An unexpected case of an adnexal hydatid cyst in a pregnant woman: a case report.

BACKGROUND: Cystic echinococcosis, also known as hydatid disease, is a chronic and endemic illness caused by infection with a parasite called Echinococcus granulosus. In Romania, this disease has an incidence rate of 5.6 per 100,000 individuals, which is the highest in the Dobrogea region. The liver is the most affected site, accounting for 68.8% of cases, followed by the lungs at 17.2%. While cases of hydatid disease in the genital organs are rare, occurring at an incidence rate of only 0.5%, it is worth noting that cases of this disease in pregnancy worldwide are also rare, occurring at an incidence rate of 1 in 20,000 to 1 in 30,000 pregnancies. CASE REPORT: A 15-year-old Eastern-European woman who was 12 weeks pregnant presented to the emergency room with acute pelvic pain, dysuria, and frequent urination. Her laboratory tests showed that she had a urinary tract infection, and pelvic ultrasound revealed that she had a mass on her right adnexa. Despite receiving treatment, her symptoms did not improve, and she had to undergo surgery to remove the mass, which turned out to be a hydatic cyst. She also had to undergo a cesarean section to deliver her baby owing to fetal distress during labor. CONCLUSIONS: This medical case report provides a detailed description of a pelvic hydatid cyst that was discovered during pregnancy. What makes this case particularly noteworthy is the cyst's unusual location-it was found at the level of the right broad ligament of the uterus. Despite the complexity of the situation, the patient was able to receive effective treatment and the cyst was successfully managed with great outcomes for both the patient and the newborn. We hope that this report serves as a valuable example of how medical professionals can navigate challenging cases and provide optimal care for their patients.

Adnexal masses and pregnancy: a single-center experience of 9 years.

PURPOSE: This study aims to analyze the experience of a tertiary health center about the management of adnexal masses that have been diagnosed during pregnancy or detected accidentally during cesarean delivery. METHODS: This is a retrospective review of 160 women who underwent concurrent surgery for adnexal mass during cesarean section, 24 women who delivered vaginally and subsequently had surgery due to the prenatal diagnosis of adnexal mass and 10 women who underwent surgery for adnexal mass during pregnancy. Corresponding to the delivery and surgery times, 200 women who had no diagnosis of pregnancy-associated adnexal mass served as controls. RESULTS: The women in the control group and study groups had statistically similar gestational age at delivery, birth weight and preterm delivery (p > 0.05 for all). Miscarriage was significantly more frequent in women undergoing surgery for adnexal mass during pregnancy (p = 0.001). The women who had surgery for adnexal mass during pregnancy, at the time of cesarean section and following delivery were statistically similar with respect to surgery type and histopathological diagnosis (p > 0.05 for both). Malignancy was detected in none of the patients who underwent surgery for adnexal mass during pregnancy. Acute abdomen was the indication for the emergency surgery in six patients (3.5%) who had surgery for adnexal mass during pregnancy. Four patients (2.4%) had surgery for adnexal mass during pregnancy due to the high index of suspicion for malignancy. CONCLUSION: The risk of malignancy was relatively lower in this cohort of adnexal masses detected during pregnancy and cesarean delivery. Surgical management of adnexal masses should be postponed to postpartum period as such management leads to an increased risk of miscarriage. Unless there is a need for emergent surgery or cancer staging, vaginal delivery should be encouraged in women diagnosed with adnexal mass during pregnancy.

Pattern Recognition or Adnexal MR Scoring System: Which Is More Accurate in Evaluating Adnexal Lesions?

PURPOSE: This study aims to compare the accuracy of the ADNEX MR scoring system and pattern recognition system to evaluate adnexal lesions indeterminate on the US exam. METHODS: In this cross-sectional retrospective study, pelvic DCE-MRI of 245 patients with 340 adnexal masses was studied based on the ADNEX MR scoring system and pattern recognition system. RESULTS: ADNEX MR scoring system with a sensitivity of 96.6% and specificity of 91% has an accuracy of 92.9%. The pattern recognition system's sensitivity, specificity, and accuracy are 95.8%, 93.3%, and 94.7%, respectively. PPV and NPV for the ADNEX MR scoring system were 85.1 and 98.1, respectively. PPV and NPV for the pattern recognition system were 89.7% and 97.7%, respectively. The area under the ROC curve for the ADNEX MR scoring system and pattern recognition system is 0.938 (95% CI, 0.909-0.967) and 0.950 (95% CI, 0.922-0.977). Pairwise comparison of these AUCs showed no significant difference (p = 0.052). CONCLUSION: The pattern recognition system is less sensitive than the ADNEX MR scoring system, yet more specific.

