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%.

Adnexal torsion in a pediatric population: Acute presentation with question of chronicity.

OBJECTIVES: To establish the frequency of torsion with multiple twists of the adnexa in girls 19 years old and younger surgically diagnosed with torsion. STUDY DESIGN: A retrospective chart review using an institutional tool to review charts of female patients 19 years old or younger who presented with acute abdominal pain leading to a surgical diagnosis of adnexal torsion. RESULTS: Of 141 pediatric patients with torsion, 61 (43%) had documentation of multiple twists, with 2 to 12 rotations present. 33% reported acute pain (<24 hrs) whereas most (67%) had pain > 24 h up to 4 weeks without abatement (23%) or experienced discrete episodes with pain resolution between episodes (44%). Even when vascular flow was demonstrated, multiple twists were frequently found (14/36 = 39%). When multiple twists were documented, more patients had an extirpative procedure due to a nonviable appearing ovary than when a single or unstated number of twists twist was found, although the results were not statistically significant (53.5% vs 42.9%, p = 0.098). CONCLUSIONS: Forty-three percent of girls presenting with symptoms of torsion had multiple twists in the adnexa. Many had provided a history of previous similar episodes of pain and presentation to emergency departments, suggesting possible previous undiagnosed episodes of torsion. Earlier diagnosis may provide a better opportunity for ovarian conservation prior to a recurrent torsion. Further study may reveal whether multiple twists are more likely to result in a nonviable ovary and need for oophorectomy.

Management of Adnexal Torsion in the Pediatric and Adolescent Population at Western Australia's Single Tertiary Children's Hospital over the Last 10 Years: Retrospective Study.

OBJECTIVE: To review our institutional data regarding the management of adnexal torsion (AT) and assess the ovarian conservation rates. DESIGN: Retrospective study. SETTING: Tertiary children's hospital. PATIENTS: Pediatric and adolescent patients with surgically diagnosed AT. Participants (n = 54, mean age 9.80 ± 3.95 years) were identified between June 2010 and May 2019. INTERVENTIONS: Surgical management of AT. MEASUREMENTS AND MAIN RESULTS: The primary outcome was to determine the ovarian conservation rates in AT cases. The secondary outcomes were to determine the incidence of AT to total emergency department (ED) presentations, decision to operation theater (OT) time in AT cases, return to OT, histopathology, and follow-up with ultrasound to determine ovarian function. Data were collected on demographic and clinical characteristics. Continuous data were compared with t tests or Kruskal-Wallis tests; categoric data were compared with chi-square tests. A total of 52 (96.29%) patients had ovarian conservation, and 53 (98.14%) had laparoscopic management. The incidence rate for AT cases to total ED presentations for the last 10 years was 9.9 per 100 000, which was based on a Poisson distribution. Presentations to an ED for AT cases have trended upward since 2010. Decision to OT time was statistically significantly shorter in cases with preoperative suspicion of AT than those with intraoperative diagnosis of AT (p = .000). A total of 7 (12.96%) patients returned to OT for suspicion of recurrent torsion. Of these, 5 (9.26%) had confirmed repeat AT. The presence of fever, pain duration, severity of pain, and severity of torsion did not correlate with the follow-up ultrasound findings of ovarian activity. CONCLUSION: The findings from our study suggest that high ovarian conservation rates are achievable in AT cases. A high index of suspicion is required to prevent a delay in surgery.

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.

Practical Recommendations for the Management of Benign Adnexal Masses.

OBJECTIVE: To perform a 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 be managed 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.

OBJETIVO: Realizar uma revisão abrangente para fornecer recomendações práticas sobre o diagnóstico e tratamento de massas anexiais benignas, bem como 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 excluir a malignidade. 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 enfoquem o impacto das massas anexiais benignas na fertilidade em longo prazo.

Prevalence of endosalpingiosis and other benign gynecologic lesions.

