Risk Of Malignancy Index Score Research Articles

Exploration of Preliminary Objective Triage by Menopause Score and CA 125 Result Prior to Accelerating Fast-Track Booking for Suspected Ovarian Cancer-A Role for the Pathway Navigator?

The 28-days-to-diagnosis pathway is the current expected standard of care for women with symptoms of ovarian cancer in the UK. However, the anticipated conversion rate of symptoms to cancer is only 3%, and use of the pathway is increasing. A rapid triage at the moment of receipt of the referral might allow resources to be allocated more appropriately. In secondary care, multidisciplinary teams (MDTs) use the risk of malignancy index (RMI) score, (multiply menopausal status pre = 1 or post = 3 × ultrasound score = 0 - 3 × the CA 125 level), using a score of >200, to triage urgency and management in possible ovarian cancer cases. The most powerful determinant of the RMI score variables is CA 125 level, an objective number. Could a simple modification of the RMI score retain a high sensitivity for cancer whilst improving specificity and, consequently, decrease the morbidity of false-positive classification? To test this hypothesis, a retrospective evaluation of an ovarian two-week-wait telephone clinic of one consultant gynaecological oncologist was undertaken. Enquiry re menopause status was scored as one for pre- and three for postmenopausal or uncertain. CA 125 levels of >67 u/mL for premenopausal and >23 u/mL for postmenopausal women were used to precipitate urgent cross-sectional imaging requests and MDT opinions. These CA 125 cut thresholds were calculated using an assumption that the RMI imaging score, regardless of whether the result was available, could be three. We contemplate that women who did not exceed a provisional RMI score of >200 might be informed they are extremely unlikely to have cancer, removed from the malignancy tracker and appropriate follow-up arranged. One hundred and forty consecutive cases were analysed; 43% were deemed premenopausal and 57% postmenopausal. Twenty of the women had cancer, eighteen (90%) of whom had an RMI > 200. One hundred and twenty were benign, and only twenty-three (19%) classified as urgent cases in need of accelerated referral to imaging. In contrast, CA 125 > 35 u/mL, whilst retaining the sensitivity of 90%, misclassified 36 (30%) of the benign cases. It is possible that a telephone triage via a questionnaire determining menopausal status and the CA 125 result could offer a sensitivity for cancer of 90% and urgent expert review of under 20% of benign cases. This rapid initial telephone assessment could be presented by a trained pathway navigator, physician associate or nurse specialist. Substantial savings in NHS cancer services resources, anxieties all around and reduced patient morbidity may occur as a result.

Diagnostic utility of Risk of Malignancy Index in differentiation of benign from malignant ovarian masses

Background: Women with adnexal masses still pose a diagnostic dilemma and require efficient triaging. The Risk of Malignancy Index (RMI) is an algorithm used for differentiation of malignant from benign ovarian masses. Aims and Objectives: The present study aimed to evaluate the four indices RMI 1, RMI 2, RMI 3, and RMI 4 to discriminate a malignant ovarian tumor from a benign one. Materials and Methods: This cross-sectional study was carried out at a tertiary care hospital of Eastern Uttar Pradesh, India, in 312 patients with ovarian masses. RMI scores were calculated based on pre-operative cancer antigen-125 levels, ultrasonography, and menopausal status followed by post-operative histopathology, taken as gold standard. Using cutoff points of RMI indices, the sensitivity, specificity, positive predictive value, and negative predictive value of RMI were assessed. Results: Out of total 312 patients, 68 (21.8%) had malignant disease and 244 (78.2%) had benign pathology. All indices presented a significantly better performance in detecting malignancy than the use of a single parameter. Each of the RMIs had a different optimal threshold; however, using a threshold of 250, RMI 1, RMI 2, RMI 3, and RMI 4 had a sensitivity and specificity of 64.7%, 70.5%, 64.7%, and 65.2% and 93.4%, 83.6%, 90.2%, and 91.4%, respectively. Conclusion: The RMI is a simple, composite tool that at lower values can reliably predict benign nature of adnexal tumors. However, at values above the cutoff points, it is helpful for appropriate surgical planning and averts radical surgeries in women of reproductive age group.

