Doppler ultrasound assessment and serum cancer antigen 125 in the diagnosis of ovarian tumors

Predicting Malignancy in Adnexal Masses by the International Ovarian Tumor Analysis-Simple Rules

BACKGROUND

Accurate prediction of adnexal tumors preoperatively is critical for optimal management of ovarian cancers. The International Ovarian Tumor Analysis Algorithms (IOTA) is a newer tool to characterize adnexal masses as benign or malignant.

OBJECTIVE

This study is aimed to predict malignancy in adnexal masses and differentiates benign from malignant, applying the sonography features of simple rules given by IOTA.

METHODOLOGY

A prospective study was carried out at AIIMS Jodhpur for 1½ years. Women presenting with adnexal masses planned for surgery were recruited. Ultrasonography-transabdominal combined with transvaginal was done, and pelvic masses were characterized using IOTA simple rules. Patients underwent their planned surgery. Histopathology is considered the gold standard and was compared with the IOTA simple rules. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.

RESULTS

One hundred and seventy-four women were included in the study, of which the majority (82.75%) were benign, the rest being frankly malignant or borderline cancer. The sensitivity of IOTA is 96.6%, specificity of 92.3%, PPV of 72.5%, NPV of 99.2%, where indeterminate cases were considered malignant.

CONCLUSION

IOTA simple rule is an effective tool for identifying malignant adnexal masses. It also suggests that IOTA-simple rules can be used as a diagnostic criterion for differentiating adnexal masses into benign and malignant on an out-patient department basis.

Management of a suspicious adnexal mass: a clinical practice guideline

QUESTIONS

What is the optimal strategy for preoperative identification of the adnexal mass suspicious for ovarian cancer? What is the most appropriate surgical procedure for a woman who presents with an adnexal mass suspicious for malignancy?

PERSPECTIVES

In Canada in 2010, 2600 new cases of ovarian cancer were estimated to have been diagnosed, and of those patients, 1750 were estimated to have died, making ovarian cancer the 7th most prevalent form of cancer and the 5th leading cause of cancer death in Canadian women. Women with ovarian cancer typically have subtle, nonspecific symptoms such as abdominal pain, bloating, changes in bowel frequency, and urinary or pelvic symptoms, making early detection difficult. Thus, most ovarian cancer cases are diagnosed at an advanced stage, when the cancer has spread outside the pelvis. Because of late diagnosis, the 5-year relative survival ratio for ovarian cancer in Canada is only 40%. Unfortunately, because of the low positive predictive value of potential screening tests (cancer antigen 125 and ultrasonography), there is currently no screening strategy for ovarian cancer. The purpose of this document is to identify evidence that would inform optimal recommended protocols for the identification and surgical management of adnexal masses suspicious for malignancy.

OUTCOMES

Outcomes of interest for the identification question included sensitivity and specificity. Outcomes of interest for the surgical question included optimal surgery, overall survival, progression-free or disease-free survival, reduction in the number of surgeries, morbidity, adverse events, and quality of life.

METHODOLOGY

After a systematic review, a practice guideline containing clinical recommendations relevant to patients in Ontario was drafted. The practice guideline was reviewed and approved by the Gynecology Disease Site Group and the Report Approval Panel of the Program in Evidence-based Care. External review by Ontario practitioners was obtained through a survey, the results of which were incorporated into the practice guideline.

PRACTICE GUIDELINE

These recommendations apply to adult women presenting with a suspicious adnexal mass, either symptomatic or asymptomatic. IDENTIFICATION OF AN ADNEXAL MASS SUSPICIOUS FOR OVARIAN CANCER: Sonography (particularly 3-dimensional sonography), magnetic resonance imaging (mri), and computed tomography (ct) imaging are each recommended for differentiating malignant from benign ovarian masses. However, the working group offers the following further recommendations, based on their expert consensus opinion and a consideration of availability, access, and harm: Where technically feasible, transvaginal sonography should be the modality of first choice in patients with a suspicious isolated ovarian mass.To help clarify malignant potential in patients in whom ultrasonography may be unreliable, mri is the most appropriate test.In cases in which extra-ovarian disease is suspected or needs to be ruled out, ct is the most useful technique.Evaluation of an adnexal mass by Doppler technology alone is not recommended. Doppler technology should be combined with a morphology assessment.Ultrasonography-based morphology scoring systems can be used to differentiate benign from malignant adnexal masses. These scoring systems are based on specific ultrasound parameters, each with several scores base on determined features. All evaluated scoring systems were found to have an acceptable level of sensitivity and specificity; the choice of scoring system may therefore be made based on clinician preference.As a standalone modality, serum cancer antigen 125 is not recommended for distinguishing between benign and malignant adnexal masses.Frozen sections for the intraoperative diagnosis of a suspicious adnexal mass is recommended in settings in which availability and patient preference allow. SURGICAL PROCEDURES FOR AN ADNEXAL MASS SUSPICIOUS FOR MALIGNANCY: To improve survival, comprehensive surgical staging with lymphadenectomy is recommended for the surgical management of patients with early-stage ovarian cancer. Laparoscopy is a reasonable alternative to laparotomy, provided that appropriate surgery and staging can be done. The choice between laparoscopy and laparotomy should be based on patient and clinician preference. Discussion with a gynecologic oncologist is recommended. Fertility-preserving surgery is an acceptable alternative to more extensive surgery in patients with low-malignant-potential tumours and those with well-differentiated surgical stage i ovarian cancer. Discussion with a gynecologic oncologist is recommended.

