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Kanti FS, Gorak Savard R, Bergeron F, Zomahoun HTV, Netter A, Maheux-Lacroix S. Transvaginal ultrasound and magnetic resonance imaging in the diagnosis of endometrioma: a systematic review and meta-analysis of diagnostic test accuracy studies. J OBSTET GYNAECOL 2024; 44:2311664. [PMID: 38348799 DOI: 10.1080/01443615.2024.2311664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/22/2024] [Indexed: 02/15/2024]
Abstract
INTRODUCTION The diagnosis of endometriomas in patients with endometriosis is of primary importance because it influences the management and prognosis of infertility and pain. Imaging techniques are evolving constantly. This study aimed to systematically assess the diagnostic accuracy of transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) in detecting endometrioma using the surgical visualisation of lesions with or without histopathological confirmation as reference standards in patients of reproductive age with suspected endometriosis. METHODS PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov databases were searched from their inception to 12 October 2022, using a manual search for additional articles. Two authors independently performed title, abstract and full-text screening of the identified records, extracted study details and quantitative data and assessed the quality of the studies using the 'Quality Assessment of Diagnostic Accuracy Study 2' tool. Bivariate random-effects models were used to determine the pooled sensitivity and specificity, compare the two imaging modalities and evaluate the sources of heterogeneity. RESULTS Sixteen prospective studies (10 assessing TVUS, 4 assessing MRI and 2 assessing both TVUS and MRI) were included, representing 1976 participants. Pooled TVUS and MRI sensitivities for endometrioma were 0.89 (95% confidence interval 'CI', 0.86-0.92) and 0.94 (95% CI, 0.74-0.99), respectively (indirect comparison p-value of 0.47). Pooled TVUS and MRI specificities for endometrioma were 0.95 (95% CI, 0.92-0.97) and 0.94 (95% CI, 0.89-0.97), respectively (indirect comparison p-value of 0.51). These studies had a high or unclear risk of bias. A direct comparison (all participants undergoing TVUS and MRI) of the modalities was available in only two studies. CONCLUSION TVUS and MRI have high accuracy for diagnosing endometriomas; however, high-quality studies comparing the two modalities are lacking.
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Affiliation(s)
- Fleur Serge Kanti
- Centre de recherche du CHU de Québec - Université Laval, Quebec City, Canada
| | - Rose Gorak Savard
- Centre de recherche du CHU de Québec - Université Laval, Quebec City, Canada
| | | | - Hervé Tchala Vignon Zomahoun
- Centre de recherche sur les soins et les services de première ligne (CERSSPL) - Université Laval, Quebec City, Canada
| | - Antoine Netter
- Department of Gynecology-Obstetrics and Reproductive Medicine, AP-HM, La Conception Hospital, Marseille, France
- Institut méditerranéen de biodiversité et d'écologie marine et continentale (IMBE), Aix Marseille University, CNRS, IRD, Marseille, France
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Marcellin L, Santulli P, Bourdon M, Comte C, Maignien C, Just PA, Streuli I, Borghese B, Chapron C. Serum antimüllerian hormone concentration increases with ovarian endometrioma size. Fertil Steril 2019; 111:944-952.e1. [DOI: 10.1016/j.fertnstert.2019.01.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 01/09/2019] [Accepted: 01/09/2019] [Indexed: 10/27/2022]
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Knific T, Vouk K, Vogler A, Osredkar J, Gstöttner M, Wenzl R, Rižner TL. Models including serum CA-125, BMI, cyst pathology, dysmenorrhea or dyspareunia for diagnosis of endometriosis. Biomark Med 2018; 12:737-747. [PMID: 29865858 DOI: 10.2217/bmm-2017-0426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To evaluate preoperative levels of CA-125 and HE4 in patients with endometriosis-like symptoms and to construct diagnostic models. PATIENTS Prospective case-control study included 124 endometriosis patients and 97 control patients. MATERIALS & METHODS Logistic regression was used to construct diagnostic models based on serum biomarker levels and clinical data. RESULTS A model with CA-125, BMI, information on cysts and dyspareunia had an area under the curve value of 0.836, sensitivity of 74.0% and specificity of 81.3%. The second model included CA-125, BMI, information on cysts and dysmenorrhea and had an area under the curve value of 0.819, sensitivity of 74.8% and specificity of 79.2%. CONCLUSION Constructed models have the potential for noninvasive diagnosis of endometriosis, and might be translated into clinical practice after additional validation.
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Affiliation(s)
- Tamara Knific
- Institute of Biochemistry, Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
| | - Katja Vouk
- Institute of Biochemistry, Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
| | - Andrej Vogler
- Department of Obstetrics & Gynaecology, University Medical Centre Ljubljana, Slovenia
| | - Joško Osredkar
- Clinical Institute of Clinical Chemistry & Biochemistry, University Medical Centre Ljubljana, Slovenia
| | - Manuela Gstöttner
- Department of Obstetrics & Gynaecology, Medical University Vienna, Austria
| | - René Wenzl
- Department of Obstetrics & Gynaecology, Medical University Vienna, Austria
| | - Tea Lanišnik Rižner
- Institute of Biochemistry, Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
