The adnexal mass: benign or malignant? Evaluation of a risk of malignancy index

External validation of mathematical models to distinguish between benign and malignant adnexal tumors: a multicenter study by the International Ovarian Tumor Analysis Group

PURPOSE

Several scoring systems have been developed to distinguish between benign and malignant adnexal tumors. However, few of them have been externally validated in new populations. Our aim was to compare their performance on a prospectively collected large multicenter data set.

EXPERIMENTAL DESIGN

In phase I of the International Ovarian Tumor Analysis multicenter study, patients with a persistent adnexal mass were examined with transvaginal ultrasound and color Doppler imaging. More than 50 end point variables were prospectively recorded for analysis. The outcome measure was the histologic classification of excised tissue as malignant or benign. We used the International Ovarian Tumor Analysis data to test the accuracy of previously published scoring systems. Receiver operating characteristic curves were constructed to compare the performance of the models.

RESULTS

Data from 1,066 patients were included; 800 patients (75%) had benign tumors and 266 patients (25%) had malignant tumors. The morphologic scoring system used by Lerner gave an area under the receiver operating characteristic curve (AUC) of 0.68, whereas the multimodal risk of malignancy index used by Jacobs gave an AUC of 0.88. The corresponding values for logistic regression and artificial neural network models varied between 0.76 and 0.91 and between 0.87 and 0.90, respectively. Advanced kernel-based classifiers gave an AUC of up to 0.92.

CONCLUSION

The performance of the risk of malignancy index was similar to that of most logistic regression and artificial neural network models. The best result was obtained with a relevance vector machine with radial basis function kernel. Because the models were tested on a large multicenter data set, results are likely to be generally applicable.

MR imaging in ovarian cancer

Magnetic resonance (MR) imaging is increasingly being used in patients with gynaecological disorders due to its high contrast resolution compared to computed tomography (CT) and ultrasound. In women presenting with an adnexal mass, ultrasound remains the primary imaging modality in the detection and characterisation of such lesions. However, in recent years overwhelming evidence has accumulated for the use of MR imaging in patients with indeterminate adnexal masses particularly in younger women and where disease markers are unhelpful. In staging ovarian cancer and for evaluating therapeutic response MR imaging is as accurate as CT but CT remains the imaging modality of choice because it is more widely available and quicker. This article reviews that evidence and outlines a place for the use of MR imaging in ovarian cancer.

The risk of malignancy index in discrimination of adnexal masses

OBJECTIVE

To assess the ability of the risk of malignancy index (RMI) based on a serum CA125 level, ultrasound findings and menopausal status, to discriminate benign from malignant adnexal masses.

METHOD

Between September 2002 and November 2004, 296 women with adnexal masses were enrolled. The sensitivity, specificity, positive (PPV) and negative predictive values (NPV) of the CA125 serum level, ultrasound findings and menopausal status in prediction of ovarian cancer were calculated and compared individually or combined into the RMI.

RESULTS

The RMI identified malignant cases more accurately than any individual criterion in diagnosing ovarian cancer. Using a cut-off level of 153 to indicate malignancy, the RMI showed a sensitivity of 76.4%, a specificity of 77.9%, a PPV of 65.9%, a NPV of 85.5% with 79.4% correct diagnosis rate.

CONCLUSION

The RMI is an appropriate method in diagnosing adnexal masses with high risk of malignancy and forwarding to gynecological oncology centers for suitable surgical operations.

"True" versus "apparent" stage I epithelial ovarian cancer: value of frozen section analysis

