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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2018. CA: a Cancer Journal for Clinicians. 68(1):7-30, 2018 01. Review/Other-Dx N/A Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data. Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data, available through 2014, were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data, available through 2015, were collected by the National Center for Health Statistics. In 2018, 1,735,350 new cancer cases and 609,640 cancer deaths are projected to occur in the United States. Over the past decade of data, the cancer incidence rate (2005-2014) was stable in women and declined by approximately 2% annually in men, while the cancer death rate (2006-2015) declined by about 1.5% annually in both men and women. The combined cancer death rate dropped continuously from 1991 to 2015 by a total of 26%, translating to approximately 2,378,600 fewer cancer deaths than would have been expected if death rates had remained at their peak. Of the 10 leading causes of death, only cancer declined from 2014 to 2015. In 2015, the cancer death rate was 14% higher in non-Hispanic blacks (NHBs) than non-Hispanic whites (NHWs) overall (death rate ratio [DRR], 1.14; 95% confidence interval [95% CI], 1.13-1.15), but the racial disparity was much larger for individuals aged <65 years (DRR, 1.31; 95% CI, 1.29-1.32) compared with those aged >/=65 years (DRR, 1.07; 95% CI, 1.06-1.09) and varied substantially by state. For example, the cancer death rate was lower in NHBs than NHWs in Massachusetts for all ages and in New York for individuals aged >/=65 years, whereas for those aged <65 years, it was 3 times higher in NHBs in the District of Columbia (DRR, 2.89; 95% CI, 2.16-3.91) and about 50% higher in Wisconsin (DRR, 1.78; 95% CI, 1.56-2.02), Kansas (DRR, 1.51; 95% CI, 1.25-1.81), Louisiana (DRR, 1.49; 95% CI, 1.38-1.60), Illinois (DRR, 1.48; 95% CI, 1.39-1.57), and California (DRR, 1.45; 95% CI, 1.38-1.54). Larger racial inequalities in young and middle-aged adults probably partly reflect less access to high-quality health care. 4
2. Timmerman D, Van Calster B, Testa A, et al. Predicting the risk of malignancy in adnexal masses based on the Simple Rules from the International Ovarian Tumor Analysis group. Am J Obstet Gynecol. 214(4):424-37, 2016 Apr. Observational-Dx 4848 patients To develop and validate a model to predict the risk of malignancy in adnexal masses using the ultrasound features in the Simple Rules. Data on 4848 patients were analyzed. The malignancy rate was 43% (1402/3263) in oncology centers and 17% (263/1585) in other centers. The area under the receiver operating characteristic curve on validation data was very similar in oncology centers (0.917; 95% confidence interval, 0.901-0.931) and other centers (0.916; 95% confidence interval, 0.873-0.945). Risk estimates showed good calibration. In all, 23% of patients in the validation data set had a very low estimated risk (<1%) and 48% had a high estimated risk (>/=30%). For the 1% risk cutoff, sensitivity was 99.7%, specificity 33.7%, LR+ 1.5, LR- 0.010, PPV 44.8%, and NPV 98.9%. For the 30% risk cutoff, sensitivity was 89.0%, specificity 84.7%, LR+ 5.8, LR- 0.13, PPV 75.4%, and NPV 93.9%. 2
3. Trimble EL. The NIH Consensus Conference on Ovarian Cancer: screening, treatment, and follow-up. Gynecol Oncol. 1994;55(3 Pt 2):S1-3. Review/Other-Dx N/A To review the NIH Consensus Conference on Ovarian Cancer. No results stated in abstract. 4
4. Vernooij F, Heintz P, Witteveen E, van der Graaf Y. The outcomes of ovarian cancer treatment are better when provided by gynecologic oncologists and in specialized hospitals: a systematic review. Gynecol Oncol. 2007;105(3):801-812. Review/Other-Dx 19 articles To present an overview and summary of the recent literature on this subject. Nineteen articles were retrieved. There were no randomized controlled trials on this subject. Staging and debulking were consistently found to be performed more adequately by gynecologic oncologists (pooled relative risk of optimal debulking by a gynecologic oncologist to <2 cm residual disease 1.4 (95%CI 1.2-1.5) and to no macroscopic disease 2.3 (95%CI 1.5-3.5)) and in specialized hospitals (odds ratios for optimal debulking varied between 1.9 and 6.0). There were no differences in postoperative complication rates between different providers. Chemotherapy was given 1-15% more often in specialized settings. Differences in chemotherapy did not lead to differences in survival of patients treated by gynecologic oncologists, but did influence the effect of hospital on survival. Long-term survival was better after treatment in a specialized hospital. Surgery by a gynecologic oncologist resulted in longer survival in subgroups of patients, leading to a 5- to 8-month median survival benefit for patients with advanced stage disease. 4
5. Giede KC, Kieser K, Dodge J, Rosen B. Who should operate on patients with ovarian cancer? An evidence-based review. Gynecol Oncol. 2005;99(2):447-461. Review/Other-Dx 18 studies To evaluate the relationship between surgical specialty and survival in patients receiving initial surgical management for ovarian epithelial cancer Eighteen studies were reviewed. The quality of evidence was good in 3, fair in 8, and poor in 7 of the studies. The most common study flaws encountered were 'failure to account for confounders' and 'incompleteness of data'. In studies focusing on advanced disease, there was good quality evidence to support a 6- to 9-month median survival benefit for patients operated on by gynecologic oncologists rather than general gynecologists and/or general surgeons (P values 0.009 to 0.01). Studies focusing on early stage disease found gynecologic oncologists more likely to carry out optimal staging (P values 0.001 to 0.01). Increased survival could be explained by improved identification of true stage I patients. 4
6. Kang SK, Reinhold C, Atri M, et al. ACR Appropriateness Criteria® Staging and Follow-Up of Ovarian Cancer. J Am Coll Radiol 2018;15:S198-S207. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for staging and follow-up of ovarian cancer. No results stated in abstract. 4
7. Glanc P, Benacerraf B, Bourne T, et al. First International Consensus Report on Adnexal Masses: Management Recommendations. J Ultrasound Med. 36(5):849-863, 2017 May. Review/Other-Dx N/A To Report on Adnexal Masses. No results stated in abstract. 4