Assessment of risk of malignancy index scoring and histopathological correlation in the diagnosis and management of adnexal mass

: Pathologies of adnexal masses are commonly benign. The malignant lesions of adnexa carries a very low five-year survival rate, and hence the early recognition need to be done. There is no single gold standard investigation for the diagnosis of the malignancy of the adnexa. Risk of Malignancy Index (RMI) scoring system, combines the Serum CA 125(U/ML), Ultrasound score (U) and the menopausal status(M).: To assess the efficiency of Risk of Malignancy Index-3 (RMI-3) scoring system in discriminating benign and malignant adnexal mass, for early detection and management of malignant ovarian mass.: This is a prospective, observational study, among 50 female patients above the age of 25 years, diagnosed with adnexal mass under the Department of obstetrics and gynaecology, Government Rajaji Hospital, affiliated to Madurai Medical College, Madurai.All the study participants were subjected to detailed history taking, thorough clinical examination, ultrasonogram of abdomen and pelvis, and markers such as CA 125. Risk of Malignancy Index was calculated and correlated with the histopathological (HPE) findings of the excised tumours. : When the cut off of RMI score for predicting malignancy is 149.2 which had a sensitivity of 79.2%, specificity of 92.3%, positive predictive value of 90.47%, negative predictive value of 82.78% and a diagnostic accuracy of 86.01%.: Risk of Malignancy Index score is a simple tool, with a good diagnostic accuracy, hence it can be used as good screening tool for identification of the malignant lesions from the adnexal mass.

EVALUATION OF THE DIAGNOSTIC PERFORMANCE OF THE ‘RISK OF MALIGNANCY INDEX’ IN DIFFERENTIATING BENIGN FROM MALIGNANT OVARIAN TUMORS

Malignant ovarian tumors are the sixth most common female cancer and constitute 7.5% of all gynecological malignancies and 3.5% of all cancers in women (1). The overall mortality in ovarian malignancy is more than 80%, contributed largely by the delay in diagnosis. Early detection of ovarian cancer and timely referral, if required to a gynecological oncologist forms the corner stone to reduce mortality from ovarian malignancy. Ovarian tumors are known to present late in the course of the disease and there is no denite test to dene whether an ovarian mass is benign or malignant . The overall performance of the Ca 125 is rather poor, considering that it may be elevated in a number of benign conditions as well. Inter observer variability and the multitude of mimickers, precludes ultrasound as the sole tool to differentiate the two. A combination of the above along with the menopausal status promises to perform better in differentiating benign vs malignant masses. Hence rests the signicance of the RMI in this study. Also knowing whether an ovarian mass is benign or malignant will be helpful not only in prognosticating the disease and planning appropriate therapy , but it has the powerful advantage of deciding who should do the surgery – the general gynecologist or the oncosurgeon . Aim : The objective of this study is to evaluate the diagnostic performance of the Risk of Malignancy Index (RMI) in differentiating between benign and malignant ovarian tumors . Materials and methods : This study was conducted in the Department of Obstetrics and Gynecology – Government medical college Trivandrum for a period of one year. All patients above the age of 30 years, admitted to the wards with an ovarian mass were included in the study. RMI scores were calculated for all patients. The RMI scores were then compared to the histopathology reports, which is the gold standard for the diagnosis of malignancy. ROC curve was drawn to conclude on the cut off value. Results : Out of the 102 patients in the study group, 24 (23.5%) had a malignant ovarian tumor. The sensitivity, specicity, PPVand NPVof RMI was 83.3%, 88.46%, 68.99% and 94.52% respectively. The sensitivity, specicity, and NPV of RMI is much higher than the individual performance of ultrasound, menopause or serum Ca 125 levels. Conclusion :RMI has proved to be a good diagnostic method to differentiate benign and malignant ovarian tumors.

Using HE4, RMI, ROMA and CPH-I in the differential diagnosis of adnexal masses

Objectives: In order to improve the early diagnosis of ovarian cancer (OC), we evaluated human epididymis secretory protein 4 (HE4), the risk of malignancy index (RMI), the risk of ovarian malignancy algorithm (ROMA), and the Copenhagen Index (CPH-I) in their ability to predict the risk of adnexal masses being malignant, and in discriminating between serous and mucinous ovarian tumors. Methods: A study consisting of 509 patients who were diagnosed with benign, borderline, and malignant adnexal tumors was conducted. We analyzed the values of HE4, RMI, ROMA, and CPH-I. In addition, CA125, CEA, CA125/CEA ratio, CA199, and CA125/CA199 ratio were also assessed to determine their predictive values to diagnoses serous or mucinous ovarian tumors. Results: To differentiate between benign and borderline ovarian tumors, we evaluated RMI and CPH-I scores which showed high AUC (0.7593, and 0.7128, respectively), but neither of them showed both high sensitivity and specificity. When discriminating benign and malignant tumors, RMI and CPH-I performed the best for premenopausal women; whereas ROMA and HE4 performed the best for postmenopausal women. Patients with values above the cutoff for CA125 (> 328.3 U/mL), CA125/CEA (> 82.26), and CA125/CA199 (> 5.633), were more likely to be diagnosed with serous carcinoma. Whereas those with higher values for CEA (> 3.7 μμg/L) and CA199 (> 27.81 ng/mL) were more likely to have a mucinous carcinoma. Conclusion: RMI and CPH-I for premenopausal women, ROMA and RMI for postmenopausal women were reliable indicators to differentiate between women with benign versus malignant tumors. In addition, the ratios CA125/CEA and CA125/CA199 could be used to distinguish serous from mucinous ovarian carcinomas.

