Use of IOTA simple rules for diagnosis of ovarian cancer: meta-analysis

Prospective external validation of IOTA methods for classifying adnexal masses and retrospective assessment of two-step strategy using benign descriptors and ADNEX model: Portuguese multicenter study

OBJECTIVES

To externally and prospectively validate the International Ovarian Tumor Analysis (IOTA) Simple Rules (SRs), Logistic Regression model 2 (LR2) and Assessment of Different NEoplasias in the adneXa (ADNEX) model in a Portuguese population, comparing these approaches with subjective assessment and the risk-of-malignancy index (RMI), as well as with each other. This study also aimed to retrospectively validate the IOTA two-step strategy, using modified benign simple descriptors (MBDs) followed by the ADNEX model in cases in which MBDs were not applicable.

METHODS

This was a prospective multicenter diagnostic accuracy study conducted between January 2016 and December 2021 of consecutive patients with an ultrasound diagnosis of at least one adnexal tumor, who underwent surgery at one of three tertiary referral centers in Lisbon, Portugal. All ultrasound assessments were performed by Level-II or -III sonologists with IOTA certification. Patient clinical data and serum CA 125 levels were collected from hospital databases. Each adnexal mass was classified as benign or malignant using subjective assessment, RMI, IOTA SRs, LR2 and the ADNEX model (with and without CA 125). The reference standard was histopathological diagnosis. In the second phase, all adnexal tumors were classified retrospectively using the two-step strategy (MBDs + ADNEX). Sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios and overall accuracy were determined for all methods. Receiver-operating-characteristics curves were constructed and corresponding areas under the curve (AUC) were determined for RMI, LR2, the ADNEX model and the two-step strategy. The ADNEX model calibration plots were constructed using locally estimated scatterplot smoothing (LOESS).

RESULTS

Of the 571 patients included in the study, 428 had benign disease and 143 had malignant disease (prevalence of malignancy, 25.0%), of which 42 had borderline ovarian tumor, 93 had primary invasive adnexal cancer and eight had metastatic tumors in the adnexa. Subjective assessment had an overall sensitivity of 97.9% and a specificity of 83.6% for distinguishing between benign and malignant lesions. RMI showed high specificity (95.6%) but very low sensitivity (58.7%), with an AUC of 0.913. The IOTA SRs were applicable in 80.0% of patients, with a sensitivity of 94.8% and specificity of 98.6%. The IOTA LR2 had a sensitivity of 84.6%, specificity of 86.9% and an AUC of 0.939, at a malignancy risk cut-off of 10%. At the same cut-off, the sensitivity, specificity and AUC for the ADNEX model with vs without CA 125 were 95.8% vs 98.6%, 82.5% vs 79.7% and 0.962 vs 0.960, respectively. The ADNEX model gave heterogeneous results for distinguishing between benign masses and different subtypes of malignancy, with the highest AUC (0.991) for discriminating benign masses from primary invasive adnexal cancer Stages II-IV, and the lowest AUC (0.696) for discriminating primary invasive adnexal cancer Stage I from metastatic lesion in the adnexa. The calibration plot suggested underestimation of the risk by the ADNEX model compared with the observed proportion of malignancy. The MBDs were applicable in 26.3% (150/571) of cases, of which none was malignant. The two-step strategy using the ADNEX model in the second step only, with and without CA 125, had AUCs of 0.964 and 0.961, respectively, which was similar to applying the ADNEX model in all patients.

CONCLUSIONS

The IOTA methods showed good-to-excellent performance in the Portuguese population, outperforming RMI. The ADNEX model was superior to other methods in terms of accuracy, but interpretation of its ability to distinguish between malignant subtypes was limited by sample size and large differences in the prevalence of tumor subtypes. The IOTA MBDs are reliable in identifying benign disease. The two-step strategy comprising application of MBDs followed by the ADNEX model if MBDs are not applicable, is suitable for daily clinical practice, circumventing the need to calculate the risk of malignancy in all patients. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Diagnostic performance of ultrasound reporting systems in evaluation of adnexal masses: A prospective observational study

OBJECTIVE(S)

To evaluate and compare diagnostic performance of ultrasound-based reporting systems IOTA SR, ADNEX, GIRADS, ORADS for discrimination between benign and malignant adnexal masses.

STUDY DESIGN

A prospective observational study in a tertiary care hospital's Obstetrics and Gynaecology department evaluated pre-operative ultrasound imaging for adnexal masses in 80 cases, comparing various reporting systems' sensitivity and specificity against histopathology as gold standard using STATA version 17.0 for data analysis.

RESULTS

Among the 80 masses, 55 % (44/80) were confirmed as benign on histopathology, while 45 % were identified as malignant. The sensitivity and specificity of SR was 100 % (95 %CI: 90.0-100) and 97.1 % (95 %CI: 84.7-99.9) respectively. Eleven masses (13.8 %) were inconclusive, reducing specificity to 75 % (95 %CI:59.7-86.8).In ADNEX optimal cut-off for risk of malignancy was 34.1 % with sensitivity of 86.1 % (95 % CI: 70.5-95.3) and specificity of 90.9 % (95 % CI: 78.3-97.5). Considering GIRADS 4-5 and risk threshold of ≥10 % (ORADS 4-5) as predictors of malignancy sensitivity was 100 % (95 %CI: 90.3-100) and specificity was 70.5 % (95 %CI: 54.8-83.2) for GIRADS and ORADS. All reporting systems were comparable (p = 0.7). ADNEX identified 72.7 % (8/11) of inconclusive cases, outperforming GIRADS/ORADS which correctly classified 27.2 % (3/11) cases. When applied to misclassified GIRADS/ORADS 4-5 category, ADNEX demonstrated superior performance by correctly classifying 76.9 % (10/13) masses, while SR achieved correct classification in only 38.5 % (5/13) masses.

CONCLUSION(S)

All classification systems showed comparable accuracy in malignancy risk identification on imaging. GIRADS/ORADS tended to overestimate malignancy risk. The present study recommends a two-step strategy, leveraging higher specificity of ADNEX model for improved stratification of adnexal masses.

Tumor Markers in Differential Diagnosis of Benign Ovarian Masses

Background

Although there are many benign tumors in the ovarian adnexal area, the four most common types are still luteal cyst, ovarian mature cystic teratoma (OMCT), ovarian endometriosis, and benign epithelial tumors of the ovary.

Purpose

This study aimed to examine the correlation between six tumor markers (CEA, AFP, CA125, CA19-9, SCC, HE4) in the differential diagnosis of female adnexal benign masses and assess their diagnostic value.

Patients and Methods

In this study, 135 patients with adnexal benign masses were treated in Zhengzhou first people's Hospital from January 2018 to January 2023. 135 patients were divided into four groups: luteal cyst (13.3%), OMCT (42.2%), ovarian endometriosis (23.7%) and benign epithelial tumors of the ovary (including mucinous cystadenoma and serous cystadenoma) in group D. The receiver-operating characteristic (ROC) curve was used to assess the diagnostic value of each marker and combined detection.

Results

The diameter of luteal cysts was significantly smaller than that of benign ovarian tumors (p < 0.001). ROC analysis showed that the combination of AFP, CA125, CA19-9, and SCC had a higher diagnostic rate for luteal cysts (AUC=0.871; sensitivity: 71.8%; specificity: 88.9). The SCC level in OMCT was significantly higher than in other benign ovarian tumors (p=0.007). ROC analysis indicated that the combination of AFP, HE4, and SCC had a higher diagnostic rate for OMCT (AUC=0.753; sensitivity: 65.4%; specificity: 75.4%). The CA125 level in ovarian endometriosis was significantly higher than in other accessory benign tumors (p < 0.001). ROC analysis demonstrated that the combination of AFP, CA125, and CA19-9 had a higher diagnostic rate for ovarian endometriosis (AUC=0.935; sensitivity: 76.7%; specificity: 96.9%). The tumor diameter of benign epithelial tumors of the ovary was significantly larger than that of other benign ovarian tumors (p < 0.001). ROC analysis revealed that the combination of CA125 and CA19-9 had a higher diagnostic rate for benign epithelial tumors of the ovary (AUC=0.792; sensitivity: 64.5%; specificity: 85.7%).

