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.

Comparison of Four Risk of Malignancy Indices for Preoperative Evaluation of Ovarian Masses: A Prospective Observational Study.

BACKGROUND: Ovarian cancer imposes a significant health burden worldwide. Although various tumor markers are available to diagnose ovarian cancer, low-resource countries like India require a humble marker or index. The Risk of Malignancy Index (RMI) has been found to be a simple yet promising tool that can be used for this purpose. In this study, we attempted to validate various RMIs with the help of menopausal status, ultrasonogram score, cancer antigen (CA) 125 value and compare all four RMIs, which would be useful to differentiate benign and malignant ovarian masses. This could be an essential tool, especially in low-resource settings. METHOD: This prospective study was conducted at Kalinga Institute of Medical Sciences in Odisha, India, from September 2020 to September 2022 involving 191 patients with ovarian mass with histopathology, which was deemed the "gold standard" diagnostic tool. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of RMI 1, 2, 3, and 4 were calculated and compared.  Results: Out of 191 patients, 32 (16%) had malignancy and 159 (83.2%) had benign pathology. It was apparent that RMI 4 was a better tool for the initial assessment of patients with ovarian masses with a sensitivity of 80.6%, specificity of 96.2%, PPV of 81%, NPV of 96% at a cutoff of 334, and an area under the curve value of 0.939. CONCLUSION: RMI 4 followed by RMI 3 were relatively better indices than RMI 1 and RMI 2 for identifying benign and malignant ovarian masses. RMI 4 was a valuable and applicable method in diagnosing pelvic masses with a high risk of malignancy.

Accuracy of the risk of malignancy index-I in diagnosing ovarian malignancy in menopausal women.

Introduction: To detect the accuracy of the risk of malignancy index-I (RMI-I) in diagnosing ovarian malignancy in menopausal women. Material and methods: Eighty-two menopausal women with suspected ovarian masses (OMs) scheduled for surgery were included in this study. Blood samples were preoperatively collected from participants to measure the CA-125, followed by transvaginal sonography to evaluate the suspected OMs regarding the consistency, whether the OMs were unilateral or bilateral, unilocular or multilocular, and for extra-ovarian metastasis. The preoperative RMIs were compared to the postoperative histology of the excised OMs to detect the accuracy of RMI-I at a cut-off value of 200 in diagnosing ovarian malignancy. The receiver operating characteristic curve was also used to detect the cut-off value of RMI-I with the highest sensitivity and specificity in diagnosing ovarian malignancy in menopausal women. Results: The incidence of benign and malignant OMs in the studied menopausal women was 59.8% and 40.2%, respectively. The risk of malignancy index-I at a cut-off value 200 in this study had 75.8% sensitivity, 91.8% specificity, 86.2% positive predictive value (PPV), and 84.9% negative predictive value (NPV) in diagnosing ovarian malignancy in menopausal women. The receiver operating characteristic curve showed that the RMI-I at a cut-off value of > 241.5 had 96% sensitivity and 94.74% specificity in diagnosing ovarian malignancy in menopausal women (AUC 0.98, 95% CI: 0.92-0.99, p < 0.001). Conclusions: The risk of malignancy index I at a cut-off value of 200 had 75.8% sensitivity, 91.8% specificity, 86.2% PPV, and 84.9% NPV in diagnosing ovarian malignancy in menopausal women. The receiver operating characteristic curve showed that the RMI-I at a cut-off value > 241.5 had 96% sensitivity and 94.74% specificity in diagnosing ovarian malignancy in menopausal women.

Comparisons of Effectiveness in Differentiating Benign from Malignant Ovarian Masses between Conventional and Modified Risk of Malignancy Index (RMI).

