Peri- and post-menopausal incidental adnexal masses and the risk of sporadic ovarian malignancy: new insights and clinical management

Spectrum of Ovarian Incidentalomas: Diagnosis and Management

Incidental ovarian lesions are asymptomatic lesions that are accidentally discovered during a CT or MRI examinations that involves the pelvic cavity or during a routine obstetric ultrasound study. Incidental ovarian masses are usually benign with a very low risk of malignancy yet underlying malignant pathology may be discovered during the diagnostic work-up of these lesions. Suspicion of malignancy is directly correlating with the increase in the patient's age, the increase in the size of the lesion, the presence of the solid components or thick septa and a high color scale of the ovarian mass. Following standard reporting and management protocols are essential to choose the proper work-up of these lesions to avoid unnecessary additional imaging and operative intervention. In this article, we will provide a review of the characteristic imaging features of some incidental and yet commonly encountered ovarian lesions. We will also summarize the recently published algorithms that are important for consistent reporting and standard management of these lesions.

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

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

Using protein microarray to identify and evaluate autoantibodies to tumor-associated antigens in ovarian cancer

The aim of this study was to develop a noninvasive serological diagnostic approach in identifying and evaluating a panel of candidate autoantibodies to tumor‐associated antigens (TAAs) based on protein microarray technology for early detection of ovarian cancer (OC). Protein microarray based on 154 proteins encoded by 138 cancer driver genes was used to screen candidate anti‐TAA autoantibodies in a discovery cohort containing 17 OC and 27 normal controls (NC). Indirect enzyme‐linked immunosorbent assay (ELISA) was used to detect the content of candidate anti‐TAA autoantibodies in sera from 140 subjects in the training cohort. Differential anti‐TAA autoantibodies were further validated in the validation cohort with 328 subjects. Subsequently, 112 sera from the patients with ovarian benign diseases with 104 OC sera and 104 NC sera together were recruited to identify the specificity of representative autoantibodies to OC among ovarian diseases. Five TAAs (GNAS, NPM1, FUBP1, p53, and KRAS) were screened out in the discovery phase, in which four of them presented higher levels in OC than controls (P < .05) in the training cohort, which was consistent with the result in the subsequent validation cohort. An optimized panel of three anti‐TAA (GNAS, p53, and NPM1) autoantibodies was identified to have relatively high sensitivity (51.2%), specificity (86.0%), and accuracy (68.6%), respectively. This panel can identify 51% of OC patients with CA125 negative. This study supports our assumption that anti‐TAA autoantibodies can be considered as potential diagnostic biomarkers for detection of OC; especially a panel of three anti‐TAA autoantibodies could be a good tool in immunodiagnosis of OC.

Serum Biomarker Based Algorithms in Diagnosis of Ovarian Cancer: A Review

Epithelial ovarian cancer accounts for more than 90% of ovarian tumours and continues as a leading cause of death from gynaecological malignancies. It is often difficult to differentiate a benign ovarian mass from malignant ones. Invasive histopathological biopsy is used as the gold standard diagnostic tool to diagnose cancer in patients with ovarian mass. A wide spectrum of Biomarkers were tried in various studies to develop a non invasive diagnostic tool, out of which HE4 and CA 125 remain the only clinically useful biomarker. Consequently various Biomarker based algorithms i.e. Risk of Malignancy Index, risk of ovarian cancer algorithm, OVA1, risk of malignancy algorithm were generated that have been developed to assess the risk of a mass being malignant. These algorithms help in timely triage of patients. Recently in 2016 FDA cleared Ova1 test (OVERA) with CA 125-II, HE4, apolipoprotein A-1, FSH, and transferring (Sensitivity 91% and Specificity 69%) as a referral or Triage test in patients presenting with ovarian mass. Combination of protein and circulating Micro RNA analysis in blood, could provide a comprehensive screening and diagnostic panel, in management of patients presenting with ovarian mass in one clinical setting.

