Audit of transvaginal sonography of normal postmenopausal ovaries by sonographers from the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS)

Background: We report on a unique audit of seven sonographers self-reporting high visualization rates of normal postmenopausal ovaries in the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS).  This audit was ordered by the trial's Ultrasound Management Subcommittee after an initiative taken in 2008 to improve the quality of scanning and the subsequent increase in the number of sonographers claiming very high ovary visualisation rates. Methods: Seven sonographers reporting high rates (>89%) of visualizing normal postmenopausal ovaries in examinations performed between 1 st January and 31 st December 2008 were identified. Eight experts in gynaecological scanning reviewed a random selection of exams performed by these sonographers and assessed whether visualization of both ovaries could be confirmed (cVR-Both) in the examinations. A random effects bivariate probit model was fitted to analyse the results.  Results: The eight experts reviewed images from 357 examinations performed on 349 postmenopausal women (mean age 60.0 years, range 50.2-73.3) by the seven sonographers. The mean cVR-Both obtained from the model for these sonographers was 67.2% with a range of 47.6-86.5% (95%CI 63.9-70.5%). The range of cVR-Both between the experts was 47.3-88.3% and the intra-class correlation coefficient (ICC) for left and right ovary confirmation was 0.39.     Conclusions: The audit suggests that self-reported visualization of postmenopausal ovaries is unreliable, as visualisation of both ovaries could not be confirmed in almost a third of examinations. The agreement for visualization of both ovaries based on review of a static image between experts and sonographers and between expert reviewers alone was only moderate. Further research is needed to develop reliable Quality Control metrics for transvaginal ultrasound.

Sonographers' self-reported visualization of normal postmenopausal ovaries on transvaginal ultrasound is not reliable: results of expert review of archived images from UKCTOCS

OBJECTIVE

In the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS), self-reported visualization rate (VR) of the ovaries by the sonographer on annual transvaginal sonographic (TVS) examinations was a key quality control (QC) metric. The objective of this study was to assess self-reported VR using expert review of a random sample of archived images of TVS examinations from UKCTOCS, and then to develop software for measuring VR automatically.

METHODS

A single expert reviewed images archived from 1000 TVS examinations selected randomly from 68 931 TVS scans performed in UKCTOCS between 2008 and 2011 with ovaries reported as 'seen and normal'. Software was developed to identify the exact images used by the sonographer to measure the ovaries. This was achieved by measuring caliper dimensions in the image and matching them to those recorded by the sonographer. A logistic regression classifier to determine visualization was trained and validated using ovarian dimensions and visualization data reported by the expert.

RESULTS

The expert reviewer confirmed visualization of both ovaries (VR-Both) in 50.2% (502/1000) of the examinations. The software identified the measurement image in 534 exams, which were split 2:1:1 providing training, validation and test data. Classifier mean accuracy on validation data was 70.9% (95% CI, 70.0-71.8%). Analysis of test data (133 exams) provided a sensitivity of 90.5% (95% CI, 80.9-95.8%) and specificity of 47.5% (95% CI, 34.5-60.8%) in detecting expert confirmed visualization of both ovaries.

CONCLUSIONS

Our results suggest that, in a significant proportion of TVS annual screens, the sonographers may have mistaken other structures for normal ovaries. It is uncertain whether or not this affected the sensitivity and stage at detection of ovarian cancer in the ultrasound arm of UKCTOCS, but we conclude that QC metrics based on self-reported visualization of normal ovaries are unreliable. The classifier shows some potential for addressing this problem, though further research is needed. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Prospective study of venous thromboembolism in patients with head and neck cancer after surgery

IMPORTANCE

Venous thromboembolism (VTE) is associated with significant morbidity and mortality in surgery patients, but little data exist on the incidence of VTE in head and neck cancer surgical patients.

OBJECTIVE

To determine the incidence of VTE in postoperative patients with head and neck cancer.

