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“Serial ultrasonography has shown that many ovarian abnormalities resolve, even if the initial appearance is complex, solid, or bilateral. Thus, it is advantageous to avoid a single transvaginal ultrasonographic abnormality as the sole trigger for surgery and to take a measured serial approach to reduce false-positive results and increase the PPV (positive predictive value).”
Pavlik EJ, Ueland FR, Miller RW, et al
Obstet Gynecol. 2013;122:210-217
The incidence of ovarian cancer is 12.5 per 100,000 females. A woman has a 1 in 70 chance in her life to be diagnosed with an ovarian malignancy. The mean age at diagnosis is 63 years, and about 10% of the cancers are diagnosed in women younger than 45 years old. Survival is affected by the stage of the disease at diagnosis. The overall survival rate was 44.2% between 2003 and 2009. The survival rate, however, is close to 90% when the disease is confined to the ovary but only about 25% when the disease has already given metastasis.
Advanced-stage cancer carries a poor prognosis, and unfortunately the majority of cases are already at stage III-IV at the time of detection. Therefore, researchers have spent the past few decades searching for effective screening tools, but because of the relatively low prevalence of the disease, even those screening tests that are associated with high sensitivity and specificity have a poor positive predictive value.
Assessment of the individual’s risk is based on reproductive factors, family background, symptom history, transvaginal ultrasound, and tumor markers. If needed, more expensive imaging studies can be considered as screening tools.
Certain ultrasound findings (increased ovarian volume, presence of septae, papillary projections, and increased flow) may all suggest malignancy. Elevated tumor markers (mainly CA 125) have been associated with epithelial cancers. This study assessed the benefits of serial transvaginal ultrasound in the management of adnexal masses as part of an ovarian cancer screening program.
The study group included 39,337 women who enrolled in the University of Kentucky Ovarian Cancer Screening Program. This report is based on those women who had an abnormal transvaginal scan during the study period between 1987 and 2012. Researchers enrolled women over the age of 50 years who did not have symptoms indicating ovarian pathology. They also enrolled asymptomatic women over the age of 25 years with a family history of ovarian cancer. The findings on transvaginal ultrasound were considered abnormal when the ovarian volume was enlarged and when cysts, septae, papillary protrusions, or solid areas were found. In cases of abnormal findings, a follow-up scan was arranged in 6 weeks to 6 months.
Surgery was recommended for cases in which the size of the ovary or the complexity of the structure increased during follow-up or if the patient developed clinical symptoms suggesting a possible malignancy.
Almost one fifth of the participants (6807) had an abnormal ultrasound at some point during the study period. About half of these patients had the abnormality picked up on the first scan. In two thirds of these cases, the follow-up scan did not find the abnormality anymore. The majority of the participants (80.9%) never had an abnormal scan.
Most abnormalities were found in premenopausal women, and they were mainly simple cysts or cysts with septae. Complex abnormalities (cysts with solid areas and solid cysts) were more likely to resolve during follow-up, and the time to resolution was significantly less when compared with simple cysts (8 weeks vs 55 weeks).
Among those operated on, 85 true positive malignancies and 472 benign adnexal masses were found (positive predictive value: 15.3%). The positive predictive value did change over time and with serial ultrasounds increased from 8% to 24.7%.
The authors concluded that for low-risk women, serial transvaginal ultrasound surveillance is an option and could reduce the number of surgeries performed for benign lesions that resolve on their own.
Ovarian cancer is the second most common cancer of the reproductive tract but is the leading cause of death due to malignancy of the reproductive organs. The main problem in preventing early diagnosis is the lack of effective screening tools. Certain well-known risk factors, including family history and genetic mutations, increase the risk of ever being diagnosed with cancer, and women with these factors would particularly benefit from effective screening.
The symptoms associated with ovarian cancer (abdominal pain, abdominal bloating, appetite change) are not necessarily specific enough to raise the concern of the patient or physician. There are certain tumor markers that are usually elevated in cancers of epithelial origin, but these are also elevated with fibroids, pelvic infections, endometriosis, liver disease, menstruation, and pregnancy and, therefore, have a limited role in premenopausal women.
