O-RADS MRI SCORE: An Essential First-Step Tool for the Characterization of Adnexal Masses.

The ovarian-adnexal reporting and data system on magnetic resonance imaging (O-RADS MRI) score is now a well-established tool to characterize pelvic gynecological masses based on their likelihood of malignancy. The main added value of O-RADS MRI over O-RADS US is to correctly reclassify lesions that were considered suspicious on US as benign on MRI. The crucial issue when characterizing an adnexal mass is to determine the presence/absence of solid tissue and thus need to perform gadolinium injection. O-RADS MR score was built on a multivariate analysis and must be applied as a step-by-step analysis: 1) Is the mass an adnexal mass? 2) Is there an associated peritoneal carcinomatosis? 3) Is there any significant amount of fatty content? 4) Is there any wall enhancement? 5) Is there any internal enhancement? 6) When an internal enhancement is detected, does the internal enhancement correspond to solid tissue or not? 7) Is the solid tissue malignant? With its high value to distinguish benign from malignant adnexal masses and its high reproducibility, the O-RADS MRI score could be a valuable tool for timely referral of a patient to an expert center for the treatment of ovarian cancers. Finally, to make a precise diagnosis allowing optimal personalized treatment, the radiologist in gynecological imaging will combine the O-RADS MRI score with many other clinical, biological, and other MR criteria to suggest a pathological hypothesis. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY STAGE: 3.

Serum miRNA improves the accuracy of a multivariate index assay for triage of an adnexal mass.

OBJECTIVE: To determine whether a multimodal assay combining serum microRNA with protein biomarkers and metadata improves triage assessment of an adnexal mass. METHODS: Serum samples from 468 training subjects (191 cancer cases and 277 benign adnexal mass controls or healthy controls) were analyzed for seven protein biomarkers and 180 miRNA. Circulating analyte data were combined with age and menopausal status (metadata) into a neural network model to classify samples as cases or controls. Forward regression with ten-fold cross-validation minimized the dimensionality of the model while maximizing linear separation between cases and controls. Model validation proceeded using both internal (44 cases and 56 controls) and external validation sets (51 cases and 59 controls). RESULTS: The total study population comprised 678 subjects, including 286 cases and 392 controls. Overall, 290 (43%) of the subjects were premenopausal. A panel of 10 miRNA delivered optimal performance when combined with protein and metadata features. The combined model improved the Receiver Operator Characteristic Area Under the Curve (ROC AUC) on the internal (AUC = 0.9; 95% CI 0.81-0.95) and external validation sets (AUC = 0.95; 95% CI 0.90-0.98) compared to miRNA alone or proteins plus metadata (without miRNA). On external validation, the combined model offered 92% sensitivity at 80% specificity overall, with 80% and 100% sensitivity for early and late-stage cancers, respectively, including 78% sensitivity for early-stage, serous ovarian cancers and 82% sensitivity for early-stage, non-serous cancers. CONCLUSIONS: A multimodal assay combining miRNA with protein biomarkers, age, and menopausal status improves surgical triage of an adnexal mass.

Neural network-derived multivariate index assay demonstrates effective clinical performance in longitudinal monitoring of ovarian cancer risk.

OBJECTIVE: We recently characterized the clinical performance of a multivariate index assay (MIA3G) to assess ovarian cancer risk for adnexal masses at initial presentation. This study evaluated how MIA3G varies when applied longitudinally to monitor risk during clinical follow-up. METHOD: The study evaluated women presenting with adnexal masses from eleven centers across the US. Patients received an initial blood draw at enrollment and at the standard-of-care follow-up visits. MIA3G was determined for all visits but physicians did not have access to MIA3G scores to determine clinical management. The primary outcome was the relative change value (RCV) of MIA3G over the period of clinical observation. RESULTS: A total of 510 patients of 785 enrolled met study criteria. Of these, 30.8% had a second, 25.4% a third and 22.2% a fourth blood draw following initial collection. The median duration from initial draw was 131 d to second draw, 301.5 d to the third draw and 365.5 d to the fourth draw. MIA3G RCV of >50% was observed in 22-26% patients, whereas 70-75% patients had MIA3G RCV >5%. An empirical baseline RCV of 56% - transformed to 1 in logarithmic scale - was calculated from averaging RCVs of all patients who had no malignancy risk after 210 days. RCV > 1 log was associated with higher incidence of surgical intervention (29.6%) compared to RCV < 1 log (16.9%). CONCLUSIONS: Variation in MI3AG does not change the accuracy of the test for excluding malignancy, while marked changes may be associated with a slightly higher likelihood of surgical intervention. In addition to MIA3G score itself, the MIA3G RCV may be important for clinical management.

