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

Risk factors and a risk scoring system for the prediction of malignancy in ovarian cysts

A retrospective study was carried out on 396 patients who presented with ovarian masses. Sixty five (16%) patients were found to have ovarian malignancy while the rest either had benign ovarian tumours (n = 159), endometriotic cysts (n = 130), physiological cysts (n = 20) or inflammatory masses (n = 7). The relative risk for ovarian malignancy among these patients increased significantly (p < 0.001) after the age of 40 years. The presence of ascites, abdominal distension, urinary complaints and loss of appetite and weight were significant individual risk factors for malignancy. Ultrasound image of a complex cyst is also associated with increased risk of malignancy in an ovarian mass. None of the individual risk factors was discriminatory between a benign and malignant cyst. However, these factors can be combined to form a 20-point risk scoring system. The risk of malignancy in an ovarian cyst increased with increasing scores. In this study, the median scores were 3 for benign cyst, 7 for borderline malignancy and 12 for malignant cysts. Using a total score of 7 as a cut off point, one can detect 75% of malignant cysts with a specificity of 84.1%, a positive predictive value of 47.5% and a negative predictive value of 94.6%. It is concluded that the majority of malignant ovarian cysts can be identified preoperatively to allow arrangement and planning of an optimal surgery.

Transvaginal color Doppler sonography and CA-125 elevation in a patient with ovarian thecoma and ascites

A postmenopausal patient presented with a pelvic mass and ascites. The CA-125 level was 329 U/ml, and transvaginal color Doppler sonography of the tumor vasculature suggested malignancy. At laparotomy, a luteinized thecoma and cytologically benign ascites were found. On rare occasions ovarian thecoma may be associated with ascites without hydrothorax. Preoperative evaluation of the patient with ascites and a pelvic mass may suggest malignancy, but histologic confirmation is necessary to exclude this rare association.

Ovarian tumors of low malignant potential: transvaginal Doppler ultrasound features

Twenty-nine patients with ovarian tumors were studied with transvaginal Doppler ultrasound before surgery. After surgery, pathological examination revealed that 26 tumors were benign and 3 were of low malignant potential (LMP). B-mode sonography, computed tomography, and magnetic resonance imaging showed no positive findings for malignancy in these 3 cases of LMP. Serum levels of the CA-125, tissue polypeptide antigen, and carcinoembryonic antigen were also within the normal range. Blood flow velocity waveforms were evaluated by the calculation of the resistance index (RI). There was a significant difference between the RI value (0.818 +/- 0.223) in benign tumors and that (0.418 +/- 0.072) in LMP (P less than 0.01). When the 0.56 (mean of LMP tumor RI value + 2SD) was considered as the cutoff value of RI, the sensitivity was 100% and the specificity was 88.5%. Transvaginal Doppler ultrasound provides a useful diagnostic information for the differentiation of benign and LMP ovarian tumors before surgery.

Ovarian cancer family and prophylactic choices

A subject from a family with ovarian cancer who has developed bilateral medullary carcinoma of the breast at the age of 40 is presented. The family is consistent with dominant inheritance of ovarian cancer and 12 female family members at 12.5%, 25%, and 50% risk, including our case, have undergone bilateral prophylactic oophorectomy and been given hormone replacement therapy. Despite the risk of further primary tumours of the breast our patient chose to have treatment with wide excision and radiotherapy. The implications for screening, prophylaxis, and hormone replacement therapy for this family are discussed.

New pelvic sonoangiography for detection of endometrial carcinoma: a preliminary report

Pelvic sonoangiography (PSAG) using transvaginal color Doppler was done on 16 postmenopausal patients with abnormal uterine bleeding. Seven women had no endometrial carcinoma and nine had carcinoma. No flow was detected around and within the endometrium in noncancer patients. PSAG showed a feeder artery (blood flow with pulsation that runs into and clings to the tumor) in all patients with endometrial carcinoma, and intratumor blood flow (a mixture of pulsating and constant flow within the tumor) was evident in 7 of 9 patients with endometrial carcinoma. These findings were confirmed by conventional pelvic angiography. In the diagnostic evaluation of PSAG for endometrial carcinoma, both sensitivity and specificity were 100%. We conclude that PSAG with transvaginal color Doppler can be used to detect endometrial carcinoma in postmenopausal women with abnormal uterine bleeding and that this method might be applicable to selecting patients who really require diagnostic surgery for endometrial cancer.

