Juniper Publishers: Malignancy Risk Index in Pelvic Mass Differentiation
JUNIPER PUBLISHERS- JOURNAL OF GYNECOLOGY AND WOMEN’S
HEALTH
Journal of Gynecology and Women’s Health-Juniper
Publishers
Authored by Claudio Sergio Batista*
Abstract
Ovarian cancer is the seventh major cause of
cancer-related death in women. Near 70% of epithelial ovarian cancers
are diagnosed when the disease is advanced, when the 5-year survival
rate is, approximately, 25%. The malignancy risk index (MRI) of ovarian
tumors associates menopausal status, ultrasound characteristics and
CA-125 serum levels, and has the goal of improving the preoperative
distinction between benign and malignant ovarian tumors. So, we approuch
this tool to regard how we should be find the best way to treat women
with pelvic mass. In this paper we made a summarized review of MRI. In
this article MRI and its componentes are reviewed. We understand that
simplicity of Malignancy Risk Index calculation allows providing, with
good accuracy, aid in differential preoperative diagnosis between benign
and malignant tumors.
Keywords: Ovarian neoplasms; Risk Index; Diagnosis; Biomarkers tumor; Ultrasonography; CA-125 antigenIntroduction
Epidemiology of ovarian cancer
Ovarian cancer is the seventh most common cancer
among women, with 238,719 cases/year (3.6%). In 2012 it was estimated
the mortality of 151,917 cases per year. It is the third most common
gynecological cancer, after cancer of the cervix and uterine body. Its
incidence is variable in different regions of the world, being greater
in northern countries and Eastern Europe and less in Southeast Asia and
Africa [1].
Ovarian cancer is the most lethal Gynecological
tumors, being the most difficult to be diagnosed and with lower chances
of cure. More women die of ovarian cancer than any other gynecological.
About of. 75 of this organ cancers are at an advanced stage at diagnosis
[2].
Pathology of ovarian cancer
Epithelial tumors account for about 90% of cases of
ovarian cancer, corresponding to the vast majority of primary neoplasms,
other types are the germ line or stromal tumors. Although referred to
as epithelial, they derive from the mesothelium surface coelomic. There
are three main types of these tumors: serous, mucinous and endometrioid,
being the frequent occurrence of tumors with mixed component. Other
histological subtypes which also emerge from the epithelial lining are
the clear cell tumors and tumor of Brenner, both with low frequency,
representing 1% to 3% of all ovarian tumors. Serosos of tumors benign,
borderline and malignant types account for about 30% of all ovarian
tumors. Cistoadenocarcinomas serosos account for approximately 40% of
all ovarian tumors, being the most common malignancies in this organ.
Mucinosos tumors are less common, accounting for approximately 25% of
all ovarian neoplasms. Cistoadenocarcinomas mucinosos account for only
10% of all ovarian cancers. Endometrióides tumors are responsible for
about 20% of ovarian tumors [3].
The most common form of dissemination of epithelial
tumours is through exfoliation of malignant cells from the surface of
ovarian capsule to the peritoneal cavity, causing peritoneal implants.
The spread to the lymph nodes is common, and approximately 10% of
patients with ovarian cancer to lymph nodes metastases to feature
located-aortic [3].
Diagnosis of ovarian cancer
For ovarian tumor diagnosis is necessary to evaluate
the clinical history, physical exam, transvaginal ultrasound finds, and
especially in postmenopausal, the determination of serum CA-125 level.
Tumor markers
Tumor markers are substances can be detected and
quantified in blood or other organic fluids of patients with neoplasms.
The ideal marker must be produced for all tumors of the same lineage and
their levels should be measurable even in presence of small amount of
cells. Serum levels should accurately reflect the clinical evolution and
regression of the disease, being their normalization associated to
disease cure. Must be sensitive and specific, present proportional
levels to the tumor size, useful in establishing prognosis, anticipate
the occurrence of recurrences and allow the selection of treatment. None
of the markers studied so far has all these features [4].
