Ovarian Adnexal Reporting Data System (O-RADS) for Classifying Adnexal Masses: A Systematic Review and Meta-Analysis

Simple Summary

We performed a systematic review and meta-analysis aiming to assess the diagnostic performance of the Ovarian Adnexal Report Data System (O-RADS) using transvaginal ultrasound for classifying adnexal masses. Data from 11 studies comprising 4634 masses showed that the pooled estimated sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of O-RADS system for classifying adnexal masses were 97% (95% confidence interval (CI) = 94%–98%), 77% (95% CI = 68%–84%), 4.2 (95% CI= 2.9–6.0), 0.04 (95% CI = 0.03–0.07), and 96 (95% CI = 50–185), respectively. We concluded that the O-RADS system has good sensitivity and moderate specificity for classifying adnexal masses.

Abstract

In this systematic review and meta-analysis, we aimed to assess the pooled diagnostic performance of the so-called Ovarian Adnexal Report Data System (O-RADS) for classifying adnexal masses using transvaginal ultrasound, a classification system that was introduced in 2020. We performed a search for studies reporting the use of the O-RADS system for classifying adnexal masses from January 2020 to April 2022 in several databases (Medline (PubMed), Google Scholar, Scopus, Cochrane, and Web of Science). We selected prospective and retrospective cohort studies using the O-RADS system for classifying adnexal masses with histologic diagnosis or conservative management demonstrating spontaneous resolution or persistence in cases of benign appearing masses after follow-up scan as the reference standard. We excluded studies not related to the topic under review, studies not addressing O-RADS classification, studies addressing MRI O-RADS classification, letters to the editor, commentaries, narrative reviews, consensus documents, and studies where data were not available for constructing a 2 × 2 table. The pooled sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio (DOR) were calculated. The quality of the studies was evaluated using QUADAS-2. A total of 502 citations were identified. Ultimately, 11 studies comprising 4634 masses were included. The mean prevalence of ovarian malignancy was 32%. The risk of bias was high in eight studies for the “patient selection” domain. The risk of bias was low for the “index test” and “reference test” domains for all studies. Overall, the pooled estimated sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and DOR of the O-RADS system for classifying adnexal masses were 97% (95% confidence interval (CI) = 94%–98%), 77% (95% CI = 68%–84%), 4.2 (95% CI = 2.9–6.0), 0.04 (95% CI = 0.03–0.07), and 96 (95% CI = 50–185), respectively. Heterogeneity was moderate for sensitivity and high for specificity. In conclusion, the O-RADS system has good sensitivity and moderate specificity for classifying adnexal masses.

Myometrial wall thickness ratio-A nomogram reference for diagnosing myometrial wall asymmetry

OBJECTIVE

Defining the normal range for the anterior/posterior myometrial wall thickness ratio in a cohort of women without adenomyosis or any other uterine wall anomaly on ultrasound examination.

METHODS

Anterior and posterior miometrial wall thickness was measured in 555 women (mean age 34.6 years old, range: 20-50 years) without any ultrasound findings of adenomiosis or other uterine pathology. Measurements were performed in the longitudinal plane of a stored 3D volume. Two observers made all measurements. The myometrial wall thickness ratio was estimated and distribution by centiles obtained. Correlation of myometrial thickness ratio with patient's age and parity was also estimated, using the Pearson's correlation coefficient. Intra- and inter-observer reproducibility were estimated using the intra-class correlation coefficient (ICC).

RESULTS

The mean ratio of the myometrial walls thickness (understood as anterior thickness/posterior thickness ratio) was 0.99 (95% CI: 0.96-1.01). The distribution of the ratio by centiles were as follows: 5%: 0.64, 10%: 0.70, 25%: 0.82, 50%: 0.96, 75%: 1.12, 90%: 1.30 and 95%: 1.45). The myometrial wall thickness ratio was not related to patient's age (Pearson's coefficient: 0.039, p = 0.371), neither to patient's parity (Pearson's coefficient: 0.004, p = 0.923). The ICC was 0.94 and 0.88 for observers 1 and 2, respectively. Inter-observer reproducibility was high (ICC: 0.83).

CONCLUSIONS

Myometrial thickness ratio in women with normal uterus at ultrasound examination is about 1. However, centile distribution shows that values as low as 0.64 or as high as 1.45 could be considered as normal.

Two-Step Strategy for Optimizing the Preoperative Classification of Adnexal Masses in a University Hospital, Using International Ovarian Tumor Analysis Models: Simple Rules and Assessment of Different NEoplasias in the adneXa Model

OBJECTIVES

To evaluate the performance of a two-step strategy compared with the International Ovarian Tumor Analysis (IOTA) - Assessment of Different NEoplasias in the adneXa (ADNEX) model for preoperative classification of adnexal masses.

METHODS

An ambispective diagnostic accuracy study based on ultrasound data collected at one university hospital between 2012 and 2018. Two ultrasonographers classified the adnexal masses using IOTA Simple Rules (first step). Not classifiable masses were evaluated using the IOTA ADNEX model (second step). Also, all masses were classified using the IOTA ADNEX model. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-), and receiver operating characteristic (ROC) curve were estimated. A P value of <.05 was used to determine statistical significance.

