Transvaginal colour flow imaging: a possible new screening technique for ovarian cancer

Colour Doppler sonography improves the pre-operative diagnosis of ovarian tumours made using conventional transvaginal sonography

OBJECTIVE

Conventional transvaginal ultrasound-and transvaginal colour Doppler flow were used to assess morphology and circulation of pelvic masses.

STUDY DESIGN

One hundred and nine adnexal masses in 101 women were examined between January 1993 and September 1994. Morphology was classified after a score published by Sassone et al. in 1991. Doppler waveforms using the lowest resistance index (RI), the pulsatility index (PI) and peak flow velocity were used for analysis. Ninety five patients underwent laparotomy. Following histopathological evaluation best cut-off values, sensitivity and specificity were calculated. Score results were compared with Doppler results and a combination of both methods.

RESULTS

A combination of Doppler sonography and conventional transvaginal sonography led to a sensitivity of 74.0% and a specificity of 73.7%. Eight out of 15 malignant masses were classified as stage I. An analysis of the false positive diagnoses showed that important information can be gained when Doppler sonography is performed. In particular, on solid appearing adnexal masses, Doppler sonography leads to a high accuracy (84.6%).

CONCLUSION

Colour Doppler sonography is not applicable in routine clinical practice, but can give important additional information in specific cases. For solid appearing masses and in early ovarian malignancy, Doppler sonography facilitates the preoperative discrimination between benign and malignant processes.

Early detection of ovarian carcinoma with transvaginal color Doppler ultrasonography

OBJECTIVE

Our purpose was to assess the potentials and limitations of the early detection of ovarian cancer in protocols that involve transvaginal color Doppler ultrasonography.

STUDY DESIGN

Retrospective analysis was performed on the data from 206 referred patients who either had surgical or clinical follow-up of ovarian masses evaluated by transvaginal color Doppler ultrasonography. Most of the patients were referrals or had risk factors.

RESULTS

In this series of 206 patients, 26 ovarian cancers were detected, > 70% of which were stage I or II.

CONCLUSION

Transvaginal color Doppler ultrasonography is capable of early detection of ovarian carcinoma. An improved detection rate may be realized with better identification of high-risk patients who should be studied with transvaginal color Doppler ultrasonography.

A comparison of intratumoural indices of blood flow velocity and impedance for the diagnosis of ovarian cancer

The aim was to assess the value of blood flow velocity indices in an ultrasound-based test to discriminate between malignant and benign adnexal tumours. Fifty-one women (35 premenopausal and 16 postmenopausal) with persistent adnexal masses were scanned prior to surgery using transvaginal sonography with colour Doppler imaging. Intratumoural flow velocity waveforms obtained by pulsed Doppler sonography were used to determine the time averaged maximum velocity (TAMXV), peak systolic velocity (PSV), pulsatility index (PI) and resistance index (RI). The tumours were classified by histologic criteria (42 benign, 1 borderline and 8 malignant tumours). Two of the malignant and the single borderline tumour were stage I, five were stage III and one was stage IV. Detectable blood flow signals were found in all malignant and borderline tumours and in 33 of 42 (78.6%) of the benign tumours. TAMXV was the best parameter for discrimination of benign and malignant adnexal pathology and at a cut-off value of TAMXV > or = 12 cm/s to indicate malignancy, the sensitivity and specificity were 88.9% and 81.0%, respectively. At the same sensitivity level, this gave a better specificity than the PI < or = 0.90 (specificity 61.9%, P = 0.036), RI < or = 0.60 (specificity 54.8%, P = 0.010) and PSV > or = 16 cm/s (specificity 71.4%, P = 0.121). Discrimination between benign and malignant tumours was improved further by using two criteria rather than one. When the two criteria of a TAMXV of > or = 12 cm/s and a PI < or = 1.0 were applied simultaneously, the tumours could be characterised with a sensitivity of 88.9% and a specificity of 88.1%. Therefore, intratumoural PSV and TAMXV could be used to discriminate between benign and malignant adnexal tumours better than values for PI and RI. The best discrimination was achieved by using a combination of cut-off values for velocity and impedance parameters as two criteria to define malignancy.

Pre-operative morphological and colour Doppler features of borderline ovarian tumours

OBJECTIVE

To evaluate pre-operatively the sonographic morphology and colour Doppler findings of borderline ovarian tumours and to compare these findings to those of benign and malignant tumours.

METHODS

Pre-operative transvaginal and colour Doppler ultrasound examinations were performed on 150 women with adnexal tumours. Pulsatility index, resistance index, peak systolic velocity, site, number and confluence of vessels were recorded.

RESULTS

Fifty-six women had malignant ovarian tumours, 74 had benign and 20 had borderline tumours. No biological, morphological or demographic parameters were specifically predictive of borderline tumours. Intratumoral vessels with a pulsatility index of below 1.0 were observed in 19 of the 20 borderline tumours; a morphological score suggested malignancy in 15 women whereas the CA125 exceeded 30 u/ml in 10 cases. Confluence of blood vessels was observed only in three cases. A model including intracystic complexity (either vegetations or septa), pulsatility index of less than 1.0, absence of confluence of vessels, CA125 of less than 150 u/L, in a woman under 60 years of age allowed borderline tumours to be detected with 85% sensitivity, 92% specificity and 91% accuracy.

CONCLUSION

Borderline tumours have haemodynamics resembling those of malignant tumours but the distribution of vessels is often similar to that observed in benign tumours; this observation should be considered when proposing multiparameter scoring systems including colour Doppler ultrasound to identify malignancies of the ovary. Colour Doppler findings may be of assistance in the follow up of women after conservative surgery for ovarian malignancies.

Evaluation of ovarian findings in asymptomatic postmenopausal women with color Doppler ultrasound

BACKGROUND

To evaluate the prevalence and significance of abnormal ovarian findings in asymptomatic postmenopausal women, screening for ovarian cancer with color Doppler ultrasound was performed.

