1
|
Kapoor S, Singhal S, Dhamija E, Manchanda S, Malhotra N, Bhatla N. Diagnostic performance of ultrasound reporting systems in evaluation of adnexal masses: A prospective observational study. Eur J Obstet Gynecol Reprod Biol 2024; 301:186-193. [PMID: 39153388 DOI: 10.1016/j.ejogrb.2024.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 08/07/2024] [Accepted: 08/12/2024] [Indexed: 08/19/2024]
Abstract
OBJECTIVE(S) To evaluate and compare diagnostic performance of ultrasound-based reporting systems IOTA SR, ADNEX, GIRADS, ORADS for discrimination between benign and malignant adnexal masses. STUDY DESIGN A prospective observational study in a tertiary care hospital's Obstetrics and Gynaecology department evaluated pre-operative ultrasound imaging for adnexal masses in 80 cases, comparing various reporting systems' sensitivity and specificity against histopathology as gold standard using STATA version 17.0 for data analysis. RESULTS Among the 80 masses, 55 % (44/80) were confirmed as benign on histopathology, while 45 % were identified as malignant. The sensitivity and specificity of SR was 100 % (95 %CI: 90.0-100) and 97.1 % (95 %CI: 84.7-99.9) respectively. Eleven masses (13.8 %) were inconclusive, reducing specificity to 75 % (95 %CI:59.7-86.8).In ADNEX optimal cut-off for risk of malignancy was 34.1 % with sensitivity of 86.1 % (95 % CI: 70.5-95.3) and specificity of 90.9 % (95 % CI: 78.3-97.5). Considering GIRADS 4-5 and risk threshold of ≥10 % (ORADS 4-5) as predictors of malignancy sensitivity was 100 % (95 %CI: 90.3-100) and specificity was 70.5 % (95 %CI: 54.8-83.2) for GIRADS and ORADS. All reporting systems were comparable (p = 0.7). ADNEX identified 72.7 % (8/11) of inconclusive cases, outperforming GIRADS/ORADS which correctly classified 27.2 % (3/11) cases. When applied to misclassified GIRADS/ORADS 4-5 category, ADNEX demonstrated superior performance by correctly classifying 76.9 % (10/13) masses, while SR achieved correct classification in only 38.5 % (5/13) masses. CONCLUSION(S) All classification systems showed comparable accuracy in malignancy risk identification on imaging. GIRADS/ORADS tended to overestimate malignancy risk. The present study recommends a two-step strategy, leveraging higher specificity of ADNEX model for improved stratification of adnexal masses.
Collapse
Affiliation(s)
- Shagun Kapoor
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Seema Singhal
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Ekta Dhamija
- Department of Radiodiagnosis, DrBRAIRCH, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Smita Manchanda
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Neena Malhotra
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Neerja Bhatla
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi 110029, India
| |
Collapse
|
2
|
Qi Y, Zhuang L, Zhu T. Ultrasonography Findings in Ovarian Hemangiomas: Report of Three Cases and Review of the Literature. Reprod Sci 2024:10.1007/s43032-024-01656-y. [PMID: 39020235 DOI: 10.1007/s43032-024-01656-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 07/11/2024] [Indexed: 07/19/2024]
Abstract
Ovarian hemangioma is a rare ovarian tumor. The imaging manifestations were rarely mentioned in previous literatures. One of the patients came to hospital with the complaints of an elevation of CA125. Another two patients found a mass in adnexa area accidentally. The oophorectomy procedures were performed and the pathological results of ovarian hemangioma were concluded. We summarized the ultrasound features of three cases retrospectively, of which could provide more information before operation to guide a management direction. A well-defined, regular-shape solid mass in ovary could be considered the possibility of hemangioma, especially when a richly vascularized tumor with prominent blood flow is detected on color Doppler sonography.
Collapse
Affiliation(s)
- Yue Qi
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Lianting Zhuang
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Tiantong Zhu
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China.
