Ultrasound evaluation of pelvic masses: predictors of malignancy for the general gynecologist

Cross talk of tumor protein D52 (TPD52) with KLF9, PKCε, and MicroRNA 223 in ovarian cancer

BACKGROUND

Gynecologic cancers comprise malignancies in the female reproductive organs. Ovarian cancer ranks sixth in terms of incidence rates while seventh in terms of mortality rates. The stage at which ovarian cancer is diagnosed mainly determines the survival outcomes of patients. Various screening approaches are presently employed for diagnosing ovarian cancer; however, these techniques have low accuracy and are non-specific, resulting in high mortality rates of patients due to this disease. Hence, it is crucial to identify improved screening and diagnostic markers to overcome this cancer. This study aimed to find new biomarkers to facilitate the prognosis and diagnosis of ovarian cancer.

METHODS

Bioinformatics approaches were used to predict the tertiary structure and cellular localization along with phylogenetic analysis of TPD52. Its molecular interactions were determined through KEGG analysis, and real-time PCR-based expression analysis was performed to assess its co-expression with another oncogenic cellular pathway (miR-223, KLF9, and PKCε) proteins in ovarian cancer.

RESULTS

Bioinformatics analysis depicted the cytoplasmic localization of TPD52 and the high conservation of its coiled-coil domains. Further study revealed that TPD52 mRNA and miRNA-223 expression was elevated, while the expression of KLF 9 and PKCε was reduced in the blood of ovarian cancer patients. Furthermore, TPD52 and miR-223 expression were upregulated in the early stages of cancer and non-metastatic cancers.

CONCLUSION

TPD52, miR-223, PKCε, and KLF9, can be used as a blood based markers for disease prognosis, metastasis, and treatment response. The study outcomes hold great potential to be translated at the clinical level after further validation on larger cohorts.

Combining A Second-Generation Multivariate Index Assay with Ovarian Imaging Improves the Preoperative Assessment of An Adnexal Mass

Background: To understand the relationship between imaging and the next generation multivariate index assay (MIA2G) in the preoperative assessment of an adnexal mass. Methods: Serum samples and imaging data from two previously published studies are reanalyzed using the MIA2G test. We calculated the clinical performance of MIA2G and discrete imaging features associated with malignant risk. Results: 878 women were eligible for this analysis, 48.3% post-menopausal and 51.7% pre-menopausal. The prevalence of having a malignant pathology was 18%. Ultrasound was the most frequently used imaging modality. The combination of MIA2G “or” ultrasound resulted in higher sensitivity than either test alone, 93.5% compared to 87.6% for MIA2G and 74.2% for ultrasound. The negative predictive value was high: 94.6% for ultrasound, 98.1% for MIA2G “or” ultrasound. MIA2G “and” ultrasound had higher specificity but lower sensitivity than MIA2G or ultrasound alone. Similar results were seen for CT scan when evaluated with MIA2G. Conclusion: MIA2G and pelvic imaging are complementary tests and interpreting them together can provide important information about the malignant risk of an ovarian tumor. For physicians making decisions about a referral to a specialist, the combination of MIA2G “or” ultrasound has the highest sensitivity in predicting ovarian malignancy.

Past, present and future ultrasonographic techniques for analyzing ovarian masses

Ultrasonography is today the method of choice for distinguishing between benign and malignant adnexal pathologies. Using pattern recognition several types of tumors can be recognized according to their characteristic appearance on gray-scale imaging. Color Doppler imaging should be used only to perform a semiquantitative color score or evaluate the flow location. International Ovarian Tumor Analysis group had standardized definitions characterizing adnexal masses and suggested the use of 'simple rules' in premenopausal women. Recently, the use of 3D vascular indices has been proposed but its potential use in clinical practice is debated. Also computerized aided diagnosis algorithms showed encouraging results to be confirmed in the future.

Ovarian cancer

The standard initial management of epithelial ovarian cancer consists of surgical staging, operative tumour debulking including total abdominal hysterectomy and bilateral salpingo-oophorectomy, and administration of six cycles of intravenous chemotherapy with carboplatin and paclitaxel. Extensive and largely retrospective experience has shown that optimum surgical debulking to leave residual tumour deposits that are less than 1 cm in size is associated with improved patient outcomes. However, 75% of patients present with advanced (stage III or IV) disease and, although more than 80% of these women benefit from first-line therapy, tumour recurrence occurs in almost all these patients at a median of 15 months from diagnosis. Second-line treatments can improve survival and quality of life but are not curative. Advances in screening and understanding of molecular pathogenesis of ovarian cancer and development of novel targeted therapies (eg, bevacizumab) and practical intraperitoneal techniques for drug delivery are most likely to improve patient outcomes.