Early-Stage Ovarian Malignancy Score versus Risk of Malignancy Indices: Accuracy and Clinical Utility for Preoperative Diagnosis of Women with Adnexal Masses.

Background and objectives: To compare the diagnostic accuracy and clinical utility of the Early-stage Ovarian Malignancy (EOM) score with the Risk of Malignancy Index (RMI) in the presurgical assessment of women presenting with adnexal masses. Materials and Methods: A secondary analysis was carried out in a retrospective cohort of women who presented with an adnexal mass and were scheduled for surgery at Phrapokklao Hospital between September 2013 and December 2017. The clinical characteristics, ultrasonographic features of the masses, and preoperative CA-125 levels were recorded. The EOM and the RMI score were calculated and compared in terms of accuracy and clinical utility. Decision curve analysis (DCA), which examined the net benefit (NB) of applying the EOM and the RMI in practice at a range of threshold probabilities, was presented. Results: In this study, data from 270 patients were analyzed. Fifty-four (20.0%) women in the sample had early-stage ovarian cancer. All four RMI versions demonstrated a lower sensitivity for the detection of patients with early-stage ovarian cancer compared to an EOM score ≥ 15. An EOM ≥ 15 resulted in a higher proportion of net true positive or NB than all versions of the RMIs from a threshold probability of 5% to 30%. Conclusions: It also showed a higher capability to reduce the number of inappropriate referrals than the RMIs at a threshold probability between 5% and 30%. The EOM score showed higher diagnostic sensitivity and has the potential to be clinically more useful than the RMIs to triage women who present with adnexal masses for referral to oncologic gynecologists. Further external validation is required to support our findings.

A prospective observational study on the effectiveness of risk of malignancy index score (RMI 3) in a tertiary care centre in Eastern India

Background: Adnexal mass is a common presentation in today’s gynecological practice. The incidence of ovarian cancer is increasing day by day and diagnosis is often difficult to be made pre operatively with inadequate surgical exploration is a regular occurrence.
 Aims and Objectives: To assess and validate the importance of RMI-3 score as pre-operative diagnostic tool of differentiating benign from malignant adnexal mass for starting first line therapy of ovarian cancer and to find out the incidences of ovarian malignancy among study population.
 Material and Methods: The study was conducted in the Department of Gynecology and Obstetrics on (n=115) patients attending GOPD and indoor with adnexal mass fulfilling the inclusion and exclusion criteria using purposive sampling technique. All the selected cases underwent ultrasonography and serum CA- 125 level estimation necessary for calculating RMI score. A score of >200 was taken as suggestive of malignancy and confirmatory diagnosis was performed by histopathological examination obtained from staging laparotomy of adnexal mass. The individual scores were then correlated with final outcomes with statistical analyses.
 Results: The study revealed benign ovarian tumors are more under 50 years (78.46%) and patients with normal BMI are diagnosed with maximum of malignancy (n = 28). History of tubal ligation carried less risk of malignancy (p<0.0001). Histologically malignant tumors found mostly in 71.4% postmenopausal group whereas 94.1% benign pathology were present in perimenopausal group and there is no association found between parity and histopathology (p=0.058). Bilateral (p=0.013), multilocular (p=0.000) tumors with solid areas (p<0.0001) and thick papillary projections (p<0.0001) had statistically significant association with malignant lesions. RMI score (>200) had more efficacy than serum CA-125 level (>46) in differentiating malignant lesions from benign one in terms of specificity (96% vs 83.87%) and positive predictive value (95% vs 79.17%).
 Conclusions: RMI-3 score is a simple, reliable and effective tool in differentiating benign from malignant adnexal masses thereby help in quick referral and management of cases with increase chances of survival of the patients.

