Management of a suspicious adnexal mass: a clinical practice guideline

O-RADS MRI scoring system: key points for correct application in inexperienced hands

OBJECTIVES

To evaluate the efficacy of the O-RADS MRI criteria in the stratification of risk of malignancy of solid or sonographically indeterminate ovarian masses and assess the interobserver agreement of this classification between experienced and inexperienced radiologists.

METHODS

This single-centre retrospective study included patients from 2019 to 2022 with sonographically indeterminate or solid ovarian masses who underwent MRI with a specific protocol for characterisation according to O-RADS MRI specifications. Each study was evaluated using O-RADS lexicon by two radiologists, one with 17 years of experience in gynaecological radiology and another with 4 years of experience in general radiology. Findings were classified as benign, borderline, or malignant according to histology or stability over time. Diagnostic performance and interobserver agreement were assessed.

RESULTS

A total of 183 patients with US indeterminate or solid adnexal masses were included. Fifty-seven (31%) did not have ovarian masses, classified as O-RADS 1. The diagnostic performance for scores 2-5 was excellent with a sensitivity, specificity, PPV, and NPV of 97.4%, 100%, 96.2%, and 100%, respectively by the experienced radiologist and 96.1%, 92.0%, 93.9%, and 94.8% by the inexperienced radiologist. Interobserver concordance was very high (Kappa index 0.92). Almost all the misclassified cases were due to misinterpretation of the classification similar to reports in the literature.

CONCLUSION

The diagnostic performance of O-RADS MRI determined by either experienced or inexperienced radiologists is excellent, facilitating decision-making with high diagnostic accuracy and high reproducibility. Knowledge of this classification and use of assessment tools could avoid frequent errors due to misinterpretation.

CRITICAL RELEVANCE STATEMENT

Up to 31% of ovarian masses are considered indeterminate by transvaginal US and 32% of solid lesions considered malignant by transvaginal US are benign. The O-RADs MRI accurately classifies these masses, even when used by inexperienced radiologists, thereby avoiding incorrect surgical approaches.

KEY POINTS

• O-RADS MRI accurately classifies indeterminate and solid ovarian masses by ultrasound. • There is excellent interobserver agreement between experienced and non-experienced radiologists. • O-RADS MRI is a helpful tool to assess clinical decision-making in ovarian tumours.

Contrast-enhanced US to Improve Diagnostic Performance of O-RADS US Risk Stratification System for Malignancy

Background The Ovarian-Adnexal Reporting and Data System (O-RADS) has limited specificity for malignancy. Contrast-enhanced US can help distinguish malignant from benign lesions, but its added value to O-RADS has not yet been assessed. Purpose To establish a diagnostic model combining O-RADS and contrast-enhanced US and to validate whether O-RADS plus contrast-enhanced US has a better diagnostic performance than O-RADS alone. Materials and Methods This prospective study included participants from May 2018 to March 2021 who underwent contrast-enhanced US before surgery and had lesions categorized as O-RADS 3, 4, or 5 by US, with a histopathologic reference standard. From April 2021 to July 2022, participants with pathologically confirmed ovarian-adnexal lesions were recruited for the validation group. In the pilot group, the initial enhancement time and enhancement intensity in comparison with the uterine myometrium, contrast agent distribution pattern, and dynamic changes in enhancement of lesions were assessed. Contrast-enhanced US features were used to calculate contrast-enhanced US scores for benign (score ≤2) and malignant (score ≥4) lesions. Lesions were then re-rated according to O-RADS category plus contrast-enhanced US scores. Receiver operating characteristic curves were constructed and compared using the DeLong method. The combined system was validated in an independent group. Results The pilot group included 76 women (mean age, 44 years ± 13 [SD]), and the validation group included 46 women (mean age, 42 years ± 14). Differences in initial enhancement time (P < .001), enhancement intensity (P < .001), and dynamic changes in enhancement (P < .001) between benign and malignant lesions were observed in the pilot group. Contrast-enhanced US scores were calculated using these features. The O-RADS risk stratification was upgraded one level for contrast-enhanced US scores of 4 or more and downgraded one level for contrast-enhanced US scores of 2 or less. In the validation group, the diagnostic performance of O-RADS plus contrast-enhanced US score was higher (area under the receiver operating characteristic curve [AUC] = 0.93) than O-RADS (AUC = 0.71, P < .001). Conclusion Contrast-enhanced US improved the diagnostic performance for malignancy of the O-RADS categories 3-5. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Grant in this issue.

Accuracy and reproducibility of the O-RADS MRI risk stratification system based on enhanced non-DCE MRI in the assessment of adnexal masses

OBJECTIVE

Evaluation of the diagnostic performance and reproducibility of the Ovarian-Adnexal Reporting and Data System (O-RADS) Magnetic Resonance Imaging (MRI) risk stratification system based on enhanced non-dynamic contrast-enhanced (non-DCE) MRI in the diagnosis of adnexal masses.

