Comparison of the diagnostic accuracy of International Ovarian Tumor Analysis simple rules and the risk of malignancy index to discriminate between benign and malignant adnexal masses

The diagnostic performance of International Ovarian Tumor Analysis: Simple Rules for diagnosing ovarian tumors-a systematic review and meta-analysis

Introduction

Adnexal masses are a common health issue in gynecology; the challenge lies in the differential diagnosis of these masses. The International Ovarian Tumor Analysis Simple Rules (IOTA-SR) offers the first scoring system to aid in diagnosis. It is based on a set of five ultrasound imaging features indicative of a malignant ovarian tumor and five features indicative of a benign tumor. This review aims to assess the diagnostic performance of IOTA-SR for classifying ovarian tumors as benign or malignant.

Methods

A systematic review was conducted on MEDLINE, Embase, Google Scholar, Scopus, and Web of Science. The terminologies "IOTA-SR", "adnexal, mass", and "ovarian tumors scoring" were employed. Twenty-seven research articles conducted from 2008 to 2022 were included in the meta-analysis; the publication outcome indicates that performance quality tests were extracted directly or indirectly, including true positive (TP), false positive (FP), true negative (TN), and false negative (FN). The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) was used to evaluate the study quality and estimate the risk of bias. After estimating the pooled effect of the sensitivity, specificity, and diagnostic odds ratio (DOR), the summary receiver operating characteristic (SROC) curve was estimated using the bivariate random effects model. Utilizing Cochran's Q statistics and Higgins's inconsistency test through the I2 index for pooled analysis, the heterogeneity of studies was quantitatively evaluated. The funnel plot and Egger's test were utilized to visually and quantitatively evaluate potential publication bias.

Results

Among 27 studies, including 7,841 adnexal masses, the results of this meta-analysis showed excellent diagnostic performance with a pooled sensitivity of 92% [95% confidence interval (CI), 0.89-0.94] and a pooled specificity of 92% (95% CI, 0.89-0.94). The IOTA-SR was applicable in 85.7% of adnexal masses.

Conclusion

The IOTA-SR is highly effective in the presurgical differentiation of malignant versus benign adnexal masses when applied by an expert ultrasonography operator.

Comparison of Two-Dimensional IOTA Simple Rules and Three-Dimensional Ultrasonography in Preoperative Assessment of Adnexal Masses

Objective  Accurate preoperative characterization of adnexal masses is essential for optimal patient management. Two-dimensional ultrasonography (USG) based "International Ovarian Tumuor Analysis Simple Rules (IOTA-SR)" are used primarily in clinical practice. Three-dimensional (3D) USG is an emerging modality. The authors conducted this study to compare the performance of 3D USG with IOTA-SR for preoperative differentiation of benign and malignant adnexal masses. Methods  This prospective observational study recruited 84 patients with adnexal masses undergoing surgical management. IOTA-SR and 3D USG with power Doppler examination were applied to characterize the masses and correlated with histopathology. Logistic regression analysis defined individual 2D and 3D USG parameters' significance in predicting malignancy. The receiver operating characteristic (ROC) curve was plotted for significant variables, and area under the curves (AUCs) with cut-off values were calculated using the Youden index. Results  Out of the 84 adnexal masses, 41 were benign and 43 were malignant. IOTA-SR were conclusive in 88.1% (74/84) cases, with a sensitivity of 83.78% (95% confidence interval [CI]: 67.99-93.81%) and specificity of 89.19% (95% CI: 74.58-96.97%). The sensitivity and specificity of 3D USG with power Doppler were 84% and 88%, respectively, with an AUC of 0.96 (95% CI: 0.92-0.99). Ten cases were inconclusive by the IOTA-SR, and 3D USG could further correctly differentiate four of these cases. Conclusion  The diagnostic performance of both techniques is comparable. With good diagnostic performance and easy applicability, IOTA-SR remain the standard of care. 3D USG, although a more objective assessment, requires further validation and standardization.