Ovarian borderline mucinous tumor in a premenarchal girl: review on ovarian epithelial cancer in young girls

Ovarian tumors constitute the most common gynecological neoplasms during childhood. Unlike in adult women, ovarian epithelial tumors are uncommon in young girls and extremely rare prior to menarche. To our knowledge this is the first report of a borderline malignant mucinous tumor of the ovary in a premenarchal girl. It was successfully treated by conservative surgery. In our review of ovarian neoplasms in girls under 20 years of age, epithelial tumors were found in 19.3%, with a malignancy rate of 15.9%. Of these malignant tumors, 39.4% were of the mucinous type and 30.3% were borderline malignant. The occurrence of such a tumor at this age underscores the possibility of malignant transformation of the ovarian epithelium even prior to menarche. Its mucinous nature confirms the predominance of the mucinous subgroup in young girls. Hypotheses on the origin of mucinous tumors are discussed.

The multidisciplinary management of a family with epithelial ovarian cancer

OBJECTIVE

To describe the management of a family with an inherited predisposition to ovarian and breast cancer. Particular attention is paid to the problems of contraception, screening, prophylactic surgery and hormone replacement therapy.

SETTING

The multidisciplinary Grampian Familial Epithelial Ovarian Cancer Study Group.

SUBJECTS

162 members of a family extending over five generations. In the third generation, five of the 10 women died with epithelial ovarian cancer. Three women in generation IV have developed pre-menopausal breast cancer. There are now 78 family members in the fifth generation aged between 2 and 22 years.

INTERVENTIONS

Counselling of female family members is started at the age of 18 years. The combined oral contraceptive pill is advocated to suppress ovulation. Gynaecological follow-up after the age of 28 includes yearly pelvic examination, transvaginal ultrasonography and serum CA125 estimation. Laparoscopy with peritoneal cytology is indicated if any part of this yearly assessment is abnormal. Prophylactic oophorectomy is advised between the ages of 35 and 40 years after the family is complete. In generation IV, 20 of the 29 women have undergone prophylactic oophorectomy. Oestrogen hormone replacement therapy with a cyclical progestogen is recommended after prophylactic oophorectomy. Breast cancer screening starts at the age of 25 and involves annual clinical breast examination augmented by mammography and breast ultrasound.

CONCLUSIONS

Only by the careful questioning and recording of family history, including at least third degree relatives (cousins), will similar groups with familial ovarian/breast cancer be identified. When predisposing genes are characterized it will be possible to identify carriers within the family and concentrate clinical effort on them while offering appropriate reassurance to those with decreased risk.

New applications of pelvic sonography

This review discusses and illustrates the many applications of transvaginal sonography in gynecology. TVS has improved the accuracy of evaluation of pelvic masses and affords a means for accurate guided aspiration. The accuracy of follicular monitoring and aspiration is also enhanced with transvaginal sonography. The possible applications of transvaginal sonography as a means for screening for early ovarian carcinoma is also discussed as well as applications involving evaluation of the uterus and endometrium.

Transvaginal color Doppler imaging for hemodynamic assessment of reproductive tract tumors

Transvaginal color Doppler flow imaging was carried out on 68 Japanese women (normal, 10; uterine myoma, 21; cervical carcinoma, 7; endometrial carcinoma, 10; benign ovarian tumor, 12; ovarian carcinoma, 8). Blood flow velocity waveforms were evaluated by calculation of the resistance index (RI). In 6 patients with cervical carcinoma neovascularization was evident within the cervix. In all patients with endometrial carcinoma such signs were present adjacent to and/or within the endometrium. These findings were absent in normal women and in those with myomata. There was a significant difference between the RI (0.510 +/- 0.097) in patients with cervical carcinoma and in normal women (0.881 +/- 0.048) in the ascending branch. In endometrial carcinoma the RI (0.535 +/- 0.158) was significantly lower in the arcuate artery compared to the normal uterus (0.768 +/- 0.075) and patients with uterine myoma (0.679 +/- 0.131), respectively. There was no area of neovascularization in the normal ovaries. Neovascularization was confirmed in four patients with a benign ovarian tumor and in all patients with an ovarian carcinoma. A significantly lower RI was obtained in cases of ovarian carcinoma (0.503 +/- 0.122) than in patients with benign ovarian tumors (0.888 +/- 0.216). Transvaginal color Doppler imaging and pulsed Doppler analysis may be useful diagnostic tools to differentiate benign and malignant tumors.

