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Pelvic Mass

Pelvic Mass. Alexander Dufort and Sean Mindra OBGYN boot camp October 17 th , 2014. Objectives. List pelvic tumors of ovarian origin. Classify ovarian pathology as benign vs. malignant. Compare and contrast functional vs. neoplastic ovarian cysts. Case.

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Pelvic Mass

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  1. Pelvic Mass Alexander Dufort and Sean Mindra OBGYN boot camp October 17th, 2014

  2. Objectives • List pelvic tumors of ovarian origin. • Classify ovarian pathology as benign vs. malignant. • Compare and contrast functional vs. neoplastic ovarian cysts.

  3. Case • An 18 yo G0 young woman presents to your office for routine gynecologic examination. She reports that her last menstrual period began about 23 days ago. It was light in flow, and lasted 4 days in length. She has minimal dysmenorrhea. She denies any history of sexually transmitted infections, and has been sexually active with two male partners in the last 2 weeks. She was given a prescription for OCP 3 months ago; however, she has not started taking these. She has no other complaints or medical/surgical history.

  4. Case – Continued • During her pelvic examination, you perform a PAP and bimanual examination. You discover a 6 cm non-tender left adnexal mass that is mobile. She has no rebound tenderness or guarding.

  5. Outline • Using the above case as a starting point, review Pelvic Masses – focus on ovarian pathology; • Review Classification of Pelvic Mass; physiologic vs. non-physiologic • Discuss necessary investigations • Review management options for this case • Review management options for pelvic mass diagnosed in a perimenopausal/postmenopausal patient

  6. Classification of Ovarian masses • Physiological/Functional cysts • Neoplastic • Benign and malignant • Pregnancy related • Ectopic pregnancy • Other • Endometrioma (Chocolate cyst) – from endometriosis

  7. Tubes Tubal: • Hydrosalpinx (blocked tube - typically bilateral – serous/clear) • Tubo-ovarian cyst • Pyosalpinx (pus-filled tube) Para-tubal: -can happen in the broad ligament, upper third of vagina, uterus, fallopian tubes

  8. Physiological/functional Mass • Follicular cyst • Formed by a dominant follicle that fails to rupture during ovulation • Luteal cyst • Formed by the premature sealing of the CL after the egg is released, causing the CL to enlarge

  9. Question 1 • Which of the following is true regarding the natural progression of a functional ovarian cyst? A) Generally asymptomatic unless bleeding or torsion occur B) 10% chance of progression to malignancy C) Grow to sizes larger then 10 cm

  10. Question 2 Which of the following is a risk factor for developing ovarian cancer? 1) Childbearing 2) Early menarche 3) Early menopause 4) OCP

  11. Risk Factors • Increasing age • Lifestyle (smoking, obesity, lack of physical activity) • infertility • Family history of ovarian ca • BRCA1 & BRCA2 • History of endometriosis • HRT

  12. Neoplastic Masses • Epithelial • Serous – most common subtype [mostly in 40-60yrs of age] • Mucinous [30-50yrs of age] • Endometrioid [50-70yrs of age] • Clear cell [40-80yrs of age] • Brenner/transitional cell [very rare] • Undifferentiated [account for about 15% of epithelial tumors] • Germ cell • Mature teratoma (Dermoid Cyst) • Sex cord / stromal • Metastatic

  13. Question 3 Which of the following is TRUE regarding this type of mass? A) They are most commonly derived from ectoderm B) It has a thin wall C) Marsupialization is a common surgical technique used for treatment D) They have short vascular pedicles

  14. Neoplastic masses • Most common neoplastic masses in a pre-menopausal women • Serous cystadenoma • Endometrioma • Mature cystic teratoma

  15. Symptoms of ovarian masses • Asymptomatic • Increased abdominal girth and distension • Acute pain • torsion, rupture and hemorrhage • Signs of infection (Fever, pain) • Chronic Pain: • Deep Dysparunia, Dysmenorrhea • Ovarian cancer can present with • Weight loss, anorexia, respiratory symptoms, urinary frequency, constipation, ascites

  16. Physical findings: Benign vs. Malignant • Benign • Unilateral • Cystic • Mobile • Malignant • Fixed • Solid/irregular shape • Associated with ascites • Rapidly increase in size

  17. Back to the Case! • 18 yo, asymptomatic, 6 cm andexal mass • Likely etiologies • Neoplastic • Mature cystic teratoma   • Serous cystadenoma • Endometrioma • Functional • Follicular Cyst • Corpus luteum cyst

  18. Back to the Case! • What is the next step in management? • Imaging, Serum bHCG, CBC • What would be the Imaging modality of choice to further investigate our patient’s mass? • X-ray • CT scan • Pelvic ultrasound • MRI

  19. Ultrasound findings • Findings suggestive of a benign process • Anechoic • Unilocular • Fluid filled cysts with thin walls • Calcification (pathognomonic for dermoid cyst) • Follicular cyst

  20. Ultrasound findings • Findings suggestive of malignant process • Solid or complex cystic/solid mass • Nodular • Thick Septations • Presence of ascities • Peritoneal masses and nodularity • Doppler demonstrating flow • Ovarian cancer

  21. Management: Premenopausal • If U/S is suggestive of a benign process • Surveillance • If asymptomatic, simple cyst (i.e. physiological), < 8 cm • Reassess in 6 weeks for regression • Suppression • OCP or GnRH analogue (ex. Lupron) • Recurrent physiological cysts • Excision • Ovarian cystectomy vs. oophorectomy  • > 8 cm, symptomatic, findings suggestive of dermoid cyst • Intervention for torsion, sever hemorrhage, abscess

  22. Management: Premenopausal • If findings suggestive of a malignant process • Surgical exploration to investigate etiology • Open (preferred) or laparoscopic oophorectomy or Hysterectomy + BSO • Staging and histological diagnosis

  23. Management: Post-menopausal • Why is the management different between premenopausal and postmenopausal women?

  24. Management: Post-menopausal • Investigations and work up • History and risk factors, physical, pelvic U/S • CA-125 • Management • Features suggestive of malignancy and/or CA-125 level above 35 U/ml and+/-or mass > 10 cm • Hysterectomy + BSO • +/- adjuvant chemotherapy (Carboplatin/Taxol) • Benign features (Low CA-125, <5 cm) • Continued CA-125 and U/S screening

  25. Summary • Many different types of ovarian masses • Functional vs. neoplastic • Functional will regress • Benign lesions common in pre-menopausal women • Often present asymptomatically • Treatment dictated by symptoms and imaging findings. • Suspicion of malignancy requires surgery

  26. Resources • Up to Date • Pelvic Masses and Pelvic Pain lecture • Toronto Notes 2014

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