstrual cycles to resolve If they are large or rupture - they can cause pain, or bleeding

Question 27

If there is symptoms, USS may reveal the presence of a cyst, what may the treatment option be?

Answer 27

The treatmen tmay be removing the cyst via a laproscopy

Question 28

What is endometriosis?

Answer 28

This is the presence of endeometrium in the wrong place eg ovaries, rectovaginal pouch, distant organs

Question 29

What is it known as when foci of endometrial glandular tissue is found in the uterine wall muscle?

Answer 29

This would be adenomyosis

Question 30

Endometriosis can cause blood filled cysts on the ovaries known as endometriotic cysts What is this cysts described as?

Answer 30

It is described as a chocolate cyst - with every menstrual period, the endometrium proliferates, bleed and sloughs off forming a dark tarry carry - described as chocolate

Question 31

What are the typical features of an endometriotic cyst? (endometrioma)

Answer 31

Usually ultrasound will be used to identify the cyst and patient presents with

• Severe dysmenorrhea, premenstrual pain, dysparenuia and often subfertility
• Occasionally asymptomatic until large chocolate cyst, which may rupture.

Question 32

Treatment option for ovarian endometriomas can include hormonal suppressive therapies to minimally invasive surgery to remove the entire cyst (cystectomy) What are the usual medical treatment options?

Answer 32

Usually Gonadotrophin releasing Hormone analogues or Combine dpill to hopefully suppress ovualtion during which lesions will atrophy

Question 33

Primary ovarian tumours can be benign or malignant They can arise from surface epithelium, germ cells and stroma What are benign tumours arising from the ovarian epithelial cells known as? What are the malignant tumours arising from here known as?

Answer 33

Bengin epithelial tumours - cystadenoma Malignant epithelial tumours - cystadenocarcinoma

Question 34

Name some different types of tumours arising from the epithelium? (there are 5 in total) These can be malignant or benign

Answer 34

Serous Mucinous Endometrial Clear cell (also Brenner)

Question 35

Listen primary ovarian tumours that can arise from surface epithelium (cystadenoma = benign, cysadenocarcinoma = malignant) (can be serous, mucinous, endometrial, clear cell or Brenner) Tumours arising from germ cells can also be benign or malignant (teratoma is a group of germ cell tumours) WHat is the most common benign tumour? Is mature or immatue teratoma benign?

Answer 35

Benign cystic teratoma - where dermoid cysts are the most common Mature teratomas are benign and immature teratomas are cancerous

Question 36

Primary ovarian tumours may also arise form the stroma If from the granulosa what may the tumorus secrete? If from the theca/leydig cells what may the tumour secrete? What is the triad known as where tumours arise form the stroma - triad is benign ovaran tumour (usually a fibroma), pleural effusion and ascites

Answer 36

If tumours arise from the granulosa - these tumours can secrete oestrogen Tumours arising from the thecal/leydig cells can secrete androgens Ovarian tumour (usually a fibroma), pleural effusion and ascites - Meigs syndrome

Question 37

Sex cord–gonadal stromal tumour (or sex cord–stromal tumour) is a group of tumors derived from the stromal component of the ovary and testis, which comprises the granulosa, thecal cells and fibrocytes. In contrast, the epithelial cells originate from the outer epithelial lining surrounding the gonad while the germ cell tumors arise from the precursor cells of the gametes, hence the name germ cell. * How does MEig’s sydnrome resolve? * How does it arise again?

Answer 37

Meig’s syndrome arises from a benign ovarian tumour (usually ovarian fibroma) + ascites + pleural effusion The symptoms resolve upon tumour resection - usually unilateral salpino-oopherectomy plus drain the fluid - thoracocentesis and paracentesis

Question 38

Malignant germ cell tumours may may produce different tumours markers, what might this be? Dermoid cysts are thought to be totipotential as they arise from the germ cells (It is a benign mature teratoma) What age group are they most common in and what may these mature (well differentiated) tumour contain?

Answer 38

Maligannt germ cell tumorous - may produce bHCG or AFP Dermoid cysts - benign mature teratomas that are well differentiated - may contain hair, teeth etc or thyroid tissue They are more common in young women

Question 39

What may granulosa cell tumours produce? What may they cause in women? What may thecal/leydig cell tumours produce? What can this lead to in the women?

