Prospective evaluation of three different models for the pre-operative diagnosis of ovarian cancer

Clinical Use of Cancer Biomarkers in Epithelial Ovarian Cancer: Updated Guidelines From the European Group on Tumor Markers

To present an update of the European Group on Tumor Markers guidelines for serum markers in epithelial ovarian cancer.

Clinical Use of Cancer Biomarkers in Epithelial Ovarian Cancer: Updated Guidelines From the European Group on Tumor Markers

OBJECTIVE

To present an update of the European Group on Tumor Markers guidelines for serum markers in epithelial ovarian cancer.

METHODS

Systematic literature survey from 2008 to 2013. The articles were evaluated by level of evidence and strength of recommendation.

RESULTS

Because of its low sensitivity (50-62% for early stage epithelial ovarian cancer) and limited specificity (94-98.5%), cancer antigen (CA) 125 (CA125) is not recommended as a screening test in asymptomatic women. The Risk of Malignancy Index, which includes CA125, transvaginal ultrasound, and menopausal status, is recommended for the differential diagnosis of a pelvic mass. Because human epididymis protein 4 has been reported to have superior specificity to CA125, especially in premenopausal women, it may be considered either alone or as part of the risk of ovarian malignancy algorithm, in the differential diagnosis of pelvic masses, especially in such women. CA125 should be used to monitor response to first-line chemotherapy using the previously published criteria of the Gynecological Cancer Intergroup, that is, at least a 50% reduction of a pretreatment sample of 70 kU/L or greater. The value of CA125 in posttherapy surveillance is less clear. Although a prospective randomized trial concluded that early administration of chemotherapy based on increasing CA125 levels had no effect on survival, European Group on Tumor Markers state that monitoring with CA125 in this situation should occur, especially if the patient is a candidate for secondary cytoreductive surgery.

CONCLUSIONS

At present, CA125 remains the most important biomarker for epithelial ovarian cancer, excluding tumors of mucinous origin.

An Evaluation of the Applicability of the Risk of Malignancy Index for Adnexal Masses to Patients Seen at a Tertiary Hospital in Chandigarh, India

BACK GROUND

The discrimination between benign and malignant ovarian tumors is important considering to optimally plan for an appropriate surgical treatment.

AIMS

To determine the applicability of risk of malignancy index (RMI 2) for triaging patients with adnexal masses seen at tertiary care hospital in India.

SUBJECTS AND METHODS

A retrospective case note review of patients with adnexal masses admitted in Gynecology department was done. RMI 2 was calculated for each patient using ultrasound score, menopausal status, and CA-125 levels (U/ml), and the value of RMI was compared to the histological diagnosis. Statistical analyses were performed using SPSS version 17.0 by descriptive and inferential statistics. The p value ≤0.05 was considered significant.

RESULTS

The Mean age and SD of hundred patients was 52.8 (10) years. Most of the patients were postmenopausal (68/100). A significant relationship of ovarian malignancy was found with increasing age, high ultrasound score, and high serum CA-125. The average value of CA-125 in benign and malignant ovarian tumor was 7.4 and 625, respectively. The RMI 2 at a cut-off value of 200 had a sensitivity of 96.7 %, specificity of 84 %, positive predictive value of 85.5 %, and negative predictive value of 67.7 %.

CONCLUSION

Our study confirms the applicability of RMI 2 >200 in diagnosing adnexal masses with high risk of malignancy. It can be easily introduced into clinical practice to facilitate the selection of the patients for surgery and also helpful in triaging patients to different treatment groups.

Ovarian cancer: risk factors, treatment and management

Ovarian cancer is the fifth most common cancer affecting women in the UK today, with associated statistics illustrating a steadily increasing rate, particularly in women aged 65 and over (Cancer Research UK, 2013). There are no recognised preventative measures and no effective screening tool. Although evidence suggests that the majority of women experience a variety of non-specific symptoms in the year before diagnosis, the disease it is not commonly recognised until an advanced stage, leading to increased mortality and morbidity. This highlights the need to raise awareness among health professionals and women as a whole, as early recognition undoubtedly improves ovarian cancer survival. Best clinical practice in the UK for the recognition and initial management of ovarian cancer is provided by the National Institute for Health and Care Excellence (NICE). Clinical guideline CG 122 (NICE, 2011) and quality standard QS 18 (NICE, 2012) use relevant clinical evidence to define high-quality care standards for ovarian cancer management. Accurate staging of ovarian cancer is essential to the provision of individualised care and management. However, there is currently no single test that provides a reliable indicator of ovarian malignancy. At present, risk-of-malignancy scores are calculated by serum cancer antigen 125 (CA 125) levels, ultrasound score and menopausal status. These are widely used to identify women who are at high risk and require referral to a specialised gynaecological oncology service. Women diagnosed with ovarian cancer require information and support. The clinical nurse specialist acts as a key worker, providing communication, support and holistic care throughout a woman's cancer journey. The value of this role cannot be underestimated. Surgery followed by platinum-based chemotherapy is the usual standard treatment pathway, although individualised assessment and management may deviate from it. Early disease may be successfully treated with surgery alone; advanced disease may require complex management and treatment. New treatments such as bevacizumab show promise of improving ovarian cancer outcomes.

