Guideline No. 403: Initial Investigation and Management of Adnexal Masses

Incidental findings of borderline ovarian tumor or ovarian cancer - real-world data on surgical and oncological outcomes

Introduction

Centralization of ovarian cancer treatment is associated with higher rates of optimal surgery and longer survival. However, preoperative diagnosis of ovarian cancer is challenging and some diagnoses are made incidentally after surgery. This study investigated the surgical and oncological outcomes of patients with incidental findings of borderline ovarian tumors or ovarian cancer who were centralized postoperatively and treated with a two-stage surgical procedure, and compared these with those of patients with adnexal masses of suspected malignancy who were offered a single-stage surgical procedure with intraoperative frozen section in a tertiary hospital.

Methods

A database of 390 patients with adnexal masses and surgical treatment at the Bern University Hospital, Switzerland was retrospectively reviewed to identify patients with borderline ovarian tumors or ovarian cancer between 2010 and 2020.

Results

Among 390 patients with adnexal masses, 223 were diagnosed with a borderline ovarian tumor or ovarian cancer. Compared with patients with suspected malignancy and a centralized single-stage surgical procedure, patients with an incidental postoperative malignancy diagnosis and a two-stage surgical procedure underwent more surgical interventions (1.3 vs. 2.1 p<.001) and had a longer time interval from diagnosis to initiation of chemotherapy (33.3 vs. 45.1 p=.005) and to completion of surgical cytoreduction (31.9 vs. 73.7 days, p<.001). However, there were no differences in the rates of complete cytoreduction (90.0% vs. 93.2%, p=.719), intraoperative (11.3% vs. 13.7%, p=.664) or postoperative (38.7% vs. 37.0%, p=.884) complication rates, and number of hospitalization days (11.1 vs. 12.0 days, p=.369). An incidental diagnosis of malignancy with postoperative referral was neither associated with an increased risk of recurrence (hazard ratio (HR) 0.8, 95% confidence interval (CI) 0.6-1.8, p=.839) nor death (HR 0.7, 95% CI 0.4-1.1, p=.113), and there was no difference in mean recurrence-free survival between the study subgroups.

Discussion

Although patients with incidental findings of borderline ovarian tumors or ovarian cancer treated with a two-stage surgical procedure had a longer time to completion of surgical staging and initiation of chemotherapy, our results showed no negative impact on oncological outcomes.

Unilateral Oophorectomy and Age at Natural Menopause: A Longitudinal Community-Based Cohort Study

OBJECTIVE

To determine the association between unilateral oophorectomy (UO) and age at natural menopause.

DESIGN

Secondary analysis of survey data from Alberta's Tomorrow Project (2000-2022).

SETTING

Prospective cohort study in Alberta, Canada.

POPULATION

23 630 women; 548 experienced UO and 23 082 did not experience UO.

METHODS

Flexible parametric survival analysis was used to analyse age at natural menopause, and logistic regression was used to analyse early menopause and premature ovarian insufficiency by UO status, controlling for birth year, parity, age at menarche, past infertility, hormonal contraceptive use and smoking.

MAIN OUTCOME MEASURES

Age at natural menopause occurred by a final menstrual period without medical cause and sub-classified as early menopause (< 45 years) and premature ovarian insufficiency (< 40 years).

RESULTS

Compared to no UO, any UO was associated with elevated risk of earlier age at natural menopause, which was strongest in early midlife (adjusted HR at age 40 1.71, 95% CI 1.31-2.19) and diminished over time. Compared to age 55 years at UO, risks of earlier age at natural menopause were largest and uniform in magnitude when UO occurred between approximately ages 20-40 years (adjusted HR for UO at age 30 2.32, 1.46-3.54) and then diminished as age at UO approached the average age at natural menopause. Any UO was associated with higher odds of early menopause (adjusted OR 1.90, 1.30-2.79) and premature ovarian insufficiency (adjusted OR 3.75, 1.72-8.16).

CONCLUSIONS

Unilateral oophorectomy is associated with earlier age at natural menopause, particularly when performed before 40 years of age.