RESULTS

The study included 548 patients and 606 masses. Patients' median age was 41 years with an interquartile range between 32 and 51 years. In the first step, 89 (14%) masses were not classifiable. In the second step, 55 (61.8%) masses were classified as malignant. Furthermore, for the totality of 606 masses, the IOTA ADNEX model estimated the probability that 126 (20.8%) masses were malignant. The two-step strategy had a sensitivity, specificity, PPV, NPV, LR+, LR-, and ROC curve of 86.8%, 91.01%, 51.9%, 98.4%, 9.7, 0.1, and 0.889, respectively; compared to IOTA ADNEX model that had values of 91.8%, 87.16%, 44.4%, 99%, 7.1, 0.09, and 0.895, respectively.

CONCLUSION

The two-step strategy shows a similar diagnostic performance when compared to the IOTA ADNEX model. The IOTA ADNEX model involves only one step and can be more practical, and thus would be recommended to use.

Effect of Hysteroscopic Metroplasty on Reproductive Outcomes in Women with Septate Uterus: Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this systematic review with meta-analysis is to evaluate the impact of hysteroscopic metroplasty on adverse reproductive outcomes such as miscarriage, preterm birth, and fetal malpresentation in patients with history of infertility or previous poor obstetrical outcomes.

DATA SOURCES

A systematic electronic search from inception each database up to April 2021 including the following databases was conducted: PubMed-MEDLINE, EMBASE, Web of Science, The Cochrane Library, the CGF Specialized Register of Controlled Trials, Google Scholar, and trial registries. A combination of the following keywords was used: uterine septum, septate uterus, congenital uterine malformation, class 2 uterus, class V uterus, metroplasty, hysteroscopic, pregnancy, clinical pregnancy, ongoing pregnancy, miscarriage, live birth, preterm birth, cesarean section, 'cesarean delivery, and fetal malpresentation.

METHODS OF STUDY SELECTION

Studies comparing reproductive outcomes between women undergoing hysteroscopic resection of the uterine septum and those with expectant management were included. Eligible population consisted of infertile women, women with poor obstetrical history, or women without previous pregnancy failures and a diagnosis of septate uterus.

TABULATION, INTEGRATION, AND RESULTS

The systematic electronic search retrieved 1076 studies; after elimination of duplicates, 688 titles and abstracts were screened, and 55 were assessed for eligibility. Eleven studies were included in the quantitative synthesis: one randomized controlled trial and 10 observational studies involving reproductive outcomes from 1589 patients with either complete or partial uterine septum. The pooled OR for miscarriage was 0.45, (95% CI, 0.22-0.90). When the analysis was performed considering subgroups according to the type of septum, pooled OR in complete septum subgroup was 0.16 (95% CI, 0.03-0.78), OR = 0.36 (95% CI, 0.19-0.71) in the partial septum subgroup and 0.58 (95% CI, 0.20-1.67) in those studies not differentiating between complete or partial septum. No significant differences were found between the 2 groups in OR of clinical pregnancy, term live birth, or risk of cesarean delivery. There was a significant decrease in the frequency of preterm birth in patients who underwent partial septum resection (OR = 0.30, 95% CI, 0.11-0.79). This difference was detected neither in patients with complete septum nor in studies not differentiating between partial or complete septum. The risk of fetal malpresentation was also significantly reduced (OR = 0.32, 95% CI, 0.16-0.65).

CONCLUSION

The results of the present meta-analysis support that hysteroscopic metroplasty is effective in reducing the risk of miscarriage in patients with complete or partial uterine septum, although these data should be confirmed with a well-designed randomized controlled trial.

Severe pain during hysterosalpingo-contrast sonography (HyCoSy): a systematic review and meta-analysis

PURPOSE

To assess the frequency of severe pain perception during hysterosalpingo-contrast sonography (HyCoSy) in infertile women and to assess whether there are differences in the frequency of associated pain according to the contrast used.

DESIGN

Systematic review and meta-analysis.

PATIENTS

Women undergoing HyCoSy due to infertility.

INTERVENTIONS

Searches were carried out in two databases (Pubmed and Web of Science). We included prospective or retrospective cohort observational studies that specified the type of contrast used during HyCoSy and reported data regarding the number of patients who perceived severe pain during the procedure and the scale used for pain perception score.

MAIN OUTCOME MEASURES

Pooled frequency of severe pain perception during HyCoSy and the pooled frequency of severe pain perception based on the contrast used.

RESULTS

Twenty-nine studies were included in this meta-analysis including a total of 7139 patients. In 10 studies, Saline solution with air was used as contrast EchoVist™ was used in ten studies, in five studies, SonoVue™ was used and in four studies, ExEm-Foam™ was used as contrast. Pooled estimated frequency of severe pain perception during HyCoSy was 6% (95% CI 4-9). No statistically significant differences have been described regarding frequency of severe pain perception in relation to the different contrasts used.

CONCLUSIONS

HyCoSy is a tolerable outpatient procedure. We did not find any evidence that one specific contrast was better tolerated than any other was.

Comparison of IOTA three-step strategy and logistic regression model LR2 for discriminating between benign and malignant adnexal masses

AIMS

To compare the diagnostic performance of two ultrasound-based diagnostic systems for the classification of benign or malignant adnexal masses, the three-step strategy and the predictive logistic regression model LR2, both proposed by the International Ovarian Tumour Analysis (IOTA) Group.

MATERIAL AND METHODS

Prospective observational study at a single centre that included patients diagnosed with a persistent adnexal mass by transvaginal ultrasound over a period of two years. They were evaluated by a non-expert sonographer by applying the three-step diagnostic strategy and the LR2 predictive model to classify the masses as benign or malignant. Patients were treated surgically or followed up for at least one year, taking as the standard reference for benignity or malignancy the histological diagnosis of the lesion or ultrasound changes suggestive of malignancy during the follow-up period. Sensitivity, specificity, positive and negative likelihood ratios and overall accuracy of both systems was calculated and compared.

