Diagnostic Value of Combining O-RADS US v2022, Contrast-enhanced Ultrasound Score, and ROMA for Differentiating Adnexal Masses

Diagnostic Value of Combining O-RADS US v2022, Contrast-enhanced Ultrasound Score, and ROMA for Differentiating Adnexal Masses | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Diagnostic Value of Combining O-RADS US v2022, Contrast-enhanced Ultrasound Score, and ROMA for Differentiating Adnexal Masses Wenting xie, Qianyi Zhang, Xiaohong Deng, Yanni Gao, Ran Huo, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9218597/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Objective Accurately differentiating malignant from benign adnexal masses (AMs) remains a considerable clinical challenge. Therefore, this study aimed to evaluate the diagnostic value of combining the Ovarian–Adnexal Reporting and Data System (O-RADS) v2022, contrast-enhanced ultrasound (CEUS) score, and Risk of Ovarian Malignancy Algorithm (ROMA) for distinguishing AMs. Methods We conducted a retrospective study of patients with AMs who underwent CEUS prior to surgery at our institution between October 2018 and February 2025. We assessed diagnostic performance using receiver operating characteristic (ROC) curves, calculating sensitivity, specificity, area under the ROC curve (AUC), and 95% confidence intervals (CIs) for each diagnostic approach. The DeLong’s test was employed to compare ROC curves. Results A total of 147 women were included, with 49 (33.3%) having benign ovarian tumors and 98 (66.7%) having malignant tumors. The AUC values were as follows: O-RADS v2022 alone, 0.755 (95% CI: 0.677–0.822); CEUS alone, 0.878 (95% CI: 0.813–0.926); O-RADS v2022 + CEUS, 0.903 (95% CI: 0.844–0.946); O-RADS v2022 + ROMA, 0.857 (95% CI: 0.790–0.909); CEUS + ROMA, 0.905 (95% CI: 0.846–0.947); and O-RADS v2022 + ROMA + CEUS, 0.920 (95% CI: 0.864–0.959). The sensitivity and specificity values for each approach were as follows: O-RADS v2022 (100% and 51.0%), CEUS (93.9% and 81.6%), O-RADS v2022 + CEUS (93.4% and 83.7%), O-RADS v2022 + ROMA (100% and 51.0%), CEUS + ROMA (95.9% and 81.6%), and O-RADS v2022 + ROMA + CEUS (95.9% and 83.7%, respectively). Conclusions The combination of O-RADS v2022, CEUS, and ROMA demonstrates superior diagnostic performance for distinguishing malignant from benign AMs compared with any single modality. Adnexal masses Ovarian-adnexal reporting and data systems contrast-enhanced ultrasound Adnexal masses Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Adnexal masses (AMs) frequently occur in women, with the primary clinical imperative being to determine their benign or malignant nature [ 1 ]. This distinction is critical as it influences subsequent treatment decisions: while benign masses are typically managed with surveillance or conservative surgery, malignant masses require urgent referral to a gynecologic oncologist for definitive interventions, such as cytoreductive surgery and chemotherapy [ 2 ]. Consequently, establishing an accurate differential diagnosis for AMs is vital for guiding optimal clinical management and enhancing patient prognosis. Currently, imaging modalities and serum tumor biomarkers are routinely employed to evaluate the nature of AMs [ 3 , 4 ]. Among these, cancer antigen 125 (CA125) and human epididymis protein 4 (HE4) are crucial for assessing ovarian malignancy. However, CA125 levels can also be elevated in benign conditions such as endometriosis, pelvic inflammatory disease, and pregnancy, limiting its sensitivity in early-stage ovarian cancer [ 5 ]. In contrast, HE4 offers greater specificity for distinguishing benign lesions and aids in early diagnosis, remission monitoring, and response assessment. To leverage their complementary strengths, the Risk of Malignancy Algorithm (ROMA) was developed, integrating CA125 and HE4 levels with menopausal status to estimate malignancy risk [ 6 ]. The ROMA index has demonstrated effectiveness in differentiating ovarian cancer and benign tumors, with a meta-analysis reporting a pooled sensitivity of 91.1% and specificity of 84.6% [ 7 ]. Despite the utility of serum biomarkers, imaging remains the cornerstone of initial evaluation [ 8 ]. Owing to its convenience, cost-effectiveness, and lack of ionizing radiation, ultrasound (US) has been established as the first-line imaging modality for assessing gynecological conditions [ 9 ]. Several US models have been formulated to determine the malignancy risk of AMs, with the recently developed Ovarian–Adnexal Reporting and Data Systems (O-RADS) US v2022, released by the American College of Radiology (ACR) in November 2022, being notable [ 10 , 11 ]. This updated version aims to improve diagnostic accuracy and specificity by refining certain risk categories and management recommendations from the 2020 edition [ 11 ]. Nevertheless, a potential limitation of this system is its evaluation of vascularity. Within O-RADS US v2022, the color Doppler blood flow score (range: 1–4 points) is assigned based on findings from conventional color Doppler US, a process that is inherently subjective and dependent on radiologist interpretation [ 12 ]. Contrast-enhanced ultrasound (CEUS) works by injecting microbubble contrast agents into the peripheral veins[ 13 ]. This technique enhances lesion conspicuity and provides objective, real-time visualization of tumor microvascular perfusion, facilitating the differentiation of benign and malignant lesions. Consequently, integrating CEUS into the O-RADS v2022 framework presents a promising strategy to overcome the limitations of conventional Doppler and improve diagnostic confidence in suspected malignancies. This study primarily aimed to investigate and compare the diagnostic value of O-RADS US v2022, the CEUS score, and the ROMA index in differentiating AMs. Building on this comparative analysis, the secondary objective was to determine whether a combined model that incorporates all three tools could achieve superior diagnostic performance in distinguishing benign from malignant AMs. Methods This prospective study was approved by the ethics review committee of Fujian Cancer Hospital (K2023-124-01), and all subjects provided written informed consent prior to the examination. Study population A total of 185 cases of AMs diagnosed at Fujian Cancer Hospital between October 2018 and February 2025 were collected, with 147 cases ultimately included in the study. The inclusion criteria were as follows: (1) Age ≥ 18 years; (2) participants with an AM who underwent US and CEUS examinations; (3) surgical or puncture pathology confirmation. The exclusion criteria were as follows: (1) Poor-quality US images; (2) incomplete clinical data; (3) contraindications to US contrast agents. Figure 1 illustrates the participant flowchart. Demographic and clinical data, including age, menopausal status, serum HE4 and CA125 levels, and pathological diagnoses, were sourced from the hospital’s electronic medical records. US acquisition All conventional US and CEUS assessments were conducted using GE Healthcare, Supersonic Aixplorer, and Philips US systems. The approach—transabdominal or transvaginal—was selected based on clinical indications, with examinations performed using the appropriate probes (transabdominal: 1–5 or 1–6 MHz; transvaginal: 5–9 or 3–12 MHz). Sequential multi-section scanning was performed to comprehensively assess the uterus, adnexa, and mass. For patients with bilateral masses, the lesion was selected based on the largest diameter or the most complex morphology. Conventional US characteristics were systematically evaluated and recorded, including lesion size, location, acoustic shadowing, solid component dimensions, number and size of papillary projections, septation, ascites, and color flow distribution. Conventional ultrasonography was initially conducted to capture imaging planes encompassing the entire mass and uterus. The system was subsequently switched to CEUS mode, operating in a dual-window display with the mechanical index set to a low range (0.06–0.08). Subsequently, a 2.4 mL bolus of SonoVue (Bracco SPA, Milan, Italy) suspension was injected via the cubital vein. The perfusion and washout dynamics of the contrast agent within the lesion and surrounding tissues were observed in real-time, and dynamic imaging sequences were stored for subsequent analysis. Image analysis Two senior sonologists, each with ≥ 8 years of experience, independently reviewed and classified all US images in a retrospective analysis based on the ACR O-RADS US v2022 guidelines. Any discrepancies in classification were resolved by consensus following a joint review of the cases. The CEUS scoring criteria included three components, compared with the myometrium [ 14 , 15 ]: enhancement timing (1 point for late enhancement and 2 points for synchronous or early enhancement); enhancement intensity (0 points for no enhancement, 1 point for hypoenhancement, and 2 points for iso- or hyperenhancement); and dynamic change in enhancement (0 points for sustained hyper-/iso-/hypoenhancement, and 1 point for washout to hypoenhancement). ROMA index Preoperative serum CA-125 and HE4 levels were measured using an electrochemiluminescence immunoassay on a COBAS 8000 system (Roche, Switzerland). The ROMA index, which incorporates menopausal status along with preoperative CA-125 and HE4 levels, was calculated utilizing a dedicated algorithm to predict the risk of ovarian tumor malignancy, as follows: ROMA = exp.(PI) / [1 + exp.