OBJECTIVE: To compare the predictive performance in differentiating benign from malignant ovarian masses between the modified risk malignancy index (RMI) and the conventional RMI (RMI-1 and RMI-2). METHODS: Women scheduled for elective surgery because of adnexal masses were recruited to undergo pelvic sonography within 24 h before surgery to assess the sonographic characteristics of the masses, focusing on loculi, solid part, ascites, bilateralness, papillary projection, and color flow mapping (CFM). Preoperative CA-125 levels were also measured. Modified RMI, RMI-1, and RMI-2 systems were used to predict malignant masses. The gold standard was pathological or intraoperative diagnosis. RESULTS: A total of 342 ovarian masses, benign: 243 (71.1%); malignant: 99 (28.9%), meeting the inclusion criteria were analyzed. The sensitivity and the specificity of the modified RMI (87.9% and 81.9%) were significantly higher than those of RMI-1 (74.7% and 84.4%), and RMI-2 (79.8% and 81.1%, respectively). Based on ROC curves, the area under the curves were 0.930, 0.881 and 0.882 for modified RMI, RMI-1 and RMI-2, respectively. CONCLUSION: Modified RMI had better predictive performance than the conventional RMI in differentiating between benign and malignant ovarian masses. Modified RMI may be useful to help general gynecologists or practitioners to triage patients with an adnexal mass, especially in settings of low resources.

Accuracy of IOTA Simple Rules, IOTA ADNEX Model, RMI, and Subjective Assessment for Preoperative Adnexal Mass Evaluation: The Experience of a Tertiary Care Referral Hospital.

OBJECTIVES: The aim of this study was to evaluate the accuracy of IOTA Simple Rules (SR), IOTA ADNEX model, Risk of Malignancy Index (RMI), and subjective assessment (SA) which is used for adnexal mass assessment in our institution. DESIGN: This is a prospective observational study. PARTICIPANTS/MATERIALS, SETTING, METHODS: We included patients with at least one adnexal mass who needed elective surgical evaluation based on clinical and laboratory findings. Patients admitted to Clinic for Gynecology and Obstetrics, University Clinical Center of Serbia, were recruited for the study between January 2019 and June 2021. Level II ultrasonographers performed a gray scale and Doppler exam for each patient. Preoperative classification of adnexal masses (benign or malignant) was performed by SA, the International Ovarian Analysis Group (IOTA) SR, IOTA ADNEX model, and Risk of Malignancy Index (RMI). Postoperatively obtained histological findings were used as a reference. RESULTS: During the study period, we enrolled 179 premenopausal and 217 postmenopausal patients, representing 396 patients in our sample. Prevalence of malignant disease in pre- and postmenopausal groups was 16.2% (29/179) and 41% (89/217), respectively. Malignant disease was diagnosed in 29.8% (118/396) of patients. SA achieved the highest discrimination accuracy between benign and malignant tumors (area under the curve [AUC] of 0.928, 95% CI [0.898-0.952]). For SA, the overall diagnostic accuracy, sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were 91.4%, 88.1%, 92.8%, 12.25, and 0.13. The AUC for Simple Rules with subjective assessment in inconclusive cases (SR + SA) was 0.912 (95% CI [0.880-0.938]). Regarding SR + SA, diagnostic accuracy, sensitivity, specificity, LR+, and LR- were 92.4%, 88.1%, 94.2%, 15.31, and 0.13. The ADNEX model had the AUC of 0.914 (95% CI [0.882-0.940]). Binary classification using the ADNEX model at a cut-off value of 10% for malignancy had the sensitivity, specificity, LR+ and LR- of 92.4%, 73.0%, 3.42, and 0.10. This resulted in the lowest overall accuracy of 78.8%. The AUC for RMI was 0.854 (95% CI [0.815-0.887]), with overall accuracy, sensitivity, specificity, LR+ and LR- of 82.3%, 73.7%, 86.0%, 5.26, and 0.31. There was no difference in the AUCs of the SA and IOTA models for the whole group, premenopausal, and postmenopausal groups. RMI performed worse compared to SA and the IOTA models. The ADNEX model achieved the highest accuracy at the cut-off value of 35%. LIMITATIONS: The data generalizability is limited by a single institution-dependent sampling. CONCLUSIONS: The IOTA SR and ADNEX model were reliable and comparable with the SA and performed better than the RMI. The IOTA SR model offers the potential for immediate and reliable diagnosis, even in the hands of less experienced ultrasonographers. Both IOTA models studied can be a valuable adjunct to a clinician's decision-making process.

Diagnostic value of risk of malignancy index in the clinical evaluation of ovarian mass.