RESULTS

One hundred patients were included, with a mean age of 50.6 years (range 18-87). Surgery was performed on 62 (62%) patients and 38 (38%) were managed expectantly. Eighty-three (83%) lesions were benign and 17 (17%) were malignant. The IOTA three-step strategy presented sensitivity of 94.1% (95%CI, 86.7-98.3%) and specificity 97.6% (95%CI, 94.8-99%). The LR2 logistic regression model showed sensitivity 94.1% (95%CI, 73-98.9%) and specificity 81.9% (95%CI 72.3-88.7%). Comparison of the two systems showed a statistically significant dif-ference in specificity in favour of the three-step strategy.

CONCLUSIONS

The IOTA three-step strategy, in addition to being sim-ple to use in clinical practice, has a high diagnostic accuracy for the classification of benignity and malignancy of the adnexal masses, overtaking that of other predictive models such as the LR2 logistic regression model.

Predictive value of hyperglycosylated human chorionic gonadotropin for pregnancy outcomes in threatened abortion in first-trimester viable pregnancies

BACKGROUND

To investigate the value of a single determination of hyperglycosylated hCG (hCG-H) for predicting the clinical outcome of patients with threatened abortion in the first trimester of pregnancy.

METHODS

Prospective study performed on 86 consecutively selected women with a diagnosis of threatened abortion and viable intrauterine pregnancy in the first trimester of pregnancy, conducted in two tertiary care hospitals. All patients underwent a single blood sample to determine hCG-H and total hCG serum levels and a transvaginal ultrasound 12-24 hours after diagnosis. Patients were monitored to determine whether the outcome was a miscarriage before the 20th week of pregnancy.

RESULTS

Forty-three women (50%) had a miscarriage during the follow-up. We observed a very high correlation between hCG-H and total hCG (r?=?0.91, p?<?0.001). Median hCG-H and total hCG from pregnancies with normal outcome was signif-icantly higher than those ending in abortion. hCG-H and total hCG were very similar predictors of pregnancy outcomes (AUC: 0.90 and 0.89, respectively). The ratio hCG-H / total hCG was a poor predictor (AUC: 0.64).

CONCLUSION

A single hCG-H assay is helpful for predicting pregnancy outcomes in women with first trimester threatened abortion and viable or potentially viable pregnancy at the time of presentation. However, hCG-H is not a better predictor than total hCG.

Feasibility, tolerability, and safety of hysterosalpingo-foam sonography (hyfosy). multicenter, prospective Spanish study

OBJECTIVE

To determine the feasibility,tolerability, and safety of the ultrasound assessment of tubal patency using foam as contrast.

METHODS

This was a prospective multicenter study of 915 infertile nulliparous women scheduled for sonohysterosalpingography with foam instillation (HYFOSY) for tubal patency testing as a part of the fertility workup. Clinical and sonographic data were recorded into a web-shared database. Tubal patency, cervical catheterization, pain during the procedure and post-procedural complications were collected. Patients reported discomfort or pain experienced during the procedure with a visual analogue scale (VAS) score.

RESULTS

Nine hundred fifteen women were included in the final analysis. Median age was 34 (range, 21-45) years and median body mass index was 23 (range, 16-41) kg/m2. Of 839 women, only 8(0.95 %) cases were abandoned due to impossibility of introducing the intracervical catheter. Most of the cervical os were easily cannulated with either paediatric nasogastric probes or special catheter for intrauterine insemination / sonohysterosalpingography 688/914(75.3 %). With a median instillation of 4 mL (range 1-16) of foam, both tubes were identified in 649/875 (70.9 %) patients, while unilateral patency was observed in 190/875 (20.8 %). Only 36/875 (3.9 %) of the women had bilateral tubal obstruction. The median VAS score for perception of pain during HyFoSy examination was 2 (range 0-10), and only 17 (1.9 %) of women reported severe pain (VAS ≥ 7). Pain was unrelated to tubal patency or tubal blockage. Unexpectedly, difficult cervical catheterizations that needed tenaculum, were more likely associated with mild pain during procedure [nasogastric probe group 176/289 (70.9 %) vs. insemination catheter group 166/399 (41.6 %) vs. tenaculum group 190/218(87.2 %) p < 0.001]. Finally, among 915 patients, we only noticed 3 (0.32 %) complications of the technique: two vasovagal episodes and a mild urinary infection.

CONCLUSION

HYFOSY is a feasible, well-tolerated and safe technique for the evaluation of tubal patency in infertile women.

Two-dimensional transvaginal sonography vs saline contrast sonohysterography for diagnosing endometrial polyps: systematic review and meta-analysis

OBJECTIVE

To compare the diagnostic performance of two-dimensional transvaginal sonography (TVS) and saline contrast sonohysterography (SCSH) for the diagnosis of endometrial polyps in studies that used both tests in the same group of patients.

METHODS

This was a systematic review and meta-analysis. An extensive search was conducted of Medline (PubMed), Cochrane Library and Web of Science, for studies comparing the diagnostic performance of TVS and SCSH for identifying endometrial polyps, published between January 1990 and December 2019, that reported a definition of endometrial polyp on TVS and SCSH and used pathologic analysis as the reference standard. Quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. A random-effects model was used to determine pooled sensitivity, specificity and positive and negative likelihood ratios of TVS and SCSH in the detection of endometrial polyps. Subanalysis according to menopausal status was performed.

