Association Between Individual Air Pollution (PM10, PM2.5) Exposure and Adverse Pregnancy Outcomes in Korea: A Multicenter Prospective Cohort, Air Pollution on Pregnancy Outcome (APPO) Study.

BACKGROUND: Prenatal exposure to ambient air pollution is linked to a higher risk of unfavorable pregnancy outcomes. However, the association between pregnancy complications and exposure to indoor air pollution remains unclear. The Air Pollution on Pregnancy Outcomes research is a hospital-based prospective cohort research created to look into the effects of aerodynamically exposed particulate matter (PM)10 and PM2.5 on pregnancy outcomes. METHODS: This prospective multicenter observational cohort study was conducted from January 2021 to June 2023. A total of 662 women with singleton pregnancies enrolled in this study. An AirguardK® air sensor was installed inside the homes of the participants to measure the individual PM10 and PM2.5 levels in the living environment. The time-activity patterns and PM10 and PM2.5, determined as concentrations from the time-weighted average model, were applied to determine the anticipated exposure levels to air pollution of each pregnant woman. The relationship between air pollution exposure and pregnancy outcomes was assessed using logistic and linear regression analyses. RESULTS: Exposure to elevated levels of PM10 throughout the first, second, and third trimesters as well as throughout pregnancy was strongly correlated with the risk of pregnancy problems according to multiple logistic regression models adjusted for variables. Except for in the third trimester of pregnancy, women exposed to high levels of PM2.5 had a high risk of pregnancy complications. During the second trimester and entire pregnancy, the risk of preterm birth (PTB) increased by 24% and 27%, respectively, for each 10 µg/m3 increase in PM10. Exposure to high PM10 levels during the second trimester increased the risk of gestational diabetes mellitus (GDM) by 30%. The risk of GDM increased by 15% for each 5 µg/m3 increase in PM2.5 during the second trimester and overall pregnancy, respectively. Exposure to high PM10 and PM2.5 during the first trimester of pregnancy increased the risk of delivering small for gestational age (SGA) infants by 96% and 26%, respectively. CONCLUSION: Exposure to high concentrations of PM10 and PM2.5 is strongly correlated with the risk of adverse pregnancy outcomes. Exposure to high levels of PM10 and PM2.5 during the second trimester and entire pregnancy, respectively, significantly increased the risk of PTB and GDM. Exposure to high levels of PM10 and PM2.5 during the first trimester of pregnancy considerably increased the risk of having SGA infants. Our findings highlight the need to measure individual particulate levels during pregnancy and the importance of managing air quality in residential environment.

Congenital Anomalies in Multiple Pregnancy: A Literature Review.

Importance: Multiple pregnancy is relatively common in many countries and is associated with various pregnancy complications, including preterm birth, low birth weight, and congenital anomalies. In particular, a poorer prognosis has been reported when congenital anomalies overlap with other pregnancy complications in multiple pregnancy compared with singleton pregnancy. Objective: This study reviews the characteristics of congenital anomalies that occur in multiple gestations as compared with singleton pregnancies. Evidence Acquisition: An extensive manual search of major electronic databases was conducted in June 2023. This literature review provides a comprehensive coverage of the congenital anomalies in multiple pregnancy. Results: Most studies have shown that multiple gestations are associated with an increased risk of congenital anomalies compared with singleton pregnancies. In addition, higher rates of congenital anomalies and concordance have been observed in monozygotic versus dizygotic twins. The effect of assisted reproductive therapies on the risk of congenital anomalies appears to be smaller in multiple gestations than in singleton pregnancies. Conclusions: Multiple pregnancy is significantly associated with an increased risk of congenital anomalies. Relevance: This review provides obstetrical providers with the requisite knowledge to offer appropriate antenatal care and prenatal anomaly screening to patients with multiple pregnancies.

Preeclampsia and aspirin.

Preeclampsia (PE) is a multisystem disorder that is an important cause of maternal and perinatal deaths. Currently, delivery is the only final treatment for PE. This practice is usually accompanied by premature birth, which inevitably increases neonatal morbidities. Aspirin is a non-selective non-steroidal anti-inflammatory drug that irreversibly inhibits cyclooxygenase enzymes involved in converting arachidonic acid to prostaglandins and thromboxane. Aspirin inhibits thromboxane A2 production via platelet aggregation, thereby increasing the prostacyclin/thromboxane A2 ratio and reducing platelet aggregation. Since the first case report of aspirin's potential use during pregnancy was reported in 1978, many studies have attempted to confirm the effect of aspirin on PE, and the results have been controversial. However, this preventive strategy is generally accepted in clinical practice. As evidence for aspirin's prevention of PE has been accumulating, a recent study investigated the effectiveness of aspirin at high doses of 150 mg, which is higher than before. However, there is an ongoing debate about how much aspirin should be used during pregnancy and when to start aspirin therapy. Guidelines for the use of prophylactic aspirin during pregnancy vary slightly among countries and groups. In this article, we review and summarize the evidence regarding the use of aspirin for PE prevention.