The role and applications of ultrasound in ambulatory gynaecology

Ultrasound has changed gynaecological practice and continues to do so. One of the earliest applications of abdominal scanning in gynaecology was for monitoring follicular development during fertility treatment with clomiphene citrate or gonadotrophins in the 1960s and 1970s. Subsequently, it was natural that with the introduction of in vitro fertilization, abdominal and transvaginal ultrasound played a key role in the development of oocyte retrieval techniques. These were truly the first interventional ultrasound-guided ambulatory procedures in gynaecology. In this chapter, the reader will be introduced to the roles that the various ultrasound modalities play in our current daily practice, and how they have changed the management of numerous gynaecological conditions in both diagnostic and therapeutic contexts. We will also outline the recent developments and the 'hot' research topics in this field.

Adnexal mass with pelvic pain

In a pregnant woman who presents with acute pelvic pain and an adnexal mass, pregnancy-related etiologies, such as ectopic pregnancy or ovarian torsion, are typically the first diagnoses to be considered. Many other causes of pelvic pain associated with an adnexal mass can occur in pregnant patients, however. Some causes are benign and others require urgent management and treatment. Clinical presentation and physical examination can be misleading in pregnancy. The location of pain may be atypical for the pathologic entity, the pain may be muted, and in the case of infection, fever and leukocytosis can be absent. US examination is a safe and effective method for evaluating these patients. Sonographic characterization of adnexal masses may make a definitive diagnosis or focus the differential, which allows for prompt and appropriate treatment of patients.

Complex pelvic mass as a target of evaluation of vessel distribution by color Doppler sonography for the diagnosis of adnexal malignancies: results of a multicenter European study

OBJECTIVE

To compare the diagnostic accuracy of gray scale sonography and color Doppler imaging in the differential diagnosis of adnexal malignancies from benign complex pelvic masses in a multicenter prospective study.

METHODS

The study was performed as a collaborative work at 3 European university departments of obstetrics and gynecology. A total of 826 complex pelvic masses on which transvaginal sonography and evaluation of cancer antigen 125 plasma concentrations were performed before surgical exploration were included in the study. The scanning procedure was the same in the 3 institutions. An adnexal mass was first studied in gray scale sonography, and a probable histologic type was predicted. Second, solid excrescences or solid portions of the tumor were evaluated for vascular flow with color Doppler sonography (conventional or power). A mass was graded malignant if flow was shown within the excrescences or solid areas and benign if there was no flow. The overall agreement between the test result and the actual outcome was calculated by kappa statistics.

RESULTS

Color Doppler evaluation was more accurate in the diagnosis of adnexal malignancies in comparison with gray scale sonography (kappa = 0.82 and 0.65, respectively) because of significantly higher specificity (0.94 versus 0.84; P < .001). The evaluation of the cancer antigen 125 plasma concentration did not seem to increase the accuracy of either method.

CONCLUSIONS

The evaluation of vessel distribution by color Doppler sonography in complex adnexal cysts seems to increase the diagnostic accuracy of gray scale sonography in the detection of adnexal malignancies in a large study population.

Comparison of conventional color Doppler imaging and power doppler imaging for the diagnosis of ovarian cancer: results of a European study

OBJECTIVE

The purpose of this prospective study was to compare the diagnostic accuracy of conventional color Doppler (CCD) imaging and power Doppler (PD) imaging in the diagnosis of ovarian cancer.

METHODS

Six hundred fifty-six consecutive women with adnexal masses scheduled for surgery in two European university departments of obstetrics and gynecology underwent preoperative transvaginal ultrasound. The scanning procedure was the same in the two institutions: after B-mode sonography, a CCD/PD imaging scan was performed before pulsed Doppler evaluation. Using both modalities of color Doppler, malignancy was suspected when arterial flow was visualized in an echogenic portion defined as malignant by B-mode. To avoid the risk of bias due to the absence of blindness of the examiner after the first Doppler evaluation, at one institution 328 consecutive women with an adnexal mass were evaluated using only CCD imaging, whereas at the second institution the ultrasonographic evaluation of the same number of masses was performed using PD imaging, and the results were compared prospectively.

RESULTS

The age, the rate of postmenopausal women, and the rate of ovarian cancer were similar in the two institutions. The false-positive rate of B-mode imaging was similar in the two institutions (17 versus 18%), while the false-positive rates of CCD and PD imaging were 4.6 and 7.4%, respectively. Although the overall diagnostic accuracy of two techniques seems comparable, with a similar value of K (0.81 versus 0.84), a significantly lower sensitivity in differentiation of benign from malignant ovarian lesions was found using CCD (87 versus 100%).

CONCLUSIONS

At least one of the two Doppler techniques should be used in conjunction with B-mode imaging in order to decrease the false-positive rate of B-mode used alone but CCD imaging showed a higher false-negative rate.