METHODS

One thousand three hundred sixty-four asymptomatic women aged 56-61 years (mean, 59 years) were examined by color Doppler sonography. Ninety-six percent of the examinations were transvaginal and 4% transabdominal. The criteria for abnormality were an ovarian volume 8 cm3 or greater, nonuniform echogenicity, and/or pulsatility index (PI) of the ovarian artery or tumor vessel, if present, 1.0 or less. Repeat sonograms were performed 1-3 months later on all patients with abnormal findings, and exploratory laparotomy was performed if a malignant tumor was suspected.

RESULTS

Abnormal ovarian findings were detected in 160 women (12%). At the time of repeat sonogram there were 28 persisting abnormalities (2%). At that time, the ovary was regarded as normal if it still contained a small clear cyst with an unchanged greatest dimension of less than 20 mm. Three women had a low PI value but all had also abnormal ovarian sonographic morphology. Two ultrasound-guided cyst punctures were performed and three patients had surgery; one benign serous cyst, one benign serous cystadenoma, and one serous cystadenoma of borderline malignancy were detected. The remaining abnormal findings disappeared or remained unchanged during a minimum follow-up of 2 years. One case of Stage IA ovarian cancer has been reported 2 years after a negative screening and one abdominal carcinomatosis 2 1/2 years after a negative screening result.

CONCLUSIONS

There is a high frequency of small ovarian cysts in asymptomatic postmenopausal women. A large percentage of these cysts regress spontaneously or remain unchanged. Transvaginal color Doppler ultrasound is an effective method for detecting these lesions. Color Doppler does not increase substantially the number of operations for benign reasons. However, as a primary screening modality, the conventional sonography seems to be quite sufficient.

Hypertensive intra-arterial chemotherapy for endometrial carcinoma assessed by transvaginal Doppler ultrasound and magnetic resonance imaging

We examined the effectiveness of hypertensive intra-arterial chemotherapy for endometrial carcinoma using transvaginal Doppler ultrasound and magnetic resonance imaging. Angiotensin II, 100 mg cisplatin, and 40 mg doxorubicin were prescribed for 8 patients with endometrial carcinoma (3 stage Ia; 3 stage Ib; 2 stage II). The resistance index (RI) was obtained for intratumoral blood flow velocity waveforms by transvaginal Doppler ultrasound and changes in RI (delta RI: differences before and after chemotherapy) were calculated. The tumor volume (TV) was also evaluated, based on the T2-weighted image of magnetic resonance imaging (MRI). The decrease in tumor size [DR-T: (TV before chemotherapy--TV after chemotherapy)/TV before chemotherapy x 100] was determined. RI measurements did not correlate with TV, either before or after chemotherapy. The delta RI varied from 0.007 to 0.615 (mean: 0.207) and DR-T varied from 20.1% to 65.0% (mean: 45.5%). The correlation between delta RI and DR-T [DR-T = 23.5 + 167.2 (delta RI)-165.6 (delta RI)2; R2 = 0.772, p < 0.05] was significant. Therefore, we confirmed the effectiveness of hypertensive intra-arterial chemotherapy for endometrial carcinoma using both transvaginal Doppler ultrasound and MRI.

A comparison of colour Doppler sonography and the pelvic arteriogram in assessment of patients with gestational trophoblastic disease

OBJECTIVE

To assess whether colour Doppler sonography can replace pelvic arteriography in the assessment of patients with gestational trophoblastic disease.

DESIGN

An observational study in which patients with gestational trophoblastic disease were assessed with both pelvic arteriography and colour Doppler sonography.

SETTING

The oncology unit of the Department of Obstetrics and Gynaecology, University of Hong Kong. The unit is the main tertiary referral centre for treatment of trophoblastic diseases in Hong Kong.

SUBJECTS

Thirty-two consecutive women referred over an 18 month period.

MAIN OUTCOME MEASURES

The site of localisation of the tumour and the size of the tumour as assessed by both methods.

RESULTS

Eleven patients had a spontaneous fall of beta-hCG titres and did not have pelvic arteriograms performed. The remaining 21 patients had both investigations performed. Four patients had no evidence of abnormal pelvic vessels either on colour Doppler sonography or on pelvic arteriography. Their raised beta hCG titres were due to metastatic disease elsewhere. In the remaining patients the location of the tumour vessels was found to be concordant between the two methods of imaging. Measurements of the mean diameter of tumour bulk by the two methods also agreed well (r = 0.93, P < 0.0001). Pelvic arteriogram over-estimated the size of the tumour in two patients by 2 and 3 cm, respectively, but this did not alter the risk categories of the patients.

CONCLUSION

Colour Doppler sonography is a noninvasive technique that can replace pelvic arteriography in the assessment of patients with trophoblastic diseases.

Ultrasonographic appearance of fallopian tube carcinoma

Preoperative diagnosis of tubal carcinoma is difficult and a diagnosis cannot usually be established until the time of operation. However, since prognosis is strictly related to the stage of the neoplasm, it is very important to be familiar with the clinical and imaging characteristics of primary fallopian tube carcinoma in order to make an early and accurate diagnosis. This report presents the ultrasonographic features of three cases of fallopian tube carcinoma and reviews the literature on the subject.

Intratumoral peak systolic velocity as a new possible predictor for detection of adnexal malignancy

OBJECTIVE

Our purpose was to evaluate whether intratumoral blood flow velocity measured by transvaginal Doppler ultrasonography would afford better discrimination between benign and malignant adnexal tumors.

STUDY DESIGN

One hundred two patients with adnexal tumors (72 benign, 30 malignant) were studied with transvaginal B-mode, color, and pulsed Doppler ultrasonography before surgery.

