Preoperative Multimodal Strategies for Risk Assessment of Adnexal Masses

Menopausal status, ultrasound and biomarker tests in combination for the diagnosis of ovarian cancer in symptomatic women

BACKGROUND

Ovarian cancer (OC) has the highest case fatality rate of all gynaecological cancers. Diagnostic delays are caused by non-specific symptoms. Existing systematic reviews have not comprehensively covered tests in current practice, not estimated accuracy separately in pre- and postmenopausal women, or used inappropriate meta-analytic methods.

OBJECTIVES

To establish the accuracy of combinations of menopausal status, ultrasound scan (USS) and biomarkers for the diagnosis of ovarian cancer in pre- and postmenopausal women and compare the accuracy of different test combinations.

SEARCH METHODS

We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), five other databases and three trial registries from 1991 to 2015 and MEDLINE (Ovid) and Embase (Ovid) form June 2015 to June 2019. We also searched conference proceedings from the European Society of Gynaecological Oncology, International Gynecologic Cancer Society, American Society of Clinical Oncology and Society of Gynecologic Oncology, ZETOC and Conference Proceedings Citation Index (Web of Knowledge). We searched reference lists of included studies and published systematic reviews.

SELECTION CRITERIA

We included cross-sectional diagnostic test accuracy studies evaluating single tests or comparing two or more tests, randomised trials comparing two or more tests, and studies validating multivariable models for the diagnosis of OC investigating test combinations, compared with a reference standard of histological confirmation or clinical follow-up in women with a pelvic mass (detected clinically or through USS) suspicious for OC.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed quality using QUADAS-2. We used the bivariate hierarchical model to indirectly compare tests at commonly reported thresholds in pre- and postmenopausal women separately. We indirectly compared tests across all thresholds and estimated sensitivity at fixed specificities of 80% and 90% by fitting hierarchical summary receiver operating characteristic (HSROC) models in pre- and postmenopausal women separately.

MAIN RESULTS

We included 59 studies (32,059 women, 9545 cases of OC). Two tests evaluated the accuracy of a combination of menopausal status and USS findings (IOTA Logistic Regression Model 2 (LR2) and the Assessment of Different NEoplasias in the adneXa model (ADNEX)); one test evaluated the accuracy of a combination of menopausal status, USS findings and serum biomarker CA125 (Risk of Malignancy Index (RMI)); and one test evaluated the accuracy of a combination of menopausal status and two serum biomarkers (CA125 and HE4) (Risk of Ovarian Malignancy Algorithm (ROMA)). Most studies were at high or unclear risk of bias in participant, reference standard, and flow and timing domains. All studies were in hospital settings. Prevalence was 16% (RMI, ROMA), 22% (LR2) and 27% (ADNEX) in premenopausal women and 38% (RMI), 45% (ROMA), 52% (LR2) and 55% (ADNEX) in postmenopausal women. The prevalence of OC in the studies was considerably higher than would be expected in symptomatic women presenting in community-based settings, or in women referred from the community to hospital with a suspicion of OC. Studies were at high or unclear applicability because presenting features were not reported, or USS was performed by experienced ultrasonographers for RMI, LR2 and ADNEX. The higher sensitivity and lower specificity observed in postmenopausal compared to premenopausal women across all index tests and at all thresholds may reflect highly selected patient cohorts in the included studies. In premenopausal women, ROMA at a threshold of 13.1 (± 2), LR2 at a threshold to achieve a post-test probability of OC of 10% and ADNEX (post-test probability 10%) demonstrated a higher sensitivity (ROMA: 77.4%, 95% CI 72.7% to 81.5%; LR2: 83.3%, 95% CI 74.7% to 89.5%; ADNEX: 95.5%, 95% CI 91.0% to 97.8%) compared to RMI (57.2%, 95% CI 50.3% to 63.8%). The specificity of ROMA and ADNEX were lower in premenopausal women (ROMA: 84.3%, 95% CI 81.2% to 87.0%; ADNEX: 77.8%, 95% CI 67.4% to 85.5%) compared to RMI 92.5% (95% CI 90.3% to 94.2%). The specificity of LR2 was comparable to RMI (90.4%, 95% CI 84.6% to 94.1%). In postmenopausal women, ROMA at a threshold of 27.7 (± 2), LR2 (post-test probability 10%) and ADNEX (post-test probability 10%) demonstrated a higher sensitivity (ROMA: 90.3%, 95% CI 87.5% to 92.6%; LR2: 94.8%, 95% CI 92.3% to 96.6%; ADNEX: 97.6%, 95% CI 95.6% to 98.7%) compared to RMI (78.4%, 95% CI 74.6% to 81.7%). Specificity of ROMA at a threshold of 27.7 (± 2) (81.5, 95% CI 76.5% to 85.5%) was comparable to RMI (85.4%, 95% CI 82.0% to 88.2%), whereas for LR2 (post-test probability 10%) and ADNEX (post-test probability 10%) specificity was lower (LR2: 60.6%, 95% CI 50.5% to 69.9%; ADNEX: 55.0%, 95% CI 42.8% to 66.6%).

