Transcript Pelvic mass - Isfahan University of Medical Sciences

‫بسم هللا الرحمن الرحيم‬
Pelvic mass
Dr.T Allameh MD
Pelvic mass :
Gynecologic
• Uterine
• Adnexal
• Ovarian
Urinary
Bowel
Pre pubertal age group
• Fewer than 5% of ovarian malignancies
occur in children and adolescents .
• Ovarian tumors occurs for approximately
1% of all tumors in these age groups
• Germ cell tumors make up ½ to 2/3 of
ovarian neoplasms in individuals younger
than 20 years old .
• In girls younger than 9 years of age
approximately 80% of the ovarian
neoplasms were found to be malignant .
• Germ cell tumors occurs for approximately
60% of ovarian neoplasms in children and
adolescents compared with 20% of these
tumors in adults .
In a review :
• 6% of all ovarian masses in childhood and
adolescence were neoplasms and only 10% of
neoplasms were malignant
In one series :
• Non neoplastic masses in young women and girls
younger than 20 years constitute 2/3 of the total
• In girls younger than 10 years of age 60% of
masses were non neoplastic and 2/3 of the
neoplastic masses were benign
Symptoms and signs
• Pelvic mass
• Abdominal mass
• Non specific
Diagnosis and management
• Unilocular cysts are virtually always benign
and will regress in 3 – 6 month
• They do not require surgical management
with oophorectomy or cystectomy .
• Close observation
• Risk of ovarian torsion
• Recurrence rate after cyst aspiration 50%
• premature surgical therapy for a functional
ovarian mass can result in ovarian and tubal
adhesions that can affect future fertility .
• CT , MRI or Doppler flow studies may
be helpful
• Because the risk of germ cell tumor ,
solid component mandates surgical
assessment
Ovarian masses in adolescent age group
• Likelihood of functional masses increases after
menarche
• The risk of malignant neoplasms is lower among
adolescents than among young children .
• Epithelial neoplasms occur with increase frequency
with age .
• Germ cell tumors are the most common tumors of
the first decade of life but occur less frequently
during adolescence .
• Mature cystic teratuma is the most frequent
neoplastic of children and adolescents accounting
for more than 1/2 of ovarian neoplasms in women
younger than 20 years of age .
Functional cysts in adolescent
• May be incidental finding on exam
• May be associated with pain ( caused by
torsions, leakage or rupture ) .
• Endometriosis is less common during
adolescence than in adulthood
Ovarian masses in reproductive ages
• During the reproductive years , the most
common ovarian masses are benign .
• 2/3 of ovarian tumors are encountered
during reproductive years
• Most ovarian tumors are benign( 80 – 85% )
• 2/3 occur in women in between 20 and 44 y
• The chance that a primary ovarian
tumor is malignant in a patient younger
than 45 years of age is less than 15.
Symptoms
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Mild , non specific
Abdominal distension , pain , discomfort
Lower abdominal pressure
Vaginal bleeding if the tumor is hormonally
active
• Urinary & GI symptoms .
• Acute pain ( due to torsion , rupture or
bleeding into a cyst )
Benign tumors :
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Unilateral
Cystic
Mobile
Smooth
Malignant masses
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Bilateral
Solid
Fixed
Irregular
Associated with :
Ascites
Cul – de – sac nodules
Rapid growth
Functional ovarian cysts :
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Follicular cysts
Corpus luteum cysts
Techa lutein cysts
All are benign and usually do not cause
symptoms or require surgical
management .
• The annual rate of hospitalization 500
per 100,000 women per year
Follicular cyst
• The most common cysts , which is
rarely larger than 8 cm .
• A cystic follicle can be defined as a
follicular cyst when it's diameter is
greater than 3 cm .
• They usually resolve in 4 to 8 weeks .
Corpus luteum cysts
• Less common than follicular cyst
• May rupture leading to a hemoperitoneum and
requiring surgical management
• Patients taking anticoagulant therapy are at
particular risk for rupture
• Rupture occurs more often on the right side
and may occur during intercourse
• Most ruptures occur on cycle days 20 to 26 .
Theca lutein cysts
• Least common of functional ovarian cysts
• Usually bilateral and occur with pregnancy .
• They may be associated with :
Multiple gestations molar pregnancies ,
clomiphen citrate use , HMG , HCG ,
and GNRH analogs .
Theca lutein cysts :
• May be quite large ( up to 30 cm )
• Are multi cystic
• Regress spontaneously
Oral Cotraception
• HD reduce the risk of functional ovarian
cysts
• LD is attenuated
• Triphasic OC is not associated with an
appreciable increased risk of functional
ovarian cysts .
Endometriosis
• Ovarian endometioma (chocolate cysts)
Can enlarge to 6 – 8 cm .
• Does not resolve by observation
Neoplastic masses
• More than 80% of benign cystic teratomas
(dermoid cysts) occur during the reproductive
years
• Dermoid cysts represented 62% of all ovarian
neoplasms in women younger than 40 years old
• Malignant transformation occurs in less than
2% of dermoid cysts in women of all ages .
(most cases occur in women older than 40
years ) .
• The risk of torsion with dermoid cysts is
15% ( more frequently than other
tumors )
• Dermoid cysts are frequently anterior
• They are bilateral in 10%
• An ovarian cystectomy is almost always
possible
Epithelial tumors
• The risk of epithelial tumors increases
with age .
• Serous cyst adenomas are often
considered
• The more common benign neoplasm
Serous tumors
• Generally are benign
• 5% -10% have borderline malignant
potential
• 20% -25% are malignant
Serous cyst adenoma
• Are often multilocular
• Sometimes with papillary component
• The surface epithelial cells secrete
sroups fluid , resulting in a watery cyst
content
• Psammoma bodies
Mucinous ovarian tumors
* May grow to large dimensions
* Benign mucinous tumors typically have:
• a lobulated , smooth surface
• are multi locular
• may be bilaterall ( 10% )
• mucoid material is present within the cystic
loculations :
* 5 – 10% mucinous ovarian tumors are
malignant
Other benign ovarian tumors :
• Fibroma
• Brenner tumors
• Mixed forms of tumors such as
cystadenofibroma .
Ultrasound
• Both abdominal and vaginal should be used:
Size :
• The normal ovary is 3.5 x 2 x 1.5 cm in premenopausal
patient and 1.5 x 0.7 x 0.5 cm two to five years after
menopause
• A postmenopausal ovary twice the size of the
contralateral ovary is considered suspicious for
malignancy .
• Ovarian cyst size dose not correlate with risk of
malignancy for unilocular cysts ( most are benign )
• Large multilocular cysts and solid tumors are more
likely to be malignant
Cystic or solid :
• 0.3% of uniloculary cysts are malignant
• 8% of multilocular cysts are malignant
• 36% of mutilocular solid tumors are
malignant
• 39% solid tumors are malignant
• Thick septa ( > 2-3 mm ) is suggestive of
malignancy .