Background: This study aimed to evaluate the diagnostic added-value of serum CA-125 to the International Ovarian Tumor Analysis (IOTA) Simple Rules in order to facilitate differentiation between malignant and benign ovarian tumors before surgery. Methods: A secondary analysis of a cross-sectional cohort of women scheduled for surgery in Maharaj Nakorn Chiang Mai Hospital between April 2010 and March 2018 was carried out. Demographic and clinical data were prospectively collected. Histopathologic diagnosis was used as the reference standard. Logistic regression was used for development of the model. Evaluation of the diagnostic added-value was based on the increment of the area under the receiver operating characteristic curve (AuROC). Results: One hundred and forty-five women (30.3%) out of a total of 479 with adnexal masses had malignant ovarian tumors. The model that included information from the IOTA Simple Rules and serum CA-125 was significantly more superior to the model that used only information from the IOTA Simple Rules (AuROC 0.95 vs. 0.89, p < 0.001 for pre-menopause and AuROC 0.98 vs 0.83, p < 0.001 for post-menopause). Conclusions: The IOTA SR X CA-125 model showed high discriminative ability and is potentially useful as a decision tool for guiding patient referrals to oncologic specialists.

Locoregional Spread and Survival of Stage IIA1 versus Stage IIA2 Cervical Cancer Cervical cancer;stage IIA;survival;radical hysterectomy; This study was undertaken to compare surgical outcomes and survival rates of patients with the 2009 International Federation of Gynecology and Obstetrics (FIGO) stage IIA1 versus IIA2 cervical cancer treated with radical hysterectomy and pelvic lymphadenectomy (RHPL). Patients with stage IIA cervical cancer undergoing primary RHPL between January 2003 and December 2012 at Chiang Mai University Hospital were retrospectively reviewed. The analysis included clinicopathologic variables, i.e. nodal metastasis, parametrial involvement, positive surgical margins, deep stromal invasion (DSI)), lymph-vascular space invasion (LVSI), adjuvant treatment, and 5-year survival. The chi square test, Kaplan-Meier method and log-rank test were used for statistical analysis. During the study period, 133 women with stage IIA cervical cancer, 101 (75.9 %) stage IIA1, and 32 (24.1 %) stage IIA2 underwent RHPL. The clinicopathologic variables of stage IIA1 compared with stage IIA2 were as follows: nodal metastasis (38.6% vs 40.6%, p=0.84), parametrial involvement (10.9% vs 15.6%, p=0.47), positive surgical margins (31.7% vs 31.3%, p=1.0), DSI (39.6% vs 53.1%, p=0.18), LVSI (52.5% vs 71.9%, p=0.05) and adjuvant radiation (72.3% vs 84.4%, p=0.33). With a median follow-up of 60 months, the 5-year disease-free survival (84.6% vs 88.7%, p=0.67) and the 5-year overall survival (83.4% vs 90.0%, P=0.49) did not significantly differ between stage IIA1 and stage IIA2 cervical cancer. In conclusion, patients with stage IIA1 and stage IIA2 cervical cancer have comparable rates of locoregional spread and survival. The need for receiving adjuvant radiation was very high in both substages. The revised 2009 FIGO system did not demonstrate significant survival differences in stage IIA cervical cancer treated with radical hysterectomy. Concurrent chemoradiation should be considered a more suitable treatment for patients with stage IIA cervical cancer.