8. Buys SS, Partridge E, Greene MH, et al. Ovarian cancer screening in the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial: findings from the initial screen of a randomized trial. Am J Obstet Gynecol. 2005;193(5):1630-1639. Observational-Dx 39,115 women To determine in healthy subjects aged 55-74 at entry whether: 1) screening with flexible sigmoidoscopy can reduce mortality from colorectal cancer in males and females; 2) screening with chest x-ray can reduce mortality from lung cancer in males and females; 3) screening with digital rectal examination plus serum prostate specific antigen (PSA) can reduce mortality from prostate cancer; and 4) screening with CA-125 and transvaginal ultrasound can reduce mortality from ovarian cancer. Of 39,115 women randomized to receive screening, 28,816 received at least 1 test. Abnormal TVU was found in 1338 (4.7%), and abnormal CA-125 in 402 (1.4%). Twenty-nine neoplasms were identified (26 ovarian, 2 fallopian, and 1 primary peritoneal neoplasm). Nine were tumors of low malignant potential and 20 were invasive. The positive predictive value for invasive cancer was 3.7% for an abnormal CA-125, 1.0% for an abnormal TVU, and 23.5% if both tests were abnormal. 3
9. Menon U, Gentry-Maharaj A, Hallett R, et al. Sensitivity and specificity of multimodal and ultrasound screening for ovarian cancer, and stage distribution of detected cancers: results of the prevalence screen of the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). Lancet Oncol. 2009; 10(4):327-340. Experimental-Tx 202,638 post-menopausal women Results of the prevalence (initial) screen of the UKCTOCS. Post-menopausal women were randomly assigned to no treatment (control; n=101,359); annual CA-125 screening (interpreted using a risk of ovarian cancer algorithm) with TVUS as a second-line test (multimodal screening; n=50,640); or annual screening with TVUS (US screening; n=50,639) alone in a 2:1:1 ratio using a computer-generated random number algorithm. Sensitivity, specificity, and PPVs for all primary ovarian and tubal cancers were 89.4%, 99.8%, and 43.3% for multimodal screening, and 84.9%, 98.2%, and 5.3% for US screening, respectively. For primary invasive epithelial ovarian and tubal cancers, the sensitivity, specificity, and PPVs were 89.5%, 99.8%, and 35.1% for multimodal screening, and 75.0%, 98.2%, and 2.8% for US screening, respectively. Significant difference in specificity (P<0.0001) but not sensitivity between the two screening groups for both primary ovarian and tubal cancers as well as primary epithelial invasive ovarian and tubal cancers. 1
10. Levine D, Brown DL, Andreotti RF, et al. Management of asymptomatic ovarian and other adnexal cysts imaged at US Society of Radiologists in Ultrasound consensus conference statement. Ultrasound Q. 2010;26(3):121-131. Review/Other-Dx N/A Consensus statement on management of ovarian and other adnexal cysts imaged sonographically in asymptomatic women. Recommendations in statement are based on analysis of current literature and common practice strategies. 4
11. Cappabianca S, Iaselli F, Reginelli A, et al. Value of diffusion-weighted magnetic resonance imaging in the characterization of complex adnexal masses. Tumori. 2013;99(2):210-217. Observational-Dx 91 patients To define the role of diffusion-weighted imaging in the characterization of adnexal complex masses, with particular regard to the distinction between benign and malignant lesions. With regard to the solid components, hypointensity on both the T2-weighted and diffusion-weighted images has proved to be a reliable indicator of benignancy. In contrast, hyperintensity on both sequences was suggestive of malignancy. Signal intensity of the cystic components and apparent diffusion coefficient values of both components have not proven useful in characterization of the masses. 2
12. Thomassin-Naggara I, Darai E, Cuenod CA, et al. Contribution of diffusion-weighted MR imaging for predicting benignity of complex adnexal masses. Eur Radiol. 2009;19(6):1544-1552. Observational-Dx 77 women with complex adnexal masses (30 benign and 47 malignant) To prospectively assess the contribution of DWI MRI for characterizing complex adnexal masses. The most significant criteria for predicting benignity were low b(1,000) signal intensity within the solid component (PLR = 10.9), low T2 signal intensity within the solid component (PLR = 5.7), absence of solid portion (PLR = 3.1), absence of ascites or peritoneal implants (PLR = 2.3) and absence of papillary projections (PLR = 2.3). ADC measurements did not contribute to differentiating benign from malignant adnexal masses. All masses that displayed simultaneously low signal intensity within the solid component on T2-weighted and on b(1,000) DWIs were benign. Alternatively, the presence of a solid component with intermediate T2 signal and high b(1,000) signal intensity was associated with a PLR of 4.5 for a malignant adnexal tumor. DWI signal intensity is an accurate tool for predicting benignity of complex adnexal masses. 3
13. Kierans AS, Bennett GL, Mussi TC, et al. Characterization of malignancy of adnexal lesions using ADC entropy: comparison with mean ADC and qualitative DWI assessment. J Magn Reson Imaging. 2013;37(1):164-171. Observational-Dx 37 female adults To establish the utility of apparent diffusion coefficient (ADC) entropy in discrimination of benign and malignant adnexal lesions, using histopathology as the reference standard, via comparison of the diagnostic performance of ADC entropy with mean ADC and with visual assessments of adnexal lesions on conventional and diffusion-weighted sequences. No statistically significant difference was observed in mean ADC between benign and malignant adnexal lesions (P = 0.768). ADC entropy was significantly higher in malignant than in benign lesions (P = 0.009). Accuracy was significantly greater for ADC entropy than for mean ADC (0.018). ADC entropy and visual assessment by the less-experienced reader showed similar accuracy (P >/= 0.204). The more experienced reader's accuracy was significantly greater than that of all other assessments (P </= 0.039). 3
