Pelvic Masses & Ovarian Cancer

• Differential diagnosis of pelvic masses• Investigations and management• Benign ovarian cysts• Ovarian cancer

Pre-pubertal1. Functional cyst2. Germ cell tumour

Adolescent1. Functional cyst2. Pregnancy3. Dermoid4. Other germ cell tumour5. Obstructing

vaginal/uterine abnormality

6. Epithelial cell tumour

Reproductive1. Pregnancy2. Functional cyst3. Fibroids4. Epithelial tumour

Perimenopausal1. Fibroids2. Epithelial tumour3. Functional cyst

Postmenopausal

1. Ovarian tumour

2. Functional cyst

3. Other malignancy

4. Metastases

Diagnosis

• History and examination

• Ultrasound

• CT/MRI

• Tumour markers – CA125, CEA, CA19,9 hCg, alpha-fetoprotein

• 50 % - asymptomatic

• 30% - menorrhagia

• Irregular bleeding

• Pressure effects

Management

Depends on symptoms and fertility issuesReassure that risk of malignancy tiny• Hysteroscopic removal (small submucosal)• Myomectomy• Embolisation• Hysterectomy

Benign Unilocular Cyst

Septate Cyst

Ovarian Cancer

Dermoid

Haematocolpos

Imperforate hymen - haematocolpos

Management - Young women

• Small, simple, asymptomatic – leave alone and rescan 3 months later

• Complex – ovarian cystectomy or oopherectomy

• MDT involvement if any suspicious features

Management – older women

• Complex in older women – MDT involvement Further imaging Tumour markers TAH/BSO

• Simple, < 5cm, normal tumour markers – consider conservative management with repeat scan.

Fibroids

• Present in 25% of women

• More common: perimenopausal family history Afro-Caribbean women

• Sub-mucosal, subserosal, intramural

Ovarian Cancer• 5th, 6th and 7th decades

• Risk inversely correlated with parity.

• Genetic component – BRCA1 & BRCA2

• Presents late – usually with a mass or ascites

• No premalignant stage - screening

• Borderline tumours

• Epithelial

• Sex cord/stromal

• Germ cell

• Metastases

Epithelial Tumours

Serous• Most common• Bilateral in 50%• Cystic and solid components

Mucinous• Contain mucinous fluid• Pseudmyxoma peritonei

Endometrioid• 30% have a coexistent endometrial CA

Sex Cord/Stromal TumoursGranulosa Cell• Secrete oestrogen – IMB or PMB

Fibroma• Usually unilateral• Meig’s Syndrome

Sertoli/Leydig Cell• Young women (20’s)• Secrete testosterone

Germ Cell TumoursDysgerminoma• Ages 10 – 30• May be raised hCG

Yolk sac tumour• Young women• Raised alphafetoprotein, normal hCG

Choriocarcinoma• Secrete hCG• Do not respond to chemotherapy

Teratoma• Usually benign -all 3 embryonic germ layers

Staging

Ia – One ovaryIb – Both ovariesIc – Ia/Ib with ruptured capsule, tumour on surface

of capsule, + ve washings or ascites

IIa – Extending to uterus and tubesIIb – Extending to other pelvic tissuesIIc - IIa/IIb with ruptured capsule, + ve washings or

ascites

IIIa – Pelvic tumour with microscopic peritonealspread

IIIb – Peritoneal spread < 2cmIIIc – Abdominal implants >2cm +/- positive

retroperitoneal or inguinal nodes

IV – Liver disease. Distant mets.

Management• CT & CXR

• Baseline tumour markers

• Surgical staging

• Debulking surgery & adjuvant chemo

• Neoadjuvant chemo with interval debulking