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<article article-type="research-article" dtd-version="1.3" xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xml:lang="ru"><front><journal-meta><journal-id journal-id-type="publisher-id">usfd</journal-id><journal-title-group><journal-title xml:lang="ru">Ультразвуковая и функциональная диагностика</journal-title><trans-title-group xml:lang="en"><trans-title>Ultrasound &amp; Functional Diagnostics</trans-title></trans-title-group></journal-title-group><issn pub-type="ppub">1607-0771</issn><issn pub-type="epub">2408-9494</issn><publisher><publisher-name>RDS-Media Ltd.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="doi">10.24835/1607-0771-2023-1-23-55</article-id><article-id custom-type="elpub" pub-id-type="custom">usfd-4</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group><subj-group subj-group-type="section-heading" xml:lang="ru"><subject>Ультразвуковая диагностика в акушерстве и гинекологии</subject></subj-group><subj-group subj-group-type="section-heading" xml:lang="en"><subject>Obstetrics and Gynecology Ultrasound</subject></subj-group></article-categories><title-group><article-title>Проспективное использование ультразвуковых систем O-RADS и ADNEX для стратификации риска злокачественных опухолей яичников</article-title><trans-title-group xml:lang="en"><trans-title>Prospective use of O-RADS and ADNEX ultrasound systems for risk stratification of ovarian malignancies</trans-title></trans-title-group></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0000-0001-8295-768X</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Буланов</surname><given-names>М. Н.</given-names></name><name name-style="western" xml:lang="en"><surname>Bulanov</surname><given-names>M. N.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Буланов Михаил Николаевич – доктор мед. наук, заведующий отделением ультразвуковой диагностики; профессор кафедры внутренних болезней Института медицинского образования</p><p>600023 Владимир, Судогодское шоссе, д. 41</p><p>173003 Великий Новгород, ул. Большая Санкт-Петербургская, д. 41</p></bio><bio xml:lang="en"><p>Mikhail N. Bulanov – Doct. of Sci. (Med.), Head of Ultrasound Diagnostics Department, Professor, Division of Internal Medicine, Institute of Medical Education</p><p>21, Sudogodskoye shosse, Vladimir 600023</p><p>41, Bolshaya St. Petersburgskaya str., Veliky Novgorod 173003</p></bio><email xlink:type="simple">doctorbulanov@gmail.com</email><xref ref-type="aff" rid="aff-1"/></contrib></contrib-group><aff-alternatives id="aff-1"><aff xml:lang="ru"><institution>ГБУЗ Владимирской области “Областная клиническая больница”; ФГБОУ ВО “Новгородский государственный университет имени Ярослава Мудрого”</institution></aff><aff xml:lang="en"><institution>Regional Clinical Hospital; Yaroslav-the-Wise Novgorod State University</institution></aff></aff-alternatives><pub-date pub-type="collection"><year>2023</year></pub-date><pub-date pub-type="epub"><day>13</day><month>12</month><year>2023</year></pub-date><volume>0</volume><issue>1</issue><fpage>23</fpage><lpage>55</lpage><permissions><copyright-statement>Copyright &amp;#x00A9; Буланов М.Н., 2023</copyright-statement><copyright-year>2023</copyright-year><copyright-holder xml:lang="ru">Буланов М.Н.</copyright-holder><copyright-holder xml:lang="en">Bulanov M.N.</copyright-holder><license xml:lang="ru" license-type="creative-commons-attribution" xlink:href="https://creativecommons.org/licenses/by/4.0/" xlink:type="simple"><license-p>Данная работа распространяется под лицензией Creative Commons Attribution 4.0.