| |
Collapse
|
3
|
Alcázar JL, Rodriguez-Guzman L, Vara J, Amor F, Diaz L, Vaccaro H. Gynecologic Imaging and Reporting Data System for classifying adnexal masses. Minerva Obstet Gynecol 2023; 75:69-79. [PMID: 36790399 DOI: 10.23736/s2724-606x.22.05122-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
INTRODUCTION To perform a systematic review and meta-analysis of the diagnostic performance of the so-called Gynecologic Imaging and Report Data System (GI-RADS) for classifying adnexal masses. EVIDENCE ACQUISITION A search for studies reporting about the use of GI-RADS system for classifying adnexal masses from January 2009 to December 2021 was performed in Medline (Pubmed), Google Scholar, Scopus, Cochrane, and Web of Science databases. Pooled sensitivity, specificity, positive and negative likelihood ratios and diagnostic odd ratio (DOR) were calculated. Studies' quality was evaluated using QUADAS-2. EVIDENCE SYNTHESIS We identified 510 citations. Ultimately, 26 studies comprising 7350 masses were included. Mean prevalence of ovarian malignancy was 26%. The risk of bias was high in eight studies for domain "patient selection" and low for "index test," "reference test" domains for all studies. Overall, pooled estimated sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio and DOR of GI-RADS system for classifying adnexal masses were 94% (95% confidence interval [CI]=91-96%), 90% (95% CI=87-92%), 9.1 (95% CI=7.0-11.9), and 0.07 (95% CI=0.05-0.11), and 132 (95% CI=78-221), respectively. Heterogeneity was high for both sensitivity and specificity. Meta-regression showed that multiple observers and study's design explained this heterogeneity among studies. CONCLUSIONS GI-RADS system has a good diagnostic performance for classifying adnexal masses.
Collapse
Affiliation(s)
- Juan L Alcázar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, Pamplona, Spain -
| | | | - Julio Vara
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Fernando Amor
- Panoramic Ultrasonic Ultrasound Center, Santiago, Chile
| | - Linder Diaz
- AGB Ultrasonography Center, Clínica Sanatorio Alemán S.A., Concepción, Chile
| | | |
Collapse
|
4
|
Wang R, Li X, Li S, Fang S, Zhao C, Yang H, Yang Z. Clinical value of O-RADS combined with serum CA125 and HE4 for the diagnosis of ovarian tumours. Acta Radiol 2023; 64:821-828. [PMID: 35291856 DOI: 10.1177/02841851221087376] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ovarian tumors (OTs) are common gynecological tumors in women. It is very important to correctly distinguish benign and malignant OTs. PURPOSE To assess the diagnostic performance of the American College of Radiology (ACR) Ovarian-Adnexal Reporting and Data System (O-RADS) and evaluate the clinical value of O-RADS combined with serum carbohydrate antigen 125 (CA125) and human epididymis protein 4 (HE4) in differentiating benign from malignant OTs. MATERIAL AND METHODS A retrospective analysis was performed on 431 cases including pathology and clinical data. The receiver operating characteristic (ROC) curve was drawn, and sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated. RESULTS In premenopausal women, O-RADS and O-RADS combined with serum CA125 and HE4 showed sensitivity at 92.2% and 94.8%, specificity at 91.8% and 93.4%, and accuracy at 91.9% and 93.8%, respectively. In postmenopausal women, the sensitivity of O-RADS, O-RADS combined with serum CA125 and HE4 was 94.8% and 95.8%, specificity was 83.9% and 93.6%, and accuracy was 90.5% and 95.6%, respectively. The sensitivity, specificity, and accuracy of O-RADS combined with CA125 and HE4 in premenopausal and postmenopausal women were higher than that of O-RADS (P<0.05). CONCLUSION O-RADS has high diagnostic performance in OTs. When O-RADS is combined with CA125 and HE4 in the diagnosis of OTs, the sensitivity and specificity are improved, which is helpful to improve the diagnostic efficiency of OTs and has high clinical application value.
Collapse
Affiliation(s)
- Rongling Wang
- Department of Abdominal Ultrasound, 235960the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Xiumei Li
- Department of Abdominal Ultrasound, 235960the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Shuqin Li
- Department of Abdominal Ultrasound, 235960the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Shibao Fang
- Department of Abdominal Ultrasound, 235960the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Cheng Zhao
- Department of Abdominal Ultrasound, 235960the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Hui Yang
- Department of Abdominal Ultrasound, 235960the Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Zongli Yang
- Department of Abdominal Ultrasound, 235960the Affiliated Hospital of Qingdao University, Qingdao, PR China
| |
Collapse
|
5
|
Wang H, Wang L, An S, Ma Q, Tu Y, Shang N, Pan Y. American college of radiology ovarian-adnexal reporting and data system ultrasound (O-RADS): Diagnostic performance and inter-reviewer agreement for ovarian masses in children. Front Pediatr 2023; 11:1091735. [PMID: 36969276 PMCID: PMC10030612 DOI: 10.3389/fped.2023.1091735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/20/2023] [Indexed: 03/29/2023] Open
Abstract
Objective To evaluate the diagnostic performance and inter-observer agreement of the American College of Radiology Ovarian-Adnexal Reporting and Data System Ultrasound (O-RADS) in the diagnosis of ovarian masses in children. Methods From June 2012 to December 2021, 163 ovarian masses in 159 patients with pathologic results were retrospectively analyzed. Each mass was classified into an O-RADS category according to the criteria. The diagnostic performance of O-RADS for detecting malignant ovarian masses was assessed using histopathology as the reference standard. Kappa (k) statistic was used to assess inter-observer agreement between a less-experienced and a well-experienced radiologist. Results Out of 163 ovarian masses, 18 (11.0%) were malignant and 145 (89.0%) were benign. The malignancy rates of O-RADS 5, O-RADS 4, and O-RADS 3 masses were 72.7%, 34.6%, and 4.8%, respectively. The area under the receiver operating characteristic curve was 0.944 (95% CI, 0.908-0.981). The optimal cutoff value for predicting malignant ovarian masses was > O-RADS 3 with a sensitivity, specificity, and accuracy of 94.4%, 86.2% and 86.2% respectively. The inter-observer agreement of the O-RADS category was good (k = 0.777). Conclusions O-RADS has a high diagnostic performance for children with ovarian masses. It provides an effective malignant risk classification for ovarian masses in children, which shows high consistency between radiologists with different levels of experience.