Effects of Iron on Efficacy of Photodynamic Therapy Using Photolon in a Mouse Model of CT26 Colon Cancer.

BACKGROUND: Photodynamic therapy (PDT) -a minimally invasive anti-cancer therapy-is undergoing experimental studies to increase its anti-cancer effects. This study investigated the influence of iron on the anti-cancer effects of PDT. METHODS: PDT was performed in a cancer-bearing mouse model, which was created by using a murine colon carcinoma (CT26) cell line after administration of Photolon and iron. Tumor volume and the results of TdT-mediated dUTP-biotin nick end labeling (TUNEL), 8-OHdG, and TBARS assays were used to measure anti-cancer effect. RESULTS: On day 14, tumor volume had increased by 49% in the PDT group and decreased by 72% in the iron+PDT group. The percentage of TUNEL-positive cells in tumor tissues was 45% in the PDT group and 69% in the iron+PDT group, suggesting that the proportion of TUNEL-positive cells had increased in the iron+PDT group. The 8-OHdG content in tumor tissues was 33% higher in the iron+PDT group than in the PDT group. The TBARS content in tumor tissues was 46% higher in the iron+PDT group than in the PDT group. CONCLUSIONS: Iron enhances the anti-cancer effect of PDT using Photolon, most likely by increasing oxidative damage.

Spontaneous Rupture of Ovarian Artery Aneurysm in a Postmenopausal Woman: A Case Report and Literature Review.

Spontaneous rupture of an ovarian artery aneurysm is an extremely rare, life-threatening disease and has been reported to be most highly associated with pregnancy. The current study presents a case of intraperitoneal and retroperitoneal hematoma caused by spontaneous rupture of a right ovarian artery aneurysm in a 56-year-old woman. A 56-year-old woman visited the emergency room with right lower quadrant abdominal pain. Contrast-enhanced computed tomography showed a large retroperitoneal and intraperitoneal hematoma and active extravasation of contrast medium in the right retroperitoneum. Consequently, transcatheter arterial embolization was successfully performed. Spontaneous rupture of an ovarian artery aneurysm should be suspected in multiparous women with abdominal or flank pain even if it is unrelated to pregnancy. Suspicion of this entity is needed for earlier diagnosis and management.

Effects of genistein on anti-tumor activity of cisplatin in human cervical cancer cell lines.

OBJECTIVE: To investigate the effect of genistein on the anticancer effects of chemotherapeutic agents, we examined the effect of a genistein and cisplatin combination on CaSki human cervical cancer cells. METHODS: After the cervical cancer cells (HeLa cells, CaSki cells) had been cultured, cisplatin and genistein were added to the culture medium, and the cell activity was measured using MTT assay. The CaSki cells were cultured in a medium containing cisplatin and genistein, and then, the cells were collected in order to measure p53, Bcl2, ERK, and caspase 3 levels by western blotting. RESULTS: Both the HeLa and CaSki cells had decreased cell viabilities when the cisplatin concentration was 10 µM or higher. When combined with genistein, the cell viabilities of the HeLa and CaSki cells decreased at cisplatin concentrations of 8 µM and 6 µM, respectively. The administration of genistein increased the toxicity of cisplatin in the HeLa and CaSki cells. In the CaSki cells, the p-ERK1/2 level decreased by 37%, the p53 expression level increased by 304%, and the cleaved caspase 3 level increased by 115% in the cisplatin+genistein group compared to that in the cisplatin group. Bcl2 expression was reduced by 69% in the cisplatin+genistein group compared to that in the cisplatin group. CONCLUSION: Genistein enhances the anticancer effect of cisplatin in CaSki cells, and can be used as a chemotherapeutic adjuvant to increase the activity of a chemotherapeutic agent.

Effect of quercetin on the anti-tumor activity of cisplatin in EMT6 breast tumor-bearing mice.