Conclusion

The findings of this study demonstrate that the combined use of tumor markers (CEA, AFP, CA125, CA19-9, SCC, and HE4) has value in diagnosing benign ovarian tumors, including luteal cysts, OMCT, ovarian endometriosis, and benign epithelial tumors of the ovary. However, it is important to acknowledge the limitations of this study, which include its single-center nature and the small sample size. Despite these limitations, the results highlight the potential utility of these markers in clinical practice.

Performance of O-RADS MRI Score in Differentiating Benign From Malignant Ovarian Teratomas: MR Feature Analysis for Differentiating O-RADS 4 From O-RADS 2

OBJECTIVE

The aim of the study is to evaluate the performance of the ovarian-adnexal reporting and data system magnetic resonance imaging (O-RADS MRI) score and perform individual MRI feature analysis for differentiating between benign and malignant ovarian teratomas.

METHODS

In this institutional review board-approved retrospective study, consecutive patients with a pathology-proven fat-containing ovarian mass imaged with contrast-enhanced MRI (1.5T or 3T) from 2013 to 2022 were included. Two blinded radiologists independently evaluated masses per the O-RADS MRI lexicon, including having a "characteristic" or "large" Rokitansky nodule (RN). Additional features analyzed included the following: nodule size/percentage volume relative to total teratoma volume, presence of bulk/intravoxel fat in the nodule, diffusion restriction in the nodule, angular interface, nodule extension through the teratoma border, presence/type of nodule enhancement pattern (solid versus peripheral), and evidence for metastatic disease. An overall O-RADS MRI score was assigned. Patient and lesion features associated with malignancy were evaluated and used to create a malignant teratoma score. χ 2 , Fisher's exact tests, receiver operating characteristic curve, and κ analysis was performed.

RESULTS

One hundred thirty-seven women (median age 34, range 9-84 years) with 123 benign and 14 malignant lesions were included. Mean teratoma size was 7.3 cm (malignant: 14.4 cm, benign: 6.5 cm). 18/123 (14.6%) of benign teratomas were assigned an O-RADS 4 based on the presence of a "large" (11/18) or "noncharacteristic" (12/18) RN. 12/14 malignant nodules occupied >25% of the total teratoma volume ( P = 0.09). Features associated with malignancy included the following: age <18 years, an enhancing noncharacteristic RN, teratoma size >12 cm, irregular cystic border, and extralesional extension; these were incorporated into a malignant teratoma score, with a score of 2 or more associated with area under the curve of 0.991 for reviewer 1 and 0.993 for reviewer 2. Peripheral enhancement in a RN was never seen with malignancy (64/123 benign, 0/14 malignant) and would have appropriated downgraded 9/18 overcalled O-RADS 4 benign teratomas.

CONCLUSIONS

O-RADS MRI overcalled 15% (18/123) benign teratomas as O-RADS 4 but correctly captured all malignant teratomas. We propose defining a "characteristic" RN as an intravoxel or bulk fat-containing nodule. Observation of a peripheral rim of enhancement in a noncharacteristic RN allowed more accurate prediction of benignity and should be added to the MRI lexicon for improved O-RADS performance.

Differentiating Benign From Malignant Ovarian Masses With Solid Components: Diagnostic Performance of CEUS Combined With IOTA Simple Rules and O-RADS

OBJECTIVE

This study aimed to apply the International Ovarian Tumor Analysis (IOTA) Simple Rules (SR), the Ovarian-Adnexal Reporting and Data System (O-RADS) and contrast-enhanced ultrasound (CEUS) in an identical cohort of Chinese patients and to analyze their performance in discrimination of ovarian masses with solid components.

METHODS

This was a two-center retrospective study that included a total of 94 ovarian lesions in 86 women enrolled from January 2018 to February 2023. The lesions were classified by using the IOTA terminology and CEUS was performed for the lesions exhibiting solid components on ultrasonography, IOTA SR and O-RADS were applied, and CEUS images were analyzed retrospectively. We assessed the time to wash-in, time to peak intensity (PI), PI compared to myometrium, and time to wash-out, and observed statistically significant differences between benign and malignant lesions in the first three parameters. CEUS characteristics were employed to determine CEUS scores for benign (score 0) and malignant (score 3) lesions. Subsequently, the lesions were reassessed based on the IOTA SR and O-RADS classifications and CEUS scores. The sensitivity, specificity, and area under the receiver-operating-characteristics curve (AUC) of the different models were also determined.

RESULTS

Among the 94 ovarian lesions, 46 (48.9%) were benign and 48 (51.1%) were malignant. It was found that in the 60 lesions to which the SR could be applied, the sensitivity, specificity, and AUC was 0.900, 0.667, and 0.783, respectively. The sensitivity, specificity, and AUC of O-RADS was observed to be 1.000, 0.283 and 0.641, respectively. When SR and O-RADS were combined with CEUS, their sensitivity, specificity, and AUC values were increased to 0.917, 0.891, 0.904, and 0.958, 0.783, 0.871, respectively.

CONCLUSION

IOTA SR and O-RADS exhibited relatively low specificity in differentiating malignant from benign ovarian lesions with the solid components, and their diagnostic performance can be significantly improved when combined with CEUS.

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.

Diagnostic Accuracy of Biomarkers and International Ovarian Tumor Analysis Simple Rules in Diagnosis of Ovarian Cancer

This study investigated whether combining International Ovarian Tumor Analysis (IOTA) Simple Rules with tumor biomarkers would improve the diagnostic accuracy for early detection of adnexal malignancies. Receiver operating characteristic curve analysis of suspected adnexal tumors was performed in 226 women admitted for surgery at the University Clinical Center of Kosovo. Primary outcome was the diagnostic accuracy of the combination of adnexal mass biomarkers and IOTA Simple Rules. IOTA Simple Rules combined with biomarker indications increased the diagnostic accuracy of classifying adnexal masses. Data analysis of individual measures showed that ferritin had the lowest rate of sensitivity.

IOTA simple rules: An efficient tool for evaluation of ovarian tumors by non-experienced but trained examiners - A prospective study

Objectives

A simple and efficient tool for evaluating ovarian tumors in general hospitals where radiologists without experience in gynecological ultrasound is necessary. This study aims to evaluate the diagnostic performance of IOTA simple rules in initial classification of ovarian tumors by non-experienced examiners who have received simple training.

Materials and method

A prospective single-center study was conducted at Hanoi Obstetrics and Gynecology Hospital. Three resident gynecologists trained themselves for two weeks and then received hands-on practice under the supervision of experts for another two weeks. The examiners performed ultrasound on 424 eligible women scheduled for surgery for ovarian tumors and classified the tumors based on IOTA simple rules. The postoperative pathology of ovarian tumors was used as the gold standard.

Results

90.8 % (385/424) of the tumors were benign. Simple rules were applicable in 399/424 (94.1 %) tumors, with a sensitivity of 84.8 % (95 % CI, 70.2-94.3), specificity of 98.9 % (95 % CI, 97.5-99.7), positive predictive value of 87.5 % (95 % CI, 73.3-95.9), and negative predictive value of 98.6 % (95 % CI, 97.1-99.5). The sensitivity of IOTA simple rules was higher in postmenopausal women (91.7 % vs. 81.0 %), while the specificity was higher in premenopausal women (99.4 % vs. 95.8 %). Accuracy was 100 % in all ten pregnant women were assessed using these rules.

Conclusion

In conclusion, in the hands of non-expert examiners who were trained thoroughly, IOTA simple rules are a simple and efficient tool for clinical practice in centers where expert radiologists in gynecology are not always available. The training program is simple and could be applied widely in other clinical centers. Further studies are necessary to evaluate the effectiveness of the IOTA simple rules in assessing ovarian tumors among pregnant women.

Current and Emerging Strategies for Tubo-Ovarian Cancer Diagnostics

Tubo-ovarian cancer is the most lethal gynaecological cancer. More than 75% of patients are diagnosed at an advanced stage, which is associated with poorer overall survival. Symptoms at presentation are vague and non-specific, contributing to late diagnosis. Multimodal risk models have improved the diagnostic accuracy of adnexal mass assessment based on patient risk factors, coupled with findings on imaging and serum-based biomarker tests. Newly developed ultrasonographic assessment algorithms have standardised documentation and enable stratification of care between local hospitals and cancer centres. So far, no screening test has proven to reduce ovarian cancer mortality in the general population. This review is an update on the evidence behind ovarian cancer diagnostic strategies.

