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Approach to the Patient with a Pelvic Mass

Approach to the Patient with a Pelvic Mass. Karen Carlson, MD Assistant Professor Department of Obstetrics and Gynecology. How do these women present?. Pressure/fullness Increasing girth Pain Annual exam Obstetrical exam Bleeding.

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Approach to the Patient with a Pelvic Mass

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  1. Approach to the Patient with a Pelvic Mass Karen Carlson, MD Assistant Professor Department of Obstetrics and Gynecology

  2. How do these women present? • Pressure/fullness • Increasing girth • Pain • Annual exam • Obstetrical exam • Bleeding

  3. The approach to the discovery of a pelvic mass should take into consideration 4 things: • Age • Tumor size • U/S features • Labs

  4. Examination Radiology U/S CT MRI Lab CBC hCG Markers Work-up

  5. Examination Always include rectal exam EUA Work-up

  6. U/S Relatively inexpensive Delineates cystic vs solid structures Assesses for ascites CT Assesses other organs Excellent for retroperitoneum (1-5 mm) MRI Allows for ID of soft tissue lesions Safe in pregnancy Can differentiate normal from malignancy Safe in women with IUD or surgical clips Does not use radiopaque contrast agent Work-up

  7. Lab - Tumor Markers • CA-125 • Epithelial tumors • Antibody for antigen produced by coelomic epithelium • Normal <35 U/mL • NOT an effective screening tool for cancer

  8. Lab - Tumor Markers • CA-125 ↑ in: • Leiomyoma • Endometriosis/adenomyosis • PID • Pregnancy • Malignancies-lung, breast, colon • Pancreatitis • Cirrhosis

  9. Lab - Tumor Markers • CA-125 • Epithelial tumors • AFP • Endodermal sinus tumor • hCG • Choriocarcinoma • LDH • Dysgerminoma

  10. Ovarian cancer is the 2nd most common malignancy of the female genital tract. Most frequent cause of death from GYN cancers. Annually, 23,000 new cases with 14,000 deaths.

  11. Median age of ovarian cancer is 52.Life-time risk is 1.4%.5% risk if 1° relative has ovarian cancer.

  12. Ovarian enlargement in the pre-menarchal female is usually the result of a benign teratoma (dermoid).

  13. 60-85% of ovarian neoplasms in the pediatric and younger adolescent age groups are of germ cell origin. In adults, germ cell tumors account for only 20% of ovarian neoplasms. Van Winter, JT. Am J Obstet Gynecol 1994;170:1780

  14. The frequency of ovarian malignancies correlates inversely with patient age. 14% of all masses and 33% of neoplastic masses were malignant in patients < 16 years of age. Van Winter, JT. Am J Obstet Gynecol 1994;170:1780

  15. In patients 16–20 years of age, 7% of all masses and 20% of neoplastic masses are malignant. Van Winter, JT. Am J Obstet Gynecol 1994;170:1780

  16. A compilation of studies conducted from 1940-1975 reported that 35% of all ovarian neoplasms in childhood were malignant. Van Winter, JT. Am J Obstet Gynecol 1994;170:1780

  17. In girls aged <9 years, approximately 80% of ovarian neoplasms were malignant. Van Winter, JT. Am J Obstet Gynecol 1994;170:1780

  18. The vast majority (97%) of mature teratomas (dermoids) are benign.

  19. Etiology of Pelvic Mass • Uterine

  20. Etiology - Uterine • Leiomyoma • Endometrioma • Pregnancy

  21. Fundus Round ligament Tube Fibroid Ovary Fimbria

  22. Etiology of Pelvic Mass • Uterine • Ovarian

  23. Etiology - Ovarian • Neoplastic • Epithelial • Germ cell • Sex cord-Stromal • Functional cysts • Torsion • Tubo-ovarian abscess (TOA)

  24. The most common benign tumor in reproductive aged women is a serous cystadenoma followed by mature teratoma.

  25. Benign serous cystadenoma 6,300 grams, 30 cm X 30 cm

  26. Benign serous cystadenoma 6,810 grams, 20 cm X 40 cm

  27. Dermoid cyst • 5-10% are bilateral • < 1% are malignant • When malignancy is encountered, the malignant cell line is of ectodermal origin

  28. ovarian capsule Epithelial ovarian cancer, stage 1C

  29. Theca-lutein cysts

  30. Etiology of Pelvic Mass • Uterine • Ovarian • GI

  31. Etiology - GI • Diverticular abscess • Appendiceal abscess • Primary malignancy

  32. Etiology of Pelvic Mass • Uterine • Ovarian • GI • Adnexal

  33. Etiology - Adnexal • Ectopic pregnancy • Abscess • Peritubular cyst • Endometrioma • Round ligament fibroid • Torsion • Hydrosalpinx • Müllerian defect

  34. R uterine horn with hematocolpos R hematosalpinx L tube and ovary L uterine horn Müllerian defect

  35. Etiology of Pelvic Mass • Uterine • Ovarian • GI • Adnexal • Infectious

  36. Etiology - Infectious • TOA • Appendiceal abscess • Diverticular abscess

  37. Etiology of Pelvic Mass • Uterine • Ovarian • GI • Adnexal • Infectious • Retroperitoneal

  38. Clinical Conundrums : • Adnexal mass in pregnancy • Persistent unilocular ovarian cysts • Whom to refer to a gynecologic oncologist

  39. Adnexal Mass in Pregnancy • 1/1,300 patients • 6% CA or LMP (8/130) • Dermoid most common (30%) • No ↑ incidence of adverse outcome • Remove for 3 reasons • Prevent dystocia • Danger of rupture, torsion, or hemorrhage • Malignancy Whitecar, P. Am J Obstet Gynecol 1999;181:19

  40. Persistent Unilocular Ovarian Cysts • Common: 3 to 17% • Expectant management is acceptable in post-menopausal women provided: • Diameter < 5 cm • No increase in size • Normal CA-125 Nardo, LG, et al. Obstet Gynecol 2003;102:589

  41. Persistent Unilocular Ovarian Cysts • 15,106 women over 50 screened • 18% found to have unilocular cyst • 69% resolved spontaneously • None of the women with isolated unilocular ovarian cysts developed ovarian CA Modesitt SC, et al. Obstet Gynecol 2003;102:594

  42. Persistent Unilocular Ovarian Cysts • 27 of 15,106 developed ovarian cancer. • 10 had previously documented simple cyst. • All 10 developed other morphologic abnormalities. • Conservative follow-up with serial TVU is acceptable with unilocular cyst <10 cm Modesitt SC, et al. Obstet Gynecol 2003;102:594

  43. Whom to refer to a gynecologist oncologist? In a retrospective chart review of 1,035 patients with a pelvic mass, this question was thoroughly evaluated. The newly developed guidelines correctly identify 70% of premenopausal and 94% of postmenopausal women with ovarian cancer. Im SS, et al., Obstet Gynecol 2005;105:35-41

  44. Referral Criteria for Women with a Pelvic Mass • Premenopausal (<50 years old) • CA-125 > 50 U/ml • Ascities • Evidence of abdominal or distant metastasis • Postmenopausal (>50 years old) • CA-125 > 35 U/ml • Ascites • Evidence of abdominal or distant metastasis Im SS, et al., Obstet Gynecol 2005;105:35-41

  45. Conclusions • Ovarian enlargement in pre-menarchal female is dermoid • 60-85% of ovarian neoplasm in women < 20 is germ cell. In adults, only 20% • Frequency of ovarian cancer is inversely related to age. 14% in women < 16 and 7% age 16-20

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