Comparison of Ultrasound Scores in Differentiating between Benign and Malignant Adnexal Masses

Can transabdominal shear wave elastography play a role in solving the dilemma of complex cystic and solid ovarian tumors by ultrasound?

PURPOSE

We aimed to assess the role of shear wave elastography in better characterizing complex cystic and solid ovarian tumors in correlation with other ultrasound features and histopathology.

MATERIALS AND METHODS

The study included 40 patients with 40 unilateral complex cystic or solid ovarian lesions with a mean age of 43.2 ± 13.27 (mean ± SD). All patients were subjected to history taking, tumor markers assessment, ultrasound with Doppler assessment giving an ORADS score, and shear wave elastography assessment. (qualitatively and quantitatively). Correlation was done with the final histopathology.

RESULTS

According to the final histopathological results of the 40 lesions, 14 (35%) were benign, four were borderline (10%), and 22 (55%) were malignant. Ultrasound and Doppler assessments revealed a higher frequency of irregular margins and Doppler score 4 in borderline/malignant patients compared to benign patients. ORADS ultrasound scoring system of the examined lesions showed a statistically significantly higher frequency of ORADS 5 in the malignant group, with ORADS sensitivity, specificity, and Diagnostic accuracy of 96.2%, 57.1, and 82.5%, respectively. Elastographic color mapping scores and elastographic readings were higher in borderline/malignant patients compared to benign patients and it significantly correlated with the Doppler score, ORADS score, color mapping score, and tumor markers.

CONCLUSION

The study detected significant associations between malignancy and higher tumor markers, marginal irregularity, higher Doppler, and higher ORADS scores. Shear wave elastography positively correlated with tumor markers, Doppler score, and ORADS score. This supports the utility of elastography in discriminating malignant from benign ovarian tumors.

Comparison of the Diagnostic Performance of Ovarian Adnexal Reporting Data System (O-RADS) With IOTA Simple Rules and ADNEX Model for Classifying Adnexal Masses: A Head-To-Head Meta-Analysis

OBJECTIVE

To compare the diagnostic accuracy of O-RADS (Ovarian Reporting and Data System) and IOTA (international Ovarian Tumor Analysis group) simple rules (SR) and ADNEX (Assessment of Different NEoplasias in the adnexa) model for discriminating benign from malignant adnexal masses using meta-analysis.

METHODS

A systematic search of studies comparing O-RADS with SR and/or ADNEX in the same set of patients with an adnexal mass was performed in Medline, Web of Science, and Scopus databases from January 2020 to September 2023. Quality was assessed using the QUADAS-2 tool. Quantitative meta-analysis was performed.

RESULTS

Nine articles comprising 3924 women (3979 adnexal masses) were ultimately included after exclusions. Three studies compared O-RADS versus SR, three studies compared O-RADS versus ADNEX, and three studies compared all three methods. The risk of bias was high for patient selection in QUADAS-2 in all studies. Six studies compared O-RADS versus SR; no significant differences were found (pooled sensitivity and specificity of O-RADS and IOTA SR were 94.0% and 77.0%, and 91.0% and 87.0%, respectively. p = 0.2204). Six studies compared O-RADS versus ADNEX; no significant differences were found (pooled sensitivity and specificity of O-RADS classification system and ADNEX were 95.0% and 79.0%, and 91.0% and 88.0%, respectively. p = 0.2307).

CONCLUSION

O-RADS classification has a similar diagnostic performance to IOTA SR and ADNEX for discriminating benign and malignant adnexal masses.

ECO-SCORE: Development of a New Ultrasound Score for the Study of Cystic and Solid-Cystic Adnexal Masses Based on Imaging Characteristics

The accurate diagnosis of adnexal masses is a critical challenge in gynecological practice. Current ultrasound-based models, such as the ADNEX model, IOTA Simple Rules, and O-RADS, have demonstrated good diagnostic performance but are limited by the inclusion of demographic factors and solid confounding lesions. This study aimed to develop and validate a novel ultrasound score (ECO-SCORE) for cystic and solid-cystic lesions based solely on imaging characteristics to improve diagnostic accuracy and applicability in clinical practice. Methods: We conducted a retrospective study on 330 women diagnosed with adnexal masses, including 251 benign and 79 malignant cases. Ultrasound features were analyzed using logistic regression to identify key predictors of malignancy. A new scoring model was developed, excluding demographic or tumor-marker data. Diagnostic performance metrics, including sensitivity, specificity, AUC, and odds ratios, were calculated and compared to existing models using a testing set (20% of the data). Results: The ECO-SCORE achieved an AUC of 97.08%, outperforming ADNEX model (87.5%), IOTA Simple Rules (85.7%), and O-RADS (87.5%). Sensitivity and specificity were 92.98% and 88.88%, respectively, with an odds ratio of 106. Key predictors included irregular contour, absence of acoustic shadows, vascularization within solid areas, and vascularization of papillae. Conclusions: The ECO-SCORE demonstrated superior diagnostic accuracy compared to established models, highlighting its potential as a reliable tool for assessing adnexal masses using ultrasound features exclusively. Further multicenter validation is needed to confirm its robustness across different clinical settings.

