Basics
Description
- Pelvic masses may be gynecologic or nongynecologic, solid or cystic.
- Pathology may occur in the uterus, bowel, urinary bladder, or the adnexal region, which contains the ovary, fallopian tube, round ligament, vessels, lymphatics, and nervous plexus.
- The etiology of pelvic masses differs between reproductive, postmenopausal, and premenarchal women.
Epidemiology
- Reproductive age
- 85% of adnexal masses are benign (3).
- Up to 6 " 7% of women have asymptomatic adnexal masses.
- Physiologic and functional ovarian cysts occur as a normal process of ovulation.
- Polycystic ovarian syndrome seen in about 22% of women.
- Uterine fibroids are found in at least 20% of women.
- Benign cystic teratoma (dermoid cyst) is the most common ovarian neoplasm in this group.
- Postmenopausal
- Approximately 30 " 60% risk of malignancy
- 1/3 of cases of ovarian cancer occur over the age of 65 years.
- Ovarian cancer is the fifth leading cause of cancer death in women.
- An estimated 21,880 new ovarian cancer cases and 13,850 deaths from ovarian cancer in 2010 (3)
- Up to 75% of ovarian cancers are diagnosed at a late stage (3).
- 5-year survival is 94% for local ovarian cancer, 73% for regional spreading cancer, and 28% with distant metastases (1).
Risk Factors
- Reproductive age
- Approximately 46% of patients with tubo-ovarian abscess have history of pelvic inflammatory disease (PID).
- Leiomyoma:
- 3 " 5 times more common in African American women
- Overweight
- Nulliparity
- Functional cysts arise from normal physiologic variation due to elevated gonadotropin, but there is increased propensity to form individual follicular cysts in cystic fibrosis patients.
- Postmenopausal
- Ovarian cancer:
- Lifetime risk increases 3 times with one first-degree relative with epithelial ovarian cancer.
- Advancing age is the most important risk factor for malignancy.
- Nulliparity, late menopause, and higher socioeconomic status are other risk factors.
Pathophysiology
- Reproductive age
- Tubo-ovarian abscess is due to undertreated or untreated PID that results in scarring of tubal fimbria leading to polymicrobial pus collection.
- Follicular cysts are thin-walled, translucent cysts filled with water, clear or straw-colored fluid, situated in the ovarian cortex.
- Mature cystic teratomas are cystic structures containing elements of all 3 germ-cell layers and may contain bone and teeth.
- Leiomyoma is a benign tumor composed of smooth muscle cells in concentric whorls.
- Postmenopausal
- Ovarian cancer may arise from the surface of the ovary (epithelial type, also the most common), egg-producing cells (germ-cell), or from supportive tissue (stromal type, least common).
Diagnosis
History
Signs and symptoms
- Reproductive age
- Tubo-ovarian abscess typically presents as abdominal/pelvic pain with fever.
- Functional cysts are frequently asymptomatic, but may cause abdominal pain and pressure if increased size or if cyst ruptures.
- Mature cystic teratomas are usually asymptomatic unless tumor ruptures or causes torsion, presenting as an acute abdomen.
- Patients with leiomyomas present with back pain, pelvic pain or pressure, dysmenorrhea, menorrhagia, and history of infertility.
- Postmenopausal
- Ovarian cancer symptoms are usually vague, leading to late detection.
- Symptoms may include pelvic or abdominal pain, increased abdominal size, urinary frequency urgency or incontinence, early satiety, and weight loss.
Physical Exam
- Pelvic/bimanual exams are important to distinguish size, location, consistency, and mobility of masses.
- Bladder should be empty during bimanual examination.
- Reproductive age
- Tubo-ovarian abscess may present as fever, purulent cervical discharge, and cervical motion tenderness.
- Functional cysts may be palpated, but may rupture during pelvic exam.
- Mature cystic teratoma on palpation has both cystic and solid components with doughy consistency; occurs bilaterally 10 " 15% of the time.
- Patients with leiomyomas present with an enlarged, irregularly shaped uterus, which may be pedunculated arising from the fundus. This condition may be misdiagnosed as an ovarian mass.
- Postmenopausal
- Ovarian cancer may be associated with pleural effusion, abdominal distention with ascites, abdominopelvic mass, cul-de-sac nodularity, and groin adenopathy.
Tests
Lab
- Quantitative serum ²- HCG to rule out Ectopic pregnancy
- CBC to check for leukocytosis
- CA-125 (2):
- Should not be used as a screening test when a mass is not identified
- Should not be used in the routine work-up of a premenopausal woman
- Increased levels >35 U/mL should prompt further evaluation.
- May be elevated in benign conditions like endometriosis, PID, liver and renal disease
Imaging
- Transvaginal/Transvaginal ultrasound not transabdominal ultrasound (2):
- Most valuable diagnostic study in the initial evaluation of pelvic mass
- Differentiates cystic (simple or complex) and solid tumors
- Presence of ascites is suspicious for malignancy.
- CT scan:
- Increased resolution and ability to distinguish subtle differences
- MRI:
- Provides detailed evaluation of pelvic anatomy with excellent tissue contrast ability
- Able to diagnose some benign entities especially endometriosis
Differential Diagnosis
- Gynecologic
- Pregnancy
- PID leading to tubo-ovarian abscess
- Ectopic pregnancy
- Polycystic ovarian syndrome
- Fallopian tube cancer
- Uterine cancer
- Functional cyst
- Benign ovarian cancer
- Endometriosis
- Leiomyoma
- Epithelial carcinoma of the ovary
- Ovarian sarcoma
- Ovarian germ-cell tumor
- Sex cord or stromal tumor
- Nongynecologic
- Appendicitis/abscess
- Diverticulosis
- Colon cancer
- Bladder tumor
- Polycystic kidney disease
- Retroperitoneal mass
- Primary adenocarcinoma of the colon with metastasis to the ovary (Krukenberg tumor)
Treatment
Additional Treatment
General Measures
Reproductive age:
- If pregnancy test is positive, rule out ectopic pregnancy (2).