RESULTS

Sixty-five benign tumors (90.3%) had abnormal morphologic features suggesting malignancy, and blood flow was detected in 29 (40.3%). The peak systolic velocity was 13.1 +/- 9.1 cm/sec and the resistance index was 0.563 +/- 0.177. All malignant tumors had abnormal morphologic features and blood flow was detectable in all cases. The peak systolic velocity was 23.9 +/- 11.5 cm/sec and the resistance index was 0.488 +/- 0.118. When 16 cm/sec was considered as the cutoff value of peak systolic velocity, the sensitivity and specificity of peak systolic velocity in detecting malignant adnexal tumors were 83.3% and 91.6%, respectively. The sensitivity and specificity of the resistance index (cutoff value 0.72) was 93.3% and 68.1%, respectively. There was no significant difference in sensitivity between peak systolic velocity and resistance index. The specificity of the peak systolic velocity was significantly higher than that of the resistance index (p < 0.05). Moreover, the sensitivity of the peak systolic velocity did not significantly differ from that with transvaginal ultrasonography diagnosis (86.7%), and the specificity of the peak systolic velocity was significantly higher than that of transvaginal ultrasonography (69.4%).

CONCLUSION

These results suggest that peak systolic velocity obtained from intratumoral abnormal morphologic features provides a superior means for differentiating malignant from benign adnexal tumors.

Value of uterine artery Doppler in endometrial cancer

Twenty-seven women with endometrial cancer were studied with Doppler ultrasound coupled with a vaginal probe. Pulsatility index of the flow velocity of the uterine artery was recorded and compared to that of a control group. The subjects and the controls did not differ in blood flow measurements. There was no correlation between severity of disease and flow velocimetry values. Eleven of the patients underwent brachytherapy prior to surgery. Administration of brachytherapy resulted in a decrease of the peripheral resistance. The results of this study indicate that Doppler velocimetry of the uterine artery is not a valuable tool in discriminating between malignant and benign endometrium.

Reproducibility of Doppler measurements of blood flow velocity in the uterine and ovarian arteries in premenopausal women

Intra- and interobserver reproducibility of Doppler measurements of the pulsatility index (PI) and time-averaged maximum velocity (TAMXV) in the uterine and ovarian arteries were evaluated in examinations of healthy premenopausal women. Each woman underwent reproducibility measurements once in the late follicular phase and once in the midluteal phase. Intraobserver repeatability was assessed in examinations of 12 women, three replicate Doppler measurements being made by one observer in the same vessel. Interobserver agreement was assessed by comparing the results of Doppler measurements made by two investigators in 11 women. The intraclass correlation coefficient (Intra-CC) was 0.78 for the TAMXV in the dominant uterine artery in the follicular phase and 0.82 for the PI in the wall of the dominant follicle. For all other measurements the Intra-CC was < 0.75, indicating poor reproducibility. The interclass correlation coefficient (Inter-CC) was > 0.75 (0.79 to 0.88) for the PI and TAMXV in the dominant uterine artery in the follicular phase and for the PI of both uterine arteries in the luteal phase. For all other measurements the Inter-CC was < 0.75.

The value of transvaginal color Doppler in the assessment of pelvic inflammatory disease

This study compares transvaginal color and pulsed Doppler (TVCD), laparoscopic and clinical findings in 102 women with proven pelvic inflammatory disease (PID). Seventy-two (72) of them had acute symptoms, 11 presented with chronic pelvic pain and 19 patients were infertility cases suspected of tubal etiology. Uterine sonographic findings were demonstrated in 72 patients (70.6%). Free fluid in the cul-de-sac was demonstrated in 39 (38.2%) patients. Ovarian enlargement as the only finding was demonstrated in 6 (5.9%) patients, 22 (21.6%) presented with tubular adnexal structure, while in 74 (72.5%) patients it was of a complex nature. Color flow was obtained in all 6 patients presenting with ovarian enlargement, in 12 (54.5%) of those presenting with tubular adnexal structure, and in 56 (75.7%) of those with complex adnexal mass. Ovarian morphology was clearly delineated from adnexal mass in 59 patients (55.9%). The ipsilateral ovarian flow was altered in 50 of them (84.7%). The mean resistance index (RI) in patients with acute symptoms was 0.53 +/- 0.09 (+/-SD). It significantly differed from those obtained in patients with chronic pelvic pain (RI = 0.71 +/- 0.07) and infertility cases (RI = 0.73 +/- 0.09). We concluded that transvaginal color Doppler is useful additional tool in diagnosis and treatment monitoring in patients with PID.

Color Doppler flow patterns and flow velocity waveforms of the intraplacental fetal circulation in growth-retarded fetuses

OBJECTIVE

We examined intraplacental color Doppler flow patterns and spectral Doppler flow velocity waveforms of villous arteries in pregnancies with intrauterine growth retardation.

STUDY DESIGN

A total of 192 uncomplicated pregnancies and 29 pregnancies with intrauterine growth retardation between 26 and 41 weeks' gestation were examined in this cross-sectional study. Intraplacental color Doppler flow findings and pulsatility indexes of umbilical and villous arteries were correlated with the presence of intrauterine growth retardation and multiple outcome variables. Villous arteries were identified by their intraplacental color Doppler flow image, and flow velocity waveforms were obtained by superimposition of pulse-wave Doppler.

RESULTS

(1) Intraplacental color Doppler flow signals from two or more villous arteries were detected in all 192 normal pregnancies but were undetectable in 8 of 29 fetuses with intrauterine growth retardation (27.6%, p < 0.0001). Absence of intraplacental color Doppler flow signals was associated with fetal distress in 6 of 8 cases (87.5%) and perinatal death in two cases (25.0%), compared with 3 of 21 (14.2%, p < 0.005) and 0 of 21 (not significant) cases of intrauterine growth retardation with detectable intraplacental color Doppler flow. Median Apgar scores at 1 minute were 5 and 8 (p < 0.05), respectively, and at 5 minutes were 8 and 8 (not significant), respectively. (2) Umbilical artery flow velocity waveforms were abnormal (> 95th percentile) in 8 of 21 cases of intrauterine growth retardation (38.0%) with detectable intraplacental color Doppler flow, including two cases with reversed end-diastolic flow. In contrast, the corresponding villous artery flow velocity waveforms were abnormal in only 1 of 21 cases (p < 0.04).

CONCLUSION

(1) Failure to detect intraplacental color Doppler flow signals is associated with intrauterine growth retardation and fetal distress. (2) Flow velocity waveforms of detectable villous arteries are usually normal in intrauterine growth retardation, even in the presence of extremely abnormal umbilical artery flow velocity waveforms.