Collapse
|
6
|
IETA Ultrasonic Features Combined with GI-RADS Classification System and Tumor Biomarkers for Surveillance of Endometrial Carcinoma: An Innovative Study. Cancers (Basel) 2022; 14:cancers14225631. [PMID: 36428723 PMCID: PMC9688181 DOI: 10.3390/cancers14225631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 11/18/2022] Open
Abstract
Objectives: We were the first to combine IETA ultrasonic features with GI-RADS and tumor biomarkers for the surveillance of endometrial carcinoma. The aim was to evaluate the efficacy of single IETA ultrasonography GI-RADS classification and combined tumor biomarkers in differentiating benign and malignant lesions in the uterine cavity and endometrium. Methods: A total of 497 patients with intrauterine and endometrial lesions who had been treated surgically between January 2017 and December 2021 were enrolled; all of them had undergone ultrasound examinations before surgery. We analyzed the correlation between the terms of ultrasonic signs of the uterine cavity and endometrial lesions defined by the expert consensus of IETA and the benign and malignant lesions and then classified these ultrasonic signs by GI-RADS. In addition, the tumor biomarkers CA125, CA15-3, CA19-9 and HE4 were combined by adjusting the classification. The results of the comprehensive analysis were compared with pathological results to analyze their diagnostic efficacy. Results: (1) The statistic analysis confirmed that there were seven independent predictors of malignant lesions, including thickened endometrium (premenopause ≥ 18.5 mm, postmenopause ≥ 15.5 mm), non-uniform endometrial echogenicity (heterogeneous with irregular cysts), endometrial midline appearance (not defined), the endometrial-myometrial junction (interrupted or not defined), intracavitary fluid (ground glass or "mixed" echogenicity), color score (3~4 points) and vascular pattern (focal origin multiple vessels or multifocal origin multiple vessels). (2) In traditional ultrasound GI-RADS (U-T-GI-RADS), if category 4a was taken as the cut-off value of benign and malignant, the diagnostic sensitivity, specificity, PPV, NPV and diagnostic accuracy were 97.2%, 65.2%, 44.0%, 98.8% and 72.2%, respectively, and the area under the ROC curve (AUC) was 0.812. If 4b was taken as the cut-off value, the diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 88.1%, 92.0%, 75.6%, 96.5% and 91.2%, 0.900, respectively. The diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 75.2%, 98.5%, 93.2%, 93.4%, 93.4% and 0.868, respectively, when taking category 5 as the cutoff point. In modified ultrasound GI-RADS (U-M-GI-RADS), if 4a was taken as the cut-off value, The diagnostic efficacy was the same as U-T-GI-RADS. If 4b was taken as the cut-off value, the diagnostic sensitivity, specificity, PPV, NPV, diagnostic accuracy and AUC were 88.1%, 92.3%, 76.2%, 96.5%, 91.3% and 0.902, respectively. If 4c was taken as the cutoff point, the diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 75.2%, 98.7%, 94.3%, 93.4%, 93.6% and 0.870, respectively. The diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 66.1%, 99.7%, 98.6%, 91.3%, 92.4% and 0.829, respectively, if taking category 5 as the cutoff point. (3) In the comprehensive diagnostic method of U-T-GI-RADS combined tumor biomarkers results, the AUC of class 4a, 4b and 5 as the cutoff value was 0.877, 0.888 and 0.738, respectively. The AUC of class 4a, 4b, 4c and 5 as the cutoff value in the comprehensive diagnostic method of U-M-GI-RADS combined tumor biomarkers results was 0.877, 0.888, 0.851 and 0.725, respectively. There was no significant difference in diagnostic efficiency between the two comprehensive diagnostic methods. Conclusions: In this study, no matter which diagnostic method was used, the best cutoff value for predicting malignant EC was ≥GI-RADS 4b. The GI-RADS classification had good performance in discriminating EC. The tumor biomarkers, CA125, CA19-9, CA15-3 and HE4, could improve the diagnostic efficacy for preoperative endometrial carcinoma assessment.
