Embarazo y tumor anexial: tratamiento laparoscópico con minilaparotomía. Reporte de caso y revisión bibliográfica / Pregnancy and annexal mass; laparoscopic with minilaparotomy management. Case report and literature review

Resumen ANTECEDENTES: Los tumores anexiales durante el embarazo requieren una conducta terapéutica segura para la madre y el feto, por lo que el obstetra debe tener claro cuándo la opción quirúrgica es la indicada y cuál la menos agresiva para la madre y el feto. Describir la implementación de la laparoscopia con minilaparotomía en un caso de tumor anexial en el embarazo puede contribuir a conocer las ventajas y desventajas de la estrategia quirúrgica de estos casos. CASO CLÍNICO: Paciente de 29 años, 70 kg de peso, talla de 1.61 m e IMC 27 en curso de las 16 semanas de embarazo, que acudió al servicio de Urgencias debido a un dolor abdominal. Ante la persistencia del síntoma se estableció el diagnóstico de síndrome doloroso abdominal, secundario a un tumor anexial gigante. Se programó para una laparoscopia diagnóstica y operatoria con minilaparotomía. Se dio de alta del hospital a las 24 horas posteriores a la cirugía y el embarazo finalizó a las 39 semanas. METODOLOGÍA: Búsqueda retrospectiva de artículos publicados durante los últimos diez años e indizados en la base de PubMed con los MeSH: adnexal masses pregnancy, adnexal masses pregnancy and laparoscopic surgery. RESULTADOS: Se incluyeron 34 artículos de revisión, 8 reportes de caso y un editorial, estos últimos 9 se consideraron cuando proveyeron información relevante para el conocimiento de una técnica quirúrgica. Se eliminaron los artículos en los que se utilizó cirugía asistida por robot o técnica con uso de orificios naturales (NOTES), revisiones que fueran exclusivas de patología oncológica, así como casos en niñas, al no disponer de esta tecnología en nuestro medio o no estar en etapa reproductiva, podría incurrirse en un riesgo de transferencia. Así mismo, se eliminaron los artículos sin explicación de las ventajas de la técnica propuesta. CONCLUSIÓN: En pacientes embarazadas con tumor anexial gigante, la laparoscopia con minilaparotomía es una opción de tratamiento segura para el feto y la madre. Con esta técnica se consigue una rápida recuperación, disminución de los riesgos de lesión uterina, pronta reintegración a la vida cotidiana y un buen desenlace cosmético.

Abstract BACKGROUND: Adnexal tumors during pregnancy require safe therapeutic behavior for the mother and the fetus, so the obstetrician must be clear when the surgical option is indicated and within the approach which would be less aggressive for the fetal-maternal binomial. Describing the implementation of laparoscopy with mini laparotomy in a case of adnexal tumor in pregnancy can contribute to understanding the advantages and disadvantages of the surgical strategy in these cases. CLINICAL CASE: Patient aged 29 years, weight 70 kg, height 1.61 m and BMI 27 in the course of 16 weeks of pregnancy, who attended the emergency department due to abdominal pain. Given the persistence of the symptom, a diagnosis of painful abdominal syndrome secondary to a giant adnexal tumour was established. She was scheduled for diagnostic and operative laparoscopy with mini-laparotomy. She was discharged from hospital 24 hours after surgery and the pregnancy ended at 39 weeks. METHODOLOGY: A literature search of the last 10 years was performed in Pubmed under the MeSH terms: adnexal masses pregnancy, adnexal masses pregnancy and laparoscopic surgery. RESULTS: Thirty-four review articles, eight case reports and one editorial were included, the latter nine were considered when they provided information relevant to the knowledge of a surgical technique. We eliminated articles in which robot-assisted surgery or a technique using natural orifices (NOTES) was used, reviews that were exclusive to oncological pathology, as well as cases in girls, as this technology was not available in our environment or they were not in the reproductive stage, which could incur a risk of transfer. Likewise, articles that did not explain the advantages of the proposed technique were eliminated. CONCLUSION: In pregnant patients with giant adnexal tumours, laparoscopy with mini-laparotomy is a safe treatment option for the foetus and the mother. This technique achieves a rapid recovery, reduced risk of uterine injury, early reintegration into daily life and a good cosmetic outcome.

Value of MRI Ovarian-Adnexal Reporting and Data System in Differentiating Benign and Malignant Ovarian-Adnexal Lesions / 中山大学学报(医学科学版)

ObjectiveTo explore the value of MRI ovarian-adnexal reporting and data system （O-RADS MRI） in differentiating benign and malignant ovarian-adnexal masses.MethodsTotally 146 patients （202 masses） with ovarian-adnexal lesions who underwent pelvic examination at 3.0 T MRI according to standardized scan protocol of O-RADS MRI and were pathologically confirmed in The First Affiliated Hospital of Sun Yat-sen University between January 2020 and February 2022 were retrospectively analyzed. Two radiologists classified the ovarian-adnexal masses as risk levels 1~5 according to O-RADS MRI and evaluated their consistency by Cohen’s kappa. Using pathological findings as the gold standard， the detection yield of malignant lesions with O-RADS MRI classification was analyzed. Sensitivity， specificity， accuracy， and the area under the receiver operating characteristic curve were calculated （cutoff for malignancy， score ≥ 4）.ResultsOf 202 masses， 62 （30.7%） were malignant， 140 （69.3%） were benign. The two radiologists presented good agreement in O-RADS MRI classification of ovarian adnexal masses （Kappa=0.932）. The malignancy rates of masses with scores of 1， 2， 3， 4 and 5 were 0%， 0%， 7.7%， 95%， 97.6%， respectively. Sensitivity， specificity， accuracy， and the area under the receiver operating characteristic curve were 96.8% （60/62）， 98.6% （138/140）， 98.0% （198/202）， 0.977.ConclusionsO-RADS MRI yields high diagnostic efficiency for benign and malignant ovarian adnexal masses and its widespread implementation will improve communication between radiologists and clinicians， and facilitate optimal patient management. Therefore， O-RADS MRI warrants widespread use in clinical setting.

