JC108 (O&G) - Pelvic Mass: Ovarian Cancer & Cysts, Uterine Fibroid, Pelvic Imaging

Question 1

Outline history taking questions for pelvic mass

Answer 1

Mass: 
 Size, site
 Onset; how the mass was discovered
 Duration; change since first noted
 Associated symptoms (e.g. distension, pressure symptoms)

Menstrual history:
 Timing: duration, cycle length
 Amount of flow
 Anaemic symptoms
 Compare with previous pattern
 Any Pain/ dysmenorrhea

Others:
 Previous gyn exam, cervical smear
 Obstetrical history (affects management)
 Sexual history, contraception
 Drug, allergy
 Family
 Medical/surgical

Question 2

Uterine fibroids

• cell of origin
• Presentation, S/S
• Major ddx

Answer 2

Uterine fibroids (leiomyomas)
- benign smooth muscle tumor

Symptoms/ signs:
- multiple, asymmetrical uterine enlargement

• Submucosal fibroid increase surface area of endometrium - menorrhagia** (different from ovarian cyst, ovarian cancer)
• mass effect and pressure effect: Abdominal distention, AROU, DVT, change in bowel habit
• Clotting in uterus or fibroid enlarges into polyp, causing dysmenorrhea ** (like ovarian cyst, cf ovarian cancer) when uterus contracts

Top Ddx: adenomyosis

Question 3

Ddx benign ovarian masses

Answer 3

 Physiological/ functional cysts (appear with menstruation)
 Endometriomas (endometriotic cyst/ chocolate cyst)
 Serous cystadenoma
 Mucinous cystadenoma
 Mature teratoma

Question 4

Ddx benign non-ovarian adnexal masses

Answer 4

Benign non-ovarian (ovary next to fallopian tube and mesosalpinx)

 Hydrosalpinges (blocked fallopian tube)

 Paratubal cyst
 Peritoneal pseudocysts

 Tubo-ovarian abscess
 Appendiceal abscess
 Diverticular abscess

 Pelvic kidney
 Distended bladder

Question 5

Ddx primary and secondary malignant ovarian masses

Answer 5

Primary
 Germ cell tumour
 Epithelial carcinoma
 Sex-cord tumour

Secondary
 Breast
 Gastrointestinal (e.g. stomach  Krukenberg tumor)

Question 6

Types of uterine fibroids

Histological features

Answer 6

Types

1. Submucosal
2. Intramural
3. Subserosal
4. Pedunculated
5. Intraligamentary
6. Parasitic
7. Cervical
8. Intracavitary

Histology: Degenerative changes:
hyaline, myxoid, calcific, cystic, hemorrhagic/red, sarcomatous (may be
malignant – leiomyosarcoma, rare), fatty

Question 7

Ovarian cyst

• Presentation
• Top ddx

Answer 7

S/S:

• Asymptomatic if small, mobile, separated from uterus, +/- tender
• Mass effect: abdominal distension, pressure symptoms, abdominal pain
• Cyst complications: Torsion, hemorrhage, rupture
• Dysmenorrhea

Top Ddx:
Endometriosis, endometriotic cyst (less mobile, adhesions to uterus)

Question 8

Ovarian cancer

• Presentation
• Top ddx

Answer 8

S/S: Similar to ovarian cysts and fibroids except no menorrhagia, constitutional and metastatic symptoms:

• Asymptomatic if small
• Mass effect and pressure symptoms: Abdominal distension, abdominal pain, ascites, DVT, AROU, bowel function
• Complications: hemorrhage, rupture
• Constitutional: LoW, LoA, Unexplained fever
• Metastatic symptoms: PR bleed, cough, IO…

Question 9

2 surgical emergencies a/w ovarian cysts

Answer 9

Torsion: compromises blood supply, but necrosis of ovary is irreversible > treat by de-torsion and cystectomy

Rupture: ovary is highly vascular > severe bleeding and hemoperitoneum

Question 10

Physical findings:

Pallor
Asymmetrical mass, irregular, in pelvis, firm, non-tender, moves with cervix

Top ddx

Answer 10

Uterine fibroids

Ddx of gynaecological masses:
If regular shape mass - adenomyosis
if tender - ovarian cysts 
if fixed - ovarian cancer 
if peritoneal signs - ovarian cyst with torsion and hemorrhage

Question 11

Physical findings: 
Pelvic mass found separated from uterus 
Tender 
Mobile 
Peritoneal signs 

Most likely gynaecological mass?