The aim of this prospective study was to determine the clinical benefits of introducing peroperative frozen section analysis into the surgical management policy of women referred with an adnexal mass suspicious of ovarian cancer. All women surgically managed at the Northern Gynaecological Oncology Centre, Gateshead, UK, between July 1, 2002, and June 30, 2003, where frozen section analysis had been utilized were included for analysis. Correlation was determined between cases surgically staged following the frozen section result and the clinical need for staging based on the pathologic diagnosis from the paraffin section. During the 12-month period, 130 women underwent frozen section analysis. Paraffin section diagnoses included 74 benign tumors, 11 borderline tumors, 34 primary epithelial cancers, 5 nonepithelial cancers, and 6 metastatic tumors. All primary epithelial ovarian cancers were correctly identified as requiring a staging procedure based on the frozen section result. Four of seventy-four cases reported as benign on frozen section analysis were underdiagnosed; two were later diagnosed on paraffin section as borderline tumors and a further two as malignant (one low-grade adenosarcoma and one primary peritoneal cancer). Of the 130 cases, 55 (42.3%) underwent a staging procedure based on the frozen section result. The value of frozen section analysis in determining the need for the performance of a staging procedure had the following statistical test results: sensitivity = 92%, specificity = 88%, positive predictive value = 82%, and negative predictive value = 95%. Excluding the borderline tumors, metastatic tumors, and primary peritoneal tumor where staging did not impact subsequent clinical management, the statistical test results for frozen section analysis in determining the need for a staging procedure were sensitivity = 97%, specificity = 95%, positive predictive value = 90%, and negative predictive value = 99%. The clinical benefits of introducing frozen section analysis in the surgical staging policy of women with an adnexal mass suspicious of ovarian malignancy included avoidance of a surgical staging procedure in 95% of cases identified on paraffin section analysis to be benign. This benefit was without compromising the avoidance of chemotherapy in true stage I epithelial ovarian cancer cases. Additional benefits included the confirmation of malignancy where extraovarian lesions were suggestive but not indicative of malignant disease, and the intraoperative identification of metastatic disease of nonovarian origin.

Risk of malignancy index for referral of ovarian cancer cases to a tertiary center: does it identify the correct cases?

Characterization of adnexal masses to identify patients with malignant ovarian tumors preoperatively for referral to a cancer center for treatment has been extensively studied. A simple algorithm called "risk of malignancy index" (RMI) reported by Jacobs incorporated the serum CA125 level, menopausal status, and ultrasound morphologic features. This algorithm has subsequently been tested on retrospective and prospective data with encouraging results. However, these studies did not include cases that had had both their serum CA125 measurements and ultrasound examinations from a diverse range of laboratories and sonographers. The purpose of this study was to determine the effectiveness of the RMI algorithm for identifying cases of ovarian malignancy presenting at cancer units for subsequent referral to a cancer center. All cases of suspected ovarian malignancy referred to the Northern Gynaecological Oncology Centre (NGOC) during an 18-month period were identified from the NGOC database. A case note review was performed, and the following data were extracted: patient demographics, the referring physician and the operating surgeon, ultrasound morphology, serum CA125 levels, and menopausal status. All patients had their ultrasound performed by sonographers at the peripheral unit according to local protocols. A total of 182 patients with a pelvic mass were referred to the center for surgery. A total of 24% patients had benign tumors, 6% had tumors of borderline malignancy, and 70% had invasive tumors. A total of 145 cases had an RMI >200; 125 of these had ovarian or peritoneal cancers. An RMI >200 had a sensitivity of 88.5% for diagnosing invasive lesions. The overall sensitivity of this algorithm for diagnosing all borderline, invasive ovarian, or primary peritoneal lesions was 87.4%, and the positive predictive value was 86.8%. Our data confirm the effectiveness of the RMI algorithm in clinical practice for the identification and subsequent referral to cancer centers of cases of potential ovarian malignancy. We therefore recommend its continued use.

The role and applications of ultrasound in ambulatory gynaecology

Ultrasound has changed gynaecological practice and continues to do so. One of the earliest applications of abdominal scanning in gynaecology was for monitoring follicular development during fertility treatment with clomiphene citrate or gonadotrophins in the 1960s and 1970s. Subsequently, it was natural that with the introduction of in vitro fertilization, abdominal and transvaginal ultrasound played a key role in the development of oocyte retrieval techniques. These were truly the first interventional ultrasound-guided ambulatory procedures in gynaecology. In this chapter, the reader will be introduced to the roles that the various ultrasound modalities play in our current daily practice, and how they have changed the management of numerous gynaecological conditions in both diagnostic and therapeutic contexts. We will also outline the recent developments and the 'hot' research topics in this field.