</license-p></license><license xml:lang="en" license-type="creative-commons-attribution" xlink:href="https://creativecommons.org/licenses/by/4.0/" xlink:type="simple"><license-p>This work is licensed under a Creative Commons Attribution 4.0 License.</license-p></license></permissions><self-uri xlink:href="https://usfd.rdsmedia.ru/jour/article/view/4">https://usfd.rdsmedia.ru/jour/article/view/4</self-uri><abstract><p>Цель исследования: проспективное изучение диагностической ценности ультразвуковых систем стратификации риска рака яичника ADNEX и O-RADS при дифференциальной диагностике доброкачественных и злокачественных опухолей яичников.Материал и методы. Проспективно обследовано 59 пациенток с 43 доброкачественными и 25 со злокачественными новообразованиями яичников. Для оценки риска рака яичников использовались ультразвуковые диагностические системы IOTA ADNEX (установлена на приборе) и O-RADS (приложение для смартфона ACR Guidance). Ультразвуковое заключение о наличии злокачественной опухоли с соответствующей маршрутизацией пациентки давалось при риске злокачественного процесса по ADNEX ≥10%, а также при ≥4 баллов риска малигнизации по O-RADS. Все 68 пациенток прошли оперативное лечение в ГБУЗ ВО “Областная клиническая больница” (г. Владимир) и ГБУЗ ВО “Област ной клинический онкологический диспансер” (г. Владимир).Результаты. Показатели чувствительности, специфичности, прогностической ценности положительного и отрицательного тестов, точности, а также площади под кривой (AUC) составили соответственно для ADNEX: 96, 81, 75, 97 и 87%, AUC 0,933; для O-RADS: 100, 74, 69, 100 и 90%, AUC 0,926.Выводы. Обе ультразвуковые диагностические системы при проспективной дифференциальной диагностике доброкачественных и злокачественных новообразований яичников продемонстрировали очень высокую чувствительность. При этом O-RADS позволила поставить правильный диагноз во всех 25 случаях злокачественных опухолей. Вместе с тем обе системы показали невысокую специфичность, причем незначительно более высокая оказалась уже у ADNEX (p &gt; 0,05). Показатели AUC были высокими у обеих диагностических систем. В связи с полученными результатами проведенного исследования считаем в настоящее время целесообразным параллельное использование систем ADNEX и O-RADS при ультразвуковом исследовании в гинекологии с отражением полученных результатов расчета риска злокачественных новообразований придатков матки в протоколе ультразвукового исследования</p></abstract><trans-abstract xml:lang="en"><p>Objectives. A prospective study of the diagnostic value of ultrasound ovarian cancer risk stratification systems ADNEX and O-RADS in the differential diagnosis of benign and malignant ovarian tumors.Material and methods. 59 patients with 43 benign and 25 with malignant ovarian tumors were prospectively examined. The ultrasound diagnostic systems IOTA ADNEX (installed on the device) and O-RADS (ACR Guidance smartphone application) were used to assess the risk of ovarian cancer. An ultrasound report on the presence of a malignant tumor with appropriate routing of the patient was given when the risk of malignancy according to ADNEX was ≥10%, as well as when the risk of malignancy was ≥4 points according to O-RADS. All patients underwent surgical treatment at the Regional Clinical Hospital (Vladimir) and the Regional Clinical Oncology Hospital (Vladimir).Results. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the curve (AUC) were respectively for ADNEX: 96, 81, 75, 97 and 87%, AUC 0.933; for O-RADS: 100, 74, 69, 10% and 90%, AUC 0.926.Conclusion. Both ultrasound diagnostic systems demonstrated very high sensitivity in the prospective differential diagnosis of benign and malignant ovarian tumors. At the same time, O-RADS made it possible to make the correct diagnosis in all 25 cases of malignant tumors. At the same time, both systems showed low specificity, with ADNEX having a slightly higher specificity (p &gt; 0.05). AUC values were high for both diagnostic systems. In connection with the results of the study, we currently consider it advisable to simultaneously use the ADNEX and O-RADS systems for ultrasound examination in gynecology, reflecting the results of calculating the risk of malignant neoplasms of the adnexal mass in the ultrasound examination protocol</p></trans-abstract><kwd-group xml:lang="ru"><kwd>ультразвуковая диагностика</kwd><kwd>опухоли яичников</kwd><kwd>ADNEX</kwd><kwd>O-RADS</kwd></kwd-group><kwd-group xml:lang="en"><kwd>ultrasound diagnostics</kwd><kwd>ovarian tumors</kwd><kwd>adnexal mass</kwd><kwd>ADNEX</kwd><kwd>O-RADS</kwd></kwd-group></article-meta></front><back><ref-list><title>References</title><ref id="cit1"><label>1</label><citation-alternatives><mixed-citation xml:lang="ru">Буланов М.Н., Зыкин Б.И., Новикова Т.И. Допплерография в диагностике рака яичников. Ультразвуковая диагностика в акушерстве, гинекологии и педиатрии. 1999; 4: 35–39.</mixed-citation><mixed-citation xml:lang="en">Bulanov M.N., Zykin B.I., Novikova T.I. Dopplerography in the diagnosis of ovarian cancer. Ultrasound diagnostics in obstetrics, gynecology and pediatrics. 1999; 4: 35–39. (In Russian)</mixed-citation></citation-alternatives></ref><ref id="cit2"><label>2</label><citation-alternatives><mixed-citation xml:lang="ru">Timmerman D., Valentin L., Bourne T.H., Collins W.P., Verrelst H., Vergote I. International Ovarian Tumor Analysis (IOTA) Group. Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis (IOTA) Group. Ultrasound Obstet. Gynecol. 2000; 16 (5): 500–505. http://doi.org/10.1046/j.1469-0705.2000.00287.x</mixed-citation><mixed-citation xml:lang="en">Timmerman D., Valentin L., Bourne T.H., Collins W.P., Verrelst H., Vergote I. International Ovarian Tumor Analysis (IOTA) Group. Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis (IOTA) Group. Ultrasound Obstet. Gynecol. 2000; 16 (5): 500–505. http://doi.org/10.1046/j.1469-0705.2000.00287.x</mixed-citation></citation-alternatives></ref><ref id="cit3"><label>3</label><citation-alternatives><mixed-citation xml:lang="ru">Van Calster B., Van Hoorde K., Froyman W., Kaijser J., Wynants L., Landolfo C., Anthoulakis C., Vergote I., Bourne T., Timmerman D. Practical guidance for applying the ADNEX model from the IOTA group to discriminate between different subtypes of adnexal tumors. Facts Views Vis. Obgyn. 2015; 7 (1): 32–41. PMID: 25897370. PMCID: PMC4402441</mixed-citation><mixed-citation xml:lang="en">Van Calster B., Van Hoorde K., Froyman W., Kaijser J., Wynants L., Landolfo C., Anthoulakis C., Vergote I., Bourne T., Timmerman D. Practical guidance for applying the ADNEX model from the IOTA group to discriminate between different subtypes of adnexal tumors. Facts Views Vis. Obgyn. 2015; 7 (1): 32–41. PMID: 25897370. PMCID: PMC4402441</mixed-citation></citation-alternatives></ref><ref id="cit4"><label>4</label><citation-alternatives><mixed-citation xml:lang="ru">Araujo K.G., Jales R.M., Pereira P.N., Yoshida A., de Angelo Andrade L., Sarian L.O., Derchain S. Performance of the IOTA ADNEX model in preoperative discrimination of adnexal masses in a gynecological oncology center. Ultrasound Obstet. Gynecol. 