{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T00:17:06Z","timestamp":1785370626866,"version":"3.55.0"},"reference-count":34,"publisher":"Wiley","issue":"3","license":[{"start":{"date-parts":[[2017,9,5]],"date-time":"2017-09-05T00:00:00Z","timestamp":1504569600000},"content-version":"vor","delay-in-days":4,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"funder":[{"DOI":"10.13039\/501100006692","name":"Universit\u00e0 degli Studi di Torino","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100006692","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["obgyn.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Ultrasound in Obstet &amp; Gyne"],"published-print":{"date-parts":[[2017,9]]},"abstract":"<jats:title>ABSTRACT<\/jats:title><jats:sec><jats:title>Objective<\/jats:title><jats:p>Transvaginal sonography (TVS) and serum biomarkers are used widely in clinical practice to triage women with adnexal masses, but the effectiveness of current biomarkers is weak. The aim of this study was to determine the best method of diagnosing patients with adnexal masses, in terms of diagnostic accuracy and economic costs, among four triage strategies: (1) the International Ovarian Tumor Analysis group's simple rules (SR) for interpretation of TVS with subjective assessment (SA) by an experienced ultrasound operator when TVS results are inconclusive (referred to hereafter as SR \u00b1 SA), (2) SR \u00b1 SA and cancer antigen 125 (CA 125), (3) SR \u00b1 SA and human epididymis protein 4 (HE4) and (4) SR \u00b1 SA and the risk of malignancy algorithm (ROMA). Our main hypothesis was that the addition of the biomarkers to SR \u00b1 SA could improve triaging of these patients in terms of diagnostic accuracy (i.e. malignant <jats:italic>vs<\/jats:italic> benign). As secondary analyses, we estimated the cost effectiveness of the four strategies and the diagnostic accuracy of SR \u00b1 SA at the study hospitals.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Between February 2013 and January 2015, 447 consecutive patients who were scheduled for surgery for an adnexal mass at the S. Anna and Mauriziano Hospitals in Turin were enrolled in this multicenter prospective cohort study. Preoperative TVS was performed and preoperative CA 125 and HE4 levels were measured. Pathology reports were used to assess the diagnostic accuracy of the four triage strategies and the cost of each strategy was calculated.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>A total of 391 patients were included in the analysis: 57% (<jats:italic>n<\/jats:italic> = 221) were premenopausal and 43% (<jats:italic>n<\/jats:italic> = 170) were postmenopausal. The overall prevalence of malignancy was 21%. SR were conclusive in 89% of patients and thus did not require SA; the overall performance of SR \u00b1 SA showed a sensitivity of 82%, specificity of 92% and positive and negative predictive values and positive and negative likelihood ratios of 74%, 95%, 10.5 and 0.19, respectively. In premenopausal women, mean cost among the four triage strategies varied from \u20ac36.41 for SR \u00b1 SA to \u20ac70.12 for SR \u00b1 SA + ROMA. The addition of biomarkers to SR \u00b1 SA showed no diagnostic advantage compared with SR \u00b1 SA alone and was more costly. Among postmenopausal women, mean cost among the four triage strategies varied from \u20ac39.52 for SR \u00b1 SA to \u20ac73.23 for SR \u00b1 SA + ROMA. Among these women, SR \u00b1 SA + CA 125 and SR \u00b1 SA + ROMA had a higher sensitivity (both 92% (95% CI, 85\u201399%)) than SR \u00b1 SA (81% (95% CI, 71\u201391%)), but SR \u00b1 SA had a higher specificity (84% (95% CI, 77\u201391%)). SR \u00b1 SA + CA 125 and SR \u00b1 SA + ROMA improved diagnostic accuracy, each diagnosing a third more malignant adnexal masses. In postmenopausal women, compared with SR \u00b1 SA alone, SR \u00b1 SA + CA 125 showed a net reclassification improvement (NRI) of 28.8% at an extra cost of \u20ac13.00, while the extra cost for SR \u00b1 SA + ROMA was \u20ac33.71, with a comparable gain, in terms of NRI, as that of SR \u00b1 SA + CA 125.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>In our study sample, SR \u00b1 SA seems to be the best strategy to triage women with adnexal masses for surgical management. Among postmenopausal women, SR \u00b1 SA + CA 125 increased the NRI at a reasonable extra cost. Our data do not justify the use of HE4 and ROMA in the initial triage of women with adnexal masses. Copyright \u00a9 2016 ISUOG. Published by John Wiley &amp; Sons Ltd.