Presurgical diagnosis of adnexal tumours using mathematical models and scoring systems: a systematic review and meta-analysis

Validation of models to diagnose ovarian cancer in patients managed surgically or conservatively: multicentre cohort study

OBJECTIVE

To evaluate the performance of diagnostic prediction models for ovarian malignancy in all patients with an ovarian mass managed surgically or conservatively.

DESIGN

Multicentre cohort study.

SETTING

36 oncology referral centres (tertiary centres with a specific gynaecological oncology unit) or other types of centre.

PARTICIPANTS

Consecutive adult patients presenting with an adnexal mass between January 2012 and March 2015 and managed by surgery or follow-up.

MAIN OUTCOME MEASURES

Overall and centre specific discrimination, calibration, and clinical utility of six prediction models for ovarian malignancy (risk of malignancy index (RMI), logistic regression model 2 (LR2), simple rules, simple rules risk model (SRRisk), assessment of different neoplasias in the adnexa (ADNEX) with or without CA125). ADNEX allows the risk of malignancy to be subdivided into risks of a borderline, stage I primary, stage II-IV primary, or secondary metastatic malignancy. The outcome was based on histology if patients underwent surgery, or on results of clinical and ultrasound follow-up at 12 (±2) months. Multiple imputation was used when outcome based on follow-up was uncertain.

RESULTS

The primary analysis included 17 centres that met strict quality criteria for surgical and follow-up data (5717 of all 8519 patients). 812 patients (14%) had a mass that was already in follow-up at study recruitment, therefore 4905 patients were included in the statistical analysis. The outcome was benign in 3441 (70%) patients and malignant in 978 (20%). Uncertain outcomes (486, 10%) were most often explained by limited follow-up information. The overall area under the receiver operating characteristic curve was highest for ADNEX with CA125 (0.94, 95% confidence interval 0.92 to 0.96), ADNEX without CA125 (0.94, 0.91 to 0.95) and SRRisk (0.94, 0.91 to 0.95), and lowest for RMI (0.89, 0.85 to 0.92). Calibration varied among centres for all models, however the ADNEX models and SRRisk were the best calibrated. Calibration of the estimated risks for the tumour subtypes was good for ADNEX irrespective of whether or not CA125 was included as a predictor. Overall clinical utility (net benefit) was highest for the ADNEX models and SRRisk, and lowest for RMI. For patients who received at least one follow-up scan (n=1958), overall area under the receiver operating characteristic curve ranged from 0.76 (95% confidence interval 0.66 to 0.84) for RMI to 0.89 (0.81 to 0.94) for ADNEX with CA125.

CONCLUSIONS

Our study found the ADNEX models and SRRisk are the best models to distinguish between benign and malignant masses in all patients presenting with an adnexal mass, including those managed conservatively.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01698632.

Validity and Reproducibility of the ADNEX MR Scoring System in the Diagnosis of Sonographically Indeterminate Adnexal Masses

BACKGROUND

The diagnosis of sonographically indeterminate adnexal masses (AM) signifies a major challenge in clinical practice. Early detection and characterization have increased the need for accurate imaging evaluation before treatment.

PURPOSE

To assess the validity and reproducibility of the ADNEX MR Scoring system in the diagnosis of sonographically indeterminate AM.

STUDY TYPE

A prospective multicenter study.

POPULATION

In all, 531 women (mean age, 44 ± 11.2 years; range, 21-79 years) with 572 sonographically indeterminate AM.

FIELD STRENGTH/SEQUENCE

1.5T/precontrast T₁ -weighted imaging (WI) fast spin echo (FSE) (in-phase and out-of-phase, with and without fat suppression); T₂ -WI FSE; diffusion-WI single-shot echo planner with b-values of 0 and 1000 s/mm² ; and dynamic contrast-enhanced perfusion T₁ -WI liver acquisition with volume acceleration (LAVA).

ASSESSMENT

All MRI examinations were evaluated by three radiologists, and the AM were categorized into five scores based on the ADNEX MR Scoring system. Score 1: no AM; 2: benign AM; 3: probably benign AM; 4: indeterminate AM; 5: probably malignant AM. Histopathology and imaging follow-up were used as the standard references for evaluating the validity of the ADNEX MR Scoring system for detecting ovarian malignancy.

STATISTICAL TESTS

Four-fold table test, kappa statistics (κ), and receiver operating characteristic (ROC) curve.

RESULTS

In all, 136 (23.8%) AM were malignant, and 436 (76.2%) were benign. Of the 350 AM classified as score 2, one (0.3%) was malignant; of the 62 AM classified as score 3, six (9.7%) were malignant; of the 73 AM classified as score 4, 43 (58.9%) were malignant; and of the 87 AM categorized as score 5, 86 (98.9%) were malignant. The best cutoff value for predicting malignant AM was score >3 with sensitivity and specificity of 92.9% and 94.9%, respectively. The interreader agreement of the ADNEX MR Scoring was very good (κ = 0.861).

DATA CONCLUSION

The current study supports the high validity and reproducibility of the ADNEX MR Scoring system for the diagnosis of sonographically indeterminate AM.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 2.

Validation of IOTA-ADNEX Model in Discriminating Characteristics of Adnexal Masses: A Comparison with Subjective Assessment

(1) Background: The aim of this study is to compare the IOTA-ADNEX (international ovarian tumor analysis–assessment of different neoplasias in the adnexa) model with gynecologic experts in differentiating ovarian diseases. (2) Methods: All participants in this prospective study underwent ultrasonography (US) equipped with the IOTA-ADNEX^TM model and subjective assessment by a sonographic expert. Receiver operating characteristic (ROC) curves were also generated to compare overall accuracies. The optimal cut-off value of the ADNEX model for excluding benign diseases was calculated. (3) Results: Fifty-nine participants were eligible: 54 and 5 underwent surgery and follow-up computed tomography (CT), respectively. Benign and malignant diseases were confirmed in 49 (83.1%) and 10 (16.9%) participants, respectively. The specificity of the ADNEX model was 0.816 (95% confidence interval (CI): 0.680–0.912) in all participants and 0.795 (95% CI, 0.647–0.902) in the surgical group. The area under the ROC curve of the ADNEX model (0.924) was not significantly different from that of subjective assessment (0.953 in all participants, 0.951 in the surgical group; p = 0.391 in all participants, p = 0.407 in the surgical group). The optimal cut-off point using the ADNEX model was 47.3%, with a specificity of 0.977 (95% CI: 0.880–0.999). (4) Conclusions: The IOTA-ADNEX model is equal to gynecologic US experts in excluding benign ovarian tumors. Subsequently, being familiar with this US software may help gynecologic beginners to reduce unnecessary surgery.

Practical Recommendations for the Management of Benign Adnexal Masses

OBJECTIVE

 To perform a comprehensive review to provide practical recommendations regarding the diagnosis and treatment of benign adnexal masses, as well as information for appropriate consent, regarding possible loss of the ovarian reserve.

METHODS

 A comprehensive review of the literature was performed to identify the most relevant data about this subject.

RESULTS

 In total, 48 studies addressed the necessary aspects of the review, and we described their epidemiology, diagnoses, treatment options with detailed techniques, and perspectives regarding future fertility.

CONCLUSIONS

 Adnexal masses are extremely common. The application of diagnosis algorithms is mandatory to exclude malignancy. A great number of cases can be managed with surveillance. Surgery, when necessary, should be performed with adequate techniques. However, even in the hands of experienced surgeons, there is a significant decrease in ovarian reserves, especially in cases of endometriomas. There is an evident necessity of studies that focus on the long-term impact on fertility.

Scoring systems for the evaluation of adnexal masses nature: current knowledge and clinical applications

Adnexal masses are a common finding in women, with 20% of them developing at least one pelvic mass during their lifetime. There are more than 30 different subtypes of adnexal tumours, with multiple different subcategories, and the correct characterisation of the pelvic masses is of paramount importance to guide the correct management. On that basis, different algorithms and scoring systems have been developed to guide the clinical assessment. The first scoring system implemented into the clinical practice was the Risk of Malignancy Index, which combines ultrasound evaluation, menopausal status, and serum CA-125 levels. Today, current guidelines regarding female patients with adnexal masses include the application of International Ovarian Tumours Analysis simple rules, logistic regression model 1 (LR1) and LR2, OVERA, cancer ovarii non-invasive assessment of treating strategy, and assessment of Different Neoplasias in the adnexa. In this scenario, the choice of the scoring system for the discrimination between benign and malignant ovarian tumours can be complex when approaching patients with adnexal masses. This review aims to summarise the available evidence regarding the different scoring systems to provide a complete overview of the topic.

Comparison of the predictive performance of risk of malignancy indexes 1-4, HE4 and risk of malignancy algorithm in the triage of adnexal masses

OBJECTIVES

For patients presenting with adnexal mass, it is important to correctly distinguish whether the mass is benign or malignant for the purpose of precise and timely referral and implication of correct line of management. The objective of this study was to evaluate the performance of Risk of malignancy Indexes (RMI) 1-4, Human Epididymis Protein 4 (HE4) and Risk of Malignancy Algorithm (ROMA) in differentiating the adnexal mass into benign and malignant.

METHODS

A retrospective study using 155 patients diagnosed with adnexal mass between January 2014 to December 2014 in The First Affiliated Hospital of Zhengzhou University was conducted. The patient records were assessed for age, menopausal status, serum CA125 and HE4 levels, ultrasound characteristics of the pelvic mass and the final pathological diagnosis of the mass. RMI1, RMI2, RMI3, RMI4, ROMA were calculated for each patient and the sensitivity, specificity and the Receiver Operating Characteristics (ROC) curves were determined for each test to evaluate their performance.

