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Scoring systems for the evaluation of adnexal masses nature: current knowledge and clinical applications

Terzic M1,2,3Aimagambetova G4Norton M5Della Corte L6Marín-Buck A7,8Lisón JF9,10Amer-Cuenca JJ11Zito G12Garzon S13Caruso S14Rapisarda AMC14Cianci A14.

J Obstet Gynaecol. 2020 Apr 29:1-8. doi: 10.1080/01443615.2020.1732892. [Epub ahead of print]



Adnexal masses are a common finding in women, with 20% of them developing at least one pelvic mass during their lifetime. There are more than 30 different subtypes of adnexal tumours, with multiple different subcategories, and the correct characterisation of the pelvic masses is of paramount importance to guide the correct management. On that basis, different algorithms and scoring systems have been developed to guide the clinical assessment. The first scoring system implemented into the clinical practice was the Risk of Malignancy Index, which combines ultrasound evaluation, menopausal status, and serum CA-125 levels. Today, current guidelines regarding female patients with adnexal masses include the application of International Ovarian Tumours Analysis simple rules, logistic regression model 1 (LR1) and LR2, OVERA, cancer ovarii non-invasive assessment of treating strategy, and assessment of Different Neoplasias in the adnexa. In this scenario, the choice of the scoring system for the discrimination between benign and malignant ovarian tumours can be complex when approaching patients with adnexal masses. This review aims to summarise the available evidence regarding the different scoring systems to provide a complete overview of the topic.


Ovarian masses are a common finding in women of all ages and require precise differentiation. Although the diagnostic method of reference is the histological evaluation of the surgical specimen obtained after surgery for both benign (El Bishry et al. 2008, Lagan

a, Vitale, et al. 2016, Vitale, Sapia, et al. 2017) and malignant conditions (Cignini et al. 2017, Rossetti et al. 2017, Shiozaki et al. 2019), only an appropriate clinical/pre-operative discrimination between benign and malignant ovarian tumours allow a proper approach to patients affected by adnexal masses. The conservative management with observation alone is sufficient in the case of benign cysts, such as functional ovarian cysts, whereas suspected malignant cysts require an appropriate surgical approach (American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins— Gynecology 2016). This is of paramount importance in benign pathologies related to enlarged ovaries, such as polycystic ovary syndrome, that has a different therapeutic approach (Chiofalo et al. 2017, Lagan

a et al. 2017, Reyes-Mu~noz et al. 2018).

On that basis, the appropriate evaluation of adnexal masses is of paramount importance to define the subsequent clinical and/or surgical management. Therefore, to increase the accuracy of the adnexal mass evaluation and the discrimination between adnexal masses at risk of malignancy versus benign masses, within the past three decades different scoring systems/algorithms were developed based on tumour serum markers and imaging methods, incorporating multiple clinical, laboratory, and radiologic parameters. As summarised in our review, no single diagnostic tool/ approach has demonstrated higher reliability and higher validity for the clinical/preoperative prediction as compared to the others to allow a clear definition of the one of choice. However, although the reported algorithms and indexes can be classified in those based on serum markers and in those based on ultrasound evaluation, it is clear that all require a diagnosis of adnexal mass and, therefore, the simple rules or LR2 are always feasible as first-line assessment and should be adopted in clinical practice as the principal test to characterise masses as benign or malignant according to the findings of the IOTA study (Timmerman et al. 2008).

Moreover, of note, some Authors reported ultrasound parameters more informative and important than tumour markers (Van Gorp T et al. 2012). However, if serum CA 125 and HE4 levels are available at the first evaluation, the Triple test and CHP-I could represent the first step to assess the risk before ultrasound characterisation. Conversely, the RMI, ROMA and ADNEX scores represent supportive tools to increase the diagnostic accuracy after the ultrasound assessment when serum tumours markers are available. Regarding the CA 125, it is of paramount importance to evaluate the absolute level as well as the trend as shown by the ROCA score. Finally, it should be highlighted the more limited role of OVA1, OVA2, and CONATS, that are primarily designed for the presurgical assessment and the choice of the surgical approach. Although a clear recommendation on the most appropriate algorithm or index tool is not feasible, it is mandatory to remember the key role of further evaluation by experts gynaecologist as well as the use of further diagnostic tools, such as magnetic resonance, in case of suspicious adnexal mass with no clear or conflicting preliminary assessment.