Laparoscopic Management Of Adnexal Mass

Background:Laparoscopy is a widely used procedure in gynecological cases both for diagnostic and operative procedures. It is recommended due to lesser hospital stay, less post operative pain and better panoramic vision. Aim of the study is to assess the effectiveness of laparoscopic intervention of adnexal masses with benign pathology in recent series of consecutive patient. The focus is on pathology findings, length of stay, operating time, complications and laparotomy conversion rate. Material And Methods: This was a prospective observational study conducted at tertiary care hospital in Department of Obstetrics & Gynaecology during period of 1stAugust 2018 to 31st July 2020.This study consists of 70 patients, who presented with symptoms like pain in abdomen, bleeding per vaginum, irregular menses, excessive white discharge, distension of abdomen, infertility visiting outdoor patient department either diagnosed clinically(sign and symptoms) or by ultrasonography of adnexal masses. Result:Maximumpatients in this study were in age group 21-30 years. Maximum patients(21.42%)were having simple cyst. Among laparoscopic procedure most common procedure was left ovarian cystectomy(38.57%). Mean operative duration was 40.78 min and average duration of hospital stay was 3 days. There were minimal peri-operative complications; commonest being postoperative fever. Conclusion:Ade quatesurgical skill, case selection, multi disciplinary team approach and expert laproscopic surgical team are imperative for good patient outcome. This study gives an overview of experience in favour of laproscopic management of benign adnexal mass

Malignidad o no de las masas anexiales de gran tamaño. Reporte de caso / Malignancy or not of large adnexal masses. Case report

Resumen ANTECEDENTES: Una masa anexial es una prominencia de localización cercana, o relacionada con los órganos reproductores femeninos y sus tejidos circundantes. En la práctica clínica, las masas anexiales representan un dilema en cuanto a su diagnóstico y tratamiento. El diagnóstico suele ser fortuito, luego de un hallazgo en el examen ginecológico o en estudios de imagen. CASO CLÍNICO: Paciente de 29 años, con antecedentes de tres embarazos, dos partos y un aborto, sin comorbilidades asociadas. El último parto se registró en enero del 2021. Acudió a consulta debido a un cuadro de dolor en la parte inferior del abdomen, tipo cólico, de intensidad progresiva 7/10 en la escala visual análoga, irradiado a la zona lumbar, asociado con episodios eméticos, sin ningún otro síntoma, de una semana de evolución. Al ingreso a Urgencias sus condiciones generales se estimaron aceptables: hidratada, álgica, sin alteraciones cardiacas ni pulmonares, sin afectación neurológica ni adenopatías. CONCLUSIONES: Es importante individualizar cada caso, determinar las características ecográficas y llevar a cabo un tratamiento escalonado conforme a la respuesta clínica de las pacientes. La bibliografía y este reporte comprueban la utilidad de los nuevos índices propuestos por la IOTA para el cálculo del riesgo de malignidad de masas complejas anexiales. En este reporte de caso se logra observar una correcta relación entre la sospecha preoperatoria y el desenlace histológico final.

Abstract BACKGROUND: An adnexal mass is a prominence of location close to, or related to, the female reproductive organs and their surrounding tissues. In clinical practice, adnexal masses represent a diagnostic and treatment dilemma. Diagnosis is usually fortuitous, following a finding on gynecological examination or imaging studies. CLINICAL CASE: 29-year-old patient, with a history of three pregnancies, two deliveries and one miscarriage, with no associated comorbidities. The last delivery was recorded in January 2021. She came for consultation due to a picture of pain in the lower abdomen, colic type, of progressive intensity 7/10 on the visual analog scale, radiating to the lumbar area, associated with emetic episodes, without any other symptoms, of one week of evolution. On admission to the emergency department, her general condition was considered acceptable: hydrated, energetic, without no cardiac or pulmonary alterations, without neurological involvement or lymphadenopathies. CONCLUSIONS: It is important to individualize each case, determine the ultrasound characteristics and carry out a stepwise treatment according to the clinical response of the patients. The literature and this report prove the usefulness of the new indexes proposed by IOTA for the calculation of the risk of malignancy of complex adnexal masses. In this case report a correct relationship between preoperative suspicion and final histologic outcome is observed.