14. Thomassin-Naggara I, Toussaint I, Perrot N, et al. Characterization of complex adnexal masses: value of adding perfusion- and diffusion-weighted MR imaging to conventional MR imaging. Radiology. 2011;258(3):793-803. Observational-Dx 87 women To retrospectively determine the value of adding perfusion-weighted and DWI sequences to a conventional MRI protocol to differentiate benign from malignant tumors. Three independent observers reviewed images. There was almost perfect agreement for lesion characterization regardless of the reader experiment or step considered (? = 0.811-0.929). AUC values were higher for conventional and DW images combined, conventional and perfusion-weighted images combined, and conventional, DWI, and perfusion-weighted images combined compared with conventional MRI alone (P<.05). For all readers, the accuracy of conventional, perfusion-weighted, and DWI combined was higher than that of conventional MRI alone for benign masses (P<.01) but not for malignant masses (P=.24). The addition of both perfusion-weighted and DWI led to a correct change in the diagnosis in 19% (11/57 patients), 23% (13/57 patients), and 24% (14/57 patients) of cases for readers 1, 2, and 3, respectively, with no incorrect changes. Conventional, perfusion-weighted, and DWI MRI criteria were combined to generate a decision tree giving an accuracy of 95%. The addition of perfusion-weighted and DWI sequences to a conventional MRI protocol improved the diagnostic accuracy in the characterization of complex adnexal masses. 2
15. Bernardin L, Dilks P, Liyanage S, Miquel ME, Sahdev A, Rockall A. Effectiveness of semi-quantitative multiphase dynamic contrast-enhanced MRI as a predictor of malignancy in complex adnexal masses: radiological and pathological correlation. Eur Radiol 2012;22:880-90. Observational-Dx 63 patients To determine whether threshold criteria using semi-quantitative multiphase-dynamic contrast-enhanced magnetic resonance imaging (DCE- MRI) can improve prediction of malignancy in complex adnexal masses. There was a significant difference in mean SI(max) (P < 0.05), SI(rel) (P < 0.01) and WIR (P < 0.001) between benign and borderline/invasive malignant groups. A cut-off WIR >/= 9.5 l/s had a specificity of 88% and positive predictive value of 86% for predicting malignancy, significantly better than conventional MRI (62%, P < 0.01). WIR <8.2 l/s had a negative predictive value of 94%. 2
16. Tang YZ, Benardin L, Booth TC, et al. Use of an internal reference in semi-quantitative dynamic contrast-enhanced MRI (DCE MRI) of indeterminate adnexal masses. Br J Radiol. 2014;87(1043):20130730. Observational-Dx 71 indeterminate lesions To assess if the use of a lesion-to-internal-reference ratio improved the performance in characterizing adnexal masses and which internal reference was suitable. When the wash in rate of the lesion was higher than that of the myometrium, 97% specificity and 12% sensitivity for borderline/malignancy was reached. When the maximum relative enhancement and maximum absolute enhancement (SImax) of the lesion was less than those of the psoas, 100% specificity for benignity was achieved. The highest area under the curve (AUC) (0.807) was achieved using a SImax lesion-myometrium ratio. A slightly lower AUC (0.799) was achieved using a SImax lesion-psoas ratio, but the psoas muscle was more frequently measurable in the same slice as the lesion ROI. Although the AUC was higher, when using ratios instead of individual DCE values, this was not significantly different. 2
17. Thomassin-Naggara I, Balvay D, Aubert E, et al. Quantitative dynamic contrast-enhanced MR imaging analysis of complex adnexal masses: a preliminary study. Eur Radiol. 22(4):738-45, 2012 Apr. Observational-Dx 56 women To evaluate the ability of quantitative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to differentiate malignant from benign adnexal tumours. Malignant tumours displayed higher F(T), Vb, rAUC and lower Ve than benign tumours (P < 0.0001, P = 0.0006, P = 0.04 and P = 0.0002, respectively). F(T) was the most relevant factor for discriminating malignant from benign tumours (AUROC = 0.86). Primary ovarian invasive tumours displayed higher F(T) and shorter Dt than borderline tumours. Malignant adnexal tumours with associated peritoneal carcinomatosis at surgery displayed a shorter Dt than those without peritoneal carcinomatosis at surgery (P = 0.01). 3
18. Telischak NA, Yeh BM, Joe BN, Westphalen AC, Poder L, Coakley FV. MRI of adnexal masses in pregnancy. AJR Am J Roentgenol. 2008;191(2):364-370. Review/Other-Dx N/A To provide a practical review of the incremental benefit of Magnetic Resonance Imaging (MRI) in the assessment of adnexal masses in pregnancy. No results stated in abstract. 4
19. American College of Radiology. Manual on Contrast Media. Available at: https://www.acr.org/Clinical-Resources/Contrast-Manual. Review/Other-Dx N/A To assist radiologists in recognizing and managing risks associated with the use of contrast media. No abstract available. 4
20. Fenchel S, Grab D, Nuessle K, et al. Asymptomatic adnexal masses: correlation of FDG PET and histopathologic findings. Radiology. 223(3):780-8, 2002 Jun. Observational-Dx 99 consecutive patients Prospective study to analyze asymptomatic adnexal masses at PET with FDG in correlation with histopathologic findings and evaluate FDG-PET for assessing malignancy in comparison with TVUS B-mode and Doppler US and MRI. Overall sensitivities and specificities were 58% and 76%, respectively, for FDG-PET; 92% and 60%, respectively, for US; 83% and 84%, respectively, for MRI; and 92% and 85% respectively, for the combination of 3 modalities. US remains the method of choice for diagnosis and assessment of asymptomatic adnexal masses. 2
21. Zor E, Stokkel MP, Ozalp S, Vardareli E, Yalcin OT, Ak I. F18-FDG coincidence-PET in patients with suspected gynecological malignancy. Acta Radiol. 2006;47(6):612-617. Observational-Dx 18 women To assess the role of FDG imaging with a dual-head coincidence mode gamma camera (Co-PET) in identifying malignant tumors in patients with a suspicious adnexal mass depicted by conventional imaging methods. Histopathological examinations of the surgically excised adnexal masses revealed eight malignant, one borderline, and nine benign neoplastic tumors. Four benign tumors had no FDG uptake, while the remaining 5 tumors, all leiomyomas, showed mild FDG accumulation. Eight malignant tumors showed intense FDG uptake. Sensitivity, specificity, PPV, and NPV of FDG co-PET in differentiating benign from malign adnexal masses were 88%, 44%, 61%, and 80%, respectively. Tumor to background ratios in benign lesions (2.04 +/- 0.27) was significantly lower than in malignant lesions (7.4 +/- 0.99). FDG Co-PET is of clinical value when assessing suspicious malignant adnexal masses. False-negative FDG results might arise from borderline disease. Moderate FDG uptake in leiomyomas can result false-positive, but tumor to background ratios may be helpful in such cases. 3
22. Zhang X, Mao Y, Zheng R, et al. The contribution of qualitative CEUS to the determination of malignancy in adnexal masses, indeterminate on conventional US - a multicenter study. PLoS One 2014;9:e93843. Observational-Dx 120 patients To evaluate the efficacy of qualitative analysis of contrast-enhanced ultrasound (CEUS) in discrimination of adnexal masses which were undetermined by conventional ultrasound (US). There were 48 malignant tumors and 72 benign tumors. The enhancement features of malignant masses were different from benign ones. Earlier or simultaneous enhancement with inhomogeneous enhancement yielded the highest capability in differential diagnosis, and Sen, Spe, PPV, NPV, ACC, Youden's index was 89.6%, 97.2%, 93.2%, 95.6%, 93.3%, and 0.88, respectively. 3
