Study on differential diagnosis of malignant and benign ovarian tumors through IOTA simple rules

doi:10.16150/j.1671-2870.2022.01.014

Abstract

Abstract:

Objective: To validate the value of IOTA simple rules (SR) in differential diagnosis of malignant and benign ovarian tumors preoperatively in a single center in Chinese population. Methods: A total of 278 patients admitted for ova-rian tumors surgery in Department of Obstetrics and Gynecology, Ruijin Hospital were enrolled. All patients underwent ultrasound examination preoperatively, and 278 ovarian tumors were detected and classified as malignant (including 75 cases of borderline), benign lesions (175 cases) and uncertain lesions (37cases) using SR. Compared with the results of postoperative pathology examination, the sensitivity, specificity of SR in diagnosing malignant tumor as well as the area under receiver operating characteristic (ROC) curve were calculated. Results: The postoperative pathology examination showed that there were 203 benign tumors and 75 malignant ones. It indicated that SR identified 86.2% benign tumors (175 out of 203) and 68.0% malignant tumors (51 cases out of 75), 15 cases were missed or misdiagnosed and 37 cases got uncertain results. Among ultrasonic features of SR, M4 (irregular multilocular-solid tumor with largest diameter ≥100 mm) had the highest predictive value (90.5%) for malignant tumors, while B3 (acoustic shadow) had the highest predictive value (100.0%) for benign tumors. In 241 patients (excluding uncertain cases), the sensitivity and specificity of SR in diagnosing ovarian tumors was 86.4%, 96.2%, respectively. In 278 patients, as the uncertain cases diagnosed with SR were classified to be malignant tumors, the sensitivity was 89.3%, specificity was 86.2%, and AUC was 0.88. However, as uncertain cases were classified to be benign ovarian, the sensitivity and specificity of SR in diagnosing tumors was 68.0% and 96.6%, and the AUC was 0.82. The efficacy between the two methods was different(P=0.04). Eight benign cases were misdiagnosed as malignancy, and the review showed that the possibility of malignancy should be considered when the inner wall of the cystic mass was not smooth, papillary processes attached to the wall, or the size of cystic mass was more than 10 cm. Seven malignant cases were misdiagnosed as benign ones. It indicated that benign mass should be considered when the solid part had insufficient blood supply or even no blood flow on ultrasound imaging. Conclusions: SR is suitable to be applied to Chinese female in diagnosing ovarian tumor. IOTA SR may have better efficacy when the uncertain cases diagnosed with SR are classified as malignant tumors

Key words: Ovarian tumor, Simple rules, Ultrasonography

CLC Number:

R541.7

YANG Bowen, JIANG Meijiao, CHEN Hui. Study on differential diagnosis of malignant and benign ovarian tumors through IOTA simple rules[J]. Journal of Diagnostics Concepts & Practice, 2022, 21(01): 74-79.