Ovarian cancer risk among older patients with stable adnexal masses.

BACKGROUND: Few studies have evaluated the risk of cancer among older patients with stable adnexal masses in community-based settings to determine the duration of observation time needed. OBJECTIVE: This study aimed to assess the ovarian cancer risk among older patients with stable adnexal masses on ultrasound. STUDY DESIGN: This was a retrospective cohort study of patients in a large community-based health system aged ≥50 years with an adnexal mass <10 cm on ultrasound between 2016 and 2020 who had at least 1 follow-up ultrasound performed ≥6 weeks after initial ultrasound. Masses were considered stable on follow-up examination if they did not exhibit an increase of >1 cm in the greatest dimension or a change in standardized reported ultrasound characteristics. Ovarian cancer risk was determined at increasing time intervals of stability after initial ultrasound. RESULTS: Among 4061 patients with stable masses, the average age was 61 years (range, 50-99), with an initial mass size of 3.8 cm (range, 0.2-9.9). With a median follow-up of 3.7 years, 11 cancers were detected, with an absolute risk of 0.27%. Ovarian cancer risk declined with longer duration of stability, from 0.73 (95% confidence interval, 0.30-1.17) per 1000 person-years at 6 to 12 weeks, 0.63 (95% confidence interval, 0.19-1.07) at 13 to 24 weeks, 0.44 (95% confidence interval, 0.01-0.87) at 25 to 52 weeks, and 0.00 (95% confidence interval, 0.00-0.00) at >52 weeks. Expressed as number needed to reimage, ongoing ultrasound imaging would be needed for 369 patients whose masses show stability at 6 to 12 weeks, 410 patients at 13 to 24 weeks, 583 patients at 25 to 52 weeks, and >1142 patients with stable masses at 53 to 104 weeks to detect 1 case of ovarian cancer. CONCLUSION: In a diverse community-based setting, among patients aged ≥50 years with an adnexal mass that was stable for at least 6 weeks after initial ultrasound, the risk of ovarian cancer was very low at 0.27%. Longer demonstrated duration of stability was associated with progressively lower risk, with no cancer cases observed after 52 weeks of stability. These findings suggest that the benefit of ultrasound monitoring of stable masses beyond 12 months is minimal and may be outweighed by potential risks of repeated imaging.

Evaluation of laparo-endoscopic single-site surgery for adnexal mass in pregnant women.

BACKGROUND: Surgery for adnexal mass does occur in pregnant women and therefore the choice of surgery during pregnancy needs to be carefully considered and studied. This study aimed to evaluate the safety and feasibility of Laparo-endoscopic Single-site Surgery (LESS) for adnexal mass during pregnancy and investigate the perioperative condition, pregnancy complications, and obstetric outcomes of operative women during pregnancy. METHODS: This study retrospectively collected medical records and surgery videos of 20 pregnant women who underwent LESS for adnexal mass between November 2019 and January 2022. Baseline characteristics, operative-related variables, and pregnancy outcomes were followed up. RESULTS: LESS for adnexal mass was successfully performed in 20 pregnant women, with very satisfactory surgery outcomes reported in all cases. The average gestational age at operation was 15+2 weeks (range, 5+1- 25+4 weeks). The median operative time was 80.8 min (range, 40 -185 min) and the average operative bleeding was 28.0 ml (range, 10-50 ml). The average VAS of 24 h postoperatively was 1 (range, 0-2), and the average length of hospital stay was 5.15 days (range, 3-7 days). All these women delivered a healthy newborn at full term except 1 woman induced abortion for her own reasons at 16+5 weeks gestational age (GA). The average GA of delivery was 39+1 weeks (range, 37-40+1 weeks), the average birth weight was 3228.95 g (range, 2740-3930 g), and the average Apgar score at 5 min was 9.95 (range, 9-10). CONCLUSIONS: LESS for adnexal mass is safe and feasible for pregnant women.

