Malignant Adnexal Masses Research Articles

Diagnostic accuracy of ultrasound classifications – O-RADS US v2022, O-RADS US v2020, and IOTA SR – in distinguishing benign and malignant adnexal masses: Enhanced by combining O-RADS US v2022 with tumor marker HE4

PurposeTo assess the diagnostic accuracy of O-RADS Ultrasound (O-RADS US) v2022, O-RADS US v2020, and IOTA SR, and to evaluate whether combining imaging findings with tumor markers enhances the diagnosis of adnexal masses. MethodsThis retrospective study, conducted between January 2018 and December 2023, included consecutive women with adnexal masses scheduled for surgery. Histopathologic results served as the reference standard. Risk factors for malignancy were identified using univariate and multivariate logistic regression analyses. ROC analysis was employed to assess diagnostic test performances, while Kappa statistics evaluated inter-reviewer agreement. ResultsA total of 613 women (mean age, 49.39 ± 12.81 years; range, 16–87 years) with pelvic masses were included. O-RADS US v2022 exhibited comparable performance to O-RADS US v2020, with areas under the curve (AUC) values of 0.940 and 0.937, respectively (p = 0.02, exceeding the adjusted significance level of 0.0167). Both O-RADS models outperformed the IOTA SR, which had an AUC of 0.862 (p < 0.0001 for both comparisons). Multivariate analysis revealed that O-RADS US v2022 [OR 9.148, 95 %CI (4.912–17.039), p < 0.001] and HE4 [OR 1.023, 95 %CI (1.010–1.036), p = 0.001] were significant factors associated with malignant lesions. Furthermore, the combination of O-RADS US v2022 and HE4 demonstrated an AUC of 0.98, significantly outperforming either O-RADS US v2022 alone (AUC = 0.94) or HE4 alone (AUC = 0.92). The Kappa values for O-RADS US v2022, O-RADS US v2020 and IOTA SR were 0.933, 0.891 and 0.923, respectively, indicating substantial inter-reader agreement. ConclusionsThe O-RADS US v2022 demonstrates comparable performance in predicting ovarian malignant lesions when compared to O-RADS US v2020, while surpassing the performance of IOTA SR. Additionally, the combination of O-RADS US v2022 and HE4 provides improved diagnostic effectiveness over using either O-RADS US v2022 or HE4 alone.

Ovarian-Adnexal Imaging-Reporting and Data System (O-RADS) ultrasound version 2019: a prospective validation and comparison to updated version (v2022) in pathologically confirmed adnexal masses.

To evaluate the diagnostic accuracy and reliability of the Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound v2019 in classifying adnexal masses (AMs) and compare the old and updated systems (v2022). This prospective study enrolled 977 consecutive women with suspected AMs from three institutions between January 2022 and December 2023. Ultrasound examinations were performed by three experienced radiologists who categorized AMs according to O-RADS ultrasound v2019. The same radiologists retrospectively reviewed the stored ultrasound images and provided the O-RADS ultrasound v2022 classification. Histopathology was used as the reference standard to calculate the diagnostic accuracy of the O-RADS versions in predicting malignant AMs. Inter-observer agreement (IOA) of the O-RADS scoring results was evaluated using the Fleiss kappa (κ) test. The final analysis included 803 women with 855 AMs (219 (25.6%) malignant and 636 (74.4%) benign). Both O-RADS versions demonstrated good diagnostic accuracy, with area under the curve (AUC) values ranging from 0.906 to 0.923 (v2019) and 0.919 to 0.936 (v2022). The updated v2022 showed a slightly higher accuracy (82.5-86.7% vs. 80.7-85.3%), sensitivity (93.6-95.0% vs. 92.2-94.1%), and specificity (78.1-84.1% vs. 76.1-82.9%) compared to v2019. The IOA for the overall O-RADS classification was perfect for both versions (κ = 0.96-0.97). The O-RADS ultrasound classification system demonstrated good diagnostic accuracy and reliability in predicting malignant AMs, with the updated v2022 showing modest improvements. Question Accurate classification of adnexal masses is essential for management. Can updated O-RADS ultrasound v2022 improve diagnostic accuracy and reliability compared to v2019 in predicting malignancies? Findings O-RADS ultrasound v2022 demonstrated slightly higher diagnostic accuracy for identifying malignant adnexal masses compared to v2019, reflecting modest improvements in risk stratification and clinical decision-making. Clinical relevance The updated O-RADS ultrasound v2022 provides improved risk stratification for adnexal masses, enhancing diagnostic confidence, supporting more precise clinical decision-making, and improving patient outcomes through timely intervention or tailored management strategies in ovarian cancer care.

Accuracy of O-RADS System in Differentiating Between Benign and Malignant Adnexal Masses Assessed via External Validation by Inexperienced Gynecologists.

