title: Prospective external validation of the 'ovarian crescent sign' as a single ultrasound parameter to distinguish between benign and malignant adnexal pathology.
abstract: OBJECTIVE
  To determine the sensitivity and specificity of the 'ovarian crescent sign' (OCS)-a rim of normal ovarian tissue seen adjacent to an ipsilateral adnexal mass-as a sonographic feature to discriminate between benign and malignant adnexal masses.
  
  
  METHODS
  The patients included were a subgroup of patients participating in the International Ovarian Tumor Analysis (IOTA) Phase 2 study, which is an international multicenter study. The subgroup comprised 1938 patients, with an adnexal mass, recruited from 19 ultrasound centers in different countries. All patients were scanned using the same standardized ultrasound protocol. Information on more than 40 demographic and ultrasound variables were collected, but the evaluation of the OCS was optional. Only patients from centers that had evaluated the OCS in > or = 90% of their cases were included. The gold standard was the histological diagnosis of the adnexal mass. The ability of the OCS to discriminate between borderline or invasively malignant vs. benign adnexal masses, as well as between invasively malignant vs. other (benign and borderline) tumors, was determined and compared with the performance of subjective evaluation of ultrasound findings by the ultrasound examiner.
  
  
  RESULTS
  The OCS was evaluated in 1377 adnexal masses from 12 centers, 938 (68%) masses being benign, 86 (6%) borderline, 305 (22%) primary invasive and 48 (3%) metastases. The OCS was present in 398 (42%) of 938 benign masses, in 14 (16%) of 86 borderline tumors, in 18 (6%) of 305 primary invasive tumors (one malignant struma ovarii, one uterine clear cell adenocarcinoma and 16 epithelial carcinomas, i.e. four Stage I and 12 Stage II-IV) and in two (4%) of 48 ovarian metastases. Hence, the sensitivity and specificity for absent OCS to identify a malignancy was 92% and 42%, respectively, and the positive and negative likelihood ratios (LR+ and LR-, respectively) were 1.60 and 0.18. Subjective impression performed significantly better than the OCS. Sensitivity and specificity were 90% and 92%, respectively, LR+ was 11.0 and LR- was 0.10. For discrimination between invasive vs. benign or borderline tumors, the sensitivity for absent OCS was 94%, the specificity was 40%, the LR+ was 1.58 and the LR- was 0.14.
  
  
  CONCLUSIONS
  This study confirms previous reports that the presence of the OCS decreases the likelihood of invasive malignancy in adnexal masses. However it is a poor discriminator between benign and malignant adnexal masses.
authors.affiliation: Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium. caroline.van.holsbeke@skynet.be
authors.forename: C
authors.initials: C
authors.lastname: Van Holsbeke
authors.forename: V
authors.initials: V
authors.lastname: Van Belle
authors.forename: F P G
authors.initials: FP
authors.lastname: Leone
authors.forename: S
authors.initials: S
authors.lastname: Guerriero
authors.forename: D
authors.initials: D
authors.lastname: Paladini
authors.forename: G B
authors.initials: GB
authors.lastname: Melis
authors.forename: S
authors.initials: S
authors.lastname: Greggi
authors.forename: D
authors.initials: D
authors.lastname: Fischerova
authors.forename: E
authors.initials: E
authors.lastname: De Jonge
authors.forename: P
authors.initials: P
authors.lastname: Neven
authors.forename: T
authors.initials: T
authors.lastname: Bourne
authors.forename: L
authors.initials: L
authors.lastname: Valentin
authors.forename: S
authors.initials: S
authors.lastname: Van Huffel
authors.forename: D
authors.initials: D
authors.lastname: Timmerman
mesh_terms: D000291:Adnexal Diseases / Q000000981:diagnostic imaging; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D009367:Neoplasm Staging; D010051:Ovarian Neoplasms / Q000000981:diagnostic imaging*; D010053:Ovary / Q000000981:diagnostic imaging*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D018608:Ultrasonography, Doppler