## 4 Discussion
When we compared the IOTA ADNEX model chance of a benign tumor for the groups defined by malign versus the non-malignant histological aspect, the Mann-Whitney U test also showed no statistical significance (\(p\) = 0.123). Thus, this score is no different when comparing the malignant versus the non-malignant group. When we compared the maximum size of the tumor for the two groups, we obtained statistical significance (\(p\) = 0.029), the maximum size being over two times larger for malignant tumors. Taking into consideration the fact that all the patients with highly suggestive malignancy ultrasound evaluations were directly referred to a gynecologic oncology center from the private sector, the IOTA ADNEX model is more specific and sensitive than ultrasound exploration alone in detecting early-stage ovarian cancer. The rate of error of this model is very low, and the accuracy tends to be closer to 98% if we exclude patients with in situ squamous carcinoma with microinvasion. The false negative evaluation of the five ovarian masses as benign tumor does not seem to be correlated with the patient's age or with their fertile status. Further, these changes were independent of menopausal status. This method is considered to be a highly useful tool in developing countries that need to be extremely effective in triaging patients to offer cost-efficient management. These changes were independent of menopausal status. Further, we found that the risk of malignancy was 3.9% and under 2.4% for a borderline tumor. The ACOG (American College of Obstetricians and Gynecologists) also suggests that the IOTA ADNEX model predicts the risk of a specific type of adnexal mass with high accuracy and can therefore offer better management for patients with ovarian tumors [25, 26]. The IOTA ADNEX model is available in two versions: with or without the inclusion of the CA-125 value. [PERSON] et al., 2014, concluded that CA-125 is a nonspecific marker in the differentiation between benign or malignant adnexal masses [10, 27]. [PERSON], 2018, used the IOTA ADNEX model algorithm in 107 patients over 43 years old. The algorithm proved to be very useful in distinguishing between benign and malignant tumors. An ultrasound examination can be used by inexperienced sonographers and may help them to correctly evaluate the findings and classify them as presumed benign or malignant, representing a useful tool for sorting these patients for further, more specific explorations [28]. As we showed in our study, [PERSON] et al., 2016, demonstrated that the results obtained using this IOTA ADNEX model were highly accurate and can be used for the differential diagnosis of ovarian masses [29]. However, our study had some limitations. First, the small number of patients included in our study and, second, the lack of evidence of the number of patients that were evaluated in the private sector that might have been directly referred to an oncological center without being evaluated in our hospital beforehand. In this context, the imagistic mechanism by which some parameters cause radically different results (malignant lesion identified on surgical samples versus the IOTA ADNEX criteria) has not been shown in all cases, as in our case. However, one of the strong points to support our findings is the fact that there are few prospective studies in the literature that evaluate the accuracy of the IOTA ADNEX model evaluation of ovarian masses. This is the main reason we want to embark on a larger prospective study with the help of our gynecologic oncology colleagues to better evaluate the accuracy of this important scoring system and help implement this protocol of evaluation in our country. Some ultrasound features may cause radically different results, such as a malignant lesion being identified on surgical samples as benign or borderline through IOTA criteria risk assessment.