Adnexal Mass in a Postmenopausal Woman
A 62-year-old G2P2 postmenopausal woman presents with vague abdominal bloating and early satiety for 3 months. She has no significant past medical history. Physical exam reveals a fixed, irregular mass in the right adnexa, approximately 8 cm. CA-125 is 250 U/mL. Transvaginal ultrasound shows a complex cystic and solid mass with thick septations and ascites. You suspect ovarian cancer.
1. What is the next best step in management, and why?
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The next best step is referral to a gynecologic oncologist for surgical exploration. This patient has a high risk of malignancy based on postmenopausal status, complex adnexal mass, ascites, and elevated CA-125. The standard of care is primary debulking surgery by a gynecologic oncologist, which includes total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymph node dissection, along with cytoreduction. Neoadjuvant chemotherapy may be considered if she is not a surgical candidate or has unresectable disease, but surgical evaluation is key. A biopsy is not recommended if surgery is planned because of the risk of tumor spillage. Preoperative evaluation includes CT of the chest/abdomen/pelvis to assess extent of disease.
2. How would you counsel her regarding fertility and genetic testing?
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Since she is postmenopausal, fertility preservation is not a concern. However, genetic testing is important because approximately 15-20% of ovarian cancers are associated with hereditary breast and ovarian cancer syndrome (BRCA1/2 mutations). She should be offered germline testing for BRCA1/2 and other genes (e.g., Lynch syndrome). If positive, this has implications for her family members. Additionally, her tumor should undergo somatic testing for BRCA mutations to guide maintenance therapy with PARP inhibitors. Counseling should include the possibility of adjuvant chemotherapy and the need for surveillance.