AUTHORS' CONCLUSIONS

In specialist healthcare settings in both premenopausal and postmenopausal women, RMI has poor sensitivity. In premenopausal women, ROMA, LR2 and ADNEX offer better sensitivity (fewer missed cancers), but for ROMA and ADNEX this is off-set by a decrease in specificity and increase in false positives. In postmenopausal women, ROMA demonstrates a higher sensitivity and comparable specificity to RMI. ADNEX has the highest sensitivity in postmenopausal women, but reduced specificity. The prevalence of OC in included studies is representative of a highly selected referred population, rather than a population in whom referral is being considered. The comparative accuracy of tests observed here may not be transferable to non-specialist settings. Ultimately health systems need to balance accuracy and resource implications to identify the most suitable test.

Prediction Models of Adnexal Masses: State-of-the-Art Review

Importance

Several predictive models and scoring systems have been developed to differentiate between benign and malignant ovarian masses, in order to guide effective management. These models use combinations of patient characteristics, ultrasound markers, and biochemical markers.

Objective

The aim of this study was to describe, compare, and prioritize, according to their strengths and qualities, all the adnexal prediction models.

Evidence Acquisition

This was a state-of-the-art review, synthesizing the findings of the current published literature on the available prediction models of adnexal masses.

Results

The existing models include subjective assessment by expert sonographers, the International Ovarian Tumor Analysis models (logistic regression models 1 and 2, Simple Rules, 3-step strategy, and ADNEX [Assessment of Different NEoplasias in the adneXa] model), the Risk of Malignancy Index, the Risk of Malignancy Ovarian Algorithm, the Gynecologic Imaging Reporting and Data System, and the Ovarian-Adnexal Reporting and Data System. Overall, subjective assessment appears to be superior to all prediction models. However, the International Ovarian Tumor Analysis models are probably the best available methods for nonexpert examiners. The Ovarian-Adnexal Reporting and Data System is an international approach that incorporates both the common European and North American approaches, but still needs to be validated.

Conclusions

Many prediction models exist for the assessment of adnexal masses. The adoption of a particular model is based on local guidelines, as well as sonographer's experience. The safety of expectant management of adnexal masses with benign ultrasound morphology is still under investigation.

Evaluation of lysophosphatidic acid in vaginal fluid as a biomarker for ovarian cancer: A pilot study

There remains a need to differentiate between women with a benign or a malignant adnexal mass prior to surgery. As part of an ongoing evaluation of vaginal fluid compounds as potential tumor biomarkers we evaluated whether vaginal lysophosphatidic acid (LPA) predicted the subsequent diagnosis of a malignant adnexal mass. In this prospective pilot study vaginal fluid was obtained from 100 post-menopausal women referred for evaluation of a suspicious adnexal mass and tested for LPA by ELISA. Clinical data and serum CA125 results were obtained only after completion of all laboratory testing. Twenty eight of the women were subsequently diagnosed with an ovarian malignancy, four had a borderline tumor and 68 had a benign diagnosis. Among women with a malignant ovarian mass, 11 (39.3%) had an endometrioid adenocarcinoma +/− Clear cell tumor components, 6 (21.4%) had a high grade serous carcinoma, 3 (10.7%) had a mucinous tumor, 2 each (7.1%) had a malignant mixed mesodermal or a granulosa tumor and 1 each (3.6%) had a Clear cell tumor, a mixed cell tumor, leimyosarcoma or metastatic adrenal tumor. Compared to the median vaginal LPA level in women with benign lesions (1.5 μM), LPA was significantly elevated only in women with endometrioid ovarian cancer (7.9 μM) (p = 0.0137). Of the 6 endometrioid tumors in which values for both plasma CA125 and vaginal LPA were available 5 were positive only for LPA while one was only CA125 positive. Detection of LPA in vaginal secretions may be of value for the noninvasive diagnosis of endometrioid ovarian malignancies in post-menopausal women.