(PI)] × 100. The Predictive Index (PI) is calculated using the following formula: - Premenopausal women: PI = − 12.0 + 2.38 × LN (natural log) [HE4] + 0.0626 × LN [CA125] - Postmenopausal women: PI = − 8.09 + 1.04 × LN [HE4] + 0.732 × LN [CA125] A high risk of ovarian cancer was defined as a ROMA index ≥ 11.4% for premenopausal patients and ≥ 29.9% for their postmenopausal counterparts [ 16 ]. Statistical analysis Statistical analyses were performed using the Statistical Package for the Social Sciences (version 27.0) and MedCalc (version 22.001) software. Categorical variables were compared using the chi-square or Fisher’s exact test, with results presented as frequencies and percentages. Normally distributed continuous variables are expressed as the mean ± standard deviation and were compared using the independent samples t-test. Non-normally distributed continuous variables are presented as medians with interquartile ranges (IQRs) and were analyzed using the Mann–Whitney U test. Receiver operating characteristic (ROC) curve analysis was conducted to calculate the area under the curve (AUC), with the corresponding sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) determined. Comparisons between AUCs were performed using DeLong’s test. All statistical tests were two-tailed, with a P-value of < 0.05 considered statistically significant. Results Clinicopathological characteristics of the patients A total of 147 patients with AMs were enrolled in this study. Table 1 summarizes their clinical characteristics. Among these, 49 masses were benign, whereas 98 were malignant. The mean age of patients with benign masses was 45.3 ± 13.9 years, while that of those with malignant masses was 52.1 ± 10.9 years. Of the 49 benign cases (30.6%), 15 were postmenopausal, compared to 56 (57.1%) of the 98 malignant cases. Malignant AMs were more frequently bilateral than benign ones (29.6% versus 8.2%). Regarding lesion size, malignant masses exhibited a larger median maximum diameter than benign ones (108.5 mm [IQR: 86.2–139.5] versus 67 mm [IQR: 51–104]). Elevated serum CA-125 levels (reference: < 35 U/mL) were observed in 38.8% and 76.5% of patients with benign and malignant masses, respectively. Furthermore, a higher frequency of elevated ROMA indices was noted in malignant cases than in benign cases (54.1% versus 6.1%). Table 2 details the pathological diagnoses, O-RADS US v2022 classifications, and CEUS scores of the included lesions. The most common benign lesion was endometriotic cysts (18.3%), while serous cystadenocarcinoma (37.8%) was the most prevalent malignant AM. Table 1 Baseline information of the participants Characteristics Benign (n = 49) Malignant (n = 98) P Value Age (years) 45.3 ± 13.9 52.1 ± 10.9 0.001 Menopausal status 0.002 Premenopausal 34(69.4) 42(42.9) Postmenopausal 15(30.6) 56(57.1) Maximum diameter of lesion (mm) median (IQR) 67(51,104) 108.5(86.2,139.5) <0.001 Maximum diameter of solid component (mm) median (IQR) 17(0,37) 74.5(46.5,104) <0.001 Laterality(%) 0.003 Unilateral 45(91.8) 69(70.4) Bilateral 4(8.2) 29(29.6) CA125 (U/ml) <0.001 < 35 30(61.2) 23(23.5) ≥ 35 19(38.8) 75(76.5) HE4 (pmol/ml) <0.001 < 140 49(100) 61(62.2) ≥ 140 0(0) 37(37.8) ROMA <0.001 Normal 46(93.9) 45(45.9) Elevated 3(6.1) 53(54.1) Table 2 Correlations of O-RADS US v2022 and CEUS score with the final pathological diagnosis of adnexal masses in this study Type of pathology n O-RADS US v2022 CEUS Score 2–3 4–5 1–3 4–5 Benign 49 Corpus luteum cyst 2 1 1 2 0 Follicular cyst 5 3 2 5 0 Endometriotic cyst 9 5 4 8 1 Serous cystadenoma 8 6 2 8 0 Mucinous cystadenoma 6 2 4 5 1 Mature teratoma 7 6 1 7 0 Struma ovarii 2 0 2 0 2 Thecoma-Fibroma 5 1 4 3 2 Sclerosing Stromal Tumor 1 0 1 0 1 Inflammatory Disease 4 1 3 1 3 Malignant 98 Borderline serous cystadenoma 10 0 10 0 10 Borderline mucinous cystadenoma 6 0 6 0 6 Borderline endometrioid tumor 2 0 2 0 2 Serous cystadenocarcinoma 37 0 37 0 37 Mucinous cystadenocarcinoma 6 0 6 0 6 Endometrioid carcinoma 5 0 5 0 5 Clear cell carcinoma 9 0 9 0 9 Adult-type granulosa cell tumor 3 0 3 1 2 Sertoli-Leydig Cell Tumor 1 0 1 1 0 Immature teratoma 3 0 3 2 1 Germ cell tumours 1 0 1 0 1 Carcinosarcoma 3 0 3 0 3 Ovarian Metastases 12 0 12 2 10 Note: O-RADS: Ovarian-Adnexal Reporting and Data System; CEUS: Contrast-enhanced ultrasound Conventional ultrasonography and CEUS findings Table 3 presents the ultrasonic findings for 147 masses. Among benign cases, the most common presentation was a unilocular cyst with solid components, accounting for 28.6% (14/49) of masses. In contrast, malignant cases predominantly exhibited solid morphology, observed in 46.9% (46/98) of lesions. Compared to benign masses, 15.3% of malignant cases demonstrated more than 10 cyst locules. Acoustic shadowing was infrequent, noted in only one benign and two malignant cases. Ascites was present in 30.6% of malignant cases, while only one case with inflammatory infiltration exhibited ascites. Table 3 Conventional two-dimensional and contrast-enhanced ultrasound findings of adnexal masses Features Benign (n = 49) Malignant (n = 98) P Value Type of lesion <0.001 Unilocular cyst without solid components 11(22.4) 0(0) Unilocular cyst with solid components 14(28.6) 31(31.6) Bi-or multilocular cyst without solid components 6(12.2) 3(3.1) Bi-or multilocular cyst with solid components 10(20.4) 18(18.4) Solid lesion 8(16.3) 46(46.9) Number of papillary structures 0.046 0 32(65.3) 60(61.2) 1–3 17(34.7) 27(27.6) >3 0(0) 11(11.2) Acoustic shadows 1.000 No 48(97.9) 96(98.0) Yes 1(2.1) 2(2.0) >10 cyst locules 0.015 No 48(98.0) 83(84.7) Yes 1(2.0) 15(15.3) Ascites <0.001 No 48(95.9) 68(69.4) Yes 1(4.1) 30(30.6) Color score <0.001 1 38(77.6) 26(26.5) 2 4(8.2) 30(30.6) 3 6(12.2) 20(20.4) 4 1(2.0) 22(22.4) O-RADS US v2022 <0.001 2 12(24.5) 0(0) 3 13(26.5) 0(0) 4 23(46.9) 32(32.7) 5 1(2.0) 66(67.3) Initial enhancement time <0.001 Late enhancement 38(77.6) 6(6.1) Synchronous or early enhancement 11(22.4) 92(93.9) Enhancement intensity <0.001 None 23(46.9) 0(0) Hypo-enhancement 16(32.7) 5(5.1) Iso- or hyper-enhancement 10(20.4) 93(94.9) Dynamic change <0.001 Sustained hyper-/iso-/hypo-enhancement 43(87.8) 25(25.5) Washout to hypoenhancement 6(12.2) 73(74.5) These differences were statistically significant. Moderate to very strong vascular flow was observed in 14.2% and 42.8% of benign and malignant masses, respectively. O-RADS classification According to the O-RADS classification (Table 3 ), among the 49 benign masses, 12 (24.5%) were classified as O-RADS 2, 13 (26.5%) as O-RADS 3, 23 (46.9%) as O-RADS 4, and 1 (2.0%) as O-RADS 5. Of the 98 malignant masses, none were classified as O-RADS 2 or 3, 32 (32.7%) were O-RADS 4, while 66 (67.3%) were O-RADS 5. The malignancy rates based on pathological findings for O-RADS 2–5 were 0% (0/0), 0% (0/0), 58.2% (32/55), and 98.5% (66/67), respectively. Notably, 24 benign tumors were classified as O-RADS 4 or 5, including ovarian endometriosis cysts, mucinous cystadenomas, thecoma-fibromas, sclerosing stromal tumors, struma ovarii, and inflammatory disease (Table 2 ). CEUS Score On CEUS (Table 3 ), benign masses predominantly presented with late enhancement (38/49, 77.6%), whereas malignant lesions primarily demonstrated synchronous or early enhancement (92/98, 93.9%). Conversely, only 6.1% (6/98) of malignant lesions exhibited late enhancement, while 22.4% (11/49) of benign masses displayed synchronous or early enhancement. Washout to hypoenhancement was observed in 12.2% (6/49) and 74.5% (73/98) of benign and malignant masses, respectively. Regarding enhancement intensity, iso- or hyperenhancement was noted in 20.4% (10/49) of benign masses and 94.9% (93/98) of malignant lesions. A CEUS score of 4–5 was assigned to 10 benign masses, including one ovarian endometriosis cyst, one mucinous cystadenoma, two thecoma-fibromas, one sclerosing stromal tumor, two struma ovarii, and three inflammatory lesions. In contrast, six malignant lesions received a CEUS score of 1–3, encompassing adult-type granulosa cell tumors, Sertoli–Leydig cell tumors, immature teratomas, and ovarian metastases (Table 2 ). Figures 2 – 5 provide representative imaging findings of benign and malignant ovarian–adnexal lesions. Diagnostic performance of O-RADS, CEUS, ROMA, and their combinations in AMs Using an O-RADS score ≥ 4 as the threshold for diagnosing adnexal malignancy, the AUC was 0.755. With a CEUS score ≥ 4 serving as the cutoff, the AUC increased to 0.878. Table 4 summarizes the sensitivity, specificity, accuracy, AUC, PPV, and NPV scores for each diagnostic modality. Combining O-RADS and CEUS scores yielded superior diagnostic performance compared to O-RADS alone (AUC: 0.903; 95% confidence interval [CI]: 0.844–0.946 versus AUC: 0.755; 95% CI: 0.677–0.822). Notably, the tripartite combination of O-RADS, CEUS, and ROMA achieved the highest diagnostic accuracy in this study, with sensitivity, specificity, and AUC values of 95.9%, 83.7%, and 0.920, respectively (Fig. 6 ). This integrated approach demonstrated excellent diagnostic performance, significantly outperforming each method individually ( P < 0.05). Table 4 Diagnostic performance of O-RADS v2022, CEUS, and ROMA in differentiating adnexal lesions Methods AUC (95%CI) Sensitivity (%) Specificity(%) Accuracy (%) PPV (%) NPV (%) O-RADS v2022* 0.755 (0.677–0.822) 100 51.0 83.6 80.3 100 CEUS** 0.878 (0.813–0.926) 93.9 81.6 89.7 91.1 87.0 O-RADS v2022 + CEUS*** 0.903 (0.844–0.946) 93.4 83.7 83.6 92.0 87.2 O-RADS v2022 + ROMA ༆ 0.857 (0.790–0.909) 100 51.0 83.6 80.3 100 CEUS+ROMA ༆༆ 0.905 (0.846–0.947) 95.9 81.6 93.8 91.3 90.9 O-RADS v2022 + ROMA+CEUS 0.920 (0.864–0.959) 95.9 83.7 94.5 92.2 91.1 Note: O-RADS, ovarian reporting and data system; CEUS, contrast-enhanced ultrasound; ROMA,;PPV, Positive predictive value; NPV, Negative predictive value;AUC, area under the receiver operating characteristic curve *indicates a significant difference compared with that of O-RADS v2022 + ROMA+CEUS, p <0.0001. **indicates a significant difference compared with that of O-RADS v2022 + ROMA+CEUS, p = 0.0243. ***indicates a significant difference compared with that of O-RADS v2022 + ROMA+CEUS, p = 0.2442. ༆ indicates a significant difference compared with that of O-RADS v2022 + ROMA+CEUS, p = 0.0002. ༆༆ indicates a significant difference compared with that