As any additional test for diagnosis, tumor markers
have precise indications and are debatable. Serum value provided by the
laboratory needs to be valued with epidemiological and critical sense,
with the characteristics of each marker and the technique used for
detecting
Risk of malignancy index (MRI)
With the aim of improving prediction of malignancy of ovarian tumors efficiency, Jacobs et al. [5].
in 1990, proposed the Malignancy Risk Index (MRI) associating
ultrasound parameters, tumor marker CA-125 and the menopausal status.
For MRI calculation CA-125 value is multiplied by the value obtained
through the ultrasound parameters and the value associated with
menopausal status IRM = Ux M x C 125. Cut-off value of 200 showed
sensitivity of 85.4%, specificity of 96.9%, positive predictive value of
42.1% and negative predictive value of 0.15%. In 2006, Bailey et al. [6].
remade the same study and confirmed the effectiveness of the risk of
malignancy Index in potential cases of ovarian malignant neoplasm in
assessing the accuracy of this content. Between malignant cases included
in your study, 87.4% presented positivity in criterion established.
In general It has been demonstrated that using a
cut-off point of 200 (irrespective of the score system) to evaluate a
risk of malignancy index achieved a sensitivity of between 70% and 87%,
and specificity of 89% and 97%. However, the risk of malignancy index
uses ultrasound, which is operator-dependent, and this is subject to the
equipment’s image resolution capacity and possible variation between
patient populations [7,8].
Ultrasound
Ultrasound study must be correlated with the history
and laboratory tests. Morphological evaluation of anexiais masses with
ultrasonography can help in the constraint of differential diagnoses,
however, cannot always distinguish between benign and malignant masses [9].
When used as the only method of screening, presents a sensitivity of
75% and specificity of 73% on presumption of malignant tumors [10].
Cystic and solid masses differentiation with better characterization of
septa, mural nodules and echogenicity of cystic and complex masses are
important roles of the ultrasound examination [11].
Ultrasound with color dopplerfluxometria was proposed
by Salem et al. to help distinguish benign and malignant adnexal
masses. Malignant masses are usually vascular and the morphology of low
doppler resistance seen in malignant lesions can also be demonstrated in
inflammatory masses, vascular benign neoplasms, endometriomas, corpus
luteum cysts and ectopic pregnancy [12].
CA-125
The most well-known tumor marker and used in
monitoring of patients with epithelial ovarian tumors is the CA-125
(Cancer Antigen 125), a sialomucina of high molecular weight. This was
initially identified by means of antibodies produced by animals
immunized with cistoadenocarcinoma cells of serous ovarian câncer [13].
CA-125 can be found at low levels in healthy people,
in both sexes. There are physiological conditions in which there is CA
125 values elevation such as menstruation, endometriosis patients and
pregnant women in the first trimester [14].
In isolation, is the best scorer of the malignant tumors of the ovary,
but does not present considerable sensitivity and specificity for risk
assessment [15].
In epithelial type sensitivity for diagnosis of ovarian cancer is 80%
to 85%. Varying according to the staging, being 50% in stage I, 90% 92%
at the stage II, stage III and the 94% in stage IV [16].
CA-125 elevation occurs in about 85% of women in
advanced stages of ovarian neoplasms, however, in early stages,
increases by only 50% of patients. Often it is also elevated in benign
tumors of ovary [17]. The elevation of CA-125 can occur from two to twelve months before any clinical evidence of recurrence.
General Considerations
The possibility of a diagnostic of ovarian malignancy
must be considered in the presence of an adnexal mass. A detailed
preoperative assessment, considering the medical history and the results
of the complementary examinations, are essential for the proper conduct
of these cases and Malignancy Risk Index is a simple algorithm to apply
in pelvic masses, and we consider as its main advantage for distinction
between benign and malignant ovarian tumors when compared to other more
complex parameters such as dopplervelocimetria, or more expensive as
the use of multiple tumor markers, is that MRI features of high accuracy
rates and with less cost.