Curva de aprendizaje para el diagnóstico ecográfico específico de masas anexiales / Learning curve for the specific ultrasound diagnosis of adnexal masses

OBJETIVO: Determinar el tiempo que requiere una curva de aprendizaje para diagnóstico ecográfico específico histopatológico en masas anexiales basándonos en cálculos estadísticos no influidos por la prevalencia según diferentes grados de experiencia. MÉTODOS: Estudio observacional, descriptivo, transversal. Se estudiaron imágenes de 108 masas anexiales. La prueba estándar de oro fue el reporte histopatológico definitivo. Se comparó el rendimiento diagnóstico de 4 examinadores con la siguiente experiencia en diagnóstico ecográfico de patología anexial: A > 20 años, B ≤ 20 hasta > 10 años, C ≤ 10 hasta > 5 años y D ≤ 5 años, analizando solo imágenes y sin datos clínicos de las pacientes, para emitir un diagnóstico específico a libre escritura. RESULTADOS: Prevalencia de masas malignas 17,2 % (15/87). Nivel de confianza en los examinadores se consideró según falta de respuesta diagnóstica: alto (<6 %) con experiencia de más de 10 años y moderado a bajo ≤ 10 años. Examinadores con más de 5 años siempre mostraron likelihood ratio positivo mayor a 10, exactitud diagnóstica mayor a 90 % y Odds ratio diagnóstica mayor a 46, no así para examinador con menor tiempo de experiencia, quién presentó resultados con mala utilidad clínica. El cambio de probabilidad de acierto específico pre-test a post-test mejoró consistentemente con los años de experiencia. CONCLUSIÓN: Se necesitarían más de 10 años de experiencia con especial dedicación a ecografía ginecológica avanzada para un rendimiento diagnóstico específico deseado junto con alta confianza en ecografía de masas anexiales.

OBJECTIVE: To determine the time required for a learning curve of histopathological specific ultrasound diagnosis in adnexal masses based on statistical calculations not influenced by prevalence according to different degrees of experience. METHODS: Observational, descriptive, cross-sectional study. Images of 108 adnexal masses were studied. The gold standard test was the definitive histopathological report. The diagnostic performance of 4 examiners with the following experience in ultrasound diagnosis of adnexal pathology: A > 20 years, B ≤ 20 to > 10 years, C ≤ 10 to > 5 years and D ≤ 5 years was compared, analyzing only images and blinded of clinical data of the patients, to issue a specific diagnosis with free writing. RESULTS: Prevalence of malignant masses 17.2% (15/87). The level of confidence in the examiners was considered according to the lack of diagnostic response: high (<6%) with experience of more than 10 years and moderate to low ≤ 10 years. The examiners with more than 5 years always showed likelihood ratio positive greater than 10, diagnostic accuracy greater than 90% and diagnostic Odds ratio greater than 46, not so for the examiner with less experience time who presented results with little clinical utility. The change in specific probability from pre-test to post-test improved consistently with years of experience. CONCLUSION: More than 10 years of experience with special dedication to advanced gynecological ultrasound are probably needed for a desired specific diagnostic performance coupled with high confidence in adnexal mass ultrasound.

Massas anexiais: descrição e interpretação ultrassonográfica por IOTA / Adnexal masses: IOTA ultrasound description and interpretation

Este artigo visa apresentar ao médico ginecologista (clínico e/ou cirurgião), de forma prática, a normatização internacional da prática da ultrassonografia ginecológica para avaliação das massas anexiais. Desde 2000, o grupo europeu IOTA (International Ovarian Tumor Analysis) vem colhendo dados e difundindo conhecimento nessa área, de forma a padronizar o exame ultrassonográfico. Quais descritores ecográficos devem ser valorizados, como devem ser descritos e medidos, como aplicar o estudo Doppler e como interpretar a presença ou ausência desses descritores ecográficos na diferenciação das massas anexiais benignas de malignas, inferindo o risco de malignidade das massas, tudo isso está bem definido.(AU)

The main aim of this article is to present to gynecologists (clinicians and/or surgeons) the practical international gynecological ultrasound standardization for adnexal masses assessment. Since 2000, European group IOTA (International Ovarian Tumor Analysis) has been collecting data and disseminating knowledge in order to standardize ultrasound examination. It is already well-defined which ultrasound features should be described and measured, how power/color Doppler have to be applied and how the presence or absence of these features can differentiate benign from malign masses, inferring tumors malignancy risk.(AU)

Role of cancer antigen-125 in diagnosing malignant adnexal masses: a prospective observational study

Background: Adnexal masses present a diagnostic and therapeutic dilemma across age-groups. This study aimed to evaluate the performance of cancer antigen-125 (CA-125) in distinguishing between benign and malignant adnexal masses.Methods: This was a prospective, observational, single tertiary-care center study, done in North India from January, 2011 till December, 2012. Serum CA-125 levels was obtained preoperatively in consecutive patients presenting with ultrasonography confirmed adnexal masses. The cut-off value between benign and malignant was taken as 35 IU/ml. Histopathological diagnosis was obtained in all patients.Results: A total of 126 patients presented with adnexal masses, of which 100 were enrolled (mean age: 37.5±14.4 years, range: 18-80 years). Most of the masses were benign 81% (malignant=19%). Dermoid cyst (25.9%) and endometriomas (21%) were the most common benign masses. Serous (21%) and mucinous cystadeno-carcinoma (15.8%) were the most common malignant masses, more often seen in elderly, married, parous and post-menopausal patients. Mean CA-125 levels were significantly higher in malignant masses (257.30 [105.68-408.92] versus 19.26 [16.53-22.00], p<0.001). Overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy of CA-125 for diagnosing malignant adnexal mass was 94.7%, 87.65%, 64.28%, 98.6%, and 88.91% respectively. The same was 100%, 85.1%, 54.5%, 100%, 87.3% in premenopausal and 85.7%, 100%, 100%, 93.3%, 95.2% in postmenopausal women respectively.Conclusion: Benign masses form the bulk of the adnexal masses in all age groups. CA-125 levels has high sensitivity and negative predictive value in premenopausal patients while as high specificity and positive predictive value in postmenopausal patients.

