 Figure 89.1 |
Table 89.1: Differential Diagnosis of an Incidental Adnexal Mass | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Case 89
Case 89
Presentation
The patient is a 22-year-old nulligravid woman who presents to the emergency room with a sudden onset of right lower quadrant pain. Her urinary pregnancy test is negative; however, she has an elevated white blood cell (WBC) count, right lower quadrant pain with guarding, rebound, and a low-grade fever to 38.2°C. She is admitted to the general surgery service where she is observed to rule out appendicitis. Her abdominal examination becomes more tender, with guarding and rebound tenderness, and she is taken to surgery for a laparotomy, during which an inflamed appendix is identified and resected. A 4-cm right ovarian cyst is identified. An intraoperative consultation is requested of the gynecology service.
▪ Intraoperative Image
Intraoperative Report
The gynecologic consultant carefully inspects and transilluminates the ovarian mass. It is small and appears to be a simple cystic mass without solid elements.
Differential Diagnosis
The differential diagnosis of an adnexal mass is quite extensive (Table 89.1); however, a simple cystic ovarian mass is most commonly a functional cyst or, less likely, a benign cystadenoma. Small, cystic adnexal masses that do not contain any solid elements are unlikely to be malignancies. Functional cysts typically are smaller than 5 cm in diameter and invariably resolve spontaneously with observation, usually within 1 or 2 menstrual cycles. Benign cystadenomas may be small or large, but do not spontaneously resolve. These lesions will eventually require surgical resection because they may grow or cause torsion of the adnexa. For the patient in this case, surgical resection was not indicated due to the absence of a definite diagnosis and the patient’s informed consent.
Discussion
Gynecologists occasionally are asked to consult intraoperatively when an unexpected adnexal mass is discovered. The absence of a preoperative evaluation and physician-patient relationship creates a dilemma for the consultant, particularly if the patient is of reproductive age. On the one hand, the patient may have a disease process that is best treated by surgical resection. On the other hand, surgical resection can compromise fertility. When an adnexal mass is unexpectedly discovered, the patient has no opportunity to be offered an informed consent, and yet deferring treatment until a later time causes even greater morbidity. For these reasons, it is important to avoid, as much as possible, the situation where an adnexal mass is found incidentally, particularly in fertile, premenopausal women. Despite everyone’s best efforts, the clinician must be prepared to care for patients with adnexal masses discovered incidentally at laparotomy.