Comparison of the ADNEX and ROMA risk prediction models for the diagnosis of ovarian cancer: a multicentre external validation in patients who underwent surgery.

BACKGROUND: Several diagnostic prediction models to help clinicians discriminate between benign and malignant adnexal masses are available. This study is a head-to-head comparison of the performance of the Assessment of Different NEoplasias in the adneXa (ADNEX) model with that of the Risk of Ovarian Malignancy Algorithm (ROMA). METHODS: This is a retrospective study based on prospectively included consecutive women with an adnexal tumour scheduled for surgery at five oncology centres and one non-oncology centre in four countries between 2015 and 2019. The reference standard was histology. Model performance for ADNEX and ROMA was evaluated regarding discrimination, calibration, and clinical utility. RESULTS: The primary analysis included 894 patients, of whom 434 (49%) had a malignant tumour. The area under the receiver operating characteristic curve (AUC) was 0.92 (95% CI 0.88-0.95) for ADNEX with CA125, 0.90 (0.84-0.94) for ADNEX without CA125, and 0.85 (0.80-0.89) for ROMA. ROMA, and to a lesser extent ADNEX, underestimated the risk of malignancy. Clinical utility was highest for ADNEX. ROMA had no clinical utility at decision thresholds <27%. CONCLUSIONS: ADNEX had better ability to discriminate between benign and malignant adnexal tumours and higher clinical utility than ROMA. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov NCT01698632 and NCT02847832.

Ultrasonographic diagnosis of adnexal masses: interobserver agreement in the interpretation of videos, using IOTA terminology.

OBJECTIVES: Aim of this study is to estimate interobserver agreement in classifying adnexal tumors using IOTA terms, simple rules and subjective assessment. In addition, we related observers' accuracy with their experience in gynecological ultrasonography and the year of IOTA certification. METHODS: Eleven observers with three different levels of experience evaluated videoclips of 70 adnexal masses, defining tumor type according to IOTA terms and definitions, classifying the mass using IOTA Simple rules and Subjective assessment as well as providing Color Score evaluation. Sensitivity, specificity and area under the ROC curve were calculated and the year of IOTA certification was related with operators' accuracy through Pearson correlation coefficient. Interobserver agreement was estimated calculating percentage of agreement, Fleiss kappa and Cohen's kappa. RESULTS: We found a positive correlation between the year of IOTA certification and operators' accuracy (Pearson coefficient 0.694), especially among the observers with the least experience, the residents (p = 0.003). For tumor type classification, identification of papillary projections and classification of tumors using subjective assessment, agreement among all observers was moderate (Fleiss kappa 0.455, 0.552, and 0.476, respectively) and increased with the years of experience. Agreement in the application of Simple Rules was moderate in all examiners with IOTA certification, with Fleiss kappa in the range of (0.403, 0.498). For Color Score assignment interobserver agreement among all observers was fair (Cohen's kappa 0.380). CONCLUSIONS: Even among expert examiners, the results of adnexal lesion assessment can be inconsistent. Experience impacts on accuracy and agreement in subjective assessment, while the application of Simple Rules can mitigate the role of experience in interobserver agreement. The knowledge of IOTA models among residents seams to improve their diagnostic accuracy, showing the benefits of IOTA terminology for in training sonographers.

Shift towards minimally invasive surgery of adnexal pathologies in children: A predictive model study.