Management of ovarian cysts

BACKGROUND

The treatment of an ovarian cyst relies on its nature, and accurate preoperative discrimination of benign and malignant cysts is therefore of crucial importance. This study was undertaken to review the literature concerning the preoperative diagnosis and treatment of ovarian cysts.

METHODS

Articles concerning ovarian cysts from a medline literature search during the period 1985-2003 were included in addition to articles found as references in the initial publications.

RESULTS

Different methods for discriminating between benign and malignant ovarian cysts are discussed. The diagnosis and the treatment are assessed in relation to age, menopausal status, pregnancy, and whether the cyst is presumed to be benign or malignant. In general, expectant management is the choice in premenopausal and pregnant women with non-suspicious cysts and normal levels of CA-125. In postmenopausal women, unilocular, anechoic cysts less than 5 cm in diameter together with a normal CA-125 may be followed up. Operation is recommended in women with cysts larger than 5 cm and/or elevated levels of CA-125. Women with symptoms should be operated regardless of age, menopausal status, or ultrasound findings.

CONCLUSIONS

The preoperative discrimination between benign and malignant ovarian cysts is a challenge. Multimodal methods improve the results of single modalities, but we still need improved preoperative diagnostic tools. Furthermore, these methods should be validated in consecutive patient populations large enough to give a reliable estimate of the method's sensitivity and specificity.

Ovarian cancer detected non-invasively by contrast-enhanced power Doppler ultrasound

Overall, about one-third of women operated upon because of suspected ovarian cancer turn out to have benign disease. This proportion will be even higher when the tumours are small. A more accurate method of determining which are malignant would reduce the number of unnecessary referrals to the cancer centre and increase the scope for conservative management. This pilot study of ultrasound and intravenous microbubble contrast in 20 women with small ovarian tumours enabled the identification of all four malignant lesions with good inter-observer agreement. These preliminary findings suggest that intravenous contrast improves the ultrasound identification of small ovarian malignancies and may provide an accurate way of selecting women who require to be referred urgently for surgery under the auspices of a gynaecological oncologist. The remainder might be considered for laparoscopic surgery or even for observation in some cases.

Risk of malignancy index in the preoperative evaluation of pelvic masses

OBJECTIVES

To assess the ability of a risk malignancy index (RMI) based on serum levels of CA 125, ultrasound findings, and menopausal status to discriminate between benign and malignant pelvic masses in a particular population.

METHODS

A retrospective study was conducted of 100 women with pelvic masses admitted for laparotomy. The sensitivity and specificity of serum levels of CA 125, ultrasound findings, and menopausal status were calculated both separately and combined into a RMI to diagnose malignancy.

RESULTS

The RMI was more accurate than any single criterion in diagnosing malignancy. Using a cut-off level of 200 to indicate malignancy, the RMI gave a sensitivity of 90%, specificity of 89%, positive predictive value of 96%, and negative predictive value of 78%.

CONCLUSION

The RMI is able to correctly discriminate between malignant and benign pelvic masses. It is a simple scoring system that can be introduced easily into clinical practice to facilitate the selection of patients who would benefit from primary surgery.

The use of mathematical models to evaluate pelvic masses; can they beat an expert operator?

The pre-operative characterization of ovarian cysts remains a major challenge. Functional cysts and some other benign cysts should be managed conservatively, whereas persistent tumours may need removal. It is crucial to distinguish between malignant tumours, which are better treated by a gynaecological oncologist, and benign tumours, which may be suitable for minimal-access surgery. Over the past decade several ultrasound-based morphological scoring systems, colour Doppler parameters, logistic regression models and artificial neural networks have been proposed and tested in order to try to predict the histology of ovarian tumours. On prospective testing none of the current models can beat an expert sonologist. Signs of malignancy include the presence of papillary structures, irregular solid areas, septa and a strong vascularization at colour Doppler imaging. Further refinement of mathematical models and the results of multicentre trials need to be reviewed before the clinical use of mathematical models can be advocated.

