Prospective Evaluation of Ultrasound Accuracy in the Detection of Pelvic Carcinomatosis in Patients with Ovarian Cancer

Ultrasound for assessing tumor spread in ovarian cancer. A systematic review of the literature and meta-analysis

In this review, we aimed to assess the diagnostic performance of ultrasound for assessing the tumor spread in the abdomen in women with ovarian cancer. A search for studies evaluating the role of ultrasound for assessing intrabdominal tumor spread in women with ovarian cancer compared to surgery from January 2011 to March 2023 was performed in PubMed/MEDLINE, Web of Science, and Scopus databases. The Quality Assessment of Diagnostic Accuracy Studies 2 evaluated the quality of the studies (QUADAS-2). All analyses were performed using MIDAS and METANDI commands in STATA 12.0 software. We identified 1552 citations. After exclusions, five studies comprising 822 women were included. Quality of studies were considered as good, except for patient selection as all studies were considered as having high risk of bias. The pooled sensitivity and specificity could be calculated for three anatomical areas (recto-sigma, major omentum and root of mesentery) and the presence of ascites. The pooled sensitivity and specificity for detecting disease in the recto-sigma, major omentum and root of mesentery were 0.83 and 0.95, 0.87 and 0.87, and 0.29 and 0.99, respectively. The pooled sensitivity and specificity for detecting ascites was 0.95 and 0.91, respectively. There is evidence that ultrasound offers good diagnostic performance for evaluating the intra-abdominal extent of disease in women with suspected ovarian cancer.

Diagnostic performance of ultrasound in assessing the extension of disease in advanced ovarian cancer

BACKGROUND

Surgical exploration remains the gold standard to evaluate the extension of disease and predict resectability. A laparoscopy-based scoring model was developed by Fagotti and colleagues in 2006 and updated in 2015, based on the intraoperative presence or absence of some specific cancer features. The model proved an overall accuracy rate of 77-100% and is considered the reference test to assess resectability in our Institution.

OBJECTIVES

The primary aim of the study was to analyze the agreement between preoperative ultrasound examination and laparoscopic findings in assessing the extension of intra-abdominal disease using six parameters described by Fagotti's score.

STUDY DESIGN

This is a prospective single-center observational study. Between January 2019 and June 2020, consecutive patients with clinical or radiological suspicion of ovarian/peritoneal cancer were assessed with preoperative ultrasound examination and assigned a score based on the six Fagotti's score parameters (great omentum, liver surface, lesser omentum/stomach/spleen, parietal peritoneum, diaphragms, bowel disease). Presence of mesenteral retraction of the small bowel and miliaric carcinomatosis on the serosa were also evaluated. Each parameter was correlated with laparoscopic findings. Concordance was calculated between ultrasound and laparoscopic parameters using Cohen's kappa(κ).

RESULTS

Cohen's κ ranged from 0.70 to 0.90 for carcinomatosis on the small/large bowel, supracolic omentum, liver surface and diaphragms. Cohen's κ test was lower for carcinomatosis on the parietal peritoneum (k=0.63) and on the lesser omentum/lesser curvature of the stomach/spleen (k=0.54). The agreement between ultrasound and surgical predictive index value (score) was κ=0.74. For the evaluation of mesenteral retraction and miliaric carcinomatosis, the agreement was low (k=0.57 and k=0.36 respectively).

CONCLUSIONS

The results of ultrasound and laparoscopy in the assessment of intra-abdominal tumor spread were in substantial agreement for almost all the parameters. Ultrasound examination can play a useful role in the preoperative management of patients with ovarian cancer when used in dedicated referral centers.

Accuracy of Pretreatment Ultrasonography Assessment of Intra-Abdominal Spread in Epithelial Ovarian Cancer: A Prospective Study