RESULTS

In total, 1278 citations were identified; after exclusions, 25 studies were included in the meta-analysis. In the included studies, the risk of bias evaluated using QUADAS-2 was low for most of the four domains, except for flow and timing, which had an unclear risk of bias in 13 studies. Pooled sensitivity, specificity and positive and negative likelihood ratios for TVS in the detection of endometrial polyps were 55.0% (95% CI, 46.0-64.0%), 91.0% (95% CI, 86.0-94.0%), 5.8 (95% CI, 3.9-8.7) and 0.5 (95% CI, 0.41-0.61), respectively. The corresponding values for SCSH were 92.0% (95% CI, 87.0-95.0%), 93.0% (95% CI, 91.0-95.0%), 13.9 (95% CI, 9.9-19.5) and 0.08 (95% CI, 0.05-0.14), respectively. Significant differences were found when comparing the methods in terms of sensitivity (P < 0.001), but not for specificity (P = 0.0918). Heterogeneity was high for TVS and moderate for SCSH. On subanalysis according to menopausal status, SCSH was found to have higher diagnostic accuracy in both pre- and postmenopausal women; sensitivity and specificity did not differ significantly between the groups for either TVS or SCSH.

CONCLUSION

Given that SCSH has better diagnostic positive and negative likelihood ratios than does TVS in both pre- and postmenopausal women, those with clinical suspicion of endometrial polyps should undergo SCSH if TVS findings are inconclusive. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Two-dimensional hysterosalpingo-contrast-sonography compared to three/four-dimensional hysterosalpingo-contrast-sonography for the assessment of tubal occlusion in women with infertility/subfertility: a systematic review with meta-analysis

In this meta-analysis, we aimed to compare the diagnostic accuracy of 2D- and 3D/4D-HyCoSy for the assessment of tubal occlusion in women with infertility, using a laparoscopic tubal chromoperturbation dye test as the reference standard. Studies assessing 2D- and 3D/4D-HyCoSy for the assessment of tubal occlusion in women with infertility were searched from January 1990 to April 2019 using Medline and Web of Science databases by three of the authors, using the terms: 'hysterosalpingo-contrast-sonography', 'sonohysterosalpingography', 'HyCoSy', 'HyFoSy', 'three-dimensional', 'four-dimensional', 'ultrasound', 'tubal patency' and 'tubal occlusion'. Data quality was determined using the QUADAS-2 tool. Thirty articles were included; twenty-one studies used 2D-HyCoSy to assess tubal occlusion, six used 3D/4D-HyCoSy, one study used both techniques but in a different set of patients and two used both techniques in the same patients. The risk of bias for most studies was low as determined by QUADAS-2, except for the patient selection domain. Overall, pooled estimated sensitivity and specificity of 2D-HyCoSy were 86% (95% CI = 80%-91%) and 94% (95% CI = 90%-96%), respectively. The corresponding figures for 3D/4D HyCoSy were 95% (95% CI = 89%-98%) and 89% (95% CI = 82%-94%). High heterogeneity was found for both sensitivity and specificity. No statistically significant differences were found between the methods (p = 0.13). We concluded that 2D-HyCoSy has a similar diagnostic performance to 3D/4D-HyCoSy.

Risk of Ovarian Malignancy Algorithm versus Risk Malignancy Index-I for Preoperative Assessment of Adnexal Masses: A Systematic Review and Meta-Analysis

PURPOSE

To perform a systematic review and meta-analysis of studies comparing the diagnostic accuracy of Risk of Ovarian Malignancy Algorithm (ROMA) and risk of malignancy index (RMI) for detecting ovarian cancer.

METHODS

A systematic review and meta-analysis was performed according to PRISMA statement. A search for studies evaluating the diagnostic performance of ROMA and RMI-I indices for detecting ovarian malignancy from January 2010 to October 2018 was performed in the PubMed/MEDLINE and Web of Science databases. The quality of the studies was evaluated by the Quality Assessment of Diagnostic Accuracy Studies 2.

RESULTS

Sixty-six citations were identified. After exclusions, 8 papers comprising 2,662 women (1,319 premenopausal and 1,343 postmenopausal) were ultimately included. The mean prevalence of ovarian malignancy was 29.0% in premenopausal women and 51.0% in postmenopausal women. High risk of bias for patient selection was observed for most studies. ROMA and RMI-I had a similar diagnostic performance in postmenopausal women (pooled sensitivity [87 vs. 77%] and specificity [75 vs. 85%], respectively. p = 0.29). In premenopausal women, RMI-I showed better specificity than ROMA (89 vs. 78%, p = 0.022) with similar sensitivity (73 vs. 80%, p= 0.27). Significant heterogeneity was found for sensitivity and specificity in comparisons of both groups.

CONCLUSIONS

ROMA and RMI-I have similar diagnostic performance for detecting ovarian cancer in women presenting with an adnexal mass. However, RMI-I showed a higher specificity than ROMA in premenopausal women. Notwithstanding, as the risk of bias is high in most studies, our results should be interpreted with caution.

Hypopressive technique versus pelvic floor muscle training for postpartum pelvic floor rehabilitation: A prospective cohort study

AIMS

Abdominal hypopressive technique (AHT) is gaining popularity as an alternative to pelvic floor muscle training (PFMT) during postpartum. Although, there is no solid evidence for its recommendation.

METHODS

We conducted a prospective observational cohort study in a university hospital with 105 primiparae who performed a two-month PFMT or AHT program. The aim was to compare the effectiveness of both treatments in terms of morphofunctional changes in 3D transperineal ultrasound, manometry, dynamometry, and differences in urinary incontinence symptoms (ICIQ-IU-SF) and satisfaction.

