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What to do when confronted by a mass arising from the pelvis
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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
2
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
3
Why the fuss?
! We all worry about cancer
! As such, all growths should be suspected cancerous
! It is our duty to confirm non-malignancy
4
We all worry about cancer
5
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
6
Aetiology
7
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
8
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)
9
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!
10
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
11
Symptoms
12
The asymptomatic patient
! during a routine medical check up – physical exam, U/S scan etc
! from Pap smear results
13
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
14
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
15
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
16
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
17
Ovarian cancer
! often manifests late
! abdominal or pelvic pain
! bloating
! abdominal distension
! other nonspecific symptoms
18
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
19
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
20
Signs
21
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
22
Palpation ! is the surface smooth or nodular?
! nodularity is not good
! is the mass fixed or mobile
! consistency - hard, firm or soft
23
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
24
Ascites
! this is never a good sign
! you must know how to evaluate for shifting dullness
25
Cervicovaginal inspection ! do not forget to
assess below!
26
An overview of cancers
27
https://www.dropbox.com/s/whhmrateafmqus7/gynaecancers.pdf
some common conditions
28
Ovarian Cysts
29
Fibroids
! quite common at a later age, about 40s
! may be asymptomatic, but most often cause heavy menstruation
30
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
32
Funny things
are seen
This is a fibroid!
33
The most common growth -
fat!
34
Investigations
35
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
36
Ultrasound TVS image produces greater
resolution
37
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
38
Other imaging
! MRI & CT
! Laparoscopy - can be diagnostic, but better to be therapeutic
39
summary
40
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
41
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
42
Let’s have coffee!
43