Figures/Tables 7

References 24

[1]	Buys SS, Partridge E, Black A, et al. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial[J]. JAMA, 2011, 305(22):2295-2303. doi: 10.1001/jama.2011.766 URL
[2]	Alcázar JL, Royo P, Jurado M, et al. Triage for surgical management of ovarian tumors in asymptomatic women: assessment of an ultrasound-based scoring system[J]. Ultrasound Obstet Gynecol, 2008, 32(2):220-225. doi: 10.1002/uog.5401 pmid: 18618475
[3]	Basha MAA, Metwally MI, Gamil SA, et al. Comparison of O-RADS, GI-RADS, and IOTA simple rules regarding malignancy rate, validity, and reliability for diagnosis of adnexal masses[J]. Eur Radiol, 2021, 31(2):674-684. doi: 10.1007/s00330-020-07143-7 URL
[4]	杨文敏, 吕国荣, 陈秋月. 卵巢-附件报告及数据系统、妇科影像报告与数据系统和简单法则风险预测模型鉴别诊断卵巢良、恶性肿瘤[J]. 中国医学影像技术, 2021, 37(9):1368-1372.
	Yang W M, LV G R, Chen Q Y. Ovarian accessory report and data system, gynecological image report and data system and simple rule risk prediction model for differential diagnosis of benign and malignant ovarian tumors[J]. Chin Med Imaging technol, 2021, 37(9):1368-1372.
[5]	Timmerman D, Testa AC, Bourne T, et al. Simple ultrasound-based rules for the diagnosis of ovarian cancer[J]. Ultrasound Obstet Gynecol, 2008, 31(6):681-690. doi: 10.1002/uog.5365 pmid: 18504770
[6]	van Calster B, Van Hoorde K, Valentin L, et al. Evalua-ting the risk of ovarian cancer before surgery using the ADNEX model to differentiate between benign, borderline, early and advanced stage invasive, and secondary metastatic tumours: prospective multicentre diagnostic study[J]. BMJ, 2014, 349:g5920. doi: 10.1136/bmj.g5920 URL
[7]	Royal College of Obstetricians and Gynaecologists. Mana-gement of suspected ovarian masses in premenopausal women[R/OL]. Green-top guideline No 62. RCOG, Nov 2011-11 [2022-01-25]. https://www.rcog.org.uk/files/rcog-corp/GTG62_021211_OvarianMasses.pdf.
[8]	American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses[J]. Obstet Gynecol. 2016, 128(5):e210-e226. doi: 10.1097/AOG.0000000000001768 URL
[9]	Glanc P, Benacerraf B, Bourne T, et al. First International Consensus Report on Adnexal Masses: Management Recommendations[J]. J Ultrasound Med, 2017, 36(5):849-863. doi: 10.1002/jum.14197 URL
[10]	Timmerman D, Valentin L, Bourne TH, et al. Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis IOTA Group[J]. Ultrasound Obstet Gynecol, 2000, 16(5):500-505. doi: 10.1046/j.1469-0705.2000.00287.x URL
[11]	Meys EMJ, Jeelof LS, Achten NMJ, et al. Estimating risk of malignancy in adnexal masses: external validation of the ADNEX model and comparison with other frequently used ultrasound methods[J]. Ultrasound Obstet Gynecol, 2017, 49(6):784-792. doi: 10.1002/uog.17225 pmid: 27514486
[12]	Meinhold-Heerlein I, Fotopoulou C, Harter P, et al. The new WHO classification of ovarian, fallopian tube, and primary peritoneal cancer and its clinical implications[J]. Arch Gynecol Obstet, 2016, 293(4):695-700. doi: 10.1007/s00404-016-4035-8 pmid: 26894303
[13]	Prat J. FIGO Committee on Gynecologic Oncology. FIGO′s staging classification for cancer of the ovary, fallopian tube, and peritoneum: abridged republication[J]. J Gynecol Oncol, 2015, 26(2):87-89. doi: 10.3802/jgo.2015.26.2.87 URL
[14]	Andreotti RF, Timmerman D, Benacerraf BR, et al. Ovarian-Adnexal Reporting Lexicon for Ultrasound: A White Paper of the ACR Ovarian-Adnexal Reporting and Data System Committee[J]. J Am Coll Radiol, 2018, 15(10):1415-1429. doi: S1546-1440(18)30839-1 pmid: 30149950
[15]	Nunes N, Ambler G, Foo X, et al. Use of IOTA simple rules for diagnosis of ovarian cancer: meta-analysis[J]. Ultrasound Obstet Gynecol, 2014, 44(5):503-514. doi: 10.1002/uog.13437 pmid: 24920435
[16]	Ruiz de Gauna B, Rodriguez D, Olartecoechea B, et al. Diagnostic performance of IOTA simple rules for adnexal masses classification: a comparison between two centers with different ovarian cancer prevalence[J]. Eur J Obstet Gynecol Reprod Biol, 2015, 191:10-14. doi: 10.1016/j.ejogrb.2015.05.024 URL
[17]	Timmerman D, Ameye L, Fischerova D, et al. Simple ultrasound rules to distinguish between benign and malignant adnexal masses before surgery: prospective validation by IOTA group[J]. BMJ, 2010, 341:c6839. doi: 10.1136/bmj.c6839 URL
[18]	刘真真, 石志敏, 徐钟慧, 等. IOTA ADNEX模型与简单法则对附件区疑难病变的诊断价值[J]. 中华医学超声杂志(电子版), 2020, 17(11):1084-1089. doi: 10.3877/cma.j.issn.1672-6448.2020.11.005
	Liu Z Z, Shi Z M, Xu Z H, et al. Diagnostic value of iota adnex model and simple rule in difficult lesions of accessory region[J]. Chin J Med Ultrasound (Electronic Edition), 2020, 17(11):1084-1089.
[19]	Ameye L, Timmerman D, Valentin L, et al. Clinically oriented three-step strategy for assessment of adnexal pathology[J]. Ultrasound Obstet Gynecol, 2012, 40(5):582-591. doi: 10.1002/uog.11177 pmid: 22511559
[20]	Brown DL, Dudiak KM, Laing FC. Adnexal masses: US characterization and reporting[J]. Radiology, 2010, 254(2):342-354. doi: 10.1148/radiol.09090552 URL
[21]	Sayasneh A, Ekechi C, Ferrara L, et al. The characteristic ultrasound features of specific types of ovarian patho-logy (review)[J]. Int J Oncol, 2015, 46(2):445-458. doi: 10.3892/ijo.2014.2764 pmid: 25406094
[22]	Timmerman D, Van Calster B, Testa A, et al. Predicting the risk of malignancy in adnexal masses based on the Simple Rules from the International Ovarian Tumor Analysis group[J]. Am J Obstet Gynecol, 2016, 214(4):424-437. doi: S0002-9378(16)00009-0 pmid: 26800772
[23]	Valentin L, Ameye L, Savelli L, et al. Unilocular adnexal cysts with papillary projections but no other solid components: is there a diagnostic method that can classify them reliably as benign or malignant before surgery?[J]. Ultrasound Obstet Gynecol, 2013, 41(5):570-581. doi: 10.1002/uog.12294 pmid: 22915541
[24]	Landolfo C, Valentin L, Franchi D, et al. Differences in ultrasound features of papillations in unilocular-solid adnexal cysts: a retrospective international multicenter study[J]. Ultrasound Obstet Gynecol, 2018, 52(2):269-278. doi: 10.1002/uog.18951 pmid: 29119698

