AN APPROACH TO EVALUATION OF PELVIC

MASSES IN WOMEN 1

Learning objectives

!   to formulate a list of differentials for a patient with a pelvic mass

!   identify the risk factors for malignancy

!   to establish a system of evaluation for such tumours

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What are they? These are growths that are

associated with the reproductive tract

They include tumours arising from the female reproductive organs

Although pertinent, breast tumours will not be discussed

here

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Why the fuss?

!   We all worry about cancer

!   As such, all growths should be suspected cancerous

!   It is our duty to confirm non-malignancy

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We all worry about cancer

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The objectives when a growth is discovered

!   Most importantly, assess the

probability of malignancy

!   If malignancy is less likely, then

assess the association with

fertility

!   Plan for management, most

likely surgery

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Aetiology

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Concepts on aetiology

!   most premenopausal tumours are benign in origin

!   malignancy can occur at all ages

!   this risk increases with age

!   postmenopausal women require aggressive evaluation

!   “cancer until proven otherwise

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General Causes !   Uterine fibroids

! Adenomyosis (older pt)

!   Functional cysts - occasionally grow large & symptomatic

!   Pregnancy

!   Ovarian cysts

•  Epithelial (arising from ovarian epithelium)

- Serous & mucinous

- most common

•  Germ cell (from egg-producing cells)

- In younger women

•  Stromal ( from hormone producing cells)

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In the reproductive age group

!   functional cysts (follicular or luteal) are most common

!   usually small but may become larger - 10 cm

!   frequently asymptomatic but can have dull, non-specific pain

!   mostly due to intracystic haemorrhage

! tumours are rare - most common dermoid cysts & benign teratomas

!   never forget pregnancy!

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nongynae causes Don’t forget there’s other stuff in the pelvis!

Brown G. A gynecologic approach to evaluation of pelvic masses in women JAAPA 2012

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Symptoms

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The asymptomatic patient

!   during a routine medical check up – physical exam, U/S scan etc

!   from Pap smear results

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Abnormal Vaginal Bleeding !   usually occurs with tumours of lower tract

!   endometrial, myometrial cervical etc..

!   fibroids are prone to heavy cyclical bleeding

!   irregular, non-menstrual bleeding is more sinister

! postcoital bleed suggests intravaginal location

!   polyps and cancers can occur, but infection is the most common cause

!   ovarian tumours mostly bleed if cancerous, & only when advanced

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Abdominal pain !   ascertain if cyclical/dysmenorrhoea - more likely

endometriosis or PID

!   how long has it been there?

!   If it has been there for a long time, is it progressively worsening?

!   remember abdominal quadrants,

!   usually, the pain will be overlying the offending organ

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Nonspecific symptoms

!   bowel or urinary, these usually are sinister associations with the tumour

!   endometriosis and/or adhesions may mimic these

!   other symptoms that should be questioned include appetite & weight loss

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Infertility

!   women in the reproductive age group must be questioned on this

!   endometriosis & adenomyosis are among the most common causes of the pelvic mass

!   the association of this symptom with a mass in most cases is due these conditions

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Ovarian cancer

!   often manifests late

!   abdominal or pelvic pain

!   bloating

!   abdominal distension

!   other nonspecific symptoms

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Postmenopausal patient !   any tumour here warrants

extensive investigation

!   postmenopausal bleeding must be taken seriously

!   commonest tumours at this age are ovarian

!   may present only with nonspecific symptoms

!   the pelvis should be looked at carefully

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TUMOUR! SUMMARY OF !CLINICAL FEATURES!

fibroids !heavy cyclical menstruation,

irregularly enlarged, mobile smooth uterus, usually non-tender

ovarian cancer!nonspecific pelvic or abd pain,

bloating, constitutional symptoms, fixed mass, may be irregular, firm,

hard or soft, ascites may be present

endometrioma!

cyclical pain, dyspareunia, infertility, abnormal menstruation,soft-to-firm

mass, usually fixed, lateral or central

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Signs

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Inspection !   overall, the patient

may look unwell

!   she may be in extreme pain

!   the abdomen may be distended, generally or asymmetrically

!   the umbilicus may be deviated

!   if acute, the abdomen may not move with respiration

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Palpation !   is the surface smooth or nodular?

!   nodularity is not good

!   is the mass fixed or mobile

!   consistency - hard, firm or soft

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Can you go below the mass?

!   important to feel if you can go below the mass

if not, then it is most likely arising from the pelvis

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Ascites

!   this is never a good sign

!   you must know how to evaluate for shifting dullness

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Cervicovaginal inspection !   do not forget to

assess below!

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An overview of cancers

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https://www.dropbox.com/s/whhmrateafmqus7/gynaecancers.pdf

some common conditions

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Ovarian Cysts

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Fibroids

!   quite common at a later age, about 40s

!   may be asymptomatic, but most often cause heavy menstruation

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Endometriosis

!   May present as either adenomyosis (uterine enlargement),

!   a cyst or

!   both. 31

Adenomyosis

Can be a diffuse or globular swelling

Endometrium-like tissue is found embedded within myometrium

K

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Funny things

are seen

This is a fibroid!

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The most common growth -

fat!

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Investigations

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Role of ultrasound

!   an essential tool for diagnosis - first Ix to be considered

!   any mass must initially be scanned

!   abdominal or transvaginal

!   features to look for include composition of tumour, size, uni- or bilateral and presence of ascites

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Ultrasound TVS image produces greater

resolution

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Blood tests

!   General - assess cell lines for health & mx issues

!   Tumour markers - limited diagnostic capability

•  May be used as surveillance when increased

!   Other tests depend on type of tumour

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Other imaging

!   MRI & CT

!   Laparoscopy - can be diagnostic, but better to be therapeutic

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summary

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Key points !   pelvic masses may have a benign or malignant

aetiology

!   the risk of malignancy is increased in postmenopausal women

!   premenopausal masses are usually benign

!   evaluation of premenopausal masses must include relationship with fertility

!   U/S is an important evaluation tool for possibility of malignancy

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References

!   Brown G. A gynecologic approach to evaluation of pelvic masses in women JAAPA 2012

!   Johnson BA. Evaluation of pelvic masses 2001 http://www.eric.vcu.edu/home/resources/whh/VIIIeEVALUATION_PELVIC_MASSES.pdf

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Let’s have coffee!

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