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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

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).
slide13

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

slide14

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

slide16
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 uterine
Etiology - Uterine
  • Leiomyoma
  • Endometrioma
  • Pregnancy
slide22

Fundus

Round ligament

Tube

Fibroid

Ovary

Fimbria

etiology ovarian
Etiology - Ovarian
  • Neoplastic
    • Epithelial
    • Germ cell
    • Sex cord-Stromal
  • Functional cysts
  • Torsion
  • Tubo-ovarian abscess (TOA)
slide25
The most common benign tumor in reproductive aged women is a serous cystadenoma followed by mature teratoma.
slide26

Benign serous cystadenoma

6,300 grams, 30 cm X 30 cm

slide27

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
slide30

ovarian capsule

Epithelial ovarian cancer, stage 1C

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
slide39

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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