Utility of a Multi-Marker Panel with Ultrasound for Enhanced Classification of Adnexal Mass

Pre-surgical clinical assessment of an adnexal mass typically relies on transvaginal ultrasound for comprehensive morphological assessment, with further support provided by biomarker measurements and clinical evaluation. Whilst effective for masses that are obviously benign or malignant, a large proportion of masses remain sonographically indeterminate at surgical referral. As a consequence, post-surgical diagnoses of benign disease can outnumber malignancies up to 9-fold, while less than 50% of cancer cases receive a primary referral to a gynecological oncology specialist. We recently described a blood biomarker signature (multi-marker panel-MMP) that differentiated patients with benign from malignant ovarian disease with high accuracy. In this study, we have examined the use of the MMP, both individually and in combination with transvaginal ultrasound, as an alternative tool to CA-125 for enhanced decision making in the pre-surgical referral process.

Comparison of Simple Ultrasound Rules by International Ovarian Tumor Analysis (IOTA) with RMI-1 and RMI-4 (Risk of Malignancy Index) in Preoperative Differentiation of Benign and Malignant Adnexal Masses

Background

IOTA proposed Simple Ultrasound Rules in 2009 for preoperative diagnosis of ovarian masses based on ultrasound only. It is an accurate, simple and inexpensive method. RMI, however, requires CA125 level. While RMI-4 is the latest, RMI-1 is still the most widely used method. The present study was done to compare IOTA Rules with RMI-1 and RMI-4.

Purpose

To differentiate benign and malignant adnexal masses preoperatively using IOTA simple rules and compare its accuracy with RMI-1 and RMI-4.

Methods

A prospective observational study was performed from 1st November 2019 to 31st March 2021 in the Department of Obstetrics and Gynaecology, ABVIMS and Dr. RML Hospital, New Delhi. This study was conducted on 70 patients with adnexal masses who underwent pre-operative evaluation using IOTA Simple Rules, RMI-1 and RMI-4. Histopathology was used to compare the results.

Results

Out of 70 patients, 59 (84.3%) cases were benign and 11 (15.7%) were malignant. The IOTA Rules were applicable to 60 cases (85.7%), and the results were inconclusive in 10 cases (14.3%). Where applicable, the sensitivity and specificity of the IOTA Rules (88.9% and 94.1%, respectively) were significantly higher than RMI-1 (45.5% and 93.2%, respectively) and RMI-4 (45.5% and 89.8%, respectively). When inconclusive results were included as malignant, the sensitivity of the IOTA Rules increased (88.9% vs 90.9%); however, the specificity decreased (94.1% vs 81.4%).

Conclusion

IOTA Simple Rules were more accurate at diagnosing benign from malignant adnexal masses than RMI-1 and RMI-4. However, the rules were not applicable to 14% of the cases.

ReClassification of Patients with Ambiguous CA125 for Optimised Pre-Surgical Triage

Pre-surgical clinical assessment of an adnexal mass is a complex process, and ideally requires accurate and rapid identification of disease status. Gold standard biomarker CA125 is extensively used off-label for this purpose; however its performance is typically inadequate, particularly for the detection of early stage disease and discrimination between benign versus malignant status. We recently described a multi-marker panel (MMP) and associated risk index for the differentiation of benign from malignant ovarian disease. In this study we applied a net reclassification approach to assess the use of MMP index to rescue those cases where low CA125 incorrectly excludes cancer diagnoses, or where benign disease is incorrectly assessed as "high risk" due to elevated CA125. Reclassification of such patients is of significant value to assist in the timely and accurate referral for patients where CA125 titer is uninformative.

Comparison of Human Epididymis Protein 4, Cancer Antigen 125, and Ultrasound Prediction Model in Differentiating Benign from Malignant Adnexal Masses

Background

This study aimed to compare the diagnostic performance of carcinogenic antigen (CA) 125, (HE)-4 (Human epididymis protein 4), and ultrasound (International Ovarian Tumor Analysis [IOTA]) Simple Rules individually and to derive a composite score in the differentiating ovarian cancer from benign ovarian mass.