The aim of this study was to test the accuracy of ultrasonography performed by gynecological oncologists for the preoperative assessment of epithelial ovarian cancer (EOC) spread in the pelvis and abdominal cavity. A prospective, observational cohort study was performed at a single tertiary cancer care unit. Patients with suspected EOC were recruited and underwent comprehensive transvaginal and abdominal ultrasonography performed by a gynecological oncologist. Sixteen intra-abdominal localizations and parameters were assessed using ultrasonography and compared with surgical-pathological status (reference standard). Sensitivity, specificity, positive and negative predictive values, and overall accuracy were calculated. Differences were analyzed using Fisher’s exact and chi-square tests. Ultimately, we included 132 patients (median age 62 years), of whom 67% were in stage IIIC–IVB and 72% had serous cancer. Overall prediction accuracies for the involvement of the omentum, small bowel mesentery root, and frozen pelvis, and detecting ascites were >90%. Detecting the involvement of the pelvis peritoneum, liver and spleen hilum, and rectosigmoid colon, and predictions of disease stage and residual disease had overall accuracies of 80–90%. The lowest accuracy was for involvement of the abdominal peritoneum (69%) and diaphragm peritoneum (right 71%; left 75%) and surgical complexity prediction (77%). Stratification of results by presence or absence of ascites revealed significantly higher specificity of ultrasonography (clinically meaningful) for assessments of the abdominal/pelvic peritoneum, spleen hilum, and rectum wall, if there were ascites. A gynecological oncologist, experienced in surgery and sonology, performing comprehensive ultrasonography on patients with EOC can accurately detect intraperitoneal lesions and recognize critical disease manifestations and predict stage, surgical complexity, and residual disease, which allow accurate qualification of patients for primary debulking surgery or neoadjuvant chemotherapy.

Diagnostic performance of ultrasound in assessing the extension of the disease in patients with suspicion of malignant ovarian tumor: correlation between ultrasound parameters and Fagotti's score

BACKGROUND

A radical surgical approach represents the mainstay treatment for gynecological malignancy, and preoperative staging of ovarian cancer is crucial. Ultrasound evaluation is widely recognized as the gold standard technique for the characterization of ovarian masses due to a high sensitivity for malignancy. In addition, its accuracy in defining intra-abdominal ovarian cancer spread has been previously proposed.

PRIMARY OBJECTIVE

To analyze the agreement between preoperative ultrasound examination and laparoscopic findings in assessing the extension of intra-abdominal disease using six parameters as described by Fagotti's score.

STUDY HYPOTHESIS

When performed by expert examiners, ultrasound can be an accurate technique to assess tumor spread in ovarian cancer and therefore to predict surgical resectability.

TRIAL DESIGN

This is a single-center prospective observational study. Patients with clinical and/or radiological suspicion of advanced ovarian or peritoneal cancer will be assessed with preoperative ultrasound and assigned a score based on the six Fagotti's laparoscopic score parameters. Each parameter will then be correlated with laparoscopic findings.

MAJOR INCLUSION/EXCLUSION CRITERIA

Eligible patients include women 18-75 years of age with clinical and/or imaging suggestive of advanced ovarian or peritoneal cancer, and an ECOG performance status 0-3.

PRIMARY ENDPOINTS

Sensitivity and specificity of ultrasound in detecting carcinomatosis, using the parameters of Fagotti's score as a reference standard. Agreement between preoperative ultrasound examination and laparoscopic findings in assessing the extension of intra-abdominal disease as described in Fagotti's score.

SAMPLE SIZE

240 patients.

ESTIMATE DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS

The accrual started in January 2019. Enrollment should be completed approximately by October 2020 and the results will be analyzed by December 2020.

TRIAL REGISTRATION

The study received the Ethical Committee approval on July 19 2018 (Protocol 28967/18 ID:2172).

Development and validation of a model that includes two ultrasound parameters and the plasma D-dimer level for predicting malignancy in adnexal masses: an observational study

Background

Pre-operative discrimination of malignant from benign adnexal masses is crucial for planning additional imaging, preparation, surgery and postoperative care. This study aimed to define key ultrasound and clinical variables and develop a predictive model for calculating preoperative ovarian tumor malignancy risk in a gynecologic oncology referral center. We compared our model to a subjective ultrasound assessment (SUA) method and previously described models.

Methods

This prospective, single-center observational study included consecutive patients. We collected systematic ultrasound and clinical data, including cancer antigen 125, D-dimer (DD) levels and platelet count. Histological examinations served as the reference standard. We performed univariate and multivariate regressions, and Bayesian information criterion (BIC) to assess the optimal model. Data were split into 2 subsets: training, for model development (190 observations) and testing, for model validation (n = 100).

Results

Among 290 patients, 52% had malignant disease, including epithelial ovarian cancer (72.8%), metastatic disease (14.5%), borderline tumors (6.6%), and non-epithelial malignancies (4.6%). Significant variables were included into a multivariate analysis. The optimal model, included three independent factors: solid areas, the color score, and the DD level. Malignant and benign lesions had mean DD values of 2.837 and 0.354 μg/ml, respectively. We transformed established formulae into a web-based calculator (http://gin-onc-calculators.com/gynonc.php) for calculating the adnexal mass malignancy risk. The areas under the curve (AUCs) for models compared in the testing set were: our model (0.977), Simple Rules risk calculation (0.976), Assessment of Different NEoplasias in the adneXa (ADNEX) (0.972), Logistic Regression 2 (LR2) (0.969), Risk of Malignancy Index (RMI) 4 (0.932), SUA (0.930), and RMI3 (0.912).