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Nisenblat V, Prentice L, Bossuyt PMM, Farquhar C, Hull ML, Johnson N. Combination of the non-invasive tests for the diagnosis of endometriosis. Cochrane Database Syst Rev 2016; 7:CD012281. [PMID: 27405583 PMCID: PMC6953325 DOI: 10.1002/14651858.cd012281] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND About 10% of women of reproductive age suffer from endometriosis, a costly chronic disease causing pelvic pain and subfertility. Laparoscopy is the gold standard diagnostic test for endometriosis, but is expensive and carries surgical risks. Currently, there are no non-invasive tests available in clinical practice to accurately diagnose endometriosis. This review assessed the diagnostic accuracy of combinations of different non-invasive testing modalities for endometriosis and provided a summary of all the reviews in the non-invasive tests for endometriosis series. OBJECTIVES To estimate the diagnostic accuracy of any combination of non-invasive tests for the diagnosis of pelvic endometriosis (peritoneal and/or ovarian or deep infiltrating) compared to surgical diagnosis as a reference standard. The combined tests were evaluated as replacement tests for diagnostic surgery and triage tests to assist decision-making to undertake diagnostic surgery for endometriosis. SEARCH METHODS We did not restrict the searches to particular study designs, language or publication dates. We searched CENTRAL to July 2015, MEDLINE and EMBASE to May 2015, as well as the following databases to April 2015: CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, DARE and PubMed. SELECTION CRITERIA We considered published, peer-reviewed, randomised controlled or cross-sectional studies of any size, including prospectively collected samples from any population of women of reproductive age suspected of having one or more of the following target conditions: ovarian, peritoneal or deep infiltrating endometriosis (DIE). We included studies comparing the diagnostic test accuracy of a combination of several testing modalities with the findings of surgical visualisation of endometriotic lesions. DATA COLLECTION AND ANALYSIS Three review authors independently collected and performed a quality assessment of the data from each study by using the QUADAS-2 tool. For each test, the data were classified as positive or negative for the surgical detection of endometriosis and sensitivity and specificity estimates were calculated. The bivariate model was planned to obtain pooled estimates of sensitivity and specificity whenever sufficient data were available. The predetermined criteria for a clinically useful test to replace diagnostic surgery were a sensitivity of 0.94 and a specificity of 0.79 to detect endometriosis. We set the criteria for triage tests at a sensitivity of 0.95 and above and a specificity of 0.50 and above, which 'rules out' the diagnosis with high accuracy if there is a negative test result (SnOUT test), or a sensitivity of 0.50 and above and a specificity of 0.95 and above, which 'rules in' the diagnosis with high accuracy if there is a positive result (SpIN test). MAIN RESULTS Eleven eligible studies included 1339 participants. All the studies were of poor methodological quality. Seven studies evaluated pelvic endometriosis, one study considered DIE and/or ovarian endometrioma, two studies differentiated endometrioma from other ovarian cysts and one study addressed mapping DIE at specific anatomical sites. Fifteen different diagnostic combinations were assessed, including blood, urinary or endometrial biomarkers, transvaginal ultrasound (TVUS) and clinical history or examination. We did not pool estimates of sensitivity and specificity, as each study analysed independent combinations of the non-invasive tests.Tests that met the criteria for a replacement test were: a combination of serum IL-6 (cut-off >15.4 pg/ml) and endometrial PGP 9.5 for pelvic endometriosis (sensitivity 1.00 (95% confidence interval (CI) 0.91 to 1.00), specificity 0.93 (95% CI, 0.80, 0.98) and the combination of vaginal examination and transvaginal ultrasound (TVUS) for rectal endometriosis (sensitivity 0.96 (95% CI 0.86 to 0.99), specificity 0.98 (95% CI 0.94 to 1.00)). Tests that met the criteria for SpIN triage tests for pelvic endometriosis were: 1. a multiplication of urine vitamin-D-binding protein (VDBP) and serum CA-125 (cut-off >2755) (sensitivity 0.74 (95% CI 0.60 to 0.84), specificity 0.97 (95% CI 0.86 to 1.00)) and 2. a combination of history (length of menses), serum CA-125 (cut-off >35 U/ml) and endometrial leukocytes (sensitivity 0.61 (95% CI 0.54 to 0.69), specificity 0.95 (95% CI 0.91 to 0.98)). For endometrioma, the following combinations qualified as SpIN test: 1. TVUS and either serum CA-125 (cut-off ≥25 U/ml) or CA 19.9 (cut-off ≥12 U/ml) (sensitivity 0.79 (95% CI 0.64 to 0.91), specificity 0.97 (95% CI 0.91 to 1.00)); 2. TVUS and serum CA 19.9 (cut-off ≥12 U/ml) (sensitivity 0.54 (95% CI 0.37 to 0.70), specificity 0.97 (95% CI 0.91 to 1.0)); 3-4. TVUS and serum CA-125 (cut-off ≥20 U/ml or cut-off ≥25 U/ml) (sensitivity 0.69 (95% CI 0.49 to 0.85), specificity 0.96 (95% CI 0.88 to 0.99)); 5. TVUS and serum CA-125 (cut-off ≥35 U/ml) (sensitivity 0.52 (95% CI 0.33 to 0.71), specificity 0.97 (95% CI 0.90 to 1.00)). A combination of vaginal examination and TVUS reached the threshold for a SpIN test for obliterated pouch of Douglas (sensitivity 0.87 (95% CI 0.69 to 0.96), specificity 0.98 (95% CI 0.95 to 1.00)), vaginal wall endometriosis (sensitivity 0.82 (95% CI 0.60 to 0.95), specificity 0.99 (95% CI 0.97 to 1.0)) and rectovaginal septum endometriosis (sensitivity 0.88 (95% CI 0.47 to 1.00), specificity 0.99 (95% CI 0.96 to 1.00)).All the tests were evaluated in individual studies and displayed wide CIs. Due to the heterogeneity and high risk of bias of the included studies, the clinical utility of the studied combination diagnostic tests for endometriosis remains unclear. AUTHORS' CONCLUSIONS None of the biomarkers evaluated in this review could be evaluated in a meaningful way and there was insufficient or poor-quality evidence. Laparoscopy remains the gold standard for the diagnosis of endometriosis and using any non-invasive tests should only be undertaken in a research setting.
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Affiliation(s)
- Vicki Nisenblat
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 6, Medical School North,Frome RdAdelaideSAAustralia5005
| | - Lucy Prentice
- Tauranga Hospital, Bay of Plenty DHBObstetrics and GynaecologyCameron RdTaurangaNew Zealand3143
| | - Patrick MM Bossuyt
- Academic Medical Center, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsRoom J1b‐217, PO Box 22700AmsterdamNetherlands1100 DE
| | - Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
| | - M Louise Hull
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 6, Medical School North,Frome RdAdelaideSAAustralia5005
| | - Neil Johnson
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 6, Medical School North,Frome RdAdelaideSAAustralia5005