Presurgical diagnosis of adnexal tumours using mathematical models and scoring systems: a systematic review and meta-analysis

BACKGROUND Characterizing ovarian pathology is fundamental to optimizing management in both pre- and post-menopausal women. Inappropriate referral to oncology services can lead to unnecessary surgery or overly radical interventions compromising fertility in young women, whilst the consequences of failing to recognize cancer significantly impact on prognosis. By reflecting on recent developments of new diagnostic tests for preoperative identification of malignant disease in women with adnexal masses, we aimed to update a previous systematic review and meta-analysis. METHODS An extended search was performed in MEDLINE (PubMed) and EMBASE (OvidSp) from March 2008 to October 2013. Eligible studies provided information on diagnostic test performance of models, designed to predict ovarian cancer in a preoperative setting, that contained at least two variables. Study selection and extraction of study characteristics, types of bias, and test performance was performed independently by two reviewers. Quality was assessed using a modified version of the QUADAS assessment tool. A bivariate hierarchical random effects model was used to produce summary estimates of sensitivity and specificity with 95% confidence intervals or plot summary ROC curves for all models considered. RESULTS Our extended search identified a total of 1542 new primary articles. In total, 195 studies were eligible for qualitative data synthesis, and 96 validation studies reporting on 19 different prediction models met the predefined criteria for quantitative data synthesis. These models were tested on 26 438 adnexal masses, including 7199 (27%) malignant and 19 239 (73%) benign masses. The Risk of Malignancy Index (RMI) was the most frequently validated model. The logistic regression model LR2 with a risk cut-off of 10% and Simple Rules (SR), both developed by the International Ovarian Tumor Analysis (IOTA) study, performed better than all other included models with a pooled sensitivity and specificity, respectively, of 0.92 [95% CI 0.88-0.95] and 0.83 [95% CI 0.77-0.88] for LR2 and 0.93 [95% CI 0.89-0.95] and 0.81 [95% CI 0.76-0.85] for SR. A meta-analysis of centre-specific results stratified for menopausal status of two multicentre cohorts comparing LR2, SR and RMI-1 (using a cut-off of 200) showed a pooled sensitivity and specificity in premenopausal women for LR2 of 0.85 [95% CI 0.75-0.91] and 0.91 [95% CI 0.83-0.96] compared with 0.93 [95% CI 0.84-0.97] and 0.83 [95% CI 0.73-0.90] for SR and 0.44 [95% CI 0.28-0.62] and 0.95 [95% CI 0.90-0.97] for RMI-1. In post-menopausal women, sensitivity and specificity of LR2, SR and RMI-1 were 0.94 [95% CI 0.89-0.97] and 0.70 [95% CI 0.62-0.77], 0.93 [95% CI 0.88-0.96] and 0.76 [95% CI 0.69-0.82], and 0.79 [95% CI 0.72-0.85] and 0.90 [95% CI 0.84-0.94], respectively. CONCLUSIONS An evidence-based approach to the preoperative characterization of any adnexal mass should incorporate the use of IOTA Simple Rules or the LR2 model, particularly for women of reproductive age.

Supporting the wider use of laparoscopy in the treatment of ovarian masses

Patients with ovarian masses which have a moderate risk of malignancy are frequently treated by open laparotomy, despite the Royal College of Obstetricians and Gynaecologists (RCOG) guidance indicating that laparoscopic oophorectomy may be performed in selected cases. The reluctance to perform laparoscopic surgery in these cases is normally due to the perception that survival is affected if the mass is subsequently diagnosed as being malignant, the risk of rupture impacting on FIGO stage and the need for additional staging surgery. However, there is no good evidence to support these views. Preoperative diagnosis of ovarian masses is limited and thus a significant number of patients are subjected to open surgery, where they may have benefitted from the advantages of laparoscopic surgery. We argue that in the absence of a definitive preoperative test, there are advantages to the laparoscopic approach in patients who have a moderate risk of malignancy and further high level evidence should be encouraged in this field.