Answer 39

Granulosa cell tumours may produce oestrogen

• * Could cause precocious puberty (Puberty occuring before age 8 in girls (9in boys) )
• * Could also cause post-menopsaual bleeding

Depends when the tumour arises

• Thecal/Leydig cell tumours may secrete androgens (which will become tesosterone) - this can lead to hirsituism and even worse virilization

Question 40

Why is it that ovarian carcinoma is the 5th commoenst cancer releated deah in females of the UK?

Answer 40

This is because ovarian carcinomas cause few symptoms until they have metastasised usually - often to pelvis with peritoneal and omental seedings

Question 41

Secondary ovarian masses are common as ovaries are a common site of metastases Where is it common for the ovarian metastases to come from?

Answer 41

Breast, pancreas, stomach and colon

Question 42

This is a primary ovarian tumour that has been removed What is it showing here?

Answer 42

This is a dermoid cyst (benign cystic teratoma) Can see as it has hair - dermoid cysts are totipotent

Question 43

What may thyroid tissue in a dermoid cyst cause? What is the type of ovarian tumour that contains maiinly thyroid tissue and can therefore cause thyrotoxicosis?

Answer 43

May cause thyrotoxicosis - thyrotoxicosis is the increase in thyroid hormone due to any cause (usually due to hyperthyroidism) Struma ovarii - rare type of ovarian tumour that is composed mainly of thyorid tissue

Question 44

How may ovarian cancer present?

Answer 44

May present with swelling, mass pressure, unexplained weight loss The symptoms are often vague

Question 45

There is usually early transperitoneal spread of ovarian cancer (transcoelomic) Where do the tumours depositis usually occur? Different tumour markers are meaured in ovarian cancer, why is it that bHCG and AFP are also measured in women under 40?

Answer 45

Ovarian cancer depositis are often on the omentum and peritoneum bHCG and AFP should be measured if suspecting ovarian cancer in patients under 40 to identify women who may not ovarian epithelial cancer (ovarian carcinoma)

Question 46

Why might the ovarian cancer cause bloating or pressure symptoms or change of bowel habit? Or SOB/Pleural effusion?

Answer 46

First of all could have metastases The ovarian cancer could be a significantly sized mass putting pressure on the bladder or rectum or diaphragm to cause these symptoms Also Meig’s syndrome for pleural effusion

Question 47

Genetics of ovarian cancer Only 5% cases have genetic basis But always ask re family history Name the genetic mutations linked to ovarian cancer?

Answer 47

* BRCA1 and BRCA2 mutations - breast and ovarian cancer * HNPCC - Hereditary Non-Polyposis Colorectal Cancer - Lynch Syndrome * Can cause cancers of colon, endometrium, ovary and others

Question 48

What are risks factors for ovarian cancer?

Answer 48

Risk factors * Null parity/late menopasue - those with many ovulations * Increasing age * Family history

Question 49

What factors may reduce the risk of ovarian carcinoma?

Answer 49

Using the combined oral contraceptive pill Reduces the risk by 20% every 5 years (max of 50% reduction in 15 years) - COC decreases risk of endometrial, ovarian and colorectal cancer (increases risk of breast and cervical)

Question 50

After history and examianation - probs a GI and a vaginal examiantion What tumour markers are usually measured for investigating suspected ovarian cancer?

Answer 50

CA-125 Carcino embryonic antigen (CEA)

Question 51

CA-125 is raised in 80% of ovarian cancers Normal levels do not excuse the diagnoses What does measuring CA-125 help you to calculate? When else can CA-125 be elevated and therefore not an accurate test for diagnoses?

Answer 51

Helps calculate the Risk of Malignancy Index (RMI) Might be elevated in endometriosis, pregnancy, pancreatitis CA-125 levels are most useful after a histological diagnosis of ovarian cancer. CA-125 can be followed to assess disease recurrence as well as response to treatment.

Question 52

CEA (carcino embryonic antigen) may be slightly raised in ovarian cancer What is the main function of measuring this?

Answer 52

The main function of measuring CEA is to exclude metastases from GI primary cancers

Question 53

What imaging techniques are used for assessing suspected ovarian cancer?

