Adenexal masses are considered one of the most frequent reasons for referrals to specialist Gynecologists. Ovarian tumors',alone represent two thirds of these cases. They represent an increasing challenge to the Gynaecologists, and ovarian cancer being the most lethal of all Gynaecological cancers, characterized by late presentation and poor response to treatment. Adenexal masses can be present in patients being evaluated for a gynecological complaint or in asymptomatic patients. Most of patients with ovarian cancer stay asymptomatic for long time. When symptoms develop, they are usually nonspecific. In early- stage disease, patients commonly suffer from lower abdominal pain or non-specific gastrointestinal complaints. Irregular uterine bleeding is rarely present. Moreover, in advanced-stage disease, patients may have symptoms related to the presence of ascites or intestinal metastases.[1,2]

In olden days, adnexal masses are identified by clinical and bimanual examination. Only vague diagnosis could be made with invention of X-ray, ultrasonography, computerized tomography, and Magnetic resonance imaging prompt and accurate diagnosis of adenexal mass is possible. The differential diagnosis of an adnexal mass varies from functional cysts to benign tumors and malignant tumors. To arrive at an accurate diagnosis &optimal 1st line treatment, a non-invasive diagnostic technique became very essential.

Preoperative suggestion of ovarian cancer can conduct the physician to refer women with doubtful adenexal masses to a skilled gynecological oncologist for appropriate therapy and optimized debulking, while patients with benign adenexal masses can undergo more conservative surgical treatment. Benign masses can be treated conservatively or by minimal invasive surgical procedures. Hence, various scoring system have been developed differentiate benign from malignant ovarian masses.  No single diagnostic tool[ultrasonography, magnetic resonance imaging, and computerized tomography] is good enough in preoperative determination of malignancy, but there is an agreement that ultrasound assessment of adnexal mass morphology by an experienced sonographer can properly estimate the risk of malignancy. Surgery is often required solely to exclude the possibility of malignancy and about 1/3rd of women operated upon for suspected ovarian carcinoma turn out to have benign disease even after using a RMI as seen in the study by D'Arcy et al.[1]

The presumptive diagnosis will determine the type of surgery and the pre-operative preparation and may influence selection of the institution and the seniority and expertise of the surgeon. Evaluation of adenexal mass as benign and malignant based on Alcazar score and  evaluate prospectively the usefulness of color Doppler and gray scale sonography in differentiating benign from malignant ovarian masses and evaluation of scoring system ALCAZAR for differentiating benign from malignant ovarian masses was done in our study. So we have comparison of ultrasound guided adenexal mass alcazar score with histopathological examination report.

This study was conducted from August 2017 – July 2018 at SRI VENKATA SAI Medical College Hospital in Mahabubnagar, Telangana, India. 100 patients with adnexal mass were included in the study based on purposive sampling technique. Written informed consent was obtained from all the participants, institutional review board, and institutional ethics committee approval was given to the study. At the time of registration, a detailed history was taken and complete examination done. All registered patients were subjected to transabdominal sonography.

The sonographic parameters of the scoring system included thick papillary projections and solid areas. The color Doppler parameters included blood flow (presentor absent), blood flow location (central or peripheral), resistance index (RI), peak systolic velocity (PSV) and velocimetry (high velocity/low resistance).

Various parameters and scoring system as proposed by Alcazaret al[2]. This scoring system yielded a total score from 0 – 12. A score of ≥ 6 was considered malignant, while a score of < 6 was considered benign.

All patients were evaluated with the use of Philips HD11 machine. They were then followed up till resolution of the mass by conservative management or surgical intervention.

The gold standard for diagnosis was histopathological examination of specimen obtained from laparotomy and or cytology of acitic fluid.

Scoring system as proposed by Alcazar et al[2]

High velocity – PSV ≥ 10cms/s
Low resistance – RI ≤ 0.45
In tumors with both central and peripheral flow, only central blood flow was used for analysis. In those with >1 vessel, the lowest RI and highest PSV were used for analysis

The data obtained was used to score each patient according to Alcazar scoring system. The Alcazar score was evaluated for its ability to accurately diagnose malignancy. Histopathology of the tumor and the ascitic fluid cytology was used as gold standard. Age distribution, menopause state and the pathological type of ovarian tumor was studied. Clinical features and investigations was correlated with their pathological tumor type. All the data was tabulated using Microsoft excel 2007. The statistical analysis was done using Pearson chi square test in Spss ver.20.

Out of the 100 patients recruited in the study, 88 were operated; the remaining 12patients were managed conservatively by hormonal treatment and followed by repeat ultrasound till resolution of the mass.