Subjects and Methods

Consecutive patients (n = 100) with pelvic mass admitted during February 2018-August 2019 were included prospectively. Patients with either known case of epithelial ovarian cancer (EOC) or metastatic EOC were excluded. The primary outcome was to assess the sensitivity and specificity of CA-125, HE-4, and IOTA Simple Rules in predicting benign from malignant mass independently, while secondary outcome was derivation of a new model incorporating these variables using multivariate logistic regression analysis to predict benign from malignant lesions. Receiver operator curve (ROC) was drawn to redefine the best-performing cutoff values and difference between area under the ROC (AUROC) were compared by DeLong's method.

Results

Out of 100 cases of adnexal mass selected, the sensitivity and specificity of CA-125 were 73.8% and 77.6%, HE-4 were 90.5% and 87.9%, and IOTA Simple Rules were 92.9% and 81.0%. CA-125, HE-4, and IOTA Simple Rules were independently associated with the likelihood of malignancy/borderline (P < 0.001). The area under the curve for the "composite score" (AUC = 0.93) was the highest and was significantly better than that of CA-125 (AUC = 0.786) (P = 0.004 using DeLong's test) and comparable with HE-4 (AUROC = 0.90; P = 0.128 using DeLong's Test).

Conclusion

The sensitivity and specificity of HE-4 and IOTA Simple Rules for predicting malignant ovarian tumor was better than those of CA-125. The diagnostic performance of "composite score" was comparable to those of either HE-4 or IOTA Simple Rules and significantly better than CA-125.

Diagnostic performance of IOTA SR and O-RADS combined with CA125, HE4, and risk of malignancy algorithm to distinguish benign and malignant adnexal masses

PURPOSE

To compare the diagnostic performance of International Ovarian Tumour Analysis Simple Rules (IOTA SR) and Ovarian-Adnexal Reporting and Data System (O-RADS), and to analyse whether combining IOTA SR and O-RADS with the biomarkers cancer antigen 125 (CA125), human epididymis protein 4 (HE4), and risk of malignancy algorithm (ROMA) further improves diagnostic performance in women with different menopause status.

METHODS

This study retrospectively included patients with ovarian adnexal masses confirmed by surgical pathology between September 2021 and February 2022. The area under the curve (AUC), sensitivity, and specificity were calculated to evaluate the diagnostic efficacy of IOTA SR, O-RADS, and their combination with CA125, HE4, and ROMA.

RESULTS

This study included 1,179 ovarian adnexal masses. In all women, the AUC of IOTA SR was comparable to O-RADS (0.879 vs. 0.889, P = 0.361), and O-RADS had a significantly higher sensitivity than IOTA SR (95.77 % vs. 87.32 %, P < 0.001). In premenopausal women, O-RADS had a significantly higher AUC than other diagnostic strategies (all P < 0.05), and the sensitivity, specificity, and accuracy were 93.33 %, 84.74 %, and 85.59 %, respectively. In postmenopausal women, IOTA SR + ROMA had a significantly higher AUC than other diagnostic strategies (all P < 0.05), and the sensitivity, specificity, and accuracy were 85.37 %, 93.88 %, and 90.00 %, respectively.

CONCLUSIONS

Our study supports the high diagnostic value of IOTA SR or O-RADS alone in all women, and O-RADS was more sensitive than IOTA SR. In premenopausal women, O-RADS had the highest diagnostic value. In postmenopausal women, IOTA SR outperformed O-RADS, and IOTA SR + ROMA had the highest diagnostic value.

Comparisons of Effectiveness in Differentiating Benign from Malignant Ovarian Masses between Conventional and Modified Risk of Malignancy Index (RMI)

OBJECTIVE

To compare the predictive performance in differentiating benign from malignant ovarian masses between the modified risk malignancy index (RMI) and the conventional RMI (RMI-1 and RMI-2).

