Agc, ultrasound score, menopausal status, B clinical inipression score and serum CA 125 level were assesscd to scc how they could best distinguish between patients with benign ( n = 101) and malignant ( n = 42) pelvic masses. Each criteria uscd alone provided statistically significant discrimination. Thc most useful individual criteria were a serum CA 125 level of 30 U/m1 (sensitivity 81 %) , specificity 75%)) anti an ultrasound score of 2 (sensitivity 71 %. specificity 83%). Three criteria could be combined in a risk ol malignancy index (RMI) which is siniply calculated using thc product of the serum CA 125 level (Uitnl), the ultrasound scan result (expressed as a score of 0, 1 or 3) and the menopausal status (1 if premenopausal and 3 if postmenopausal). This index was statistically virtually as effective a discriminant hetween cancer and benign lesions as more formal methods. Using an KMI cut-off level of 200, the sensitivity was 85%) and thc specificity was 97%. Patients with an RMT score of grcatcr than 200 had, on average, 32 times the background risk of cancer and those with a lower value 0.15 times the background risk.The greatest opportunity to influence the naturai history ol' ovarian cancer occurs at the time of the initial laparotamy. The aims of surgical management at this time arc to determine accurately the cxtent of disease and to I-educe residual tumour volume to a minimum (Griffiths l9S7 Hackcr 1987). In spite of the knowlcdgc of thc bcncfits of accurate surgical staging and cyto-reductive surgery, many patients do not receive appropriate surgery at the time of surgical diagnosis (Young ff d. . Adequate treatment at primary laparotamy is generally considered to require persistent, time consuming and aggi-essive surgery that ia oftcn not fcasihlc during a routine operatiiig list. Ideally. patients with ovarian maligiiancy should therefore he referred

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Objective To assess the relation between maternal serum pregnancy associated plasma protein A (PAPP‐A) in the first trimester and the outcome of pregnancy by karyotype. Design A retrospective study of PAPP‐A levels in blood samples collected prior to chorionic villus sampling. Setting Milan, Italy. Subjects Five hundred twenty‐two women, aged 20 to 47, at 7 to 11 weeks gestation, prior to undergoing chorionic villus sampling. Four hundred forty‐five women had a pregnancy with a normal karyotype; in 30 pregnancies the karyotype was abnormal (including 14 cases of Down's syndrome and 7 of trisomy 18). Main outcome measures Normal or abnormal fetal karyotype. Serum PAPP‐A at 6 to 11 weeks gestation measured by radioimmunoassay. Results The median value of PAPP‐A in the abnormal group was 0.27 multiples of the normal median (MoM). This is significantly lower than the median value in the normal group (1.01 MoM) (95% CI for the difference 0.46–0.84 MoM; P<0.00001 Mann‐Whitney test). Conclusions There is an association between low levels of PAPP‐A in the first trimester with chromosome anomalies. Screening by measurement of PAPP‐A might detect 60% of cases of Down's syndrome in the first trimester with a false positive rate of 5%.