In the present study, the Risk Malignancy Index (RMI) was calculated based on menopausal status, ultrasound (US) findings and serum biological cancer antigen 125 (CA-125) levels as a scoring system in Libyan females with ovarian masses (OMs) to differentiate between benign and malignant tumors. A total of 51 females with OMs referred to the Gynaecology Department of the National Cancer Institute in Misurata (Libya) between January 2019 and December 2020 were retrospectively reviewed for diagnostic testing. Clinicopathological and demographic data were obtained from patient records. A cut-off point of RMI=200 was used to differentiate between benign and malignant tumors. The mean age of the patients was 47 years (range, 19-90 years) and 60% of the patients were premenopausal. Examination of the four RMI indices and disease status indicated that the association with the US score (P<0.0001) and with CA-125 (P=0.017) was highly significant. However, the age at diagnosis and menopausal status did not have any significant association with the disease status. The RMI with a cut-off point of 200 had a sensitivity and specificity of 87.5 and 90.7%, respectively, and a positive and negative predictive value of 63.6 and 97.5%, respectively. The association between the RMI and disease status was highly significant (P<0.0001). In conclusion, the RMI appears to be a reliable, simple and cost-effective tool for clinical differentiation between benign and malignant OMs. This may help to improve the optimal diagnosis and planning of an individualized treatment strategy. However, given the small sample size of the cohort, further validation using larger cohorts in other settings is recommended.

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.

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.

Assessing the diagnostic performance of four ovarian malignancy prediction risk models in differentiating benign and malignant ovarian masses in a tertiary hospital / Philippine Journal of Obstetrics and Gynecology

Introduction@#Ovarian cancer is considered the most lethal gynecologic malignancy because it is difficult to diagnose in its early stages. Ovarian malignancy prediction models may be useful in discriminating between benign and malignant masses, allowing for accurate and timely referral as well as proper therapeutic care@*Objective@#To evaluate the diagnostic performance of the four ovarian prediction models: Risk of Malignancy Index‑4 (RMI‑4), Risk of Ovarian Malignancy Algorithm (ROMA), Copenhagen Index (CPH‑I), and International Ovarian Tumor Analysis (IOTA)‑Assessment of Different NEoplasias in the AdneXa (ADNEX) in identifying malignant and benign ovarian masses@*Materials and Methods@#This was a retrospective, cross‑sectional, analytical diagnostic study in a tertiary hospital between January 2017 and December 2020. Receiver operating characteristic (ROC) curves, area under the curves (AUCs), sensitivities, specificities, positive and negative predictive values, and positive and negative likelihood ratios were used to assess the diagnostic performance of the prediction models.@*Results@#We analyzed a total of 248 patients. One hundred and sixty‑one (65%) had benign tumors, 28 (11%) had borderline, and 59 (24%) had malignant tumors. The AUCs of all models were all above 90%, but when compared to the other models, CPH‑I had the best estimate. RMI‑4 had the highest sensitivity (98.3%) in diagnosing malignancy. For appropriately diagnosing benign disease, the IOTA‑ADNEX model exhibited the highest specificity (92.1%). Overall, RMI‑4 had the lowest diagnostic accuracy (74.6%), whereas IOTA‑ADNEX had the greatest (93.2%).@*Conclusion@#The four malignancy prediction models in this study were all useful tools in discriminating between benign and malignant ovarian tumors. IOTA‑ADNEX, CPH‑I, and ROMA all demonstrated overlapping diagnostic performances indicating that they are equal in that regard. In terms of sensitivity in predicting malignancy, RMI‑4 was the most sensitive. CPH‑I is the predictor with the best overall estimate. Lastly, IOTA‑ADNEX was the most specific, and displayed highest diagnostic accuracy among the four

Transferability of the early-stage ovarian malignancy (EOM) score: an external validation study that includes advanced-stage and metastatic ovarian cancer.