Practical recommendations for the management of benign adnexal masses / Recomendações práticas para o tratamento de massas anexiais benignas

Abstract Objective To performa comprehensive review to provide practical recommendations regarding the diagnosis and treatment of benign adnexal masses, as well as information for appropriate consent, regarding possible loss of the ovarian reserve. Methods A comprehensive review of the literature was performed to identify the most relevant data about this subject. Results In total, 48 studies addressed the necessary aspects of the review, and we described their epidemiology, diagnoses, treatment options with detailed techniques, and perspectives regarding future fertility. Conclusions Adnexal masses are extremely common. The application of diagnosis algorithms is mandatory to exclude malignancy. A great number of cases can bemanaged with surveillance. Surgery, when necessary, should be performed with adequate techniques. However, even in the hands of experienced surgeons, there is a significant decrease in ovarian reserves, especially in cases of endometriomas. There is an evident necessity of studies that focus on the long-term impact on fertility.

Resumo Objetivo Realizar uma revisão abrangente para fornecer recomendações práticas sobre o diagnóstico e tratamento demassas anexiais benignas, bemcomo informações para um consentimento adequado com relação à possível perda da reserva ovariana. Métodos Uma revisão abrangente da literatura foi realizada para identificar os dados mais relevantes sobre o assunto. Resultados No total, 48 estudos abordaram os aspectos necessários da revisão, e descrevemos sua epidemiologia, diagnósticos, opções de tratamento com técnicas detalhadas, e perspectivas sobre fertilidade futura. Conclusões As massas anexiais são extremamente comuns. A aplicação de algoritmos de diagnóstico é obrigatória para excluiramalignidade. A maioria dos casos pode ser manejada conservadoramente. A cirurgia, quando necessária, deve ser realizada com técnicas adequadas. No entanto, mesmo nas mãos de cirurgiões experientes, há diminuição significativa da reserva ovariana, principalmente nos casos de endometriomas. Há uma evidente necessidade de estudos que enfoquemo impacto das massas anexiais benignas na fertilidade em longo prazo.

Diagnostic value of the neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and thrombocytosis in the preoperative investigation of ovarian masses / Valor diagnóstico das razões neutrófilo/linfócito, plaqueta/ linfócito, e trombocitose na investigação pré-operatória de massas ovarianas

Abstract Objective To evaluate the diagnostic accuracy of cancer antigen 125 (CA125) and complete blood count (CBC) parameters, such as the neutrophil to lymphocyte ratio (NLR), the platelet to lymphocyte ratio (PLR), and thrombocytosis in patients with ovarian masses. Methods The present is a retrospective study conducted at a single tertiary hospital from January 2010 to November 2016. We included consecutive women referred due to suspicious adnexal masses. The CBC and CA125 were measured in the serum of 528 women with ovarian masses before surgery or biopsy. We evaluated the diagnostic performance of the NLR, PLR, platelets (PLTs), CA125, and the associations between them. We tested the clinical utility of the CBC parameters and CA125 in the discrimination of ovarian masses through decision curve analysis (DCA). Results The best balance between sensitivity and specificity was obtained by the associations of CA125 or PLTs ≥ 350/nL, with 70.14% and 71.66%, CA125 or PLTs ≥ 400/ nL, with 67.30% and 81.79%, CA125 or PLR, with 76.3% and 64.87%, and CA125 or NLR, with 71.09% and 73.89% respectively. In the DCA, no isolated CBC parameter presented a higher clinical utility than CA125 alone. Conclusion We showed that no CBC parameter was superior to CA125 in the prediction of the malignancy of ovarian tumors in the preoperative scenario.

Resumo Objetivo Avaliar a acurácia diagnóstica do antígeno de câncer 125 (cancer antigen 125, CA125, em inglês) e dos parâmetros do hemograma como as razões neutrófilo/linfócito (RNL), plaqueta/linfócito (RPL), e trombocitose em pacientes com massas ovarianas. Métodos Este é um estudo retrospectivo realizado em um hospital terciário no período de janeiro de 2010 a novembro de 2016. Foram incluídas de forma consecutiva mulheres encaminhadas por massas anexiais suspeitas. Foram dosados hemogramas e CA125 no soro de 528 mulheres com massas ovarianas antes da cirurgia ou biópsia. Foram avaliados os desempenhos diagnósticos da RNL, da RPL, das plaquetas (PLQs) e do CA125, considerando-os isoladamente e associados entre si. Testamos a utilidade clínica dos parâmetros do hemograma e do CA125 na discriminação das massas ovarianas por análise de curva de decisão (ACD). Resultados Os melhores equilíbrios entre sensibilidade e especificidade foram obtidos por meio das associações do CA125 ou PLQs ≥ 350/nL, com 70,14% e 71,66%, CA125 ou PLQs ≥ 400/nL, com 67,30% e 81,79%, CA125 ou RPL, com76,3% e 64,87%, e CA125 ou RNL, com 71,09% e 73,89%, respectivamente. Conclusão Na ACD, nenhum parâmetro do hemograma isolado se mostrou superior ao CA125 na predição de malignidade de tumores ovarianos no pré-operatório.