23. Schelling M, Braun M, Kuhn W, et al. Combined transvaginal B-mode and color Doppler sonography for differential diagnosis of ovarian tumors: results of a multivariate logistic regression analysis. Gynecol Oncol. 77(1):78-86, 2000 Apr. Observational-Dx 257 patients To determine if color-coded Doppler US can improve the diagnostic accuracy of B-mode US in ovarian masses. Preoperative B-mode and Doppler US was performed prospectively in 63 patients with unclear adnexal lesions prior to operation. Using multiple logistic regression, the independent variables of each procedure were selected and combined to yield a diagnostic flow chart. 39 malignant, 218 benign. Combining independent significant variables of 2 procedures raised the diagnostic accuracy to 90% (sensitivity 86%, specificity 93%). The validity achieved by this combination was confirmed by the independent application of this method to the 257 adnexal tumors with unclear malignancy status (diagnostic accuracy 93%, sensitivity 92%, and specificity 94%).Combination of US and Doppler US yields high and reproducible diagnostic accuracy. 3
24. Hu R, Xiang H, Mu Y, Feng Y, Gu L, Liu H. Combination of 2- and 3-dimensional contrast-enhanced transvaginal sonography for diagnosis of small adnexal masses. J Ultrasound Med. 33(11):1889-99, 2014 Nov. Observational-Dx 57 cases To evaluate the efficacy of the combination of 2-dimensional (2D) and 3-dimensional (3D) contrast-enhanced sonography in discriminating between benign and malignant small adnexal masses. Forty-seven cases of benign and 10 cases of malignant small adnexal masses were discovered. Significant differences in perfusion patterns, time-intensity curve shapes for 2D contrast-enhanced sonography, grayscale contrast-enhanced sonography, and blood flow imaging on 3D contrast-enhanced sonography were observed between benign and malignant masses (P< .05). Two-dimensional contrast-enhanced sonography, 3D contrast-enhanced sonography, parallel combination of 2D and 3D contrast-enhanced sonography, and serial combination of 2D and 3D contrast-enhanced sonography all reached diagnostic sensitivity of 100% for discriminating benign from malignant masses, whereas specificity values were 61.7%, 63.8%, 68.1%, and 57.4%, respectively. Areas under the receiver operating characteristic curves were 0.809, 0.819, 0.840, and 0.787. 2
25. Xiang H, Huang R, Cheng J, et al. Value of three-dimensional contrast-enhanced ultrasound in the diagnosis of small adnexal masses. Ultrasound Med Biol 2013;39:761-8. Observational-Dx 47 patients To determine whether three-dimensional contrast-enhanced ultrasound (3D-CEUS) can provide useful information to distinguish malignant from benign adnexal masses (#4 cm). The 51 masses included 43 benign and 8 malignant lesions. On 3D-CEUS images, benign lesions appeared as round structures formed by sparse and straight capillary vessels. Malignant lesions showed irregular stereo structures with dense and tortuous vascular distribution. A 3D-CEUS scoring system was established. There were no statistically significant differences in scores at each time point between the 20th and 70th seconds, and the area under the receiver operating characteristic curve for this time period was the largest (0.995). A cut-off score of 8 was established, with scores >/=8 being suggestive of malignancy. The 3D-CEUS scoring system had a high sensitivity (100%) and specificity (98%). 2
26. Huchon C, Metzger U, Bats AS, et al. Value of three-dimensional contrast-enhanced power Doppler ultrasound for characterizing adnexal masses. J Obstet Gynaecol Res. 38(5):832-40, 2012 May. Observational-Dx 99 patients To assess the diagnostic performance of 3-D contrast-enhanced power Doppler ultrasonography (3-D CEPDUS) for differentiating benign and malignant adnexal masses. Of 99 patients, 88 had benign tumors and were compared to the 11 patients with borderline (n = 5) or malignant (n = 6) tumors. The sensitivity of the subjective 2-D score was 55% (95% confidence interval [CI], 25-84) and specificity 94% (95%CI, 89-99). The sensitivity of the subjective 3-D score was 82% (95%CI, 58-100) and specificity 90% (95%CI, 83-96). Improvement of detection of malignant or borderline tumors by subjective 3-D score was 150%. Vessel density and patterns were not more efficient than the subjective 3-D score. The mean vascular index values were significantly different between benign and borderline/malignant groups: VI, 7.2 versus 35.5 (P < 0.0001); FI, 37.0 versus 48.2 (P = 0.003); and VFI, 2.9 versus 17.6 (P < 0.0001), respectively. 1
27. Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR, Jr. Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter. Obstet Gynecol. 2003;102(3):594-599. Review/Other-Dx 15,106 asymptomatic women To determine the natural history and estimate the risk of malignancy of unilocular ovarian cystic tumors <10 cm in diameter followed by TVS. The risk of malignancy in unilocular ovarian cystic tumors <10 cm in diameter in women 50 years or older is extremely low. Majority will resolve and can be followed with serial TVS. 4
28. Dorum A, Blom GP, Ekerhovd E, Granberg S. Prevalence and histologic diagnosis of adnexal cysts in postmenopausal women: an autopsy study. Am J Obstet Gynecol. 192(1):48-54, 2005 Jan. Review/Other-Dx 234 postmenopausal women Autopsy study was performed to examine the prevalence and histologic condition of adnexal cysts in postmenopausal women. Ovarian cysts were found in 36 of the women (15.4%). Nine women (3.8%) had ovarian cysts with a diameter between 20 and =50 mm; 4 women (1.7%) had cysts that were >50 mm in diameter. Four women had bilateral ovarian cysts. Paraovarian cysts were found in 11 women (4.7%). All cysts were benign, except for 1 woman, who had bilateral serous cystadenoma of borderline type. Macroscopically, the borderline cysts were multilocular with mean diameters of 60 mm and 15 mm, respectively. Because of the high prevalence of benign adnexal cysts, the identification of small unilocular cysts in postmenopausal women should be regarded as a normal finding. 4