The Ovarian-Adnexal Reporting and Data System (O-RADS) US Score Effect on Surgical Resection Rate

Background The Ovarian-Adnexal Imaging Reporting and Data System (O-RADS) US risk score can be used to accurately stratify ovarian lesions based on morphologic characteristics. However, there are no large multicenter studies assessing the potential impact of using O-RADS US version 2022 risk score in patients referred for surgery for an ovarian or adnexal lesion. Purpose To retrospectively determine the proportion of patients with ovarian or adnexal lesions without acute symptoms who may have been managed conservatively by using the O-RADS US version 2022 risk score. Materials and Methods This multicenter retrospective study included patients with ovarian cystic lesions and nonacute symptoms who underwent surgical resection after US before the introduction of O-RADS US between January 2011 and December 2014. Investigators blinded to the final diagnoses recorded lesion imaging features and O-RADS US risk scores. The frequency of malignancy and the diagnostic performance of the risk score were calculated. The Mann-Whitney test and Fisher exact test were performed, with P < .05 indicating a statistically significant difference. Results A total of 377 patients with surgically resected lesions were included. Among the resected lesions, 42% (157 of 377) were assigned an O-RADS US risk score of 2. Of the O-RADS US 2 lesions, 54% (86 of 157) were nonneoplastic, 45% (70 of 157) were dermoids or other benign tumors, and less than 1% (one of 157) were malignant. Using O-RADS US 4 as the optimal threshold for malignancy prediction yielded a 94% (68 of 72) sensitivity, 64% (195 of 305) specificity, 38% (68 of 178) positive predictive value, and 98% (195 of 199) negative predictive value. Conclusion In patients without acute symptoms who underwent surgery for ovarian and adnexal lesions before the O-RADS US risk score was published, nearly half (42%) of surgically resected lesions retrospectively met the O-RADS US 2 version 2022 criteria. In these patients, imaging follow-up or conservative management could have been offered. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Fournier in this issue.

Diagnostic performance of contrast-enhanced ultrasound (CEUS) combined with Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound risk stratification for adnexal masses: a systematic review and meta-analysis

AIM

A number of studies have reported that contrast-enhanced ultrasound (CEUS) imaging might be used for the early diagnosis of adnexal masses. A meta-analysis was performed to evaluate the diagnostic accuracy of CEUS combined with Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound risk stratification for adnexal masses.

MATERIALS AND METHODS

Related articles were retrieved from PubMed, Web of Science, Embase, and the Cochrane Library in strict accordance with established standards, and data (including true positive, false positive, false negative, and true negative values) was extracted from the original articles. The Quality Assessment of Diagnostic Accuracy Studies 2 was used to evaluate the quality of articles and the possibility of bias. STATA 12.0 software was used to perform statistical analysis.

RESULTS

Five articles that included 598 patients were analyzed in this meta-analysis. The pooled sensitivity and specificity of CEUS combined with O-RADS for the diagnosis of adnexal masses were 0.95 (95% confidence interval [CI]: 0.91-0.98) and 0.86 (95% CI: 0.79-0.91). Moreover, the positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio (DOR), and area under the curve (AUC) were 6.81 (95% CI: 4.61-10.08), 0.05 (95% CI: 0.03-0.11), 111.30 (95% CI: 65.32-189.65), and 0.97 (95% CI: 0.95-0.98), respectively. The pooled AUC and DOR for the detection of CEUS combined with O-RADS were superior to O-RADS US.

CONCLUSION

Our findings revealed that O-RADS combined with CEUS can improve the diagnostic accuracy of ovarian adnexal masses.

ACR Appropriateness Criteria® Clinically Suspected Adnexal Mass, No Acute Symptoms: 2023 Update

Asymptomatic adnexal masses are commonly encountered in daily radiology practice. Although the vast majority of these masses are benign, a small subset have a risk of malignancy, which require gynecologic oncology referral for best treatment outcomes. Ultrasound, using a combination of both transabdominal, transvaginal, and duplex Doppler technique can accurately characterize the majority of these lesions. MRI with and without contrast is a useful complementary modality that can help characterize indeterminate lesions and assess the risk of malignancy is those that are suspicious. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Guideline No. 449: Diagnosis and Impact of Endometriosis - A Canadian Guideline

OBJECTIVE

To provide a contemporary approach to the understanding of the impact and methods for the diagnosis of endometriosis in Canada.

TARGET POPULATION

Individuals, families, communities, health care providers, and health care administrators who are affected by, care for patients with, or manage delivery of services for endometriosis.