METHODS

Patients who underwent conventional pelvic enhanced non-DCE MRI examination within one month prior to surgery formed the study population. Two experienced radiologists independently evaluated the images and assigned a score according to the O-RADS MRI risk stratification system. One of the radiologists reviewed the images and reassigned the scores after three months. Intra- and inter-observer agreement was evaluated with the k coefficient value. The adnexal masses that attained scores between 1 and 3 were considered benign, while those with scores of 4 or 5 were considered malignant. Analyses were conducted to determine the sensitivity, specificity, positive and negative predictive values, and receiver operating characteristic (ROC) curve, which were then used for evaluating the diagnostic efficacy of the developed system based on enhanced non-DCE MRI scan. The reference standard was histology.

RESULTS

A total of 308 patients (mean age: 42.09 ± 12.42 years, age range: 20-84 years) were enrolled in the study. Among the 362 adnexal masses from the included patients, there were 320 benign masses and 42 malignant masses. In the case of three readers, there were no malignant tumors scored 1-2. The O-RADS MRI score ≥ 4 was associated with malignancy resulted in a good diagnostic efficacy with the areas under the curve (AUC) values of 0.918 (95 % CI, 0.864-0.972), 0.905 (95 % CI, 0.842-0.968), and 0.882 (95 % CI, 0.815-0.950), the sensitivity values of 90.5 % (95 % CI, 87.5-93.5 %), 85.7 % (95 % CI, 82.1-89.3 %), and 83.3 % (95 % CI, 79.5-87.2 %), and the specificity values of 93.1 % (95 % CI, 90.5-95.7 %), 95.3 % (95 % CI, 93.1-97.5 %), and 93.1 % (95 % CI, 90.5-95.7 %) obtained for the three readers, respectively. Excellent intra-observer agreement and inter-observer agreement were observed with the k values of 0.883 (95 % CI, 0.814-0.952) and 0.848 (95 % CI, 0.770-0.926), respectively.

CONCLUSIONS

The O-RADS MRI risk stratification system based on enhanced non-DCE MRI scans exhibited high accuracy and reproducibility in the prediction of adnexal masses malignancy. Enhanced non-DCE MRI scan may offer an alternative diagnostic tool when DCE is not possible.

Recurrent malignant ovarian adenocarcinoma with central nervous system metastasis successfully treated with paclitaxel, carboplatin, capecitabine, and gemcitabine

Ovarian carcinoma is a common malignancy with a grim prognosis and a high mortality rate. Here, we report a rare case of an Iranian woman with four episodes of recurrent metastatic ovarian carcinoma. She was initially diagnosed with stage IVa high-grade serous ovarian adenocarcinoma (HGSOC), treated with paclitaxel-carboplatin and capecitabine, followed by total abdominal hysterectomy and bilateral salpingo-oophorectomy. Two years later, she developed cerebellar metastasis and received whole-brain radiotherapy and paclitaxel-carboplatin. Eighteen months later, she had peritoneal metastasis and had sequential gemcitabine-carboplatin-paclitaxel. One year later, she had splenic metastasis, treated with splenectomy and adjuvant carboplatin and nano-albumin bond paclitaxel. The patient remains in remission until now, 11 months after completing the most recent regimen. This report emphasizes the potential to successfully use chemoradiotherapy with sequential courses of platinum-based agents in patients with recurrent metastatic HGSOC.

Diagnostics of Ovarian Tumors in Postmenopausal Patients

Early diagnosis of ovarian cancer remains an urgent issue owing to the continuing trend towards increasing incidence along with only marginal improvements in mortality and 5-year survival rates. Furthermore, there is a lack of a clear formulation of the concept of pathogenesis. The diagnostic values of tumor markers, their potential advantages and disadvantages, and their combination with radiation imaging methods and transvaginal sonography are discussed. More advanced imaging techniques, such as computed tomography and magnetic resonance imaging have proven too expensive for widespread use. According to the World Health Organization, more than half of the world’s population does not have access to diagnostic imaging. Consequently, there is high demand for a low-cost, reliable, and safe imaging system for detecting and monitoring cancer. Currently, there is no clear algorithm available for examining and accurately diagnosing patients with postmenopausal ovarian tumors; moreover, reliable criteria allowing dynamic observation and for determining surgical access and optimal surgical intervention measures in postmenopausal patients are lacking. Medical microwave radiometry shows promising results yielding an accuracy of 90%.

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

Management of adnexal mass: A comparison of five national guidelines

OBJECTIVES

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Magnetic resonance scoring system for assessment of adnexal masses: added value of diffusion-weighted imaging including apparent diffusion coefficient map

OBJECTIVES

To validate prospectively the ADNEX magnetic resonance (MR) scoring system to assess adnexal masses and to evaluate a new, modified ADNEX MR scoring system that incorporates diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) mapping.

METHODS

Between January 2015 and September 2018, 323 consecutive women with adnexal masses diagnosed on transvaginal ultrasound (TVS) underwent standardized MR imaging (MRI) including diffusion and dynamic contrast-enhanced sequences. Of these, 131 underwent subsequent surgery. For interpretation of the MRI examinations, we applied the five-category ADNEX MR scoring system, along with a modified scoring system including DWI with ADC mapping. For both scoring systems, a score was given for all adnexal masses. Histological diagnosis was considered as the gold standard and lesions were classified as benign or malignant. The difference between the predictive values for diagnosing malignancy of the classical and modified scoring systems was assessed on the basis of the areas under the receiver-operating-characteristics (AUC) curves. The sensitivity and specificity for diagnosing malignancy of each score were also calculated.