Abstract
Ovarian cancer is the seventh major cause of
cancer-related death in women. Near 70% of epithelial ovarian cancers
are diagnosed when the disease is advanced, when the 5-year survival
rate is, approximately, 25%. The malignancy risk index (MRI) of ovarian
tumors associates menopausal status, ultrasound characteristics and
CA-125 serum levels, and has the goal of improving the preoperative
distinction between benign and malignant ovarian tumors. So, we approuch
this tool to regard how we should be find the best way to treat women
with pelvic mass. In this paper we made a summarized review of MRI. In
this article MRI and its componentes are reviewed. We understand that
simplicity of Malignancy Risk Index calculation allows providing, with
good accuracy, aid in differential preoperative diagnosis between benign
and malignant tumors.
Keywords: Ovarian neoplasms; Risk Index; Diagnosis; Biomarkers tumor; Ultrasonography; CA-125 antigenIntroduction
Epidemiology of ovarian cancer
Ovarian cancer is the seventh most common cancer
among women, with 238,719 cases/year (3.6%). In 2012 it was estimated
the mortality of 151,917 cases per year. It is the third most common
gynecological cancer, after cancer of the cervix and uterine body. Its
incidence is variable in different regions of the world, being greater
in northern countries and Eastern Europe and less in Southeast Asia and
Africa [1].
Ovarian cancer is the most lethal Gynecological
tumors, being the most difficult to be diagnosed and with lower chances
of cure. More women die of ovarian cancer than any other gynecological.
About of. 75 of this organ cancers are at an advanced stage at diagnosis
[2].
Pathology of ovarian cancer
Epithelial tumors account for about 90% of cases of
ovarian cancer, corresponding to the vast majority of primary neoplasms,
other types are the germ line or stromal tumors. Although referred to
as epithelial, they derive from the mesothelium surface coelomic. There
are three main types of these tumors: serous, mucinous and endometrioid,
being the frequent occurrence of tumors with mixed component. Other
histological subtypes which also emerge from the epithelial lining are
the clear cell tumors and tumor of Brenner, both with low frequency,
representing 1% to 3% of all ovarian tumors. Serosos of tumors benign,
borderline and malignant types account for about 30% of all ovarian
tumors. Cistoadenocarcinomas serosos account for approximately 40% of
all ovarian tumors, being the most common malignancies in this organ.
Mucinosos tumors are less common, accounting for approximately 25% of
all ovarian neoplasms. Cistoadenocarcinomas mucinosos account for only
10% of all ovarian cancers. Endometrióides tumors are responsible for
about 20% of ovarian tumors [3].
The most common form of dissemination of epithelial
tumours is through exfoliation of malignant cells from the surface of
ovarian capsule to the peritoneal cavity, causing peritoneal implants.
The spread to the lymph nodes is common, and approximately 10% of
patients with ovarian cancer to lymph nodes metastases to feature
located-aortic [3].
Diagnosis of ovarian cancer
For ovarian tumor diagnosis is necessary to evaluate
the clinical history, physical exam, transvaginal ultrasound finds, and
especially in postmenopausal, the determination of serum CA-125 level.
Tumor markers
Tumor markers are substances can be detected and
quantified in blood or other organic fluids of patients with neoplasms.
The ideal marker must be produced for all tumors of the same lineage and
their levels should be measurable even in presence of small amount of
cells. Serum levels should accurately reflect the clinical evolution and
regression of the disease, being their normalization associated to
disease cure. Must be sensitive and specific, present proportional
levels to the tumor size, useful in establishing prognosis, anticipate
the occurrence of recurrences and allow the selection of treatment. None
of the markers studied so far has all these features [4].