of O-RADS v2022 + ROMA+CEUS, p = 0.0416. Discussion While the O-RADS US v2022 improves specificity by incorporating acoustic shadows and bilocular cysts, research indicates that its specificity remains relatively limited despite high sensitivity [ 17 ]. CEUS can effectively complement O-RADS by better characterizing masses with ambiguous morphological features [ 18 , 19 ]. Our findings corroborate those of previous studies, indicating that CEUS features significantly differentiate between benign and malignant AMs [ 20 ]. Malignant ovarian tumors typically exhibit synchronous or early contrast perfusion relative to the myometrium, along with higher enhancement intensity [ 14 ]. In this study, 10 out of 13 O-RADS 4 cystic-solid masses displayed minimal to no vascularity on contrast-enhanced imaging—consistent with their pathological diagnoses of mucinous cystadenomas, endometriotic cysts, or hemorrhagic cysts—resulting in low CEUS scores. This ability to definitively assess blood supply effectively addresses the limitations of conventional US in detecting low-velocity flow. Conversely, five malignant ovarian masses demonstrated late enhancement with hypo- or isoenhancement, yielding low CEUS scores; these included immature teratomas, adult-type granulosa cell tumors, and ovarian metastases. This may be attributed to insufficient microcirculatory changes in some malignant tumors to produce typical perfusion patterns. Misdiagnosis using O-RADS and CEUS primarily arose from overlapping ultrasonographic features and contrast enhancement patterns between benign and malignant ovarian tumors. For instance, one patient presented with a sclerosing stromal tumor appearing as a well-defined solid hypoechoic mass with abundant blood flow on two-dimensional US, resulting in high CEUS enhancement and a classification of O-RADS 4 with a CEUS score of 5. However, the ultrasonographic characteristics of this lesion differed from those previously reported by Xu et al., who described sclerosing stromal tumors as possessing poor blood supply [ 21 ]. In this study, both conventional US and CEUS misdiagnosed this lesion, possibly due to the rarity of such tumors complicating preoperative diagnosis. In another case, a moderately differentiated Sertoli–Leydig cell tumor was categorized as O-RADS 4 yet received a low CEUS score that might have suggested a benign mass, leading to diagnostic inconsistency. Additionally, three inflammatory masses were misidentified as malignant on CEUS—likely attributed to inflammatory factors stimulating local blood flow—leading to increased vascularity and rapid enhancement. Overall, tumor markers can serve as valuable adjunctive tools for refining differential diagnosis for patients with inconclusive ultrasound findings. While ROMA demonstrates comparable sensitivity to CA125, it exhibits superior specificity, particularly in premenopausal women [ 22 ]. These findings have motivated efforts to integrate imaging features with serum biomarkers such as CA125 and HE4. Previous studies have revealed that the triple combination of O-RADS, CEUS, and CA125 enhances diagnostic accuracy for ovarian–adnexal malignancies [ 23 , 24 ]. In line with prior research, we observed a higher rate of elevated ROMA scores in malignant lesions than in benign ones [ 25 ]. Nonetheless, to the best of our knowledge, no study has yet investigated whether adding ROMA to O-RADS and CEUS assessments improves differentiation between benign and malignant AMs. Our study demonstrates that this combined approach enhances diagnostic performance, yielding sensitivity, specificity, PPV, NPV, and accuracy scores of 95.9%, 83.7%, 92.2%, 91.1%, and 94.5%, respectively. Notwithstanding, this study has certain limitations. First, its retrospective, single-center design, along with an imbalance in the number of malignant and benign cases, necessitates validation through prospective, multicenter studies with larger sample sizes. Second, the absence of quantitative CEUS analysis might have introduced subjectivity into the interpretations. Finally, the exclusive consideration of surgically treated cases might have resulted in selection bias. Conclusions This study demonstrates that CEUS provides superior diagnostic efficacy compared to conventional US for AMs. Moreover, integrating O-RADS, CEUS, and ROMA significantly enhances differentiation between benign and malignant lesions. Declarations Ethics approval and consent to participate This prospective study was approved by the ethics review committee of Fujian Cancer Hospital (K2023-124-01), and all subjects provided written informed consent prior to the examination. Consent for publication Not applicable. Availability of data and materials All data generated or analysed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding This study was supported by the Fujian Provincial Natural Science Foundation of China [Grant number 2023J011240]; Joint Funds for the innovation of science and Technology, Fujian province [Grant number 2023Y9397]. Author Contributions W. T.X. and Y.Q.W. wrote the main manuscript text and were major contributors to the writing of the manuscript. Q.Y.Z. and X.H.D. collected and analyzed the patient data regarding the adnexal masses. R.H. and Y.N.G. performed the laboratory examination of the adnexal masses. L.N.T. edited the manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable References Smolarz B, Biernacka K, Łukasiewicz H, Samulak D, Piekarska E, Romanowicz H, Makowska M. 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The value of contrast-enhanced ultrasonography in differential diagnosis of benign and malignant ovarian sex cord stromal tumors. Gland Surg. 2022;11(6):1086–93. Fathi A, Heidari M, Rasouli J, Ghasemnejad-Berenji H. Diagnostic value of the Risk of Ovarian Malignancy Algorithm (ROMA) index in the detection of ovarian cancer in postmenopausal women: a systematic review and meta-analysis. BMC Womens Health. 2025;25(1):280. Jiang Z, Pu W, Luo X, Zhang J, Jia S, Zhang G, Zhu Y. Integrating O-RADS US v2022, CEUS, and CA125 to enhance the diagnostic differentiation of ovarian masses: development of the OCC-US model. Cancer Imaging. 2025;25(1):96. Zhang J. Efficacy of a combination of O-RADS, CEUS, and CA125, in identification of ovary-adnexal malignant lesions. Am J Cancer Res. 2025;15(2):631–42. Tangjanyatham P, Chaowawanit W. Comparison of sensitivity for Risk of Ovarian Malignancy Algorithm (ROMA) and Assessment of Different NEoplasias in the adneXa (ADNEX) model for predicting ovarian cancer in a woman with adnexal masses. Int J Gynecol cancer: official J Int Gynecol Cancer Soc. 2025;35(6):101827. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 06 May, 2026 Reviewers agreed at journal 26 Apr, 2026 Reviewers invited by journal 23 Apr, 2026 Editor invited by journal 27 Mar, 2026 Editor assigned by journal 26 Mar, 2026 Submission checks completed at journal 26 Mar, 2026 First submitted to journal 25 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9218597","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633600996,"identity":"11129051-09c0-435b-a195-5fab6bb84fa3","order_by":0,"name":"Wenting xie","email":"","orcid":"","institution":"Fujian Provincial Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wenting","middleName":"","lastName":"xie","suffix":""},{"id":633600997,"identity":"10991223-2e21-45f7-b8c8-0074e6a2bd20","order_by":1,"name":"Qianyi Zhang","email":"","orcid":"","institution":"Fujian Provincial Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qianyi","middleName":"","lastName":"Zhang","suffix":""},{"id":633600998,"identity":"4090463e-3042-4ff8-8134-65800325e66d","order_by":2,"name":"Xiaohong Deng","email":"","orcid":"","institution":"Fujian Provincial Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaohong","middleName":"","lastName":"Deng","suffix":""},{"id":633600999,"identity":"c5adfa93-2dc3-4903-86f0-473f1e8a0bef","order_by":3,"name":"Yanni Gao","email":"","orcid":"","institution":"Fujian Provincial Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yanni","middleName":"","lastName":"Gao","suffix":""},{"id":633601000,"identity":"d44fff6c-789d-418e-a72a-910ee1738c51","order_by":4,"name":"Ran Huo","email":"","orcid":"","institution":"Fujian Provincial Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ran","middleName":"","lastName":"Huo","suffix":""},{"id":633601001,"identity":"c734af25-ee7d-4eda-9056-fb186272c4f7","order_by":5,"name":"Lina Tang","email":"","orcid":"","institution":"Fujian Provincial Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lina","middleName":"","lastName":"Tang","suffix":""},{"id":633601002,"identity":"ce98b834-310e-43cb-8791-244bc9257444","order_by":6,"name":"Yaoqin Wang","email":"data:image/png;base64,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","orcid":"","institution":"Fujian Provincial Cancer Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yaoqin","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2026-03-25 05:53:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9218597/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9218597/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108734790,"identity":"c66662e4-2413-4da1-b7db-6703f7bde57f","added_by":"auto","created_at":"2026-05-07 19:56:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":496827,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flowchart.