Tissue Retrieval of Laparoscopically Excised Adnexal Specimens in Gynecologic Surgery: Posterior Culdotomy versus Abdominal Extraction.

OBJECTIVE: The objective of this study is to compare intraoperative and postoperative outcomes in women undergoing removal of adnexal structures by either posterior culdotomy or abdominal extraction. DESIGN: This is a retrospective cohort study conducted via medical record review. Demographic, clinical, and operative variables were abstracted from the medical records. Statistical analysis consisted of descriptive statistics, Fisher's exact tests, Wilcoxon rank sum tests, and multivariable logistic regression models. SETTING: Single academic tertiary care center between 2010 and 2022. PARTICIPANTS: A total of 718 patients were identified and included in our analysis who underwent minimally invasive ovarian cystectomy or oophorectomy. Patients were excluded if they underwent concomitant hysterectomy. INTERVENTIONS: Patients underwent minimally invasive oophorectomy or ovarian cystectomy, and specimens were extracted by either abdominal extraction (AE) or culdotomy extraction (CE). MEASUREMENTS AND MAIN RESULTS: Of the 718 patients who met inclusion criteria, 127 (17.7%) underwent CE, and 591 (82.3%) underwent abdominal extraction. The CE group had longer operative times (113 minutes vs 96 minutes, p <.001) and higher estimated blood loss (25 mL vs 10 mL, p <.001) compared to the abdominal extraction group. There were more malignancies in the CE than the abdominal extraction group (15.7% vs 8.1%, respectively, p <.001). After adjusting for potential confounders, those who underwent CE were more likely to have 2 or more clinic visits (OR 2.89; 95% confidence interval, 1.66-5.03; p <.001) and call or message the clinic (OR 2.08; 95% confidence interval, 1.35-3.20; p <.001). There were no incidences of cuff dehiscence, cuff cellulitis, or pelvic abscess in either group. CONCLUSION: Removal of adnexal specimens via abdominal port site or posterior culdotomy incision is a feasible option for specimen extraction and can be individualized based on patient and surgeon preference and patient factors. Those undergoing CE may require more preoperative counseling due to higher rate of postoperative messages seen in our cohort.

Diagnostic Value of Contrast-Enhanced Ultrasound in Benign and Malignant Adnexal Masses: A Meta-Analysis.

In the diagnosis of gynecological tumors, determining the benign or malignant nature of adnexal masses is a crucial and complex issue. Contrast-enhanced ultrasound (CEUS) is a relatively novel and increasingly used diagnostic method. Therefore, this study evaluated the diagnostic value of CEUS in differentiating benign and malignant adnexal masses through meta-analysis and systematic review. We systematically searched PubMed, Embase, Web of Science, and the Cochrane Library for studies published up to April 2024 regarding the use of CEUS in diagnosing benign and malignant adnexal masses. STATA 14.0 software was used for data analysis, pooling the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio (DOR) of eligible studies. After initial screening, 305 studies were identified, 13 of which met the inclusion criteria and were analyzed in this meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and DOR of CEUS for the diagnosis of benign and malignant adnexal masses were 0.92 (95% confidence interval [CI]: 0.88-0.95), 0.88 (95% CI: 0.82-0.93), 8.00 (95% CI: 5.00-12.90), 0.09 (95% CI: 0.06-0.14), and 91.00 (95% CI: 45.00-185.00), respectively. The area under the summary receiver operating characteristic curve (AUC) was 0.95 (95% CI: 0.93-0.97). CEUS is a noninvasive, nonradiative imaging modality with high accuracy and reliability in the diagnosis of benign and malignant adnexal masses. To provide an effective adjunct tool in the clinic, future studies can further explore the specific application value of CEUS and its performance in different populations.

Validation of the IOTA ADNEX Model Among Japanese Women Performed by Gynecology Trainees and Ultrasound Specialists: A Retrospective Diagnostic Accuracy Study.