OPTIONS

The diagnosis of endometriosis is facilitated by a detailed history, examination, and imaging tests with providers who are experienced in endometriosis care. Surgical evaluation with pathology confirms a diagnosis of endometriosis; however, it is not required for those whose diagnosis was confirmed with imaging.

OUTCOMES

There is a need to address earlier recognition of endometriosis to facilitate timely access to care and support. Education directed at the public, affected individuals and families, health care providers, and health care administrators are essential to reduce delays in diagnosis and treatment.

BENEFITS, HARMS, AND COSTS

Increased awareness and education about the impact and approach to diagnosis may support timely access to care for patients and families affected by endometriosis. Earlier and appropriate care may support a reduced health care system burden; however, improved clinical evaluation may require initial investments.

EVIDENCE

Each section was reviewed with a unique search strategy representative of the evidence available in the literature related to the area of focus. The literature searches for each section of this guideline are listed in Appendix A and include information from published systematic reviews described in the text.

VALIDATION METHODS

The recommendations were developed following two rounds of review by a national expert panel through an iterative 2-year consensus process. Further details on the process are shared in Appendix B. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix C (Table C1 for definitions and Table C2 for interpretations of strong and conditional recommendations).

INTENDED AUDIENCE

This guideline is intended to support health care providers and policymakers involved in the care of those impacted by endometriosis and the systems required to support them.

TWEETABLE ABSTRACT

Endometriosis impact and diagnosis updated guidelines for Canadian health care providers and policymakers.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Canadian Association of Radiologists Obstetrics and Gynecology Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Obstetrics and Gynecology Expert Panel consists of radiologists specializing in obstetrics and gynecology, obstetrics and gynecology physicians, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 12 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 46 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 68 recommendation statements across the 12 scenarios related to the evaluation of obstetrics and gynecology clinical and diagnostic scenarios. This guideline presents the methods of development and the imaging recommendations for a variety of obstetrical and gynecological conditions including pregnancy assessment, recurrent first trimester pregnancy loss, post-partum indications, disorders of menstruation, localization of intra-uterine contraceptive device, infertility assessment, assessment of adnexal mass, pelvic pain of presumed gynecological origin, and pelvic floor evaluation.

Survival time prediction in patients with high-grade serous ovarian cancer based on 18F-FDG PET/CT- derived inter-tumor heterogeneity metrics

BACKGROUND

The presence of heterogeneity is a significant attribute within the context of ovarian cancer. This study aimed to assess the predictive accuracy of models utilizing quantitative 18F-FDG PET/CT derived inter-tumor heterogeneity metrics in determining progression-free survival (PFS) and overall survival (OS) in patients diagnosed with high-grade serous ovarian cancer (HGSOC). Additionally, the study investigated the potential correlation between model risk scores and the expression levels of p53 and Ki-67.

METHODS

A total of 292 patients diagnosed with HGSOC were retrospectively enrolled at Shengjing Hospital of China Medical University (median age: 54 ± 9.4 years). Quantitative inter-tumor heterogeneity metrics were calculated based on conventional measurements and texture features of primary and metastatic lesions in 18F-FDG PET/CT. Conventional models, heterogeneity models, and integrated models were then constructed to predict PFS and OS. Spearman's correlation coefficient (ρ) was used to evaluate the correlation between immunohistochemical scores of p53 and Ki-67 and model risk scores.

RESULTS

The C-indices of the integrated models were the highest for both PFS and OS models. The C-indices of the training set and testing set of the integrated PFS model were 0.898 (95% confidence interval [CI]: 0.881-0.914) and 0.891 (95% CI: 0.860-0.921), respectively. For the integrated OS model, the C-indices of the training set and testing set were 0.894 (95% CI: 0.871-0.917) and 0.905 (95% CI: 0.873-0.936), respectively. The integrated PFS model showed the strongest correlation with the expression levels of p53 (ρ = 0.859, p < 0.001) and Ki-67 (ρ = 0.829, p < 0.001).

CONCLUSIONS

The models based on 18F-FDG PET/CT quantitative inter-tumor heterogeneity metrics exhibited good performance for predicting the PFS and OS of patients with HGSOC. p53 and Ki-67 expression levels were strongly correlated with the risk scores of the integrated predictive models.

Application of transumbilical single port laparoscopic surgery for adnexal masses in pregnancy

OBJECTIVE

To evaluate the safety and feasibility of single-port laparoscopy during pregnancy in short term and long term.

