Towards an evidence-based approach for diagnosis and management of adnexal masses: findings of the International Ovarian Tumour Analysis (IOTA) studies

Whilst the outcomes for patients with ovarian cancer clearly benefit from centralised, comprehensive care in dedicated cancer centres, unfortunately the majority of patients still do not receive appropriate specialist treatment. Any improvement in the accuracy of current triaging and referral pathways whether using new imaging tests or biomarkers would therefore be of value in order to optimise the appropriate selection of patients for such care. An analysis of current evidence shows that such tests are now available, but still await recognition, acceptance and widespread adoption. It is therefore to be hoped that present guidance relating to the classification of ovarian masses will soon become more "evidence-based". These promising tests include the International Ovarian Tumour Analysis (IOTA) LR2 model and ultrasound-based Simple Rules (SR). Based on a comprehensive recent meta-analysis both currently offer the optimal "evidence-based" approach to discriminating between cancer and benign conditions in women with adnexal tumours needing surgery. LR2 and SR are reliable tests having been shown to maintain a high sensitivity for cancer after independent external and temporal validation by the IOTA group in the hands of examiners with various levels of ultrasound expertise. They also offer more accurate triage compared to the existing Risk of Malignancy Index (RMI). The development of the IOTA ADNEX model represents an important step forward towards more individualised patient care in this area. ADNEX is a novel test that enables the more specific subtyping of adnexal cancers (i.e. borderline, stage 1 invasive, stage II-IV invasive, and secondary metastatic malignant tumours) and shares similar levels of accuracy to IOTA LR2 and SR for basic discrimination between cancer and benign disease. The IOTA study has made significant progress in relation to the classification of adnexal masses, however what is now needed is to see if these or new diagnostic tools can assist clinicians to select patients with adnexal masses that are suitable for expectant management, and that will work in all health care settings (i.e. primary vs secondary vs tertiary care). These important themes will likely control the future agenda of the IOTA project.