International Ovarian Tumor Analysis Research Articles

Performance of the IOTA ADNEX model combined with HE4 for identifying early-stage ovarian cancer

ObjectiveThis work was designed to investigate the performance of the International Ovarian Tumor Analysis (IOTA) ADNEX (Assessment of Different NEoplasias in the adneXa) model combined with human epithelial protein 4 (HE4) for early ovarian cancer (OC) detection.MethodsA total of 376 women who were hospitalized and operated on in Women and Children’s Hospital of Chongqing Medical University were selected. Ultrasonographic images, cancer antigen-125 (CA 125) levels, and HE4 levels were obtained. All cases were analyzed and the histopathological diagnosis serves as the reference standard. Based on the IOTA ADNEX model post-processing software, the risk prediction value was calculated. We analyzed receiver operating characteristic curves to determine whether the IOTA ADNEX model alone or combined with HE4 provided better diagnostic accuracy.ResultsThe area under the curve (AUC) of the ADNEX model alone or combined with HE4 in predicting benign and malignant ovarian tumors was 0.914 (95% CI, 0.881–0.941) and 0.916 (95% CI, 0.883–0.942), respectively. With the cutoff risk of 10%, the ADNEX model had a sensitivity of 0.93 (95% CI, 0.87–0.97) and a specificity of 0.73 (95% CI, 0.67–0.78), while combined with HE4, it had a sensitivity of 0.90 (95% CI, 0.84–0.95) and a specificity of 0.81 (95% CI, 0.76–0.86). The IOTA ADNEX model combined with HE4 was better at improving the accuracy of the differential diagnosis between different OCs than the IOTA ADNEX model alone. A significant difference was found in separating borderline masses from Stage II–IV OC (p = 0.0257).ConclusionsA combination of the IOTA ADNEX model and HE4 can improve the specificity of diagnosis of ovarian benign and malignant tumors and increase the sensitivity and effectiveness of the differential diagnosis of Stage II–IV OC and borderline tumors.

Imaging in gynecological disease (24): clinical and ultrasound characteristics of ovarian mature cystic teratomas.

To describe the clinical and ultrasound features of ovarian mature cystic teratomas (MCTs). This was a retrospective study. From the International Ovarian Tumor Analysis (IOTA) database, we identified patients with a histologically confirmed diagnosis of MCT who had undergone transvaginal ultrasound examination between 1999 and 2016 (IOTA phases 1, 2, 3 and 5) in one of five centers. Ultrasound was performed by an experienced examiner who used the standardized IOTA examination technique and terminology. In addition to extracting data from the IOTA database, available two-dimensional grayscale and color or power Doppler images were reviewed retrospectively to identify typical ultrasound features of MCT described previously and detect possible new features using pattern recognition. All images were reviewed by two independent examiners and further discussed with two ultrasound experts to reach consensus. Included in the study were 454 patients with histologically confirmed MCT. Median age was 33 (range, 8-90) years and 66 (14.5%) patients were postmenopausal. Most MCTs were described by the original ultrasound examiner as unilocular (262/454 (57.7%)) or multilocular (70/454 (15.4%)) cysts with mixed echogenicity of cystic fluid (368/454 (81.1%)), acoustic shadowing (328/454 (72.2%)) and no or little vascularization on color Doppler (color score 1, 240/454 (52.9%); color score 2, 123/454 (27.1%)). The median largest lesion diameter was 66 (range, 15-310) mm. A correct preoperative diagnosis of MCT was suggested by the original ultrasound examiner in 372/454 (81.9%) cases. On retrospective review of ultrasound images of 334 MCTs that had quality sufficient for assessment, 'dots and/or lines' and/or 'echogenic white ball' (typical features according to the literature) were present in 271/334 (81.1%) masses. We identified four new ultrasound features characteristic of MCT: 'cotton wool tufts', 'mushroom cap sign', 'completely hyperechogenic lesion' and 'starry sky sign'. At least one classical or novel ultrasound feature was present in 315/334 (94.3%) MCTs. Twenty-nine (8.7%) MCTs manifested vascularized solid tissue, of which seven exhibited no typical features. We provide a comprehensive overview of conventional and newly described ultrasound features of MCTs. Only a small proportion of MCTs did not manifest any of the typical features. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Comparison of diagnostic efficiency between IOTA LR2 model and doctors' experiences.