OBJECTIVE: The purpose of this article is to investigate these difficulties and to provide a modernized and comprehensive understanding of the diagnosis, management, and long-term outcomes of adnexal masses in pediatrics. SUBJECTS AND METHODS: This study retrospectively reviewed the medical records of 428 patients who were diagnosed with adnexal pathologies and underwent Surgery. RESULTS: In pre-adolescents, the duration of symptoms shows a statistically significant positive correlation with lesion size (p=0.006, r=0.621). The duration of symptoms shows a statistically significant positive correlation with lesion size (p<0.001, r=0.460). The formula is a mathematical model developed to predict the size of a lesion (a cyst or mass) in centimeters, based on the duration of the patient's symptoms in months. For mass size, the optimal cut-off was found to be 4.5 cm. This value yielded a higher AUC of 0.85 (95% CI:0.74-0.96), with a sensitivity of 94% and a specificity of 55%. CONCLUSIONS: This study on adnexal pathologies in children indicates a shift towards minimally invasive laparoscopic surgery. A novel model predicting lesion size based on symptom duration was developed, and surgical intervention thresholds were established.

Adnexal torsion in childhood and adolescence.

The incidence of adnexal torsion in childhood and adolescence is 4.9 per 100,000 girls. Torsion of the adnexa is caused by rotation of the ovary usually with the fallopian tube around the infundibulopelvic ligament. The torsion leads primarily to the interruption of both venous outflow and lymphatic drainage. It causes enlargement of the ovary due its edema with occurrence of hemorrhagic infarctions. Interruption of the arterial inflow leads finally to the necrosis of ovarian tissue. Torsion of the adnexa in childhood occurs usually in enlarged ovary, particularly by a cyst, or when the non-enlarged ovary is excessively mobile due to the extended infundibulopelvic ligament. The characteristic clinical symptoms of adnexal torsion are sudden pain in the lower abdomen with nausea and vomiting. The dia-gnosis of adnexal torsion is based on the typical symptoms, clinical course, and the results of physical and ultrasound examinations. Torsion of the adnexa should be considered in every girl with sudden abdominal pain. To preserve reproductive functions, an early surgery with detorsion of the adnexa should be performed.

Evaluating the risk of malignancy in adnexal masses: validation of O-RADS and comparison with ADNEX model, SA, and RMI.

OBJECTIVES: To evaluate the diagnostic value of Ovarian-adnexal Reporting and Data System (O-RADS), and to compare it with Assessment of Different NEoplasias in the adnexa (ADNEX) model, Subjective Assessment (SA), and Risk of Malignancy Index (RMI) in differentiating benign and malignant adnexal masses (AMs). MATERIAL AND METHODS: Ultrasound characteristics of 445 patients included in the study were retrospectively analyzed and evaluated using diagnostic models. The diagnostic performances of ultrasound diagnostic models were measured by assessing, receiver-operating characteristic curves, sensitivities, positive predictive values, positive likelihood ratios, specificities, negative predictive values, and negative likelihood ratios. Kappa values were used to evaluate inter-reviewer agreement (IRA). RESULTS: Of the 445 AMs, 265 were benign and 180 were malignant. The area under the curve (AUC) of O-RADS (0.941), ADNEX model (0.925), and SA (0.931) were higher than RMI (0.815) (all p < 0.05). The sensitivity of O-RADS (93.3%), ADNEX model (94.4%), and SA (96.1%) were higher than RMI (70.6%) (p > 0.05), and there was no statistical significance among them (p > 0.05). The specificity of O-RADS, ADNEX model, SA, and RMI was 90.2%, 90.6%, 90.2%, and 92.5%, respectively, with no statistical significance (p > 0.05). All four ultrasound diagnostic methods showed better IRA. CONCLUSIONS: O-RADS, ADNEX model and SA have better diagnostic value in differentiating benign and malignant AMs than RMI.

A reflex testing protocol using two multivariate index assays improves the risk assessment for ovarian cancer in patients with an adnexal mass.

OBJECTIVES: Patients with adnexal masses suspicious for malignancy benefit from referral to oncology specialists during presurgical assessment of the mass. OVA1 is a multivariate assay using a five-biomarker panel which offers high overall and early-stage sensitivity. However, OVA1 has a high false-positive rate for benign masses. Overa, a second-generation multivariate index assay was developed to reduce the false-positive rate. The aim of the present study was to use Overa as a reflex for OVA1 and increase specificity. METHODS: OVA1 cut-off scores were established to place patients into three categories: low, intermediate, and high cancer risk. Samples with intermediate-risk OVA1 scores were reflexed to the Overa and defined as high or low risk. This protocol was tested with 1035 prospectively collected serum samples and validated with an independent prospectively collected sample set (N = 207). RESULTS: Thirty-five per cent (359) of samples had intermediate OVA1 scores. Reflexing these to Overa eliminated 58% of the false-positives and improved the overall specificity from 50% to 72%. This finding was confirmed in the independent dataset, in which the specificity increased from 56% to 73%. CONCLUSIONS: Reflexing samples with intermediate OVA1 scores significantly decreases the false-positive rate, thereby reducing unnecessary surgical referrals.