Objective: To evaluate the accuracy of the O-RADS system in differentiating between benign and malignant adnexal masses, as assessed by inexperienced gynecologists. Methods: Ten gynecologic residents attended a 20 h training course on the O-RADS system conducted by experienced examiners. Following the training, the residents performed ultrasound examinations on patients admitted with adnexal masses under supervision, recording the data in a database that included videos and still images. The senior author later accessed this ultrasound database and presented the cases offline to ten residents for O-RADS rating, with the raters being blinded to the final diagnosis. The efficacy of the O-RADS system by the residents and inter-observer variability were assessed. Results: A total of 201 adnexal masses meeting the inclusion criteria were evaluated, consisting of 136 (67.7%) benign masses and 65 (32.3%) malignant masses. The diagnostic performance of the O-RADS system showed a sensitivity of 90.8% (95% CI: 82.2-96.2%) and a specificity of 86.8% (95% CI: 80.4-91.8%). Inter-observer variability in scoring was analyzed using multi-rater Fleiss Kappa analysis, yielding Kappa indices of 0.642 (95% CI: 0.641-0.643). The false positive rate was primarily due to the misclassification of solid components in classic benign masses as O-RADS-4 or O-RADS-5. Conclusions: The O-RADS system demonstrates high diagnostic performance in distinguishing benign from malignant adnexal masses, even when used by inexperienced examiners. However, the false positive rate remains relatively high, mainly due to the over-interpretation of solid-appearing components in classic benign lesions. Despite this, inter-observer variability among non-expert raters was substantial. Incorporating O-RADS system training into residency programs is beneficial for inexperienced practitioners. This study could be an educational model for gynecologic residency training for other systems of sonographic features.

Clinical Utility and Diagnostic Accuracy of ROMA, RMI, ADNEX, HE4, and CA125 in the Prediction of Malignancy in Adnexal Masses.

We aimed to compare the clinical utility and diagnostic accuracy of the ADNEX model, ROMA score, RMI I, and RMI IV, as well as two serum markers (CA125 and HE4) in preoperative discrimination between benign and malignant adnexal masses (AMs). We conducted a retrospective study extracting all consecutive patients with AMs seen at our Institution between January 2015 and December 2020. Accuracy metrics included sensitivity (SE), specificity (SP), and area under the receiver operating characteristic curve (AUC), and their 95% confidence intervals (CI) were calculated for basic discrimination between AMs. Model performance was evaluated in terms of discrimination ability and clinical utility (net benefit, NB). A total of 581 women were included; 481 (82.8%) had a benign ovarian tumor and 100 (17.2%) had a malignant tumor. The SE and SP of CA125, HE4, ROMA score, RMI I, RMI IV, and ADNEX model were 0.60 (0.54-0.66) and 0.80 (0.76-0.83); 0.39 (0.30-0.49) and 0.96 (0.94-0.98); 0.59 (0.50-0.68) and 0.92 (0.88-0.95); 0.56 (0.46-0.65) and 0.98 (0.96-0.99); 0.54 (0.44-0.63) and 0.96 (0.94-0.98); 0.82 (0.73-0.88) and 0.91 (0.89-0.94), respectively. The overall AUC was 0.76 (0.74-0.79) for CA125, 0.81 (0.78-0.83) for HE4, 0.82 (0.80-0.85) for ROMA, 0.86 (0.84-0.88) for RMI I, 0.83 (0.81-0.86) for RMI IV, and 0.92 (0.90-0.94) for ADNEX. The NB for ADNEX was higher than other biomarkers and models across all decision thresholds between 5% and 50%. The ADNEX model showed a better discrimination ability and clinical utility when differentiating malignant from benign Ams, compared to CA125, HE4, ROMA score, RMI I, and RMI IV.

Diagnostic Value of Contrast-Enhanced Ultrasound in Benign and Malignant Adnexal Masses: A Meta-Analysis.

In the diagnosis of gynecological tumors, determining the benign or malignant nature of adnexal masses is a crucial and complex issue. Contrast-enhanced ultrasound (CEUS) is a relatively novel and increasingly used diagnostic method. Therefore, this study evaluated the diagnostic value of CEUS in differentiating benign and malignant adnexal masses through meta-analysis and systematic review. We systematically searched PubMed, Embase, Web of Science, and the Cochrane Library for studies published up to April 2024 regarding the use of CEUS in diagnosing benign and malignant adnexal masses. STATA 14.0 software was used for data analysis, pooling the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio (DOR) of eligible studies. After initial screening, 305 studies were identified, 13 of which met the inclusion criteria and were analyzed in this meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and DOR of CEUS for the diagnosis of benign and malignant adnexal masses were 0.92 (95% confidence interval [CI]: 0.88-0.95), 0.88 (95% CI: 0.82-0.93), 8.00 (95% CI: 5.00-12.90), 0.09 (95% CI: 0.06-0.14), and 91.00 (95% CI: 45.00-185.00), respectively. The area under the summary receiver operating characteristic curve (AUC) was 0.95 (95% CI: 0.93-0.97). CEUS is a noninvasive, nonradiative imaging modality with high accuracy and reliability in the diagnosis of benign and malignant adnexal masses. To provide an effective adjunct tool in the clinic, future studies can further explore the specific application value of CEUS and its performance in different populations.