Endosalpingiosis, traditionally regarded as an incidental pathological finding, was recently reported to have an association with gynecologic malignancies. To determine the prevalence of endosalpingiosis, we evaluated all benign appearing adnexal lesions using the Sectioning and Extensively Examining-Fimbria (SEE-Fim) protocol, and queried the pathology database for the presence of endosalpingiosis, gynecologic malignancy, endometriosis, Walthard nests, and paratubal cysts. Using the SEE-Fim protocol, the prevalence of endosalpingiosis, endometriosis, Walthard nests, and paratubal cysts were 22%, 45%, 33%, and 42% respectively, substantially higher than previously reported. All lesions were observed to increase with age except endometriosis which increased until menopause then decreased dramatically. Among specimens including ovarian tissue, the prevalence of implantation of at least one lesion type was ubiquitous in patients age 51 and older (93%). The clinical significance of endosalpingiosis should be a continued area of research with larger trials assessing prevalence, factors affecting incidence, and association with malignancy. Our findings contribute to elucidating the origin of ectopic lesions and gynecologic disease risk.

Histopathologic spectrum of paediatric eye and ocular adnexal tumours: A 10-year review from a referral centre in Nigeria.

BACKGROUND: Tumours of the eye and adnexa demonstrate great histologic variety and constitute a serious threat to vision especially in children. AIMS: The study aims to review the epidemiologic and pathologic characteristics of tumours of the eye and ocular adnexa in the paediatric age group (0-14 years). METHODS: All the cases entered into the departmental records as tumours of the eye and ocular adnexa over a 10-year period in the age group 0-14 years were extracted. The patients' request cards with all relevant Haematoxylin & Eosin (H & E)-stained histology slides were retrieved. All the slides were reviewed and the cases were classified in accordance with the 4th edition of the WHO Classification of Tumours of the Eye (2018). The collected data were subjected to descriptive statistical tabulation and analysis. RESULTS: A total of 104 tumours of the eye and ocular adnexae were diagnosed in the paediatric age group, accounting for 40.5% of all eye and ocular adnexal tumours diagnosed over the study period. The male to female ratio was 1.7:1 and malignant tumours greatly outnumbered benign tumours by a ratio of 5.5:1. Majority (76%) of the tumours occurred in the retina with retinoblastoma representing all the tumours diagnosed in this location. Rhabdomyosarcoma was the most common paediatric orbital tumour accounting for over half (53.8%) of all tumours in the orbit. Tumours of the conjunctiva and the eyelid were infrequent with benign soft tissue tumours (vascular, neural and lipomatous tumours) being the major tumours at these sites. CONCLUSION: Retinoblastoma is the single most common tumour in this age group.

Conservative surgery for ovarian torsion in young women: perioperative complications and national trends.

OBJECTIVE: To analyse populational trends and perioperative complications following conservative surgery versus oophorectomy in women <50 years of age with ovarian torsion. DESIGN: Population-based retrospective observational study. SETTING: Nationwide Inpatient Sample in the USA (2001-2015). POPULATION: In all, 89 177 ovarian torsions including 20 597 (23.1%) conservative surgeries and 68 580 (76.9%) oophorectomies. METHODS: (1) Trend analysis to assess utilisation of conservative surgery over time, (2) multivariable binary logistic regression to identify independent factors associated with conservative surgery and (3) inverse probability of treatment weighting with a generalised estimating equation to analyze perioperative complications. MAIN OUTCOME MEASURES: Trends, characteristics and complications related to conservative surgery. RESULTS: Performance of conservative surgery increased from 18.9 to 25.1% between 2001 and 2015 (32.8% relative increase, P = 0.001) but decreased steadily after age 15, and sharply declined after age 35 (P < 0.001). On multivariable analysis, younger age exhibited the largest effect size for conservative surgery among the independent factors (adjusted odds ratios 3.39-7.96, P < 0.001). In the weighted model, conservative surgery was associated with an approximately 30% decreased risk of perioperative complications overall (10.0% versus 13.6%, odds ratio 0.73, 95% confidence interval 0.62-0.85, P < 0.001) and was not associated with venous thromboembolism (0.2 versus 0.3%, P = 0.457) or sepsis (0.4 versus 0.3%, P = 0.638). CONCLUSION: There has been an increasing utilisation of conservative surgery for ovarian torsion in the USA in recent years. Our study suggests that conservative surgery for ovarian torsion may not be associated with increased perioperative complications. TWEETABLE ABSTRACT: Conservative surgery for ovarian torsion may not be associated with increased perioperative complications.