METHODS

A multicenter retrospective study was conducted to investigate the clinical data of 38 pregnant women with adnexal masses who underwent transumbilical single-port laparoscopic surgery from January 2017 to March 10, 2023.

RESULTS

The mean operation time was 72.7 ± 29.6 (30-160) min. The mean intraoperative blood loss was 30.5 ± 80.4 mL, the mean postoperative first defecation time was 2.5 ± 0.7 days, and the mean total hospital stay was 6.9 ± 1.4 days. None of the patients used analgesic drugs postoperatively. Two patients developed missed abortions within 1 month of surgery, one underwent induction of labor due to a dead fetus at 24 weeks and 5 days of gestation, and the other patients did not develop adverse events after surgery. Mean birth weight was 3322.3 ± 396.3 g. The fetal heart rate was 139 ± 6.4 bpm before operation and 149 ± 2.7 bpm after operation. The APGAR score at 1 and 10 min was 9.2 ± 0.6 points and 9.9 ± 0.2 points, respectively. The mean follow-up time was 23.9 ± 16.1 (4.7-56) months, 90% (27/30) of the children had moderate developmental quotient, and 10% (3/30) of the children had good developmental quotient, without borderline low developmental quotient or mental retardation.

CONCLUSION

It is safe, practical, and worthwhile to promote transumbilical single port laparoscopic surgery for pregnancies with adnexal masses in both short and long term.

Liability, risks, and recommendations for ultrasound use in the diagnosis of obstetrics diseases

This literature review will summarize the liability issues, risks, and ultrasound recommendations for diagnosing obstetrics diseases. One liability issue is related to misdiagnosis or failure to detect abnormalities during an ultrasound examination. Ultrasound images can be subjective interpretations, and errors may occur due to factors such as operator skill, equipment limitations, or fetal positioning. Another liability concern is related to the potential adverse effects of ultrasound exposure on both the mother and fetus. While extensive research has shown that diagnostic ultrasound is generally safe when used appropriately, there are still uncertainties regarding long-term effects. Some studies suggest a possible association between prolonged or excessive exposure to ultrasound waves and adverse outcomes such as low birth weight, developmental delays, or hearing impairment. Additionally, obtaining informed consent from patients is crucial in mitigating liability risks. Patients should be informed about the purpose of the ultrasound examination, its benefits, limitations, potential risks (even if minimal), and any alternative diagnostic options available. This ensures that patients know the procedure and can make informed decisions about their healthcare. Proper documentation helps establish a clear record of the care provided and can serve as evidence in any legal disputes.

O-RADS US v2022: An Update from the American College of Radiology's Ovarian-Adnexal Reporting and Data System US Committee

First published in 2019, the Ovarian-Adnexal Reporting and Data System (O-RADS) US provides a standardized lexicon for ovarian and adnexal lesions, enables stratification of these lesions with use of a numeric score based on morphologic features to indicate the risk of malignancy, and offers management guidance. This risk stratification system has subsequently been validated in retrospective studies and has yielded good interreader concordance, even with users of different levels of expertise. As use of the system increased, it was recognized that an update was needed to address certain clinical challenges, clarify recommendations, and incorporate emerging data from validation studies. Additional morphologic features that favor benignity, such as the bilocular feature for cysts without solid components and shadowing for solid lesions with smooth contours, were added to O-RADS US for optimal risk-appropriate scoring. As O-RADS US 4 has been shown to be an appropriate cutoff for malignancy, it is now recommended that lower-risk O-RADS US 3 lesions be followed with US if not excised. For solid lesions and cystic lesions with solid components, further characterization with MRI is now emphasized as a supplemental evaluation method, as MRI may provide higher specificity. This statement summarizes the updates to the governing concepts, lexicon terminology and assessment categories, and management recommendations found in the 2022 version of O-RADS US.

Executive Summary of the Ovarian Cancer Evidence Review Conference

The Centers for Disease Control and Prevention awarded funding to the American College of Obstetricians and Gynecologists to develop educational materials for clinicians on gynecologic cancers. The American College of Obstetricians and Gynecologists convened a panel of experts in evidence review from the Society for Academic Specialists in General Obstetrics and Gynecology and content experts from the Society of Gynecologic Oncology to review relevant literature, best practices, and existing practice guidelines as a first step toward developing evidence-based educational materials for women's health care clinicians about ovarian cancer. Panel members conducted structured literature reviews, which were then reviewed by other panel members and discussed at a virtual meeting of stakeholder professional and patient advocacy organizations in February 2022. This article is the executive summary of the relevant literature and existing recommendations to guide clinicians in the prevention, early diagnosis, and special considerations of ovarian cancer. Substantive knowledge gaps are noted and summarized to provide guidance for future research.