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.

Value of the Copenhagen index in the diagnosis of malignant adnexal tumors: A meta-analysis.

Ovarian cancer is a common gynecological malignant tumor. Early diagnosis is important for the prognosis of patients with ovarian cancer. To evaluate the accuracy of the Copenhagen Index (CPH-I) in detecting malignant adnexal tumors and to compare the diagnostic accuracy of CPH-I and the Risk of Ovarian Malignancy Algorithm (ROMA). PubMed, Web of Science, and Cochrane Library databases were used to retrieve eligible studies. The overall sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the (summary receiver operating characteristic) curve (AUC) were 0.81, 0.88, 6.61, 0.22, 30.43, and 0.91, respectively, in diagnosing malignant adnexal tumors. In addition, using ROMA, the sensitivity, specificity, and AUC were 0.83, 0.85, and 0.90, respectively. CPH-I showed high accuracy in diagnosing malignant adnexal tumors, which could be an alternative method with similar efficacy to ROMA. CPH-I was more advantageous in diagnosing adnexal tumors in postmenopausal women.

External Validation of the Ovarian-Adnexal Reporting and Data System (O-RADS) Lexicon and the International Ovarian Tumor Analysis 2-Step Strategy to Stratify Ovarian Tumors Into O-RADS Risk Groups.

Importance: Correct diagnosis of ovarian cancer results in better prognosis. Adnexal lesions can be stratified into the Ovarian-Adnexal Reporting and Data System (O-RADS) risk of malignancy categories with either the O-RADS lexicon, proposed by the American College of Radiology, or the International Ovarian Tumor Analysis (IOTA) 2-step strategy. Objective: To investigate the diagnostic performance of the O-RADS lexicon and the IOTA 2-step strategy. Design, Setting, and Participants: Retrospective external diagnostic validation study based on interim data of IOTA5, a prospective international multicenter cohort study, in 36 oncology referral centers or other types of centers. A total of 8519 consecutive adult patients presenting with an adnexal mass between January 1, 2012, and March 1, 2015, and treated either with surgery or conservatively were included in this diagnostic study. Twenty-five patients were excluded for withdrawal of consent, 2777 were excluded from 19 centers that did not meet predefined data quality criteria, and 812 were excluded because they were already in follow-up at recruitment. The analysis included 4905 patients with a newly detected adnexal mass in 17 centers that met predefined data quality criteria. Data were analyzed from January 31 to March 1, 2022. Exposures: Stratification into O-RADS categories (malignancy risk <1%, 1% to <10%, 10% to <50%, and ≥50%). For the IOTA 2-step strategy, the stratification is based on the individual risk of malignancy calculated with the IOTA 2-step strategy. Main Outcomes and Measures: Observed prevalence of malignancy in each O-RADS risk category, as well as sensitivity and specificity. The reference standard was the status of the tumor at inclusion, determined by histology or clinical and ultrasonographic follow-up for 1 year. Multiple imputation was used for uncertain outcomes owing to inconclusive follow-up information. Results: Median age of the 4905 patients was 48 years (IQR, 36-62 years). Data on race and ethnicity were not collected. A total of 3441 tumors (70%) were benign, 978 (20%) were malignant, and 486 (10%) had uncertain classification. Using the O-RADS lexicon resulted in 1.1% (24 of 2196) observed prevalence of malignancy in O-RADS 2, 4% (34 of 857) in O-RADS 3, 27% (246 of 904) in O-RADS 4, and 78% (732 of 939) in O-RADS 5; the corresponding results for the IOTA 2-step strategy were 0.9% (18 of 1984), 4% (58 of 1304), 30% (206 of 690), and 82% (756 of 927). At the 10% risk threshold (O-RADS 4-5), the O-RADS lexicon had 92% sensitivity (95% CI, 87%-96%) and 80% specificity (95% CI, 74%-85%), and the IOTA 2-step strategy had 91% sensitivity (95% CI, 84%-95%) and 85% specificity (95% CI, 80%-88%). Conclusions and Relevance: The findings of this external diagnostic validation study suggest that both the O-RADS lexicon and the IOTA 2-step strategy can be used to stratify patients into risk groups. However, the observed malignancy rate in O-RADS 2 was not clearly below 1%.