Learning Curve Analysis of Transvaginal Natural Orifice Adnexal Surgery.

STUDY OBJECTIVE: This study was designed to evaluate the learning curve of transvaginal natural orifice surgery (NOS) for adnexal tumors based on the type of procedure (adnexectomy or cystectomy). DESIGN: Retrospective cohort study. SETTING: Tertiary-care university hospital. PATIENTS: One hundred thirty-six women with adnexal tumors. INTERVENTIONS: A series of 136 consecutive transvaginal NOS for adnexal tumor were performed between April 2011 and June 2016. Eighty-five patients (62.5%) had undergone cystectomy, and 51 patients (37.5%) had undergone adnexectomy. MEASUREMENTS AND MAIN RESULTS: The transvaginal NOS procedures included vaginal, endoscopic, single-port access techniques and were divided into 2 categories: adnexectomy and cystectomy. Operating time was electronically recorded and was defined as the time from the creation of a posterior colpotomy incision until the complete closure of the posterior colpotomy opening. The average operating time for the cystectomy and adnexectomy groups was 42.7 and 37.7 minutes, respectively (p = .015). The learning curve was analyzed using the cumulative summation method and showed that 36 cases were needed to achieve proficiency in transvaginal NOS for ovarian cystectomy. However, there was no significant cut-off point to determine the number of patients who had undergone adnexectomy. CONCLUSION: A well-trained gynecologic endoscopist can achieve surgical proficiency in transvaginal NOS cystectomy after 36 cases. It is suggested that the surgical transvaginal NOS procedure should begin with adnexectomy rather than with cystectomy to avoid initial technical challenges.

Performance of IOTA ADNEX model in evaluating adnexal masses in a gynecological oncology center in China.

OBJECTIVE: To evaluate the diagnostic accuracy of the International Ovarian Tumor Analysis (IOTA) Assessment of Different NEoplasias in the adneXa (ADNEX) model in the preoperative diagnosis of adnexal masses using data from a gynecological oncology center in China. METHODS: This was a single-center, retrospective diagnostic accuracy study based on ultrasound data collected prospectively, between May and December 2017, from 278 patients with at least one adnexal (ovarian, paraovarian or tubal) mass. Clinical and pathologic information, serum CA 125 level and ultrasonographic findings were collected. All patients underwent surgery and the histopathological diagnosis was used as reference standard. The final diagnosis was classified into five tumor types according to the ADNEX model: benign ovarian tumor, borderline ovarian tumor (BOT), Stage-I ovarian cancer (OC), Stages-II-IV OC and ovarian metastasis. Receiver-operating characteristics (ROC) curve analysis was used to evaluate the diagnostic accuracy of the ADNEX model, with and without inclusion of CA 125 level in the model. RESULTS: Of the 278 women included, 203 (73.0%) had a benign ovarian tumor and 75 (27.0%) had a malignant ovarian tumor, including 18 (6.5%) with BOT, 17 (6.1%) with Stage-I OC, 32 (11.5%) with Stages-II-IV OC and eight (2.9%) with ovarian metastasis. The performance of the IOTA ADNEX model was good for discriminating between benign and malignant tumors, with an area under the ROC curve (AUC) of 0.94 (95% CI, 0.91-0.97) when CA 125 was included in the model and AUC of 0.93 (95% CI, 0.90-0.96) without CA 125. The AUC values of the model including CA 125 ranged between 0.61 and 0.99 for distinguishing between the different types of tumor, and it showed excellent performance in discriminating between a benign ovarian tumor and Stages-II-IV OC, with an AUC of 0.99 (95% CI, 0.97-1.00). The performance of the model was less effective at distinguishing between BOT and Stage-I OC and between Stages-II-IV OC and ovarian metastasis, with AUC values of 0.61 (95% CI, 0.43-0.77) and 0.78 (95% CI, 0.62-0.90), respectively. Although inclusion of CA 125 did not alter the performance of the ADNEX model in discriminating between benign and malignant lesions (AUC of 0.94 and 0.93 with and without CA 125 level, respectively; P = 0.54), the inclusion of CA 125 in the model improved its performance in discriminating between Stage-I OC and Stages-II-IV OC (AUC increased from 0.81 to 0.92; P = 0.04) and between Stages-II-IV OC and metastatic cancer (AUC increased from 0.58 to 0.78; P = 0.01). CONCLUSIONS: The IOTA ADNEX model showed good to excellent performance in distinguishing between benign and malignant adnexal masses and between the different types of ovarian tumor in a Chinese setting. Based on our findings, the ADNEX model has high value in clinical practice and can aid in the preoperative diagnosis of patients with an adnexal mass. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Analysis of adnexal mass managed during cesarean section.

