A 21-year-old woman presents with left lower quadrant pain. An anterior 7-cm firm adnexal mass is palpated. Ultrasound confirms a complex left adnexal mass with solid components that appears to contain a tooth.
What percentage of these tumors is bilateral?
Benign cystic teratomas (dermoids) are the most common germ cell tumors, and account for about 20% to 25% of all ovarian neoplasms. They occur primarily during the reproductive years, but may also occur in postmenopausal women and in children. Dermoids are usually unilateral, but 10% are bilateral. Usually the tumors are asymptomatic, but they can cause severe pain if there is torsion or if the sebaceous material perforates, spills, and creates a reactive peritonitis.
A 54-year-old woman is scheduled for laparotomy due to a pelvic mass. At the time of exploratory laparotomy, a unilateral ovarian neoplasm is discovered that is accompanied by a large omental metastasis. Frozen section diagnosis confirms metastatic serous cystadenocarcinoma.
Which of the following is the most appropriate intraoperative course of action?
The survival of women who have ovarian carcinoma varies inversely with the amount of residual tumor left after the initial surgery. At the time of laparotomy, a maximum effort should be made to determine the sites of tumor spread and to excise all resectable tumor. Although the uterus and ovaries may appear grossly normal, there is a relatively high incidence of occult metastases to these organs; for this reason, they should be removed during the initial surgery. Ovarian cancer metastasizes outside the peritoneum via the pelvic or para-aortic lymphatics, and from there into the thorax and the remainder of the body. Therefore, a complete staging procedure also includes pelvic washings, pelvic and abdominal exploration for metastatic disease, appendectomy, and lymph node sampling.
A 68-year-old woman is seen for evaluation of a swelling in the right, posterior aspect of her vaginal opening. She has noted pain in this area when walking and during intercourse. At the time of pelvic examination, a mildly tender, firm mass is noted just outside the introitus in the right vulva at approximately 8 o’clock.
Which of the following is the most appropriate treatment?
Although rare, adenocarcinoma of the Bartholin gland must be excluded in women older than 40 years of age who present with a cystic or solid mass in this area. The incidence peaks in women in their sixties. The appropriate treatment in these cases is surgical excision of the Bartholin gland to allow for a careful pathologic examination. In cases of abscess formation, both marsupialization of the sac and incision with drainage as well as appropriate antibiotics are accepted modes of therapy. In the case of the asymptomatic Bartholin cyst, no treatment is necessary.
A 51-year-old woman is diagnosed with invasive cervical carcinoma by cone biopsy. Pelvic examination and rectal-vaginal examination reveal the parametrium to be free of disease, but the upper portion of the vagina is involved with tumor. Intravenous pyelography (IVP) and sigmoidoscopy are negative, but a computed tomography (CT) scan of the abdomen and pelvis shows grossly enlarged pelvic and periaortic nodes.
This patient is classified at which of the following stages?
Cervical cancer is still staged clinically, not surgically. Physical examination, routine x-rays, barium enema, colposcopy, cystoscopy, proctosigmoidoscopy, and IVP are used to stage the disease. CT scan results, while clinically useful, are not used to stage the disease. The stage does not include information about lymph node involvement. Stage I disease is limited to the cervix. Stage Ia disease is preclinical (ie, microscopic), while stage Ib denotes macroscopic disease that is clinical visible. Stage II invades beyond the uterus but not to the pelvic side wall or lower third of the vagina. It may involve the upper vagina and/or the parametrium. Stage IIa denotes tumor without parametrial invasion or involvement of the lower third of the vagina, while stage IIb denotes parametrial extension. Stage III involves the lower one-third of the vagina or extends to the pelvic side wall; there is no cancer-free area between the tumor and the pelvic wall. Stage IIIa lesions have not extended to the pelvic wall, but involve the lower one-third of the vagina. Stage IIIb tumors have extension to the pelvic wall and/or are associated with hydronephrosis or a nonfunctioning kidney caused by tumor. Stage IV is outside the reproductive tract, such as invasion of the mucosa of the bladder or rectum.
A 45-year-old G1P1 presents for her routine annual examination. The patient is a healthy smoker who has no medical problems. Her surgical history is significant for a cesarean delivery with bilateral tubal interruption. You perform a Pap smear, which returns showing high grade squamous intraepithelial lesion (HSIL). She undergoes colposcopy, which is inadequate.
What is the next step in management?
An adequate colposcopy requires that the entire squamocolumnar junction and all lesions be visualized, and that the biopsies of the lesion explain the abnormal cytology. Since her colposcopy was not adequate, an excisional procedure is required.
Click to expand