10. Pelvic masses Flashcards
(46 cards)
1
Q
Pelvic masses are common and can be found in females at what age? (1)
A
at any age (fetal to postmenopausal).
2
Q
Pelvic masses may originate from what? (2)
A
- gynecologic organs (ovary, fallopian tube, cervix, or uterus)
- or from other nongynecologic pelvic organs (bowel, bladder, ureters, skeletal muscle, or bone)
3
Q
The key objectives when investigating a woman with a pelvic mass are determination of what? (2)
A
- Their pregnancy status (b-hCG testing)
- Whether the mass is gynecologic versus nongynecologic
4
Q
Name PREPUBERTAL OVARY DDx of pelvic mass (4)
A
- Benign simple ovarian cysts (i.e., germinal inclusion cyst, paraovarian cyst)
- Dermoid cysts (benign cystic teratoma)
- Malignant germ cell tumors
- Dysgerminoma
- Yolk sac/endodermal sinus tumors
- Embryonal carcinomaa
- Granulosa cell/Sertoli-Leydiga
- Gonadoblastomas (rare)
5
Q
Name PREPUBERTAL FALLOPIAN TUBE DDx of pelvic mass (2)
A
- Peritubular cyst
- Congenital cysts
- Mesonephric
- Paramesonephric
6
Q
Name PREPUBERTAL UTERUS DDx of pelvic mass (1)
A
Uterine anomaly (bicornuate uterus, uterus didelphys)
7
Q
Name PREPUBERTAL NON-GYNECOLOGIC DDx of pelvic mass (3)
A
- Pelvic kidney
- Distended bladder
- Appendiceal abscess
8
Q
Name REPRODUCTIVE OVARY DDx of pelvic mass (7)
A
- Functional ovarian cysts (follicular, corpus luteum, thecal lutein, hemorrhagic)
- Polycystic ovaries
- Endometrioma
- Luteoma of pregnancy
- Benign neoplasm (such as dermoid or fibroma)
- Borderline epithelial ovarian tumors
- Malignant epithelial and germ cell tumors
- Serous
- Mucinous
- Endometrioid
- Clear cell
- Teratoma (solid/cystic)
- Choriocarcinomaa
- Polyembryonic CAa
- Endodermal sinus/yolk sac (rare)
- Granulosa cell /Sertoli-Leydiga
9
Q
Name REPRODUCTIVE FALLOPIAN DDx of pelvic mass (7)
A
- Ectopic pregnancy
- Tubo-ovarian abscess
- Hydrosalpinx/ pyosalpinx
- Embryologic remnant cysts
- Mesonephric
- Paramesonephric
- 1° fallopian tube neoplasm
10
Q
Name REPRODUCTIVE UTERUS DDx of pelvic mass (6)
A
- Pregnancy
- Adenomyoma
- Leiomyoma (fibroid)
- Hematometra/ pyometra
- Endometrial CA (rare)
- Leiomyosarcoma (rare)
11
Q
Name REPRODUCTIVE NON-GYNECO DDx of pelvic mass (7)
A
- Distended bladder
- Appendiceal abscess
- Diverticular disease
- Pelvic kidney
- Redundant sigmoid colon
- 1°CA (rectal, colon, or bladder)
- Metastatic CA (breast, colon, lung)
12
Q
Name POST-MENOPAUSE OVARY DDx of pelvic mass (4)
A
Malignant neoplasms
- Epithelial cell tumors
- Cystadenocarcinomas (serous or mucinous)
- Endometrioid
- Clear cell
- Sex cord neoplasms
- Granulosa cell tumora
- Sertoli-Leydig cell tumora
- Metastases (i.e., Krukenberg tumor from GICA)
Benign neoplasms (rare) - thecoma or fibromas
13
Q
Name POST-MENOPAUSE FALLOPIAN TUBE DDx of pelvic mass (4)
A
- Tubo-ovarian abscess
- Hydrosalpinx/pyosalpinx
- Embryologic remnant cysts
- Mesonephric
- Paramesonephric
- 1° fallopian tube neoplasm
14
Q
Name POST-MENOPAUSE UTERUS DDx of pelvic mass (5)
A
- Endometrial CA
- Leiomyosarcoma (rare)
- Adenomyoma
- Leiomyoma ( broid)
- Hematometra/ pyometra
15
Q
Name POST-MENOPAUSE NONGYNECOLOGIC DDx of pelvic mass (7)
A
- Distended bladder
- Appendiceal abscess
- Diverticular disease
- Pelvic kidney
- Redundant sigmoid colon
- 1°CA (rectal, colon, or bladder)
- Metastatic CA (breast, colon, lung)
16
Q