Clinicopathological profile of adnexal masses presenting to a tertiary-care hospital in Bhutan.

Context:Adnexal masses of ovarian origin are of growing concern due to high fatality associated with ovarian malignancy because they are diagnosed at advanced stage due to vague symptoms and absence of recommended screening tests.Aims:The aim was to study the prevalence of histopathologic types of adnexal masses in different age groups and to analyze the accuracy of preoperative evaluation in diagnosing ovarian malignancy.Settings and Design:This was a cross-sectional study carried out in the Department of Obstetrics and Gynecology of a tertiary care hospital in Bhutan with gynecologic-oncology services, from January to December 2017.Subjects and Methods:Women presenting with adnexal mass were evaluated and those meeting criteria were enrolled. They were evaluated preoperatively with complete history, examination, ultrasound, and tumor markers. Risk of malignancy index (RMI) was calculated for all patients. Following surgery, histopathology results were compared with preoperative evaluation.Statistical Analysis Used:Chi-square test, t-test, Cohen's Kappa, and receiver operating characteristic curve analysis were used for statistical analysis.Results:Of 165 patients evaluated, 127 fulfilling criteria were enrolled. Adnexal masses of ovarian origin were most common (n = 102, 80.3%), of which 12.7% were malignant. Epithelial ovarian malignancy was the most common malignant ovarian tumor, serous cystadenocarcinoma being the most common. Malignancy was significantly more in older, postmenopausal women with high RMI. Seven out of 11 women with high RMI were diagnosed in Stage 3 or 4. RMI score at cutoff of 200 was 54.6% sensitive and 85.7% specific.Conclusions:Adnexal mass of ovarian origin was the most common. Malignancy was significantly more in older, postmenopausal women with high RMI. RMI showed moderate correlation in diagnosing epithelial ovarian malignancies.

Assessment of Diagnostic Value of Serum Ca-125 and Risk of Malignancy Index Scoring in the Evaluation of Adnexal Masses.

Introduction:Adnexal masses have a wide spectrum with respect to the age of presentation, signs and symptoms, imaging findings, and histopathology report.Materials and Methods:This is a cross-sectional diagnostic study, conducted at All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India. The data were collected from department of gynecology over a period of 1½ years from June 2017 to December 2018. All women who were diagnosed to have an adnexal mass irrespective to age, parity, and menopausal status were included in the study. Ultrasonography of the abdomen with the pelvis was ordered in all patients followed by contrast-enhanced computed tomography or magnetic resonance imaging in selective patients. Tumor markers such as Ca-125 was measured, and risk of malignancy index (RMI) was calculated for each tumor. The clinical and imaging findings were correlated with intra-operative findings and finally with the histopathology examination report.Results:A total of 171 women were included in the study who were diagnosed to have adnexal mass. A total of 137 women (80.1%) had benign tumor (Group B), whereas 34 women (19.9%) were found to have malignant tumor (Group M). Mean age in Group B was 35.85 ± 12.46 and in Group M was 46.12 ± 13.46 (P = 0.001). Ca-125 was significantly higher in Group M (1350 U/ml) than Group B (175 U/ml) (P = 0.008). The RMI score was also found to significantly increased in Group M than Group B (P = 0.007).Conclusion:With respect to adnexal masses, both Ca-125, as well as RMI scoring, are important diagnostic tools. RMI scoring has a better overall diagnostic performance than Ca-125 in predicting malignancy.

Is the Risk of Ovarian Malignancy Algorithm Better Than Other Tests for Predicting Ovarian Malignancy in Women with Pelvic Masses?

Aim: The study aimed to compare the risk of ovarian malignancy algorithm (ROMA) with risk of malignancy index (RMI), cancer antigen 125 (CA125), human epididymis protein 4 (HE4) and Sassone ultrasonography (US) score in predicting ovarian cancer (OC) in women who present with pelvic or adnexal masses. Methods: Pelvic US, serum CA125 and HE4 levels were investigated preoperatively in consecutively enrolled Thai women over 18 years with clinically diagnosed pelvic or adnexal masses who were undergoing elective surgery at a super tertiary hospital in Thailand in 2012. ROMA, RMI and Sassone US score were calculated. Results: Of 260 women who were evaluated, 74 had OC. Areas under the receiver operating characteristic curve (AUC) in predicting OC were ROMA, 86.2%; RMI, 87.6%; CA125, 80.6%; HE4, 82.4%; and Sassone score, 77.1%. ROMA and RMI performed similarly well (AUCs 84.4 and 85.6%) in premenopausal women but RMI outperformed ROMA in postmenopausal women (AUCs 87.9 and 84.0%, respectively). At the conventional cutoff value, ROMA and CA125 showed the highest sensitivity (83.8%) but HE4 had the highest specificity (86.0%). Conclusions: ROMA was comparable to RMI in predicting OC. Either ROMA or RMI can be applied to women with pelvic masses, stratified into low- and high-risk groups for OCs.

