Criteria

Risk of malignancy index (RMI)[30]

RMI = U × M × CA-125

Ultrasound scans are scored 1 point for each of the following characteristics:

  • Multilocular cyst

  • Evidence of solid areas

  • Evidence of metastases

  • Presence of ascites

  • Bilateral lesions.

U = 0 (for ultrasound score of 0);

U = 1 (for ultrasound score of 1);

U = 3 (for ultrasound score of 2-5).

M = 3 for all post-menopausal women dealt with by this guideline.

Cancer antigen (CA)-125 is serum CA-125 measurement in U/mL.

  • Low-risk RMI = <25 (40% of women; risk of cancer is <3%).

  • Moderate-risk RMI = 25-250 (30% of women; risk of cancer is 20%).

  • High-risk RMI = >250 (30% of women; risk of cancer is 75%).

Other scoring systems include the ovarian adnexal mass assessment score test system and the risk of malignancy algorithm, but these require specific assays so may not be practical for routine use.[30] The International Ovarian Tumor Analysis classification has comparable sensitivity and specificity to RMI, and is based on specific ultrasound expertise.[30][55]

DePriest ultrasound morphology index[32]

The ultrasound morphology index is a cost-effective adjuvant method that significantly increases the specificity and positive predictive value of transvaginal sonography and is based on the following:[32]

  • Tumour volume (<10 cm³, 10-50 cm³, >50-200 cm³, >200 cm³)

  • Cyst wall structure and wall thickness (smooth <3 mm, smooth >3 mm, papillary <3 mm, papillary >3 mm)

  • Septal structure (no septa, thin septa <3 mm, thick septa 3-10 mm, solid area >10 mm).

A point scale (0-4) was developed within each category, with the total points per evaluation varying from 0-12.

An ultrasound morphology index score <5 in a pre-menopausal woman is in keeping with a benign aetiology.

In post-menopausal patients, a morphology index score ≥5 has a positive predictive value for malignancy of 0.45.

Ovarian malignancies are more likely to have thickened wall structure and a total volume in excess of 10 cm³.

American College of Obstetricians and Gynecologists guidelines for referral to gynaecological oncology[31]

Post-menopausal women with suspicious pelvic mass and:

  • Elevated CA-125 level (>35 U/mL)

  • Ascites

  • A nodular or fixed pelvic mass

  • Evidence of abdominal or distant metastasis

  • A family history of one or more first-degree relatives with ovarian or breast cancer.

Pre-menopausal women with a suspicious pelvic mass and:

  • Greatly elevated CA-125 level (> 200 U/mL)

  • Ascites

  • Evidence of abdominal or distant metastasis

  • A family history of one or more first-degree relatives with ovarian or breast cancer.

Genetic risk assessment[56]

Patients with a greater than 20% to 25% (approximately) chance of having an inherited predisposition to breast cancer should be referred for genetic risk assessment, including:

  • Women with a personal history of both breast cancer and ovarian cancer

  • Women with ovarian cancer and a close relative with ovarian cancer or pre-menopausal breast cancer, or both

  • Women with ovarian cancer who are of Ashkenazi Jewish ancestry

  • Women with breast cancer at age 50 years or younger and a close relative with ovarian cancer or male breast cancer at any age

  • Women of Ashkenazi Jewish ancestry in whom breast cancer was diagnosed at age 40 years or younger

  • Women with a close relative with a known BRCA-1 or BRCA-2 mutation.

Patients with a greater than 5% to 10% (approximately) chance of having an inherited predisposition to breast cancer and ovarian cancer should also consider referral, including:

  • Women with breast cancer at age 40 years or younger

  • Women with ovarian cancer, primary peritoneal cancer, or fallopian tube cancer of high grade, serous histology at any age

  • Women with bilateral breast cancer (particularly if the first case of breast cancer was diagnosed at age 50 years or younger)

  • Women with breast cancer at age 50 years or younger and a close relative with breast cancer at age 50 years or younger

  • Women of Ashkenazi Jewish ancestry with breast cancer at age 50 years or younger

  • Women with breast cancer at any age and two or more close relatives with breast cancer at any age (particularly if at least one case of breast cancer was diagnosed at age 50 years or younger)

  • Unaffected women with a close relative that meets one of the previous criteria.

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