Evaluation of tumor-associated glycoprotein-72 and CA 125 serum markers in patients with gynecologic diseases

OBJECTIVE

This study was performed to evaluate the clinical values of tumor-associated glycoprotein-72 serum levels alone or in combination with CA 125 in the diagnosis and monitoring of patients with ovarian cancer.

STUDY DESIGN

Serum samples from 293 patients, 142 with primary carcinoma and 151 with benign diseases of the genital tract, were evaluated for the presence of CA 125, tumor-associated glycoprotein-72, and carcinoembryonic antigen. All patients underwent surgery for the primary tumor, and stage was defined according to the classification of International Federation of Gynecology and Obstetrics.

RESULTS

When the measurement of serum tumor-associated glycoprotein-72 is combined with that of CA 125, the sensitivity for the detection of primary ovarian cancer increased from 60% to 73%, with no significant change in specificity, and resulted in a more accurate clinical assessment for detection of residual disease before the second-look procedure. In fact, when both markers were positive, 100% specificity was achieved; conversely, when both markers were negative, no residual disease was found.

CONCLUSION

These findings suggest that tumor-associated glycoprotein-72 may be considered as a supplementary serum marker for CA 125, providing further clinical information for the diagnosis of primary and recurrent ovarian cancer.

Feasibility study of a randomised trial of ovarian cancer screening

OBJECTIVES

To assess the feasibility of a randomised trial of ovarian cancer screening by vaginal ultrasonography.

SETTING

A population based study, recruiting a random sample of the female population aged 46 to 65 years living in Copenhagen, Denmark.

DESIGN

Randomised controlled trial allocating 50% to the study group having vaginal ultrasonography, and 50% to the control group having no examination. (a) Acceptability of the study was evaluated by the proportion of eligible women willing to participate in the study. (b) The false positive rate was evaluated as the proportion of women without ovarian cancer referred for an operation because of abnormal ovaries detected by ultrasonography.

RESULTS

950 (64.3%) of the 1477 eligible women participated in the study. At the first scan abnormal ovaries were detected in 54 of 435 women (12%), significantly more frequently among younger women. Nine women were referred for an operation because of abnormal findings in the ovaries, giving a false positive rate of 2%. Ovarian size and morphology found at operation corresponded with those at ultrasonography; none of them was malignant.

CONCLUSIONS

A randomised controlled trial of ovarian cancer screening using vaginal ultrasonography seems acceptable in the general population. The rate of abnormal ovaries at ultrasonography with the cut offs used in this study was quite high. Such a study is, therefore, feasible, but it is proposed that it is carried out in an older age group (50-64 years) and that the cut offs used for ovarian size and morphology are re-evaluated. Second line tests, such as colour Doppler flow, should be considered in order to reduce the false positive rate.

Color Doppler ultrasonography and serum CA 125 in the differentiation of benign and malignant ovarian tumors

Color Doppler ultrasonography and serum CA 125 were used to evaluate 114 adnexal tumors prior to surgery. Six patients were excluded from this study because of ovarian cancer, borderline ovarian malignancy, and tubal gestation. A total of 108 patients were eligible: 83 patients with benign and 25 patients with malignant ovarian tumors. Resistance index (RI) was used to determine the peripheral resistance of intratumoral vessels. The cutoff point for the RI was defined as 0.5. The blood flow was considered to be normal when the RI was greater than 0.5 and abnormal when it was less than 0.5. The blood flow was detected in 100% of malignant tumors and 59% of benign tumors. The initial cutoff value for CA 125 was 35 U/mL. Sensitivity, specificity, positive predictive value, and negative predictive value were compared in terms of RI, serum CA 125, and a combination of the two. Our conclusion is that the combination of RI and CA 125 gives a sensitivity of 100% and negative predictive value of 100%. If the cutoff point of CA 125 was raised from 35 to 65 U/mL, then a specificity of 100% and positive predictive value of 100% were also attained with the use of RI and CA 125 without changes in sensitivity or negative predictive value. We conclude that the combination of color Doppler ultrasonography and serum CA 125 is an effective method to differentiate benign from malignant ovarian tumors.

Feasibility study of a randomised trial of ovarian cancer screening among the general population

OBJECTIVE

To determine the feasibility of a randomised trial of ovarian cancer screening among women attending a breast cancer screening centre.

DESIGN

Randomised controlled trial of ovarian cancer screening using transvaginal ultrasonography as a primary screening test and colour Doppler imaging as a secondary screening test in the screened group and no intervention in the control group.

SETTING

Reading breast cancer screening centre (United Kingdom).

SUBJECTS

8678 women, without a bilateral oophorectomy or hysterectomy, aged between 50 and 64 attending for NHS breast cancer screening between September 1989 and February 1993.

MAIN OUTCOME MEASURES

Uptake of ovarian cancer screening among eligible women and the screening false positive rate (considered as the referral rate to a gynaecologist for surgical intervention).

RESULTS

82% (7124/8678) of eligible women agreed to join the trial and were randomly allocated in equal numbers to each arm of the trial. 3280 women had an initial scan. The false positive rate after ultrasonography alone was 2.9% (86/2952), but this dropped to 0.5% after colour Doppler as a secondary screening test. One stage I primary ovarian cancer was detected at screening in a 58 year old women.

CONCLUSIONS

A randomised trial of ovarian cancer screening using ultrasonography and colour Doppler imaging is feasible and acceptable among women attending a breast cancer screening centre. The results indicate that the expected odds of being affected given a positive result in the general population would be about 1:12. A full randomised trial of ovarian cancer screening with mortality as the end point is needed to assess whether screening reduces mortality from this disease. A multicentre European trial is currently in progress.