Collapse
|
7
|
Timmerman D, Planchamp F, Bourne T, Landolfo C, du Bois A, Chiva L, Cibula D, Concin N, Fischerova D, Froyman W, Gallardo G, Lemley B, Loft A, Mereu L, Morice P, Querleu D, Testa AC, Vergote I, Vandecaveye V, Scambia G, Fotopoulou C. ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumors. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:148-168. [PMID: 33794043 DOI: 10.1002/uog.23635] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the preoperative diagnosis of ovarian tumors, including imaging techniques, biomarkers and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the preoperative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the preoperative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.
Collapse
Affiliation(s)
- D Timmerman
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - F Planchamp
- Clinical Research Unit, Institut Bergonie, Bordeaux, France
| | - T Bourne
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Metabolism, Digestion and Reproduction, Queen Charlotte's & Chelsea Hospital, Imperial College, London, UK
| | - C Landolfo
- Department of Woman, Child and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - A du Bois
- Department of Gynaecology and Gynaecological Oncology, Evangelische Kliniken Essen-Mitte, Essen, Germany
| | - L Chiva
- Department of Gynaecology and Obstetrics, University Clinic of Navarra, Madrid, Spain
| | - D Cibula
- Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University, General University Hospital in Prague, Prague, Czech Republic
| | - N Concin
- Department of Gynaecology and Gynaecological Oncology, Evangelische Kliniken Essen-Mitte, Essen, Germany
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - D Fischerova
- Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University, General University Hospital in Prague, Prague, Czech Republic
| | - W Froyman
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
| | - G Gallardo
- Department of Radiology, University Clinic of Navarra, Madrid, Spain
| | - B Lemley
- Patient Representative, President of Kraefti Underlivet (KIU), Denmark
- Chair Clinical Trial Project of the European Network of Gynaecological Cancer Advocacy Groups, ENGAGe
| | - A Loft
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - L Mereu
- Department of Gynecology and Obstetrics, Gynecologic Oncology Unit, Santa Chiara Hospital, Trento, Italy
| | - P Morice
- Department of Gynaecological Surgery, Institut Gustave Roussy, Villejuif, France
| | - D Querleu
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
- Department of Obstetrics and Gynecologic Oncology, University Hospital, Strasbourg, France
| | - A C Testa
- Department of Woman, Child and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - I Vergote
- Department of Obstetrics and Gynaecology and Gynaecologic Oncology, University Hospital Leuven, Leuven Cancer Institute, Leuven, Belgium
| | - V Vandecaveye
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
- Division of Translational MRI, Department of Imaging & Pathology KU Leuven, Leuven, Belgium
| | - G Scambia
- Department of Woman, Child and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - C Fotopoulou
- Department of Gynecologic Oncology, Hammersmith Hospital, Imperial College, London, UK
| |
Collapse
|
8
|
Timmerman D, Planchamp F, Bourne T, Landolfo C, du Bois A, Chiva L, Cibula D, Concin N, Fischerova D, Froyman W, Gallardo Madueño G, Lemley B, Loft A, Mereu L, Morice P, Querleu D, Testa AC, Vergote I, Vandecaveye V, Scambia G, Fotopoulou C. ESGO/ISUOG/IOTA/ESGE Consensus Statement on pre-operative diagnosis of ovarian tumors. Int J Gynecol Cancer 2021; 31:961-982. [PMID: 34112736 PMCID: PMC8273689 DOI: 10.1136/ijgc-2021-002565] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group, and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the pre-operative diagnosis of ovarian tumors, including imaging techniques, biomarkers, and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the pre-operative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when a consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the pre-operative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.