METHODS

Women scheduled for elective surgery because of adnexal masses were recruited to undergo pelvic sonography within 24 h before surgery to assess the sonographic characteristics of the masses, focusing on loculi, solid part, ascites, bilateralness, papillary projection, and color flow mapping (CFM). Preoperative CA-125 levels were also measured. Modified RMI, RMI-1, and RMI-2 systems were used to predict malignant masses. The gold standard was pathological or intraoperative diagnosis.

RESULTS

A total of 342 ovarian masses, benign: 243 (71.1%); malignant: 99 (28.9%), meeting the inclusion criteria were analyzed. The sensitivity and the specificity of the modified RMI (87.9% and 81.9%) were significantly higher than those of RMI-1 (74.7% and 84.4%), and RMI-2 (79.8% and 81.1%, respectively). Based on ROC curves, the area under the curves were 0.930, 0.881 and 0.882 for modified RMI, RMI-1 and RMI-2, respectively.

CONCLUSION

Modified RMI had better predictive performance than the conventional RMI in differentiating between benign and malignant ovarian masses. Modified RMI may be useful to help general gynecologists or practitioners to triage patients with an adnexal mass, especially in settings of low resources.

The Value of IOTA Simple Rules Combined With CEUS Scoring System in the Diagnosis of Benign and Malignant Ovarian Masses and Its Correlation With MVD and VEGF: A Preliminary Study

OBJECTIVES

To investigate the diagnostic value of International Ovarian Tumor Analysis (IOTA) simple rules combined with contrast-enhanced ultrasound (CEUS) scoring system in the differential diagnosis of ovarian tumors, and the correlations of the scoring system with microvessel density (MVD) and vascular endothelial growth factor (VEGF).

METHODS

One hundred eighty-nine patients with ovarian tumors were examined by routine ultrasound and CEUS. The enhanced characteristics of CEUS were observed, and the masses were classified by IOTA simple rules. To compare the diagnostic value of IOTA simple rules combined with CEUS scoring system and IOTA simple rules in the diagnosis of ovarian tumors. Immunohistochemistry was used to detect the expression of MVD and VEGF in postoperative tissue samples. The correlations between the new scoring system with MVD and VEGF were analyzed.

RESULTS

The sensitivity (93.98%), specificity (94.34%), positive predictive value (92.86%), negative predictive value (95.24%), and accuracy (94.18%) of IOTA simple rules combined with CEUS scoring system in the diagnosis of ovarian tumors were higher than those of IOTA simple rules alone (all P < .05). The score system was significantly positively correlated with MVD and VEGF, and the r values were 0.77 and 0.63, respectively (P < .001).

CONCLUSIONS

IOTA simple rules combined with CEUS scoring system was helpful to improve the accuracy of ultrasound diagnosis of ovarian tumors, which was significantly correlated with MVD and VEGF. It could provide important reference information for treatment scheme formulation and prognosis evaluation.

Ovarian Cancer: Applications of Chickens to Humans

The lack of preclinical models of spontaneous ovarian cancer (OVCA), a fatal gynecological malignancy, is a significant barrier to generating information on early changes indicative of OVCA. In contrast to rodents, laying hens develop OVCA spontaneously, with remarkable similarities to OVCA in women regarding tumor histology, OVCA dissemination, immune responses, and risk factors. These important features of OVCA will be useful to develop an early detection test for OVCA, which would significantly reduce mortality rates; preventive strategies; immunotherapeutics; prevention of resistance to chemotherapeutics; and exploration of gene therapies. A transvaginal ultrasound (TVUS) imaging method for imaging of hen ovarian tumors has been developed. Hens can be monitored prospectively by using serum markers, together with TVUS imaging, to detect early-stage OVCA, provided that a panel of serum markers can be established and imaging agents developed. Recent sequencing of the chicken genome will further facilitate the hen model to explore gene therapies against OVCA.

