What is the next step in management for a 70-year-old female with bilateral grade II renal parenchymal changes and a pelvic cystic lesion with a mural nodule?

Management of Pelvic Cystic Lesion with Mural Nodule in a 70-Year-Old Female with Renal Parenchymal Changes

The next step in management for this 70-year-old female should be an MRI of the pelvis and CA-125 testing as recommended in the ultrasound report, followed by gynecologic oncology consultation.

Assessment of Current Findings

Renal Findings

• Bilateral grade II renal parenchymal changes with:
  • Increased parenchymal echotexture
  • Partial obliteration of corticomedullary differentiation (CMD)
  • Normal parenchymal thickness (14-15mm)
  • No hydronephrosis or calculi
• These findings suggest chronic kidney disease that requires renal function testing (RFT) as recommended in the report

Pelvic Cystic Lesion

• 10.0 × 7.4 cm well-defined thick-walled cyst superior to the bladder
• Contains sedimented echogenic contents
• Presence of a 6.9 mm isoechoic mural nodule
• Location in the pelvis midline suggests possible ovarian origin, though the ovaries were not visualized separately

Diagnostic Workup

For the Pelvic Cystic Lesion

1. MRI of the pelvis (highest priority)

   • Superior to ultrasound for characterizing complex cystic lesions 1
   • Can better define the origin of the mass (ovarian vs. other pelvic structures)
   • Can better characterize the mural nodule and internal components

2. CA-125 testing

   • Important tumor marker for ovarian malignancy
   • Elevated levels may suggest malignant potential
   • Should be performed concurrently with MRI

3. Gynecologic oncology consultation

   • Essential for evaluation of complex pelvic cystic lesions with suspicious features
   • The presence of a mural nodule increases concern for malignancy

For the Renal Parenchymal Changes

1. Renal function testing
   • Complete metabolic panel including BUN, creatinine, eGFR
   • Urinalysis to assess for proteinuria and hematuria
   • These are recommended for monitoring of renal parenchymal disease 2, 1

Management Considerations

Pelvic Cystic Lesion

• The presence of a mural nodule in a thick-walled cyst raises significant concern for malignancy
• In a 70-year-old female, ovarian malignancy must be ruled out
• If MRI confirms complex features, surgical evaluation is likely necessary
• The differential diagnosis includes:
  • Ovarian cystadenoma/cystadenocarcinoma
  • Complex ovarian cyst
  • Other pelvic cystic lesions (less likely)

Renal Parenchymal Changes

• Grade II renal parenchymal changes suggest moderate chronic kidney disease
• Renal function must be considered when planning any interventions for the pelvic mass
• Nephron-sparing approaches should be prioritized in any future interventions 2, 1
• Regular monitoring of renal function is necessary

Follow-up Plan

1. Short-term (1-2 weeks):

   • Complete MRI of pelvis and CA-125 testing
   • Renal function testing
   • Gynecologic oncology consultation

2. Medium-term (based on initial results):

   • If suspicious for malignancy: surgical planning with consideration of renal function
   • If indeterminate: possible biopsy or short-interval follow-up imaging
   • If benign features: surveillance imaging

3. Long-term:

   • Regular monitoring of renal function
   • Annual abdominal imaging to monitor both renal parenchymal changes and any residual or recurrent pelvic pathology

Pitfalls and Considerations

• Diagnostic pitfalls: Pelvic cysts can sometimes be misidentified between renal and ovarian origin 3
• Procedural considerations: Renal function must be considered when using contrast for MRI
• Age-related factors: At 70 years old, the risk of malignancy in complex cystic lesions is higher
• Comorbidity management: The bilateral renal parenchymal changes may impact treatment options and should be carefully evaluated

The presence of both a suspicious pelvic cystic lesion with a mural nodule and bilateral renal parenchymal changes requires careful coordination between gynecologic oncology and nephrology to ensure optimal management of both conditions.