OBJECTIVE: The purpose of this study was to determine the effect of quercetin on the antitumor activity of cisplatin and its side-effects. METHODS: EMT6 cells, a mouse breast cancer cell line, were injected subcutaneously in mice to generate a breast tumor-bearing mouse model. Experimental groups were divided into four groups: control (C), quercetin (Q), cisplatin (CP), and cisplatin+quercetin (CP+Q). RESULTS: The tumor volume of the CP+Q group was significantly lower than that of the CP group. Serum blood urea nitrogen and creatinine levels in the CP+Q group were lower than those in the CP group. Renal γ-glutamyltranspeptidase and alkaline phosphatase activities were significantly higher in the CP+Q group than in the CP group, and the content of renal thiobarbituric acid reactive substance was significantly lower in the CP+Q group than that in the CP group. These results suggested that quercetin and cisplatin synergistically increased cellular toxicity in breast cancer cells and mediated cancer growth inhibition, thereby enhancing the antitumor effect of cisplatin compared to when only cisplatin was administered. Quercetin also reduced renal toxicity, which arose as a potential a side effect of cisplatin. CONCLUSION: The enhanced antitumor effect of cisplatin and decreased renal toxicity after quercetin treatment suggested the applicability of quercetin as an adjuvant for chemotherapeutic agents.

Effects of cisplatin on photosensitizer-mediated photodynamic therapy in breast tumor-bearing nude mice.

OBJECTIVE: This study aimed to evaluate the potential effects of cisplatin on photodynamic therapy (PDT) in breast cancer using a breast tumor-bearing mouse model. METHODS: In this study, breast tumor (experimental mammary tumour-6 cell)-bearing nude mice were used as experimental animals. Photolon® (photosensitizer, 2.5 mg/kg body weight [BW]) was injected intraperitoneally; after 2 hours, the tumors were irradiated (660 nm, 80 J/cm2) using a diode laser tool. Cisplatin (3 mg/kg BW) was injected intraperitoneally 1 hour before the Photolon® injection. RESULTS: Tumor volume increased over time in the control group and was not different from that in the cisplatin group. In the PDT group, the tumor volume increased on day 3, but not on day 7. In the cisplatin+PDT group, tumor volume increased on day 3 but decreased on day 7. There was no significant difference in the levels of thiobarbituric acid reactive substance (TBARS) in tumor tissues between the control and cisplatin groups. The levels of TBARS in the cisplatin+PDT group were higher (47%) than those in the PDT group. Analysis of tumor tissue transcriptomes showed that the expression of genes related to the inflammatory response including CL and XCL genes increased, while that of Fn1 decreased in the cisplatin+PDT group compared with the PDT group. CONCLUSION: These results suggest that cisplatin enhances the therapeutic effect of PDT in a breast tumor-bearing mouse model. However, further clinical studies involving patients with breast cancer is needed.

Perfluorooctanoic acid (PFOA) and perfluooctane sulfonate (PFOS) induce different modes of action in reproduction to Japanese medaka (Oryzias latipes).

Perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS) have widely and frequently used in many industrial sectors, and thus have been frequently found in the environment. These chemicals may act as endocrine disrupting chemicals (EDCs), although the molecular mechanisms are still debated. In this study, Japanese medaka (Oryzias latipes) were exposed to 10 mg/l PFOA and 1 mg/l PFOS for 21 days, and the reproductive responses, such as the fecundity, secondary sexual characteristics and transcriptional levels of vitellogenin (vtg1 and vtg2) and choriogenin (chgh, chghm and chgl), were time-dependently evaluated (day 7, 14 and 21). PFOA and PFOS significantly reduced fecundity, and caused expression changes in the genes with time, although the patterns were different for each chemical and each sex. Different transcriptional regulations of vitellogenin and choriogenin in male suggest that PFOA and PFOS have different mode of actions in reproductive effects despite their similar chemical structure.

Gestational Diabetes Affects the Growth and Functions of Perivascular Stem Cells.

Gestational diabetes mellitus (GDM), one of the common metabolic disorders of pregnancy, leads to functional alterations in various cells including stem cells as well as some abnormalities in fetal development. Perivascular stem cells (PVCs) have gained more attention in recent years, for the treatment of various diseases. However, the effect of GDM on PVC function has not been investigated. In our study, we isolated PVCs from umbilical cord of normal pregnant women and GDM patients and compared their phenotypes and function. There is no significant difference in phenotypic expression, response to bFGF exposure and adipogenic differentiation capacity between normal (N)-PVCs and GDM-PVCs. However, when compared with N-PVCs, early passage GDM-PVCs displayed decreased initial rates of cell yield and proliferation as well as a reduced ability to promote wound closure. These results suggest that maternal metabolic dysregulation during gestation can alter the function of endogenous multipotent stem cells, which may impact their therapeutic effectiveness.