Screening for ovarian cancer: a review

A review of the literature was done to assess the evidence for ovarian cancer screening, and the effectiveness of the different methods of screening. There is not yet sufficient evidence that an ovarian cancer screening programme would be cost-effective, given the current range of available tests. The high rate of surgical intervention makes the choice of screening test extremely important. No single test is able to provide a positive predictive value of greater than 10%. For women over 30 years of age with a strong family history of ovarian cancer (two or more first-degree relatives) there is an increased risk, potentially as high as one in two, of developing a carcinoma. These women should be offered counselling and annual serum CA 125 and ultrasonography as part of a coordinated research programme, which includes genetic studies.

Diagnostic value of pelvic examination, ultrasound, and serum CA 125 in postmenopausal women with a pelvic mass. An international multicenter study

BACKGROUND

In a prospective study, the differential diagnostic potential of pelvic examination, ultrasound, and serum CA 125 assay in postmenopausal patients presenting with a pelvic mass was assessed.

METHODS

A total of 228 patients were evaluated preoperatively in an international, multicenter, prospective study using a standard protocol for pelvic examination, transvaginal (occasionally additional abdominal) ultrasound, and serum CA 125 determination with a cut-off level of 35 U/ml.

RESULTS

Ninety-five malignant (41.7%) and 127 benign (55.7%) pelvic tumors were found in addition to 6 borderline ovarian tumors (2.6%) in the 228 patients. Seventy-two patients had ovarian carcinoma, 49 of whom were International Federation of Gynecology and Obstetrics Stage III or IV. Borderline tumors were excluded from the statistical calculations. The individual accuracy of pelvic examination, ultrasound, and serum CA 125 in discriminating between benign and malignant pelvic masses was approximately the same (76, 74, and 77%, respectively). Using logistic regression analysis, the power of pelvic examination appeared to be the most relevant factor (adjusted odds ratio, 9.2), followed by serum CA 125 (odds ratio, 5.6), and ultrasound (odds ratio, 4.9). Age appeared to be nonpredictive. No cancer was found in any patient in whom all three methods scored negative (n = 53; positive predictive value for malignancy = 0 and 95%; confidence interval, 0-7).

CONCLUSIONS

The combined use of pelvic examination, ultrasound, and serum CA 125 leads to improved discrimination between malignant and benign pelvic masses, because malignancy can be excluded when all three examination methods are negative. A change to a more patient-tailored surgical approach could be considered in those cases.

Evaluation of transvaginal color Doppler sonography, transvaginal sonography and CA 125 for prediction of ovarian malignancy

OBJECTIVES

To evaluate the efficacy of color Doppler ultrasonography as the predictor of malignant ovarian tumors and to compare the results with CA 125 levels and ultrasonographic morphological patterns.

METHODS

We compared color Doppler ultrasound with sonographic findings and serum CA 125 levels for predicting ovarian malignancy in 16 patients with malignant and 12 patients with benign ovarian tumors.

RESULTS

There was a significant difference in pulsatility index (PI) value of ovarian vessel between benign and malignant tumors (2.42 +/- 0.67 for benign and 1.35 +/- 0.78 for malignant, respectively, P < 0.01). The specificity of morphological findings and CA 125 was lower than that of PI measurements, but sensitivity was not different between the three methods. In addition, the combination of color Doppler and CA 125 or morphological assessments resulted in a sensitivity of 100% and a negative predictive value of 100%, respectively.

CONCLUSION

PI measurements by transvaginal color Doppler ultrasound combined with CA 125 levels or morphological findings could be an accurate and appropriate screening method for ovarian tumors.

Screening in breast cancer families: is it useful?

In 5% of the cases of breast cancer, the condition is attributable to a genetic predisposition. The clinical relevance of inherited forms of cancer lies in the fact that periodic screening of close relatives of patients may prevent disease and death due to cancer. Although surveillance programmes for hereditary cancers have been recommended for many years, there is still little or no evidence that surveillance will improve the prognosis. In particular, screening for breast and ovarian cancers gives rise to many problems, because there is no precursor lesion that can easily be identified, such as an adenomatous polyp in familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer. This means that prospective controlled studies are urgently needed to assess the value of the recommended screening protocols. National and regional hereditary cancer registries may play an important role in the evaluation of the effect of long-term surveillance. Presymptomatic testing based on DNA technology will probably become feasible for breast cancer in the near future. A major advantage of DNA analysis in this context is that screening can be focused on high-risk individuals and the family members at low risk can be less rigorously followed. Because of unanticipated consequences associated with DNA analysis, much research remains to be done to define the psychosocial implications of presymptomatic DNA diagnosis.

Screening for ovarian cancer: the role of noninvasive imaging techniques

In spite of diagnostic and therapeutic improvements the Surveillance Epidemiology and End Results Program data suggest that the overall cure rate for patients with ovarian cancer is 39%. Because of the dramatic difference in cure between patients with local disease (80% to 90%) and those with distant disease (15% to 25%), screening to find early ovarian cancer or its precursors is desirable. Transvaginal ultrasonography is the most efficient, accurate, and least expensive of the imaging modalities (transabdominal ultrasonography, computed tomography, magnetic resonance imaging, radioimmunoscintigraphy) for this purpose. To date, 10,000 women have been screened in three large programs; 11 cancers were detected (10 stage I, one occult stage IIIB) and all have apparently been cured. Doppler flow imaging and morphology index values improve the accuracy of transvaginal ultrasonography. A cost analysis suggests that screening costs are not yet less than treatment costs if there is to be universal screening of 27 million women at risk in the United States. However, for a population with a lifetime risk for ovarian cancer of 1%, screening will save five lives per 2000 patients screened.

