Masses In Postmenopausal Women Research Articles

Management of ovarian masses in postmenopausal women

Introduction: The discovery of an adnexal mass in the postmenopausal period is a common situation and concerns 15 to 20% of this population. The development of gynecological ultrasound and technical advances in medical imaging as well as advances in laparoscopic surgery have changed the management of these ovarian tumors.

Asymptomatic adnexal mass in postmenopausal women

The widespread use of vaginal ultrasound as an integral part of the gynecologic clinical examination in many countries has led to the unexpected finding of adnexal mass. The implications of the finding of an adnexal mass in an asymptomatic postmenopausal woman can be serious if it is malignant and is not excised, because ovarian cancer has an indolent course and when it becomes symptomatic it is often fatal. The aim of the present review is to discuss the evaluation and management of incidental adnexal masses in postmenopausal women. Despite careful evaluation with ultrasound and biomarkers, a small number of patients will remain without a conclusive diagnosis. It is our opinion, based on empirical evidence discussed here, that conservative therapy with observation can be safely applied in the majority of these patients.

Serum HE4 and diagnosis of ovarian cancer in postmenopausal women with adnexal masses

BackgroundTransvaginal ultrasound and serum CA125 are routinely used for differential diagnosis of pelvic adnexal mass. Use of human epididymis 4 was approved in the United States in 2011. However, there is scarcity of studies evaluating the additional value of human epididymis 4.ObjectiveThe objective of the study was to evaluate the performance characteristics of transvaginal ultrasound, CA125, and human epididymis 4 for differential diagnosis of ovarian cancer in postmenopausal women with adnexal masses.Study DesignThis was a cohort study nested within the screen arms of the multicenter randomized controlled trial, United Kingdom Collaborative Trial of Ovarian Cancer Screening, based in England, Wales, and Northern Ireland. In United Kingdom Collaborative Trial of Ovarian Cancer Screening, 48,230 women randomized to transvaginal ultrasound screening and 50,078 to multimodal screening (serum CA125 interpreted by Risk of Ovarian Cancer Algorithm with second line transvaginal ultrasound) underwent the first (prevalence) screen. Women with adnexal lesions and/or persistently elevated risk were clinically assessed and underwent surgery or follow-up for a median of 10.9 years. Banked samples taken within 6 months of transvaginal ultrasound from all clinically assessed women were assayed for human epididymis 4 and CA125. Area under the curve and sensitivity for diagnosing ovarian cancer of multiple penalized logistic regression models incorporating logCA125, log human epididymis 4, age, and simple ultrasound features of the adnexal mass were compared.ResultsOf 1590 (158 multimodal, 1432 ultrasound) women with adnexal masses, 78 were diagnosed with ovarian cancer (48 invasive epithelial ovarian, 14 type I, 34 type II; 24 borderline epithelial; 6 nonepithelial) within 1 year of scan. The area under the curve (0.893 vs 0.896; P = .453) and sensitivity (74.4% vs 75.6% ;P = .564) at fixed specificity of 90% of the model incorporating age, ultrasound, and CA125 were similar to that also including human epididymis 4. Both models had high sensitivity for invasive epithelial ovarian (89.6%) and type II (>91%) cancers.ConclusionOur population cohort study suggests that human epididymis 4 adds little value to concurrent use of CA125 and transvaginal ultrasound in the differential diagnosis of adnexal masses in postmenopausal women.

Evaluation and Management of Adnexal Masses in Postmenopausal Women

In the postmenopausal women, adnexal masses can have numerous etiologies. They can range from benign to neoplastic, with origins from a variety of organ systems. The diagnostic work up includes a thorough history, physical exam, as well as potential imaging and laboratory testing. There should be a low threshold for consultations with oncologists when there are cancer concerns. Specifically for gynecologic neoplasms, a referral to a gynecologic oncologist should be strongly considered. In this paper, there is particular attention to ovarian cancer given the gravity of delayed diagnosis.

Bioimpedance analysis vs. DEXA as a screening tool for osteosarcopenia in lean, overweight and obese Caucasian postmenopausal females.

