Week 6-pelvic mass Flashcards
Name some non-gynaelogical causes of pelvic mass?
Bowel- constipation, caecal carcinoma, appendix abscess, diverticular abscess
Bladder-Urinary retention, pelvic kidney
Other- retroperitoneal tumour.
What are some causes of uterine masses?
Pregnancy Fibroids (commonest)
Endometrial cancer- usually presents early PMB therefore pelvic mass is unusual.
Cervical cancer- only in late presentation +/- renal failure, bleeding and pain.
What is the other name for uterine fibroids?
Leiomyomas- benign smooth muscle tumours.
Who gets uterine fibroids?
They are very common, especially in the over 40’s.
This is how uterine fibroids are classified.
How do uterine fibroids present?
May be asymptomatic/incidental finding
or
Menorrhagia
Pelvic mass
Pain and tenderness- not usually disproportionate. This usually only happens if something compromises the blood supply e.g. in pregnancy or menopause- called red degeneration.
Pressure symptoms e.g. press on the bladder. Present with nocturia, frequency and pressure.
How would you investigate suspected fibroids?
Hb if heavy bleeding
Ultrasound is usually diagnostic- seeing a smooth echogenic mass-often multiple.
MRI to precisely locate.
Fibroid on MRI
Multiple fibroids on MRI
How would you treat fibroids?
Expectant if they are asymptomatic.
Otherwise traditionally do hysterectomy if the family is complete.
Alternatively-
- myomectomy (remove the fibroid)
- Uterine artery embolisation (disrupt their blood supply)
- Hysteroscopic resection
What are some causes of tubal swellings?
Ectopic pregnancy
Hydrosalpinx
Pyosalpinx
Paratubal cysts.
What symptoms/signs would be present in an ectopic pregnancy?
Empty uterus
Pain
Bleeding
May detect adenexal mass on USS.
What is hydrosalpinx?
A distally blocked fallopian tube with serous or clear fluid. The blocked tube may become substantially distended giving it a sausage like appearence.
It can be longstanding or acute. Usually due to pelvic infection- mucous secreted in the lining of the tube builds up due to infection blocking.
What is pyosalpinx?
The fallopian tube is filled/blocked with pus. Its generally acute or inflammatory.
This is usually when the hydrosalpinx becomes infected.
What are paratubal cysts?
Fluid filled sac (cyst) growing beside the ovaries. They are usually small and incidental (can be due to embryological remnants).
What are the broad categories of causes of ovarian masses?
Tumours- benign or malignant
Non tumours- Functional cysts (cysts related to ovulation), endometriotic cysts.
What are functional cysts related too?
Ovulation- follicular cysts or luteal cysts.
How do you manage functional cysts? Do they present with symptoms?
Usually they are asymptomatic/incidental findings. However they bleed or rupture which can cause pain.
They usually resolve spontaneously but expectant management is appropriate.
What are endometriotic cysts also known as?
Endometriosis.
What are blood filled ovarian endometriotic cysts known as?
Chocolate cysts.
What symptoms are associated with endometriosis?
Typically associated with dyssmenorrhoea, premenstrual pain and dyspareunia.
Typically a tender mass with nodularity and tenderness behind the uterus.
(NOTE- they are occasionally asymptomatic until a large chocolate cyst rupture).
NOTE- think about which layer these tumours arise from. All in previous lecture but this is for revision.
What may malignant germ cell tumours secrete?
May secrete HCG or AFP. Will give a false positive pregnancy test.
What may a dermoid cyst rarely present with?
Thyrotoxicosis (if it has thyroid tissue).
What may granulosa cell tumours secrete? What can this cause?
May secrete oestrogen leading to precocious puberty (early puberty), PMD.
What might thecal/leydig tumours produce?
May secrete androgens. Leading to hiurtism and virilisation.
What is Meigs syndrome?
Pleural effusion and ascites caused by benign ovarian tumour (fibroma)
Which types of tumours commonly metastasise to the ovary?
Breast
Pancreas
Stomach
GI primaries
This is what was explained in the last few cards from the lecture.
This shows a dermoid cyst on Xray. YOu can see the calcified rim, with fat density inside and a small area of calcification (a tooth).
How does ovarian cancer present?
May be a mass, swelling or pressure
Early transperitoneal spread-deposits on peritoneal surfaces, omental disease, malignant ascites.
Insidious symptoms
In the image are some varied presentations of ovarian cancer.
What percentage of ovarian cancer cases have a genetic cause?
Only 5%.
BRCA 1 and 2 cause which types of cancer?
Breast and ovarian.
Lynch syndrome causes which type of cancers?
Bowel
Endometrial
Ovarian
and more.
What is protective against ovarian cancer?
The oral contraceptive pill.
What are risk factors for ovarian cancer?
Nulliparous
Family Hx
Increasing age.
How would you investigate ovarian cancer?
Hx and exam
Tumour markers-CA125, carcino-embryonic antigen (CEA)
Imaging-USS better for imaging nature of the cyst
CT better for assessing disease outwit the ovary e.g. omental, peritoneal, lymph nodes.
When is CA 125 raised?
Does a normal level exclude cancer?
Raised in 80% of ovarian cancers. However a normal level does not exclude cancer.
When is CA 125 moderately elevated?
Endometriosis
Peritonitis/infection
Pregnancy
Pancreatitis
Ascites from any cause e.g. liver disease
Other malignancies- gynae/non gynae
Which ovarian cancer doesnt secrete CA 125?
Mucinous doesnt.
NOTE- upper level of CA 125 is about 30. If someone has a level of over 1000 they are likely to have cancer. However things like endometriosis can put it up to about 150.
When is CEA elevated?
What is its main function?
May be moderately elevated in ovarian tumours esp mucinous tumours.
Main function is to exclude metastasis from the GI system.
What is the risk of malignancy index (RMI)?
What do you do if RMI is elevated?
Menopausal status x serum Ca125 x USS score.
If RMI is elevated, refer to gynae.
This shows a simple ovarian cyst.
This shows a multi-loculated ovarian cyst.
How do you treat ovarian cysts/masses?
Removal or drainage if its likely to be benign
Otherwise- removal of ovaries and uterus with removal/biopsy of omentum, debulking of tumour and complete examination/inspection of all peritoneal surfaces.
Chemotherapy may be given pre or post surgery
Cure is unlikely unless confined to ovary at presentation.
What are the likely causes of acute presentation with pelvic mass?
Cyst accident- rupture or haemorrhage or torsion
Fibroid- usually red degeneration due to compromised blood supply, seen in pregnancy and peri-menopause.