Ultrasound Features and Clinical Outcome of Patients with Ovarian Masses Diagnosed during Pregnancy: Experience of Single Gynecological Ultrasound Center

(1) Background: The number of adnexal masses detected during pregnancy has increased due to the use of first-trimester screening and increasingly advanced maternal age. Despite their low risk of malignancy, other risks associated with these masses include torsion, rupture and labor obstruction. Correct diagnosis and management are needed to guarantee both maternal and fetal safety. Adnexal masses may be troublesome to classify during pregnancy due to the increased volume of the uterus and pregnancy-related hormonal changes. Management should be based on ultrasound examination to provide the best treatment. The aim of this study was to describe the ultrasound features of ovarian masses detected during pregnancy and to optimize and personalize their management with the expertise of gynecologists, oncologists and sonographers. (2) Methods: Clinical, ultrasound, histological parameters and type of management (surveillance vs. surgery) were retrospectively retrieved. Patient management, perinatal outcomes and follow-up were also evaluated. (3) Results: according to the literature, these masses are most frequently benign, ultrasound follow-up is the best management, and obstetric outcomes are not considerably influenced by the presence of adnexal masses. (4) Conclusions: the management of patients with ovarian masses detected during pregnancy should be based on ultrasound examination, and a centralization in referral centers for ovarian masses should be considered.

Simple rules, O-RADS, ADNEX and SRR model: Single oncologic center validation of diagnostic predictive models alone and combined (two-step strategy) to estimate the risk of malignancy in adnexal masses and ovarian tumors

OBJECTIVE

To compare performance of Assessment of Different NEoplasias in the adneXa (ADNEX model), Ovarian-Adnexal Reporting and Data System (O-RADS), Simple Rules Risk (SRR) assessment and the two-step strategy based on the application of Simple Rules (SR) followed by SRR and SR followed by ADNEX in the pre-operative discrimination between benign and malignant adnexal masses (AMs).

METHODS

We conducted a retrospective study from January-2018 to December-2021 in which consecutive patients with at AMs were recruited. Accuracy metrics included sensitivity (SE) and specificity (SP) with their 95% confidence intervals (CI) were calculated for ADNEX, O-RADS and SRR. When SR was inconclusive a "two-step strategy" was adopted applying SR + ADNEX model and SR + SRR assessment.

RESULTS

A total of 514 women were included, 400 (77.8%) had a benign ovarian tumor and 114 (22.2%) had a malignant tumor. At a threshold malignancy risk of >10%, the SE and SP of ADNEX model, O-RADS and SRR were: 0.92 (95% CI, 0.86-0.96) and 0.88 (95% CI, 0.85-0.91); 0.93 (95% CI, 0.87-0.97) and 0.89 (95% CI, 0.96-0.92); 0.88 (95% CI, 0.80-0.93) and 0.84 (95% CI, 0.80-0.87), respectively. When we applied SR, 109 (21.2%) cases resulted inconclusive. The SE and SP of two-step strategy SR + SRR assessment and SR + ADNEX model were 0.88 (95% CI, 0.80-0.93) and 0.92 (95% CI, 0.89-0.94), SR + ADNEX model 0.90 (95% CI, 0.83-0.95) and 0.93 (95% CI, 0.90-0.96), respectively.

CONCLUSIONS

O-RADS presented the highest SE, similar to ADNEX model and SR + ADNEX model. However, the SR + ADNEX model presented the higher performance accuracy with the higher SP and PPV. This two-step strategy, SR and ADNEX model applicated to inconclusive SR, is convenient for clinical evaluation.

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.

Advantages and Limitations of Ultrasound as a Screening Test for Ovarian Cancer

Ovarian cancer (OC) is the seventh most common malignancy diagnosed among women, the eighth leading cause of cancer mortality globally, and the most common cause of death among all gynecological cancers. Even though recent advances in technology have allowed for more accurate radiological and laboratory diagnostic tests, approximately 60% of OC cases are diagnosed at an advanced stage. Given the high mortality rate of advanced stages of OC, early diagnosis remains the main prognostic factor. Our aim is to focus on the sonographic challenges in ovarian cancer screening and to highlight the importance of sonographic evaluation, the crucial role of the operator΄s experience, possible limitations in visibility, emphasizing the importance and the necessity of quality assurance protocols that health workers have to follow and finally increasing the positive predictive value. We also analyzed how ultrasound can be combined with biomarkers (ex. CA-125) so as to increase the sensitivity of early-stage OC detection or, in addition to the gold standard examination, the CT (Computed tomography) scan in OC follow-up. Improvements in the performance and consistency of ultrasound screening could reduce the need for repeated examinations and, mainly, ensure diagnostic accuracy. Finally, we refer to new very promising techniques such as liquid biopsies. Future attempts in order to improve screening should focus on the identification of features that are unique to OC and that are present in early-stage tumors.

Adnexal Lesion Imaging: Past, Present, and Future

Currently, imaging is part of the standard of care for patients with adnexal lesions prior to definitive management. Imaging can identify a physiologic finding or classic benign lesion that can be followed up conservatively. When one of these entities is not present, imaging is used to determine the probability of ovarian cancer prior to surgical consultation. Since the inclusion of imaging in the evaluation of adnexal lesions in the 1970s, the rate of surgery for benign lesions has decreased. More recently, data-driven Ovarian-Adnexal Reporting and Data System (O-RADS) scoring systems for US and MRI with standardized lexicons have been developed to allow for assignment of a cancer risk score, with the goal of further decreasing unnecessary interventions while expediting the care of patients with ovarian cancer. US is used as the initial modality for the assessment of adnexal lesions, while MRI is used when there is a clinical need for increased specificity and positive predictive value for the diagnosis of cancer. This article will review how the treatment of adnexal lesions has changed due to imaging over the decades; the current data supporting the use of US, CT, and MRI to determine the likelihood of cancer; and future directions of adnexal imaging for the early detection of ovarian cancer.

O-RADS MRI After Initial Ultrasound for Adnexal Lesions: AJR Expert Panel Narrative Review

The Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) and MRI risk stratification systems were developed by an international group of experts in adnexal imaging to aid radiologists in assessing adnexal lesions. The goal of imaging is to appropriately triage patients with adnexal lesions. US is the first-line imaging modality for assessment, whereas MRI can be used as a problem-solving tool. Both US and MRI can accurately characterize benign lesions such as simple cysts, endometriomas, hemorrhagic cysts, and dermoid cysts, avoiding unnecessary or inappropriate surgery. In patients with a lesion that does not meet criteria for one of these benign diagnoses, MRI can further characterize the lesion with an improved specificity for cancer and the ability to provide a probable histologic subtype in the presence of certain MRI features. This allows personalized treatment, including avoiding overly extensive surgery or allowing fertility-sparing procedures for suspected benign, borderline, or low-grade tumors. When MRI findings indicate a risk of an invasive cancer, patients can be expeditiously referred to a gynecologic oncologic surgeon. This narrative review provides expert opinion on the utility of multiparametric MRI when using the O-RADS US and MRI management systems.

Diagnostic Performance of Ultrasound-Based International Ovarian Tumor Analysis Simple Rules and Assessment of Different NEoplasias in the adneXa Model for Predicting Malignancy in Women with Ovarian Tumors: A Prospective Cohort Study

Background

Comparative performance of various ultrasound models in diagnosing ovarian lesions has not been adequately studied. This study aimed to evaluate the diagnostic performance of the International Ovarian Tumor Analysis (IOTA) simple rules and Assessment of Different NEoplasias in the adneXa (ADNEX) models in women with ovarian lesions.

Methods

Women 18-80 years, with an ovarian lesion planned for surgery were recruited in this prospective observational cohort study. Preoperative risk stratification was done by both IOTA simple rules and the ADNEX model. The diagnostic performance of both models was estimated using histopathology as the gold standard.