RESULTS

Among 155 patients with adnexal masses meeting inclusion criteria, 120 (77.4%) were benign, 8 (5.2%) borderline and 27 (17.4%) were malignant. RMI2 and RMI4 had the highest sensitivity (66.7%) while HE4 had the highest specificity (96.9%).Although ROMA had the highest area under the curve (AUC) of 0.886 it was not found to be statistically superior to the other tests. For epithelial ovarian cancers, ROMA (80%), HE4 (96.9%) and RMI 4 (0.868) had the highest sensitivity, specificity and AUC respectively however, the AUC characteristics were not statistically significant between any groups. Compared to the postmenopausal group (sensitivity 72.2-77.8%) all the tests showed lower sensitivity (42.9%) for the premenopausal group of patients.

CONCLUSIONS

RMI 1-4, ROMA and HE4 were all found to be useful for differentiating benign/borderline adnexal masses from malignant ones for deciding optimal therapy, however no test was found to be significantly better than the other. None were able to differentiate between benign and borderline tumors. All of the tests demonstrated increased sensitivity when borderline tumors were considered low-risk, and when only epithelial ovarian cancers were considered.

Ovarian-Adnexal Reporting Data System Magnetic Resonance Imaging (O-RADS MRI) Score for Risk Stratification of Sonographically Indeterminate Adnexal Masses

IMPORTANCE

Approximately one-quarter of adnexal masses detected at ultrasonography are indeterminate for benignity or malignancy, posing a substantial clinical dilemma.

OBJECTIVE

To validate the accuracy of a 5-point Ovarian-Adnexal Reporting Data System Magnetic Resonance Imaging (O-RADS MRI) score for risk stratification of adnexal masses.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study was conducted between March 1, 2013, and March 31, 2016. Among patients undergoing expectant management, 2-year follow-up data were completed by March 31, 2018. A routine pelvic MRI was performed among consecutive patients referred to characterize a sonographically indeterminate adnexal mass according to routine diagnostic practice at 15 referral centers. The MRI score was prospectively applied by 2 onsite readers and by 1 reader masked to clinical and ultrasonographic data. Data analysis was conducted between April and November 2018.

MAIN OUTCOMES AND MEASURES

The primary end point was the joint analysis of true-negative and false-negative rates according to the MRI score compared with the reference standard (ie, histology or 2-year follow-up).

RESULTS

A total of 1340 women (mean [range] age, 49 [18-96] years) were enrolled. Of 1194 evaluable women, 1130 (94.6%) had a pelvic mass on MRI with a reference standard (surgery, 768 [67.9%]; 2-year follow-up, 362 [32.1%]). A total of 203 patients (18.0%) had at least 1 malignant adnexal or nonadnexal pelvic mass. No invasive cancer was assigned a score of 2. Positive likelihood ratios were 0.01 for score 2, 0.27 for score 3, 4.42 for score 4, and 38.81 for score 5. Area under the receiver operating characteristic curve was 0.961 (95% CI, 0.948-0.971) among experienced readers, with a sensitivity of 0.93 (95% CI, 0.89-0.96; 189 of 203 patients) and a specificity of 0.91 (95% CI, 0.89-0.93; 848 of 927 patients). There was good interrater agreement among both experienced and junior readers (κ = 0.784; 95% CI, 0.743-0824). Of 580 of 1130 women (51.3%) with a mass on MRI and no specific gynecological symptoms, 362 (62.4%) underwent surgery. Of them, 244 (67.4%) had benign lesions and a score of 3 or less. The MRI score correctly reclassified the mass origin as nonadnexal with a sensitivity of 0.99 (95% CI, 0.98-0.99; 1360 of 1372 patients) and a specificity of 0.78 (95% CI, 0.71-0.85; 102 of 130 patients).

CONCLUSIONS AND RELEVANCE

In this study, the O-RADS MRI score was accurate when stratifying the risk of malignancy in adnexal masses.

[Pelvic Inflammatory Disease - Synergies between Family Practices and Gynaecological Specialised Assessment]

Pelvic Inflammatory Disease - Synergies between Family Practices and Gynaecological Specialised Assessment Abstract. The 'pelvic inflammatory disease' (PID) describes an ascending inflammation of the upper female genital tract, beginning with a local cervicitis and proceeding to endometritis and adnexitis. It is a common clinical picture with rising numbers in recent years, and it occurs both in gynaecological and general practice. The symptoms are often unspecific, discrete or althogehter lacking. In order to reduce long-term risks of chronic pelvic pain, sterility and/or ectopic pregnancies, rapid diagnosis followed by immediate therapy and a good interdisciplinary cooperation are necessary. Screening programs for chlamydia and gonococcus as the most common pathogens of PID have not yet been implemented in Switzerland so far.

Performance of IOTA ADNEX model in evaluating adnexal masses in a gynecological oncology center in China

OBJECTIVE

To evaluate the diagnostic accuracy of the International Ovarian Tumor Analysis (IOTA) Assessment of Different NEoplasias in the adneXa (ADNEX) model in the preoperative diagnosis of adnexal masses using data from a gynecological oncology center in China.

METHODS

This was a single-center, retrospective diagnostic accuracy study based on ultrasound data collected prospectively, between May and December 2017, from 278 patients with at least one adnexal (ovarian, paraovarian or tubal) mass. Clinical and pathologic information, serum CA 125 level and ultrasonographic findings were collected. All patients underwent surgery and the histopathological diagnosis was used as reference standard. The final diagnosis was classified into five tumor types according to the ADNEX model: benign ovarian tumor, borderline ovarian tumor (BOT), Stage-I ovarian cancer (OC), Stages-II-IV OC and ovarian metastasis. Receiver-operating characteristics (ROC) curve analysis was used to evaluate the diagnostic accuracy of the ADNEX model, with and without inclusion of CA 125 level in the model.

RESULTS

Of the 278 women included, 203 (73.0%) had a benign ovarian tumor and 75 (27.0%) had a malignant ovarian tumor, including 18 (6.5%) with BOT, 17 (6.1%) with Stage-I OC, 32 (11.5%) with Stages-II-IV OC and eight (2.9%) with ovarian metastasis. The performance of the IOTA ADNEX model was good for discriminating between benign and malignant tumors, with an area under the ROC curve (AUC) of 0.94 (95% CI, 0.91-0.97) when CA 125 was included in the model and AUC of 0.93 (95% CI, 0.90-0.96) without CA 125. The AUC values of the model including CA 125 ranged between 0.61 and 0.99 for distinguishing between the different types of tumor, and it showed excellent performance in discriminating between a benign ovarian tumor and Stages-II-IV OC, with an AUC of 0.99 (95% CI, 0.97-1.00). The performance of the model was less effective at distinguishing between BOT and Stage-I OC and between Stages-II-IV OC and ovarian metastasis, with AUC values of 0.61 (95% CI, 0.43-0.77) and 0.78 (95% CI, 0.62-0.90), respectively. Although inclusion of CA 125 did not alter the performance of the ADNEX model in discriminating between benign and malignant lesions (AUC of 0.94 and 0.93 with and without CA 125 level, respectively; P = 0.54), the inclusion of CA 125 in the model improved its performance in discriminating between Stage-I OC and Stages-II-IV OC (AUC increased from 0.81 to 0.92; P = 0.04) and between Stages-II-IV OC and metastatic cancer (AUC increased from 0.58 to 0.78; P = 0.01).

CONCLUSIONS

The IOTA ADNEX model showed good to excellent performance in distinguishing between benign and malignant adnexal masses and between the different types of ovarian tumor in a Chinese setting. Based on our findings, the ADNEX model has high value in clinical practice and can aid in the preoperative diagnosis of patients with an adnexal mass. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Feelings, thoughts and experiences of women diagnosed with adnexal mass: A qualitative study

Adnexal masses have a risk of malignancy, especially in postmenopausal women, thus affecting the physical, psychological, and social lives of women with such masses. In addition, patients require a long duration of hospitalization during treatment. In earlier studies, researchers have focused on the experiences of newly diagnosed women or the side effects of treatment. However, women's experiences during the hospitalization period have been ignored. In this study we explored the feelings, thoughts, experiences, and nursing care needs of women hospitalized with adnexal mass diagnosis. In this qualitative study, interviews were conducted with 11 women hospitalized for an adnexal mass or ovarian cancer diagnosis. The feelings, thoughts, and experiences of the women were negatively affected. They were more likely to rely on internal motivation and had lesser expectations of professional support. Thus, nurses should provide women with this diagnosis social support and facilitate their adaptation to the hospital. The diagnosis and treatment of adnexal masses is a complex process that requires teamwork. Therefore, navigator nurses can be of great help to women during their illness.

Methods of Assessing Ovarian Masses: International Ovarian Tumor Analysis Approach

There are many diagnostic methods to assist clinicians in assessing adnexal masses on ultrasound. After suggesting a standardized terminology and measurement technique to evaluate adnexal masses, the International Ovarian Tumor Analysis (IOTA) group has developed different strategies such as the Simple Rules and Assessment of Different Neoplasias in the adneXa (ADNEX) model, which have been shown to outperform other available methods. Besides differentiating between benign neoplasms and malignancies, the ADNEX model can also give the predicted risk for different subtypes of malignant adnexal masses, which is clinically very relevant for guiding patient management.

