***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The aim of this work was to test and compare the accuracy of five different morphological scoring systems to identify  malignant ovarian masses  in a prospect i ve multicenter study . Four of the systems had previously been reported by Granberg , Sassone , De Priest and Lerner and the fifth is newly developed . A total of 330 ovarian neoplasms were collected in three different centers , which adopted the same diagnostic procedures . Of these , 261 masses were benign ( mean diameter 50 + /- 26 mm ) and 69 were malignant ( mean diameter 69 + /- 33 mm ) ( prevalence 21 % ) . The area under the receiver operating characteristic ( ROC ) curve for the multicenter score was 0.84 . This was significantly better than the areas of the other four scores which ranged from 0.72 to 0.75 . The cut-off levels derived from the five ROC curves achieved a sensitivity that ranged from 74 % ( Sassone score ) to 88 % ( De Priest score > or = 5 ) , and a specificity from 40 % ( De Priest ) to 67 % ( multicenter ) ; the highest positive predictive value was 41 % ( multicenter ) . With a cut-off level of 9 , the accuracy of the multicenter score was significantly better than the scores of Granberg and De Priest ( McNemar 's test p < 0.0001 ) . Similar results were obtained in 207 ovarian masses of < or = 5 cm in mean diameter , and when 19 borderline and 11 stage 1 cancers only were considered . For the clinical purpose s of a screening test we also checked a possible cut-off level of > or = 8 , which increased the sensitivity to 93 % with a drop of specificity to 56 % . With the use of the same criteria for the scores of the different authors , the following values were obtained for sensitivity : 96 % , 81 % , 93 % and 90 % ; and for specificity : 23 % , 56 % , 28 % and 49 % . The multicenter score performed well at distinguishing malignant from benign lesions , and was better than the other four traditional scores , for both large and small masses . This was mainly due to the introduction of two criteria that allowed correction for typical dermoids and endohemorrhagic corpora lutea . A completely reliable differentiation of benign from malignant masses can not be obtained by sonographic imaging alone Background . In a prospect i ve study , the differential dignostic potential of peovic examination , ultrasound , and serum CA 125 assay in postmenopausal patients presenting with a pelvic mass was assessed In a prospect i ve study , 32 women with suspected pelvic masses at physical examination underwent both endovaginal ultrasound ( US ) and magnetic resonance ( MR ) imaging to compare their ability in diagnosis of adnexal masses . Criteria for the diagnosis of various types of adnexal masses with MR imaging and endovaginal US were prospect ively defined , and the ability of either modality to allow a specific diagnosis was assessed . For each modality , measures of sensitivity , specificity , and accuracy were obtained . Results indicated higher diagnostic capability of  endovaginal US  for simple cysts ( five of five ) , hemorrhagic cysts ( eight of nine ) , endometriomas ( nine of 14 ) , and ovarian carcinomas ( three of three ) . MR imaging demonstrated higher diagnostic capability for dermoids ( three of three ) . MR imaging and endovaginal US showed equal diagnostic capability for pedunculated fibroids ( two of two ) . For all masses , observers , and observations , the overall sensitivity of endovaginal US  was 76 % versus 49 % for MR imaging , and the overall accuracy of endovaginal US  was 83 % versus 70 % for MR imaging . The authors suggest that endovaginal US is a better modality than MR imaging for the assessment of suspected pelvic masses Objective : To assess the accuracy of pelvic sonography in distinguishing benign from malignant lesions in postmenopausal women , using morphologic criteria and Doppler flow characteristics . Methods : All postmenopausal patients scanned from March 1992 to April 1993 with sonographically identified and pathologically confirmed adnexal masses formed the study group . The adnexal lesions were morphologically categorized prospect ively as benign or malignant , and pulsed Doppler flow studies were measured using the lowest resistance index obtained from each mass . The sensitivity and specificity were determined for morphologic and Doppler flow assessment s , as well as for a combination of these methods , for predicting the presence of malignancy . Results : Thirty-three postmenopausal patients formed the study group ; 12 lesions were malignant and 21 were benign