Results

A total of 90 women were recruited into the study. The IOTA simple rules were applicable to 77 (85.5%) participants and the ADNEX model on 100% women. Both the simple rules and the ADNEX model had good diagnostic performance. The sensitivity and specificity of the IOTA simple rules for predicting malignancy was 66.6% and 91%, while that of the ADNEXA model was 80% and 94%, respectively. The maximum diagnostic accuracy for prediction of both benign and malignant tumors was obtained when cancer antigen-125 (CA-125) was combined with the IOTA ADNEX model (91.0%), but for Stage I malignancy, the maximum diagnostic accuracy was for ADNEX without CA-125 (91.0%).

Conclusion

Both the IOTA models have a good diagnostic accuracy and are of paramount importance in differentiating benign from malignant tumors and predicting the stage of the malignant disease.

Evaluation of IOTA-ADNEX Model and Simple Rules for Identifying Adnexal Masses by Operators with Varying Levels of Expertise: A Single-Center Diagnostic Accuracy Study

Objectives The discrimination of ovarian lesions presents a significant problem in everyday clinical practice with ultrasonography appearing to be the most effective diagnostic technique. The aim of our study was to externally evaluate the performance of different diagnostic models when applied by examiners with various levels of experience. Methods This was a diagnostic accuracy study including women who were admitted for adnexal masses, between July 2018 and April 2021, to a Greek tertiary oncology center. Preoperatively sonographic data were evaluated by an expert gynecologist, a 6 th and a 1 st year gynecology resident, who applied the International Ovarian Tumor Analysis (IOTA) Simple Rules (SR) and Assessment of Different NEoplasias in the adneXa (ADNEX) model to discriminate between benign and malignant ovarian tumors. The explant pathology report was used as the reference diagnosis. Kappa statistics were used for the investigation of the level of agreement between the examined systems and the raters. Results We included 66 women, 39 with benign and 27 with malignant ovarian tumors. ADNEX (with and without "CA-125") had high sensitivity (96-100%) when applied by all raters but a rather low specificity (36%) when applied by the 1st year resident. SR could not be applied in 6% to 17% of the cases. It had slightly lower sensitivity, higher specificity, and higher overall accuracy, especially when applied by the 1st year resident (61% vs. 92%), compared to ADNEX. Conclusion Both ADNEX and SR can be utilized for screening in non-oncology centers since they offer high sensitivity even when used by less experienced examiners. In the hands of inexperienced examiners, SR appears to be the best model for assessing ovarian lesions.

Surgical outcomes of adnexal masses classified by IOTA ultrasound simple rules

IOTA (International Ovarian Tumor Analysis) Simple Rules classifies adnexal masses as benign, malignant, or indeterminate based on sonographic features. We seek to determine if IOTA inappropriately directed women to surgery, or more aggressive surgery, than their final diagnosis warranted. This is a retrospective study of sonographically detected adnexal masses with known clinical outcomes from two institutions (n = 528). Surgically managed patients (n = 172) were categorized based on pathology and compared using Chi-square and t-test for categorical and continuous variables respectively. A logistic regression was used to predict characteristics that predicted surgery or imaging follow up of indeterminate masses. Of the 528 masses imaged, 29% (n = 155) underwent surgery for benign pathology. Only 1.9% (n = 10) underwent surgery after classification as malignant by IOTA for what was ultimately a benign mass. Surgical complications occurred in 10 cases (5.8%), all benign. Fifteen (3.2%) patients went into surgically induced menopause for benign masses, one of which was inaccurately classified by IOTA as malignant. Of the 41 IOTA indeterminate masses, the presence of soft tissue nodules on ultrasound was the only statistically significant predictor of the patient being triaged directly to surgery (OR 1.79, p = 0.04). Our findings support that the IOTA ultrasound classification system can provide clinical guidance without incurring unnecessary surgeries or surgical complications.

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.

Menopausal status, ultrasound and biomarker tests in combination for the diagnosis of ovarian cancer in symptomatic women

BACKGROUND

Ovarian cancer (OC) has the highest case fatality rate of all gynaecological cancers. Diagnostic delays are caused by non-specific symptoms. Existing systematic reviews have not comprehensively covered tests in current practice, not estimated accuracy separately in pre- and postmenopausal women, or used inappropriate meta-analytic methods.

OBJECTIVES

To establish the accuracy of combinations of menopausal status, ultrasound scan (USS) and biomarkers for the diagnosis of ovarian cancer in pre- and postmenopausal women and compare the accuracy of different test combinations.

SEARCH METHODS

We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), five other databases and three trial registries from 1991 to 2015 and MEDLINE (Ovid) and Embase (Ovid) form June 2015 to June 2019. We also searched conference proceedings from the European Society of Gynaecological Oncology, International Gynecologic Cancer Society, American Society of Clinical Oncology and Society of Gynecologic Oncology, ZETOC and Conference Proceedings Citation Index (Web of Knowledge). We searched reference lists of included studies and published systematic reviews.

SELECTION CRITERIA

We included cross-sectional diagnostic test accuracy studies evaluating single tests or comparing two or more tests, randomised trials comparing two or more tests, and studies validating multivariable models for the diagnosis of OC investigating test combinations, compared with a reference standard of histological confirmation or clinical follow-up in women with a pelvic mass (detected clinically or through USS) suspicious for OC.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed quality using QUADAS-2. We used the bivariate hierarchical model to indirectly compare tests at commonly reported thresholds in pre- and postmenopausal women separately. We indirectly compared tests across all thresholds and estimated sensitivity at fixed specificities of 80% and 90% by fitting hierarchical summary receiver operating characteristic (HSROC) models in pre- and postmenopausal women separately.

MAIN RESULTS

We included 59 studies (32,059 women, 9545 cases of OC). Two tests evaluated the accuracy of a combination of menopausal status and USS findings (IOTA Logistic Regression Model 2 (LR2) and the Assessment of Different NEoplasias in the adneXa model (ADNEX)); one test evaluated the accuracy of a combination of menopausal status, USS findings and serum biomarker CA125 (Risk of Malignancy Index (RMI)); and one test evaluated the accuracy of a combination of menopausal status and two serum biomarkers (CA125 and HE4) (Risk of Ovarian Malignancy Algorithm (ROMA)). Most studies were at high or unclear risk of bias in participant, reference standard, and flow and timing domains. All studies were in hospital settings. Prevalence was 16% (RMI, ROMA), 22% (LR2) and 27% (ADNEX) in premenopausal women and 38% (RMI), 45% (ROMA), 52% (LR2) and 55% (ADNEX) in postmenopausal women. The prevalence of OC in the studies was considerably higher than would be expected in symptomatic women presenting in community-based settings, or in women referred from the community to hospital with a suspicion of OC. Studies were at high or unclear applicability because presenting features were not reported, or USS was performed by experienced ultrasonographers for RMI, LR2 and ADNEX. The higher sensitivity and lower specificity observed in postmenopausal compared to premenopausal women across all index tests and at all thresholds may reflect highly selected patient cohorts in the included studies. In premenopausal women, ROMA at a threshold of 13.1 (± 2), LR2 at a threshold to achieve a post-test probability of OC of 10% and ADNEX (post-test probability 10%) demonstrated a higher sensitivity (ROMA: 77.4%, 95% CI 72.7% to 81.5%; LR2: 83.3%, 95% CI 74.7% to 89.5%; ADNEX: 95.5%, 95% CI 91.0% to 97.8%) compared to RMI (57.2%, 95% CI 50.3% to 63.8%). The specificity of ROMA and ADNEX were lower in premenopausal women (ROMA: 84.3%, 95% CI 81.2% to 87.0%; ADNEX: 77.8%, 95% CI 67.4% to 85.5%) compared to RMI 92.5% (95% CI 90.3% to 94.2%). The specificity of LR2 was comparable to RMI (90.4%, 95% CI 84.6% to 94.1%). In postmenopausal women, ROMA at a threshold of 27.7 (± 2), LR2 (post-test probability 10%) and ADNEX (post-test probability 10%) demonstrated a higher sensitivity (ROMA: 90.3%, 95% CI 87.5% to 92.6%; LR2: 94.8%, 95% CI 92.3% to 96.6%; ADNEX: 97.6%, 95% CI 95.6% to 98.7%) compared to RMI (78.4%, 95% CI 74.6% to 81.7%). Specificity of ROMA at a threshold of 27.7 (± 2) (81.5, 95% CI 76.5% to 85.5%) was comparable to RMI (85.4%, 95% CI 82.0% to 88.2%), whereas for LR2 (post-test probability 10%) and ADNEX (post-test probability 10%) specificity was lower (LR2: 60.6%, 95% CI 50.5% to 69.9%; ADNEX: 55.0%, 95% CI 42.8% to 66.6%).