组织学类型	例数（n）	SR未能分类	SR分类
组织学类型	例数（n）	SR未能分类	分类正确	分类错误
良性	203	21（10.3）	175（86.2）	7（3.5）
恶性
交界性	18	7（38.9）	7（38.9）	4（22.2）
原发恶性	49	8（16.3）	37（75.5）	4（8.2）
转移癌	8	1（12.5）	7（87.5）	-
总计	278	37（13.3）	226（81.3）	15（5.4）

指标	良性（n=203）	恶性（n=75）	P值
临床资料
年龄（岁）	41（14~83）	51（20~84）	<0.001
绝经状态（绝经前/后）	145/58	35/40	<0.001
CA125（U/mL）	18（5~1 672）	68（5~10 000）	<0.001
卵巢癌家族史	1（0.5%）	2（2.7%）	0.178
超声特征
病灶最大径（mm）	55（16~252）	75（21~294）	<0.001
实性成分
存在实性成分	57（28.1%）	66（88.0%）	<0.001
实性成分最大径（mm）	24（3~132）	53（5~166）	<0.001
乳头状突起
>0^*	21（10.3%）	25（33.3%）	<0.001
0	182（89.7%）	50（66.7%）
1	12（5.9%）	7（9.3%）
2	2（1.0%）	3（4.0%）
3	2（1.0%）	3（4.0%）
>3	5（2.5%）	12（16.0%）
病灶彩色多普勒血流
1级	159（78.3%）	8（10.7%）	<0.001
2级	27（13.3%）	23（30.7%）
3级	11（5.4%）	18（24.0%）
4级	6（3.0%）	26（34.7%）
肿块类型
单房囊性	99（48.8%）	2（2.7%）	<0.001
单房囊实性	26（12.8%）	18（24.0%）	0.023
多房囊性	48（23.6%）	7（9.3%）	0.008
多房囊实性	14（6.9%）	24（32.0%）	<0.001
实性	16（7.9%）	24（32.0%）	<0.001
声影	24（11.8%）	0（0）	0.002
腹水	3（1.5%）	24（32.0%）	<0.001

超声特征	例数(n/n)	预测价值（95%CI）
恶性超声特征（M）
M1	23/31	74.2%（57.9%~90.5%）
M2	24/27	88.9%（76.2%~100.0%）
M3	12/17	70.6%（46.4%~94.7%）
M4	19/21	90.5%（76.8%~100.0%）
M5	26/32	81.3%（67.0%~95.5%）
良性超声特征（B）
B1	99/101	98.0%（95.3%~100.0%）
B2	4/5	80.0%（24.5%~100.0%）
B3	24/24	100.0%（100.0%~100.0%）
B4	36/39	92.3%（83.6%~100.0%）
B5	159/167	95.2%（91.9%~98.5%）

组别	灵敏度 [%（95%CI）]	特异度 [%（95%CI）]	阳性预测值 [%（95%CI）]	阴性预测值 [%（95%CI）]	阳性似然比（95%CI）	阴性似然比（95%CI）	诊断比值比
方法一（n=278）	89.3（80~95）	86.2（81~90）	70.5（60~79）	95.6（91~98）	6.5（5~9）	0.1（0~1）	54.0
方法二（n=278）	68.0（56~78）	96.6（93~98）	87.9（76~95）	89.1（84~93）	19.7（9~42）	0.3（0~1）	59.8
方法三（n=241）	86.4（74~94）	96.2（92~98）	87.9（76~95）	95.6（91~98）	22.5（11~48）	0.1（0~1）	160.5