Management of a suspicious adnexal mass: a clinical practice guideline

QUESTIONS

What is the optimal strategy for preoperative identification of the adnexal mass suspicious for ovarian cancer? What is the most appropriate surgical procedure for a woman who presents with an adnexal mass suspicious for malignancy?

PERSPECTIVES

In Canada in 2010, 2600 new cases of ovarian cancer were estimated to have been diagnosed, and of those patients, 1750 were estimated to have died, making ovarian cancer the 7th most prevalent form of cancer and the 5th leading cause of cancer death in Canadian women. Women with ovarian cancer typically have subtle, nonspecific symptoms such as abdominal pain, bloating, changes in bowel frequency, and urinary or pelvic symptoms, making early detection difficult. Thus, most ovarian cancer cases are diagnosed at an advanced stage, when the cancer has spread outside the pelvis. Because of late diagnosis, the 5-year relative survival ratio for ovarian cancer in Canada is only 40%. Unfortunately, because of the low positive predictive value of potential screening tests (cancer antigen 125 and ultrasonography), there is currently no screening strategy for ovarian cancer. The purpose of this document is to identify evidence that would inform optimal recommended protocols for the identification and surgical management of adnexal masses suspicious for malignancy.

OUTCOMES

Outcomes of interest for the identification question included sensitivity and specificity. Outcomes of interest for the surgical question included optimal surgery, overall survival, progression-free or disease-free survival, reduction in the number of surgeries, morbidity, adverse events, and quality of life.

METHODOLOGY

After a systematic review, a practice guideline containing clinical recommendations relevant to patients in Ontario was drafted. The practice guideline was reviewed and approved by the Gynecology Disease Site Group and the Report Approval Panel of the Program in Evidence-based Care. External review by Ontario practitioners was obtained through a survey, the results of which were incorporated into the practice guideline.

PRACTICE GUIDELINE

These recommendations apply to adult women presenting with a suspicious adnexal mass, either symptomatic or asymptomatic. IDENTIFICATION OF AN ADNEXAL MASS SUSPICIOUS FOR OVARIAN CANCER: Sonography (particularly 3-dimensional sonography), magnetic resonance imaging (mri), and computed tomography (ct) imaging are each recommended for differentiating malignant from benign ovarian masses. However, the working group offers the following further recommendations, based on their expert consensus opinion and a consideration of availability, access, and harm: Where technically feasible, transvaginal sonography should be the modality of first choice in patients with a suspicious isolated ovarian mass.To help clarify malignant potential in patients in whom ultrasonography may be unreliable, mri is the most appropriate test.In cases in which extra-ovarian disease is suspected or needs to be ruled out, ct is the most useful technique.Evaluation of an adnexal mass by Doppler technology alone is not recommended. Doppler technology should be combined with a morphology assessment.Ultrasonography-based morphology scoring systems can be used to differentiate benign from malignant adnexal masses. These scoring systems are based on specific ultrasound parameters, each with several scores base on determined features. All evaluated scoring systems were found to have an acceptable level of sensitivity and specificity; the choice of scoring system may therefore be made based on clinician preference.As a standalone modality, serum cancer antigen 125 is not recommended for distinguishing between benign and malignant adnexal masses.Frozen sections for the intraoperative diagnosis of a suspicious adnexal mass is recommended in settings in which availability and patient preference allow. SURGICAL PROCEDURES FOR AN ADNEXAL MASS SUSPICIOUS FOR MALIGNANCY: To improve survival, comprehensive surgical staging with lymphadenectomy is recommended for the surgical management of patients with early-stage ovarian cancer. Laparoscopy is a reasonable alternative to laparotomy, provided that appropriate surgery and staging can be done. The choice between laparoscopy and laparotomy should be based on patient and clinician preference. Discussion with a gynecologic oncologist is recommended. Fertility-preserving surgery is an acceptable alternative to more extensive surgery in patients with low-malignant-potential tumours and those with well-differentiated surgical stage i ovarian cancer. Discussion with a gynecologic oncologist is recommended.

Comparison of risk of malignancy index (RMI), CA125, CA 19-9, ultrasound score, and menopausal status in borderline ovarian tumor

OBJECTIVE

The aim of this study was to assess the prognostic values of risk of malignancy index (RMI IV), ultrasound score, menopausal status, and serum CA125 and CA19-9 level in patients with borderline ovarian tumor (BOT).

METHODS

Fifty women having borderline ovarian tumor (BOT) and 5O individuals with benign adnexal mass were enrolled in this retrospective study. The sensitivity, specificity, positive predictive values, negative predictive values and diagnostic accuracy of preoperative serum levels of the CA125 and CA19-9, ultrasound findings and menopausal status, and RMI IV were calculated for prediction of discrimination between BOTs and benign adnexal masses and the results were compared.