Transvaginal sonographic characterization combined with cytologic evaluation in the diagnosis of ovarian and adnexal cysts

A transvaginal sonographic (TVS) scoring system using morphologic features has been developed at our institution to maximize discrimination between benign and malignant ovarian and adnexal cysts. Low (4-7) or intermediate (8-9) scores have been found to correlate with benignity, hence TVS-guided or laparoscopically directed needle aspiration of low-scoring lesions may safely be performed. High-scoring lesions (10-14) are often malignant, therefore in situ needle aspiration of such lesions is not recommended. The aim of our study was to correlate the results of TVS characterization of ovarian and adnexal cysts with the aspiration cytologic evaluation. Twenty-three of the 43 cysts studied were aspirated in situ from the patient; 20 were aspirated from resected surgical specimens. Thirty-six benign cysts had TVS scores ranging from 4 to 12, with a median score of 7. All 25 cysts that were benign by TVS and/or histology were also cytologically benign as well as an additional 11 cysts that were not resected (TVS scores: 4 to 9). Seven cytologically and histologically malignant cysts had high TVS scores (TVS scores 10-14; median = 12). The combination of TVS and needle aspiration cytology is valuable, particularly in the diagnosis of cysts having low or intermediate TVS scores and benign cytology. Aspiration of cysts or masses with high TVS scores is not recommended. This combined evaluation may allow a more limited surgical approach, such as operative laparoscopy, or, in some cases, obviate the need for operative treatment altogether.

Incremental angiogenesis assessed by color Doppler ultrasound in the tumorigenesis of ovarian neoplasms

BACKGROUND

The crucial role of angiogenesis in tumor behaviour has been studied extensively in vitro. The authors assessed the in vivo angiogenesis in ovarian neoplasms by color Doppler ultrasound and waveform analysis.

METHODS

The intratumor artery resistance index (RI) of 222 ovarian neoplasms referred for color Doppler ultrasound evaluation was measured, and the corresponding histopathologic diagnosis was recorded.

RESULTS

Satisfactory intratumor artery waveforms were obtained at an average of 1.12 sites in 44.7% (68 of 152) of benign tumors and at 6.28 sites in 97.1% (68 of 70) of the malignant group. Great heterogeneity in RI values existed. The RI of the intratumor artery in the benign group during the follicular phase (mean, 0.678) was significantly higher (P < 0.001) than that of the luteal phase (mean, 0.414), epithelial ovarian carcinoma (n = 34; mean, 0.402), malignant germ cell tumor (n = 6; mean, 0.413), malignancy metastasized to the ovary (n = 18; mean, 0.357), and other rare malignancies (n = 4; mean, 0.435). The RI of primary ovarian malignancy (n = 41; mean, 0.411) was significantly higher than that of malignancy metastasized to the ovary (P < 0.05). The RI values of epithelium-originated neoplasms showed a significant incremental decrease from benign tumors (n = 48; mean, 0.695) toward borderline malignancy (n = 6; mean, 0.535; P < 0.01), early-stage ovarian carcinoma (n = 10; mean, 0.485; P < 0.01), and, finally, to advanced-stage ovarian malignancies (n = 29; mean, 0.398; P < 0.05).

CONCLUSIONS

Angiogenesis is a common phenomenon in malignant ovarian neoplasms, but the intensity of neovascularization may depend on individual tumor characteristics. The authors documented the incremental decrease of the resistance index in ovarian neoplasms, which may reflect the increase in angiogenesis intensity as an indication of malignant potential.

The adnexal mass: benign or malignant? Evaluation of a risk of malignancy index

OBJECTIVE

To validate a risk of malignancy index incorporating menopausal status, serum CA 125 level and pelvic ultrasound features in the pre-operative diagnosis of ovarian cancer.

DESIGN

A retrospective observational study.

SETTING

Department of Obstetrics and Gynaecology, The Royal London Hospital.

SUBJECTS

One hundred and twenty-four women admitted consecutively to the gynaecology department for surgical exploration of an adnexal mass.

MAIN OUTCOME MEASURES

The sensitivities and specificities of menopausal status, serum CA 125 level and ultrasound features, in isolation and combined (the risk of malignancy index (RMI)), for diagnosing ovarian cancer.

RESULTS

Tested on a new population of women, the RMI retained the high sensitivity for diagnosing ovarian cancer seen in the original report describing its derivation. The specificity, however, was lower. The study confirmed that the RMI is more accurate than the individual criteria in diagnosing ovarian cancer, and was comparable with other scoring systems.

CONCLUSIONS

The risk of malignancy index is a simple scoring system for ovarian cancer. Application of the risk of malignancy index in clinical practice may provide a rational basis for specialist referral of patients with ovarian cancer before diagnostic surgery.

A multidisciplinary approach to the early detection of ovarian carcinoma: rationale, protocol design, and early results

OBJECTIVE

This study was undertaken to determine the feasibility of currently available tests to detect ovarian cancer at a curable stage. By studying women at risk for the disease on the basis of their family histories of cancer, we hope to gain insight into the genetics and biologic characteristics of ovarian cancer.

STUDY DESIGN

Asymptomatic women with a family history of cancer are interviewed by geneticists to obtain accurate pedigree and epidemiologic data. Screening tests including transvaginal ultrasonography, color Doppler imaging, CA 125 measurement, and other investigative biomarkers are performed between cycle days 3 and 8 and repeated biannually.

RESULTS

A total of 597 women without symptoms were screened between July 1991 and June 1992. Cystic or complex adnexal masses were detected in 6.2% of patients. A pulsatile index value < 1.0 was measured in 80% of premenopausal patients and 24% of postmenopausal patients, whereas a resistance index value < 0.4 occurred in 12% of premenopausal and 3% of postmenopausal patients. A CA 125 level > 35 U/ml was found in 11.4% of the study participants. To date, one stage IA borderline ovarian tumor and one endometrial carcinoma have been found.

CONCLUSIONS

Ovarian cancer screening needs to be investigated in a controlled fashion to determine means that will ultimately improve the survival from the disease.

Color-Doppler Ultrasound in Ovarian Masses: Anatomo-Pathologic Correlation

Background and aims

In the radiologic assessment of ovarian masses, the major difficulty consists in the late recognition and lack of parameters for a differential diagnosis between benign and malignant lesions, especially in the post-menopause when the incidence of cancer is higher. The use of a transvaginal probe and the color-Doppler examination have recently improved the study of the female pelvis. This study is aimed to verify the possibility of the color-Doppler imaging to differentiate between malignant and benign ovarian lesions during transvaginal echographies, on the basis of the qualitative and quantitative characteristics of the vascular pattern of the ovarian lesions.