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9218597/v1/753efd66c215c1c9e4025bb6.png"},{"id":108806019,"identity":"f31fb401-b9f3-4236-8b7c-6033cf76158f","added_by":"auto","created_at":"2026-05-08 15:27:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":8240219,"visible":true,"origin":"","legend":"\u003cp\u003eExample images from a 31-year-old woman with an endometriotic cyst and a normal risk of malignancy algorithm (ROMA) index. (A) The ultrasound image depicts a multilocular cyst with a solid component in the left adnexal region, classified as Ovarian–Adnexal Reporting and Data System (O-RADS) category 4. (B) Color Doppler flow imaging reveals minimal vascularity within the lesion. (C-D) Side-by-side grayscale ultrasound (left) and contrast-enhanced ultrasound (CEUS, right) images obtained from the same plane. (C) CEUS demonstrates a septal area illustrating late enhancement and isoenhancement intensity (arrows) relative to the myometrium (*), while the solid component exhibits no enhancement. (D) Dynamic CEUS imaging depicts sustained isoenhancement of the septum compared with the myometrium (*), with the solid component remaining non-enhancing throughout. The lesion received a CEUS score of 3 and was ultimately diagnosed as benign.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-9218597/v1/aeb08cf181d6831cbfd8a75e.png"},{"id":108806158,"identity":"4ef20bf8-9e36-4944-b027-f2e77505d25e","added_by":"auto","created_at":"2026-05-08 15:27:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":8341797,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasonographic images of a sclerosing stromal tumor in the left adnexa of a 20-year-old female patient with a ROMA index of 1.54%. (A) Grayscale ultrasound illustrates a solid lesion in the left adnexal region. (B) Color Doppler imaging reveals relatively abundant blood flow signals within the lesion (color score = 3). Based on these features, the lesion was classified as O-RADS US v2022 category 4. (C) CEUS demonstrates synchronous enhancement with isoenhancement intensity (arrows) relative to the myometrium (*). (D) Dynamic CEUS imaging depicts a washout pattern, with the lesion transitioning from isoenhancement to hypoenhancement compared with the myometrium (*). The overall CEUS score was 5.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-9218597/v1/f0a08e54d3583b76aa46ba5d.png"},{"id":108734789,"identity":"84ee1e59-01fe-4f0c-a33c-788ec5fc5cb3","added_by":"auto","created_at":"2026-05-07 19:56:02","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":6945856,"visible":true,"origin":"","legend":"\u003cp\u003eExample images from a 40-year-old woman diagnosed with borderline serous cystadenoma and a ROMA index of 8%. (A) Ultrasound image illustrates a unilocular cyst with more than three papillary projections in the right adnexal region, classified as O-RADS category 5. (B) Color Doppler imaging reveals no detectable blood flow within the papillary projections. (C-D) Side-by-side CEUS (left) and grayscale ultrasound (right) images obtained from the same plane. (C) CEUS displays early enhancement with hyperenhancement intensity (arrows) relative to the myometrium (*). (D) Dynamic CEUS imaging demonstrates a washout pattern, with the lesion transitioning from hyperenhancement to hypoenhancement (arrows) compared with the myometrium (*). Based on these findings, the lesion remained classified as O-RADS category 5, with a corresponding CEUS score of 5.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-9218597/v1/33ca3b30989ecbda116c7dc3.png"},{"id":108806802,"identity":"ef66b43e-b7e3-462f-b1a0-c9bfb26eedb8","added_by":"auto","created_at":"2026-05-08 15:29:30","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":7340372,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasonographic images of serous cystadenocarcinoma in a 65-year-old woman with a ROMA index of 98.3%. (A) Grayscale ultrasound indicates an irregularly shaped solid mass in the left adnexal region. (B) Color Doppler imaging reveals abundant vascularity within the lesion (color score = 4). Based on these features, the mass was classified as O-RADS US v2022 category 5. (C) Contrast-enhanced ultrasound (CEUS) demonstrates early enhancement with hyperenhanced intensity (arrows) relative to the myometrium (*). (D) Dynamic CEUS imaging depicts a washout pattern, with the lesion transitioning from hyper- to hypoenhancement compared with the myometrium (*). The overall CEUS score was 5, consistent with the O-RADS 5 classification.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-9218597/v1/8de178c4559241cec227f636.png"},{"id":108734792,"identity":"ef32882e-3750-4acb-ba6b-62a92ba21793","added_by":"auto","created_at":"2026-05-07 19:56:02","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":507880,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of the diagnostic performance of O-RADS, CEUS, ROMA, and their combination using receiver operating characteristic (ROC) curves.\u003c/p\u003e\n\u003cp\u003eAUC, area under the receiver operating characteristic curve; O-RADS, Ovarian–Adnexal Reporting and Data System; CEUS, contrast-enhanced ultrasound.\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-9218597/v1/d3c78675f81e5cf478d7cdb0.png"},{"id":108809876,"identity":"778eaa7b-d5e6-450f-b733-f9b794f5799d","added_by":"auto","created_at":"2026-05-08 15:56:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":30242905,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9218597/v1/24afe926-36d8-4f09-bde3-84008c73cd6d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Diagnostic Value of Combining O-RADS US v2022, Contrast-enhanced Ultrasound Score, and ROMA for Differentiating Adnexal Masses","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdnexal masses (AMs) frequently occur in women, with the primary clinical imperative being to determine their benign or malignant nature [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This distinction is critical as it influences subsequent treatment decisions: while benign masses are typically managed with surveillance or conservative surgery, malignant masses require urgent referral to a gynecologic oncologist for definitive interventions, such as cytoreductive surgery and chemotherapy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Consequently, establishing an accurate differential diagnosis for AMs is vital for guiding optimal clinical management and enhancing patient prognosis.\u003c/p\u003e \u003cp\u003eCurrently, imaging modalities and serum tumor biomarkers are routinely employed to evaluate the nature of AMs [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Among these, cancer antigen 125 (CA125) and human epididymis protein 4 (HE4) are crucial for assessing ovarian malignancy. However, CA125 levels can also be elevated in benign conditions such as endometriosis, pelvic inflammatory disease, and pregnancy, limiting its sensitivity in early-stage ovarian cancer [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In contrast, HE4 offers greater specificity for distinguishing benign lesions and aids in early diagnosis, remission monitoring, and response assessment. To leverage their complementary strengths, the Risk of Malignancy Algorithm (ROMA) was developed, integrating CA125 and HE4 levels with menopausal status to estimate malignancy risk [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The ROMA index has demonstrated effectiveness in differentiating ovarian cancer and benign tumors, with a meta-analysis reporting a pooled sensitivity of 91.1% and specificity of 84.6% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the utility of serum biomarkers, imaging remains the cornerstone of initial evaluation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Owing to its convenience, cost-effectiveness, and lack of ionizing radiation, ultrasound (US) has been established as the first-line imaging modality for assessing gynecological conditions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Several US models have been formulated to determine the malignancy risk of AMs, with the recently developed Ovarian\u0026ndash;Adnexal Reporting and Data Systems (O-RADS) US v2022, released by the American College of Radiology (ACR) in November 2022, being notable [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This updated version aims to improve diagnostic accuracy and specificity by refining certain risk categories and management recommendations from the 2020 edition [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Nevertheless, a potential limitation of this system is its evaluation of vascularity. Within O-RADS US v2022, the color Doppler blood flow score (range: 1\u0026ndash;4 points) is assigned based on findings from conventional color Doppler US, a process that is inherently subjective and dependent on radiologist interpretation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Contrast-enhanced ultrasound (CEUS) works by injecting microbubble contrast agents into the peripheral veins[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This technique enhances lesion conspicuity and provides objective, real-time visualization of tumor microvascular perfusion, facilitating the differentiation of benign and malignant lesions. Consequently, integrating CEUS into the O-RADS v2022 framework presents a promising strategy to overcome the limitations of conventional Doppler and improve diagnostic confidence in suspected malignancies.\u003c/p\u003e \u003cp\u003eThis study primarily aimed to investigate and compare the diagnostic value of O-RADS US v2022, the CEUS score, and the ROMA index in differentiating AMs. Building on this comparative analysis, the secondary objective was to determine whether a combined model that incorporates all three tools could achieve superior diagnostic performance in distinguishing benign from malignant AMs.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This prospective study was approved by the ethics review committee of Fujian Cancer Hospital (K2023-124-01), and all subjects provided written informed consent prior to the examination.