RESULTS

The RMI IV was the best method for discrimination between BOTs and benign adnexal masses and was more accurate than the other parameters. When Receiver Operator Characteristic area under the curves for menopausal status was analyzed, serum CA 125 and CA19-9 level, ultrasound score, RMI IV(CA125), and RMI IV(CA19-9) were, 0.580, 0.625, 0.548, 0.694, 0.734 and 0.711, respectively. The best RMI IV cut-off was found to be 200 for discrimination of benign and BOT lesions. In the RMI formulation, replacing CA125 with CA19-9 didn't affect RMI IV sensitivity and specificity for discrimination.

CONCLUSION

Compared to ultrasound, menopausal status, CA-125, CA19-9, the RMI IV was found to be the best predictive method for differentiation of BOTs from benign adnexal masses. RMI IV cut-off value of 200 is suitable for differentiation of benign and BOT's.

Differential diagnosis of adnexal masses: sequential use of the risk of malignancy index and HistoScanning, a novel computer-aided diagnostic tool

OBJECTIVE

To assess the value of ovarian Histo-Scanning(™) , a novel computerized technique for interpreting ultrasound data, in combination with the risk of malignancy index (RMI) in improving triage for women with adnexal masses.

METHODS

RMI indices were assessed in 199 women enrolled in a prospective study to investigate the use of HistoScanning. Ultrasound scores were obtained by blinded analysis of archived images. The following sequential test was developed: HistoScanning was modeled as a second-line test for RMI between a lower cut-off and an upper cut-off. The optimal combination of these cut-offs that together maximized the Youden index (Sensitivity + Specificity - 1) was determined.

RESULTS

Using RMI at the standard cut-off value of 250 resulted in a sensitivity of 74% and a specificity of 86%. When RMI was combined with HistoScanning, the highest accuracy was achieved by using HistoScanning as a sequential second-line test for patients with RMI values between 105 and 2100. At these cut-off values, sequential use of RMI and HistoScanning resulted in mean sensitivity and specificity estimates of 88% and 95%, respectively.

CONCLUSIONS

Our data suggest that HistoScanning may have the potential to improve the diagnostic accuracy of RMI, which could result in better triage for women with adnexal masses. Further prospective validation is warranted.

Adnexal masses suspected to be benign treated with laparoscopy

OBJECTIVE

Guidelines for referring women with pelvic masses suspicious for ovarian cancer to gynecologic oncologists have been developed by the American College of Obstetrician Gynecologists (ACOG). We set out to evaluate the negative predictive value of these guidelines and to assess a modified algorithm involving minimally invasive surgery in the treatment of women with masses suspected to be benign.

METHODS

257 consecutive patients with adnexal masses of 8cm to 13cm on preoperative ultrasound examination meeting Triage Criteria set forth in ACOG Committee Opinion 280. Patients meeting the selection criteria were scheduled for operative laparoscopy, washings, adnexectomy, bagging, and colpotomy. A total of 240 patients successfully completed intended treatment (93.38%), and 234 of these did not require admission (97.5%). There was a low incidence of significant complications: 97.50% of women were successfully treated as outpatients, 97.92% of surgeries lasted <136 minutes, and <97.08% had blood loss <200mL. The negative predictive value of ACOG Committee Opinion 280 Triage Criteria as a deselector for having invasive ovarian malignancy in our population was 95.57% for premenopausal and 90.91% for postmenopausal women.

CONCLUSIONS

Laparoscopic adnexectomy, bagging, and colpotomy is a desirable goal for patients with ovarian masses in the 8cm to 13cm range meeting selection criteria affording a minimally invasive approach with attendant benefits including outpatient treatment (97.5%), few complications, low likelihood of iatrogenic rupture of the ovarian capsule (1.25%), and low necessity for reoperation after final pathology is evaluated (6.03%). Negative predictive value of ACOG Committee Opinion 280 is confirmed in a community gynecology practice and is recommended to form the basis of a new treatment algorithm for women with adnexal masses.

Evaluation of the Risk of Malignancy Index in daily clinical management of adnexal masses

OBJECTIVE

To verify the effectiveness of the Risk of Malignancy Index in the discrimination between non-invasive (benign and borderline) lesions and invasive malignant adnexal masses in daily clinical practice.

METHODS

This prospective observational study was conducted in a multicentre cooperation of 11 hospitals. A total of 548 women with adnexal masses were included. Ultrasound characteristics, menopausal status and serum CA 125 level were registered preoperatively, and combined into the RMI afterwards. Final diagnosis was based on routine histopathologic examination. The decision to have patients operated by or with a gynecologic oncologist was based on the clinical impression of the gynecologist in the local hospital, based on physical examination, testing of serum samples, and ultrasound examination. This was compared with the hypothetical situation in which the RMI would have been applied as method of selection.

