Pelvic Mass

Question 1

What are common uterine masses?

Answer 1

Pregnancy
Fibroids
Endometrial cancer (presents early with PMB)
Cervical cancer

Question 2

What is a fibroid?

Answer 2

Leiomyoma

Usually a few cm but can be much bigger and multiple

Question 3

What are the different forms of fibroids?

Answer 3

Pedunculated
Intramural 
Submucosal
Subserosal
Intracavitary

Question 4

What is the presentation of a uterine fibroid?

Answer 4

Asymptomatic or incidental finding 
Menorrhagia
Pelvic mass
Pain/ tenderness 
Pressure symptoms

Question 5

When is the pain/ tenderness of uterine fibroids disproportionate?

Answer 5

Red degeneration in pregnancy or menopause

Question 6

What investigation should be performed for suspected fibroids?

Answer 6

Hb if heavy bleeding
USS usually diagnostic (smooth echogenic mass often multiple)
MRI for more precise localisation

Question 7

What is the treatment for fibroids?

Answer 7

Expectant if asymptomatic
Myomectomy
Uterine artery embolisation 
Hysteroscopic resection 
Hysterectomy if family complete

Question 8

What are the different causes of tubal swellings?

Answer 8

Ectopic pregnancy (emergency, adnexal mass on USS) 
Hydrosalpinx (longstanding) 
Pyosalpinx (acute/ inflammatory) 
Paratubal cyst (small and incidental)

Question 9

What are the causes of an ovarian mass?

Answer 9

Tumours/ neoplastic; benign or malignant

Not tumours; functional cysts, endometriotic cysts

Question 10

What are the two types of functional cysts?

Answer 10

Follicular cysts

Luteal cysts

Question 11

What size are functional cysts?

Answer 11

<5cm in diameter

Question 12

Will functional cysts resolve spontaneously?

Answer 12

Yes; often asymptomatic/ incidental finding

Question 13

What symptoms can functional cysts present with?

Answer 13

Menstrual disturbance

Can bleed/ rupture and cause pain

Question 14

What is endometriosis?

Answer 14

Endometrial glands and stroma in the wrong place

Question 15

What will endometriotic cysts look like?

Answer 15

Endometriomas

Chocolate cysts

Question 16

What is endometriosis associated with?

Answer 16

Severe dysmenorrhoea
Pre-menstrual pain
Dyspareunia
Subfertility

Question 17

Where are endometriotic cysts typically found?

Answer 17

Tender mass with nodularity behind uterus

Question 18

What are the primary ovarian tumours that arise from the surface epithelium?

Answer 18

Serous
Mucinous
Endometrioid
Clear cell
Brenner

Question 19

What are the primary ovarian tumours that arise from the germ cells?

Answer 19

Benign cystic teratoma

Malignant germ cell tumour

Question 20

What are the primary ovarian tumours that arise from the stroma?

Answer 20

Granulosa cell may secrete oestrogen
Theca/ leydig cell may secrete androgens
Fibroma = meig’s syndrome

Question 21

How can malignant germ cell tumours present?

Answer 21

hCG (false positive IPT) or AFP

Question 22

How can dermoid cysts present?

Answer 22

Totipotential
Teeth, sebaceous material, hair
Thyroid tissue -> thyrotoxicosis

Question 23

How can granulosa cell tumours present?

Answer 23

Oestrogens

Precocious puberty or PMB

Question 24

How can thecal tumours present?

Answer 24

Androgens
Hirsutism
Virilisation

Question 25

How can meig's syndrome present?

Answer 25

Fibroma Ascites Right sided pleural effusion

Question 26

Is the ovary a common site for metastatic spread of disease?

Answer 26

Yes

Question 27

What primary tumours will commonly spread to the ovaries?

Answer 27

Breast Pancreas Stomach GI

Question 28

How will ovarian cancer present?

Answer 28

``` Mass Swelling Pressure Early satiety Wt loss Bloating Change of bowel habit SOB/ pleural effusion Leg oedema/ DVT Early transperitoneal spread; deposits on all peritoneal surfaces, omental disease, malignant ascites with protein exudate Insidious symptoms ```

Question 29

What genetic syndromes are assoc with ovarian cancer?

Answer 29

``` BRCA 1 and 2 (breast and ovarian) Lynch syndrome (colorectal, endometrial, ovarian) ```

Question 30

What are risk factors for ovarian cancer?

Answer 30

Increasing age Nulliparity Family history OCP is PROTECTIVE

Question 31

What are the ix for suspected ovarian ca?

Answer 31

History and exam Tumour markers; ca-125 and CEA Imaging; USS, CT (omental and peritoneal disease, lymph nodes)

Question 32

What can cause moderate elevation of Ca-125?

Answer 32

``` Endometriosis Peritonitis/ infection Pregnancy Pancreatitis Ascites from other causes Other malignancies gynae/ non gynae ```

Question 33

What is the main function of doing CEA in ovarian cancer?

Answer 33

Exclude mets from GI primary | Raised esp in mucinous tumours

Question 34

What are suspicious USS findings for ovarian cancer?

Answer 34

``` Complex mass with solid and cystic area Multi-loculated Thick septations Assoc ascites Bilateral disease ```

Question 35

How is the RMI calculated?

Answer 35

Menopausal status x serum ca 125 x USS score

Question 36

How is an ovarian cyst treated?

Answer 36

Removal or drainage if likely benign

Question 37

What is the surgical treatment of an ovarian tumour?

Answer 37

Midline laparotomy to allow thorough assessment of the abdomen and pelvis; a total abdominal hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy; biopsies of any peritoneal deposits; random biopsies of the pelvic and abdominal peritoneum; and retroperitoneal lymph node assessment

Question 38

When is chemo given in ovarian cancer?

Answer 38

Can be neo adjuvant or adjuvant | Platinum based

Question 39

What history is important to take in a pelvic mass presentation?

Answer 39

``` Speed of onset/ duration of symptoms Mass/ swelling/ bloating Pressure symptoms (bladder or bowel) Pain (with periods, between, post coital) Menstrual hx (heaviness, cycle) Cervical smear history Parity and fertility problems Family history Previous gynae problem ```

Question 40

What are the acute presentations of a pelvic mass?

Answer 40

Cyst accident; rupture, haemorrhage, torsion | Fibroid degeneration; red, compromised blood supply

Question 41

How is ascites examined for?

Answer 41

Shifting dullness | Fluid thrill

Question 42

How should the pelvic mass be described?

Answer 42

``` Size; cm or weeks gestation Consistency; soft, firm, hard, craggy, indurated, boggy, fluctuant Surface; smooth, irregular Tenderness Mobility Relation to uterus Pouch of douglas ```

Question 43

When is an MRI indicated in work up of a pelvic mass?

Answer 43

Fibroids or uterine mass

Question 44

When is a CT indicated in the work up for a pelvic mass?

Answer 44

Suspected ovarian ca