We aimed at evaluating the efficiency of a newly developed, advanced Bioimpedance Analysis (BIA-ACC®) device as a screening tool for determining the degree of obesity and osteosarcopenia in postmenopausal women with normal or decreased bone density determined by Dual-Energy X-Ray absorptiometry (DEXA) in a representative sample of Greek postmenopausal women. This is a single-gate cross-sectional study of body composition measured by BIA-ACC® and DEXA. Postmenopausal females with BMI ranging from 18.5 to 40 kg/m2 were subjected to two consecutive measurements of DEXA and BIA-ACC® within 5-10 minutes of each other. We used Pearson's co-efficient to examine linear correlations, the intraclass correlation co-efficient (ICC) to test reliability, Bland-Atman plots to assess bias and Deming regressions to establish the agreement in parameters measured by BIA-ACC® and DEXA. Last, we used ANOVA, with Bonferroni correction and Dunnett T3 post hoc tests, for assessing the differences between quantitative and Pearson's x2 between qualitative variables. Our sample consisted of 84 overweight/obese postmenopausal women, aged 39-83 years, of whom 22 had normal bone density, 38 had osteopenia and 24 had osteoporosis based on DEXA measurements, using quota sampling. ICCs and Deming regressions showed strong agreement between BIA-ACC® and DEXA and demonstrated minimal proportional differences of no apparent clinical significance. Bland-Altman plots indicated minimal biases. Fat, skeletal and bone mass measured by BIA-ACC® and DEXA were increased in the non-osteopenic/non-osteoporotic women compared with those of the osteopenic and osteoporotic groups. BIA-ACC® is a rapid, bloodless and useful screening tool for determining body composition adiposity and presence of osteo-sarcopenic features in postmenopausal women. Women with osteopenia and osteoporosis evaluated by DEXA had decreased fat, skeletal and bone mass compared with normal bone density women, suggesting concordance in the change of these three organ masses in postmenopausal women.

Evaluation of Probably Benign Adnexal Masses in Postmenopausal Women.

Background Preoperatively identification of malignancy potential of a postmenopausal adnexal masses is important. Aim To evaluate the effectiveness of the Risk of Malignancy Index-2 in presumably benign adnexal masses in postmenopausal women. Study Design Retrospective, observational study. Methods 119 women with postmenopausal adnexal masses with a preliminary diagnosis of benign tumors according to the Risk of Malignancy Index-2 were included. Age, duration of menopause, ultrasonographic findings, and serum CA-125 levels were recorded preoperatively. The definitive diagnosis was based on postoperative histopathological examination. Results Of 119 adnexal mass, 10 were malignant and 109 were benign. There was no statistically significant difference with regard to age and tumor size between the groups. The two significant ultrasonographic parameter between groups were the presence of solid area in the mass and bilaterality. Moreover, if the cut off point for serum CA-125 was adjusted to 14.75 IU/mL according to ROC curve, a sensitivity value of 80% and a specificity value of 72% could be achieved to discriminate benign and malign cysts. Conclusion In the differential diagnosis of benign and malignant adnexal masses in postmenopausal women, the presence of a solid component, bilaterallity based on ultrasonography and high CA-125 values may be used as discriminative criteria. There is no direct relation between the size of the adnexal mass and malignancy potential. Therefore, in the malignancy indexes of postmenopausal women, we recommend lower cut-off values of CA-125 to increase the sensitivity of preoperative evaluation tests without having a great impact on negative predictive values.

Role of Imaging in Dilemma of Adnexal Masses in Postmenopausal Women

ABSTRACT Adnexal masses in postmenopausal women represent a spectrum of conditions from gynaecologic and non gynaecologic sources. Post-menopausal women are especially at high risk of gynaecologic malignancy however even in this population majority of adnexal masses are benign. Tumor markers and high frequency transvaginal ultrasonography with doppler studies project high quality images allowing for detailed macroscopic appearances of masses and remain the least expensive modalities available. Adnexal masses that are suspicious for cancer, women should be referred to gynaecologic oncologist for optimal care. How to cite this article Yadav P, Gupta M, Agarwal M, Garg R, Verma U, Gupta S. Role of Imaging in Dilemma of Adnexal Masses in Postmenopausal Women. J South Asian Feder Menopause Soc 2017;5(1):45-50.