PURPOSE: To validate the diagnostic performance of the Early-stage Ovarian Malignancy (EOM) score in an external dataset that includes advanced-stage and metastatic ovarian cancer. METHODS: The data from two cross-sectional cohorts were used in the statistical analysis. The development dataset of the EOM score was collected in Phrapokklao Hospital between September 2013 and December 2017. The validation dataset was collected in Maharaj Nakorn Chiang Mai Hospital between April 2010 and March 2018. The internal and external performance of the EOM score was evaluated in terms of discrimination via area under the receiver-operating characteristic curve (AuROC) and calibration. RESULTS: There were 270 and 479 patients included in the development and validation datasets, respectively. The prevalence of ovarian malignancy was 20.0% (54/270) in the development set and 30.3% (145/479) in the validation set. The EOM score had excellent discriminative ability in both the development and validation sets (AuROC 88.0 (95% CI 82.6, 93.9) and 88.0 (95% CI 84.3, 91.4), respectively). The EOM score also showed good calibration in both datasets. CONCLUSIONS: The EOM score had consistent diagnostic performance in the external validation data. It is recommended for use as a triage tool in patient referrals instead of the RMI in settings where experienced sonographers are not available.

Comparison of the four malignancy risk indices in the discrimination of malignant ovarian masses: A cross-sectional study.

OBJECTIVE: To evaluate the accuracy of the four malignancy risk indices to distinguish benign from malignant ovarian masses MATERIALS AND METHODS: This was an observational cross-sectional study conducted on 155 patients between January 2016 and January 2019. Women with ovarian masses planned for surgical management were recruited from the outpatient Gynecology clinic of the hospital. The risk of malignancy index (RMI 1-4) was calculated for all women with ovarian masses. Biopsies obtained from the ovarian masses after the surgical intervention was sent to the pathology lab for histopathological examination. The histopathologic diagnosis of the ovarian masses was considered the gold standard for diagnosis. RESULTS: The participants' mean age in the group of patients with benign masses was 33.50 ± 14.53 years versus 45.09 ± 13.67 years in the malignant group. The two most prominent features in the malignant group were solid areas in 85.3 % of malignant masses and about 91.2 % of malignant masses showing size <7 cm in their largest diameter. The RMI's most sensitive individual parameter was the CA-125 level, while the lowest sensitivity was for the menopausal status. RMI 2 had the highest sensitivity of 76.47 %, while RMI 1 and 3 had the highest specificity, 92.56 %. RMI 2 had the highest AUC, 0.83. CONCLUSIONS: RMI 2 is a simple and reliable tool and had the best performance among all RMIs in benign discrimination from malignant ovarian masses with high sensitivity and accuracy.

The Comparison of Pelvic Mass Score and Risk of Malignancy Index-3 in Discrimination of Benign and Malignant Adnexal Masses.

OBJECTIVES: Discrimination of benign and malignant adnexal masses is crucial for the follow-up and prognosis of the patient. Since each modality alone does not have enough sensitivity, the combination of all methods called multimodal screening is currently being used. In this study, we aimed to compare pelvic mass score (PMS) and the risk of malignancy index (RMI-3) scoring systems in determining the malignant potential of adnexal masses. METHODS: In this prospective observational study, 40 patients between the age of 15-79 who were diagnosed as an adnexal mass were included between March and October 2016. Patients were classified as benign (n=20) and malignant (n=20). The age, gravida, parity, findings of a pelvic examination, medical and family history, laboratory parameters, sonographic findings, histopathological results, PMS and RMI-3 scores of the patients were recorded. RESULTS: The mean age, CA-125 levels, Sassone scores and ultrasonography scores of patients were higher in malignant cases, whereas the resistance index was lower. Both RMI-3 and PMS scores were higher in the malignant group (1728.14±325.3 vs. 36.27±31.01, p<0.001 and 55.31±40.96 vs. 9.91±5.29, p<0.001, respectively). Receiver operating curve for the predictive value of PMS to diagnose malignancy was performed and a cut-off value of 14 was determined with the area under the curve (AUC) 0.955 (p<0.001). The sensitivity was 95%, specificity was 80%, positive and negative predictive values were 82.6% and 94.1%. Likewise, the discriminative value of RMI-3 to diagnose malignancy was evaluated by the ROC curve. AUC for RMI-3 was 0.930 with a sensitivity of 95%, the specificity of 75%, the positive predictive value of 79.1% and negative predictive value of 93.7% with a cut-off value of >53.2 (p<0.001). CONCLUSION: Age, menopause status, tumor markers and sonographic parameters may be beneficial alone for determining malignancy, whereas the scoring systems integrating all the parameters are more powerful. According to our findings, PMS is more sensitive and more practical than the RMI-3 scoring system.