Risk of malignancy index in the preoperative evaluation of patients with adnexal masses

OBJECTIVE

The aim of this study was to evaluate the use of a Risk of Malignancy Index (RMI) in primary evaluation of patients with adnexal masses.

METHODS

The RMI is based on menopausal status, ultrasonographic findings, and serum CA 125 level. A cutoff level of 200 was chosen as the threshold for referral for centralized primary surgery. This setup was evaluated by sensitivity, specificity, and positive predictive (PPV) and negative predictive (NPV) values with respect to the ability to distinguish malignant from benign pelvic masses.

RESULTS

The sensitivity was 70.6%, specificity 89.3%, PPV 66.1%, and NPV 91.1% for the total material. For the patients undergoing surgery the sensitivity was 70.6%, specificity 87.7%, PPV 66.1%, and NPV 89.8%. If stage I disease is considered "benign" disease, the sensitivity is 95.5%, specificity 87.9%, PPV 57.8%, and NPV 99.1%.

CONCLUSIONS

RMI is a simple, easily applicable method in the primary evaluation of patients with adnexal masses. It is usable as a method for selective referral of relevant patients for centralized primary surgery. The method has significant limitations in borderline ovarian tumors, stage I invasive cancers, and nonepithelial tumors. Other methods should be evaluated to increase diagnostic accuracy in these cases.

Pelvic tumours in adolescence

Malignant pelvic tumours in adolescents are rare. Cancers most commonly associated with adolescent women are ovarian germ-cell tumours, ovarian stromal tumours, genital rhabdomyosarcomas and cervico-vaginal clear-cell adenocarcinomas. The incidence of the last of these has reduced with the abandonment of diethylstilbestrol (stilboestrol) therapy in pregnancy. With sexual activity among adolescent women increasing, the incidence of cervical cancer and gestational trophoblastic tumours is rising. Treatment for pelvic cancers in adolescence should be in a multidisciplinary setting and in most cases surgery should be conservative with the aim of preserving sexual and reproductive function. With a few notable exceptions, the prognosis for most malignant pelvic tumours that occur in adolescence is good and treatment is with curative intent.

The differential diagnostic potential of a panel of tumor markers (CA 125, CA 15-3, and CA 72-4 antigens) in patients with a pelvic mass

OBJECTIVE

The purpose of this study was to assess the differential diagnostic potential of a combination of CA 125, CA 15-3, and CA 72-4 antigens in the definition of malignant disease, especially ovarian carcinoma in patients with a pelvic mass.

STUDY DESIGN

A total of 412 patients were evaluated in a multicenter, retrospective study.

RESULTS

Two hundred twenty-six malignant, 171 benign pelvic tumors (of which 129 were benign ovarian tumors), and 15 borderline tumors were evaluated. One hundred thirty-three patients had ovarian carcinoma. In 76 cases (55%), the International Federation of Gynecology and Obstetrics stage was III or IV. Borderline tumors (n = 15) were excluded from the statistical calculations. CA 125 antigen was the most sensitive marker for ovarian carcinoma (81%). The highest specificity and positive predictive value was obtained with CA 15-3 antigen (95% and 92%, respectively). Considering a concomitant elevation of all 3 markers as positive, a positive predictive value of 97% was found. However, only 28% of the patients in the total group and 41% of the patients with ovarian carcinoma had a concomitant elevation of all 3 markers. The combination of all 3 markers with levels below the cut-off resulted in a (false-positive) positive predictive value for malignancy between 12% and 36%. With the use of logistic regression analysis, we found a correct prediction in 73% of the cases. CA 15-3 antigen makes the most significant (P <.0001) contribution to the logistic model in the prediction of malignancy in the total group, with all pelvic masses with an odds ratio of 3.86.

CONCLUSION

The combination of a simultaneous elevated level of CA 125, CA 15-3, and CA 72-4 antigens was predictive for malignant disease in almost all cases. However, such concomitant elevation was found in few of the malignant masses. Logistic regression analysis revealed that CA 15-3 antigen makes the most significant contribution to a model for the prediction of malignancy in the total group. The logistic model gave a correct prediction in 73% to 83%. The present tumor marker panel seems inferior to combinations with other test modalities, which include ultrasonography and/or physical examination and/or menopausal status or age.

