What is the best approach for an 85-year-old patient with right lower quadrant (RLQ) pain and a complex right ovarian mass measuring 21.3 × 16.7 × 23.3 cm?

Management of Complex Ovarian Mass in an 85-Year-Old with RLQ Pain

Urgent surgical evaluation by a gynecologic oncologist is the most appropriate approach for this 85-year-old patient with right lower quadrant pain and a large complex ovarian mass measuring 21.3 × 16.7 × 23.3 cm, as this presentation strongly suggests ovarian malignancy requiring specialized care.

Initial Assessment and Imaging

• The large size (21.3 × 16.7 × 23.3 cm) and complex nature of the ovarian mass in an elderly patient are highly concerning for malignancy
• Transvaginal and transabdominal ultrasound should be performed if not already done to further characterize the mass
• CT abdomen and pelvis with IV contrast is indicated to:
  • Evaluate for metastatic disease
  • Assess for lymphadenopathy
  • Determine if there is peritoneal spread
  • Plan for potential surgical intervention 1

Surgical Management Considerations

Referral Decision

• Immediate referral to a gynecologic oncologist is essential, as this is the second most important prognostic factor after stage for long-term survival in ovarian malignancy 1
• Only 33% of women with eventual diagnosis of ovarian cancer are appropriately referred to gynecologic oncologists for initial management 1

Surgical Approach

• Standard surgical treatment for suspected advanced ovarian cancer includes:

  • Bilateral salpingo-oophorectomy
  • Total hysterectomy with vaginal closure
  • Complete infragastric omentectomy
  • Appendectomy 1
  • Tumor debulking to achieve minimal or no residual disease

• The volume of tumor left after initial surgery is of significant prognostic value:

  • Patients with complete excision or minimal residual disease have better survival outcomes
  • Patients with significant residual tumor have poorer prognosis 1

Age-Specific Considerations

• Advanced age (85 years) presents additional surgical risks that must be carefully weighed:
  • In patients >80 years, serious medical comorbidities and advanced ASA status are common
  • Despite aggressive surgical efforts, optimal debulking (<1 cm residual disease) is achieved in only 25% of very elderly patients
  • Postoperative morbidity is significant in this age group 2

Alternative Approaches

If the patient is deemed too frail for immediate definitive surgery:

• Limited exploration (laparotomy or laparoscopy) for precise staging and ovarian biopsy
• Followed by 2-3 courses of chemotherapy before attempting interval debulking surgery 1

Important Caveats

• Preoperative bowel preparation should be identical to that used for bowel surgery, as bowel resection may be necessary 1
• If recto-sigmoid resection is required, a low colorectal anastomosis should be attempted if possible to avoid permanent colostomy, which negatively affects quality of life 1
• The operation report must include detailed descriptions of all lesions, surgical procedures performed, and precise documentation of any residual tumor 1

Diagnostic Considerations

While ovarian malignancy is most likely given the patient's age and mass characteristics, other diagnoses to consider include:

• Ovarian torsion (though rare in postmenopausal women) 3
• Massive ovarian edema (rare but can present as large solid masses) 4
• Benign ovarian tumors (less common in this age group) 5

The large size, complex nature, and patient's advanced age strongly favor malignancy as the most likely diagnosis, necessitating prompt gynecologic oncology evaluation and intervention to optimize survival outcomes.