OBJECTIVES: This study aimed to validate the diagnostic accuracy of the International Ovarian Tumor Analysis (IOTA) Assessment of Different NEoplasias in the adneXa (ADNEX) model in Japanese women, population with a distinct adnexal mass distribution compared with European women, and to evaluate the model's utility by gynecology trainees and ultrasound specialists. METHODS: This single-center, retrospective study analyzed ultrasound data from January 2017 to March 2020 of 206 women with adnexal masses. Patients who underwent ultrasonography and serum CA-125 measurement and received postsurgery histological diagnosis were included. The ADNEX model's diagnostic performance was evaluated by two trainees and two specialists using the area under the receiver operating characteristic curve (AUC) and measures of accuracy, sensitivity, specificity, and predictive values for overall performance and each examiner. RESULTS: Of the 206 included Japanese women, the prevalence of malignancy was 30.1%, including borderline cases. The overall AUC for distinguishing malignancy was 0.848 (95% confidence interval [CI]: 0.817-0.880). The AUC for each examiner ranged from 0.791 to 0.898, with Specialist 2 showing the highest accuracy and sensitivity varying between 0.677 and 0.839. A moderate degree of agreement was noted among the four examiners (Fleiss' kappa was 0.586). The performance of trainees and specialists differed significantly in evaluating the solid tissue and the papillary projections in both malignant and benign groups (P < .001). CONCLUSIONS: The IOTA ADNEX model effectively differentiates benign and malignant adnexal masses in Japanese women. Although the accuracy matched up moderately among the four examiners, better accuracy is expected with training in evaluating solid tissue and papillary projections.

Evaluation of American College of Radiology Ovarian-Adnexal Reporting and Data System ultrasound to predict malignancy risk in adnexal lesions.

AIMS: To validate the diagnostic performance of Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound for preoperative adnexal lesions in an external center. The secondary aim was to evaluate the performance of a strategy test including O-RADS ultrasound evaluation and subjective assessment of higher malignant risk lesions. METHODS: One hundred thirty patients with 158 ovarian-adnexal lesions were enrolled in the study. Each lesion was assigned an O-RADS score after real-time ultrasound examination by one experienced radiologist. A second subjective assessment by an expert was performed for O-RADS 4 and O-RADS 5 lesions. The histopathological diagnosis was used as the reference standard. RESULTS: A total of 126 benign and 32 malignant adnexal masses were included in the study. The area under the receiver operating characteristic curve of O-RADS ultrasound was 0.950, with a cutoff value > O-RADS 3. The sensitivity, specificity, and negative and positive predictive values were 100% (95% confidence interval [CI], 0.867-1), 83.3% (95% CI, 0.754-0.892), 60.4% (95% CI, 0.460-0.732), and 100% (95% CI, 0.956-1), respectively. For the strategy test, the sensitivity, specificity, negative and positive predictive values were 100% (95% CI, 0.867-1), 92.1% (95% CI, 0.855-0.959), 76.2% (95% CI, 0.602-0.874), and 100% (95% CI, 0.960-1), respectively. In comparison with O-RADS ultrasound, the specificity and negative predictive value of the strategy test were slightly higher (p < 0.05). CONCLUSIONS: Good diagnostic performance of the O-RADS ultrasound in adnexal lesions can be achieved by experienced radiologists in clinical practice. A second subjective assessment of sonographic findings can be applied to O-RADS 4 and 5 lesions.

Is single-port laparoscopy or vaginal natural orifice transluminal endoscopic surgery the better option for salpingo-oophorectomy?

