Evaluation and Management of Ultrasonographically Detected Ovarian Tumors in Asymptomatic Women

Validity of ultrasound with color Doppler to differentiate between benign and malignant ovarian tumours

OBJECTIVE

To assess the utility of ultrasound and color Doppler and the Accuracy of International Ovarian Tumor Analysis (IOTA) group classification in the preoperative evaluation of ovarian neoplasms to assess benign or malignant histopathology in the diagnosis of ovarian tumors.

METHODS

This observational longitudinal prospective analysis of 60 patients was performed over a period of 2 years (2017- 2019). The mean age of the patients was 43.75 years. Ultrasonography of ovarian masses were evaluated, and cancer antigen-125 (CA-125) levels were evaluated. Based on the IOTA classification, the B and M features of adnexal masses were studied. Color Doppler imaging was performed to evaluate the patterns of vascularity and indices.

RESULTS

Sixty patients with 35 benign, 23 malignant, and two borderline lesions were included in the study. In malignant lesions, 17 women (73.9%) were above the age of 45. The CA-125 cut off was ≥35 internatioal units/mL. Based on the IOTA classification, 27/35 (77.1%) benign cases, were correctly identified as benign, 6/35 (17.1%) benign cases were incorrectly identified as malignant, and two (5.7%) were found to be inconclusive. In the malignant group, 17 of the 23 patients were identified as having malignancy. Color Doppler showed three (18.8%) benign tumors had a pulsatality index (PI) of <0.8 and 21 malignant tumors had a PI of <0.8. Four benign tumors had an resistive index (RI) of <0.6 and 100% of malignant tumors had an RI <0.6.

CONCLUSION

The IOTA classification is a reliable scoring system for adnexal masses, and color Doppler can help to minimize interobserver variation.

Variables Associated With Resolution and Persistence of Ovarian Cysts

OBJECTIVE

To estimate surveillance intervals of incident ovarian cysts, and describe variables associated with cyst resolution times.

METHODS

The UK-OCST (University of Kentucky Ovarian Cancer Screening Trial) was a prospective cohort that enrolled 47,762 individuals over 30 years, including 2,638 individuals with incident cysts. Cyst diameter and structure and patient age, body mass index, use of hormone therapy (HT), family history of ovarian cancer, and menopausal status were examined as variables associated with cyst resolution using t tests, χ 2 test, Kaplan Meier, and Cox multiple regression.

RESULTS

Of 2,638 individuals with incident cysts, 1,667 experienced resolution (63.2%) within 1.2 years, and 971 experienced persistence (36.8%). Within 1 year, unilocular and septated cysts had similar resolution rates (35.4% and 36.7%, respectively, P >.05), but time to resolution was shorter for unilocular cysts compared with septated cysts (mean 1.89 years vs 2.58 years, respectively, P <.001). Both unilocular and septated cysts smaller than 3 cm resolved faster than cysts larger than 6 cm ( P <.001). Variables associated with percent resolution included being of younger age, premenopausal status (but not for synchronous bilateral cysts), and those reporting a family history of ovarian cancer ( P <.05). Variables associated with a faster cyst resolution rate included being older than age 70 years and not using hormone therapy. Body mass index and family history were not associated with cyst resolution time.

CONCLUSION

Different surveillance times may be appropriate depending on cyst structure and size and patient age and HT use.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT04473833.

Value of Contrast-Enhanced Ultrasound Parameters in the Evaluation of Adnexal Masses with Ovarian-Adnexal Reporting and Data System Ultrasound

OBJECTIVE

The aim of this study was to determine whether incorporating qualitative parameters of contrast-enhanced ultrasound (CEUS) can increase the accuracy of adnexal lesion assessments with Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound category 4 or 5.

METHODS

Retrospective analysis of patients with adnexal masses who underwent conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS) examinations between January and August of 2020. The study investigators reviewed and analyzed the morphological features of each mass before categorizing the US images independently according to the O-RADS system published by the American College of Radiology. In the CEUS analysis, the initial time and intensity of enhancement involving the wall and/or septation of the mass were compared with the uterine myometrium. Internal components of each mass were observed for signs of enhancement. The sensitivity, specificity, and Youden's index were calculated as the contrast variables and O-RADS.

