A 53-year-old woman, gravida 2 para 2, comes to the office due to right-sided pelvic pain that has worsened over the past 3 months. She has experienced bloating and hot flashes since her last menstrual period a year ago. The patient has recently become sexually active with a new partner and is not using condoms. She was diagnosed and treated for chlamydia in her 40s. She has no other medical problems and had a bilateral tubal ligation at age 35 after cesarean delivery of her second child. The patient smokes 10 cigarettes daily and drinks alcohol socially. Her temperature is 36.7 C (98 F) and blood pressure is 110/70 mm Hg. Leukocyte count is 8200/mm³. β-hCG is undetectable. Pelvic ultrasonography shows a 7-cm right ovarian mass with solid components, thick septations, and a moderate amount of peritoneal fluid. Which of the following is the most likely explanation for these findings?

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11ec25c8_d9d0_a835_bc81_ada41bbf3b96_MD0003_00 Epithelial ovarian carcinoma refers to a malignancy involving the ovary, fallopian tube, and peritoneum. Histologically, abnormalities can begin at any of these sites and present with the hallmark large ovarian mass and widespread pelvic and abdominal metastasis regardless of primary origin. Ultrasound is the first-line imaging modality to investigate pelvic pain and/or an adnexal mass. This patient's findings of a large ovarian mass with thick septations, solid components, and peritoneal free fluid (ascites) are concerning for malignancy rather than a benign or infectious etiology. The presence of peritoneal fluid in a postmenopausal woman is pathologic and is the origin of the typical symptoms of bloating, pain, early satiety/anorexia, and abdominal distension seen in ovarian cancer. (Choice B) Ascending infection from the cervix causes pelvic inflammatory disease with a potential complication of tubo-ovarian abscess (TOA). A TOA appears as a complex multilocular mass involving the tube and ovary on pelvic ultrasound. Pelvic inflammatory disease is unlikely in a patient without a fever and leukocytosis. (Choice C) Endometriomas are ovarian masses arising from ectopic implantation of endometrial gland on the ovarian surface, and are a common cause of pelvic pain in premenopausal patients. Ultrasonography demonstrates a homogenous cyst with internal echoes (eg, "ground glass") rather than a multiloculated mass with septations in a postmenopausal patient. (Choice D) Hyperechoic nodules and calcifications are ultrasound features of a mature cystic teratoma (eg, dermoid cyst), a benign ovarian tumor arising from ectodermal cells. Dermoid cysts can have solid components but do not exhibit multiple septae or cause ascites. (Choice E) A hydrosalpinx is caused by fluid accumulation in a fallopian tube due to blockage by either adhesions (eg, pelvic inflammatory disease) or surgery (eg, bilateral tubal ligation). Ultrasound would demonstrate a mass separate from the ovary rather than an ovarian tumor. Educational objective: Ovarian cancer can present as an adnexal mass with pelvic pain and bloating due to abnormal proliferation of ovarian or tubal epithelium or peritoneum. Ultrasound features suggesting malignancy are a solid mass with thick septations and the presence of ascites. References: Adnexal masses: characterization and imaging strategies. (http://www.ncbi.nlm.nih.gov/pubmed/20974354)

A 53-Year-Old Woman, Gravida 2 Para 2, Comes to the Office