AUTHORS' CONCLUSIONS

In specialist healthcare settings in both premenopausal and postmenopausal women, RMI has poor sensitivity. In premenopausal women, ROMA, LR2 and ADNEX offer better sensitivity (fewer missed cancers), but for ROMA and ADNEX this is off-set by a decrease in specificity and increase in false positives. In postmenopausal women, ROMA demonstrates a higher sensitivity and comparable specificity to RMI. ADNEX has the highest sensitivity in postmenopausal women, but reduced specificity. The prevalence of OC in included studies is representative of a highly selected referred population, rather than a population in whom referral is being considered. The comparative accuracy of tests observed here may not be transferable to non-specialist settings. Ultimately health systems need to balance accuracy and resource implications to identify the most suitable test.

Diagnostic Performance of the Ovarian-Adnexal Reporting and Data System (O-RADS) Ultrasound Risk Score in Women in the United States

IMPORTANCE

The American College of Radiology (ACR) Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) risk scoring system has been studied in a selected population of women referred for suspected or known adnexal lesions. This population has a higher frequency of malignant neoplasms than women presenting to radiology departments for pelvic ultrasonography for a variety of indications, potentially impacting the diagnostic performance of the risk scoring system.

OBJECTIVE

To evaluate the risk of malignant neoplasm and diagnostic performance of O-RADS US risk scoring system in a multi-institutional, nonselected cohort.

DESIGN, SETTING, AND PARTICIPANTS

This multi-institutional cohort study included a population of nonselected women in the United States who presented to radiology departments for routine pelvic ultrasonography between 2011 and 2014, with pathology confirmation imaging follow up or 2 years of clinical follow up.

EXPOSURE

Analysis of 1014 adnexal lesions using the O-RADS US risk stratification system.

MAIN OUTCOMES AND MEASURES

Frequency of ovarian cancer and diagnostic performance of the O-RADS US risk stratification system.

RESULTS

This study included 913 women with 1014 adnexal lesions. The mean (SD) age of the patients was 42.4 (13.9 years), and 674 of 913 (73.8%) were premenopausal. The overall frequency of malignant neoplasm was 8.4% (85 of 1014 adnexal lesions). The frequency of malignant neoplasm for O-RADS US 2 was 0.5% (3 of 657 lesions; <1% expected); O-RADS US 3, 4.5% (5 of 112 lesions; <10% expected); O-RADS US 4, 11.6% (18 of 155; 10%-50% expected); and O-RADS 5, 65.6% (59 of 90 lesions; >50% expected). O-RADS US 4 was the optimum cutoff for diagnosing cancer with sensitivity of 90.6% (95% CI, 82.3%-95.9%), specificity of 81.9% (95% CI, 79.3%-84.3%), positive predictive value of 31.4% (95% CI, 25.7%-37.7%) and negative predictive value of 99.0% (95% CI, 98.0%-99.6%).

CONCLUSIONS AND RELEVANCE

In this cohort study of a nonselected patient population, the O-RADS US risk stratification system performed within the expected range as published by the ACR O-RADS US committee. The frequency of malignant neoplasm was at the lower end of the published range, partially because of the lower prevalence of cancer in a nonselected population. However, a high negative predictive value was maintained, and when a lesion can be classified as an O-RADS US 2, the risk of cancer is low, which is reassuring for both clinician and patient.

Value of Assessment of Different Neoplasias in the Adnexa in the Differential Diagnosis of Malignant Ovarian Tumor and Benign Ovarian Tumor: A Meta-analysis

To evaluate the accuracy of the assessment of different neoplasias in the adnexa (ADNEX) model in the differential diagnosis of malignant and benign ovarian tumors, the optimal cutoff value and the accuracy in diagnosing ovarian tumors at different stages, PubMed, Web of Science and Cochrane Library databases were retrieved to search literature with per-patient analysis until publication of the last study in November 2021. STATA 14.1, Meta-Disc 1.4 and Revman software 5.3 were used in the performance of meta-analysis. To explore sources of heterogeneity, a subgroup analysis was conducted for the ADNEX model. The pooled sensitivity, specificity, diagnostic odds ratio, positive likelihood, negative likelihood ratio and area under the summary receiver operating characteristic curve were 0.91 (95% confidence interval [CI]: 0.89-0.93), 0.84 (95% CI: 0.80-0.88), 55.55 (95% CI: 40.47-76.26), 5.71 (95% CI: 4.49-7.26), 0.10 (95% CI: 0.08-0.13) and 0.94 (95% CI: 0.92-0.96) in differentiating benign and malignant ovarian tumors, respectively. The area under the curve in identifying benign, borderline, stage I and stages II-IV were 0.93, 0.73, 0.27 and 0.92. The ADNEX model had high diagnostic performance was influential in the diagnosis of benign and stage II-IV ovarian tumors.

Appearances Are Deceptive: Two Case Reports in Teenagers on the Conservative Laparoscopic Surgery for Adnexal Torsion with Apparent Infarction

Introduction. Torsion of the ovary, tube, or both is estimated to be responsible for 2-7% of all gynaecological emergencies. Oophorectomy is commonly performed for adnexal torsion with a possible negative impact on fertility in women of reproductive age. Case Presentations. We report two cases of teenage girls presented with adnexal torsion describing their laparoscopy features. Detorsion without additional surgical intervention could save their ovaries. Discussion. Detorsion is a more conservative surgical approach that should be considered in all younger women with ovarian torsion.

Ovarian Cancer Detection in Average-Risk Women: Classic- versus Nonclassic-appearing Adnexal Lesions at US

Background Several US risk stratification schemas for assessing adnexal lesions exist. These multiple-subcategory systems may be more multifaceted than necessary for isolated adnexal lesions in average-risk women. Purpose To explore whether a US-based classification scheme of classic versus nonclassic appearance can be used to help appropriately triage women at average risk of ovarian cancer without compromising diagnostic performance. Materials and Methods This retrospective multicenter study included isolated ovarian lesions identified at pelvic US performed between January 2011 and June 2014, reviewed between September 2019 and September 2020. Lesions were considered isolated in the absence of ascites or peritoneal implants. Lesions were classified as classic or nonclassic based on sonographic appearance. Classic lesions included simple cysts, hemorrhagic cysts, endometriomas, and dermoids. Otherwise, lesions were considered nonclassic. Outcomes based on histopathologic results or clinical or imaging follow-up were recorded. Diagnostic performance and frequency of malignancy were calculated. Frequency of malignancy between age groups was compared using the χ² test, and Poisson regression was used to explore relationships between imaging features and malignancy. Results A total of 970 isolated lesions in 878 women (mean age, 42 years ± 14 [SD]) were included. The malignancy rate for classic lesions was less than 1%. Of 970 lesions, 53 (6%) were malignant. The malignancy rate for nonclassic lesions was 32% (33 of 103) when blood flow was present and 8% (16 of 194) without blood flow (P < .001). For women older than 60 years, the malignancy rate was 50% (10 of 20 lesions) when blood flow was present and 13% (five of 38) without blood flow (P = .004). The sensitivity, specificity, positive predictive value, and negative predictive value of the classic-versus-nonclassic schema was 93% (49 of 53 lesions), 73% (669 of 917 lesions), 17% (49 of 297 lesions), and 99% (669 of 673 lesions), respectively, for detection of malignancy. Conclusion Using a US classification schema of classic- or nonclassic-appearing adnexal lesions resulted in high sensitivity and specificity in the diagnosis of malignancy in ovarian cancer. The highest risk of cancer was in isolated nonclassic lesions with blood flow in women older than 60 years. © RSNA, 2022 See also the editorial by Baumgarten in this issue.

