Journal Reading:

Management of A Pelvic
Mass
Timothy J Duncan, Diana Marcus
Obstetrics, Gynaecology and Reproductive
Medicine (2016)

Mentor: dr. Lubena Sp.OG

COASS:
1. Ramadhan Conny S (22010119220134)
2. Fatan Khalif Koncara (22010119220209)
3. Nisa Aulia Paramitha (22010119220070)
4. Cecilia Noviyanti Salim (22010119220023)
5. Steffi Kurniati (22010119220204)
● Pelvic mass is a common clinical problem
● Clinical history + examination + various
investigations  character & origin of the ABSTRACT
mass? Risk of malignancy? Management?
● Problem-based review: 3 case histories
● A common clinical problem affecting the ovary,
fallopian tube or surrounding connective tissue; can
present in females of all ages
● Mostly arise from ovary
INTRODUCTION:
● May be symptomatic or incidentally discovered ADNEXAL MASS
during imaging for another indication
● Broad DD
● Primary aim of investigation = identification of
malignancy
 INTRODUCTION:
ADNEXAL MASS
 A 45 y.o. woman was seen in the general gynaecology
clinic presenting with menorrhagia and pressure
symptoms (distension, urinary frequency, and
constipation). The symptoms had worsened over the
CAS E 1 last year. She was otherwise in good health with a
BMI of 34. Examination revealed a 16 week size
(SARCOMA, uterus. She had tried empirical treatment with
FIBROID) tranexamic acid, norethisterone and the Mirena IUS,
but to no avail. She is keen on surgical treatment, but
declined endometrial ablation.
 
● Highly suggestive of a fibroid uterus
● National Institute for Clinical Excellence (NICE)  
ultrasound = 1st line diagnostic tool for identifying structural
abnormalities + endometrial sampling to exclude
endometrial Ca/atypical hyperplasia (in women ≥45
y.o./persistent intermenstrual bleeding/treatment failure)
DISCUSSION
● Management:
o Ulipristal acetate (esmya)  orally active selective
progesterone receptor modulator
o GnRH agonist prior to myomectomy or hysterectomy
(to reduce size of incision)
o Definitive: hysterectomy
● Ultrasound  multiple small intramural and serosal
fibroids @2-3 cm
● Hysteroscopy  12 cm uterine cavity, thickened
endometrium, small submucosal fibroid
● Endometrial biopsy  leiomyosarcoma (LMS)
FURTHER CASE
● Pelvic MRI & CT chest, abdomen, pelvis  stage 1B HISTORY
● Histological exam  grade III (high grade) LMS with
tumour mass of 15 cm (stage IB)
● Tx: midline laparotomy, TAH, bilateral salpingo-
oophorectomy, omentectomy + 4-monthly chest X-ray and
pelvic MRI + counselled about the high risk of recurrence
 PELVIC MRI OF
UTERINE LEIOMYOSARCOMA
● Rare group of soft tissue tumours, from mesenchymal cells,
include myometrium/endometrial connective tissue elements
● <1% of gynaecological malignancies, 3-7% of uterine
malignancies
● More aggressive & far worse prognosis than other uterine
DISCUSSION:
Ca UTERINE SARCOMA
● Classified according to distinct tissue types & presumed origin:
o LMS (55%)
o Endometrial stromal sarcomas (20%)
o Undifferentiated sarcomas (15%)
o Others, incl. fibrosarcoma (10%)
● No specific symptoms, most women present with abnormal vaginal
bleeding
● Pressure symptoms (bladder & bowel changes), abdominal distension,
noticeable lump from pelvis  ~ leiomyomas (fibroids)
● Age range between 22-89 y.o., median 45-64 y.o.
● Risk factors: nulliparity, obesity, >> age, tamoxifen use, history of
pelvic radiation DISCUSSION:
● Often diagnosed post OP LEIOMYOSARCOMA
Current NICE guidelines for heavy menstrual bleeding  non- (LMS)
surgical management of fibroids as 1st line (Mirena, progestogens,
GnRH analogue, uterine artery embolization)  delayed dx of LMS 
may affect long-term prognosis
● If LMS is histologically confirmed prior to surgery  imaging to assess
size of tumour & evidence of metastases
 FIGO STAGING OF
UTERINE LEIOMYOSARCOMA
● Prognosis is improved if there is no residual disease following surgery 
aggressive debulking
● Lymph node metastasis has been reported in <5% for early stage cases
● Evidence of enlarged nodes  debulking lymphadenectomy can be performed
● Extra pelvic-disease (stage 3/>)  !!! patient wishes, co-morbidities, disease
extent
DISCUSSION:
● Stage IV surgery only for symptom control (eg. to palliate bleeding)
LEIOMYOSARCOMA
● If :
MANAGEMENT
o Unexpected histological dx following myomectomy  hysterectomy & full
surgical staging
o Dx follows a hysterectomy  further staging w/ imaging of chest, abdomen,
and pelvis. Additional surgery is not recommended (ovarian metastases do
occur and some tumours express oestrogen receptors but it’s not clear whether
removing ovaries influences survival)
 Chemotherapy  modest << in relapse rates, prolonged
Chemo-radiotherapy survival in advanced cases
in combination  Anthracycline-based doxorubicin, cyclophosphamide,
significant toxicity nucleoside analogue gemcitabine, etc.

