1. Short case: “Pelvic Mass: Ovarian Mass 1”
Instruction: Examine this 45 years old Malay Lady’s abdomen
On inspection, the abdomen is distended. It moves with each inspiration and expiration. The
umbilicus is centrally located and inverted. There is a low transverse abdominal scar, well
healing with no keloid. There was no cutaneous sign of pregnancy, no skin hyperpigmentation,
no dilated vein and no visible persitalsis. The cough reflex is negative.
On superficial palpation, the abdomen is soft and no tender. On deep palpation, I can appreciate
a mass at the right lower quadrant which measure about 15 cm X 10 cm. It is a single mass, firm
in consistency, the surface is smooth. The edge is well define. It is mobile up and down and also
in the sideway direction. I can get below and above the mass. There is no hepatosplenomegally.
The scar is non tender.
The percussion note is resonant and there is no shifting dullness. On auscultation, the bowel
sound is heard and normal. There is no bruit over the mass.
Question
1) What do you think is the mass and why?
2) What is your differential diagnosis?
3) How do you know that the mass is not arise from retroperitoneal organ, skin or muscle?
4) How do you know that it is not fibroid?
5) How do you know patient is not pregnant?
6) Do you think it is a benign or malignant?
7) How do you confirm the diagnosis?
8) If it is a malignant, what do you want to do next?
Answer
1) I think that it is a ovarian mass because of
a) The location of the mass
b) It is mobile and can move in all direction
c) I can get below the mass.
2) My differential diagnosis would be
a) Pedunculated uterine fibroid
b) Appendicular mass
c) Tumor arising from GIT especially from terminal ileum and cecum
d) Bladder mass
e) Kidney mass

2. 3) How do you know that the mass did not arise from these structures
Mass Skin Muscle Bladder Retroperitoneum
Explaination I can pinch the
skin without
feeling the mass
attach to it
When I ask the
patient to
contract the
abdominal
muscle, the mass
did not reduce in
size
Patient did not
feel the urge to
pass urine when I
palpate the mass
It is very mobile.
Usually the
retroperitoneal
mass has a
restricted
mobility or fix in
place.
4) Uterine Fibroid:
Can not get below, not move vertically but move horizontally, centrally located, well
defined margin.
5) How do you know patient is not pregnant
No cutaneous sign of pregnancy, no fetal part palpated per abdominally. No S&S
pregnancy.
6) I think that it is a benign because
a) General condition of the patient in which she looks fit, does not lethargic or cachexic
b) The mass is well defined, single and unilateral. (note: solidity does not means that it
is a malignant because teratoma may also solid)
c) The age of the patient.
d) There is no hepatomegally and ascites to suggest metastesize.
7) To confirm the diagnosis, I would like to do
a) Abdominal Ultrasound to see the origin and nature of the mass
Notes: do not answer bimanual palpation because it is just another physcial
examination and not a confirmatory diagnosis.
Benign Malignant
• Thin-walled cyst
• Simple cyst
• No loculations
• Recent onset
• Shrinking in size
• Stable in size
• Rapidly changing appearance
• Thick-walled cyst
• Solid tumor
• Mixed cystic and solid mass
• Internal papillary excrescences
• Large amount of free fluid in the pelvis
or abdomen
• Gradually enlarging
Sources: http://www.brooksidepress.org/Products/Military_OBGYN/Textbook/Problems/OvarianNeoplasm.htm

3. 8) Next management of the patient
a) Check for serum biomarker for carcinoma. In this case, I would like to order serum
CA 125 as I suspect it is from ovarian tumor and I’m thinking of epithelial lining
origin. I would also order Carcinoembryonic antigen (CEA) to exclude colon ca.
furthermore, it may also elevated in epithelial type of ovarian tumor.
b) Then I would like to see the extension of the disease by ordering CT scan of the
thorax, abdomen and pelvis.
c) I will council this patient for exploratory laparotomy with Total Abdominal
Hysterectomy with Bilateral Salphingo oophorectomy
d) Before operation, I would like to optimize the patient condition and take necessary
investigation
- FBC to ensure hemoglobin level more than 10.
- GSH and ensure the avaibality of the blood.
- Baseline BUSE/Creat. and LFT.
- ECG because of patient >40 years old
e) Next is to prepare the patient for the operation
- Fasting over night.
- Pre medication
- Catherize the bladder
f) During operation, I would like to stage the patient based on visualization. I will
perform omentectomy if it is involve. Then I would palpate the lymph node to feel the
texture and consistency to determine any lymph node involvement or not. (no need to
take biopsy in ovarian ca. only take in endometrial ca)
g) After that, I will manage accordingly post operatively.
h) Based on operation finding and result of histopathology. I would justify whether to
use adjunct chemotherapy or not. If so, I will choose platinum based chemotherapy.