Evaluation of risk of malignancy index in adnexal masses at a tertiary hospital: a prospective study

Background: The discrimination between benign and malignant adnexal masses is important in deciding clinical management and optimal surgical planning. The aim of the study was to evaluate the effectiveness of risk of malignancy index (RMI) to identify cases with high potential of ovarian malignancy at a tertiary hospital.Methods: This prospective study was conducted over a period of two years from September 2017 to August 2019 at obstetrics and gynecology department of M. K. C. G. Medical College and Hospital, Berhampur. A total case of 130 patients with adnexal masses who underwent surgical treatment were included as histopathological report was taken as gold standard to calculate accuracy of RMI.Results: Of the total masses, 85 (65.4%) were benign and 45 (34.6%) were malignant. The mean age of patients was 41.03±14 years. The best cut off value for the RMI-3 was 225 with highest area under the ROC curve 87%, sensitivity of 75.55%, specificity of 98.82%, PPV of 97.14%, NPV of 88.42% and an accuracy of 90.76%.Conclusions: The present study demonstrated that RMI was a reliable method in detecting malignant ovarian tumors. The RMI is a simple and practically applicable tool in preoperative discrimination between benign and malignant adnexal masses in non-specialized gynecologic departments, particularly in developing countries.

GIRADS: método de clasificación de masas anexiales, revisión sistemática y metanálisis. 10 años de experiencia / GIRADS: adnexal masses classification method, systematic review and metanalysis. 10 years of experience

OBJETIVO: evaluar la experiencia en la utilización del método GIRADS para clasificar masas anexiales a diez años de su primera publicación. MÉTODO: Se realizó búsqueda de estudios que utilizan el sistema GIRADS: Medline (Pubmed), Google Scholar y Web of Science, desde enero de 2009 hasta diciembre de 2019. Se calculó la sensibilidad y especificidad agrupada, Likelihood ratio (LR) (+) y LR (-) y Odds ratio de diagnóstico (DOR). La calidad de los estudios se evaluó con QUADAS-2. RESULTADOS: Se identificaron 15 estudios y se incluyeron 13 de ellos con 4473 masas, 878 de ellas malignas. La prevalencia media de malignidad ovárica fue del 23 % y la agrupada de 19.6%. El riesgo de sesgo fue alto en cuatro estudios para el dominio "selección de pacientes" y fue bajo en todos en todos los estudios para los dominios "prueba índice" y "prueba de referencia". La sensibilidad, especificidad, LR (+) y LR (-) agrupadas y el DOR del sistema GIRADS para clasificar las masas anexiales fueron: 96.8% (intervalo de confianza [IC] 95% = 94% - 98%), 91.2 % (IC 95 % = 85% - 94%), 11.0 (IC 95% = 6.9 -13.4) y 0.035 (IC 95% = 0.02- 0.09), y 209 (IC 95% = 99-444), respectivamente. La heterogeneidad fue alta para la sensibilidad y especificidad. De acuerdo a la metaregresión, la heterogeneidad entre los estudios se explica por la prevalencia de malignidad, múltiples observadores y la ausencia de diagnóstico histopatológico para todos los casos incluidos en un determinado estudio. CONCLUSIÓN: el sistema GIRADS tiene un buen rendimiento diagnóstico para clasificar masas anexiales.

OBJECTIVE: to evaluate the experience of using GIRADS method to classify adnexal masses ten years after its publication. METHOD: A search was carried out for studies reporting on the use of the GIRADS system in the Medline (Pubmed), Google Scholar and Web of Science databases, from January 2009 to December 2019. Pooled sensitivity and specificity, Likelihood ratio (LR) (+) and LR (-) and Diagnostic Odds ratio (DOR) were calculated. The quality of the studies was assessed by QUADAS-2. RESULTS: 15 studies were identified, and 13 of them were included with 4473 masses, of which 878 were malignant. The mean prevalence of ovarian malignancy was 23% and the prevalence pooled. of 19.6%. The risk of bias was high in four studies for the domain 'patient selection' and low for all studies for the domains 'index test' and 'reference test'. The sensitivity, specificity, pooled LR (+) and LR (-) and the DOR of the GIRADS system to classify adnexal masses were 96.8% (95% confidence interval [CI] = 94% -98%), 91.2 % (95% CI = 85% -94%), 11.0 (95% CI = 6.9-13.4) and 0.035 (95% CI = 0.02-0.09), and 209 (95% CI = 99-444), respectively. Heterogeneity was high for both sensitivity and specificity. According to meta-regression, this heterogeneity was explained by the prevalence of malignancy, the use of multiple observers, and the absence of histopathological diagnosis for all cases included in a given study. CONCLUSION: the GIRADS system has a good diagnostic performance to classify adnexal masses.

Correlation between Ultrasound Features and Histopathological Findings in Adnexal Masses – A Study in a Tertiary Care Center in Central India

Background: Ovarian cancer has emerged as one of the most common malignancies affecting women in India. Amultidisciplinaryapproach is needed for the optimal management of patients presenting with adnexal mass wherein the radiologist and thepathologist play an important role in assisting in clinical decision-making. The present study is done to correlate the ultrasoundfindings with the histopathological findings and to study the whole spectrum of adnexal masses.Methods: This is a prospective observational study carried out on 60 patients with adnexal masses and pre-operative ultrasoundassessment and who underwent surgical resection of their masses in a tertiary care center.Results: The pre-menopausal age group was more frequently affected than post-menopausal age group. A large number ofadnexal masses were of ovarian origin. The incidence of neoplastic adnexal masses is much higher than the non-neoplasticmasses. Among the neoplastic adnexal masses majority were ovarian tumors. The incidence of benign ovarian tumors is higherthan malignant tumors. Among the malignant tumors, serous cystadenocarcinoma was the most common tumor. Majorityof the ovarian tumors diagnosed by ultrasonography (USG) as purely cystic in architecture were proven benign tumors onhistopathology. Of the solid-cystic tumors, 50% were benign, and 50% malignant on histopathology solid architecture of thetumors was the least common, and the majority were malignant. USG diagnosis of adnexal masses revealed a sensitivity of94.4%, specificity of 83.3%, positive predictive value of 70.8%, and negative predictive value of 97.2%.Conclusions: USG is a sensitive and specific modality in pre-operative diagnosis of the malignant nature of lesions. Thepresence of solid component in an ovarian mass was a highly accurate predictor of malignancy.