Low Grade Well-circumscribed Well Differentiated Liposarcoma Developed in Fibroadenoma with Stromal adipose differentiation of the Breast; A Case Report

Fibroadenomas are the most common breast tumor in adolescents and young women.They comprise 20% of benign breast masses and 12% of all breast masses in postmenopausal women. Smooth muscle metaplasia and adipose differentiation are uncommon forms of stromal differentiation encountered in a minority of fibroadenomas. Liposarcoma can arise from pre-existing benign lesions like phylloides tumour or from lipoid tissue in the breast. In this article we present a case of 38 year-old female who presented with a right breast mass which was clinically diagnosed as a case of fibroadenoma, but histologically showed a low grade well-circumscribed liposarcoma discovered in a pericanalicular type of fibroadenoma with stromal adipose differentiation. According to our knowledge, this the first case of a well-circumscribed liposarcoma arises in fibroadenoma of the breast. Virtual Slides: www.diagnosticpathology.eu/vs/2016_2_100/

Development of a multi-marker model combining HE4, CA125, progesterone, and estradiol for distinguishing benign from malignant pelvic masses in postmenopausal women.

The purpose of this study was to evaluate HE4, CA125, progesterone (Prog), and estradiol (E2) for differentiating pelvic masses in postmenopausal women and aimed to build a multi-marker model which may improve the diagnostic value. HE4, CA125, Prog, and E2 were detected in 57 benign pelvic masses (BPM) and 92 epithelial ovarian cancer (EOC) patients. A total of 66.66% of the BPM and EOC serum samples were used for building the differentiation model, and the remaining 33.33% of the BPM and EOC serum samples were used for validation of the differentiation model. After comparing by Z score statistics, HE4 + CA125 + E2 model was chosen as the best multi-marker model. In the training group, the area under curve of the HE4 + CA125 + E2 model was 0.97 (0.93, 1.00), sensitivities of the model for distinguishing BPM from EOC, from early EOC, and from advanced EOC were 90.16, 86.21, and 95.65%; specificities were 92.11, 92.11, and 92.11%. In the validation group, sensitivities of HE4 + CA125 + E2 model for distinguishing BPM from EOC, from early EOC, and from advanced EOC were 96.77, 100.00, and 87.50%, specificities were 84.21, 100.00, and 84.21%. The multi-marker model showed significant improvement when compared to CA125 or HE4, and it might be an effective pelvic mass differentiation method.

Small Complex Ovarian Masses in Postmenopausal Women are Rarely Malignant

Women older than 50 with small (1–6 cm) complex ovarian masses on ultrasound pose diagnostic dilemmas, especially if CA125 levels are normal. Should

Laparoscopy as the Most Effective Tool for Management of Postmenopausal Complex Adnexal Masses When Expectancy is Not Advisable

Postmenopausal women with adnexal masses suspicious for malignancy must undergo surgery for histopathologic confirmation. The low positive predictive value for malignancy of the currently available preoperative examinations results in 5 to 220 surgeries performed for each case of pelvic malignancy detected, depending on the evaluation method and patient selection. Although extensively reviewed as an effective tool for the investigation and treatment of adnexal masses, laparoscopy is still underused for this purpose in postmenopausal women. Some reasons are uncertainty about the incidental diagnosis of a malignant lesion during laparoscopy, concern about the effect of laparoscopy over the course of a pelvic malignant lesion, and inadequate referral of patients at high risk to specialized centers with oncologic gynecologists. Identification of patients at low risk might also be inadequate, causing them to undergo unnecessary laparotomy. Herein we demonstrate through a comprehensive literature review that laparoscopy is a highly effective tool for investigation and treatment of suspected adnexal masses in postmenopausal women, both in general medical settings without oncologic backup and in specialized centers. The indications for laparoscopy in this context can be further expanded without oncologic harm if patients at low and high risk are appropriately selected for surgery at general and specialized settings, respectively.