Evaluation of machine learning methods with Fourier Transform features for classifying ovarian tumors based on ultrasound images

Introduction

Ovarian tumors are the most common diagnostic challenge for gynecologists and ultrasound examination has become the main technique for assessment of ovarian pathology and for preoperative distinction between malignant and benign ovarian tumors. However, ultrasonography is highly examiner-dependent and there may be an important variability between two different specialists when examining the same case. The objective of this work is the evaluation of different well-known Machine Learning (ML) systems to perform the automatic categorization of ovarian tumors from ultrasound images.

Methods

We have used a real patient database whose input features have been extracted from 348 images, from the IOTA tumor images database, holding together with the class labels of the images. For each patient case and ultrasound image, its input features have been previously extracted using Fourier descriptors computed on the Region Of Interest (ROI). Then, four ML techniques are considered for performing the classification stage: K-Nearest Neighbors (KNN), Linear Discriminant (LD), Support Vector Machine (SVM) and Extreme Learning Machine (ELM).

Results

According to our obtained results, the KNN classifier provides inaccurate predictions (less than 60% of accuracy) independently of the size of the local approximation, whereas the classifiers based on LD, SVM and ELM are robust in this biomedical classification (more than 85% of accuracy).

Conclusions

ML methods can be efficiently used for developing the classification stage in computer-aided diagnosis systems of ovarian tumor from ultrasound images. These approaches are able to provide automatic classification with a high rate of accuracy. Future work should aim at enhancing the classifier design using ensemble techniques. Another ongoing work is to exploit different kind of features extracted from ultrasound images.

Development and validation of a model that includes two ultrasound parameters and the plasma D-dimer level for predicting malignancy in adnexal masses: an observational study

Background

Pre-operative discrimination of malignant from benign adnexal masses is crucial for planning additional imaging, preparation, surgery and postoperative care. This study aimed to define key ultrasound and clinical variables and develop a predictive model for calculating preoperative ovarian tumor malignancy risk in a gynecologic oncology referral center. We compared our model to a subjective ultrasound assessment (SUA) method and previously described models.

Methods

This prospective, single-center observational study included consecutive patients. We collected systematic ultrasound and clinical data, including cancer antigen 125, D-dimer (DD) levels and platelet count. Histological examinations served as the reference standard. We performed univariate and multivariate regressions, and Bayesian information criterion (BIC) to assess the optimal model. Data were split into 2 subsets: training, for model development (190 observations) and testing, for model validation (n = 100).

Results

Among 290 patients, 52% had malignant disease, including epithelial ovarian cancer (72.8%), metastatic disease (14.5%), borderline tumors (6.6%), and non-epithelial malignancies (4.6%). Significant variables were included into a multivariate analysis. The optimal model, included three independent factors: solid areas, the color score, and the DD level. Malignant and benign lesions had mean DD values of 2.837 and 0.354 μg/ml, respectively. We transformed established formulae into a web-based calculator (http://gin-onc-calculators.com/gynonc.php) for calculating the adnexal mass malignancy risk. The areas under the curve (AUCs) for models compared in the testing set were: our model (0.977), Simple Rules risk calculation (0.976), Assessment of Different NEoplasias in the adneXa (ADNEX) (0.972), Logistic Regression 2 (LR2) (0.969), Risk of Malignancy Index (RMI) 4 (0.932), SUA (0.930), and RMI3 (0.912).

Conclusions

Two simple ultrasound predictors and the DD level (also included in a mathematical model), when used by gynecologist oncologist, discriminated malignant from benign ovarian lesions as well or better than other more complex models and the SUA method. These parameters (and the model) may be clinically useful for planning adequate management in the cancer center. The model needs substantial validation.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5629-x) contains supplementary material, which is available to authorized users.

Prospective external validation of IOTA three-step strategy for characterizing and classifying adnexal masses and retrospective assessment of alternative two-step strategy using simple-rules risk

OBJECTIVES

To perform an external validation of the diagnostic performance of the three-step strategy proposed by the International Ovarian Tumor Analysis (IOTA) group for classifying adnexal masses as benign or malignant, when ultrasound is performed by non-expert sonographers in the first two steps. The second objective was to assess the diagnostic performance of an alternative strategy using simple-rules risk (SRR), instead of simple rules (SR), in the second step.

METHODS

This was a prospective observational study conducted at two university hospitals, from September 2015 to August 2017, of consecutive patients diagnosed with an adnexal mass. All women were evaluated by ultrasound using the IOTA three-step strategy. Non-expert sonographers performed the first step (use of simple descriptors to classify the masses) and the second step (use of SR if the mass could not be classified in the first step); masses that could not be classified in the first two steps were categorized by an expert sonographer based on their subjective assessment (third step). The reference standard was histological diagnosis in patients who underwent surgery or at least 12 months of follow-up in cases managed expectantly. The sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios and overall accuracy of the IOTA three-step strategy were estimated. Furthermore, we evaluated retrospectively an alternative two-step strategy using SRR in the second step to categorize the masses not classifiable with simple descriptors, classifying the lesions as being of low, intermediate or high risk for malignancy. The diagnostic performance of this strategy was estimated by calculating its sensitivity and specificity, assuming surgical intervention for intermediate- or high-risk lesions.

RESULTS

The study included 283 patients (median age, 48 (range, 18-90) years), of whom 165 (58.3%) were premenopausal and 118 (41.7%) postmenopausal. Two hundred and sixteen (76.3%) women underwent surgery (154 benign and 62 malignant masses) and 67 (23.7%) were managed expectantly with serial ultrasound follow-up for at least 12 months. All expectantly managed masses were considered benign because no sonographic changes suggestive of malignancy were observed during follow-up. Simple descriptors could be applied in 126 (44.5%) masses. Of the remaining 157 lesions, 112 (39.6%) could be characterized using SR. Therefore, 238 (84.1%) masses could be classified by non-expert sonographers in the first two steps. Of the remaining 45 (15.9%) masses, all could be classified by an expert sonographer. Overall sensitivity, specificity, LR+ and LR- of the IOTA three-step strategy were 95.2%, 97.7%, 42.1 and 0.05, respectively. The diagnostic accuracy was 97.2%. Following the two-step strategy using SRR in the second step, of the 157 lesions not classified with simple descriptors, 42, 38 and 77 presented low, intermediate or high risk for malignancy, respectively. Based on this method, 210 women would have undergone surgical treatment. The sensitivity and specificity of this two-step strategy were 98.4% and 63.8%, respectively.

CONCLUSIONS

The IOTA three-step strategy shows high accuracy for discriminating between benign and malignant adnexal lesions when used by non-expert sonographers. An alternative strategy using the SRR calculator in the second step might improve on this diagnostic performance by decreasing the number of surgical interventions and increasing sensitivity. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

The contribution and perspectives of proteomics to uncover ovarian cancer tumor markers

Despite all the advances in understanding the mechanisms involved in ovarian cancer (OC) development, many aspects still need to be unraveled and understood. Tumor markers (TMs) are of special interest in this disease. Some aspects of clinical management of OC might be improved by the use of validated TMs, such as differentiating subtypes, defining the most appropriate treatment, monitoring the course of the disease, or predicting clinical outcome. The Food and Drug Administration (FDA) has approved a few TMs for OC: CA125 (cancer antigen 125; monitoring), HE4 (Human epididymis protein; monitoring), ROMA (Risk Of Malignancy Algorithm; HE4+CA125; prediction of malignancy) and OVA1 (Vermillion's first-generation Multivariate Index Assay [MIA]; prediction of malignancy). Proteomics can help advance the research in the field of TMs for OC. A variety of biological materials are being used in proteomic analysis, among them tumor tissues, interstitial fluids, tumor fluids, ascites, plasma, and ovarian cancer cell lines. However, the discovery and validation of new TMs for OC is still very challenging. The enormous heterogeneity of histological types of samples and the individual variability of patients (lifestyle, comorbidities, drug use, and family history) are difficult to overcome in research protocols. In this work, we sought to gather relevant information regarding TMs, OC, biological samples for proteomic analysis, as well as markers and algorithms approved by the FDA for use in clinical routine.

[Diagnostic value of imaging (ultrasonography, doppler, CT, MR, PET-CT) for the diagnosis of a suspicious ovarian mass and staging of ovarian, tubal or primary peritoneal cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

Transvaginal ultrasound is the first-line examination allowing characterizing 80 to 90% of adnexal masses (LP1). If performed by an expert, a subjective analysis is optimal. If performed by a non-expert, combining the use of Simple Rules with subjective analysis can achieve the diagnostic performance of an expert (LP1). Whichever the chosen model (subjective analysis by an expert or combination of the Simple Rules with a subjective analysis by a non-expert), a second-line examination will have to be proposed in the complex or indeterminate cases (about 20% of the masses) (grade A). The best-performing second-line test for characterization is pelvic MRI (LP1). If read by an expert, a pathological hypothesis can or should be suggested (grade D). In case of non-expert reading, the use of the ADNEXMR score allows a reliable assessment of the positive predictive value of malignancy to guide the patient towards the best management (gradeC). For preoperative assessment and evaluation of resectability of ovarian, fallopian tube or primary peritoneal cancer, it is recommended to perform a chest abdomen and pelvis CT with contrast agent injection (LP2, grade B). In the event of a contraindication to the injection of iodinated contrast agent (severe renal insufficiency, GFR <30mL/min), an abdomen and pelvis MRI completed with a non-injected chest CT may be proposed (LP3, grade C). By analogy, the same examinations are recommended to evaluate the disease after neo-adjuvant chemotherapy (LP3, Recommendation grade C). Further studies will be required to determine whether PET-CT provides better lymph node assessment before retroperitoneal and pelvic lymphadenectomy. PET-CT may be used to eliminate lymph node involvement in the absence of suspicious lymph nodes on morphological examination (LP3, grade C). The report should specify the localizations leading to a risk of incomplete cytoreductive surgery and lesions outside the field explored during surgery.