RESULTS

Receiver operating characteristic curve analysis revealed that the best cutoff value was higher than O-RADS 4. When information on the extent of enhancement was applied to selectively upgrade O-RADS category 4 and selectively downgrade O-RADS category 5, the overall sensitivity increased to 90.2%, while the level of specificity (91.3%) remained the same.

CONCLUSION

Incorporating additional information from CEUS with respect to the extent of enhancement helped to improve the sensitivity of O-RADS category 4 and 5 masses without loss of specificity.

Impact of Multiparametric MRI (mMRI) on the Therapeutic Management of Adnexal Masses Detected with Transvaginal Ultrasound (TVUS): An Interdisciplinary Management Approach

RATIONALE AND OBJECTIVES

Adnexal masses detected incidentally at transvaginal ultrasound (TVUS) are a common and still challenging diagnostic problem. The primary goal of further imaging is an accurate tissue characterization so an optimal treatment plan can be devised including surgery only for lesions that are indeterminate or malignant. The aim of this prospective study was to evaluate the diagnostic utility of complementary multiparametric magnetic resonance imaging (mMRI) for treatment planning in patients with adnexal masses, and to assess how it ultimately correlates with subsequent histopathologic findings.

MATERIAL AND METHODS

A total of 126 women (mean age: 54.6 years) with indeterminate adnexal masses underwent mMRI at 3T in addition to TVUS and testing to determine their CA-125 levels. The mMRI protocol consisted of a high-resolution T2-TSE in three planes, diffusion weighted images and dynamic contrast enhanced. First the character of the adnexal mass and the associated management decision (follow-up, laparoscopy or laparotomy) were assessed independently for each diagnostic method (TVUS + CA-125 and mMRI). All methods were then assessed in synopsis. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each diagnostic method alone and in combination were calculated. The standard of reference was either final histology in women who underwent surgery or follow-up of at least 24 months in women who underwent follow-up.

RESULTS

In 67.5% (85/126) of all patients, the adnexal mass was benign; a malignant tumor was diagnosed in 28.6% (36/126) and a borderline tumor in the remaining 4% (5/126) of patients. The diagnostic indices were as follows for TVUS + CA 125 alone, mMRI alone and all three methods combined: sensitivity 86% (31/36), 97% (35/36), and 100% (36/36); specificity 32% (29/90), 83% (75/90), and 80% (68/90); PPV 34% (31/91), 70% (35/50), and 74% (40/54); and NPV 65% (29/44), 98% (75/76), and 100% (72/72). Complementary use of mMRI changed the therapeutic management decision in 34% (41/126) of all patients. In 40.7% (37/91) of patients for whom surgery had been recommended based on TVUS + CA-125, MRI revealed a typical benign finding such that those patients underwent follow-up instead of surgery. None of the examined masses exhibited (tumor) progression or malignancy during the follow-up period. A laparotomy was performed instead of a laparoscopy in 8.7% (11/126) based on the mMRI result.

CONCLUSION

MRI helps significantly improve sensitivity and specificity of diagnosis in patients with indeterminate adnexal masses detected at TVUS. Its diagnostic information revised the planned treatment in more than one-third of women.

Quantitative analysis of the MRI features in the differentiation of benign, borderline, and malignant epithelial ovarian tumors

Objective

This study aims to investigate the value of the quantitative indicators of MRI in the differential diagnoses of benign, borderline, and malignant epithelial ovarian tumors (EOTs).

Materials and methods

The study population comprised 477 women with 513 masses who underwent MRI and operation, including benign EOTs (BeEOTs), borderline EOTs (BEOTs), and malignant EOTs (MEOTs). The clinical information and MRI findings of the three groups were compared. Then, multivariate logistic regression analysis was performed to find the independent diagnostic factors. The receiver operating characteristic (ROC) curves were also used to evaluate the diagnostic performance of the quantitative indicators of MRI and clinical information in differentiating BeEOTs from BEOTs or differentiating BEOTs from MEOTs.