Ovarian cancer: patterns of care in Victoria during 1993-1995

OBJECTIVE

To describe the management of and outcomes in patients with newly diagnosed ovarian cancer during 1993, 1994 and 1995 in Victoria.

DESIGN AND SETTING

Retrospective cohort study conducted by surveying doctors involved in managing incident ovarian cancer cases identified from the population-based Victorian Cancer Registry. The survey was conducted in 1997 and the cohort was followed up until the end of 1999 to obtain at least four years of follow-up data on all patients.

PATIENTS

All women with invasive epithelial ovarian cancer diagnosed during 1993, 1994 and 1995.

MAIN OUTCOME MEASURES

Reported management in terms of staging, treatment and survival.

RESULTS

Management details were obtained for 84.5% (562/665) of eligible patients. Median age at diagnosis was 66 years (range, 22-98 years). Surgery was the primary therapy in 77.2% of women (434/562). Only one in three women had adequate surgery, which was less likely to be performed by general gynaecologists and general surgeons than gynaecological oncologists (21.3% [35/164] v 13.3% [8/60] v 52% [105/202]). After surgery 78.6% of women (341/434) received chemotherapy, usually with platinum-based regimens. The overall five-year relative survival was 46% for women treated surgically; poor survival was related to increasing age, later tumour stage, presence of ascites, residual disease > 2 cm and poorer histological differentiation of the tumour.

CONCLUSIONS

For optimal care a preoperative carcinoma antigen (CA)-125 assay, chest x-ray and pelvic ultrasound should be performed, and early referral to a multi-disciplinary unit for definitive surgery is advised. Every effort should be made to adequately stage or debulk the tumour. Women with high-risk early-stage and advanced disease should be considered for platinum-based chemotherapy.

Can pre-operative computed tomography predict resectability of ovarian carcinoma at primary laparotomy?

OBJECTIVE

To assess the ability of computed tomography in predicting whether suspected ovarian cancer could be fully excised at primary laparotomy.

DESIGN

Retrospective analysis of patient notes and pre-operative computed tomography scans. Setting A UK NHS cancer centre.

POPULATION

Seventy-seven women who underwent laparotomy for an ovarian tumour and who had had a pre-operative computed tomography scan.

METHODS

Women who had a computed tomography scan before laparotomy for an ovarian tumour were identified. Analysis was undertaken to determine the accuracy of computed tomography in predicting malignancy, stage and residual disease. The computed tomography parameters significantly associated with residual disease were determined by a chi2 analysis. These parameters, in addition to age and CA125, were used to generate a predictive model. This model was further refined by stepwise logistic regression and a clinical scoring index was generated.

MAIN OUTCOME MEASURES

To identify those computed tomography parameters significantly associated with residual disease and to use these with CA125 and age to generate a useful clinical scoring index to predict residual disease in suspected ovarian cancer.

RESULTS

Seventy-seven women underwent a laparotomy for an ovarian tumour and had a pre-operative computed tomography scan. Fifty-one of these women had malignant disease and twenty-five of these women had residual disease remaining. The sensitivity of computed tomography in predicting malignancy was 90% with a specificity of 85% and the overall accuracy of computed tomography for predicting stage of disease was 73% (37/51). The overall sensitivity of computed tomography in predicting residual disease was 88%, the specificity was 92% and the positive predictive value was 85%. The parameters on computed tomography that were significantly (P < 0.05) associated with residual disease were ascites, omental cake, mesenteric disease, paracolic gutter deposits, diaphragmatic deposits and pleural effusion. The predictive model generated was more accurate than computed tomography alone (sensitivity 88%, specificity 98%, positive predictive value 95%). Using stepwise logistic regression enabled the predictive model to be simplified to include mesenteric disease, omental cake, age and CA125 without any change in sensitivity or specificity and this model was used to generate a scoring index.