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eA total of 185 cases of AMs diagnosed at Fujian Cancer Hospital between October 2018 and February 2025 were collected, with 147 cases ultimately included in the study. The inclusion criteria were as follows: (1) Age\u0026thinsp;\u0026ge;\u0026thinsp;18 years; (2) participants with an AM who underwent US and CEUS examinations; (3) surgical or puncture pathology confirmation. The exclusion criteria were as follows: (1) Poor-quality US images; (2) incomplete clinical data; (3) contraindications to US contrast agents. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the participant flowchart. Demographic and clinical data, including age, menopausal status, serum HE4 and CA125 levels, and pathological diagnoses, were sourced from the hospital\u0026rsquo;s electronic medical records.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eUS acquisition\u003c/h3\u003e\n\u003cp\u003eAll conventional US and CEUS assessments were conducted using GE Healthcare, Supersonic Aixplorer, and Philips US systems. The approach\u0026mdash;transabdominal or transvaginal\u0026mdash;was selected based on clinical indications, with examinations performed using the appropriate probes (transabdominal: 1\u0026ndash;5 or 1\u0026ndash;6 MHz; transvaginal: 5\u0026ndash;9 or 3\u0026ndash;12 MHz). Sequential multi-section scanning was performed to comprehensively assess the uterus, adnexa, and mass. For patients with bilateral masses, the lesion was selected based on the largest diameter or the most complex morphology. Conventional US characteristics were systematically evaluated and recorded, including lesion size, location, acoustic shadowing, solid component dimensions, number and size of papillary projections, septation, ascites, and color flow distribution.\u003c/p\u003e \u003cp\u003eConventional ultrasonography was initially conducted to capture imaging planes encompassing the entire mass and uterus. The system was subsequently switched to CEUS mode, operating in a dual-window display with the mechanical index set to a low range (0.06\u0026ndash;0.08). Subsequently, a 2.4 mL bolus of SonoVue (Bracco SPA, Milan, Italy) suspension was injected via the cubital vein. The perfusion and washout dynamics of the contrast agent within the lesion and surrounding tissues were observed in real-time, and dynamic imaging sequences were stored for subsequent analysis.\u003c/p\u003e\n\u003ch3\u003eImage analysis\u003c/h3\u003e\n\u003cp\u003e Two senior sonologists, each with \u0026ge;\u0026thinsp;8 years of experience, independently reviewed and classified all US images in a retrospective analysis based on the ACR O-RADS US v2022 guidelines. Any discrepancies in classification were resolved by consensus following a joint review of the cases.\u003c/p\u003e \u003cp\u003eThe CEUS scoring criteria included three components, compared with the myometrium [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]: enhancement timing (1 point for late enhancement and 2 points for synchronous or early enhancement); enhancement intensity (0 points for no enhancement, 1 point for hypoenhancement, and 2 points for iso- or hyperenhancement); and dynamic change in enhancement (0 points for sustained hyper-/iso-/hypoenhancement, and 1 point for washout to hypoenhancement).\u003c/p\u003e\n\u003ch3\u003eROMA index\u003c/h3\u003e\n\u003cp\u003ePreoperative serum CA-125 and HE4 levels were measured using an electrochemiluminescence immunoassay on a COBAS 8000 system (Roche, Switzerland). The ROMA index, which incorporates menopausal status along with preoperative CA-125 and HE4 levels, was calculated utilizing a dedicated algorithm to predict the risk of ovarian tumor malignancy, as follows:\u003c/p\u003e \u003cp\u003eROMA\u0026thinsp;=\u0026thinsp;exp.(PI) / [1\u0026thinsp;+\u0026thinsp;exp.(PI)] \u0026times; 100.\u003c/p\u003e \u003cp\u003eThe Predictive Index (PI) is calculated using the following formula:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e- Premenopausal women: PI\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;12.0\u0026thinsp;+\u0026thinsp;2.38 \u0026times; LN (natural log) [HE4]\u0026thinsp;+\u0026thinsp;0.0626 \u0026times; LN [CA125]\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- Postmenopausal women: PI\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;8.09\u0026thinsp;+\u0026thinsp;1.04 \u0026times; LN [HE4]\u0026thinsp;+\u0026thinsp;0.732 \u0026times; LN [CA125]\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eA high risk of ovarian cancer was defined as a ROMA index\u0026thinsp;\u0026ge;\u0026thinsp;11.4% for premenopausal patients and \u0026ge;\u0026thinsp;29.9% for their postmenopausal counterparts [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using the Statistical Package for the Social Sciences (version 27.0) and MedCalc (version 22.001) software. Categorical variables were compared using the chi-square or Fisher\u0026rsquo;s exact test, with results presented as frequencies and percentages. Normally distributed continuous variables are expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and were compared using the independent samples t-test. Non-normally distributed continuous variables are presented as medians with interquartile ranges (IQRs) and were analyzed using the Mann\u0026ndash;Whitney U test. Receiver operating characteristic (ROC) curve analysis was conducted to calculate the area under the curve (AUC), with the corresponding sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) determined. Comparisons between AUCs were performed using DeLong\u0026rsquo;s test. All statistical tests were two-tailed, with a P-value of \u0026lt;\u0026thinsp;0.05 considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eClinicopathological characteristics of the patients\u003c/h2\u003e \u003cp\u003eA total of 147 patients with AMs were enrolled in this study. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes their clinical characteristics. Among these, 49 masses were benign, whereas 98 were malignant. The mean age of patients with benign masses was 45.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.9 years, while that of those with malignant masses was 52.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9 years. Of the 49 benign cases (30.6%), 15 were postmenopausal, compared to 56 (57.1%) of the 98 malignant cases. Malignant AMs were more frequently bilateral than benign ones (29.6% versus 8.2%). Regarding lesion size, malignant masses exhibited a larger median maximum diameter than benign ones (108.5 mm [IQR: 86.2\u0026ndash;139.5] versus 67 mm [IQR: 51\u0026ndash;104]). Elevated serum CA-125 levels (reference: \u0026lt; 35 U/mL) were observed in 38.8% and 76.5% of patients with benign and malignant masses, respectively. Furthermore, a higher frequency of elevated ROMA indices was noted in malignant cases than in benign cases (54.1% versus 6.1%). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e details the pathological diagnoses, O-RADS US v2022 classifications, and CEUS scores of the included lesions. The most common benign lesion was endometriotic cysts (18.3%), while serous cystadenocarcinoma (37.8%) was the most prevalent malignant AM.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline information of the participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBenign\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMalignant\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;98)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenopausal status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePremenopausal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34(69.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42(42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostmenopausal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15(30.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56(57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximum diameter of lesion (mm)\u003c/p\u003e \u003cp\u003emedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67(51,104)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108.5(86.2,139.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximum diameter of solid component (mm)\u003c/p\u003e \u003cp\u003emedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(0,37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.5(46.5,104)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaterality(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45(91.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69(70.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(29.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCA125 (U/ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30(61.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19(38.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75(76.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHE4 (pmol/ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61(62.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37(37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eROMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46(93.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45(45.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53(54.