Collapse
Affiliation(s)
- Dirk Timmerman
- Gynecology and Obstetrics, University Hospitals KU Leuven, Leuven, Belgium .,Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | - Tom Bourne
- Gynecology and Obstetrics, University Hospitals KU Leuven, Leuven, Belgium.,Development and Regeneration, KU Leuven, Leuven, Belgium.,Metabolism Digestion and Reproduction, Queen Charlotte's & Chelsea Hospital, Imperial College, London, UK
| | - Chiara Landolfo
- Woman, Child and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Andreas du Bois
- Gynaecology and Gynaecological Oncology, Evangelische Kliniken Essen-Mitte, Essen, Germany
| | - Luis Chiva
- Gynaecology and Obstetrics, University Clinic of Navarra, Madrid, Spain
| | - David Cibula
- Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Nicole Concin
- Gynaecology and Gynaecological Oncology, Evangelische Kliniken Essen-Mitte, Essen, Germany.,Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniela Fischerova
- Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Wouter Froyman
- Gynecology and Obstetrics, University Hospitals KU Leuven, Leuven, Belgium
| | | | - Birthe Lemley
- European Network of Gynaecological Cancers Advocacy Groups (ENGAGe) Executive Group, Prague, Czech Republic.,KIU - Patient Organisation for Women with Gynaecological Cancer, Copenhagen, Denmark
| | - Annika Loft
- Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Liliana Mereu
- Gynecology and Obstetrics, Gynecologic Oncology Unit, Santa Chiara Hospital, Trento, Italy
| | - Philippe Morice
- Gynaecological Surgery, Institut Gustave Roussy, Villejuif, France
| | - Denis Querleu
- Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy.,Obstetrics and Gynecologic Oncology, University Hospital, Strasbourg, France
| | - Antonia Carla Testa
- Woman, Child and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy.,Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ignace Vergote
- Obstetrics and Gynaecology and Gynaecologic Oncology, University Hospital Leuven, Leuven Cancer Institute, Leuven, Belgium
| | - Vincent Vandecaveye
- Radiology, University Hospitals Leuven, Leuven, Belgium.,Division of Translational MRI, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Giovanni Scambia
- Woman, Child and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy.,Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
| | | |
Collapse
|
9
|
Timmerman D, Planchamp F, Bourne T, Landolfo C, du Bois A, Chiva L, Cibula D, Concin N, Fischerova D, Froyman W, Gallardo G, Lemley B, Loft A, Mereu L, Morice P, Querleu D, Testa C, Vergote I, Vandecaveye V, Scambia G, Fotopoulou C. ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumours. Facts Views Vis Obgyn 2021; 13:107-130. [PMID: 34107646 PMCID: PMC8291986 DOI: 10.52054/fvvo.13.2.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the preoperative diagnosis of ovarian tumours, including imaging techniques, biomarkers and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the preoperative diagnosis of ovarian tumours and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when a consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the preoperative diagnosis of ovarian tumours and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.
Collapse
|
10
|
Abstract
Importance Several predictive models and scoring systems have been developed to differentiate between benign and malignant ovarian masses, in order to guide effective management. These models use combinations of patient characteristics, ultrasound markers, and biochemical markers. Objective The aim of this study was to describe, compare, and prioritize, according to their strengths and qualities, all the adnexal prediction models. Evidence Acquisition This was a state-of-the-art review, synthesizing the findings of the current published literature on the available prediction models of adnexal masses. Results The existing models include subjective assessment by expert sonographers, the International Ovarian Tumor Analysis models (logistic regression models 1 and 2, Simple Rules, 3-step strategy, and ADNEX [Assessment of Different NEoplasias in the adneXa] model), the Risk of Malignancy Index, the Risk of Malignancy Ovarian Algorithm, the Gynecologic Imaging Reporting and Data System, and the Ovarian-Adnexal Reporting and Data System. Overall, subjective assessment appears to be superior to all prediction models. However, the International Ovarian Tumor Analysis models are probably the best available methods for nonexpert examiners. The Ovarian-Adnexal Reporting and Data System is an international approach that incorporates both the common European and North American approaches, but still needs to be validated. Conclusions Many prediction models exist for the assessment of adnexal masses. The adoption of a particular model is based on local guidelines, as well as sonographer's experience. The safety of expectant management of adnexal masses with benign ultrasound morphology is still under investigation.
Collapse
|
11
|
Guo W, Zou X, Xu H, Zhang T, Zhao Y, Gao L, Duan W, Ma X, Zhang L. The diagnostic performance of the Gynecologic Imaging Reporting and Data System (GI-RADS) in adnexal masses. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:398. [PMID: 33842619 PMCID: PMC8033324 DOI: 10.21037/atm-20-5170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Adnexal masses, mostly benign, are common in the female genital system. However, adnexal masses are the leading cause of death among women with gynecologic cancer. Ultrasound is a common imaging method for diagnosing adnexal masses. Gynecologic Imaging Reporting and Data System (GI-RADS) is a useful diagnostic tool based on objective ultrasound features to diagnose the malignancy of the female genital system. Therefore, we conducted a meta-analysis to evaluate the ability of GI-RADS to differentiate adnexal masses. Methods Published articles were searched in PubMed, Medline, and Embase from 1990 to February 2020. Pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio, and area under the curve (AUC) were estimated via the extracted data from the selected studies. Results Ten studies and 2,474 patients were included in this meta-analysis. The pooled sensitivity of selected studies was 0.95 [95% confidence intervals (CI): 0.94-0.97], and the pooled specificity was 0.86 (95% CI: 0.84-0.88). The pooled NLR and PLR were 0.06 (95% CI: 0.04-0.10), and 8.30 (95% CI: 4.93-13.97), respectively. Moreover, the pooled diagnostic odds ratio for GI-RADS was 174.59 (95% CI: 76.70-397.42), and the AUC was 0.9806. Conclusions This research indicates that GI-RADS might be a valuable tool to distinguish malignancies from adnexal masses.