Ultrasound screening for familial ovarian cancer

We have used transvaginal ultrasonography to screen 776 asymptomatic women for familial ovarian cancer. Every woman had at least one first- or second-degree relative develop the disease (677, 87%; and 98, 13%, respectively). The mean age of the study population was 51 years (range, 24 to 78 years); 52% were premenopausal, 36% were naturally postmenopausal, and 12% had undergone a hysterectomy. Overall, 43 women (5.5%) were referred for surgical investigation and 39 had a laparatomy. Nineteen/thirty-nine (48%) had bilateral ovarian masses, and 15% of abnormal ovaries had more than one type of histopathology. Twenty-three tumors and thirty-two tumor-like conditions were detected. There were 3 cases of primary ovarian cancer (prevalence, 3.9/1000), all FIGO stage Ia. None of the women has developed ovarian cancer within the first year of the scan (giving a provisional detection rate of 100%). The false positive rate was 40/773 (5.2%), the predictive value of a positive screen result was 7.7%, and the odds in favor of finding any mass at laparotomy were about 19 to 1 or for any tumor, 1 to 1. At surgery the odds against finding primary ovarian cancer were 12 to 1. The positive predictive value of the screening procedure and the prevalence of the disease were significantly higher than the corresponding values from a previous population-based screening program.

Coordinate elevation of serum markers in ovarian cancer but not in benign disease

Effective screening for occult ovarian cancer will require a strategy that is both sensitive and specific. Preliminary data suggest that CA 125 is elevated at diagnosis in a majority of patients with ovarian cancer. Although CA 125 is sufficiently specific to prompt its evaluation as one component of a strategy to detect ovarian cancer in postmenopausal women, a further improvement in specificity would facilitate cost-effective screening. In an attempt to develop a more specific screening strategy, multiple markers were assayed in a panel of sera from 47 patients with ovarian cancer and in a separate panel of sera from 50 individuals with benign disease whose serum CA 125 levels exceeded 35 U/ml. Among the patients with ovarian cancer, elevations of CA 125 (greater than 35 U/ml) were observed in 91%, CA 15-3 (greater than 30 U/ml) in 57%, TAG 72 (greater than 10 U/ml) in 49%, placental alkaline phosphatase (PLAP) in 25%, human milk fat globule protein (HMFG) 1 in 77%, HMFG2 in 62%, and NB/70K in 57%. Among the 50 sera selected from patients with benign disease, CA 125 was more than 35 U/ml in 100% and more than 65 U/ml in 42%. Among those patients with benign disease and elevated CA 125, NB/70K was elevated in 62%, HMFG1 in 26%, and HMFG2 in 12%, whereas TAG 72 and CA 15-3 were elevated in only 6% and 2%, respectively. In addition PLAP appeared promising; elevated enzyme levels were not found in the benign disease group. Among patients with ovarian cancer with CA 125 levels more than 35 U/ml, either TAG 72 or CA 15-3 was elevated in 77%. In the false-positive group, only 6% had elevations of one or the other marker. The CA 125 levels in cancer patients were, however, substantially greater than in patients with benign disease. If sera from patients with ovarian cancer were diluted to a range comparable to that found in benign disease, at least one of the two confirmatory tests was elevated in 63% of the samples from the malignant cases. Consequently, use of CA 15-3 and TAG 72 in combination with CA 125 can increase the apparent specificity of the CA 125 assay for distinguishing malignant from benign disease. Prospective studies will be required to test critically whether the use of additional serum markers in combination with the CA 125 assay would contribute to the specificity of a cost-effective screening strategy for ovarian cancer.