RESULTS

Among the 131 women with adnexal mass(es) diagnosed on TVS who underwent MRI and subsequent surgery, the surgery revealed 161 adnexal masses in 126 women; five women had no mass. Histological examination confirmed 161 adnexal masses, of which all had been detected on MRI: 32 malignant tumors, 15 borderline tumors, which were classified as part of the malignant group (n = 47), and 114 benign lesions. The AUC for prediction of a malignant lesion was 0.938 (95% CI, 0.902-0.975) using the classical ADNEX MR scoring system and 0.974 (95% CI, 0.953-0.996) using the modified scoring system. Pairwise comparison of these AUCs revealed a significant difference (P = 0.0032). The sensitivity and specificity for diagnosing malignancy with an ADNEX MR score of 4 or more were 95.5% and 86.6%, respectively, using the classic scoring system, and 95.7% and 93.3%, respectively, using the modified scoring system.

CONCLUSION

DWI with ADC mapping could be integrated into the ADNEX MR scoring system to improve specificity, thereby potentially optimizing clinical management by avoiding unnecessary surgery. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Ovarian Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States and is the country's fifth most common cause of cancer mortality in women. A major challenge in treating ovarian cancer is that most patients have advanced disease at initial diagnosis. These NCCN Guidelines discuss cancers originating in the ovary, fallopian tube, or peritoneum, as these are all managed in a similar manner. Most of the recommendations are based on data from patients with the most common subtypes─high-grade serous and grade 2/3 endometrioid. The NCCN Guidelines also include recommendations specifically for patients with less common ovarian cancers, which in the guidelines include the following: carcinosarcoma, clear cell carcinoma, mucinous carcinoma, low-grade serous, grade 1 endometrioid, borderline epithelial, malignant sex cord-stromal, and malignant germ cell tumors. This manuscript focuses on certain aspects of primary treatment, including primary surgery, adjuvant therapy, and maintenance therapy options (including PARP inhibitors) after completion of first-line chemotherapy.

O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee

The Ovarian-Adnexal Reporting and Data System (O-RADS) US risk stratification and management system is designed to provide consistent interpretations, to decrease or eliminate ambiguity in US reports resulting in a higher probability of accuracy in assigning risk of malignancy to ovarian and other adnexal masses, and to provide a management recommendation for each risk category. It was developed by an international multidisciplinary committee sponsored by the American College of Radiology and applies the standardized reporting tool for US based on the 2018 published lexicon of the O-RADS US working group. For risk stratification, the O-RADS US system recommends six categories (O-RADS 0-5), incorporating the range of normal to high risk of malignancy. This unique system represents a collaboration between the pattern-based approach commonly used in North America and the widely used, European-based, algorithmic-style International Ovarian Tumor Analysis (IOTA) Assessment of Different Neoplasias in the Adnexa model system, a risk prediction model that has undergone successful prospective and external validation. The pattern approach relies on a subgroup of the most predictive descriptors in the lexicon based on a retrospective review of evidence prospectively obtained in the IOTA phase 1-3 prospective studies and other supporting studies that assist in differentiating management schemes in a variety of almost certainly benign lesions. With O-RADS US working group consensus, guidelines for management in the different risk categories are proposed. Both systems have been stratified to reach the same risk categories and management strategies regardless of which is initially used. At this time, O-RADS US is the only lexicon and classification system that encompasses all risk categories with their associated management schemes.

Laparoscopy vs. laparotomy for advanced ovarian cancer: a systematic review of the literature

INTRODUCTION

In the last decade, laparoscopy has been progressively introduced in the management of advanced-stage ovarian cancer (AOC) to evaluate tumor resectability, avoiding an explorative laparotomy, to identify non-responders to submit to second-line chemotherapy and to perform primary or interval minimally invasive debulking surgery in selected patients. This review aims to deeply focus on the differences between laparoscopy and laparotomy in the management of advanced ovarian cancer.

EVIDENCE ACQUISITION

The electronic database search provided a total of 80 results. Out of these, 63 results were excluded because considered not relevant to the review, for linguistic reasons or case reports. A total of 17 articles were considered eligible for the review.

EVIDENCE SYNTHESIS

Many studies have assessed the value of laparoscopy in predicting the optimal resectability of AOC patients avoiding exploratory laparotomies. More recently, its role in primary and interval cytoreduction has been investigated for selected patients in terms of safety, feasibility and oncological outcomes. Published data are comparable to the standard laparotomic management in terms of oncological outcomes but with improved perioperative and psychological results. The selection of patients is crucial to perform a successful surgery.

CONCLUSIONS

To date, laparoscopy has replaced the primary laparotomic approach in the evaluation of optimal resectability. As far as primary and interval minimally invasive debulking surgery are concerned, instead, most of the works report an overlap of oncological outcomes compared to traditional surgery. The selection of patients is a crucial point to reach a successful minimally invasive surgical treatment, taking into account surgical complexity and surgical adequacy.