GI-RADS versus O-RADS in the differential diagnosis of adnexal masses: a systematic review and head-to-head meta-analysis.

The aim of this study was to compare the diagnostic performance of the Gynecology Imaging Reporting and Data System (GI-RADS) and Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) classification systems and assess their capacity to stratify the risk of malignancy in adnexal masses (AMs). A comprehensive search of MEDLINE (PubMed), Scopus, Web of Science, and Google Scholar was conducted to identify articles published between January 2020 and August 2023. The quality of the studies, the risk of bias, and concerns regarding applicability were assessed using QUADAS-2. The search yielded 132 citations. Five articles, which included a total of 2,448 AMs, were ultimately selected for inclusion. The risk of bias was high in all articles regarding patient selection, low in four studies for the index test, and unclear in three papers for the reference test. For GI-RADS, the pooled sensitivity and specificity were 90.8% (95% confidence interval [CI], 86.0% to 94.0%) and 91.5% (95% CI, 89.0% to 93.0%), respectively. For O-RADS, the pooled sensitivity and specificity were 95.1% (95% CI, 93.0% to 97.0%) and 88.8% (95% CI, 85.0% to 92.0%), respectively. O-RADS demonstrated greater sensitivity for malignancy than GI-RADS (P<0.05). Heterogeneity was moderate for both sensitivity and specificity with respect to GIRADS; for O-RADS, heterogeneity was moderate for sensitivity and high for specificity. Both GI-RADS and O-RADS US demonstrate good diagnostic performance in the preoperative assessment of AMs. However, the O-RADS classification provides superior sensitivity.

Validation of ADNEX and IOTA two-step strategy and estimation of risk of complications during follow-up of adnexal masses in low-risk population.

To evaluate the ability of the Assessment of Different NEoplasias in the adneXa (ADNEX) model and the International Ovarian Tumour Analysis (IOTA) two-step strategy to predict malignancy in adnexal masses detected in an outpatient low-risk setting, and to estimate the risk of complications in masses with benign ultrasound morphology managed using clinical and ultrasound follow-up. This single-center study was performed at Hospital Universitari Dexeus, Barcelona, Spain, using interim data from the ongoing prospective observational IOTA Phase-5 (IOTA5) study. The primary aim of the IOTA5 study is to describe the cumulative incidence of complications during follow-up of adnexal masses classified as benign on ultrasound examination. Consecutive patients with an adnexal mass detected between June 2012 and September 2016 in a private center offering screening for gynecological cancer were included and followed up until February 2020. Tumors were classified as benign or malignant based on histology (if patients underwent surgery) or the outcome of clinical and ultrasound follow-up at 12 (range, 10-14) months. Multiple imputation was used when outcomes were uncertain. The ability of the ADNEX model without CA125 and of the IOTA two-step strategy to distinguish benign from malignant masses was evaluated retrospectively using the prospectively collected data. We assessed performance with regard to discrimination (area under the receiver-operating-characteristics curve (AUC)), calibration, classification (sensitivity and specificity) and clinical utility (Net Benefit). In the group of patients with a mass judged to be benign who were selected for conservative management, we evaluated the occurrence of spontaneous resolution or any mass complication during the first 5 years of follow-up by assessing the cumulative incidence of malignancy, torsion, cyst rupture and minor mass complications (inflammation, infection or adhesions) and the time to occurrence of an event. A total of 2654 patients were recruited to the study. After application of exclusion criteria, 2039 patients with a newly detected mass were included for the model validation. Of those, 1684 (83%) masses were benign, 49 (2%) masses were malignant and, for 306 (15%) masses, the outcome was uncertain and therefore imputed. The AUC was 0.95 (95% CI, 0.89-0.98) for ADNEX without CA125 and 0.94 (95% CI, 0.88-0.97) for the two-step strategy. Calibration performance could not be meaningfully interpreted because the small number of malignancies resulted in very wide confidence intervals. The two-step strategy had better clinical utility than did the ADNEX model at malignancy risk thresholds < 3%. There were 1472 (72%) patients whose mass was judged to be benign based on pattern recognition by an experienced ultrasound examiner and were managed with clinical and ultrasound follow-up. In this group, the 5-year cumulative incidence was 66% (95% CI, 63-69%) for spontaneous resolution of the mass, 0% (95% CI, 0-0.2%) for torsion, 0.1% (95% CI, < 0.1-0.4%) for cyst rupture, 0.2% (95% CI, 0.1-0.6%) for a borderline tumor and 0.2% (95% CI, 0.1-0.6%) for invasive malignancy. The ADNEX model and IOTA two-step strategy performed well to distinguish benign from malignant adnexal masses detected in a low-risk population. Conservative management is safe for masses with a benign ultrasound appearance in this population. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Diagnostic performance of ultrasound reporting systems in evaluation of adnexal masses: A prospective observational study