<\/jats:p><\/jats:sec>","DOI":"10.1002\/uog.17320","type":"journal-article","created":{"date-parts":[[2016,10,13]],"date-time":"2016-10-13T23:06:59Z","timestamp":1476400019000},"page":"395-403","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":42,"title":["Diagnostic accuracy and cost\u2010effectiveness of different strategies to triage women with adnexal masses: a prospective study"],"prefix":"10.1002","volume":"50","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5629-703X","authenticated-orcid":false,"given":"E.","family":"Piovano","sequence":"first","affiliation":[{"name":"Department of Surgical Sciences University of Turin  Turin Italy"},{"name":"Obstetrics &amp; Gynecology Unit, Ospedale Martini  Turin Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"C.","family":"Cavallero","sequence":"additional","affiliation":[{"name":"Department of Surgical Sciences University of Turin  Turin Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"L.","family":"Fuso","sequence":"additional","affiliation":[{"name":"Obstetrics &amp; Gynecology Academic Unit, Ospedale Mauriziano  Turin Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"E.","family":"Viora","sequence":"additional","affiliation":[{"name":"Department of Gynecology and Obstetrics, Division of Ultrasound and Prenatal Diagnosis \u2018Citt\u00e0 della Salute e della Scienza di Torino\u2019 University Hospital  Turin Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"A.","family":"Ferrero","sequence":"additional","affiliation":[{"name":"Obstetrics &amp; Gynecology Academic Unit, Ospedale Mauriziano  Turin Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"G.","family":"Gregori","sequence":"additional","affiliation":[{"name":"Department of Gynecology and Obstetrics, Obstetrics &amp; Gynecology Unit no. 3 \u2018Citt\u00e0 della Salute e della Scienza di Torino\u2019 University Hospital  Turin Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"C.","family":"Grillo","sequence":"additional","affiliation":[{"name":"Department of Lab Medicine, Clinical Biochemistry Unit \u2018Citt\u00e0 della Salute e della Scienza di Torino\u2019 University Hospital  Turin Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"C.","family":"Macchi","sequence":"additional","affiliation":[{"name":"Department of Surgical Sciences University of Turin  Turin Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"G.","family":"Mengozzi","sequence":"additional","affiliation":[{"name":"Department of Lab Medicine, Clinical Biochemistry Unit \u2018Citt\u00e0 della Salute e della Scienza di Torino\u2019 University Hospital  Turin Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"M.","family":"Mitidieri","sequence":"additional","affiliation":[{"name":"Department of Surgical Sciences University of Turin  Turin Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"E.","family":"Pagano","sequence":"additional","affiliation":[{"name":"Unit of Clinical Epidemiology \u2018Citt\u00e0 della Salute e della Scienza di Torino\u2019 University Hospital and CPO Piemonte  Turin Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"P.","family":"Zola","sequence":"additional","affiliation":[{"name":"Department of Surgical Sciences University of Turin  Turin Italy"},{"name":"Department of Gynecology and Obstetrics Obstetrics &amp; Gynecology Academic Unit no. 2, \u2018Citt\u00e0 della Salute e della Scienza di Torino\u2019 University Hospital  Turin Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2017,9,5]]},"reference":[{"key":"e_1_2_6_2_1","doi-asserted-by":"publisher","DOI":"10.1097\/00003081-200609000-00013"},{"key":"e_1_2_6_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejca.2011.12.003"},{"key":"e_1_2_6_4_1","doi-asserted-by":"publisher","DOI":"10.1002\/uog.6415"},{"key":"e_1_2_6_5_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.c6839"},{"key":"e_1_2_6_6_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.bpobgyn.2003.09.009"},{"key":"e_1_2_6_7_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1471-0528.1990.tb02448.x"},{"key":"e_1_2_6_8_1","volume-title":"Clinical Guideline 122: Ovarian cancer: recognition and initial management","author":"National Institute for Health and Clinical Excellence (NICE)","year":"2011"},{"key":"e_1_2_6_9_1","volume-title":"Management of suspected ovarian masses in premenopausal women. 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