CONCLUSION

This study shows that prediction of resectability by computed tomography is excellent and is further improved by the generation of a predictive model, which can be used to generate a simple scoring index. This scoring system now needs to be tested prospectively to ensure that its performance remains as good in an independent sample population.

Comparison of three risk of malignancy indices in evaluation of pelvic masses

OBJECTIVES

The aims of this study were to validate the risk of malignancy index (RMI) incorporating menopausal status, serum CA 125 levels, and ultrasound features for discriminating benign from malignant pelvic masses and to evaluate the performance of the three different risk of malignancy indices (RMI 1, RMI 2, and RMI 3).

METHODS

This is a retrospective study of 152 women admitted at Kasturba Hospital, Manipal, between January 1997 and August 1999 for surgical exploration of pelvic masses. The sensitivity, specificity, and positive predictive value of serum CA 125 levels, ultrasound findings, and menopausal status were taken separately and combined into the RMI 1, RMI 2, and RMI 3 to diagnose ovarian cancer. The risk of malignancy index is the product of menopausal score, ultrasound score, and serum CA 125 levels.

RESULTS

The study confirms that the malignancy risk index is more accurate than the menopausal status, serum CA 125 levels, and ultrasound features separately in diagnosing malignancy. There was no statistically significant difference in the performance of these three different malignancy risk indices in identifying malignancy.

CONCLUSIONS

The risk of malignancy index is able to identify malignant and benign pelvic masses efficiently to optimize therapy. The risk of malignancy index is a simple scoring system which can be used in less specialized gynecology centers. We recommend the use of any of these risk of malignancy indices to facilitate the selection of cases for referral to an oncological unit for adequate staging and optimal debulking.

Comparison of two malignancy risk indices based on serum CA125, ultrasound score and menopausal status in the diagnosis of ovarian masses

OBJECTIVE

To evaluate the ability of two malignancy risk indices (RMI 1 and RMI 2) incorporating menopausal status, serum CA125 level and ultrasound findings, to discriminate a benign from a malignant pelvic mass.

DESIGN

A retrospective study.

SETTING

Department of Obstetrics and Gynaecology, University of Siena, Italy.

POPULATION

One hundred and twenty-four women over 30 years of age admitted consecutively between January 1995 and December 1997 for surgical excision of ovarian masses.

MAIN OUTCOME MEASURES

The sensitivity, specificity, and positive predictive value of serum CA125, ultrasound findings and menopausal status, separately and combined into the RMI 1 and RMI 2, to diagnose ovarian cancer.

RESULTS

The RMI 1 and RMI 2 were more accurate than menopausal status, ultrasound findings, and CA 125 separately in diagnosing cancer. For all cut off values between 80 and 250, RMI 2 performed better than RMI 1. The RMI 2 at a cut off level of 125 gave a sensitivity of 81%, specificity of 90%, and positive predictive value of 74%.

CONCLUSIONS

We found that RMI 2 was more reliable in discriminating benign and malignant ovarian disease than RMI 1. RMI is a simple method which can be used in gynaecology clinics and less specialised centres.

Combination of multiple serum markers using an artificial neural network to improve specificity in discriminating malignant from benign pelvic masses

A panel of four selected tumor markers, CA 125 II, CA 72-4, CA 15-3, and lipid-associated sialic acid, was analyzed collectively using an artificial neural network (ANN) approach to differentiate malignant from benign pelvic masses. A dataset of 429 patients, 192 of whom had malignant histology, was retrospectively used in the study. A prototype ANN classifier was developed using a subset of the data which included 73 patients with malignant conditions and 101 patients with benign conditions. The ANN classifier demonstrated a much improved specificity over that of the assay CA 125 II alone (87.5% vs 68.4%) while maintaining a statistically comparable sensitivity (79.0% vs 82.4%) in discriminating malignant from benign pelvic masses in an independent validation test using data from the remaining 255 patients which had been set aside and kept blind to the developers of the ANN system. A similar improvement in specificity was observed among patients under 50 years of age (82.3% vs 62.0%). The ANN system was further tested using additional serum specimens collected from 196 apparently healthy women. The ANN system had a specificity of 100.0% compared to that of 94.8% with the assay CA 125 II alone.

