Review Question - QID 213870

The most appropriate next step in management is to measure CA-125 levels. Given the patient's age, symptoms, and ultrasound findings, ovarian cancer is a significant concern, and CA-125 is the initial diagnostic marker for risk stratification.

The patient's age, symptoms of bloating, abdominal pain, weight loss, and a palpable adnexal mass on pelvic exam are all alarming signs that heighten the suspicion for ovarian cancer. The combination of CA-125 measurement and pelvic ultrasound is the preferred initial diagnostic strategy for women suspected of having ovarian cancer. If CA-125 levels are elevated, further imaging and likely surgical intervention would be the next steps for diagnosis and treatment. Methotrexate usage for rheumatoid arthritis could potentially influence malignancy risk but is not the primary issue here.

As stated in ACOG committee opinion 477, patients who are suspected fo being at risk for ovarian cancer should be evaluated by a combined assessment of ultrasound and CA-125. CA-125 nor ultrasound should be used for screening. They have been shown to be ineffective for screening, rather a good rapport and discussion of any new symptoms with patients needs to be at the forefront of early detection.

Figure/Illustration A represents an ovarian mass with characteristics concerning for malignancy, which include multiple septae (yellow arrow), papillary projections (blue arrow), solid components (orange arrow), increased vascularity on Doppler (white arrow), and ascites.

Incorrect Answers:
Answer 1: An abdominal CT scan is often considered after elevated CA-125 levels for further evaluation and staging of suspected ovarian cancer. However, initiating workup with a CT scan without first evaluating CA-125 levels could expose the patient to unnecessary radiation and would not provide adequate risk stratification in the initial evaluation.

Answer 3: Diagnostic laparoscopy is an invasive procedure typically reserved for instances where less invasive diagnostic methods, such as CA-125 measurement and ultrasound, have been inconclusive or suggest a high likelihood of malignancy. Opting for laparoscopy without preliminary risk stratification exposes the patient to the risks of surgery, including infection and complications related to anesthesia, without sufficient justification.

Answer 4: Endometrial biopsy is primarily focused on diagnosing diseases of the endometrium and would not serve as a suitable diagnostic tool for suspected ovarian pathology, which is the main concern here. Performing an endometrial biopsy would not address the adnexal mass and could potentially delay more focused and appropriate diagnostic steps.

Answer 5: Immediate surgical resection, although an eventual treatment option for confirmed ovarian cancer, is premature at this stage. Before proceeding to surgical intervention, it is crucial to confirm the diagnosis and understand the extent of disease through methods like CA-125 measurement and additional imaging. Premature surgical intervention could expose the patient to unnecessary risks, including surgical complications and the psychosocial repercussions of a major, yet unwarranted, surgical procedure.

Bullet Summary:
In older women presenting with symptoms such as bloating, abdominal pain, and weight loss, along with a palpable adnexal mass, the initial diagnostic approach for suspected ovarian cancer should include CA-125 level measurement and pelvic ultrasound.