Risk of Malignant Ovarian Cancer Based on Ultrasonography Findings in a Large Unselected Population

IMPORTANCE

The risk of malignant ovarian cancer associated with simple cysts is unknown.

OBJECTIVE

To quantify the risk of ovarian cancer based on ultrasonographic characteristics of ovarian masses, including simple cysts, in a large unselected population.

DESIGN, SETTING, AND PARTICIPANTS

This was a nested case-control study of patients enrolled in Kaiser Permanente Washington, a large integrated health care system in Washington State. Participants were 72 093 women who underwent pelvic ultrasonography between January 1, 1997, and December 31, 2008. Analysis was completed in April 2017.

EXPOSURES

Ultrasonographic characteristics of ovarian masses measured in 1043 women, and also, using weights derived from the sampling strategy, estimated frequencies for the entire cohort.

MAIN OUTCOMES AND MEASURES

Malignant ovarian cancer, identified through December 31, 2011, by cancer registry linkage.

RESULTS

Among 210 women who were diagnosed as having ovarian cancer, 49 were younger than 50 years, and 161 were 50 years or older. Ultrasonography findings were predictive of cancer (C statistic, 0.89). The risk of cancer was significantly elevated in women with complex cysts or solid masses, with likelihood ratios relative to women with normal ovaries ranging from 8 to 74 and the 3-year risk of cancer ranging from 9 to 430 cases per 1000 women based on patient age and ultrasonography findings. In contrast, the 23.8% of women younger than 50 years and the 13.4% of women 50 years or older with simple cysts were not at a significantly increased risk of ovarian cancer compared with women with normal ovaries. Likelihood ratios associated with the detection of a simple cyst were 0.00 in women younger than 50 years (no cancers were identified) and 0.10 (95% CI, 0.01-0.48) in women 50 years or older, and the absolute 3-year risk of cancer ranged from 0 to 0.5 cases per 1000 women.

CONCLUSIONS AND RELEVANCE

According to this study, the ultrasonographic appearance of ovarian masses is strongly associated with a woman's risk of ovarian cancer. Simple cysts are not associated with an increased risk of ovarian cancer, whereas complex cysts or solid masses are associated with a significantly increased risk of ovarian cancer.

Factors associated with misdiagnosis of frozen section of mucinous borderline ovarian tumor

Objective

This study was performed to investigate the diagnostic accuracy of frozen section (FS) of mucinous borderline ovarian tumors (mBOTs) and the diagnostic value of various risk factors for misdiagnosis.

Methods

Patients with either an FS or permanent pathologic diagnosis of mBOT were included. Optimum cut-off values for serum tumor markers and maximal tumor diameter were determined, and risk factors for underdiagnosis of mucinous malignant ovarian tumors (mMOTs) were evaluated. The sensitivity, specificity, Youden’s index, and diagnostic odds ratio of the risk factors were assessed to determine their diagnostic value for mMOTs.

Results

Of 121 included patients, 97 were diagnosed with mBOTs by FS. Relatively abnormal cancer antigen 125 (CA125), carbohydrate antigen 19-9 (CA19-9), and carcinoembryonic antigen (CEA) levels; bilateral tumors; and specific pathological features showed significant associations with underdiagnosis of mMOTs in the univariate analysis. The presence of specific pathological features was the only significant risk factor in the multivariate analysis. The CA125, CA19-9, and CEA levels and specific pathological features demonstrated certain diagnostic value in detecting malignant cases among FS-diagnosed mBOTs.

Conclusions

In patients with FS-diagnosed mBOT, significant predictors of malignancy were relatively higher CA125, CA19-9, and CEA levels; bilateral tumors; and tumors with specific pathological features.

Association between the sonographer's experience and diagnostic performance of IOTA simple rules

Background

To validate the clinical value of simple rules in distinguishing malignant adnexal masses from benign ones and to explore the effect of simple rules for experienced and less-experienced sonographers.

Methods

Patients with persistent adnexal masses were enrolled between November 2013 and December 2015. All masses were proven through histological examinations. Five sets of diagnoses were made and compared with one another. Diagnosis 1 was made, according to the simple rules, by a trainee with little clinical diagnostic experience. Diagnoses 2 and 3 were made by experienced and less-experienced sonographers, respectively, according to their clinical experiences. With diagnosis 1 as a reference, the two sonographers were asked to provide a second diagnosis, which were diagnoses 4 and 5. The efficiency of the five sets of diagnoses was compared using ROC curves.

Results

In total, 75 malignant (37.7%) and 124 benign lesions (62.3%) were enrolled in this study. The mean diameter of the benign masses was obviously smaller than that of the malignant ones (6.8 ± 3.4 cm vs. 9.3 ± 4.9 cm, p < 0.01). The malignant ratio in postmenopausal women was much higher (66.1%) than that in the premenopausal population (25.7%) (p < 0.0001). Totally, 156 of the 199 cases (79.4%) resulted in conclusive diagnoses. Sensitivity and specificity were 98.4% and 73.9%, respectively, among the conclusive cases. The area under the ROC curve (Az) for the simple rule diagnosis was significantly lower than that for the experienced sonographer diagnosis (0.85 vs. 0.96, p < 0.0001); compared with the less-experienced sonographer, this difference was not significant (0.85 vs. 0.86, p = 0.9776). No significant difference was found in the comparison between the diagnoses made by the experienced sonographer before and after referencing the simple rule diagnosis (Az, 0.96 vs. 0.97, p = 0.2055). Using diagnosis 1 as a reference, the diagnostic performance of the less-experienced sonographer increased (from 0.86 to 0.92, p = 0.012); however, it was still lower than that of the experienced sonographer (Az, 96% vs. 92%, p = 0.0241).

Conclusions

The simple rules was an appealing method for discriminating malignant masses from benign ones, particularly for a less-experienced sonographer.

Correlation of ultrasound features and the Risk of Ovarian Malignancy Algorithm score for different histopathological subtypes of benign adnexal masses

Ovarian masses are one of the most frequently identified entities in gynecological practice. Early differential diagnosis is a key factor in the medical management of each patient. Transvaginal ultrasound along with additional preoperative testing, such as serum cancer antigen 125 (CA-125) levels and the Risk of Ovarian Malignancy Algorithm (ROMA) score, usually provide sufficient information for a presumptive diagnosis. Minimally invasive surgery as a therapeutic approach is the standard procedure for uncomplicated and benign adnexal masses. Histopathological examination alone, or in conjunction with immunohistochemical testing establishes a more certain diagnosis in the final step of the patient management plan. We developed a retrospective descriptive observational study based on the evaluation of 107 patients admitted to the Department of Obstetrics and Gynecology at "Sf Pantelimon" Clinical Emergency Hospital in Bucharest between January 2000 and July 2017. Each patient was diagnosed with an ovarian mass and underwent laparoscopic surgery for treatment. All data underwent descriptive statistical analysis in order to establish correlations between preoperative test results and definitive diagnoses. The typical ultrasound findings of endometriotic cysts were histopathologically confirmed in 52.6% of the examined patients. Using ultrasound, benign teratomas were suspected in 66.6% of all documented dermoid cysts and 90% of the patients with a calculated ROMA score had corresponding values less than 15%. Mean CA-125 value was 26.58 U/mL. Laparoscopic surgery with ovarian cystectomy was performed for 78.5% of the cases. Histopathological examinations established endometriosis was present in 26.16% of cases. According to an independent samples t test (with 2 extreme values eliminated), patients in the premenopausal group had a significantly lower mean ROMA score than postmenopausal patients (6.87% vs 20.98%, respectively; P < .001). The groups had similar homogeneity (P = .131 according to the Levene test). Our results showed that transvaginal ultrasound established a presumptive diagnosis for almost half of our patients. Cystectomy was the main surgical procedure used for the management of benign ovarian masses. Endometriosis was the most common benign ovarian pathology evaluated and treated in our study.

Pelvic Inflammatory Disease: Possible Catches and Correct Management in Young Women

The incidence of adnexal masses increases exponentially with age and the most frequent causes in young women are physiologic cysts and pelvic abscesses with pelvic inflammatory disease (PID). Clinical examination can direct physicians to an appropriate management of adnexal mass, but the role of transvaginal ultrasound is crucial for diagnosis and treatment decision, even if it sometimes can be misleading, especially in young women. Ca 125, blood count, and CRP are useful to clarify suspected etiology of a pelvic mass, but specificity and positive predictive value are low because elevation of laboratory tests may occur in several benign conditions. In our work we present four cases of suspected pelvic masses. Despite guidelines for management of PID, the right timing to switch to surgical therapy is not clear. Therefore, the treatment decision should be based on a careful evaluation of various parameters such as signs symptoms and above all age. Moreover, we believe that, for a correct diagnosis and for the best fertility sparing treatment, it is also extremely important to refer to a gynecological oncology unit with an expert surgeon.

