Pelvic Mass/GONC

Question 1

Pelvic Mass

Scenario 1 - 6/12 RIF pain, 14cm solid mass R ov, pelvic pain, endo on USS

Scenario 2 - 47yo symptomatic abdo mass

Scenario 3 - 33yo, nulliparous, non-specific abdo-pelvic pain & irregular menstrual

Scenario 4 - 70yo, severe abdo pain, LOW & loss of appetite

RANZCOG mock - 50yo LAP+diarrhoea w VMS sx + hormones showing menospausal range & current smoker on OP USS

Answer 1

postmeno/no fert

DDx
- benign/malignant ov mass
- ruptured haemorrhagic cyst
- ovarian torsion
- PID/TOA

1st encounter (workup - what is it, are they fit for surgery)
- fatig/anorexia/low/urine/bow
- pain/bleeding/fever/chills
+/- menopausal sx impact
+/- CI to HRT
- menarche/CST/contraception
- OGHx/phx/surg/med/fhx-brca/shx
- BMI/card/resp/abdo-pelvic/bimanual
- baseline bloods + TMs
- MCS - MSU/HVS/STI screen
- +/- CTAP - in secondary centers
- +/- COGU USS ?DIE
- +/- MRI - locoregional d/blood flow
- Likely rx = … premeno or post, fertility or not, cancer or benign…
- Plan = chase result, MDT, F/U visit

2nd encounter (treatment, who’s doing the surgery, how and any pre-op optimization)
- ? changes to HE
- cancer or not - IOTA/RMI
+/- further investigation
(e.g. HDC for if ?GCT)
- gynae or gonc
- MDT to plan
- PAC +/- optimization

If suspicious for cancer (ovarian origin)
#pre-meno/fert
USO +/- cystectomy or bx of contra ov+ PW + omentum +/- LN +/- appendix

TAH/BSO + PW + omentum +/- LN +/- appendix

3rd encounter (postop mx - what is the dx and prognosis & F/U)
- ? changes to HE - postop recovery
- see mx plan for each
- germ/GCT/BOT all staged like EOC.

Question 2

Pelvic mass removal under emergency situation without adequate workup - suspicious of cancer

Answer 2

• urgent HEI as above
• resus as req - IVT +/- IV abx +/- PRBC
• prep for OT - NBM/consent…
• open surgery, senior support
• procedure based on meno/fert
• procedure to include +/- staging
• consent - esp spillage/upstage
• IO - gonc sup/frozen/pw/staging/spill
• debrief/document/FU plan

Question 3

Germ cell

Answer 3

DDx
- dysgerminoma (LDH)
- yolk sac tumour (AFP)
- choriocarcinoma (bHCG)
- immature teratoma

• germ cell malignancy
• stage is …
• prognosis good - sensitive to chemo
• BEP - bleo/etop/cisplatin
• GONC MDT to plan
• consider RBU/ovarian tissue cryo
• contraception during rx
• recurrence sx
• GONC F/U - USS & TMs

Question 4

GCT

Scenario 1 - large mass, thickened endo, elevated inhibin

Answer 4

• sex cord stromal tumor
• stage is…
• stage 1a (most) 90% 5yrs
• MDT rv of results
• may need adjuvant chemo
• consider RBU/ovarian tissue cryo
• contraception during rx
• recurrence sx
• GONC F/U - USS & TMs

Question 5

BOT

Scenario 1 - post emergency laparotomy with BOT dx

Scenario 2 - 50yo RIF pain had emergency mx with BOT dx postop

Answer 5

• tumor of unknown malig potential
• stage is
• stage 1 (most) - ~99% 5yrs
• 20% recurrence in same ov cystectomy
• 10% recurrence in other ov USO
• 5% recurrence if TAH/BSO
• GONC MDT +/- re-staging surgery
• consider RBU/ovarian tissue cryo
• consider OCP
• recurrence sx
• GONC F/U - USS & TMs

Question 6

EOC

Scenario 1 - endometrioid on bx

Scenario 2 - mucinous on torted ovary

Answer 6

• epithelial ovarian ca
• serous most common
• stage is…
• prognosis based on stage
• GONC MDT rv of plan
• likely adjuvant chemo
• further surgery rare
• recurrence - pain/ascites/p.effusion
• surveillance in OPC
• stage 1 - confine to ovary 90% 5yrs
• stage 2 - to pelvis
• stage 3 - outside pelvis
• stage 4 - distant 15% 5yrs

Question 7

LMS

Scenario 1 - incidental rapid growing uterine mass in postmenopausal woman presenting with SUI issues

Answer 7

• uterine sarcoma
• poor prognosis
• Stage 1 75% 5yrs, Stage 4 30%
• GONC MDT
• TAH/BSO + LN +/- adjuvant chemoRT
• surveillance in OPC
• Pall ref/Psych support

Question 8

Krukenberg mx

Scenario 1 - on histology from ovarian torsion in postmenopausal woman

Scenario 2 - on histology from TAH/BSO for ovarian mass on USS

Answer 8

• Met from GIT/breast primary
• Stage 4 by definition
• Poor prognosis
• Further ix to identify primary
• Imaging - CTCAP/PET/MMG
• Scopes - G-scope/C-scope
• GONC MDT
• surgery +/- adjuvant chemo
• surveillance in OPC
• Pall ref/Psych support

Question 9

Peritoneal ca mx

Scenario 1 - 33yo, diagnostic lap FI of non-specific abdominal pain & irregular menstrual sx -> extensive primary peritoneal ca with abdominal mets

Answer 9

• similar to EOC/Tubal ca
• stage is …
• poor prognosis…
• MDT …
• likely TAH/BSO/oment/LN + adj chemo
• surveillance in OPC
• Pall ref/Psych support