Conclusions

Two simple ultrasound predictors and the DD level (also included in a mathematical model), when used by gynecologist oncologist, discriminated malignant from benign ovarian lesions as well or better than other more complex models and the SUA method. These parameters (and the model) may be clinically useful for planning adequate management in the cancer center. The model needs substantial validation.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5629-x) contains supplementary material, which is available to authorized users.

[Diagnostic value of imaging (ultrasonography, doppler, CT, MR, PET-CT) for the diagnosis of a suspicious ovarian mass and staging of ovarian, tubal or primary peritoneal cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

Transvaginal ultrasound is the first-line examination allowing characterizing 80 to 90% of adnexal masses (LP1). If performed by an expert, a subjective analysis is optimal. If performed by a non-expert, combining the use of Simple Rules with subjective analysis can achieve the diagnostic performance of an expert (LP1). Whichever the chosen model (subjective analysis by an expert or combination of the Simple Rules with a subjective analysis by a non-expert), a second-line examination will have to be proposed in the complex or indeterminate cases (about 20% of the masses) (grade A). The best-performing second-line test for characterization is pelvic MRI (LP1). If read by an expert, a pathological hypothesis can or should be suggested (grade D). In case of non-expert reading, the use of the ADNEXMR score allows a reliable assessment of the positive predictive value of malignancy to guide the patient towards the best management (gradeC). For preoperative assessment and evaluation of resectability of ovarian, fallopian tube or primary peritoneal cancer, it is recommended to perform a chest abdomen and pelvis CT with contrast agent injection (LP2, grade B). In the event of a contraindication to the injection of iodinated contrast agent (severe renal insufficiency, GFR <30mL/min), an abdomen and pelvis MRI completed with a non-injected chest CT may be proposed (LP3, grade C). By analogy, the same examinations are recommended to evaluate the disease after neo-adjuvant chemotherapy (LP3, Recommendation grade C). Further studies will be required to determine whether PET-CT provides better lymph node assessment before retroperitoneal and pelvic lymphadenectomy. PET-CT may be used to eliminate lymph node involvement in the absence of suspicious lymph nodes on morphological examination (LP3, grade C). The report should specify the localizations leading to a risk of incomplete cytoreductive surgery and lesions outside the field explored during surgery.

Pre-operative assessment of intra-abdominal disease spread in epithelial ovarian cancer: a comparative study between ultrasound and computed tomography

Objective

To compare the diagnostic performance of ultrasound and computed tomography (CT) for detecting pelvic and abdominal tumor spread in women with epithelial ovarian cancer.

Methods

An observational cohort study of 93 patients (mean age 57.6 years) with an ultrasound diagnosis of adnexal mass suspected of malignancy and confirmed histologically as epithelial ovarian cancer was undertaken. In all cases, transvaginal and transabdominal ultrasound as well as CT scans were performed to assess the extent of the disease within the pelvis and abdomen prior to surgery. The exploration was systematic, analyzing 12 anatomical areas. All patients underwent surgical staging and/or cytoreductive surgery with an initial laparoscopy for assessing resectability. The surgical and pathological findings were considered as the 'reference standard'. Sensitivity and specificity of ultrasound and CT scanning were calculated for the different anatomical areas and compared using the McNemar test. Agreement between ultrasound and CT staging and the surgical stage was estimated using the weighted kappa index.

Results

The tumorous stage was International Federation of Gynecology and Obstetrics (FIGO) stage I in 26 cases, stage II in 11 cases, stage III in 47 cases, and stage IV in nine cases. Excluding stages I and IIA cases (n=30), R0 (no macroscopic residual disease) was achieved in 36 women (62.2%), R1 (macroscopic residual disease <1 cm) was achieved in 13 women (25.0%), and R2 (macroscopic residual disease >1 cm) debulking surgery occurred in three women (5.8%). Eleven patients (11.8%) were considered not suitable for optimal debulking surgery during laparoscopic assessment. Overall sensitivity of ultrasound and CT for detecting disease was 70.3% and 60.1%, respectively, and specificity was 97.8% and 93.7%, respectively. The agreement between radiological stage and surgical stage for ultrasound (kappa index 0.69) and CT (kappa index 0.70) was good for both techniques. Overall accuracy to determine tumor stage was 71% for ultrasound and 75% for CT.

Conclusion

Detailed ultrasound examination renders a similar diagnostic performance to CT for assessing pelvic/abdominal tumor spread in women with epithelial ovarian cancer.