Comparison of the predictive performance of risk of malignancy indexes 1-4, HE4 and risk of malignancy algorithm in the triage of adnexal masses.

OBJECTIVES: For patients presenting with adnexal mass, it is important to correctly distinguish whether the mass is benign or malignant for the purpose of precise and timely referral and implication of correct line of management. The objective of this study was to evaluate the performance of Risk of malignancy Indexes (RMI) 1-4, Human Epididymis Protein 4 (HE4) and Risk of Malignancy Algorithm (ROMA) in differentiating the adnexal mass into benign and malignant. METHODS: A retrospective study using 155 patients diagnosed with adnexal mass between January 2014 to December 2014 in The First Affiliated Hospital of Zhengzhou University was conducted. The patient records were assessed for age, menopausal status, serum CA125 and HE4 levels, ultrasound characteristics of the pelvic mass and the final pathological diagnosis of the mass. RMI1, RMI2, RMI3, RMI4, ROMA were calculated for each patient and the sensitivity, specificity and the Receiver Operating Characteristics (ROC) curves were determined for each test to evaluate their performance. RESULTS: Among 155 patients with adnexal masses meeting inclusion criteria, 120 (77.4%) were benign, 8 (5.2%) borderline and 27 (17.4%) were malignant. RMI2 and RMI4 had the highest sensitivity (66.7%) while HE4 had the highest specificity (96.9%).Although ROMA had the highest area under the curve (AUC) of 0.886 it was not found to be statistically superior to the other tests. For epithelial ovarian cancers, ROMA (80%), HE4 (96.9%) and RMI 4 (0.868) had the highest sensitivity, specificity and AUC respectively however, the AUC characteristics were not statistically significant between any groups. Compared to the postmenopausal group (sensitivity 72.2-77.8%) all the tests showed lower sensitivity (42.9%) for the premenopausal group of patients. CONCLUSIONS: RMI 1-4, ROMA and HE4 were all found to be useful for differentiating benign/borderline adnexal masses from malignant ones for deciding optimal therapy, however no test was found to be significantly better than the other. None were able to differentiate between benign and borderline tumors. All of the tests demonstrated increased sensitivity when borderline tumors were considered low-risk, and when only epithelial ovarian cancers were considered.

Ultrasound Features Improve Diagnostic Performance of Ovarian Cancer Predictors in Distinguishing Benign and Malignant Ovarian Tumors.

To determine whether ultrasound features can improve the diagnostic performance of tumor markers in distinguishing ovarian tumors, we enrolled 719 patients diagnosed as having ovarian tumors at Nanfang Hospital from September 2014 to November 2016. Age, menopausal status, histopathology, the International Federation of Gynecology and Obstetrics (FIGO) stages, tumor biomarker levels, and detailed ultrasound reports of patients were collected. The area under the curve (AUC), sensitivity, and specificity of the bellow-mentioned predictors were analyzed using the receiver operating characteristic curve. Of the 719 patients, 531 had benign lesions, 119 had epithelial ovarian cancers (EOC), 44 had borderline ovarian tumors (BOT), and 25 had non-EOC. AUCs and the sensitivity of cancer antigen 125 (CA125), human epididymis-specific protein 4 (HE4), Risk of Ovarian Malignancy Algorithm (ROMA), Risk of Malignancy Index (RMI1), HE4 model, and Rajavithi-Ovarian Cancer Predictive Score (R-OPS) in the overall population were 0.792, 0.854, 0.856, 0.872, 0.893, 0.852, and 70.2%, 56.9%, 69.1%, 60.6%, 77.1%, 71.3%, respectively. For distinguishing EOC from benign tumors, the AUCs and sensitivity of the above mentioned predictors were 0.888, 0.946, 0.947, 0.949, 0.967, 0.966, and 84.0%, 79.8%, 87.4%, 84.9%, 90.8%, 89.1%, respectively. Their specificity in predicting benign diseases was 72.9%, 94.4%, 87.6%, 95.9%, 86.3%, 90.8%, respectively. Therefore, we consider biomarkers in combination with ultrasound features may improve the diagnostic performance in distinguishing malignant from benign ovarian tumors.

