Evaluate pelvic tumours


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What to do when confronted by a mass arising from the pelvis

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Evaluate pelvic tumours

  2. 2. 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
  3. 3. These are growths that areassociated with the reproductive What are they? tractThey include tumours arising from the female reproductive organs Although pertinent, breast tumours will not be discussed here 3
  4. 4. 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
  5. 5. We all worry about cancer 5
  6. 6. 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
  7. 7. Aetiology 7
  8. 8. 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
  9. 9. General Causes!   Uterine fibroids !   Ovarian cysts! Adenomyosis (older pt) •  Epithelial (arising from ovarian epithelium)!   Functional cysts - - Serous & mucinous occasionally grow large & symptomatic - most common!   Pregnancy •  Germ cell (from egg-producing cells) - In younger women •  Stromal ( from hormone producing cells) 9
  10. 10. 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
  11. 11. 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
  12. 12. Symptoms 12
  13. 13. The asymptomatic patient!   during a routine medical check up – physical exam, U/S scan etc!   from Pap smear results 13
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. Ovarian cancer!   often manifests late!   abdominal or pelvic pain!   bloating!   abdominal distension!   other nonspecific symptoms 18
  19. 19. 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
  20. 20. SUMMARY OF ! TUMOUR! CLINICAL FEATURES! heavy cyclical menstruation, fibroids ! irregularly enlarged, mobile smooth uterus, usually non-tender nonspecific pelvic or abd pain, bloating, constitutional symptoms,ovarian cancer! fixed mass, may be irregular, firm, hard or soft, ascites may be present cyclical pain, dyspareunia, infertility, abnormal menstruation,soft-to-firmendometrioma! mass, usually fixed, lateral or central 20
  21. 21. Signs 21
  22. 22. 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
  23. 23. Palpation!   is the surface smooth or nodular?!   nodularity is not good!   is the mass fixed or mobile!   consistency - hard, firm or soft 23
  24. 24. Can you go below the mass?!   important to feel if you can go below the massif not, then it is most likely arising from the pelvis 24
  25. 25. Ascites !   this is never a good sign !   you must know how to evaluate for shifting dullness25
  26. 26. Cervicovaginal inspection!   do not forget to assess below! 26
  27. 27. An overview of cancershttps://www.dropbox.com/s/whhmrateafmqus7/gynaecancers.pdf 27
  28. 28. some common conditions 28
  29. 29. Ovarian Cysts 29
  30. 30. !   quite common at a later age, about 40s!   may be asymptomat ic, but most often cause heavy menstruatio n 30 Fibroids
  31. 31. Endometriosis!   May present as either adenomyosis (uterine enlargement),!   a cyst or!   both. 31
  32. 32. Adenomyosis Can be a diffuse or globular swellingK Endometrium-like tissue is found embedded within myometrium 32
  33. 33. Funny things are seenThis is a fibroid! 33
  34. 34. The most common growth - fat!34
  35. 35. Investigations 35
  36. 36. 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
  37. 37. Ultrasound TVS image produces greater resolution37
  38. 38. 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
  39. 39. Other imaging!   MRI & CT!   Laparoscopy - can be diagnostic, but better to be therapeutic 39
  40. 40. summary 40
  41. 41. 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
  42. 42. 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
  43. 43. Let s have coffee! 43