Discrimination between benign and malignant adnexal masses by specialist ultrasound examination versus serum CA-125

Comparison of the ADNEX and ROMA risk prediction models for the diagnosis of ovarian cancer: a multicentre external validation in patients who underwent surgery

BACKGROUND

Several diagnostic prediction models to help clinicians discriminate between benign and malignant adnexal masses are available. This study is a head-to-head comparison of the performance of the Assessment of Different NEoplasias in the adneXa (ADNEX) model with that of the Risk of Ovarian Malignancy Algorithm (ROMA).

METHODS

This is a retrospective study based on prospectively included consecutive women with an adnexal tumour scheduled for surgery at five oncology centres and one non-oncology centre in four countries between 2015 and 2019. The reference standard was histology. Model performance for ADNEX and ROMA was evaluated regarding discrimination, calibration, and clinical utility.

RESULTS

The primary analysis included 894 patients, of whom 434 (49%) had a malignant tumour. The area under the receiver operating characteristic curve (AUC) was 0.92 (95% CI 0.88-0.95) for ADNEX with CA125, 0.90 (0.84-0.94) for ADNEX without CA125, and 0.85 (0.80-0.89) for ROMA. ROMA, and to a lesser extent ADNEX, underestimated the risk of malignancy. Clinical utility was highest for ADNEX. ROMA had no clinical utility at decision thresholds <27%.

CONCLUSIONS

ADNEX had better ability to discriminate between benign and malignant adnexal tumours and higher clinical utility than ROMA.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov NCT01698632 and NCT02847832.

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.

Liquid biopsy in ovarian cancer in China and the world: current status and future perspectives

Ovarian cancer (OC) is the eighth most common cancer in women, but the mild, non-specific clinical presentation in early stages often prevents diagnosis until progression to advanced-stage disease, contributing to the high mortality associated with OC. While serum cancer antigen 125 (CA-125) has been successfully used as a blood-borne marker and is routinely monitored in patients with OC, CA-125 testing has limitations in sensitivity and specificity and does not provide direct information on important molecular characteristics that can guide treatment decisions, such as homologous recombination repair deficiency. We comprehensively review the literature surrounding methods based on liquid biopsies, which may provide improvements in sensitivity, specificity, and provide valuable additional information to enable early diagnosis, monitoring of recurrence/progression/therapeutic response, and accurate prognostication for patients with OC, highlighting applications of this research in China.

Mutations in circulating tumor DNA detected in the postoperative period predict poor survival in patients with ovarian cancer

BACKGROUND

We investigated whether mutations in plasma circulating tumor DNA (ctDNA) can provide prognostic insight in patients with different histological types of ovarian carcinoma. We also examined the concordance of mutations detected in ctDNA samples with those identified in the corresponding formalin-fixed paraffin-embedded (FFPE) tumor specimens.

METHODS

Between July 2016 and December 2017, 29 patients with ovarian carcinoma were prospectively enrolled. FFPE tumor specimens were obtained from all participants. A total of 187 blood samples for ctDNA analysis were collected before surgery (C0), immediate after surgery before adjuvant chemotherapy (C1), and at six-month intervals. Progression-free survival (PFS) and overall survival (OS) served as the main outcome measures.

RESULTS

The study cohort consisted of 13 (44.8%) patients with high-grade serous carcinomas (HGSC), 9 (31.0%) with clear cell carcinoma, 2 (6.9%) with mucinous carcinomas, 4 (13.8%) with low-grade serous carcinomas, and 1 (3.4%) with endometrioid carcinoma. Twenty-four (82.8%) patients had at least one detectable ctDNA variant. The concordance rate between mutations identified in pretreatment ctDNA and corresponding FFPE tumor specimens was 92.3% for patients with HGSC and 58.6% for the entire cohort. The median follow-up time was 33.15 months (range: 0.79-46.13 months). Patients with an advanced stage disease more likely had detectable ctDNA mutations before surgery (C0) and after surgery at C1, while those with HGSC more likely had ctDNA mutations detected before surgery. The presence of ctDNA mutations at C1 was an independent predictor of worse OS with a hazard ratio of 6.56 (95% confidence interval, (1.07-40.17) for detectable versus undetectable C1 ctDNA variants, p = 0.042).

CONCLUSIONS

ctDNA mutations are common in patients with ovarian carcinoma. The presence of ctDNA mutations after surgery was an independent predictor of less favorable PFS and OS.

Evaluation of Borderline Ovarian Tumor Recurrence Rate after Surgery with or without Fertility-Sparing Approach: Results of a Retrospective Analysis

Borderline ovarian tumors (BOTs) comprise 15-20% of primary ovarian neoplasms and represent an independent disease entity among epithelial ovarian cancers. The present study (Clinical Trial ID: NCT05791838) aimed to report a retrospective analysis of the management and outcomes of 86 consecutive BOTs patients, 54 of which were at a reproductive age. All patients with BOTs undergoing surgical treatment from January 2010 to December 2017 were included. Data were retrospectively reviewed. High levels of Ca-125 were observed in 25.6% of the FIGO stage I patients and 58.3% of the advanced disease patients. Fertility-sparing surgery and comprehensive surgical staging were performed in 36.7% and 49.3% of the patients, respectively. Laparotomy was the most frequent surgical approach (65.1%). The most common diagnosis at frozen sections was serous BOT (50.6%). Serous BOTs have significantly smaller tumor diameters than mucinous BOTs (p < 0.0001). The mean postoperative follow-up was 29.8 months (range 6-87 months). Three patients experienced a recurrence, with an overall recurrence rate of 3.5% (10% considering only the patients who underwent fertility-sparing treatment). BOTs have low recurrence rates, with excellent prognosis. Surgery with proper staging is the main treatment. Conservative surgery is a valid option for women with reproductive potential.

Adnexal Mass Imaging: Contemporary Guidelines for Clinical Practice

Several recent guidelines have been published to improve accuracy and consistency of adnexal mass imaging interpretation and to guide management. Guidance from the American College of Radiology (ACR) Appropriateness Criteria establishes preferred adnexal imaging modalities and follow-up. Moreover, the ACR Ovarian-Adnexal Reporting Data System establishes a comprehensive, unified set of evidence-based guidelines for classification of adnexal masses by both ultrasound and MR imaging, communicating risk of malignancy to further guide management.

A panel of seven protein tumour markers for effective and affordable multi-cancer early detection by artificial intelligence: a large-scale and multicentre case-control study

Background

Early detection of cancer aims to reduce cancer deaths. Unfortunately, many established cancer screening technologies are not suitable for use in low- and middle-income countries (LMICs) due to cost, complexity, and dependency on extensive medical infrastructure. We aimed to assess the performance and robustness of a protein assay (OncoSeek) for multi-cancer early detection (MCED) that is likely to be more practical in LMICs.