AIM: To compare postoperative pain and recovery in patients undergoing oophorectomy with single-port laparoscopic surgery (SPLS) versus vaginal natural orifice transluminal endoscopic surgery (vNOTES). METHOD: Patients who underwent salpingo-oophorectomy with SPLS or vNOTES between 2016 and 2023 were analyzed retrospectively. Oophorectomy was performed based on the presence of an adnexal mass or breast cancer susceptibility gene mutation. RESULTS: Fifty-two patients underwent oophorectomy with SPLS and 35 underwent vNOTES. Although the mean mass size was slightly larger in the SPLS group than in the vNOTES group (8.0 ± 4.1 vs. 6.8 ± 3.3 cm), the difference was not significant. There was no difference in operating times between SPLS and vNOTES. The mean visual analog scale and faces pain scale scores 2 and 6 h postoperatively were lower in the vNOTES group. The mean quality of recovery-40 (QoR-40) score was higher in the vNOTES group (156 ± 14 vs. 148 ± 11; p = 0.009). This analysis identified vNOTES as an independent predictor of a high QoR-40 score. CONCLUSION: The vNOTES group experienced less pain during the early postoperative period than the SPLS group. Although the operating and removal times were similar, the port setup time was longer for the vNOTES group.

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

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

Adnexal masses during pregnancy: diagnosis, treatment, and prognosis.

Adnexal masses are identified in pregnant patients at a rate of 2 to 20 in 1000, approximately 2 to 20 times more frequently than in the age-matched general population. The most common types of adnexal masses in pregnancy requiring surgical management are dermoid cysts (32%), endometriomas (15%), functional cysts (12%), serous cystadenomas (11%), and mucinous cystadenomas (8%). Approximately 2% of adnexal masses in pregnancy are malignant. Although most adnexal masses in pregnancy can be safely observed and approximately 70% spontaneously resolve, a minority of cases warrant surgical intervention because of symptoms, risk of torsion, or suspicion of malignancy. Ultrasound is the mainstay of evaluation of adnexal masses in pregnancy because of accuracy, safety, and availability. Several ultrasound mass scoring systems, including the Sassone, Lerner, International Ovarian Tumor Analysis Simple Rules, and International Ovarian Tumor Analysis Assessment of Different NEoplasias in the adneXa scoring systems have been validated specifically in pregnant populations. Decisions regarding expectant vs surgical management of adnexal masses in pregnancy must balance the risks of torsion or malignancy with the likelihood of spontaneous resolution and the risks of surgery. Laparoscopic surgery is preferred over open surgery when possible because of consistently demonstrated shorter hospital length of stay and less postoperative pain and some data demonstrating shorter operative time, lower blood loss, and lower risks of fetal loss, preterm birth, and low birthweight. The best practices for laparoscopic surgery during pregnancy include left lateral decubitus positioning after the first trimester of pregnancy, port placement with respect to uterine size and pathology location, insufflation pressure of less than 12 to 15 mm Hg, intraoperative maternal capnography, pre- and postoperative fetal heart rate and contraction monitoring, and appropriate mechanical and chemical thromboprophylaxes. Although planning surgery for the second trimester of pregnancy generally affords time for mass resolution while optimizing visualization with regards to uterine size and pathology location, necessary surgery should not be delayed because of gestational age. When performed at a facility with appropriate obstetrical, anesthetic, and neonatal support, adnexal surgery in pregnancy generally results in excellent outcomes for pregnant patients and fetuses.

Spontaneous bilateral tubal ectopic pregnancy preoperatively diagnosed by the ultrasound: a case report.

BACKGROUND: Bilateral ectopic pregnancy is extremely rare, with a tremendous maternal mortality and morbidity risk, requiring rapid diagnosis and management. This condition is usually diagnosed during surgery, as radiologists may not pay enough attention to the contralateral side of interest. Therefore, reminding of this rare but emergent situation can be beneficial for both radiologists and gynecologists. Here we report a case of bilateral ectopic pregnancy, which was first diagnosed with ultrasound and was confirmed during laparoscopy. CASE PRESENTATION: A 34 years old woman complaining of light vaginal bleeding at 6 weeks of gestation by her last menstrual period presented to our institute. The serum ß-HCG levels were analyzed and followed during patient's admission. Unfortunately, serum levels weren't decreasing and blood test titration before surgery were as: 851,894,975 IU/l (checked daily and not every 48 h because of patient's status and being bilateral). There was no evidence of intrauterine pregnancy at the transvaginal ultrasound, but heterogeneous adnexal masses were seen at both adnexa, suspected of bilateral ectopic pregnancy. She underwent laparoscopic exploration, which confirmed the diagnosis. Bilateral salpingostomy was done to preserve fertility, and the patient's recovery was uneventful. CONCLUSIONS: Even with a unilateral report of ectopic pregnancy preoperatively in ultrasonography, surgeons should always be aware of the probability of bilateral ectopic pregnancies anytime facing susceptible cases, especially in patients with known risk factors. Also, it is an important reminder for radiologists to check both adnexa when facing a unilateral adnexal mass resembling ectopic pregnancy.