An adolescent with an asymptomatic adnexal cyst: To worry or not to worry? Medical versus surgical management options

Paraovarian cysts or paratubal cysts (PTCs) arise from either the mesothelium or from paramesonephric remnants. These present as either adnexal mass or as an incidental finding. Diagnosis is usually established on ultrasound and it is important to differentiate these from ovarian cysts. Typically PCTs appear as simple cysts by ultrasound and are indistinguishable from ovarian cysts if one does not recognize the extraovarian location. Occasionally, PTCs have internal echoes due to hemorrhage. PTCs are usually asymptomatic and benign. The differential diagnosis includes a simple ovarian cyst, peritoneal inclusion cyst and hydrosalpinx. Malignant changes have been reported in about 2% to 3%, and it should be suspected if papillary projections are present. PTCs management depend upon the presence and severity of the symptoms, the cyst size and US characteristics, CA 125 results, age of the patient and the risk of malignancy. Simple PTCs can be expected to regress and may be managed expectantly. When surgery is indicated, a joint multidisciplinary management by the paediatric surgeons and trained paediatric gynaecologists should be the gold standard. (www.actabiomedica.it)

[Ovarian tumors in postmenopausal women: report of 100 cases and review of the literature]

Le but de notre travail est d’étudier les particularités de prise en charge des tumeurs de l'ovaire chez la femme ménopausée. L’étude rétrospective porte sur 100 patientes opérées pour des tumeurs ovariennes en post ménopause durant une période de 5 ans. L’âge moyen des patientes était de 61,3 ans (extrêmes: 47- 84 ans). L'aspect échographique était liquidien pur dans 40% des cas, mixte ou solide dans 30% des cas. Le dosage de CA 125 était élevé dans 25% des cas. Un traitement chirurgical a été pratiqué chez toutes les patientes: Laparotomie de première intention dans 43 cas,cœliochirurgie dans 51 cas, cœlioscopie puis laparotomie dans 6 cas. L'examen anatomopathologique définitif a révélé 22% de tumeurs malignes et 10% de kystes fonctionnels. Le geste chirurgical était une annexectomie bilatérale pour la majorité des tumeurs bénignes et carcinologique en cas de tumeurs malignes. La stratégie diagnostique des tumeurs ovariennes en post ménopause reste de nos jours basée sur la clinique, l’échographie et les marqueurs tumoraux. Les bénéfices de la cœlioscopie sont indiscutables. L'attitude à opérer systématiquement les kystes uniloculaires ayant les critères de bénignité est actuellement révisée.

Vascular endothelial growth factor (VEGF) improves the sensitivity of CA125 for differentiation of epithelial ovarian cancers from ovarian cysts

BACKGROUND

The present study aimed to compare the diagnostic value of preoperative serum levels of CA125 and vascular endothelial growth factor (VEGF), and the combination of both biomarkers for differentiating early stage epithelial ovarian cancers from ovarian cysts.

MATERIALS AND METHODS

In this study, preoperative and postoperative serum levels of CA125 and VEGF of 30 patients with epithelial ovarian cancers (cancer arm) compared with that of 30 patients with benign ovarian cysts (cyst arm). Initial eligibility included having an ovarian cystic or solid mass detected by transvaginal ultrasonography at the hospital clinic. Included patients had to have localized pelvic disease and no clinical or imaging evidence of extrapelvic disease, ascites and distant metastasis. Initial exclusion criteria included prior history of malignancy or any type of cancer treatment. After surgery, only patients with pathologic diagnosis of early stage epithelial ovarian cancer and ovarian cyst were included.

RESULTS

Preoperative serum levels of CA125 (P < 0.001) and VEGF (P < 0.001) were significantly higher in the study arm compared to the control arm. In addition, postoperative serum levels of CA125 (P < 0.001) and VEGF (P < 0.001) in study arm were significantly decreased compared to preoperative serum levels. At usual clinical cut-off levels of 17.6 pg/ml for VEGF and 35 U/ml for CA125, the sensitivity and specificity for detecting early stage epithelial ovary cancer were 90 and 57 % for VEGF and 66.6 and 73 % for CA125, respectively. At 100 % specificity for each test, the addition of VEGF to CA125 increased the sensitivity of early ovarian cancer detection from 60 to 73.3 %.

