From the Guidelines
The next steps for this 86-year-old female patient should include urgent gynecologic oncology and colorectal surgery consultations due to the concerning pelvic mass with possible ovarian origin and sigmoid colon involvement. The patient requires prompt surgical planning with preoperative assessment including complete blood count, comprehensive metabolic panel, CA-125 tumor marker, and CEA testing 1. Additional imaging with pelvic MRI would help better characterize the mass and its relationship to surrounding structures. A tissue diagnosis is essential, likely requiring CT-guided biopsy if surgery is not immediately planned. The patient also needs nephrology consultation and possible urologic intervention with ureteral stent placement to address the right hydroureteronephrosis caused by obstruction from the mass. This approach is necessary because the CT findings suggest a potentially malignant pelvic mass causing urinary tract obstruction, which requires multidisciplinary management to address both the primary lesion and its complications, as highlighted in the management of hydronephrosis and renal cell carcinoma 1. The patient's advanced age necessitates careful consideration of surgical risks versus benefits, making comprehensive preoperative evaluation particularly important. Key considerations in the management of this patient include:
- Prompt treatment to prevent permanent renal damage 1
- Multidisciplinary management involving gynecologic oncology, colorectal surgery, nephrology, and urology
- Comprehensive preoperative evaluation to assess surgical risks and benefits
- Consideration of less invasive options, such as CT-guided biopsy and ureteral stent placement, to minimize complications in an elderly patient.
From the Research
Next Steps for Patient Disposition
The patient's CT reading indicates a partially delayed nephrogram on the right with moderate severe right hydroureteronephrosis, likely caused by a large mass in the right lower pelvis. The following steps can be considered:
- Referral to a urologist or gynecologic oncologist for further evaluation and management of the suspected malignancy 2, 3
- Consideration of percutaneous nephrostomy (PCN) to relieve the obstruction and improve renal function, although the decision should be made in the context of the patient's overall prognosis and quality of life 2, 4
- Imaging-guided percutaneous renal mass biopsy to obtain a tissue diagnosis and guide further management 5
- Multidisciplinary discussion to determine the best course of treatment, including the potential for further oncological treatment 6, 4
Considerations for Patient Care
- The patient's age and overall health status should be taken into account when making decisions about further treatment 2, 4
- The potential benefits and risks of PCN, including the risk of morbidity and mortality, should be carefully considered 2, 4
- The patient's quality of life and prognosis should be discussed with the patient and their family to ensure that treatment decisions align with their values and goals 2, 4
Potential Treatment Options
- PCN to relieve the obstruction and improve renal function 2, 4
- Chemotherapy, radiation, or surgery to treat the underlying malignancy 6
- Imaging-guided percutaneous renal mass biopsy to obtain a tissue diagnosis and guide further management 5
- Supportive care to manage symptoms and improve quality of life 2, 4