Diagnostic extended usefulness of RMI: comparison of four risk of malignancy index in preoperative differentiation of borderline ovarian tumors and benign ovarian tumors.

BACKGROUND: This study aimed to examine the performance of the four risk of malignancy index (RMI) in discriminating borderline ovarian tumors (BOTs) and benign ovarian masses in daily clinical practice. METHODS: A total of 162 women with BOTs and 379 women with benign ovarian tumors diagnosed at the Second Affiliated Hospital of Harbin Medical University from January 2012 to December 2016 were enrolled in this retrospective study. Also, we classified these patients into serous borderline ovarian tumor (SBOT) and mucinous borderline ovarian tumor (MBOT) subgroup. Preoperative ultrasound findings, cancer antigen 125 (CA125) and menopausal status were reviewed. The area under the curve (AUC) of receiver operator characteristic curves (ROC) and performance indices of RMI I, RMI II, RMI III and RMI IV were calculated and compared for discrimination between benign ovarian tumors and BOTs. RESULTS: RMI I had the highest AUC (0.825, 95% CI: 0.790-0.856) among the four RMIs in BOTs group. Similar results were found in SBOT (0.839, 95% CI: 0.804-0.871) and MBOT (0.791, 95% CI: 0.749-0.829) subgroups. RMI I had the highest specificity among the BOTs group (87.6, 95% CI: 83.9-90.7%), SBOT (87.6, 95% CI: 83.9-90.7%) and MBOT group (87.6, 95% CI: 83.9-90.7%). RMI II scored the highest overall in terms of sensitivity among the BOTs group (69.75, 95% CI: 62.1-76.7%), SBOT (74.34, 95% CI: 65.3-82.1%) and MBOT (59.18, 95% CI: 44.2-73.0%) group. CONCLUSION: Compared to other RMIs, RMI I was the best-performed method for differentiation of BOTs from benign ovarian tumors. At the same time, RMI I also performed best in the discrimination SBOT from benign ovarian tumors.

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.

Comparison of the diagnostic accuracy of International Ovarian Tumor Analysis simple rules and the risk of malignancy index to discriminate between benign and malignant adnexal masses.

OBJECTIVE: To compare the diagnostic accuracy of International Ovarian Tumor Analysis (IOTA) simple rules and risk of malignancy index (RMI 1/RMI 2) scoring to discriminate between benign and malignant adnexal masses. METHODS: Secondary analysis of a cohort of patients scheduled for surgery for adnexal masses in a tertiary center between April 2010 and March 2018. Ultrasound examinations were performed by general gynecologists within 24 hours prior to surgery to evaluate sonographic features. Demographic data and preoperative CA 125 levels were recorded. IOTA rules and RMI scoring were applied to predict malignancy and prospectively recorded. Final diagnosis was based on pathological or intraoperative diagnosis. RESULTS: A total of 479 masses met the inclusion criteria and were retrieved from the database: 334 (69.7%) benign and 145 (30.3%) malignant. IOTA rules could be applied to 392 (81.8%) masses and were inconclusive in 87 (18.2%). Sensitivity and specificity of IOTA rules (83.8% and 92.0%, respectively) were significantly higher than RMI 1 (77.2% and 86.8%, respectively) and RMI 2 (82.1% and 82.6%, respectively). CONCLUSION: IOTA simple rules had higher diagnostic accuracy compared with RMI to discriminate between benign and malignant adnexal masses; however, nearly 20% of IOTA results were inconclusive and needed expert consultation.

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.