Objective(s)To evaluate and compare diagnostic performance of ultrasound-based reporting systems IOTA SR, ADNEX, GIRADS, ORADS for discrimination between benign and malignant adnexal masses. Study designA prospective observational study in a tertiary care hospital’s Obstetrics and Gynaecology department evaluated pre-operative ultrasound imaging for adnexal masses in 80 cases, comparing various reporting systems’ sensitivity and specificity against histopathology as gold standard using STATA version 17.0 for data analysis. ResultsAmong the 80 masses, 55 % (44/80) were confirmed as benign on histopathology, while 45 % were identified as malignant. The sensitivity and specificity of SR was 100 % (95 %CI: 90.0–100) and 97.1 % (95 %CI: 84.7–99.9) respectively. Eleven masses (13.8 %) were inconclusive, reducing specificity to 75 % (95 %CI:59.7–86.8).In ADNEX optimal cut-off for risk of malignancy was 34.1 % with sensitivity of 86.1 % (95 % CI: 70.5–95.3) and specificity of 90.9 % (95 % CI: 78.3–97.5). Considering GIRADS 4–5 and risk threshold of ≥10 % (ORADS 4–5) as predictors of malignancy sensitivity was 100 % (95 %CI: 90.3–100) and specificity was 70.5 % (95 %CI: 54.8–83.2) for GIRADS and ORADS. All reporting systems were comparable (p = 0.7). ADNEX identified 72.7 % (8/11) of inconclusive cases, outperforming GIRADS/ORADS which correctly classified 27.2 % (3/11) cases. When applied to misclassified GIRADS/ORADS 4–5 category, ADNEX demonstrated superior performance by correctly classifying 76.9 % (10/13) masses, while SR achieved correct classification in only 38.5 % (5/13) masses. Conclusion(s)All classification systems showed comparable accuracy in malignancy risk identification on imaging. GIRADS/ORADS tended to overestimate malignancy risk. The present study recommends a two-step strategy, leveraging higher specificity of ADNEX model for improved stratification of adnexal masses.

Agreement between frozen section and histopathology to detect malignancy in adnexal masses according to size and morphology by ultrasound.

Management of suspect adnexal masses involves surgery to define the best treatment. Diagnostic choices include a two-stage procedure for histopathology examination (HPE) or intraoperative histological analysis - intraoperative frozen section (IFS) and formalin-fixed and paraffin-soaked tissues (FFPE). Preoperative assessment with ultrasound may also be useful to predict malignancy. We aimed at determining the accuracy of IFS to evaluate adnexal masses stratified by size and morphology having HPE as the diagnostic gold standard. A retrospective chart review of 302 patients undergoing IFS of adnexal masses at Hospital de Clínicas de Porto Alegre, between January2005 and September2011 was performed. Data were collected regarding sonographic size (≤10cm or >10cm), characteristics of the lesion, and diagnosis established in IFS and HPE. Eight groups were studied: unilocular lesions; septated/cystic lesions; heterogeneous (solid/cystic) lesions; and solid lesions, divided in two main groups according to the size of lesion, ≤10cm or >10cm. Kappa agreement between IFS and HPE was calculated for each group. Overall agreement between IFS and HPE was 96.1% for benign tumors, 96.1% for malignant tumors, and 73.3% for borderline tumors. Considering the combination of tumor size and morphology, 100% agreement between IFS and HPE was recorded for unilocular and septated tumors ≤10cm and for solid tumors. Stratification of adnexal masses according to size and morphology is a good method for preoperative assessment. We should wait for final HPE for staging decision, regardless of IFS results, in heterogeneous adnexal tumors of any size, solid tumors ≤10cm, and all non-solid tumors >10cm.

Validation of the IOTA ADNEX Model Among Japanese Women Performed by Gynecology Trainees and Ultrasound Specialists: A Retrospective Diagnostic Accuracy Study.