Benign-appearing Incidental Adnexal Cysts at US, CT, and MRI: Putting the ACR, O-RADS, and SRU Guidelines All Together

Adnexal cysts are a common incidental finding at US, CT, and MRI but have historically caused a diagnostic dilemma for determining when to follow up and how to manage them. Characteristic imaging features of simple adnexal cysts include a simple fluid collection with smooth walls and no solid or vascular components. Day-to-day practice guidelines were recently updated to reflect the overwhelming evidence that incidental cystic adnexal masses are almost always benign. Three major consensus articles on adnexal cystic masses were published between 2019 and 2020: the Society of Radiologists in Ultrasound (SRU) consensus update on adnexal cysts, the Ovarian-Adnexal Reporting and Data System (O-RADS) US consensus guideline, and the American College of Radiology (ACR) white paper on the management for incidental adnexal findings at CT and MRI. All three standardize reporting terminology, are based on evidence-based data and institutional practice patterns, and apply to nonpregnant women of average risk for ovarian cancer. While there are small differences in follow-up recommendations based on size thresholds, the goal of each is the same-to limit unnecessary imaging follow-up and, by doing so, save the patient time, money, and anxiety. For the diagnostic radiologist to use these guidelines, it is essential that the entire mass is visualized well. Without adequate visualization, further characterization of the mass may be necessary. To put it all together, the SRU consensus guideline and ACR white paper are easily applied in day-to-day practice for masses that are O-RADS 2 and below. An invited commentary by Patel is available online. The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2022.

Two-Step Strategy for Optimizing the Preoperative Classification of Adnexal Masses in a University Hospital, Using International Ovarian Tumor Analysis Models: Simple Rules and Assessment of Different NEoplasias in the adneXa Model

OBJECTIVES

To evaluate the performance of a two-step strategy compared with the International Ovarian Tumor Analysis (IOTA) - Assessment of Different NEoplasias in the adneXa (ADNEX) model for preoperative classification of adnexal masses.

METHODS

An ambispective diagnostic accuracy study based on ultrasound data collected at one university hospital between 2012 and 2018. Two ultrasonographers classified the adnexal masses using IOTA Simple Rules (first step). Not classifiable masses were evaluated using the IOTA ADNEX model (second step). Also, all masses were classified using the IOTA ADNEX model. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-), and receiver operating characteristic (ROC) curve were estimated. A P value of <.05 was used to determine statistical significance.

RESULTS

The study included 548 patients and 606 masses. Patients' median age was 41 years with an interquartile range between 32 and 51 years. In the first step, 89 (14%) masses were not classifiable. In the second step, 55 (61.8%) masses were classified as malignant. Furthermore, for the totality of 606 masses, the IOTA ADNEX model estimated the probability that 126 (20.8%) masses were malignant. The two-step strategy had a sensitivity, specificity, PPV, NPV, LR+, LR-, and ROC curve of 86.8%, 91.01%, 51.9%, 98.4%, 9.7, 0.1, and 0.889, respectively; compared to IOTA ADNEX model that had values of 91.8%, 87.16%, 44.4%, 99%, 7.1, 0.09, and 0.895, respectively.

CONCLUSION

The two-step strategy shows a similar diagnostic performance when compared to the IOTA ADNEX model. The IOTA ADNEX model involves only one step and can be more practical, and thus would be recommended to use.

O-RADS MRI Risk Stratification System: Guide for Assessing Adnexal Lesions from the ACR O-RADS Committee

MRI plays an important role as a secondary test or problem-solving modality in the evaluation of adnexal lesions depicted at US. MRI has increased specificity compared with US, decreasing the number of false-positive diagnoses for malignancy and thereby avoiding unnecessary or over-extensive surgery in patients with benign lesions or borderline tumors, while women with possible malignancies can be expeditiously referred for oncologic surgical evaluation. The Ovarian-Adnexal Reporting and Data System (O-RADS) MRI Committee is an international collaborative effort formed under the direction of the American College of Radiology and includes a diverse group of experts on adnexal imaging and management who developed the O-RADS MRI risk stratification system. This scoring system assigns a probability of malignancy based on the MRI features of an adnexal lesion and provides information to facilitate optimal patient management. The widespread implementation of a codified reporting system will lead to improved interpretation agreement and standardized communication between radiologists and referring physicians. In addition, it will allow for high-quality multi-institutional collaborations-an important unmet need that has hampered the performance of high-quality research in this area in the past. This article provides guidelines on using the O-RADS MRI risk stratification system in clinical practice, as well as in the educational and research settings.

Comparison of HE4, CA125, ROMA and CPH-I for Preoperative Assessment of Adnexal Tumors

(1) OBJECTIVE: To assess the performance of CA125, HE4, ROMA index and CPH-I index to preoperatively identify epithelial ovarian cancer (EOC) or metastatic cancer in the ovary (MCO). (2) METHODS: single center retrospective study, including women with a diagnosis of adnexal mass. We obtained the AUC, sensitivity, specificity and predictive values were of HE4, CA125, ROMA and CPH-I for the diagnosis of EOC and MCO. Subgroup analysis for women harboring adnexal masses with inconclusive diagnosis of malignancy by ultrasound features and Stage I EOC was performed. (3) RESULTS: 1071 patients were included, 852 (79.6%) presented benign/borderline tumors and 219 (20.4%) presented EOC/MCO. AUC for HE4 was higher than for CA125 (0.91 vs. 0.87). No differences were seen between AUC of ROMA and CPH-I, but they were both higher than HE4 AUC. None of the tumor markers alone achieved a sensitivity of 90%; HE4 was highly specific (93.5%). ROMA showed a sensitivity and specificity of 91.1% and 84.6% respectively, while CPH-I showed a sensitivity of 91.1% with 79.2% specificity. For patients with inconclusive diagnosis of malignancy by ultrasound features and with Stage I EOC, ROMA showed the best diagnostic performance (4) CONCLUSIONS: ROMA and CPH-I perform better than tumor markers alone to identify patients harboring EOC or MCO. They can be helpful to assess the risk of malignancy of adnexal masses, especially in cases where ultrasonographic diagnosis is challenging (stage I EOC, inconclusive diagnosis of malignancy by ultrasound features).

Pearls and Potential Pitfalls for Correct Diagnosis of Ovarian Cystadenofibroma in MRI: A Pictorial Essay

Ovarian cystadenofibroma is a benign ovarian tumor that is characterized by a consistent percentage of masses, which remain indeterminate in ultrasonography and require magnetic resonance (MR) investigation; they may mimic borderline or malignant lesions. Three main morphologic patterns, resembling different ovarian neoplasms, can be identified in cystadenofibromas: multilocular solid lesions, unilocular cystic lesions with parietal thickening, and purely cystic masses. However, a cystoadenofibroma has typical features, such as T2-weighted hypointensity associated with no restrictions in diffusion-weighted imaging (the so-called "dark-dark appearance") and progressive post-contrast enhancement (type I perfusion curve). The purpose of this study was to review the features of ovarian cystadenofibromas in MR imaging and to suggest pearls and pitfalls regarding their correct diagnosis.

HE4 might be a more useful tumor biomarker to detect malignancy in patients with ovarian endometrioma when malignancy is suspected

Objective

To analyze the utility of carbohydrate antigen (CA)125 and human epididymis protein 4 (HE4) to detect malignancy in women with ovarian endometriosis, when ovarian cancer is suspected and ultrasonography results are inconclusive.

Methods

Women who underwent surgery between 2015 and 2019 for ovarian endometriosis or for adnexal masses, with a final diagnosis of ovarian carcinoma (clear cell and endometrioid) were included in this retrospective study. The women were divided into three groups: ovarian endometriosis (OE), ovarian carcinoma without endometriosis (OC), and ovarian carcinoma with endometriosis (OC + E). Adnexal masses were assessed preoperatively by transvaginal ultrasonography according to the International Ovarian Tumor Analysis (IOTA) simple rules, and CA125 and HE4 blood levels were obtained.

Results

Of 208 women, 45 had malignancy, 16 in the OC + E group and 29 in the OC group. According to transvaginal ultrasonography, 13 were classified as undetermined risk of malignancy: OC group: 3, OE group: 3, and OC + E group: 7. When we compared the tumor biomarkers, significant differences in HE4 but not in CA125 levels were found between the groups.

Conclusions

When ovarian malignancy is suspected in patients with ovarian endometriosis, HE4 is a more useful tumor biomarker to diagnose OC when ultrasonography results are inconclusive.