DESIGN, SETTING, AND PARTICIPANTS

A prospective study of 100 consecutive patients hospitalized at a tertiary care academic surgical center who underwent surgery to treat head and neck cancer. Routine chemoprophylaxis was not used. On postoperative day (POD) 2 or 3, participants received clinical examination and duplex ultrasonographic evaluation (US). Participants with negative findings on clinical examination and US were followed up clinically; participants with evidence of deep venous thrombosis (DVT) or pulmonary embolism (PE) were given therapeutic anticoagulation. Participants with superficial VTE underwent repeated US on POD 4, 5, or 6. Participants were monitored for 30 days after surgery.

MAIN OUTCOME AND MEASURE

Total number of new cases of VTE (superficial and deep) identified within 30 days of surgery and confirmed on diagnostic imaging.

RESULTS

Of the 111 participants enrolled, 11 withdrew before completing the study; thus, 100 participants were included. The overall incidence of VTE was 13%. Eight participants were identified with clinically significant VTE: 7 DVT and 1 PE. An additional 5 participants had asymptomatic lower extremity superficial VTE detected on US alone. Fourteen percent of patients received some form of postoperative anticoagulation therapy; the rate of bleeding complications in these patients (30.1%) was higher than that in patients without anticoagulation therapy (5.6%) (P = .01).

CONCLUSIONS AND RELEVANCE

Hospitalized patients with head and neck cancer not routinely receiving anticoagulation therapy after surgery have an increased risk of VTE. Bleeding complications are elevated in patients receiving postoperative anticoagulation.

Prospective study of venous thromboembolism in patients with head and neck cancer after surgery: interim analysis

OBJECTIVES

To prospectively determine the incidence of venous thromboembolism (VTE) following major head and neck surgery. At the midpoint of enrollment, an interim analysis was performed to determine if it was ethical to continue this study as an observational study without routine anticoagulation.

DESIGN

Prospective, observational cohort study.

SETTING

Academic surgical center.

PATIENTS

The interim analysis comprised 47 subjects.

MAIN OUTCOME MEASURE

The total number of new cases of VTE (superficial and deep) identified within 30 days of surgery and confirmed on diagnostic imaging. These cases were further categorized as clinically relevant and nonclinically relevant. Clinically relevant VTEs were those requiring more than 6 weeks of anticoagulation or were associated with any negative impact on clinical course. On postoperative day 2 or 3, subjects were clinically examined and received duplex ultrasonography. Subjects with negative findings from examination and ultrasonography were followed up clinically; subjects with evidence of deep venous thrombus or pulmonary embolism were given therapeutic anticoagulation. Subjects with superficial VTE received repeated ultrasonography on postoperative days 4 to 6. Subjects were monitored for 30 days after surgery.

RESULTS

Three subjects (6%) were identified as having clinically significant VTE: 2 cases of deep venous thrombus and 1 case of pulmonary embolism. Two additional subjects had lower extremity superficial VTE without clinical findings, which were detected by ultrasonography alone. No statistically significant differences were seen between patients with VTE and those without VTE.

CONCLUSIONS

This interim analysis of the first prospective study of the incidence of VTE in patients with head and neck cancer showed a VTE rate slightly higher than previously estimated in retrospective studies. There have been no unexpected serious adverse events and no rationale for early termination of the study.

Overall survival (OS) and risk of distant failure among malignant salivary gland tumors (MSGTs) in a large single-institution registry cohort