A preliminary study: The sequential use of the risk malignancy index and contrast-enhanced ultrasonography in differential diagnosis of adnexal masses

The aim of this study was to explore the sequential use of risk malignancy index (RMI) combined with contrast-enhanced ultrasonography (CEUS) in identification diagnosis of adnexal masses.This study contained 2 steps: first, 151 patients were analyzed retrospectively with RMI 1, RMI 2, and RMI 3 indices; receiver operating characteristic (ROC) curves were plotted to analyze area under the curves (AUC), and then RMI cut-off value was obtained according to maximum Youden index (YI, Sensitivity + Specificity - 1) and calculating diagnostic sensitivity, specificity, positive/negative predictive value, and accuracy. Second, 151 cases were divided into 2 groups randomly (105 in study group and 46 in test group); in the study group, the lower cut-off value (LC), upper cut-off value (UC), CEUS cut-off value according to maximum YI, and then these cut-offs were validated in test group.There was no statistical significance in 3 RMI models (P = .35), and RMI1 model was established randomly for following study. When the RMI1 cut-off value was 149, the YI was maximal (0.53), and the sensitivity, specificity, positive/negative predictive value, and accuracy were 71.0%, 81.7%, 77.1%, 75.6%, and 76.2%, respectively. The LC was 15 (sensitivity was 98.0%), the UC was 3000 (specificity was 98.0%), and the CEUS cut-off value was 7 (maximal YI was 0.81). In the test group (46 cases), combining RMI1 LC (15) and UC (3000) with CEUS cut-off value (7), the sensitivity, specificity, positive/negative predictive value, and accuracy were up to 85.7%, 92.0%, 90.0%, 88.5%, and 89.1%, respectively.CEUS can help RMI to make a more effective differential diagnosis of the adnexal mass. Further validation by additional multicenter prospective trials is required.

Transvaginal Ultrasound-Guided Core Needle Biopsy of Pelvic Masses

OBJECTIVES

This study assessed the efficacy and safety of transvaginal ultrasound (US)-guided core needle biopsy (CNB) for obtaining adequate pelvic mass samples for histologic analysis and evaluated factors that may affect biopsy success.

METHODS

Two hundred cases underwent transvaginal US-guided CNBs for primary inoperable tumors, suspicion of metastases to the ovaries or peritoneum, recurrence, or other solid lesions in the pelvis. Biopsy samples were obtained from the pelvic cavity (67.0%), vaginal cuff or vaginal wall (17.5%), or peritoneal cake (15.5%). The potential influences of the biopsy site (pelvic cavity, vaginal cuff or vaginal wall, or peritoneal cake), vascularization, ascites, tumor size, and tumor type (inoperable, metastases, recurrence, or solid pelvic tumor) on the success of transvaginal US-guided CNB were evaluated by a univariate analysis.

RESULTS

Adequate samples were obtained in 192 of 200 biopsies (96.0%), of which 190 yielded successful diagnoses (95.0%). The biopsy site had a significant effect on biopsy adequacy, as there was a significantly lower probability of obtaining satisfactory specimens for histologic verification from the peritoneal cake compared to pelvic tumors and the vaginal cuff or vaginal wall (P < .01). Adequacy was also affected by tumor size (P < .05) but not by vascularization, ascites, or tumor type. No complications occurred during the biopsy procedures.

CONCLUSIONS

Transvaginal US-guided CNB is a safe and effective alternative to more invasive methods for evaluating pelvic lesions, such as laparoscopy and laparotomy.

[Factors influencing the quality of clinical practice guidelines in ovarian cancer]

OBJECTIVE

To identify the characteristics of the published clinical practice guidelines for the management of epithelial ovarian cancer that suggest a good methodological quality.

MATERIAL AND METHODS

A literature review was performed on 25 clinical practice guidelines for epithelial ovarian cancer that were identified in different databases (MEDLINE, Guidelines International Network, National Guidelines Clearing house) published between 2007 and 2014. The quality of the guidelines was evaluated using the Appraisal of Guidelines Research and Evaluation II tool. Descriptive and bivariate analyses were performed to assess the association between the quality of the guidelines and of some of their features and their developers.

RESULTS

Just under half (48%) of the guidelines were rated as low quality. Scientific societies or independent centres and private funding, or under-reporting the source of funding, were statistically associated with lower quality of clinical practice guidelines (P<.01). The guidelines developed by National Program Guidelines had a median of consistently higher scores in all domains of the Appraisal of Guidelines Research and Evaluation II, with significant differences in the definition of scope and objectives, the participation of stakeholders, the methodological rigour of development, and applicability to the context.

CONCLUSIONS

Features such as the nature of the developer and funding of the guidelines are predictors of quality that should be taken into account prior to the use of the recommendations of a document.

Staging for low malignant potential ovarian tumors: a global perspective

OBJECTIVE

We describe current evidence for staging low malignant potential ovarian tumors and their conformity to current consensus guidelines and practice from an international perspective.

DATA SOURCES

A search of MEDLINE, EMBASE, and SCOPUS databases was conducted for articles published between January 1990 and April 2015.