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Nisenblat V, Bossuyt PMM, Shaikh R, Farquhar C, Jordan V, Scheffers CS, Mol BWJ, Johnson N, Hull ML. Blood biomarkers for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev 2016; 2016:CD012179. [PMID: 27132058 PMCID: PMC7076288 DOI: 10.1002/14651858.cd012179] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND About 10% of reproductive-aged women suffer from endometriosis, a costly chronic disease causing pelvic pain and subfertility. Laparoscopy is the gold standard diagnostic test for endometriosis, but is expensive and carries surgical risks. Currently, there are no non-invasive or minimally invasive tests available in clinical practice to accurately diagnose endometriosis. Although other reviews have assessed the ability of blood tests to diagnose endometriosis, this is the first review to use Cochrane methods, providing an update on the rapidly expanding literature in this field. OBJECTIVES To evaluate blood biomarkers as replacement tests for diagnostic surgery and as triage tests to inform decisions on surgery for endometriosis. Specific objectives include:1. To provide summary estimates of the diagnostic accuracy of blood biomarkers for the diagnosis of peritoneal, ovarian and deep infiltrating pelvic endometriosis, compared to surgical diagnosis as a reference standard.2. To assess the diagnostic utility of biomarkers that could differentiate ovarian endometrioma from other ovarian masses. SEARCH METHODS We did not restrict the searches to particular study designs, language or publication dates. We searched CENTRAL to July 2015, MEDLINE and EMBASE to May 2015, as well as these databases to 20 April 2015: CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, DARE and PubMed. SELECTION CRITERIA We considered published, peer-reviewed, randomised controlled or cross-sectional studies of any size, including prospectively collected samples from any population of reproductive-aged women suspected of having one or more of the following target conditions: ovarian, peritoneal or deep infiltrating endometriosis (DIE). We included studies comparing the diagnostic test accuracy of one or more blood biomarkers with the findings of surgical visualisation of endometriotic lesions. DATA COLLECTION AND ANALYSIS Two authors independently collected and performed a quality assessment of data from each study. For each diagnostic test, we classified the data as positive or negative for the surgical detection of endometriosis, and we calculated sensitivity and specificity estimates. We used the bivariate model to obtain pooled estimates of sensitivity and specificity whenever sufficient datasets were available. The predetermined criteria for a clinically useful blood test to replace diagnostic surgery were a sensitivity of 0.94 and a specificity of 0.79 to detect endometriosis. We set the criteria for triage tests at a sensitivity of ≥ 0.95 and a specificity of ≥ 0.50, which 'rules out' the diagnosis with high accuracy if there is a negative test result (SnOUT test), or a sensitivity of ≥ 0.50 and a specificity of ≥ 0.95, which 'rules in' the diagnosis with high accuracy if there is a positive result (SpIN test). MAIN RESULTS We included 141 studies that involved 15,141 participants and evaluated 122 blood biomarkers. All the studies were of poor methodological quality. Studies evaluated the blood biomarkers either in a specific phase of the menstrual cycle or irrespective of the cycle phase, and they tested for them in serum, plasma or whole blood. Included women were a selected population with a high frequency of endometriosis (10% to 85%), in which surgery was indicated for endometriosis, infertility work-up or ovarian mass. Seventy studies evaluated the diagnostic performance of 47 blood biomarkers for endometriosis (44 single-marker tests and 30 combined tests of two to six blood biomarkers). These were angiogenesis/growth factors, apoptosis markers, cell adhesion molecules, high-throughput markers, hormonal markers, immune system/inflammatory markers, oxidative stress markers, microRNAs, tumour markers and other proteins. Most of these biomarkers were assessed in small individual studies, often using different cut-off thresholds, and we could only perform meta-analyses on the data sets for anti-endometrial antibodies, interleukin-6 (IL-6), cancer antigen-19.9 (CA-19.9) and CA-125. Diagnostic estimates varied significantly between studies for each of these biomarkers, and CA-125 was the only marker with sufficient data to reliably assess sources of heterogeneity.The mean sensitivities and specificities of anti-endometrial antibodies (4 studies, 759 women) were 0.81 (95% confidence interval (CI) 0.76 to 0.87) and 0.75 (95% CI 0.46 to 1.00). For IL-6, with a cut-off value of > 1.90 to 2.00 pg/ml (3 studies, 309 women), sensitivity was 0.63 (95% CI 0.52 to 0.75) and specificity was 0.69 (95% CI 0.57 to 0.82). For CA-19.9, with a cut-off value of > 37.0 IU/ml (3 studies, 330 women), sensitivity was 0.36 (95% CI 0.26 to 0.45) and specificity was 0.87 (95% CI 0.75 to 0.99).Studies assessed CA-125 at different thresholds, demonstrating the following mean sensitivities and specificities: for cut-off > 10.0 to 14.7 U/ml: 0.70 (95% CI 0.63 to 0.77) and 0.64 (95% CI 0.47 to 0.82); for cut-off > 16.0 to 17.6 U/ml: 0.56 (95% CI 0.24, 0.88) and 0.91 (95% CI 0.75, 1.00); for cut-off > 20.0 U/ml: 0.67 (95% CI 0.50 to 0.85) and 0.69 (95% CI 0.58 to 0.80); for cut-off > 25.0 to 26.0 U/ml: 0.73 (95% CI 0.67 to 0.79) and 0.70 (95% CI 0.63 to 0.77); for cut-off > 30.0 to 33.0 U/ml: 0.62 (95% CI 0.45 to 0.79) and 0.76 (95% CI 0.53 to 1.00); and for cut-off > 35.0 to 36.0 U/ml: 0.40 (95% CI 0.32 to 0.49) and 0.91 (95% CI 0.88 to 0.94).We could not statistically evaluate other biomarkers meaningfully, including biomarkers that were assessed for their ability to differentiate endometrioma from other benign ovarian cysts.Eighty-two studies evaluated 97 biomarkers that did not differentiate women with endometriosis from disease-free controls. Of these, 22 biomarkers demonstrated conflicting results, with some studies showing differential expression and others no evidence of a difference between the endometriosis and control groups. AUTHORS' CONCLUSIONS Of the biomarkers that were subjected to meta-analysis, none consistently met the criteria for a replacement or triage diagnostic test. A subset of blood biomarkers could prove useful either for detecting pelvic endometriosis or for differentiating ovarian endometrioma from other benign ovarian masses, but there was insufficient evidence to draw meaningful conclusions. Overall, none of the biomarkers displayed enough accuracy to be used clinically outside a research setting. We also identified blood biomarkers that demonstrated no diagnostic value in endometriosis and recommend focusing research resources on evaluating other more clinically useful biomarkers.
