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Tingulstad, Solveig MD; Hagen, Bjørn MD, PhD; Skjeldestad, Finn Egil MD, PhD; Halvorsen, Tore MD, PhD; Nustad, Kjell MD, PhD; Onsrud, Mathias MD, PhD

Instruments & Methods

Objective: To assess the risk-of-malignancy index (a scoring system based on menopausal status, ultrasound features, and serum CA 125) at district hospitals for referral of women with suspected malignant pelvic masses for primary surgery at a central gynecologic oncology unit.

Methods: All seven hospitals in Health Region IV, Norway, agreed to refer women with pelvic masses and risk-of-malignancy indices of 200 or more for centralized primary surgery. In total, 365 women 30 years of age or older, admitted consecutively at the local hospitals, were enrolled in the study from February 1, 1995, to January 31, 1997.

Results: Compliance with the study was satisfactory; 84% (65 of 77) of women with risk-of-malignancy indices of at least 200 were referred for centralized primary surgery. Sensitivity and specificity to malignancy were 71% and 92%, respectively, which is in agreement with previous validation of the risk-of-malignancy index in teaching hospital settings. False negatives were due mainly to stage Ia (18 of 24) ovarian cancer, whereas 27 of 28 stage II–IV ovarian cancer cases were identified correctly.

Conclusion: The risk-of-malignancy index identified women with malignant pelvic masses efficiently. Our study showed the risk-of-malignancy index strategy in a practical setting to be able to centralize primary surgery for advanced ovarian cancer from local hospitals to a subspecialty unit. We recommend the risk-of-malignancy index for detection of patients with advanced ovarian cancer for centralized primary surgery.

Surgical staging and cytoreductive surgery remain important in the management of ovarian carcinoma. However, extensive staging procedures such as pelvic and para aortic lymphadenectomy, increasingly advocated,1 often are beyond the skill of general gynecologists. In advanced disease, the aim of primary surgery is maximal tumor volume reduction.2 Residual tumor volume after surgery is an important prognostic factor for survival and quality of life.3,4 Aggressive cytoreductive surgery demands the specific skills and experience of trained gynecologic oncologists.5 A method for differentiating between benign and malignant pelvic tumors is needed for rational referral of ovarian cancer patients to gynecologic oncology units. The risk-of-malignancy index was developed for this purpose by Jacobs et al.,6 based on menopausal status, ultrasound features and serum level of CA 125, and has been validated in subspecialized teaching hospitals.7,8 The aim of the present study was to assess the risk-of-malignancy index in practice for referring women with suspected malignant pelvic masses from local hospitals to a centralized gynecologic oncology unit for primary surgery.

The risk-of-malignancy index–based on menopausal status, ultrasound features, and serum CA 125–is a simple method of detecting patients with advanced ovarian cancer for referral to centralized primary surgery.

Departments of Obstetrics and Gynecology and Pathology, University Hospital of Trondheim, Trondheim, Norway; Section of Epidemiological Research, SINTEF, UNIMED, Trondheim; and Central Laboratory, The Norwegian Radium Hospital, Oslo, Norway.

Address reprint requests to: Solveig Tingulstad, MD, Department of Gynecology and Obstetrics, University Hospital of Trondheim, 7006 Trondheim, Norway

Received May 22, 1998. Received in revised form August 21, 1998. Accepted September 3, 1998.

© 1999 The American College of Obstetricians and Gynecologists