Dear Editor, dear Dr. Xi,

Thank you for commenting on our review article concerning the special role of ultrasound for the detection of ovarian cancer [1]. In the letter by Xi et al. [2] the authors propose to consider and rule out Meigs syndrome before applying the simple rules for ultrasound features suggestive of malignant or benign tumors [3] as proposed by the International Ovarian Tumor Analysis (IOTA) group. The authors refer to a rare syndrome associated with ovarian fibroma that typically shows malignant features on ultrasound [4]. We agree that Meigs syndrome will not be considered benign according to the “simple rules” [3]. It certainly is one of the “false positives” that are important to keep in mind when counseling the patient. However, the proposed ultrasound features were developed as triage criteria for preoperative planning and are not used for diagnosing the adnexal mass. The classification of ovarian masses therefore directs the triage of the vast majority of malignant ovarian tumors to a gynecologic-oncologic specialist in order to optimize the therapy and ultimately the prognosis. Therefore, all cases of suspected malignancy including the benign cases of Meigs syndrome will be triaged to a gynecologic-oncologic specialist. However, Meigs syndrome cannot be diagnosed without a histopathologic report of the ovary and therefore a surgical intervention cannot be prevented.

In conclusion, the simple ultrasound features [3] can be used as a preoperative triage of adnexal masses and will correctly triage masses with suspected malignancy accepting that in the rare case of Meigs syndrome this triage will be “false positive”.