A 60-year-old woman, gravida 3 para 3, comes to the office due to progressive bloating. The patient has noticed that she cannot fit into any of her pants despite recent nausea and a decreased appetite. She feels full quickly with meals and has increasing constipation. Menopause was at age 51, and she has had no postmenopausal bleeding or hormone replacement therapy. The patient has had no surgeries and all of her children were born via spontaneous vaginal delivery. Temperature is 36.7 C (98.1 F), blood pressure is 120/70 mm Hg, and pulse is 88/min. Cardiopulmonary examination is unremarkable. The abdomen is nontender and mildly distended. Bowel sounds are normal and there is no fluid wave. Pelvic examination reveals a firm, immobile mass in the left adnexa and rectovaginal nodularity. A pelvic ultrasound and CT scan of the abdomen and pelvis confirm the physical examination findings. CA-125 is 57 U/mL (normal:

Question

A 60-year-old woman, gravida 3 para 3, comes to the office due to progressive bloating.  The patient has noticed that she cannot fit into any of her pants despite recent nausea and a decreased appetite.  She feels full quickly with meals and has increasing constipation.  Menopause was at age 51, and she has had no postmenopausal bleeding or hormone replacement therapy.  The patient has had no surgeries and all of her children were born via spontaneous vaginal delivery.  Temperature is 36.7 C (98.1 F), blood pressure is 120/70 mm Hg, and pulse is 88/min.  Cardiopulmonary examination is unremarkable.  The abdomen is nontender and mildly distended.  Bowel sounds are normal and there is no fluid wave.  Pelvic examination reveals a firm, immobile mass in the left adnexa and rectovaginal nodularity.  A pelvic ultrasound and CT scan of the abdomen and pelvis confirm the physical examination findings.  CA-125 is 57 U/mL (normal: <35 U/mL).  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d9d1_4476_bc81_818478c78cbc_MD0003_00 Epithelial ovarian cancer (EOC) occurs primarily in postmenopausal women and most often presents with advanced disease because the earliest symptoms of disease are vague and nonspecific (eg, constipation, bloating). This postmenopausal woman's firm, nonmobile pelvic mass with nodularity is concerning for EOC that has extended beyond the adnexa. Initial evaluation of postmenopausal women with suspected EOC is with pelvic imaging (eg, ultrasound), which identifies mass characteristics (eg, thick septations, increased vascularity), and CA-125, which is released by cells from the peritoneum, uterus, and fallopian tubes, all of which are in close proximity to the rapidly growing ovary (ie, malignancy). In postmenopausal women with a malignant-appearing mass, CA-125 aids in disease monitoring and response to treatment (ie, chemotherapy). In contrast, in postmenopausal women with a benign-appearing mass, CA-125 stratifies the risk for cancer. Additional imaging (eg, CT scan) is performed in patients with suspected EOC to evaluate for distant metastases and for surgical planning. In the absence of distant metastases, suspected EOC is treated with exploratory laparotomy and surgical staging and tumor debulking. (Choice A) Colorectal cancer symptoms overlap with those of ovarian cancer (eg, bloating, constipation, rectovaginal nodularity). However, this patient has a fixed adnexal mass with an elevated CA-125 more likely indicating ovarian cancer. Colorectal cancer often presents with an elevated CEA. (Choice B) Estrogen and FSH levels are not routinely used to evaluate for EOC because the malignant cells do not alter hormonal secretion. However, they can be helpful in patients with an adnexal mass and signs of hyperestrogenism (eg, postmenopausal bleeding, breast tenderness) to evaluate for a suspected granulosa cell tumor, which causes high levels of estradiol and inhibin (which typically inhibits FSH). (Choice D) Image-guided biopsy is contraindicated in patients with suspected EOC because biopsy can lead to rupture of the mass and result in spreading of the cancerous cells throughout the abdomen, significantly increasing the disease stage. Ideally, the mass is removed intact during exploratory laparotomy. (Choice E) A small bowel follow-through can evaluate for small intestine function, obstruction, or masses in patients with suspected obstruction. Nausea/vomiting and early satiety can be symptoms of partial obstruction; however, this diagnosis is less likely in a patient with a nontender abdomen and normal bowel sounds. Educational objective: Advanced ovarian cancer may present in postmenopausal women with an immobile pelvic mass. Suspected ovarian cancer with no distant metastases is managed with exploratory laparotomy, staging, and tumor debulking. References: Optimal primary therapy of ovarian cancer. (http://www.ncbi.nlm.nih.gov/pubmed/27141074)

A 60-Year-Old Woman, Gravida 3 Para 3, Comes to the Office