pathologically . Using morphologic criteria alone , the sensitivity in detecting malignancy was 91 % and specificity was 52 % . Using pulsed Doppler alone with a resistance index limit of 0.6 , the sensitivity in predicting malignancy was 66 % , with a specificity of 81 % . If a resistance index limit of 0.8 were used , the sensitivity and specificity would be the same as those for morphology alone . Combining morphology and resistance index , a single malignancy would still have been missed ( sensitivity 91 % ) . Conclusion : In our experience , Doppler flow studies did not add substantially to the prediction of malignancy using morphologic assessment alone BACKGROUND To assess the differential diagnostic potential of physical examination , ultrasound , the serum CA 125 assay , and serum CA 72 - 4 assay , and the contribution of each parameter to a logistic model predicting the probability of malignancy in postmenopausal patients presenting with a pelvic mass . PATIENTS AND METHODS In a multicenter , prospect i ve study a total of 155 patients were evaluated preoperatively using a st and ard protocol for pelvic examination , transvaginal ( occasionally additional abdominal ) ultrasound , and serum CA 72 - 4 ( cutoff level 3 U/ml ) and CA 125 ( cutoff level 35 U/ml ) . RESULTS Fifty-nine malignant ( 39 % ) and 92 benign ( 61 % ) pelvic tumors were found in addition to 4 borderline tumors ( 3 % ) . Forty-three patients appeared to have ovarian carcinoma , FIGO Stage III or IV in 28 cases . Borderline tumors were excluded from the statistical calculations . The diagnostic accuracy of each single parameter , i.e. ,  pelvic examination , ultrasound , and serum CA 125 and CA 72 - 4 in discriminating between benign and malignant pelvic masses gave highly similar results ( 81 , 76 , 78 , and 81 % respectively ) . Best sensitivity was found in pelvic examination ( 92 % ) ; best specificity was found in CA 72 - 4 ( 93 % ) . Using logistic regression analysis the power of pelvic examination appeared to be the most relevant ( adjusted odds ratio 12.1 ) , followed by ultrasound ( odds ratio 9.7 ) , serum CA 125 ( odds ratio 5.0 ) , and serum CA 72 - 4 ( odds ratio 4.9 ) . Age appeared to be nonpredictive . The logistic model gives a correct prediction in 87 % of all cases . CONCLUSIONS The addition of serum CA 72 - 4 to the combination of pelvic examination , ultrasound , and serum CA 125 leads to an improved discrimination between malignant and benign pelvic masses OBJECTIVE To prospect ively evaluate the accuracy of a multiparameter , ultrasound-based triage and its impact on surgical management of adnexal masses . METHODS Masses evaluated as normal according to Ferrazzi 's sonographic morphological score were considered as being at low risk of malignancy and eligible for laparoscopic treatment without further evaluation . Masses evaluated as abnormal , but without additional risk factors such as ascites , diameter > or = 10 cm , bilaterality , immobility , resistance index < or = 0.6 and serum CA 125 > 35 IU/mL were considered at moderate risk and eligible for laparoscopic evaluation and treatment . Masses with abnormal morphological score and any of these additional risk factors were considered at high risk and treated by laparotomy . The results of pathological examination were obtained for each mass . RESULTS Two hundred and four ( 87 % ) masses were benign and 30 ( 13 % ) were malignant . Among 182 low-risk , 19 moderate-risk and 33 high-risk masses , the odds of malignancy were 1 : 90 , 1 : 18 and 4.5 : 1 , respectively . To calculate the diagnostic accuracy of this algorithm , low- and moderate-risk groups were considered together : the sensitivity was 90 % , specificity 97 % , positive predictive value 82 % and negative predictive value 99 % . The new algorithm was significantly more accurate than was morphological score alone ( P = 0.0002 ) . Ninety-six percent of benign masses were treated by laparoscopy . All three patients with malignant masses that were incorrectly assigned to laparoscopy underwent laparoscopic adnexectomy and frozen section . CONCLUSIONS The accuracy of this new algorithm was higher than that of the sonographic morphological scoring system alone . In the present series , it allowed the treatment by laparoscopy of 96 % of benign adnexal masses without mismanagement of any cases of ovarian cancer Objective To determine the ability of pelvic examination , tumor marker assessment , and transvaginal ultrasonography , with selected use of Doppler ultrasonography , to predict pelvic malignancy . Methods Two hundred twenty-six