Prophylactic oophorectomy in Northern Ireland

A postal questionnaire was sent to all gynaecological consultants and senior registrars (n = 50) in Northern Ireland to establish the prevalence of prophylactic oophorectomy. Forty three (84%) replied. 72% performed prophylactic oophorectomy (28% unilateral), 28% did not. With reference to the world literature, there appears to be no benefit from the unilateral procedure but a consensus that bilateral oophorectomy is an option which should be considered in certain cases where there is a high risk of ovarian cancer.

Ovarian cancer. Advances in management

Substantial progress has been made in understanding the biologic behavior of ovarian cancer and in assessing disease states and response to therapy with transvaginal sonography, CT scan, and tumor markers such as CA-125. There is no longer controversy regarding the importance and feasibility of adequate surgical staging, the need for cytoreduction, and the utility of cisplatin- or carboplatin-based combination chemotherapy in the management of patients with ovarian cancer. Increasing chemotherapy dose through escalated systemic doses or intraperitoneal administration, revising multidrug resistance, the use of biologic response modifiers, and the development of new methods of chemosensitivity testing may help improve the current 5-year survival rate of less than 30% for patients with stage III ovarian cancer. Significant improvement in screening tests and diagnostic capabilities will be necessary for a dramatic increase in survival.

Ultrasonography in the diagnosis of gynecologic disorders

Ultrasonographic examination is being used with progressively greater frequency as an aid in diagnosis of gynecologic disorders but too often without consideration of whether information other than that obtained from clinical examination is needed and whether ultrasonography can supply it. The size, number, and position of pelvic masses and, in some instances, the type of tumor can be identified, but it is not often necessary when operation is clearly indicated. Ultrasonographic screening for diseases of the reproductive organs has been proposed, but its use for this purpose is limited and it is not cost-effective. It should be used as an adjunct to clinical diagnosis, not as a primary diagnostic procedure.

Detection of endometrial cancer by transvaginal ultrasonography with color flow imaging and blood flow analysis: a preliminary report

A prospective study was undertaken to assess whether changes in uterine blood flow could be used to detect endometrial cancer in 138 selected postmenopausal women (34 had uterine bleeding, 17 with endometrial cancer; 104 did not have uterine bleeding; 1 had endometrial cancer). Thirty-five of the asymptomatic women were receiving estrogen replacement therapy (ERT). The endpoints were endometrial (including tumoral) thickness and a pulsatility index (PI) derived from flow velocity waveforms recorded from both uterine arteries and from within a tumor. We found an overlap in endometrial thickness between those women with endometrial cancer and those without. The mean arterial PI value was invariably lower in women with postmenopausal bleeding and endometrial cancer (mean 0.91, range 0.31-1.49) than in those with other reasons for the blood loss (mean 3.83, range 1.95-6.40). The index was 1.10 in the woman with endometrial cancer but no sign of postmenopausal bleeding. Blood flow impedance was inversely related to stage of cancer. PI values in healthy women tended to increase slightly with age, but decrease during ERT. The detection rate was 100% within the limitations of the study design, and the false-positive rate was 1% for all women not receiving ERT and 11% for patients receiving ERT. Malignant tumors show signs of altered vascularization and a low PI (mean 0.49, range 0.29-0.92). We conclude that transvaginal ultrasonography, with or without color flow imaging, and blood flow analysis can be used to detect endometrial cancer in women with postmenopausal bleeding. A screening procedure for asymptomatic women must allow for changes in uterine blood flow during ERT.

