Risk scoring for adnexal masses and endoscopic management

Abstract

Endoscopic surgery is the treatment of choice for adnexal masses in premenopausal women. A prospective observational study was conducted with 100 consecutive premenopausal women with adnexal masses who had been referred for endoscopic management to the University Hospital of Larissa, Larissa, Greece. The aim of the study was to compare the ability of the risk malignancy index (RMI) [1,2] and the Ferrazzi score [3] (Table 1) to discriminate preoperatively between benign and malignant masses. Histopathologic diagnosis was regarded as the final arbiter. Patients with a RMI of 150 or greater or a Ferrazzi score of 8 or greater were referred to the oncology team and explorative laparotomy was performed. All other patients were treated endoscopically and a frozen-section biopsy was performed. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the Ferrazzi score and RMI were calculated at various cut-off points, separately or in combination, for different age groups. Of the 89 patients who had benign disease, 76 were treated endoscopically. The 10 patients found to have malignant disease underwent explorative laparotomy. The remaining patient (who also had ovarian torsion) underwent staging laparotomy after the results of her frozen-section biopsy indicated that she had a borderline tumor. Her serum concentration of cancer antigen (CA)-125 was 192 U/ mL, but the value had not been available preoperatively. Mean age was significantly higher for cancer patients (45.4 years) than for patients with benign disease (30.8 years) (P<0.001). Ferrazzi score, RMI, and CA-125 levels were significantly associated with cancer diagnosis, but the Ferrazzi score proved the more accurate predictor of malignancy (Fig. 1). Specificity was 86.5% and NPV was 93.9 for a RMI of 150 or greater whereas specificity was 100% and NPV was 92.7 for a Ferrazzi score of 8 or greater. These results suggest that the Ferrazzi score can be strongly recommended. Moreover, specificity was 100% and NPV was 98 among patients aged 40 years or older who had both a RMI of 150 or greater and a Ferrazzi score of 8 or greater. A possible explanation is that the primary purpose of introducing RMI was to improve the referral of older patients with advanced ovarian cancer to oncology centers [1,2,4]. In this study 36% of the patients younger than 40 years had endometriosis, a disease associated with higher CA-125 values, and this high proportion decreased the predictive performance of the RMI. The Ferrazzi score is a detailed morphometric ultrasonographic score that excludes dermoid cysts, which may explain its superior performance [3] (Table 1). Preoperative risk scoring for adnexal masses with both Ferrazzi score and RMI can be reliably performed by a generalist gynecologist and would allow for a more effective referral to experienced subspecialists.