Using a logistic model to predict malignancy of adnexal masses based on menopausal status, ultrasound morphology, and color Doppler findings

In the present study we aimed to develop a formula for predicting adnexal malignancy based on menopausal status, ultrasound morphology, and color Doppler findings. Logistic regression analysis was performed retrospectively in 79 adnexal masses (59 benign and 20 malignant) in 73 unselected and consecutive patients. All these masses had been preoperatively evaluated using transvaginal color Doppler ultrasonography. In logistic analysis menopausal status (premenopausal vs postmenopausal), color Doppler findings (no flow or lowest resistance index >0.45 vs lowest resistance index </=0.45) and ultrasound morphology (nonsuspicious vs suspicious) were entered as categorical variables. Morphology and color Doppler were found to be independent predictors, whereas menopausal status was not. To assess the validity of the developed mathematical formula, this was applied prospectively in a second series of 58 consecutive and unselected patients diagnosed of adnexal mass and scheduled for surgery. The probability of malignancy was estimated in each case. Overall, 56 of 58 (96.5%) adnexal masses were correctly classified. We conclude that the formula developed in this study is easy to apply and could be useful to predict malignancy or benignity of adnexal masses.

Endoscopic surgery for mature teratoma of the ovary

BACKGROUND

This study was undertaken to assess the value of laparoscopic surgery as treatment for benign mature teratomas of the ovary.

METHODS

A total of 70 patients treated exclusively with laparoscopic surgery for ovarian mature teratoma were studied. The tumors were either enucleated with preservation of the ovary or removed by salpingo-oophorectomy.

RESULTS

Ovary-preserving surgery was performed in 60 cases; salpingo-oophorectomy was accomplished in 10 cases. All tumors removed were histologically benign. No surgical complications were encountered throughout the series. In eight patients who underwent primary ovary-preserving surgery, a second-look laparoscopy was undertaken with virtually no pathological findings noted.

CONCLUSIONS

Our findings confirm those of other authors- when performed by experienced surgeons, laparoscopic removal of ovarian mature teratomas is a safe and recommendable alternative to laparotomy. Preoperative diagnosis and intraoperative inspection of the tumor must be as thorough as possible.

Evaluation of a risk of malignancy index based on serum CA125, ultrasound findings and menopausal status in the pre-operative diagnosis of pelvic masses

OBJECTIVE

To evaluate the ability of a risk of malignancy index (RMI), based on a serum CA125 level, ultrasound findings and menopausal status, to discriminate a benign from a malignant pelvic mass and to discriminate early stage (Figo Stage I) from Stages II, III and IV of ovarian cancer.

DESIGN

A prospective study.

SETTING

Department of Gynaecology, Trondheim University Hospital, Trondheim, Norway.

PARTICIPANTS

One hundred and seventy-three women, 30 years or older, consecutively admitted between February 1992 and February 1994 for primary laparotomy of a pelvic mass.

MAIN OUTCOME MEASURES

The sensitivity, specificity and positive predictive value of serum CA125 level, ultrasound findings and menopausal status, separately and combined into the RMI, to diagnose ovarian cancer.

RESULTS

The RMI was more accurate than any individual criterion in diagnosing cancer. Using a RMI cut-off level of 200 to indicate malignancy, the RMI derived from this dataset gave a sensitivity of 80%, specificity of 92% and positive predictive value of 83%. Applying RMI criteria developed by others, the following test performance was found: sensitivity 71%, specificity 96% and positive predictive value 89%. For the Stages II, III and IV of ovarian cancer the sensitivity increased to approximately 90% without any substantial loss in specificity.

CONCLUSIONS

The risk of malignancy index is able to correctly discriminate between malignant and benign pelvic masses. It is a scoring system which can be introduced easily into clinical practice to facilitate the selection of patients for primary surgery at an oncological unit.