RESULTS

An RMI of 200 achieved a sensitivity of 81% and specificity of 85% in the detection of ovarian cancer. Positive and negative predictive values were 48% and 96% respectively. In current practice, 64% of ovarian cancer patients were operated by a gynecologic oncologist. This percentage would have increased to 80% if the RMI with a cutoff value of 200 would have been used as method of selection.

CONCLUSIONS

In our study population, introduction of the RMI would improve the management of adnexal masses, with a higher percentage of ovarian cancer patients that are operated by a gynecologic oncologist. At the same time, referral of patients with non-invasive (benign and borderline) lesions would be reduced.

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

OBJECTIVE

To determine if the risk of malignancy index (RMI) can distinguish between benign and malignant adnexal masses in a population of women referred to a department of gynaecologic oncology for surgical resection of an adnexal mass.

METHODS

We performed a retrospective review of the medical of charts of 259 consecutive patients. Ninety-six charts did not have data available to calculate the RMI, leaving a total of 163 for review. Three definitions of RMI were compared; each incorporated menopausal status of the patient, ultrasound characteristics of the adnexal mass, and serum CA-125 level.

RESULTS

Of the masses resected, 105 were benign and 58 were malignant. The area under the ROC curve for all three definitions of RMI was 0.87. Using a cut-off of 120, the first RMI definition (RMI 1) had a sensitivity of 72% and a specificity of 87%; the second (RMI 2) had a sensitivity of 76% and a specificity of 81%; and the third (RMI 3) had a sensitivity of 74% and a specificity of 84%. These results are generally in agreement with published values.

CONCLUSION

We have validated the use of RMI to predict the risk of malignancy in a Nova Scotia population of women with adnexal masses. This will aid in more selective referral of patients to specialized oncology centres for cancer surgery, allowing for appropriate management of health care resources and optimization of treatment for women with gynaecological malignancies.

Power Doppler in the assessment of pelvic masses in a low risk group

Discrimination between benign and malignant adnexal masses aids in optimising the management of women with pelvic tumours. A grading system incorporating grey-scale and power Doppler measurements might increase the accuracy of pre-operative assessment. The present study aimed to assess the sensitivity and specificity of a grading system including grey-scale and power Doppler findings. A total of 179 women who had undergone power Doppler Ultrasound for a pelvic mass between April 2001 and March 2003 were identified. Masses were surveyed by grey-scale and power Doppler and graded in relation to the estimated risk of malignancy. Clinicians were provided with the findings. The results were compared with the findings at surgery. A total of 74.3% were premenopausal. Some 94.4% (n = 169) had benign; 1.7% borderline and 3.9% malignant histology. A total of 69% underwent surgery. Specificity was 72.2 - 95.9%; sensitivity 55.6 - 88.9% and negative predictive value 97.6 - 99.2%. Power Doppler as an additional diagnostic aid may help the clinician in the management of pelvic masses. Further research is needed to clarify sensitivity and specificity.

The accuracy of risk scores in predicting ovarian malignancy: a systematic review

OBJECTIVE

To perform a systematic review of the literature on the accuracy of prediction models in the preoperative assessment of adnexal masses.

DATA SOURCES

Studies were identified through the MEDLINE and EMBASE databases from inception to March 2008. The MEDLINE search was performed using the keywords ["ovarian neoplasms"[MeSH] NOT "therapeutics"[MeSH] AND "model"] and ["ovarian neoplasms"[MeSH] NOT "therapeutics"[MeSH] AND "prediction"]. The Embase search was performed using the keywords [ovary tumor AND prediction], [ovary tumor AND Mathematical model], and [ovary tumor AND statistical model].

METHODS OF STUDY SELECTION

The search detected 1,161 publications; from the cross-references, another 116 studies were identified. Language restrictions were not applied. Eligible studies contained data on the accuracy of models predicting the risk of malignancy in ovarian masses. Models were required to combine at least two parameters.

TABULATION, INTEGRATION, AND RESULTS

Two independent reviewers selected studies and extracted study characteristics, study quality, and test accuracy. There were 109 accuracy studies that met the selection criteria. Accuracy data were used to form two-by-two contingency tables of the results of the risk score compared with definitive histology. We used bivariate meta-analysis to estimate pooled sensitivities and specificities and to fit summary receiver operating characteristic curves.Studies included in our analysis reported on 83 different prediction models. The model developed by Sassone was the most evaluated prediction model. All models has acceptable sensitivity and specificity. However, the Risk of Malignancy Index I and the Risk of Malignancy Index II, which use the product of the serum CA 125 level, an ultrasound scan result, and the menopausal state, were the best predictors. When 200 was used as the cutoff level, the pooled estimate for sensitivity was 78% for a specificity of 87%.