RESULTS

The average change in levator ani muscle was 1.2 mm higher in AHT group vs PFMT (95% confidence interval [CI], -2.2 to -0.2; P = .017). No statistically significant differences were shown in maximal strength changes between groups. After AHT, basal tone change was 63.0 g/cm² higher than PFMT (95% CI, -129 to 2.9; P = .06). A statistically significant reduction in ICIQ-IU-SF was observed after both treatments [(PFMT, -0.8 points; 95% CI, -1.4 to -0.1; P = .015), (AHT, -0.7 points; 95% CI, -1.3 to -0.1; P = .018]. AHT showed a higher median satisfaction score than PFMT (P = .004).

CONCLUSIONS

This preliminary study is the first that analyses the effect of AHT vs PFMT during postpartum. The results suggest a higher improve for AHT in levator muscle thickness and satisfaction compared to PFMT. These must be considered with caution due to the limitations of the study. Further randomized clinical trials about both techniques during postpartum are required.

Prospective external validation of IOTA three-step strategy for characterizing and classifying adnexal masses and retrospective assessment of alternative two-step strategy using simple-rules risk

OBJECTIVES

To perform an external validation of the diagnostic performance of the three-step strategy proposed by the International Ovarian Tumor Analysis (IOTA) group for classifying adnexal masses as benign or malignant, when ultrasound is performed by non-expert sonographers in the first two steps. The second objective was to assess the diagnostic performance of an alternative strategy using simple-rules risk (SRR), instead of simple rules (SR), in the second step.

METHODS

This was a prospective observational study conducted at two university hospitals, from September 2015 to August 2017, of consecutive patients diagnosed with an adnexal mass. All women were evaluated by ultrasound using the IOTA three-step strategy. Non-expert sonographers performed the first step (use of simple descriptors to classify the masses) and the second step (use of SR if the mass could not be classified in the first step); masses that could not be classified in the first two steps were categorized by an expert sonographer based on their subjective assessment (third step). The reference standard was histological diagnosis in patients who underwent surgery or at least 12 months of follow-up in cases managed expectantly. The sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios and overall accuracy of the IOTA three-step strategy were estimated. Furthermore, we evaluated retrospectively an alternative two-step strategy using SRR in the second step to categorize the masses not classifiable with simple descriptors, classifying the lesions as being of low, intermediate or high risk for malignancy. The diagnostic performance of this strategy was estimated by calculating its sensitivity and specificity, assuming surgical intervention for intermediate- or high-risk lesions.

RESULTS

The study included 283 patients (median age, 48 (range, 18-90) years), of whom 165 (58.3%) were premenopausal and 118 (41.7%) postmenopausal. Two hundred and sixteen (76.3%) women underwent surgery (154 benign and 62 malignant masses) and 67 (23.7%) were managed expectantly with serial ultrasound follow-up for at least 12 months. All expectantly managed masses were considered benign because no sonographic changes suggestive of malignancy were observed during follow-up. Simple descriptors could be applied in 126 (44.5%) masses. Of the remaining 157 lesions, 112 (39.6%) could be characterized using SR. Therefore, 238 (84.1%) masses could be classified by non-expert sonographers in the first two steps. Of the remaining 45 (15.9%) masses, all could be classified by an expert sonographer. Overall sensitivity, specificity, LR+ and LR- of the IOTA three-step strategy were 95.2%, 97.7%, 42.1 and 0.05, respectively. The diagnostic accuracy was 97.2%. Following the two-step strategy using SRR in the second step, of the 157 lesions not classified with simple descriptors, 42, 38 and 77 presented low, intermediate or high risk for malignancy, respectively. Based on this method, 210 women would have undergone surgical treatment. The sensitivity and specificity of this two-step strategy were 98.4% and 63.8%, respectively.

CONCLUSIONS

The IOTA three-step strategy shows high accuracy for discriminating between benign and malignant adnexal lesions when used by non-expert sonographers. An alternative strategy using the SRR calculator in the second step might improve on this diagnostic performance by decreasing the number of surgical interventions and increasing sensitivity. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Gastrointestinal Endoscopic Ultrasound-Guided Fine-Needle Aspiration for Assessing Suspected Deep Pelvic or Abdominal Recurrence in Gynecologic Cancer: A Feasibility Study

OBJECTIVES

To assess the feasibility of gastrointestinal endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for histologic confirmation of cancer recurrence in women with gynecologic cancer.

METHODS

This work was a retrospective cohort study comprising 46 consecutive women treated for gynecologic cancer and suspected of having a deep pelvic or abdominal recurrence on ultrasound imaging, computed tomography, positron emission tomography-computed tomography, or magnetic resonance imaging, evaluated at our institution from January 2010 to December 2017. Primary cancer was ovarian (n = 22), cervical (n = 13), endometrial (n = 4), sarcoma (n = 4), and other (n = 3). All women underwent EUS examinations for locating the lesion and guiding FNA. The results of FNA (benign/malignant) were assessed. Procedure-related complications were recorded.

RESULTS

The patients' mean age was 57.8 years. A total of 66 procedures were performed. Eleven women underwent 2 procedures; 2 women underwent 3 procedures; and 1 woman underwent 6 procedures at different times during the study period. In 1 case, no lesion was detected on the EUS assessment, and in 2 cases, FNA was not successful. Most lesions were located in the retroperitoneum or involved the intestine. Fine-needle aspiration could be performed in 63 cases (94.5%). Cytologic samples were adequate in 62 of 63 (98.4%). Recurrence was confirmed in 56 cases (90.3%) and ruled out in 6 (9.7%). No patient had any complication related to the procedure.

