Pelvic Masses & Ovarian Cancer

1. Pelvic Masses & Ovarian Cancer

2. Differential diagnosis of pelvic masses • Investigations and management • Benign ovarian cysts • Ovarian cancer

3. Pre-pubertal Adolescent Functional cyst Pregnancy Dermoid Other germ cell tumour Obstructing vaginal/uterine abnormality Epithelial cell tumour • Functional cyst • Germ cell tumour

4. Reproductive Perimenopausal Fibroids Epithelial tumour Functional cyst • Pregnancy • Functional cyst • Fibroids • Epithelial tumour

5. Postmenopausal • Ovarian tumour • Functional cyst • Other malignancy • Metastases

6. Diagnosis • History and examination • Ultrasound • CT/MRI • Tumour markers – CA125, CEA, CA19,9 hCg, alpha-fetoprotein

8. 50 % - asymptomatic • 30% - menorrhagia • Irregular bleeding • Pressure effects

9. Management Depends on symptoms and fertility issues Reassure that risk of malignancy tiny • Hysteroscopic removal (small submucosal) • Myomectomy • Embolisation • Hysterectomy

10. Benign Unilocular Cyst

11. Septate Cyst

12. Ovarian Cancer

13. Dermoid

14. Haematocolpos

15. Imperforate hymen - haematocolpos

16. Management - Young women • Small, simple, asymptomatic – leave alone and rescan 3 months later • Complex – ovarian cystectomy or oopherectomy • MDT involvement if any suspicious features

17. Management – older women • Complex in older women – MDT involvement Further imaging Tumour markers TAH/BSO • Simple, < 5cm, normal tumour markers – consider conservative management with repeat scan.

18. Fibroids • Present in 25% of women • More common: perimenopausal family history Afro-Caribbean women • Sub-mucosal, subserosal, intramural

19. Ovarian Cancer • 5th, 6th and 7th decades • Risk inversely correlated with parity. • Genetic component – BRCA1 & BRCA2 • Presents late – usually with a mass or ascites • No premalignant stage - screening

20. Borderline tumours • Epithelial • Sex cord/stromal • Germ cell • Metastases

21. Epithelial Tumours Serous • Most common • Bilateral in 50% • Cystic and solid components Mucinous • Contain mucinous fluid • Pseudmyxomaperitonei

22. Endometrioid • 30% have a coexistent endometrial CA

23. Sex Cord/Stromal Tumours Granulosa Cell • Secrete oestrogen – IMB or PMB Fibroma • Usually unilateral • Meig’s Syndrome Sertoli/Leydig Cell • Young women (20’s) • Secrete testosterone

24. Germ Cell Tumours Dysgerminoma • Ages 10 – 30 • May be raised hCG Yolk sac tumour • Young women • Raised alphafetoprotein, normal hCG Choriocarcinoma • Secrete hCG • Do not respond to chemotherapy Teratoma • Usually benign -all 3 embryonic germ layers

25. Staging Ia – One ovary Ib – Both ovaries Ic – Ia/Ib with ruptured capsule, tumour on surface of capsule, + ve washings or ascites IIa – Extending to uterus and tubes IIb – Extending to other pelvic tissues IIc - IIa/IIb with ruptured capsule, + ve washings or ascites

26. IIIa – Pelvic tumour with microscopic peritoneal spread IIIb – Peritoneal spread < 2cm IIIc – Abdominal implants >2cm +/- positive retroperitoneal or inguinal nodes IV – Liver disease. Distant mets.

27. Management • CT & CXR • Baseline tumour markers • Surgical staging • Debulking surgery & adjuvant chemo • Neoadjuvant chemo with interval debulking