Serum from pregnant women with gestational diabetes mellitus increases the expression of FABP4 mRNA in primary subcutaneous human pre-adipocytes.

OBJECTIVE: Gestational diabetes mellitus (GDM) is defined as glucose intolerance first detected during pregnancy. It can result in pregnancy complications such as birth injury, stillbirth. Fatty acid-binding protein 4 (FABP4), found in adipose tissue, is associated with insulin resistance, and type 2 diabetes. The aim of this study was to investigate whether FABP4 in the placenta and decidua of pregnant women with GDM is higher than that in normal pregnant women, and whether serum from pregnant women with GDM may cause adipocytes to secrete more FABP4 than does serum from a normal pregnant group. METHODS: We obtained placentas, deciduas, and serum from 12 pregnant women with GDM and 12 normal pregnant women and performed enzyme-linked immunosorbent assay, real time quantitative-polymerase chain reaction. We cultured human pre-adipocytes for 17 days with GDM and non-GDM serum and performed western blot, real time quantitative-polymerase chain reaction, and oil red O staining. RESULTS: Expression of FABP4 in serum, placenta and decidua of pregnant women with GDM was significantly higher than that in normal pregnant women. Serum from pregnant women with GDM increased the expression of FABP4 mRNA and decreased the expression of adiponectin mRNA in human pre-adipocytes significantly. Adipocyte cultured in GDM serum showed significantly greater lipid accumulation than those cultured in normal serum. CONCLUSION: Our results suggest that FABP4 is higher in placenta and decidua from pregnant women with GDM. Increased circulating FABP4 in maternal serum from pregnant women with GDM may originate from adipocytes and the placenta. Circulating FABP4 can induce increased insulin resistance and decreased insulin sensitivity.

Effect of bihemispheric anodal transcranial direct current stimulation for dysphagia in chronic stroke patients: A randomized clinical trial.

OBJECTIVE: To investigate whether bihemispheric anodal transcranial direct current stimulation (tDCS) with conventional dysphagia therapy could improve swallowing function in chronic stroke patients with dysphagia. DESIGN: Randomized controlled trial. SUBJECTS: Twenty-six patients with dysphagia for at least 6 months post-stroke were randomly assigned into: (i) bihemispheric anodal tDCS group; or (ii) sham group. METHODS: All patients underwent 10 tDCS sessions with simultaneous conventional swallowing therapy for 2 weeks. Both anodal electrodes were attached bilaterally to the pharyngeal motor cortices, and cathodal electrodes were attached to both supraorbital regions. Swallowing function was evaluated with the Dysphagia Outcome and Severity Scale (DOSS) before and immediately after the last intervention session. RESULTS: The bihemispheric anodal tDCS group showed a mean significant improvement 0.62 points; standard deviation (SD) 0.77, in the DOSS immediately after all sessions (p = 0.02). However, there was no mean significant improvement in the sham group (0.38 points; SD 0.65(p = 0.06)). There was no significant difference between the 2 groups (p = 0.48). CONCLUSION: The bihemispheric anodal tDCS with conventional dysphagia therapy had additional helpful effects on the improvement in swallowing function in chronic stroke patients.

Short-Term and Long-Term Postnatal Outcomes of Expectant Management After Previable Preterm Premature Rupture of Membranes With and Without Persistent Oligohydramnios.