Analysis of HOXA9 methylated ctDNA in ovarian cancer using sense-antisense measurement

DNA promoter methylation is an early event in tumorigenesis and holds promise as a valuable marker in ovarian cancer (OC). It can be measured using circulating tumor specific DNA (ctDNA) isolated from the bloodstream. Sensitivity, however, is a limiting factor of its diagnostic feasibility in OC. DNA methylation analyses are based on bisulfite conversion, resulting in two DNA strands that are no longer complementary. The current standard strategy would then target only one of the double stranded DNA strands, but the potential to increase the sensitivity by targeting both DNA strands is available. In this study, we aimed at evaluating the diagnostic potential of methylated HOXA9 ctDNA in OC by targeting both the DNA sense and antisense strand. Methylated HOXA9 was detected in the plasma of 47/79 (59.5%) patients with newly diagnosed OC using sense-antisense droplet digital PCR. Simultaneous sense-antisense measurement increased the sensitivity by 14.6% (51.9% to 59.5%) as compared to antisense only. In patients with FIGO stage I-II disease the sensitivity was increased by 25%. In conclusion, simultaneous measurement targeting both DNA strands can increase the sensitivity and the analytical approach appears valuable in the diagnostic setting of OC.

Ultrasound Assessment of Adnexal Pathology: Standardized Methods and Different Levels of Experience

Background and objectives: An expert’s subjective assessment is still the most reliable evaluation of adnexal pathology, thus raising the need for methods less dependent on the examiner’s experience. The aim of this study was to evaluate the performance of standardized methods when applied by examiners with different levels of experience and to suggest the most suitable method for less-experienced gynecologists. Materials and methods: This single-center retrospective study included 50 cases of histologically proven first-time benign or malignant adnexal pathology. Three examiners evaluated the same transvaginal ultrasound images: an expert (level III), a 4th year resident in gynecology (level I), and a final year medical student after basic training (labeled as level 0). The assessment methods included subjective evaluation, Simple Rules (SR) with and without algorithm, ADNEX and Gynecologic Imaging Reporting and Data System (GI-RADS) models. Sensitivity, specificity, accuracy, positive and negative predictive values with 95% confidence interval were calculated. Results: Out of 50 cases, 33 (66%) were benign and 17 (34%) were malignant adnexal masses. Using only SR, level III could classify 48 (96%), level I—41 (82%) and level 0—40 (80%) adnexal lesions. Using SR and algorithm, the performance improved the most for all levels and yielded sensitivity and specificity of 100% for level III, 100% and 97% for level I, 94.4% and 100% for level 0, respectively. Compared to subjective assessment, ADNEX lowered the accuracy of level III evaluation from 97.9% to 88% and GI-RADS had no impact. ADNEX and GI-RADS improved the sensitivity up to 100% for the less experienced; however, the specificity and accuracy were notably decreased. Conclusions: SR and SR+ algorithm have the most potential to improve not only sensitivity, but also specificity and accuracy, irrespective of the experience level. ADNEX and GI-RADS can yield sensitivity of 100%; however, the accuracy is decreased.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumors

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the preoperative diagnosis of ovarian tumors, including imaging techniques, biomarkers and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the preoperative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the preoperative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on pre-operative diagnosis of ovarian tumors

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group, and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the pre-operative diagnosis of ovarian tumors, including imaging techniques, biomarkers, and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the pre-operative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when a consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the pre-operative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

Comparison of the Diagnostic Performances of Ultrasound-Based Models for Predicting Malignancy in Patients With Adnexal Masses

AIM

This study aimed to compare different ultrasound-based International Ovarian Tumor Analysis (IOTA) prediction models, namely, the Simple Rules (SRs) the Assessment of Different NEoplasias in the adneXa (ADNEX) models, and the Risk of Malignancy Index (RMI), for the pre-operative diagnosis of adnexal mass.

METHODS

This single-centre diagnostic accuracy study involved 486 patients. All ultrasound examinations were analyzed and the prediction models were applied. Pathology was the clinical reference standard. The diagnostic performances of prediction models were measured by evaluating receiver-operating characteristic curves, sensitivities, specificities, positive and negative predictive values, positive and negative likelihood ratios, and diagnostic odds ratios.

RESULTS

To discriminate benign and malignant tumors, areas under the ROC curves (AUCs) for ADNEX models were 0.94 (95% CI: 0.92-0.96) with CA125 and 0.94 (95% CI: 0.91-0.96) without CA125, which were significantly higher than the AUCs for RMI I-III: 0.87 (95% CI: 0.83-0.90), 0.83 (95% CI: 0.80-0.86), and 0.82 (95% CI: 0.78-0.86), (all P < 0.0001). At a cut-off of 10%, the ADNEX model with CA125 had the highest sensitivity (0.93; 95% CI: 0.87-0.97) compared with the other models. The SRs model achieved a sensitivity of 0.93 (95% CI: 0.86-0.97) and a specificity of 0.86 (95% CI: 0.82-0.89) when inconclusive diagnoses (11.7%) were classified as malignant.

CONCLUSION

ADNEX and SRs models were excellent at characterising adnexal masses which were superior to the RMI in Chinese patients.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumours

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the preoperative diagnosis of ovarian tumours, including imaging techniques, biomarkers and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the preoperative diagnosis of ovarian tumours and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when a consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the preoperative diagnosis of ovarian tumours and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

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.

Ovary: MRI characterisation and O-RADS MRI

Ultrasound has a high specificity for the diagnosis of a benign lesion in cases of classic appearing simple cyst, hemorrhagic cyst, endometrioma and dermoid. However, ultrasound can sometimes be limited for definitive characterisation and risk stratification of other types of lesions, including those with echogenic content that may appear solid, with or without blood flow. Frequently, MRI can be used to further characterise these types of lesions, due to its ability to distinguish solid tissue from non-tissue solid components such as fat, blood, or debris. Incorporating the MR imaging into the evaluation of adnexal lesions can improve diagnostic certainty and guide clinical management potentially avoiding inappropriate surgery for benign lesions and expediting appropriate treatment for malignant lesions, particularly in the females with sonographically indeterminate adnexal lesions.

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.

Sonographic Assessment of Complex Ultrasound Morphology Adnexal Tumors in Pregnant Women with the Use of IOTA Simple Rules Risk and ADNEX Scoring Systems

Background: To evaluate the accuracy of subjective assessment (SA), the International Ovarian Tumor Analysis (IOTA) group Simple Rules Risk (SRR) and the Assessment of Different NEoplasias in the adneXa (ADNEX) model for the preoperative differentiation of adnexal masses in pregnant women. Methods: The study population comprised 36 pregnant women (median age: 28.5 years old, range: 20–42 years old) with a mean gestation age of 13.5 (range: 8–31) weeks at diagnosis. Tumors were prospectively classified by local sonographers as probably benign or probably malignant using SA. Final tumor histological diagnosis was used as the reference standard in all cases. Logistic regression SRR and ADNEX models were used to obtain a risk score for every case. Serum CA125 and human epidydimis protein 4 (HE4) concentrations were also retrieved and the Risk of Ovarian Malignancy Algorithm (ROMA) value was calculated. The calculated predictive values included positive and negative likelihood ratios of ultrasound and biochemical tests. Results: Final histology confirmed 27 benign and 9 malignant (including 2 borderline) masses. The highest sensitivity (89%) and specificity (70%) were found for the subjective tumor assessment. Although no malignancy was classified as benign using the SRR criteria (sensitivity = 100%), the specificity of this scoring system was only 37%. At the cut-off risk level of >20%, the ADNEX model had a sensitivity of 78% and a specificity of 70%. Serum levels of CA125, HE4 and the ROMA risk model correctly identified adnexal malignant tumors with a sensitivity of 67%, 25% and 25%, respectively. Corresponding specificities were 72%, 100% and 100%, respectively. The highest positive and negative likelihood ratios were found for SA (LR+ = 3.0 and LR− = 0.16, respectively). Overall diagnostic accuracy of all predictive methods used in this study were similar (range: 70–75%) except for SRR (53%). Conclusion: Subjective assessment remains the best predictive method in complex adnexal masses found at prenatal ultrasound in pregnant women. For less experienced sonographers, both the SRR and ADNEX scoring systems may be also used for the characterization of such tumors, while serum tumor markers CA125 and HE4, along with the ROMA algorithm appear to be less accurate.