Ultrasound is an excellent imaging modality of the female reproductive organs. It may detect size change, cysts, septae, papillary projections, and solid areas. Doppler can also measure flow in the ovary.
Complex adnexal masses (cysts with septae, solid components) do raise the possibility of malignancy, but many benign tumors and hemorrhagic functional cysts may have similar sonographic appearance. A previous report showed that complex cysts (cysts with septae) can be followed by serial ultrasounds because close to 40% of them regress spontaneously. According to the report, none of the patients who had surgery for the complex cysts were diagnosed with cervical cancer. Only 1 patient was diagnosed with ovarian cancer 3.2 years after the initial diagnosis of the cyst.
Screening for ovarian cancer remains challenging. It is important to assess the individual’s risk based on her history. It is equally important to look for any symptoms that may suggest malignancy. On physical exam, the size of the mass and its mobility need to be assessed. Ultrasonographic findings and tumor markers could further raise suspicion. Low-risk patients can probably be safely followed with serial ultrasounds; and if there is an increase in size or complexity of the mass or if new clinical symptoms develop, surgery can be performed to establish the correct diagnosis. High-risk patients should undergo surgical evaluation when suspicion is raised based on imaging studies or clinical symptoms. The management of intermediate-risk patients remains difficult. In their case, serial ultrasounds with close follow-up and a low threshold for surgery could be recommended. Obviously, the current findings will need to be confirmed by other groups in a more everyday setting, and the optimal follow-up intervals need to be established as well.
Frequency and Disposition of Ovarian Abnormalities Followed with Serial Transvaginal Ultrasonography.
Obstet Gynecol. 2013; 122(2 Pt 1):210-7 (ISSN: 1873-233X)
Pavlik EJ; Ueland FR; Miller RW; Ubellacker JM; DeSimone CP; Elder J; Hoff J; Baldwin L; Kryscio RJ; van Nagell JR
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, the University of Kentucky Chandler Medical Center-Markey Cancer Center, Lexington, Kentucky 40536, USA. firstname.lastname@example.org
OBJECTIVE: To examine the prevalence, incidence, persistence, and resolution of ovarian abnormalities using serial transvaginal ultrasonography.
METHODS: A group of 39,337 women in the University of Kentucky Ovarian Cancer Screening Program were monitored with 221,576 baseline and interval transvaginal ultrasonography.
RESULTS: The transvaginal ultrasonogram was normal for first and all subsequent visits for 31,834 participants (80.9%), whereas 6,807 women (17.3%) had transvaginal ultrasonograms interpreted as abnormal and were monitored over 21,588 ultrasonograms. Ovarian cysts were more common in premenopausal (prevalence 34.9%, incidence 15.3%) than in postmenopausal women (prevalence 17.0%, incidence 8.2%). For the group with abnormalities, the initial transvaginal ultrasonogram was abnormal in 46.7% of the cases, of which 63.2% resolved to normal on subsequent ultrasonograms. Of 35,314 cases classified as normal on the first examination, 9.9% were abnormal on subsequent annual examinations. The abnormal findings were classified as follows: unilocular cysts (11.5%), cysts with septations (9.8%), cysts with solid areas (7.1%), and solid masses (1.8%). Many transvaginal ultrasonographic abnormalities were followed to resolution. Surgery was performed on 557 participants for 85 ovarian malignancies and 472 nonmalignancies. Over the duration of the study, the positive predictive value (PPV) increased from 8.1% to 24.7%.
CONCLUSION: Serial ultrasonography has shown that many ovarian abnormalities resolve, even if the initial appearance is complex, solid, or bilateral. Thus, it is advantageous to avoid a single transvaginal ultrasonographic abnormality as the sole trigger for surgery and to take a measured serial approach to reduce false-positive results and increase the PPV.
LEVEL OF EVIDENCE: II.