Approach to the patient with a pelvic mass
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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

Approach to the Patient with a Pelvic Mass

Karen Carlson, MD

Assistant Professor

Department of Obstetrics and Gynecology


How do these women present
How do these women present?

  • Pressure/fullness

  • Increasing girth

  • Pain

  • Annual exam

  • Obstetrical exam

  • Bleeding


The approach to the discovery of a pelvic mass should take into consideration 4 things
The approach to the discovery of a pelvic mass should take into consideration 4 things:

  • Age

  • Tumor size

  • U/S features

  • Labs


Work up

Examination into consideration 4 things:

Radiology

U/S

CT

MRI

Lab

CBC

hCG

Markers

Work-up


Work up1

Examination into consideration 4 things:

Always include rectal exam

EUA

Work-up


Work up2

U/S into consideration 4 things:

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


Lab tumor markers
Lab - Tumor Markers into consideration 4 things:

  • CA-125

    • Epithelial tumors

    • Antibody for antigen produced by coelomic epithelium

    • Normal <35 U/mL

    • NOT an effective screening tool for cancer


Lab tumor markers1
Lab - Tumor Markers into consideration 4 things:

  • CA-125 ↑ in:

    • Leiomyoma

    • Endometriosis/adenomyosis

    • PID

    • Pregnancy

    • Malignancies-lung, breast, colon

    • Pancreatitis

    • Cirrhosis


Lab tumor markers2
Lab - Tumor Markers into consideration 4 things:

  • CA-125

    • Epithelial tumors

  • AFP

    • Endodermal sinus tumor

  • hCG

    • Choriocarcinoma

  • LDH

    • Dysgerminoma


Ovarian cancer is the 2 nd most common malignancy of the female genital tract

Ovarian cancer is the 2 into consideration 4 things:nd 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.


Median age of ovarian cancer is 52 life time risk is 1 4 5 risk if 1 relative has ovarian cancer
Median age of ovarian cancer is 52. into consideration 4 things:Life-time risk is 1.4%.5% risk if 1° relative has ovarian cancer.


Ovarian enlargement in the pre menarchal female is usually the result of a benign teratoma dermoid
Ovarian enlargement in the into consideration 4 things:pre-menarchal female is usually the result of a benign teratoma (dermoid).


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


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


In patients 16 20 years of age 7 of all masses and 20 of neoplastic masses are malignant
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


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


In girls aged 9 years approximately 80 of ovarian neoplasms were malignant
In girls aged <9 years, approximately 80% of ovarian neoplasms were malignant.

Van Winter, JT. Am J Obstet Gynecol 1994;170:1780



Etiology of pelvic mass
Etiology of Pelvic Mass benign.

  • Uterine


Etiology uterine
Etiology - Uterine benign.

  • Leiomyoma

  • Endometrioma

  • Pregnancy


Fundus benign.

Round ligament

Tube

Fibroid

Ovary

Fimbria


Etiology of pelvic mass1
Etiology of Pelvic Mass benign.

  • Uterine

  • Ovarian


Etiology ovarian
Etiology - Ovarian benign.

  • Neoplastic

    • Epithelial

    • Germ cell

    • Sex cord-Stromal

  • Functional cysts

  • Torsion

  • Tubo-ovarian abscess (TOA)


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


Benign serous cystadenoma benign.

6,300 grams, 30 cm X 30 cm


Benign serous cystadenoma benign.

6,810 grams, 20 cm X 40 cm


Dermoid cyst
Dermoid cyst benign.

  • 5-10% are bilateral

  • < 1% are malignant

  • When malignancy is encountered, the malignant cell line is of ectodermal origin


ovarian capsule benign.

Epithelial ovarian cancer, stage 1C



Etiology of pelvic mass2
Etiology of Pelvic Mass benign.

  • Uterine

  • Ovarian

  • GI


Etiology gi
Etiology - GI benign.

  • Diverticular abscess

  • Appendiceal abscess

  • Primary malignancy


Etiology of pelvic mass3
Etiology of Pelvic Mass benign.

  • Uterine

  • Ovarian

  • GI

  • Adnexal


Etiology adnexal
Etiology - Adnexal benign.

  • Ectopic pregnancy

  • Abscess

  • Peritubular cyst

  • Endometrioma

  • Round ligament fibroid

  • Torsion

  • Hydrosalpinx

  • Müllerian defect


R uterine horn with hematocolpos benign.

R hematosalpinx

L tube and ovary

L uterine horn

Müllerian defect


Etiology of pelvic mass4
Etiology of Pelvic Mass benign.

  • Uterine

  • Ovarian

  • GI

  • Adnexal

  • Infectious


Etiology infectious
Etiology - Infectious benign.

  • TOA

  • Appendiceal abscess

  • Diverticular abscess


Etiology of pelvic mass5
Etiology of Pelvic Mass benign.

  • Uterine

  • Ovarian

  • GI

  • Adnexal

  • Infectious

  • Retroperitoneal


Clinical conundrums
Clinical Conundrums : benign.

  • Adnexal mass in pregnancy

  • Persistent unilocular ovarian cysts

  • Whom to refer to a gynecologic oncologist


Adnexal mass in pregnancy
Adnexal Mass in Pregnancy benign.

  • 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


Persistent unilocular ovarian cysts
Persistent Unilocular Ovarian Cysts benign.

  • 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


Persistent unilocular ovarian cysts1
Persistent Unilocular Ovarian Cysts benign.

  • 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


Persistent unilocular ovarian cysts2
Persistent Unilocular Ovarian Cysts benign.

  • 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


Whom to refer to a gynecologist oncologist

Whom to refer to a gynecologist oncologist? benign.

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


Referral criteria for women with a pelvic mass
Referral Criteria for Women with a Pelvic Mass benign.

  • 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


Conclusions
Conclusions benign.

  • 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


Conclusions1
Conclusions benign.

  • Dermoid is the most common mass in pregnancy

  • Unilocular cysts can be followed if < 10 cm and stable with normal CA-125


Conclusions2
Conclusions benign.

  • Refer premenopausal patients with a CA-125 > 50 U/ml and ascites and evidence of abdominal or distant metastasis to a gynecologic oncologist.

  • Refer postmenopausal patients with a CA-125 > 35 U/ml with ascites and evidence of abdominal or distant metastasis to a gynecologic oncologist.


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