Methods

This observational study comprises a retrospective analysis on the data generated from the routine clinical testings at SeekIn and Sun Yat-sen Memorial Hospital. 7565 participants (954 with cancer and 6611 without) from the two sites were divided into training and independent validation cohort. The second validation cohort (1005 with cancer and 812 without) was from Johns Hopkins University School of Medicine. Patients with cancer prior to therapy were eligible for inclusion in the study. Individuals with no history of cancer were enrolled from the participating sites as the non-cancer group. One tube of peripheral blood was collected from each participant and quantified a panel of seven selected protein tumour markers (PTMs) by a common clinical electrochemiluminescence immunoassay analyser. An algorithm named OncoSeek was established using artificial intelligence (AI) to distinguish patients with cancer from those without cancer by calculating the probability of cancer (POC) index based on the quantification results of the seven PTMs and clinical information including sex and age of the individuals and to predict the possible affected tissue of origin (TOO) for those who have been detected with cancer signals in blood.

Findings

Between November 2012 and May 2022, 7565 participants were enrolled at SeekIn and Sun Yat-sen Memorial Hospital. The conventional clinical method, which relies only on a single threshold for each PTM, would suffer from a high false positive rate that accumulates as the number of markers increased. OncoSeek was empowered by AI technology to significantly reduce the false positive rate, increasing the specificity from 56.9% (95% confidence interval [CI]: 55.8-58.0) to 92.9% (92.3-93.5). In all cancer types, the overall sensitivity of OncoSeek was 51.7% (49.4-53.9), resulting in 84.3% (83.5-85.0) accuracy. The performance was generally consistent in the training and the two validation cohorts. The sensitivities ranged from 37.1% to 77.6% for the detection of the nine common cancer types (breast, colorectum, liver, lung, lymphoma, oesophagus, ovary, pancreas, and stomach), which account for ∼59.2% of global cancer deaths annually. Furthermore, it has shown excellent sensitivity in several high-mortality cancer types for which routine screening tests are lacking in the clinic, such as the sensitivity of pancreatic cancer which was 77.6% (69.3-84.6). The overall accuracy of TOO prediction in the true positives was 66.8%, which could assist the clinical diagnostic workup.

Interpretation

OncoSeek significantly outperforms the conventional clinical method, representing a novel blood-based test for MCED which is non-invasive, easy, efficient, and robust. Moreover, the accuracy of TOO facilitates the follow-up diagnostic workup.

Funding

The National Key Research and Development Programme of China.

Clinical Performance of a Multivariate Index Assay in Detecting Early-Stage Ovarian Cancer in Filipino Women

This study evaluated the clinical performance and overall utility of a multivariate index assay in detecting early-stage ovarian cancer in a Filipino population. This is a prospective cohort study among Filipino women undergoing assessment for an ovarian mass in a tertiary center. Patients diagnosed with early-stage ovarian cancer and who underwent a physical examination before level III specialist ultrasonographic and Doppler evaluation, multivariate index assay (MIA2G), and surgery for an adnexal mass were included in this study. Ovarian tumors were classified as high-risk for malignancy based on the IOTA-LR2 score. The ovarian imaging and biomarker results were correlated with the reference standard: surgico-pathologic findings. The MIA2G exhibited the best overall performance among individual classifiers with a sensitivity of 91.7% and NPV of 84.7%, with a concomitant higher sensitivity in early-stage disease, whether as an individual classifier (93.5%) or in serial combination with ultrasound (85.5%). The performance of biomarkers (specificity, positive predictive values, and AUROC) such as MIA2G and CA-125 significantly improved when combined with an ultrasound risk scoring approach (p < 0.01). MIA2G showed a higher sensitivity for detecting lesions among EOC and late-stage ovarian cancers than otherwise. The application of biomarkers for evaluating ovarian masses in our local setting is secondary to ultrasound but adopting multivariate index assays rather than CA-125 would increase the detection of early-stage ovarian cancers regardless of menopausal status. This is most relevant in areas where level III sonographers or gynecologic oncologists are limited and preoperative referrals to these specialists can improve the survival of our patients.

Protein Panel of Serum-Derived Small Extracellular Vesicles for the Screening and Diagnosis of Epithelial Ovarian Cancer

Although ovarian cancer, a gynecological malignancy, has the highest fatality rate, it still lacks highly specific biomarkers, and the differential diagnosis of ovarian masses remains difficult to determine for gynecologists. Our study aimed to obtain ovarian cancer-specific protein candidates from the circulating small extracellular vesicles (sEVs) and develop a protein panel for ovarian cancer screening and differential diagnosis of ovarian masses. In our study, sEVs derived from the serum of healthy controls and patients with cystadenoma and ovarian cancer were investigated to obtain a cancer-specific proteomic profile. In a discovery cohort, 1119 proteins were identified, and significant differences in the protein profiles of EVs were observed among groups. Then, 23 differentially expressed proteins were assessed using the parallel reaction monitoring in a validation cohort. Through univariate and multivariate logistic regression analyses, a novel model comprising three proteins (fibrinogen gamma gene (FGG), mucin 16 (MUC16), and apolipoprotein (APOA4)) was established to screen patients with ovarian cancer. This model exhibited an area under the receiver operating characteristic curve (AUC) of 0.936 (95% CI, 0.888–0.984) with 92.0% sensitivity and 82.9% specificity. Another panel comprising serum CA125, sEV-APOA4, and sEV-CD5L showed excellent performance (AUC 0.945 (95% CI, 0.890–1.000), sensitivity of 88.0%, specificity of 93.3%, and accuracy of 89.2%) to distinguish malignancy from benign ovarian masses. Altogether, our study provided a proteomic signature of circulating sEVs in ovarian cancer. The diagnostic proteomic panel may complement current clinical diagnostic measures for screening ovarian cancer in the general population and the differential diagnosis of ovarian masses.

Prevalence of ovarian mass and diagnostic performance of ultrasonography pattern recognition among women at the Gynaecologic Ultrasonography Unit at University Hospital in Thailand