Efficacy of IOTA simple rules, O-RADS, and CA125 to distinguish benign and malignant adnexal masses

Objective

Ovarian cancer is the most deadly deadliest gynecological tumor in the female reproductive system. Therefore, the present study sought to determine the diagnostic performance of International Ovarian Tumor Analysis Simple Rules (IOTA SR), the Ovarian-Adnexal Reporting and Data System (O-RADS), and Cancer Antigen 125 (CA125) in discriminating benign and malignant ovarian tumors. The study also assessed whether a combination of the two ultrasound categories systems and CA125 can improve the diagnostic performance.

Methods

A total of 453 patients diagnosed with ovarian tumors were retrospectively enrolled from Fujian Cancer Hospital between January 2017 and September 2020. The data collected from patients included age, maximum lesion diameter, location, histopathology, levels of CA125, and detailed ultrasound reports. Additionally, all ultrasound images were independently assessed by two ultrasound physicians with more than 5 years of experience in the field, according to the IOTA simple rules and O-RADS guidelines. Furthermore, the area under the curve (AUC), sensitivity, and specificity of the above mentioned predictors were calculated using the receiver operating characteristic curve.

Results

Out of the 453 patients, 184 had benign lesions, while 269 had malignant ovarian tumors. In addition, the AUCs of IOTA SR, O-RADS, and CA125 in the overall population were 0.831, 0.804, and 0.812, respectively, and the sensitivities of IOTA SR, O-RADS, and CA125 were 94.42, 94.42, and 80.30%, respectively. On the other hand, the AUCs of IOTA SR combined with CA125, O-RADS combined with CA125, and IOTA SR plus O-RADS combined with CA125 were 0.900, 0.891, and 0.909, respectively. The findings also showed that the AUCs of a combination of the three approaches were significantly higher than those of individual strategies (p<0.05) but not significantly higher than the AUC of a combination of two methods (p>0.05).

Conclusion

The findings showed that a combination of IOTA SR or O-RADS in combination with CA125 may improve the ability to distinguish benign from malignant ovarian tumors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13048-022-00947-9.

Spontaneous vaginoperitoneal fistula as a rare complication of carcinoma ovary: a case report

BACKGROUND

Spontaneous vaginoperitoneal fistula formation in a case of carcinoma ovary is a very rare occurrence and has never been reported.

CASE PRESENTATION

A 55-year-old postmenopausal lady presented with complaints of abdominal distention and mass coming out of the vagina for the last 10 days. On examination, she had tense ascites, uterovaginal prolapse and hard, fixed mass felt anteriorly on per-rectal examination. Biochemical investigations and radiological imaging suggested advanced stage ovarian neoplasm. She was planned for neoadjuvant chemotherapy. During the second cycle of chemotherapy, she developed spontaneous vaginoperitoneal fistula which was confirmed on exploratory laparotomy where interval debulking surgery was performed in collaboration with gastro-surgeons on a semi-emergency basis. The postoperative course was uneventful.

CONCLUSION

Spontaneous vaginoperitoneal fistula is a rare complication and should be kept in mind while managing advanced ovarian neoplasm.

Borderline ovarian tumor in pregnancy: can surgery wait? A case series

PURPOSE

To study the characteristics of borderline tumors (BOT) diagnosed during pregnancy, as either first diagnosis or relapse, to evaluate safety of expectant management.

METHODS

15 women affected by BOT during pregnancy were included, to evaluate clinical and histo-pathological characteristics. Age of patient, parity, gestational age, follow-up time, size of tumor, surgical approach, type and timing of surgery, FIGO stage, and histologic type were obtained through retrospective review.

RESULTS

All patients except one were diagnosed with serous BOT (BOTs). Median follow-up time was 147 ± 57 months. Eight women received first diagnosis of BOT and seven had diagnosis of BOT recurrence during pregnancy, including three with a second relapse and four with a third relapse. BOT were diagnosed at FIGO stage I in most patients (75%) of the first group and in 14.3% of the second group, respectively. Micropapillary pattern was present in 71.4% of patients with first diagnosis of BOT, but only in 14.2% in case of relapse. All relapses were BOTs. No patient with BOT and concomitant pregnancy developed an invasive recurrence later. Overall, 24 relapses occurred in 10 patients (66.7%). Altogether 24 pregnancies occurred during follow-up, with a high livebirth rate (91.6%) and only 2 spontaneous miscarriages.