Large adnexal mass: is laparoscopic surgery a safe option?

Background: Laparoscopic surgery is regarded as the gold standard for management of adnexal tumours due to many advantages. Currently, the exact size of the adnexal tumour contraindicating laparoscopic management has not been clearly defined. Some studies suggest laparotomy for the treatment of adnexal tumours larger than 8 to 10 cm. Risk of malignancy increases with large cysts. Issues with operation of huge adnexal masses are limited surgical field, difficulty in inserting trocars and removing the specimen without rupture. This study aims to evaluate the feasibility and surgical outcomes of laparoscopic surgery for large adnexal masses.Methods: A prospective observational study was conducted in the Department of Obstetrics and Gynaecology, JSS Medical College, Mysuru.Results: 35 patients with large adnexal masses, which were thought to be benign, were subjected to laparoscopic surgery. Mean diameter of masses as per the pre-operative ultrasound measurements was 12.2cm (range: 10.1-20.4cm). The mean operative time was 51.15minutes, estimated blood loss was 85.4ml, duration of postoperative hospital stay was 2.8 days. Serous cystadenoma was the most common histopathological finding. However, one case of borderline tumour was found.Conclusions: The potential risk of malignancy is the most important limiting factor for laparoscopic management of large ovarian cysts. Therefore, it is necessary to establish risk profiles of patients with adnexal masses in order to benefit from minimally invasive surgery wherever possible. The current study supports laparoscopic management of large ovarian cysts as a technically feasible method if proper case selection is made.

Role of laparoscopy in the diagnosis and management of benign adnexal masses

Background: Adnexal masses are frequent findings in women of all age groups. It consists of the ovaries, fallopian tubes and uterine ligaments. Women can present with various gynaecological complaints and adnexal masses could be detected while examining and investigating for these complaints. The aim was to study the role of laparoscopy in diagnosis and management of benign adnexal masses.Methods: The study was conducted on 48 women of reproductive age group. Per speculum examination was done and PAP smear was taken before bimanual examination was done. A complete per vaginum examination was done and the adnexal mass was assessed for its size, side, consistency, laterality and tenderness. Laparoscopy was done to confirm preoperative diagnosis and appropriate procedure done depending on diagnosis.Results: Pain in the lower abdomen was the commonest chief complaint seen in 87.5% cases. 41.67% cases were suspected to have endometriosis while on laparoscopy it was seen in 47.92%, 33.33% were suspected to have ovarian cyst which decreased to 25% on laparoscopy, ectopic pregnancy in 16.67% cases both pre-operative and on laparoscopic examination and tubo-ovarian mass in 8.33% cases pre-operatively and 2.08% on laparoscopy.Conclusions: This study has shown that if proper preoperative evaluation was done, author can select the appropriate patients for laparoscopic approach.

Diagnostic accuracy performance of the International Ovarian Tumour Analysis (IOTA) simple rules and assessment of different neoplasias in the Adnexa (ADNEX) model for identifying benign or malignant Adnexal masses against histopathological diagnosis in patients seen and admitted at Dr. Jose Fabella Memorial Hospital / Philippine Journal of Obstetrics and Gynecology

Objective@#To know the diagnostic accuracy performance of the International Ovarian Tumour Analysis (IOTA) Simple Rules and Assessment of Different NEoplasias in the AdneXa (IOTA-ADNEX) Model for identifying benign or malignant adnexal masses against histopathological diagnosis. @*Methods@#This was a prospective single-center, cross-sectional diagnostic accuracy study including 53 women with an adnexal mass between May 2017 and March 2018. Pelvic ultrasound examination was done and serum levels of tumor marker CA 125 were obtained in all subjects prior to surgery. Adnexal masses were categorized according to the IOTA Simple rules and IOTA ADNEX model. The gold standard was histopathological diagnosis. The sensitivity, specificity, positive and negative predictive values of each scoring system utilized was determined and compared with the histopathologic result.@*Results@#Using the IOTA Simple rules, 35 adnexal masses classified as benign are 94.28 % truly benign by histopathologic diagnosis and 5.72% came out to be malignant; All 12 malignant tumors were truly malignant; there were 6 inconclusive tumors and came out to be malignant. In this study, IOTA Simple rules obtained a sensitivity of 90%, specificity of 100%, positive predictive value of 100%, Negative predictive value of 94% and Accuracy of 96%. Using the baseline risks assessment proposed by IOTA ADNEX Model, overall computation are as follows: (1) Sensitivity of 96.88 %, (2) Specificity of 90.48, (3) Positive Predictive Value of 93.94%, and a (4) Negative Predicitve Value of 95% @*Conclusion@#The majority of adnexal masses in our study were classified correctly using the IOTA Simple rules and IOTA ADNEX model. Due to high statistical significant values obtained by IOTA Simple rules, its use is validated and is encouraged to be the standard of use in scoring adnexal masses. In this study, we are able to prove that by subjective expert opinion from an expert sonographer in reclassifying those that are unclassified by IOTA simple rules approximates 100% accuracy.