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Affiliation(s)
- Vicki Nisenblat
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 6, Medical School North,Frome RdAdelaideSAAustralia5005
| | - Patrick MM Bossuyt
- Academic Medical Center, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsRoom J1b‐217, PO Box 22700AmsterdamNetherlands1100 DE
| | - Rabia Shaikh
- IVF AustraliaWestmead Fertility ClinicLevel 2 20‐22 Mons Road, WestmeadSydneyVictoriaAustralia2145
| | - Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
| | - Vanessa Jordan
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
| | - Carola S Scheffers
- University of GroningenWenckebachlaan 53GroningenGroningenNetherlands9728 JL
| | - Ben Willem J Mol
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 6, Medical School North,Frome RdAdelaideSAAustralia5005
| | - Neil Johnson
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 6, Medical School North,Frome RdAdelaideSAAustralia5005
| | - M Louise Hull
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 6, Medical School North,Frome RdAdelaideSAAustralia5005
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Nisenblat V, Bossuyt PMM, Farquhar C, Johnson N, Hull ML. Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev 2016; 2:CD009591. [PMID: 26919512 PMCID: PMC7100540 DOI: 10.1002/14651858.cd009591.pub2] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND About 10% of women of reproductive age suffer from endometriosis. Endometriosis is a costly chronic disease that causes pelvic pain and subfertility. Laparoscopy, the gold standard diagnostic test for endometriosis, is expensive and carries surgical risks. Currently, no non-invasive tests that can be used to accurately diagnose endometriosis are available in clinical practice. This is the first review of diagnostic test accuracy of imaging tests for endometriosis that uses Cochrane methods to provide an update on the rapidly expanding literature in this field. OBJECTIVES • To provide estimates of the diagnostic accuracy of imaging modalities for the diagnosis of pelvic endometriosis, ovarian endometriosis and deeply infiltrating endometriosis (DIE) versus surgical diagnosis as a reference standard.• To describe performance of imaging tests for mapping of deep endometriotic lesions in the pelvis at specific anatomical sites.Imaging tests were evaluated as replacement tests for diagnostic surgery and as triage tests that would assist decision making regarding diagnostic surgery for endometriosis. SEARCH METHODS We searched the following databases to 20 April 2015: MEDLINE, CENTRAL, EMBASE, CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, MEDION, DARE, and PubMed. Searches were not restricted to a particular study design or language nor to specific publication dates. The search strategy incorporated words in the title, abstracts, text words across the record and medical subject headings (MeSH). SELECTION CRITERIA We considered published peer-reviewed cross-sectional studies and randomised controlled trials of any size that included prospectively recruited women of reproductive age suspected of having one or more of the following target conditions: endometrioma, pelvic endometriosis, DIE or endometriotic lesions at specific intrapelvic anatomical locations. We included studies that compared the diagnostic test accuracy of one or more imaging modalities versus findings of surgical visualisation of endometriotic lesions. DATA COLLECTION AND ANALYSIS Two review authors independently collected and performed a quality assessment of data from each study. For each imaging test, data were classified as positive or negative for surgical detection of endometriosis, and sensitivity and specificity estimates were calculated. If two or more tests were evaluated in the same cohort, each was considered as a separate data set. We used the bivariate model to obtain pooled estimates of sensitivity and specificity when sufficient data sets were available. Predetermined criteria for a clinically useful imaging test to replace diagnostic surgery included sensitivity ≥ 94% and specificity ≥ 79%. Criteria for triage tests were set at sensitivity ≥ 95% and specificity ≥ 50%, ruling out the diagnosis with a negative result (SnNout test - if sensitivity is high, a negative test rules out pathology) or at sensitivity ≥ 50% with specificity ≥ 95%, ruling in the diagnosis with a positive result (SpPin test - if specificity is high, a positive test rules in pathology). MAIN RESULTS We included 49 studies involving 4807 women: 13 studies evaluated pelvic endometriosis, 10 endometriomas and 15 DIE, and 33 studies addressed endometriosis at specific anatomical sites. Most studies were of poor methodological quality. The most studied modalities were transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), with outcome measures commonly demonstrating diversity in diagnostic estimates; however, sources of heterogeneity could not be reliably determined. No imaging test met the criteria for a replacement or triage test for detecting pelvic endometriosis, albeit TVUS approached the criteria for a SpPin triage test. For endometrioma, TVUS (eight studies, 765 participants; sensitivity 0.93 (95% confidence interval (CI) 0.87, 0.99), specificity 0.96 (95% CI 0.92, 0.99)) qualified as a SpPin triage test and approached the criteria for a replacement and SnNout triage test, whereas MRI (three studies, 179 participants; sensitivity 0.95 (95% CI 0.90, 1.00), specificity 0.91 (95% CI 0.86, 0.97)) met the criteria for a replacement and SnNout triage test and approached the criteria for a SpPin test. For DIE, TVUS (nine studies, 12 data sets, 934 participants; sensitivity 0.79 (95% CI 0.69, 0.89) and specificity 0.94 (95% CI 0.88, 1.00)) approached the criteria for a SpPin triage test, and MRI (six studies, seven data sets, 266 participants; sensitivity 0.94 (95% CI 0.90, 0.97), specificity 0.77 (95% CI 0.44, 1.00)) approached the criteria for a replacement and SnNout triage test. Other imaging tests assessed in small individual studies could not be statistically evaluated.TVUS met the criteria for a SpPin triage test in mapping DIE to uterosacral ligaments, rectovaginal septum, vaginal wall, pouch of Douglas (POD) and rectosigmoid. MRI met the criteria for a SpPin triage test for POD and vaginal and rectosigmoid endometriosis. Transrectal ultrasonography (TRUS) might qualify as a SpPin triage test for rectosigmoid involvement but could not be adequately assessed for other anatomical sites because heterogeneous data were scant. Multi-detector computerised tomography enema (MDCT-e) displayed the highest diagnostic performance for rectosigmoid and other bowel endometriosis and met the criteria for both SpPin and SnNout triage tests, but studies were too few to provide meaningful results.Diagnostic accuracies were higher for TVUS with bowel preparation (TVUS-BP) and rectal water contrast (RWC-TVS) and for 3.0TMRI than for conventional methods, although the paucity of studies precluded statistical evaluation. AUTHORS' CONCLUSIONS None of the evaluated imaging modalities were able to detect overall pelvic endometriosis with enough accuracy that they would be suggested to replace surgery. Specifically for endometrioma, TVUS qualified as a SpPin triage test. MRI displayed sufficient accuracy to suggest utility as a replacement test, but the data were too scant to permit meaningful conclusions. TVUS could be used clinically to identify additional anatomical sites of DIE compared with MRI, thus facilitating preoperative planning. Rectosigmoid endometriosis was the only site that could be accurately mapped by using TVUS, TRUS, MRI or MDCT-e. Studies evaluating recent advances in imaging modalities such as TVUS-BP, RWC-TVS, 3.0TMRI and MDCT-e were observed to have high diagnostic accuracies but were too few to allow prudent evaluation of their diagnostic role. In view of the low quality of most of the included studies, the findings of this review should be interpreted with caution. Future well-designed diagnostic studies undertaken to compare imaging tests for diagnostic test accuracy and costs are recommended.