BACKGROUND: Pregnancy with an adnexal mass is one of the most common complications during pregnancy and clinicians are sometimes caught in a dilemma concerning the decision to be made regarding clinical management. OBJECTIVES: The objective of this study was to outline and discuss the clinical features, management and outcomes of adnexal masses that were encountered during a cesarean section (CS) at a university affiliated hospital in China. MATERIAL AND METHODS: The medical records of the patients with an adnexal mass observed during a CS were retrospectively collected at Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China, from January 1991 to December 2011. RESULTS: The incidence of adnexal masses was 16.40 per 1000 CSs. The most common pathologic diagnosis was benign ovarian tumor, the 2nd was ovarian endometrioma and the 3rd was theca lutein cyst. Thirteen cases of ovarian malignancies were diagnosed during a CS. Only 388 cases (29.78%) were detected by an ultrasonography (USG) examination before a CS. Eight cases required emergency CS due to abdominal pain; all other patients were clinically asymptomatic. The reasons for abdominal pain included torsion (n = 5), rupture (n = 2) and ovarian enlargement (n = 1). In 13 cases with ovarian endometrioma, cysts ruptured during a CS without any clinical manifestation. No maternal and fetal complications related to surgery were observed. CONCLUSIONS: Preconception care and routine prenatal care, including USG examination, may optimize the detection and management of an adnexal mass. The presumptive ovarian endometrioma detected before pregnancy could be the indication for surgery due to the possibility of spontaneous hemoperitoneum. Theca lutein cysts might be huge and exist throughout the whole pregnancy period. Expectant management is reasonable for an adnexal mass that emerged during pregnancy without suspicion of malignancy. Abdominal pain might be a clue for cyst torsion or rupture.

Can Replacing CA125 with HE4 in Risk of Malignancy Indices 1-4 Improve Diagnostic Performance in the Presurgical Assessment of Adnexal Tumors?

AIMS: To assess whether replacing CA125 with HE4 in the classical formulas of risk of malignancy indices (RMIs) can improve diagnostic performance. METHODS: For each of 312 patients with an adnexal mass, classical RMIs 1-4 were computed based on ultrasound score, menopausal status, and serum CA125 levels. Additionally, modified RMIs (mRMIs) 1-4 were recalculated by replacing CA125 with HE4. RESULTS: Malignant pathology was diagnosed in 52 patients (16.67%). There was no significant difference in diagnostic performance (area under the receiver operating characteristic curve [AUC]) between each classical RMI and its corresponding mRMI. In the entire sample, the AUC was 0.899, 0.900, 0.895, and 0.908 for classical RMIs 1-4 compared to 0.903, 0.929, 0.930, and 0.931 for mRMIs 1-4. In premenopausal patients, the AUC was 0.818, 0.798, 0.795, and 0.802 for classical RMIs 1-4 compared to 0.839, 0.875, 0.876, and 0.856 for mRMIs 1-4. In postmenopausal patients, the AUC was 0.906, 0.895, 0.896, and 0.906 for classical RMIs 1-4 compared to 0.907, 0.923, 0.924, and 0.930 for mRMI 1-4. CONCLUSIONS: Use of HE4 instead of CA125 did not significantly improve diagnostic performance of RMIs 1-4 in patients with an adnexal mass.

Preoperative C-reactive protein serum levels as a predictive diagnostic marker in patients with adnexal masses.

