Tutorial 18: Pelvic Mass

Question 1

What are some common and important causes of a pelvic mass?

Answer 1

1. Ovaries:
   
   • Benign: functional cyst, beningn ovarian tumour
   • Malignant: ovarian malignany
2. Tubes:
   
   • Benign: ectopic, hydrosaplhinx, abscess
3. Uterus:
   
   • Benign: Pregnancy, fibroid, endometriosis
4. Other: Bladder and Bowel
   
   1. Benign: Pelvic abscess
   • Malignant: Bladder malignancy

Question 2

What are some common causes of a pelvic mass in a pre-menopausal woman?

Answer 2

1. Ovaries:
   
   • Benign ovarian tumour
   • Malignant: ovarian malignany
2. Tubes: Benign: ectopic, hydrosaplhinx, abscess
3. Uterus: fibroid
4. Other: Bladder and Bowel
   
   • Benign: Pelvic abscess
   • Malignant: Bladder malignancy, Bowel malignancy

Question 3

What are some important parts of the history for a woman with a pelvic mass?

Answer 3

General:

• Weight loss
• Fever
• Malaise
• Pain (reflects late stage disease in ovarian cancer OR cyst rupture)
• Jaundice

Obstetric / Gynaecological:

• Sexually active
• Past history of breast, colon (HNPCC), endometrial cancer
• Menstruation history / menorrhagia
• Nulliparity / Absence of breastfeeding
• Family history of ovarian, breast, colon (HNPCC) or endometrial cancer
• HRT

Other: Gastrointestinal and Urinary symptoms

Question 4

What would you include in the examination of a woman with a pelvic mass?

Answer 4

1. General: cachexia, anaemia, lymphadenopathy
2. Abdominal examination: distention (reflects late stage disease in ovarian cancer), mass palpable, ascites (metastases to peritoneum), PR exam
3. Pelvic examination: inspect with speculum, bimanual: mobility + consistency of mass, separate from uterus?
4. Breast examination: Feel for any lumps (10% ovarian cancers associated with BRCA1 / BRCA 2 gene).

Question 5

What investigations would you perform for a lady presenting witha pelvic mass?

Answer 5

1. Bloods
   
   • CA 125 (serum tumor marker, part of RMI), CEA, CA19-9
   • FBC (anaemia of chronic disease), U&E’s, LFTs (metastases to liver)
2. Radiology
   
   • USS
   • CXR
   • ? cytoscopy
   • ? colonoscopy
   • CT for surgery

Question 6

What do you do when traiging a woman with an ovarian mass?

Answer 6

The “Risk of Malignancy Index” is used for traiging a woman with an ovarian mass.

The RMI is a calculation used to estimate the risk of a pelvic mass being malignant. It is products of the ultrasound scan score (U), menopausal status (M) and serum CA125 level multiplied together.

RMI = U x M x CA125

• If the summation of this equation is >250, then the women needs urgent referral to a specialist multidisciplinary team for further investigation.

U = Ultrasound scan

U=0 if 0 points. U=1 if 1 point. U=3 if 2–5 points.
1 point each for: multilocular cysts, solid areas, metastases, ascites, bilateral lesions.
Menopausal Status
1=pre-menopausal

3=post-menopausal = a woman who has had no period for more than 1 year or a woman over 50 who has had a hysterectomy.

Question 7

What USS features can increase a patients Risk of Malignancy Index /RMI score?

Answer 7

1 point each:

• Multiocular cysts
• Solid areas
• Metastases
• Ascites
• Bilateral lesions

Question 8

What are some commong presenting symptoms of ovarian cancer?

Answer 8

Ovarian carcinoma is associated with a poor overall survival, which is largely attributed to the vagueness of the symptoms associated with the disease. The generalized associated symptoms and of silent progression of the cancer play a major contribution in the late presentation of patients to seek medical care (30-40% of patients present with stage 3-4 disease).

Presenting Symptoms:

• Pelvic mass
• Anorexia / weight loss
• Malaise / early satiety
• Abdominal distention
• Pelvic pain
• Increased urinary urgency

Question 9

Where are common sites of ovarian metastases?

Answer 9

• Liver: jaundice
• Peritoneum: distended abdomen
• Lung: hemoptysis

Question 10

What is the pathogenesis of Ovarian cancer?

Answer 10

Aetiology of ovarian ancer isnt well understood.

It is hypothesized that the ovarian epithelial cells undergo repeated division and growth to heal the ‘wound’ in the germinal epithelium resulting from ovulation, therefore increasing the chance of a genetic error to occur.

Question 11

What are some risk factors for ovarian cancer?

Answer 11

• Nulliparity
• Absence from breastfeeding
• Total menstrual years
• Infertility
• Unopposed exogenous estrogen
• Family history
• Personal history of breast, colon and endometrial cancer

Question 12

What are some epidemiological features of ovarian cancer?

Answer 12

• Ovarian cancer represents the 4th most common cause of female cancer associated with mortality after breast, colon and lung cancer.
• 80% of cases occurring in >50 years old, highest rates in women ages 80-84 years old.
• 90% of carcinoma are epithelial in origin.
• The prognosis of ovarian cancer is poor; the average 5-year survival rate is below 35%.
• NOTE: Use of COCP reduces risk of ovarian cancer by 50%, though to be contributing to declining rates.

Question 13

What CT Staging (of the abdo and pelvis) is used for ovarian cancer?

Answer 13

• Stage 1: disease macroscopically confined to the ovaries
  
  • 75% 5year survival
• Stage 2: disease confined to the pelvis
  
  • 45% 5year survival rate
• Stage 3: disease confided to the abdomen (SB, omentum, peritoneum)
  
  • 25% 5year survival rate
• Stage 4: disease is beyond the abdomen (liver and lung)
  
  • 5% 5year survival rate

Question 14

What is the treatment regime for ovarian cancer?

Answer 14

1. CHEMOTHERAPY (Tissue diagnosis by histology)
   
   • Stage 1: X6 cycles
   • Stage 2-3: Of those women who have chemotherapy treatment 2/3 will relapse within 2 years.
2. Surgery
   
   • Assessment of fitness for surgery
   • Laparotomy: total hysterectomy, bilateral salpingo-oophorectomy and partial omentectomy (+ retroperitoneal lymphadenectomy). Tissue sent for histology.
3. FOLLOW-UP
   
   • CA 125 are useful after treatment, can determine relapse
   • CT scanning air is detection of residual disease or relapse
   • Education and psychological support
   • PALLIATIVE CARE

Question 15

What measures form the followup regime for ovarian cancer?

Answer 15

• CA 125 are useful after treatment, can determine relapse
• CT scanning air is detection of residual disease or relapse
• Education and psychological support
• PALLIATIVE CARE