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Affiliation(s)
- Vicki Nisenblat
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 6, Medical School North,Frome RdAdelaideSAAustralia5005
| | - Patrick MM Bossuyt
- Academic Medical Center, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsRoom J1b‐217, PO Box 22700AmsterdamNetherlands1100 DE
| | - Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
| | - Neil Johnson
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 6, Medical School North,Frome RdAdelaideSAAustralia5005
| | - M Louise Hull
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 6, Medical School North,Frome RdAdelaideSAAustralia5005
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Reid S, Lu C, Casikar I, Mein B, Magotti R, Ludlow J, Benzie R, Condous G. The prediction of pouch of Douglas obliteration using offline analysis of the transvaginal ultrasound 'sliding sign' technique: inter- and intra-observer reproducibility. Hum Reprod 2013; 28:1237-46. [DOI: 10.1093/humrep/det044] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Testa AC, Timmerman D, Van Holsbeke C, Zannoni GF, Fransis S, Moerman P, Vellone V, Mascilini F, Licameli A, Ludovisi M, Di Legge A, Scambia G, Ferrandina G. Ovarian cancer arising in endometrioid cysts: ultrasound findings. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:99-106. [PMID: 21351179 DOI: 10.1002/uog.8970] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/14/2011] [Indexed: 05/30/2023]
Abstract
OBJECTIVES To describe sonographic characteristics of malignant transformation in endometrioid cysts. METHODS Women with a histological diagnosis of ovarian endometrioid cysts, borderline tumors arising in endometrioid cysts and carcinoma arising in endometrioid cysts, preoperatively examined sonographically, were included in this retrospective study. Gray-scale and Doppler ultrasound characteristics of the endometrioid cysts were compared with those of the borderline tumors and primary cancers arising in endometrioid cysts. The performance of an experienced examiner in classifying the masses was also assessed. RESULTS Of 324 cases collected for the study, 309 (95.3%) lesions were classified as endometrioid cysts, four (1.2%) as borderline tumors arising in endometrioid cysts and 11 (3.4%) as carcinoma arising in endometrioid cysts. Women with malignant findings (borderline ovarian tumors and cancers) were older (median age 52 (range, 28-79) years) than those with benign endometrioid cysts (median age 34 (range, 18-76) years) (P<0.0001), and the prevalence of postmenopausal status was significantly higher in malignant cases. All (15/15) malignant tumors vs. 16% (50/309) of benign tumors were characterized by the presence of solid tissue (P<0.0001). The prevalence of solid tissue with positive Doppler signals was higher in malignant tumors (100%) than in benign cysts (7.8%) (P<0.0001). Papillary projections were a more frequent sonographic feature among malignant lesions (86.7%) than among benign endometrioid cysts (11.3%) (P<0.0001); power Doppler signals were detected within the projections in 92.3% and 37.1% of malignant and benign lesions, respectively. The examiner correctly diagnosed 94.8% (293/309) of benign lesions as benign and 93.3% (14/15) of malignant lesions as malignant. The risk estimation of the examiner was 'uncertain' in three (20%) and 'probably/certainly malignant' in 12 (80%) of 15 malignant cases. CONCLUSION Borderline tumors and carcinomas arising in endometrioid cysts show a vascularized solid component at ultrasound examination.
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Affiliation(s)
- A C Testa
- Department of Obstetrics and Gynecology, Catholic University, Rome, Italy.
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9
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Ultrasound-guided aspiration and ethanol sclerotherapy for treating endometrial cysts. Radiol Med 2010; 115:1330-9. [DOI: 10.1007/s11547-010-0586-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Accepted: 12/29/2009] [Indexed: 12/22/2022]
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10
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Sokalska A, Timmerman D, Testa AC, Van Holsbeke C, Lissoni AA, Leone FPG, Jurkovic D, Valentin L. Diagnostic accuracy of transvaginal ultrasound examination for assigning a specific diagnosis to adnexal masses. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 34:462-470. [PMID: 19685552 DOI: 10.1002/uog.6444] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To determine the sensitivity and specificity of subjective evaluation of gray-scale and Doppler ultrasound findings (here called pattern recognition) when used by experienced ultrasound examiners with regard to making a specific diagnosis of adnexal masses. METHODS Within the framework of a European multicenter study, the International Ovarian Tumor Analysis study, comprising nine ultrasound centers, women with at least one adnexal mass were examined with gray-scale and color Doppler ultrasonography by experienced ultrasound examiners. A standardized examination technique, and standardized terms and definitions were used. Using pattern recognition the examiners classified each mass as benign or malignant and suggested a specific diagnosis (e.g. dermoid cyst or endometrioma). The reference standard was the histology of the surgically removed adnexal tumors. RESULTS A total of 1066 women were included, of whom 800 had a benign mass and 266 a malignant mass. A specific diagnosis based on ultrasound findings was suggested in 899 (84%) tumors. The specificity was high for all diagnoses (range, 94-100%). The sensitivity was highest for benign teratoma/dermoid cysts (86%, 100/116), hydrosalpinges (86%, 18/21), peritoneal pseudocysts (80%, 4/5) and endometriomas (77%, 153/199), and lowest for functional cysts (17%, 4/24), paraovarian/parasalpingeal cysts (14%, 3/21), benign rare tumors (11%, 1/9), adenofibromas (8%, 3/39), simple cysts (6%, 1/18) and struma ovarii (0%, 0/5). The positive and negative likelihood ratios of pattern recognition with regard to dermoid cysts, hydrosalpinges and endometriomas were 68.2 and 0.14, 38.9 and 0.15, and 33.3 and 0.24, respectively. Dermoid cysts, hydrosalpinges, functional cysts, paraovarian cysts, peritoneal pseudocysts, fibromas/fibrothecomas and simple cysts were never misdiagnosed as malignancies by the ultrasound examiner, whereas more than 10% of inflammatory processes, adenofibromas and rare benign tumors including struma ovarii were misdiagnosed as malignancies. CONCLUSIONS Using subjective evaluation of gray-scale and Doppler ultrasound findings it is possible to make an almost conclusive diagnosis of a dermoid cyst, endometrioma and hydrosalpinx. Many other adnexal pathologies can be recognized but not confidently confirmed or excluded.
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Affiliation(s)
- A Sokalska
- Division of Infertility and Reproductive Endocrinology, Department of Gynecology, Obstetrics and Gynecological Oncology, Karol Marcinkowski University of Medical Sciences, Poznan, Poland
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11
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Guerriero S, Alcazar JL, Pascual MA, Ajossa S, Gerada M, Bargellini R, Virgilio B, Melis GB. Intraobserver and interobserver agreement of grayscale typical ultrasonographic patterns for the diagnosis of ovarian cancer. ULTRASOUND IN MEDICINE & BIOLOGY 2008; 34:1711-1716. [PMID: 18524459 DOI: 10.1016/j.ultrasmedbio.2008.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Revised: 03/27/2008] [Accepted: 04/11/2008] [Indexed: 05/26/2023]
Abstract
The purpose of this study was to evaluate the intraobserver and interobserver agreement for identifying ovarian malignancy using typical grayscale ultrasonographic patterns. Digitally stored grayscale sonographic images from a random sample of 98 women with an adnexal mass submitted to surgery after a grayscale transvaginal sonography were evaluated by five different examiners with different degrees of experience in three European university departments of obstetrics and gynecology. Masses in which the echo features were highly characteristic of a benign pathology were categorized as benign. Any cystic mass containing excrescences, thick septations, multiple irregular septations or solid component in which the echo architecture was not highly suggestive of benign histology was categorized as malignant. Intraobserver and interobserver agreement according to the level of experience were assessed by calculating the kappa index. Of the 98 cases randomly selected, 28 (29%) were malignant masses and 70 (71%) were benign. Intraobserver agreement was good or very good for all examiners with different degrees of experience (kappa = 0.72 to 1). Interobserver agreement was good for all expert operators (kappa = 0.69 to 0.75). Interobserver agreement between experts and highly experienced operators was moderate or good (kappa = 0.51 to 0.63). Interobserver agreement between the moderately experienced operator and experts was fair to moderate (kappa = 0.29 to 0.46). Interobserver agreement between moderately and highly experienced operators was fair (kappa = 0.33). Our results indicate that ultrasonographic malignant patterns are reproducible, even in moderately experienced examiners, although more experience is associated with better interobserver agreement.