Collapse
Affiliation(s)
- Wen Guo
- Department of Biotherapy, State Key Laboratory of Biotherapy, West China Hospital, Cancer Center, Sichuan University, Chengdu, China.,West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Xiuhe Zou
- Department of Thyroid Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Hanyue Xu
- Department of Biotherapy, State Key Laboratory of Biotherapy, West China Hospital, Cancer Center, Sichuan University, Chengdu, China.,West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Tao Zhang
- Department of Biotherapy, State Key Laboratory of Biotherapy, West China Hospital, Cancer Center, Sichuan University, Chengdu, China.,West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Yunuo Zhao
- Department of Biotherapy, State Key Laboratory of Biotherapy, West China Hospital, Cancer Center, Sichuan University, Chengdu, China.,West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Lu Gao
- Department of Oncology, The General Hospital of Western Theater Command, Chengdu, China.,College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Wenyue Duan
- Department of Oncology, The General Hospital of Western Theater Command, Chengdu, China.,College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Xuelei Ma
- Department of Biotherapy, State Key Laboratory of Biotherapy, West China Hospital, Cancer Center, Sichuan University, Chengdu, China
| | - Ling Zhang
- Department of Oncology, The General Hospital of Western Theater Command, Chengdu, China
| |
Collapse
|
12
|
Tumour markers and their utility in imaging of abdominal and pelvic malignancies. Clin Radiol 2020; 76:99-107. [PMID: 32861463 DOI: 10.1016/j.crad.2020.07.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/31/2020] [Indexed: 01/15/2023]
Abstract
The utility of tumour biomarkers has increased considerably in the era of personalised medicine and individualised therapy in oncology. Biomarkers may be prognostic or predictive, and only a handful of markers are currently US Food and Drug Administration (FDA)-approved for clinical use. Tumour markers have a wide array of uses such as screening, establishing a differential diagnosis, assessing risk, prognosis, and treatment response, as well as monitoring disease status. Major overlap exists between biomarkers and their associated pathologies; therefore, despite suggestive imaging features, establishing a differential diagnosis may be challenging for the radiologist. We review common biomarkers that are of interest to radiologists such as carcinoembryonic antigen (CEA), lactate dehydrogenase (LDH), prostate-specific antigen (PSA), beta human chorionic gonadotropin (β-hCG), carbohydrate antigen 19-9 (CA 19-9), alpha fetoprotein (AFP), and carbohydrate or cancer antigen 125 (CA 125), as well as their associated malignant and non-malignant pathologies. We also present relevant case examples from our practice.
Collapse
|
13
|
Basha MAA, Metwally MI, Gamil SA, Khater HM, Aly SA, El Sammak AA, Zaitoun MMA, Khattab EM, Azmy TM, Alayouty NA, Mohey N, Almassry HN, Yousef HY, Ibrahim SA, Mohamed EA, Mohamed AEM, Afifi AHM, Harb OA, Algazzar HY. Comparison of O-RADS, GI-RADS, and IOTA simple rules regarding malignancy rate, validity, and reliability for diagnosis of adnexal masses. Eur Radiol 2020; 31:674-684. [PMID: 32809166 DOI: 10.1007/s00330-020-07143-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/27/2020] [Accepted: 08/03/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The American College of Radiology (ACR) recently published the ovarian-adnexal reporting and data system (O-RADS) to provide guidelines to physicians who interpret ultrasound (US) examinations of adnexal masses (AM). This study aimed to compare the O-RADS with two other well-established US classification systems for diagnosis of AM. METHODS This retrospective multicenter study between May 2016 and December 2019 assessed consecutive women with AM detected by the US. Five experienced consultant radiologists independently categorized each AM according to O-RADS, gynecologic imaging reporting and data system (GI-RADS), and international ovarian tumor analysis (IOTA) simple rules. Pathology and adequate follow-up were used as reference standards for calculating the validity of three US classification systems for diagnosis of AM. Kappa statistics were used to assess the inter-reviewer agreement (IRA). RESULTS A total of 609 women (mean age, 48 ± 13.7 years; range, 18-72 years) with 647 AM were included. Of the 647 AM, 178 were malignant and 469 were benign. Malignancy rates were comparable to recommended rates by previous literature in O-RADS and IOTA, but higher in GI-RADS. O-RADS had significantly higher sensitivity for malignancy than GI-RAD and IOTA (p = 0.003 and 0.0007, respectively), but non-significant slightly lower specificity (p > 0.05). O-RADS, GI-RADS, and IOTA showed similar overall IRA (κ = 0.77, 0.69, and 0.63, respectively) with a tendency toward higher IRA with O-RADS than with GI-RADS and IOTA. CONCLUSIONS O-RADS compares favorably with GI-RADS and IOTA. O-RADS had higher sensitivity than GI-RADS and IOTA simple rules with relatively similar specificity and reliability. KEY POINTS • The malignancy rates were comparable to recommended rates by previous literature in O-RADS and IOTA, but higher in GI-RADS. • The O-RADS had significantly higher sensitivity for malignancy than GI-RADS and IOTA (96.8% vs 92.7% and 92.1%; p = 0.003 and 0.0007, respectively), but non-significant slightly lower specificity (92.8% vs 93.6% and 93.2%, respectively; p > 0.05). • The O-RADS, GI-RADS, and IOTA showed similar overall inter-reviewer agreement (IRA) (κ = 0.77, 0.69, and 0.63, respectively), with a tendency toward higher IRA with O-RADS than with GI-RADS and IOTA.