Describe: Approach to the Dx of pelvic mass. (Figure)
A
17
Q
Describe: Approach to the management of ovarian cysts (Figure)
A
18
Q
Name Features of Androgenization (7)
A
- Prepubertal age:
- Clitoromegaly (> 5 mm wide)
- Hirsutism
- Reproductive age:
- Hirsutism
- Acne and/or seborrhea
- Alopecia
- Deepening of voice
- ↑ Muscle bulk
19
Q
Name Features of Estrogenization (2)
A
Prepubertal age:
- Premature menarche
- Precocious puberty (advanced Tanner staging)
20
Q
Describe Approach to the management of uterine leiomyomas (Figure)
A
21
Q
Describe: Symptomatic leiomyomas (2)
A
- ~ 40%
- Abnormal uterine bleeding (AUB), pressure/ compromise of pelvic organs → ↑ irritative voiding Sx (UTI), ↑ abdo size, acute pelvic pain due to fibroid torsion or degeneration, infertility.
22
Q
Describe: Asymptomatic leiomyomas (4)
A
- ~60%
- minimal or no Sx
- fibroid <6 cm or stable size
- not located in submucosa
23
Q
Name structures
A
24
Q
Describe HPI and Hx: Pelvic mass (14)
A
- Characterize any abdo/pelvic pain (OPQRST)
- Bloating or early satiety
- Review of Sx
- Weight D, energy level
- Skin/hair D
- Acne/hirsutism
- Breast discharge/pain
- Urinary/bowel patterns
- Constitutional Sx
- GI: early satiety
- Abdo fullness
- Medications
- Past surgical Hx
- FHx or personal Hx of breast, ovarian, GI, endometrial CA
25
Describe menstrual Hx: Pelvic mass (7)
* Menarche
* Cycle length
* Flow duration + heaviness
* Dinmenstrual pattern
* Abnormal Uterine Bleeding
* PMS
* Menstrual pain
26
Describe Sexual Hx: Pelvic mass (3)
* # Partners
* Method(s) of contraception
* Dyspareunia
27
Describe OB/GYN Hx: Pelvic mass (6)
* Hx STIs, vaginitis
* Hx vaginal discharge
* Pap smear status
* GTPAL status
* Mode of delivery
* Hx pregnancy complications
28
Describe focused physical exam for pelvic mass: Breats (4)
* Tanner staging
* Tenderness
* Masses
* Discharge
29
Describe focused physical exam for pelvic mass: Abdo (3)
* Masses or organomegaly
* Tenderness, guarding, rebound
* Ascites
30
Describe focused physical exam for pelvic mass: Pelvic +/- bimanual exam (3)
* **External** : clitoromegaly (\> 5 mm wide), Tanner staging
* **Speculum**: vagina (color, odor, physiologic leukorrhea, rugae,
* discharge), cervix (discharge, color, abnormalities)
* **bimanual**:
* Cervix (motion tenderness)
* Uterus (position, size, shape, mobility, symmetry, tenderness, consistency)
* Adnexa (size, shape, mobility, tenderness, consistency, location of mass)
31
Describe focused physical exam for pelvic mass: Other (3)
* Assess lymph nodes (cervical, supraclavicular, and inguinal)
* DRE
* Rectovaginal exam (assess posterior uterine surface, uterosacral ligaments, parametria, pouch of Douglas, and rectum)
32
Differentiate characteristics of benign versus malignant ovarian masses
* Patient age
* Location
* Size
* Consistency
* Shape
* Mobility
* Other
33
Name Diagnostic Imaging of Pelvic Masses (4)
* U/S
* First choice
* Delineates mass qualities (cystic vs. solid, size, location)
* Assesses for ascites
* Safe in pregnancy
* CT
* Suboptimal for assessing the ovary
* Assesses all other organs, lymph nodes
* Assesses retroperitoneum
* MRI
* Identification of soft tissue lesions
* Safe in pregnancy
* Other
* Abdo XR
* IV pyelogram
34
Describe the management of ovarian masses (4)
* Depends on the age of patient, size of the mass, U/S features, and tumor markers.