CONCLUSIONS

Endoscopic ultrasound-guided FNA is a minimally invasive, feasible, and safe technique for confirming pelvic/abdominal recurrence of gynecologic cancer.

Pre-operative assessment of intra-abdominal disease spread in epithelial ovarian cancer: a comparative study between ultrasound and computed tomography

Objective

To compare the diagnostic performance of ultrasound and computed tomography (CT) for detecting pelvic and abdominal tumor spread in women with epithelial ovarian cancer.

Methods

An observational cohort study of 93 patients (mean age 57.6 years) with an ultrasound diagnosis of adnexal mass suspected of malignancy and confirmed histologically as epithelial ovarian cancer was undertaken. In all cases, transvaginal and transabdominal ultrasound as well as CT scans were performed to assess the extent of the disease within the pelvis and abdomen prior to surgery. The exploration was systematic, analyzing 12 anatomical areas. All patients underwent surgical staging and/or cytoreductive surgery with an initial laparoscopy for assessing resectability. The surgical and pathological findings were considered as the 'reference standard'. Sensitivity and specificity of ultrasound and CT scanning were calculated for the different anatomical areas and compared using the McNemar test. Agreement between ultrasound and CT staging and the surgical stage was estimated using the weighted kappa index.

Results

The tumorous stage was International Federation of Gynecology and Obstetrics (FIGO) stage I in 26 cases, stage II in 11 cases, stage III in 47 cases, and stage IV in nine cases. Excluding stages I and IIA cases (n=30), R0 (no macroscopic residual disease) was achieved in 36 women (62.2%), R1 (macroscopic residual disease <1 cm) was achieved in 13 women (25.0%), and R2 (macroscopic residual disease >1 cm) debulking surgery occurred in three women (5.8%). Eleven patients (11.8%) were considered not suitable for optimal debulking surgery during laparoscopic assessment. Overall sensitivity of ultrasound and CT for detecting disease was 70.3% and 60.1%, respectively, and specificity was 97.8% and 93.7%, respectively. The agreement between radiological stage and surgical stage for ultrasound (kappa index 0.69) and CT (kappa index 0.70) was good for both techniques. Overall accuracy to determine tumor stage was 71% for ultrasound and 75% for CT.

Conclusion

Detailed ultrasound examination renders a similar diagnostic performance to CT for assessing pelvic/abdominal tumor spread in women with epithelial ovarian cancer.

Diagnostic Performance of Transvaginal Ultrasound for Detecting Cervical Invasion In Women With Endometrial Carcinoma: A Systematic Review and Meta-analysis

OBJECTIVES

To evaluate the role of transvaginal ultrasound (TVUS) for diagnosing cervical invasion in the preoperative assessment of endometrial carcinoma.

METHODS

A search for studies evaluating the role of TVUS for assessing cervical invasion in endometrial carcinoma from January 1990 to December 2016 was performed in the PubMed/MEDLINE, Web of Science, www.ClinicalTrials.gov, and www.who.int/trialsearchdatabases. The quality of the studies was evaluated by the Quality Assessment of Diagnostic Accuracy Studies 2.

RESULTS

We identified 211 citations. Ultimately, 17 studies comprising 1751 women were included. The mean prevalence of cervical invasion was 16.3%. The risk of bias was high in 7 studies for the domains "patient selection" and "index test," whereas it was considered low for the "reference test" domain. Overall, the pooled estimated sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of TVUS for detecting cervical invasion were 63% (95% confidence interval [CI], 51%-74%), 91% (95% CI, 87%-94%), 10.2 (95% CI, 5.7-18.3), and 0.38 (95% CI, 0.28-0.53), respectively. Heterogeneity was high for both sensitivity and specificity.

CONCLUSIONS

Transvaginal ultrasound has acceptable diagnostic performance for detecting cervical invasion in women with endometrial carcinoma.

Risk of endometrial cancer and endometrial hyperplasia with atypia in asymptomatic postmenopausal women with endometrial thickness ≥11 mm: A systematic review and meta-analysis

PURPOSE

To evaluate the risk of endometrial cancer and/or endometrial hyperplasia with atypia in asymptomatic postmenopausal women with endometrial thickness ≥ 11 mm.

METHODS

Systematic review of literature using database search (PubMed and Web of Science) of articles published between January 1990 and December 2016 evaluating the correlation between endometrial thickness as measured by transvaginal ultrasound (double layer) and histopathological findings in asymptomatic postmenopausal women, using the following terms: "endometrial thickness," "postmenopausal," "postmenopause," and "asymptomatic." Inclusion criteria were prospective or retrospective studies of more than 150 cases that provided information on endometrial thickness and its correlation with histopathological data. Studies that included patients with hormone replacement therapy, tamoxifen, or aromatase inhibitors were excluded. The overall relative risk (RR) for EC/EHA was calculated, stratifying the patients into two groups according to endometrial thickness (<11 mm and ≥11 mm). Heterogeneity was assessed by calculating I² .

RESULTS

The search identified 289 studies. After exclusions, nine articles that met all the inclusion criteria were included, comprising data from 4751 women. The prevalence of endometrial cancer and/or endometrial hyperplasia with atypia was 2.4%. The relative risk of endometrial cancer and/or endometrial hyperplasia with atypia in the ≥11 mm group was 2.59 (95% CI: 1.66-4.05). High heterogeneity was observed between studies (I² : 57.3%, P = .016).