OBJECTIVE: To evaluate C-reactive protein (CRP) serum levels as a preoperative predictive marker for ovarian cancer in patients with adnexal masses. METHODS: CRP serum levels of 1843 adnexal masses and subsequent surgery were investigated (patients with benign ovarian tumors: n=1423; borderline tumor of the ovary [BTO]: n=83; EOC: n=337). Test characteristics and predictive values of CRP serum levels were investigated by univariate analysis and multivariate binary logistic regression models. RESULTS: Median (interquartile range) serum CRP levels in patients with benign ovarian tumors, BTO, and EOC were 0.4 (0.1-0.6)mg/dL, 0.5 (0.2-0.9)mg/dL, and 1.6 (0.5-5.4)mg/dL, respectively (p<0.001). Sensitivity and specificity of the combination of CRP and CA-125 was 80.1% and 90.8%, negative predictive value (NPV) and positive predictive value (PPV) was 92.2% and 76.9%, respectively. In univariate and multivariate analysis, CRP serum levels were independently associated with presence of BTO and EOC (HR 6.7 [5.2-8.5], p<0.001 and HR 2.2 [1.4-3.3], p<0.001). The combination of CRP and CA-125 serum levels resulted in a number needed to treat of 2.11 to detect one case of EOC or BTO. CONCLUSION: CRP serum levels independently predicted the presence of BTO and EOC in patients with suspicious adnexal masses. CRP serum levels seem to be of additional value to CA-125 in the preoperative differential diagnosis of adnexal masses and might be particularly in combination with CA-125 clinically useful.

Postoperative Outcomes after Single-port Laparoscopic Removal of Adnexal Masses in Patients Referred to Gynecologic Oncology at a Large Academic Center.

STUDY OBJECTIVE: To report surgical and pathologic outcomes after single-port laparoscopy (SPL) for adnexal masses in patients referred to a gynecologic oncology practice at a single academic institution. DESIGN: A retrospective analysis (Canadian Task Force Classification II.2). SETTING: A single academic institution with multiple hospital centers. PATIENTS: Women who underwent at least 1 single-port laparoscopic surgery for the treatment of an adnexal mass from 2009 to 2015 after referral to a gynecologic oncology practice. INTERVENTION: Data were collected on the surgical procedure, patient demographic variables, 30-day surgical outcomes, and hernia development. MEASUREMENTS AND MAIN RESULTS: Three hundred twenty-five surgeries were performed in 322 patients with a median follow-up of 42.7 months. The median age was 54.5 years, and the median body mass index was 28.1 kg/m2. All patients underwent unilateral or bilateral salpingectomy or oophorectomy with or without hysterectomy (26.5%). The median operative time was 90.0 minutes. The median mass dimension was 6.4 cm with 17.9% (n = 60) greater than 10 cm. Masses were categorized as simple (11.4%) and complex (69.5%). Although the majority (87.4%) of masses were benign, 7.4% were malignant, and 5.2% were borderline. Benign masses were physiologic (16.6%), serous cystadenomas (19.1%), mucinous cystadenomas (6.8%), endometriomas (12.3%), myomas (12.3%), and mature teratomas (9.2%). In malignant cases (7.4%), serous carcinoma was the most frequent histology (58.3%). The rate of adverse outcomes within 30 days, including reoperation (0.0%), intraoperative injury (1.5%), venous thromboembolism (0.3%), and transfusion (0.6%), was low. The development of incisional cellulitis was 4.6%. The rate of incisional hernia was 4.0%, with a median occurrence of 18.3 months. Diabetes mellitus (p = .03) and obesity (p = .04) were significant predictors for a hernia, but mass complexity (p = .28), American Society of Anesthesiologists class (p = .83), and smoking (p = .82) were not. CONCLUSION: In patients undergoing SPL for the removal of adnexal masses in a gynecologic oncology practice, the rate of benign disease is high. SPL removal of adnexal masses is feasible and safe with favorable surgical outcomes, rare short-term adverse outcomes, and a low incisional hernia rate.

Risk Stratification of Adnexal Cysts and Cystic Masses: Clinical Performance of Society of Radiologists in Ultrasound Guidelines.