Ovarian cysts

The Author intends to compare the data available in literature on the topic of 'laparoscopic surgery of ovarian cysts' to his case material. From 1985 to 1994, the author carried out 920 laparoscopic operations for the removal of ovarian cysts. Of these, 13 were converted to laparotomies, mostly because of peri-adnexal adhesions. There were 22 recurrences (endometriosic and mucinous multilocular cysts), and five severe complications (two purulent inflammations, one intra-operative haemorrhage and one post-operative one, one post-operative acute abdomen sine causa). In one case, an unrecognised endometrioid carcinoma was inadequately treated with laparoscopy. The author considers laparoscopy as the elective choice for surgical treatment of ovarian cysts. Suspect malignancy is not a contra-indication to laparoscopic surgery, since the removal of the operative specimen and its subsequent histological examination can be effected-in the large majority of cases-with the same results both laparoscopically and laparotomically. There is a problem with undiagnosed carcinomas in fertile females, but it is equally present in laparotomy.

Ovarian cancers related to minimal access surgery

OBJECTIVE

To review the clinical features of women with ovarian cancer on whom minimal access surgery has been performed and to determine guidelines for the safe use of minimal access surgery for adnexal masses.

DESIGN

Postal survey of members of the British Gynaecological Cancer Society (BGCS) and retrospective case review.

RESULTS

BGCS consultants used ultrasound scanning (70%) and serum CA-125 estimations (53%) prior to adnexal mass surgery. The membership felt that adnexal masses with solid elements, diameter greater than 8 cm, multi-ocular or bilateral cysts or increased blood flow on Doppler scanning should not be operated on by minimal access surgery. A positive family history was also considered to be a contraindication. A total of 29 cases of ovarian cancer were identified on whom MAS had been performed. The incidence of cases was 4.1% of referrals to a tertiary referral centre (the Royal Marsden Hospital). The median age of patients was 37 years (range 20 to 68 years) and 13 had State I cancers. The mean delay between diagnosis and staging was 6.5 weeks.

CONCLUSION

Guidelines on the use of minimal access surgery in the management of adnexal masses need to be agreed. Women who have an ovarian cancer diagnosed whilst having minimal access surgery should have an accepted staging procedure. We do not recommend the routine use of minimal access surgery for the treatment of ovarian cancer outside a trial.

Endoscopic surgery in gynecologic practice

In recent decades, the operative approach for several gynecologic diseases has changed from laparotomy to laparoscopy. New techniques and indications are continuously being developed. Laparoscopy offers a lot of advantages for the patient, but still a lot of additional data are required to determine the exact indications. Operative laparoscopy requires not only skill and experience, but also specialized equipment and paramedical staff. The most important topics for the gynecologist will be reviewed in this article.

Differential diagnosis of ovarian cancer with tumour markers CA 125, CA 15-3 and TAG 72.3

OBJECTIVE

To determine the accuracy of tumour associated antigens CA 125, CA 15-3 and TAG 72.3 in the differential diagnosis of benign and malignant pelvic masses and to compare the results with a previously defined risk of malignancy index (RMI).

DESIGN

Retrospective analysis of samples collected during a prospective observational study.

SETTING

Department of Obstetrics and Gynaecology, the Royal London Hospital and Duke University Medical Center.

SUBJECTS

One hundred and forty-three consecutive patients undergoing surgery for an adnexal mass.

METHOD

Tumour marker levels were determined by radio-immunoassay in stored serum samples obtained from 143 study subjects.

RESULTS

The highest diagnostic accuracy of the tumour marker panel was achieved by defining a positive result as elevation of any two of CA 125 (> 30 u/ml), CA 15-3 (> 30 u/ml) and TAG 72.3 (> 10 u/ml), (sensitivity 66.7%, specificity 93.1%). Similar diagnostic accuracy could be achieved by CA 125 alone using an upper limit of 50 u/ml (sensitivity 66.7%, specificity 94.1%). Inclusion of CA 15-3 or TAG 72.3 in stepwise logistic regression analysis did not improve the discriminative performance of the RMI.

CONCLUSION

The risk of malignancy index incorporating CA 125, menopausal status and ultrasound is superior to the panel of three tumour markers for pre-operative differential diagnosis of the pelvic mass.