Tratamiento laparoscópico de masas anexiales en el embarazo: reporte de dos casos / Laparoscopic management of adnexal masses in pregnancy: Report of two cases

Resumen ANTECEDENTES Las masas ováricas detectadas durante el embarazo tienden a la desaparición espontánea. Casi siempre se trata de quistes funcionales, foliculares, cuerpos lúteos y quistes tecaluteínicos. CASO CLÍNICO Se reportan dos casos de pacientes en el segundo trimestre del embarazo en quienes se estableció el diagnóstico de masas anexiales en la ecografía del primer trimestre, con aumento del tamaño y dolor. CONCLUSIONES El riesgo de malignidad en pacientes con masas anexiales es muy bajo y el tratamiento quirúrgico está determinado por los síntomas de dolor o crecimiento rápido. En estas pacientes el acceso laparoscópico es factible y debe considerarse una alternativa segura.

Abstract BACKGROUND Ovarian masses detected during pregnancy tend to spontaneously disappear. It is almost always functional cysts, follicular, corpora lutea and tecaluteinic cysts. CLINICAL CASE Two cases of patients in the second trimester of pregnancy were reported in whom the diagnosis of adnexal masses was established in the ultrasound of the first trimester, with an increase in size and pain. CONCLUSIONS The risk of malignancy in patients with adnexal masses is very low and surgical treatment is determined by symptoms of pain or rapid growth. In these patients, laparoscopic access is feasible and should be considered a safe alternative.

Comparación de tres índices ecográficos para evaluación del riesgo de malignidad de los tumores anexiales / Comparison of three ultrasound index in evaluating the risk of malignancy of adnexal tumors

Resumen Objetivo: Determinar y comparar el rendimiento diagnóstico de las Reglas Ecográficas Simples (RES), Índice Morfológico Ecográfico (IME) e Índice de Riesgo de Malignidad de Jacobs (IRM) en el diagnóstico de benignidad o malignidad de un tumor anexial. Material y método: Estudio retrospectivo, transversal y analítico efectuado en el Hospital Militar de Especialidades de la Mujer y Neonatología de la Ciudad de México. Se incluyeron pacientes con diagnóstico ecográfico de tumor anexial intervenidas quirúrgicamente. Se estudió el rendimiento diagnóstico de los índices comparado con el diagnóstico histopatológico mediante tablas de contingencia. Resultados: Se analizaron 141 pacientes y 166 tumores; 22 casos fueron bilaterales. De la muestra analizada, 79 eran pacientes premenopáusicas y 62 posmenopáusicas. Los casos de neoplasia maligna fueron 43 (26%) y benigna 123 (74%). El Índice Morfológico Ecográfico tuvo sensibilidad de 98.8%, especificidad de 33.3%, valor predictivo positivo de 33.9% y valor predictivo negativo de 97.6%. Las Reglas Ecográficas Simples reportaron una sensibilidad de 97.2%, especificidad de 71.1%, valor predictivo positivo de 55.6% y valor predictivo positivo de 98.6%; y el Índice de Riesgo de Malignidad de Jacobs una sensibilidad de 72.7%, especificidad de 79.3%, valor predictivo positivo de 55.8% y valor predictivo positivo de 89.4%. Conclusiones: Las Reglas Ecográficas Simples son un modelo prequirúrgico que en 82% de los casos permitieron clasificar los tumores anexiales en benignos o malignos. Los casos indeterminados deben ser reevaluados por un ecografista experto. El método es reproducible por evaluadores de mediana experiencia y susceptible de aplicarse en instituciones hospitalarias de segundo y tercer nivel de atención.

Abstract Objective: To determine and compare the diagnostic performance of the Simple Ultrasound-Based Rules (SUR), Sonographic Morphology Index (SMI) and the Jacob´s Risk Malignancy Index (RMI) in the diagnosis of benignity or malignancy to an adnexal tumor. Materials and methods: Retrospective, cross-sectional and analytical study at the at the Hospital Militar de Especialidades de la Mujer y Neonatología of Mexico City. Patients with ultrasound diagnosis of adnexal tumor who underwent surgery were included. The diagnostic performance of the indices compared to histopathological diagnosis was studied using contingency tables. Results: 141 women and 166 tumors were included for analysis, 22 cases were bilateral. Of the sample analyzed, 79 were premenopausal and 62 postmenopausal. Cases of malignant neoplasm were 43 (25.9%) and benign 123 (74.1%). The SMI had a sensitivity of 98.8%, specificity of 33.3%, positive predictive value (PPV) of 33.9%, and negative predictive value (NPV) of 97.6%. SUR showed a sensitivity of 97.2%, specificity of 71.1%, PPV of 55.6% and NPV of 98.6%; And RMI had a sensitivity of 72.7%, specificity of 79.3%, PPV of 55.8% and NPV of 89.4%. Conclusions: The simple ultrasonographic rules are a presurgical model that in 82% of the cases allowed to classify the adnexal tumors in benign or malignant. Indeterminate cases should be reevaluated by an expert sonographer. The method is reproducible by evaluators of medium experience and susceptible of being applied in hospital institutions of the second and third level of care.