The aim of this retrospective study was to determine the prevalence of ovarian masses and calculate the diagnostic performance of the pattern recognition approach in ovarian pathology. A total of 1001 patients diagnosed with ovarian mass were included, of which 92.6% were diagnosed with ovarian pathology and the presence of a pathological result, while 7.4% of cases were diagnosed with functional ovarian cyst. The prevalence of ovarian malignancy was 15%. A specific ultrasound diagnosis was suggested in 62.9% of all cases, while sonographers did not explicitly provide a diagnosis in remaining cases. A subjective assessment showed 80.3% sensitivity (95% confidence interval (CI) 68.7-89.1) and 97.6% specificity (95% CI 96-98.6) in differentiating between benign and malignant ovarian masses. The sensitivity and specificity for the diagnosis of endometriotic cyst were 77.03% and 90.63% and 63.19% and 94.3% for mature cystic teratoma, respectively. In conclusion, assessment showed good performance in differentiating between benign and malignant ovarian mass and it was possible to diagnose several specific ovarian tumours. Impact StatementWhat is already known on this subject? Pattern recognition is an acceptable method for classifying ovarian mass, which exhibits specific morphological features on grey-scale ultrasonography, and can be used to predict nature and histological type.What do the results of this study add? Even in the hands of an expert examiner, there were a number of cases in which the diagnoses could not be specifically stated. Pattern recognition correctly classified 90.3% of ovarian masses as either benign or malignant and correctly provided specific histologic diagnoses after exclusion of unspecified diagnosis in 80.6% of all cases. The diagnostic performance of this approach was high in differentiating between benign and malignant ovarian mass and in diagnosing some specific ovarian pathologies.What are the implications of these findings for clinical practice and/or further research? A subjective assessment is simple and easy to use in clinical practice and has shown promising results in classifying benign and malignant ovarian mass. Moreover, it can also be used to make some specific diagnoses. However, specialised and experienced gynaecological ultrasound examiners are required to provide the most accurate diagnosis. Therefore, criteria to describe ultrasound features and convincing operators to make a definite diagnosis as often as possible should be encouraged. A prospective study to verify diagnostic performance of pattern recognition or comparing with other ultrasonographic diagnostic tools should be considered.

Circulating Exosomal miR-1290 for Diagnosis of Epithelial Ovarian Cancer

The aim of the study was to develop a new diagnostic biomarker for identifying serum exosomal miRNAs specific to epithelial ovarian cancer (EOC) and to find out target gene of the miRNA for exploring the molecular mechanisms in EOC. A total of 84 cases of ovarian masses and sera were enrolled, comprising EOC (n = 71), benign ovarian neoplasms (n = 13). We detected expression of candidate miRNAs in the serum and tissue of both benign ovarian neoplasm group and EOC group using real-time polymerase chain reaction. Immunohistochemistry were constructed using formalin fixed paraffin embedded (FFPE) tissue to detect expression level of suppressor of cytokine signaling 4 (SOCS4). In the EOC group, miRNA-1290 was significantly overexpressed in serum exosomes and tissues as compared to benign ovarian neoplasm group (fold change ≥ 2, p < 0.05). We observed area under the receiver operating characteristic curve (AUC) for miR-1290, using a cut-off of 0.73, the exosomal miR-1290 from serum had AUC, sensitivity, and specificity values of 0.794, 69.2 and 87.3, respectively. In immunohistochemical study, expression of SOCS4 in EOC was lower than that in benign ovarian neoplasm. Serum exosomal miR-1290 could be considered as a biomarker for differential diagnosis of EOC from benign ovarian neoplasm and SOCS4 might be potential target gene of miR-1290 in EOC.

Comparison of conventional, doppler and contrast-enhanced ultrasonography in differential diagnosis of ovarian masses: a systematic review and meta-analysis

OBJECTIVES

To assess the value of conventional, Doppler and contrast-enhanced ultrasonography (CEUS) (conventional ultrasonography (US), Doppler US and CEUS) for diagnosing ovarian cancer.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase and the Cochrane Library were conducted for studies published until October 2021.

ELIGIBILITY CRITERIA

Studies assessed the diagnostic value of conventional US, Doppler US or CEUS for detecting ovarian cancer, with no restrictions placed on published language and status.

DATA EXTRACTION AND SYNTHESIS

The study selection and data extraction were performed by two independent authors. The sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR), diagnostic OR (DOR) and area under the receiver operating characteristic curve (AUC) were pooled using the bivariate generalised linear mixed model and random effects model.

RESULTS

The meta-analysis included 72 studies and involved 9296 women who presented with ovarian masses. The pooled sensitivity, specificity, PLR, NLR, DOR and AUC for conventional US were 0.91 (95% CI: 0.87 to 0.94) and 0.87 (95% CI: 0.82 to 0.91), 6.87 (95% CI: 4.98 to 9.49) and 0.10 (95% CI: 0.07 to 0.15), 57.52 (95% CI: 36.64 to 90.28) and 0.95 (95% CI: 0.93 to 0.97), respectively. The sensitivity, specificity, PLR, NLR, DOR and AUC for Doppler US were 0.93 (95% CI: 0.91 to 0.95) and 0.85 (95% CI: 0.80 to 0.89), 6.10 (95% CI: 4.59 to 8.11) and 0.08 (95% CI: 0.06 to 0.11), 61.76 (95% CI: 39.99 to 95.37) and 0.96 (95% CI: 0.94 to 0.97), respectively. The pooled sensitivity, specificity, PLR, NLR, DOR and AUC for CEUS were 0.97 (95% CI: 0.92 to 0.99) and 0.92 (95% CI: 0.85 to 0.95), 11.47 (95% CI: 6.52 to 20.17) and 0.03 (95% CI: 0.01 to 0.09), 152.11 (95% CI: 77.77 to 297.51) and 0.99 (95% CI: 0.97 to 0.99), respectively. Moreover, the AUC values for conventional US (p=0.002) and Doppler US (p=0.005) were inferior to those of CEUS.

CONCLUSIONS

Conventional US, Doppler US and CEUS have a relatively high differential diagnostic value for differentiating between benign and malignant ovarian masses. The diagnostic performance of CEUS was superior to that of conventional US and Doppler US.

Estimating the risk of malignancy of adnexal masses: validation of the ADNEX model in the hands of nonexpert ultrasonographers in a gynaecological oncology centre in China

Background

This study aims to validate the diagnostic accuracy of the International Ovarian Tumor Analysis (IOTA) the Assessment of Different NEoplasias in the adneXa (ADNEX) model in the preoperative diagnosis of adnexal masses in the hands of nonexpert ultrasonographers in a gynaecological oncology centre in China.

Methods

This was a single oncology centre, retrospective diagnostic accuracy study of 620 patients. All patients underwent surgery, and the histopathological diagnosis was used as a reference standard. The masses were divided into five types according to the ADNEX model: benign ovarian tumours, borderline ovarian tumours (BOTs), stage I ovarian cancer (OC), stage II-IV OC and ovarian metastasis. Receiver operating characteristic (ROC) curve analysis was used to evaluate the ability of the ADNEX model to classify tumours into different histological types with and without cancer antigen 125 (CA 125) results.

Results

Of the 620 women, 402 (64.8%) had a benign ovarian tumour and 218 (35.2%) had a malignant ovarian tumour, including 86 (13.9%) with BOT, 75 (12.1%) with stage I OC, 53 (8.5%) with stage II-IV OC and 4 (0.6%) with ovarian metastasis. The AUC of the model to differentiate benign and malignant adnexal masses was 0.97 (95% CI, 0.96–0.98). Performance was excellent for the discrimination between benign and stage II-IV OC and between benign and ovarian metastasis, with AUCs of 0.99 (95% CI, 0.99–1.00) and 0.99 (95% CI, 0.98–1.00), respectively. The model was less effective at distinguishing between BOT and stage I OC and between BOT and ovarian metastasis, with AUCs of 0.54 (95% CI, 0.45–0.64) and 0.66 (95% CI, 0.56–0.77), respectively. When including CA125 in the model, the performance in discriminating between stage II–IV OC and stage I OC and between stage II–IV OC ovarian metastasis was improved (AUC increased from 0.88 to 0.94, P = 0.01, and from 0.86 to 0.97, p = 0.01).

