Pelvic Masses & Ovarian Cancer

Differential diagnosis of pelvic masses Investigations and management Benign ovarian cysts Ovarian cancer

Pre-pubertal 1.Functional cyst 2.Germ cell tumour Adolescent 1.Functional cyst 2.Pregnancy 3.Dermoid 4.Other germ cell tumour 5.Obstructing vaginal/uterine abnormality 6.Epithelial cell tumour

Reproductive 1.Pregnancy 2.Functional cyst 3.Fibroids 4.Epithelial tumour Perimenopausal 1.Fibroids 2.Epithelial tumour 3.Functional cyst

Postmenopausal 1.Ovarian tumour 2.Functional cyst 3.Other malignancy 4.Metastases

Diagnosis History and examination Ultrasound CT/MRI Tumour markers – CA125, CEA, CA19,9 hCg, alpha-fetoprotein

50 % - asymptomatic 30% - menorrhagia Irregular bleeding Pressure effects

Management Depends on symptoms and fertility issues Reassure that risk of malignancy tiny Hysteroscopic removal (small submucosal) Myomectomy Embolisation Hysterectomy

Benign Unilocular Cyst

Septate Cyst

Ovarian Cancer

Dermoid

Haematocolpos

Imperforate hymen - haematocolpos

Management - Young women Small, simple, asymptomatic – leave alone and rescan 3 months later Complex – ovarian cystectomy or oopherectomy MDT involvement if any suspicious features

Management – older women Complex in older women – MDT involvement Further imaging Tumour markers TAH/BSO Simple, < 5cm, normal tumour markers – consider conservative management with repeat scan.

Fibroids Present in 25% of women More common: perimenopausal family history Afro-Caribbean women Sub-mucosal, subserosal, intramural

Ovarian Cancer 5 th, 6 th and 7 th decades Risk inversely correlated with parity. Genetic component – BRCA1 & BRCA2 Presents late – usually with a mass or ascites No premalignant stage - screening

Borderline tumours Epithelial Sex cord/stromal Germ cell Metastases

Epithelial Tumours Serous Most common Bilateral in 50% Cystic and solid components Mucinous Contain mucinous fluid Pseudmyxoma peritonei

Endometrioid 30% have a coexistent endometrial CA

Sex Cord/Stromal Tumours Granulosa Cell Secrete oestrogen – IMB or PMB Fibroma Usually unilateral Meig’s Syndrome Sertoli/Leydig Cell Young women (20’s) Secrete testosterone

Germ Cell Tumours Dysgerminoma Ages 10 – 30 May be raised hCG Yolk sac tumour Young women Raised alphafetoprotein, normal hCG Choriocarcinoma Secrete hCG Do not respond to chemotherapy Teratoma Usually benign -all 3 embryonic germ layers

Staging Ia – One ovary Ib – Both ovaries Ic – Ia/Ib with ruptured capsule, tumour on surface of capsule, + ve washings or ascites IIa – Extending to uterus and tubes IIb – Extending to other pelvic tissues IIc - IIa/IIb with ruptured capsule, + ve washings or ascites

IIIa – Pelvic tumour with microscopic peritoneal spread IIIb – Peritoneal spread < 2cm IIIc – Abdominal implants >2cm +/- positive retroperitoneal or inguinal nodes IV – Liver disease. Distant mets.

Management CT & CXR Baseline tumour markers Surgical staging Debulking surgery & adjuvant chemo Neoadjuvant chemo with interval debulking