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

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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


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

  • Age

  • Tumor size

  • U/S features

  • Labs


Examination

Radiology

U/S

CT

MRI

Lab

CBC

hCG

Markers

Work-up


Examination

Always include rectal exam

EUA

Work-up


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


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


Lab - Tumor Markers

  • CA-125 ↑ in:

    • Leiomyoma

    • Endometriosis/adenomyosis

    • PID

    • Pregnancy

    • Malignancies-lung, breast, colon

    • Pancreatitis

    • Cirrhosis


Lab - Tumor Markers

  • CA-125

    • Epithelial tumors

  • AFP

    • Endodermal sinus tumor

  • hCG

    • Choriocarcinoma

  • LDH

    • Dysgerminoma


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.


Median age of ovarian cancer is 52.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).


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.

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.

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


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


Etiology of Pelvic Mass

  • Uterine


Etiology - Uterine

  • Leiomyoma

  • Endometrioma

  • Pregnancy


Fundus

Round ligament

Tube

Fibroid

Ovary

Fimbria


Etiology of Pelvic Mass

  • Uterine

  • Ovarian


Etiology - Ovarian

  • Neoplastic

    • Epithelial

    • Germ cell

    • Sex cord-Stromal

  • Functional cysts

  • Torsion

  • Tubo-ovarian abscess (TOA)


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


Benign serous cystadenoma

6,300 grams, 30 cm X 30 cm


Benign serous cystadenoma

6,810 grams, 20 cm X 40 cm


Dermoid cyst

  • 5-10% are bilateral

  • < 1% are malignant

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


ovarian capsule

Epithelial ovarian cancer, stage 1C


Theca-lutein cysts


Etiology of Pelvic Mass

  • Uterine

  • Ovarian

  • GI


Etiology - GI

  • Diverticular abscess

  • Appendiceal abscess

  • Primary malignancy


Etiology of Pelvic Mass

  • Uterine

  • Ovarian

  • GI

  • Adnexal


Etiology - Adnexal

  • Ectopic pregnancy

  • Abscess

  • Peritubular cyst

  • Endometrioma

  • Round ligament fibroid

  • Torsion

  • Hydrosalpinx

  • Müllerian defect


R uterine horn with hematocolpos

R hematosalpinx

L tube and ovary

L uterine horn

Müllerian defect


Etiology of Pelvic Mass

  • Uterine

  • Ovarian

  • GI

  • Adnexal

  • Infectious


Etiology - Infectious

  • TOA

  • Appendiceal abscess

  • Diverticular abscess


Etiology of Pelvic Mass

  • Uterine

  • Ovarian

  • GI

  • Adnexal

  • Infectious

  • Retroperitoneal


Clinical Conundrums :

  • Adnexal mass in pregnancy

  • Persistent unilocular ovarian cysts

  • Whom to refer to a gynecologic oncologist


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


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


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


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


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


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


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


Conclusions

  • Dermoid is the most common mass in pregnancy

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


Conclusions

  • 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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