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations of O-RADS US v2022 and CEUS score with the final pathological diagnosis of adnexal masses in this study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eType of pathology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eO-RADS US v2022\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eCEUS Score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u0026ndash;5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u0026ndash;5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorpus luteum cyst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollicular cyst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometriotic cyst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerous cystadenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMucinous cystadenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMature teratoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStruma ovarii\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThecoma-Fibroma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSclerosing Stromal Tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInflammatory Disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorderline serous cystadenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorderline mucinous cystadenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorderline endometrioid tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerous cystadenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMucinous cystadenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrioid carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClear cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdult-type granulosa cell tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSertoli-Leydig Cell Tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmature teratoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGerm cell tumours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCarcinosarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvarian Metastases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: O-RADS: Ovarian-Adnexal Reporting and Data System; CEUS: Contrast-enhanced ultrasound\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eConventional ultrasonography and CEUS findings\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the ultrasonic findings for 147 masses. Among benign cases, the most common presentation was a unilocular cyst with solid components, accounting for 28.6% (14/49) of masses. In contrast, malignant cases predominantly exhibited solid morphology, observed in 46.9% (46/98) of lesions. Compared to benign masses, 15.3% of malignant cases demonstrated more than 10 cyst locules. Acoustic shadowing was infrequent, noted in only one benign and two malignant cases. Ascites was present in 30.6% of malignant cases, while only one case with inflammatory infiltration exhibited ascites.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eConventional two-dimensional and contrast-enhanced ultrasound findings of adnexal masses\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeatures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBenign\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMalignant\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;98)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnilocular cyst without solid components\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(22.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnilocular cyst with solid components\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31(31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBi-or multilocular cyst without solid components\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBi-or multilocular cyst with solid components\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(20.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(18.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSolid lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46(46.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of papillary structures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32(65.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60(61.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(34.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(27.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcoustic shadows\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48(97.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96(98.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;10 cyst locules\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48(98.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83(84.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscites\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48(95.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68(69.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(30.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColor score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38(77.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26(26.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(30.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(20.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22(22.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eO-RADS US v2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(24.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(26.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(46.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32(32.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66(67.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInitial enhancement time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLate enhancement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38(77.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSynchronous or early enhancement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(22.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92(93.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnhancement intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(46.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypo-enhancement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16(32.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIso- or hyper-enhancement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(20.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93(94.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDynamic change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSustained hyper-/iso-/hypo-enhancement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43(87.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25(25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWashout to hypoenhancement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73(74.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThese differences were statistically significant. Moderate to very strong vascular flow was observed in 14.2% and 42.8% of benign and malignant masses, respectively.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eO-RADS classification\u003c/h2\u003e \u003cp\u003eAccording to the O-RADS classification (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), among the 49 benign masses, 12 (24.5%) were classified as O-RADS 2, 13 (26.5%) as O-RADS 3, 23 (46.9%) as O-RADS 4, and 1 (2.0%) as O-RADS 5. Of the 98 malignant masses, none were classified as O-RADS 2 or 3, 32 (32.7%) were O-RADS 4, while 66 (67.3%) were O-RADS 5. The malignancy rates based on pathological findings for O-RADS 2\u0026ndash;5 were 0% (0/0), 0% (0/0), 58.2% (32/55), and 98.5% (66/67), respectively. Notably, 24 benign tumors were classified as O-RADS 4 or 5, including ovarian endometriosis cysts, mucinous cystadenomas, thecoma-fibromas, sclerosing stromal tumors, struma ovarii, and inflammatory disease (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCEUS Score\u003c/h2\u003e \u003cp\u003eOn CEUS (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), benign masses predominantly presented with late enhancement (38/49, 77.6%), whereas malignant lesions primarily demonstrated synchronous or early enhancement (92/98, 93.9%). Conversely, only 6.1% (6/98) of malignant lesions exhibited late enhancement, while 22.4% (11/49) of benign masses displayed synchronous or early enhancement. Washout to hypoenhancement was observed in 12.2% (6/49) and 74.5% (73/98) of benign and malignant masses, respectively. Regarding enhancement intensity, iso- or hyperenhancement was noted in 20.4% (10/49) of benign masses and 94.9% (93/98) of malignant lesions. A CEUS score of 4\u0026ndash;5 was assigned to 10 benign masses, including one ovarian endometriosis cyst, one mucinous cystadenoma, two thecoma-fibromas, one sclerosing stromal tumor, two struma ovarii, and three inflammatory lesions. In contrast, six malignant lesions received a CEUS score of 1\u0026ndash;3, encompassing adult-type granulosa cell tumors, Sertoli\u0026ndash;Leydig cell tumors, immature teratomas, and ovarian metastases (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Figures\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e provide representative imaging findings of benign and malignant ovarian\u0026ndash;adnexal lesions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDiagnostic performance of O-RADS, CEUS, ROMA, and their combinations in AMs\u003c/h2\u003e \u003cp\u003eUsing an O-RADS score\u0026thinsp;\u0026ge;\u0026thinsp;4 as the threshold for diagnosing adnexal malignancy, the AUC was 0.755. With a CEUS score\u0026thinsp;\u0026ge;\u0026thinsp;4 serving as the cutoff, the AUC increased to 0.878. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e summarizes the sensitivity, specificity, accuracy, AUC, PPV, and NPV scores for each diagnostic modality. Combining O-RADS and CEUS scores yielded superior diagnostic performance compared to O-RADS alone (AUC: 0.903; 95% confidence interval [CI]: 0.844\u0026ndash;0.946 versus AUC: 0.755; 95% CI: 0.677\u0026ndash;0.822). Notably, the tripartite combination of O-RADS, CEUS, and ROMA achieved the highest diagnostic accuracy in this study, with sensitivity, specificity, and AUC values of 95.9%, 83.7%, and 0.920, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). This integrated approach demonstrated excellent diagnostic performance, significantly outperforming each method individually (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiagnostic performance of O-RADS v2022, CEUS, and ROMA in differentiating adnexal lesions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMethods\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAUC\u003c/p\u003e \u003cp\u003e(95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSensitivity (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSpecificity(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAccuracy\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePPV\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNPV\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eO-RADS v2022*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.755\u003c/p\u003e \u003cp\u003e(0.677\u0026ndash;0.822)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e83.