29. Atri M, Nazarnia S, Bret PM, Aldis AE, Kintzen G, Reinhold C. Endovaginal sonographic appearance of benign ovarian masses. Radiographics. 1994;14(4):747-760; discussion 761-742. Review/Other-Dx 118 patients To illustrate the different appearances of benign ovarian and paraovarian masses at endovaginal sonography. A retrospective study was performed of the records for 118 patients with 140 surgically proved benign adnexal masses, including dermoid cysts (n = 27), endometriomas (n = 40), epithelial inclusion cysts (n = 14), serous cystadenomas (n = 11), mucinous cystadenomas (n = 14), fibromas (n = 11), cystadenofibromas (n = 12), paratubal cysts (n = 5), hydrosalpinges (n = 3), and tubo-ovarian abscesses (n = 3). Preoperative diagnosis was made in 96% of the dermoid cysts on the basis of a hyperechoic attenuating component or multiple small horizontal interfaces and in 100% of uncomplicated fibromas on the basis of a hypoechoic attenuating mass. There was an overlap among the endovaginal sonographic appearances of the other condition. 4
30. McClure MJ, Atri M, Haider MA, Murphy J. Perineural cysts presenting as complex adnexal cystic masses on transvaginal sonography. AJR Am J Roentgenol. 2001;177(6):1313-1318. Review/Other-Dx N/A To describe the sonographic features of sacral perineural cysts that initially presented as adnexal complex cystic masses on transvaginal sonography. No results stated in abstract. 4
31. Payson M, Leppert P, Segars J. Epidemiology of myomas. Obstetrics and gynecology clinics of North America. 2006;33(1):1-11. Review/Other-Dx N/A Review epidemiology of uterine fibroids. No results stated in abstract. 4
32. Timmerman D, Valentin L, Bourne TH, et al. Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis (IOTA) Group. [Review] [12 refs]. Ultrasound Obstet Gynecol. 16(5):500-5, 2000 Oct. Review/Other-Dx N/A To describe the sonographic features of adnexal tumors No results stated in abstract. 4
33. Kaijser J, Sayasneh A, Van Hoorde K, et al. Presurgical diagnosis of adnexal tumours using mathematical models and scoring systems: a systematic review and meta-analysis. [Review]. Hum Reprod Update. 20(3):449-62, 2014 May-Jun. Meta-analysis 195 studies To review Presurgical diagnosis of adnexal tumours using mathematical models and scoring systems. Our extended search identified a total of 1542 new primary articles. In total, 195 studies were eligible for qualitative data synthesis, and 96 validation studies reporting on 19 different prediction models met the predefined criteria for quantitative data synthesis. These models were tested on 26 438 adnexal masses, including 7199 (27%) malignant and 19 239 (73%) benign masses. The Risk of Malignancy Index (RMI) was the most frequently validated model. The logistic regression model LR2 with a risk cut-off of 10% and Simple Rules (SR), both developed by the International Ovarian Tumor Analysis (IOTA) study, performed better than all other included models with a pooled sensitivity and specificity, respectively, of 0.92 [95% CI 0.88-0.95] and 0.83 [95% CI 0.77-0.88] for LR2 and 0.93 [95% CI 0.89-0.95] and 0.81 [95% CI 0.76-0.85] for SR. A meta-analysis of centre-specific results stratified for menopausal status of two multicentre cohorts comparing LR2, SR and RMI-1 (using a cut-off of 200) showed a pooled sensitivity and specificity in premenopausal women for LR2 of 0.85 [95% CI 0.75-0.91] and 0.91 [95% CI 0.83-0.96] compared with 0.93 [95% CI 0.84-0.97] and 0.83 [95% CI 0.73-0.90] for SR and 0.44 [95% CI 0.28-0.62] and 0.95 [95% CI 0.90-0.97] for RMI-1. In post-menopausal women, sensitivity and specificity of LR2, SR and RMI-1 were 0.94 [95% CI 0.89-0.97] and 0.70 [95% CI 0.62-0.77], 0.93 [95% CI 0.88-0.96] and 0.76 [95% CI 0.69-0.82], and 0.79 [95% CI 0.72-0.85] and 0.90 [95% CI 0.84-0.94], respectively. Good
34. Alcazar JL, Guerriero S, Laparte C, Ajossa S, Jurado M. Contribution of power Doppler blood flow mapping to gray-scale ultrasound for predicting malignancy of adnexal masses in symptomatic and asymptomatic women. Eur J Obstet Gynecol Reprod Biol. 155(1):99-105, 2011 Mar. Observational-Dx 1,094 women To determine the contribution of power Doppler blood flow mapping to gray-scale US for predicting malignancy of adnexal masses in symptomatic and asymptomatic women. Definitive histological diagnosis used as standard reference. In group A, B-mode was significantly more sensitive (98.1%) than Doppler US (91.3%) (P<0.01). In group B Doppler US (97.0%) was more specific than B-mode US (92.2%) (P<0.001). In group C Doppler US (84.0%) was more specific than B-mode US (68.0%) (P<0.001). Positive LR was significantly higher after Doppler evaluation in all groups (30.5 vs 12.8 in group A, 33.2 vs 12.8 in group B and 6.0 vs 3.1 in group C). The diagnostic performance of B-mode and power Doppler US is different depending on patients' complaints. 3
35. Guerriero S, Alcazar JL, Ajossa S, et al. Transvaginal color Doppler imaging in the detection of ovarian cancer in a large study population. Int J Gynecol Cancer. 20(5):781-6, 2010 Jul. Observational-Dx 2,148 pelvic masses To compare the diagnostic accuracy of grayscale US and that of color Doppler imaging in the diagnosis of ovarian malignancy in a prospective study by the Sardinia-Navarra group. 468 masses were malignant. Color Doppler evaluation was more accurate in the diagnosis of adnexal malignancies in comparison with grayscale US because of a significantly higher specificity (94% vs 89%, P=0.001), with similar sensitivity (95% vs 98%, P=0.44). The pretest probability of ovarian cancer was 22%, and this probability rose to 82% when the diagnosis was suggested by color Doppler evaluation. The diagnostic accuracy of the tests was also dependent on menopausal status. The evaluation of vessel distribution by color Doppler US in adnexal masses increases the diagnostic accuracy of grayscale sonography in the detection of adnexal malignancies in a large study population. 3
36. Brown DL, Doubilet PM, Miller FH, et al. Benign and malignant ovarian masses: selection of the most discriminating gray-scale and Doppler sonographic features. Radiology. 208(1):103-10, 1998 Jul. Observational-Dx 194 patients (211 lesions) To determine the gray-scale and Doppler US features that best enable discrimination between malignant and benign ovarian masses and develop a scoring system for accurate diagnosis with these features. 28 malignant, 183 benign masses. Masses with markedly hyperechoic solid component or no solid component were benign. In masses with non-hyperechoic solid component, other features helped to discriminate between benign and malignant masses. Scoring formula developed, cut off score yielded sensitivity of 93% and specificity of 93%. 2