Objective: The aim of the study was evaluate the diagnostic performance of the ADNEX model performed by non-expert examiners in differentiating between benign and malignant adnexal masses and to compare its performance with the IOTA Simple Rules. Methods: This diagnostic study was a secondary analysis based on a prospectively collected database of gynecological patients scheduled for elective surgery for adnexal masses. Preoperative ultrasound was performed within 24 h before surgery by second- and third-year gynecology residents who had completed a 20 h training course on adnexal mass ultrasound. Ultrasound data, CA-125 levels, and demographic information were reviewed and validated. Malignancy risk assessment using the IOTA Simple Rules was based on M-rules and B-rules, while risk calculations with the ADNEX model were conducted using an online application. Results: The area under the curve (AUC) for the ADNEX model was 0.958 (95% CI: 0.936–0.980), which was significantly higher than that of the IOTA Simple Rules at 0.886 (95% CI: 0.840–0.931; p < 0.001). Using a 10% cutoff, the ADNEX model demonstrated a sensitivity of 93.9% and a specificity of 81.0%, while the IOTA Simple Rules had a sensitivity of 84.0% and a specificity of 93.1%. The AUCs of the ADNEX model did not significantly differ when center status was considered (oncologic vs. non-oncologic centers). Conclusions: The ADNEX model, using a 10% cutoff, exhibited superior efficacy in differentiating benign from malignant adnexal masses compared with the IOTA Simple Rules. Furthermore, the sensitivity and specificity of the ADNEX model did not significantly differ between oncologic and non-oncologic centers. Both methods demonstrated high diagnostic accuracy, even when performed by non-expert examiners, suggesting that their diagnostic performance is reproducible and applicable in general clinical practice by general practitioners and gynecologists.

Objective: To evaluate the accuracy of the O-RADS system in differentiating between benign and malignant adnexal masses, as assessed by inexperienced gynecologists. Methods: Ten gynecologic residents attended a 20 h training course on the O-RADS system conducted by experienced examiners. Following the training, the residents performed ultrasound examinations on patients admitted with adnexal masses under supervision, recording the data in a database that included videos and still images. The senior author later accessed this ultrasound database and presented the cases offline to ten residents for O-RADS rating, with the raters being blinded to the final diagnosis. The efficacy of the O-RADS system by the residents and inter-observer variability were assessed. Results: A total of 201 adnexal masses meeting the inclusion criteria were evaluated, consisting of 136 (67.7%) benign masses and 65 (32.3%) malignant masses. The diagnostic performance of the O-RADS system showed a sensitivity of 90.8% (95% CI: 82.2–96.2%) and a specificity of 86.8% (95% CI: 80.4–91.8%). Inter-observer variability in scoring was analyzed using multi-rater Fleiss Kappa analysis, yielding Kappa indices of 0.642 (95% CI: 0.641–0.643). The false positive rate was primarily due to the misclassification of solid components in classic benign masses as O-RADS-4 or O-RADS-5. Conclusions: The O-RADS system demonstrates high diagnostic performance in distinguishing benign from malignant adnexal masses, even when used by inexperienced examiners. However, the false positive rate remains relatively high, mainly due to the over-interpretation of solid-appearing components in classic benign lesions. Despite this, inter-observer variability among non-expert raters was substantial. Incorporating O-RADS system training into residency programs is beneficial for inexperienced practitioners. This study could be an educational model for gynecologic residency training for other systems of sonographic features.

Objective: To compare the predictive performance in differentiating benign from malignant ovarian masses between the modified risk malignancy index (RMI) and the conventional RMI (RMI-1 and RMI-2). Methods: Women scheduled for elective surgery because of adnexal masses were recruited to undergo pelvic sonography within 24 h before surgery to assess the sonographic characteristics of the masses, focusing on loculi, solid part, ascites, bilateralness, papillary projection, and color flow mapping (CFM). Preoperative CA-125 levels were also measured. Modified RMI, RMI-1, and RMI-2 systems were used to predict malignant masses. The gold standard was pathological or intraoperative diagnosis. Results: A total of 342 ovarian masses, benign: 243 (71.1%); malignant: 99 (28.9%), meeting the inclusion criteria were analyzed. The sensitivity and the specificity of the modified RMI (87.9% and 81.9%) were significantly higher than those of RMI-1 (74.7% and 84.4%), and RMI-2 (79.8% and 81.1%, respectively). Based on ROC curves, the area under the curves were 0.930, 0.881 and 0.882 for modified RMI, RMI-1 and RMI-2, respectively. Conclusion: Modified RMI had better predictive performance than the conventional RMI in differentiating between benign and malignant ovarian masses. Modified RMI may be useful to help general gynecologists or practitioners to triage patients with an adnexal mass, especially in settings of low resources.