Purpose To evaluate the performance of the 2010 Society of Radiologists in Ultrasound (SRU) consensus guidelines in the risk stratification of symptomatic and asymptomatic adnexal cysts. Materials and Methods An institutional review board-approved retrospective review was performed, including adnexal cysts detected with ultrasonography (US) with surgical diagnosis or at least 2 years of imaging or clinical follow-up, from January to June 2011. SRU management recommendations were scored as 0, no follow-up; 1, US follow-up; 2, magnetic resonance (MR) imaging follow-up; and 3, surgical evaluation. Distribution of outcomes (nonneoplastic cyst, benign neoplasm, malignant neoplasm) was compared in each rating group by using the Cochran-Armitage trend test. Where SRU guidelines allow more than one management option, they were classified as being interpreted in either a "surgically focused" environment, with limited MR imaging availability, or an "MR-capable" center, where MR imaging is selected whenever it is an option. Predictors of neoplasms and malignancy were evaluated by using multivariate logistic regression. Results A total of 570 cysts in 500 women aged 18-90 years (mean, 42 years) were included. There were 475 (83.3%) nonneoplastic cysts, 77 (13.5%) benign neoplasms, and 18 (3.2%) malignant neoplasms. Of the 500 women, 161 (32.2%) were asymptomatic. In the surgically focused interpretation of guidelines, proportions of any neoplasm and malignant neoplasm, respectively, were 1% and 0% in SRU 0, 17% and 1% in SRU 1, 48% and 0% in SRU 2, and 48% and 16% in SRU 3 (P < .0001 for both trends). In the interpretation of SRU guidelines with MR imaging when it was an option, proportions of any neoplasm and malignant neoplasm, respectively, were 1% and 0% in SRU 0, 17% and 1% in SRU 1, 38% and 5% in SRU 2, and 81% and 52% in SRU 3 (P < .0001, both trends) and 82 (89.1%) fewer benign cysts would have gone directly to surgical evaluation. In multivariate regression, SRU rating predicted both any neoplasm (odds ratio, 2.58; P < .0001) and malignant neoplasm (odds ratio, 4.94; P = .005). Conclusion SRU consensus guidelines effectively stratified the risk of neoplasia and malignancy. Selecting MR imaging when it is an option in the guidelines would have reduced the number of benign cysts sent for surgical evaluation. © RSNA, 2017.

Clinical Utility of Risk Models to Refer Patients with Adnexal Masses to Specialized Oncology Care: Multicenter External Validation Using Decision Curve Analysis.

Purpose: To evaluate the utility of preoperative diagnostic models for ovarian cancer based on ultrasound and/or biomarkers for referring patients to specialized oncology care. The investigated models were RMI, ROMA, and 3 models from the International Ovarian Tumor Analysis (IOTA) group [LR2, ADNEX, and the Simple Rules risk score (SRRisk)].Experimental Design: A secondary analysis of prospectively collected data from 2 cross-sectional cohort studies was performed to externally validate diagnostic models. A total of 2,763 patients (2,403 in dataset 1 and 360 in dataset 2) from 18 centers (11 oncology centers and 7 nononcology hospitals) in 6 countries participated. Excised tissue was histologically classified as benign or malignant. The clinical utility of the preoperative diagnostic models was assessed with net benefit (NB) at a range of risk thresholds (5%-50% risk of malignancy) to refer patients to specialized oncology care. We visualized results with decision curves and generated bootstrap confidence intervals.Results: The prevalence of malignancy was 41% in dataset 1 and 40% in dataset 2. For thresholds up to 10% to 15%, RMI and ROMA had a lower NB than referring all patients. SRRisks and ADNEX demonstrated the highest NB. At a threshold of 20%, the NBs of ADNEX, SRrisks, and RMI were 0.348, 0.350, and 0.270, respectively. Results by menopausal status and type of center (oncology vs. nononcology) were similar.Conclusions: All tested IOTA methods, especially ADNEX and SRRisks, are clinically more useful than RMI and ROMA to select patients with adnexal masses for specialized oncology care. Clin Cancer Res; 23(17); 5082-90. ©2017 AACR.

Diagnostic accuracy and cost-effectiveness of different strategies to triage women with adnexal masses: a prospective study.