Economic evaluation of an expert examiner and different ultrasound models in the diagnosis of ovarian cancer

The Risk of Malignancy Index (RMI) is commonly used to diagnose adnexal masses. The aim of the present study was to determine the cost-effectiveness of the RMI compared with subjective assessment (SA) by an expert and the following novel ultrasound models: Cost-effectiveness and budget impact analyses were performed from a societal perspective. A decision tree was constructed, and short-term costs and effects were examined in women with adnexal masses. Sensitivity, specificity and the costs of diagnostic strategies were incorporated. Incremental cost-effectiveness ratios were expressed as costs/additional percentage of correctly diagnosed patients. Probabilistic and deterministic sensitivity analyses were performed. Effectiveness was highest for SA (90.7% [95% confidence interval = 77.3-100]), with a cost saving of 5.0% (-€398 per patient [-€1403 to 549]) compared with the RMI. The costs of SR + SA were the lowest (€7180 [6072-8436]), resulting in a cost saving of 9.0% (-€709 per patient [-€1628 to 236]) compared with the RMI, with an effectiveness of 89.6% (75.8-100). SR + SA showed the highest probability of being the most cost-effective when willingness-to-pay was <€350 per additional percentage of correctly diagnosed patients. The RMI had low cost-effectiveness probabilities (<3%) and was inferior to SA, SR + SA and LR2. Budget impact in the Netherlands compared with that of the RMI varied between a cost saving of €4.67 million for SR + SA and additional costs of €3.83 million when implementing ADNEX (cut-off: 10%). The results were robust when tested in sensitivity analyses. Although SA is the best strategy in terms of diagnostic accuracy, SR + SA might be preferred from a cost-effectiveness perspective.

Prospective evaluation of IOTA logistic regression models LR1 and LR2 in comparison with subjective pattern recognition for diagnosis of ovarian cancer in an outpatient setting

OBJECTIVE

To determine whether International Ovarian Tumor Analysis (IOTA) logistic regression models LR1 and LR2 developed for the preoperative diagnosis of ovarian cancer could also be used to differentiate between benign and malignant adnexal tumors in the population of women attending gynecology outpatient clinics.

METHODS

This was a single-center prospective observational study of consecutive women attending our gynecological diagnostic outpatient unit, recruited between May 2009 and January 2012. All the women were first examined by a Level-II ultrasound operator. In those diagnosed with adnexal tumors, the IOTA-LR1/2 protocol was used to evaluate the masses. The LR1 and LR2 models were then used to assess the risk of malignancy. Subsequently, the women were also examined by a Level-III examiner, who used pattern recognition to differentiate between benign and malignant tumors. Women with an ultrasound diagnosis of malignancy were offered surgery, while asymptomatic women with presumed benign lesions were offered conservative management with a minimum follow-up of 12 months. The initial diagnosis was compared with two reference standards: histological findings and/or a comparative assessment of tumor morphology on follow-up ultrasound scans. All women for whom the tumor classification on follow-up changed from benign to malignant were offered surgery.

RESULTS

In the final analysis, 489 women who had either or both of the reference standards were included. Their mean age was 50 years (range, 16-91 years) and 45% were postmenopausal. Of the included women, 342/489 (69.9%) had surgery and 147/489 (30.1%) were managed conservatively. The malignancy rate was 137/489 (28.0%). Overall, sensitivities of LR1 and LR2 for the diagnosis of malignancy were 97.1% (95% CI, 92.7-99.2%) and 94.9% (95% CI, 89.8-97.9%) and specificities were 77.3% (95% CI, 72.5-81.5%) and 76.7% (95% CI, 71.9-81.0%), respectively (P > 0.05). In comparison with pattern recognition (sensitivity 94.2% (95% CI, 88.8-97.4%), specificity 96.3% (95% CI, 93.8-98.0%)), the specificities of the IOTA models were significantly lower (P < 0.0001). A significantly higher number of women would have been offered surgery for suspected cancer if the women had been assessed using the IOTA models instead of pattern recognition (213/489 (43.6%) vs 142/489 (29.0%); P < 0.001).

CONCLUSIONS

The IOTA models maintained their high sensitivity when used in an outpatient setting. Specificity was relatively low, which indicates that a significant proportion of the women would have been offered unnecessary surgery for suspected ovarian cancer. These findings show that the IOTA models could be used as a first-stage test to diagnose ovarian cancer in an outpatient setting, but a different second-stage test is required to minimize the number of false-positive findings. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

PRRT genomic signature in blood for prediction of 177Lu-octreotate efficacy

BACKGROUND

Peptide receptor radionuclide therapy (PRRT) utilizes somatostatin receptor (SSR) overexpression on neuroendocrine tumors (NET) to deliver targeted radiotherapy. Intensity of uptake at imaging is considered related to efficacy but has low sensitivity. A pretreatment strategy to determine individual PRRT response remains a key unmet need. NET transcript expression in blood integrated with tumor grade provides a PRRT predictive quotient (PPQ) which stratifies PRRT "responders" from "non-responders". This study clinically validates the utility of the PPQ in NETs.

METHODS

The development and validation of the PPQ was undertaken in three independent ¹⁷⁷Lu-PRRT treated cohorts. Specificity was tested in two separate somatostatin analog-treated cohorts. Prognostic value of the marker was defined in a cohort of untreated patients. The developmental cohort included lung and gastroenteropancreatic [GEP] NETs (n = 72) from IRST Meldola, Italy. The majority were GEP (71%) and low grade (86% G1-G2). Prospective validation cohorts were from Zentralklinik Bad Berka, Germany (n = 44), and Erasmus Medical Center, Rotterdam, Netherlands (n = 42). Each cohort included predominantly well differentiated, low grade (86-95%) lung and GEP-NETs. The non-PRRT comparator cohorts included SSA cohort I, n = 28 (100% low grade, 100% GEP-NET); SSA cohort II, n = 51 (98% low grade; 76% GEP-NET); and an untreated cohort, n = 44 (64% low grade; 91% GEP-NET). Baseline evaluations included clinical information (disease status, grade, SSR) and biomarker (CgA). NET blood gene transcripts (n = 8: growth factor signaling and metabolism) were measured pre-therapy and integrated with tumor Ki67 using a logistic regression model. This provided a binary output: "predicted responder" (PPQ+); "predicted non-responder" (PPQ-). Treatment response was evaluated using RECIST criteria [Responder (stable, partial and complete response) vs Non-Responder)]. Sample measurement and analyses were blinded to study outcome. Statistical evaluation included Kaplan-Meier survival and standard test evaluation analyses.

RESULTS

In the developmental cohort, 56% responded to PRRT. The PPQ predicted 100% of responders and 84% of non-responders (accuracy: 93%). In the two validation cohorts (response: 64-79%), the PPQ was 95% accurate (Bad Berka: PPQ + =97%, PPQ- = 93%; Rotterdam: PPQ + =94%, PPQ- = 100%). Overall, the median PFS was not reached in PPQ+ vs PPQ- (10-14 months; HR: 18-77, p < 0.0001). In the comparator cohorts, the predictor (PPQ) was 47-50% accurate for SSA-treatment and 50% as a prognostic. No differences in PFS were respectively noted (PPQ+: 10-12 months vs. PPQ-: 9-15 months).

CONCLUSION

The PPQ derived from circulating NET specific genes and tumor grade prior to the initiation of therapy is a highly specific predictor of the efficacy of PRRT with an accuracy of 95%.

Ovarian mass-differentiating benign from malignant: the value of the International Ovarian Tumor Analysis ultrasound rules

Ovarian cancer, the fifth most common cause of cancer death among women, has the highest mortality rate of all gynecologic cancers. General survival rate is <50% but can reach 90% if disease is detected early. Ultrasound is presently the best modality to differentiate between benign and malignant status. The patient with a malignant mass should be referred to an oncology surgeon since results have been shown to be superior to treatment by a specialist. Several ultrasound-based scoring systems exist for assessing the risk of an ovarian tumor to be malignant. The International Ovarian Tumor Analysis group published 2 such systems: the ultrasound Simple Rules and the Assessment of Different NEoplasias in the adneXa model. The Simple Rules classifies a tumor as benign, malignant, or indeterminate and the Assessment of Different NEoplasias in the adneXa model determines the risk for a tumor to be benign or malignant and, if malignant, the risk of various stages. Sensitivity of the Simple Rules and Assessment of Different NEoplasias in the adneXa model (using a cut-off of 10% to predict malignancy) are 92% and 96.5%, respectively, and specificities are 96% and 71.3%, respectively. These models are the best predictive tests for the preoperative classification of adnexal tumors. Their intent is to help the specialist make management decisions when faced with a patient with a persistent ovarian mass. The models are simple, are easy to use, and have been validated in multiple reports but not in the United States. We suggest they should be validated and widely introduced into medical practice in the United States.

Diagnostic accuracy and cost-effectiveness of different strategies to triage women with adnexal masses: a prospective study

OBJECTIVE

Transvaginal sonography (TVS) and serum biomarkers are used widely in clinical practice to triage women with adnexal masses, but the effectiveness of current biomarkers is weak. The aim of this study was to determine the best method of diagnosing patients with adnexal masses, in terms of diagnostic accuracy and economic costs, among four triage strategies: (1) the International Ovarian Tumor Analysis group's simple rules (SR) for interpretation of TVS with subjective assessment (SA) by an experienced ultrasound operator when TVS results are inconclusive (referred to hereafter as SR ± SA), (2) SR ± SA and cancer antigen 125 (CA 125), (3) SR ± SA and human epididymis protein 4 (HE4) and (4) SR ± SA and the risk of malignancy algorithm (ROMA). Our main hypothesis was that the addition of the biomarkers to SR ± SA could improve triaging of these patients in terms of diagnostic accuracy (i.e. malignant vs benign). As secondary analyses, we estimated the cost effectiveness of the four strategies and the diagnostic accuracy of SR ± SA at the study hospitals.