Results

The MEOTs likely involved postmenopausal women and showed higher CA-125, HE4 levels, ROMA indices, peritoneal carcinomatosis and bilateral involvement than BeEOTs and BEOTs. Compared with BEOTs, BeEOTs and MEOTs appeared to be more frequently oligocystic (P < 0.001). BeEOTs were more likely to show mild enhancement (P < 0.001) and less ascites (P = 0.003) than BEOTs and MEOTs. In the quantitative indicators of MRI, BeEOTs usually showed thin-walled cysts and no solid component. BEOTs displayed irregular thickened wall and less solid portion. MEOTs were more frequently characterized as solid or predominantly solid mass (P < 0.001) than BeEOTs and BEOTs. The multivariate logistic regression analysis showed that volume of the solid portion (P = 0.006), maximum diameter of the solid portion (P = 0.038), enhancement degrees (P < 0.001), and peritoneal carcinomatosis (P = 0.011) were significant indicators for the differential diagnosis of the three groups. The area under the curves (AUCs) of above indicators and combination of four image features except peritoneal carcinomatosis for the differential diagnosis of BeEOTs and BEOTs, BEOTs and MEOTs ranged from 0.74 to 0.85, 0.58 to 0.79, respectively.

Conclusion

In this study, the characteristics of MRI can provide objective quantitative indicators for the accurate imaging diagnosis of three categories of EOTs and are helpful for clinical decision-making. Among these MRI characteristics, the volume, diameter, and enhancement degrees of the solid portion showed good diagnostic performance.

A Novel Classifier Based on Urinary Proteomics for Distinguishing Between Benign and Malignant Ovarian Tumors

Background

Preoperative differentiation of benign and malignant tumor types is critical for providing individualized treatment interventions to improve prognosis of patients with ovarian cancer. High-throughput proteomics analysis of urine samples was performed to identify reliable and non-invasive biomarkers that could effectively discriminate between the two ovarian tumor types.

Methods

In total, 132 urine samples from 73 malignant and 59 benign cases of ovarian carcinoma were divided into C1 (training and test datasets) and C2 (validation dataset) cohorts. Mass spectrometry (MS) data of all samples were acquired in data-independent acquisition (DIA) mode with an Orbitrap mass spectrometer and analyzed using DIA-NN software. The generated classifier was trained with Random Forest algorithm from the training dataset and validated in the test and validation datasets. Serum CA125 and HE4 levels were additionally determined in all patients. Finally, classification accuracy of the classifier, serum CA125 and serum HE4 in all samples were evaluated and plotted via receiver operating characteristic (ROC) analysis.

Results

In total, 2,199 proteins were quantified and 69 identified with differential expression in benign and malignant groups of the C1 cohort. A classifier incorporating five proteins (WFDC2, PTMA, PVRL4, FIBA, and PVRL2) was trained and validated in this study. Evaluation of the performance of the classifier revealed AUC values of 0.970 and 0.952 in the test and validation datasets, respectively. In all 132 patients, AUCs of 0.966, 0.947, and 0.979 were achieved with the classifier, serum CA125, and serum HE4, respectively. Among eight patients with early stage malignancy, 7, 6, and 4 were accurately diagnosed based on classifier, serum CA125, and serum HE4, respectively.

Conclusion

The novel classifier incorporating a urinary protein panel presents a promising non-invasive diagnostic biomarker for classifying benign and malignant ovarian tumors.

Computer Tomography in the Diagnosis of Ovarian Cysts: The Role of Fluid Attenuation Values

Pathological analysis of ovarian cysts shows specific fluid characteristics that cannot be standardly evaluated on computer tomography (CT) examinations. This study aimed to assess the ovarian cysts’ fluid attenuation values on the native (Np), arterial (Ap), and venous (Vp) contrast phases of seventy patients with ovarian cysts who underwent CT examinations and were retrospectively included in this study. Patients were divided according to their final diagnosis into the benign group (n = 32) and malignant group (n = 38; of which 27 were primary and 11 were secondary lesions). Two radiologists measured the fluid attenuation values on each contrast phase, and the average values were used to discriminate between benign and malignant groups and primary tumors and metastases via univariate, multivariate, multiple regression, and receiver operating characteristics analyses. The Ap densities (p = 0.0002) were independently associated with malignant cysts. Based on the densities measured on all three phases, neoplastic lesions could be diagnosed with 89.47% sensitivity and 62.5% specificity. The Np densities (p = 0.0005) were able to identify metastases with 90.91% sensitivity and 70.37% specificity, while the combined densities of all three phases diagnosed secondary lesions with 72.73% sensitivity and 92.59% specificity. The ovarian cysts’ fluid densities could function as an adjuvant criterion to the classic CT evaluation of ovarian cysts.

