الفهرس 
Introduction
Adnexal MassesOnly 14 pages are availabe for public view
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Abstract
The uterine adnexa consist of the ovaries, the Fallopian tubes, and the uterine ligaments. Although adnexal pathology often involves one of these structures, contiguous structures of non-gynecologic origin also may be involved.
Adnexal masses are common among women of all ages and two thirds of ovarian tumors are encountered during reproductive years, of those the risk of malignancy in an ovarian mass in patients above 40 years is remarkably high although the premenarchal lesions are usually malignant. Although most tumors are benign, it is of great importance to correctly characterize whether ovarian masses constitute benign or malignant disease. This is particularly important in premenopausal women where preservation of fertility is an important issue.
Ovaries are highly capable of producing both benign and malignant tumors throughout a woman’s life. Due to the complex ovarian structure, histopeathological findings of adnexal tumors can be quite different. Ovarian cancer, a disease of no settled screening or prevention approaches until now, is still a silent killer of many women because of its late presentation, so it does not need an extra delay in management which could be caused by misleading preoperative data or suboptimal surgical intervention.
Patients with diagnosed ovarian cancer should be treated in special centers that provide the most comprehensive cancer care, whereas for benign masses expectant or conservative surgical management may be warranted due to reduced morbidity and the importance of fertility preservation.
Many scoring models composed of certain parameters have been supposed to differentiate between benign and malignant adnexal masses.
One of these models is the Risk of malignancy index which was introduced by Jacobs et al., in (1990), which was term as RMI 1. It is a product of ultrasound findings (U), the menopausal status (M), and serum CA-125 levels (RMI = U X M X CA-125). The original RMI (RMI-1) has been modified in 1996 by Tingulstad et al., Known as (RMI2) and again in 1999 known as (RMI3) and the last modification was by Yammoto et al., in (2009) who added another ultrasound parameter which is the tumor size (S). The difference between the new indices lies in the different scoring of ultrasound characteristics and menopausal status.
A new scoring model for characterization of adnexal masses based on two-dimensional gray-scale and color Doppler sonographic features was adapted in Women’s Health Hospital – Assiut University in 2014 [Assiut Scoring Model (ASM)]. by (Abbas et al., 2014)
However, These models have not been routinely implemented in Women’s Health Hospital – Assiut University, despite their ease of use.
The aim of this work was to assess the ability of the four RMI and ASM in preoperative distinguishing benign from malignant adnexal tumors and compare between their performances.
Two hundred women with adnexal masses were recruited in our study, 25 cases were excluded, 6 were inoperable, 7 unfit for surgery and 12 were recurrent cases with previously known diagnosis of the mass. Moreover 20 subjects managed conservatively have been excluded (no final histopathology diagnosis). Finally 155 were managed surgically either by laparoscopy or laparotomy. 34 cases were malignant (22%) and 121 cases were benign (78%).
The mean age of patients in benign group was 33.50 ± 14.53 yeras versus 45.09 ± 13.67 years for patients in malignant group. (P=0.000)
There was statistically significant difference between both groups as regard age, menopausal status and family history of adnexal masses.
As regard the ultrasonographic features of the RMI, there was statistically significant differences between both groups as regard all features. The most consistent ultrasound feature was the presence of solid areas in 85.3% of malignant masses.
CA125 showed the highest sensitivity among all individual parameters of RMI 91.18% while menopausal status and tumor size had the lowest sensitivity (37.93% and 25.83% respectively). And the sensitivity of ultrasound score was 67.65%.
RMI 2 had the best performance among all Risk of maliganacy indices with sensitivity 76.47% specificity 90.08% PPV 68.4% NPV 93.2% accuracy 87.1%.
As regard ASM it has the lowest sensitivity among all tested indices 52.94%, regarding the ultrasound features of ASM most of malignant masses were unilocular solid and multilocular solid masses.
We assigned the best cut off for each model tested in our study, it was 65 for RMI 1&3, 75 for RMI 2 and 140 for RMI4. 3 for ASM.
In conclusion, the present study demonstrated that in the absence of a definite biomarker, the multi parametric Risk of Malignancy Index is a better estimate in diagnosing adnexal masses with high risk of malignancy and subsequently guiding the patients to gynecological oncology centers for suitable and effective surgical interventions.
Our recommendations, regarding diagnosis of any case with an adnexal mass, is its meticulous evaluation by skilled experts in ultrasound, and using the highest quality ultrasound equipments, with using of the Risk of malignancy index for appropriate diagnosis and of triage of patients with adnexal masses and once there is suspicion of malignancy, the case should be referred to a gynecologic oncology unit for professional skilled surgeons to thoroughly investigate and operate upon.