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

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

Radiology

U/S

CT

MRI

Lab

CBC

hCG

Markers

Work-up


Work up1

Examination

Always include rectal exam

EUA

Work-up


Work up2

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

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 markers1

Lab - Tumor Markers

  • CA-125 ↑ in:

    • Leiomyoma

    • Endometriosis/adenomyosis

    • PID

    • Pregnancy

    • Malignancies-lung, breast, colon

    • Pancreatitis

    • Cirrhosis


Lab tumor markers2

Lab - Tumor Markers

  • 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 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

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

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


Approach to the patient with a pelvic mass

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


Approach to the patient with a pelvic mass

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


Approach to the patient with a pelvic mass

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


The vast majority 97 of mature teratomas dermoids are benign

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


Etiology of pelvic mass

Etiology of Pelvic Mass

  • Uterine


Etiology uterine

Etiology - Uterine

  • Leiomyoma

  • Endometrioma

  • Pregnancy


Approach to the patient with a pelvic mass

Fundus

Round ligament

Tube

Fibroid

Ovary

Fimbria


Etiology of pelvic mass1

Etiology of Pelvic Mass

  • Uterine

  • Ovarian


Etiology ovarian

Etiology - Ovarian

  • Neoplastic

    • Epithelial

    • Germ cell

    • Sex cord-Stromal

  • Functional cysts

  • Torsion

  • Tubo-ovarian abscess (TOA)


Approach to the patient with a pelvic mass

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


Approach to the patient with a pelvic mass

Benign serous cystadenoma

6,300 grams, 30 cm X 30 cm


Approach to the patient with a pelvic mass

Benign serous cystadenoma

6,810 grams, 20 cm X 40 cm


Dermoid cyst

Dermoid cyst

  • 5-10% are bilateral

  • < 1% are malignant

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


Approach to the patient with a pelvic mass

ovarian capsule

Epithelial ovarian cancer, stage 1C


Approach to the patient with a pelvic mass

Theca-lutein cysts


Etiology of pelvic mass2

Etiology of Pelvic Mass

  • Uterine

  • Ovarian

  • GI


Etiology gi

Etiology - GI

  • Diverticular abscess

  • Appendiceal abscess

  • Primary malignancy


Etiology of pelvic mass3

Etiology of Pelvic Mass

  • Uterine

  • Ovarian

  • GI

  • Adnexal


Etiology adnexal

Etiology - Adnexal

  • Ectopic pregnancy

  • Abscess

  • Peritubular cyst

  • Endometrioma

  • Round ligament fibroid

  • Torsion

  • Hydrosalpinx

  • Müllerian defect


Approach to the patient with a pelvic mass

R uterine horn with hematocolpos

R hematosalpinx

L tube and ovary

L uterine horn

Müllerian defect


Etiology of pelvic mass4

Etiology of Pelvic Mass

  • Uterine

  • Ovarian

  • GI

  • Adnexal

  • Infectious


Etiology infectious

Etiology - Infectious

  • TOA

  • Appendiceal abscess

  • Diverticular abscess


Etiology of pelvic mass5

Etiology of Pelvic Mass

  • Uterine

  • Ovarian

  • GI

  • Adnexal

  • Infectious

  • Retroperitoneal


Clinical conundrums

Clinical Conundrums :

  • Adnexal mass in pregnancy

  • Persistent unilocular ovarian cysts

  • Whom to refer to a gynecologic oncologist


Adnexal mass in pregnancy

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

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 cysts1

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 cysts2

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

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

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

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


Conclusions1

Conclusions

  • Dermoid is the most common mass in pregnancy

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


Conclusions2

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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