DISCUSSION:
LEIOMYOSARCOMA
01 02 03 04 ADJUVANT THERAPY
& SURVIVAL RATES

Pelvic radiotherapy  5y survival rates 62-65% for stage

<< in local recurrence 1, as low as 29% for advanced
rates, no benefit to disease
overall survival
 A 31 y.o. low risk woman attended ultrasound for a routine
dating scan. This revealed a single viable intrauterine
pregnancy of 11 week gestation. In addition a 7 cm right-
sided complex ovarian cyst was noted with a hyperechoic
CAS E 2 nodule and acoustic shadowing on a background of low-level
echoes. She was booked in for antenatal clinic at 14 weeks
OVARIAN for discussion of the cyst but presented to A&E the day
TORSION IN before her clinic appointment with sudden onset severe pain
PREGNANCY associated with nausea and vomiting. She was apyrexic.
 Examination revealed RLQ rebound tenderness and
guarding. A full blood count showed mild leucocytosis and
a raised CRP but other laboratory investigations were
normal. She was admitted for analgesia and given IV fluids.
CAS E 2 A diagnostic laparoscopy was performed due to the clinical
suspicion of ovarian cyst torsion or appendicitis. Intra-
operatively the appendix was normal but a 12 cm
OVARIAN
engorged torted right ovary was seen. She therefore
TORSION IN underwent a right oophorectomy. The histology confirmed a
PREGNANCY torted and infarcted mature teratoma. She had an
uncomplicated recovery and, the remainder of her pregnancy
was uneventful.
● Reported incidence of antenatal ovarian cysts: 0,2-2%
● Most common cysts in pregnancy: functional cysts such as follicular
cysts and corpus luteal cysts
● Most common non-functional cysts: dermoid cysts (mature
cystic teratomas) and endometriomas
● Non-specific symptoms: abdominal/back pain (+/- radiation to
thigh), constipation/urinary symptoms DISCUSSION:
Acute onset of severe pain + vomiting  TORSION? OVARIAN CYSTS
● Torsion
o 18x >> likely in pregnancy
o >> likely in the presence of ovarian cysts, particulary 6-8 cm
in size, between 10th-17th week gestation. After the 17th week  uterus
>>  ovaries are pushed out of pelvis against
abdominal wall  risk <<
● Ultrasound can be used to characterize ovarian masses, although
histological examination is required to confirm the diagnosis
 USG features suspicious of malignancy  bilateral lesions,
solid components, septations or presence of ascites
● International Ovarian Tumour Analysis (IOTA): benign or
malignant rules with 95% sensitivity and 91% specificity DISCUSSION:
● Malignancy risk >> when the growth rate ≥3,5 cm/week DIAGNOSIS OF
● MRI can be safety used in the latter half of pregnancy to evaluate OVARIAN
cysts (contrast should be avoided) MASSES
● Tumour marker specificity is low in pregnancy because levels are
normally elevated in pregnancy and fluctuate with GA
After the 1st trimester, markedly elevated CA125/significant
increase during consecutive measurements  malignancy?
(though are often raised in PE); cut off 112 IU/ml
SONOGRAPHIC
APPEARANCE
OF ADNEXAL
MASSES
SONOGRAPHIC
APPEARANCE
OF ADNEXAL
MASSES
● Majority of ovarian cysts without suspicious features
will resolve by the 2nd/3rd trimester
o Asymptomatic simple ovarian cysts <5 cm  no
follow up/surgical intervention DISCUSSION:
o Larger simple cysts  repeat USS in 4 weeks MANAGEMENT OF
● All suspicious cysts of any size  repeat USS in 4 weeks OVARIAN CYSTS
to identify growth
● Complications: torsion, rupture, haemorrhage,
obstruction of labour
● Symptoms in pregnancy = in non-pregnant = lower abdominal pain, nausea,
vomiting, low-grade fever
● Diagnosis:
o Changes in the position of intra-abdominal organs  physical exam in
pregnancy is often difficult
o Lab tests: non specific
o Imaging: DISCUSSION:
 USS can detect adnexal mass although has limited ability to OVARIAN
predicting torsion TORSION
 Doppler blood flow imaging: high false (-)
 MRI has no benefit over USS
 CT is contraindicated in pregnancy
o Surgery: should be avoided, if required  early to mid 2nd trimester
(risk of miscarriage <<, organogenesis completed, no association w/ preterm
labour, fetal loss, or risk of teratogenicity, operative
exposure to pelvis isn’t restricted significantly by enlarged uterus)
● Laparotomy = mainstay
● Decision to perform cystectomy/oophorectomy is based on size
of cyst, degree of suspicion of malignancy, vascular compromise,
and appearance of contralateral ovary
Salpingo-oophorectomy: most common, as recurrent DISCUSSION:
torsion >> in pregnant patients SURGERY FOR
● Laparoscopy  concerns include trauma during insertion of OVARIAN
Veress needle or trocars, << in uterine blood flow e.c. raised TORSION
intra-abdominal pressure, absorption of CO2 by fetus IN PREGNANCY