CONCLUSIONS

Overall the risk for EC/EHA was 2.6 times greater in women with ET ≥11 mm vs women with ET 5-10 mm, although there was significant heterogeneity in estimates across studies.

Deep Infiltrating Endometriosis: Comparison Between 2-Dimensional Ultrasonography (US), 3-Dimensional US, and Magnetic Resonance Imaging

OBJECTIVES

To evaluate the diagnostic accuracy of 2-dimensional (2D) and 3-dimensional (3D) transvaginal ultrasonography (US) in comparison with magnetic resonance imaging (MRI) for identification of deep infiltrating endometriosis.

METHODS

In this prospective observational study, 159 premenopausal women who underwent surgery for a clinical suspicion of deep infiltrating endometriosis were prospectively enrolled. All women underwent 2DUS, 3DUS, and MRI. The following 3 locations of deep endometriosis were considered: (1) intestinal; (2) other posterior lesions (retrocervical septum, rectovaginal septum, uterosacral ligaments, and vaginal fornix); and (3) anterior. The sensitivity, specificity, positive predictive value, and negative predictive value of 2D and 3D transvaginal US in comparison with MRI were determined.

RESULTS

Intestinal deep infiltrating endometriosis was identified by 2DUS in 56 of 66 patients, by 3DUS in 59 of 66, and by MRI in 61 of 66. A receiver operating characteristic curve analysis showed optimal results for 2DUS, 3DUS, and MRI (areas under the curve, 0.86, 0.915, and 0.935, respectively) with a statistically significant difference between 2DUS and MRI (P = .0103), even when the 95% confidence interval showed an overlap. Other posterior deep infiltrating endometriosis was identified by 2DUS in 55 of 75 patients, by 3DUS in 65 of 75, and by MRI in 66 of 75. A receiver operating characteristic curve analysis showed very good results for 2DUS, 3DUS, and MRI (areas under the curve, 0.801, 0.838, and 0.857) with no statistically significant differences. In the 12 women with deep infiltrating endometriosis in the anterior location, the nodules were correctly identified by 2DUS in 3 of 12 patients, by 3DUS in 5 of 12, and by MRI in 6 of 12.

CONCLUSIONS

Our results seem to suggest that there is a statistically significant difference between 2DUS and MRI for the intestinal location of deep infiltrating endometriosis, whereas no differences were found among the techniques for the other locations.

Transvaginal ultrasound versus magnetic resonance imaging for preoperative assessment of myometrial infiltration in patients with endometrial cancer: a systematic review and meta-analysis

Objective

To compare the diagnostic accuracy of transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) for detecting myometrial infiltration (MI) in endometrial carcinoma.

Methods

An extensive search of papers comparing TVS and MRI in assessing MI in endometrial cancer was performed in MEDLINE (PubMed), Web of Science, and Cochrane Database from January 1989 to January 2017. Quality was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool.

Results

Our extended search identified 747 citations but after exclusions we finally included in the meta-analysis 8 articles. The risk of bias for most studies was low for most 4 domains assessed in QUADAS-2. Overall, pooled estimated sensitivity and specificity for diagnosing deep MI were 75% (95% confidence interval [CI]=67%–82%) and 82% (95% CI=75%–93%) for TVS, and 83% (95% CI=76%–89%) and 82% (95% CI=72%–89%) for MRI, respectively. No statistical differences were found when comparing both methods (p=0.314). Heterogeneity was low for sensitivity and high for specificity for TVS and MRI.

Conclusion

MRI showed a better sensitivity than TVS for detecting deep MI in women with endometrial cancer. However, the difference observed was not statistically significant.

Reproducibility of the International Endometrial Analysis Group Color Score for Assigning the Amount of Flow Within the Endometrium Using Stored 3-Dimensional Volumes

OBJECTIVES

To estimate intraobserver and interobserver reproducibility for assigning an International Endometrial Tumor Analysis (IETA) group color score for endometrial vascularization on color Doppler imaging.

METHODS

Sixty-eight endometrial 3-dimensional volumes from endometrial color Doppler assessments of women with different endometrial disorders were evaluated by 8 different examiners (4 skilled examiners and 4 obstetric and gynecologic trainees). One skilled examiner who did not participate in the assessments selected the 68 volumes from a database to select a balanced number of each IETA score. Each examiner evaluated the 68 endometrial volumes to assign the IETA color score (1, absence of vascularization; 2, low vascularization; 3, moderate vascularization; or 4, abundant vascularization) using tomographic ultrasound imaging. The analysis was repeated 4 weeks later, and interobserver and intraobserver reproducibility was analyzed by calculating the weighted κ index. The second of the measurements made by each observer was used to estimate interobserver reproducibility.

RESULTS

The intraobserver reproducibility was very good for all examiners, with a weighted κ index ranging from 0.84 to 0.91. The interobserver reproducibility was good or very good for all estimated comparisons, with a weighted κ index ranging from 0.77 to 0.96, regardless of experience level.

CONCLUSIONS

The reproducibility of assigning the IETA color score for assessing endometrial vascularization using 3-dimensional volumes is good or very good regardless of the experience of the examiner.

Clinical and ultrasound features of benign, borderline, and malignant invasive mucinous ovarian tumors

OBJECTIVE

To compare clinical and sonographic features of benign, borderline, and malignant invasive mucinous ovarian tumors (MOTs).