OBJECTIVE: Transvaginal sonography (TVS) and serum biomarkers are used widely in clinical practice to triage women with adnexal masses, but the effectiveness of current biomarkers is weak. The aim of this study was to determine the best method of diagnosing patients with adnexal masses, in terms of diagnostic accuracy and economic costs, among four triage strategies: (1) the International Ovarian Tumor Analysis group's simple rules (SR) for interpretation of TVS with subjective assessment (SA) by an experienced ultrasound operator when TVS results are inconclusive (referred to hereafter as SR ± SA), (2) SR ± SA and cancer antigen 125 (CA 125), (3) SR ± SA and human epididymis protein 4 (HE4) and (4) SR ± SA and the risk of malignancy algorithm (ROMA). Our main hypothesis was that the addition of the biomarkers to SR ± SA could improve triaging of these patients in terms of diagnostic accuracy (i.e. malignant vs benign). As secondary analyses, we estimated the cost effectiveness of the four strategies and the diagnostic accuracy of SR ± SA at the study hospitals. METHODS: Between February 2013 and January 2015, 447 consecutive patients who were scheduled for surgery for an adnexal mass at the S. Anna and Mauriziano Hospitals in Turin were enrolled in this multicenter prospective cohort study. Preoperative TVS was performed and preoperative CA 125 and HE4 levels were measured. Pathology reports were used to assess the diagnostic accuracy of the four triage strategies and the cost of each strategy was calculated. RESULTS: A total of 391 patients were included in the analysis: 57% (n = 221) were premenopausal and 43% (n = 170) were postmenopausal. The overall prevalence of malignancy was 21%. SR were conclusive in 89% of patients and thus did not require SA; the overall performance of SR ± SA showed a sensitivity of 82%, specificity of 92% and positive and negative predictive values and positive and negative likelihood ratios of 74%, 95%, 10.5 and 0.19, respectively. In premenopausal women, mean cost among the four triage strategies varied from €36.41 for SR ± SA to €70.12 for SR ± SA + ROMA. The addition of biomarkers to SR ± SA showed no diagnostic advantage compared with SR ± SA alone and was more costly. Among postmenopausal women, mean cost among the four triage strategies varied from €39.52 for SR ± SA to €73.23 for SR ± SA + ROMA. Among these women, SR ± SA + CA 125 and SR ± SA + ROMA had a higher sensitivity (both 92% (95% CI, 85-99%)) than SR ± SA (81% (95% CI, 71-91%)), but SR ± SA had a higher specificity (84% (95% CI, 77-91%)). SR ± SA + CA 125 and SR ± SA + ROMA improved diagnostic accuracy, each diagnosing a third more malignant adnexal masses. In postmenopausal women, compared with SR ± SA alone, SR ± SA + CA 125 showed a net reclassification improvement (NRI) of 28.8% at an extra cost of €13.00, while the extra cost for SR ± SA + ROMA was €33.71, with a comparable gain, in terms of NRI, as that of SR ± SA + CA 125. CONCLUSIONS: In our study sample, SR ± SA seems to be the best strategy to triage women with adnexal masses for surgical management. Among postmenopausal women, SR ± SA + CA 125 increased the NRI at a reasonable extra cost. Our data do not justify the use of HE4 and ROMA in the initial triage of women with adnexal masses. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

1,138 women with adnexal mass: pathologic findings according to age.

Purpose ofinvestigation: Influence of the patients' age are not well established to predict the malignancy potential of adnexal masses. This study was conducted to evaluate the impact of women's age on both histopathology and malignancy potential of adnexal masses. MATERIALS AND METHODS: This is a retrospective chart review study. Patients who were operated for suspected adnexal masses were included in the study. Malignancy potentials of tumors were divided in benign and at least borderline in univariate and multivariate analyses. Univariate analyses and RR calculations were performed according to malignancy potential for age, serum cancer antigen-125 (CA-125) levels and menopause status. RESULTS: A total of 1,138 women were included for this study; median age was 39 (16-92) years. Patients > 50 years had 5.920 times higher risk (95% CI 4.091-8.566; p = 0.0001) of having at least borderline tumor compared the younger group. The risk of at least borderline pathology was calculated as 3.723 (95% CI 2.595-5.342;p = 0.0001) in patients with CA 125 ≥ 35 IU/ml compared to the others. In multivariate analyses, only ≥ 35 IU/ml CA 125 level and > 50 years age groups were defined as independent variables for having at least borderline tumor. (OR: 4.456, 95% CI 2.982-6.659, p = 0.0001 and OR: 3.134, 95% CI 1.435-6.843, p = 0.004, respectively). CONCLUSION: In this study; the age of > 50 years was detected as an independent factor for having at least borderline pathology for adnexal masses. The data from these results might be used as a differential diagnostic tool in a new combination for benign and malignant adnexal masses in future studies.