METHODS

Between February 2013 and January 2015, 447 consecutive patients who were scheduled for surgery for an adnexal mass at the S. Anna and Mauriziano Hospitals in Turin were enrolled in this multicenter prospective cohort study. Preoperative TVS was performed and preoperative CA 125 and HE4 levels were measured. Pathology reports were used to assess the diagnostic accuracy of the four triage strategies and the cost of each strategy was calculated.

RESULTS

A total of 391 patients were included in the analysis: 57% (n = 221) were premenopausal and 43% (n = 170) were postmenopausal. The overall prevalence of malignancy was 21%. SR were conclusive in 89% of patients and thus did not require SA; the overall performance of SR ± SA showed a sensitivity of 82%, specificity of 92% and positive and negative predictive values and positive and negative likelihood ratios of 74%, 95%, 10.5 and 0.19, respectively. In premenopausal women, mean cost among the four triage strategies varied from €36.41 for SR ± SA to €70.12 for SR ± SA + ROMA. The addition of biomarkers to SR ± SA showed no diagnostic advantage compared with SR ± SA alone and was more costly. Among postmenopausal women, mean cost among the four triage strategies varied from €39.52 for SR ± SA to €73.23 for SR ± SA + ROMA. Among these women, SR ± SA + CA 125 and SR ± SA + ROMA had a higher sensitivity (both 92% (95% CI, 85-99%)) than SR ± SA (81% (95% CI, 71-91%)), but SR ± SA had a higher specificity (84% (95% CI, 77-91%)). SR ± SA + CA 125 and SR ± SA + ROMA improved diagnostic accuracy, each diagnosing a third more malignant adnexal masses. In postmenopausal women, compared with SR ± SA alone, SR ± SA + CA 125 showed a net reclassification improvement (NRI) of 28.8% at an extra cost of €13.00, while the extra cost for SR ± SA + ROMA was €33.71, with a comparable gain, in terms of NRI, as that of SR ± SA + CA 125.

CONCLUSIONS

In our study sample, SR ± SA seems to be the best strategy to triage women with adnexal masses for surgical management. Among postmenopausal women, SR ± SA + CA 125 increased the NRI at a reasonable extra cost. Our data do not justify the use of HE4 and ROMA in the initial triage of women with adnexal masses. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Development of a tool for prediction of ovarian cancer in patients with adnexal masses: Value of plasma fibrinogen

Objective

To develop a tool for individualized risk estimation of presence of cancer in women with adnexal masses, and to assess the added value of plasma fibrinogen.

Study design

We performed a retrospective analysis of a prospectively maintained database of 906 patients with adnexal masses who underwent cystectomy or oophorectomy. Uni- and multivariate logistic regression analyses including pre-operative plasma fibrinogen levels and established predictors were performed. A nomogram was generated to predict the probability of ovarian cancer. Internal validation with split-sample analysis was performed. Decision curve analysis (DCA) was then used to evaluate the clinical net benefit of the prediction model.

Results

Ovarian cancer including borderline tumours was found in 241 (26.6%) patients. In multivariate analysis, elevated plasma fibrinogen, elevated CA-125, suspicion for malignancy on ultrasound, and postmenopausal status were associated with ovarian cancer and formed the basis for the nomogram. The overall predictive accuracy of the model, as measured by AUC, was 0.91 (95% CI 0.87–0.94). DCA revealed a net benefit for using this model for predicting ovarian cancer presence compared to a strategy of treat all or treat none.

Conclusion

We confirmed the value of plasma fibrinogen as a strong predictor for ovarian cancer in a large cohort of patients with adnexal masses. We developed a highly accurate multivariable model to help in the clinical decision-making regarding the presence of ovarian cancer. This model provided net benefit for a wide range of threshold probabilities. External validation is needed before a recommendation for its use in routine practice can be given.

Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses

Adnexal masses (ie, masses of the ovary, fallopian tube, or surrounding tissues) commonly are encountered by obstetrician-gynecologists and often present diagnostic and management dilemmas. Most adnexal masses are detected incidentally on physical examination or at the time of pelvic imaging. Less commonly, a mass may present with symptoms of acute or intermittent pain. Management decisions often are influenced by the age and family history of the patient. Although most adnexal masses are benign, the main goal of the diagnostic evaluation is to exclude malignancy. The purpose of this document is to provide guidelines for the evaluation and management of adnexal masses in adolescents, pregnant women, and nonpregnant women and to outline criteria for the identification of adnexal masses that are likely to be malignant and may warrant referral to or consultation with a gynecologic oncologist.

Validation of the Performance of International Ovarian Tumor Analysis (IOTA) Methods in the Diagnosis of Early Stage Ovarian Cancer in a Non-Screening Population

Background: The aim of this study was to assess and compare the performance of different ultrasound-based International Ovarian Tumor Analysis (IOTA) strategies and subjective assessment for the diagnosis of early stage ovarian malignancy. Methods: This is a secondary analysis of a prospective multicenter cross-sectional diagnostic accuracy study that included 1653 patients recruited at 18 centers from 2009 to 2012. All patients underwent standardized transvaginal ultrasonography by experienced ultrasound investigators. We assessed test performance of the IOTA Simple Rules (SRs), Simple Rules Risk (SRR), the Assessment of Different NEoplasias in the adneXa (ADNEX) model and subjective assessment to discriminate between stage I-II ovarian cancer and benign disease. Reference standard was histology after surgery. Results: 230 (13.9%) patients proved to have stage I–II primary invasive ovarian malignancy, and 1423 (86.1%) had benign disease. Sensitivity and specificity with respect to malignancy (95% confidence intervals) of the original SRs (classifying all inconclusive cases as malignant) were 94.3% (90.6% to 96.7%) and 73.4% (71.0% to 75.6%). Subjective assessment had a sensitivity and specificity of 90.0% (85.4% to 93.2%) and 86.7% (84.9% to 88.4%), respectively. The areas under the receiver operator characteristic curves of SRR and ADNEX were 0.917 (0.902 to 0.933) and 0.905 (0.920 to 0.934), respectively. At a 1% risk cut-off, sensitivity and specificity for SRR were 100% (98.4% to 100%) and 38.0% (35.5% to 40.6%), and for ADNEX were 100% (98.4% to 100%) and 19.4% (17.4% to 21.5%). At a 30% risk cut-off, sensitivity and specificity for SRR were 88.3% (83.5% to 91.8%) and 81.1% (79% to 83%), and for ADNEX were 84.5% (80.5% to 89.6%) and 84.5% (82.6% to 86.3%). Conclusion: This study shows that all three IOTA strategies have good ability to discriminate between stage I-II ovarian malignancy and benign disease.

Performance of the IOTA ADNEX model in preoperative discrimination of adnexal masses in a gynecological oncology center

OBJECTIVE

To evaluate the performance of the International Ovarian Tumor Analysis (IOTA) ADNEX model in the preoperative discrimination between benign ovarian (including tubal and para-ovarian) tumors, borderline ovarian tumors (BOT), Stage I ovarian cancer (OC), Stage II-IV OC and ovarian metastasis in a gynecological oncology center in Brazil.

METHODS

This was a diagnostic accuracy study including 131 women with an adnexal mass invited to participate between February 2014 and November 2015. Before surgery, pelvic ultrasound examination was performed and serum levels of tumor marker CA 125 were measured in all women. Adnexal masses were classified according to the IOTA ADNEX model. Histopathological diagnosis was the gold standard. Receiver-operating characteristics (ROC) curve analysis was used to determine the diagnostic accuracy of the model to classify tumors into different histological types.

RESULTS

Of 131 women, 63 (48.1%) had a benign ovarian tumor, 16 (12.2%) had a BOT, 17 (13.0%) had Stage I OC, 24 (18.3%) had Stage II-IV OC and 11 (8.4%) had ovarian metastasis. The area under the ROC curve (AUC) was 0.92 (95% CI, 0.88-0.97) for the basic discrimination between benign vs malignant tumors using the IOTA ADNEX model. Performance was high for the discrimination between benign vs Stage II-IV OC, BOT vs Stage II-IV OC and Stage I OC vs Stage II-IV OC, with AUCs of 0.99, 0.97 and 0.94, respectively. Performance was poor for the differentiation between BOT vs Stage I OC and between Stage I OC vs ovarian metastasis with AUCs of 0.64.

CONCLUSION

The majority of adnexal masses in our study were classified correctly using the IOTA ADNEX model. On the basis of our findings, we would expect the model to aid in the management of women with an adnexal mass presenting to a gynecological oncology center. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Estimating risk of malignancy in adnexal masses: external validation of the ADNEX model and comparison with other frequently used ultrasound methods

OBJECTIVES

To validate externally the performance of the Assessment of Different NEoplasias in the adneXa (ADNEX) model and compare this model with other frequently used models in the differentiation between benign and malignant adnexal masses.

METHODS

In this retrospective diagnostic accuracy study, we assessed data collected prospectively from patients with adnexal pathology who underwent real-time transvaginal or transrectal ultrasound by a single expert ultrasonographer in a tertiary care hospital between July 2011 and July 2015. The presence of a malignancy was determined by subjective assessment and use of four prediction models: the ADNEX model, simple ultrasound-based rules (simple rules), Logistic Regression model 2 (LR2) and the Risk of Malignancy Index (RMI), of which three different variants were assessed. Pathology was the clinical reference standard.