Table-1: Demographic distribution of the patients

Malignant ovarian masses were seen to peak in the age groups 30-39 years and40-49 years as seen in fig. 6. Benign ovarian masses were more commonly seen in younger age groups of 10-19 years and 20-29 years.

Table-2: Velocimetry

Figure-1: Age as per the menopausal status of the patient

Age was significantly higher in menopausal women

Table-3: Univariate analysis of age distribution in the two groups.

There was no statistically significant difference in the ages between the benign and malignant groups.

Table-4: Efficacy of Alcazar’s scoring system for diagnosing malignant tumors.

Diagnostic efficacy of the Alcazar system as seen in this study, with sensitivity 100%, specificity 91.89%, positive predictive value 81.25% and negative predictive value 100%.

Table-5: Univariate analysis of variables used in assessment of adnexal mass.

the 34 masses in postmenopausal patients, 14 were malignant, while 12 malignant masses were seen in the 66 masses in premenopausal patients with no statistical significance (P=0.172). In 8 of the 26 malignant cases, thick papillary projections were present as compared to 2 of the 74 benign masses (P=0.021). In all 26 of the malignant masses solid elements were present as compared to 28 of the 74 benign masses(P=0.000). In 24 of the 26 malignant masses, central flow was detected as compared to 6of the 74 benign masses (P=0.000). In 22 of the 26 malignant masses, velocimetry(PSV>10cms/s, RI<0.45) was present as compared to 2 of the 74 benign mass (P=0.000).

Table-6: Comparison between Alcazar Scoring System and histopathology.

Out of the 100 patients 68 (68%) had a score between0 -5 and all 68 (100%) were found to be benign by histopathology. 32 of the 100 (32%) cases had a score from 6-12 and 26 (81.25%) of them were malignant on histopathology.

Table-7:Test Result Variable(s): Score

This showed a good positive correlation of the score with the final diagnosis. Coordinates of the Curve

Figure-2: Receiver operator characteristic curve

Area Under the Curve 0.984

The receiver operator characteristic (ROC) curve showed that the best cut of value was a score of ≥ 6 with a sensitivity of 100% and a specificity of 91.89%.

Figure-3: Images in study

The present study was conducted utilizing ultrasonography and color Doppler inpatients with ovarian mass. The objective was to evaluate the role of color Doppler and the new scoring system of Alcazar[2] in differentiation of benign from malignant ovarian mass.

In the current study, thick papillary projections (≥3mm) was statistically significant (P<0.021) in the differentiation of benign from malignant ovarian mass. In the study by Singh and co-workers[4] , papillary thickness ≥3mm was found to be significant(P<0.02). Alcazar and colleagues[2]  in their study showed that thick papillary projections were significant (P<0.0001). However, Brown et al[5]  found absence of septations to have higher association with malignancy than thick saptations, which in turn had higher association than thin septations.

In this study, solid areas was statistically significant (P<0.000) in the differentiation of benign from malignant ovarian mass. Similar findings were documented in the studies by Alcazar and colleagues[2](P<0.0001) and Singh and co-workers[4] (P<0.028). Brown et al[5] in their study found that a solid component is the most statistically significant predicter of a malignant ovarian mass (P<0.001). In the study published by Schelling et al[6] papillary structure in cysts had a sensitivity of 67% and a specificity of 81% , while detection of solid area had sensitivity of 95% and specificity of 68% for the detection of malignancy.

The Doppler parameter central flow was found to be statistically significant(P0.000) in the present study. Carter et al[7] studied flow characteristics in benign and malignant gynaecologic tumors and found that intratumor colour flow was more common in malignant than in benign tumors (P<0.0001). Merce and co-workers[8] in a study of 213tumors: vascularization was detected in 100 % of the malignancies, for 90% of these cases in central areas. In contrast, only 52% of the benign tumors were vascularized, 98%of these in peripheral areas.

Singh and co-workers[4] showed that presence of central vascularization was significant (P<0.001). In the study by Alcazar and co-workers[2], central blood flow was found to be a predicter of malignancy (P<0.0001). Brown et al[5] found that central flow has a stronger association with malignancy than doe’s solely peripheral flow, which has a stronger association than no flow.

In our study, velocimetry (high velocity/low resistance) was of statistical significance (P0.000). Similar findings were seen in studies by Singh and colleagues[4](P<0.001) and Alcazar and co-workers[2](P<0.001).The study by Timor-Trisch and colleagues[9] used a resistance index of 0.46 as cut-off for detection of malignancy with a sensitivity of 93.8%, specificity of 98.7%, positive predictive value of 93.8%, negative predictive value of 98.7%.

