Clinicopathologic Case Presentation

OB-Gyne Department

Lopez, Vicheryl M.
General Data
Age: 48 y.o.
P3003
LMP: November 26, 2006
Chief Complaint
Mass at the hypogastric area
 History of Present Illness
1 year PTA, patient noted fist size mass at
hypogastric area, gradually enlarging, not
associated with pain or vaginal bleeding.
Consulted a physician and UTS done showed
Uterine myoma. She was advised to have
surgery but refused.
2 months PTA, the gradually enlarging
mass was associated with intermenstrual
bleeding with no dizziness. No weight
loss. No changes in bowel movement
and urination. Consulted a physician and
repeat UTZ showed an enlarged uterus
measuring 13.1x10.4x10.4 cm, the entire
myometrium demonstrates coarse
echopattern suggestive of a diffuse
adenomyosis. Thus advised surgery.
Menstrual History
12y.o. x 28-30 days x 3-4 days,
moderate flow, no dysmenorrhea
Obstetrical History
3 FTS delivered NSVD w/o
complications
Past Medical History
Non-hypertensive, non-diabetic, non-
bronchial athmatic, no cardiac disease
Physical Examination
General survey: conscious, coherent,
afebrile
BP 110/80 mmHg HR 78 bpm
RR 21 cpm
Eyes: pinkish palpebral conjunctiva
C/L: ECE, CBS, no rales, no wheeze
Heart: DHS, normal rate, regular rhythm
Abdomen: 18x15 cm lower abdominal mass,
symmetrically enlarged, firm, slightly
movable, well delineated border, non-tender
S/E: cervix smooth, pinkish, no lesion, slit-like
os, no bleeding
BPE: cervix closed, firm, movable, non tender
U: 16-18 weeks size, same mass palpated
abdominally
Adnexa: negative
Cul de sac: no nodularity
Questions:
Familyhistory of Ovarian Cancer?
Dyspareunia?
Differential Diagnosis
1. Epithelial Ovarian Tumors
2. Ovarian cysts
3. Adenomyosis
Epithelial Ovarian Neoplasms
Most frequent ovarian neoplasms
Believed to arise from the surface
(coelomic)epithelium
 Frequency Epithelial Ovarian Tumor Cell Types