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.

Multimodality imaging review of complex pelvic lesions in female pelvis

Complex pelvic lesions can originate from various anatomical structures in the pelvis and pose a diagnostic dilemma due to a wide range of possible diagnoses. Accurate characterisation of these lesions would often require an algorithmic approach, which incorporates clinical findings, sequential use of multiple imaging modalities and a multiparametric approach. This approach usually aims at identifying key imaging features, which aid in anatomical localisation, morphology and tissue characterisation. There have been various attempts to standardise the lexicon used for describing adnexal masses in female patients; stratify their risk of cancer and suggest appropriate next steps in the management pathway. Through this review, we extend this approach to complex pelvic masses in female pelvis in general and will focus on optimal use of different imaging modalities to arrive at definitive diagnosis or meaningful differential diagnosis. We will also discuss potential pitfalls of imaging diagnosis and common mimics.

Prospective revalidation of IOTA "two-step", "alternative two-step" and "three-step" strategies for characterization of adnexal masses - An Indian study focussing the radiology context

Objectives:

The purpose of this study was to revalidate the diagnostic performance of IOTA “two step” (Simple Descriptors and Simple Rules), “ alternative two step” (Simple Rules Risk Calculation tool / SRrisk score), and three step (two step with subjective assessment) strategies, for characterization of adnexal masses as benign or malignant, using histopathology as gold standard.

Materials and Methods:

This prospective, study comprised of 100 patients with newly diagnosed adnexal masses, who underwent ultrasound evaluation first by a level I and then by a level III investigator (EFSUMB criteria). Initially, the level I investigator evaluated each adnexal mass, applying IOTA “two-step” strategy and simultaneously assigned a risk category, by applying the simple rules risk score (SRrisk score) or performing the “alternative two step” strategy. Subsequently the inconclusive masses were evaluated by the level III investigator using “real time subjective assessment”, thereby performing the third step. Following histopathology diagnosis, the performance of each strategy was evaluated using diagnostic tests.

Results:

The sensitivity, specificity, PPV, NPV, and diagnostic accuracy of “two-step” strategy were 87.5%, 79.2%, 89.4%, 76%, and 84.7%, respectively; those of “alternative two-step” strategy were 91.5%, 75.6%, 84.4%, 86.1% and 88%; and those of “three-step” strategy were 98.2%, 93.3%, 94.7%, 97.7% and 96%, respectively.

Conclusion:

All IOTA strategies showed good diagnostic performance for characterization of adnexal masses and the “three-step” strategy performed best. We believe this is the first ever prospective re-validation and comparative evaluation of all three IOTA strategies by Indian Radiologists. Since ultrasound is the primary modality for evaluation of adnexal masses, based on the good results of our study, a recommendation for henceforth standard application, of the three-step IOTA strategy in routine Radiology practice appears justified. Although, IOTA strategies been proposed and validated mainly by Gynaecologists and Oncology surgeons, based on the results of our study, this paradigm can now be made to shift back to the arena of Radiology and Radiologists, the imaging experts.

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.

Obstetrics and Gynecology Residents Can Accurately Classify Benign Ovarian Tumors Using the International Ovarian Tumor Analysis Rules

OBJECTIVES

Recognition of benign versus malignant tumors is essential in gynecologic ultrasound (US). The International Ovarian Tumor Analysis (IOTA) rules have been proposed as part of resident US training. The objective of this study was to examine whether they could be accurately used by obstetrics and gynecology residents in Rwanda.

METHODS

Patients undergoing explorative laparotomy for adnexal masses at the University Teaching Hospital of Kigali were included. Before the study, a didactic lecture on the IOTA rules for classifying adnexal masses was performed. Preoperative transabdominal US examinations were performed by residents at different levels of training, who were blinded to the results of prior US examinations. The IOTA classification was compared to the final pathologic diagnosis.

RESULTS

There were 72 patients who underwent 116 US examinations. Only 15.5% of US examinations were considered inconclusive. First-year residents (12) correctly diagnosed 18 of 20 masses (90%) as benign and 4 of 4 as malignant. Second-year residents (9) classified 29 of 29 masses correctly. Third-year residents (10) accurately identified 21 of 22 (95.5%) as benign and 5 of 5 as malignant. Fourth-year residents (13) accurately identified 11 of 12 (91.7%) as benign and 6 of 6 as malignant. Therefore, 74 of 78 tumors (94.9%) considered benign by IOTA rules were confirmed by histologic results. Similarly, all 20 tumors classified as malignant were confirmed. Overall, the sensitivities to diagnose benign and malignant tumors by the IOTA rules were 83.3% and 100%, respectively. The positive and negative predictive values were 100% and 94.9%. There were no significant differences noted between residency years.

CONCLUSIONS

All levels of Rwandan obstetrics and gynecology residents were able to use the IOTA rules to accurately distinguish benign from malignant tumors.

Characteristics and prognosis of borderline ovarian tumors in pre and postmenopausal patients

OBJECTIVE

To compare patient characteristics, imaging results, surgical management and prognosis of borderline ovarian tumors (BOT) between pre and postmenopausal patients.

MATERIALS AND METHODS

A retrospective cohort of all cases of histologically verified BOT between 1990-2018, comparing presentation, imaging, surgical procedures and recurrence. Patients were included in the postmenopausal group if they reported 12 months of amenorrhea with or without menopausal symptoms.

RESULTS

During this 28 year study period, 66 operations were performed in which BOT was confirmed. Postmenopausal patients were 37-89 years old and premenopausal patients 18-50 years old, with an average age of 63.9 ± 13.4 and 36.2 ± 8.4 years, respectively (p < 0.001). The majority of patients in both groups were diagnosed due to abdominal pain, followed by incidental diagnosis on routine ultrasound. Imaging and CA-125 levels upon presentation were similar. Almost sixty percent of postmenopausal and 26.3% of premenopausal patients underwent laparotomy (p = 0.01), while those who underwent laparoscopy were 35.7% and 60.5%, respectively (p = 0.03). Most postmenopausal patients underwent bilateral salpingo-oophorectomy (BSO), whereas premenopausal surgeries involved cystectomy. Nearly all study patients were diagnosed in stage one. Malignant transformation occurred in 7.1% of postmenopausal patients. No malignant transformation was found in premenopausal patients.

CONCLUSION

BOT's present similarly in pre and postmenopausal patients. Postmenopausal patients undergo more extensive surgery, and are diagnosed in early stage disease. Despite a tendency for a more conservative approach in premenopausal patients, prognosis is similar in both groups.

The prevalence of freezing of gait in Parkinson's disease and in patients with different disease durations and severities

Background

The prevalence rates of freezing of gait (FOG) in Parkinson’s disease (PD) vary widely, ranging from 14.0 to 55.1%. Our aim is to calculate the overall prevalence of FOG in all PD patients with different disease durations and severities.

Methods

Using Medline/PubMed/Embase, we carried out a systematic literature search for studies reporting the PD and clinically relevant FOG.

Results

After primary screening, a total of 35 studies were identified and further analyzed for inclusion into the analysis, and 29 studies fulfilled the quality criteria and included in this meta-analysis. The overall prevalence of FOG in PD was 39.9% (95% CI 35.3-44.5%). The FOG identified by the freezing of gait questionnaire item 3 may be more prevalent (43.8%, 95% CI 38.5-49.1%) than the FOG identified by the Unified Parkinson’s Disease Rating Scale item 14 (36.0%, 95% CI 29.0-43.1%). Disease duration and severity are both the clinical features associated with the FOG. The highest FOG prevalence rate in PD patients was seen in patients with disease durations ≥ 10 years, at 70.8%, followed that of PD patients with disease durations ≥ 5 years (53.3%), and PD patients with disease durations < 5 years (22.4%). FOG presented in 28.4% of PD patients with Hoehn and Yahr staging (H&Y) score ≤ 2.5, and in 68.4% of PD patients with H&Y score ≥ 2.5.

Conclusion

This meta-analysis confirms that the prevalence of FOG in PD is considerable, and highlights the need for accurate identification of FOG in PD.

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.