RESULTS

In total, 851 consecutive patients underwent ultrasound examination for an adnexal mass. For 326 patients (128 premenopausal and 198 postmenopausal), pathology results were available (211 (64.7%) benign; 115 (35.3%) malignant) and these were included in the analysis. The area under the receiver-operating characteristics curve (AUC) of the ADNEX model for the discrimination between benign and malignant tumors was 0.93 (95% CI, 0.89-0.95). AUCs for the subtypes of malignancy (i.e. borderline, Stage I-IV and metastatic adnexal tumors) ranged between 0.60 and 0.90. Only subjective assessment (AUC, 0.96 (95% CI, 0.93-0.98)) was superior to the ADNEX model (P = 0.01) in differentiating malignant from benign tumors. AUCs for the other models were 0.92 (95% CI, 0.89-0.95) for LR2, 0.85 (95% CI, 0.81-0.89) for RMI-I, 0.82 (95% CI, 0.77-0.86) for RMI-II and 0.84 (95% CI, 0.80-0.88) for RMI-III. At the proposed cut-off of ≥ 10%, the ADNEX model had the highest sensitivity (0.98 (95% CI, 0.93-1.00)) but the lowest specificity (0.62 (95% CI, 0.55-0.68)) compared with the other models. Both subjective assessment (sensitivity, 0.90 (95% CI, 0.83-0.95); specificity 0.91 (95% CI, 0.86-0.94)) and the simple rules model with inconclusive cases classified by subjective assessment (sensitivity, 0.89 (95% CI, 0.81-0.94); specificity, 0.90 (95% CI, 0.85-0.94)) had lower sensitivity, but their sensitivity and specificity were better balanced.

CONCLUSIONS

Although the test performance of subjective assessment by an expert remains superior, the ADNEX model can help in the differentiation between benign and malignant ovarian tumors. The advantage of the ADNEX model as a polytomous model remains to be shown. © 2016 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Clinical Utility of Risk Models to Refer Patients with Adnexal Masses to Specialized Oncology Care: Multicenter External Validation Using Decision Curve Analysis

Purpose: To evaluate the utility of preoperative diagnostic models for ovarian cancer based on ultrasound and/or biomarkers for referring patients to specialized oncology care. The investigated models were RMI, ROMA, and 3 models from the International Ovarian Tumor Analysis (IOTA) group [LR2, ADNEX, and the Simple Rules risk score (SRRisk)].Experimental Design: A secondary analysis of prospectively collected data from 2 cross-sectional cohort studies was performed to externally validate diagnostic models. A total of 2,763 patients (2,403 in dataset 1 and 360 in dataset 2) from 18 centers (11 oncology centers and 7 nononcology hospitals) in 6 countries participated. Excised tissue was histologically classified as benign or malignant. The clinical utility of the preoperative diagnostic models was assessed with net benefit (NB) at a range of risk thresholds (5%-50% risk of malignancy) to refer patients to specialized oncology care. We visualized results with decision curves and generated bootstrap confidence intervals.Results: The prevalence of malignancy was 41% in dataset 1 and 40% in dataset 2. For thresholds up to 10% to 15%, RMI and ROMA had a lower NB than referring all patients. SRRisks and ADNEX demonstrated the highest NB. At a threshold of 20%, the NBs of ADNEX, SRrisks, and RMI were 0.348, 0.350, and 0.270, respectively. Results by menopausal status and type of center (oncology vs. nononcology) were similar.Conclusions: All tested IOTA methods, especially ADNEX and SRRisks, are clinically more useful than RMI and ROMA to select patients with adnexal masses for specialized oncology care. Clin Cancer Res; 23(17); 5082-90. ©2017 AACR.

First International Consensus Report on Adnexal Masses: Management Recommendations

The First International Consensus Conference on Adnexal Masses was convened to thoroughly examine the state of the science and to formulate recommendations for clinical assessment and management. The panel included representatives of societies in the fields of gynecology, gynecologic oncology, radiology, and pathology and clinicians from Europe, Canada, and the United States. In the United States, there are approximately 9.1 surgeries per malignancy compared to the European International Ovarian Tumor Analysis center trials, with only 2.3 (oncology centers) and 5.9 (other centers) reported surgeries per malignancy, suggesting that there is room to improve our preoperative assessments. The American College of Obstetricians and Gynecologists Practice Bulletin on "Management of Adnexal Masses," reaffirmed in 2015 (Obstet Gynecol 2007; 110:201-214), still states, "With the exception of simple cysts on a transvaginal ultrasound finding, most pelvic masses in postmenopausal women will require surgical intervention." The panel concluded that patients would benefit not only from a more conservative approach to many benign adnexal masses but also from optimization of physician referral patterns to a gynecologic oncologist in cases of suspected ovarian malignancies. A number of next-step options were offered to aid in management of cases with sonographically indeterminate adnexal masses. This process would provide an opportunity to improve risk stratification for indeterminate masses via the provision of alternatives, including but not limited to evidence-based risk-assessment algorithms and referral to an "expert sonologist" or to a gynecologic oncologist. The panel believed that these efforts to improve clinical management and preoperative triage patterns would ultimately improve patient care.

Reliability of preoperative evaluation of postmenopausal ovarian tumors

Background

Preoperative evaluation of ovarian tumors is challenging. This study was undertaken to evaluate the performance of conventional two-dimensional (2D) ultrasound and CA125 in predicting malignant or benign nature of pelvic masses, and to investigate if three-dimensional power Doppler (3DPD) ultrasound provides any added value. Ninety-six postmenopausal and four perimenopausal women with supposed ovarian tumors were examined by standardized 2D and 3DPD ultrasounds preoperatively. The tumors were evaluated using the risk of malignancy index (RMI), International Ovarian Tumors Analysis (IOTA) group simple rules, expert opinion, IOTA logistic regression model 2 (LR2) and 3D vascular indices, and were postoperatively compared to histopathological results.

Results

Ninety-eight tumors turned out to be ovarian in origin. Of these, 66 were benign and 32 malignant. RMI (cut-off value 200), simple rules, expert opinion and LR2 (cut-off value 25) were used to predict malignant nature of the tumors and had sensitivities of 71.9, 90.6, 87.5 and 90.6%, and specificities of 80.3, 84.6, 92.4 and 77.3%, respectively. When the 3D vascularization flow index (VFI) was added to RMI and LR2, the accuracy of the test improved from 77.6 to 81.4% and from 81.6 to 86.5%, respectively, at the expense of sensitivity, while VFI gave no added benefit for simple rules and expert opinion. Agreement between two examiners using expert opinion was good (Cohen’s kappa = 0.89).

Conclusions

The subjective opinion of an expert seems to be the most reliable method in assessing ovarian tumors, and the 3DPD indices seem to provide no significant added value.

Comparison of two protocols for the management of asymptomatic postmenopausal women with adnexal tumours - a randomised controlled trial of RMI/RCOG vs Simple Rules

BACKGROUND

Adnexal tumours are frequently diagnosed in asymptomatic postmenopausal women due to more liberal use of modern high-resolution imaging. This study's objective was to determine if there would be a difference in the intervention rates when using the Simple Rules Management Protocol (SRMP) as compared to the Risk of Malignancy Index in the Royal College of Obstetricians and Gynaecologists guideline (RMI/RCOG).

METHODS

This was a prospective randomised controlled trial with the participants and the researchers non-blinded, and the surgeons and pathologists blinded. We recruited pain-free postmenopausal women who were diagnosed with an adnexal tumour on ultrasound scan. Women were randomised to either of the two protocols, which then determined if they were offered conservative or surgical management. An intention-to-treat analysis was performed. The primary outcome measure was rate of surgical interventions for ovarian cysts up to 12 months after randomisation. The secondary outcome measures were the number of staging surgical procedures, surgical complications and number of delayed diagnoses of ovarian cancer.

RESULTS

A total of 148 women were randomised over 39 months with 73 in the RMI/RCOG arm and 75 in the SRMP arm with outcome data for 136 at 12 months. The two groups were balanced in terms of age, length of time since menopause and use of hormone replacement therapy. There were 18 out of 68 (28.1%) women in the RMI/RCOG arm who had surgery vs 7 out of 68 (10.3%) women in the SRMP arm (P=0.015, χ²-test). The difference in these proportions was 16.2% (95% confidence interval (CI): 3.4-28.9%) and the relative risk was 2.57 (95% CI: 1.15-5.76). There were no significant differences in the number of staging surgical procedures and the surgical complications between the two groups and there were no delayed diagnoses of ovarian cancer at 12 months.

CONCLUSIONS

Surgical intervention rates in asymptomatic postmenopausal women with an ultrasound diagnosis of adnexal tumours are significantly lower when the novel SRMP protocol is used for triaging compared to the standard RMI/RCOG protocol without an increase in delayed malignant diagnoses.