CONCLUSION

Based on our review, the Risk of Malignancy Index should be the prediction model of choice in the preoperative assessment of the adnexal mass.

Magnetic Resonance Imaging in Gynecological Oncology

Magnetic resonance imaging (MRI) has become an indispensable tool in the assessment of malignant disease. With increasingly sophisticated systems and technical advancements, MRI has continued to expand its role in providing crucial information regarding cancer diagnosis and management. In gynecological malignancies, this modality has assumed greater responsibility, particularly in the evaluation of cervical and endometrial cancers. In addition to conventional imaging, innovative techniques such as dynamic contrast-enhanced MRI and diffusion-weighted MRI show promise in offering early assessment of tumor response. This paper reviews the current role of MRI in gynecological cancers and highlights the potential of novel techniques in improving patient care.

Comparison of the risk of malignancy index and self-constructed logistic regression models in preoperative evaluation of adnexal masses

OBJECTIVE

The aim of this study was to evaluate women with adnexal masses in the preoperative period by creating 2 logistic regression models, 1 including sonographic morphologic characteristics and the other including both morphologic and color Doppler characteristics, to compare the diagnostic accuracy of these 2 models with the risk of malignancy index (RMI).

METHODS

This prospective study included 38 malignant, 7 borderline, and 244 benign ovarian masses. The menopausal status, presence of septa, presence of papillary projections, location of the tumor, presence of ascites, presence of metastases, cancer antigen 125 level, tumor volume, septa thickness, and percentage of the solid component were included in the initial analysis. A second regression analysis was performed with the addition of Doppler parameters (location of blood flow and lowest resistive index) in the data set. Diagnostic performance of the 2 regression models and RMI were described and compared by generating receiver operating characteristic curves for each model.

RESULTS

The area under the curve values for the morphologic model (model 1), Doppler model (model 2), and RMI were 0.907, 0.971, and 0.889, respectively. Significance levels of model 1 and the RMI were similar (P = .23), whereas model 2 had a significantly higher area under the curve compared with both model 1 (P = .037) and the RMI (P = .018).

CONCLUSIONS

The addition of Doppler parameters in the regression model significantly increases the predictive performance. Nevertheless, in low-resource settings, the RMI remains the method of choice for distinguishing adnexal masses and referral to gynecologic oncology clinics.

Doppler Evaluation of the Ovary: Clinical Applications and Challenges

Transvaginal sonography has been shown to be an accurate technique for discriminating between benign and malignant adnexal masses. Accurate preoperative differential diagnosis of adnexal masses is essential for optimizing patients’ treatment. The advancement and wider availability of therapies of assisted conception have occurred to a large extent as a result of developments in ultrasonography. Transvaginal color Doppler has opened up exciting new possibilities for the better understanding of the physiology and pathophysiology of ovarian blood flow, resulting in a number of completely new diagnostic parameters.

Accuracy of ultrasound subjective 'pattern recognition' for the diagnosis of borderline ovarian tumors

OBJECTIVES

To assess the value of pattern recognition for the preoperative ultrasound diagnosis of borderline ovarian tumors (BOTs).

METHODS

This was a prospective study of women who were referred to our regional cancer center with the diagnosis of an adnexal mass on a Level II (routine) gynecological ultrasound scan. Women with lesions of uncertain nature were referred for a Level III (expert) ultrasound scan in our tertiary center. The tumor pattern recognition method was used to differentiate between various types of ovarian tumors. Morphological features suggestive of BOTs were: unilocular cyst with a positive ovarian crescent sign and extensive papillary projections arising from the inner wall, or a cyst with a well defined multilocular nodule. The ultrasound findings were compared with the final histological diagnosis.

RESULTS

A total of 224 women with an adnexal mass of uncertain nature were referred for an expert scan, 166 (74.1%) of whom underwent surgery. In this group of women the final histological diagnoses were: 99 (60%) benign lesions, 32 (19%) invasive ovarian cancer and 35 (21%) BOTs. Using pattern recognition combining the different morphological features, a correct preoperative diagnosis of BOT was made in 24/35 (68.6%) women: area under the receiver-operating characteristics curve 0.812 (standard error 0.049; 95% CI, 0.716-0.908), sensitivity 0.69 (95% CI, 0.52-0.81), specificity 0.94 (95% CI, 0.88-0.97), positive likelihood ratio 11.3 (95% CI, 5.53-22.8) and negative likelihood ratio 0.34 (95% CI, 0.21-0.55).