Comparison of Ultrasound Scores in Differentiating between Benign and Malignant Adnexal Masses

Subjective ultrasound assessment by an expert examiner is meant to be the best option for the differentiation between benign and malignant adnexal masses. Different ultrasound scores can help in the classification, but whether one of them is significantly better than others is still a matter of debate. The main aim of this work is to compare the diagnostic performance of some of these scores in the evaluation of adnexal masses in the same set of patients. This is a retrospective study of a consecutive series of women diagnosed as having a persistent adnexal mass and managed surgically. Ultrasound characteristics were analyzed according to IOTA criteria. Masses were classified according to the subjective impression of the sonographer and other ultrasound scores (IOTA simple rules -SR-, IOTA simple rules risk assessment -SRRA-, O-RADS classification, and ADNEX model -with and without CA125 value-). A total of 122 women were included. Sixty-two women were postmenopausal (50.8%). Eighty-one women had a benign mass (66.4%), and 41 (33.6%) had a malignant tumor. The sensitivity of subjective assessment, IOTA SR, IOTA SRRA, and ADNEX model with or without CA125 and O-RADS was 87.8%, 66.7%, 78.1%, 95.1%, 87.8%, and 90.2%, respectively. The specificity for these approaches was 69.1%, 89.2%, 72.8%, 74.1%, 67.9%, and 60.5%, respectively. All methods with similar AUC (0.81, 0.78, 0.80, 0.88, 0.84, and 0.75, respectively). We concluded that IOTA SR, IOTA SRRA, and ADNEX models with or without CA125 and O-RADS can help in the differentiation of benign and malignant masses, and their performance is similar to the subjective assessment of an experienced sonographer.

Incidental discovery of a giant ovarian cystadenoma

Introduction

Serous cystadenomas account for approximately 25% of benign ovarian tumors in patients of childbearing age. Their growth is insidious, and the diagnosis can be difficult as they are often asymptomatic, Patients with serous cystadenoma often experience symptoms only if the lesion is twisted or has a mass effect because of its size.This was the case in our patient, whose cough and low back pain prompted her To consult a doctor, which led to the definitive diagnosis and treatment.

Materials and methods

We report a case of a patient admitted for strangulated umbilical hernia with fortuitous discovery of a giant ovarian mass in the P35 visceral emergency department at the CHU ibn rochd hospital in Casablanca, Morocco.

Results

the patient were operated in the emergency room, approached by laparotomy with the exploration we found umbilical hernia with a 6 cm long neck and necrotic bowel content a left latero-uterine mass of 40 cm of solid-cystic aspect and tube and right ovary without abnormalities and uterus of normal size the patient had an Segmental resection of 10 cm at 2.60 m from the ADJ and 1 m from the JIC with T-T grelo-grelic anastomosis and a left adnexectomy with a left latero-uterine mass of 45 cm and Epipoic and parietal peritoneum biopsy and Examination of the patient's spicemen showed serous cystadenoma weighing 10 kg and measuring 30 × 36*20 cm adjoining a tubular formation measuring 11 × 10*5 cm with bowel resection showed ischemic and hemorrhagic necrosis related to the occlusion with acellular ascites fluid.

Discussion

Very Cystadenomas There are 2 types: Pleudomucinous cystadenomas or mucoid cysts, These are the most frequent neoplastic cysts of the ovary which are, in general, lumpy, multilocular, producing a gelatinous substance [8]. Their consistency is variable, some taut and firm, others semi-solid, spongy, thick, hollowed out “honeycomb” parts, which contain thick, stringy mucus. The coloration is variable: grayish white when the wall is thick, translucent in some places, with yellowish or white reflections, blue-black or reddish if there is spilled blood, grayish if there is cholesterol. on the other hand Serous cystadenomas or papillary cysts A little less frequent than mucoid cysts. Usually unilocular or paucicular, round or relatively flat, they contain protein-rich serous fluid. The coloration varies according to the content and thickness of the wall: light yellow or brown if the wall is thin, purplish red if there is blood, greyish white if the wall is thick. Consistency clearly fluctuates on the whole but can be hard in places, semi-solid, if there are abundant vegetations inside.