Radiomic Analysis of MRI Images is Instrumental to the Stratification of Ovarian Cysts

The imaging diagnosis of malignant ovarian cysts relies on their morphological features, which are not always specific to malignancy. The histological analysis of these cysts shows specific fluid characteristics, which cannot be assessed by conventional imaging techniques. This study investigates whether the texture-based radiomics analysis (TA) of magnetic resonance (MRI) images of the fluid content within ovarian cysts can function as a noninvasive tool in differentiating between benign and malignant lesions. Twenty-eight patients with benign (n = 15) and malignant (n = 13) ovarian cysts who underwent MRI examinations were retrospectively included. TA of the fluid component was undertaken on an axial T2-weighted sequence. A comparison of resulted parameters between benign and malignant groups was undertaken using univariate, multivariate, multiple regression, and receiver operating characteristics analyses, with the calculation of the area under the curve (AUC). The standard deviation of pixel intensity was identified as an independent predictor of malignant cysts (AUC = 0.738; sensitivity, 61.54%; specificity, 86.67%). The prediction model was able to identify malignant lesions with 84.62% sensitivity and 80% specificity (AUC = 0.841). TA of the fluid contained within the ovarian cysts can differentiate between malignant and benign lesions and potentially act as a noninvasive tool augmenting the imaging diagnosis of ovarian cystic lesions.

Guideline No. 404: Initial Investigation and Management of Benign Ovarian Masses

OBJECTIVE

To provide recommendations for a systematic approach to the initial investigation and management of a benign ovarian mass and facilitate patient referral to a gynaecologic oncologist for management.

INTENDED USERS

Obstetricians, gynaecologists, family physicians, internists, nurse practitioners, radiologists, general surgeons, medical students, medical residents, fellows, and other health care providers.

TARGET POPULATION

Women ≥18 years of age presenting for evaluation of an ovarian mass (including simple and unilocular cystic masses, endometriomas, dermoids, fibromas, and hemorrhagic cysts) who are not acutely symptomatic and without known genetic predisposition to ovarian cancer.

OUTCOMES

This guideline aims to encourage conservative management and help reduce unnecessary surgery and long-term health complications, maintain fertility, and decrease operative costs and improve overall patient care and outcomes by providing criteria for referral of patients with ultrasound imaging findings suggestive of a malignant mass to a gynaecologic oncologist.

EVIDENCE

Databases searched: Medline, Cochrane, and PubMed. Medical terms used: benign asymptomatic and symptomatic ovarian cysts, adnexal masses, oophorectomy, ultrasound diagnosis of cysts, simple ultrasound rules, surgical and medical therapies for cysts, screening for ovarian cancer, ovarian torsion, and menopause. Initial search was completed by 2017 and updated in 2018. Exclusion criteria were malignant ovarian cystic masses, endometriosis therapies, and other adnexal pathologies unrelated to the ovary.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the authors. The Society of Obstetricians and Gynaecologists of Canada's Board of Directors approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework.

BENEFITS, HARMS, COSTS

Implementation of the recommendations could reduce costs due to unnecessary surgeries and hospitalizations and reduce lost work days and the risk of loss of fertility, early menopause, and surgical complications.

SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES)

RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Investigation of treatment efficacy of 10% povidone–iodine sclerotherapy on ovarian cyst diameter: an experimental study

Background/aim

The purpose of this study was toinvestigate the effects of 10% povidone–iodine (PI) sclerotherapyon ovarian cyst diameter through an experimental study.

Materials and methods

To be able to create ovarian cysts, right unilateral salpingectomy was performed on 20 Wistar albino rats. One month after the operation, the abdomens of all rats were reopened. Sixteen rats with macroscopic ovarian cysts were divided randomly into 2 groups consisting of 8 rats. Group 1 (G1): the cyst content was only aspirated. Group 2 (G2): the ovarian cyst was aspirated and then the cystic cavity was irrigated with PI. Abdomens of all rats were closed and 1 month later they were reopened. Tissues of the right ovaries of the rats were embedded in paraffin blocks for histopathological examination. Follicle count, fibrosis, and congestion were evaluated under a light microscope.