International Ovarian Tumor Analysis (IOTA) working group proposed a logistic regression (IOTA LR2) model. It is served as a risk prediction model for benign and malignant adnexal tumors. This study aims to compare the diagnostic efficiency between the IOTA LR2 model and doctors' subjective assessment on diagnosing benign and malignant adnexal mass. The ultrasonographic images of 616 adnexal masses were retrospectively analyzed by the senior doctors' group and the junior doctors' group using the IOTA LR2 model and subjective assessment. The postoperative pathological diagnosis was used as the gold standard to compare the diagnostic efficiency of the 2 methods. The area under the curves of subjective assessment and IOTA LR2 model for diagnosing malignant adnexal masses were 0.86 and 0.90 for the senior doctors' group and 0.79 and 0.88 for the junior doctors' group, respectively. The sensitivity and specificity of subjective assessment for diagnosing the malignant adnexal masses were 81.0% and 91.3% for the senior doctors' group and 70.1% and 88.7% for the junior doctors' group, respectively. The sensitivity and specificity of the IOTA LR2 model for diagnosing the malignant adnexal masses were 79.6% and 88.1% for the senior doctors' group, and 79.6% and 81.7% for the junior doctors' group, respectively.There were no significant difference in the sensitivities between the senior doctors' group and junior doctors' group using the IOTA LR2 model and the senior doctors' group using subjective assessment (both P>0.05). The diagnostic efficiency of the IOTA LR2 model is equal to the senior doctors' experiences. This model can help junior doctors to reduce the missed diagnosis of malignant adnexal masses.

Predictive features of borderline ovarian tumor recurrence in patients with childbearing potential undergoing conservative treatment.

Borderline ovarian tumors (BOT) represent 10-12% of ovarian cancer cases with a higher prevalence in young patients. Although reproductive outcomes are satisfactory after conservative treatment, several authors reported a higher relapse rate in patients undergoing fertility-sparing surgery compared with radical treatment. The aim of the present study was to identify predictive factors of BOT recurrence in patients with childbearing potential undergoing conservative treatment with unilateral salpingo-oophorectomy. From January 2010 to December 2020 all patients with childbearing potential undergoing conservative treatment for early-stage BOT were included in the analysis. Expert sonographers performed the ultrasounds and classified the ovarian lesion according to International Ovarian Tumor Analysis criteria. A total of 230 patients with BOT that underwent surgical treatment during the study period were analyzed. Of these, 82 patients met the inclusion criteria. Relapse was experienced in 11 cases (13.4%), one (1.2%) peritoneal surface and 10 (12.2%) recurrences on the contralateral ovary. Ovarian tumor size >50 mm (P=0.032; OR 7.317; 95% CI 0.89-60.29), multilocular cysts >10 loculi (P=0.016; OR 7.543; 95% CI 1.64-34.78), cysts with >4 papillae (P=0.025; OR 6.190; 95% CI 1.40-27.36) were statistically correlated with recurrent BOT. Overall, the present study showed that lesions with maximum diameter >50 mm (P=0.014), multilocular cysts >10 loculi (P=0.012) and cysts with >4 papillae (P=0.003) were independent predictive factors of BOT recurrence (P<0.001; correlation coefficient R=0.481) in patients with the potential to bear children undergoing conservative treatment.

A machine learning approach applied to gynecological ultrasound to predict progression-free survival in ovarian cancer patients

In a growing number of social and clinical scenarios, machine learning (ML) is emerging as a promising tool for implementing complex multi-parametric decision-making algorithms. Regarding ovarian cancer (OC), despite the standardization of features that can support the discrimination of ovarian masses into benign and malignant, there is a lack of accurate predictive modeling based on ultrasound (US) examination for progression-free survival (PFS). This retrospective observational study analyzed patients with epithelial ovarian cancer (EOC) who were followed in a tertiary center from 2018 to 2019. Demographic features, clinical characteristics, information about the surgery and post-surgery histopathology were collected. Additionally, we recorded data about US examinations according to the International Ovarian Tumor Analysis (IOTA) classification. Our study aimed to realize a tool to predict 12 month PFS in patients with OC based on a ML algorithm applied to gynecological ultrasound assessment. Proper feature selection was used to determine an attribute core set. Three different machine learning algorithms, namely Logistic Regression (LR), Random Forest (RFF), and K-nearest neighbors (KNN), were then trained and validated with five-fold cross-validation to predict 12 month PFS. Our analysis included n. 64 patients and 12 month PFS was achieved by 46/64 patients (71.9%). The attribute core set used to train machine learning algorithms included age, menopause, CA-125 value, histotype, FIGO stage and US characteristics, such as major lesion diameter, side, echogenicity, color score, major solid component diameter, presence of carcinosis. RFF showed the best performance (accuracy 93.7%, precision 90%, recall 90%, area under receiver operating characteristic curve (AUROC) 0.92). We developed an accurate ML model to predict 12 month PFS.

The Value of IOTA Simple Rules Combined With CEUS Scoring System in the Diagnosis of Benign and Malignant Ovarian Masses and Its Correlation With MVD and VEGF: A Preliminary Study.

