Transvaginal Sonography & Postmenopausal Ovarian Screening

August 9, 2011

Galal Lotfi, MD, MRCOG

Galal Lotfi, MD, MRCOG

•	The incidence of ovarian carcinoma has increased and is now the commonest malignancy of the female genital tract in much of the western world( William's 1992).
•	Ovarian cancer presents in its late stages, (75% of ovarian cancer); Killing more women than does cancer of the cervix and uterine body combined (Silverberg et al l990).

•	Ovarian cancer screening tests are the subject of endless debate. Some say it may progress to a late stage so quickly as to make screening impractical. This could be minimized by decreasing the time between follow up tests
•	The screening tests tried for ovarian cancer included variety of techniques. Clinical examination, culdocentesis, immunoscintigraphy, tumor marker but all are insensitive.

•	Ultrasound has been an efficient tool for studying structural changes associated with human follicular development and ovulation, it was therefore a logical step to use the same technology for morphological changes in the ovary that may suggest the presence of early ovarian cancer. The use of ultrasound as a screening device for ovarian cancer was first proposed by Campbell et al (1982).
•	The aim of that work was to implement a screening test to decrease the incidence of advancing ovarian carcinoma.

•	198 women who were postmenopausal.
•	TVS for all women.
•	Ovaries were classified with a score according to morphological and structural ultrasonic appearance on both sides.
•	The TVS score (combined to both ovaries) was added to the clinical score, according to the woman's history, to get the total score.
•	Another scan after a year was carried out for all women.

Appearance	Score
Atrophic	0
Volume >8cm.	1
Simple anechoic <3cm	1
Simple anechoic <5cm	2
Simple anechoic >5cm	3
Multilocular <5cm	2
Multilocular >5cm	3
Complex, cyst with echoic shadows.	4
Solid cyst (solid areas >50%)	5

Appearance	Score
Atrophic	0
Volume >8cm.	1
Simple anechoic <3cm	1
Simple anechoic <5cm	2
Simple anechoic >5cm	3
Multilocular <5cm	2
Multilocular >5cm	3
Complex, cyst with echoic shadows.	4
Solid cyst (solid areas >50%)	5

TVS finding	TVS score	Other Ovary	Family History	Malignant History	OCP History	Total Score
Simple cyst < 3cm (Persistent)	1$	0	2	0	1	4
Simple cyst < 5cm	1	1	0	1	0	3
Simple cyst =>5cm	1	0	0	0	0	1
Multiloc < 5cm	1	1	0	0	1	3
Multiloc =>5cm	2$	2	2	0	1	7
Complex	2$	0	0	1	0	3
Solid	2	0	0	0	0	2

TVS result	No.	Result
Volume > 8Cm3	1	Not operated
Simple cyst < 3cm (persistent)	4	1 Malignant 3 Benign
Simple cyst < 5cm	5	2 Malignant 1 inflammatory 2Benign
Simple cyst =>5cm	3	3 simple serous
Multilocucyst < 5cm	1	Inflammatory
Multilocular cyst =>5cm	2	1 malignant 1 inflammatory
Complex cyst	1	Malignant
Solid cyst	1	Malignant
Total	18

TVS	Surgical stage	Path. Grade	Pathology
	1ai	I	Cystadenocarcinoma
Simple <5cm	1ai	I	Mucinous carcinoma
Simple <5cm	1aii	I	Cystadenocarcinoma
Multiloc. >5cm	1bi	II	Endometroid
Complex	1ai	I	Cystadenocarcinoma
Solid cyst	1c	I	Endometroid

TVS result	No.	Result
Volume > 8Cm3	1	Not operated
Simple cyst < 3cm (persistent)	2	Simple serous
Simple cyst < 5cm	2	Simple serous
Simple cyst =>5cm	0
Multilocucyst < 5cm	0
Multilocular cyst =>5cm	0
Complex cyst	0
Solid cyst	0
Total	5

TVS finding	TVS score	Other Ovary	Family History	Malignant History	OCP History	Total Score
Simple cyst < 3cm (Persistent)	1	0	2	0	1	4
Simple cyst < 5cm	2	0	0	0	1	3
2	0	0	0	1

Lesion	No.	Min Score	Max score	Mean	SD
Malignant	6	3	13	6.33	3.1
Benign	15	1	4	2.93	0.88

•	Abnormal ovarian conditions detection rate was 9. 1%and 2.2%of cases in initial examination and subsequent year follow up.
•	Malignant detection rate was 3%.

•	Andolf & Jorgensen (1989) found no malignancy in 58 anechoic lesions less than 5cm as detected by ultrasound.
•	Rodrigenz et al (1988) reported 3 cancers detected in simple cystic lesions with a diameter greater than 5cm.
•	In the present study, small cysts were found to be not immune for malignancy, 3 cases with cyst diameter less than 3cmwere found to be malignant.

•	With small cyst and in situations where we are in doubt, the implemented score could help in deciding up. For big, multilocular, complex or solid cysts, the answer is straight forward, surgical intervention.
•	TVS, cheap compared to other imaging techniques, non invasive, seems to provide a simple screening technique for early ovarian cancer.

•	Its strength resides in its high sensitivity 62.5%, however we cannot deny the false positive rates which is present in any diagnostic tool.
•	Till we find another test with the least false positive results, TVS should be appreciated as a screening tool for such a lethal disease not only for susceptible women with family history or history of other malignancies but for the whole population.

•	Application of the suggested scoring system could help in differentiating between benign and malignant lesions.
•	The new advances in ultrasonography may enable us to better understand and recognize the earliest stages of oncogenesis with the ovary.