Results

For G1, there was no difference in cyst diameters before and after aspiration. In G2, a decrease was observed in cyst diameter. There was no difference in ovarian reserve between the 2 groups. When compared with G1, an increase in fibrosis and congestion was determined in G2.

Conclusion

Sclerotherapyinto the ovarian cyst for a 5-min period using 10% PI reduces cyst diameter without any change in ovarian reserve.

Risk of Malignant Ovarian Cancer Based on Ultrasonography Findings in a Large Unselected Population

IMPORTANCE

The risk of malignant ovarian cancer associated with simple cysts is unknown.

OBJECTIVE

To quantify the risk of ovarian cancer based on ultrasonographic characteristics of ovarian masses, including simple cysts, in a large unselected population.

DESIGN, SETTING, AND PARTICIPANTS

This was a nested case-control study of patients enrolled in Kaiser Permanente Washington, a large integrated health care system in Washington State. Participants were 72 093 women who underwent pelvic ultrasonography between January 1, 1997, and December 31, 2008. Analysis was completed in April 2017.

EXPOSURES

Ultrasonographic characteristics of ovarian masses measured in 1043 women, and also, using weights derived from the sampling strategy, estimated frequencies for the entire cohort.

MAIN OUTCOMES AND MEASURES

Malignant ovarian cancer, identified through December 31, 2011, by cancer registry linkage.

RESULTS

Among 210 women who were diagnosed as having ovarian cancer, 49 were younger than 50 years, and 161 were 50 years or older. Ultrasonography findings were predictive of cancer (C statistic, 0.89). The risk of cancer was significantly elevated in women with complex cysts or solid masses, with likelihood ratios relative to women with normal ovaries ranging from 8 to 74 and the 3-year risk of cancer ranging from 9 to 430 cases per 1000 women based on patient age and ultrasonography findings. In contrast, the 23.8% of women younger than 50 years and the 13.4% of women 50 years or older with simple cysts were not at a significantly increased risk of ovarian cancer compared with women with normal ovaries. Likelihood ratios associated with the detection of a simple cyst were 0.00 in women younger than 50 years (no cancers were identified) and 0.10 (95% CI, 0.01-0.48) in women 50 years or older, and the absolute 3-year risk of cancer ranged from 0 to 0.5 cases per 1000 women.

CONCLUSIONS AND RELEVANCE

According to this study, the ultrasonographic appearance of ovarian masses is strongly associated with a woman's risk of ovarian cancer. Simple cysts are not associated with an increased risk of ovarian cancer, whereas complex cysts or solid masses are associated with a significantly increased risk of ovarian cancer.

Can Presurgical Ultrasound Predict Survival in Women With Ovarian Masses?

PURPOSE

This study aimed to determine the ability of ultrasound to predict survival and detect more aggressive tumors in women with ovarian masses.

MATERIALS AND METHODS

Institutional review board approval was obtained. A total of 167 patients who presented with adnexal mass/masses were included. These were documented as benign or malignant on ultrasound. Age, date of diagnosis and date of death, type of tumor, and tumor marker cancer antigen 125 (CA-125) values were recorded. A CA-125 value of less than 35 U/mL was considered normal. All cases underwent surgery. Pathologic findings were considered as reference standard. The 2 × 2 cross-tabulations were used to correlate dichotomized CA-125, US diagnosis (benign vs malignant), and pathologic status. Difference of distributions was tested using the Wilcoxon rank sum test, and their association was tested using the Fisher exact test. All tests were 2-sided, and P values of 0.05 or less were considered statistically significant. Kaplan-Meir curves were generated to estimate survival.

RESULTS

There was a statistically significant difference in patients with benign versus malignant tumors based on pathology (P < 0.0001) and ultrasound (P < 0.0003). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ultrasound were 55%, 86%, 90% and 46%, and 81%. Patients diagnosed as having malignant tumors based on ultrasound had statistically significant worse overall survival. Probability of survival based on pathologic diagnosis of malignancy was statistically significant at P < 0.0003; based on ultrasound, P < 0.0001; and based on CA-125, P < 0.041.

CONCLUSION

Patients who had ultrasound-based prediction of ovarian malignancy had overall worse survival probability (P < 0.0001) compared with CA-125- or pathology-based prediction.