Assessment of the Value of a Modified Risk of Malignancy Index (RMI) in Preoperative Discrimination Between Benign and Malignant Ovarian Masses

Objectives: To assess the diagnostic accuracy of different risk of malignancy index (RMI) scores and to evaluate the role of a modified RMI (RMI 5) in pre-operative discrimination between benign and malignant ovarian masses. Study Design: Prospective observational study. Patients and methods: Women with a suspicious ovarian mass scheduled for laparotomy or laparoscopy were potentially eligible for inclusion in the current study. Trans-abdominal and trans-vaginal ultrasound with Doppler assessment of the adnexal masses was done. Calculation of the RMI 1, RMI2, RMI 3, RMI 4, and RMI5 was done. We compared RMI to histopathological outcome. In the current study, a new RMI score was created by adding Doppler blood flow of the ovarian mass to the calculation of the previous RMI1. Results: One hundred and fifty women with ovarian masses were included in the current study. Ninety six women (64%) had benign ovarian masses while, malignant ovarian masses were found in 54 women (36%). Comparison between benign and malignant ovarian masses regarding to the risk of malignancy indices revealed that that there was a statistically significant difference between the two groups regarding to the risk of malignancy indices with Pvalue< 0.001. Receiver operator characteristic curve analysis of the 5 RMI indices shows that the best method for prediction of malignant ovarian tumor was RMI 1. Also there was no statistically significant difference between the five methods in prediction of malignant ovarian tumors. RMI5 with cut off value of 250 is reliable tool at a tertiarycenter to discriminate between ovarian cancer and benign ovarian masses with a sensitivity of 90.38% and specificity of 93.88%. There was statistically significant difference between the different stages of ovarian cancer and RMI 5 with (P<0.05). Conclusion: The RMI 1 is the gold standard for preoperative discrimination between benign and malignant ovarian masses. Adding Doppler flow to the parameters of RMI 1 (RMI 5) increased specificity of RMI 1 in detecting malignant ovarian masses.

Evaluation of risk of malignancy index in the preoperative assessment of ovarian tumors: Study from a tertiary care center

Objectives: Risk of malignancy index (RMI) is a mathematical formula using a combination of diagnostic modulations to predict whether an adnexal mass is benign or malignant. The aim of this study was to evaluate the diagnostic performance of RMI in differentiating benign and malignant ovarian tumors, in comparison with histopathology, the gold standard and to identify the patients with likely ovarian cancer for a referral to a specialist gynecological oncologist, for proper surgical staging and treatment. Materials and Methods: The descriptive study was done on 102 patients referred to a tertiary care center for 12 months from June 2006 to May 2007. RMI is the product of menopausal score, ultrasound score, and absolute value of serum CA-125 levels. RMI score was calculated and compared with histopathology, the gold standard. Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated for individual parameters and for RMI to assess malignancy. Chi-square test, Cohen's Kappa, and receiver operator characteristic (ROC) analysis was carried out. ROC curve was drawn to conclude on the cutoff value of RMI. Results: Analyzing the diagnostic performance of RMI, we found that RMI performed better than individual parameters in differentiating benign and malignant ovarian tumors at the cutoff score of 200. The present study gives 195 as best cutoff point for RMI to differentiate benign and malignant ovarian neoplasms. Conclusion: RMI can be used by the general gynecologists at the periphery for referral of suspected ovarian tumors to oncology centers, thus improving the survival and prognosis of women undergoing surgery for ovarian tumors.

