Approach to the Patient with a Pelvic Mass

1
Approach to the Patient with a Pelvic Mass
Lloyd D. Holm, D.O. Associate Professor Department
of Obstetrics and Gynecology
2
How do these women present?

• Pressure/fullness
• Increasing girth
• Pain
• Annual exam
• Obstetrical exam
• Bleeding

3
The approach to the discovery of a pelvic mass
should take into consideration 4 things

• Age
• Tumor size
• U/S features
• Labs

4
Work-up

• Examination
• Radiology
• U/S
• CT
• MRI

• Lab
• CBC
• hCG
• Markers

5
Work-up

• Examination
• Always include rectal exam
• EUA

6
Work-up

• 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

7
Lab - Tumor Markers

• CA-125
• Epithelial tumors
• Antibody for antigen produced by coelomic
  epithelium
• Normal
• NOT an effective screening tool for cancer

8
Lab - Tumor Markers

• CA-125 ? in
• Leiomyoma
• Endometriosis/adenomyosis
• PID
• Pregnancy
• Malignancies-lung, breast, colon
• Pancreatitis
• Cirrhosis

9
Lab - Tumor Markers

• CA-125
• Epithelial tumors
• AFP
• Endodermal sinus tumor
• hCG
• Choriocarcinoma
• LDH
• Dysgerminoma

10
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.

11
Median age of ovarian cancer is 52.Life-time
risk is 1.4.5 risk if 1 relative has ovarian
cancer.
12
Ovarian enlargement in the pre-menarchal female
is usually the result of a benign teratoma
(dermoid).
13
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 19941701780
14
The frequency of ovarian malignancies correlates
inversely with patient age. 14 of all masses
and 33 of neoplastic masses were malignant in
patients Van Winter, JT. Am J Obstet Gynecol 19941701780
15
In patients 1620 years of age, 7 of all masses
and 20 of neoplastic masses are malignant.
Van Winter, JT. Am J Obstet Gynecol 19941701780
16
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 19941701780
17
In girls aged ovarian neoplasms were malignant.
Van Winter, JT. Am J Obstet Gynecol 19941701780
18
The vast majority (97) of mature teratomas
(dermoids) are benign.
19
Etiology of Pelvic Mass

• Uterine

20
Etiology - Uterine

• Leiomyoma
• Endometrioma
• Pregnancy

21
(No Transcript)
22
Fundus
Round ligament
Tube
Fibroid
Ovary
Fimbria
23
Etiology of Pelvic Mass

• Uterine
• Ovarian

24
Etiology - Ovarian

• Neoplastic
• Epithelial
• Germ cell
• Sex cord-Stromal
• Functional cysts
• Torsion
• Tubo-ovarian abscess (TOA)

25
The most common benign tumor in reproductive aged
women is a serous cystadenoma followed by mature
teratoma.
26
Benign serous cystadenoma
6,300 grams, 30 cm X 30 cm
27
Benign serous cystadenoma
6,810 grams, 20 cm X 40 cm
28
Dermoid cyst

• 5-10 are bilateral
• When malignancy is encountered, the malignant
  cell line is of ectodermal origin

29
(No Transcript)
30
ovarian capsule
Epithelial ovarian cancer, stage 1C
31
(No Transcript)
32
(No Transcript)
33
Theca-lutein cysts
34
Etiology of Pelvic Mass

• Uterine
• Ovarian
• GI

35
Etiology - GI

• Diverticular abscess
• Appendiceal abscess
• Primary malignancy

36
Etiology of Pelvic Mass

• Uterine
• Ovarian
• GI
• Adnexal

37
Etiology - Adnexal

• Ectopic pregnancy
• Abscess
• Peritubular cyst
• Endometrioma
• Round ligament fibroid
• Torsion
• Hydrosalpinx
• Müllerian defect

38
(No Transcript)
39
R uterine horn with hematocolpos
R hematosalpinx
L tube and ovary
L uterine horn
Müllerian defect
40
Etiology of Pelvic Mass

• Uterine
• Ovarian
• GI
• Adnexal
• Infectious

41
Etiology - Infectious

• TOA
• Appendiceal abscess
• Diverticular abscess

42
Etiology of Pelvic Mass

• Uterine
• Ovarian
• GI
• Adnexal
• Infectious
• Retroperitoneal

43
Clinical Conundrums

• Adnexal mass in pregnancy
• Persistent unilocular ovarian cysts
• Whom to refer to a gynecologic oncologist

44
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 199918119
45
Persistent Unilocular Ovarian Cysts

• Common 3 to 17
• Expectant management is acceptable in
  post-menopausal women provided
• Diameter
• No increase in size
• Normal CA-125

Nardo, LG, et al. Obstet Gynecol 2003102589
46
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 2003102594
47
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

Modesitt SC, et al. Obstet Gynecol 2003102594
48
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 200510535-41
49
Referral Criteria for Women with a Pelvic Mass

• Premenopausal (
• 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 200510535-41
50
Conclusions

• Ovarian enlargement in pre-menarchal female is
  dermoid
• 60-85 of ovarian neoplasm in women cell. In adults, only 20
• Frequency of ovarian cancer is inversely related
  to age. 14 in women

51
Conclusions

• Dermoid is the most common mass in pregnancy
• Unilocular cysts can be followed if cm and stable with normal CA-125

52
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.

53
(No Transcript)