Laparoscopy to Predict the Result of Primary Cytoreductive Surgery in Patients With Advanced Ovarian Cancer: A Randomized Controlled Trial

Purpose To investigate whether initial diagnostic laparoscopy can prevent futile primary cytoreductive surgery (PCS) by identifying patients with advanced-stage ovarian cancer in whom > 1 cm of residual disease will be left after PCS. Patients and Methods This multicenter, randomized controlled trial was undertaken within eight gynecologic cancer centers in the Netherlands. Patients with suspected advanced-stage ovarian cancer who qualified for PCS were eligible. Participating patients were randomly assigned to either laparoscopy or PCS. Laparoscopy was used to guide selection of primary treatment: either primary surgery or neoadjuvant chemotherapy followed by interval surgery. The primary outcome was futile laparotomy, defined as a PCS with residual disease of > 1 cm. Primary analyses were performed according to the intention-to-treat principle. Results Between May 2011 and February 2015, 201 participants were included, of whom 102 were assigned to diagnostic laparoscopy and 99 to primary surgery. In the laparoscopy group, 63 (62%) of 102 patients underwent PCS versus 93 (94%) of 99 patients in the primary surgery group. Futile laparotomy occurred in 10 (10%) of 102 patients in the laparoscopy group versus 39 (39%) of 99 patients in the primary surgery group (relative risk, 0.25; 95% CI, 0.13 to 0.47; P < .001). In the laparoscopy group, three (3%) of 102 patients underwent both primary and interval surgery compared with 28 (28%) of 99 patients in the primary surgery group ( P < .001). Conclusion Diagnostic laparoscopy reduced the number of futile laparotomies in patients with suspected advanced-stage ovarian cancer. In women with a plan for PCS, these data suggest that performance of diagnostic laparoscopy first is reasonable and that if cytoreduction to < 1 cm of residual disease seems feasible, to proceed with PCS.

A novel hysteroscopic approach for ovarian cancer screening/early diagnosis

The lethality of epithelial ovarian cancer (EOC) may be due to common misconceptions regarding etiology and the absence of effective screening and early diagnostic tools. Reviews of histopathological surveys performed on the resected fallopian tubes of breast cancer (BRCA) mutation carriers, who underwent risk-reducing salpingo-oophorectomy, unexpectedly revealed the presence of occult carcinomas of the fallopian tubes. This finding prompted studies that demonstrated the most accredited theory of type II EOC development, which suggests that a large proportion of these tumors are derived from the fallopian tube. At present, no diagnostic tools or screening programs have been demonstrated to be effective or cost-effective in improving the outcome of EOC; it is therefore imperative that the scientific community unite its efforts in the identification of a valid screening and/or early diagnostic method for the treatment of this lethal gynecological malignancy. To this end, the present paper proposes a novel tool for the screening/early diagnosis of EOC: The 'Tuba-check'. This novel approach is based on the possibility of acquiring specimens for tubal lumen cytology via hysteroscopy in a minimally-invasive outpatient setting. The present study protocol aimed to validate the technical feasibility and oncological accuracy of the proposed approach, commencing with a cohort of patients with an expected increased oncological risk, including BRCA mutation carriers or those with a gene expression profile of 'BRCA-ness'. If the data collected by the present study protocol validates this approach, the 'Tuba-check' may, in the near future, be extended for the treatment of all women, therefore reducing the number of victims of epithelial ovarian carcinoma.

Chromosomal Instability in Cell-Free DNA as a Highly Specific Biomarker for Detection of Ovarian Cancer in Women with Adnexal Masses

Purpose: Chromosomal instability is a hallmark of ovarian cancer. Here, we explore copy-number alteration (CNA) profiling in cell-free DNA as a potential biomarker to detect malignancy in patients presenting with an adnexal mass.Experimental Design: We prospectively enrolled 68 patients with an adnexal mass, of which 57 were diagnosed with invasive or borderline carcinoma and 11 with benign disease. Cell-free DNA was extracted from plasma and analyzed by low-coverage whole-genome sequencing.Results: Patterns of chromosomal instability were detectable in cell-free DNA using 44 healthy individuals as a reference. Profiles were representative of those observed in matching tumor tissue and contained CNAs enriched in two large datasets of high-grade serous ovarian cancer (HGSOC). Quantitative measures of chromosomal instability, referred to as genome-wide z-scores, were significantly higher in patients with ovarian carcinoma than in healthy individuals or patients with benign disease. Cell-free DNA testing improved malignancy detection (AUC 0.89) over serum CA-125 (AUC 0.78) or the risk of malignancy index (RMI, AUC 0.81). AUC values of cell-free DNA testing even further increased for HGSOC patients specifically (AUC 0.94). At a specificity of 99.6%, a theoretical threshold required for ovarian cancer screening, sensitivity of cell-free DNA testing was 2- to 5-fold higher compared with CA-125 and RMI testing.Conclusions: This is the first study evaluating the potential of cell-free DNA for the diagnosis of primary ovarian cancer using chromosomal instability as a read-out. We present a promising method to increase specificity of presurgical prediction of malignancy in patients with adnexal masses. Clin Cancer Res; 23(9); 2223-31. ©2016 AACR.

ESUR recommendations for MR imaging of the sonographically indeterminate adnexal mass: an update

Abstract

An update of the 2010 published ESUR recommendations of MRI of the sonographically indeterminate adnexal mass integrating functional techniques is provided. An algorithmic approach using sagittal T2 and a set of transaxial T1 and T2WI allows categorization of adnexal masses in one of the following three types according to its predominant signal characteristics. T1 'bright' masses due to fat or blood content can be simply and effectively determined using a combination of T1W, T2W and FST1W imaging. When there is concern for a solid component within such a mass, it requires additional assessment as for a complex cystic or cystic-solid mass. For low T2 solid adnexal masses, DWI is now recommended. Such masses with low DWI signal on high b value image (e.g. > b 1000 s/mm²) can be regarded as benign. Any other solid adnexal mass, displaying intermediate or high DWI signal, requires further assessment by contrast-enhanced (CE)T1W imaging, ideally with DCE MR, where a type 3 curve is highly predictive of malignancy. For complex cystic or cystic-solid masses, both DWI and CET1W—preferably DCE MRI—is recommended. Characteristic enhancement curves of solid components can discriminate between lesions that are highly likely malignant and highly likely benign.

Key Points

• MRI is a useful complementary imaging technique for assessing sonographically indeterminate masses.

• Categorization allows confident diagnosis in the majority of adnexal masses.

• Type 3 contrast enhancement curve is a strong indicator of malignancy.

• In sonographically indeterminate masses, complementary MRI assists in triaging patient management.

Electronic supplementary material

The online version of this article (doi:10.1007/s00330-016-4600-3) contains supplementary material, which is available to authorized users.

External validation of IOTA simple descriptors and simple rules for classifying adnexal masses

OBJECTIVE

To assess the diagnostic performance of a three-step strategy proposed by the International Ovarian Tumor Analysis (IOTA) Group for discriminating between benign and malignant adnexal masses.

METHODS

This was a prospective observational study, performed at two tertiary-care university hospitals, of women diagnosed with an adnexal mass on transvaginal or transabdominal ultrasound between December 2012 and December 2014. Women were scheduled for an ultrasound evaluation, which was initially performed by non-expert examiners. The examiner had to classify the mass using 'simple descriptors' (first step) and, if not possible, using 'simple rules' (second step). For inconclusive masses, an expert examiner classified the mass according to their subjective impression (third step). Masses were managed expectantly, with serial follow-up examinations, or surgically, according to ultrasound findings and clinical symptoms. Histology was used as the reference standard. Masses that were managed expectantly with at least 1 year of follow-up were considered as benign for analytical purposes. Women with less than 1 year of follow-up were not included in the study.

RESULTS

Six hundred and sixty-six women were included (median age, 41 (range, 18-81) years) of whom 514 were premenopausal and 152 were postmenopausal. Based on the three-step strategy, 362 women had surgical removal of the mass (53 malignant and 309 benign), 71 masses resolved spontaneously and 233 persisted. Four hundred and forty-eight (67.3%) of 666 masses could be classified using simple descriptors and, of the 218 that could not, 147 (67.4%) were classified using simple rules. Of the remaining 71 masses, the expert examiner classified 45 as benign, 12 as malignant and 14 as uncertain. Overall sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of the three-step strategy were 94.3%, 94.9%, 18.6 and 0.06, respectively.

CONCLUSION

The IOTA three-step strategy, based on the sequential use of simple descriptors, simple rules and expert evaluation, performs well for classifying adnexal masses as benign or malignant. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Refining Ovarian Cancer Test accuracy Scores (ROCkeTS): protocol for a prospective longitudinal test accuracy study to validate new risk scores in women with symptoms of suspected ovarian cancer

INTRODUCTION

Ovarian cancer (OC) is associated with non-specific symptoms such as bloating, making accurate diagnosis challenging: only 1 in 3 women with OC presents through primary care referral. National Institute for Health and Care Excellence guidelines recommends sequential testing with CA125 and routine ultrasound in primary care. However, these diagnostic tests have limited sensitivity or specificity. Improving accurate triage in women with vague symptoms is likely to improve mortality by streamlining referral and care pathways. The Refining Ovarian Cancer Test Accuracy Scores (ROCkeTS; HTA 13/13/01) project will derive and validate new tests/risk prediction models that estimate the probability of having OC in women with symptoms. This protocol refers to the prospective study only (phase III).

METHODS AND ANALYSIS

ROCkeTS comprises four parallel phases. The full ROCkeTS protocol can be found at http://www.birmingham.ac.uk/ROCKETS. Phase III is a prospective test accuracy study. The study will recruit 2450 patients from 15 UK sites. Recruited patients complete symptom and anxiety questionnaires, donate a serum sample and undergo ultrasound scored as per International Ovarian Tumour Analysis (IOTA) criteria. Recruitment is at rapid access clinics, emergency departments and elective clinics. Models to be evaluated include those based on ultrasound derived by the IOTA group and novel models derived from analysis of existing data sets. Estimates of sensitivity, specificity, c-statistic (area under receiver operating curve), positive predictive value and negative predictive value of diagnostic tests are evaluated and a calibration plot for models will be presented. ROCkeTS has received ethical approval from the NHS West Midlands REC (14/WM/1241) and is registered on the controlled trials website (ISRCTN17160843) and the National Institute of Health Research Cancer and Reproductive Health portfolios.