Answer 11

Ovarian cyst with torsion or hemorrhage leading to peritonitis

If less mobile - adhesions with surround structures, endometriosis, stuck to uterus and becomes endometriotic cyst
If ascites - Meig’s syndrome: triad of benign ovarian tumor
+ ascites + pleural effusion

Question 12

Define Meig’s syndrome

Answer 12

triad of benign ovarian tumor + ascites + pleural effusion,

resolves after tumor resection

Question 13

Physical findings:

Cachexic, lymphadenopathy, DVT
Pelvic mass is non-tender, fixed, hard, irregular surface
Ascites
Organomegaly
Nodular deposits in Pouch
Stony dull percussion on respiratory exam

Most likely gynaecological mass?

Answer 13

Ovarian cancer

Ascites (shifting dullness due to peritoneal metastasis/ liver metastasis
= stage IV
Nodular deposits in Pouch of Douglas (sign of peritoneal metastasis)
Pleural effusion – stony dull (sign of metastasis)

Question 14

Outline P/E for pelvic mass

Answer 14

General:

• vital signs, BMI, performance status, pallor, lymphadenopathy
• pregnancy test

Abdominal: Full set

Pelvic:
 Vulva, vagina, cervix (speculum)
 Uterine size
 Adnexal mass: size, tenderness, mobility with uterus, arising from pelvis
 Pouch of Douglas: nodularity, thickening, tenderness

Metastasis: Respiratory examination, rectal examination

Question 15

Uterine fibroid

Describe features of the mass on P/E

Answer 15

Mass:

• Symmetrical/ asymmetrical
• Irregular shape
• Usually non-tender
• Moves with cervix
• Arise from pelvis
• Consistency varies: firm if calcified, rubbery if normal

Special notes:

• If tender&raquo_space;> Red degeneration due to fast fibroid growth under hormonal stimulation, outgrowing vessels and causing ischemia
• Special locations: pedunculated mass - very mobile, subserosal fibroid does not present as a uterine mass
• Pallor&raquo_space;> severe menorrhagia

Question 16

Ovarian cyst

Describe features of the mass on physical exam

Answer 16

Mass:

• Non-palpable if small
• Separated from uterus
• Tender
• Mobile
• Soft
• Does not move with cervix

Special notes:

• If complicated with hemorrhage or torsion&raquo_space; peritoneal signs and severe abdominal pain
• If stuck on uterus with adhesions and moves with cervix&raquo_space; endometriotic cyst or ovarian cyst adhered to uterus
• If pleural effusion&raquo_space; Meig’s syndrome

Question 17

Ovarian cancer

Features of the mass on physical exam

Answer 17

Mass:

• Arise from pelvis
• Non-tender
• Hard consistency
• Irregular surface
• Mobile or fixed

Signs of metastasis: lymphadenopathy, DVT, pleural effusion, organomegaly, nodular deposits in Pouch of Douglas (peritoneal met.)

Question 18

Most common gynaecological masses

Answer 18

Uterine fibroid 
Ovarian masses: e.g. cysts, cancer 
Adenomyosis 
Paraovarian cysts 
Hydrosalpinx 
Pregnancy

Question 19

First-line investigations for pelvic mass

Answer 19

Pelvic ultrasound:
Transabdominal for large fibroids
Transvaginal for small fibroids
Sonohysterogram for fibroid polyp, endometrial polyp

Menorrhagia - CBC with diff. for anaemia

Ovarian cancer - CA125 , imaging by CT, MRI, PET-CT

Question 20

Radiological features of uterine fibroids

Answer 20

• Well- circumscribed
• pseudocapsule from surrounding compressed myometrium
• Hypoechoic/ heterogeneous echoes

Question 21

5 metrics to describe an adnexal mass on ultrasound

Answer 21

Size

Laterality

Cyst content

Septations

Ascites

Question 22

7 different types of cyst content in an adnexal mass ultrasound

Answer 22

Benign content:

• Anechoic (black)
• Low-level echoes with thin septum (homogenous low echogenicity): old bleed from endometriotic cyst, hemorrhagic cyst

Non-specific content:
- Ground glass appearance (homogeneous dense echoes): e.g. mucinous cystadenoma

Malignant content:

• Hemorrhagic (thread-like fibrin strands)
• Mixed (heterogeneous echoes): tooth-like structure in teratoma, papillary growth in malignant tumors
• Mixed with blood-fluid or fat-fluid level
• Mixed with abscess

Question 23

Indicators of benign vs malignant pelvic mass on USG

Answer 23

International Ovarian Tumor Analysis (IOTA) simple rules:

Benign (B-rules)
 Unilocular cyst
 Smooth multilocular with largest diameter <100mm
 Largest solid component <7mm
 Acoustic shadowing (purely cystic)

Malignant (M-rule)
 Irregular multilocular/ Solid-cystic mass (thick septum)
 >4 papillary structures (>3mm in height)
 Irregular solid tumor with largest diameter >100mm
 Ascites
 Strong intratumoral color flow

Classified malignant: >1 M feature + no B feature
Classified benign: >1 B feature + no M feature
Inconclusive: no B/M features, or both B+M features

Question 24

CA125

• Molecular structure
• Produced by which cells
• Cut-off level

Answer 24

celomic epithelium-related glycoprotein

Present in most serous (high-grade), endometrioid, and clear cell ovarian carcinomas (mucinous tumors express it less frequently)

Present in epithelium of fallopian tubes, endometrium, and uterine cervix

usual cutoff = around 35 u/ml

Question 25

Confounding factors that increase CA125 concentration

Answer 25

Elevated in anything irritating mesothelium/ epithelium: ```  Menstruating, pregnant women  Endometriosis/ endometriotic cyst (20-30%)  Fibroids  Benign ovarian tumours (10%)  Acute PID  Liver cirrhosis (60-70%) >> ascites  Pancreatitis (30%) >> ascites  COPD, kidney problem, flu, CA breast, CA lung etc. ```

Question 26

CA125 Practical clinical uses

Answer 26

- More sensitive and specific in postmenopausal women | - Useful in follow-up of patients after treatment for proven CA ovary with elevated CA 125 level before treatment

Question 27

Index for risk of ovarian cancer based on CA125 levels

Answer 27

Risk of malignancy index (RMI): RMI = U x M x CA125 ``` U = ultrasound features M = 3 for all post-menopausal women CA-125 = measurement in u/mL ``` Low risk = RMI < 25 = 3% risk of cancer Moderate risk = 25-250 RMI = 20% risk of cancer High risk = RMI >250 = 75% risk of cancer

Question 28

Uterine fibroids - Treatment options

Answer 28

Asymptomatic = observation and reassurance Symptomatic: Symptom relief by: - transamin/ tranexamic acid to stop bleeding - Mirena (IUCD secreting progestogens to decrease menstrual flow) Surgical removal: if mass effect or pressure effect is severe: - Myomectomy/ Hysterectomy - Approach: open/ laparoscopic/ vaginal/ hysteroscopic Minimal invasive: - Uterine artery embolisation - High intensity focused ultrasound

Question 29

Indications for different types of surgical treatment for uterine fibroids

Answer 29

Small fibroid = vaginal approach myomectomy Deep fibroid to submucosal level = full-thickness myomectomy Submucosal fibroid/ fibroid polyp = hysteroscopic resection Large fibroid = open approach myomectomy or hysterectomy No fertility wish: hysterectomy, UAE, HIFU

Question 30

Adnexal mass/ cyst Treatment options for pre-menopausal women

Answer 30

Simple, functional cysts, asymptomatic, <5cm = close case Simple, functional cysts, asymptomatic, 5-7cm = observe and repeat ultrasound in 3-6 months for regression Persistent cyst/ increases in size or >7cm: - Cystectomy or salpingo- oophorectomy - Approach: Laparoscopy (small)/ laparotomy (big or suspicious-looking) Symptomatic mass/ suspect cancer: - Refer gynecology - Exclude secondary from colon, stomach, breast...etc - Staging surgery +/- chemotherapy

Question 31

Adnexal mass/ cyst Treatment for post-menopausal women

Answer 31

Asymptomatic + simple + unilateral + unilocular + <5cm + normal CA125: repeat assessment in 4-6 months - consider intervention (prophylactic removal) if change in feature All other cysts (i.e. symptomatic/ non-simple features/ >5cm/ multilocular/ bilateral): - BSO (bilateral salpingo-oophorectomy) by laparotomy/ laparoscopy approach RMI>200: - CT scan (abdomen, pelvis) or laparotomy - Low likelihood of malignancy: pelvic clearance (total abdominal hysterectomy) + BSO + omentectomy + peritoneal cytology - Malignant: surgery, chemotherapy, targeted therapy

Question 32

Ovarian cancer Treatment options for early and late stage

Answer 32

Early stage: surgery (histological diagnosis + treatment) +/- chemotherapy Late stage: stage: surgery and chemotherapy +/- targeted therapy