Spectrum of epithelial ovarian tumors with HER2/neu expression by the carcinomas among patients admitted in a tertiary care hospital in Eastern India

Background: Women in India constitute a neglected part of the society and their sufferings are least highlighted. Ovarian cancer is a fatal disease that affects them silently. Its incidence is rising with progressively enlarging elderly population. Early diagnosis is challenging, since majority of the cases of ovarian carcinomas are detected in advanced stage with nonspecific symptoms. Neo-adjuvant chemotherapy, a useful therapeutic modality, is limited by toxicity and resistance. Hence, targeted therapy is now being proposed to overcome these hurdles. Objectives: 1. To study the histopathological spectrum of epithelial ovarian tumors. 2. To study the expression of HER2/neu among carcinomas on immunohistochemistry. Materials and Methods: It was an observational, descriptive, cross-sectional study carried out among 68 patients admitted in the hospital, who were newly diagnosed as having primary epithelial ovarian tumor. Postoperatively, the surgical specimens were processed accordingly. Histopathological sections were examined under Hematoxylin and Eosin stain. Histopathologically confirmed carcinomas were analyzed for HER2/neu expression status on immunohistochemistry. Statistical analysis was carried out using SPSS software, version 20. Results: Of the total cancer cases, 64.71% were benign, 5.88% borderline, 29.41% malignant. Serous type constituted majority for both benign and malignant variants (59.09% and 70% respectively). Overall, serous type constituted 58.82% of total population studied. Risk of malignancy index score was >200 for 95% of carcinomas in sharp contrast to benign tumors (15.91%). Grade 3+ HER2/neu expression was found in 35% of malignant cases, of which 85.71% were at advanced stage (FIGO III and IV). Conclusion: Serous type was the most common type of epithelial ovarian tumor. Risk of malignancy index score had strongly correlated with the malignant nature of tumor (p < 0.001). Grade 3+ HER2/neu expression was associated with advanced stage carcinomas.

Is Risk Malignancy Index a Useful Tool for Predicting Malignant Ovarian Masses in Developing Countries?

Introduction. Risk of Malignancy Index (RMI) is widely studied for prediction of malignant pelvic masses in Western population. However, little is known regarding its implication in the developing countries. The objective of this study is to determine how accurately the RMI can predict the malignant pelvic masses. Materials and Methods. The study is a retrospective review of patients attending the gynecological clinic between January 2004 and December 2008 with adnexal masses. Information on demographic characteristics, ultrasound findings, menopausal status, CA125, and histopathology was collected. RMI score for each patient in the study group was calculated. Results. The study group included a total of 283 patients. Analysis of the individual parameters of RMI revealed that ultrasound was the best predictor of malignancy with a sensitivity, specificity, and positive likelihood ratio of 78.3%, 81.5%, and 4.2, respectively. At a standard cut-off value of 250, RMI had a positive likelihood ratio of 8.1, while it was 6.8 at a cut-off of 200, albeit with comparable sensitivity and specificity. Conclusion. RMI is a sensitive tool in predicting malignant adnexal masses. A cut-off of 200 may be suitable in developing countries for triaging and early referral to tertiary care centers.

Addition of parity to the risk of malignancy index score in evaluating adnexal masses

ObjectiveThe aim of our study was to evaluate the individual contribution of parity when incorporated as another parameter into the four risk of malignancy indices (RMI 1–4) to differentiate noninvasive benign lesions from invasive malignant ovarian lesions. Materials and methodsAfter calculating RMI 1–4 for each patient included in this study, the resulting RMI scores were further multiplied by the parity score (P) of each patient to calculate the RMI parity (RMIP) score. ResultsA cutoff value of 300 for RMIP 1 yielded 95.0% specificity, 97.4% negative predictive value (NPV), 88.5% sensitivity, and 79.3% positive predictive value (PPV) and performed better than RMI 1 in the preoperative diagnosis of invasive malignant lesions. RMIP 2 with a cutoff value of 400 yielded 95.0% specificity, 97.4% NPV, 88.5% sensitivity, and 79.3% PPV, and it also performed better than RMI 2. A cutoff value of 400 for RMIP 3 provided 97.5% specificity, 97.5% NPV, 88.5% sensitivity, and 88.5% PPV and performed better than RMI 3. However, a cutoff value of 400 for RMIP 4 provided 90.0% specificity, 97.3% NPV, 88.5% sensitivity, and 65.7% PPV but did not perform better than RMI 4 in the preoperative diagnosis of invasive malignant lesions. ConclusionRMIP 1–3 scales were more reliable tools for the preoperative diagnosis of invasive adnexal masses compared with the traditional RMI 1–3 scales.