This study aimed to validate the diagnostic accuracy of the International Ovarian Tumor Analysis (IOTA) Assessment of Different NEoplasias in the adneXa (ADNEX) model in Japanese women, population with a distinct adnexal mass distribution compared with European women, and to evaluate the model's utility by gynecology trainees and ultrasound specialists. This single-center, retrospective study analyzed ultrasound data from January 2017 to March 2020 of 206 women with adnexal masses. Patients who underwent ultrasonography and serum CA-125 measurement and received postsurgery histological diagnosis were included. The ADNEX model's diagnostic performance was evaluated by two trainees and two specialists using the area under the receiver operating characteristic curve (AUC) and measures of accuracy, sensitivity, specificity, and predictive values for overall performance and each examiner. Of the 206 included Japanese women, the prevalence of malignancy was 30.1%, including borderline cases. The overall AUC for distinguishing malignancy was 0.848 (95% confidence interval [CI]: 0.817-0.880). The AUC for each examiner ranged from 0.791 to 0.898, with Specialist 2 showing the highest accuracy and sensitivity varying between 0.677 and 0.839. A moderate degree of agreement was noted among the four examiners (Fleiss' kappa was 0.586). The performance of trainees and specialists differed significantly in evaluating the solid tissue and the papillary projections in both malignant and benign groups (P < .001). The IOTA ADNEX model effectively differentiates benign and malignant adnexal masses in Japanese women. Although the accuracy matched up moderately among the four examiners, better accuracy is expected with training in evaluating solid tissue and papillary projections.

Radiomics analysis of ultrasound images to discriminate between benign and malignant adnexal masses with solid ultrasound morphology.

Our primary aim was to identify radiomic ultrasound features that can distinguish benign from malignant adnexal masses with solid ultrasound morphology, and primary invasive from metastatic solid ovarian masses, and to develop ultrasound-based machine learning models that include radiomics features to discriminate between benign and malignant solid adnexal masses. Our secondary aim was to compare the diagnostic performance of our radiomics models with that of the ADNEX model and subjective assessment by an experienced ultrasound examiner. This is a retrospective observational single center study. Patients with a histological diagnosis of an adnexal tumor with solid morphology at preoperative ultrasound examination performed between 2014 and 2021 were included. The patient cohort was split into training and validation sets with a ratio of 70:30 and with the same proportion of benign and malignant (borderline, primary invasive and metastatic) tumors in the two subsets. The extracted radiomic features belonged to two different families: intensity-based statistical features and textural features. Models to predict malignancy were built based on a random forest classifier, fine-tuned using 5-fold cross-validation over the training set, and tested on the held-out validation set. The variables used in model building were patient's age, and those radiomic features that were statistically significantly different between benign and malignant adnexal masses (Wilcoxon-Mann-Whitney Test with Benjamini-Hochberg correction for multiple comparisons) and assessed as not redundant based on the Pearson correlation coefficient. We describe discriminative ability as area under the receiver operating characteristics curve (AUC) and classification performance as sensitivity and specificity. 326 patients were identified and 775 preoperative ultrasound images were analyzed. 68 radiomic features were extracted, 52 differed statistically significantly between benign and malignant tumors in the training set, and 18 features were selected for inclusion in model building. The same 52 radiomic features differed statistically significantly between benign, primary invasive malignant and metastatic tumors. However, the values of the features manifested overlap between primary malignant and metastatic tumors and did not differ statistically significantly between them. In the validation set, 25/98 tumors (25.5%) were benign, 73/98 (74.5%) were malignant (6 borderline, 57 primary invasive, 10 metastases). In the validation set, a model including only radiomics features had an AUC of 0.80, and 78% sensitivity and 76% specificity at its optimal risk of malignancy cutoff (68% based on Youden's index). The corresponding results for a model including age and radiomics features were 0.79, 86% and 56% (cutoff 60% based on Youden's method), while those of the ADNEX model were 0.88, 99% and 64% (at 20% malignancy cutoff). Subjective assessment had sensitivity 99% and specificity 72%. Even though our radiomics models had discriminative ability inferior to that of the ADNEX model, our results are promising enough to justify continued development of radiomics analysis of ultrasound images of adnexal masses. This article is protected by copyright. All rights reserved.