[Usefulness and reliability of abdominal point of care ultrasound in family practice (2): Large abdominal vessels, spleen, nephrourological and gynecological ultrasound]

This article is a continuation of the review initiated in the previous issue about the usefulness of point of care ultrasound in Primary Care, completing the scenarios of large abdominal vessels, spleen, nephrourological and gynecological ultrasound.

Ovarian mass-differentiating benign from malignant: the value of the International Ovarian Tumor Analysis ultrasound rules

Ovarian cancer, the fifth most common cause of cancer death among women, has the highest mortality rate of all gynecologic cancers. General survival rate is <50% but can reach 90% if disease is detected early. Ultrasound is presently the best modality to differentiate between benign and malignant status. The patient with a malignant mass should be referred to an oncology surgeon since results have been shown to be superior to treatment by a specialist. Several ultrasound-based scoring systems exist for assessing the risk of an ovarian tumor to be malignant. The International Ovarian Tumor Analysis group published 2 such systems: the ultrasound Simple Rules and the Assessment of Different NEoplasias in the adneXa model. The Simple Rules classifies a tumor as benign, malignant, or indeterminate and the Assessment of Different NEoplasias in the adneXa model determines the risk for a tumor to be benign or malignant and, if malignant, the risk of various stages. Sensitivity of the Simple Rules and Assessment of Different NEoplasias in the adneXa model (using a cut-off of 10% to predict malignancy) are 92% and 96.5%, respectively, and specificities are 96% and 71.3%, respectively. These models are the best predictive tests for the preoperative classification of adnexal tumors. Their intent is to help the specialist make management decisions when faced with a patient with a persistent ovarian mass. The models are simple, are easy to use, and have been validated in multiple reports but not in the United States. We suggest they should be validated and widely introduced into medical practice in the United States.

First International Consensus Report on Adnexal Masses: Management Recommendations

The First International Consensus Conference on Adnexal Masses was convened to thoroughly examine the state of the science and to formulate recommendations for clinical assessment and management. The panel included representatives of societies in the fields of gynecology, gynecologic oncology, radiology, and pathology and clinicians from Europe, Canada, and the United States. In the United States, there are approximately 9.1 surgeries per malignancy compared to the European International Ovarian Tumor Analysis center trials, with only 2.3 (oncology centers) and 5.9 (other centers) reported surgeries per malignancy, suggesting that there is room to improve our preoperative assessments. The American College of Obstetricians and Gynecologists Practice Bulletin on "Management of Adnexal Masses," reaffirmed in 2015 (Obstet Gynecol 2007; 110:201-214), still states, "With the exception of simple cysts on a transvaginal ultrasound finding, most pelvic masses in postmenopausal women will require surgical intervention." The panel concluded that patients would benefit not only from a more conservative approach to many benign adnexal masses but also from optimization of physician referral patterns to a gynecologic oncologist in cases of suspected ovarian malignancies. A number of next-step options were offered to aid in management of cases with sonographically indeterminate adnexal masses. This process would provide an opportunity to improve risk stratification for indeterminate masses via the provision of alternatives, including but not limited to evidence-based risk-assessment algorithms and referral to an "expert sonologist" or to a gynecologic oncologist. The panel believed that these efforts to improve clinical management and preoperative triage patterns would ultimately improve patient care.

Ultrasound Monitoring of Extant Adnexal Masses in the Era of Type 1 and Type 2 Ovarian Cancers: Lessons Learned From Ovarian Cancer Screening Trials

Women that are positive for an ovarian abnormality in a clinical setting can have either a malignancy or a benign tumor with probability favoring the benign alternative. Accelerating the abnormality to surgery will result in a high number of unnecessary procedures that will place cost burdens on the individual and the health delivery system. Surveillance using serial ultrasonography is a reasonable alternative that can be used to discover if changes in the ovarian abnormality will occur that favor either a malignant or benign interpretation. Several ovarian cancer screening trials have had extensive experiences with changes in subclinical ovarian abnormalities in normal women that can define growth, stability or resolution and give some idea of the time frame over which changes occur. The present report examines these experiences and relates them to the current understanding of ovarian cancer ontology, presenting arguments related to the benefits of surveillance.