Conclusions

The IOTA ADNEX model has excellent performance in differentiating benign and malignant adnexal masses in the hands of nonexpert ultrasonographers with limited experience in China. In classifying different subtypes of ovarian cancers, the model has difficulty differentiating BOTs from stage I OC and BOTs from ovarian metastases.

Neo-Adjuvant Chemotherapy Reduces, and Surgery Increases Immunosuppression in First-Line Treatment for Ovarian Cancer

In monotherapy, immunotherapy has a poor success rate in ovarian cancer. Upgrading to a successful combinatorial immunotherapy treatment implies knowledge of the immune changes that are induced by chemotherapy and surgery.

METHODOLOGY

Patients with a new d ovarian cancer diagnosis underwent longitudinal blood samples at different time points during primary treatment.

RESULTS

Ninety patients were included in the study (33% primary debulking surgery (PDS) with adjuvant chemotherapy (ACT), 61% neo-adjuvant chemotherapy (NACT) with interval debulking surgery (IDS), and 6% debulking surgery only). Reductions in immunosuppression were observed after NACT, but surgery reverted this effect. The immune-related proteins showed a pronounced decrease in immune stimulation and immunosuppression when primary treatment was completed. NACT with IDS leads to a transient amelioration of the immune microenvironment compared to PDS with ACT.

CONCLUSION

The implementation of immunotherapy in the primary treatment schedule of ovarian cancer cannot be induced blindly. Carboplatin-paclitaxel seems to ameliorate the hostile immune microenvironment in ovarian cancer, which is less pronounced at the end of primary treatment. This prospective study during primary therapy for ovarian cancer that also looks at the evolution of immune-related proteins provides us with an insight into the temporary windows of opportunity in which to introduce immunotherapy during primary treatment.

Photoacoustic tomography reconstruction using lag-based delay multiply and sum with a coherence factor improves in vivo ovarian cancer diagnosis

Ovarian cancer is the fifth most common cause of death due to cancer, and it is the deadliest of all gynecological cancers. Diagnosing ovarian cancer via conventional photoacoustic delay-and-sum beamforming (DAS) presents several challenges, such as poor image resolution and low lesion to background tissue contrast. To address these concerns, we propose an improved beamformer named lag-based delay multiply and sum combined with coherence factor (DMAS-LAG-CF). Simulations and phantom experiments demonstrate that compared with the conventional DAS, the proposed algorithm can provide 1.39 times better resolution and 10.77 dB higher contrast. For patient data, similar performance on contrast ratios has been observed. However, since the diagnostic accuracy between cancer and benign/normal groups is a significant measure, we have extracted photoacoustic histogram features of mean, kurtosis and skewness. DMAS-LAG-CF can improve cancer diagnosis with an AUC of 0.91 for distinguishing malignant vs. benign ovarian lesions when mean and skewness are used as features.

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.

Vessel morphology depicted by three-dimensional power Doppler ultrasound as second-stage test in adnexal tumors that are difficult to classify: prospective diagnostic accuracy study

OBJECTIVES

To assess whether vessel morphology depicted by three-dimensional (3D) power Doppler ultrasound improves discrimination between benignity and malignancy if used as a second-stage test in adnexal masses that are difficult to classify.

METHODS

This was a prospective observational international multicenter diagnostic accuracy study. Consecutive patients with an adnexal mass underwent standardized transvaginal two-dimensional (2D) grayscale and color or power Doppler and 3D power Doppler ultrasound examination by an experienced examiner, and those with a 'difficult' tumor were included in the current analysis. A difficult tumor was defined as one in which the International Ovarian Tumor Analysis (IOTA) logistic regression model-1 (LR-1) yielded an ambiguous result (risk of malignancy, 8.3% to 25.5%), or as one in which the ultrasound examiner was uncertain regarding classification as benign or malignant when using subjective assessment. Even when the ultrasound examiner was uncertain, he/she was obliged to classify the tumor as most probably benign or most probably malignant. For each difficult tumor, one researcher created a 360° rotating 3D power Doppler image of the vessel tree in the whole tumor and another of the vessel tree in a 5-cm³ spherical volume selected from the most vascularized part of the tumor. Two other researchers, blinded to the patient's history, 2D ultrasound findings and histological diagnosis, independently described the vessel tree using predetermined vessel features. Their agreed classification was used. The reference standard was the histological diagnosis of the mass. The sensitivity of each test for discriminating between benign and malignant difficult tumors was plotted against 1 - specificity on a receiver-operating-characteristics diagram, and the test with the point furthest from the reference line was considered to have the best diagnostic ability.

RESULTS

Of 2403 women with an adnexal mass, 376 (16%) had a difficult mass. Ultrasound volumes were available for 138 of these cases. In 79/138 masses, the ultrasound examiner was uncertain about the diagnosis based on subjective assessment, in 87/138, IOTA LR-1 yielded an ambiguous result and, in 28/138, both methods gave an uncertain result. Of the masses, 38/138 (28%) were malignant. Among tumors that were difficult to classify as benign or malignant by subjective assessment, the vessel feature 'densely packed vessels' had the best discriminative ability (sensitivity 67% (18/27), specificity 83% (43/52)) and was slightly superior to subjective assessment (sensitivity 74% (20/27), specificity 60% (31/52)). In tumors in which IOTA LR-1 yielded an ambiguous result, subjective assessment (sensitivity 82% (14/17), specificity 79% (55/70)) was superior to the best vascular feature, i.e. changes in the diameter of vessels in the whole tumor volume (sensitivity 71% (12/17), specificity 69% (48/70)).