MATERIALS AND METHODS

Retrospective observational multicenter study comprising 365 women (mean age: 46.1 years) with a histologically confirmed benign, borderline or malignant invasive MOT. Clinical data (patient's age, patient's complaints), tumor markers (CA-125 and CA-1 9.9), and sonographic data (tumor size, bilaterality, morphology -unilocular, multilocular, unilocular-solid, multilocular-solid and solid-, and IOTA color score) were reviewed and compared among these three groups. Women with ultrasound evidence on intra-abdominal disease spread were excluded.

RESULTS

Three hundred seventy-eight MOTs (14 women had bilateral lesions) were analyzed. Histologically, 287 tumors were benign, 51 were borderline, and 40 were malignant. No difference in patient's mean age was observed. Women with borderline or invasive tumors were less frequently asymptomatic. Tumors were larger in case of invasive lesions. Borderline and invasive tumors showed solid components and exhibited IOTA color score 3 or 4, more frequently than benign lesions (p < 0.001). However, the authors discovered that 16 out of 51 (31.4%) of borderline tumors and six out of 40 (15.0%) of invasive cancers had no solid components and a color score 1 or 2, and were considered as a benign lesion by the sonolo- gist. On the other hand, 96 out of 287 (33.4%) benign mucinous cystadenoma exhibited solid components and/or a color score of 3 or 4.

CONCLUSIONS

In spite of statistical differences, the authors observed significant overlapping in ultrasound features among benign, borderline, and invasive ovarian mucinous tumors that renders a difficult accurate preoperative discrimination among these lesions.

External validation of IOTA simple descriptors and simple rules for classifying adnexal masses

OBJECTIVE

To assess the diagnostic performance of a three-step strategy proposed by the International Ovarian Tumor Analysis (IOTA) Group for discriminating between benign and malignant adnexal masses.

METHODS

This was a prospective observational study, performed at two tertiary-care university hospitals, of women diagnosed with an adnexal mass on transvaginal or transabdominal ultrasound between December 2012 and December 2014. Women were scheduled for an ultrasound evaluation, which was initially performed by non-expert examiners. The examiner had to classify the mass using 'simple descriptors' (first step) and, if not possible, using 'simple rules' (second step). For inconclusive masses, an expert examiner classified the mass according to their subjective impression (third step). Masses were managed expectantly, with serial follow-up examinations, or surgically, according to ultrasound findings and clinical symptoms. Histology was used as the reference standard. Masses that were managed expectantly with at least 1 year of follow-up were considered as benign for analytical purposes. Women with less than 1 year of follow-up were not included in the study.

RESULTS

Six hundred and sixty-six women were included (median age, 41 (range, 18-81) years) of whom 514 were premenopausal and 152 were postmenopausal. Based on the three-step strategy, 362 women had surgical removal of the mass (53 malignant and 309 benign), 71 masses resolved spontaneously and 233 persisted. Four hundred and forty-eight (67.3%) of 666 masses could be classified using simple descriptors and, of the 218 that could not, 147 (67.4%) were classified using simple rules. Of the remaining 71 masses, the expert examiner classified 45 as benign, 12 as malignant and 14 as uncertain. Overall sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of the three-step strategy were 94.3%, 94.9%, 18.6 and 0.06, respectively.

CONCLUSION

The IOTA three-step strategy, based on the sequential use of simple descriptors, simple rules and expert evaluation, performs well for classifying adnexal masses as benign or malignant. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Three-Dimensional Transvaginal Sonography and Magnetic Resonance Imaging for Local Staging of Cervical Cancer: An Agreement Study

OBJECTIVES

To evaluate the agreement of clinical examination, 2-dimensional (2D) sonography, and 3-dimensional (3D) sonography with magnetic resonance imaging (MRI) for local staging of cervical cancer.

METHODS

We conducted a prospective study including women with a diagnosis of carcinoma of the cervix. All women were staged clinically and underwent 2D and 3D transvaginal sonography and MRI before treatment for assessing tumor size and parametrial, bladder, and rectal involvement using the examiner's subjective impression. Agreement between sonography and MRI was assessed by calculating the κ index and percentage of agreement.

RESULTS

Forty women were included (mean age ± SD, 46.6 ± 11.4 years). Eleven had early-stage (IA and IB1) disease, and 29 had advanced-stage (IB2-IVB) disease. A significant correlation for tumor size estimation was found between MRI and pelvic examination (r = 0.754; P < .001), MRI and 2D sonography (r = 0.649; P < .001), and MRI and 3D sonography (r = 0.657; P< .001). Agreement for parametrial infiltration between MRI and pelvic examination was fair (κ = 0.26; 95% confidence interval [CI], 0.10-0.54; 62.5% agreement), between MRI and 2D sonography was moderate (κ = 0.41; 95% CI, 0.15-0.66; 70.0% agreement), and between MRI and 3D sonography was good (κ = 0.60; 95% CI, 0.35-0.85; 80.0% agreement). Agreement for bladder involvement between MRI and pelvic examination was moderate (κ = 0.48; 95% CI, 0.10-0.99; 95.0% agreement), between MRI and 2D sonography was moderate (κ = 0.48; 95% CI, 0.10-0.99; 95.0% agreement), and between MRI and 3D sonography was very good (κ = 0.84; 95% CI, 0.55-1.0; 97.5% agreement). Agreement for rectal involvement was not calculated because of the very small number of cases.

CONCLUSIONS

Three-dimensional sonography showed good agreement with MRI for assessing parametrial infiltration and bladder involvement in cervical cancer.