As any additional test for diagnosis, tumor markers
have precise indications and are debatable. Serum value provided by the
laboratory needs to be valued with epidemiological and critical sense,
with the characteristics of each marker and the technique used for
detecting
Risk of malignancy index (MRI)
With the aim of improving prediction of malignancy of ovarian tumors efficiency, Jacobs et al. [5].
in 1990, proposed the Malignancy Risk Index (MRI) associating
ultrasound parameters, tumor marker CA-125 and the menopausal status.
For MRI calculation CA-125 value is multiplied by the value obtained
through the ultrasound parameters and the value associated with
menopausal status IRM = Ux M x C 125. Cut-off value of 200 showed
sensitivity of 85.4%, specificity of 96.9%, positive predictive value of
42.1% and negative predictive value of 0.15%. In 2006, Bailey et al. [6].
remade the same study and confirmed the effectiveness of the risk of
malignancy Index in potential cases of ovarian malignant neoplasm in
assessing the accuracy of this content. Between malignant cases included
in your study, 87.4% presented positivity in criterion established.
In general It has been demonstrated that using a
cut-off point of 200 (irrespective of the score system) to evaluate a
risk of malignancy index achieved a sensitivity of between 70% and 87%,
and specificity of 89% and 97%. However, the risk of malignancy index
uses ultrasound, which is operator-dependent, and this is subject to the
equipment’s image resolution capacity and possible variation between
patient populations [7,8].
Ultrasound
Ultrasound study must be correlated with the history
and laboratory tests. Morphological evaluation of anexiais masses with
ultrasonography can help in the constraint of differential diagnoses,
however, cannot always distinguish between benign and malignant masses [9].
When used as the only method of screening, presents a sensitivity of
75% and specificity of 73% on presumption of malignant tumors [10].
Cystic and solid masses differentiation with better characterization of
septa, mural nodules and echogenicity of cystic and complex masses are
important roles of the ultrasound examination [11].
Ultrasound with color dopplerfluxometria was proposed
by Salem et al. to help distinguish benign and malignant adnexal
masses. Malignant masses are usually vascular and the morphology of low
doppler resistance seen in malignant lesions can also be demonstrated in
inflammatory masses, vascular benign neoplasms, endometriomas, corpus
luteum cysts and ectopic pregnancy [12].
CA-125
The most well-known tumor marker and used in
monitoring of patients with epithelial ovarian tumors is the CA-125
(Cancer Antigen 125), a sialomucina of high molecular weight. This was
initially identified by means of antibodies produced by animals
immunized with cistoadenocarcinoma cells of serous ovarian câncer [13].
CA-125 can be found at low levels in healthy people,
in both sexes. There are physiological conditions in which there is CA
125 values elevation such as menstruation, endometriosis patients and
pregnant women in the first trimester [14].
In isolation, is the best scorer of the malignant tumors of the ovary,
but does not present considerable sensitivity and specificity for risk
assessment [15].
In epithelial type sensitivity for diagnosis of ovarian cancer is 80%
to 85%. Varying according to the staging, being 50% in stage I, 90% 92%
at the stage II, stage III and the 94% in stage IV [16].
CA-125 elevation occurs in about 85% of women in
advanced stages of ovarian neoplasms, however, in early stages,
increases by only 50% of patients. Often it is also elevated in benign
tumors of ovary [17]. The elevation of CA-125 can occur from two to twelve months before any clinical evidence of recurrence.
General Considerations
The possibility of a diagnostic of ovarian malignancy
must be considered in the presence of an adnexal mass. A detailed
preoperative assessment, considering the medical history and the results
of the complementary examinations, are essential for the proper conduct
of these cases and Malignancy Risk Index is a simple algorithm to apply
in pelvic masses, and we consider as its main advantage for distinction
between benign and malignant ovarian tumors when compared to other more
complex parameters such as dopplervelocimetria, or more expensive as
the use of multiple tumor markers, is that MRI features of high accuracy
rates and with less cost.
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