CONCLUSION

Vessel morphology depicted by 3D power Doppler ultrasound may slightly improve discrimination between benign and malignant adnexal tumors that are difficult to classify by subjective ultrasound assessment. For tumors in which the IOTA LR-1 model yields an ambiguous result, subjective assessment is superior to vessel morphology as a second-stage test. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Diagnostic accuracy of transvaginal ultrasound examination for assigning a specific diagnosis to adnexal masses: A meta-analysis

Transvaginal ultrasound (TVUS) is a standard imaging modality for differentiating patients with benign or malignant suspected adnexal mass. To date, numerous studies have assessed the diagnostic accuracy of TVUS in various settings but with variable results. Therefore, the purpose of the present study was to perform a meta-analysis to evaluate the diagnostic accuracy of TVUS for the differentiation of adnexal masses. An electronic search in the Medline, Scopus, Cochrane and Embase databases from inception till November 2019 was carried out. Meta-analysis was performed to obtain pooled sensitivity and specificity of TVUS to distinguish malignant from benign adnexal masses. The quality assessment of diagnostic accuracy studies-2 tool was used to assess the quality of trials. A total of 41 studies with 18,391 patients were included. The pooled sensitivity and specificity of TVUS was 92% (95% CI: 90-94%) and 89% (95% CI: 85-92%), respectively. The area under the receiver operating characteristic curve was 0.96 (95% CI: 0.84-1.00). There was considerable heterogeneity with a statistically significant chi-square test (P<0.001) and I² of 99%. Meta-regression results indicated that index test standards, patient selection bias and study design were potential sources of heterogeneity (P<0.05). The funnel plot was symmetrical and low publication bias was confirmed by an insignificant Deek's test (P=0.90). The present systematic review and meta-analysis indicated that TVUS is useful in differentiating between benign and malignant tumours among patients with suspected adnexal mass with high sensitivity and specificity.

Assessment of protein biomarkers for preoperative differential diagnosis between benign and malignant ovarian tumors

OBJECTIVE

To estimate the diagnostic value of tumor and immune related proteins in the discrimination between benign and malignant adnexal masses, and between different subgroups of tumors.

METHODS

In this exploratory diagnostic study, 254 patients with an adnexal mass scheduled for surgery were consecutively enrolled at the University Hospitals Leuven (128 benign, 42 borderline, 22 stage I, 55 stage II-IV, and 7 secondary metastatic tumors). The quantification of 33 serum proteins was done preoperatively, using multiplex high throughput immunoassays (Luminex) and electrochemiluminescence immuno-assay (ECLIA). We calculated univariable areas under the Receiver Operating Characteristic Curves (AUCs). To discriminate malignant from benign tumors, multivariable ridge logistic regression with backward elimination was performed, using bootstrapping to validate the resulting AUCs.

RESULTS

CA125 had the highest univariable AUC to discriminate malignant from benign tumors (0.85, 95% confidence interval 0.79-0.89). Combining CA125 with CA72.4 and HE4 increased the AUC to 0.87. For benign vs borderline tumors, CA125 had the highest univariable AUC (0.74). For borderline vs stage I malignancy, no proteins were promising. For stage I vs II-IV malignancy, CA125, HE4, CA72.4, CA15.3 and LAP had univariable AUCs ≥0.80.

CONCLUSIONS

The results confirm the dominant role of CA125 for identifying malignancy, and suggest that other markers (HE4, CA72.4, CA15.3 and LAP) may help to distinguish between stage I and stage II-IV malignancies. However, further research is needed, also to investigate the added value over clinical and ultrasound predictors of malignancy, focusing on the differentiation between subtypes of malignancy.

Role of Combining Colour Doppler and Grey Scale Ultrasound in Differentiating Benign from Malignant Ovarian Masses

The aim of this study was to evaluate ovarian masses with conventional grey scale ultrasonography and colour Doppler flow imaging and to assess the diagnostic reliability of these methods in differentiating benign and malignant ovarian masses.

We assessed 56 patients with an ovarian mass. Morphological characterisation of the mass was performed utilising the Sassone score. Colour Doppler parameters were recorded for each patient, and the Caruso vascular score was also applied. The results were compared with surgical/pathological and/or follow-up scans.

Using the Sassone score, overall reliability in differentiating ovarian masses had a sensitivity of 89.5% and a specificity of 78.4%. Using the Caruso score alone, we found a sensitivity of 89.5% and a specificity of 86.5%. Using the Sassone and Caruso scores together, we found a sensitivity of 94.7% and a specificity of 89.1%.

Combining both morphological and colour Doppler scores in the evaluation of ovarian masses obtained higher specificity, sensitivity, and accuracy than was obtained using a single score only.

Evaluation of the value of preoperative CYFRA21-1 in the diagnosis and prognosis of epithelial ovarian cancer in conjunction with CA125

Growing evidence indicates that the tumor biomarker cytokeratin 19 fragment (CYFRA21-1) is significant for a variety of cancers. However, its role in epithelial ovarian cancer (EOC) has rarely been reported. In this study, a receiver operating characteristic (ROC) curve was utilized to estimate the diagnostic efficiency of CYFRA21-1. The correlation between the CYFRA21-1 level and prognosis was analyzed by Kaplan-Meier survival analysis and univariable and multivariable analyses. The relationship between serum CYFRA21-1 levels and different clinicopathological variables was also analyzed. At the same time, the standard serum marker cancer antigen 125 (CA125) was measured. The results demonstrated that CYFRA21-1 expression was significantly increased in EOC compared with expression in benign ovarian diseases and healthy controls, which was similar to CA125 (P < 0.001). CYFRA21-1 expression was positively correlated with CA125 (r = 0.201; P = 0.0032). CYFRA21-1 expression was significantly correlated with lymph node metastasis and ascites (P < 0.001). Furthermore, the median survival time of EOC patients with high CYFRA21-1 expression was 42 months, compared with 54 months in the low CYFRA21-1 expression patients by Kaplan-Meier analysis (P < 0.05), while the high and low CA125 expression groups had no difference in median survival time. Univariate and multivariate analyses indicated that CYFRA21-1 was a poor prognostic factor associated with overall survival (OS), while CA125 was not. Our study indicates that CYFRA21-1 acts as a good complementary diagnostic biomarker and may be superior to CA125 as a prognostic indicator in EOC.

The Abnormal Ovary: Evolving Concepts in Diagnosis and Management

Ovarian lesions are common and require a consistent approach to diagnosis and management for best patient outcomes. In the past 20 years, there has been an evolution in the approach to abnormal ovarian lesions, with increasing emphasis on reducing surgery for benign disease, standardizing terminology, assessing risk of malignancy through use of evidence-based scoring systems, and triaging suspicious abnormalities to dedicated oncology centers. This article provides an evidence-based review of how these changes in diagnosis and management of ultrasound-detected abnormal ovarian lesions have occurred. Current recommended practices are summarized. The current literature on transvaginal screening for ovarian cancer also is reviewed and summarized.

Clinical Performance Comparison of Two In-Vitro Diagnostic Multivariate Index Assays (IVDMIAs) for Presurgical Assessment for Ovarian Cancer Risk

INTRODUCTION

Adnexal or pelvic mass is a finding that commonly raises suspicion for malignancy, especially for ovarian cancer. Proper identification prior to surgery would permit appropriate referral to a specialty center in cases likely to be ovarian cancer, as optimal outcomes in such cases are obtained when surgical staging and treatment are provided at the time of initial surgery.

METHODS

We compared the screening capabilities of two in vitro diagnostic multivariate index assays (IVDMIAs), a new IVDMIA (second-generation multivariate index assay: MIA2G) and a currently used triage algorithm (Risk of Ovarian Malignancy Assay: ROMA).

