Pelvic Mass. Alexander Dufort and Sean Mindra OBGYN boot camp October 17 th , 2014. Objectives. List pelvic tumors of ovarian origin. Classify ovarian pathology as benign vs. malignant. Compare and contrast functional vs. neoplastic ovarian cysts. Case.
Pelvic Mass Alexander Dufort and Sean Mindra OBGYN boot camp October 17th, 2014
Objectives • List pelvic tumors of ovarian origin. • Classify ovarian pathology as benign vs. malignant. • Compare and contrast functional vs. neoplastic ovarian cysts.
Case • An 18 yo G0 young woman presents to your office for routine gynecologic examination. She reports that her last menstrual period began about 23 days ago. It was light in flow, and lasted 4 days in length. She has minimal dysmenorrhea. She denies any history of sexually transmitted infections, and has been sexually active with two male partners in the last 2 weeks. She was given a prescription for OCP 3 months ago; however, she has not started taking these. She has no other complaints or medical/surgical history.
Case – Continued • During her pelvic examination, you perform a PAP and bimanual examination. You discover a 6 cm non-tender left adnexal mass that is mobile. She has no rebound tenderness or guarding.
Outline • Using the above case as a starting point, review Pelvic Masses – focus on ovarian pathology; • Review Classification of Pelvic Mass; physiologic vs. non-physiologic • Discuss necessary investigations • Review management options for this case • Review management options for pelvic mass diagnosed in a perimenopausal/postmenopausal patient
Classification of Ovarian masses • Physiological/Functional cysts • Neoplastic • Benign and malignant • Pregnancy related • Ectopic pregnancy • Other • Endometrioma (Chocolate cyst) – from endometriosis
Tubes Tubal: • Hydrosalpinx (blocked tube - typically bilateral – serous/clear) • Tubo-ovarian cyst • Pyosalpinx (pus-filled tube) Para-tubal: -can happen in the broad ligament, upper third of vagina, uterus, fallopian tubes
Physiological/functional Mass • Follicular cyst • Formed by a dominant follicle that fails to rupture during ovulation • Luteal cyst • Formed by the premature sealing of the CL after the egg is released, causing the CL to enlarge
Question 1 • Which of the following is true regarding the natural progression of a functional ovarian cyst? A) Generally asymptomatic unless bleeding or torsion occur B) 10% chance of progression to malignancy C) Grow to sizes larger then 10 cm
Question 2 Which of the following is a risk factor for developing ovarian cancer? 1) Childbearing 2) Early menarche 3) Early menopause 4) OCP
Risk Factors • Increasing age • Lifestyle (smoking, obesity, lack of physical activity) • infertility • Family history of ovarian ca • BRCA1 & BRCA2 • History of endometriosis • HRT
Neoplastic Masses • Epithelial • Serous – most common subtype [mostly in 40-60yrs of age] • Mucinous [30-50yrs of age] • Endometrioid [50-70yrs of age] • Clear cell [40-80yrs of age] • Brenner/transitional cell [very rare] • Undifferentiated [account for about 15% of epithelial tumors] • Germ cell • Mature teratoma (Dermoid Cyst) • Sex cord / stromal • Metastatic
Question 3 Which of the following is TRUE regarding this type of mass? A) They are most commonly derived from ectoderm B) It has a thin wall C) Marsupialization is a common surgical technique used for treatment D) They have short vascular pedicles
Neoplastic masses • Most common neoplastic masses in a pre-menopausal women • Serous cystadenoma • Endometrioma • Mature cystic teratoma
Symptoms of ovarian masses • Asymptomatic • Increased abdominal girth and distension • Acute pain • torsion, rupture and hemorrhage • Signs of infection (Fever, pain) • Chronic Pain: • Deep Dysparunia, Dysmenorrhea • Ovarian cancer can present with • Weight loss, anorexia, respiratory symptoms, urinary frequency, constipation, ascites
Physical findings: Benign vs. Malignant • Benign • Unilateral • Cystic • Mobile • Malignant • Fixed • Solid/irregular shape • Associated with ascites • Rapidly increase in size
Back to the Case! • 18 yo, asymptomatic, 6 cm andexal mass • Likely etiologies • Neoplastic • Mature cystic teratoma • Serous cystadenoma • Endometrioma • Functional • Follicular Cyst • Corpus luteum cyst
Back to the Case! • What is the next step in management? • Imaging, Serum bHCG, CBC • What would be the Imaging modality of choice to further investigate our patient’s mass? • X-ray • CT scan • Pelvic ultrasound • MRI
Ultrasound findings • Findings suggestive of a benign process • Anechoic • Unilocular • Fluid filled cysts with thin walls • Calcification (pathognomonic for dermoid cyst) • Follicular cyst
Ultrasound findings • Findings suggestive of malignant process • Solid or complex cystic/solid mass • Nodular • Thick Septations • Presence of ascities • Peritoneal masses and nodularity • Doppler demonstrating flow • Ovarian cancer
Management: Premenopausal • If U/S is suggestive of a benign process • Surveillance • If asymptomatic, simple cyst (i.e. physiological), < 8 cm • Reassess in 6 weeks for regression • Suppression • OCP or GnRH analogue (ex. Lupron) • Recurrent physiological cysts • Excision • Ovarian cystectomy vs. oophorectomy • > 8 cm, symptomatic, findings suggestive of dermoid cyst • Intervention for torsion, sever hemorrhage, abscess
Management: Premenopausal • If findings suggestive of a malignant process • Surgical exploration to investigate etiology • Open (preferred) or laparoscopic oophorectomy or Hysterectomy + BSO • Staging and histological diagnosis
Management: Post-menopausal • Why is the management different between premenopausal and postmenopausal women?
Management: Post-menopausal • Investigations and work up • History and risk factors, physical, pelvic U/S • CA-125 • Management • Features suggestive of malignancy and/or CA-125 level above 35 U/ml and+/-or mass > 10 cm • Hysterectomy + BSO • +/- adjuvant chemotherapy (Carboplatin/Taxol) • Benign features (Low CA-125, <5 cm) • Continued CA-125 and U/S screening
Summary • Many different types of ovarian masses • Functional vs. neoplastic • Functional will regress • Benign lesions common in pre-menopausal women • Often present asymptomatically • Treatment dictated by symptoms and imaging findings. • Suspicion of malignancy requires surgery
Resources • Up to Date • Pelvic Masses and Pelvic Pain lecture • Toronto Notes 2014