A 38-year-old woman with abdominal pain and a palpable mass

A 38-Year-Old Woman With Abdominal Pain and a Palpable Mass

A 38-year-old woman presents with a 2-year history of an abdominal wall mass that has recently enlarged in size. She reports unusual sensations of soreness and pain in her abdomen associated with the mass. The symptoms are predominantly premenstrual and have progressed to the point of debilitation. She has not noticed any other masses or lesions on her body. Three years prior to presentation, the patient began experiencing menorrhagia and dysmenorrhea.

The patient’s gynecologic history is significant for menarche at 10 years of age, an elective abortion at age 18, and an ectopic pregnancy treated by left salpingectomy at age 25. She has never taken hormonal contraception. She underwent ovarian stimulation and uterine preparation for in vitro fertilization (IVF) at age 25. Ovarian stimulation was achieved with progesterone and leuprolide acetate and was followed by laparoscopic retrieval of her ova. The patient later had 4 transvaginal IVF embryo transfers resulting in 3 pregnancies and 4 children. Her first 2 children were born via normal spontaneous vaginal deliveries when the patient was 26 and 28 years old. At age 30, she gave birth to twins, one via normal spontaneous vaginal delivery and the other via cesarean because of failure to progress.

She has had no other surgeries. She has no other significant medical history. She denies any allergies and, at presentation, she is not on any medications. She denies any recent weight loss, fevers, or chills.

On initial examination, her temperature is 97.6°F (36.4°C), blood pressure is 126/83 mm Hg, heart rate is 67 beats/min, respiratory rate is 12 breaths/min, and oxygen saturation is 99% on room air. She has a firm, nonmobile, nonpulsatile, ill-defined, tender mass palpated to the left of her umbilicus. The mass is not in the area of her prior incisions. The remainder of her examination, including the pelvic examination, is unremarkable.

The preoperative laboratory findings are within normal limits. An MRI demonstrates a 3.2 × 2.4 × 1.8 cm mass within the left abdominal rectus muscle, which deforms the posterior rectus fascia. The radiologic features are interpreted as being most compatible with abdominal wall fibromatosis. Intraoperatively, the mass is excised from within the musculature of the rectus without disturbing the posterior rectus fascia. Grossly, the mass is found to be 3.7 × 3.3 × 1.4 cm and composed of tan-yellow, soft, lobular, fibrous adipose tissue. Histologic sections are shown (Figures 1 and 2).

What is the most likely diagnosis?

Hint: The pain is premenstrual.

Desmoid tumor
Synovial sarcoma

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A 38-year-old woman with abdominal pain and a palpable mass