MRI Accuracy in Diagnosing Sonographically Indeterminate Masses Taking Histopathology as Standard

Introduction: Approximately 25% of ultrasound-detected adnexal masses pose clinical challenges, being indeterminately categorized as benign or malignant. Characterizing them is pivotal for deciding surgery or pelvic MRI. Aims and Objectives: To validate the accuracy of MRI for diagnosing sonographically indeterminate masses using biopsy as the gold standard. Place and Duration of study: A validation cross-sectional study was performed at the Department of Radiology, Mayo Hospital, Lahore, for a period of six months i.e. from December 2019 to June 2020. Material and Methods: Non-probability consecutive sampling was employed to select 289 patients (12-60 years) with sonographically indeterminate adnexal masses. All those patients who were unwilling to participate or had MRI contraindications like metallic inserts, pacemakers, and claustrophobia were excluded from the study. Data was collected using the proforma as approved by IRB. All patients underwent MR imaging on a 1.5-T GE unit, and MRI accuracy was calculated. The analysis of data was performed using SPSS 25.0 version software, p-value ? 0.05 was taken as significant. Results: MRI sensitivity, specificity, PPV, NPV, FP, FN, and diagnostic accuracy in sonographically inconclusive adnexal lesions were 94.25%, 85.22%, 90.61%, 90.74%, 3.46%, 5.88% and 90.66%, respectively, referencing histopathology. Conclusion: The study concludes MRI as a noninvasive, accurate modality for distinguishing benign and malignant adnexal masses. While IOTA Simple Rules can't categorize all masses, around 20% with inconclusive results may need alternative evaluation, like skilled ultrasound examination&amp; MRI. It significantly enhances preoperative differentiation, aiding surgeons in making informed decisions regarding treatment approaches.

Comparison of conventional diffusion-weighted imaging, diffusion kurtosis imaging and intravoxel incoherent motion in characterization of sonographically indeterminate adnexal masses.

To evaluate the role of conventional diffusion weighted imaging, diffusion kurtosis imaging (DKI), and intravoxel incoherent motion (IVIM) in distinguishing benign from malignant adnexal masses. 38 patients with 45 adnexal masses were enrolled in this prospective study and assessed with multiparametric MRI, including the IVIM-DKI sequence, on a 3T MRI system. The mean apparent diffusion coefficient (ADC) from conventional DWI, the apparent diffusion coefficient derived from DKI (Dapp), the apparent kurtosis coefficient (Kapp), true diffusion coefficient (Dt), perfusion fraction (f) and pseudo-diffusion coefficient (Dp) were measured. The mean ADC, Dapp, and Dt were significantly higher in benign adnexal masses than in malignant adnexal masses (p < 0.001). f and Dp were also significantly higher in benign adnexal masses, with p values of 0.026 and 0.002, respectively. Kapp was higher in malignant masses (p < 0.001). Among mean ADC, Dapp, and Dt, mean ADC had the highest area under the curve (AUC) of 0.885. However, no statistically significant differences were observed between the ROCs of various diffusion parameters. The mean ADC, Dapp, and Kapp are useful parameters in discriminating between benign and malignant adnexal masses. Dt derived from IVIM also helps in distinguishing benign and malignant adnexal masses; however, no incremental role of IVIM and DKI over ADC could be identified in our study.

Performance of Pre-Operative IOTA Three-Step Algorithm in Detecting Ovarian Carcinoma in a Referral Center in Indonesia

Background: To assess the diagnostic performance of a three-step algorithm using the International Ovarian Tumor Analysis (IOTA) Group ‘simple rules’, ‘simple descriptors’, and Assessment of Different NEoplasias in the adneXa (ADNEX) model for discriminating benign and malignant adnexal masses. Methods: This was a retrospective observational study, performed at a tertiary-care university hospital, on women diagnosed with adnexal mass on ultrasonography from January 2021 and February 2022. The examiner first classified the mass using ‘simple descriptors’ (first step) and, if not possible, using ‘simple rules’ (second step). For inconclusive masses, an assessment using the ADNEX model was done as the third step. All masses were managed surgically. Histopathology results were used as the reference standard.Results: One hundred and forty-one women were included (median age of 48 years). Histopathology results showed 104 (73.76%) mass to be malignant, and 37 (26.24%) mass to be benign. Twelve (8.51%) of 141 masses could be classified using simple descriptors, 89 (63.12%) masses were classified using simple rules, and 40 (28.37%) masses were classified using the ADNEX model. Overall accuracy, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of the three-step algorithm were 89.36%, 94.23%, 75.68%, 91.59%, 82.35%, 3.87, and 0.08 respectively.Conclusions: The IOTA three-step algorithm, based on the sequential use of simple descriptors, simple rules, and ADNEX model, performs well for classifying adnexal masses as benign or malignant

Comparison of Two-Dimensional IOTA Simple Rules and Three-Dimensional Ultrasonography in Preoperative Assessment of Adnexal Masses.

