Pelvic Mass
K. Carlson, M.D.
Dept. of Ob-Gyn
Pelvic Mass Etiology
•Cervix
•Uterus
•Adnexa
•GU tract
•Bowel
•Musculoskeletal system
•Vascular lymphatic system
•Nervous system
•Infectious
How do these women
present?
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Pressure/fullness
Increasing girth
Pain
Annual exam
Obstetrical exam
4 considerations
• Age
• Tumor size
• U/S features
Age
• Reproductive years
– Majority are follicle cysts, disappear in 3 months
– Corpora lutea also common
– Pelvic kidney
• Childhood
– Rare
Adolescence
– Hematocolpos
– Hematometrium
most common benign tumor in
reproductive aged women
1. serous cystadenoma
2. mature teratoma.
Age
• Perimenopause and postmenopausal
– Fibroids should regress
– Malignancy suggested
• Bilateral adnexal masses
• Ascites
– Diverticulitis
– Lymphomas
– Metastatic cancer to ovary
Work-up
• Examination
• Radiology
– U/S
• Lab
– hCG
– Markers
Work-up
• Examination
– Always include rectal exam
– EUA
Work-up
• U/S
– Relatively inexpensive
– Delineates cystic vs solid structures
– Assesses for ascites
• CT
– Assesses other organs
– Excellent for retroperitoneum (1-5 mm)
• MRI
– Allows for ID of soft tissue lesions
– Safe in pregnancy
– Can differentiate normal from malignancy
Lab - Tumor Markers
• CA-125
– Epithelial tumors
– Antibody for antigen produced
by coelomic epithelium
– Normal <35 U/mL
– NOT an effective screening tool
for cancer
Lab - Tumor Markers
• CA-125 ↑ in:
– Leiomyoma
– Endometriosis/adenomyosis
– PID
– Pregnancy
– Malignancies-lung, breast,
colon
– Pancreatitis
– Cirrhosis
Lab - Tumor Markers
• CA-125
– Epithelial tumors
• AFP
– Endodermal sinus tumor
• hCG
– Choriocarcinoma
• LDH
– Dysgerminoma
Pelvic Mass Etiology
•Cervix
•Uterus
•Adnexa
•GU tract
•Bowel
•Musculoskeletal system
•Vascular lymphatic system
•Nervous system
•Infectious
Etiology of Pelvic Mass
• Uterine
Etiology - Uterine
• Leiomyoma
• Pregnancy
• Polyp
Fundus
Round ligament
Tube
Fibroid
Ovary
Fimbria
Etiology of Pelvic Mass
• Uterine
• Ovarian
Etiology - Ovarian
• Neoplastic
– Epithelial
– Germ cell
– Sex cord-Stromal
• Functional cysts
• Torsion
• Tubo-ovarian abscess (TOA)
Fine internal echoes with a fishnet appearance of thin, linear, fibrous
strands are characteristic of hemorrhage.
Benign serous cystadenoma
6,300 grams, 30 cm X 30 cm
Benign serous cystadenoma
6,810 grams, 20 cm X 40 cm
Dermoid
• Most common enlargement in young female
• Rarely malignant
Dermoid cyst
• 5-10% are bilateral
• < 1% are malignant
• malignant cell line is of
ectodermal origin
Ovarian Cancer
2nd most common malignancy of
female genital tract
Most frequent cause of death from
GYN cancers.
Annually, 23,000 new cases with
14,000 deaths.
Ovarian Cancer
-Median age is 52.
-Life-time risk is 1.4%.
-if 1° relative has ovarian cancer
5% risk
ovarian capsule
Epithelial ovarian cancer, stage 1C
Theca-lutein cysts
Etiology of Pelvic Mass
• Uterine
• Ovarian
• GI
Etiology - GI
• Diverticular abscess
• Appendiceal abscess
• Primary malignancy
Etiology of Pelvic Mass
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Uterine
Ovarian
GI
Adnexal
Etiology - Adnexal
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Ectopic pregnancy
Abscess
Peritubular cyst
Endometrioma
Round ligament fibroid
Torsion
Hydrosalpinx
Müllerian defect
• Echogenic foci in the wall (red arrows) are a subtle
but characteristic sign of endometrioma.
Etiology of Pelvic Mass
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Uterine
Ovarian
GI
Adnexal
Infectious
Etiology - Infectious
• TOA
• Appendiceal abscess
• Diverticular abscess
Etiology of Pelvic Mass
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Uterine
Ovarian
GI
Adnexal
Infectious
Retroperitoneal
Meningioma
3 Important Points
1.Adnexal mass in pregnancy
 2.Persistent unilocular ovarian cysts
 3.Whom to refer to a gynecologic
oncologist
Adnexal Mass in Pregnancy
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1/1,300 patients
6% CA or LMP (8/130)
Dermoid most common (30%)
No ↑ incidence of adverse outcome
Remove for 3 reasons
– Prevent dystocia
– Danger of rupture, torsion, or hemorrhage
– Malignancy
Whitecar, P. Am J Obstet Gynecol 1999;181:19
Persistent Unilocular
Ovarian Cysts
• Common: 3 to 17%
• Expectant management is acceptable
in post-menopausal women provided:
– Diameter < 5 cm
– No increase in size
– Normal CA-125
Nardo, LG, et al. Obstet Gynecol 2003;102:589
Persistent Unilocular
Ovarian Cysts
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15,106 women over 50 screened
18% found to have unilocular cyst
69% resolved spontaneously
None of the women with isolated
unilocular ovarian cysts developed
ovarian CA
Modesitt SC, et al. Obstet Gynecol 2003;102:594
Referral Criteria for Women with
a Pelvic Mass
• Premenopausal (<50 years old)
– CA-125 > 50 U/ml
• Ascities
• Evidence of abdominal or distant metastasis
• Postmenopausal (>50 years old)
– CA-125 > 35 U/ml
• Ascites
• Evidence of abdominal or distant metastasis
Im SS, et al., Obstet Gynecol 2005;105:35-41
Conclusions
• Ovarian enlargement in pre-menarchal
female is dermoid
• 60-85% of ovarian neoplasm in women
< 20 is germ cell. In adults, only 20%
• Frequency of ovarian cancer is inversely
related to age. 14% in women < 16 and
7% age 16-20
Conclusions
• Dermoid is the most common mass in
pregnancy
• Unilocular cysts can be followed if
< 10 cm and stable with normal CA-125
Conclusions
• Refer premenopausal patients with a
CA-125 > 50 U/ml and ascites and
evidence of abdominal or distant
metastasis to a gynecologic oncologist.
• Refer postmenopausal patients with a
CA-125 > 35 U/ml with ascites and
evidence of abdominal or distant
metastasis to a gynecologic oncologist.