All Ovarian Neoplasms Ovarian Cancers

Serous 20-50 35-40

Mucinous 15-25 6-10
Endometrioid 5 15-25
Clear Cell <5 5
(Mesonephroid)
Brenner 2-3 rare
Clinical Features
 More than 80% of epithelial ovarian cancers are
found in postmenopausal women
 The peak incidence of invasive epithelial ovarian
cancer is at 56 to 60 years of age
 The age-specific incidence of ovarian epithelial
cancer rises precipitously from 20 to 80 years of age
and subsequently declines.
 These cancers are relatively uncommon in women
younger than age 45.
Etiology
low parity and infertility
Early menarche and late menopause-suppression
of ovulation
Family History-mutations in them BRCA1 gene,
located on chromosome 17 and BRCA2, located
on chromosome 13
Pathogenesis
Theoretically, the surface epithelium
undergoes repetitive disruption and repair.
It is thought that this process might lead
to a higher probability of spontaneous
mutations that can unmask germline
mutations or otherwise lead to the
oncogenic phenotype
Symptoms
 vague and nonspecific symptoms.
 In early-stage disease, the patient may
experience irregular menses if she is
premenopausal.
 If a pelvic mass is compressing the bladder or
rectum, she may report urinary frequency or
constipation
 Occasionally, she may perceive lower abdominal
distention, pressure, or pain, such as dyspareunia.
 Acute symptoms, such as pain secondary to rupture
or torsion, are unusual.
 In advanced-stage disease, patients most often have
symptoms related to the presence of ascites, omental
metastases, or bowel metastases.
 The symptoms include abdominal distention,
bloating, constipation, nausea, anorexia, or early
satiety.
 Premenopausal women may report irregular or
heavy menses, whereas vaginal bleeding may occur
in postmenopausal women
Signs
 The most important sign of epithelial ovarian
cancer is the presence of a pelvic mass on physical
examination.
 A solid, irregular, fixed pelvic mass is highly
suggestive of an ovarian malignancy.
 If, in addition, an upper abdominal mass or ascites
is present, the diagnosis of ovarian cancer is almost
certain.
Diagnosis
 For the premenopausal patient, a period of
observation is reasonable provided the adnexal mass
does not have characteristics that suggest
malignancy (i.e., it is mobile, mostly cystic,
unilateral, and of regular contour).
 Serum CA125 levels
 Premenopausal patients whose lesions are clinically
suspicious (i.e., large, predominantly solid,
relatively fixed, or irregularly shaped) should
undergo laparotomy, as should postmenopausal
patients with complex adnexal masses of any size.
Basis for ruling in: Basis for ruling out:
Age Not Low parity
Mass at the hypogastric area Not Infertile
Intermenstrual bleeding Not Fixed pelvic mass
Not Early menarche
No Family history
UTZ result showed
uterine origin
Ovarian cysts:
 An ovarian cyst is any collection of fluid, surrounded by
a very thin wall, within an ovary.
 Any ovarian follicle that is larger than about 2cms is
termed an ovarian cyst.
 Ovarian cysts affect women of all ages. They occur most
often, however, during a woman's childbearing years.
 One of the common causes of pelvic mass in
premenopausal period
 Most ovarian cysts are functional in nature, and
harmless (benign).
 These types of cysts occur during ovulation. If the
egg is not released, the ovary can fill up with fluid.
eg:Follicular cyst,corpus luteum cyst and theca lutein
cyst
 Non-functional cysts include dermoid and
endometroid cyst
Risk factors

 History of previous ovarian cysts

 Irregular menstrual cycles
 Increased upper body fat distribution
 Early menstruation (11 years or younger)
 Infertility
 Hypothyroidism or hormonal imbalance
 Tamoxifen therapy for breast cancer
 Cigarette smoking
 Theca Lutein cysts-maybe associated with
multiple gestations, molar pregnancies,
choriocarcinoma, diabetes,Rh
sensitization, clomiphene citrate use,
human menopausal gonadotropin–human
chorionic gonadotropin ovulation
induction, and the use of GnRH analogs.
Pathogenesis
If a follicle fails to rupture and release the
egg, the fluid remains and can form a cyst
in the ovary.
Small cysts (<1/2”) may be present in a
normal ovary while follicles are being
formed.
 These cysts can be stimulated by
gonadotropins, including FSH and hCG
Signs and Symptoms
Lower abdominal or pelvic pain
Irregular menstrual periods
Feeling of lower abd. or pelvic pressure or
fullness
Pain or pressure with urination or bowel
movements
Nausea and vomiting
Vaginal pain or spots of blood from vagina
Infertility
Abdominal swelling or unusual increased
abdominal girth
Basis for inclusion Basis for exclusion
• No pain or pressure with
Intermenstrual bleeding urination or bowel
Pelvic mass movements
Abdominal enlargement • No Vaginal pain or spots
of blood from vagina
• Not infertile

