Postmenopausal Ovarian Masses: Morphology and Presurgical Differential Diagnosis
Study Objective: To study the prevalence and morphology of ovarian masses (OM) in postmenopausal women and assess the prognostic value of measuring СА-125 and НЕ-4, as well as of the Risk Malignancy Index (RMI), and Risk of Malignancy Algorithm (ROMA), during preoperative examination, for differential diagnosis between benign and malignant OM. Study Design: This was a combined retrospective and prospective study. Materials and Methods: In the first stage, retrospective analysis was done on data collected from 2,177 autopsy reports of women who died in 1976-2016. One hundred (4.6%) of the reports contained results of gross examination and/or microscopy of diseased ovaries: 2.2% of these results were autopsy protocols of postmenopausal women (over the age of 55). In the second stage, a prospective study was conducted, which included 36 postmenopausal patients (one to 30 years of amenorrhea), aged 42 to 79. Serum levels of СА-125 and НЕ-4 tumor markers were measured, and RMI and ROMA were calculated for these patients. After surgery and histological examination of samples collected during surgery, statistical analysis was done using SPSS Version 20. СА-125, НЕ-4, RMI, and ROMA were assessed for sensitivity and specificity. Study Results: Analysis of the autopsy protocols showed that the prevalence of OM in these postmenopausal women was 2.2%. Histology confirmed benign OM in 83.7% of them, and malignant OM in 16.3%. Epithelial tumors were the most common type (24.5%) of benign OM, including serous cystadenoma (20.5%), serous adenofibroma (2.0%), and an endometriotic cyst (2.0%). Simple (unclassified) ovarian cysts and inclusion cysts were found slightly less frequently (in 18.4% and 8.2% of the women, respectively). Sex cord-stromal tumors (fibromas) were detected in 4.1% of the deceased women. Germ cell tumors (matured teratomas) were observed in 2.0% of them. Other types of masses found included ovarian follicular cysts (in 8.2% of the women), paraovarian cysts (4.1%), corpus luteum cysts (2.0%), stromal hyperthecosis (8.2%), polycystic ovaries (2.0%), and a ruptured corpus luteum (2.0%). Malignant ovarian tumors were of the following histological types: serous cystadenocarcinoma (4.1%), mucinous cystadenocarcinoma (6.1%), ovarian embryonal carcinoma (2.0%), and undifferentiated carcinoma of the ovary (4.1%). Of the OM detected in the second stage, 88.9% were benign, and 11.1% were malignant. The benign OM measured from 4 to 200 mm, and the malignant OM were from 88 to 300 mm (р = 0.006). More than half (55.6%) of the benign ovarian masses were epithelial tumors: serous cystadenomas (38.9%), mucinous cystadenocarcinomas (8.3%), serous adenofibroma (5.6%), and an endometriotic cyst (2.8%). One patient (2.8%) had a mature teratoma. Other types of changes included stromal hyperthecosis (8.3%), fibromatosis (5.6%), ovarian stromal hyperplasia (2.8%), and simple and small inclusion cysts (13.8%). The malignant OM were epithelial tumors of the following types: serous carcinoma (two cases), mucinous carcinoma (one case), and clear cell carcinoma (one case). CA-125 was 1.78-31.0 U/mL in patients with benign OM and 31.0-524.7 U/mL in patients with malignant OM (р = 0.001). HE-4 was 30.9-100.4 pmol/L in patients with benign OM and 37.3-235.9 pmol/L in patients with malignant OM (р = 0.082). RMI was 7.12-164.64 and 124.0-2,098.8 in patients with benign and malignant OM, respectively, (р = 0.002) and ROMA was 2.5-22.8% and 14.0-80.2% in patients with benign and malignant OM, respectively, (р = 0.001). In this study the sensitivity of CA-125 and HE-4 measurement, RMI, and ROMA in postmenopausal women was 75%, 25%, 75%, and 75%, respectively, and the specificity of these four parameters was 100%. Conclusion: Although the study demonstrated the high sensitivity of СА-125 measurement, RMI, and ROMA as diagnostic markers and the high specificity of СА-125 and HE-4 measurement, RMI, and ROMA, surgical treatment should be the method of choice for