women scheduled for operative removal of a pelvic mass were entered in the study prospect ively . Each woman underwent pelvic examination , tumor marker assessment , and transvaginal ultrasonography preoperatively . Women whose gray-scale findings were suspicious for malignancy underwent Doppler ultrasonography . Suspicious findings included masses that were fixed or irregular on pelvic examination ; CA 125 level greater than 35 U/mL ; elevations in serum lactic dehydrogenase , alphafetoprotein , or hCG ; and the presence of a substantial solid component on gray-scale ultrasonography . Suspicious Doppler findings included intratumoral color flow , pulsatility index less than 1.0 , or resistance index 0.4 or lower . The findings were correlated with the presence of malignancy . Results If all three indicators ( examination , tumor marker assessment , and gray-scale ultrasound findings ) were nonsuspicious , 99 % of premenopausal women and 100 % of postmenopausal women had benign masses . If all three indicators were suspicious , 77 % of premenopausal women and 83 % of postmenopausal women had malignant tumors . Logistic regression identified ultrasound impression and tumor size to be significant predictors of malignancy in premenopausal women , whereas CA 125 level and ultrasound impression were significant in postmenopausal women . In patients with suspicious gray-scale findings , recategorization based on Doppler findings result ed in inferior diagnostic indices . Conclusions Ultrasonographic tumor size and appearance are the best predictors of pelvic malignancy in premenopausal women , whereas CA 125 level and ultrasonographic appearance are the best predictors in postmenopausal women . Neither color nor spectral Doppler is useful in this setting OBJECTIVE To investigate the potential efficacy of real-time contrast-enhanced power Doppler sonography in the differentiation of benign and malignant adnexal masses in a pilot study . METHODS Before surgical treatment , adnexal masses were prospect ively evaluated with power Doppler sonography before and after injection of a contrast agent . Real-time postinjection sequences were computerized with time-intensity analysis software to determine an enhancement curve and contrast parameters . The intraobserver and interobserver reproducibilities of these criteria were assessed on a sub sample . These contrast parameters were compared between benign and malignant tumors using logistic regression . Sensitivity and specificity were used to compare contrast parameters with sonographic and Doppler variables . RESULTS Ninety-nine women were included , for a total of 101 adnexal masses . There were 23 cases of ovarian malignancies and 78 benign adnexal lesions . Our procedure had excellent intraobserver and interobserver reproducibility , with an average intraclass correlation coefficient of 0.92 . The time before enhancement and intensity ratio did not reliably differentiate between the benign and malignant masses . Washout times and areas under the curves were significantly greater in ovarian malignancies than in other benign tumors ( P < .001 ) , leading to sensitivity estimates between 96 % and 100 % and specificity estimates between 83 and 98 % . Contrast parameters had slightly higher sensitivity and slightly lower specificity when compared with transvaginal sonographic variables of the resistive index and serum cancer antigen 125 levels . CONCLUSIONS Contrast-enhanced power Doppler imaging may easily and precisely discriminate benign from malignant adnexal lesions . Larger studies are needed to determine the appropriate use and benefits of this new procedure OBJECTIVE The purpose of this study was to evaluate prospect ively the relative usefulness of color Doppler , spectral Doppler , and gray-scale sonography in differentiating benign from malignant adnexal masses . SUBJECTS AND METHODS A total of 170 adnexal masses in 161 patients were classified prospect ively as suggestive of or not suggestive of malignant tumor on the basis of gray-scale morphology , internal flow versus peripheral or no flow , and spectral Doppler pulsatility , as measured by a pulsatility index ( PI ) threshold of 1.0 and a resistive index ( RI ) threshold of 0.4 . RESULTS Surg 
    Output:
    
As a st and alone modality , serum cancer antigen 125 is not recommended for distinguishing between benign and malignant adnexal masses .
Fertility-preserving surgery is an acceptable alternative to more extensive surgery in patients with low-malignant-potential tumours and those with well-differentiated surgical stage i ovarian cancer .