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e80.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCEUS**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.878\u003c/p\u003e \u003cp\u003e(0.813\u0026ndash;0.926)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e81.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e89.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e91.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e87.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eO-RADS v2022\u0026thinsp;+\u0026thinsp;CEUS***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.903\u003c/p\u003e \u003cp\u003e(0.844\u0026ndash;0.946)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e83.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e83.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e92.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e87.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eO-RADS v2022\u0026thinsp;+\u0026thinsp;ROMA\u003csup\u003e༆\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.857\u003c/p\u003e \u003cp\u003e(0.790\u0026ndash;0.909)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e83.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e80.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCEUS+ROMA\u003csup\u003e༆༆\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.905\u003c/p\u003e \u003cp\u003e(0.846\u0026ndash;0.947)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e81.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e93.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e91.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e90.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eO-RADS v2022\u0026thinsp;+\u0026thinsp;ROMA+CEUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.920\u003c/p\u003e \u003cp\u003e(0.864\u0026ndash;0.959)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e83.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e94.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e92.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e91.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: O-RADS, ovarian reporting and data system; CEUS, contrast-enhanced ultrasound; ROMA,;PPV, Positive predictive value; NPV, Negative predictive value;AUC, area under the receiver operating characteristic curve\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*indicates a significant difference compared with that of O-RADS v2022\u0026thinsp;+\u0026thinsp;ROMA+CEUS, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.0001.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e**indicates a significant difference compared with that of O-RADS v2022\u0026thinsp;+\u0026thinsp;ROMA+CEUS, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0243.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e***indicates a significant difference compared with that of O-RADS v2022\u0026thinsp;+\u0026thinsp;ROMA+CEUS, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.2442.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003e༆\u003c/sup\u003eindicates a significant difference compared with that of O-RADS v2022\u0026thinsp;+\u0026thinsp;ROMA+CEUS, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0002.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003e༆༆\u003c/sup\u003eindicates a significant difference compared with that of O-RADS v2022\u0026thinsp;+\u0026thinsp;ROMA+CEUS, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0416.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":" \u003cp\u003eWhile the O-RADS US v2022 improves specificity by incorporating acoustic shadows and bilocular cysts, research indicates that its specificity remains relatively limited despite high sensitivity [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. CEUS can effectively complement O-RADS by better characterizing masses with ambiguous morphological features [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Our findings corroborate those of previous studies, indicating that CEUS features significantly differentiate between benign and malignant AMs [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Malignant ovarian tumors typically exhibit synchronous or early contrast perfusion relative to the myometrium, along with higher enhancement intensity [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In this study, 10 out of 13 O-RADS 4 cystic-solid masses displayed minimal to no vascularity on contrast-enhanced imaging\u0026mdash;consistent with their pathological diagnoses of mucinous cystadenomas, endometriotic cysts, or hemorrhagic cysts\u0026mdash;resulting in low CEUS scores. This ability to definitively assess blood supply effectively addresses the limitations of conventional US in detecting low-velocity flow. Conversely, five malignant ovarian masses demonstrated late enhancement with hypo- or isoenhancement, yielding low CEUS scores; these included immature teratomas, adult-type granulosa cell tumors, and ovarian metastases. This may be attributed to insufficient microcirculatory changes in some malignant tumors to produce typical perfusion patterns.\u003c/p\u003e \u003cp\u003eMisdiagnosis using O-RADS and CEUS primarily arose from overlapping ultrasonographic features and contrast enhancement patterns between benign and malignant ovarian tumors. For instance, one patient presented with a sclerosing stromal tumor appearing as a well-defined solid hypoechoic mass with abundant blood flow on two-dimensional US, resulting in high CEUS enhancement and a classification of O-RADS 4 with a CEUS score of 5. However, the ultrasonographic characteristics of this lesion differed from those previously reported by Xu et al., who described sclerosing stromal tumors as possessing poor blood supply [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In this study, both conventional US and CEUS misdiagnosed this lesion, possibly due to the rarity of such tumors complicating preoperative diagnosis. In another case, a moderately differentiated Sertoli\u0026ndash;Leydig cell tumor was categorized as O-RADS 4 yet received a low CEUS score that might have suggested a benign mass, leading to diagnostic inconsistency. Additionally, three inflammatory masses were misidentified as malignant on CEUS\u0026mdash;likely attributed to inflammatory factors stimulating local blood flow\u0026mdash;leading to increased vascularity and rapid enhancement. Overall, tumor markers can serve as valuable adjunctive tools for refining differential diagnosis for patients with inconclusive ultrasound findings.\u003c/p\u003e\u003cp\u003eWhile ROMA demonstrates comparable sensitivity to CA125, it exhibits superior specificity, particularly in premenopausal women [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. These findings have motivated efforts to integrate imaging features with serum biomarkers such as CA125 and HE4. Previous studies have revealed that the triple combination of O-RADS, CEUS, and CA125 enhances diagnostic accuracy for ovarian\u0026ndash;adnexal malignancies [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In line with prior research, we observed a higher rate of elevated ROMA scores in malignant lesions than in benign ones [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Nonetheless, to the best of our knowledge, no study has yet investigated whether adding ROMA to O-RADS and CEUS assessments improves differentiation between benign and malignant AMs. Our study demonstrates that this combined approach enhances diagnostic performance, yielding sensitivity, specificity, PPV, NPV, and accuracy scores of 95.9%, 83.7%, 92.2%, 91.1%, and 94.5%, respectively.\u003c/p\u003e \u003cp\u003eNotwithstanding, this study has certain limitations. First, its retrospective, single-center design, along with an imbalance in the number of malignant and benign cases, necessitates validation through prospective, multicenter studies with larger sample sizes. Second, the absence of quantitative CEUS analysis might have introduced subjectivity into the interpretations. Finally, the exclusive consideration of surgically treated cases might have resulted in selection bias.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates that CEUS provides superior diagnostic efficacy compared to conventional US for AMs. Moreover, integrating O-RADS, CEUS, and ROMA significantly enhances differentiation between benign and malignant lesions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis prospective study was approved by the ethics review committee of Fujian Cancer Hospital (K2023-124-01), and all subjects provided written informed consent prior to the examination.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Fujian Provincial Natural Science Foundation of China [Grant number 2023J011240]; Joint Funds for the innovation of science and Technology, Fujian province [Grant number 2023Y9397].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eW. T.X. and Y.Q.W. wrote the main manuscript text and were major contributors to the writing of the manuscript. Q.Y.Z. and X.H.D. collected and analyzed the patient data regarding the adnexal masses. R.H. and Y.N.G. performed the laboratory examination of the adnexal masses. L.N.T. edited the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSmolarz B, Biernacka K, Łukasiewicz H, Samulak D, Piekarska E, Romanowicz H, Makowska M. Ovarian Cancer-Epidemiology, Classification, Pathogenesis, Treatment, and Estrogen Receptors' Molecular Backgrounds. Int J Mol Sci. 2025;26(10):4611.