CONCLUSION

According to our experience, an "expectation management" could be a safe option in case of both relapse of BOTs during pregnancy and first suspicion of BOT in pregnant women at advanced gestational age.

External validation of Risk of Malignancy Index compared to IOTA Simple Rules

BACKGROUND

Mathematical predictive models for ovarian tumors have an advantage over subjective assessment due to their relative simplicity, and therefore usefulness for less experienced sonographers. It is currently unclear which predictive model is best at predicting the nature of an ovarian tumor.

PURPOSE

To compare the diagnostic predictive accuracy of the International Ovarian Tumour Analysis Simple Rules (IOTA SR) with Risk of Malignancy Index (RMI), to differentiate between benign and malignant ovarian tumors.

MATERIAL AND METHODS

A total of 202 women diagnosed with ovarian tumor(s) were included. Preoperatively, patients were examined through transvaginal ultrasonography and CA-125 (U/mL) levels were measured. RMI and IOTA SR were determined, and where possible compared to definitive histopathological diagnosis.

RESULTS

Of the 202 women with ovarian tumors, 168 women were included in this cohort study. Of these tumors, 118 (70.2%) were benign, 17 (10.1%) were borderline, and 33 (19.7%) were malignant. The sensitivity, specificity, and area under the curve for the RMI were 72.0%, 90.7%, and 0.896, respectively. For the IOTA SR, these were 90.0%, 68.6%, and 0.793, respectively.

CONCLUSION

This cohort study shows that the RMI is a relatively useful diagnostic model in characterizing ovarian tumors, compared to the IOTA SR. However, due to the relatively low sensitivity of the RMI and high rate of inconclusive results of the IOTA SR, both diagnostic tests do not seem discriminative enough. Therefore, alternative diagnostic models are necessary.

Prediction Models of Adnexal Masses: State-of-the-Art Review

Importance

Several predictive models and scoring systems have been developed to differentiate between benign and malignant ovarian masses, in order to guide effective management. These models use combinations of patient characteristics, ultrasound markers, and biochemical markers.

Objective

The aim of this study was to describe, compare, and prioritize, according to their strengths and qualities, all the adnexal prediction models.

Evidence Acquisition

This was a state-of-the-art review, synthesizing the findings of the current published literature on the available prediction models of adnexal masses.

Results

The existing models include subjective assessment by expert sonographers, the International Ovarian Tumor Analysis models (logistic regression models 1 and 2, Simple Rules, 3-step strategy, and ADNEX [Assessment of Different NEoplasias in the adneXa] model), the Risk of Malignancy Index, the Risk of Malignancy Ovarian Algorithm, the Gynecologic Imaging Reporting and Data System, and the Ovarian-Adnexal Reporting and Data System. Overall, subjective assessment appears to be superior to all prediction models. However, the International Ovarian Tumor Analysis models are probably the best available methods for nonexpert examiners. The Ovarian-Adnexal Reporting and Data System is an international approach that incorporates both the common European and North American approaches, but still needs to be validated.

Conclusions

Many prediction models exist for the assessment of adnexal masses. The adoption of a particular model is based on local guidelines, as well as sonographer's experience. The safety of expectant management of adnexal masses with benign ultrasound morphology is still under investigation.

Preoperative Evaluation of the ADNEX Model for the Prediction of the Ovarian Cancer Risk of Adnexal Masses at Siriraj Hospital

INTRODUCTION

Distinguishing benign adnexal masses from malignant tumors plays an important role in preoperative planning and improving patients' survival rates. The International Ovarian Tumor Analysis (IOTA) group developed a model termed the Assessment of Different NEoplasias in the adneXa (ADNEX).

OBJECTIVE

Our objective was to evaluate the performance of the ADNEX model in distinguishing between benign and malignant tumors at a cutoff value of 10%.