Answer 53

USS - better for imaging the nature of the cyst When a pelvic mass is detected on physical examination, transvaginal ultrasound is the preferred imaging modality. Furthermore, ultrasound can characterise the mass (e.g., solid, cystic, complex) and Doppler flow can also be assessed. Ovarian cancers tend to have increased DOppler flow CT or assessing the disease outwith the ovary

Question 54

On USS, what findings are suspicious of ovarian cancer?

Answer 54

* Complex mass with a solid and cystic area * Multi-loculated * Associated ascites * Bilateral disease * Intra-abdominal mets

Scan on left -multiloculated, thick sspetations, (maybe solid and cytsic area)

Question 55

Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer. If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis. If TVUS is also suggestive of ovarian cancer then calcuate what?

Answer 55

Calculate the Risk of Malignancy index = Menopausal status x Serum CA125 x Uultrasound score If RMI elevated refer to gynae cancer team.

Question 56

What is an elevated RMI score? If the ultrasound, serum CA125 and clinical status suggest ovarian cancer, what is carried out in secondary care?

Answer 56

RMI score of greater than 250 then refer to gynaecology If ultrasound and serum CA125 suggestive, carry out a CT scan to asses for any spread of disease

Question 57

RMI I = U x M x CA125

• * The ultrasound result is scored 1 point for each of the following characteristics: multilocular cysts, solid areas, metastases, ascites & bilateral lesions.
• U = 0 (for an ultrasound score of 0), U = 1 (for an ultrasound score of 1), U = 3 (for an ultrasound score of 2–5). *
• The menopausal status is scored as 1 = pre-menopausal and 3 = post-menopausal.
• * Serum CA125 is measured in IU/ml and can vary between 0&hundreds or even thousands of units.

How is postmenopasual defined?

Answer 57

Postmenopasual means the woman has not had a period for a year or a woman over 50 with a hysterectomy

Question 58

Treatment of an ovarian mass How is it treated if it is likely that the mass is benign? On the left is an image of a simple cyst shown - very large

Answer 58

If it is very likely that the mass is benign - then removal or drainage is usually the treatment option

Question 59

Laparoscoy may distinguish a cyst from an ectopic pregnancy if unsure IF there is a possibility that the ovarian mass is a tumour, it is not appropriate to take a biopsy of the ovarian cancer, why is this?

Answer 59

This is because seeding of the cancer along the surgical tract may occur and therefore you may spread the cancer

Question 60

If it is suspected that it is ovarian cancer, usually surgery is the option and the surgery removes as much of the tumour as possible at which point the tissue diagnosis is carried out WHat procedure is used to remove the tumour?

Answer 60

Usually laparotomy

Question 61

Ultimately, the diagnosis of ovarian cancer is based on histopathology, which is the definitive test. Usually, surgical extirpation of the affected ovary is necessary (as opposed to biopsy), or paracentesis or thoracentesis of peritoneal/pleural fluid. Biopsy elevates the risk of cancer cell spillage into the abdominal cavity. Thus, the presence of a complex ovarian mass should warrant referral to a gynaecological oncologist prior to surgical evaluation. What is usually given after surgery?

Answer 61

It is ususal to follow up the surgery with chemo-therapy post-op

Question 62

What is asked in the history?

Answer 62

* Speed of onset/duration of all symptoms * Mass/swelling/bloatedness * Pressure symptoms (bladder/bowel) * Pain (with periods/between periods/dyspareunia) * Menstrual history (heaviness,cycle, unscheduled) * Cervical smear history * Parity and fertility problems. * Family history. * Previous gynaecological and surgical history. * Ovarian cancer symptoms - basically Socrates

Question 63

What are the main things looked at on ultrasound again? What tumour markers are measured and why?

Answer 63

USS scan - Mutlilocular mass, intra-abdominal mets, complex mass with solid and cystic area, associated ascites, bilateral disease * CA125 - associated with ovarian cancer - if greater than 35IU/ml then refer for USS (This is a protein that is a so-called tumor marker or biomarker,) * Carcinoembryonic antigen - excludes GI primary * bHCG and AFP - measure in under 40s to rule out non overian epithelial carcinomas