37. Guerriero S, Ajossa S, Risalvato A, et al. Diagnosis of adnexal malignancies by using color Doppler energy imaging as a secondary test in persistent masses. Ultrasound Obstet Gynecol. 11(4):277-82, 1998 Apr. Observational-Dx 192 consecutive lesions Prospective study to compare the accuracy of B-mode TVS alone and in combination with color Doppler energy (or power Doppler) imaging in differentiating benign from malignant adnexal masses. 159 benign, 33 malignant. Intratumoral arterial blood flow detected in 100% malignant and in 94% benign. Combined use of TVS and color Doppler has greater accuracy for diagnosing ovarian malignancy than TVS alone (kappa: 0.81 and 0.63). 3
38. Alcazar JL, Rodriguez D. Three-dimensional power Doppler vascular sonographic sampling for predicting ovarian cancer in cystic-solid and solid vascularized masses. J Ultrasound Med. 28(3):275-81, 2009 Mar. Observational-Dx 143 consecutive women To explore the role of 3D power Doppler US to discriminate between benign and malignant cystic-solid and solid vascularized adnexal masses and to define cutoff values for 3D power Doppler US indices to be used in a clinical setting. 113 masses (74%) were malignant, and 39 (26%) were benign. Morphologic evaluation revealed 30 unilocular solid masses (19.7%), 43 multilocular solid masses (28.3%), and 79 mostly solid masses (52%). The mean vascularization index (9.365% vs 3.3%; P<.001), flow index (34.318 vs 28.794; P<.001), and vascularization-flow index (3.233 vs1.15; P<0.01) were significantly higher in malignant tumors. No differences were found in the RI, PI, and peak systolic velocity. AUC revealed 0.77 (95% CI, 0.69-0.85), 0.71 (0.60-0.81), and 0.75 (0.66-0.83) for the vascularization index, flow index and vascularization-flow index, respectively. For reducing the false-positive rate by almost one-third, sensitivity values for the vascularization index (cutoff, 1.556%), flow index (25.212%), and vascularization-flow index (0.323%) were 92%, 95%, and 93%, respectively. 3D power Doppler US vascular indices could be helpful for reducing the false-positive rate in cystic-solid and solid vascularized adnexal masses. 3
39. Mansour GM, El-Lamie IK, El-Sayed HM, et al. Adnexal mass vascularity assessed by 3-dimensional power Doppler: does it add to the risk of malignancy index in prediction of ovarian malignancy?: four hundred-case study. Int J Gynecol Cancer. 19(5):867-72, 2009 Jul. Observational-Dx 400 cases of ovarian masses To determine whether adnexal mass vascularity assessed by 3D power Doppler adds to the risk of malignancy index in prediction of ovarian malignancy. Sensitivity of risk of malignancy index for prediction of malignancy was 88%, with a cutoff value of 202.5 at 95% CI. Sensitivity of 3D power Doppler for prediction of malignancy was 75%, adding 3D power Doppler to risk of malignancy index increased its sensitivity to 99%. Considering the pilot nature of the study, further studies are needed to corroborate such findings. 3
40. Schneider VL, Schneider A, Reed KL, Hatch KD. Comparison of Doppler with two-dimensional sonography and CA 125 for prediction of malignancy of pelvic masses. Obstet Gynecol. 81(6):983-8, 1993 Jun. Observational-Dx 55 patients Cross-sectional study to assess the validity of Doppler flow US for the prediction of malignancy in adnexal masses and to compare the results with 2D US examination and CA 125 levels. Doppler US evaluation of RI in the vessels of adnexal masses increased the sensitivity of 2D US and CA 125. However, 46% of positive Doppler results were false and 37.5% of the benign tumors had low RI, thus limiting the validity of this technique for screening programs. 2
41. Chou CY, Chang CH, Yao BL, Kuo HC. Color Doppler ultrasonography and serum CA 125 in the differentiation of benign and malignant ovarian tumors. J Clin Ultrasound. 22(8):491-6, 1994 Oct. Observational-Dx 108 patients To evaluate the use of Color Doppler US and CA 125 in adnexal masses before surgery. A combination of color Doppler US and CA 125 is effective in differentiating benign from malignant tumors. A combination of RI and CA 125 gives sensitivity of 100%, NPV 100%. 3
42. Mancuso A, De Vivo A, Triolo O, Irato S. The role of transvaginal ultrasonography and serum CA 125 assay combined with age and hormonal state in the differential diagnosis of pelvic masses. Eur J Gynaecol Oncol. 25(2):207-10, 2004. Observational-Dx 125 women To evaluate the ability of CA 125 and US alone and in combination with clinical parameters (>50 years and postmenopausal state) in the diagnosis of a malignant pelvic mass. The best results were obtained from the association of CA 125 and menopause; an increase in CA 125 in menopausal women most likely suggests pelvic mass is malignant. 3
43. Hartman CA, Juliato CR, Sarian LO, et al. Ultrasound criteria and CA 125 as predictive variables of ovarian cancer in women with adnexal tumors. Ultrasound Obstet Gynecol. 40(3):360-6, 2012 Sep. Observational-Dx 103 women To evaluate the capacity to predict malignancy in women with adnexal tumors using CA 125 measurement and ultrasound criteria. Of 110 tumors, 79 (71.8%) were benign and 31 (28.2%) were malignant on histopathology. Ultrasound criteria could be applied to 91 (82.7%) tumors, resulting in a sensitivity of 90%, specificity of 87%, positive predictive value (PPV) of 69% and negative predictive value (NPV) of 97%. In tumors not classifiable according to ultrasound criteria, subjective sonographic assessment gave a sensitivity of 67%, specificity of 80%, PPV of 75% and NPV of 73%. At a cut-off point of 37.4 U/mL, CA 125 had a sensitivity of 69%, a specificity of 87.8%, a PPV of 69% and a NPV of 88% for detection of malignancy. When CA 125 was associated with age and ultrasound criteria in a logistic regression model, the sensitivity and specificity increased in the subset of sonographically malignant tumors. 3
44. Anthoulakis C, Nikoloudis N. Pelvic MRI as the "gold standard" in the subsequent evaluation of ultrasound-indeterminate adnexal lesions: a systematic review. [Review]. Gynecol Oncol. 132(3):661-8, 2014 Mar. Review/Other-Dx 10 references To conduct a systematic review, following the PRISMA guidelines, and critically appraise pelvic MR Imaging as the preferred advanced second imaging test, as regards detection of ovarian cancer and assessment of indeterminate adnexal masses, with respect to pre-operatively improving the assignment of these patients to the appropriate level of care. Computerized database search revealed 37 citations of relevance, 10 of which fulfilled the inclusion/exclusion criteria. From the aforementioned, 8 articles were acquired (2 authors were contacted but did not respond) as well as assessed with AHRQ, QUADAS, and STARD evaluation tools. Finally, 6 papers (5 prospective and 1 retrospective) were included in the systematic review. 4