METHODS

This was a prospective diagnostic study. 357 patients with an adnexal mass who were scheduled for surgery at Siriraj Hospital were included from May 1, 2018, to May 30, 2019. All patients were undergoing ultrasonography, and serum CA125 was measured. Data were calculated by the ADNEX model via an IOTA ADNEX calculator.

RESULTS

Of the 357 patients, 296 had benign tumors and 61 had malignant tumors. The area under the receiver operating characteristic curve for using the ADNEX model was 0.975 (95% confidence interval, 0.953-0.988). At a 10% cutoff, the sensitivity was 98.4% and specificity was 87.2%. The best cutoff value was at 16.6% in our population.

CONCLUSIONS

The performance of the ADNEX model in differentiating benign and malignant tumors was excellent.

Diagnostic Added-Value of Serum CA-125 on the IOTA Simple Rules and Derivation of Practical Combined Prediction Models (IOTA SR X CA-125)

Background: This study aimed to evaluate the diagnostic added-value of serum CA-125 to the International Ovarian Tumor Analysis (IOTA) Simple Rules in order to facilitate differentiation between malignant and benign ovarian tumors before surgery. Methods: A secondary analysis of a cross-sectional cohort of women scheduled for surgery in Maharaj Nakorn Chiang Mai Hospital between April 2010 and March 2018 was carried out. Demographic and clinical data were prospectively collected. Histopathologic diagnosis was used as the reference standard. Logistic regression was used for development of the model. Evaluation of the diagnostic added-value was based on the increment of the area under the receiver operating characteristic curve (AuROC). Results: One hundred and forty-five women (30.3%) out of a total of 479 with adnexal masses had malignant ovarian tumors. The model that included information from the IOTA Simple Rules and serum CA-125 was significantly more superior to the model that used only information from the IOTA Simple Rules (AuROC 0.95 vs. 0.89, p < 0.001 for pre-menopause and AuROC 0.98 vs 0.83, p < 0.001 for post-menopause). Conclusions: The IOTA SR X CA-125 model showed high discriminative ability and is potentially useful as a decision tool for guiding patient referrals to oncologic specialists.

Transferability of the early-stage ovarian malignancy (EOM) score: an external validation study that includes advanced-stage and metastatic ovarian cancer

PURPOSE

To validate the diagnostic performance of the Early-stage Ovarian Malignancy (EOM) score in an external dataset that includes advanced-stage and metastatic ovarian cancer.

METHODS

The data from two cross-sectional cohorts were used in the statistical analysis. The development dataset of the EOM score was collected in Phrapokklao Hospital between September 2013 and December 2017. The validation dataset was collected in Maharaj Nakorn Chiang Mai Hospital between April 2010 and March 2018. The internal and external performance of the EOM score was evaluated in terms of discrimination via area under the receiver-operating characteristic curve (AuROC) and calibration.

RESULTS

There were 270 and 479 patients included in the development and validation datasets, respectively. The prevalence of ovarian malignancy was 20.0% (54/270) in the development set and 30.3% (145/479) in the validation set. The EOM score had excellent discriminative ability in both the development and validation sets (AuROC 88.0 (95% CI 82.6, 93.9) and 88.0 (95% CI 84.3, 91.4), respectively). The EOM score also showed good calibration in both datasets.

CONCLUSIONS

The EOM score had consistent diagnostic performance in the external validation data. It is recommended for use as a triage tool in patient referrals instead of the RMI in settings where experienced sonographers are not available.