Simple laboratory score improves the preoperative diagnosis of adnexal mass

We assessed the diagnostic accuracy of a newly developed laboratory score-based on CA125, platelet count (PLT), C-reactive protein (CRP), and fibrinogen levels-in the preoperative diagnosis of adnexal mass. In this retrospective single-center study, we analyzed records of 142 patients with 54 malignant (38 %) and 88 benign (62 %) ovarian tumors. Preoperative levels of CA125, PLT, CRP, and fibrinogen were dichotomized according to the common cutoff values (CA125, 35 U/ml; PLT, 350/nl; CRP, 5.0 mg/l; fibrinogen, 400 mg/dl), resulting in "1" for results above the cutoff and "0" for results within the normal ranges. The values (1 or 0) were summarized to a "low" (0-2) or "high" (3-4) score. Its diagnostic accuracy was compared to the "gold standard," CA125. All parameters differed significantly between malignant and benign cases. The score was false positive in 5/88 (5.7 %) and false negative in 13/54 (24 %) of cases. Conversely, CA125 was false positive in 18/88 (20.4 %) and false negative in 4/54 (7.4 %). The diagnostic accuracy of CA125 (>35 U/ml) was sensitivity 0.93, specificity 0.80, positive predictive value (PPV) 0.74, negative predictive value (NPV) 0.95, and positive likelihood ratio (weighted by prevalence) (+LH/p) 2.78. The diagnostic accuracy of the score was sensitivity 0.76, specificity 0.94, PPV 0.89, NPV 0.86, and +LH/p 8.2. In conclusion, the score is easy to use and generates no additional costs. It provides a better specificity, PPV, and +LH/p than CA125. The sensitivity and NPV are lower, but acceptable. A validation of the score in a large patient cohort is needed.

Inhibition of autophagy in peripheral blood mononuclear cells by vaginal fluid from women with a malignant adnexal mass

Inhibition of autophagy is a characteristic of ovarian cancer. We determined whether inhibition of autophagy by vaginal fluid could provide a non-invasive test for cancer risk stratification in women presenting with an adnexal mass. Vaginal fluid supernatants from 90 women undergoing evaluation for a suspicious adnexal mass were incubated with peripheral blood mononuclear cells (PBMCs) obtained from healthy women under conditions that induce autophagy. Rapamycin, an autophagy inducer, was added to some cultures. After 48 hr the cells were collected, lysed and assayed by ELISA for intracellular p62 concentration. p62 is a cytoplasmic protein that is consumed during autophagy induction. Its concentration is inversely proportional to the extent of autophagy induction. Clinical information including pathological diagnoses was obtained after completion of laboratory studies. Mean p62 levels were 9.4 ng/ml in the 21 women with a subsequent malignant diagnosis, 4.5 ng/ml in the eight women with a borderline tumor diagnosis and 3.6 ng/ml in the 61 women with benign disease (p < 0.0001, malignant vs. others). When rapamycin was added to the vaginal fluid-PBMC co-incubation, p62 levels in samples from women with a malignant diagnosis decreased to 3.3 ng/ml, a level comparable to what was observed with the nonmalignant samples. Vaginal fluid inhibition of autophagy can differentiate between women with malignant and benign adnexal masses.

Usefulness of diagnostic indices comprising clinical, sonographic, and biomarker data for discriminating benign from malignant ovarian masses

The objective of this study was to review the accuracy of indices combining several diagnostic variables, in comparison to other models, sonography alone, and biomarker assays, for predicting benign or malignant ovarian lesions. Different single modalities were reviewed. The most useful complex models were International Ovarian Tumor Analysis (IOTA) sonographic logistic regression model 2 (area under the curve, 0.949), risk of malignancy index-cancer antigen 125-human epididymis protein 4 (0.950), risk of malignancy algorithm (0.953), pelvic mass score (0.960), non-IOTA logistic regression model (0.970), and histoscanning score logistic regression model (0.970). None of the indices was superior to an expert subjective sonographic assessment (0.968). For women with adnexal tumors, indices with high accuracy are available that are applicable in clinical practice and comparable to an expert subjective sonographic assessment for discriminating benign from malignant masses.