Early detection of ovarian cancer: background, rationale, and structure of the Yale Early Detection Program

Ovarian cancer has received national attention as a highly virulent disease. Its lack of early warning symptoms and the failure to develop highly sensitive screening tests have led some physicians to recommend prophylactic oophorectomies to women with relatives who have had ovarian cancer. Others have recommended routine screening of otherwise normal women for CA 125, a circulating tumor marker, and ultrasound examinations. Each of these techniques is associated with substantial false-positive rates that could lead to unnecessary surgery. A review of epidemiologic data suggests that familial ovarian cancer kindreds are rare, but women with first-degree relatives who have had ovarian cancer have a significant risk themselves for developing ovarian cancer. In addition, women with a great number of ovulatory cycles are at an increased risk for the disease. Circulating tumor markers are frequently elevated in women with advanced ovarian cancer, but their value in early detection of ovarian cancer has yet to be established. Advances in endovaginal ultrasound and color Doppler flow technology have significantly improved our ability to assess pelvic organs. This article presents the background, rationale, and structure of the Yale Early Detection Program for ovarian cancer, whose goals are to identify the best techniques for diagnosing ovarian cancer in an early stage, to determine the frequency with which such tests should be employed, to assess false-positive results, and to identify women who might benefit from prophylactic oophorectomies.

A risk of malignancy index incorporating CA 125, ultrasound and menopausal status for the accurate preoperative diagnosis of ovarian cancer

Age, ultrasound score, menopausal status, a clinical impression score and serum CA 125 level were assessed to see how they could best distinguish between patients with benign (n = 101) and malignant (n = 42) pelvic masses. Each criteria used alone provided statistically significant discrimination. The most useful individual criteria were a serum CA 125 level of 30 U/ml (sensitivity 81%, specificity 75%) and an ultrasound score of 2 (sensitivity 71%, specificity 83%). Three criteria could be combined in a risk of malignancy index (RMI) which is simply calculated using the product of the serum CA 125 level (U/ml), the ultrasound scan result (expressed as a score of 0, 1 or 3) and the menopausal status (1 if premenopausal and 3 if postmenopausal). This index was statistically virtually as effective a discriminant between cancer and benign lesions as more formal methods. Using an RMI cut-off level of 200, the sensitivity was 85% and the specificity was 97%. Patients with an RMI score of greater than 200 had, on average, 42 times the background risk of cancer and those with a lower value 0.15 times the background risk.

Novel screening strategies for early ovarian cancer by transabdominal ultrasonography

Data collected during a prospective study to assess the efficacy of detecting early ovarian cancer by transabdominal ultrasonography have been used to refine and extend the screening procedure. The analysis was based on results from 5479 self-referred asymptomatic women, who were scheduled to undergo three annual screens consisting of one or more ultrasound scans. A positive result (based mainly on the presence of abnormal morphology) was obtained at 338 screens (326 women). Five patients with primary ovarian cancer (four stage 1a, one stage 1b; two at screen 1, three at screen 2) were identified (prevalence 0.09%). The apparent detection rate was 100% and the false-positive rate (FPR) was 3.5% at screen 1 and 2.3% overall. The use of abnormal morphology, or the maximum ovarian volume (MOV) greater than 96th centile as alternative criteria for a positive screen result, together with a defined volume change at rescan (VC) would give a FPR of 3.1% at screen 1 and 2.0% overall. The use of abnormal morphology alone at scan 1 and VC at rescan would give an overall FPR of 1.6%. The odds that a positive screen result would indicate the presence of an ovarian mass, a benign tumour, any ovarian cancer or primary ovarian cancer would be about 4 to 1, 2 to 1, 1 to 26, and 1 to 50 respectively. The results provide a more rational basis for the application and development of screening procedures for early ovarian cancer in both pre- and post-menopausal women.