Surgical disorders in pediatric and adolescent gynecology: Adnexal abnormalities.

Surgical abnormalities of the adnexa in children and adolescents include a variety of ovarian and paraovarian lesions ranging from benign functional cysts to malignant tumors, torsion of the ovary and/or the fallopian tube, and adnexal infectious lesions ranging from salpingitis to tubo-ovarian abscesses. Presentations vary from asymptomatic pelvic masses to acute abdomen, and some ovarian tumors might present with precocious puberty or virilization. Acute pain might be caused by hemorrhage or rupture of ovarian or paraovarian cysts, adnexal torsion or adnexal infection. Differential diagnosis of adnexal masses should include peri-appendiceal abscess in all age groups, and endometriomas and ectopic pregnancy in adolescents. This review provides guidance on the differentiation between adnexal abnormalities, based on important clues from clinical assessment and diagnostic workup, and ultimately on the decision making about the need for surgery, its level of urgency, and the type of surgery to clinicians of all specialties involved in the care of young females.

Rethinking ovary preservation by adnexal torsion reversal in adolescents: a case of delayed diagnosis.

BACKGROUND: This article discusses the management of an adolescent woman with a delayed diagnosis of adnexal torsion (AT) whose ovaries were successfully preserved. CASE PRESENTATION: The patient was a 14-year-old female teen admitted with the chief complaint of lower abdominal pain for 3 days and worsening pain for 2 days. Magnetic resonance imaging suggested a high possibility of torsion in the anterosuperior uterine mass and was accompanied by severe ovarian edema, bleeding, and enlargement. Intraoperatively, the left fallopian tube was characterized by thickening and torsion and appeared blackish purple. The left fallopian tube paraovarian cyst was about 20 cm in size, and the left adnexa was twisted 1080° along the left infundibulopelvic ligament (suspensory ligament of the left ovary). The left ovary appeared blackish purple, with an enlarged diameter of about 10 cm. At the request and with the informed consent of the patient's parents, we preserved the left ovary and removed the left fallopian tube. The results of the endocrine, ultrasound, and tumor marker tests were normal 1 month after surgery. Follicles and blood flow signals seen in ultrasound examinations indirectly proved the successful preservation of the left ovary in the follow-up. CONCLUSIONS: Our attempt to preserve the ovaries in an adolescent with a delayed diagnosis of AT was successful.

Comparison of diagnostic efficiency between IOTA LR2 model and doctors' experiences. / IOTA LR2模型与医师经验诊断效能的比较.

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

A cavernous hemangioma of infundibulopelvic vessels presenting as an adnexal tumor: A rare case report and literature review.

RATIONALE: Female reproductive organ angiomas are rarely reported and are accidentally found during surgery. Angiomas arising from infundibulopelvic vessels presenting as adnexal masses are even rarer, and a few doctors have experience in their management. PATIENTS MAIN CONCERNS AND IMPORTANT CLINICAL FINDINGS: Herein, we report the case of a 40-year-old woman who was admitted after a physical examination revealed an ovarian mass. The physical examination revealed a palpable adnexal mass in the right pelvic cavity. Ultrasound showed a 4.5 × 4.0 × 5.0 cm space-occupying lesion close to the right ovary, which had many echogenic lines and calcifications in its cystic cavity. PRIMARY DIAGNOSIS: Right adnexal mass. INTERVENTIONS: Laparoscopic surgery was performed in all the patients. During the surgery, the mass was found to be a retroperitoneal hemangioma with distorted and dilated vessels. We separated the right infundibulopelvic vessels and performed tumor resection with minimal blood loss. OUTCOMES: The patient recovered well, and no abnormalities were observed during the following 2 years. Pathological results showed that this adnexal mass was a type of cavernous hemangioma arising from the infundibulopelvic vessels. LESSONS: Surgical removal of the affected tissues is an aggressive treatment of choice for cavernous hemangiomas. Laparoscopic resection of infundibulopelvic hemangioma is feasible, and gynecologists are qualified for this operation, as long as damage to the iliac vessels is avoided.