● Risk of surgery had to be balanced vs risk of delaying it: ovarian
infarction, haemorrhage/peritonitis
● Routine staging is required but lymphadenectomy usually not
performed in pregnancy
● Epithelial Ca
o No evidence of peritoneal spread  preservation of uterus DISCUSSION:
can be offered TREATMENT OF
o Advanced Ca  debulking surgery isn’t possible without OVARIAN CANCER
terminating the pregnancy with hysterectomy IN PREGNANCY
● Chemotherapy is associated with congenital malformation in 1st
trimester
 A 22 y.o. woman was referred to the emergency gynaecology
service complaining of severe bilateral lower abdominal pain
that began 2 weeks after the insertion of a copper
contraceptive coil. This had been associated with nausea,
diarrhoea, and offensive vaginal discharge. Her past medical
CAS E 3 history was unremarkable except a treated episode of chlamydia
4 years ago and a BMI of 38. On admission, the patient was
TUBOOVARIAN pyrexial with a temperature of 38,4°C and a urine pregnancy test
MASS was negative. Examination revealed mild tenderness and a
palpable mass in the lower abdomen but no signs of
peritonism. Genital swabs were taken and the coil was removed
and sent for microbiology and culture.
 An USS revealed a 11 cm complex pelvic mass of uncertain
origin. Biochemical investigations showed a raised CRP level
(395), leucocytosis (22x109/l) and raised serum CA125 (2100
U/ml). The patient was treated with IV broad-spectrum
antibiotics for presumed pelvic infection with tubo-ovarian
CAS E 3 abscess (TOA). However, she failed to respond to medical
therapy. Three days after admission she underwent diagnostic
TUBOOVARIAN laparoscopy and drainage of TOA. She was discharged on oral
MASS antibiotics 7 days after admission. Her bloods prior to discharge
were markedly improved with a CRP of 82, CA125 of 800 U/ml
and WCC of 11x109/l. The swabs and copper coil grew mixed
aerobes only.
● TOA = inflammatory mass involving the ovary, fallopian tube, or
occassionally neighbouring structures
● Rates are higher in women hospitalised for acute PID, may
follow pelvic surgery, or result from bowel perforation typically
from sigmoid diverticulum, and intraperitoneal spread of
infection; most frequently results from upper
genital tract infection DISCUSSION:
● In post-menopausal women  investigations to exclude TUBOOVARIAN MASS
malignancy/other pelvic pathology
● Most common organisms: streptococcal species, E. coli, other
Gram (-) enteric organisms
 Most frequent anaerobes: Bacteroides, Peptostreptococcus
● Risk factors: multiple sexual partners, age 15-25 years,
previous pelvic infections
● In this case: insertion of copper coil  spread of pathogens
to upper genital tract  risk of PID >> in the first 3 weeks DISCUSSION:
after insertion PELVIC
● In a study of 499 women with PID: >> age, IUD insertion, INFLAMMATORY
chlamydia infection, >> CRP & CA-125 = independent DISEASE
factors predictive of TOA
● Abdominal and/or pelvic pain = most common
 Fever and leucocytosis are also common (60-80%), along with vaginal
discharge and diarrhoea
● Gram stain and microscopic examination of vaginal discharge + NAAT for
chlamydia and gonococcus may provide useful information to guide AB
used
● Imaging method of choice = ultrasonography  masses that are
relatively homogenous, well demarcated, cystic and thin-walled, contain DISCUSSION:
speckled fluid with internal echoes consistent with inflammatory debris +/- DIAGNOSIS OF
air fluid level and septations
● Lab: full blood count, CRP, tests for renal & liver function TUBOOVARIAN MASS
o Leucocytosis and elevated CRP  indicator of disease severity and to
monitor treatment response
o Renal & liver function tests  to identify and monitor dysfunction
secondary to sepsis
o Fever (+)  urine & blood cultures
o CA125 was performed in this case e.c. adnexal mass (+)
Hemodinamically stable, small abscesses, pre-menopausal women, adequate
response to AB medical treatment alone
● IV triple AB: broad-spectrum beta-lactam (ex. Ceftriaxone) +
metronidazole/clindamycin (for anaerobic) + gentamycin
● AB should be continued for at least 2 weeks + monitoring (resolution may
take several months)
● No improvement within 48-72h  evaluated for surgical intervention
DISCUSSION:
Surgical
● Laparoscopy/laparotomy TREATMENT OF
● Objectives: confirmation of TOA, drainage of abscess, removal of abscess TUBOOVARIAN MASS
cavity along with inflammatory and infective debris, and extensive
peritoneal-cavity irrigation
● Severe pain, peritonism, signs of septic shock  rupture?  immediate
surgical management + IV AB
● Alternative: transvaginal/percutaneous abscess drainage  minimally
invasive
 POPULATION