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaruso G, Weroha SJ, Cliby W. Ovarian Cancer: A Review. JAMA. 2025;334(14):1278\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoro F, Ciancia M, Sciuto M, Baldassari G, Tran HE, Carcagn\u0026igrave; A, Fagotti A, Testa AC. Performance of radiomics analysis in ultrasound imaging for differentiating benign from malignant adnexal masses: A systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2025;104(8):1433\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu S, Gong W, Chen X, Wang J, Zhu Y, Zhang T, Gu Y, Zheng J, Xu J. Tumor biomarkers contribute to the diagnosis and clinical management of the O-RADS MRI risk stratification system for epithelial ovarian tumors. World J Surg Oncol. 2025;23(1):7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaaks R, Cooley V, Mukama T, Teras LR, Patel AV, Masala G, Crous-Bou M, Harris HR, Langseth H, Surcel HM, et al. 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Diagnostics. 2022;12(1):226.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eD\u0026rsquo;Amario A, Ambrosini R, Gullino A, Grazioli L. Role of Imaging Techniques in Ovarian Cancer Diagnosis: Current Approaches and Future Directions. Cancers. 2026;18(1):173.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeng S, Lin S. Multimodal ultrasound assessment of ovarian reserve. Abdom Radiol 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoshida A, Stecca CM, de Oliveira AH, Pereira PN, Sarian LO. Comparative Diagnostic Performance of IOTA Simple Rules, O-RADS US, and Subjective Assessment in Differentiating Benign from Malignant Adnexal Masses. J ultrasound medicine: official J Am Inst Ultrasound Med 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrachowski LM, Jha P, Phillips CH, Blanchette Porter MM, Froyman W, Glanc P, Guo Y, Patel MD, Reinhold C, Suh-Burgmann EJ, et al. O-RADS US v2022: An Update from the American College of Radiology\u0026rsquo;s Ovarian-Adnexal Reporting and Data System US Committee. Radiology. 2023;308(3):e230685.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXun L, Zhai L, Xu H. Comparison of conventional, doppler and contrast-enhanced ultrasonography in differential diagnosis of ovarian masses: a systematic review and meta-analysis. BMJ Open. 2021;11(12):e052830.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReid M, Brisebois K, Merrill C, Wilson SR. Contrast-Enhanced Ultrasound of the Ovary Technique and Lexicon Recommendations: Technique and Lexicon Recommendations. J ultrasound medicine: official J Am Inst Ultrasound Med. 2026;45(3):653\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan K, Huang Y-J, Mao M-Y, Li T, Wang S-J, He D-N, Liu W-F, Li M-X, Zhu X-M, Chen X-Y, et al. Contrast-enhanced US to Improve Diagnostic Performance of O-RADS US Risk Stratification System for Malignancy. Radiology. 2023;308(2):e223003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu C, Zhu Y, Dai K, Tan B, Dong H, Lin J, He R, Lu M, Li Y. Accurate prediction of benign and malignant adnexal tumors in surgical resection and conservative treatment: construction and external validation of a diagnostic model based on CEUS, HE4, and O-RADS US v2022 evaluation. J Ovarian Res. 2025;18(1):123.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTran DT, Vo VK, Le MT, Chuang L, Nguyen VQH. Copenhagen Index versus ROMA in preoperative ovarian malignancy risk stratification: Result from the first Vietnamese prospective cohort study. Gynecol Oncol. 2021;162(1):113\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHack K, Gandhi N, Bouchard-Fortier G, Chawla TP, Ferguson SE, Li S, Kahn D, Tyrrell PN, Glanc P. External Validation of O-RADS US Risk Stratification and Management System. Radiology. 2022;304(1):114\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi H, Li G, Gao Y, Yang Z, Zhao C, Yang H. Contrast-enhanced ultrasound and Ovarian-Adnexal Reporting and Data System ultrasound classification for risk assessment of ovarian and adnexal lesions: a systematic review and meta-analysis. Quant imaging Med Surg. 2026;16(1):44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu Z, Fan S, Feng X, Liu L, Zhou J, Wu Z, Zhou L. Performance of grayscale combined with contrast-enhanced ultrasound in differentiating benign and malignant pediatric ovarian masses. Eur Radiol. 2024;35(2):828\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFu Q, Yuan Y, Zhou Z, Huang Y, Lin Y, Ouyang D, Shi W. Clinical application of O-RADS combined with CEUS and HE4 in the diagnosis of adnexal masses. Med ultrasonography 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu Y, Xue N, Zhang S, Wei Z. The value of contrast-enhanced ultrasonography in differential diagnosis of benign and malignant ovarian sex cord stromal tumors. Gland Surg. 2022;11(6):1086\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFathi A, Heidari M, Rasouli J, Ghasemnejad-Berenji H. Diagnostic value of the Risk of Ovarian Malignancy Algorithm (ROMA) index in the detection of ovarian cancer in postmenopausal women: a systematic review and meta-analysis. BMC Womens Health. 2025;25(1):280.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang Z, Pu W, Luo X, Zhang J, Jia S, Zhang G, Zhu Y. Integrating O-RADS US v2022, CEUS, and CA125 to enhance the diagnostic differentiation of ovarian masses: development of the OCC-US model. Cancer Imaging. 2025;25(1):96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang J. Efficacy of a combination of O-RADS, CEUS, and CA125, in identification of ovary-adnexal malignant lesions. Am J Cancer Res. 2025;15(2):631\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTangjanyatham P, Chaowawanit W. Comparison of sensitivity for Risk of Ovarian Malignancy Algorithm (ROMA) and Assessment of Different NEoplasias in the adneXa (ADNEX) model for predicting ovarian cancer in a woman with adnexal masses. Int J Gynecol cancer: official J Int Gynecol Cancer Soc. 2025;35(6):101827.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adnexal masses, Ovarian-adnexal reporting and data systems, contrast-enhanced ultrasound, Adnexal masses","lastPublishedDoi":"10.21203/rs.3.rs-9218597/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9218597/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eAccurately differentiating malignant from benign adnexal masses (AMs) remains a considerable clinical challenge. Therefore, this study aimed to evaluate the diagnostic value of combining the Ovarian\u0026ndash;Adnexal Reporting and Data System (O-RADS) v2022, contrast-enhanced ultrasound (CEUS) score, and Risk of Ovarian Malignancy Algorithm (ROMA) for distinguishing AMs.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective study of patients with AMs who underwent CEUS prior to surgery at our institution between October 2018 and February 2025. We assessed diagnostic performance using receiver operating characteristic (ROC) curves, calculating sensitivity, specificity, area under the ROC curve (AUC), and 95% confidence intervals (CIs) for each diagnostic approach. The DeLong\u0026rsquo;s test was employed to compare ROC curves.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 147 women were included, with 49 (33.3%) having benign ovarian tumors and 98 (66.7%) having malignant tumors. The AUC values were as follows: O-RADS v2022 alone, 0.755 (95% CI: 0.677\u0026ndash;0.822); CEUS alone, 0.878 (95% CI: 0.813\u0026ndash;0.926); O-RADS v2022\u0026thinsp;+\u0026thinsp;CEUS, 0.903 (95% CI: 0.844\u0026ndash;0.946); O-RADS v2022\u0026thinsp;+\u0026thinsp;ROMA, 0.857 (95% CI: 0.790\u0026ndash;0.909); CEUS\u0026thinsp;+\u0026thinsp;ROMA, 0.905 (95% CI: 0.846\u0026ndash;0.947); and O-RADS v2022\u0026thinsp;+\u0026thinsp;ROMA\u0026thinsp;+\u0026thinsp;CEUS, 0.920 (95% CI: 0.864\u0026ndash;0.959). The sensitivity and specificity values for each approach were as follows: O-RADS v2022 (100% and 51.0%), CEUS (93.9% and 81.6%), O-RADS v2022\u0026thinsp;+\u0026thinsp;CEUS (93.4% and 83.7%), O-RADS v2022\u0026thinsp;+\u0026thinsp;ROMA (100% and 51.0%), CEUS\u0026thinsp;+\u0026thinsp;ROMA (95.9% and 81.6%), and O-RADS v2022\u0026thinsp;+\u0026thinsp;ROMA\u0026thinsp;+\u0026thinsp;CEUS (95.9% and 83.7%, respectively).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe combination of O-RADS v2022, CEUS, and ROMA demonstrates superior diagnostic performance for distinguishing malignant from benign AMs compared with any single modality.\u003c/p\u003e","manuscriptTitle":"Diagnostic Value of Combining O-RADS US v2022, Contrast-enhanced Ultrasound Score, and ROMA for Differentiating Adnexal Masses","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-07 19:55:53","doi":"10.21203/rs.3.rs-9218597/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-06T15:14:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"307723781453661911107852075277954684061","date":"2026-04-26T08:14:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-23T11:39:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-27T13:53:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-26T05:58:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-26T05:58:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2026-03-25T05:41:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5f28d698-906b-4f4d-8c04-699070c57af0","owner":[],"postedDate":"May 7th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-06T15:14:29+00:00","index":58,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T19:55:53+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-07 19:55:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9218597","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9218597","identity":"rs-9218597","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}