Primary Mucinous Cystadenocarcinoma of the Breast: Cytologic Finding and Expression of MUC5 Are Different from Mucinous Carcinoma

Mucinous cystadenocarcinoma (MCA) in the breast is a rare neoplasm. There have been 13 cases of primary breast MCA reported. The MCA presents as a large, partially cystic mass in postmenopausal woman with a good prognosis. The microscopic findings resemble those of ovarian, pancreatic, or appendiceal MCA. The aspiration findings showed mucin-containing cell clusters in the background of mucin and necrotic material. The cell clusters had intracytoplasmic mucin displacing atypical nuclei to the periphery. Histologically, the tumor revealed an abundant mucin pool with small floating clusters of mucin-containing tumor cells. There were also small cysts lined by a single layer of tall columnar mucinous cells, resembling those of the uterine endocervix. The cancer cells were positive for mucin (MUC) 5 and negative for MUC2 and MUC6. This mucin profile is different from ordinary mucinous carcinoma and may be a unique characteristic of breast MCA.

The Effects Of Different Mode Of Low-intensity Exercise Training On Bone Mineral Density And Bone Metabolism In Postmenopausal Woman

PURPOSE: To investigate the effects of 12-month low-intensity resistance training using the elastic band and brisk walking on bone mineral density, body composition, and bone formation marker in postmenopausal woman. METHODS:Thirty-two postmenopausal women (49-63 yr) were assigned to resistance training group (RTG) (n=11; 55.9 ± 4.28 yrs), brisk walking group (BWG) (n=10; 53.2 ± 4.24 yrs) and control group (CG) (n=11; 54.4 ± 3.42 yrs). The training program consisted of resistance exercises using elastic bands and brisk walking for 2 sessions and one hour for each session per week. Total bone mineral density (TBMD), total bone mineral content (TBMC), lumbar spine (LS), femoral neck (FN), body fat, and lean body mass were measured at baseline and after one year training. Duel-energy X-ray absorptiometry (DXA) was used to measure subjects' body composition, regional and total bone mineral density. Serum intact N-terminal propeptide of type I collagen (PINP) and carboxyterminal telopeptide of type I collagen (ICTP) were determined as indices of bone metabolism. The statistical comparisons for the changes of different variables among the three groups were performed by applying one-way ANOVA. RESULTS: The three groups had similar BMD and BC characteristics at baseline. After the training period, there was a tendency of decline in BMD with age, and group differences change were not significant (p > 0.05) except for the spine of BWG. The BWG increased significantly in TBMC (1.4%), lumbar spine (1.3%), and PINP (12%) among groups (p<.05). In body composition, RTG showed significant decrease in body fat in the arm, leg, and total body than the other two groups (p<0.05). Leg lean mass in the walking group increased significantly than both the RTG and CG (p<0.05). CONCLUSIONS: These findings suggest that brisk walking is a medium-impact and weight-bearing exercise which is beneficial on bone mass in postmenopausal woman. Therefore, the impact of exercise training on bone metabolism may depend on the type of exercise during the early phase of training. However, the different mode of low-resistance exercises training on body composition have the different effects which is relatively site specific to the working muscle, thus, brisk walking is more beneficial on the leg and resistance training benefits more towards the whole body.

Endometriomas: their ultrasound characteristics

To describe the ultrasound characteristics of endometriomas in pre- and postmenopausal patients and to develop rules that characterize endometriomas. All patients included in the International Ovarian Tumor Analysis (IOTA) studies were used in our analysis. Patients with an adnexal mass were scanned by experienced sonologists using a standardized research protocol. The gold standard was the histology of the surgically removed adnexal mass. The gray-scale and Doppler ultrasound characteristics of the endometriomas were compared with those of other benign and malignant masses. Based on decision-tree analysis, the existing literature and clinical experience, ultrasound rules for the detection of endometriomas were created and evaluated. Of all 3511 patients included in the IOTA studies, 713 (20%) had endometriomas. Fifty-one per cent of the endometriomas were unilocular cysts with ground glass echogenicity of the cyst fluid. These characteristics were found less often among other benign tumors or malignancies, or among the small set of endometriomas (4%) that were found in postmenopausal patients. Based on the decision-tree analysis, the optimal rule to detect endometriomas was 'an adnexal mass in a premenopausal patient with ground glass echogenicity of the cyst fluid, one to four locules and no papillations with detectable blood flow'. Based on clinical considerations, the following rule: 'premenopausal status, ground glass echogenicity of the cyst fluid, one to four locules and no solid parts' seems preferable. Several rules had a good ability to characterize endometriomas. The ultrasound characteristics of endometriomas differ between pre- and postmenopausal patients. Masses in postmenopausal women whose cystic contents have a ground glass appearance have a high risk of malignancy.