45. Sohaib SA, Mills TD, Sahdev A, et al. The role of magnetic resonance imaging and ultrasound in patients with adnexal masses. Clin Radiol. 60(3):340-8, 2005 Mar. Observational-Dx 72 women Prospective study to evaluate the accuracy of US and MRI in characterizing adnexal masses and to determine which patients may benefit from MRI. Sensitivity (US 100%, MRI 96.6%). Specificity (US 39.5%, MRI 83.7%). Accuracy (US 63.9%, MRI 88.9%). MRI is more specific and accurate than US and Doppler assessment for characterizing adnexal masses. 2
46. Sohaib SA, Sahdev A, Van Trappen P, Jacobs IJ, Reznek RH. Characterization of adnexal mass lesions on MR imaging. AJR Am J Roentgenol. 2003;180(5):1297-1304. Observational-Dx 104 patients (163 lesions) Prospective study to evaluate the accuracy of MRI in the detection and characterization of adnexal masses and to determine which imaging features are predictive of malignancy. MR1: 95% lesions were detected. Accuracy 91%. MRI is highly accurate in characterization of adnexal masses and the best predictors of malignancy are vegetation in a cystic lesion and ascites. 2
47. Adusumilli S, Hussain HK, Caoili EM, et al. MRI of sonographically indeterminate adnexal masses. AJR. 2006;187(3):732-740. Observational-Dx 87 patients (95 lesions) Retrospective, blinded review to assess the ability of MRI to characterize sonographically indeterminate adnexal masses and to define the US features contributing to indeterminate diagnoses. Sensitivity of MRI for identifying malignancy (n=5) was 100%, specificity for benignity (n=90) was 94%. Main reason for indeterminate US was inability to determine origin because of location and large mass size and appearance of purely solid or complex cystic masses. 2
48. Haggerty AF, Hagemann AR, Chu C, Siegelman ES, Rubin SC. Correlation of pelvic magnetic resonance imaging diagnosis with pathology for indeterminate adnexal masses. Int J Gynecol Cancer. 2014;24(7):1215-1221. Observational-Dx 237 female patients To determine the accuracy of pelvic magnetic resonance imaging (MRI) diagnoses compared with the final pathology diagnoses for a series of women with indeterminate adnexal masses. Data from 237 female patients who underwent pelvic MRI were included, and 41.35% underwent surgical intervention for the adnexal mass. Pelvic MRI (n = 88) was determined to have a sensitivity of 95.0% and specificity of 94.1%. The predicted specific histologic subtype by MRI (n = 84) was accurate in 56 (98.25%) of 57 women with an anticipated benign diagnosis and in 23 (85.19%) of 27 women with an anticipated malignancy. The agreement between a benign diagnosis from MRI and benign final surgical pathology was 0.85 (95% confidence interval, 0.716-0.976). 3
49. Yamashita Y, Torashima M, Hatanaka Y, et al. Adnexal masses: accuracy of characterization with transvaginal US and precontrast and postcontrast MR imaging. Radiology. 1995;194(2):557-565. Observational-Dx 72 patients To determine the accuracy of transvaginal ultrasound (TVUS) and of precontrast and contrast material-enhanced magnetic resonance (MR) imaging in the differentiation of adnexal masses. Higher diagnostic accuracy was attained with MR imaging in mature cystic teratomas and endometriomas. However, better accuracy was achieved with contrast-enhanced MR imaging and TVUS in simple cysts, cystadenomas, and malignant tumors because internal details could be visualized. Receiver operating characteristic study indicated that observer confidence was significantly higher with contrast-enhanced MR imaging than with precontrast MR imaging (P = .011) or TVUS (P = .002) in the differentiation of benign and malignant masses. 2
50. Togashi K.. Ovarian cancer: the clinical role of US, CT, and MRI. [Review] [55 refs]. Eur Radiol. 13 Suppl 4:L87-104, 2003 Dec. Review/Other-Dx N/A Review the clinical roles of US, CT and MRI in the diagnosis of ovarian cancer. US is the modality of choice in evaluation of suspected adnexal masses. CT is not indicated for differential diagnosis of adnexal masses because of poor soft tissue discrimination. MRI may help in distinguishing benign from malignant. 4
51. Healy DL, Bell R, Robertson DM, et al. Ovarian status in healthy postmenopausal women. Menopause. 2008;15(6):1109-1114. Review/Other-Dx 515 women To describe the ovaries in healthy women at least 5 years after menopause by questionnaire, TVS, and blood ovarian cancer markers. Both ovaries were identified by TVS in 71% of women. The right ovary was visualized in 86.3% of these volunteers, and the left ovary was visualized in 78%. The presence of small unilocular cysts and echogenic foci facilitated identification of the ovary in some women. Ovarian/paraovarian lesions were present in 12.6% of women. Abnormalities of the endometrium and uterus were also common, prompting surgery in 7.2% of the women. Total serum inhibin concentrations were normal for postmenopausal women, whereas serum CA-125 was elevated in two women. Description and detection of postmenopausal ovaries by TVS allows the identification of both ovaries in most postmenopausal women. US-detected abnormalities of the ovary and/or the uterus/endometrium are common in women at this stage of life. The potential need for surgical intervention after the detection of such abnormalities needs to be carefully evaluated when considering TVS as a screening tool for ovarian cancer. 4
52. Levine D, Gosink BB, Wolf SI, Feldesman MR, Pretorius DH. Simple adnexal cysts: the natural history in postmenopausal women. Radiology. 184(3):653-9, 1992 Sep. Review/Other-Dx 184 asymptomatic postmenopausal volunteers To determine prospectively, the frequency of simple adnexal cysts in postmenopausal women using TAS and TVS associated with hormones and time since menopause. Cyst frequency 17%; 53% disappeared, 28% constant, 11% enlarged, 3% decreased, 6% decreased and increased. No relationship with hormones or time from menopause. 4
53. Alcazar JL, Castillo G, Jurado M, Garcia GL. Is expectant management of sonographically benign adnexal cysts an option in selected asymptomatic premenopausal women?. Hum Reprod. 20(11):3231-4, 2005 Nov. Review/Other-Dx 120 women Prospective observational longitudinal study to assess whether expectant management of US benign ovarian cysts may be an option for selected asymptomatic premenopausal women. Most lesions remained unchanged both in size and sonographic appearance. In ten patients (8.3%) the lesion disappeared, no patient developed signs or symptoms of ovarian cancer. 4