To investigate the diagnostic value of International Ovarian Tumor Analysis (IOTA) simple rules combined with contrast-enhanced ultrasound (CEUS) scoring system in the differential diagnosis of ovarian tumors, and the correlations of the scoring system with microvessel density (MVD) and vascular endothelial growth factor (VEGF). One hundred eighty-nine patients with ovarian tumors were examined by routine ultrasound and CEUS. The enhanced characteristics of CEUS were observed, and the masses were classified by IOTA simple rules. To compare the diagnostic value of IOTA simple rules combined with CEUS scoring system and IOTA simple rules in the diagnosis of ovarian tumors. Immunohistochemistry was used to detect the expression of MVD and VEGF in postoperative tissue samples. The correlations between the new scoring system with MVD and VEGF were analyzed. The sensitivity (93.98%), specificity (94.34%), positive predictive value (92.86%), negative predictive value (95.24%), and accuracy (94.18%) of IOTA simple rules combined with CEUS scoring system in the diagnosis of ovarian tumors were higher than those of IOTA simple rules alone (all P < .05). The score system was significantly positively correlated with MVD and VEGF, and the r values were 0.77 and 0.63, respectively (P < .001). IOTA simple rules combined with CEUS scoring system was helpful to improve the accuracy of ultrasound diagnosis of ovarian tumors, which was significantly correlated with MVD and VEGF. It could provide important reference information for treatment scheme formulation and prognosis evaluation.

Evaluation of Women's Age and Ultrasonographic Features to Choose Surgical Treatment for Endometriosis Associated with Ovarian Cancer.

Adequate surgical management of malignant endometriosis remains a clinical challenge in gynecology. Age, sonography variables, and tumor biomarkers have been reported as candidates in the clinical decision. This study aims were to analyze the factors of women’s age, body mass index, ultrasound features, and tumor biomarkers to predict endometriosis-associated ovarian cancer in a large series of endometriomas and to study the surgical treatment performed in this cohort. In this retrospective study, we reviewed the medical records of patients with ultrasound diagnosis of ovarian cyst classified as endometrioma (benign as well as with risk of malignancy), surgically treated in the endometriosis unit of Hospital Universitario La Paz (Madrid, Spain) between January 2019 and July 2021. According to the final histology examination, the women were clustered as non-endometriosis-associated ovarian cancer (OE, benign endometriomas, n = 59) and endometriosis-associated ovarian cancer (EAOC) (n = 17). Demographic, clinical, and surgical data were collected from these women. International Ovarian Tumor Analysis (IOTA) criteria were assessed for the ultrasound examination. The age of the women in the EAOC group was 50.0 [43.0; 63.0] years, which was significantly higher than OE (39.0 [34.0; 46.0] years; p-value < 0.001). In addition, the body mass index for the OE group (24.9 ± 5.3 kg/m2) was significantly higher than for the EAOC group (23.3 ± 4.6 kg/m2; p-value < 0.001). However, the tumor biomarker levels (CA 125, CA 19.9 and He4) were not significantly different among the groups. We performed 51.4% cystectomies and 48.6% adnexectomies, with an association between the adnexectomy and EAOC group (p-value < 0.001). In addition, a significant association was found between ultrasound features suspicious for malignancy and the EAOC group. Conclusively, women’s age and ultrasound features, such as papillary projections, septa, and positive echo-Doppler, were the main factors to consider when evaluating the malignancy risk associated with endometriosis.

External Validation of O-RADS US Risk Stratification and Management System

Background The Ovarian-Adnexal Reporting and Data System (O-RADS) US risk stratification and management system (O-RADS US) was designed to improve risk assessment and management of ovarian and adnexal lesions. Validation studies including both surgical and nonsurgical treatment as the reference standard remain lacking. Purpose To externally validate O-RADS US in women who underwent either surgical or nonsurgical treatment and to determine if incorporating acoustic shadowing as a benign finding improves diagnostic performance. Materials and Methods This retrospective study included consecutive women who underwent pelvic US between August 2015 and April 2017 at a tertiary referral oncology center. Two independent readers blinded to clinical and histologic outcome assigned an O-RADS risk category and an International Ovarian Tumor Analysis (IOTA) Assessment of Different NEoplasias in the adneXa (ADNEX) model risk of malignancy score to assessable lesions. Reference standards were surgical histopathology or 2-year imaging follow-up. Receiver operating characteristic (ROC) curve analysis was used to evaluate performance of the O-RADS US, ADNEX, and modified O-RADS models incorporating acoustic shadowing. Results In total, 227 women (mean age, 52 years ± 16 [SD]) with 262 ovarian or adnexal lesions were evaluated. Of these lesions, 187 (71%) were benign and 75 (29%) were malignant. The proportion of malignancy was 0% (0 of 100) for O-RADS 2, 3% (one of 32) for O-RADS 3, 35% (22 of 63) for O-RADS 4, and 78% (52 of 67) for O-RADS 5. The area under the ROC curve (AUC) for O-RADS and ADNEX was 0.91 (95% CI: 0.88, 0.94) and 0.95 (95% CI: 0.92, 0.97; P = .01), respectively. The addition of acoustic shadowing as a benign finding improved O-RADS AUC to 0.94 (95% CI: 0.91, 0.96; P = .01). Use of O-RADS 4 as a threshold yielded a sensitivity of 99% (74 of 75; 95% CI: 96, 100) and a specificity of 70% (131 of 187; 95% CI: 64, 77). Conclusion In a tertiary referral oncology center, the Ovarian-Adnexal Reporting and Data System US risk stratification and management system enabled accurate distinction of benign from malignant ovarian and adnexal lesions. Adding acoustic shadowing as a benign finding improved its diagnostic performance. © RSNA, 2022 See also the editorial by Levine in this issue.