STUDY ELIGIBILITY CRITERIA

Studies on low malignant potential ovarian tumors that evaluated the prognostic value of disease stage, staging vs no staging, complete vs incomplete staging, or discrete components of staging were eligible. Studies that described only crude survival rates were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

Eligible studies were categorized according to their outcome (disease stage, staging procedure, or discrete staging elements). Data were abstracted using a standard form. Inconsistencies on data abstraction were resolved by consensus among the authors. Risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

Of 1116 studies, 702 were excluded for irrelevance and 364 for not meeting inclusion criteria. Nine studies were excluded for describing crude survival rates without a comparative conclusion. We found that studies supporting the value of defining disease stage or staging procedures (mostly conducted in northern Europe) included more patients than studies that did not find disease stage or staging useful (predominantly from North America, 4072 vs 3951). Disease stage correlated with survival in 13 of 25 studies, whereas none of the studies that evaluated the value of staging found it beneficial (9 studies, 1979 patients). Studies that evaluated isolated components of staging found no benefit to these procedures. Regional guidelines and consensus reviews drew conclusions based on a limited number of studies that generally originated from the same region.

CONCLUSIONS

Although the correlation of stage with survival was mixed, performing staging procedures for low malignant potential ovarian tumors is not supported by the best available evidence. Guidelines in support of staging based their recommendations on a few regional studies and conflict with better-quality data that do not support staging procedures. An international consensus statement is needed to standardize the surgical management of low malignant potential ovarian tumors.

Level of HE4 is Correlated with Diagnosis of Struma Ovarii: A Case Report

BACKGROUND Struma ovarii is a rare ovarian teratoma with non-specific clinical presentation that can mimic malignancy, especially when combined with the presence of ascites. Since the surgical procedures performed for benign and malignant tumors are quite different, pre-operative differential diagnosis is key. In this case report we compare the levels of biomarkers CA 125 and HE4 in the differential diagnosis of a suspicious ovarian tumor. CASE REPORT A 75-year-old woman with a palpable mass at the left adnexa, ascites, and high levels of CA 125, underwent a subtotal abdominal hysterectomy and bilateral salpingo-oophorectomy. Histology reported benign struma ovarii. CONCLUSIONS Even though transvaginal ultrasound and CA 125 levels suggested malignancy, HE4 measurements correctly diagnosed benignity.

Validation of a second-generation multivariate index assay for malignancy risk of adnexal masses

BACKGROUND

Women with adnexal mass suspected of ovarian malignancy are likely to benefit from consultation with a gynecologic oncologist, but imaging and biomarker tools to ensure this referral show low sensitivity and may miss cancer at critical stages.

OBJECTIVE

The multivariate index assay (MIA) was designed to improve the detection of ovarian cancer among women undergoing surgery for a pelvic mass. To improve the prediction of benign masses, we undertook the redesign and validation of a second-generation MIA (MIA2G).

STUDY DESIGN

MIA2G was developed using banked serum samples from a previously published prospective, multisite registry of patients who underwent surgery to remove an adnexal mass. Clinical validity was then established using banked serum samples from the OVA500 trial, a second prospective cohort of adnexal surgery patients. Based on the final pathology results of the OVA500 trial, this intended-use population for MIA2G testing was high risk, with an observed cancer prevalence of 18.7% (92/493). Coded samples were assayed for MIA2G biomarkers by an external clinical laboratory. Then MIA2G results were calculated and submitted to a clinical statistics contract organization for decoding and comparison to MIA results for each subject. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated, among other measures, and stratified by menopausal status, stage, and histologic subtype.

RESULTS

Three MIA markers (cancer antigen 125, transferrin, and apolipoprotein A-1) and 2 new biomarkers (follicle-stimulating hormone and human epididymis protein 4) were included in MIA2G. A single cut-off separated high and low risk of malignancy regardless of patient menopausal status, eliminating potential for confusion or error. MIA2G specificity (69%, 277/401 [n/N]; 95% confidence interval [CI], 64.4-73.4%) and PPV (40%, 84/208; 95% CI, 33.9-47.2%) were significantly improved over MIA (specificity, 54%, 215/401; 95% CI, 48.7-58.4%, and PPV, 31%, 85/271; 95% CI, 26.1-37.1%, respectively) in this cohort. Sensitivity and NPV were not significantly different between the 2 tests. When combined with physician assessment, MIA2G correctly identified 75% of the malignancies missed by physician assessment alone.

CONCLUSION

MIA2G specificity and PPV were significantly improved compared with MIA, while sensitivity and NPV were unchanged. The second-generation test significantly improved the predicted efficiency of triage vs MIA without sacrificing high sensitivity and NPV, which are essential for effectiveness.