Results

Twenty-six expansive ovarian lesions were studied: 8/26 showed no vascular signals and were considered benign as confirmed at histology. In the remaining lesions with some vascularization, the resistance index (RI) was evaluated: those with RI > 0.40 were considered benign, those with RI < 0.40 malignant. In 8/9 benign lesions and in 7/9 malignant neoplasms, the results of color-Doppler were coherent with histology. The results showed a sensibility of 87.5 % and a specificity of 88.8 % for the transvaginal examination.

Conclusions

The main advantages of the color-Doppler transvaginal examination are: the high frequency of visualization of the ovaries, even in postmenopausal patients; the definition of small lesions; the visualization of small parenchymal vessels, both physiologic and pathologic, and their quantitative analysis. The importance of the RI cutoff was critical for the differential diagnosis between benign and malignant lesions: we think that a cutoff of 0.50, instead of 0.40 proposed by other authors, would be far more appropriate.

Screening in gynecologic cancers

Gynecologic malignancies account for approximately 13% of cancers in women. Ovarian and uterine cancer are among the five most common causes of cancer deaths in women, exceeded in incidence only by cancers of the breast, colon, and lung. Improved survival in patients with genital cancers predominantly reflects early diagnosis and not improved treatments. Even cancers for which there are effective screening and satisfactory treatments are seen more often than is acceptable. It is paramount that those entrusted with the health of women be knowledgeable about all cancer screening techniques and be able to identify the patient at risk for gynecologic malignancy. The provider's obligation to be vigilant about the signs and symptoms of cancer must be matched by the patients' responsibility to her own health. Regular gynecologic examinations, Papanicolaou (Pap) tests, and immediate reporting of unusual signs and symptoms are requirements that cannot be dismissed by patients. Education directed toward patients and health care providers can optimize survival. The Pap test for cervical cancer remains a universally accepted screening procedure. Human papillomavirus (HPV) DNA typing, cervicography, loop electrosurgical excision procedure (LEEP), transvaginal ultrasonography, color flow doppler, endometrial sampling, and serum CA 125 measurements are some of the newer techniques being investigation as potential screening tools. Although additional prospective studies are needed to establish the value of these modalities, there is little doubt that prognostic information obtained from these modalities will influence the clinical care of patients in the near future.

Limitations of CA125 in the preoperative evaluation of a pelvic mass: struma ovarii and ascites

This report discusses the limitations of using the serum tumour marker CA 125 in the preoperative evaluation of a woman presenting with a pelvic mass. We present 2 cases of benign struma ovarii which were associated with elevated levels of CA 125.

Screening for early familial ovarian cancer with transvaginal ultrasonography and colour blood flow imaging

OBJECTIVE

To assess the value of transvaginal ultrasonography with colour blood flow imaging in detecting early ovarian cancer in women with a family history of the disease.

DESIGN

Study of self referred symptomless women with a close relative who had developed the disease. Each woman was screened to detect persistent lesions and defined changes in ovarian volume. Morphological score and pulsatility index were recorded.

SETTING

Ovarian screening clinic.

SUBJECTS

1601 self referred women.

INTERVENTIONS

Women with a positive screening result were recommended to have further investigations.

MAIN OUTCOME MEASURES

Findings at surgery and histology of abnormal ovaries. Morphological score > or = 5 and pulsatility index < 1.0 at last scan.

RESULTS

Women were aged 17 to 79 (mean 47) years; 959 (60%) were premenopausal, 469 (29%) were naturally postmenopausal, and 173 (11%) had had a hysterectomy. 157 women had a pedigree suggestive of the site specific ovarian cancer syndrome and 288 of multiple site cancers. 61 women had a positive screening result (3.8%, 95% confidence interval 2.9 to 4.9%), six of whom had primary ovarian cancer detected at surgery (five stage Ia, one stage III). Use of a high morphological score or a low pulsatility index increased the odds of finding ovarian cancer from 1:9 to about 2:5 (1:1 in the highest risk groups). Five interval cancers were reported (three ovarian and two peritoneal). Eight of the 11 cancers developed in women with pedigrees suggestive of inherited cancer.

CONCLUSIONS

Transvaginal ultrasonography with colour flow imaging can effectively detect early ovarian cancer in women with a family history of the disease. The screening interval should be less than two years.

Prevalence screening for ovarian cancer in postmenopausal women by CA 125 measurement and ultrasonography

OBJECTIVE

To assess the performance of the sequential combination of serum CA 125 measurement and ultrasonography in screening for ovarian cancer.

DESIGN

The serum CA 125 concentration of each subject was determined and those with a concentration > or = 30 U/ml were recalled for abdominal ultrasonography. If ultrasonography gave abnormal results surgical investigation was arranged. Volunteers were followed up by annual postal questionnaire.

SETTING

General practice, occupational health departments, ovarian cancer screening clinic.

SUBJECTS

22,000 women volunteers who were postmenopausal and aged over 45 years.

MAIN OUTCOME MEASURES

Apparent sensitivity, specificity, positive predictive value, years of cancer detected.

RESULTS

41 women had a positive screening result and were investigated surgically. 11 had ovarian cancer (true positive result) and 30 had other disorders or no abnormality (false positive result). Of the 21,959 volunteers with a negative screening result, eight subsequently presented clinically with ovarian cancer (false negative result) and 21,951 had not developed ovarian cancer during follow up (apparent true negative result). The screening protocol achieved a specificity of 99.9%, a positive predictive value of 26.8%, and an apparent sensitivity of 78.6% and 57.9% at one year and two year follow up respectively. The estimated number of years of cancer detected by the prevalence screen was 1.4 years.

CONCLUSIONS

This screening protocol is highly specific for ovarian cancer and can detect a substantial proportion of cases at a preclinical stage. Further investigation is required to determine the effect of the screening protocol on the ratio of early to late stage disease detected and on mortality from ovarian cancer.