CONCLUSIONS

Ultrasound diagnosis of BOTs is highly specific. However, typical features are absent in one-third of cases, which are typically misdiagnosed as benign lesions.

Differential diagnosis of adnexal masses: risk of malignancy index, ultrasonography, magnetic resonance imaging, and radioimmunoscintigraphy

A risk of malignancy index (RMI), based on menopausal status, ultrasound (US) findings, and serum CA125, has previously been described and validated in the primary evaluation of women with adnexal masses and is widely used in selective referral of women from local cancer units to specialized cancer centers. Additional imaging modalities could be useful for further characterization of adnexal masses in this group of women. A prospective cohort study was conducted of 196 women with an adnexal mass referred to a teaching hospital for diagnosis and management. Follow-up data was obtained for 180 women; 119 women had benign and 61 women malignant adnexal masses. The sensitivity and specificity of specialist US, magnetic resonance imaging (MRI), radioimmunoscintigraphy (RS), and the RMI were determined. We identified a subgroup of women with RMI values of 25-1000 where the value of further specialist imaging was evaluated. Sensitivity and specificity for specialist US were 100% and 57%, for MRI 92% and 86%, and for RS 76% and 87%, respectively. Analysis of 123 patients managed sequentially, using RMI cutoff values of > or =25 and <1000 and then US and MRI provided a sensitivity of 94% and a specificity of 90%. Using this RMI cutoff followed by specialist US and MRI, as opposed to the traditional RMI cutoff value of 250, can increase the proportion of patients with cancer appropriately referred in to a cancer center, with no change in the proportion of patients with benign disease being managed in a local unit.

A comparative study of the risk of malignancy index and the ovarian crescent sign for the diagnosis of invasive ovarian cancer

OBJECTIVE

To compare the value of the risk of malignancy index (RMI) and the ovarian crescent sign (OCS) in the diagnosis of ovarian malignancy.

METHODS

This was a prospective observational study of women with ultrasonographic diagnosis of an ovarian cyst. The RMI was calculated in all cases using a previously published formula (RMI = U (ultrasound score) x M (menopausal status) x serum CA125 (kU/L)). A value > 200 was considered to be diagnostic of ovarian cancer. The OCS was defined as a rim of visible healthy ovarian tissue in the ipsilateral ovary. Its absence was taken as being diagnostic of invasive cancer.

RESULTS

A total of 106 consecutive women were included in the study, of whom 92 (86.8%) had a benign ovarian tumor, five (4.7%) had borderline lesions and nine (8.5%) had an invasive ovarian cancer. The absence of an OCS diagnosed invasive ovarian cancer with a sensitivity of 100% (95% CI, 70-100%), specificity of 93% (95% CI, 86-96%), positive predictive value (PPV) of 56%, negative predictive value (NPV) of 100% and positive likelihood ratio (LR+) of 13.86 (95% CI, 6.79-28.29). This compared favorably with a sensitivity of 89% (95% CI, 57-98%), specificity of 92% (95% CI, 85-96%), PPV of 50%, NPV of 99% and LR+ of 10.78 (95% CI, 5.34-21.77), which were achieved using RMI > 200 (P < 0.01).

CONCLUSIONS

The RMI and the OCS are useful tests for discriminating between invasive and non-invasive ovarian tumors. The application of these tests in a sequential manner might improve the overall accuracy of ovarian cancer diagnosis.

Serum tumor necrosis factor alpha receptors p55/p75 ratio and ovarian cancer detection

OBJECTIVE

Early ovarian cancer detection is still very difficult and patients are mostly in advanced stages, with obvious influence on poor prognosis.

METHOD

Fifty-one ovarian cancer patients and 16 healthy controls had the serum concentrations of TNF alpha receptor p55, p75 and CA-125 measured prospectively and preoperatively.

RESULT

Mean concentrations of TNF alpha receptor p55, p75 and CA-125 in patients with ovarian cancer were higher than in controls. The ratios of p55 and p75 receptor in ovarian cancer and controls were 0.73+/-0.38 and 0.55+/-0.06 respectively. The areas under ROC curve in detecting malignancy (all FIGO stages) were 0.73, 0.65, 0.88 and 0.85 for p55, p75, p55/p75 ratio and CA-125 respectively. The areas under ROC curve in detecting stage I of ovarian cancer were 0.52, 0.60, 0.84 and 0.66 for p55, p75, p55/p75 ratio and CA-125 respectively.

CONCLUSION

Serum TNF alpha p55/p75 ratio showed promising value in ovarian cancer detection.

Preoperative serum inhibin levels in patients with ovarian tumors

AIM

To assess the value of preoperative determination of serum inhibin levels in the prediction of malignancy in women with ovarian tumors. The prediction of malignancy not only helps patient counseling regarding prognosis and extent of surgery but also allows for proper specialist referral.