Comparison of the diagnostic efficiency between the O-RADS US risk stratification system and doctors' subjective judgment.

BACKGROUND: This study aimed to compare the diagnostic efficiency of Ovarian-Adnexal Reporting and Data System (O-RADS) and doctors' subjective judgment in diagnosing the malignancy risk of adnexal masses. METHODS: This was an analysis of 616 adnexal masses between 2017 and 2020. The clinical findings, preoperative ultrasound images, and pathological diagnosis were recorded. Each adnexal mass was evaluated by doctors' subjective judgment and O-RADS by two senior doctors and two junior doctors. A mass with an O-RADS grade of 1 to 3 was a benign tumor, and a mass with an O-RADS grade of 4-5 was a malignant tumor. All outcomes were compared with the pathological diagnosis. RESULTS: Of the 616 adnexal masses, 469 (76.1%) were benign, and 147 (23.9%) were malignant. There was no difference between the area under the curve of O-RADS and the subjective judgment for junior doctors (0.83 (95% CI: 0.79-0.87) vs. 0.79 (95% CI: 0.76-0.83), p = 0.0888). The areas under the curve of O-RADS and subjective judgment were equal for senior doctors (0.86 (95% CI: 0.83-0.89) vs. 0.86 (95% CI: 0.83-0.90), p = 0.8904). O-RADS had much higher sensitivity than the subjective judgment in detecting malignant tumors for junior doctors (84.4% vs. 70.1%) and senior doctors (91.2% vs. 81.0%). In the subgroup analysis for detecting the main benign lesions of the mature cystic teratoma and ovarian endometriosic cyst, the junior doctors' diagnostic accuracy was obviously worse than the senior doctors' on using O-RADS. CONCLUSIONS: O-RADS had excellent performance in predicting malignant adnexal masses. It could compensate for the lack of experience of junior doctors to a certain extent. Better performance in discriminating various benign lesions should be expected with some complement.

Accuracy of IOTA Simple Rules, IOTA ADNEX Model, RMI, and Subjective Assessment for Preoperative Adnexal Mass Evaluation: The Experience of a Tertiary Care Referral Hospital.

OBJECTIVES: The aim of this study was to evaluate the accuracy of IOTA Simple Rules (SR), IOTA ADNEX model, Risk of Malignancy Index (RMI), and subjective assessment (SA) which is used for adnexal mass assessment in our institution. DESIGN: This is a prospective observational study. PARTICIPANTS/MATERIALS, SETTING, METHODS: We included patients with at least one adnexal mass who needed elective surgical evaluation based on clinical and laboratory findings. Patients admitted to Clinic for Gynecology and Obstetrics, University Clinical Center of Serbia, were recruited for the study between January 2019 and June 2021. Level II ultrasonographers performed a gray scale and Doppler exam for each patient. Preoperative classification of adnexal masses (benign or malignant) was performed by SA, the International Ovarian Analysis Group (IOTA) SR, IOTA ADNEX model, and Risk of Malignancy Index (RMI). Postoperatively obtained histological findings were used as a reference. RESULTS: During the study period, we enrolled 179 premenopausal and 217 postmenopausal patients, representing 396 patients in our sample. Prevalence of malignant disease in pre- and postmenopausal groups was 16.2% (29/179) and 41% (89/217), respectively. Malignant disease was diagnosed in 29.8% (118/396) of patients. SA achieved the highest discrimination accuracy between benign and malignant tumors (area under the curve [AUC] of 0.928, 95% CI [0.898-0.952]). For SA, the overall diagnostic accuracy, sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were 91.4%, 88.1%, 92.8%, 12.25, and 0.13. The AUC for Simple Rules with subjective assessment in inconclusive cases (SR + SA) was 0.912 (95% CI [0.880-0.938]). Regarding SR + SA, diagnostic accuracy, sensitivity, specificity, LR+, and LR- were 92.4%, 88.1%, 94.2%, 15.31, and 0.13. The ADNEX model had the AUC of 0.914 (95% CI [0.882-0.940]). Binary classification using the ADNEX model at a cut-off value of 10% for malignancy had the sensitivity, specificity, LR+ and LR- of 92.4%, 73.0%, 3.42, and 0.10. This resulted in the lowest overall accuracy of 78.8%. The AUC for RMI was 0.854 (95% CI [0.815-0.887]), with overall accuracy, sensitivity, specificity, LR+ and LR- of 82.3%, 73.7%, 86.0%, 5.26, and 0.31. There was no difference in the AUCs of the SA and IOTA models for the whole group, premenopausal, and postmenopausal groups. RMI performed worse compared to SA and the IOTA models. The ADNEX model achieved the highest accuracy at the cut-off value of 35%. LIMITATIONS: The data generalizability is limited by a single institution-dependent sampling. CONCLUSIONS: The IOTA SR and ADNEX model were reliable and comparable with the SA and performed better than the RMI. The IOTA SR model offers the potential for immediate and reliable diagnosis, even in the hands of less experienced ultrasonographers. Both IOTA models studied can be a valuable adjunct to a clinician's decision-making process.