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Affiliation(s)
- Stefano Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy.
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12
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Raine-Fenning N, Jayaprakasan K, Deb S. Three-dimensional ultrasonographic characteristics of endometriomata. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 31:718-724. [PMID: 18504776 DOI: 10.1002/uog.5380] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- N Raine-Fenning
- Academic Division of Reproductive Medicine and Surgery, School of Human Development, Queen's Medical Centre, University of Nottingham, Nottingham, UK.
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13
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14
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Bazot M, Malzy P, Cortez A, Roseau G, Amouyal P, Daraï E. Accuracy of transvaginal sonography and rectal endoscopic sonography in the diagnosis of deep infiltrating endometriosis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2007; 30:994-1001. [PMID: 17992706 DOI: 10.1002/uog.4070] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES To compare the accuracy of transvaginal sonography (TVS) and rectal endoscopic sonography (RES) for the diagnosis of deep infiltrating endometriosis (DIE), with respect to surgical and histological findings. METHODS This was a longitudinal study of 81 consecutive patients referred for surgical management of DIE, who underwent both TVS and RES preoperatively. The diagnostic criteria were identical for TVS and RES, and were based on visualization of hypoechoic areas in specific locations (uterosacral ligaments, vagina, rectovaginal septum and intestine). We calculated the sensitivity, specificity, predictive values and accuracy of TVS and RES for the diagnosis of DIE. RESULTS Endometriosis was confirmed histologically in 80/81 (98.7%) patients. Endometriomas and DIE were present in 43.2% and 97.5% of the women, respectively. For the diagnosis of DIE overall, TVS and RES, respectively, had a sensitivity of 87.3% and 74.7%, a positive predictive value of 98.6% and 98.3%, and an accuracy of 86.4% and 74%. For the diagnosis of uterosacral endometriosis, they had a sensitivity of 80.8% and 46.6%, a specificity of 75% and 50.0%, a positive predictive value of 96.7% and 89.5% and a negative predictive value of 30% and 9.3%. For the diagnosis of intestinal endometriosis, they had a sensitivity of 92.6% and 88.9%, a specificity of 100% and 92.6%, a positive predictive value of 100% and 96% and a negative predictive value of 87% and 80.6%. CONCLUSION TVS is apparently more accurate than is RES for predicting DIE in specific locations, and should thus be the first-line imaging technique in this setting.
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Affiliation(s)
- M Bazot
- Services de Radiologie, Hôpital Tenon, APHP, Paris, France.
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15
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Abstract
Pelvic endometriosis primarily affects the ovaries, pelvic peritoneum, utero-sacral ligaments, Douglas pouch, vagina, rectum and bladder. Clinical assessment is difficult, and imaging proves necessary to determine location and extent of the disease. We review pelvic endometriosis with regards to imaging modalities: technical considerations, imaging patterns, diagnostic performance and respective place of ultrasound and MRI.
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Affiliation(s)
- A Maubon
- Service de Radiologie et Imagerie Médicale, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France.
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Clarke L, Edwards A, Pollard K. Acoustic streaming in ovarian cysts. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2005; 24:617-621. [PMID: 15840792 DOI: 10.7863/jum.2005.24.5.617] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE The purpose of this study was to investigate the hypothesis that endometriomas do not show acoustic streaming and then to quantify the streaming velocity of the particles within ovarian cysts that do show acoustic streaming. METHODS Ovarian cysts greater than 2 cm in diameter, with internal echoes seen on B-mode sonography, were prospectively evaluated for the presence of acoustic streaming. If acoustic streaming was present, a 2-mm pulsed Doppler sample volume was then placed within the distal portion of the cyst, and the streaming velocity was recorded. Follow-up included review of subsequent sonographic examinations, surgical notes, and histopathologic reports, with the latter being considered the final results if available. RESULTS Acoustic streaming was detected in 10 (38%) of 26 ovarian cysts, but of the 10 endometriomas, none (0%) showed acoustic streaming (P = .002). Acoustic streaming was detected in 86% (n = 6) of cystadenomas. Four of these were serous cystadenomas, which all showed acoustic streaming, with a velocity range of 1.5 to 3.6 cm/s. Two mucinous cystadenomas showed acoustic streaming with velocities of 0.8 and 2.0 cm/s. CONCLUSIONS Endometriomas appear as cysts containing homogeneous, low-level, "ground glass" echoes on gray scale sonography. Other types of ovarian cysts can also have these appearances. Endometriomas do not show acoustic streaming. Cystadenomas may have streaming velocities within a defined range. Acoustic streaming assessment may therefore prove to be an additional useful tool in assessing ovarian cysts and in completely excluding endometrioma as a diagnosis if a cyst shows acoustic streaming.
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Affiliation(s)
- Lisa Clarke
- Ultrasound Department, Diagnostic Imaging, Monash Medical Centre, 246 Clayton Rd, Clayton, Victoria, Australia.
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Garcia-Velasco JA, Mahutte NG, Corona J, Zúñiga V, Gilés J, Arici A, Pellicer A. Removal of endometriomas before in vitro fertilization does not improve fertility outcomes: a matched, case–control study. Fertil Steril 2004; 81:1194-7. [PMID: 15136074 DOI: 10.1016/j.fertnstert.2003.04.006] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2003] [Revised: 04/30/2003] [Accepted: 04/30/2003] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate whether conservative surgery on ovarian endometriomas before an IVF cycle improves fertility outcomes. DESIGN Retrospective, matched case-control study. SETTING Two academic IVF programs. PATIENT(S) One hundred eighty-nine women with endometriomas who underwent IVF treatment: 56 women proceeded directly to IVF, and 133 first underwent conservative ovarian surgery. INTERVENTION(S) Controlled ovarian hyperstimulation and IVF-ET. MAIN OUTCOME MEASURE(S) Response to gonadotropins, fertilization, implantation, and pregnancy rates. RESULT(S) Aside from lower peak E(2) levels on the day of hCG and a higher total FSH dose in women previously operated for an endometrioma, no significant differences were found between the two groups in the different IVF variables analyzed. CONCLUSION(S) Laparoscopic cystectomy for endometriomas before commencing an IVF cycle does not improve fertility outcomes. Proceeding directly to controlled ovarian hyperstimulation in women with asymptomatic ovarian endometriomas might reduce the time to pregnancy, the costs of treatment, and the hypothetical complications of laparoscopic surgery. Conversely, conservative surgical treatment of ovarian endometriomas in symptomatic women does not impair IVF or intracytoplasmic sperm injection success rates.
