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Zorluk: ZorGynecologic Oncology

A 62-year-old woman comes to the office reporting a three-week history of breast tenderness, abdominal bloating, and intermittent vaginal spotting. She underwent menopause at age 51 and has not experienced any vaginal bleeding until now. Her past medical history is notable for well-controlled hypertension. She takes amlodipine and has no history of hormone replacement therapy. Vital signs are within normal limits. Pelvic examination reveals a parous cervix with a small amount of dark blood in the vaginal vault. Bimanual examination is notable for a slightly enlarged, mobile uterus and a palpable, firm, 9-cm mass in the left adnexa. Transvaginal ultrasound demonstrates a 9.5-cm complex, solid and cystic left ovarian mass and an endometrial stripe thickness of 16 mm. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the evaluation of this patient?

  1. Endometrial biopsyCevap
  2. B
    Measurement of serum CA-125 concentration
  3. C
    Percutaneous core needle biopsy of the ovarian mass
  4. D
    Diagnostic laparoscopy with left ovarian cystectomy
  5. E
    Reassurance and repeat transvaginal ultrasound in 3 months

Cevap

Endometrial biopsy
The correct answer is endometrial biopsy. This patient presents with a classic constellation of symptoms for an estrogen-secreting granulosa cell tumor of the ovary. Granulosa cell tumors are malignant sex cord-stromal tumors that autonomously produce excess estrogen. In a postmenopausal woman, this unregulated estrogen stimulation causes endometrial proliferation, presenting as a markedly thickened endometrial stripe and postmenopausal bleeding. Because 5% to 10% of these patients will have a concurrent endometrial carcinoma (and up to 50% will have endometrial hyperplasia), it is mandatory to perform an office endometrial biopsy. Establishing the presence or absence of endometrial cancer is a critical preliminary step, as a diagnosis of uterine malignancy dictates a more extensive surgical staging procedure (e.g., total extrafascial hysterectomy, bilateral salpingo-oophorectomy, and comprehensive lymph node dissection) than the ovarian mass might require on its own.

Adım Adım Çözüm

1
Identify the patient's key clinical presentation
Postmenopausal bleeding, breast tenderness, a 9.5-cm complex ovarian mass, and a 16-mm thickened endometrial stripe.
Synthesizing these findings points toward a specific etiology.
2
Correlate the symptoms with potential ovarian pathology
The triad of a solid/cystic ovarian mass, signs of hyperestrogenism (breast tenderness), and postmenopausal bleeding is highly characteristic of a granulosa cell tumor.
Granulosa cell tumors are sex cord-stromal tumors that secrete large amounts of estrogen.
3
Determine the most critical immediate diagnostic intervention
Tissue diagnosis of the thickened endometrium via endometrial biopsy is mandatory.
Up to 50% of patients with granulosa cell tumors have concurrent endometrial hyperplasia, and 5-10% have endometrial carcinoma. Diagnosing a concurrent uterine malignancy is essential before planning surgical intervention for the ovarian mass.

Anahtar Kavram

Patients with suspected estrogen-secreting ovarian tumors (e.g., granulosa cell tumors) who present with postmenopausal bleeding and a thickened endometrium must undergo an endometrial biopsy to rule out concurrent endometrial carcinoma before surgical staging.
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Gynecologic Oncology

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