Pelvic Mass Flashcards by Aliya Hussain

Non-gynaecological causes of pelvic masses?

Bowel:
• Constipation
• Caecal carcinoma
• Appendix abscess
• Diverticular abscess

Bladder / urological:
• Urinary retention
• Pelvic kidney (rare)

Other:
• Retroperitoneal tumours

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Sites of gynaecological causes of pelvic masses?

Uterine:
• Body
• Cervix

Tubal (& para-tubal)

Ovarian

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Causes of uterine masses?

Pregnancy

Commonest fibroids

Endometrial cancer

Cervical cancer

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PC of endometrial cancer?

Usually presents early with post-menopausal bleeding (PMB); for this reason, pelvic masses are unusual

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PC of cervical cancer?

May present late with renal failure, bleeding and pain

Patients may not have a pelvic mass

NOTE - beware defaulters from screening

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What are uterine fibroids?

AKA leiomyomas - benign smooth muscle tumours

They are usually a few cm in size but may be much larger and multiple

NOTE - the malignant counterpart is leiomyosarcomas

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Occurrence of uterine fibroids?

Very common, esp. >40 years of age

More common in the Afro-Caribbean population

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PC of uterine fibroids?

Common cause of pelvic mass

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Locations of uterine fibroids?

Pedunculated - fibroid hands from a stalk outside the uterus

Intracavitary - fibroid inside the uterine cavity

Intramural - fibroid inside the uterine wall

Submucous

Subserous

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PC of uterine fibroids?

Can be asymptomatic or an incidental finding

Symptoms include:
• Menorrhagia
• Pelvic mass
• Pain / tenderness - painful fibroids are uncommon and generally indicate a change in blood supply
• Pressure symptoms (often P on the bladder, resulting in frequency, nocturia, etc)

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When are fibroids disproportionately painful?

Only disproportionate if there is ‘red degeneration’; this can occur during PREGNANCY or MENOPAUSE

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Ix for suspected fibroids?

Hb (if there is heavy bleeding)

USS is usually diagnostic; a smooth, echogenic mass will be visible and these are often multiple

MRI is used for more precise localisation

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Treatment of fibroids?

If asymptomatic, expectant management

If family is complete, hysterectomy; alternatives include:
• Myomectomy
• Uterine artery embolisation
• Hysteroscopic resection

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Causes of tubal swellings?

Ectopic pregnancy - implantation occurs outwith the uterus, commonly in the fallopian tube; this presents as an emergency

Hydrosalpinx - collection of fluid in the fallopian tube; it is often a complication of infection and is often longstanding and an incidental finding

Pyosalpinx - collection of pus in the fallopian tube; this tends to present with an acute inflammatory response

Paratubal cysts - remnant of the Wolffian duct (from when the embryo was developing before genitalia formed)

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Ix for ectopic pregnancy?

+ve pregnancy test but empty uterus

Pain and bleeding

On USS, there may be an adnexal mass (often not seen due to most ectopic pregnancies only growing to 1-2cm before causing problems)

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Causes of ovarian masses?

Tumours / neoplastic:
• Benign
• Malignant

Other than tumours:
• Functional cysts
• Endometriotic cysts

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What are functional cysts?

These are physiological and related to ovulation:
• Follicular cysts
• Luteal cysts

Once the egg is released, the follicle disappears

Sometimes the follicle persists and a cyst forms

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PC of functional cysts?

Often asymptomatic and an incidental finding

Symptoms may include:
• Menstrual disturbance
• Bleeding
• Rupture and pain (gynae emergency)

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Mx of functional cysts?

They are rarely >5cm in diameter and they usually resolve spontaneously

Expectant management is appropriate

NOTE - if rupture occurs, this is a gynae emergency

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What is endometriosis?

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Endometrial tissue is present in the wrong location, often the ovaries, pouch of Douglas, etc

It can cause ‘chocolate’ cysts (AKA endometriomas), filled with blood, on the ovaries

PC of endometriotic cysts?

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Typically assoc. with severe dysmenorrhoea and pre-menstrual pain

Typically assoc. with dyspareunia

Often assoc. with sub-fertility

Tender mass with nodularity and tenderness behind the uterus

Occasionally, patients are asymptomatic until a large chocolate cyst ruptures

Types of primary ovarian tumours?

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Those that arise from the surface epithelium:
• Serous
• Mucinous
• Endometrioid
• Clear cell
• Brenner
NOTE - in this category, the most common are serous, mucinous and endometrioid types:
• If benign, these are cystadenomas
• If malignant, these are cystadenocarcinomas

Those that arise from germ cells:
• Benign cystic teratoma (AKA dermoid cyst) - common
• Malignant germ cells tumours - very rare

Those that arise from stroma:
• If from granulosa cells, may secrete oestrogens
• If from theca / leydig cells, may secrete androgens
• Ovarian fibroma

What is Meigs syndrome?Tr

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Triad of:

Benign ovarian tumour
Ascites
Pleural effusion

This is important as the tumour is often a benign fibroma; with symptoms like pleural effusion and ascites, an automatic suspicion is ovarian cancer

Rare presentations of malignant germ cell tumours?

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May produce HCG, causing a false +ve pregnancy test

May produce AFP

Rare presentations of dermoid cyst?