54. Heaps JM, Nieberg RK, Berek JS. Malignant neoplasms arising in endometriosis. Obstet Gynecol. 1990;75(6):1023-1028. Review/Other-Tx 10 cases To report on ten cases of malignant neoplasms arising in endometriosis. Tumors arising in endometriosis were predominantly low grade and confined to the site of origin. Radiation therapy was often able to control completely tumors limited to the pelvis, but was not beneficial in metastatic disease. Only one patient had a response to chemotherapy. Fourteen patients received postoperative progestin therapy, with a 77% 5-year survival. Follow-up has been reported in 86 patients. The tumor was either confined to the ovary (57), confined to the extragonadal site of origin (11), or spread throughout the peritoneal cavity (18). With each of these situations, the 5-year survival was 65, 100, and 10%, respectively. Fourteen patients had malignant transformation in endometriosis associated with presumed estrogenic stimulation; most lesions (69%) were well differentiated and the 5-year survival was 82%. 4
55. Goh W, Bohrer J, Zalud I. Management of the adnexal mass in pregnancy. [Review]. Curr Opin Obstet Gynecol. 26(2):49-53, 2014 Apr. Review/Other-Dx N/A To highlight the increasing sensitivity of ultrasound imaging in diagnosing the rare malignant lesion, allowing for antenatal expectant management of benign asymptomatic adnexal masses until delivery or postpartum. Most adnexal masses are benign and ultrasound characteristics can help guide the assessment of asymptomatic ovarian masses. When surgical management is chosen, laparoscopy can be safely performed in pregnancy. Ovarian torsion is a complication for persistent masses in pregnancy. 4
56. Zanetta G, Mariani E, Lissoni A, et al. A prospective study of the role of ultrasound in the management of adnexal masses in pregnancy. BJOG. 2003;110(6):578-583. Review/Other-Dx 6636 women To assess the clinical relevance of adnexal masses in pregnancy and the usefulness of ultrasound in their management. We detected 82 cysts in 79 of 6636 women (1.2 in 100 term pregnancies). Sixty-eight women were asymptomatic at the time of diagnosis, whereas 11 (13.9%) were diagnosed because of pain. Diagnosis occurred in the first trimester for 57 cases and in the second or third trimester in 22 (27.8%). One-half of the cysts were simple and anechoic at ultrasound. Fifty-seven had a diameter not exceeding 5 cm. Forty-two cyst resolved in pregnancy without treatment. Three cysts required surgery within few days (torsion). One woman required laparotomy at the 37th week of gestation, due to torsion. When one case of termination was excluded, 78 women delivered at term (66 vaginally, 12 by caesarean section). Nineteen women underwent surgery after pregnancy. We recorded three Stage Ia borderline tumours, accounting for 3/82 cysts (3.6%) and 3/30 persisting masses (10%). 4
57. Spitzer M, Kaushal N, Benjamin F. Maternal CA-125 levels in pregnancy and the puerperium. J Reprod Med 1998;43:387-92. Observational-Dx 34 patients To determine the levels of CA-125 throughout pregnancy and the puerperium to establish a baseline, thereby indicating what values may be indicative of the pathologic conditions usually associated with elevated CA-125 levels. Of 34 women enrolled in the study, 20 completed the evaluations throughout pregnancy and in the puerperium. The remaining 14 had evaluations for varying portions of their pregnancies but not throughout pregnancy or during the puerperium. The results in these two groups were compared and found not to be statistically significantly different. For the group as a whole, the levels of CA-125 were high, with wide fluctuations in the first trimester; the levels in the early first trimester (five to eight weeks) were particularly high, with a mean of 55.8 and median of 36.2 (range, 6.9-251.2) U/mL. The levels then dropped and remained < 35 U/mL through the rest of pregnancy (including immediately prior to delivery). Another peak, with wide fluctuations, occurred soon after delivery, with a mean of 39.8 and median of 41.9 (range, 10.7-296.7) U/mL. In the late postpartum period (2-10 weeks after delivery) there was a return to baseline levels in all subjects. 3
58. Thomassin-Naggara I, Fedida B, Sadowski E, et al. Complex US adnexal masses during pregnancy: Is pelvic MR imaging accurate for characterization? Eur J Radiol. 2017;93:200-208. Observational-Dx 31 pregnant women To retrospectively evaluate the accuracy of pelvic magnetic resonance (MR) imaging for the characterization of complex sonographic adnexal masses discovered in women during pregnancy. Prospective US and MR imaging correctly identified the diagnosis in 27/36 (75%) (95% confidence interval (CI): 58.9%-86.2%) and in 32/36 (88.9%) (95% CI: 74.6%-95.6%) of lesions, respectively. MR imaging with ADNEXMR-SCORE allowed a correct diagnosis in 32/36 (88.9%) (95% CI: 74.6%-95.6%) of lesions for R1 and in 30/36 (83.3%) (95% CI: 68.1%-92.1%) of lesions for R2. The sensitivities and specificities of MR imaging using the MR ADNEXMR-SCORE were 100% (95% CI: 70.1%-1000%) for both readers and 85.1% (95% CI: 67.5%-94%) and 77.7% (95% CI: 59.2%-89.4%) for R1 and R2, respectively. No malignancy was classified as benign using MR criteria. The reproducibility between the two readers was almost perfect, with a kappa of 0.914. 2
59. American College of Radiology. ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/mr-fetal.pdf Review/Other-Dx N/A To promote safe and optimal performance of fetal magnetic resonance imaging (MRI). No abstract available. 4
60. American College of Radiology. ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Adolescents and Women with Ionizing Radiation. Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/pregnant-pts.pdf Review/Other-Dx N/A To assist practitioners in providing appropriate radiologic care for pregnant or potentially pregnant adolescents and women by describing specific training, skills and techniques. No abstract available. 4
61. American College of Radiology. ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound. Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/us-ob.pdf Review/Other-Dx N/A To promote the safe and effective use of diagnostic and therapeutic radiology by describing the key elements of standard ultrasound examinations in the first, second, and third trimesters of pregnancy. No abstract available. 4
62. Expert Panel on MR Safety, Kanal E, Barkovich AJ, et al. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging. 37(3):501-30, 2013 Mar. Review/Other-Dx N/A To help guide MR practitioners regarding MR safety issues and provide a basis for them to develop and implement their own MR policies and practices. No abstract available. 4
63. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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