Week 3 Flashcards
(34 cards)
Basic compartments of pelvic cavity
Anterior compartment – BLADDER
Middle compartment – UTERUS
Posterior compartment – BOWEL
Lateral Compartment - ADNEXAE
Most common pelvic mass by cavity
anterior - bladder tumour, distension
middle - uterine fibroid, adenomyosis, cervical/ovarian mass
posterior - bowel tumour, appenidiceal, diverticulae, hernias
lateral - tubal abscess, ectopic, hydrosalpinx
pregnancy, plevic kidney, ascites
Symptom vs origin in pelvic mass
BLEEDING - uterine
PAIN - ovarian
PRESSURE SYMPTOMS- uterine/ovarian
LONG TERM SYMPTOMS (m/y) - benign
SHORT TERM SYMPTOMS (w) - malignant
DOUBLING PAIN WITH NAUSEA - acute
Midline vs forniceal mass on bimanual exam
Uterine - midline, in line with cervix
Ovarian - occupying fornices, no movement with cervix
Investigation of pelvic mass
Always USS first
MRI best second line (visualise uterus and ovaries)
CT for wider picture and in post-menopausal patients
Tumour markers used to ID pelvic masses
Premeno - markers cA125 and AFP,HCG,LDH**
Postmeno - CA125
Not reliable on own, use alongside imaging
Tumour markers other than CA125 used in women <40y
Alpha Foeto-protein – raised in embryonal carcinoma
HCG – raised in choriocarcinoma
LDH – raised in dysgerminoma
How to calculate RMI in pelvic mass?
A - 1=premeno, 3=post meno
B - no US feature=0, one feature=1, >1 feature=3
C - serum CA125
RMI<30 = 3 in 100
RMI 30-200 = 20 in 100
RMI>200 = 75 in 100
Clin pres of functional cysts
Related to ovulation
Rarely >5cm diameter
Usually resolve spontaneously
May cause menstrual disturbance
Consider as differential in acute abdomen as may bleed or rupture
Often asymptomatic
Clin pres of endometriotic cysts
PRES:
Severe dysmenorrhea/premenstrual pain
Dyspareunia
Associated with sub fertility
Occasionally asymptomatic
Acute abdomen if ruptures
EXAM:
Tender mass with modularity
Tenderness behind uterus
Mangement benign ovarian tumour
CONSERVATIVE
MEDICAL –GnRH analogues, OCP
SURGICAL - lap ovarian cystectomy, oopherectomy, pelvic clearance
Describe borderline tumours
Masses grow slowly and may spread but not into stroma or parenchyma of other organs
Specific to pelvis
Management uterine fibroids
CONSERVATIVE
MEDICAL - hormonal management of bleeding, GnRH agonists
SURGICAL - myomectomy, hysterectomy
IR - uterine artery emolisation
Pres of endo hyperplasia
- Causes: often unknown; may be persistent oestrogen stimulation
- Presents with abnormal bleeding (dysfunctional uterine bleeding or
postmenopausal bleeding).
2 main endo carcinoma and their precursor lesions
– Endometrioid carcinoma:
precursor atypical hyperplasia
– Serous carcinoma:
precursor serous intraepithelial carcinoma
Why are people with PCOS more likely to get endo cancer earlier?
They don’t ovulate so constantly secreting oestrogen
In a constate proliferative state and rarely reach secretory to release progesterone
2 main clinicopath types of endo cancer
Endometrioid (and mucinous) – type 1 tumours (80%)
- Related to unopposed oestrogen e.g. PCOS or obesity
- Associated with atypical hyperplasia
Serous (and clear cell) – type 2 tumours
- Not associated with unopposed oestrogen
- Affect elderly post‐menopausal women
- TP53 often mutated
Commonest mutations in endo carcinoma
PTEN, KRAS, PIK3CA
Can get germline mutation causing microsatellite instability due to Lynch’s
Why does obesity put you at higher risk of endo cancer?
Adipocytes express aromatase that converts ovarian androgens into oestrogens, which induce endometrial proliferation.
Sex hormone-binding globulin levels are lower in obese women, and therefore the level of unbound, biologically active hormone is higher.
Insulin action is often altered in obese women which exerts proliferative effect on endometrium.
Med management of endo cancer if surgery is not an option
Progestogens
Put in 1 or 2 mirena coils
Serous carcinoma on micro
Characterised by a complex papillary and/or glandular archietecture with diffuse, marked nuclear pleomorphism
Describe endo stromal sarcoma
Low or high grade
Very invasive, esp with blood
Rare, cells resemble endometrial stroma. Infiltrate myometrium and often lymphovascular spaces
Presents with abnormal uterine bleeding but initial presentation may be as metastasis e.g. ovary, lung
Stage for prognosis
Features of carcinosarcoma
High grade carcinomatous and sarcomatous elements
Heterologous elements commonly seen in about 50% cases (rhabdomyosarcoma, chrondrosarcoma, osteosarcoma)
Poor prognosis
Big bulky tumours obstructing uterus
Features of leiomyosarcoma
A malignant smooth muscle tumour commonly displaying a spindle cell morphology
Rare
Presents with abnormal vaginal bleeding, palpable pelvic mass and pelvic pain
Poor prognosis even if
