Re: clinical problem
From: James S Smeltzer MD (gaperina@mindspring.com)
Thu Jan 7 09:56:21 1999
It bothers me when TAS does not show a uterus. It should be visible even
if a large mass. This is why I think Gyns do the best exams, as they can
do a combined exam, which has often provided the answer in very perplexing
cases. You are right that definitive stanging for ovarian is surgical. I
would be surprised that there was normal Ca125 if this were ovarian in
origin. What about CEA? I would do an abdominal CTS with contrast without
hesitation, and do her after bowel prep, unless you are prepared to
coordinate an army of Gen Surg, Gy & Gyn Onc?!
Other questions: Is there ascites? Is the diaphragm clean by US? What was
the doppler of the mass? Do a bowel prep unless you know it is not bowel.
Is this hemorrhage into a fibroid or a hematometria of a retroverted
uterus?
Let us know how it comes out! Jim Smeltzer MD, FACOG
At 09:46 PM 1/6/1999 -0600, you wrote:
>, 6 Jan 1999, Natalie Sohn wrote:Some how vital info was lost in
>transmission and I apologize....
>Both trans abdominal and a transvaginal ultrasounds were performed--they
>revealed a 14cm partially cystic and solid mass ( very suspicious
>looking) which probably is displacing the uterus although the uterus
>could not be clearly delineated. My question is as follows: is a ct or
>mri necc since this patient clearly needs to have exploratory surgery
>and removal of the mass be it ovarian, uterine or colon. As long as you
>have the appropriate surgeon(s) to tackle the problem. My first step in
>evaluating these types of patients is a sonogram (usually
>transvaginal).you could not do any endometrial testing at all (
>technically impossible). A pap was reported as nml but this was taken 3
>months prior ( they must have been able to see the cervix then and no
>mass was reported in that exam. Any comments now that the correct in is
>given?
>>At Tue, 05 Jan 1999, Deborah Richert wrote:
>>>Thank you for your suggestions-but a transvaginal us was done. as far as
a sonohysterogram, it was techically impossible ( as was any endometial
testing)
>>>At 09:06 PM 1/5/99 -0600, you wrote:
>>>>I would like to hear some expert opinion on the following case:
>>>>64 year old post menopausal female in good health getsreferred by her
>>>>primary care doc ( actually the nurse practitioner) for post menopausal
>>>>spotting. Pap, mammo all normal. My exam reveals a mass which
>>>>displaces the cervix way upward ( you cant visualize it at all with the
>>>>speculum--and endo biopsy is impossible. Rectal exam reveals the mass (
>>>>and/or uterus?) above the rectum and shes guiac neg. There is no
>>>>ascities and ca125 is wnl. The radiologist wanted me to order a ct scan
>>>>but I dont feel this is necessary since this most likely uterine or
>>>>ovarian neoplasm clearly needs to come out.(Ido these cases with a
>>>>gyn-onc who can stage these tumors adequately.)I am not sure if this is
>>>>malignat or benign. r/o colon tumor ?-although this seems highly
>>>>unlikely. My one reservation about ordering these tests is that the the
>>>>hmo medical directors might delay my case ruling out distant spread when
>>>>none exists. ( such a thing happened recently to me and there was a 4
>>>>week delay-- that woman had ovarian cancer. Any insights? My point here
>>>>is how would additional testing in this case alter management?
>>>>
>>>>--
>>>>nsohn
>>>>
>>>Natalie -
>>>
>>>How about ordering a transvaginal pelvic ultrasound exam to see if this
>>>patient has a retropositioned uterus or possibly a uterine fibroid? I've
>>>done many transvaginal ultrasounds for a possible cul de sac mass that
>>>turned out to be a retropositioned uterus. Also, with a transvaginal
>>>ultrasound exam, sonohysterography could be performed as needed to see if
>>>there may be a polyp or fibroid within the endometrial cavity as a cause
for
>>>the PMP spotting. Just a thought.
>>>
>>>Deb Richert, AAS, RDMS, RVT
>>>La Crosse, WI
>
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