Spherical tissue sampling in 3-dimensional power Doppler angiography: a new approach for evaluation of ovarian tumors

OBJECTIVE

The purpose of this study was to evaluate the usefulness of virtual spherical tissue sampling using 3-dimensional (3D) ultrasound power Doppler angiography to enhance differentiation between normal and pathologic ovaries.

METHODS

Twenty-seven cases with ovarian tumors were analyzed: 14 with invasive cancers and 13 with borderline tumors confirmed by surgery. The control subjects consisted of 53 healthy ovulating women. Ultrasound scans were done, and 3D volumes were analyzed with 3-/4-dimensional software for personal computers based on 3D vascularity indices: the vascularization index, flow index, and vascularization-flow index. A virtual spherical tissue sample of 1 cm3 was taken from the place of the highest vessel density contained completely within the contours of the ovary. Calculations for the whole solid volume were done for comparison.

RESULTS

Vascularity indices for both 1-cm3 spherical samples and whole dense parts of the ovaries were compared in the following groups: (1) ovarian tumors versus controls, (2) normal ovaries in the proliferative versus secretory phase, (3) invasive cancers versus borderline tumors, (4) invasive cancers versus normal ovaries, and (5) borderline tumors versus normal ovaries. Spherical 1-cm3 sampling achieved a higher degree of discrimination between the groups compared with the whole solid-part approach.

CONCLUSIONS

Spherical 1-cm3 sampling of ovarian tissue with 3D ultrasound power Doppler angiography is a sensitive and promising approach to differentiate between ovarian tumors and normal ovaries. It opens the possibility to implement objective computerized positioning, standardized comparison, and analysis of ovarian tumors.

Three-dimensional quantification of tumor vascularity as a tertiary test after B-mode and power Doppler evaluation for detection of ovarian cancer

OBJECTIVE

The purpose of this study was to investigate the role of 3-dimensional (3D) quantification of tumor vascularity in the differential diagnosis of pelvic indeterminate masses with a solid appearance or unilocular or multilocular cysts with a solid component showing central vascularization on 2-dimensional power Doppler sonography.

METHODS

One hundred fifty-seven consecutive pelvic masses in 153 patients were included in this study and underwent sonography before surgery. Masses that showed a typical benign pattern on B-mode sonography (n = 112) and indeterminate masses with peripheral or absent flow on power Doppler sonography (n = 10) were not evaluated by 3D sonography. Only masses with central vascularization were submitted to 3D power Doppler imaging (n = 35). The following 3D vascular parameters were calculated: relative color and flow measure (similar to the vascularization flow index obtained with other systems).

RESULTS

With receiver operating characteristic curve analysis, the best cutoff values for relative color and flow measure were 4.4 and 2.7, respectively. Flow measure had sensitivity of 68% and specificity of 40% in the overall population submitted to 3D power Doppler sonography. Accuracy slightly increased when masses with small papillary projections (<10 mL) were excluded. In this group (n = 22), sensitivity was 83%, and specificity was 50%.

CONCLUSIONS

In masses with central vascularization on 2-dimensional power Doppler sonography, the use of 3D quantification of tumor vascularity had low diagnostic accuracy in the detection of adnexal malignancies, although an increase in accuracy in masses with a solid portion of greater than 10 mL was reported.

Ultrasonography, computed tomography and magnetic resonance imaging for diagnosis of ovarian carcinoma

Our objective was to compare US, CT, and MR imaging in differentiation of malignant from benign ovarian tumors. Through an electronic literature search and manual review of bibliographies (January 1990 to June 2006), relevant studies on the diagnostic performance of US, CT, and MR imaging in the differentiation between benign and malignant ovarian tumours were identified. Sixty-nine articles were included, yielding 143 studies. Data on the accuracy of the different imaging modalities were analyzed and compared by constructing summary receiver-operating characteristic (ROC) curves. Our results suggest that US techniques seems to be similar with CT and MRI in differentiation of malignant from benign ovarian tumors. The results also revealed that color Doppler flow imaging alone is significantly inferior to combined US techniques, morphologic assessment alone and contrast enhanced US in diagnosis of ovarian cancer. In conclusion, US morphologic assessment still is the most important and common modality in detect ovarian cancer.

Tumeurs de l'ovaire et CA 125 en 2006

The authors propose to report progress on the use of the CA 125 serum assay. It affects three situations: screening, diagnosis and the follow-up of the patients dealt with ovarian tumour either of benign or malignant nature. For each situation the interest and the relevance of CA 125 assay will be approached.