* Must take into consideration the patient’s age, desire to preserve fertility, and patient preference.
* Any ovarian mass in a postmenopausal woman is considered CA until proven otherwise.
* Any solid ovarian mass in childhood is considered malignant until proven otherwise.
35
Name: Indications for Specialty Referral with Pelvic Mass (2)
* Persistent masses (\> 2 menstrual cycles) in reproductive-aged women
* Any postmenopausal mass
36
Name lab markers for ovarian masses (4)
* CA-125 Sensitivity \> \> specificity
* AFP
* LDH
* hCG
37
Describe this marker: CA-125
* Source
* Normal value
* Levels found in
* Sensitivity
* Source: Glycoprotein produced by fetal coelomic epithelium
* Normal value: \< 35 U/mL
* Levels found in:
* Epithelial cell ovarian tumors
* Also elevated in: fibroids, PID endometriosis, cirrhosis, adenomyosis, pregnancy, appendicitis breast/lung/ovarian/colon/fallopian tube CAs, pancreatitis, renal failure, ascites
* Sensitivity:
* ↑ In ~85% of ovarian CAs
* ↑ In ~50% of stage I ovarian CAs
* If postmenopausal with complex adnexal mass and Ca-125 \> 200, 96% PPV for ovarian CA
* Testing for CA-125 in premenopausal women not diagnostic on its own because of ↑ # benign causes of its elevation
38
Describe this marker: AFP
* Source
* Normal value
* Levels found in
* Sensitivity
* Source: Major protein in fetal serum; **not** detectable after birth
* Normal value: \< 5.4 ng/mL
* Levels found in:
* Germ cell tumors (i.e., endodermal sinus)
* Also dermoids, pregnancy, HCC
* Sensitivity
* ↑ In ~85% of germ cell tumors
* ↑ In ~20% of stage I germ cell tumors
39
Describe this marker: AFP
* Source
* Normal value
* Levels found in
* Sensitivity
* Source: Enzyme found in almost all body tissues
* Normal value: \< 250 U/L
* Levels found in: Dysgerminomas
40
Describe this marker: hCG
* Source
* Normal value
* Levels found in
* Sensitivity
* Source: Normally produced by the placenta
* Normal value: \< 5 mIU/mL
* Levels found in:
* Germ cell tumors GTD (i.e., choriocarcinoma)
* Also in pregnancy, marijuana use
* Sensitivity:
* ↑ In ~80% of germ cell tumors
* ↑ In ~20% of stage I germ cell
41
Name characteristics of masses that are suspected abnormal pregnancy, malignancy, and masses requiring surgical intervention? (regardless of if patient is asymptomatic) (4)
* \>5 cm with growth
* Nodular, fixed, solid
* Presence of ascites
* ↑ CA-125
42
Describe epidemiology: Ovarian Carcinoma—Epithelial (2)
* Approximately 80% of ovarian CAs
* Lifetime incidence 1.5%
43
Name RFs: Ovarian Carcinoma—Epithelial (5)
* FHx of ovarian CA (5% if one rst-degree relative affected; 7% if two)
* Excess ovulation (low parity, nulliparity, early menarche, late menopause)
* Increasing age
* Lynch II syndrome: familial disposition to endometrial, ovarian, and GU CAs
* Mutations in BRCA1 (chr17q) and BRCA2 (chr13q) tumor suppress or genes which account for familial breast ovarian CA
44
Name protective factors: Ovarian Carcinoma—Epithelial (3)
* OCP use
* Lactation
* Tubal ligationor salpingectomy
45
Describe screening: Ovarian Carcinoma—Epithelial (1)
No reliable screening test available
46
Describe RX: Ovarian Carcinoma—Epithelial (4)
* Surgical debulking
* Chemotherapy.
* Follow progress with serum CA-125 levels.
* If carrier of BRCA1 or BRAC2 can recommend prophylactic bilateral salpingectomy ± oophorectomy when child bearing is complete.