Early-Stage Ovarian Malignancy Score versus Risk of Malignancy Indices: Accuracy and Clinical Utility for Preoperative Diagnosis of Women with Adnexal Masses

Background and objectives: To compare the diagnostic accuracy and clinical utility of the Early-stage Ovarian Malignancy (EOM) score with the Risk of Malignancy Index (RMI) in the presurgical assessment of women presenting with adnexal masses. Materials and Methods: A secondary analysis was carried out in a retrospective cohort of women who presented with an adnexal mass and were scheduled for surgery at Phrapokklao Hospital between September 2013 and December 2017. The clinical characteristics, ultrasonographic features of the masses, and preoperative CA-125 levels were recorded. The EOM and the RMI score were calculated and compared in terms of accuracy and clinical utility. Decision curve analysis (DCA), which examined the net benefit (NB) of applying the EOM and the RMI in practice at a range of threshold probabilities, was presented. Results: In this study, data from 270 patients were analyzed. Fifty-four (20.0%) women in the sample had early-stage ovarian cancer. All four RMI versions demonstrated a lower sensitivity for the detection of patients with early-stage ovarian cancer compared to an EOM score ≥ 15. An EOM ≥ 15 resulted in a higher proportion of net true positive or NB than all versions of the RMIs from a threshold probability of 5% to 30%. Conclusions: It also showed a higher capability to reduce the number of inappropriate referrals than the RMIs at a threshold probability between 5% and 30%. The EOM score showed higher diagnostic sensitivity and has the potential to be clinically more useful than the RMIs to triage women who present with adnexal masses for referral to oncologic gynecologists. Further external validation is required to support our findings.

Predicting Malignancy in Adnexal Masses by the International Ovarian Tumor Analysis-Simple Rules

BACKGROUND

Accurate prediction of adnexal tumors preoperatively is critical for optimal management of ovarian cancers. The International Ovarian Tumor Analysis Algorithms (IOTA) is a newer tool to characterize adnexal masses as benign or malignant.

OBJECTIVE

This study is aimed to predict malignancy in adnexal masses and differentiates benign from malignant, applying the sonography features of simple rules given by IOTA.

METHODOLOGY

A prospective study was carried out at AIIMS Jodhpur for 1½ years. Women presenting with adnexal masses planned for surgery were recruited. Ultrasonography-transabdominal combined with transvaginal was done, and pelvic masses were characterized using IOTA simple rules. Patients underwent their planned surgery. Histopathology is considered the gold standard and was compared with the IOTA simple rules. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.

RESULTS

One hundred and seventy-four women were included in the study, of which the majority (82.75%) were benign, the rest being frankly malignant or borderline cancer. The sensitivity of IOTA is 96.6%, specificity of 92.3%, PPV of 72.5%, NPV of 99.2%, where indeterminate cases were considered malignant.

CONCLUSION

IOTA simple rule is an effective tool for identifying malignant adnexal masses. It also suggests that IOTA-simple rules can be used as a diagnostic criterion for differentiating adnexal masses into benign and malignant on an out-patient department basis.

Management of adnexal masses' torsion during pregnancy

With the increased use and quality of ultrasound in pregnancy, adnexal masses are being encountered with greater frequency. Most of the time such masses are asymptomatic. It can be discovered in an emergency. Surgical intervention may cause risks to the mother and her fetus, while observation without intervention may also lead to unfavorable complications, such as ovarian torsion or the development of a tumor. Therefore, the management requires a balance between the maternal and fetal risks. We report two cases of torsion of adnexal masses during pregnancy, and we provide a brief literature review on the management and prognosis of this condition in pregnancy.

Adnexal masses in pregnancy: an updated review on diagnosis and treatment

Adnexal masses are not common in pregnancy. They are often discovered incidentally during routine ultrasound examinations. In general, 24%-40% of the cases are benign tumors; up to 8% are malignant tumors. Adnexal masses are usually asymptomatic, but sometimes can be responsible for abdominal or pelvic pain. Transvaginal and transabdominal ultrasound is essential to define the morphology of pelvic masses and to distinguish between benign and malignant cases. Magnetic resonance imaging can be a complementary examination when ultrasound findings are equivocal and a useful additional examination to better define tissue planes and relations with other organs. Patient counseling can be challenging because there is no clear consensus on the management of adnexal masses during pregnancy. Treatment options consist of observational management (in case of asymptomatic women with reassuring instrumental findings) or surgery (via laparoscopy or laparotomy). Surgery can be offered as a primary tool when cancer is suspected or when acute complications such as ovarian torsion occur.