RESULTS

Among 245 subjects (24.7%) determined to have a malignancy, ROMA misclassified 51 malignancies (including 10 high-grade ovarian malignancies), whereas MIA2G misclassified 22 (including 5 high-grade ovarian malignancies). Early stage cancers were more frequently misclassified by ROMA (20 vs. 8 cases). The rate of "test-negative" malignancies was significantly higher for ROMA, while the rate of "test-positive" benign cases was significantly higher for MIA2G.

CONCLUSION

Triage algorithms play an important role in improving clinical outcomes for women presenting with an adnexal mass regardless of the eventual diagnosis. In this study, MIA2G was shown to correctly predict more cases of ovarian cancer than the ROMA algorithm.

FUNDING

Aspira Labs/Vermillion Inc.

Synchronous primary cancers of endometrium and ovary vs endometrial cancer with ovarian metastasis: an observational study

OBJECTIVE

To compare the ultrasound characteristics of patients with synchronous primary cancers of the endometrium and ovary vs those of patients with endometrial cancer with ovarian metastasis.

METHODS

This was a single-institution retrospective observational study of patients with a histological diagnosis of endometrial cancer and an ovarian malignant mass, who had undergone preoperative ultrasound examination at our unit. Based on the histological diagnosis, patients were classified into two groups: those with synchronous primary cancers of the endometrium and ovary (synchronous group) and patients with endometrial cancer with ovarian metastasis (metastasis group). We compared the ultrasound features of ovarian malignant masses and of endometrial cancers between the two groups. Student's t-test, Mann-Whitney U-test, χ² test or Fisher's exact test were used for comparisons of variables between the two histological groups, as appropriate.

RESULTS

We identified 131 patients, of whom 51 had synchronous primary cancers of the endometrium and ovary (synchronous group) and 80 had endometrial cancer with ovarian metastasis (metastasis group). On ultrasound examination, ovarian masses in the synchronous group were more often multilocular-solid and less often bilateral than those in the metastasis group. With respect to the ultrasound features of the endometrial lesions, the median largest diameter was 29 (range, 11-118) mm in the synchronous group in comparison with 51.5 (range, 6-150) mm in the metastasis group (P < 0.0001). Endometrial lesions in the synchronous group presented more often with no myometrial infiltration and less often with a multiple-vessel pattern on color Doppler compared with the endometrial lesions in the metastasis group.

CONCLUSIONS

Synchronous primary cancers of the endometrium and ovary have significantly different sonomorphological patterns compared with endometrial cancer with ovarian metastasis. Ovarian masses in women with synchronous primary cancers of the endometrium and ovary appeared as unilateral multilocular-solid or solid masses, whereas ovarian masses in women with endometrial cancer with ovarian metastasis were mostly bilateral solid masses. The different sonomorphology of these two cancers may facilitate their preoperative identification, helping the surgeon to determine optimum management for the patient. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

IOTA Simple Ultrasound Rules for Triage of Adnexal Mass: Experience from South India

Objective

To assess the diagnostic performance of International Ovarian Tumor Analysis (IOTA) simple ultrasound rules to discriminate adnexal masses as benign or malignant.

Methods

A cross-sectional prospective study was conducted on women scheduled for elective surgery due to adnexal masses. Ultrasound examiner systematically assessed the tumors according to the IOTA simple rules to determine the risk of the tumor being malignant. If the simple rules yielded inconclusive result, pattern recognition was used to categorize the mass. Results were then compared with histologic findings after surgery. Diagnostic performance was assessed by calculating sensitivity and specificity.

Results

Two hundred and five women undergoing surgery were included. The rules were applicable in 183 (89.3%) of the tumors; and for these tumors, sensitivity was 92.8% (95% CI 77-99%) and specificity was 92.9% (95% CI 88-96.4%). Of the tumors, 144 were benign and 39 were malignant. The simple rules yielded inconclusive results in 22 masses which were analyzed by pattern recognition.

Conclusion

IOTA simple rules provide excellent discrimination between benign and malignant adnexal masses.

Classification of human ovarian cancer using functional, spectral, and imaging features obtained from in vivo photoacoustic imaging

We report in this pilot study the diagnostic results of in vivo imaging of patients with ovarian lesions, using a co-registered photoacoustic and ultrasound (PAT/US) system. A total of 39 ovaries from 24 patients were imaged in vivo. PAT functional features, i.e., blood oxygen saturation (sO2) and relative total hemoglobin (rHbT), PAT image features, and PAT spectral features within a region of interest (ROI) in each ovarian tissue were extracted. To select the significant features, a t-test on each feature was performed, and the independent predictors were determined by evaluating correlation between each pair of predictors. To classify the ovarian lesions, we employed a generalized linear model (GLM) and a support vector machine (SVM). We used these classifiers first to distinguish benign/normal lesions from ovaries with invasive epithelial tumors and then to separate normal/benign lesions from all types of ovarian tumors. We developed classifiers once by inclusion of PAT functional features to assess the best diagnostic performance of the classifiers when multiple wavelengths data are available. Second time, we excluded the PAT functional features from the features set to evaluate the best diagnostic performance if only a single wavelength is available. Our results show that using functional features improves the classification performance, especially for distinguishing normal/benign ovarian lesions from all types of tumors. In this case, an area under ROC curve (AUC) of 0.92, 0.93 of testing data was achieved using a GLM and SVM classifier when functional features were included in the feature set while excluding these features resulted in an AUC of 0.89, 0.92, respectively.

RETROSPECTIVE ANALYSIS OF BORDERLINE OVARIAN TUMORS: OUTCOMES AT A SINGLE CENTER

We wanted to discuss our experiences in the approach to borderline ovarian tumors, which constitute a group different from epithelial ovarian tumors with respect to their biological structure in line with retrospective information gathered from our cases. A total of 25 patients operated on for the indication of adnexal masses diagnosed as borderline ovarian tumors based on frozen section results were included in our study. Patient age, tumor diameter, tumor markers and surgeries performed were discussed in the light of the literature. Statistical analyses were performed using the SPSS software. The patient mean age was 43.84±11.34 years. The mass was localized in the right (n=13), left (n=11) or both (n=1) adnexal regions. The mean tumor diameter was 12.9±5.84 cm. Histopathologic examination established the diagnosis of serous borderline (n=14 patients) and mucinous borderline (n=11) ovarian tumors. Although the results of our study are consistent with current literature data, a greater number of current studies should be performed on borderline ovarian tumors, which are defined as a class of tumors different from epithelial ovarian tumors.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

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

Bilateral Ovarian Tumors on MRI: How Should We Differentiate the Lesions?

Background

We investigated the distinguishing pathological features of bilateral ovarian tumors using magnetic resonance (MR) imaging.