2017; 49 (6): 778–783. http://doi.org/10.1002/uog.15963</mixed-citation><mixed-citation xml:lang="en">Araujo K.G., Jales R.M., Pereira P.N., Yoshida A., de Angelo Andrade L., Sarian L.O., Derchain S. Performance of the IOTA ADNEX model in preoperative discrimination of adnexal masses in a gynecological oncology center. Ultrasound Obstet. Gynecol. 2017; 49 (6): 778–783. http://doi.org/10.1002/uog.15963</mixed-citation></citation-alternatives></ref><ref id="cit5"><label>5</label><citation-alternatives><mixed-citation xml:lang="ru">Landolfo C., Valentin L., Franchi D., Van Holsbeke C., Fruscio R., Froyman W., Sladkevicius P., Kaijser J., Ameye L., Bourne T., Savelli L., Coosemans A., Testa A., Timmerman D. Differences in ultrasound features of papillations in unilocularsolid adnexal cysts: a retrospective international multicenter study. Ultrasound Obstet. Gynecol. 2018; 52 (2): 269–278. http://doi.org/10.1002/uog.18951. PMID: 29119698</mixed-citation><mixed-citation xml:lang="en">Landolfo C., Valentin L., Franchi D., Van Holsbeke C., Fruscio R., Froyman W., Sladkevicius P., Kaijser J., Ameye L., Bourne T., Savelli L., Coosemans A., Testa A., Timmerman D. Differences in ultrasound features of papillations in unilocularsolid adnexal cysts: a retrospective international multicenter study. Ultrasound Obstet. Gynecol. 2018; 52 (2): 269–278. http://doi.org/10.1002/uog.18951. PMID: 29119698</mixed-citation></citation-alternatives></ref><ref id="cit6"><label>6</label><citation-alternatives><mixed-citation xml:lang="ru">Landolfo C., Bourne T., Froyman W., Van Calster B., Ceusters J., Testa A.C., Wynants L., Sladkevicius P., Van Holsbeke C., Domali E., Fruscio R., Epstein E., Franchi D., Kudla M.J., Chiappa V., Alcazar J.L., Leone F.P.G., Buonomo F., Coccia M.E., Guerriero S., Deo N., Jokubkiene L., Savelli L., Fischerova D., Czekierdowski A., Kaijser J., Coosemans A., Scambia G., Vergote I., Timmerman D., Valentin L. Benign descriptors and ADNEX in two-step strategy to estimate risk of malignancy in ovarian tumors: retrospective validation in IOTA5 multicenter cohort. Ultrasound Obstet. Gynecol. 2023; 61 (2): 231–242. http://doi.org/10.1002/uog.26080</mixed-citation><mixed-citation xml:lang="en">Landolfo C., Bourne T., Froyman W., Van Calster B., Ceusters J., Testa A.C., Wynants L., Sladkevicius P., Van Holsbeke C., Domali E., Fruscio R., Epstein E., Franchi D., Kudla M.J., Chiappa V., Alcazar J.L., Leone F.P.G., Buonomo F., Coccia M.E., Guerriero S., Deo N., Jokubkiene L., Savelli L., Fischerova D., Czekierdowski A., Kaijser J., Coosemans A., Scambia G., Vergote I., Timmerman D., Valentin L. Benign descriptors and ADNEX in two-step strategy to estimate risk of malignancy in ovarian tumors: retrospective validation in IOTA5 multicenter cohort. Ultrasound Obstet. Gynecol. 2023; 61 (2): 231–242. http://doi.org/10.1002/uog.26080</mixed-citation></citation-alternatives></ref><ref id="cit7"><label>7</label><citation-alternatives><mixed-citation xml:lang="ru">Andreotti R.F., Timmerman D., Benacerraf B.R., Bennett G.L., Bourne T., Brown D.L., Coleman B.G., Frates M.C., Froyman W., Goldstein S.R., Hamper U.M., Horrow M.M., Hernanz-Schulman M., Reinhold C., Strachowski L.M., Glanc P. Ovarian- Adnexal Reporting Lexicon for Ultrasound: A White Paper of the ACR Ovarian-Adnexal Reporting and Data System Committee. J. Am. Coll. Radiol. 2018; 15 (10): 1415–1429. http://doi.org/10.1016/j.jacr.2018.07.004 [Published correction appears in J. Am. Coll. Radiol. 2019; 16 (3): 403–406.