Improving the performance of IOTA simple rules: sonographic assessment of adnexal masses with resource-effective use of a magnetic resonance scoring (ADNEX MR scoring system)

Pereira, Patrick Nunes; Sarian, Luís Otávio; Yoshida, Adriana; Araújo, Karla Galvão; Silva, Ana Carolina Baião; Barros, Ricardo Hoelz de Oliveira; Jales, Rodrigo Menezes; Derchain, Sophie

doi:10.1007/s00261-019-02207-9

Cited by 22 publications

(19 citation statements)

References 21 publications

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“…Because of the low malignancy rate (2%) in this subgroup, the confidence interval around the AUC was wide. Calibration analysis indicated that the risk of malignancy was overestimated in this subgroup (supplementary figs[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34]. The results obtained in the sensitivity analyses were similar to those in the primary analysis (supplementary figs[35][36][37][38][39][40][41][42][43].…”

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confidence: 54%

“…19 Pereira and colleagues (n=170) evaluated the clinical utility of simple rules and SRRisk. 20 Other published validation studies were limited to patients who underwent surgery. These studies showed that IOTA models distinguished better between benign and malignant adnexal masses than RMI, and that ADNEX might be the best performing model.…”

Section: Auc (95% Ci)mentioning

confidence: 99%

“… 12 13 14 However, only three validation studies reported on model calibration, that is, the agreement between predicted malignancy risk and observed proportion of malignancy; only one compared the clinical utility of different prediction models for referring patients with an adnexal mass to an oncology centre. 15 16 17 18 More importantly, all model development and validation studies, except for two small single centre validation studies, 19 20 recruited patients who underwent surgery with histology as the reference standard. Therefore, current evidence is limited to patients for whom the decision to operate had already been made.…”

Section: Introductionmentioning

confidence: 99%

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Validation of models to diagnose ovarian cancer in patients managed surgically or conservatively: multicentre cohort study

Calster

Valentin

Froyman

et al. 2020

BMJ

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ObjectiveTo evaluate the performance of diagnostic prediction models for ovarian malignancy in all patients with an ovarian mass managed surgically or conservatively.DesignMulticentre cohort study.Setting36 oncology referral centres (tertiary centres with a specific gynaecological oncology unit) or other types of centre.ParticipantsConsecutive adult patients presenting with an adnexal mass between January 2012 and March 2015 and managed by surgery or follow-up.Main outcome measuresOverall and centre specific discrimination, calibration, and clinical utility of six prediction models for ovarian malignancy (risk of malignancy index (RMI), logistic regression model 2 (LR2), simple rules, simple rules risk model (SRRisk), assessment of different neoplasias in the adnexa (ADNEX) with or without CA125). ADNEX allows the risk of malignancy to be subdivided into risks of a borderline, stage I primary, stage II-IV primary, or secondary metastatic malignancy. The outcome was based on histology if patients underwent surgery, or on results of clinical and ultrasound follow-up at 12 (±2) months. Multiple imputation was used when outcome based on follow-up was uncertain.ResultsThe primary analysis included 17 centres that met strict quality criteria for surgical and follow-up data (5717 of all 8519 patients). 812 patients (14%) had a mass that was already in follow-up at study recruitment, therefore 4905 patients were included in the statistical analysis. The outcome was benign in 3441 (70%) patients and malignant in 978 (20%). Uncertain outcomes (486, 10%) were most often explained by limited follow-up information. The overall area under the receiver operating characteristic curve was highest for ADNEX with CA125 (0.94, 95% confidence interval 0.92 to 0.96), ADNEX without CA125 (0.94, 0.91 to 0.95) and SRRisk (0.94, 0.91 to 0.95), and lowest for RMI (0.89, 0.85 to 0.92). Calibration varied among centres for all models, however the ADNEX models and SRRisk were the best calibrated. Calibration of the estimated risks for the tumour subtypes was good for ADNEX irrespective of whether or not CA125 was included as a predictor. Overall clinical utility (net benefit) was highest for the ADNEX models and SRRisk, and lowest for RMI. For patients who received at least one follow-up scan (n=1958), overall area under the receiver operating characteristic curve ranged from 0.76 (95% confidence interval 0.66 to 0.84) for RMI to 0.89 (0.81 to 0.94) for ADNEX with CA125.ConclusionsOur study found the ADNEX models and SRRisk are the best models to distinguish between benign and malignant masses in all patients presenting with an adnexal mass, including those managed conservatively.Trial registrationClinicalTrials.gov NCT01698632.

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confidence: 54%

Section: Auc (95% Ci)mentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Validation of models to diagnose ovarian cancer in patients managed surgically or conservatively: multicentre cohort study

Calster

Valentin

Froyman

et al. 2020

BMJ

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“…Acquisition of the DCE protocol proposed by Thomassin-Naggara et al [10,11] significantly extends the MRI examination which may be a challenge in certain patients or clinical scenarios. Although Pereira et al recently proposed a simplified dynamic MRI protocol including 5 post-contrast phases with 30-s delays [13,14], off-line post-processing of dynamic imaging still contributes significantly to the workload. In addition, there are significant concerns regarding the administration of GBCAs in relation to the development of nephrogenic systemic fibrosis and the potential impact of long-term gadolinium retention in a range of tissues and organs [15].…”