OBJECTIVE: To compare postnatal outcomes in pregnancies managed expectantly after previable preterm premature rupture of membranes (PROM) in relation to amniotic fluid volume. METHODS: A retrospective cohort study was performed in 92 women with amniotic fluid leakage for more than a week after previable preterm PROM (gestational age 14 1/7-24 0/7 weeks) who delivered a liveborn neonate at or after 24 1/7 weeks of gestation from 2002 to 2014. Short-term (sepsis, intracerebral hemorrhage, retinopathy of prematurity, respiratory distress syndrome, bronchopulmonary dysplasia) and long-term (cerebral palsy and developmental delay) outcomes were compared between women with (n=58) and without persistent oligohydramnios (n=34), defined as maximal vertical pocket less than 2 cm or amniotic fluid index less than 5 cm. We analyzed discrete data using the χ2 or Fisher's exact test and continuous variables using Student's t test or Mann-Whitney U test. We also performed multivariable analyses. RESULTS: There was a significant difference in survival rate at discharge (44/58 [75.9%] compared with 34/34 [100%], P=.001) and developmental delay at a median age of 4 years after performing multiple regression analysis (adjusted odds ratio [OR] 70.3, 95% confidence interval [CI] 2.9-1,719.9, P=.009) between participants with persistent oligohydramnios and participants with normal amniotic fluid volume. A multiple regression analysis, performed to control for confounders, revealed that gestational age at delivery (adjusted OR 0.3, 95% CI 0.1-0.7, P=.008) and breech presentation (adjusted OR 90.8, 95% CI 2.2-3,778.1, P=.018) were significant factors affecting survival of children with persistent oligohydramnios. CONCLUSION: The postnatal survival rate after previable preterm PROM was lower and developmental delay more frequent in participants with persistent oligohydramnios than in participants with normal amniotic fluid volume. Even so, most neonates born alive after previable preterm PROM and persistent oligohydramnios survived to discharge and were developmentally normal. The overall survival rate was higher than in previous studies. LEVEL OF EVIDENCE: II.

Protective effects of green tea polyphenol against cisplatin-induced nephrotoxicity in rats.

OBJECTIVE: This study is to compare the effects of green tea polyphenol (GTP) pre-treatment with those of GTP post-treatment on cisplatin (CP)-induced nephrotoxicity in rat. METHODS: Male Sprague-Dawley rats were randomly divided into six groups. Animals in the control group received 0.9% saline (intraperitoneal); animals in the GTP group received 0.9% saline and GTP (0.2% GTP as their sole source of drinking water); the CP group received only CP (7 mg/kg, intraperitoneal); the CP+preGTP group received GTP from two days before CP to four days after CP and the CP+postGTP group received GTP for four days after CP. CP-induced renal toxicity was evaluated by plasma creatinine and blood urea nitrogen (BUN) concentrations; kidney tissue γ-glutamyl transpeptidase (GGT) and alkaline phosphatase (AP) activities and histopathological examinations. RESULTS: High serume creatinine and BUN concentrations were observed in CP treated rats. The GGT and AP activites were lower in kidney of CP treated rats compared to control rats. In addition, treatment with CP resulted in development of a marked tubular necrosis, and tubular dilation in kidney of rats. Pretreatment with GTP resulted in markedly reduced elevation of serum creatinine and BUN amounts and changes of GGT and AP activity in kidney induced by CP. CP-induced histopathological changes, including tubular necrosis and dilation, were ameliorated in GTP pre-treated rats, compared to CP alone or GTP post-treated rats. CONCLUSION: These results demonstrate that GTP might have some protective effect against CP-induced nephrotoxicity in rat, and GTP pre-treatment was more effective than GTP post-treatment on reduction of CP-induced renal dysfunction.

Breast diseases during pregnancy and lactation.

Breast is a typical female sexual physiologic organ that is influenced by steroid hormone from menarche until menopause. Therefore various diseases can be developed by continuous action of estrogen and progesterone. Breast diseases are mainly categorized as benign and malignant. It is very important to distinguish the malignancy from breast diseases. However, it is very difficult to diagnose malignancy in pregnant and lactating women even though the same breast diseases took place. Therefore, we will review breast diseases such as breast carcinoma during pregnancy and lactation.

Comparison of single-, double- and triple-combined testing, including Pap test, HPV DNA test and cervicography, as screening methods for the detection of uterine cervical cancer.

Cervical cancer is a serious disease that threatens the health of women worldwide. This study compared the sensitivities and false-positive rates of cervical cytology (Pap smear), human papilloma virus (HPV) DNA test, cervicography, first double-combined testing (cervical cytology and HPV DNA test), second double-combined testing (cervical cytology and cervicography) and triple-combined testing (cervical cytology, HPV DNA test and cervicography). The study included 261 patients screened for uterine cervical cancer. All women simultaneously underwent cervical cytology, HPV DNA test and cervicography for uterine cervical cancer screening and colposcopically directed biopsy for diagnostic evaluation. The triple-combined testing was consistently the most sensitive among the cervical screening tests. The second double-combined testing, with a sensitivity rate of 98.1% was more sensitive than the first double-combined test (92.3%). However, cervical cytology was most specific (93.5%) and showed the highest positive predictive value (77.8%). The sensitivity of cervical cytology was markedly improved in combination with HPV DNA test and cervicography. Thus, the triple-combined testing, which improves the high false negativity of cervical cytology, may be an effective tool in uterine cervical cancer screening, pending confirmation of the effectiveness in a mass screening study.