Objective Accurate preoperative characterization of adnexal masses is essential for optimal patient management. Two-dimensional ultrasonography (USG) based "International Ovarian Tumuor Analysis Simple Rules (IOTA-SR)" are used primarily in clinical practice. Three-dimensional (3D) USG is an emerging modality. The authors conducted this study to compare the performance of 3D USG with IOTA-SR for preoperative differentiation of benign and malignant adnexal masses. Methods This prospective observational study recruited 84 patients with adnexal masses undergoing surgical management. IOTA-SR and 3D USG with power Doppler examination were applied to characterize the masses and correlated with histopathology. Logistic regression analysis defined individual 2D and 3D USG parameters' significance in predicting malignancy. The receiver operating characteristic (ROC) curve was plotted for significant variables, and area under the curves (AUCs) with cut-off values were calculated using the Youden index. Results Out of the 84 adnexal masses, 41 were benign and 43 were malignant. IOTA-SR were conclusive in 88.1% (74/84) cases, with a sensitivity of 83.78% (95% confidence interval [CI]: 67.99-93.81%) and specificity of 89.19% (95% CI: 74.58-96.97%). The sensitivity and specificity of 3D USG with power Doppler were 84% and 88%, respectively, with an AUC of 0.96 (95% CI: 0.92-0.99). Ten cases were inconclusive by the IOTA-SR, and 3D USG could further correctly differentiate four of these cases. Conclusion The diagnostic performance of both techniques is comparable. With good diagnostic performance and easy applicability, IOTA-SR remain the standard of care. 3D USG, although a more objective assessment, requires further validation and standardization.

Decoding the diagnostic landscape of adnexal masses: a retrospective observational study at a tertiary care centre assessing the efficacy of the RMI-2 index

Background: This study aimed to determine the utility of RMI 2 in distinguishing benign and malignant adnexal masses in low-income countries. Methods: For the purpose of this retrospective observational study, relevant data from patients who attended a tertiary care institution in central Gujarat between June 2020 and June 2022 were obtained from the Medical Records Department (MRD). Ultrasound and biochemical parameters along with epidemiological factors were identified and an RMI 2 score was calculated followed by statistical analysis. Results: Twenty-five (37.87%) of the sixty-six instances that were investigated were benign, two (3.03%) were borderline, and thirty-nine (59.09%), were malignant. Using RMI 2 at the traditional cut-off value of 250, results showed a sensitivity of 85.2% (95 %; CI=68.9-95.05), a specificity of 66.6% (95 %; CI=47.1-82.7 %), a positive predictive value of 74.36%, and a negative predictive value of 80.0 %. The ROC showed an AUC of 0.68 (CI=0.5-0.7) with a standard error of 0.07 (p=0.009). Conclusions: With a cut-off point of 250, RMI 2 was able to identify malignant masses with an 85.2% sensitivity and 66.6% specificity to enable timely referral to more advanced institutions for improved management in resource-constrained settings where its affordability and user-friendliness are favourable.

Clinical value of ACR O-RADS combined with CA125 in the risk stratification of adnexal masses.

To develop a combined diagnostic model integrating the subclassification of the 2022 version of the American College of Radiology (ACR) Ovarian-Adnexal Reporting and Data System (O-RADS) with carbohydrate antigen 125 (CA125) and to validate whether the combined model can offer superior diagnostic efficacy than O-RADS alone in assessing adnexal malignancy risk. A retrospective analysis was performed on 593 patients with adnexal masses (AMs), and the pathological and clinical data were included. According to the large differences in malignancy risk indices for different image features in O-RADS category 4, the lesions were categorized into groups A and B. A new diagnostic criterion was developed. Lesions identified as category 1, 2, 3, or 4A with a CA125 level below 35 U/ml were classified as benign. Lesions identified as category 4A with a CA125 level more than or equal to 35 U/ml and lesions with a category of 4B and 5 were classified as malignant. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and area under the curve (AUC) of O-RADS (v2022), CA125, and the combined model in the diagnosis of AMs were calculated and compared. The sensitivity, specificity, PPV, NPV, accuracy, and AUCs of the combined model were 92.4%, 96.5%, 80.2%, 98.8%, 94.1%, and 0.945, respectively. The specificity, PPV, accuracy, and AUC of the combined model were significantly higher than those of O-RADS alone (all P < 0.01). In addition, both models had acceptable sensitivity and NPV, but there were no significant differences among them (P > 0.05). The combined model integrating O-RADS subclassification with CA125 could improve the specificity and PPV in diagnosing malignant AMs. It could be a valuable tool in the clinical application of risk stratification of AMs.

From symptoms to surgery-A pathway through uncertainty and hope: An interview study of women facing ovarian surgery.