Clinical Performance of a Multivariate Index Assay in Detecting Early-Stage Ovarian Cancer in Filipino Women.

This study evaluated the clinical performance and overall utility of a multivariate index assay in detecting early-stage ovarian cancer in a Filipino population. This is a prospective cohort study among Filipino women undergoing assessment for an ovarian mass in a tertiary center. Patients diagnosed with early-stage ovarian cancer and who underwent a physical examination before level III specialist ultrasonographic and Doppler evaluation, multivariate index assay (MIA2G), and surgery for an adnexal mass were included in this study. Ovarian tumors were classified as high-risk for malignancy based on the IOTA-LR2 score. The ovarian imaging and biomarker results were correlated with the reference standard: surgico-pathologic findings. The MIA2G exhibited the best overall performance among individual classifiers with a sensitivity of 91.7% and NPV of 84.7%, with a concomitant higher sensitivity in early-stage disease, whether as an individual classifier (93.5%) or in serial combination with ultrasound (85.5%). The performance of biomarkers (specificity, positive predictive values, and AUROC) such as MIA2G and CA-125 significantly improved when combined with an ultrasound risk scoring approach (p < 0.01). MIA2G showed a higher sensitivity for detecting lesions among EOC and late-stage ovarian cancers than otherwise. The application of biomarkers for evaluating ovarian masses in our local setting is secondary to ultrasound but adopting multivariate index assays rather than CA-125 would increase the detection of early-stage ovarian cancers regardless of menopausal status. This is most relevant in areas where level III sonographers or gynecologic oncologists are limited and preoperative referrals to these specialists can improve the survival of our patients.

Adnexal torsion: a review of diagnosis and management strategies.

PURPOSE OF REVIEW: Adnexal torsion remains a diagnostic challenge heavily reliant on high clinical suspicion, with patient presentation and imaging used as adjuncts to aid in its diagnosis. This review summarizes diagnostic and management techniques of adnexal torsion to assist providers when encountering this surgical emergency. RECENT FINDINGS: Common findings of adnexal torsion include abdominal pain, nausea, vomiting, and adnexal mass or ovarian enlargement. An elevated neutrophil to lymphocyte ratio may be useful for diagnosis. A 'whirlpool' sign, 'follicular ring' sign, enlarged/edematous ovary, and absent Doppler flow to the ovary are highly suggestive of adnexal torsion. Intraoperative visual diagnosis of ovarian death is highly inaccurate, with only 18-20% of ovaries necrotic on pathological examination. Necrotic appearing ovaries have been shown to have follicular activity on ultrasound one year postoperatively. SUMMARY: Pelvic ultrasound remains the first-line imaging modality. In patients of reproductive age, we recommend performing detorsion with ovarian conservation, even in cases where the tissue appears necrotic, given poor intraoperative diagnostic rates of tissue death. Retention of ovarian function is also reliant on a timely diagnosis and intervention. We emphasize that the risk of ovarian damage/loss outweigh the risk of a diagnostic laparoscopy in patients of reproductive age.

Extramedullary haematopoiesis presenting as an adnexal mass in a patient with ß-thalassaemia.

Solid masses of the ovaries raise the suspicion of malignancy or metastasis and require histological diagnosis. Extramedullary haematopoesis (EMH) is a rare histological finding of a mass of the adnexa. The sonographic pattern of EMH has rarely been described in the literature. Transvaginal biopsy of EMH has not been reported in the literature. We present a case of adnexal EMH in a patient affected with ß-thalassaemia, and we performed a narrative review. Only in our case, the sonographic pattern was described, and a transvaginal ultrasound-guided core biopsy was used. Assessing patients' medical history and correlating it to the findings of diagnostic imaging is of paramount importance when evaluating patients with adnexal masses. The correct interpretation of sonographic images can avoid unnecessarily invasive procedures. A transvaginal biopsy could be a safe, easy and well-tolerated method to gain definite histological diagnosis in cases where a primary ovarian malignancy is not suspected.