Ten Important Considerations for Ovarian Cancer Screening

The unique intricacies of ovarian cancer screening and perspectives of different screening methods are presented as ten considerations that are examined. Included in these considerations are: (1) Deciding on the number of individuals to be screened; (2) Anticipating screening group reductions due to death; (3) Deciding on the duration and frequency of screening; (4) Deciding on an appropriate follow-up period after screening; (5) Deciding on time to surgery when malignancy is suspected; (6) Deciding on how screen-detected ovarian cancers are treated and by whom; (7) Deciding on how to treat the data of enrolled participants; (8) Deciding on the most appropriate way to assign disease-specific death; (9) Deciding how to avoid biases caused by enrollments that attract participants with late-stage disease who are either symptomatic or disposed by factors that are genetic, environmental or social; and (10) Deciding whether the screening tool or a screening process is being tested. These considerations are presented in depth along with illustrations of how they impact the outcomes of ovarian cancer screening. The considerations presented provide alternative explanations of effects that have an important bearing on interpreting ovarian screening outcomes.

Ovarian Cancer Incidence Corrected for Oophorectomy

Current reported incidence rates for ovarian cancer may significantly underestimate the true rate because of the inclusion of women in the calculations who are not at risk for ovarian cancer due to prior benign salpingo-oophorectomy (SO). We have considered prior SO to more realistically estimate risk for ovarian cancer. Kentucky Health Claims Data, International Classification of Disease 9 (ICD-9) codes, Current Procedure Terminology (CPT) codes, and Kentucky Behavioral Risk Factor Surveillance System (BRFSS) Data were used to identify women who have undergone SO in Kentucky, and these women were removed from the at-risk pool in order to re-assess incidence rates to more accurately represent ovarian cancer risk. The protective effect of SO on the population was determined on an annual basis for ages 5-80+ using data from the years 2009-2013. The corrected age-adjusted rates of ovarian cancer that considered SO ranged from 33% to 67% higher than age-adjusted rates from the standard population. Correction of incidence rates for ovarian cancer by accounting for women with prior SO gives a better understanding of risk for this disease faced by women. The rates of ovarian cancer were substantially higher when SO was taken into consideration than estimates from the standard population.

Complications from Surgeries Related to Ovarian Cancer Screening

The aim of this study was to evaluate complications of surgical intervention for participants in the Kentucky Ovarian Cancer Screening Program and compare results to those of the Prostate, Lung, Colorectal and Ovarian Cancer Screening trial. A retrospective database review included 657 patients who underwent surgery for a positive screen in the Kentucky Ovarian Cancer Screening Program from 1988–2014. Data were abstracted from operative reports, discharge summaries, and office notes for 406 patients. Another 142 patients with incomplete records were interviewed by phone. Complete information was available for 548 patients. Complications were graded using the Clavien–Dindo (C–D) Classification of Surgical Complications and considered minor if assigned Grade I (any deviation from normal course, minor medications) or Grade II (other pharmacological treatment, blood transfusion). C–D Grade III complications (those requiring surgical, endoscopic, or radiologic intervention) and C–D Grade IV complications (those which are life threatening) were considered “major”. Statistical analysis was performed using SAS 9.4 software. Complications were documented in 54/548 (10%) subjects. For women with malignancy, 17/90 (19%) had complications compared to 37/458 (8%) with benign pathology (p < 0.003). For non-cancer surgery, obesity was associated with increased complications (p = 0.0028). Fifty patients had minor complications classified as C–D Grade II or less. Three of 4 patients with Grade IV complications had malignancy (p < 0.0004). In the Prostate, Lung, Colorectal and Ovarian Cancer Screening trial, 212 women had surgery for ovarian malignancy, and 95 had at least one complication (45%). Of the 1080 women with non-cancer surgery, 163 had at least one complication (15%). Compared to the Prostate, Lung, Colorectal and Ovarian Cancer Screening trial, the Kentucky Ovarian Cancer Screening Program had significantly fewer complications from both cancer and non-cancer surgery (p < 0.0001 and p = 0.002, respectively). Complications resulting from surgery performed as a result of the Kentucky Ovarian Cancer Screening Program were infrequent and significantly fewer than reported in the Prostate, Lung, Colorectal and Ovarian Cancer Screening trial. Complications were mostly minor (93%) and were more common in cancer versus non-cancer surgery.