Photodynamic therapy for breast cancer in a BALB/c mouse model.

OBJECTIVE: Photodynamic therapy (PDT) has been used for superficial neoplasms and its usage has been recently extended to deeper lesions. The purpose of this study was to observe whether or not PDT can cure breast cancer in the solid tumor model, and to define the critical point of laser amount for killing the cancer cells. METHODS: Twenty four BALB/c mouse models with subcutaneous EMT6 mammary carcinomas were prepared. Mice were divided into eight groups depending on the amount of illumination, and the tumor size was between 8 mm and 10 mm. We began by peritoneal infiltration with a photosensitizer 48 hours prior to applying the laser light, and then we applied a non-thermal laser light. The energy was from 350 J/cm(2) to 30 J/cm(2) to the cancer. RESULTS: Regardless of the tumor size from 8 mm to 10 mm, all mice apparently showed positive results via PDT. We also did not find any recurrence over 90 J/cm(2). In all models, the color of the breast cancer lesions began to vary to dark on 2 days post PDT and the tumor regression began simultaneously. Also, we confirmed the complete regression of the breast cancer 21 days after PDT. CONCLUSION: We confirmed that PDT may treat breast cancers that are sized less 10 mm in mouse models. The moderate energy to destruct the breast cancer cells may be 90 J/cm(2). Therefore, we can expcect that PDT may be utilized to treat breast cancer, but we need more experience, skills and processing for clinical trials.

Successful full term pregnancy and delivery after concurrent chemo-photodynamic therapy (CCPDT) for the uterine cervical cancer staged 1B1 and 1B2: Preserving fertility in young women.

► Photodynamic therapy can treat lesions with highly reactive single oxygen. ► CCPDT (Concurrent Chemo Photodynamic Therapy) is defined as PDT with chemotherapy. ► CCPDT can treat larger and deeper lesions than PDT due to PCI concept. ► Complete remission would be possible in uterine cervical cancer by CCPDT. ► Uterine cervix and corpus can be preserved in CCPDT.

A case of neutrophilia related to a cytokine-producing relapsed squamous cell carcinoma of the uterine cervix arising from the rectovaginal septum.

Paraneoplastic neutrophilia caused by a squamous cell carcinoma of the uterine cervix has been seen rarely. We report a case of relapsed squamous cell carcinoma of the uterine cervix with severe neutrophilia, rapid tumor growth and aggressive clinical course, possibly due to autocrine stimulation of cell growth by G-CSF and IL-6 without other possible causes of neutrophilia.

The efficacy of sonographic morphology indexing and serum CA-125 for preoperative differentiation of malignant from benign ovarian tumors in patients after operation with ovarian tumors.

OBJECTIVE: To evaluate the value of sonographic morphology indexing (MI) system and serum CA-125 levels in the assessment of the malignancy risk in patients with ovarian tumors. METHODS: From September 2000 to July 2006, 202 patients who underwent surgery for ovarian tumors were reviewed retrospectively. In all patients, the MI score and serum CA-125 level were measured preoperatively. The association of the final pathologic diagnosis with the MI score and serum CA-125 level were examined. RESULTS: There were 26 malignant tumors out of 141 ovarian tumors with a MI >/=5 (18%). With a cut-off value of 5, the sensitivity, specificity, PPV, and NPV of MI scores were 0.743, 0.293, 0.181, and 0.845, respectively. There were 22 malignant tumors out of 54 ovarian tumors with serum CA-125 >30 u/ml (41%). With a cut-off value of 30 u/ml, the sensitivity, specificity, PPV, and NPV of serum CA-125 level were 0.667, 0.808, 0.407, and NPV 0.925, respectively. On ROC curve, the optimal cut-off value of MI score was 6.5-7.5 and that of serum CA-125 level was 25.6-28.5 u/ml. With a cut-off value of 7, the sensitivity and 1-specificity of MI score were 0.875-0.917 and 0.023-0.203, respectively. After the exclusion of teratoma cases, the sensitivity and 1-specificity of MI score were 0.875-0.917 and 0.046-0.138, respectively. With a cut-off value of 25.6-28.5 u/ml, the sensitivity and 1-specificity of serum CA-125 level were 0.958 and 0.203-0.215, respectively. CONCLUSION: The sonographic MI system is an accurate and simple method to differentiate a malignant tumor from a benign ovarian tumor. The accuracy of the sonographic MI system improved when the serum CA-125 level was considered and ovarian teratomas were excluded.