Assessment of ovarian and uterine blood flow by transvaginal color Doppler in ovarian-stimulated women: correlation with the number of follicles and steroid hormone levels

OBJECTIVE

To study the changes that occur in vascular resistance to flow in the utero-ovarian circulation and their correlation with the number of follicles and steroid hormone levels in patients undergoing ovarian stimulation with gonadotropin.

DESIGN

In a prospective study, the impedance to flow in the intraovarian and uterine vessels was measured by means of transvaginal color flow Doppler imaging throughout the cycle.

SETTING

University-based IVF program.

PATIENTS

Eleven infertile patients undergoing ovarian stimulation with gonadotropin in preparation for IVF and ET.

MAIN OUTCOME MEASURES

Intraovarian, uterine, and arcuate artery blood flow velocity waveforms, follicular growth, and serum E2 and P concentrations throughout the cycle.

RESULTS

Pulsatility index (PI) of the intraovarian blood vessels and uterine artery decreased gradually during the follicular and luteal phase. The PI of the arcuate artery did not change significantly. The PI of the intraovarian blood vessels correlated with the number of follicles (> 15 mm; day of hCG). Serum E2 concentrations but not P demonstrated negative linear correlation with the PI of the intraovarian vessels and uterine artery.

CONCLUSIONS

Induced cycles are associated with decreased impedance to blood flow in the utero-ovarian circulation. Intraovarian PI correlates negatively at each stage of the cycle with the eventual number of preovulatory follicles. Little or no changes are observed when the response to ovarian stimulation is poor.

Transvaginal ultrasonographic characterization of ovarian masses by means of color flow-directed Doppler measurements and a morphologic scoring system

OBJECTIVE

The aim of the study was to test the hypothesis that a combination of a previously devised morphologic scoring system and color flow-directed Doppler measurements would afford better discrimination between benign and malignant ovarian masses.

STUDY DESIGN

The scoring system and color flow-directed Doppler measurements for 115 masses were prospectively analyzed and correlated with histopathologic surgical findings.

RESULTS

In 21 masses (18 patients) no flow was obtained. Seventy-eight masses in 70 patients were benign, and 16 masses in 12 patients were malignant. The mean total score for the benign masses was 6.7 and for the malignant masses 11.7. The resistance index was 0.64 for the benign lesions and 0.39 for the malignant masses (range 0.2 to 0.98). The mean pulsatility index of the benign masses was 1.17 and 0.52 for the malignancies (range 0.2 to 2.6). There were no malignancies in the group with no flow obtained. The sensitivity and specificity of score alone was 94% and 87%, respectively, with a 60% positive predictive value. By means of resistance index or pulsatility index the sensitivity was 94%, the specificity 99%, and the positive predictive value 94%.

CONCLUSION

These results suggest that Doppler flow measurements alone and in conjunction with a scoring system help differentiate benign from malignant masses.

Angiogenesis: a new diagnostic aspect of obstetric and gynecologic echography

An ultrasounds triplex system (pulsed Doppler, Color mode, B mode) has been employed to study ovarian and uterine circulatory changes in fertile, infertile and postmenopausal patients. PI and mean percentage variation of PI mean values have been used. No difference has been detected in uterine haemodynamics between fertile women and those infertile patients getting pregnant by IVF-ET procedure. Patients who did not obtain the pregnancy showed different uterine and endometrial Color Doppler patterns. Furthermore, a typical endometrial blood flow has been detected both in fertile patients and infertile patients who get pregnant. Color Doppler seems to be an useful tool in the monitoring of fibroids blood supply and the uterine blood supply, especially for the clinical monitoring of GnRH analogues therapies. The technique has been also employed for the study of ectopic pregnancy. The evaluation of both uterine and throphoblast haemodynamics has resulted in a good indicator of the pregnancy progression. Concerning the ovarian pathology the color Doppler evaluation has been useful to differentiate ovarian malignant cysts from inflammatory or disfunctional masses. Nevertheless, the most interesting results have been obtained from the study of endometrial and ovarian tumors. Indeed, in the most cases, a mass supply blood flow has been detected, although in some cases no angiogenetic color flow has been found. No difference has been found in uterine artery velocimetry between malign or benign pathologies. Furthermore, histological data supporting our findings are presented.

Preoperative diagnosis of primary fallopian tube carcinoma by transvaginal ultrasound, cytological finding and CA-125

Primary Fallopian tube carcinoma is rarely diagnosed preoperatively. We present the case of a 69-year-old woman with primary tubal carcinoma, which was diagnosed preoperatively on the basis of the cytological finding, characteristic features on transvaginal sonography, transvaginal color flow imaging and elevated CA-125. Transvaginal color Doppler imaging demonstrated the tumor revealed areas of neovascularization with characteristic low impedance (resistance index, 0.34 and pulsatility index, 0.62). Pathohistologic confirmation of the clearcell carcinoma has been done.

Use of family history in a screening clinic for familial ovarian cancer

We have estimated the risks of ovarian and other types of cancer in first-degree relatives of women who have developed the disease (the index patients). The number of deaths from each type of cancer was determined from pedigrees taken from 391 self-referred, asymptomatic women attending a screening clinic for familial ovarian cancer. These values were compared with the expected number of deaths for women in the general population (calculated from life tables), and the relative risks were used to estimate lifetime risks. The overall relative risk were 4.5, 1.4, 1.3, and 1.1 for ovarian, stomach, breast, and endometrial cancers, respectively. The risks were invariably higher if the index patient was < 55 years old. Ovarian cancer appeared to have no clear inheritance pattern in 290 pedigrees and there was no increased risk for the first-degree relatives. Eighty-two pedigrees were compatible with a diagnosis of a multiple-site cancer family syndrome and the relative risks were 6.1, 2.8, 3.7, and 2.7 for ovarian, breast, stomach, and colorectal cancer, respectively. There was evidence of site-specific ovarian cancer in 19 families; the relative risk for the first-degree relatives was 39.1 and the lifetime risk 1 in 2. We believe that family history can be used to identify women who are at a high risk of developing ovarian and certain other types of cancer. This information can be used to counsel women attending ovarian cancer screening clinics and to maximize the usefulness of current resources.