• UTZ result showed

uterine in origin
• No cyst in ovary seen in
UTZ
Adenomyosis
defined as presence of endometrial tissue within
the myometrium, at least 1 high-power field
from the basis of the endometrium,
the average age of symptomatic women is
usually older than 40 years.
Increasing parity may be a risk factor according
to one study
Pathogenesis
Unknown but theorized to be associated
with disruption of the barrier between the
endometrium and myometrium as an
initiating step
Symptoms
often is asymptomatic
excessively heavy or prolonged menstrual
bleeding
Dyspareunia
dyschezia,
dysmenorrhea.
Symptoms often begin up to a week before
the onset of a menstrual flow and may not
resolve until after the cessation of menses.
Signs
uterus is diffusely enlarged, although
usually less than 14 cm in size, and is
often soft and tender, particularly at the
time of menses.
Mobility of the uterus is not restricted,
and there is no associated adnexal
pathology
Diagnosis
 clinical
diagnosis and can be confirmed only by
pathology review.
 Imaging studies, although helpful, are not definitive.
 Pathologic confirmation of suspected adenomyosis can
be made only at the time of hysterectomy.
Basis for inclusion Basis for exclusion
 Age • No heavy menstrual
Increase bleeding
Intermenstrual Bleeding • No dyspareunia and
Pelvic mass dysmenorrhea.
• No pain or pressure with
Uterine enlargement,
slightly movable urination or bowel
UTZ showed entire
movements
• UTZ result showed
myometrium
demonstrates uterine in origin
echopattern suggestive • No cyst in ovary seen in
of diffuse adenomyosis UTZ
• Uterus 16-18 weeks size
LEIOMYOMA OF
THE UTERUS
Leiomyomas of the Uterus
Also called myomas, are benign solid
tumors of muscle cell origin
Often referred by their popular names,
fibroids or fibromyomas- most
leiomyomas contain varying amounts of
fibrous tissue, believed to be secondary to
degeneration of some of the smooth
muscle cells
Most frequent pelvic tumors and the most
common tumor in women, with the
highest prevalence occuring during the 5 th
decade of woman’s life
 Uterine leiomyomas in various anatomic locations. (From Hacker NF, Moore JG.
Essentials of obstetrics and gynecology. 3rd ed. Philadelphia, PA: WB Saunders, 1998:413,
with permission.)
Risk factors:
Increasing age
Early menarche
Low parity
Tamoxifen use
Obesity
High-fat diet
African-American women have the
highest incidence
Pathogenesis:
Normal myocyte
Tumor initiators
Genetic factors
Somatic mutation
Mutated myocyte
Estrogen- ER induction Progesterone
PR induction
Growth factor production
Growth factor induction
Extracellular matrix production
Mitogenesis
Clonal expansion

MYOMA
SIGNS AND SYMPTOMS
Pressure from an enlarging pelvic mass
Pain including dysmenorrhea
Abnormal uterine bleeding
Abdominal examination reveals an irregular
solid mass or masses arising from the uterus.
If degeneration occurs, the inflammation can
cause abdominal tenderness in response to
palpation and mild localized rebound
tenderness.
Elevation of temperature and leukocytosis
also can occur.
The following urinary symptoms may be present:
Frequency may result from extrinsic pressure on
the bladder.
Partial ureteral obstruction may be caused by
pressure from large tumors at the pelvic brim.
Reports suggest some degree of ureteral
obstruction in 30% to 70% of tumors above the
pelvic brim. Ureteral compression is three to four
times more common on the right, because the left
ureter is protected by the sigmoid colon.
Rarely, complete urethral obstruction results from
elevation of the base of the bladder by the cervical
or lower uterine leiomyoma with impingement on
the region of the internal sphincter.
The following symptoms may infrequently be
associated with leiomyomas:
Rectosigmoid compression, with constipation or
intestinal obstruction
Prolapse of a pedunculated submucous tumor
through the cervix, with associated symptoms of
severe cramping and subsequent ulceration and
infection (uterine inversion also can occur)
Venous stasis of the lower extremities and
possible thrombophlebitis secondary to pelvic
compression
Polycythemia
Ascites
Diagnosis and Management
 Ultrasound is useful in distinguishing adnexal from
uterine etiology of an eccentric mass. However, if
fever is present, it is important to rule out tubo-
ovarian abscess.
 Degeneration of a leiomyoma is treated with
observation and pain medication.
 A pedunculated, torqued, subserosal leiomyoma can
easily be excised laparoscopically; however,
surgery is not mandatory.
 A submucous leiomyoma with pain and
hemorrhage should be excised transcervically, with
hysteroscopic guidance if needed
Management
dependent on the patient's age and
proximity, to anticipated menopause,
symptoms, patient preference, and the
experience and skills of the clinician.
BASIS:
age
enlarging pelvic mass
Intermenstrual bleeding
Abdominal examination
BPE
UTZ