</mixed-citation><mixed-citation xml:lang="en">Andreotti R.F., Timmerman D., Benacerraf B.R., Bennett G.L., Bourne T., Brown D.L., Coleman B.G., Frates M.C., Froyman W., Goldstein S.R., Hamper U.M., Horrow M.M., Hernanz-Schulman M., Reinhold C., Strachowski L.M., Glanc P. Ovarian- Adnexal Reporting Lexicon for Ultrasound: A White Paper of the ACR Ovarian-Adnexal Reporting and Data System Committee. J. Am. Coll. Radiol. 2018; 15 (10): 1415–1429. http://doi.org/10.1016/j.jacr.2018.07.004 [Published correction appears in J. Am. Coll. Radiol. 2019; 16 (3): 403–406.</mixed-citation></citation-alternatives></ref><ref id="cit8"><label>8</label><citation-alternatives><mixed-citation xml:lang="ru">Буланов М.Н., Чекалова М.А., Мазуркевич М.В., Ветшева Н.Н. Применение системы O-RADS при ультразвуковом исследовании придатков матки: Методические рекомендации. Серия “Лучшие практики лучевой и инструментальной диагностики”. М.: ГБУЗ “НПКЦ ДиТ ДЗМ”, 2022. 28 с.</mixed-citation><mixed-citation xml:lang="en">Bulanov M.N., Chekalova M.A., Mazurkevich M.V., Vetsheva N.N. Application of the O-RADS system for ultrasound examination of the adnexal mass: Guidelines. Series “Best practices in radiation and instrumental diagnostics”. M.: GBUZ “NPKTs DiT DZM”, 2022. 28 p. (In Russian)</mixed-citation></citation-alternatives></ref><ref id="cit9"><label>9</label><citation-alternatives><mixed-citation xml:lang="ru">Strachowski L.M., Jha P., Phillips C.H., Blanchette Porter M.M., Froyman W., Glanc P., Guo Y., Patel M.D., Reinhold C., Suh-Burgmann E.J., Timmerman D., Andreotti R.F. O-RADS US v2022: An Update from the American College of Radiology's Ovarian-Adnexal Reporting and Data System US Committee. Radiology. 2023; 308 (3): e230685. http://doi.org/10.1148/radiol.230685</mixed-citation><mixed-citation xml:lang="en">Strachowski L.M., Jha P., Phillips C.H., Blanchette Porter M.M., Froyman W., Glanc P., Guo Y., Patel M.D., Reinhold C., Suh-Burgmann E.J., Timmerman D., Andreotti R.F. O-RADS US v2022: An Update from the American College of Radiology's Ovarian-Adnexal Reporting and Data System US Committee. Radiology. 2023; 308 (3): e230685. http://doi.org/10.1148/radiol.230685</mixed-citation></citation-alternatives></ref><ref id="cit10"><label>10</label><citation-alternatives><mixed-citation xml:lang="ru">Andreotti R.F., Timmerman D., Strachowski L.M., Froyman W., Benacerraf B.R., Bennett G.L., Bourne T., Brown D.L., Coleman B.G., Frates M.C., Goldstein S.R., Hamper U.M., Horrow M.M., Hernanz-Schulman M., Reinhold C., Rose S.L., Whitcomb B.P., Wolfman W.L., Glanc P. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian- Adnexal Reporting and Data System Committee. Radiology. 2020; 294 (1): 168–185. http://doi.org/10.1148/radiol.2019191150</mixed-citation><mixed-citation xml:lang="en">Andreotti R.F., Timmerman D., Strachowski L.M.,</mixed-citation></citation-alternatives></ref><ref id="cit11"><label>11</label><citation-alternatives><mixed-citation xml:lang="ru">Hack K., Gandhi K., Kahn D., Glanc P. External validation O-RADS ultrasound risk stratificationand management system. Ultrasound Obstet. Gynecol. 2021; 58 (Suppl. 1): 1–57.</mixed-citation><mixed-citation xml:lang="en">Froyman W., Benacerraf B.R., Bennett G.L., Bourne T., Brown D.L., Coleman B.G., Frates M.C., Goldstein S.R., Hamper U.M., Horrow M.M., Hernanz-Schulman M., Reinhold C., Rose S.L., Whitcomb B.P., Wolfman W.L., Glanc P. O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian- Adnexal Reporting and Data System Committee. Radiology. 2020; 294 (1): 168–185. http://doi.org/10.1148/radiol.2019191150</mixed-citation></citation-alternatives></ref><ref id="cit12"><label>12</label><citation-alternatives><mixed-citation xml:lang="ru">Rodriguez N., Rodriguez N., Solano D.A., Pitalua N., Huertas B., Esquivel A., Buritica C. An external validation of the O-RADS risk stratification to differentiate between benign and malignant adnexal masses. Ultrasound Obstet. Gynecol. 