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Exacoustos C, Zupi E, Carusotti C, Rinaldo D, Marconi D, Lanzi G, Arduini D. Staging of Pelvic Endometriosis: Role of Sonographic Appearance in Determining Extension of Disease and Modulating Surgical Approach. THE JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS 2003; 10:378-82. [PMID: 14567816 DOI: 10.1016/s1074-3804(05)60266-6] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE To estimate whether laparoscopic staging of endometriosis can be predicted by ultrasound findings. DESIGN Prospective study (Canadian Task Force classification II-2). SETTING Obstetrics and Gynecology Department, University of Rome Tor Vergata. PATIENTS One hundred twenty-one women with histologically confirmed sonographic diagnosis of endometriomas. INTERVENTIONS Ultrasonographic staging and laparoscopic assessment. MEASUREMENTS AND MAIN RESULTS All patients underwent transvaginal and/or transrectal sonographic evaluation of ovarian endometriomas and other sonographic markers (anatomic sites and their relation to abdominovaginal palpation, adhesions, deep or infiltrating nodules) to stage the disease before surgery. These results were compared with laparoscopic staging. Concordance between methods was 83.5%. Specificity and sensitivity of ultrasonographic staging of stages 3 and 4 disease were 86% and 82% and 76% and 91%, respectively. CONCLUSION Ultrasonographic findings can predict pelvic extension and stage of endometriosis.
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Affiliation(s)
- Caterina Exacoustos
- Department of Obstetrics and Gynecology, University of Rome Tor Vergata, Rome, Italy
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Edwards A, Clarke L, Piessens S, Graham E, Shekleton P. Acoustic streaming: a new technique for assessing adnexal cysts. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2003; 22:74-78. [PMID: 12858308 DOI: 10.1002/uog.156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVES To determine whether acoustic streaming has clinical value in the differentiation between various ovarian and adnexal cysts. METHODS We assessed 29 adnexal cysts, for which pathological diagnosis was available, for the presence of acoustic streaming during B-mode and color sonographic evaluation. RESULTS Acoustic streaming was detected in 15 (52%) of the cysts. The most common cyst, endometrioma (n = 7), did not exhibit acoustic streaming in any case, while of the remaining 22 cysts, 15 exhibited acoustic streaming (P = 0.0017). Dermoid cysts exhibited acoustic streaming in two of six (33%) cases. In addition acoustic streaming was noted in two of two (100%) hemorrhagic cysts, eight of ten (80%) cystadenomas, two of three (67%) malignant cysts and in the one abscess. CONCLUSIONS Acoustic streaming is the first sonographic feature that may be able to completely exclude endometrioma as a possible diagnosis for an adnexal cyst.
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Affiliation(s)
- A Edwards
- Ultrasound Department, Monash Medical Centre, Southern Health, Clayton Road, Clayton, Victoria, Australia.
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Moore J, Copley S, Morris J, Lindsell D, Golding S, Kennedy S. A systematic review of the accuracy of ultrasound in the diagnosis of endometriosis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2002; 20:630-634. [PMID: 12493057 DOI: 10.1046/j.1469-0705.2002.00862.x] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To evaluate transvaginal and transabdominal ultrasound scanning, with or without Doppler, as a diagnostic test for the accurate diagnosis of pelvic endometriosis. METHODS The MEDLINE (1966-2001) and EMBASE (1980-2001) databases were searched for relevant studies, published in English. Only studies fulfilling predefined criteria were selected. An assessment of quality was made for each study, and data were then reanalyzed using likelihood ratios to determine the usefulness of the test. RESULTS In total, 67 papers were identified using the search strategy, of which 17 described relevant studies. Of these, seven fulfilled the inclusion criteria. All seven related to the use of transvaginal gray-scale imaging in the diagnosis of ovarian endometriomata specifically, rather than endometriosis. The positive likelihood ratios ranged from 7.6 to 29.8, and the negative likelihood ratios ranged from 0.1 to 0.4. Confidence intervals were wide. One paper addressed the use of conventional color Doppler with ultrasound: the positive likelihood ratio was 1.2, with a negative likelihood ratio of 0.4. One paper assessed the use of color Doppler energy imaging, and showed a positive likelihood ratio of 33.5 and a negative likelihood ratio of 0.1. CONCLUSIONS Transvaginal ultrasound appears to be a useful test both to make and to exclude the diagnosis of an ovarian endometrioma.
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Affiliation(s)
- J Moore
- Nuffield Department of Obstetrics and Gynecology, John Radcliffe Hospital, Oxford, UK.
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22
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Guerriero S, Alcazar JL, Coccia ME, Ajossa S, Scarselli G, Boi M, Gerada M, Melis GB. Complex pelvic mass as a target of evaluation of vessel distribution by color Doppler sonography for the diagnosis of adnexal malignancies: results of a multicenter European study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2002; 21:1105-1111. [PMID: 12369665 DOI: 10.7863/jum.2002.21.10.1105] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To compare the diagnostic accuracy of gray scale sonography and color Doppler imaging in the differential diagnosis of adnexal malignancies from benign complex pelvic masses in a multicenter prospective study. METHODS The study was performed as a collaborative work at 3 European university departments of obstetrics and gynecology. A total of 826 complex pelvic masses on which transvaginal sonography and evaluation of cancer antigen 125 plasma concentrations were performed before surgical exploration were included in the study. The scanning procedure was the same in the 3 institutions. An adnexal mass was first studied in gray scale sonography, and a probable histologic type was predicted. Second, solid excrescences or solid portions of the tumor were evaluated for vascular flow with color Doppler sonography (conventional or power). A mass was graded malignant if flow was shown within the excrescences or solid areas and benign if there was no flow. The overall agreement between the test result and the actual outcome was calculated by kappa statistics. RESULTS Color Doppler evaluation was more accurate in the diagnosis of adnexal malignancies in comparison with gray scale sonography (kappa = 0.82 and 0.65, respectively) because of significantly higher specificity (0.94 versus 0.84; P < .001). The evaluation of the cancer antigen 125 plasma concentration did not seem to increase the accuracy of either method. CONCLUSIONS The evaluation of vessel distribution by color Doppler sonography in complex adnexal cysts seems to increase the diagnostic accuracy of gray scale sonography in the detection of adnexal malignancies in a large study population.
