Pelvic Mass

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Pelvic Mass

Basics

Description

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]

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.

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 age85% 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.
PostmenopausalApproximately 30 " 60% risk of malignancy1/3 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).

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.

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 ageApproximately 46% of patients with tubo-ovarian abscess have history of pelvic inflammatory disease (PID).Leiomyoma:3 " 5 times more common in African American womenOverweightNulliparityFunctional cysts arise from normal physiologic variation due to elevated gonadotropin, but there is increased propensity to form individual follicular cysts in cystic fibrosis patients.
PostmenopausalOvarian 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.

Approximately 46% of patients with tubo-ovarian abscess have history of pelvic inflammatory disease (PID).
Leiomyoma:3 " 5 times more common in African American womenOverweightNulliparity
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.

3 " 5 times more common in African American women
Overweight
Nulliparity

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.

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 ageTubo-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.
PostmenopausalOvarian 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).

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.

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

Reproductive ageTubo-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.
PostmenopausalOvarian 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.

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.

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 ageTubo-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.
PostmenopausalOvarian cancer may be associated with pleural effusion, abdominal distention with ascites, abdominopelvic mass, cul-de-sac nodularity, and groin adenopathy.

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.

Ovarian cancer may be associated with pleural effusion, abdominal distention with ascites, abdominopelvic mass, cul-de-sac nodularity, and groin adenopathy.

Tests

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 identifiedShould not be used in the routine work-up of a premenopausal womanIncreased levels >35 U/mL should prompt further evaluation.May be elevated in benign conditions like endometriosis, PID, liver and renal disease

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

Transvaginal/Transvaginal ultrasound not transabdominal ultrasound (2):Most valuable diagnostic study in the initial evaluation of pelvic massDifferentiates cystic (simple or complex) and solid tumorsPresence 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 abilityAble to diagnose some benign entities especially endometriosis

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.

Increased resolution and ability to distinguish subtle differences

Provides detailed evaluation of pelvic anatomy with excellent tissue contrast ability
Able to diagnose some benign entities especially endometriosis

Differential Diagnosis

GynecologicPregnancyPID leading to tubo-ovarian abscessEctopic pregnancyPolycystic ovarian syndromeFallopian tube cancerUterine cancerFunctional cystBenign ovarian cancerEndometriosisLeiomyomaEpithelial carcinoma of the ovaryOvarian sarcomaOvarian germ-cell tumorSex cord or stromal tumor
NongynecologicAppendicitis/abscessDiverticulosisColon cancerBladder tumorPolycystic kidney diseaseRetroperitoneal massPrimary adenocarcinoma of the colon with metastasis to the ovary (Krukenberg tumor)

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

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

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 complexThere 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 abdomenOperative treatment is cystectomy with preservation of normal ovarian tissue if possible.

Broad-spectrum IV antibiotics

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).

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

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.

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

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

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 ageTubo-ovarian abscess:Increased likelihood of infertility and ectopic pregnancyFunctional cyst:Recurrence after laparoscopy may be 2%.Higher recurrence up to 40% for simple drainageRupture 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 40May be associated with thyrotoxicosis, carcinoid syndrome, and autoimmune hemolytic anemiaRupture 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.
PostmenopausalOvarian cancer:Outcomes are poor with 5-year survival rates for all stages of only 46%.

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 drainageRupture 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 40May be associated with thyrotoxicosis, carcinoid syndrome, and autoimmune hemolytic anemiaRupture 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.

Increased likelihood of infertility and ectopic pregnancy

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.

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.

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.

Ovarian cancer:Outcomes are poor with 5-year survival rates for all stages of only 46%.

Outcomes are poor with 5-year survival rates for all stages of only 46%.

References

Additional Reading

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 ageBilaterality, rapid growth, irregularity, and size >10 cmPersistence >12 weeksComplex or solid appearing cystPresence 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.

Prepubertal or postmenopausal age
Bilaterality, rapid growth, irregularity, and size >10 cm
Persistence >12 weeks
Complex or solid appearing cyst
Presence of ascites