Presurgical diagnosis of adnexal tumours using mathematical models and scoring systems: a systematic review and meta-analysis

BACKGROUND Characterizing ovarian pathology is fundamental to optimizing management in both pre- and post-menopausal women. Inappropriate referral to oncology services can lead to unnecessary surgery or overly radical interventions compromising fertility in young women, whilst the consequences of failing to recognize cancer significantly impact on prognosis. By reflecting on recent developments of new diagnostic tests for preoperative identification of malignant disease in women with adnexal masses, we aimed to update a previous systematic review and meta-analysis. METHODS An extended search was performed in MEDLINE (PubMed) and EMBASE (OvidSp) from March 2008 to October 2013. Eligible studies provided information on diagnostic test performance of models, designed to predict ovarian cancer in a preoperative setting, that contained at least two variables. Study selection and extraction of study characteristics, types of bias, and test performance was performed independently by two reviewers. Quality was assessed using a modified version of the QUADAS assessment tool. A bivariate hierarchical random effects model was used to produce summary estimates of sensitivity and specificity with 95% confidence intervals or plot summary ROC curves for all models considered. RESULTS Our extended search identified a total of 1542 new primary articles. In total, 195 studies were eligible for qualitative data synthesis, and 96 validation studies reporting on 19 different prediction models met the predefined criteria for quantitative data synthesis. These models were tested on 26 438 adnexal masses, including 7199 (27%) malignant and 19 239 (73%) benign masses. The Risk of Malignancy Index (RMI) was the most frequently validated model. The logistic regression model LR2 with a risk cut-off of 10% and Simple Rules (SR), both developed by the International Ovarian Tumor Analysis (IOTA) study, performed better than all other included models with a pooled sensitivity and specificity, respectively, of 0.92 [95% CI 0.88-0.95] and 0.83 [95% CI 0.77-0.88] for LR2 and 0.93 [95% CI 0.89-0.95] and 0.81 [95% CI 0.76-0.85] for SR. A meta-analysis of centre-specific results stratified for menopausal status of two multicentre cohorts comparing LR2, SR and RMI-1 (using a cut-off of 200) showed a pooled sensitivity and specificity in premenopausal women for LR2 of 0.85 [95% CI 0.75-0.91] and 0.91 [95% CI 0.83-0.96] compared with 0.93 [95% CI 0.84-0.97] and 0.83 [95% CI 0.73-0.90] for SR and 0.44 [95% CI 0.28-0.62] and 0.95 [95% CI 0.90-0.97] for RMI-1. In post-menopausal women, sensitivity and specificity of LR2, SR and RMI-1 were 0.94 [95% CI 0.89-0.97] and 0.70 [95% CI 0.62-0.77], 0.93 [95% CI 0.88-0.96] and 0.76 [95% CI 0.69-0.82], and 0.79 [95% CI 0.72-0.85] and 0.90 [95% CI 0.84-0.94], respectively. CONCLUSIONS An evidence-based approach to the preoperative characterization of any adnexal mass should incorporate the use of IOTA Simple Rules or the LR2 model, particularly for women of reproductive age.

Diagnostic value of ultrasound indicators of neoplastic risk in preoperative differentiation of adnexal masses

AIM

To assess the diagnostic value of the risk of malignancy indices and simple ultrasound- based rules in preoperative differentiation of adnexal masses.

MATERIAL AND METHODS

Retrospective examination of 87 patients admitted to hospital due to adnexal tumors. The lesions were evaluated on the basis of international ultrasound classification of ovarian tumors and four risk of malignancy indices were calculated based on ultrasound examination, concentration of CA 125 and menopausal status.

RESULTS

The patients were aged between 17 and 79, the mean age was 44.5 (standard deviation SD=16.6). Most of the patients (60.91%) were before their menopause. The sensitivity of the simple ultrasound-based rules in the diagnosis of malignancies equaled 64.71% and the specificity constituted 90.00%. A significant statistical difference in the presence of the malignant process was demonstrated in relation to age, menopausal status, CA 125 concentration and analyzed ultrasound score. All indices were characterized by similar sensitivity and specificity. The highest specificity and predictive value of malignant lesions out of the assessed ones was demonstrated by the risk of malignancy index proposed by Yamamoto. The risk of malignancy index according to Jacobs, however, showed the highest predictive value in the case of non-malignant lesions.

CONCLUSIONS

The multiparametric ultrasound examination may facilitate the selection of patients with adnexal tumors to provide them with an appropriate treatment - observation, laparotomy and laparoscopy. These parameters constitute a simple ambulatory method of determining the character of adnexal masses before recommending appropriate treatment.