Blood flow: insights from ultrasound

Ultrasonic pulse-echo systems can provide range-finding, time-position and real-time two-dimensional images of soft-tissue structures within the body. The Doppler effect can be used to study motion and blood flow. Continuous wave Doppler instruments provide information about velocity and direction of flow; depth discrimination can be obtained by pulsing the ultrasound. Two-dimensional Doppler flow imaging can be achieved by manual scanning of a probe over the skin surface. The combination of real-time pulse-echo imaging with pulsed Doppler blood flow detection in the duplex scanner makes it possible to localize the anatomical position of the Doppler sample volume. Real-time Doppler colour flow imaging combines traditional ultrasonic scanning with a two-dimensional flow map. Using appropriate ultrasonic instruments, blood flow volume rates, blood flow velocity profiles, pressure gradients, orifice areas, flow disturbances, jets, characteristics of blood vessels and the circulatory system, and tissue perfusion can all be investigated. These investigations have clinical applications in the study of cardiac, cerebral and peripheral blood flow, blood flow in the female pelvis, the fetus, the abdomen, the neonate, and in malignant tumours. Contemporary ultrasonic diagnosis employs exposure levels that are apparently free from biological risk, but other factors need to be taken into account in considering the prudent use of ultrasonic methods. Promising research is being carried out into the mechanism of ultrasonic scattering by blood, Doppler speckle, time-domain processing for blood flow imaging, methods for increasing the scanning speed, Doppler flow microscopy and contrast agents. The new technology that will result from this research should lead to further substantial progress in ultrasonic blood flow studies.

The assessment of luteal blood flow in pregnant and non-pregnant women by transvaginal color Doppler

Transvaginal color Doppler of luteal flow was performed on 58 patients with normal early pregnancy before artificial abortion, 73 patients with proven ectopic pregnancy and 75 non-gravid patients in luteal part of menstrual cycle. The equipment used were Aloka Color Doppler SSD-350 and SSD-680 with a 5 MHz transvaginal probe. Obtained color flow from ovarian tissue was explored with pulsed Doppler and the Pourcelot resistance index was calculated. Typical luteal low-impedance flow was detected in 82.8% cases of early pregnancy, 80.8% cases of ectopic pregnancy and 69.3% cases of non-pregnant women. The lowest resistance index (RI = 0.42 +/- 9.12) of luteal flow was found in cases of non-pregnant women, and the highest resistance index (RI = 0.53 +/- 0.09) was obtained in cases of early normotopic pregnancy. RI in cases of ectopic pregnancy was 0.48 +/- 0.07. Statistical analysis has shown significantly different RI in each of 3 groups of patients (P greater than 0.001). Corpus luteum was seen as early as a few days after ovulation in non-pregnant women and was present until about the 11th week of amenorrhea in pregnant women. In 86.4% patients with proven ectopic pregnancy, luteal flow was detected on the same side as the ectopic pregnancy. Our results have shown different RI value of corpus luteum flow in different groups of patients. Such findings could help to exclude pregnancy, specially with non-specific B-mode ultrasound features. Corpus luteum flow could be used as a guide for searching for ectopic pregnancy.

Transabdominal ultrasound screening for early ovarian cancer

OBJECTIVE

To assess the value of ultrasonography in a screening procedure for early ovarian cancer.

DESIGN

Prospective study of at least 5000 self referred women without symptoms of ovarian cancer. Each woman was scheduled to undergo three annual screenings (consisting of one or more scans) to detect grossly abnormal ovaries or non-regressing masses.

SETTING

The ovarian screening clinic at King's College Hospital, London.

SUBJECTS

5479 Self referred women without symptoms (aged 18-78, mean age 52).

INTERVENTIONS

Women with a positive result on screening were referred for laparoscopy or laparotomy, or both.

MAIN OUTCOME MEASURES

Findings at surgery and from histology of abnormal ovaries.

RESULTS

A total of 14,594 screenings (15,977 scans) were performed. A positive result was obtained at 338 screens (2.3%) comprising 326 subjects (5.9%). Five patients with primary ovarian cancer (four stage Ia, one stage Ib; two at first screening three at second) were identified (prevalence 0.09%). An additional four patients had metastatic ovarian cancer (three at first screening, one at second). The apparent detection rate was 100%. It was not possible to differentiate between the ultrasonic appearance of early malignant and benign tumours. The rate of false positive results for primary ovarian cancer was 3.5% at the first screening, 1.8% at the second, and 1.2% at the third. Overall the rate of false positive results was 2.3%; the specificity was 97.7% and the predictive value of a positive result on screening was 1.5%. The odds that a positive result on screening indicated the presence of an ovarian tumour, any ovarian cancer, or primary ovarian cancer were about one to two, one to 37, and one to 67 respectively.

CONCLUSION

Ultrasonography can be used to screen women without symptoms for persistent ovarian masses that will include early ovarian cancer.