National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines for Use of Tumor Markers in Testicular, Prostate, Colorectal, Breast, and Ovarian Cancers

Updated National Academy of Clinical Biochemistry (NACB) Laboratory Medicine Practice Guidelines for the use of tumor markers in the clinic have been developed. Published reports relevant to use of tumor markers for 5 cancer sites--testicular, prostate, colorectal, breast, and ovarian--were critically reviewed. For testicular cancer, alpha-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase are recommended for diagnosis/case finding, staging, prognosis determination, recurrence detection, and therapy monitoring. alpha-Fetoprotein is also recommended for differential diagnosis of nonseminomatous and seminomatous germ cell tumors. Prostate-specific antigen (PSA) is not recommended for prostate cancer screening, but may be used for detecting disease recurrence and monitoring therapy. Free PSA measurement data are useful for distinguishing malignant from benign prostatic disease when total PSA is <10 microg/L. In colorectal cancer, carcinoembryonic antigen is recommended (with some caveats) for prognosis determination, postoperative surveillance, and therapy monitoring in advanced disease. Fecal occult blood testing may be used for screening asymptomatic adults 50 years or older. For breast cancer, estrogen and progesterone receptors are mandatory for predicting response to hormone therapy, human epidermal growth factor receptor-2 measurement is mandatory for predicting response to trastuzumab, and urokinase plasminogen activator/plasminogen activator inhibitor 1 may be used for determining prognosis in lymph node-negative patients. CA15-3/BR27-29 or carcinoembryonic antigen may be used for therapy monitoring in advanced disease. CA125 is recommended (with transvaginal ultrasound) for early detection of ovarian cancer in women at high risk for this disease. CA125 is also recommended for differential diagnosis of suspicious pelvic masses in postmenopausal women, as well as for detection of recurrence, monitoring of therapy, and determination of prognosis in women with ovarian cancer. Implementation of these recommendations should encourage optimal use of tumor markers.

SERUM TUMOR MARKERS

With the advent of new generations of chemotherapeutic agents andadvances in radiation therapy in the management of malignancies, an understanding of tumor markers is becomingincreasingly important. These soluble molecules in the blood are usually glycoproteins detected by monoclonalantibodies. Each tumor marker has a variable profile of usefulness for screening, determining diagnosis and prognosis,assessing response to therapy, and monitoring for cancer recurrence. Monoclonal antibodies are used to detect serumantigens associated with specific malignancies. These tumor markers are most useful for monitoring response totherapy and detecting early relapse. With the exception of Prostate-Specific Antigen (PSA), tumor markers do not havesufficient sensitivity or specificity for use in screening. Cancer Antigen (CA) 27.29 most frequently is used to followresponse to therapy in patients with metastatic breast cancer. Carcinoembryonic antigen is used to detect relapse ofcolorectal cancer, and CA 19-9 may be helpful in establishing the nature of pancreatic masses. CA 125 is useful forevaluating pelvic masses in postmenopausal women, monitoring response to therapy in women with ovarian cancer,and detecting recurrence of this malignancy. Alpha-fetoprotein (AFP), a marker for hepatocellular carcinoma,sometimes is used to screen highly selected populations and to assess hepatic masses in patients at particular riskfor developing hepatic malignancy. Testing for the beta subunit of human chorionic gonadotropin (b-hCG) is an integralpart of the diagnosis and management of gestational trophoblastic disease. Combined AFP and b-hCG testing is anessential adjunct in the evaluation and treatment of nonseminomatous germ cell tumors, and in monitoring theresponse to therapy. AFP and b-hCG also may be useful in evaluating potential origins of poorly differentiatedmetastatic cancer. PSA is used to screen for prostate cancer, detect recurrence of the malignancy, and evaluatespecific syndromes of adenocarcinoma of unknown primary. This review article describes the use of common tumormarkers in primary care practice. Particular emphasis is given to when these tests should be ordered and to commonfactors that influence the interpretation of tumor marker levels.