Section: Introductionmentioning

confidence: 99%

Non-contrast MRI can accurately characterize adnexal masses: a retrospective study

et al. 2021

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Objective To determine the accuracy of interpretation of a non-contrast MRI protocol in characterizing adnexal masses. Methods and materials Two hundred ninety-one patients (350 adnexal masses) who underwent gynecological MRI at our institution between the 1st of January 2008 and the 31st of December 2018 were reviewed. A random subset (102 patients with 121 masses) was chosen to evaluate the reproducibility and repeatability of readers’ assessments. Readers evaluated non-contrast MRI scans retrospectively, assigned a 5-point score for the risk of malignancy and gave a specific diagnosis. The reference standard for the diagnosis was histopathology or at least one-year imaging follow-up. Diagnostic accuracy of the non-contrast MRI score was calculated. Inter- and intra-reader agreement was analyzed with Cohen’s kappa statistics. Results There were 53/350 (15.1%) malignant lesions in the whole cohort and 20/121 (16.5%) malignant lesions in the random subset. Good agreement between readers was found for the non-contrast MRI score (к = 0.73, 95% confidence interval [CI] 0.58–0.86) whilst the intra-reader agreement was excellent (к = 0.81, 95% CI 0.70–0.88). The non-contrast MRI score value of ≥ 4 was associated with malignancy with a sensitivity of 84.9%, a specificity of 95.9%, an accuracy of 94.2% and a positive likelihood ratio of 21 (area under the receiver operating curve 0.93, 95% CI 0.90–0.96). Conclusion Adnexal mass characterization on MRI without the administration of contrast medium has a high accuracy and excellent inter- and intra-reader agreement. Our results suggest that non-contrast studies may offer a reasonable diagnostic alternative when the administration of intravenous contrast medium is not possible. Key Points • A non-contrast pelvic MRI protocol may allow the characterization of adnexal masses with high accuracy. • The non-contrast MRI score may be used in clinical practice for differentiating benign from malignant adnexal lesions when the lack of intravenous contrast medium precludes analysis with the O–RADS MRI score.

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“…MRI is also considered a good modality for differentiating adnexal masses and ADNEX MRI scores have been proposed toward this goal. [ 31 32 33 ] However, MRI suffers from limitations such as prolonged examination time, contraindications in patients with metallic implants, contraindication for contrast administration in those with compromised renal functions, besides high cost and lack of wide availability in resource poor countries. We are, therefore, in agreement with other investigators who believe that MRI should be considered the preferred modality mainly for local staging in ovarian cancer but not for primary diagnosis, wherein ultrasound remains the recommended tool.…”

Section: Discussionmentioning

confidence: 99%

Prospective revalidation of IOTA “two-step”, “alternative two-step” and “three-step” strategies for characterization of adnexal masses – An Indian study focussing the radiology context

Grover

Patra

Grover

et al. 2020

Indian J Radiol Imaging

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Objectives: The purpose of this study was to revalidate the diagnostic performance of IOTA “two step” (Simple Descriptors and Simple Rules), “ alternative two step” (Simple Rules Risk Calculation tool / SRrisk score), and three step (two step with subjective assessment) strategies, for characterization of adnexal masses as benign or malignant, using histopathology as gold standard. Materials and Methods: This prospective, study comprised of 100 patients with newly diagnosed adnexal masses, who underwent ultrasound evaluation first by a level I and then by a level III investigator (EFSUMB criteria). Initially, the level I investigator evaluated each adnexal mass, applying IOTA “two-step” strategy and simultaneously assigned a risk category, by applying the simple rules risk score (SRrisk score) or performing the “alternative two step” strategy. Subsequently the inconclusive masses were evaluated by the level III investigator using “real time subjective assessment”, thereby performing the third step. Following histopathology diagnosis, the performance of each strategy was evaluated using diagnostic tests. Results: The sensitivity, specificity, PPV, NPV, and diagnostic accuracy of “two-step” strategy were 87.5%, 79.2%, 89.4%, 76%, and 84.7%, respectively; those of “alternative two-step” strategy were 91.5%, 75.6%, 84.4%, 86.1% and 88%; and those of “three-step” strategy were 98.2%, 93.3%, 94.7%, 97.7% and 96%, respectively. Conclusion: All IOTA strategies showed good diagnostic performance for characterization of adnexal masses and the “three-step” strategy performed best. We believe this is the first ever prospective re-validation and comparative evaluation of all three IOTA strategies by Indian Radiologists. Since ultrasound is the primary modality for evaluation of adnexal masses, based on the good results of our study, a recommendation for henceforth standard application, of the three-step IOTA strategy in routine Radiology practice appears justified. Although, IOTA strategies been proposed and validated mainly by Gynaecologists and Oncology surgeons, based on the results of our study, this paradigm can now be made to shift back to the arena of Radiology and Radiologists, the imaging experts.

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Improving the performance of IOTA simple rules: sonographic assessment of adnexal masses with resource-effective use of a magnetic resonance scoring (ADNEX MR scoring system)

Cited by 22 publications

References 21 publications

Validation of models to diagnose ovarian cancer in patients managed surgically or conservatively: multicentre cohort study

Validation of models to diagnose ovarian cancer in patients managed surgically or conservatively: multicentre cohort study

Non-contrast MRI can accurately characterize adnexal masses: a retrospective study

Prospective revalidation of IOTA “two-step”, “alternative two-step” and “three-step” strategies for characterization of adnexal masses – An Indian study focussing the radiology context

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