2021; 58 (Suppl. 1): 1–57. https://doi.org/10.1002/uog.23787</mixed-citation><mixed-citation xml:lang="en">Hack K., Gandhi K., Kahn D., Glanc P. External validation O-RADS ultrasound risk stratificationand management system. Ultrasound Obstet. Gynecol. 2021; 58 (Suppl. 1): 1–57.</mixed-citation></citation-alternatives></ref><ref id="cit13"><label>13</label><citation-alternatives><mixed-citation xml:lang="ru">Vara J., Manzour N., Chacón E., López-Picazo A., Linares M., Pascual M.Á., Guerriero S., Alcázar J.L. Ovarian Adnexal Reporting Data System (O-RADS) for Classifying Adnexal Masses: A Systematic Review and Meta-Analysis. Cancers (Basel).2022; 14 (13): 3151. http://doi.org/10.3390/cancers14133151</mixed-citation><mixed-citation xml:lang="en">Rodriguez N., Rodriguez N., Solano D.A., Pitalua N., Huertas B., Esquivel A., Buritica C. An external validation of the O-RADS risk stratification to differentiate between benign and malignant adnexal masses. Ultrasound Obstet. Gynecol. 2021; 58 (Suppl. 1): 1–57. https://doi.org/10.1002/uog.23787</mixed-citation></citation-alternatives></ref><ref id="cit14"><label>14</label><citation-alternatives><mixed-citation xml:lang="ru">Буланов М.Н. Ультразвуковая диагностика в гине кологии: Руководство для врачей. М.: Издательский дом Видар-М, 2022. 712 с.</mixed-citation><mixed-citation xml:lang="en">Vara J., Manzour N., Chacón E., López-Picazo A., Linares M., Pascual M.Á., Guerriero S., Alcázar J.L. Ovarian Adnexal Reporting Data System (O-RADS) for Classifying Adnexal Masses: A Systematic Review and Meta-Analysis. Cancers (Basel). 2022; 14 (13): 3151. http://doi.org/10.3390/cancers14133151</mixed-citation></citation-alternatives></ref><ref id="cit15"><label>15</label><citation-alternatives><mixed-citation xml:lang="ru">Hiett A.K., Sonek J.D., Guy M., Reid T.J. Performance of IOTA Simple Rules, Simple Rules risk assessment, ADNEX model and O-RADS in differentiating between benign and malignant adnexal lesions in North American women. Ultrasound Obstet. Gynecol. 2022; 59 (5): 668–676. http://doi.org/10.1002/uog.24777</mixed-citation><mixed-citation xml:lang="en">Bulanov M.N. Ultrasound diagnostics in gynecology. Guide for doctors. Moscow: Vidar-M Publishing House, 2022. 712 p. (In Russian)</mixed-citation></citation-alternatives></ref><ref id="cit16"><label>16</label><citation-alternatives><mixed-citation xml:lang="ru">Hiett A.K., Sonek J.D., Guy M., Reid T.J. Performance of IOTA Simple Rules, Simple Rules risk assessment, ADNEX model and O-RADS in differentiating between benign and malignant adnexal lesions in North American women. Ultrasound Obstet. Gynecol. 2022; 59 (5): 668–676. http://doi.org/10.1002/uog.24777</mixed-citation><mixed-citation xml:lang="en">Hiett A.K., Sonek J.D., Guy M., Reid T.J. Performance of IOTA Simple Rules, Simple Rules risk assessment, ADNEX model and O-RADS in differentiating between benign and malignant adnexal lesions in North American women. Ultrasound Obstet. Gynecol. 2022; 59 (5): 668–676. http://doi.org/10.1002/uog.24777</mixed-citation></citation-alternatives></ref><ref id="cit17"><label>17</label><citation-alternatives><mixed-citation xml:lang="ru"></mixed-citation><mixed-citation xml:lang="en"></mixed-citation></citation-alternatives></ref></ref-list><fn-group><fn fn-type="conflict"><p>The authors declare that there are no conflicts of interest present.</p></fn></fn-group></back></article>