METHODS

Fifty women with clinically diagnosed ovarian tumors before surgery (patients group) and 32 healthy non-pregnant women in the early follicular phase of their cycle (controls) were studied. Serum inhibin (total) levels and CA125 were determined using immunoenzymometric assay and enzyme immunoassay, respectively.

RESULTS

In the patients group, 31 women had malignant ovarian tumors and 19 had benign tumors. Mean (SEM) serum inhibin levels were 0.94 (0.13) U/mL in the control group, 0.91 (0.7) U/mL in women with benign tumors and 1.9 (0.12) U/mL in women with malignant tumors; the differences are statistically significant (P < 0.01). Inhibin levels were significantly higher in women with late-stage malignant ovarian tumors (III and IV) than in early stages (I and II) and showed no significant difference in relation to menopausal status or the presence of ascites. Taking the 95th centile inhibin level in the control group (1.155 U/mL) as a discriminator level, all women with benign tumors were negative while 67.7% of women with malignant tumors were positive. The inhibin level testing predicted malignancy with a sensitivity of 67.7%, 100% specificity, 100% positive predictive value and 65.52% negative predictive value. Combining CA125 levels (>35 U/mL) with serum inhibin levels (> 1.155 U/mL) improves sensitivity of predicting malignancy to 83.87% and negative predictive value to 75% while maintaining a specificity of 100% and a positive predictive value of 100%. Combining serum inhibin with sonography achieves 96.77% sensitivity and 73.68% specificity for detecting malignancy.

CONCLUSION

Preoperative serum inhibin levels in women with ovarian tumors are useful in the prediction of malignancy especially when combined with sonography.

The value of detection of normal ovarian tissue (the 'ovarian crescent sign') in the differential diagnosis of adnexal masses

OBJECTIVE

The aim of the study was to evaluate whether the presence of normal ovarian tissue adjacent to an adnexal tumor (the 'ovarian crescent sign') could assist in the preoperative differential diagnosis of adnexal lesions.

METHODS

This was a prospective observational study including 100 women with a preoperative diagnosis of an adnexal mass. Demographic and biochemical data were collected and all women underwent a detailed transvaginal ultrasound scan. Tumor volume, morphological characteristics and Doppler features were recorded in each case. In addition, the tissue adjacent to the cyst was systematically examined for the presence of normal ovarian tissue. All the findings were compared to the final histological diagnosis.

RESULTS

Sixty-seven (67%) of the cysts removed were benign, nine (9%) were borderline and 24 (24%) women had invasive malignant lesions. Normal ovarian tissue was seen in 58/76 (76%) women with non-invasive lesions, and in one woman (4%) with an invasive malignancy. In the absence of normal ovarian tissue, ovarian cancer was diagnosed with a sensitivity of 96% and specificity of 76%.

CONCLUSION

The presence of normal ovarian tissue adjacent to an ovarian cyst is a useful morphological feature that may be used to help exclude an invasive ovarian malignancy in women with adnexal masses detected on ultrasound scan.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

How significant is a cervical smear showing glandular dyskaryosis?

OBJECTIVE

To evaluate the incidence, outcome and predictive value of cytology showing glandular dyskaryosis.

PARTICIPANTS

Fifty-seven women with a smear diagnosis of glandular dyskaryosis registered between January 1997 and December 2001.

SETTING

Colposcopy and cytopathology units in a large district general hospital.

RESULTS

Sixty smears in 57 women showing glandular dyskaryosis were identified from a cohort of 135,120 smears, giving an incidence of 0.05%. Hospital records were available for 50 women. Final diagnosis included 13 cases of cervical glandular intraepithelial neoplasia (CGIN), 4 microinvasive cervical adenocarcinomas, 2 undifferentiated tumours, 1 microinvasive squamous carcinoma, 21 cases of CIN and 13 cases of endometrial pathology (8 endometrial cancers). Twelve women had coexistent squamous and glandular disease. Forty-five out of 50 women had significant pathology (positive predictive value 90%). Colposcopy was seen to be of limited value in assessment of smears showing glandular dyskaryosis. Only 1 out of 13 glandular lesions was diagnosed by colposcopy.

CONCLUSION

Smears showing glandular dyskaryosis are associated with significant pathology in 90% of cases and malignancy in 32% of cases. Hence, women with a smear showing glandular dyskaryosis should be referred urgently to a colposcopy clinic and flagged up as suspected cancer. Glandular dyskaryosis should be included in the national referral criteria for suspected gynaecological cancer.

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

OBJECTIVE

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

DESIGN

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

POPULATION

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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