Pelvic Masses: Ovary, Tube and Uterine Growths

Ovary - (mostly) cystic

• follicle(s)
• functional ovarian cyst - simple
• persistent corpus luteum
• hemorrhagic corpus luteum
• endometrioma
• polycystic ovary

Background

Most ovarian enlargement is discovered either on pelvic examination or on imaging studies such as pelvic ultrasound or CAT scans obtained for various reasons. With the advent of more frequent use of vaginal probe ultrasound, this category of problems has increased significantly. It is important to take into account that the ovary in a reproductive women undergoes monthly egg formation, ovulation and corpus luteum formation in normal physiology. Follicles may be entirely normal up to 2.5 centimeters in size and should not be called cysts of the ovary. Corpus luteum size may easily reach 3 -3.5 centimeters and still be normal. This normal physiologic process however can appear abnormal and thus this is a frequently occurring set up problems.

Goals

Simple cystic masses in reproductive age women that are less than 8 centimeters in size should always be followed for at least 4-6 weeks to see if there is regression in the size of the cyst. Regression would indicate that the cyst was due to a physiologic process that may well resolve on its own. Simple cystic masses usually are not associated with malignancy and can be followed for a short period of time. Cystic masses of the ovary that are over 8 centimeters in the reproductive age women and over 2 centimeters in the post-menopausal woman or premenarchal girls, have a high probability of being a neoplastic process and therefore often require surgery to obtain tissue for pathology . This necessary in order to rule out the chance of a malignant process.

Other cystic adnexal masses

• broad ligament paraovarian cyst
• hydatids of mortgagni
• hydrosalpinx

Background

Adnexal (non-ovarian) cystic masses are less common than ovarian cystic masses but they do occur. They are usually discovered incidentally on imaging studies and rarely produce symptoms.

Goals

Both tubal structures (hydrosalpinx, hydatids) and congenital broad ligament cystic masses (paramesonephric remnants) can appear to be ovarian cysts if the ovary is not seen in imaging separately on that side. Simple cystic masses in the adnexa are almost always benign and if it can be determined that they do not involve the ovary, they can be followed without surgery.

Ovary - mixed cystic and solid (complex)

• teratoma

• serous cystadenoma
• mucinous cystadenoma

Background

Neoplasms of the ovary occur infrequently but when they do, they usually are painless and are found only on routine examination. The presence of solid components increases the likelihood of a neoplastic process rather than a physiologic process of the ovary. As long as there are not excrescences with areas of irregular solid mixed with cystic, this is still unlikely to be a malignant process. However pathological specimens must be obtained to make sure that there is no malignancy present.

Goals

In this category, exploratory surgery is performed in order to get a tissue specimen for diagnoses. Because ovarian neoplasms can show different pathologic features in the various areas of the neoplasm, the entire neoplasm is submitted for pathological examination which means removal of that entire ovary.

Other complex cystic/solid adnexal masses (w/wo fever)

• chronic pelvic inflammatory disease
• appendiceal abscess
• tuberculosis
• actinomycosis
• endometriosis with tuboovarian adhesions
• regional enteritis
• diverticulitis
• bowel/sigmoid adhesions to adnexa

Background

If an ovary is not distinctly seen on an imaging study but there is a mixed cystic and solid mass in the adnexal region, it is most likely to be a benign lesion. It can be a common finding because hemorrhagic corpus lutea present this way and are frequent in incidence.

Goals

Complex adnexal masses in reproductive age women should usually be followed over at least 4-6 weeks just as a simple cystic mass would be. These still may represent physiologic processes of the ovary or even the bowel with stool contents. A changing image over that time period can confirm that the process is unlikely to be neoplastic. A complex adnexal mass usually means that the ovary cannot be distinctly identified. While it is possible that this represents a ovarian mass with mostly solid components, it is much more commonly a benign process involving the bowel, tube or adhesive disease around the ovary.

Ovary - mostly solid

• malignant teratoma
• dysgerminoma

• fibroma
• brenner tumor
• granulosa-theca
• sertoli-leydig
• sarcoma

• serous cystadenocarcinoma - borderline lesion
• serous cystadenocarcinoma
• mucinous cystadenocarcinoma - borderline lesion
• mucinous cystadenocarcinoma
• endometroid adenocarcinoma - borderline lesion
• endometroid adenocarcinoma

Background

Not all ovaries that are mostly solid contain malignancy, but the probability is increased. The frequency of ovarian cancer is approximately 1 in 70 women during their lifetime.

Goals

Because cancer of the ovary grows silently, characteristically it does not produce symptoms until an advanced stage. It is extremely important to find ovarian malignancies when they are small and confined. Ovaries that show a predominately solid component end up being removed in order to pathologically check the entire specimen.

Other solid adnexal masses

• fallopian tube carcinoma
• pelvic kidney
• metastatic nongynecologic cancer

Background

Solid, non-ovarian adnexal masses are rare. They are usually indistinguishable from solid ovarian masses.

Goals

As with solid ovarian masses, a heightened concern about cancer should be present. An IVP (intravenous pyleogram) may help to rule out pelvic kidney and also to show the path of the ureter is surgery for diagnosis is planned.

Central pelvic mass

Uterus-corpus (non-pregnant)
• uterine hypertrophy
• leiomyomata (fibroids)
• leiomyosarcoma
• endometrial stromal sarcoma
• mixed mesodermal tumor of uterus
• other stromal tumors
• bladder distension
• constipation/stool impaction
• (see also other complex cystic/solid adnexal masses

Background

Central pelvic masses are quite common because of the common occurrence of pregnancy. Uterine fibroids (leiomyomata) which may enlarge the uterus are also common and occur in almost 25% of women. Central pelvic masses are usually detected on the bimanual part of a pelvic examination, although sometimes they are discovered primarily by imaging techniques such as pelvic ultrasound or magnetic resonance imaging (MRI).

Goals

If a uterus is present there is always a normal "physiologic" pelvic mass present. It is important to distinguish any further enlargement that may represent a malignancy. Critical to the diagnostic processes is ruling out pregnancy because that will greatly influence all other diagnostic studies and therapeutic modalities used. Also, it can be embarrassing to pursue a very expensive workup for possible malignancy when in fact the central mass represents physiologic events such as a very full bladder, hard stool in the colon and small bowel, or a pregnant uterus. Imaging studies such as ultrasound and occasionally MRI, are helpful in differentiating central pelvic masses.