A 19-year-old female comes to the physician because of left lower quadrant pain for 2 months. She states that she first noticed the pain 2 months ago but now it seems to be growing worse. She has had no changes in bowel or bladder function. She has no fevers or chills and no nausea, vomiting, or diarrhea. The pain is intermittent and sometimes feels like a dull pressure. Pelvic examination is significant for a left adnexal mass that is mildly tender. Urine hCG is negative. Pelvic ultrasound shows a 6 cm complex left adnexal mass with features consistent with a benign cystic teratoma. Which of the following is the most appropriate next step in management?
This patient has a presentation and findings that are most consistent with a benign cystic teratoma. Dermoids are a type of ovarian germ cell tumor. Germ cell tumors are the most common type of ovarian neoplasm in females under the age of 20 and dermoids are the most common benign ovarian neoplasm.Dermoids can range in size from small masses that are noted ncidentally on ultrasound and cause no symptoms, to large cysts that cause pain and pressure, as this patient has. Laparotomy is the most appropriate next step in the management of this patient because, as adnexal masses enlarge--especially when they become greater than 5 cm--the risk of ovarian torsion increases. Thus, laparotomy withremoval of the dermoid is indicated to prevent torsion. Also, this patient's mass is causing her symptoms of pain and pressure and, on that basis, should be removeD. Finally, while the mass most likely is a dermoid, this is not ceain without pathologic diagnosis and, therefore, the cyst should be removed and evaluated by a pathologist. At the time of surgery, close examination should be made of the other ovary because dermoids may be found bilaterally in more than 10% of cases. To repeat pelvic examination in 1 year (Choice A)would not be correct management. This patient is symptomatic with a 6 cm ovarian mass that is at risk for torsion. She should, therefore, be managed surgically. To repeat pelvic ultrasound in 6 weekschoice B. is appropriate for some adnexal masses. For example, in a young woman with a small complex cyst that appears consistent with a corpus luteum, it may be most prudent to recheck an ultrasound in 6 weeks to see if the cyst has resolveD. This patient, however, is symptomatic with a 6 cm cyst that appears to be adermoid, which will not resolve spontaneously. She, therefore, requires surgery. To prescribe the oral contraceptive pill (Choice C) may help to prevent future ovarian cysts but it will not resolve this cyst, which requires surgical management.
Repeat pelvic examination in 1 year
Repeat pelvic ultrasound in 6 weeks
Prescribe the oral contraceptive pill
Perform Laparotomy