Diagnostic Efficacy of Ultrasound-Based International Ovarian Tumor Analysis Simple Rules and Assessment of the Different Neoplasias in the Adnexa Model in Malignancy Prediction Among Women With Adnexal Masses: A Systematic Review

Transvaginal ultrasonography (USG) is most commonly used before surgery to accurately diagnose benign and malignant ovarian masses for effective treatment, avoid unnecessary interventions, improve the prognosis of patients, and preserve fertility in patients with benign tumors. Therefore, the objective of the present systematic review was to assess the diagnostic efficacy of ultrasound-based International Ovarian Tumor Analysis (IOTA) Simple Rules (SR) and Assessment of Different NEoplasias in the adneXa (ADNEX) model in predicting malignancy among women with adnexal masses. A systematic literature search was carried out on electronic databases consisting of Science Direct, PubMed, and Google Scholar. The keywords utilized to perform the literature search and include relevant articles consisted of "Diagnostic Efficacy", AND "Ultrasound-Based International Ovarian Tumor Analysis Simple Rules", AND "International Ovarian Tumor Analysis ADNEX Model", AND "Adnexal masses", AND "Ovarian tumors". Based on the selection criteria, a total of five studies were included. The study concluded that both the models showed high diagnostic efficacy for malignancy prediction; however, in comparison to the IOTA SR, the IOTA ADNEX model demonstrated good diagnostic efficacy.

Utility of a Multi-Marker Panel with Ultrasound for Enhanced Classification of Adnexal Mass

Pre-surgical clinical assessment of an adnexal mass typically relies on transvaginal ultrasound for comprehensive morphological assessment, with further support provided by biomarker measurements and clinical evaluation. Whilst effective for masses that are obviously benign or malignant, a large proportion of masses remain sonographically indeterminate at surgical referral. As a consequence, post-surgical diagnoses of benign disease can outnumber malignancies up to 9-fold, while less than 50% of cancer cases receive a primary referral to a gynecological oncology specialist. We recently described a blood biomarker signature (multi-marker panel-MMP) that differentiated patients with benign from malignant ovarian disease with high accuracy. In this study, we have examined the use of the MMP, both individually and in combination with transvaginal ultrasound, as an alternative tool to CA-125 for enhanced decision making in the pre-surgical referral process.

Comparison of O-RADS with the ADNEX model and IOTA SR for risk stratification of adnexal lesions: a systematic review and meta-analysis

Purpose

This study aims to systematically compare the diagnostic performance of the Ovarian-Adnexal Reporting and Data System with the International Ovarian Tumor Analysis Simple Rules and the Assessment of Different NEoplasias in the adneXa model for risk stratification of ovarian cancer and adnexal masses.

Methods

A literature search of online databases for relevant studies up to July 2023 was conducted by two independent reviewers. The summary estimates were pooled with the hierarchical summary receiver-operating characteristic model. The quality of the included studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 and the Quality Assessment of Diagnostic Accuracy Studies-Comparative Tool. Metaregression and subgroup analyses were performed to explore the impact of varying clinical settings.

Results

A total of 13 studies met the inclusion criteria. The pooled sensitivity and specificity for eight head-to-head studies between the Ovarian-Adnexal Reporting and Data System and the Assessment of Different NEoplasias in the adneXa model were 0.96 (95% CI 0.92-0.98) and 0.82 (95% CI 0.71-0.90) vs. 0.94 (95% CI 0.91-0.95) and 0.83 (95% CI 0.77-0.88), respectively, and for seven head-to-head studies between the Ovarian-Adnexal Reporting and Data System and the International Ovarian Tumor Analysis Simple Rules, the pooled sensitivity and specificity were 0.95 (95% CI 0.93-0.97) and 0.75 (95% CI 0.62-0.85) vs. 0.91 (95% CI 0.82-0.96) and 0.86 (95% CI 0.76-0.93), respectively. No significant differences were found between the Ovarian-Adnexal Reporting and Data System and the Assessment of Different NEoplasias in the adneXa model as well as the International Ovarian Tumor Analysis Simple Rules in terms of sensitivity (P = 0.57 and P = 0.21) and specificity (P = 0.87 and P = 0.12). Substantial heterogeneity was observed among the studies for all three guidelines.