Performance of IOTA Simple Rules, Simple Rules risk assessment, ADNEX model and O-RADS in differentiating between benign and malignant adnexal lesions in North American women.

To apply the International Ovarian Tumor Analysis (IOTA) Simple Rules (SR), the IOTA Simple Rules risk assessment (SRR), the IOTA Assessment of Different NEoplasias in the adneXa (ADNEX) model and the Ovarian-Adnexal Reporting and Data System (O-RADS) in the same cohort of North American patients and to compare their performance in preoperative discrimination between benign and malignant adnexal lesions. This was a single-center diagnostic accuracy study, performed between March 2018 and February 2021, which included 150 women with an adnexal lesion. Using the ADNEX model, lesions were classified prospectively, whereas the SR, SRR assessment and O-RADS were applied retrospectively. Surgery with histological analysis was performed within 6 months of the ultrasound exam. Sensitivity and specificity were determined for each testing modality and the performance of the different modalities was compared. Of the 150 women, 110 (73.3%) had a benign ovarian tumor and 40 (26.7%) had a malignant tumor. The mean risk of malignancy generated by the ADNEX model without CA 125 was significantly higher in malignant vs benign lesions (63.3% vs 11.8%) and the area under the receiver-operating-characteristics curve (AUC) of the ADNEX model for differentiating between benign and malignant adnexal masses at the time of ultrasound examination was 0.937. The mean risk of malignancy generated by SRR assessment was also significantly higher in malignant vs benign lesions (74.1% vs 15.9%) and the AUC was 0.941. To compare the ADNEX model, SRR assessment and O-RADS, the malignancy risk threshold was set at ≥ 10%. This cut-off differentiates O-RADS low-risk categories (Category ≤ 3) from intermediate-to-high-risk categories (Categories 4 and 5). At this cut-off, the sensitivity of the ADNEX model was 97.5% (95% CI, 85.3%-99.9%) and the specificity was 63.6% (95% CI, 53.9%-72.4%), and, for the SRR model, the sensitivity was 100% (95% CI, 89.1%-100%) and the specificity was 51.8% (95% CI, 42.1%-61.4%). In the 113 cases to which the SR could be applied, the sensitivity was 100% (95% CI, 81.5%-100%) andthe specificity was 95.6% (95% CI, 88.5%-98.6%). If the remaining 37 cases, which were inconclusive under SR, were designated 'malignant', the sensitivity remained at 100% but the specificity was reduced to 79.1% (95% CI, 70.1%-86.0%). The 150 cases fell into the following O-RADS categories: 17 (11.3%) lesions in Category 2, 34 (22.7%) in Category 3, 66 (44.0%) in Category 4 and 33 (22.0%) in Category 5. There were no histologically proven malignant lesions in Category 2 or 3. There were 14 malignant lesions in Category 4 and 26 in Category 5. The sensitivity of O-RADS using a malignancy risk threshold of ≥ 10% was 100% (95% CI, 89.1%-100.0%) and the specificity was 46.4% (95% CI, 36.9%-56.1%). When IOTA terms and techniques are used, the performance of IOTA models in a North American patient population is in line with published IOTA results in other populations. The IOTA SR, SRR assessment and ADNEX model and O-RADS have similar sensitivity in the preoperative discrimination of malignant from benign pelvic tumors; however, the IOTA models have higher specificity and the algorithm does not require the use of magnetic resonance imaging. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Diagnostic Performance of Risk of Malignancy Algorithm (ROMA), Risk of Malignancy Index (RMI) and Expert Ultrasound Assessment in a Pelvic Mass Classified as Inconclusive by International Ovarian Tumour Analysis (IOTA) Simple Rules.