Clinical management of incidental findings on pelvic adnexal masses

Due to widespread use of pelvic and transvaginal ultrasound in routine gynecological evaluation, the incidental finding of adnexal masses has led to discussions about management in asymptomatic patients regarding the risk of ovarian cancer. Transvaginal ultrasonography remains the modality of choice in the evaluation of suspicious characteristics. The combined analysis of ultrasound morphological parameters with Doppler study, serum carcinoma antigen 125 and investigation of a symptom index may improve diagnosis. Surgical approach should be considered whenever there are suspicious images, rapid growth of cysts, changes in the appearance compared to the initial evaluation or when the patient has symptoms. Future studies on genetic and molecular mechanisms may help explain the pathophysiology of ovarian cancer, improving early diagnosis and treatment.

CEA in evaluation of adnexal mass: retrospective cohort analysis and review of the literature

BACKGROUND

The aim of this study was to estimate the diagnostic accuracy of serum carcinoembryonic antigen (CEA) levels in conjunction with Ca125 in the triage of adnexal masses.

METHODS

This retrospective cohort study was carried out in 495 patients referred to the Gynecology Department at Carmel Medical Center due to adnexal mass, between 2005 and 2012. All patients underwent surgery with histopathologically confirmed diagnosis and preoperative measurements of serum Ca125 and CEA. For each marker, sensitivity, specificity, positive predictive value, negative predictive value and risk ratio were calculated.

RESULTS

Combination of CEA with Ca125, compared with Ca125 levels alone, yielded a nonsignificant effect on sensitivity (87.4% vs. 88.9%, respectively, p = 0.64) and specificity (79.3% vs. 74.3%, p = 0.18) in differentiating malignant from benign adnexal masses. CEA levels were higher in mucinous histological types, but were not helpful in detection of borderline tumors. Significantly higher CEA (21.4 ± 53.6 vs. 3.2 ± 11.9 ng/mL, p = 0.0002) and lower Ca125 values (103.9 ± 84.9 vs. 796 ± 1,331.5 U/mL, p = 0.0338) were demonstrated in the 17 metastatic cases compared with 181 primary ovarian malignancies.

CONCLUSIONS

The combination of the tumor markers CEA and Ca125 did not contribute significantly to the detection of malignant adnexal masses compared with Ca125 alone. As our results suggest that higher CEA levels could be useful in differentiating metastatic tumors from primary ovarian malignancy and in diagnosis of mucinous histology, this issue should be investigated in large, well-designed, prospective cohort trials.

Differentiating between benign and malignant adnexal lesions with contrast-enhanced transvaginal ultrasonography

OBJECTIVE

To analyze the relationship between contrast kinetics in tumorous vessels and lesion histologic type in an attempt to differentiate between malignant and benign disease.

METHODS

In a single-center prospective study, patients who had been referred for elective surgery because of a diagnosis of unilateral and/or bilateral adnexal masses were enrolled at Dr Jan Biziel University Hospital, Bydgoszcz, Poland, between January 2012 and September 2013. Participants underwent contrast-enhanced ultrasonography examination (CEUS). Contrast kinetics were obtained and compared with the neovascularization of the tumor. Accuracy, and positive and negative predictive values were calculated.

RESULTS

Among 160 enrolled patients, 84 underwent CEUS examination and 51 lesions were studied. Baseline and maximum color Doppler intensities were significantly higher in malignant than in benign tumors (P < 0.001 for both). Similarly, the absolute and relative increases in color Doppler intensity were significantly higher in malignant tumors (P < 0.001). The estimated positive predictive value was 97.1%, the negative predictive value was 100%, and the accuracy was 100%. Peak enhanced intensity of fractional color Doppler Area and area under the time-intensity curve (S-parameter) correlated significantly with the histology of the lesion (P < 0.001). Probability curves demonstrated that higher S-parameter values were correlated with a higher risk of malignancy.

CONCLUSION

Transvaginal CEUS is a reliable and reproducible way to differentiate between benign and malignant adnexal lesions.

CA 19-9 in evaluation of adnexal mass: retrospective cohort analysis and review of the literature

OBJECTIVE

The aim of this study was to estimate the diagnostic accuracy of serum marker CA 19-9 levels in the triage of adnexal masses.

METHODS

This retrospective cohort study was carried out in patients referred to the Gynecology Department at Carmel Medical Center due to adnexal masses. All patients underwent preoperative measurements of serum CA 125 and CA 19-9 and surgery with histopathologically confirmed diagnosis.

RESULTS

Between January 2005 and December 2012, 503 patients with adnexal masses were evaluated with serum tumor markers. Combination of CA 19-9 with CA 125, compared with CA 125 levels alone, suggested a nonsignificant effect on sensitivity (86.9% vs. 88.9%, respectively, p = 0.54) or specificity (79.5% vs. 73.5%, p = 0.1) in differentiating malignant from benign adnexal masses. CA 19-9 was not helpful in detecting mucinous histological types or borderline tumors. Mean CA 19-9 levels were higher in metastatic cases compared with primary ovarian malignancy (488.7 ± 1,457 vs. 46.3 ± 149.8 U/mL, respectively, p = 0.001). In mature cystic teratomas, mean CA 19-9 levels were higher and CA 125 levels were lower than in ovarian carcinoma (p = 0.049 and p = 0.0012, respectively).

