Transvaginal Sonography & Postmenopausal Ovarian Screening

August 9, 2011



 


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.

 


AppearanceScore
Atrophic0
Volume >8cm.1
Simple anechoic <3cm1
Simple anechoic <5cm2
Simple anechoic >5cm3
Multilocular <5cm2
Multilocular >5cm3
Complex, cyst with echoic shadows.4
Solid cyst (solid areas >50%)5


AppearanceScore
Atrophic0
Volume >8cm.1
Simple anechoic <3cm1
Simple anechoic <5cm2
Simple anechoic >5cm3
Multilocular <5cm2
Multilocular >5cm3
Complex, cyst with echoic shadows.4
Solid cyst (solid areas >50%)5


TVS findingTVS scoreOther OvaryFamily HistoryMalignant HistoryOCP HistoryTotal Score
Simple cyst < 3cm (Persistent)1$02014
Simple cyst < 5cm110103
Simple cyst =>5cm100001
Multiloc < 5cm110013
Multiloc =>5cm2$22017
Complex2$00103
Solid200002


TVS resultNo.Result
Volume > 8Cm31Not operated
Simple cyst < 3cm (persistent)41 Malignant 3 Benign
Simple cyst < 5cm52 Malignant 1 inflammatory 2Benign
Simple cyst =>5cm33 simple serous
Multilocucyst < 5cm1Inflammatory
Multilocular cyst =>5cm21 malignant 1 inflammatory
Complex cyst1Malignant
Solid cyst1Malignant
Total18 


TVSSurgical stagePath. GradePathology
 1aiICystadenocarcinoma
Simple <5cm1aiIMucinous carcinoma
Simple <5cm1aiiICystadenocarcinoma
Multiloc. >5cm1biIIEndometroid
Complex1aiICystadenocarcinoma
Solid cyst1cIEndometroid


TVS resultNo.Result
Volume > 8Cm31Not operated
Simple cyst < 3cm (persistent)2Simple serous
Simple cyst < 5cm2Simple serous
Simple cyst =>5cm0 
Multilocucyst < 5cm0 
Multilocular cyst =>5cm0 
Complex cyst0 
Solid cyst0 
Total5 


TVS findingTVS scoreOther OvaryFamily HistoryMalignant HistoryOCP HistoryTotal Score
Simple cyst < 3cm (Persistent)102014
Simple cyst < 5cm200013
20001


LesionNo.Min ScoreMax scoreMeanSD 
Malignant63136.333.1 
Benign15142.930.88 


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.