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Pelvic Mass Flashcards

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1
Q

what are non gynaecological causes of a mass in the pelvis

A
  • bowel: constipation, caecal carcinoma, appendix abscess, diverticular abscess
  • bladder/ urological: urinary retention
  • other: retroperitoneal tumour, ascites (non gynae origin)
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2
Q

what are the three categories of gynae pelvic masses

A

pregnancy
uterine (benign and malignant)
adnexal (benign and malignant)

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3
Q

what are the causes of a uterine mass

A

pregnancy
fibroids- commonest
endometrial cancer (usually presents early as PMB so mass unlikely)
cervical cancer
(would be late presentation so +/- renal failure/ bleeding/ pain)

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4
Q

what are uterine fibroids

A

leiomyomas- benign smooth muscle tumours

usually a few cm but can be bigger and multiple

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5
Q

are uterine fibroid common

A

yes (esp >40s)

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6
Q

what are the types of uterine fibroids

A 
pedunculated 
intracavitary 
intramural 
submucous 
subserous
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7
Q

what is the presentation of uterine fibroids

A 
may be asymptomatic/ incidental finding 
menorrhagia 
pelvic mass
pain/ tenderness 
pressure symptoms
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8
Q

what investigations for suspected fibroids

A

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

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9
Q

what is the treatment for fibroids

A 
nothing if asymptomatic 
hysterectomy if family complete 
or: 
-myomectomy 
-uterine artery embolisation 
-hysteroscopic resection
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10
Q

what are the causes of tubal swelling

A

ectopic pregnancy
hydrosalpinx (often longstanding/ incidental)
pyosalpinx (acute/ inflammatory)
paratubal cysts (embryological remnants, usually small and incidental)

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11
Q

is an ectopic pregnany an emergency

A

yes

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12
Q

what are the causes of an ovarian mass

A

tumours - benign or malignant

not tumours- functional cysts, endometriotic cysts

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13
Q

what are functional cysts

A

related to ovulation- follicular or luteal cysts
rarely >5cm, usually resolve spontaneously
often asymptomatic/ incidental finding
expectant management
can have menstrual disturbance/ bleed/ rupture and cause pain

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14
Q

what are endometriotic cysts

A

when endometriosis results in cblood filled (chocolate) cysts on ovaries (endometriomas)

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15
Q

how do endometriotic cysts present

A

Typically associated with severe dysmenhorrhoea, and premenstrual pain.
Typically associated with dyspareunia
Often associated with subfertility
Typically tender mass with ‘nodularity’ and tenderness behind uterus.
Occasionally asymptomatic until large chocolate cyst, which may rupture.

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16
Q

what are the types of primary ovarian tumours

A

arising from surface epithelium:

  • serous
  • mucinous
  • endometrioid
  • clear cell
  • brenner

arising from germ cells:

  • benign cystic teratoma (dermoid cyst, common)
  • malignant germ cell tumours (VV rare)
  • malignant cystic teratoma
  • dysgerminoma (usually malignant)

arising from stroma:

  • if granula cell may secrete oestrogen
  • if theca/ leydig cell may secrete androgens
  • fibroma
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17
Q

what is meigs syndrome

A

triad of ascites, pleural effusion and benign ovarian fibroma

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18
Q

what might malignant germ cell ovarian tumours produce

A

HCG (false pos IPT) or AFP

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19
Q

what happens if a dermoid cyst produced thyroid tissue

A

can cause thyrotoxicosis

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20
Q

what can a dermoid cysts form

A

Totipotential e.g.

Teeth, sebaceous material, hair

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21
Q

what can granulosa cell tumour secretions cause

A

May produce oestrogens

–> precocious puberty, PMB

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22
Q

what can thecal cell tumour secretions cause

A

produce androgens

–> hirsutism —> virilisation

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23
Q

what cancers spread to the ovaries

A

breast
pancreas
stomach
GI primaries

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24
Q

how can dermoid cysts be diagnosed on imaging

A

contain fat- no fat in ovaries so if see this= germ cell tumour
also might contain calcification= teeth