Collapse
Affiliation(s)
| | | | - Shrif A Gamil
- Department of Radio-diagnosis, Al-Ahrar Teaching Hospital, Zagazig, Egypt
| | - Hamada M Khater
- Department of Radio-diagnosis, Benha University, Benha, Egypt
| | | | | | | | - Enass M Khattab
- Department of Radio-diagnosis, Zagazig University, Zagazig, Egypt
| | - Taghreed M Azmy
- Department of Radio-diagnosis, Zagazig University, Zagazig, Egypt
| | | | - Nesreen Mohey
- Department of Radio-diagnosis, Zagazig University, Zagazig, Egypt
| | | | - Hala Y Yousef
- Department of Radio-diagnosis, Zagazig University, Zagazig, Egypt
| | - Safaa A Ibrahim
- Department of Obstetrics & Gynecology, Zagazig University, Zagazig, Egypt
| | - Ekramy A Mohamed
- Department of Obstetrics & Gynecology, Zagazig University, Zagazig, Egypt
| | | | | | - Ola A Harb
- Department of Pathology, Zagazig University, Zagazig, Egypt
| | | |
Collapse
|
14
|
Khalaf LMR, Desoky HHM, Seifeldein GS, El-Sharkawy M, Sayed MM, Ahmed S, Rezk K, Hussien MT. The diagnostic efficacy of Gynecology Imaging Reporting and Data System (GI-RADS): single-center prospective cross-sectional study. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2019. [DOI: 10.1186/s43055-019-0071-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To assess the validity and accuracy of GI-RADS classification in the prediction of malignancy and in triaging the management protocol in ovarian lesions.
Results
One hundred fifty-six ovarian lesions were detected in the examined 116 women. The prevalence of malignant tumors was 44%. Overall GI-RADS classification rates were as follows: 41 cases (26.3%) were classified as GI-RADS 1, 26 cases (16 .7%) as GI-RADS 2, 34 cases (21.8%) as GI-RADS 3, 14 cases (8.9%) as GI-RADS 4, and 41 cases (26.3%) as GI-RADS 5. No follow-up was done in GI-RADS 1 patients. A final diagnosis of all GI-RADS 2 ovarian masses such as functional cyst (n = 10), hemorrhagic cysts (n = 8), corpus luteal cysts (n = 6), and some GI-RADS 3 as simple cysts (n = 10) was made by spontaneous resolution of these masses at follow-up after 6 weeks. Fifteen cases of GI-RADS 3 as mature teratoma, serous and mucinous cystadenoma, endometrioma, and ovarian torsion and all GI-RADS 4 and 5 underwent laparoscopic or surgical removal of the ovarian mass with histopathological examination. The diagnostic performance of the GI-RADS in predicting the risk of malignancy in ovarian masses was as follows: 98.11% sensitivity, 95.15% specificity, 91.2% positive predictive value (PPV), 99.2% negative predictive value (NPV), and 20.2 positive likelihood ratio, and the overall accuracy was 96.2% (area under receiver operating curve (AUC) = 0.96, P < 0.001).
Conclusion
GI-RADS classification performs well as a reporting system of the ovarian masses with high diagnostic performance in the prediction of malignancy, and it seems to be a helpful tool in triaging management in patients with ovarian masses.
Trial registration
The trial was registered in the US National Library of Medicine, under clinical trial number NCT03175991. Also, the ethical committee approval number of the Faculty of Medicine, Assiut University, was 17100016 on February 28, 2017.