e16045

Background: MSGTs are rare, biologically diverse cancers. Registry data and large series suggest 5-year OS exceeding 50%, superior to historical data and attributed to postoperative radiation (pXRT). Hypothesizing OS has remained poor despite modern therapy, we reviewed our cancer registry (OHSUCR), which began collecting data on MSGTs in 1995. Methods: We interrogated the OHSUCR for pts with MSGTs (WHO classification) and obtained data on age, sex, race, AJCC stage, histology, primary site, surgery, pXRT. OS was estimated using the Kaplan Meier (KM) method. The log rank test was used to compare OS among pts treated with and without pXRT, and those diagnosed between 1995-2000, 2001-2005, and 2005-present. Results: 110 pts with MSGTs were entered into the OHSUCR from 5/1996 to 5/2011. The median age was 60 (range 10-90), 65 (59%) were male, and 106 (96%) were white. The primary site was: 101 (92%) parotid, 3 (3%) unspecified major salivary gland, 4 (3%) submandibular gland, and 2 (2%) minor salivary gland. MSGT histologies were: 41 (37%) mucoepidermoid carcinoma, 24 (22%) adenoid cystic carcinoma, 21 (19%) adenocarcinoma, 12 (11%) acinar cell carcinoma, 5 (4%) carcinoma ex pleomorphic adenoma, 3 (3%) epithelial-myoepithelial carcinoma, 1 (1%) undifferentiated carcinoma, 1 (1%) small cell carcinoma, 1(1%) salivary duct carcinoma, 1 (1%) carcinosarcoma. AJCC Stage was: I in 29, (26%) II in 20 (18%), III in 16 (15%), IV in 45 (41%). 102 (96%) underwent surgical resection, 73 (66%) pXRT. 89 (81%) pts were rendered disease free, although 23 (21%) eventually recurred, 20 in distant sites. At the time of analysis 57 (52%) pts were alive and disease free. With a median follow up of 30 months (range 1 to 165), the 5 year KM OS for the entire cohort is 46%. Median survival was not influenced by pXRT (p=0.93) or period of diagnosis (1995-2000, 2001-2005, or 2005-present; p=0.83). Conclusions: In this large single institution series, pts with MSGT remain at high risk for mortality despite routine administration of pXRT. Distant metastasis is the most common pattern of failure indicating a clear unmet need for improved systemic therapy for MSGTs.

Outcomes of surveillance in unselected patients with clinical stage I testicular germ cell tumors: Results of a modern single institution series

5085

Background: Orchiectomy is curative in 50–80% of patients (pts) with clinical stage I testicular germ cell cancer (CSITC) and modern chemotherapy at the time of relapse is nearly always curative. Traditional management in the US and Europe, which includes retroperitoneal lymph node dissection (RPLND) or adjuvant radiation or chemotherapy, imposes a significant treatment burden on all patients with CSITC. This study investigated outcomes of active surveillance in all pts with CSITC, with additional post-orchiectomy therapy reserved for only those pts who recur. Methods: Since 1998, Oregon Health & Science University’s institutional policy has been to recommend active surveillance alone to all CSITC pts after orchiectomy, independent of known risk factors. We retrospectively identified and reviewed the charts of 90 pts with CSITC treated between 1998 and 2006. Prognostic factors for relapse, time to relapse, post-orchiectomy treatment required, and overall survival rates were tabulated. Results: Of the 53 pts with CSI nonseminoma, complete data are currently available for 36. 12 (33%) relapsed at a median of 6 months (range 3–48) and all received 3 cycles of bleomycin, etoposide, and cisplatin (BEP). 2 pts (5.5% of total population) required RPLND post-chemotherapy for residual teratoma. No additional relapses have been seen, and all 36 pts are alive at a median follow-up of 51 months. Of 37 pts with CSI seminoma, complete data are available for 28. Seven pts (25%) experienced abdominal relapse, at a median of 10 months (range 3–14 months) after orchiectomy. All 7 pts were treated with abdominal radiation. Two pts subsequently relapsed and were cured with chemotherapy. All CSITC pts are alive without disease at a median follow-up of 60 months. Complete data on all 90 pts will be available this spring. Conclusion: This, the largest modern US series of surveillance alone after orchiectomy, resulted in uniformly excellent outcomes suggesting that primary active surveillance reduces the global burden of treatment for pts with CSITC and is appropriate for all pts with clinical stage I disease, independent of clinical risk factors or pathological subtype.

No significant financial relationships to disclose.

Maternal cocaine use without evidence of fetal exposure

We report a case of lack of fetal exposure to cocaine and benzoylecgonine as evidenced by meconium and hair analysis, but exposure to nicotine and its metabolite cotinine, after extensive maternal use of cocaine and nicotine. These data suggest that the mode of maternal use of cocaine and individual differences in placental handling of the drug may protect some fetuses, and highlight the need to address interpatient variability.