Clinically oriented three-step strategy to the assessment of adnexal pathology.
ABSTRACT Objective If we exclude masses likely to be judged as easy and "instant" to diagnose by an ultrasound examiner, what is the diagnostic performance of ultrasound based simple rules, RMI, two logistic regression models and real-time subjective assessment by experienced ultrasound examiners? Patients and methods 3511 patients with at least one persistent adnexal mass preoperatively underwent transvaginal ultrasonography to assess tumor morphology and vascularity. They were included in two consecutive prospective studies by the International Ovarian Tumor Analysis (IOTA) group: phase 1 (1999-2005) development of the simple rules and logistic regression models LR1 and LR2, and phase 2 a validation study (2005-2007). Results Almost half of the cases (43%) were identified as "instant" to diagnose on the basis of descriptors applied to the database. To assess the performance in the more difficult "non-instant" masses, we used only phase 2 data (N = 1036). The sensitivity of LR2 was 88%, RMI 41% and subjective assessment 87%. The specificity of LR2 was 67%, RMI 90% and subjective assessment 86%. The simple rules yielded a conclusive result in almost 2/3 of the masses where they resulted in sensitivity and specificity similar to real-time subjective assessment by experienced ultrasound examiners: sensitivity 89% vs. 89% (P-value 0.76), specificity 91% vs. 91% (P-value 0.65). If we apply a three-step strategy with easy "instant" diagnoses as step 1, simple rules as step 2 and subjective assessment by an experienced ultrasound examiner in the remaining masses as step 3 we obtain a sensitivity of 92% and specificity of 92% compared to sensitivity 90% (P = 0.03) and specificity 93% (P = 0.44) when using real-time subjective assessment by experts in all tumors, respectively. Conclusion A diagnostic strategy using simple descriptors and ultrasound rules when applied to the variables contained in the IOTA database obtains results that are at least as good as those obtained by subjective assessment of a mass by an expert. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.
Article: How do you distinguish a malignant pelvic mass from a benign pelvic mass? Imaging, biomarkers, or none of the above.Journal of Clinical Oncology 10/2007; 25(27):4159-61. · 18.37 Impact Factor
Article: Macroscopic characterization of ovarian tumors and the relation to the histological diagnosis: criteria to be used for ultrasound evaluation.[show abstract] [hide abstract]
ABSTRACT: Ultrasound is now frequently used for evaluation of pathological findings discovered on gynecological examination and for puncture of ovarian cysts. Although the new, high-frequency vaginal transducers have a very high resolution, only macroscopically visible structures of the tumors can be imaged. For this reason, it seemed important to classify ovarian tumors according to their macroscopic appearance and then relate this to whether the tumor was benign, borderline, or malignant. Such a classification has not been performed before. Medical records from women operated upon due to pelvic tumors over a period of 11 years were scrutinized. There were 1017 women included in the study. Among those tumors characterized as unilocular cysts 0.3% (1/296) was malignant; this tumor had macroscopically visible papillary vegetations on the inside of the cyst wall. This cyst was found in a woman 60 years old. Sixty percent (178/296) of the women who had a unilocular cyst were over the age of 40. Two percent (4/203) of the unilocular solid tumors were classified as malignant. The malignancy rates for multilocular cysts was 8% (20/229), multilocular solid tumors 36% (147/209), and solid tumors 39% (31/80). Papillary vegetation on the cyst wall was the structure that was most frequent in malignant tumors. Neither the thickness of the cyst wall nor the thickness of septa inside the tumor seemed to correlate with malignancy. Among the simple ovarian cysts, 65 had a diameter over 10 cm but none of them was malignant. The one that was malignant had a diameter of approximately 5 cm. In conclusion, unilocular ovarian cyst seems to carry a very slight chance of malignancy even in women over the age of 40. Papillary vegetation on the cyst wall, a structure that can be seen by ultrasound, seems to be a serious sign.Gynecologic Oncology 12/1989; 35(2):139-44. · 3.89 Impact Factor
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ABSTRACT: To assess whether changes in the intraovarian vasculature or blood flow impedance can be used to identify potentially malignant masses. Open, non-comparative prospective study. Ovarian screening clinics at King's College Hospital and the Hallam Medical Centre. 50 Women selected on the basis of their medical history and the result of a previous transvaginal ultrasound scan. Thirty women (10 premenopausal (scan taken on days 1 to 8 of the menstrual cycle) and 20 postmenopausal) had normal ovaries, and 20 had at least one ovary with an abnormal morphology or volume, or both. Women with a positive result on screening were referred for laparotomy. Presence or absence of coloured areas (neovascularisation) and the pulsatility index within each ovary. The pulsatility index is a measure of the impedance to blood flow, a low value indicating decreased impedance and a high value increased impedance to blood flow. Two women with a positive result on screening had hydrosalpinges, 10 a benign tumour or a tumour-like condition, and eight primary ovarian cancers. No areas of neovascularisation were seen in the 30 women with morphologically normal ovaries and the two patients with hydrosalpinges; the pulsatility index ranged from 3.1 to 9.4. Similarly, nine patients (10 affected ovaries) with a non-malignant mass had no signs of neovascularisation and the pulsatility index varied from 3.2 to 7.0. One patient with bilateral dermoid cysts containing nests of thyroid-like cells had vascular changes and pulsatility index values of 0.4 and 0.8. Seven patients (eight ovaries) with primary ovarian cancer (one stage IV, four stage II, and two stage Ia) showed clear evidence of neovascularisation and pulsatility index values were from 0.3 to 1.0. One patient with an intraepithelial serous cystadenocarcinoma in a small ovary (less than 5 ml volume) had no signs of any vascular change and the pulsatility index was 5.5. Transvaginal colour flow imaging may be used to identify potentially malignant ovarian masses and help elucidate the early stages of tumorigenesis. The routine application of this technique may reduce the rate of false positive results of an ultrasonography based screening procedure.BMJ 01/1990; 299(6712):1367-70. · 14.09 Impact Factor