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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? • • • • • • 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: • • • • 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 – – – – – 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 nd 2 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 • • • • Uterine Ovarian GI Adnexal Etiology - Adnexal • • • • • • • • 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 • • • • • Uterine Ovarian GI Adnexal Infectious Etiology - Infectious • TOA • Appendiceal abscess • Diverticular abscess Etiology of Pelvic Mass • • • • • • 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 • • • • • 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 • • • • 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.