Predictive accuracy and reproducibility of the O-RADS US scoring system among sonologists with different training levels.

PURPOSE: To investigate the predictive performance and reproducibility of Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) system in evaluating adnexal masses between sonologists with varying levels of expertise. METHODS: This was a single-center retrospective study conducted between May 2019 and May 2020, which included 147 adnexal mases with pathological results. Four sonologists with varying experiences independently assigned an O-RADS US category to each adnexal mass twice. The intra- and inter-observer agreement was assessed using weighted kappa values. The area under the curve (AUC), sensitivity, specificity, positive and negative predictive value (PPV and NPV) were assessed for each sonologist. RESULTS: Of the 147 adnexal mases, 115 (78.2%) lesions were benign and 32 (21.8%) lesions were malignant. Considering O-RADS > 3 as a predictor for adnexal malignancy, the predictive accuracies of the four sonologists were excellent, with AUCs ranging from 0.831 to 0.926. The predictive accuracies of O-RADS US by experienced sonologists were significantly higher compared to inexperienced sonologists (all P values < 0.005). The O-RADS US presented high sensitivity and NPV value for each sonologist. With regard to the reproducibility of O-RADS, the intra- and inter-observer agreement among experienced sonologists performed better than inexperienced sonologists. CONCLUSION: O-RADS showed difference in the predictive accuracy and reproducibility in the evaluation of adnexal masses among sonologists with different levels of expertise. Training is required for inexperienced sonologists before the generalization of O-RADS classification system in clinical practice.

Recurrence Rate and Morbidity after Ultrasound-guided Transvaginal Aspiration of Ultrasound Benign-appearing Adnexal Cystic Masses with and without Sclerotherapy: A Systematic Review and Meta-analysis.

OBJECTIVE: To determine the pooled recurrence rate of benign adnexal masses/cysts (namely simple cyst, endometrioma, hydrosalpinx, peritoneal cyst) after transvaginal ultrasound-guided aspiration, with or without sclerotherapy. DATA SOURCES: Search of studies published in PubMed and Web of Science databases between January 1990 and December 2020. METHODS OF STUDY SELECTION: A systematic search strategy was done using Medical Subject Heading terms. Only randomized trials and prospective studies published in English language were included. TABULATION, INTEGRATION, AND RESULTS: A total of 395 articles were screened. After applying inclusion and exclusion criteria, 20 studies were included in this review comprising data from 1386 patients with a mean follow-up of 11.4 months (range 0.5-26.5 months). The overall pooled rate of recurrence of adnexal masses was 27%, (95% confidence interval [CI], 18%-39%). Recurrence rate was significantly higher after only aspiration than after sclerotherapy (53%; 95% CI, 46%-60% vs 14%; 95% CI, 8%-22%; p <.001). However, a high heterogeneity across the studies was found. A total of 10 major complications were recorded in the different publications. CONCLUSION: In a selected population, aspiration with sclerotherapy had a lower recurrence rate than aspiration without sclerotherapy. However, these results should be interpreted with caution given the heterogeneity of the studies and the paucity of randomized controlled trials. Regarding the adoption of this procedure in routine clinical practice, we believe that aspiration should be considered an experimental procedure as there are few studies addressing long-term recurrence rate, and data comparing this technique with surgical cystectomy are lacking.