As it develops from a totipotential germ cell, may contain teeth, sebaceous material, hair, etc; on X-ray, a tooth may be seen Rarely, contain thyroid tissue, resulting in thyrotoxicosis

Rare presentations of thecal tumours?

May produce androgens, leading to hirsutism and virilisation

Rare presentation of fibromas?

Meigs syndrome (benign fibroma with pleural effusion and ascites)

Metastatic disease of the ovaries?

Secondary ovarian tumours - ovaries are a common site of metastatic disease, most often from the breast, pancreas, stomach and GI primaries

Presentation of ovarian cancer?

May be with a mass, swelling and pressure symptoms However, symptoms are usually more insidious and patients tend to have a protracted referral pathway, after being referred to non-gynae specialties

Symptoms of ovarian cancer?

Heartburn / indigestion Early satiety Weight loss / anorexia Bloating Pressure symptoms, esp. due to P on the bladder Change in bowel habit SoB / pleural effusion Leg oedema or DVT NOTE - i.e: the patient may not present with a pelvic mass

Why does ovarian cancer generally have a poor prognosis?

Early trans-peritoneal spread: • Deposits on all peritoneal surfaces • Omental disease / infiltration • Malignant ascites with protein exudate

Genetic basis of ovarian cancer?

Only 5% of cases have a genetic basis but FH should always be checked Most common are BRCA1 & 2, which cause breast and ovarian carcinoma Lynch syndrome (AKA HNPCC) causes bowel, endometrial, ovarian carcinomas and many others

Effectiveness of screening for ovarian cancer?

Not proven to detect early disease

Risk factors for ovarian carcinoma?

Increasing age Nulliparity FH

Protection against ovarian cancer?

Oral Contraceptive Pill (OCP) is protective

Ix for suspected ovarian carcinoma?

Tumour markers: • CA 125 - main marker that is raised in ~80% of ovarian cancers but a normal level does not exclude cancer; it is often more useful for follow-up than for diagnosis • CEA (carcino-emrbyonic antigen) - may be moderately elevated in ovarian carcinoma, esp. with mucinous tumours; main purpose is to exclude metastases from GI primary cancer (if it is very high, suspect a GI primary) Imaging: • USS - better for imaging the nature of the cyst • CT scan - better for assessing disease outwith the ovaries, esp. omental disease, peritoneal disease and lymph nodes

Situations where CA 125 is moderately elevated?

Endometriosis Peritonitis / infection Pregnancy Pancreatitis Ascites from any cause, e.g: liver disease Other malignancies (gynae / non-gynae)

Suspicious USS findings that indicate ovarian carcinoma?

Complex mass with SOLID and cystic areas NOTE - if solid areas are present, suspicious Multi-loculated Thick septations Assoc. ascites Bilateral disease

What is the 'risk of malignant' index and how is it used in the diagnosis of ovarian cancer?

If the RMI is raised, refer to the gynae cancer team Menopausal status x serum CA 125 x USS score

Treatment of ovarian cysts / masses?

If likely to be benign, removal OR drainage Otherwise: • Removal of ovaries and uterus with removal/biopsy of omentum • De-bulking of tumour • Complete examination / inspection of all peritoneal surfaces Chemotherapy may be given prior to or after the surgery NOTE - cure is unlikely, unless disease is confined to the ovary at presentation

History points to cover with a pelvic mass?

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 FH Previous gynaecological and surgical history Ovarian cancer symptoms

Reasons for which a pelvic mass presents as an emergency with acute abdomen?

Cyst 'accident': • Rupture • Haemorrhage (into cyst) • Torsion Fibroid degeneration - usually red degeneration (compromised blood supply); it is seen in pregnancy and the peri-menopause

Examination of a pelvic mass?

Anaemia Cachexia Chest and breast examination Lymph node examination Leg / peripheral oedema

Abdominal examination of a pelvic mass?

Scars Distension Ascites - symmetrical, in flanks; presence of shifting dullness and fluid thrill Mass: • Is it arising from the pelvis? • Can you get below it?

Vaginal examination of a pelvic mass?

BIMANUAL EXAMINATION Speculum examination

Describing the pelvic mass?

Size - in cm or weeks gestation Consistency, e.g: soft, firm, hard, craggy, indurated, boggy, fluctuant Surface: • Smooth • Irregular • Bosselated - smoothly irregular (typical of fibrois) Tenderness Mobility Relation to uterus Pouch of Douglas - nobbliness in the POD is a typical sign of endometriosis or ovarian carcinoma

Ix with a pelvic mass?

Hb If suspecting an inflammatory mass, WCC and CRP Biochemistry, esp. serum albumin; if serum albumin is normal, unlikely to be ovarian carcinoma Tumour markers: • CA 125 • CEA CXR USS (transabdominal / transvaginal) +/- MRI (for fibroid / uterine mass, if there is suspicion) +/- CT (for suspected ovarian carcinoma)

Overall diagnosis of pelvic masses?

May be obvious May require surgery for diagnosis and for treatment (removal): • If suspected ovarian cancer, open surgery (laparotomy) Benign cases may be managed laparoscopically

Pelvic Mass Flashcards

(48 cards)