Simple SummaryThe accurate prediction of malignancy for a pelvic mass detected on ultrasound allows for appropriate referral to specialised care. IOTA simple rules are one of the best methods but are inconclusive in 25% of cases, where subjective assessment by an expert sonographer is recommended but may not always be available. In the present paper, we evaluate the methods for assessing the nature of a pelvic mass, including IOTA with subjective assessment by expert ultrasound, RMI and ROMA. In particular, we investigate whether ROMA can replace expert ultrasound when IOTA is inconclusive. When IOTA was inconclusive, we found that expert ultrasound was more sensitive in diagnosing a malignant mass than ROMA, with no significant difference in the specificity or accuracy. All the assessment methods involving IOTA had similar accuracies, and they were more accurate than RMI or ROMA alone. Thus, IOTA should be the first step for assessing a pelvic mass. If inconclusive, an assessment by expert ultrasound is preferrable.The accurate prediction of malignancy for a pelvic mass detected on ultrasound allows for appropriate referral to specialised care. IOTA simple rules are one of the best methods but are inconclusive in 25% of cases, where subjective assessment by an expert sonographer is recommended but may not always be available. In the present paper, we evaluate the methods for assessing the nature of a pelvic mass, including IOTA with subjective assessment by expert ultrasound, RMI and ROMA. In particular, we investigate whether ROMA can replace expert ultrasound when IOTA is inconclusive. This prospective study involves one cancer centre and three general units. Women scheduled for an operation for a pelvic mass underwent a pelvic ultrasound pre-operatively. The final histology was obtained from the operative sample. The sensitivity, specificity and accuracy for each method were compared with the McNemar test. Of the 690 women included in the study, 171 (25%) had an inconclusive IOTA. In this group, expert ultrasound was more sensitive in diagnosing a malignant mass compared to ROMA (81% vs. 63%, p = 0.009) with no significant difference in the specificity or accuracy. All assessment methods involving IOTA had similar accuracies and were more accurate than RMI or ROMA alone. In conclusion, when IOTA was inconclusive, assessment by expert ultrasound was more sensitive than ROMA, with similar specificity.

Imaging in gynecological disease (23): clinical and ultrasound characteristics of ovarian carcinosarcoma.

To describe the clinical and ultrasound characteristics of ovarian carcinosarcoma. This was a retrospective multicenter study. Patients with a histological diagnosis of ovarian carcinosarcoma, who had undergone preoperative ultrasound examination between 2010 and 2019, were identified from the International Ovarian Tumor Analysis (IOTA) database. Additional patients who were examined outside of the IOTA study were identified from the databases of the participating centers. The masses were described using the terms and definitions of the IOTA group. Additionally, two experienced ultrasound examiners reviewed all available images to identify typical ultrasound features using pattern recognition. Ninety-one patients with ovarian carcinosarcoma who had undergone ultrasound examination were identified, of whom 24 were examined within the IOTA studies and 67 were examined outside of the IOTA studies. Median age at diagnosis was 66 (range, 33-91) years and 84/91 (92.3%) patients were postmenopausal. Most patients (67/91, 73.6%) were symptomatic, with the most common complaint being pain (51/91, 56.0%). Most tumors (67/91, 73.6%) were International Federation of Gynecology and Obstetrics (FIGO) Stage III or IV. Bilateral lesions were observed on ultrasound in 46/91 (50.5%) patients. Ascites was present in 38/91 (41.8%) patients. The median largest tumor diameter was 100 (range, 18-260) mm. All ovarian carcinosarcomas contained solid components, and most were described as solid (66/91, 72.5%) or multilocular-solid (22/91, 24.2%). The median diameter of the largest solid component was 77.5 (range, 11-238) mm. Moderate or rich vascularization was found in 78/91 (85.7%) cases. Retrospective analysis of ultrasound images and videoclips using pattern recognition in 73 cases revealed that all tumors had irregular margins and inhomogeneous echogenicity of the solid components. Forty-seven of 73 (64.4%) masses appeared as a solid tumor with cystic areas. Cooked appearance of the solid tissue was identified in 28/73 (38.4%) tumors. No pathognomonic ultrasound sign of ovarian carcinosarcoma was found. Ovarian carcinosarcomas are usually diagnosed in postmenopausal women and at an advanced stage. The most common ultrasound appearance is a large solid tumor with irregular margins, inhomogeneous echogenicity of the solid tissue and cystic areas. The second most common pattern is a large multilocular-solid mass with inhomogeneous echogenicity of the solid tissue. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Efficacy of IOTA simple rules, O-RADS, and CA125 to distinguish benign and malignant adnexal masses

ObjectiveOvarian cancer is the most deadly deadliest gynecological tumor in the female reproductive system. Therefore, the present study sought to determine the diagnostic performance of International Ovarian Tumor Analysis Simple Rules (IOTA SR), the Ovarian-Adnexal Reporting and Data System (O-RADS), and Cancer Antigen 125 (CA125) in discriminating benign and malignant ovarian tumors. The study also assessed whether a combination of the two ultrasound categories systems and CA125 can improve the diagnostic performance.MethodsA total of 453 patients diagnosed with ovarian tumors were retrospectively enrolled from Fujian Cancer Hospital between January 2017 and September 2020. The data collected from patients included age, maximum lesion diameter, location, histopathology, levels of CA125, and detailed ultrasound reports. Additionally, all ultrasound images were independently assessed by two ultrasound physicians with more than 5 years of experience in the field, according to the IOTA simple rules and O-RADS guidelines. Furthermore, the area under the curve (AUC), sensitivity, and specificity of the above mentioned predictors were calculated using the receiver operating characteristic curve.ResultsOut of the 453 patients, 184 had benign lesions, while 269 had malignant ovarian tumors. In addition, the AUCs of IOTA SR, O-RADS, and CA125 in the overall population were 0.831, 0.804, and 0.812, respectively, and the sensitivities of IOTA SR, O-RADS, and CA125 were 94.42, 94.42, and 80.30%, respectively. On the other hand, the AUCs of IOTA SR combined with CA125, O-RADS combined with CA125, and IOTA SR plus O-RADS combined with CA125 were 0.900, 0.891, and 0.909, respectively. The findings also showed that the AUCs of a combination of the three approaches were significantly higher than those of individual strategies (p<0.05) but not significantly higher than the AUC of a combination of two methods (p>0.05).ConclusionThe findings showed that a combination of IOTA SR or O-RADS in combination with CA125 may improve the ability to distinguish benign from malignant ovarian tumors.