Comparison of ADNEX model, simple rules risk model and risk of malignancy index in diagnosis of benign and malignant ovarian tumors / 中国医学影像技术

Objective To compare the value of ADNEX model, simple rules risk model and the risk of malignancy index (RMI) in diagnosis of benign and malignant ovarian tumors. Methods The preoperative ultrasonic images of 286 patients with ovarian tumors were retrospectively analyzed. ADNEX model, simple rules risk model and RMI were used to differentiate benign and malignant ovarian tumors. Taken histopathological results after surgery as golden standards, the sensitivity and specificity were calculated and compared among 3 methods. ROC curve was used to obtain the area under the curves. Results Among 286 ovarian tumors, 142 were benign and 144 were malignant. The sensitivity of ADNEX model, simple rules risk model and RMI was 83.33% (120/144), 80.56% (116/144) and 65.97% (95/144), respectively, while the specificity was 89.44% (127/142), 92.96% (132/142) and 90.14% (128/142), respectively. There was no statistical difference of sensitivity nor specificity between ADNEX model and simple rules risk model (χ2=0.352, 1.784, P=0.554, 0.182). The sensitivity of ADNEX model and simple rules risk model was higher than that of RMI (χ2=16.691, 7.533, respectively, both P<0.001), while there was no statistical difference of specificity (χ2=0, 0.561, P=1, 0.454). The AUC of ADNEX model, simple rules risk model and RMI was 0.864, 0.868 and 0.788, respectively (all P<0.001). Conclusion ADNEX model and simple rules risk model are better than RMI in differentiating benign and malignant ovarian tumors.

Malignant risk index in evaluation of menopausal ovarian cystic and cystic-solid tumors / 中华全科医师杂志

Clinical data of 349 patients with postmenopausal ovarian cystic and cystic solid tumors undergoing surgical treatment in Beijing Obstetrics and Gynecology Hospital affiliated to Capital Medical University from May 2013 to May 2017 were retrospectively analyzed.Postoperative pathology confirmed 100 cases of malignant tumor,228 cases of benign tumor,and 21 cases of borderline tumor.The malignant risk index (RMI) score was calculated based on the preoperative pelvic ultrasound and serum CA125 level,and the score＜200 was classified as benign tumors and ≥200 as malignant tumors.The postoperative pathological results were used as gold standard,the sensitivity,specificity,accurate rate of RMI in diagnosis of malignant tumors was 0.840(84/100),0.987 (225/228) and 94.2％ (309/328),respectively.The consistency of RMI with pathological diagnosis was high (Kappa=0.858,P＜0.05).The study suggests that RMI has a high degree of credibility for the evaluation of postmenopausal ovarian cystic and cystic solid tumors.

Discriminative value of CA-125, HE4, Risk of Malignancy Index II (RMI-II) and Risk of Malignancy Algorithm (ROMA) in the differential diagnosis of pelvic masses: conclusions from a referral Centre in Portugal.

The major purpose of this article was to compare the discriminative value of different algorithms and serum biomarkers in the differential diagnosis of adnexal masses. We performed a retrospective study with 247 women with adnexal neoplasia, submitted to surgical treatment and with a histological diagnosis. The evaluation of the area under the curve (AUC) for isolated CA-125 and HE4, and for ROMA and RMI-II, showed a better specificity of HE4 and RMI-II in premenopausal women. In the postmenopausal group, ROMA and RMI-II were the algorithms with a better performance. Impact Statement What is already known on this subject? CA-125 remains the most commonly used biomarker used to predict the behaviour of an adnexal mass, but it has a low sensitivity for stage I tumours. Other isolated serum markers have emerged more recently, such as HE4, as well as more complex algorithms, such as RMI or ROMA. It remains unclear which is the best marker/algorithm to predict the behaviour of an adnexal mass. What do the results of this study add? Our findings showed that ROMA is a suitable marker for postmenopausal women, with no advantage found in the premenopausal women when compared with an isolated HE4. What are the implications of these findings for clinical practice and/or further research? The different algorithms of the preoperative discrimination of ovarian neoplasia appear to have different AUC, SN and SP in the pre- or the postmenopausal patients. For the premenopausal women, the use of ROMA does not seem to have any advantage over the isolated use of HE4, which does not lose specificity even when the borderline tumours are considered for discrimination. In the postmenopausal women, ROMA is a valid algorithm with a good sensitivity. The RMI-II showed a good performance in both groups, although it depends on the ultrasound findings and has an important interobserver variability. This information allows a more targeted selection of markers and algorithms to be requested prior to surgery of ovarian neoplasms regarding the menopausal status of each patient.