Collapse
|
15
|
Abstract
Ovarian cancer is the seventh most common cancer affecting women. Despite advances in cancer control and healthcare in general, mortality from ovarian cancer remains unacceptably high due to diagnosis at an advanced stage of the disease. The 5-year survival rate is 47.4% because a majority of ovarian cancers are diagnosed when advanced. Only 14.9% of ovarian cancers are diagnosed when localized where the survival rate is 92.3%. Mortality rate reduction by screening has not been proven in women at an average risk for ovarian cancer. Ultrasound remains the primary modality for assessment of ovarian tumors. The need for standardizing terminology is critical for optimal assessment of the risk of malignancy in an ovarian tumor. The international ovarian tumor analysis group and more recently the American College of Radiology Ovarian - Adnexal Reporting and Data System Committee have published standardized lexicon for ovarian lesions and encourage ultrasound imagers to adopt this standardized terminology. The aim is to apply the lexicon for risk stratification to allow for consistent follow-up and management. Various methodologies have been tested for characterization of adnexal tumors and to assess risk of malignancy preoperatively. Risk assessment models have been studied against the gold standard of a pattern recognition approach and subjective assessment by an experienced imager. The morphologic patterns of ovarian tumors are detailed and features that are more discriminatory than others in suggesting an ovarian malignancy are described. The imaging pathologic correlation for different tumor types is presented. A brief summary of the ovarian cancer pathologic types and staging of cancer is presented. Finally, the current role of transvaginal sonography as a screening modality for ovarian cancer is discussed. Recently published data show encouraging results, that a multimodal approach of screening for ovarian cancer using transvaginal sonography in women with an elevated CA-125 may prove beneficial and cost effective.
Collapse
Affiliation(s)
- Mahesh Shetty
- Department of Radiology, Baylor College of Medicine, Houston, TX.
| |
Collapse
|
16
|
Basha MAA, Refaat R, Ibrahim SA, Madkour NM, Awad AM, Mohamed EM, El Sammak AA, Zaitoun MMA, Dawoud HA, Khamis MEM, Mohamed HAE, El-Maghraby AM, Abdalla AAEHM, Assy MM, Nada MG, Obaya AA, Abdelbary EH. Gynecology Imaging Reporting and Data System (GI-RADS): diagnostic performance and inter-reviewer agreement. Eur Radiol 2019; 29:5981-5990. [PMID: 30993433 DOI: 10.1007/s00330-019-06181-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 03/12/2019] [Accepted: 03/19/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate diagnostic performance and inter-reviewer agreement (IRA) of the Gynecologic Imaging Reporting and Data System (GI-RADS) for diagnosis of adnexal masses (AMs) by pelvic ultrasound (US). PATIENTS AND METHODS A prospective multicenter study included 308 women (mean age, 41 ± 12.5 years; range, 15-73 years) with 325 AMs detected by US. All US examinations were analyzed, and AMs were categorized into five categories according to the GI-RADS classification. We used histopathology and US follow-up as the reference standards for calculating diagnostic performance of GI-RADS for detecting malignant AMs. The Fleiss kappa (κ) tests were applied to evaluate the IRA of GI-RADS scoring results for predicting malignant AMs. RESULTS A total of 325 AMs were evaluated: 127 (39.1%) were malignant and 198 (60.9%) were benign. Of 95 AMs categorized as GI-RADS 2 (GR2), none was malignant; of 94 AMs categorized as GR3, three were malignant; of 13 AMs categorized as GR4, six were malignant; and of 123 AMs categorized as GR5, 118 were malignant. On a lesion-based analysis, the GI-RADS had a sensitivity, a specificity, and an accuracy of 92.9%, 97.5%, and 95.7%, respectively, when regarding only those AMs classified as GR5 for predicting malignancy. Considering combined GR4 and GR5 as a predictor for malignancy, the sensitivity, specificity, and accuracy of GI-RADS were 97.6%, 93.9%, and 95.4%, respectively. The IRA of the GI-RADS category was very good (κ = 0.896). The best cutoff value for predicting malignant AMs was >GR3. CONCLUSIONS The GI-RADS is very valuable for improving US structural reports. KEY POINTS • There is still a lack of a standard in the assessment of AMs. • GI-RADS is very valuable for improving US structural reports of AMs. • GI-RADS criteria are easy and work at least as well as IOTA.
Collapse
Affiliation(s)
| | - Rania Refaat
- Department of Radiodiagnosis, Ain Shams University, Cairo, Egypt
| | - Safaa A Ibrahim
- Department of Obstetrics & Gynecology, Zagazig University, Zagazig, Egypt
| | - Nadia M Madkour
- Department of Obstetrics & Gynecology, Zagazig University, Zagazig, Egypt
| | - Awad Mahmoud Awad
- Department of Obstetrics & Gynecology, Al-Azhar University, Cairo, Egypt
| | | | | | | | - Hitham A Dawoud
- Department of Radiodiagnosis, Zagazig University, Zagazig, Egypt
| | - Mai E M Khamis
- Department of Radiodiagnosis, Zagazig University, Zagazig, Egypt
| | - Heba A E Mohamed
- Department of Radiodiagnosis, Zagazig University, Zagazig, Egypt
| | | | | | | | | | - Ahmed Ali Obaya
- Department of Clinical Oncology, Zagazig University, Zagazig, Egypt
| | | |
Collapse
|