Identification of Effective Model for Prediction of Ovarian Malignancy Risk using Models like Risk of Malignancy Index, Logistic Regression, International Ovarian Tumour Analysis- Simple Rules

Introduction: Ovarian tumour is not a single entity it is a spectrum of neoplasm involving variety of histological tissues. Use of mathematical formula as malignancy index which is based on logistic model, menopausal status, serum levels of Cancer Antigen 125 (CA-125) and ultrasound findings in a score system is not so popular which can be a useful predictor for diagnosing and monitoring the progression of ovarian malignancy. Aim: To determine the effectiveness of the three models i.e., Risk of Malignancy Index (RMI-1,2,3 and 4), Logistic Regression 2 (LR-2), International Ovarian Tumour Analysis (IOTA) - simple rules in predicting ovarian malignancy. Materials and Methods: This prospective cohort observational study was conducted in Department of Obstetrics and Gynaecology at Saveetha Medical College and Hospital, Tamil Nadu, India, from June 2017 to July 2018. The study included a total of 70 female subjects with ovarian mass. Information obtained by investigations, ultrasound was used to predict the risk of malignancy by using the three models {Risk of Malignancy Index (RMI-1,2,3 and 4), Logistic Regression 2 (LR-2), International Ovarian Tumour Analysis (IOTA)- simple rules}. CA-125 level was considered as primary outcome variable. Study group histopathology impression (malignant Vs benign) was considered as primary explanatory variable. The result from the above models was compared with the postoperative histopathological report. The sensitivity and specificity of each model was also identified. Results: Majority of the study participants 49 (70%) were in premenopausal status and only 21 (30%) were in menopausal status. The mean CA-125 level was 108.82±233.13 in the study population (95% CI: 53.23-164.41). Among the 70 study subjects, 53 (75.70%) patients were RMI-1 benign and only 17 (24.30%) were RMI-1 malignant. Majority of the study participants 42 (60%) were IOTA impression benign and only 28 (40%) were IOTA malignant. The difference in the proportion of IOTA-simple rules between histopathology impression was statistically significant (p-value &lt;0.001). The sensitivity of IOTA-simple rules in predicting malignant histopathology was 92%, Specificity was 90.48%, diagnostic accuracy was 91.04%. Conclusion: For early risk stratification of adnexal masses, IOTAsimple rules can be used as a screening tool due to its high sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy.

World Federation for Ultrasound in Medicine Review Paper: Incidental Findings during Obstetrical Ultrasound.

Although the prevalence of incidental findings revealed during an obstetric ultrasound examination is low, the findings may include adnexal and cervical masses, uterine or urinary congenital malformations, free fluid in the pouch of Douglas or tortuous vessels (varices). Adnexal masses are the most common finding and vary in imaging characteristics. They are mainly unilateral, cystic masses with a low risk of malignancy that are treated conservatively. The International Ovarian Tumor Analysis scoring models may be helpful in differentiating benign from malignant masses. For those masses >5 cm, follow-up is recommended, and resection could be considered to avoid risk of torsion, rupture and hemorrhage, which may compromise pregnancy outcome. Uterine masses such as fibroids are commonly diagnosed early in the first trimester and should be followed up during pregnancy to evaluate any changes. Transabdominal and transvaginal ultrasound is the first-line test for the diagnosis of such incidentalomas; however, magnetic resonance ultrasound may have a useful role in excluding malignancy potential. As a result of their low frequency and the lack of good evidence, there are no specific guidelines on the management of incidentalomas detected at obstetric scans. Their management should follow the related general guidelines for ovarian, cervical and uterine masses, with individualized management depending on the pregnancy status.