Methods

Eighty-six patients with bilateral ovarian tumors on MR imaging were evaluated. The pathological diagnosis was investigated, and the results were subjected to statistical analysis using Mann-Whitney U test, Fisher's exact test, Chi-squared test and receiver operating characteristic (ROC) curve to determine the features useful for the differentiation of distinct types of lesions.

Results

The diagnosis of bilateral ovarian tumors was confirmed in eighty-one patients and the majority of the lesions were further classified into serous carcinoma (n = 36), mature teratoma (n = 20) and metastasis (n = 12). We assessed the existence of factors useful for the MR imaging differentiation between metastasis and serous carcinoma or primary malignant ovarian tumors. Cancer antigen (CA) 125 serum level and maximum tumor diameter were significantly different between metastasis and serous carcinoma and similarly, between metastasis and primary malignant ovarian tumors. MR imaging morphology, ascites and peritoneal implants did not show any significant difference between the different types of lesions.

Conclusion

Within our patient cohort, most bilateral ovarian tumor lesions were determined to be serous carcinoma, mature teratoma or metastasis. CA 125 serum level and maximum tumor diameter are useful markers for the differentiation between metastasis and serous carcinoma or primary malignant ovarian tumors.

Decreased Serum Levels of Carboxylesterase-2 in Patients with Ovarian Cancer

Aims and background

Carboxylesterase-2 has been identified as the key enzyme in the metabolic activation of irinotecan, a topoisomerase I inhibitor commonly used in the treatment of many solid tumors. Previous studies have shown that carboxylesterase-2 is down-regulated in colorectal cancer following progression of the disease. However, very limited information is available on carboxylesterase-2 expression in ovarian cancer. The aim of the present study was to detect the serum level and the tissue expression of carboxylesterase-2 in human ovarian cancer patients at different stages of the disease.

Methods

Carboxylesterase-2 levels in the serum of ovarian cancer patients were investigated by western blot and ELISA and in the tumor mass of ovarian cancer patients by western blot.

Results

Both the serum carboxylesterase-2 level and the expression of carboxylesterase-2 in tumor tissues were significantly different among patients at different stages of the disease (n = 40). No positive correlation was found between the serum carboxylesterase-2 level and the cancer antigen 125 level (n = 40). Serum carboxylesterase-2 is more sensitive than cancer antigen 125 in detecting the early stage patient with ovarian cancer.

Conclusions

Our results indicate that serum carboxylesterase-2 level might be a potential marker in the diagnosis of the early stage ovarian cancer.

MRI features and score for differentiating borderline from malignant epithelial ovarian tumors

PURPOSE

To identify the MRI features of borderline epithelial ovarian tumors (BEOTs) and to differentiate BEOTs from malignant epithelial ovarian tumors (MEOTs).

MATERIALS AND METHODS

The clinical and MRI data of 89 patients with a BEOT and 109 patients with a MEOT proven by surgery and histopathology were retrospectively reviewed. MRI features, including bilaterality, size, shape, margin, cystic-solid interface, configuration, papillae or nodules, signal intensity, enhancement, presence of an ipsilateral ovary, peritoneal implants and ascites were analyzed and compared. Based on the odds ratio (OR) values, the significant risk features for BEOTs were scored as 3 (OR≈∞), 2 (5≤OR<∞) or 1 (OR<5).

RESULTS

There were 89 BEOT patients with 113 tumors [mean size of (13±6.7)cm], with bilateral ovary involvement in 24 cases. There were 109 MEOT patients with 142 tumors [(9.3±4.2)cm] with bilateral ovary involvement in 33 cases. There were eight significant risk factors for BEOTs, including round or oval shape (OR=2.714), well-defined margins (OR=3.318), clear cystic-solid interfaces (OR=5.593), purely cystic (OR=15.206), predominantly cystic with papillae or nodules (OR=2.579), exophytic papillae or nodules (OR=5.351), branching papilla (OR≈∞) and the presence of an ipsilateral ovary (OR≈∞). Based on the scoring of the eight risk factors, a cut-off score of 3.5 yielded a differential sensitivity, specificity, and accuracy of 82%, 85% and 84%, respectively.

CONCLUSION

In contrast to MEOTs, BEOTs frequently had the following features on MRI: round or oval, with well-defined margins and clear cystic-solid interfaces, purely cystic or predominantly cystic with papillae or nodules, branching or exophytic papillae, with the presence of an ipsilateral ovary. MRI can reveal the distinct morphological features of BEOTs and MEOTs and facilitate their discrimination.

Ovarian torsion of mixed epithelial tumor misdiagnosed as a malignancy in postmenopausal woman: A case report

RATIONALE

Adnexal torsion is 1 of the most common emergency gynecological disease. It is more often diagnosed in reproductive age, but rarely in postmenopausal women. The clinical symptoms of adnexal torsion are nonspecific in postmenopausal women. Epithelial ovarian tumors are common in adults, and the risk of malignancy increases with age, especially after menopause. So, it is difficult to diagnose adnexal torsion precisely compared with reproductive women, and most cases of adnexal torsion with postmenopausal women are diagnosed as a malignancy preoperatively. We report a case of ovarian torsion with mixed epithelial tumor misdiagnosed as a malignancy in postmenopausal woman.

PATIENT CONCERNS

A 65-year-old woman presented lower left abdominal pain, and there was slight abdominal distension, but no tenderness or rebound tenderness on abdominal palpation.

DIAGNOSES

Radiologic assessments showed a huge multiseptated cystic mass with solid portion in the left ovary, and malignancy was suspected. The test for serum tumor markers revealed normal levels of cancer antigen 125 (CA-125).

INTERVENTIONS

The patient underwent a laparotomy and there was torsion of the left ovary. We conducted frozen biopsy of left ovary for confirming malignancy before performing staging surgery.

OUTCOMES

The result of a frozen section biopsy confirmed a borderline Brenner tumor associated with a benign mucinous tumor. Subsequently, total hysterectomy and right salpingo-oophorectomy were performed. The operation was completed without addition procedures LESSONS:: Ovarian torsion is benign in most cases and malignancy is rare. Although very rare, ovarian torsion can occur in postmenopausal women, and it should be taken into consideration that the possibility of malignancy is low in postmenopausal women with normal CA-125 levels. Instead of performing staging surgery, it appears to be appropriate to carry out surgery based on the result of intraoperative frozen section biopsy so that we were able to avoid unnecessary surgical procedures.

Management of Borderline Ovarian Tumors-Still a Gray Zone

Borderline ovarian tumors (BOTs) are a heterogeneous group of non-invasive epithelial ovarian tumors that occur at a younger age, present in early stage, frequently associated with infertility but are easily curable. Although they may have symptomatic long-term recurrences, they have an excellent prognosis in spite of peritoneal spread. Among the epithelial tumors of the ovary, BOTs fall in the spectrum lying between cystadenomas (benign) and cystadenocarcinomas (malignant). Their oncological behavior is more aggressive than benign ovarian tumors but relatively less than that of malignant ovarian tumors. Since the age group affected is usually young females, preservation of fertility is an important aspect of treatment protocol. Although the management of these tumors has been extensively discussed, it still remains a controversial gray zone. In this review, epidemiology, pathogenesis, histologic subtypes, various surgical approaches, follow-up, and management of recurrence have been discussed. Choosing the best treatment still poses a challenge for the treating oncosurgeon.

