A pelvic mass is an abnormal growth of tissue in the lower
abdomen or pelvis. It is sometimes called an adnexal mass. We use the word mass to describe an abnormal area found on scans (like a CT scan or ultrasound) or during a physical exam before we know more specifically what it is. Mass can refer to a benign cyst, an enlarged ovary, or a cancerous or non-cancerous tumor. It can be difficult to tell from a CT scan or ultrasound just what organ is abnormal and what is wrong with it. Most of the time, an adnexal mass turns out to be an enlarged or cystic ovary, but sometimes the mass is a fibroid attached to the uterus, an abscess of the appendix, a swollen fallopian tube or some other organ in the area, or, rarely, a cancer of the ovary.
Pelvic masses are described as simple or complex on CT scans and ultrasounds depending on how they look. A simple pelvic mass is like a water balloon—thin, watery fluid enclosed by a thin layer of cells. Complex masses have either thicker fluid, more layers of cells surrounding the fluid or multiple compartments of fluid formed by cell layers connecting the sides of the mass. The most complex masses have solid areas with thick layers of cells making several compartments. Simple masses (sometimes called simple cysts) are generally benign. Very complex masses are concerning for cancer. However, the only way to be sure what is causing any pelvic mass, simple or complex, is to remove it during surgery and have the pathologist look at it under a microscope.
Treatment of Pelvic Masses
The treatment for a pelvic mass is to remove it during surgery. The type of surgery we recommend depends on your age, whether you want to have children in the future, your medical history, and how complex the mass is.
For patients whose ovaries are no longer making hormones and who no longer have periods, we may recommend removing both ovaries and tubes and the uterus, even if only one ovary is involved in the mass. Since the ovaries are no longer functioning, it is best to take them both out during surgery to prevent the need for future surgery if the other ovary develops a cyst. Whether to allow an ovary to remain will be discussed preoperatively at your office visit.
We recommend removing the uterus (with the cervix) to prevent future bleeding and possible future surgery. By removing these organs, we also prevent the development of a uterine, cervical or ovarian cancer. (The risk for these cancers rises as women age.) Most post-menopausal women have no noticeable change in well-being after surgery and do not need hormones.
Women in their 40s and 50s.
The ovaries slowly begin to make less of the female hormones after the age of 40 until they make so little that a woman stops having periods (the definition of menopause). In the United States, most women stop having periods in their early 50s. Though the ovaries are making some hormones in this age group, we recommend removing the uterus (with the cervix) and possibly both ovaries and tubes to prevent the need for future surgeries and the development of cancer. Some women in this age group will have symptoms of menopause (hot flashes, night sweats, mood swings, difficulty sleeping) after removing both ovaries. Women who are very uncomfortable from these symptoms may want to use hormones and most can do so safely at low doses to ease the transition into menopause.
Women under 40.
Before age 40, the ovaries are making significant amounts of hormones that regulate a woman's periods and allow for pregnancy. In this age group, we usually recommend removing only the ovary involved with the mass unless it is found to be cancer or in certain other situations (for example, severe endometriosis, breast cancer or high risk of breast or ovarian cancer). Most women under 40 who have both ovaries removed will have significant symptoms of menopause (hot flashes, night sweats, mood swings, difficulty sleeping) and will need hormones to manage the symptoms. Women who have had breast cancer or a blood clot in a large vein should not have hormones at all, even for severe symptoms. Non-hormonal medications can help with some symptoms though they do not work as well as hormones.
The main purpose of surgery is to remove the pelvic mass and determine if it is benign or cancerous. Before surgery, we will perform a few tests. These may include:
- Blood tests to determine anemia and check kidney and liver function
- Chest x-ray
- CT scan of abdomen and pelvis and possibly chest.
- Colonoscopy (depending on age and symptoms)
- Consultation with urologist for possible cystoscopy (depending on age and symptoms
- Consultation with primary care physician or specialist to determine your risk for surgery
(depending on age, your medical history and symptoms)
You will also have a teaching visit with one of our nurses to tell you what to expect, how to prepare for surgery and recovery, and to answer any questions you may have. The day before surgery, we ask you to clean out your intestines (called a bowel prep). This helps your surgeon to safely move the intestines out of the way during surgery or operate on them if needed.
At the time of surgery, the mass is removed first and sent to the pathologist who will look at samples under the microscope immediately to see if the mass looks like cancer (called a frozen section because of the way the tissue is prepared). If the tissue looks entirely benign, then the surgery will be limited to the recommendations given by your surgeon based on your age and medical history.
Even if the mass is not cancer and minimal surgery was planned, it may sometimes be necessary to do other procedures depending on what the surgeon finds. For example, if an ovary is so damaged by the mass so that it no longer functions or is stuck to other tissue, it may be removed even if only removal of a cyst was planned. Sometimes we remove your appendix during surgery if it is abnormal.
What if it is cancer?
If the pathologist finds that the mass is a cancer and your surgeon determines that the cancer is only in one or both ovaries, your surgeon will probably go forward with a staging operation. Staging removes tissue where ovarian cancer is likely to be found but may be too small to be seen at surgery. Staging includes removing the uterus, including the cervix, fallopian tubes, ovaries and appendix (if it has not already been removed). The omentum, an apron of fat tissue that hangs down from the colon (large intestine) and drapes over the small intestine, is also removed. Everyone has this apron of fat, and ovarian cancer often spreads there. Lastly, your physician will check the lymph nodes in the pelvis and sometimes higher up toward the heart (in the para-aortic region).
Lymph nodes are found throughout the body as part of the filtration system. They catch cancer cells that break off from the original tumor. Finding cancer cells in the lymph nodes tells us that the cancer has begun to spread. Even if we cannot see or feel any other cancer, the lymph nodes may have cancer cells inside them. The pathologist looks at all tissues we remove to see if the cancer has spread. This tells us the stage of the cancer and whether chemotherapy is needed.
If there has been spread of cancer beyond the ovaries, further surgery, called debulking, may be necessary. The goal of debulking is to remove all visible tumor or to remove as much tumor as possible. (Optimal debulking means removing all visible tumor or leaving tumor that is less than 1.5 centimeters in diameter. Suboptimal debulking means remaining tumor is larger than 1.5 cm.) The most common debulking procedures are to remove parts of the small or large intestine since those areas are often involved with ovarian cancer. The pre-operative bowel prep enables the surgeon to safely reattach the intestines. Rarely, you may need a colostomy or ileostomy, which is done only if absolutely necessary. Other rare procedures involve the liver, spleen, and bladder.
For any additional procedure, your surgeon performs only what is in your best interest. Your physician considers the benefits and risks of the procedure. Only if the benefits for the patient outweigh the risks will the procedure be done. If the risks and benefits seem equal or if the risks outweigh the benefits, the procedure is not performed.