Application of the new classification criteria in ovarian pathology (IOTA – O-RADS)

The Ovarian-Adnexal Reporting and Data System (O-RADS) risk stratification and management system is designed to provide consistent interpretations, to decrease or eliminate ambiguity in ultrasound (US) reports, resulting in a higher accuracy in assigning the risk of malignancy for ovarian and other adnexal masses, and to provide accurate management recommendations for each risk category. It was developed by experts in radiology, gynecology, pathology and gynecologic oncology from the United States, Canada and Europe, under the supervision of the ACR (American College of Radiology). This unique system represents a collaboration between the pattern-based approach, commonly used in North America, and the widely used, European-based, algorithmic-style of the 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 Ovarian-Adnexal Reporting and Data System US risk stratification and management system for evaluation of ovarian and other adnexal masses is based on a standardized lexicon, incorporates all classes of risk, and offers an associated management strategy for each risk category. US is widely considered the primary imaging modality in the evaluation of women with suspected adnexal pathology. Standardized terms and definitions to describe the sonographic features of adnexal lesions have been proposed, and several US reporting models can aid in differentiating benign from malignant adnexal masses. However, approximately 20% to 25% of adnexal masses remain indeterminate after the initial sonographic evaluation. Furthermore, studies have demonstrated variable positive predictive values for the detection of ovarian cancer using US, with certain studies showing low positive predictive values in the general population in which the incidence of ovarian cancer is low. Secondary tests such as MRI could help decrease the number of false-positive lesions when using US in certain settings and avoid unnecessary surgery in benign lesions. The ACR Ovarian-Adnexal Reporting and Data Systems (O-RADS) MRI Committee has developed an evidence-based lexicon and risk stratification system for MRI evaluation of adnexal lesions.

External Validation of the Assessment of Different NEoplasias in the adneXa Model Performance in Evaluating the Risk of Ovarian Carcinoma Before Surgery in China: A Tertiary Center Study.

The Assessment of Different NEoplasias in the adneXa (ADNEX) model was developed by the International Ovarian Tumor Analysis group to assess the risk of an ovarian mass being malignant. This study aimed to externally validate the ADNEX model performance in a tertiary center in China. This retrospective, single-center university hospital study assessed the model diagnostic accuracy. All patients were examined by transvaginal ultrasonography, and serum CA125 levels were measured. Moreover, clinicopathological information was collected. The diagnostic performance of the ADNEX model was calculated with and without CA125 as a predictor. We retrieved data of 335 patients, of which 53 were excluded based on the exclusion criteria. Of the included 282 patients, 178 (63.1%) had benign tumors, and 104 (36.9%) had malignant tumors. When CA125 was factored in, the area under the receiver operating characteristic curve (AUC) for the distinction between benign and malignant tumors was 0.93 (95% confidence interval [CI], 0.90-0.96), whereas it was 0.91 (95% CI, 0.88-0.95) without CA125. The concordance between the predicted risk of malignancy and the proportion of observed malignancies was well demonstrated by the calibration plots. The proper performance of the ADNEX model was verified externally in a tertiary center in China, showing a good distinction between tumour subtypes. Our findings suggest the ADNEX model is a valuable tool in clinical practice and may help in managing patients with adnexal masses.

A Comparative Study of International Ovarian Tumor Analysis Simple Ultrasound Rules and Risk of Malignancy Index in Differentiating benign from Malignant Ovarian Masses Coming to Tertiary Care Hospital

Aims and Objectives: The main objective of our study was to determine the sensitivity and specificity of International Ovarian Tumor Analysis (IOTA) Simple Ultrasound Rules and Risk of Malignancy Index (RMI) in differentiating benign from malignant ovarian masses and to compare the results generated with histological diagnosis. Materials and Methods: A total of 50 consenting patients with ovarian mass coming to the Department of Obstetrics and Gynecology of our college in reproductive and menopausal age group were enrolled over a period of nine months. Data was collected using a standardized pretested proforma. Detailed examination of the subjects was done following which ultrasonographic assessment was done by gynecologists. In the subsequent visit or post admission blood investigations including CA-125 was done. Patient management as per departmental protocol was continued. Results: The sensitivity, specificity, Positive Predictive value and Negative Predictive Value of RMI 2 in our study was 75.75%, 64.7%, 80.6% and 57.8% respectively. The sensitivity, specificity, Positive Predictive value and Negative Predictive Value of IOTA Simple Ultrasound rules in our study was 96.96%, 71.4%, 88.8% and 90.9% respectively. Conclusion: In the present study we have seen that IOTA Simple USG Rules had better Sensitivity, Specificity, Positive Predictive Value and Negative Predictive Value than Risk of Malignancy Index (RMI 2). Though both the scoring systems have their own set of limitations IOTA Simple USG rules in our study seems to be a better scoring system; still we need to have a larger sample size, more Indian populationbased studies to extrapolate the same results to Indian populations.

Ultrasonographic ovarian mass scoring system for predicting malignancy in pregnant women with ovarian mass.

