A 60-year-old woman comes to the office due to new-onset pelvic pressure. The patient reports increasing pelvic pressure over the last 3 months, now with associated urinary frequency. She has no abdominal pain, dysuria, or hematuria. The patient reports some dyspnea on exertion; review of systems is otherwise negative. The patient has a history of breast cancer at age 45; it was treated with radical mastectomy, chemotherapy, and adjuvant tamoxifen therapy. The cancer has since been in remission and she had a normal mammogram last year. The patient has no other chronic medical conditions. She underwent menopause 8 years ago and has had no episodes of postmenopausal vaginal bleeding. The patient has had no abnormal Pap tests, the last of which was 3 years ago. She does not use tobacco, alcohol, or illicit drugs. Blood pressure is 130/80 mm Hg, pulse is 80/min, and respirations are 18/min. BMI is 26 kg/m². Decreased breath sounds are noted over the lower base of the right lung. Abdominal examination reveals normoactive bowel sounds and mild distension but no tenderness. On bimanual examination, a 12-week-sized, irregularly shaped uterus is noted, but there are no adnexal masses. Urinalysis is within normal limits. Pelvic ultrasound shows a dense focal mass measuring 9 cm in the anterior fundus of the uterus, normal ovaries bilaterally, and a moderate amount of free fluid in the posterior cul-de-sac. Which of the following is the best next step in management of this patient?

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Explanation: 11ec2b69_bf17_a10e_8f63_8ba32194aa73_MD0005_00 This patient has metastatic uterine sarcoma, a malignancy originating from the myometrium or endometrial connective tissue. The ultrasonographic appearance of sarcomas is often indistinguishable from that of leiomyomas. Therefore, sarcomas are often incidentally diagnosed via histopathologic evaluation of specimens removed from patients who underwent surgery for presumed benign disease (eg, leiomyomas). However, uterine sarcoma should be suspected in postmenopausal patients with new-onset pelvic pressure or pain, uterine mass, and ascites (eg, free fluid in the posterior cul-de-sac). Other clinical features include postmenopausal or abnormal uterine bleeding and abdominal distension. The most common site of metastasis is the lungs (eg, pleural effusion). Risk factors for uterine sarcoma include tamoxifen use and pelvic radiation. A hysterectomy is performed to confirm the diagnosis and stage the disease. Adjuvant chemotherapy and/or radiation therapy may be indicated. Uterine sarcoma is an aggressive tumor with a high risk of recurrence and poor prognosis. (Choices A and B) Gonadotropin-releasing hormone (GnRH) agonists temporarily cause amenorrhea and decrease leiomyoma size in patients with leiomyomas that are causing symptoms (eg, heavy bleeding). GnRH agonists are used primarily as preoperative therapy in patients with benign disease. In patients with suspected malignancy, observation and GnRH agonist therapy delay diagnosis and allow disease progression. (Choices D and E) Myomectomy and uterine artery embolization are indicated for patients who have symptomatic leiomyomas that failed medical management and who would like uterine conservation. However, in patients with malignancy, both surgeries result in incomplete cancer staging and inadequate tumor debulking. Educational objective: Uterine sarcoma typically presents in postmenopausal patients with a history of previous tamoxifen use or pelvic radiation. Presenting symptoms can include new-onset pelvic pressure or pain, a uterine mass, ascites, and symptoms of metastasis (eg, pleural effusion). Treatment is with hysterectomy. References: Uterine leiomyosarcoma: epidemiology, contemporary treatment strategies and the impact of uterine morcellation. (http://www.ncbi.nlm.nih.gov/pubmed/28209496) Uterine leiomyosarcoma: a review article. (http://www.ncbi.nlm.nih.gov/pubmed/25304676)

A 60-Year-Old Woman Comes to the Office Due to New-Onset