Preoperative Multimodal Strategies for Risk Assessment of Adnexal Masses

Abstract

Assessment of adnexal masses focuses on the accurate discrimination between benign and malignant lesions. In our tertiary referral center, we evaluated the discriminative power of expert sonography, serum CA-125 measurement, risk malignancy index (RMI) by Jacobs, and 2 preoperative triage strategies (combination of CA-125 measurement and RMI assessment with expert sonography). From 2002 to 2008, a total of 1362 surgical explorations with indication of an adnexal mass from our department were included in this study. Preoperative workup in all patients comprised a gynecologic examination, expert sonography, and serum CA-125 measurement. We calculated sensitivity, specificity, positive and negative predictive value (PPV and NPV), and Cohen κ (prevalence-adjusted measurement) to evaluate the discriminative power of each diagnostic test. Discriminative power of the evaluated tests differed depending on patients' menopausal state. In the premenopause, expert sonography reached the highest discriminative power with a κ value of 0.53, a PPV of 0.45, and an NPV of 0.99. In the postmemopause, the combinations of expert sonography with CA-125 serum measurement or RMI assessment achieved the highest discriminative power: The combination of CA-125 and expert sonography reached a PPV of 0.89 and an NPV of 0.97; κ yielded 0.84. The RMI combined with expert sonography as a triage strategy showed comparable results with a PPV of 0.89, an NPV of 0.96, and a κ value of 0.82. Preoperative assessment of an adnexal mass may be guided by the patient's menopausal state. In premenopausal patients, expert sonography is helpful for preoperative differentiation between benign and malignant lesions; in postmenopausal patients, the use of triage strategies of either CA-125 serum measurement or RMI combined with expert sonography can be recommended.