Diagnostic Accuracy of Preoperative Prediction of Malignancy in Ovarian Cysts

In this review, we will critically evaluate the evolution of the diagnostic tools used in the prediction of ovarian malignancy preoperatively, that has shown to get a better outcome for ovarian cancer patients. It will triage women to the best place for their surgery and by ensuring the expertise available to perform the surgery reducing the rate of incomplete primary surgery, that has reflected into improve survival of ovarian cancer patients. The Risk of Malignancy Index (RMI) was the first diagnostic tool developed to help clinicians differentiate between benign and malignant ovarian tumours. Jacob et al. [1] described how it was developed and assesses its performance amongst a cohort 143 patients referred to a London hospital for elective surgical investigation of an adnexal mass. Each patient had five criteria assessed preoperatively: age, menopausal status, and clinical impression score (as determined by an experienced gynaecologist using all of the patient’s preoperative clinical information; out of 5, high = more likely to be malignant), ultrasound score (out of 5, high = more likely to be malignant), and CA-125 level. Following surgery, it was determined that 101 of the patients had benign masses and 42 had malignant tumours. Patients in the malignant group had a higher mean age, were more commonly post-menopausal, and had higher clinical impression scores, ultrasound scores and CA-125 levels than patients in the benign group; all of these differences were statistically significant. However, when used individually, the criteria had inadequate sensitivity and specificity for malignancy. Logistic regression analysis revealed that only menopausal status, ultrasound score and CA-125 levels were significantly and independently related to the likelihood ratio for malignancy. These three criteria were then combined to form the RMI: RMI = U × M × CA-125 U = 0 for ultrasound score of 0 = 1 for ultrasound score of 1 = 3 for ultrasound score of 2-5 M = 1 if premenopausal = 3 if postmenopausal When a cutoff score of 200 was used, the RMI showed excellent diagnostic performance, with a sensitivity of 85% and a specificity of 97%. Patients with an RMI score in excess of 200 had 42 times the background risk of cancer, whilst those with a score less than 200 had 0.15 times the risk. The authors concluded that the RMI was a valuable tool for the preoperative assessment of benign and malignant adnexal masses, and that it gave a higher level of discrimination than could be achieved by individual criteria alone. Overall, this is a good study. The sample size was sufficiently large to allow statistically significant differences between groups to be seen. The criteria used for the RMI were not chosen at

Modification of Cutoff Values for HE4, CA125, the Risk of Malignancy Index, and the Risk of Malignancy Algorithm for Ovarian Cancer Detection in Jakarta, Indonesia

CA125 and HE4 are used in calculating Risk of Malignancy Algorithm (ROMA); and Risk of Malignancy Index (RMI). However, studies showed that normal levels of CA125, and HE4 differ among ethnicities such as between Asians and Caucasians, thus affecting the accuracy of the RMI score and ROMA in predicting ovarian malignancy. This study aimed to determine whether new or modified cutoff values for Ca- 125, HE4, the RMI score, and ROMA resulted in a better prediction of malignancy compared with the previous or standard ones. Serum level of CA125 and HE4 from 128 patients with diagnosis of ovarian tumor that had been collected before surgery at Cipto Mangunkusumo General Hospital (CMH) in Jakarta from November 2010 until May 2011 were reviewed and analysed. The standard cutoff values of these biomarkers, RMI, and ROMA were modified by using logistic regression model. The modified cutoff values were compared to the standard cutoff values in terms of sensitivity, specificity, and accuracy. The modified cutoff value of CA125, HE4, RMI score and ROMA were 165.2 U/mL, 103.4 pM, 368.7, 28/54. The sensitivity and specificity of the modified cutoff values CA125, HE 4, RMI score and ROMA in differentiating benign from malignant and borderline were 67% and 75,4%; 73.1% and 85.2%; 73.1% and 80.3%; and 77.6% and 86.9%. While the sensitivity and specificity of the standard cutoff value of CA125; HE4; RMI score; and ROMA were 91% and 24.6%; 83.6% and 65%; 80.6% and 65.6%; and 91.0% and 42.6%. The accuracy of modified cutoff values compared with standard cutoff values were: 71.2% vs 59.3%, 78.9% vs 75% vs, 76.5% vs 73.4%, and 82% vs 67.9%. The new or modified cutoff values of Ca125, HE4, RMI score and ROMA resulted in higher accuracy compared to the previous or standard ones, at the cost of reduced sensitivity.