Conclusion

Very large tumors have become curiosities in industrialized countries where the health care system is well developed. On the other hand, they are not rare in developing countries. The delay in diagnosis is most often due to the patient herself who does not consult out of ignorance or refusal of her pathology. But it can happen, and this is serious.

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The largest tumors found in the human species are essentially represented by human species are essentially represented by ovarian tumors.

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Its diagnosis is still very difficult.

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The treatment Serous cystadenomas geant is in most cases surgical.

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The diagnosis Serous cystadenomas is histological.

Management of adnexal mass: A comparison of five national guidelines

OBJECTIVES

General gynecologists are often the first to face a newly diagnosed adnexal mass. Bothering mass symptoms, fertility issues, and the effect of a possible surgical intervention on fertility in term of mechanical factor and ovarian follicular reserve are all considerations that should be accounted for. This study summarizes and compares five different adnexal mass management guidelines, enabling clinicians to peruse consensus and controversy issues, thus choosing the optimal management method.

DESIGN

We retrieved, reviewed and compared the most recent national guidelines of adnexal mass management from the national societies of the United States (American College of Obstetricians and Gynecologists), England (the Royal College of Obstetricians and Gynecologists), Canada (the Society of Obstetricians and Gynaecologists of Canada), Australia (the Royal Australian College of General Practitioners), and France (French College of Gynaecologists and Obstetricians).

RESULTS

There is a broad consensus regarding the role of transvaginal ultrasound as part of the initial evaluation of an adnexal mass and the radiological characteristics suggesting it being malignant. The role of transabdominal ultrasound or doppler mode is controversial. The use of MRI in cases of indeterminate adnexal masses is widely accepted. Ultrasound-guided aspiration is generally not recommended. There is a broad consensus that CA-125 should not be used as an ovarian cancer disease screening tool, though its role in the initial evaluation of adnexal masses is controversial. Risk prediction models are generally accepted, particularly the 'International Ovarian Tumor Analysis simple rules' and the 'Risk of Malignancy Index'.

CONCLUSION

Adnexal mass management national guidelines, though similar, had noticeable variations in the content, references cited, and recommendations made. While this variation might raise a concern as to the reproducibility of synthesizing literature, it can help practitioners present all spectra of recommendations and available data.

Decrease in Neutrophil-to-Lymphocyte Ratio during Neoadjuvant Chemotherapy as a Predictive and Prognostic Marker in Advanced Ovarian Cancer

Since chronic inflammation is associated with ovarian cancer growth and progression, some clinical studies have assessed the association between the pre-treatment neutrophil-to-lymphocyte ratio (NLR) and the prognosis of ovarian cancer. The purpose of this study was to assess the dynamic behavior of the NLR during the course of neoadjuvant chemotherapy (NACT) in patients with high grade serous (HGS) advanced epithelial ovarian cancer and assess its correlation with clinical response, progression free survival (PFS) and changes in other inflammatory indexes. We performed a prospective observational study on 161 patients who underwent NACT at the Department of Gynecologic Oncology, ARNAS G. Brotzu, Cagliari, between 2009 and 2019. NLR was evaluated before starting and after three cycles of NACT. Based on response after three cycles of NACT, patients were divided into two groups: responsive and non-responsive. The primary endpoint was to assess the predictive role of NLR by comparing the responsive and non-responsive patients at baseline and after three cycles of NACT. Secondary endpoints were (a) to correlate NLR with other inflammation markers (CRP, fibrinogen, ferritin, IL-6), albumin, and modified Glasgow Prognostic Score (mGPS) with NLR at baseline and after NACT; (b) to assess the association between NLR and PFS. We found that the NLR value at baseline was not associated with response to NACT, while a decrease in NLR after three cycles was correlated with a better response to NACT. Also, values of CRP, IL-6, ferritin, and mGPS after three cycles of NACT (but not at baseline) were significantly associated with clinical response. Moreover, we found that patients with a low NLR value after 3 cycles of NACT, but not at baseline, had a significantly higher PFS than patients with high NLR after 3 cycles of NACT. In conclusion, NLR change during treatment could serve as a predictive marker of response to NACT in patients with HGS advanced ovarian cancer. This allows for the early identification of non-responsive patients who will need treatment remodeling.