Aim: The study aimed to compare the risk of ovarian malignancy algorithm (ROMA) with risk of malignancy index (RMI), cancer antigen 125 (CA125), human epididymis protein 4 (HE4) and Sassone ultrasonography (US) score in predicting ovarian cancer (OC) in women who present with pelvic or adnexal masses. Methods: Pelvic US, serum CA125 and HE4 levels were investigated preoperatively in consecutively enrolled Thai women over 18 years with clinically diagnosed pelvic or adnexal masses who were undergoing elective surgery at a super tertiary hospital in Thailand in 2012. ROMA, RMI and Sassone US score were calculated. Results: Of 260 women who were evaluated, 74 had OC. Areas under the receiver operating characteristic curve (AUC) in predicting OC were ROMA, 86.2%; RMI, 87.6%; CA125, 80.6%; HE4, 82.4%; and Sassone score, 77.1%. ROMA and RMI performed similarly well (AUCs 84.4 and 85.6%) in premenopausal women but RMI outperformed ROMA in postmenopausal women (AUCs 87.9 and 84.0%, respectively). At the conventional cutoff value, ROMA and CA125 showed the highest sensitivity (83.8%) but HE4 had the highest specificity (86.0%). Conclusions: ROMA was comparable to RMI in predicting OC. Either ROMA or RMI can be applied to women with pelvic masses, stratified into low- and high-risk groups for OCs.

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Cystic teratomas can produce a wide spectrum of sonographic appearances, which depends on their major content 1 . Teratomas may be predominantly cystic, of complex mass, or even of solid appearance if the intracystic fat tissue, epithelial debris and hairs are conglomerated and produce hyperechogenic features filling the entire cyst 2 . Many specific ultrasonographic appearances of cystic teratoma have been reported including the tip of the iceberg sign, fat-fluid level, dermoid mesh and Rokitansky's protuberance (dermoid plug) 3 -6 . We present a case of another distinct ultrasonographic feature, namely multiple, discrete, uniform globules floating within the cyst. On examination of the gross specimen these globules were fat balls composed of cheese-like sebum material and hairs. This unique finding was discovered when a 33-year-old woman presented with abdominal distension and discomfort that she had experienced for 1 year. Physical examination showed that her abdomen was slightly distended with a midline, tense cystic mass of about 20 cm diameter in her lower abdomen. On pelvic examination, a large cystic mass of 20 cm diameter occupying most of the lower abdomen was noted. It had a smooth external wall and was slightly mobile but not tender. A normal-size uterus was palpated just posterior to this cyst. Transabdominal sonography revealed a large cystic mass of 20 cm diameter occupying the whole pelvic cavity extending up to the level of the umbilicus. This cyst had a striking ultrasound appearance with multiple, distinct, round, bright, echogenic, uniform globules of about 2 cm diameter floating in hypoechogenic fluid (Figure 1). A broad hyperechogenic area with multiple bright linear echoes and spots that were characteristic of cystic teratoma (dermoid plug) was also noted in the upper part of the cyst. Because the uterus and normal ovaries could not be depicted, transvaginal sonography was suggested but the patient refused the procedure. A preoperative ultrasonographic diagnosis of dermoid cyst was made. On exploratory laparotomy the week following ultrasound examination, a 16-cm unilocular left ovarian cyst was found. It contained serous fluid and numerous small, soft, cheese-like sebum balls of about 2 cm diameter with hairs in many of them (Figure 2). A broad, thick mass of cheese-like sebum tissue and hairs that represented a dermoid plug was also noted. The right ovary and the uterus were normal. Left salpingo-oophorectomy was performed

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