● Case 1: A 45-year-old woman with menorrhagia and pressure

symptoms (distension, urinary frequency, and constipation)
● Case 2: A 31-year-old pregnant woman of 11-week gestation CRITICAL APPRAISAL:
PICO VIA
with a 7 cm right-sided complex ovarian cyst.
● Case 3: A 22-year-old woman with severe bilateral lower
abdominal pain that began 2 weeks after insertion of a copper
contraceptive coil.
 INTERVENTION

CAS E 1
SARCOMA, FIBROID
An ultrasound performed revealed multiple small intramural and serosa
fibroids. After that, a hysteroscopy was performed, which demonstrated CRITICAL APPRAISAL:
a 12 cm uterine cavity and submucosal fibroid. Endometrial biopsy was PICO VIA
also carried out and it was identified as a leiomyosarcoma (LMS). MRI
and CT chest, abdomen, and pelvis suggested stage 1B disease, while
from histological examination, it was confirmed as a grade III (high
grade) LMS. The patient was then treated with a midline laparotomy,
total abdominal hysterectomy, bilateral salpingo-oophorectomy, and
omentectomy.
 INTERVENTION

CASE 2
OVARIAN TORSION IN PREGNANCY
Full blood count was carried out, which showed mild leukocytosis and
a raised CRP. Then, a diagnostic laparoscopy was performed due to CRITICAL APPRAISAL:
clinical suspicion of ovarian cyst torsion or appendicitis. The patient PICO VIA
therefore underwent a right oophorectomy after a torted right ovary was
confirmed.
 INTERVENTION

CASE 3
TUBOOVARIAN MASS
A genital swab, culture, and an USS were done, which identified a 11
cm complex pelvic mass of uncertain origin. Biochemical investigations
CRITICAL APPRAISAL:
showed a raised in CRP, leukocytosis, and raised serum CA125. The PICO VIA
patient was then treated with IV broad-spectrum antibiotics and
underwent diagnostic laparoscopy along with drainage of tubo-ovarian
abcess (TOA). After that, the patient was discharged on oral antibiotics
7 days after admission.
 COMPARISON

There was no comparison done in this journal CRITICAL APPRAISAL:

PICO VIA
 OUTCOME

● Case 1: Complete resolution of leiomyosarcoma with no

relapse. The patient was followed up with 4-monthly chest
X-ray and pelvic MRI to detect any metastasis. CRITICAL APPRAISAL:
● Case 2: The patient had an uncomplicated recovery of PICO VIA
ovarian cyst and torsion with uneventful pregnancy.
● Case 3: There was an improvement in blood count result,
where there was a decrease in CRP level, serum CA125, and
white blood cell count.c
 VALIDITY

This journal is valid as it used the most updated and CRITICAL APPRAISAL:
trusted references. PICO VIA
 IMPORTANT

This journal is really important as it identified some of

pelvic mass’ characteristics, informed which was the
CRITICAL APPRAISAL:
best modality should be used in each cases, and also
PICO VIA
what kind of treatment should be taken considering the
advantages and disadvantages.
 APPLICABLE

This journal is applicable as there are lots of pelvic

mass cases in Indonesia, such as leiomyosarcoma, cyst, CRITICAL APPRAISAL:
PICO VIA
and tubo-ovarian abcess.
THANKS
Does anyone have any questions?