Conclusion

All three guidelines demonstrated high diagnostic performance, and no significant differences in terms of sensitivity or specificity were observed between the three guidelines.

ReClassification of Patients with Ambiguous CA125 for Optimised Pre-Surgical Triage

Pre-surgical clinical assessment of an adnexal mass is a complex process, and ideally requires accurate and rapid identification of disease status. Gold standard biomarker CA125 is extensively used off-label for this purpose; however its performance is typically inadequate, particularly for the detection of early stage disease and discrimination between benign versus malignant status. We recently described a multi-marker panel (MMP) and associated risk index for the differentiation of benign from malignant ovarian disease. In this study we applied a net reclassification approach to assess the use of MMP index to rescue those cases where low CA125 incorrectly excludes cancer diagnoses, or where benign disease is incorrectly assessed as "high risk" due to elevated CA125. Reclassification of such patients is of significant value to assist in the timely and accurate referral for patients where CA125 titer is uninformative.

ADNEX risk prediction model for diagnosis of ovarian cancer: systematic review and meta-analysis of external validation studies

Objectives

To conduct a systematic review of studies externally validating the ADNEX (Assessment of Different Neoplasias in the adnexa) model for diagnosis of ovarian cancer and to present a meta-analysis of its performance.

Design

Systematic review and meta-analysis of external validation studies.

Data sources

Medline, Embase, Web of Science, Scopus, and Europe PMC, from 15 October 2014 to 15 May 2023.

Eligibility criteria for selecting studies

All external validation studies of the performance of ADNEX, with any study design and any study population of patients with an adnexal mass. Two independent reviewers extracted the data. Disagreements were resolved by discussion. Reporting quality of the studies was scored with the TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) reporting guideline, and methodological conduct and risk of bias with PROBAST (Prediction model Risk Of Bias Assessment Tool). Random effects meta-analysis of the area under the receiver operating characteristic curve (AUC), sensitivity and specificity at the 10% risk of malignancy threshold, and net benefit and relative utility at the 10% risk of malignancy threshold were performed.

Results

47 studies (17 007 tumours) were included, with a median study sample size of 261 (range 24-4905). On average, 61% of TRIPOD items were reported. Handling of missing data, justification of sample size, and model calibration were rarely described. 91% of validations were at high risk of bias, mainly because of the unexplained exclusion of incomplete cases, small sample size, or no assessment of calibration. The summary AUC to distinguish benign from malignant tumours in patients who underwent surgery was 0.93 (95% confidence interval 0.92 to 0.94, 95% prediction interval 0.85 to 0.98) for ADNEX with the serum biomarker, cancer antigen 125 (CA125), as a predictor (9202 tumours, 43 centres, 18 countries, and 21 studies) and 0.93 (95% confidence interval 0.91 to 0.94, 95% prediction interval 0.85 to 0.98) for ADNEX without CA125 (6309 tumours, 31 centres, 13 countries, and 12 studies). The estimated probability that the model has use clinically in a new centre was 95% (with CA125) and 91% (without CA125). When restricting analysis to studies with a low risk of bias, summary AUC values were 0.93 (with CA125) and 0.91 (without CA125), and estimated probabilities that the model has use clinically were 89% (with CA125) and 87% (without CA125).

Conclusions

The results of the meta-analysis indicated that ADNEX performed well in distinguishing between benign and malignant tumours in populations from different countries and settings, regardless of whether the serum biomarker, CA125, was used as a predictor. A key limitation was that calibration was rarely assessed.

Systematic review registration

PROSPERO CRD42022373182.

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.

Clinical value of quantitative analysis of contrast-enhanced ultrasonography in the differential diagnosis of benign and malignant pelvic tumors

Background

Cervical cancer, endometrial cancer, and ovarian cancer are among the top 10 most common cancers in women, with ovarian cancer in particular being considered a "silent killer". Therefore, early detection, diagnosis, and treatment constitute important means of care for women's health. This study investigated the clinical value of the quantitative analysis of contrast-enhanced ultrasonography (CEUS) in the differential diagnosis of benign and malignant pelvic tumors.

Methods

CEUS was performed on 151 patients with pelvic masses. Subsequently, a qualitative diagnosis was completed using the image enhancement features and tumor parameters. A multiparametric analysis of CEUS images was performed, which included the following parameters: arrival time (AT), time to peak (TTP), peak intensity (PI), and ascent slope (AS). In addition, the qualitative diagnostic efficiency of CEUS was assessed in a multiparametric analysis, and the results were compared with pathological findings.