Primary ovarian fibrosarcoma: a case report and review of the literature

Primary ovarian fibrosarcomas are very rare tumors with great heterogeneity among reported cases. There are only a few reports of the subject in the literature, and along with the nature of the disease, diagnosis and treatment still remain to be established. In this report, we reviewed the cases published in the English literature within the past 30 years and tried to highlight certain aspects of the disease. A 52-year-old parous woman was admitted to our hospital with the complaints of abdominopelvic pain. Initial diagnostic work-up revealed a solid mass on the right ovary. After explorative laparotomy, the pathologic examination reported a primary ovarian fibrosarcoma. The patient has been free of disease for 1 year without any adjuvant therapy. Although ovarian fibrosarcomas are unusual causes of solid masses in postmenopausal women, it should be kept in mind when evaluating adnexal masses in this age group.

Management of adnexal masses in postmenopausal women

With the increased use of transvaginal sonography (TVS) both for ovarian cancer screening and as an adjunct to pelvic examination, more adnexal masses are being detected in postmenopausal patients. Screening studies have indicated that approximately 3% to 5% of asymptomatic postmenopausal women will have an adnexal mass confirmed sonographically.1,2 It is well documented that pelvic examination is inadequate in assessing ovarian size, particularly in women who are postmenopausal, overweight (≥200 lbs), or who have an enlarged uterus.

Selected Adnexal Cystic Masses in Postmenopausal Women Can be Safely Managed by Laparoscopy

The aim of this study was to assess the efficacy and safety of laparoscopic treatment for adnexal cystic masses that were predicted to be benign in postmenopausal women. Postmenopausal women found to have an adnexal cystic mass were retrospectively evaluated with transvaginal ultrasonography, and serum CA-125 levels. The selection criteria were adnexal cystic masses greater than 3 cm but less than 10 cm, the masses were in the benign range (4-8) of Sassone's scoring system for transvaginal ultrasonography, and the patients had serum CA-125 levels less than 65 IU/mL. Two hundred nineteen women fulfilled the criteria and underwent operative laparoscopy. Almost all the masses (99.5%) were accurately predicted to be benign except for one borderline ovarian tumor. Two hundreds thirteen (97.3%) women were successfully managed by operative laparoscopy and six (2.7%) required laparotomy. For the patients managed by laparoscopy, the mean operative time was 51.3 min; the mean hospital stay was 2.5 days. There was no significant morbidity and surgery-related mortality. The combination of the Sassone's scoring system for transvaginal ultrasonography and serum CA-125 level can accurately predict benign cystic masses, and operative laparoscopy is technically feasible and safe for the management of adnexal mass in postmenopausal women.

The value of cancer antigen 125 (CA 125) during treatment and follow-up of patients with ovarian cancer

Although the nature of the cancer antigen 125 leaves many questions unanswered, the use of serum measurements as a means to assess the response to surgery and chemotherapy in ovarian cancer is now well documented. Good prognostic significance is attributed to a rapid decline in cancer antigen 125 levels after chemotherapy in patients with advanced ovarian cancer. Pre-operative serum cancer antigen 125 levels may successfully discriminate benign from malignant adnexal masses in postmenopausal women, but in women in their reproductive years the specificity is low. In stage I ovarian cancer patients, high preoperative cancer antigen 125 levels are reported to lead to a sixfold increase in the risk of dying from the disease. Low expectations on the specificity and outcome of cancer antigen 125-based screening of asymptomatic women are contradicted by the first results of screening programmes for postmenopausal women. Large, randomized, controlled studies will assess if survival can be improved by early detection of ovarian cancer. Experimental immunotherapy by activation of the idiotypic network directed against cancer antigen 125 may offer new possibilities to prolong survival in advanced ovarian cancer.