Pediatric Adnexal Torsion: Not Just a Postmenarchal Problem.

BACKGROUND: Pediatric adnexal torsion is rare, can be challenging to recognize, and may result in ovarian loss. OBJECTIVE: We sought to identify and compare the defining characteristics of adnexal torsion in premenarchal and postmenarchal girls. METHODS: A retrospective cohort study was performed at a tertiary care children's hospital, including patients diagnosed postnatally with adnexal (ovarian or tubal) torsion between 1997 and 2013. Proportions were compared using relative risk regression. RESULTS: Adnexal torsion was found in 59 premenarchal and 43 postmenarchal girls. Abdominal pain was the most common chief complaint (54%). History included reports of pain (96%), vomiting (67%), and fever (19%). Excluding 12 patients with isolated tubal torsion and 19 with a teratoma, there were no statistically significant differences in ovarian loss in premenarchal vs. postmenarchal girls (47% and 25% respectively; relative risk [RR] = 1.8 [95% confidence interval {CI} 0.9-3.8]), left- vs. right-sided torsion (47% and 32%; RR = 1.5 [95% CI 0.8-2.7]), pain duration ≤ 2 days vs. > 2 days (31% and 41%; RR = 0.8 [95% CI 0.4-1.5]; n = 64) and severe pain vs. mild to moderate (38% and 33%; RR = 1.1 [95% CI 0.7-1.5]; n = 56). CONCLUSIONS: The diagnosis of pediatric adnexal torsion is difficult and often delayed. Pain and tenderness may not be isolated to a unilateral lower quadrant. Although traditionally considered a postmenarchal problem, in a pediatric academic emergency department adnexal torsion occurred with similar frequency in premenarchal and postmenarchal girls. The potential for organ salvage means that adnexal torsion should be considered in all females presenting with acute abdominal pain regardless of age or menstrual history.

Chronic adnexal torsion: An under-recognized disease entity.

OBJECTIVE: To clarify the incidence, clinical background and surgical characteristics of chronic adnexal torsion in comparison to acute adnexal torsion. STUDY DESIGN: The patients were divided into three categories based on the period from the onset of symptoms to surgical management: acute (≤24h), subacute (2days) and chronic adnexal torsions (≥3days). Cases, in which the onset of symptoms was unspecified, were included in the chronic adnexal torsion group. Then, a retrospective comparative study of acute (49 patients) and chronic adnexal torsion (45 patients) was performed. Laparoscopic surgery was performed as a primary surgical procedure. RESULTS: In chronic adnexal torsion, surgery was performed at a median of 9days (range: 3-270days) after the onset of symptoms. The apparent onset of symptoms was not noted in 2 cases. All cases with acute adnexal torsion received emergency surgery. In contrast, emergency surgery was performed only in 13 patients with chronic adnexal torsion. Patients with chronic adnexal torsion were significantly older than those with acute adnexal torsion. Isolated tubal torsion was more frequent in chronic adnexal torsion. With the exception of 2 cases with chronic adnexal torsion in which laparotomic conversion was required due to severe adhesion, and 2 cases with acute adnexal torsion with advanced gestational age, who were managed by initial laparotomy, laparoscopic surgery was successful. Unilateral salpingo-oophorectomy was the most frequent surgical procedure in both groups. When confined to the patients who expressed a wish for adnexal preservation, adnexal cystectomy or detorsion was possible in 60.9% of the acute torsion cases and 57.1% of the chronic adnexal torsion cases. Severe necrosis of the adnexal tissue and extensive pelvic adhesion were the more frequent associated conditions in chronic adnexal torsion. Among the patients who were successfully managed by laparoscopic surgery, the duration of surgery was significantly longer in the patients with chronic adnexal torsion. Severe necrosis that makes a pathological diagnosis difficult was the most frequent finding in cases of chronic adnexal torsion. CONCLUSION: Chronic adnexal torsion still represents a diagnostic and therapeutic challenge that should be recognized as a distinct and more frequently encountered disease entity.