CONCLUSIONS

The combination of the tumor markers CA 19-9 and CA 125 did not contribute significantly to the detection of malignant adnexal masses compared with CA 125 alone. As our results suggest that higher CA 19-9 levels could be helpful in differentiating metastatic tumors from primary ovarian malignancy; this issue should be investigated in large well-designed prospective cohort trials.

Performance of three-dimensional power Doppler angiography as third-step assessment in differential diagnosis of adnexal masses

OBJECTIVE

To evaluate the contribution of three-dimensional (3D) power Doppler angiography (3D-PDA) to the differential diagnosis of adnexal masses.

METHODS

This was a prospective study in women diagnosed with a persistent adnexal mass and subsequently scheduled for surgery in a tertiary university hospital. All women were evaluated by transvaginal/transrectal ultrasound according to a predetermined three-step protocol, with transabdominal ultrasound being performed in some cases. First, morphological evaluation of the mass was performed using gray-scale 'pattern recognition' (first step). Lesions diagnosed as having a benign pattern were considered as being at low risk of malignancy whereas tumors with solid components, ascites and/or signs of carcinomatosis were considered as being at high risk of malignancy. In both cases no further test was performed and a decision regarding clinical management, either for follow-up or surgery, was taken. Tumors with solid components but without signs of ascites or carcinomatosis were considered as being at intermediate risk of malignancy. These lesions were assessed by two-dimensional (2D) PDA to evaluate tumor vascularity (color score) (second step). Solid tumors with a color score of 1 or 2 were considered as benign and no further test was performed, while tumors with a color score of 2, 3 or 4 within solid components or a color score of 3 or 4 in the case of a solid tumor were considered as malignant. The latter group underwent 3D-PDA assessment (third step). Vascularization index (VI) was calculated in a 1-mL sphere of the most vascularized area of the tumor. When a VI ≥ 24.015% was found, the tumor was considered as malignant. All masses were removed surgically and definitive histological diagnosis was used as the gold standard. Sensitivity and specificity for each strategy were calculated and compared. In the case of bilateral tumors, only the more suspicious one was used for analysis.

RESULTS

A total of 367 adnexal masses diagnosed in 367 women (mean age, 46.5 (range, 18-80) years) were evaluated during the study period. Of these, 86 masses were malignant and 281 were benign. The sensitivity and specificity for each assessment strategy were as follows: one-step, 97.7% and 78.6%; two-step, 94.2% and 97.9% (P < 0.001 for specificity when compared with that of one-step); three-step, 90.7% and 98.9% (not statistically significant when compared with that of two-step).

CONCLUSIONS

The addition of 2D-PDA in the differential diagnosis of an adnexal mass significantly increases specificity while sensitivity remains high; however performing subsequent 3D-PDA does not provide additional information or further improve diagnostic performance subsequent to 2D-PDA.

A case of abdominoplasty after removal of giant ovarian cyst

Summary:

When treating a giant ovarian cyst, management of inferior vena cava (IVC) syndrome, bleeding, abdominal competence, and cosmetic appearance are difficult. The details of abdominoplasty for patients with such a cyst have not been discussed. We present a patient requiring 85,000 ml of fluid evacuation before surgery.

Clinical practice guidelines and consensus statements in oncology--an assessment of their methodological quality

BACKGROUND

Consensus statements and clinical practice guidelines are widely available for enhancing the care of cancer patients. Despite subtle differences in their definition and purpose, these terms are often used interchangeably. We systematically assessed the methodological quality of consensus statements and clinical practice guidelines published in three commonly read, geographically diverse, cancer-specific journals. Methods Consensus statements and clinical practice guidelines published between January 2005 and September 2013 in Current Oncology, European Journal of Cancer and Journal of Clinical Oncology were evaluated. Each publication was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) rigour of development and editorial independence domains. For assessment of transparency of document development, 7 additional items were taken from the Institute of Medicine's standards for practice guidelines and the Journal of Clinical Oncology guidelines for authors of guidance documents.

METHODS

Consensus statements and clinical practice guidelines published between January 2005 and September 2013 in Current Oncology, European Journal of Cancer and Journal of Clinical Oncology were evaluated. Each publication was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) rigour of development and editorial independence domains. For assessment of transparency of document development, 7 additional items were taken from the Institute of Medicine's standards for practice guidelines and the Journal of Clinical Oncology guidelines for authors of guidance documents.

FINDINGS

Thirty-four consensus statements and 67 clinical practice guidelines were evaluated. The rigour of development score for consensus statements over the three journals was 32% lower than that of clinical practice guidelines. The editorial independence score was 15% lower for consensus statements than clinical practice guidelines. One journal scored consistently lower than the others over both domains. No journals adhered to all the items related to the transparency of document development. One journal's consensus statements endorsed a product made by the sponsoring pharmaceutical company in 64% of cases.

CONCLUSION

Guidance documents are an essential part of oncology care and should be subjected to a rigorous and validated development process. Consensus statements had lower methodological quality than clinical practice guidelines using AGREE II. At a minimum, journals should ensure that that all consensus statements and clinical practice guidelines adhere to AGREE II criteria. Journals should consider explicitly requiring guidelines to declare pharmaceutical company sponsorship and to identify the sponsor's product to enhance transparency.