Cytodiagnosis of bilateral abdominopelvic masses in a postmenopausal woman.

Cytologic diagnosis of ovarian low-grade serous carcinoma.

The value of 'raspberry bodies' in intraoperative cytologic evaluation of adnexal masses for the diagnosis of clear cell carcinoma of the ovary: A cytological-pathological correlation.

We report a case of a 48-year-old female who presented to the emergency department with pelvic/abdominal pain and a recent history of irregular periods. Pelvic ultrasound and computed tomography (CT) scan of the abdomen/pelvis revealed a 7.3 cm adnexal mass with suspicious features. During the intraoperative evaluation, a frozen section slide and a cytological smear were prepared. The cytological preparation was moderately cellular, showing cohesive groups of atypical cells with anisonucleosis, high nuclear to cytoplasmic ratio, and oval nuclei with prominent nucleoli. The tumor cells surrounded extracellular, magenta hyaline globules, forming raspberry bodies. Raspberry bodies are comprised of basement membrane deposits and are a unique finding in ovarian clear cell carcinoma. Raspberry bodies were also found in the frozen section slide, but, in comparison to the cytological preparation, were rare, difficult to identify, and resembled necrotic debris. The intraoperative diagnosis of a clear cell carcinoma is important because the surgical management will be more aggressive, as optimal tumor debulking is shown to have better overall survival. In this manuscript, we detail the intraoperative evaluation of an ovarian mass, the utility of cytological preparation and importance of identifying raspberry bodies in the evaluation of ovarian masses, and surgical management of clear cell carcinoma.

Comparison of laparoscopic adnexal mass extraction via the transumbilical and transvaginal routes.

This study was performed to compare the transumbilical (TU) and transvaginal (TV) routes for adnexal mass removal from the abdominal cavity. Data from 93 women who underwent laparoscopic (LS) surgery for the removal of benign adnexal masses at three centres between January 2016 and December 2020 were examined retrospectively. The specimen retrieval times in the TU and TV groups were 9.0 ± 2.0 and 9.8 ± 2.5 min, respectively (p = .373). Additional analgesic was required in 13.8% and 14.3% of cases in the TU and TV groups, respectively. The mean 3-month (2-4 months) postoperative visual analogue scale (VAS) score was lower in the TV group than in the TU group. The postoperative vaginal length did not differ between the TU and TV groups (8.9 (8.7-9.1) vs. 8.7 (8.4-9.1) cm; p = .465). Oophorectomy and the TU route were found to be independent risk factors for the worsening of the VAS score. Sexual function index scores were similar in the two groups. The TV method for specimen removal in LS surgery may cause less pain in the early postoperative period and less dyspareunia in the later period without shortening the length of the vagina.Impact StatementWhat is already known on this subject? Compared with open procedures, minimally invasive surgery (MIS) is associated with faster recovery times, better patient quality of life and lower postoperative complication rates. The removal of an adnexal mass from the abdominal cavity is performed most commonly using the suprapubic, transumbilical (TU) or transvaginal (TV) route.What do the results of this study add? The specimen retrieval times in the TU and TV groups were 9.0 ± 2.0 and 9.8 ± 2.5 min, respectively (p = .373). The mean 3-month (2-4 months) postoperative visual analogue scale (VAS) score was lower in the TV group than in the TU group. Oophorectomy and the TU route were found to be independent risk factors for the worsening of the VAS score. Sexual function index scores were similar in the two groups.What are the implications of these findings for clinical practice and/or further research? In conclusion, specimen removal via the TV route in LS surgery may cause less pain in the early postoperative period and less dyspareunia in the later period without reducing the length of the vagina.