Results

The patients in the malignant group were older (P=0.001) and had larger lesion PI values (P<0.01) than those in the benign group. The PI difference (PId) and the AS difference (ASd) showed statistical differences (P<0.01) between the myometrium and lesion tissues in the same patient. Moreover, the PId and ASd showed the largest receiver operating characteristic (ROC) curve and area under the ROC curve (AUC), with sensitivities of 90.9% and 91.7% and specificities of 86.4% and 72.5%, respectively.

Conclusions

The quantitative analysis of CEUS provides a new, simpler, and more accurate method for the differential diagnosis of benign and malignant pelvic masses in clinical practice. The sensitivities and specificities of PId and ASd were higher compared to other parameters from the same patient.

Application of Ultrasound Scores (Subjective Assessment, Simple Rules Risk Assessment, ADNEX Model, O-RADS) to Adnexal Masses of Difficult Classification

BACKGROUND

Ultrasound features help to differentiate benign from malignant masses, and some of them are included in the ultrasound (US) scores. The main aim of this work is to describe the ultrasound features of certain adnexal masses of difficult classification and to analyse them according to the most frequently used US scores.

METHODS

Retrospective studies of adnexal lesions are difficult to classify by US scores in women undergoing surgery. Ultrasound characteristics were analysed, and masses were classified according to the Subjective Assessment of the ultrasonographer (SA) and other US scores (IOTA Simple Rules Risk Assessment-SRRA, ADNEX model with and without CA125 and O-RADS).

RESULTS

A total of 133 adnexal masses were studied (benign: 66.2%, n:88; malignant: 33.8%, n:45) in a sample of women with mean age 56.5 ± 7.8 years. Malignant lesions were identified by SA in all cases. Borderline ovarian tumors (n:13) were not always detected by some US scores (SRRA: 76.9%, ADNEX model without and with CA125: 76.9% and 84.6%) nor were serous carcinoma (n:19) (SRRA: 89.5%), clear cell carcinoma (n:9) (SRRA: 66.7%) or endometrioid carcinoma (n:4) (ADNEX model without CA125: 75.0%). While most teratomas and serous cystadenomas have been correctly differentiated, other benign lesions were misclassified because of the presence of solid areas or papillae. Fibromas (n:13) were better identified by SA (23.1% malignancy), but worse with the other US scores (SRRA: 69.2%, ADNEX model without and with CA125: 84.6% and 69.2%, O-RADS: 53.8%). Cystoadenofibromas (n:10) were difficult to distinguish from malignant masses via all scores except SRRA (SA: 70.0%, SRRA: 20.0%, ADNEX model without and with CA125: 60.0% and 50.0%, O-RADS: 90.0%). Mucinous cystadenomas (n:12) were misdiagnosed as malignant in more than 15% of the cases in all US scores (SA: 33.3%, SRRA: 16.7%, ADNEX model without and with CA125: 16.7% and 16.7%, O-RADS:41.7%). Brenner tumors are also difficult to classify using all scores.

CONCLUSION

Some malignant masses (borderline ovarian tumors, serous carcinoma, clear cell carcinoma, endometrioid carcinomas) are not always detected by US scores. Fibromas, cystoadenofibromas, some mucinous cystadenomas and Brenner tumors may present solid components/papillae that may induce confusion with malignant lesions. Most teratomas and serous cystadenomas are usually correctly classified.

Ultrasound Features and Ultrasound Scores in the Differentiation between Benign and Malignant Adnexal Masses

BACKGROUND

Several ultrasound (US) features help ultrasound experts in the classification of benign vs. malignant adnexal masses. US scores serve in this differentiation, but they all have misdiagnoses. The main objective of this study is to evaluate what ultrasound characteristics are associated with malignancy influencing ultrasound scores.

METHODS

This is a retrospective analysis of ultrasound features of adnexal lesions of women managed surgically. Ultrasound characteristics were analyzed, and masses were classified by subjective assessment of the ultrasonographer (SA) and other ultrasound scores (IOTA Simple Rules Risk Assessment SRRA, ADNEX model, and O-RADS).

RESULTS

Of a total of 187 adnexal masses studied, 134 were benign (71.7%) and 53 were malignant (28.3%). SA, IOTA SRRA, ADNEX model with or without CA125 and O-RADS had high levels of sensitivity (93.9%, 81.1%, 94.3%, 88.7%, 98.1%) but lower specificity (80.2%, 82.1%, 82.8%, 77.6%, 73.1%) with similar AUC (0.87, 0.87, 0.92, 0.90, 0.86). Ultrasound features significantly related with malignancy were the presence of irregular contour, absence of acoustic shadowing, vascularized solid areas, ≥1 papillae, vascularized septum, and moderate-severe ascites.

CONCLUSION

IOTA SRRA, ADNEX model, and O-RADS can help in the classification of benign and malignant masses. Certain ultrasound characteristics studied in ultrasound scores are associated with malignancy.