Valor del ultrasonido en el diagnóstico de las masas anexiales / Value of ultrasound in the diagnosis of adnexal masses

Introducción: el empleo de técnicas de diagnóstico por imágenes ha cambiado el enfoque sobre el manejo de muchas afecciones en Medicina. Objetivo: determinar el valor del ultrasonido en el diagnóstico de las masas anexiales y correlacionarlo con los hallazgos anatomopatológicos. Métodos: estudio descriptivo longitudinal a 92 mujeres realizado entre el 1ro. de enero de 2008 al 1ro. de enero de 2010, con el diagnóstico de masa anexial por ultrasonido. Se seleccionaron las pacientes atendidas en consulta con el objetivo de obtener información de diferentes variables: tamaño de las masas anexiales, ecogenicidad, grosor de la pared y contornos, vascularización con técnica de Doppler y correlación entre el diagnóstico ultrasonográfico e histopatológico. Las muestras histológicas fueron procesadas a partir de las piezas quirúrgicas en las pacientes operadas. Resultados: los tumores benignos y malignos por lo general medían más de 5 cm para el 13,04 porciento y el 23,9 porciento respectivamente, predominó el aspecto complejo de las masas anexiales, fueron los tumores malignos de ovario, con 20 pacientes (74,4 porciento), los que aportaron el mayor porcentaje, los contornos regulares predominaron en los tumores de ovario benignos y en las lesiones pseudotumorales y en los tumores malignos los contornos se mostraron irregulares (25 porciento)los tumores malignos se mostraron con vascularización central aumentada en 24 pacientes (88,8 porciento de los casos). Conclusiones: los estudios ultrasonográficos de las masas anexiales permiten precisar el diagnóstico de su naturaleza benigna o maligna. Existe una alta concordancia entre el diagnóstico ultrasonográfico e histológico

Introduction: the use of imaging techniques has shifted the focus on the management of many conditions in medicine. Objective: to determine the value of ultrasound in the diagnosis of adnexal masses and to correlate it with pathologic findings. Methods: a descriptive longitudinal study was performed to 92 women between 1 January 1st, 2008 to January 1st, 2010 with the diagnosis of adnexal masses by ultrasound. Patients were selected in consultation with the objective of getting information of different variables: size of adnexal masses, echogenicity, wall and contour thickness, vascularization with Doppler technique and correlation between sonographic and histopathologic diagnosis. The histological samples were processed from surgical specimens in the patients treated. Results: benign and malignant tumors usually were more than 5 cm, 13.04 percent and 23.9 percent respectively, the complex appearance of adnexal masses dominated and there were malignant ovarian tumors in 20 patients (74.4 percent), which contributed the largest percentage; regular contours predominated in benign ovarian tumors and pseudotumoral lesions whereas malignant tumors showed irregular contours (25 percent). Malignant tumors showed increased center vascularization in 24 patients (88.8 percent of cases). Conclusions: the ultrasound studies of adnexal masses allow specifying the benign or malignant diagnosis. There is a high correlation between ultrasound and histological diagnosis

White blood cell differential count and adnexal mass size may predict potential malignancies in laparoscopic surgery / 대한산부인과내시경학회지

OBJECTIVE: We investigated the clinical value of using preoperative differential white blood cell (WBC) count to predict the potential for malignancy of adnexal masses in laparoscopic surgery. METHODS: The electronic medical records of 1325 patients who underwent laparoscopic surgery for adnexal masses between July 2005 and December 2008 were analyzed retrospectively. RESULTS: Of 1325 patients, 30 (2.3%) had adnexal masses with malignant potential. Analysis of differential WBC count, neutrophil to lymphocyte ratio (NLR), neutrophil to monocyte ratio (NMR), serum CA 125, mass size showed that only cyst size was significantly different between patients with potentially malignant adnexal masses, those with benign disease (averages of 9.45 cm vs. 6.23 cm, p=0.001). Further analysis was performed using a combination of various markers and multiplication of cyst size and NMR yielded the highest area under the curve, at 0.711(95% confidential interval 0.619~0.806, p<0.001), with a sensitivity and specificity of 86.7% and 48.3% respectively, at a cut off value of 67.23. These values were also significantly different between patients with potentially malignant adnexal masses, and dermoid cyst or endometrioma (p=0.038 and 0.002 respectively, by analysis of variance, post hoc test). CONCLUSION: Preoperative measurement of NMR in conjunction with cyst size may be used as a simple, non invasive marker for predicting the malignant potential of adnexal masses before laparoscopic surgery.

Surgical Management of Adnexal Masses in Pregnancy: Laparoscopy Versus Laparotomy / 대한산부인과학회잡지

OBJECTIVE: To determine the feasibility, safety, advantages and limitations of laparoscopic management of adnexal masses in pregnancy by comparing with laparotomy. METHODS: Between Jan 2001 to Jan 2003, 36 laparoscopic procedures and 15 laparotomy procedures were performed in 51 patients with adnexal masses in pregnancy. Operation time, hospital stay, pathologic findings, complications and pregnancy outcome were analyzed in these patients. RESULTS: Most common pathologic finding was mature cystic teratoma (45%) and malignancy of adnexal tumors were 3 cases (5.9%). There were no differences in size of adnexal tumor, operation time, hemoglobin level change after operation, gestational age at delivery, birth weight, Apgar score, preterm delivery and fetal anomaly between the two groups. Hospital stays was shorter and gestational age at operation was earlier in laparoscopy than explolaparotomy. CONCLUSION: Laparoscopic management of adnexal masses in pregnancy is safe and effective procedure.