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25
what are the features of ovarian cancers spreading
early tranperitoneal spread(trans-coelomic) -Deposits on all peritoneal surfaces -Omental disease/infiltration =Malignant ascites with protein exudate
26
how do ovarian cancers present
``` May be mass, swelling, pressure symptoms. Usually more insidious symptoms: Heartburn/indigestion Early satiety Weight loss/anorexia. Bloating ‘Pressure’ symptoms (esp bladder) Change of bowel habit SOB/ Pleural effusion Leg oedema or DVT (generalised oedema if low albumin) N.B May not be a pelvic mass. ```
27
how many ovarian cancers have genetic cause, and what are they
``` 5% BRCA1 & 2 Breast & ovarian Ca HNPCC (Lynch syndrome) Bowel, endometrial, ovarian ca + many others ```
28
what are the risk factors for ovarian cancer
Increasing age Nulliparity Family history (OCP protective against it)
29
what Ix for suspected ovarian cancer
``` Hx and exam Ca125 carcino-embryonic antigen CEA imaging: -USS -CT (to assess disease outwith ovary: omental disease, peritoneal disease, lymph involvement) ```
30
what else can cause increased Ca125
``` Endometriosis Peritonitis/infection pregnancy Pancreatitis Ascites from any cause.e.g. liver disease Other malignancies gynae/non gynae. ```
31
how sensitive is Ca125
Raised in ≈80% ovarian cancers. | Normal level does not exclude cancer
32
what is CEA (carcinoembryonic antigen)
May be moderately elevated in ovarian Ca Esp mucinous tumours Main function = exclude mets from GI primary.
33
what USS findings are suspicious of ovarian Cancer
``` Complex mass with solid & cystic area. Multi-loculated Thick septations Associated ascites Bilateral disease. ```
34
what does the risk of malignancy index consider
menopause status (post higher risk= 3, pre scores 1) x serum Ca125 (absolute level) x USS score (multiloculated, solid areas, bilaterality, ascites, mets= none 1, 1 feature 1, >1 scores 3)
35
how is an ovarian cyst/ mass treated
Removal or drainage if likely benign Otherwise removal of ovaries and uterus with removal/biopsy of omentum, ‘debulking’ of tumour and complete examination/inspection of all peritoneal surfaces. Chemotherapy may be given pre-surgery or after surgery
36
how likely is ovarian cancer to be cured
unlikely unless confined to ovary at presentation
37
what questions should you include in a pelvic mass history
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. Family history. Previous gynaecological and surgical history. Ovarian cancer symptoms
38
what can cause acute presentation of an ovarian mass
cysts: - rupture - haemorrhage - torsion fibroid degeneration: - usually red degeneration - compromised blood supply - seen in pregnancy, peri menopause
39
what should you look for on exam in pelvic mass
``` generally: Anaemia Cachexia Chest examination Breast examination Nodes. Leg/peripheral oedema ``` ``` abdomen: Scars Distension Ascites -Symmetrical -In flanks -Shifting dullness -Fluid thrill Mass -Is it arising from the pelvis -Can you get below it? ``` vaginal: speculum and bimanual
40
how should you describe a pelvic mass
``` Size -cms or ‘weeks gestation’ Consistency -e.g. soft, firm, hard, craggy, indurated, boggy, fluctuant Surface -Smooth, irregular, ‘bosselated’ Tenderness Mobility Relation to uterus Pouch of douglas. ```
41
when would you do an MRI
fibroids/ uterine mass
42
what tests if you suspect an inflammatory mass
WCC/CRP
43
what surgery if you suspect ovarian caner
lapartomy (open to assess spread)
44
what is the association in HLRCC
fibroids and renal cancer
45
why do you test LFTs in pelvic mass
ascites
46
what should you suspect and test in a young person with an ovarian mass
germ tumour- LDH, AFP, HCG
47
when would you do a hysteroscopy
only if bleeding problem and want to see what is in uterine cavity
48
when do you get shifting dullness and fluid thrill
ascites large volume= thrill less = shifting
49
what do the RMI levels mean
<30 3 in 100 OC 30-200 20 in 100 OC >200 75 in 100 OC OC= ovarian cancer
50
why is albumin low in cancer
ascites
51
what causes ascites in ovarian cancer
increased capillary permeability
52
what lymph nodes do the ovaries drain to
lumbar
53
what are the features of a fibroma
benign tumour of the stroma tissue of the ovary, white whirled appearance, looks like fibroid
54
are you more likely to have a right or left plerual effusion in meigs syndrome
right
55
what is the most common malignant ovarian tumour
high grade serous
56
what are the medical treatment options for benign ovarian tumours
only for endometriomas | GnRH analogues, OCP
57
what surgical options for benign ovarian tumours
ovarian cystectomy unilateral oophrectomy bilateral oophrectomy pelvic clearance (post menopausal only)
58
what are the treatment options for ovarian germ cell tumours
fertility sparing | unilateral salpingoophrectomy +/- chemo
59
what is the basis for ovarian cancer Tx
chemo and surgery | expect if stage 1A then just surgery
60
what is a krunckenberg tumour
secondary ovarian tumour (usually from stomach) that has signet ring on histology
61
how bad are borderline ovarian tumuors
can spread transcoelomic | risk of recurrence 5-10%
62
heavy periods, pressure symptoms and pain =?
uterine fibroids
63
do mucinous cells ina cyst mean it is benign or malignant
benign
64
how do benign ovarian cysts present
long history of abdominal bloating regular menses smooth mobile midline swelling arising from midline
65
what do fibroids look like on USS, pathology and histology
USS- whirly, homogenous, solid mass in utero pathology- uniform, whirled appearance histology- smooth muscle spindle cells, no disorientation
66
what do mucinous cysts look like on histology
``` benign mucinous cells fluid fills BM intact nuclei in line along bottom ```
67
in ovarian cancer, what does Ca125 measure
peritoneal disease (spread)- also a marker of inflammation
68
what are the risk factors for endometrial cancer
age past menopause nulliparity obesity
69
how do endometrial polyps present
period like bleeding, short history | abdo swelling
70
how might atrophic vaginitis present
vaginal spotting feels dry and irritated punctate spots on vaginal wall
71
what are the types of endometrial cancer
Adenocarcinomas: – Endometrioid carcinoma: precursor atypical hyperplasia, most common type, usually due to high oestrogen levels driving the endometrium – Serous carcinoma: precursor serous intraepithelial carcinoma, atrophic endometrium- older women
72
can a smear be used to diagnose someone with symptoms
no
73
what is koilocytosis
abnormal nuclei - caused by HPV

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