Diagnosis of an adnexal mass might be a sign of ovarian cancer, with an overall poor prognosis. This study aimed to explore women's experiences and perceptions of facing ovarian surgery due to an adnexal mass, and expectations on life after surgery. Individual in-depth interviews with 15 women facing ovarian surgery due to an adnexal mass. Interviews were analysed using qualitative content analysis. An overarching theme, From symptoms to surgery-a pathway through uncertainty and hope, was identified. The theme was made up of three categories; I. The road to diagnosis, II. Striving for information and guidance, and III. Balancing emotions of hope and fear. The period between discovering the adnexal mass and surgery was often described as chaotic and difficult to manage. However, the diagnostic procedures were mostly described as timely and efficient, and participants felt safe and cared for. Person-centred care was considered crucial when being in this vulnerable situation, and the nurse navigator was described as a key person to approach for any queries. While participants expressed overall satisfaction with the information provided by health professionals, some reported a lack of information regarding the surgery's potential impact on hormonal production and sexuality. Restrictions during the COVID-19 pandemic forced participants to attend healthcare visits alone, and some wished that health professionals had taken more responsibility for informing their relatives. Many participants focused on the positive aspects of the information gained about the adnexal mass, and that the entire situation gave perspective of what was important in life. Waiting for surgery on a possibly malignant adnexal mass can be very stressful, however person-centred care and the guidance of a nurse navigator can make the process more manageable. To improve women's experience, health professionals may involve relatives more often and make sure to inform of potential hormonal loss and sexuality after ovarian surgery.

Comparison of Simple Ultrasound Rules by International Ovarian Tumor Analysis (IOTA) with RMI-1 and RMI-4 (Risk of Malignancy Index) in Preoperative Differentiation of Benign and Malignant Adnexal Masses.

IOTA proposed Simple Ultrasound Rules in 2009 for preoperative diagnosis of ovarian masses based on ultrasound only. It is an accurate, simple and inexpensive method. RMI, however, requires CA125 level. While RMI-4 is the latest, RMI-1 is still the most widely used method. The present study was done to compare IOTA Rules with RMI-1 and RMI-4. To differentiate benign and malignant adnexal masses preoperatively using IOTA simple rules and compare its accuracy with RMI-1 and RMI-4. A prospective observational study was performed from 1st November 2019 to 31st March 2021 in the Department of Obstetrics and Gynaecology, ABVIMS and Dr. RML Hospital, New Delhi. This study was conducted on 70 patients with adnexal masses who underwent pre-operative evaluation using IOTA Simple Rules, RMI-1 and RMI-4. Histopathology was used to compare the results. Out of 70 patients, 59 (84.3%) cases were benign and 11 (15.7%) were malignant. The IOTA Rules were applicable to 60 cases (85.7%), and the results were inconclusive in 10 cases (14.3%). Where applicable, the sensitivity and specificity of the IOTA Rules (88.9% and 94.1%, respectively) were significantly higher than RMI-1 (45.5% and 93.2%, respectively) and RMI-4 (45.5% and 89.8%, respectively). When inconclusive results were included as malignant, the sensitivity of the IOTA Rules increased (88.9% vs 90.9%); however, the specificity decreased (94.1% vs 81.4%). IOTA Simple Rules were more accurate at diagnosing benign from malignant adnexal masses than RMI-1 and RMI-4. However, the rules were not applicable to 14% of the cases.

Evaluation of American College of Radiology Ovarian-Adnexal Reporting and Data System ultrasound to predict malignancy risk in adnexal lesions.

To validate the diagnostic performance of Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound for preoperative adnexal lesions in an external center. The secondary aim was to evaluate the performance of a strategy test including O-RADS ultrasound evaluation and subjective assessment of higher malignant risk lesions. One hundred thirty patients with 158 ovarian-adnexal lesions were enrolled in the study. Each lesion was assigned an O-RADS score after real-time ultrasound examination by one experienced radiologist. A second subjective assessment by an expert was performed for O-RADS 4 and O-RADS 5 lesions. The histopathological diagnosis was used as the reference standard. A total of 126 benign and 32 malignant adnexal masses were included in the study. The area under the receiver operating characteristic curve of O-RADS ultrasound was 0.950, with a cutoff value > O-RADS 3. The sensitivity, specificity, and negative and positive predictive values were 100% (95% confidence interval [CI], 0.867-1), 83.3% (95% CI, 0.754-0.892), 60.4% (95% CI, 0.460-0.732), and 100% (95% CI, 0.956-1), respectively. For the strategy test, the sensitivity, specificity, negative and positive predictive values were 100% (95% CI, 0.867-1), 92.1% (95% CI, 0.855-0.959), 76.2% (95% CI, 0.602-0.874), and 100% (95% CI, 0.960-1), respectively. In comparison with O-RADS ultrasound, the specificity and negative predictive value of the strategy test were slightly higher (p < 0.05). Good diagnostic performance of the O-RADS ultrasound in adnexal lesions can be achieved by experienced radiologists in clinical practice. A second subjective assessment of sonographic findings can be applied to O-RADS 4 and 5 lesions.