A 34-year-old nulligravid woman comes to the office for evaluation of abdominal pain. For the last 3 months, the patient has had intermittent abdominal cramping but no nausea, vomiting, or changes in bowel patterns. She stopped taking her combined oral contraceptives 6 months ago to try for pregnancy. Since then, her menses have occured monthly with 5 days of moderate bleeding. The patient's mother had a hysterectomy at age 30 for heavy menstrual bleeding, and her paternal grandmother had breast cancer at age 64. BMI is 24 kg/m². Vital signs are normal. Pelvic examination reveals a palpable right adnexal mass. On ultrasound, there is a 4-cm right adnexal mass that appears thin-walled and has multiple irregular, thickened internal septations. The left ovary appears normal, and there is no free fluid in the pelvis. Urine pregnancy test is negative. Which of the following features indicates a need for additional evaluation in this patient?

Question

A 34-year-old nulligravid woman comes to the office for evaluation of abdominal pain.  For the last 3 months, the patient has had intermittent abdominal cramping but no nausea, vomiting, or changes in bowel patterns.  She stopped taking her combined oral contraceptives 6 months ago to try for pregnancy.  Since then, her menses have occured monthly with 5 days of moderate bleeding.  The patient's mother had a hysterectomy at age 30 for heavy menstrual bleeding, and her paternal grandmother had breast cancer at age 64.  BMI is 24 kg/m².  Vital signs are normal.  Pelvic examination reveals a palpable right adnexal mass.  On ultrasound, there is a 4-cm right adnexal mass that appears thin-walled and has multiple irregular, thickened internal septations.  The left ovary appears normal, and there is no free fluid in the pelvis.  Urine pregnancy test is negative.  Which of the following features indicates a need for additional evaluation in this patient?

Quizplus · Accepted Answer

11ec25c8_d9d9_33c1_bc81_65feefe588e2_MD0003_00 Adnexal masses are common in premenopausal women and may cause symptoms (eg, pain, pressure) or be found incidentally on examination. Most premenopausal adnexal masses are benign, but all require evaluation for malignancy. Initial evaluation is with pelvic ultrasound, which provides optimal visualization of adnexal mass size and features. Ultrasound findings can increase or decrease the clinical suspicion for malignancy. Patients with a low clinical suspicion for malignancy (eg, simple, fluid-filled ovarian cyst) are typically managed expectantly (eg, observation and repeat examination in 6 weeks). In contrast, malignant adnexal masses are characterized by disordered, uncontrolled tissue proliferation. Therefore, they often have a complex appearance (ie, cystic and solid) with abnormal internal features such as irregular, thickened septations or papillary projections. Patients with these adnexal mass findings require further evaluation (eg, additional imaging, surgery). (Choice A) Adnexal mass size alone is not predictive of malignancy because benign masses (eg, mucinous cystadenomas) can also be significantly enlarged. However, rapid interval growth on repeat imaging may suggest malignancy. (Choice B) Associated symptoms concerning for malignancy include chronic (>6 months) or worsening pelvic pain, mass symptoms (eg, bloating, distension), and gastrointestinal symptoms (eg, changes in bowel patterns), which are not seen in this patient. (Choices C and F) The risk of epithelial ovarian cancer correlates with the number of lifetime ovulatory cycles. Ovulation causes tissue trauma to the ovarian surface epithelium, thereby rendering it susceptible to potential malignant transformation. Fewer lifetime ovulatory cycles (eg, use of combined oral contraceptives), as in this patient, decreases the risk of ovarian cancer. Although multiparity would further decrease this patient's risk of ovarian cancer, nulliparity alone is not a significant risk factor and does not warrant additional evaluation. (Choice D) Although family history and genetic mutations (eg, BRCA) are risk factors for ovarian cancer, having an affected second-degree relative (eg, grandmother with postmenopausal breast cancer) does not warrant further evaluation. Educational objective: In the evaluation of an adnexal mass, ultrasound findings concerning for ovarian malignancy include complex appearance and abnormal internal features (eg, irregular thickened septations, papillary projections). Patients with these suspicious adnexal mass findings require further evaluation. References: Diagnosis and management of adnexal masses. (http://www.ncbi.nlm.nih.gov/pubmed/27175840) The characteristic ultrasound features of specific types of ovarian pathology (review). (http://www.ncbi.nlm.nih.gov/pubmed/25406094)

A 34-Year-Old Nulligravid Woman Comes to the Office for Evaluation