Multiparametric MRI for differentiation of borderline ovarian tumors from stage I malignant epithelial ovarian tumors using multivariate logistic regression analysis

OBJECTIVE

To assess the value of contrast-enhanced MRI, apparent diffusion coefficient (ADC) measurement, and CA-125 measurement for differentiating borderline ovarian tumors (BOTs) from stage I malignant epithelial ovarian tumors (MEOTs).

MATERIAL AND METHODS

This retrospective study included 43 patients with BOTs and 43 patients with stage I MEOTs who underwent contrast-enhanced MRI with DWI and CA-125 analysis. Two radiologists evaluated the MRI findings in consensus. Univariate and multivariate analyses were performed to detect the best predictor variables for MEOTs.

RESULTS

Mixed cystic/solid and predominantly solid appearances, as well as thickened irregular septa, were more frequent in MEOTs. A papillary architecture and internal branching (PA&IB) pattern was more frequent in BOTs. MEOTs had thicker walls and septa, larger solid components, and higher CA-125 values. The mean ADC value of solid components (ADC_mean) and minimum ADC value of whole lesions (ADC_min) were lower in MEOTs. Multivariate analysis revealed that ADC_min and maximum diameter of the solid components were independent indicators of MEOTs with an AUC, sensitivity, and specificity of 0.86, 81%, and 84%, respectively.

CONCLUSION

ADC_min and maximum diameter of solid components were useful for differentiating BOTs from MEOTs.

Retrospective analysis of suspicious pelvic masses using the Pelvic Mass Index (PMI) scoring system from 2007 to 2014

OBJECTIVES

This study aims to validate the accuracy of the Pelvic Mass Index (PMI) by comparing it with Risk of Malignancy Index (RMI) in a large patient cohort.

STUDY DESIGN

This retrospective study used data of women with ovarian masses collected from 2007 to 2014, referred to the Pelvic Mass Clinic (PMC) at University Hospital of Wales in Cardiff. The locally developed PMI was used to triage patients for surgery, surveillance or discharge. Performance measures for PMI, RMI and CA125 are reported as sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), receiver operating characteristic (ROC) curves and area under the curve (AUC) for premenopausal and postmenopausal women alike.

RESULTS

PMI was calculated on 1468 patients of whom 497 underwent surgery, 176 (71.0%) were in the high risk group, 63 (68.0%) intermediate and 258 (23%) amongst low risk women. Compared to RMI, PMI had a higher sensitivity (90.4%) and NPV (96.9%) for the entire cohort, as well as in the premenopausal (88.9%; 97.6%) and postmenopausal (91.5%; 95.6%) subcategories. ROC curves indicated better performance in the total group (AUC 0.823 vs. 0.770) and the premenopausal group (AUC 0.847 vs. 0.728), though AUC in the postmenopausal group was similar (0.779 vs. 0.791) - likely due to increased specificity of CA125 after menopause. Histology revealed PMI significantly outperforms RMI in diagnosing malignancy, missing only 1 compared to 20 cancers.

CONCLUSIONS

The high sensitivity and NPV of PMI makes it a useful tool in triaging patients with suspicious ovarian masses.

HE4, CA125 and risk of ovarian malignancy algorithm (ROMA) as diagnostic tools for ovarian cancer in patients with a pelvic mass: An Italian multicenter study

OBJECTIVE

This multicenter study aims to evaluate HE4, CA125 and risk of ovarian malignancy algorithm (ROMA) performance in the differential diagnosis of epithelial ovarian cancer (EOC).

METHODS

A total of 405 patients referred to gynecological oncologist with suspicious pelvic mass requiring a surgery for identification of EOC were consecutively enrolled; 387 patients satisfied inclusion criteria: 290 benign diseases; 15 borderline neoplasia and 82 tumors (73 EOC).

RESULTS

Good diagnostic performance in discriminating benign from EOC patients was obtained for CA125, HE4 and ROMA when calculating optimal cut-off values: premenopause, specificity (SP) >86.6, sensitivity (SN) >82.6, area under the curves (AUC)≥0.894; postmenopause, SP>93.2, SN>82, AUC≥0.928. Fixing SP at 98%, performance indicators obtained for benign vs EOC patients were: premenopause, SN:65.2%, positive predictive value (+PV): 75%, positive likelihood ratio (+LR): 26.4 for CA125; SN:69.6%, +PV:76.2%, +LR:28.1 for HE4; SN:69.6%, +PV: 80%; +LR:35.1 for ROMA; postmenopause, SN:88%, +PV: 95.7%, +LR:38.7 for CA125; SN:78%, +PV:95.1%, +LR:34.3 for HE4; SN:88%, +PV:97.8%, +LR:77.4 for ROMA. When using routine cut-off thresholds, ROMA showed better well-balanced values of both SP and SN (premenopause, SN:87%, SP:86.1%; postmenopause, SN:90%; SP:94.3%).

CONCLUSIONS

Overall, ROMA showed well balanced diagnostic performance to differentiate EOC from benign diseases. Meaningful differences of +PVs and +LRs between HE4 and CA125 suggest that the two markers may play at least in part different roles in EOC diagnosis, with HE4 seeming to be more efficient than CA125 in ruling in EOC patients in the disease group, also in early stages tumors, both in pre and postmenopause.

Design of optimal light delivery system for co-registered transvaginal ultrasound and photoacoustic imaging of ovarian tissue

A hand-held transvaginal probe suitable for co-registered photoacoustic and ultrasound imaging of ovarian tissue was designed and evaluated. The imaging probe consists of an ultrasound transducer and four 1-mm-core multi-mode optical fibers both housed in a custom-made sheath. The probe was optimized for the highest light delivery output and best beam uniformity on tissue surface, by simulating the light fluence and power output for different design parameters. The laser fluence profiles were experimentally measured through chicken breast tissue and calibrated intralipid solution at various imaging depths. Polyethylene tubing filled with rat blood mimicking a blood vessel was successfully imaged up to ∼30 mm depth through porcine vaginal tissue at 750 nm. This imaging depth was achieved with a laser fluence on the tissue surface of 20 mJ/cm(2), which is below the maximum permissible exposure (MPE) of 25 mJ/cm(2) recommended by the American National Standards Institute (ANSI). Furthermore, the probe imaging capability was verified with ex vivo imaging of benign and malignant human ovaries. The co-registered images clearly showed different vasculature distributions on the surface of the benign cyst and the malignant ovary. These results suggest that our imaging system has the clinical potential for in vivo imaging and characterization of ovarian tissues.