A 62-year-old nulligravid woman comes to the office for follow-up of a right adnexal mass. The patient was undergoing a pelvic examination and Pap testing 2 weeks ago when a right adnexal mass was palpated on bimanual examination. The Pap test was normal, and she has had no symptoms. Menopause occurred at age 52, and there has been no postmenopausal spotting. The patient's medical history is otherwise unremarkable. She does not use tobacco, alcohol, or illicit drugs. There is no family history of ovarian or breast cancer. Temperature is 36.7 C (98.1 F), blood pressure is 120/70 mm Hg, and pulse is 72/min. The abdomen is soft, nondistended, and has no palpable masses. A pelvic ultrasound reveals a 5-cm right ovarian cyst. Which of the following is the best next step in management of this patient?

Question

A 62-year-old nulligravid woman comes to the office for follow-up of a right adnexal mass.  The patient was undergoing a pelvic examination and Pap testing 2 weeks ago when a right adnexal mass was palpated on bimanual examination.  The Pap test was normal, and she has had no symptoms.  Menopause occurred at age 52, and there has been no postmenopausal spotting.  The patient's medical history is otherwise unremarkable.  She does not use tobacco, alcohol, or illicit drugs.  There is no family history of ovarian or breast cancer.  Temperature is 36.7 C (98.1 F), blood pressure is 120/70 mm Hg, and pulse is 72/min.  The abdomen is soft, nondistended, and has no palpable masses.  A pelvic ultrasound reveals a 5-cm right ovarian cyst.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d9ce_ac63_bc81_afd012afa5a4_MD0003_00 Initial management in all women with an adnexal mass is with a pelvic ultrasound, which evaluates for malignant (solid components, thick septations, increased vascularity) versus benign (smooth and simple wall, no vascularity) features. Women with malignant features, regardless of age, are managed with immediate surgery (eg, laparoscopy). In contrast, benign-appearing masses, as in this patient whose pelvic ultrasound revealed an ovarian cyst, are further evaluated based on menopausal status. In premenopausal women, most adnexal masses are due to benign causes (eg, functional cysts) and the risk of malignancy is low; therefore, asymptomatic patients are managed with reassurance and observation (Choice D). In contrast, postmenopausal women are less likely to have benign causes of adnexal masses because menses and ovulation have ceased; however, benign masses are occasionally found. Therefore, in postmenopausal women, adnexal masses are risk stratified (ie, benign or malignant) with a CA-125 level. Cancer antigen 125 (CA-125) is released by cells from the peritoneum and müllerian structures (eg, uterus, Fallopian tubes). Conditions that irritate or stimulate these cells (eg, endometriosis, malignancy) cause elevations in this level; therefore, a CA-125 level is not used in premenopausal women because it is often falsely elevated. Although it is not diagnostic of ovarian cancer (ie, histopathologic diagnosis required), CA-125 testing in postmenopausal women helps further categorize simple-appearing masses as either benign or malignant. Simple masses with a normal CA-125 suggest that the mass is not growing and is not stimulating the peritoneal tissue, meaning it is likely benign. These are managed with observation and serial ultrasounds. In contrast, simple masses with an elevated CA-125 suggest that the mass is growing and is either stimulating the peritoneal tissue or invading other pelvic structures, likely indicating malignancy. Further imaging (eg, CT scan) is used to assess the extent of disease and guide management (eg, laparoscopic surgical exploration) (Choice B). (Choice A) Endometrial biopsy investigates endometrial carcinoma and is indicated in patients with postmenopausal bleeding, abnormal uterine bleeding, age >45, or thickened endometrial stripe with an ovarian mass (ie, granulosa cell tumor), none of which are seen in this patient. (Choice C) Needle aspiration is contraindicated in adnexal masses due to the risk of seeding the abdomen with malignant cells, which can increase the cancer stage. Educational objective: Ovarian masses in postmenopausal patients are initially evaluated with a pelvic ultrasound. In postmenopausal women with a benign-appearing mass, a CA-125 level can further risk stratify the mass as either likely benign or malignant to further guide management (eg, observation, surgical exploration). References: The value of ultrasound monitoring of adnexal masses for early detection of ovarian cancer. (http://www.ncbi.nlm.nih.gov/pubmed/26904503) Adnexal masses: characterization and imaging strategies. (http://www.ncbi.nlm.nih.gov/pubmed/20974354)

A 62-Year-Old Nulligravid Woman Comes to the Office for Follow-Up