بسم الله الرحمن بسم الله الرحمن الرحيم الرحيم

Pelvic massPelvic mass

Dr.T Allameh MD

Pelvic massPelvic mass: :

Gynecologic

• Uterine

• Adnexal

• Ovarian

Urinary

Bowel

Pre pubertal age groupPre 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 reviewIn 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 signsSymptoms and signs

• Pelvic mass

• Abdominal mass

• Non specific

Diagnosis and managementDiagnosis 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 groupOvarian 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 adolescentFunctional 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 agesOvarian 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.

SymptomsSymptoms

• 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 tumorsBenign tumors: :

• Unilateral

• Cystic

• Mobile

• Smooth

Malignant massesMalignant masses • Bilateral • Solid • Fixed • Irregular • Associated with :• Ascites • Cul – de – sac nodules • Rapid growth

Functional ovarian cystsFunctional ovarian cysts: :

• 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 cystFollicular 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 cystsCorpus 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 cystsTheca 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 cystsTheca lutein cysts: :

• May be quite large ( up to 30 cm )

• Are multi cystic

• Regress spontaneously

Oral CotraceptionOral 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 .

EndometriosisEndometriosis

• Ovarian endometioma (chocolate cysts)

Can enlarge to 6 – 8 cm .

• Does not resolve by observation

Neoplastic massesNeoplastic 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 tumorsEpithelial tumors

• The risk of epithelial tumors increases with age .

• Serous cyst adenomas are often considered

• The more common benign neoplasm

Serous tumorsSerous tumors

• Generally are benign

• 5% -10% have borderline malignant potential

• 20% -25% are malignant

Serous cyst adenomaSerous 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 tumorsMucinous 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 tumorsOther benign ovarian tumors: :

• Fibroma

• Brenner tumors

• Mixed forms of tumors such as cystadenofibroma .

UltrasoundUltrasound • 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 solidCystic 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 .