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Approach to the Patient with a
Pelvic Mass
Karen Carlson, MD
Assistant Professor
Department of Obstetrics and
Gynecology
How do these women
present?
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Pressure/fullness
Increasing girth
Pain
Annual exam
Obstetrical exam
Bleeding
The approach to the discovery
of a pelvic mass should take
into consideration 4 things:
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Age
Tumor size
U/S features
Labs
Work-up
• Examination
• Radiology
– U/S
– CT
– MRI
• Lab
– CBC
– hCG
– Markers
Work-up
• Examination
– Always include rectal exam
– EUA
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
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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
Lab - Tumor Markers
• CA-125
– Epithelial tumors
– Antibody for antigen produced
by coelomic epithelium
– Normal <35 U/mL
– NOT an effective screening tool
for cancer
Lab - Tumor Markers
• CA-125 ↑ in:
– Leiomyoma
– Endometriosis/adenomyosis
– PID
– Pregnancy
– Malignancies-lung, breast,
colon
– Pancreatitis
– Cirrhosis
Lab - Tumor Markers
• CA-125
– Epithelial tumors
• AFP
– Endodermal sinus tumor
• hCG
– Choriocarcinoma
• LDH
– Dysgerminoma
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Ovarian cancer is the
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.
Median age of ovarian
cancer is 52.
Life-time risk is 1.4%.
5% risk if 1° relative has
ovarian cancer.
Ovarian enlargement in the
pre-menarchal female is
usually the result of a benign
teratoma (dermoid).
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 1994;170:1780
The frequency of ovarian
malignancies correlates
inversely with patient age.
14% of all masses and 33% of
neoplastic masses were
malignant in patients < 16
years of age.
Van Winter, JT. Am J Obstet Gynecol 1994;170:1780
In patients 16–20 years of age,
7% of all masses and 20% of
neoplastic masses are
malignant.
Van Winter, JT. Am J Obstet Gynecol 1994;170:1780
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 1994;170:1780
In girls aged <9 years,
approximately 80% of ovarian
neoplasms were malignant.
Van Winter, JT. Am J Obstet Gynecol 1994;170:1780
The vast majority (97%) of
mature teratomas (dermoids)
are benign.
Etiology of Pelvic Mass
• Uterine
Etiology - Uterine
• Leiomyoma
• Endometrioma
• Pregnancy
Fundus
Round ligament
Tube
Fibroid
Ovary
Fimbria
Etiology of Pelvic Mass
• Uterine
• Ovarian
Etiology - Ovarian
• Neoplastic
– Epithelial
– Germ cell
– Sex cord-Stromal
• Functional cysts
• Torsion
• Tubo-ovarian abscess (TOA)
The most common benign
tumor in reproductive aged
women is a serous
cystadenoma followed by
mature teratoma.
Benign serous cystadenoma
6,300 grams, 30 cm X 30 cm
Benign serous cystadenoma
6,810 grams, 20 cm X 40 cm
Dermoid cyst
• 5-10% are bilateral
• < 1% are malignant
• When malignancy is
encountered, the malignant
cell line is of ectodermal
origin
ovarian capsule
Epithelial ovarian cancer, stage 1C
Theca-lutein cysts
Etiology of Pelvic Mass
• Uterine
• Ovarian
• GI
Etiology - GI
• Diverticular abscess
• Appendiceal abscess
• Primary malignancy
Etiology of Pelvic Mass
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Uterine
Ovarian
GI
Adnexal
Etiology - Adnexal
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Ectopic pregnancy
Abscess
Peritubular cyst
Endometrioma
Round ligament fibroid
Torsion
Hydrosalpinx
Müllerian defect
R hematosalpinx
L tube and
ovary
R uterine
horn with
hematocolpos
L uterine horn
Müllerian defect
Etiology of Pelvic Mass
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Uterine
Ovarian
GI
Adnexal
Infectious
Etiology - Infectious
• TOA
• Appendiceal abscess
• Diverticular abscess
Etiology of Pelvic Mass
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Uterine
Ovarian
GI
Adnexal
Infectious
Retroperitoneal
Clinical Conundrums :
 Adnexal mass in pregnancy
 Persistent unilocular ovarian cysts
 Whom to refer to a gynecologic
oncologist
Adnexal Mass in Pregnancy
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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 1999;181:19
Persistent Unilocular
Ovarian Cysts
• Common: 3 to 17%
• Expectant management is acceptable
in post-menopausal women provided:
– Diameter < 5 cm
– No increase in size
– Normal CA-125
Nardo, LG, et al. Obstet Gynecol 2003;102:589
Persistent Unilocular
Ovarian Cysts
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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 2003;102:594
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 <10 cm
Modesitt SC, et al. Obstet Gynecol 2003;102:594
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 2005;105:35-41
Referral Criteria for Women with
a Pelvic Mass
• Premenopausal (<50 years old)
– 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 2005;105:35-41
Conclusions
• Ovarian enlargement in pre-menarchal
female is dermoid
• 60-85% of ovarian neoplasm in women
< 20 is germ cell. In adults, only 20%
• Frequency of ovarian cancer is inversely
related to age. 14% in women < 16 and
7% age 16-20
Conclusions
• Dermoid is the most common mass in
pregnancy
• Unilocular cysts can be followed if
< 10 cm and stable with normal CA-125
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.