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Affiliation(s)
- Stefano Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Italy
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Guerriero S, Alcazar JL, Ajossa S, Lai MP, Errasti T, Mallarini G, Melis GB. Comparison of conventional color Doppler imaging and power doppler imaging for the diagnosis of ovarian cancer: results of a European study. Gynecol Oncol 2001; 83:299-304. [PMID: 11606088 DOI: 10.1006/gyno.2001.6377] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this prospective study was to compare the diagnostic accuracy of conventional color Doppler (CCD) imaging and power Doppler (PD) imaging in the diagnosis of ovarian cancer. METHODS Six hundred fifty-six consecutive women with adnexal masses scheduled for surgery in two European university departments of obstetrics and gynecology underwent preoperative transvaginal ultrasound. The scanning procedure was the same in the two institutions: after B-mode sonography, a CCD/PD imaging scan was performed before pulsed Doppler evaluation. Using both modalities of color Doppler, malignancy was suspected when arterial flow was visualized in an echogenic portion defined as malignant by B-mode. To avoid the risk of bias due to the absence of blindness of the examiner after the first Doppler evaluation, at one institution 328 consecutive women with an adnexal mass were evaluated using only CCD imaging, whereas at the second institution the ultrasonographic evaluation of the same number of masses was performed using PD imaging, and the results were compared prospectively. RESULTS The age, the rate of postmenopausal women, and the rate of ovarian cancer were similar in the two institutions. The false-positive rate of B-mode imaging was similar in the two institutions (17 versus 18%), while the false-positive rates of CCD and PD imaging were 4.6 and 7.4%, respectively. Although the overall diagnostic accuracy of two techniques seems comparable, with a similar value of K (0.81 versus 0.84), a significantly lower sensitivity in differentiation of benign from malignant ovarian lesions was found using CCD (87 versus 100%). CONCLUSIONS At least one of the two Doppler techniques should be used in conjunction with B-mode imaging in order to decrease the false-positive rate of B-mode used alone but CCD imaging showed a higher false-negative rate.
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Affiliation(s)
- S Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy.
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24
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Abstract
Endometriosis is an important gynecologic disorder primarily affecting women during their reproductive years. Pathologically, it is the result of functional endometrium located outside the uterus. It may vary from microscopic endometriotic implants to large cysts (endometriomas). The physical manifestations are protean, with some patients being asymptomatic and others having disabling pelvic pain, infertility, or adnexal masses. Symptoms do not necessarily correlate with the severity of the disease. Ultrasonographic (US) features are variable and can mimic those of other benign and malignant ovarian lesions. Low-level internal echoes and echogenic wall foci are more specific US features for endometriomas. Magnetic resonance imaging improves diagnostic accuracy, with endometriotic cysts typically appearing with high signal intensity on T1-weighted images and demonstrating "shading" on T2-weighted images. The ovaries are the most common sites affected, but endometriosis can also involve the gastrointestinal tract, urinary tract, chest, and soft tissues. Small implants and adhesions are not well evaluated radiologically; therefore, laparoscopy remains the standard of reference for diagnosis and staging. Both medical and surgical treatment options are available depending on the patient's specific case.
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Affiliation(s)
- P J Woodward
- Departments of Radiologic Pathology, Armed Forces Institute of Pathology, Bldg 54, Room M-121, Washington, DC 20306-6000, USA.
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26
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Abstract
PURPOSE To determine the diagnostic performance of specific ultrasonographic (US) features in discriminating endometriomas from other adnexal masses. MATERIALS AND METHODS Two sonologists independently reviewed the sonograms of 252 adnexal masses in 226 women and recorded US features by using a standardized checklist. The diagnostic performance of specific US features and overall reviewer impression in discriminating endometriomas from other adnexal masses were evaluated. RESULTS There were 40 endometriomas. Diffuse low-level internal echoes were present in 38 (95%) endometriomas and 40 (19%) nonendometriomas (positive likelihood ratio, 5). The positive likelihood ratio for the diagnosis of endometrioma increased to 8 if masses with neoplastic features at gray-scale US were excluded, allowing identification of 30 endometriomas (75%). The presence of multilocularity or hyperechoic wall foci further increased the positive likelihood ratio to 48, allowing the identification of 18 endometriomas (45%). CONCLUSION An adnexal mass with diffuse low-level internal echoes and absence of particular neoplastic features is highly likely to be an endometrioma if multilocularity or hyperechoic wall foci are present. A patient with a mass with diffuse low-level internal echoes and other US features may benefit from additional imaging.
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Affiliation(s)
- M D Patel
- Department of Radiology, University of California, San Francisco, USA
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Koninckx PR. Biases in the endometriosis literature. Illustrated by 20 years of endometriosis research in Leuven. Eur J Obstet Gynecol Reprod Biol 1998; 81:259-71. [PMID: 9989875 DOI: 10.1016/s0301-2115(98)00200-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AIM To review the Leuven data on endometriosis to demonstrate the shifts that occurred over the years in diagnosis of endometriosis, classification of women with endometriosis and thus in interpretation of results. RESULTS The contributions to the LUF syndrome, to non-pigmented endometriosis, to cystic ovarian endometriosis, to deep endometriosis, to endometriosis as an immunologic disease and to the development of an animal model of endometriosis, illustrate the persistent interest in endometriosis over 20 years. Using these data it can be shown how progressively the recognition of endometriosis caused important shifts from women who in the beginning of this period were classified as normal, to women who later became classified as having minimal or mild endometriosis. This was caused initially by the active search for small typical lesions and later by the recognition of non-pigmented lesions as endometriosis. The second important shift was caused by the recognition that deep endometriosis is not only a frequent disease, but that these women are predominantly classified as having mild to moderate endometriosis and even as women without endometriosis. The third shift is still ongoing, since the deep lesions reported become progressively smaller, by the "enthusiasm" of the surgeons, and by the introduction of a menstrual clinical exam. A fourth bias in the literature concerns the diagnosis and treatment of cystic ovarian endometriosis. Together with these shifts in recognition and treatment of endometriosis, our understanding of the physiopathology of endometriosis has changed. This is illustrated by the new concepts which have emerged over this period. These are, the focal treatment of cystic ovarian endometriosis, the concept that mild endometriosis could be a normal physiological condition and the endometriotic disease theory. CONCLUSION To interpret the data of the literature we should be aware of the shifts that have occurred in the classification of endometriosis over the past 20 years, and which still can hamper the comparison of results between research groups.
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Affiliation(s)
- P R Koninckx
- Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, and Center for Surgical Technologies, Catholic University Leuven (K.U.Leuven), Belgium
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Reply. Am J Obstet Gynecol 1997. [DOI: 10.1016/s0002-9378(97)70477-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Guerriero S, Ajossa S, Melis GB. The preoperative evaluation of ovarian tumors can be improved? Am J Obstet Gynecol 1997; 177:246-7. [PMID: 9240618 DOI: 10.1016/s0002-9378(97)70476-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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