Abstract
Study Objective
To develop a new decision tree system (DTS) for the management of adnexal masses in
prepubertal and adolescent girls, aimed to improve the distinction between benign
and malignant masses, help preserve affected ovaries during surgery, and reduce the
rate of surgical management of uncomplicated functional ovarian cysts.
Design
A prospective diagnostic study using clinical and ultrasound data collected for all
patients younger than 19 years of age with adnexal masses managed between 2006 and 2015.
Setting
Mother and Child Health Institute of Serbia ‘Dr Vukan Čupić’ (Belgrade, Serbia).
Participants
Patients (N = 1499) with adnexal masses, of whom 318 were surgically treated.
Interventions and Main Outcome Measures
Ultrasonographic characteristics (Ueland's Morphology Index [MI] and the ovarian crescent
sign [OCS]). Patients were managed expectantly or surgically, in line with 3 rules
of the DTS. Rule 1: asymptomatic patients having a mass with MI of 4 or less and OCS
present, were managed expectantly. Rule 2 (emergency): malignancy was suspected if
the MI was 7 or more and no edema of the OCS was present. Rule 3 (nonemergency): malignancy
was suspected if the OCS was absent and MI was 5 or more. The diagnostic accuracy
was assessed using sensitivity and specificity (P < .05).
Results
No malignancy was found in the group of 1236 patients selected according to the DTS
rule 1. Torsion was confirmed in 36% of surgically treated masses (n = 115). The OCS
was present in 96% of benign masses in the non-emergency group (n = 149) and in three
with microscopic malignancy. In predicting malignancy, the DTS (rules 2 and 3) showed
a sensitivity of 93 (95% confidence interval [C.I.]: 82–98); and a specificity of
97 (C.I.: 95–99). Ovarian tissue was preserved from benign (n = 254, 93%) and malignant
tumors (n = 3, 7%). Only five (2%) uncomplicated ovarian cysts were surgically treated.
Conclusion
The DTS with 3 rules is a very accurate diagnostic tool in the differentiation between
benign and malignant ovarian masses. The DTS rule 1 reduces the number of surgical
procedures on functional cysts, rules 2 and 3 are very useful in choosing the optimal
treatment of adnexal masses, whether or not they are twisted.
Key Words
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Article info
Publication history
Published online: January 27, 2017
Footnotes
The authors indicate no conflicts of interest.
Identification
Copyright
© 2017 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc.