Risk of Malignancy Index is not accurate as a Triage Tool for Ovarian Cancer

Objective: To evaluate Risk of Malignancy Index (RMI) as a triage tool for ovarian cancer in Dr. Cipto Mangunkusumo Hospital.&#x0D; Method: This is a retrospective study conducted from January 2008-December 2012 in patients diagnosed with ovarian mass. Patients admitted for surgery due to ovarian masses were included to this study. RMI 3 score was calculated based on ultrasonography examination in Dr. Cipto Mangunkusumo Hospital, CA-125 test and menopausal status. Patients without final pathological report and incomplete data were excluded from study. Data were analysed using SPSS 20 to evaluate RMI result and final pathlogical report in benign and malignant case.&#x0D; Result: From 882 patients identified with ovarian masses from cancer registry, only 99 patients aged 17-70 y.o were included in this study. Most of the patients were nully-parity (28.3%), non-menopausal women (60.6%), normal body mass index (40.4%), and with stage IIIC ovarian cancer (33.3%). Ultrasonography examination showed that most of patients had solid mass and ascites (19.2%). Meanwhile, CA-125 showed that patients with &lt;35 U/ml were 10.1% and ≥ 35 U/ml were 89.9%. Patients with RMI scores &lt;200 (benign cases) were 19 cases (19.2%) and ≥ 200 (malignant cases) were 80 cases (80.8%). Meanwhile, patients with benign final pathological report were 23 cases (23.2%) and malignant cases were 76 cases (76.8%). There was no statistical difference in RMI between benign and malignant cases based on final pathological report.&#x0D; Conclusion: Our study showed that RMI was not accurate as triage tool for ovarian cancer in our hospital. Further investigation and more patients are needed to confirm this study.&#x0D; Keywords: CA-125, menopausal status, ovarian cancer, risk of malignancy index (RMI), ultrasonography.

ONCOGYNECOLOGICAL ASPECTS ОF ADNEXAL MASSES

Adnexal masses are frequently found in both symptomatic and asymptomatic women. The frequency of them is 7,8% in reproductive aged women and 2,5-18% in postmenopausal patients. to investigate clinical significance of the Risk of Malignancy Index (RMI) and to compare it with histological findings in patients with adnexal masses. 345 patients with adnexal masses were evaluated. Depending on the menopausal status, serum CA-125 level and ultrasonographic findings RMI scores were calculated for each of patients. according to RMI all the patients were divided in to two groups: first group - 283 (62%) of patients with RMI less then 200 and the second group -52 (38%) women with RMI more then 200. The patients of the second group were referred to the oncologist. Among the patients with RMI <200, 137(48,4%) endometriomas, 73(25,8%) serous cystadenoma, 45(15,9%) dermoid cysts, 22(7,8%) paraovarian cysts, 2 (0,7%) adenocarcinoma were detected after histological examination. In patients with RMI >200, 25% of benign ovarian tumors, 34,6% of borderline and 40, 4% of malignant tumors were verified. RMI when used in the presence of a pelvic mass is a useful triage tool to determine those women who should be referred to a gynaecological oncologist. During laparoscopy, in cases of intraoperative malignancy suspicion staging should be performed: videorecord of the surgery, biopsy of the adnexal mass and contralateral ovary, biopsy of the omentum and peritoneum, and aspiration of the peritoneal fluid for cytological examination.

Ovarian fibroma/fibrothecoma: Retrospective cohort study shows limited value of risk of malignancy index score

Ovarian fibromas/fibrothecomas are uncommon benign tumours of ovary. Due to their solid structure, these benign tumours are sometimes confused with malignant tumours during clinical evaluation. To determine the clinico-pathological characteristics of ovarian fibroma/fibrothecoma and analyse the efficiency of risk of malignancy index (RMI) scoring system to distinguish malignancy among these tumours. Between November 2001 and February 2012, women with a pathological diagnosis of ovarian fibroma/fibrothecoma were identified. Depending on the menopausal status, serum CA-125 level and ultrasonographic findings, RMI scores were calculated for each of the patients. During the study period, 43 ovarian fibroma/fibrothecoma (4.7%) were detected among 912 adnexal masses operated. The mean age of the women was 52.2 (range, 21-80years). Upon calculating RMI scores, 33 women (76.7%) were classified as low risk and 10 women (23.3%) as high risk for malignancy. Sensitivity, specificity, positive predictive value and negative predictive value of the RMI scoring for identification of malignant lesions preoperatively were found as 0%, 76%, 0% and 97%, respectively. Final pathological diagnosis was ovarian fibroma in 13 (30%) women, fibrothecoma in 29 (67%) and fibrosarcoma in one woman (2%). There are no specific markers for accurate preoperative diagnosis of ovarian fibroma/fibrothecoma. Moreover, according to our results, RMI scoring system does not aid clinicians in this issue either, with a high false-positive rate and very low sensitivity. Further studies with higher number of cases are needed to state clearly the role of RMI scores in preoperative discrimination of malignancy.