Natural history of ovarian cancer

Ovarian cancer is a disease laden with paradigms, and it is a serious health problem. It is important to know its natural history, as it is multifactorial in origin, and also to understand its behaviour given its risk factors which can lead to death from metastasis in patients. It continues to be a challenge for oncologists. An analytical literature review was performed to update the latest concepts of its origin, evolution, risk factors, pre-clinical horizon, and its clinical manifestations; until the death of the patient.

Diffusion-weighted MR imaging for differentiating borderline from malignant epithelial tumours of the ovary: pathological correlation

OBJECTIVES

To investigate diffusion-weighted (DW) magnetic resonance (MR) imaging for differentiating borderline from malignant epithelial tumours of the ovary.

METHODS

This retrospective study included 60 borderline epithelial ovarian tumours (BEOTs) in 48 patients and 65 malignant epithelial ovarian tumours (MEOTs) in 54 patients. DW imaging as well as conventional MR imaging was performed. Signal intensity on DW imaging was assessed and apparent diffusion coefficient (ADC) value was measured. The results were correlated with histopathology and cell density.

RESULTS

The majority of MEOTs showed high signal intensity on DW imaging, whereas most BEOTs showed low or moderate signal intensity (P = 0.000). The mean ADC value of the solid components in BEOTs (1.562 ± 0.346 × 10(-3) mm(2)/s) was significantly higher than in MEOTs (0.841 ± 0.209 × 10(-3) mm(2)/s). A threshold value of 1.039 × 10(-3) mm(2)/s permitted the distinction with a sensitivity of 97.0%, a specificity of 92.2% and an accuracy of 96.4%. There was an inverse correlation between ADC value and cell density (r = -0.609; P = 0.0000) which was significantly lower in BEOTs than in MEOTs.

CONCLUSIONS

DW imaging is useful for differentiating borderline from malignant epithelial tumours of the ovary.

KEY POINTS

DW MR imaging is useful for differentiating BEOTs from MEOTs. Patients with BEOTs are treated differently from patients with MEOTs. Conservative fertility-sparing laparoscopic surgery can be performed in patients with BEOTs. BEOTs often affect young women of childbearing age.

Imaging techniques for the pre-surgical diagnosis of adnexal tumours

A correct diagnosis of any adnexal mass is essential to triage women to appropriate treatment pathways. Several imaging techniques are available that may be used to provide an assessment of a mass before treatment, such as transvaginal ultrasonography, magnetic resonance imaging, computed tomography, and positron emission tomography combined with computed tomography. In this chapter, we focus in depth on the role of transvaginal ultrasonography, as current evidence suggests it is the most appropriate initial imaging investigation to identify and characterise any mass if present in women suspected of having adnexal pathology. Subjective assessment by an experienced ultrasound examiner is the optimal approach to diagnose masses, followed by risk models and rules developed by the International Ovarian Tumor Analysis study. A group of tumours has proven difficult to classify with transvaginal ultrasound, and remain a diagnostic challenge for which accurate second-stage tests would be of value. Some studies suggest that magnetic resonance imaging (MRI), compared with other imaging modalities, may play a role in the assessment of this cohort of 'difficult to classify' adnexal masses. These studies, however, did not report quality of transvaginal ultrasonography (i.e. experience level of the examiner) and lacked uniformity in describing the criteria used to define such 'difficult' masses. On the basis of standardised terminology developed by the International Ovarian Tumor Analysis study to describe adnexal masses, as well as prediction models and rules developed in the course of the study, we propose new criteria that we can use to clearly define complex or 'difficult to classify' adnexal masses to focus the role for second-line imaging tests, such as conventional magnetic resonance imaging combined with dynamic contrast-enhanced or diffusion-weighted sequences on masses where further tests other than ultrasonography would be of value.

The special role of ultrasound for screening, staging and surveillance of malignant ovarian tumors: distinction from other methods of diagnostic imaging

Ovarian cancer is the most aggressive gynecologic malignancy, with a 5-year survival rate ranging around 40%. A crucial factor influencing the prognosis is early detection of a suspicious mass and referral to a gynecologic oncology center for further diagnosis, staging and debulking surgery. Here, we present the different imaging methods ultrasound (US), magnetic resonance imaging, computer tomography (CT) and 18F-fluoro-deoxyglucose positron emission tomography (PET)/CT that are used for the characterization, diagnosis, staging and surveillance of ovarian cancer. In this review, we focus on US and discuss in detail the advantages and the limitations, as well as the appropriate indications for each of the individual imaging techniques.

Clinical and research applications of simultaneous positron emission tomography and MRI

Evaluation of the molecular processes responsible for disease pathogenesis and progression represents the new frontier of clinical radiology. Multimodality imaging lies at the cutting edge, combining the power of MRI for tissue characterization, microstructural appraisal and functional assessment together with new positron emission tomography (PET) tracers designed to target specific metabolic processes. The recent commercial availability of an integrated clinical whole-body PET-MRI provides a hybrid platform for exploring and exploiting the synergies of multimodal imaging. First experiences on the clinical and research application of hybrid PET-MRI are emerging. This article reviews the rapidly evolving field and speculates on the potential future direction.