CONCLUSION

This study indicates that the addition of VEGF serum value improves the specificity and the sensitivity of CA125 to detect early stage epithelial ovarian cancers, and to differentiate these neoplasms from ovarian cyst.

Role of multidetector computed tomography (MDCT) in patients with ovarian masses

Objective:

To evaluate the diagnostic accuracy of multidetector 64-slice computed tomography (MDCT) in the diagnosis and differentiation of benign and malignant ovarian masses using histopathology and surgical findings as the gold standard.

Material and methods:

This study was conducted in Aga Khan University Hospital, Karachi, Pakistan. Data was reviewed retrospectively from 1 November 2008 to 12 December 2009. One hundred patients found to have ovarian masses on CT scan were included in the study. CT scan was performed in all these patients after administration of oral and IV contrast. Ovarian masses were classified as benign and malignant on scan findings. Imaging findings were compared with histopathologic results and surgical findings. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of MDCT were calculated.

Results:

MDCT was found to have 97% sensitivity, 91% specificity, and an accuracy of 96% in the differentiation of benign and malignant ovarian masses, while PPV and NPV were 97% and 91%, respectively.

Conclusion:

MDCT imaging offers a safe, accurate and noninvasive modality to differentiate between benign and malignant ovarian masses.

The ROMA (Risk of Ovarian Malignancy Algorithm) for estimating the risk of epithelial ovarian cancer in women presenting with pelvic mass: is it really useful?

BACKGROUND

The study is aimed at evaluating the performance of the predictive model ROMA (Risk of Ovarian Malignancy Algorithm), which utilizes the combination of human epididymis protein 4 (HE4) and CA125 values to assess the risk of epithelial ovarian cancer (EOC) in women with a pelvic mass.

METHODS

One hundred and four women diagnosed with a pelvic mass (55 EOC and 49 benign cases) and scheduled to have surgery were enrolled, along with 49 healthy females. Preoperative serum concentrations of HE4 and CA125 were measured. Separate logistic regression algorithms ROMA for pre-menopausal and post-menopausal women were used to categorize patients into low- and high-risk groups for EOC. The area under the curve (AUC), sensitivity and specificity were calculated for HE4, CA125 and ROMA for the diagnosis of ovarian cancer using receiver operating characteristic (ROC) analysis.

RESULTS

The median CA125 and HE4 serum concentrations were significantly higher among EOC patients than in healthy females (both p<0.05) and those with a benign mass (both p<0.05). The pre-menopausal group included 36 benign cases (29 of which were classified by ROMA as low-risk with a specificity of 80.6%; 95% CI: 64.0%-91.8%), and 15 EOC (eight of which were classified by ROMA as high-risk, with a sensitivity of 53.3%; 95% CI: 26.6%-78.7%). The post-menopausal group enclosed 13 benign cases (11 of which were classified by ROMA as low-risk with a specificity of 84.6%; 95% CI: 54.6%-98.0%), and 40 EOC (33 of which were classified by ROMA as high-risk with a sensitivity of 82.5%; 95% CI: 67.2%-92.7%). In the pre-menopausal group, the AUC was 0.64 (p=0.12, 95% CI: 0.44-0.83) for CA125, 0.77 (p=0.003, 95% CI: 0.62-0.92) for HE4 and 0.77 (p=0.002, 95% CI: 0.63-0.92) for ROMA. In the post-menopausal group, the AUC was 0.84 (p=0.0003, 95% CI: 0.73-0.94) for CA125, 0.94 (p<0.0001, 95% CI: 0.88-0.99) for HE4 and 0.92 (p<0.0001, 95% CI: 0.85-0.99) for ROMA.

CONCLUSIONS

The ROMA is a simple scoring system which shows excellent diagnostic performance for the detection of EOC in post-menopausal women, but not in pre-menopausal women. Moreover, the dual marker combination of HE4 and CA125 (ROMA) does not show better performance than HE4 alone.