A 56-year-old woman, gravida 2, para 2, comes to the office due to a 1-month history of in… — USMLE Step 2 CK

A 56-year-old woman, gravida 2, para 2, comes to the office due to a 1-month history of intermittent vaginal spotting and new-onset breast tenderness. Her last menstrual period was 5 years ago. She has no significant past medical history and takes no medications. Vital signs are within normal limits. Body mass index is $23 \text{ kg/m}^2$ . Pelvic examination reveals normal external genitalia and vagina. The cervix appears grossly normal. Bimanual examination is notable for an $8 \text{ cm}$ , mobile, non-tender right adnexal mass. The uterus is of normal size and mobility. Transvaginal ultrasound demonstrates an $8.5 \text{ cm}$ complex, multiloculated solid and cystic right ovarian mass. The endometrial stripe thickness is $14 \text{ mm}$ . Which of the following is the most appropriate next step in management?

Endometrial biopsyAnswer
B
Exploratory laparotomy
C
Image-guided percutaneous biopsy of the mass
D
Pelvic magnetic resonance imaging
E
Reassurance and repeat ultrasound in 3 months

Answer

Endometrial biopsy

The correct answer is to perform an endometrial biopsy. This patient's clinical picture is classic for a granulosa cell tumor. These sex cord-stromal ovarian tumors secrete high levels of estrogen. In a postmenopausal woman, this unopposed estrogenic stimulation leads to breast tenderness and endometrial proliferation (evidenced by the postmenopausal bleeding and a highly abnormal

14 \text{ mm}

endometrial stripe). Because

10\%

15\%

of women with granulosa cell tumors have concomitant endometrial adenocarcinoma, an endometrial biopsy is mandatory. Establishing this diagnosis preoperatively is essential because it significantly alters the surgical plan; a patient with concurrent endometrial cancer will require comprehensive surgical staging (including lymph node dissection) rather than just removal of the uterus and adnexa.

Step-by-Step Solution

Analyze the clinical presentation.

The patient has postmenopausal bleeding, a complex right adnexal mass, breast tenderness, and a thickened endometrial stripe (

14 \text{ mm}

Identifying the combination of symptoms points toward a unifying diagnosis rather than isolated findings.

Identify the likely underlying pathology.

The combination of a solid/cystic ovarian mass with signs of hyperestrogenism (breast tenderness, endometrial proliferation) strongly suggests a granulosa cell tumor of the ovary.

Granulosa cell tumors are sex cord-stromal tumors that classically secrete estradiol.

Determine the secondary risks of the pathology.

Unopposed estrogen secretion leads to continuous endometrial stimulation. Up to 15% of patients with granulosa cell tumors have concurrent endometrial carcinoma.

The presence of a

14 \text{ mm}

stripe in a postmenopausal woman (normal is

\le 4 \text{ mm}

) indicates abnormal proliferation.

Select the most appropriate immediate next step.

An office-based endometrial biopsy must be performed prior to definitive surgical management.

Knowing if concurrent endometrial cancer is present is critical because it dictates the need for comprehensive surgical staging (e.g., pelvic and para-aortic lymphadenectomy) during the exploratory laparotomy.

Key Concept

Patients with suspected estrogen-secreting ovarian tumors (e.g., granulosa cell tumors) who present with a thickened endometrial stripe or abnormal uterine bleeding must undergo an endometrial biopsy to rule out concurrent endometrial hyperplasia or carcinoma prior to definitive surgery.

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