During routine antenatal ultrasound examinations, an ovarian mass can be found incidentally. In clinical practice, the differential diagnosis between benign and malignant ovarian masses is essential for planning further management. Ultrasound imaging has become the most popular diagnostic tool during pregnancy, with the recent development of ultrasonography. In non-pregnant women, several methods have been used to predict malignant ovarian masses before surgery. The International Ovarian Tumor Analysis (IOTA) group reported several scoring systems, such as the IOTA simple rules, IOTA logistic regression models, and IOTA assessment of different NEoplasias in the adneXa. Other researchers have also evaluated the malignancy of ovarian masses before surgery using scoring systems such as the Sassone score, pelvic mass score, DePriest score, Lerner score, and Ovarian-Adnexal Reporting and Data System. These researchers suggested specific features of ovarian masses that can be used for differential diagnosis, including size, proportion of solid tissue, papillary projections, inner wall structure, locules, wall thickness, septa, echogenicity, acoustic shadows, and presence of ascites. Although these factors can also be measured in pregnant women using ultrasound, only a few studies have applied ovarian scoring systems in pregnant women. In this article, we reviewed various scoring systems for predicting malignant tumors of the ovary and determined whether they can be applied to pregnant women.

Estimating the risk of malignancy of adnexal masses: validation of the ADNEX model in the hands of nonexpert ultrasonographers in a gynaecological oncology centre in China

BackgroundThis study aims to validate the diagnostic accuracy of the International Ovarian Tumor Analysis (IOTA) the Assessment of Different NEoplasias in the adneXa (ADNEX) model in the preoperative diagnosis of adnexal masses in the hands of nonexpert ultrasonographers in a gynaecological oncology centre in China.MethodsThis was a single oncology centre, retrospective diagnostic accuracy study of 620 patients. All patients underwent surgery, and the histopathological diagnosis was used as a reference standard. The masses were divided into five types according to the ADNEX model: benign ovarian tumours, borderline ovarian tumours (BOTs), stage I ovarian cancer (OC), stage II-IV OC and ovarian metastasis. Receiver operating characteristic (ROC) curve analysis was used to evaluate the ability of the ADNEX model to classify tumours into different histological types with and without cancer antigen 125 (CA 125) results.ResultsOf the 620 women, 402 (64.8%) had a benign ovarian tumour and 218 (35.2%) had a malignant ovarian tumour, including 86 (13.9%) with BOT, 75 (12.1%) with stage I OC, 53 (8.5%) with stage II-IV OC and 4 (0.6%) with ovarian metastasis. The AUC of the model to differentiate benign and malignant adnexal masses was 0.97 (95% CI, 0.96–0.98). Performance was excellent for the discrimination between benign and stage II-IV OC and between benign and ovarian metastasis, with AUCs of 0.99 (95% CI, 0.99–1.00) and 0.99 (95% CI, 0.98–1.00), respectively. The model was less effective at distinguishing between BOT and stage I OC and between BOT and ovarian metastasis, with AUCs of 0.54 (95% CI, 0.45–0.64) and 0.66 (95% CI, 0.56–0.77), respectively. When including CA125 in the model, the performance in discriminating between stage II–IV OC and stage I OC and between stage II–IV OC ovarian metastasis was improved (AUC increased from 0.88 to 0.94, P = 0.01, and from 0.86 to 0.97, p = 0.01).ConclusionsThe IOTA ADNEX model has excellent performance in differentiating benign and malignant adnexal masses in the hands of nonexpert ultrasonographers with limited experience in China. In classifying different subtypes of ovarian cancers, the model has difficulty differentiating BOTs from stage I OC and BOTs from ovarian metastases.

Ovarian Masses-Applicable IOTA ADNEX Model versus Morphological Findings for Accurate Diagnosis and Treatment

A common problem in gynecological practice is the differential diagnosis of the ovarian masses. The clinician must apply the IOTA (International Ovarian Tumor Analysis) ADNEX (Assessment of Different Neoplasia in the Adnexa) model criteria to evaluate the risk of benign, borderline or malignant tumors. The aim of this study was to verify if the IOTA ADNEX model is a practical tool to be used before surgery and if there is a significant difference between IOTA ADNEX criteria and histological findings. A prospective single center study was performed between January 2017 and December 2019 in Obstetrics and Gynecology Hospital “Cuza-Voda”, Iasi, Romania. The study included 230 patients between 17 and 74 years old diagnosed with persistent adnexal masses. We applied the IOTA ADNEX model protocol predicting the risk of benign, borderline or malignant masses. The golden standard remains the histological diagnosis of the surgically removed mass. The patients that had been diagnosed using ultrasonography with persistent adnexal masses between 30 and 291 mm were operated on in our clinic. In our study. the majority of patients had benign ovarian tumor mass, these being 223 (96.96%) patients, from whom, according to IOTA ADNEX protocol, the correspondence was: 91.8–99.7% at risk of benign tumors, 0.3–4.5% at risk of borderline tumors and 0.3–8.2% at risk of malignant masses. Unexpected findings were obtained from the malignant group that included five patients (2.17%) with the following correspondence: 96.1–99% at risk of benign tumors, 0.6–2.4% at risk of borderline tumors and 1–3.9% at risk of malignant masses. After applying the IOTA ADNEX model criteria, the patients with a suspicion of malignant disease were correctly guided towards surgical treatment in an oncological center. In our hospital, surgical treatment was only proposed to those patients with high suspicion of benign masses.