Kurtz et al[10] in their study found the thresholds for malignancy were a pulsatility index of <1.0 and a resistive index of >0.4. Szpurek and colleagues[11] found statistically significant differences in PSV median values when considering histological grade(P=0.01) and also when considering clinical stage of disease according to FIGO(P=0.001). However, they found no significant difference in the median values of the blood flow parameters of PI and RI.

The current study showed no statistical significance when comparing menopausal status of the benign and malignant groups. In the series by Alcazar and co-workers3the performance of the scoring system did not alter with the menopausal status of the patient.

However, a lower sensitivity in women who were postmenopausal was found for the scoring systems of Sassoneet al[12] and Ferrazzi et al[13]. Kudlaet al[14] in their study suggest that the detection of early ovarian carcinoma is much more difficult in a younger group compared with atypical hyper vascularized pathologic ovaries after menopause, when physiological vascularization is low.

Singh and colleagues[4] found post-menopausal status to be a significant predicter of malignancy (P0.023).Davis and co-workers[14] developed a RMI using gray scale ultrasound, menopausal status and serum CA 125 levels. They found post-menopausal status to be a significant independent predicter of malignancy (P<0.001).

Table-8: Comparison of efficacy of Alcazar scoring system as applied to this study with efficacy of earlier published scoring systems

Efficacy of various known scoring systems in differentiating benign from malignant tumours as published previously in comparison to that of Alcazar scoring system in this study. In the study by Alcazar and co-workers[2], none of the ovarian teratomas had a score of ≥ 6 .However, in the present study, one case of false positive was a case of mature cystic teratoma, which showed solid element with central flow.

The scoring system as proposed by Sassoneet al[12] has a considerable false-positive rate, basically because of ovarian cystic teratomas. To overcome this problem, Lerner et al[15] proposed a modified scoring system that included ‘0’ score for the purpose of acoustic shadowing which is characteristic of this type of tumor. However, the false-positive rate remained high in this study. In this study, one case of fibroma of the ovary showed solid are, central flow and velocimetry, resulting in a false-positive result. The false-positive result in the scoring systems of Sassone[12] and De Priest[16] were basically due to high scoring of benign lesions like teratoma, endometrioma and ovarian fibroma. The main source of false-positive results in the series by Alcazar and co-workers[2] was ovarian cyst adenofibromas, which frequently are encountered as unilocular cysts with solid areas and central flow, and ovarian fibromas which are typically solid tumors.

Analyzing false-positive results for each scoring system, the current identified 3cases (1 cystadenofibroma, 1 mature cystic teratoma and 1 hemorrhagic cyst) ; the scoring system by Alcazar and co-workers[2] identified 3cases( 2 cystadenofibromas and 1Brenner’s tumor); the scoring system by Sassone et al[12] identified 7 cases (2 teratomas, 2leiomyomas, 1 Brenner’s tumor, 1 granulosa cell tumor, 1 ovarian fibroma); the scoring system of De Priest and colleagues[16] identified 10 cases (3 teratomas, 2cystadenofibromas, 2 leiomyomas, 1 granulosa cell tumor, 1 ovarian fibroma, 1 Brenner’s tumor); and the scoring system by Ferrazi et al[13] identified 9 cases (2 teratomas, 2leiomyomas, 2 cystadenofibromas, 1 granulosa cell tumor, 1 Brenner’s tumor). There were no false-negative results in the current study with a negative predictive value of 100%. De Priest and colleagues[16] and Alcazar and co-workers[2] showed no false-negative results. The scoring system of Sassone et al4had 11 false-negative cases(9primary ovarian carcinomas and 2 metastatic cancers). The scoring system of Ferrazi et al[13] had 7 false-negative cases (4 primary and 3 metastatic carcinomas).

Alcazar and co-workers[2] tested 4 scoring systems and found the best diagnostic performance was achieved by their new proposed scoring system with 100% sensitivity ,94.9% specificity and the highest AUC, which was significantly higher than for the scoring systems of Sassone et al[12], De Priest and colleagues[16] and Ferrazi et al[13]. This improvement in the diagnostic performance as compared to the previous scoring system was as the analytical approach was more statistically accurate and only parameters truly predictors of malignancy were included. The respective importance of parameters, namely score was assigned according to the odds ratio. Further, Doppler parameters were included, which altered the false-positive rate by decreasing it.

Alcazar scoring system is useful in differentiating benign from malignant ovarian masses. It is simple, easy to memorize and it is reproducible. Alcazar scoring system was found to be more sensitive and specific than other available scoring systems. However, it is highly operator dependent, which leads to inter observer variability and needs expert sinologist

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