Adnexal masses are tumors which may be located either in the ovary or the fallopian tubes or the surrounding connective tissue, i.e. mesosalpinx, the mesovarian section and the broad ligament. It is a common gynecological issue. Thus a previous determination of the benignancy or malignancy risk is essential for a subsequently careful management. There is a variety of radiological approaches, biomarkers or clinically pre-surgical procedures and predictive models studied and validated all over the world in order to differentiate the etiology of adnexal masses. Dr. J. Kaijser and his clinical research team conducted a systematic review and meta-analysis over the use of mathematically predictive models of diagnosis beforehand of adnexal masses. Nowadays the analysis of different studies and systematic reviews prove that both IOTA LR2 and Simple Rules are the best diagnostic approaches available in the preoperatively differentiation of both benign and malignant adnexal masses. Such disquisition is vitally important for women of reproductive age, as it deals with fertility preservation. Furthermore, having obtained predictive outcomes over benign diseases, women are more likely to be treated by obstetrician-gynecologists (OB-GYN) or in general hospitals and patients given a diagnostically suspected malignancy would be referred to and treated by gynecologic oncologists.

Keywords: Adnexal mass, predictive model, ovarian cancer

Adnexal masses are tumors which may be located either in the ovary or the fallopian tubes or the surrounding connective tissue, i.e. mesosalpinx, mesovarian section and broad ligament, being a relatively common gynecological issue. When a woman is diagnosed with an adnexal mass adnexal, it is very important for doctors to define whether they are dealing with a benign illness, i.e. endometriosis, cystadenomas -among others- or an ovary cancer since the illness treatment and prognosis drastically change in both cases. According to the last 2010-2012 Metropolitan Lima Cancer Record, the ovary cancer is placed ninth among the most common tumors affecting female population in Peru, with a 7.73 Standardized Age Rate out of 100,000 women and a 3.57 Mortality Rate out of 100,000 women.¹ Women diagnosed with ovary cancer have subtle and unspecified symptoms such as abdominal pain, polaquiuria, intestinal discomfort, which makes ovary cancer diagnosis difficult.^2,3

In the last few years in many countries clinical guides to cancer treatment recommend that patients with adnexal masses and posing a high malignancy risk are to be referred to a gynecologic oncologist.⁴ A wide variety of radiological procedures, biomarkers or clinically pre-surgical procedures have been studied and validated worldwide in order to differentiate benign adnexal masses from those in suspicious cancer.⁵ Different studies have proven that survival rates for patients with initially ovarian cancer are better when the surgery is carried out by a gynecologic oncologist.^6–10

Different predictive models of diagnosis help doctors to make a suitable triage in order to decide on the best treatment. However, neither of them has been universally accepted by clinically everyday practice. In fact, clinical guides of the National Institute of Clinical Excellence and Royal College of Obstetrics and Gynecology suggest utilizing the Risk of Malignancy Index (RMI) as a primarily diagnostic tool in the United Kingdom. Whereas in other countries, the use of biomarkers in combination with algorithms is strongly recommended such as the ROMA -Risk of Ovarian Malignancy Algorithm- one in clinical practice. Other guides suggest utilizing ultrasound screening and clinical models, i.e. IOTA - LR2.^11,12

The aim of the article herein is to update different diagnostic approaches for the pre-surgical assessment of adnexal masses.

Results suggest that the 3D-ultrasound screening has better sensitivity and specificity in relation to that of the 2D one.¹³ The adnexal mass assessment by performing a color Doppler study does not have a bigger sensitivity or specificity than that of simple ultrasonography. Furthermore, an exact diagnosis only based on Doppler studies may derive on distortion of the results due to superimposition of vascular parameters between malign and benign masses.¹⁴

Of all imaging methods, MRI has the best results, however with no significant difference in relation to CAT scan technology. On the other hand, the CA 125 screening measurement is the least reliable among the different assessment methods due to variations shown in pre- and post-menopausal women even if they are suffering from malign or benign illnesses.^15,16

Dr. J. Kaijser and his clinical research team conducted a systematic review and meta-analysis over the use of mathematically predictive models of presurgical diagnosis of adnexal masses (Table 1).¹⁷ All predictive models were classified on the basis of type of model, i.e. morphologically scoring systems, Risk of Malignancy Index -RMI, logistical regression as well as ultrasound ruling and biomarking-ROMA. Table 2 below shows sensitivity and specificity of the various models with their different cut sections and a 95%- confidence interval. Unlike other models, ROMA takes account of different cut sections for pre- and post-menopausal patients. In addition, such values change by being subject to the type of kit utilized in the measurement of serum CA125 and HE4 levels (Chart 3).

The Simple Rules ultrasound study and the IOTA LR2 logistical regression had the best results over sensitivity and specificity. Subjectivity and dependence on the ultrasound operators experience and skill are part of the criticisms leveled at the transvaginal ultrasonography as a diagnostic approach to women with adnexal masses. Thus the International Ovarian Tumor Analysis -IOTA- was aimed at solving such issue apart from developing models and rules that enable less experienced operators to copy the "experts’" results. The IOTA study developed simple rules and mathematical models based on logistical regression (LR 1-2), which are very easy to utilize in clinical practice in order to assess the malignancy risk of adnexal masses.¹⁸ Such models have been externally and exploratively validated by achieving extremely good outcomes, that is to say, close to those obtained by an expert ultrasound operator (Table 3).

IOTA assessment model

(http://www.iotagroup.org/adnexmodel/site%20iota.html)

1. Age of patient (years)
2. Referral Oncology Center
3. Maximal diameter of lesion (mm)
4. Maximum diameter of solid part (mm)
5. More than 10 locules
6. Number of papillary projections
7. Acoustic shadows present
8. Ascites
9. CA125 (U/ml) 

All required data are input to a calculator and the following risks are detected: Chance of Benign Tumor

Risk of Malignancy:

1. Risk of Borderline
2. Risk of EC I Ovary Cancer
3. Risk of EC II. IV Ovary Cancer
4. Risk of Metastasis

It is worth mentioning that almost all existing diagnosis approaches -including IOTA LR2 and Simple Rules- are based on patients scheduled for surgical treatment and they utilize the finally histological outcome as their reference standard. There is no information available in relation to the group of women who were conservatively observed or managed and the final outcome of likely complications or malign transformation of the adnexal mass such as rupture, twisting, hemorrhage, etc.

Nowadays the review of different studies and systematic research prove that both IOTA LR2 and Simple Rules are the best diagnosis approaches available in order to differentiate benign and malign adnexal masses beforehand. Such disquisition is vitally important for women of reproductive age, as it deals with fertility preservation. Furthermore, having obtained predictive outcomes over benign diseases, women are more likely to be treated by obstetrician-gynecologists (OB-GYN) or in general hospitals and patients given a diagnostically suspected malignancy would be referred to and treated by gynecologic oncologists.

None.

The authors declare no conflicts of interest.

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