- Refer to gynecology if mass >10 cm, concerning ultrasonographic findings or persistence >12 weeks
- Tubo-ovarian abscess:
- Broad-spectrum IV antibiotics
- Functional cysts:
- Majority will spontaneously be reabsorbed or ruptured within 4 " 8 weeks of the initial diagnosis.
- Ultrasonography to establish if cyst is simple or complex
- There is no evidence that oral contraceptive pills are beneficial in decreasing the size of the cysts (2).
- Leiomyoma:
- For symptomatic patients, progesterone (with or without estrogen), danazol, or GnRH agonists may be used.
- Myomectomy may be done.
- Hysterectomy if pregnancy is not desired
- Mature cystic teratoma:
- Risk of rupture or slow spilling of sebaceous fluid from tumor; may present as an acute abdomen
- Operative treatment is cystectomy with preservation of normal ovarian tissue if possible.
Postmenopausal age:
- Refer to gynecologist if mass >10 cm, concerning ultrasonographic findings, CA-125 level >35 U/mL or persistence >12 weeks (2)
- Annual rectovaginal evaluation, CA-125 determination, and transvaginal ultrasound are recommended for high-risk patients.
- Chance of malignancy increases with age (>50 years old) and size of cyst.
- Simple cyst <10 cm, asymptomatic with normal Pap smears, and CA-125 levels may be observed but with serial follow-up with ultrasonography every 4 " 6 weeks.
Surgery
Laparotomy vs. laparoscopy
- Laparoscopy has the accompanying risk of spilling malignant cells into peritoneal cavity by rupture of ovarian capsule during removal of mass.
- Preoperative criteria for laparoscopy:
- Age (postmenopausal has increased likelihood of malignancy)
- Ultrasonographic characteristics including nonadherent smooth and thin-walled cysts, absence of papillae, or internal echoes
Ongoing Care
Complications
- Reproductive age
- Tubo-ovarian abscess:
- Increased likelihood of infertility and ectopic pregnancy
- Functional cyst:
- Recurrence after laparoscopy may be 2%.
- Higher recurrence up to 40% for simple drainage
- Rupture of corpus luteum cyst may cause slight-to-severe bleeding.
- Rarely, adnexal torsion may occur in 1% of cases of theca lutein cysts.
- Mature cystic teratoma:
- May undergo malignant transformation in 1 " 2%, usually over age 40
- May be associated with thyrotoxicosis, carcinoid syndrome, and autoimmune hemolytic anemia
- Rupture of contents in peritoneal cavity is the most serious complication, occurring in 0.7 " 4.6% of the patients.
- Leiomyoma:
- Degeneration occurs when there is decreased blood supply, but has a 0.3 " 0.7% chance for malignant degeneration.
- Approximately 1 in 4 women eventually undergo hysterectomy after myomectomy due to recurrence.
- Postmenopausal
- Ovarian cancer:
- Outcomes are poor with 5-year survival rates for all stages of only 46%.
References
1 Cancer facts & figures 2010. Atlanta, GA: American Cancer Society, 2010.2Givens V, Mitchell GE, Harraway-Smith C. Diagnosis and management of adnexal masses. Am Fam Physician. 2009;80(8):815 " 820. [View Abstract]3McBee WCJr, Escobar PF, Falcone T. Which ovarian masses need intervention? Cleve Clin J Med. 2007;74(2):149 " 157. [View Abstract]
Additional Reading
1Droegemueller W., Stenchever M Comprehensive gynecology. St. Louis, MO: Mosby, 2001;726 " 727.2Stenchever M., Stenchever M Comprehensive gynecology, 4th ed. St. Louis, MO: Mosby, 2001:665 " 713.
Codes
ICD9
- 256.4 Polycystic ovaries
- 620.2 Other and unspecified ovarian cyst
- 789.30 Abdominal or pelvic swelling, mass, or lump, unspecified site
- 220 Benign neoplasm of ovary
- 183.0 Malignant neoplasm of ovary
ICD10
- E28.2 Polycystic ovarian syndrome
- N83.29 Other ovarian cysts
- R19.00 Intra-abd and pelvic swelling, mass and lump, unsp site
- D27.9 Benign neoplasm of unspecified ovary
- C56.9 Malignant neoplasm of unspecified ovary
SNOMED
- 74285003 mass of pelvic structure (finding)
- 79883001 cyst of ovary (disorder)
- 69878008 polycystic ovaries (disorder)
- 119424003 mature cystic teratoma of ovary (disorder)
- 363443007 malignant tumor of ovary (disorder)
Clinical Pearls
- Pregnancy should be ruled out first in reproductive age women.
- Goal of evaluation is to differentiate between benign and more serious malignant masses.
- Increased likelihood of malignancy with:
- Prepubertal or postmenopausal age
- Bilaterality, rapid growth, irregularity, and size >10 cm
- Persistence >12 weeks
- Complex or solid appearing cyst
- Presence of ascites
- Avoid laparoscopic attempt if suspicious for malignancy to prevent risk of rupture and spilling of malignant cells in the pelvis.
- Transvaginal ultrasound is the standard for evaluation of adnexal masses (2).
- All prepubertal girls with an adnexal mass should be referred to a specialist with experience in pediatric gynecology.