Improving the quality of pre-operative ultrasound examination (ultrasonography) could lead to a significant decrease in the number of unnecessary major surgical operations done on women with suspected ovarian cancer, who in fact have benign ovarian disease, according to an Article to be published early Online and in the February issue of The Lancet Oncology.
Ultrasonography is routinely used to assess women with various gynaecological symptoms including the detection of adnexal abnormalities*. However, the diagnostic accuracy of ultrasonography for preoperative differentiation between benign and malignant adnexal tumours is variable and depends on the experience and skill of the operator. Studies have shown that gynaecological ultrasonography done by experts can distinguish between benign and malignant adnexal tumours with an accuracy of 95%. However, the accuracy of routine ultrasonography, which is usually done by less experienced operators, is likely to be lower. Whether improved diagnostic accuracy has a measurable effect on the management of these tumours is still unclear.
Therefore, Dr Joseph Yazbek (Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK) and colleagues did a randomised trial to assess the effect of the quality of gynaecological ultrasonography on the management of women with suspected ovarian cancer. They studied 165 patients who were referred to the regional Southeast Gynaecological Cancer Centre (London, UK) with suspected adnexal tumours between June 2004 and April 2006. Of these patients, 77 were randomly assigned to level III ultrasonography (expert)** and 73 were randomly assigned to level II ultrasonography (routine)***.
The number of major surgical staging procedures for suspected ovarian cancer was significantly higher after a routine scan (level II) than after level III (expert) ultrasonography (27 of 73 [37%] vs 17 of 77 [22%]). All women with proven ovarian cancer, however, received appropriate surgical treatment and the decrease in the number of major surgeries was limited to women with benign ovarian disease. Crucially, a conclusive ultrasonographic diagnosis of the nature of the adnexal tumour was made in 76 of 77 (99%) patients in the level III group compared with only 38 of 73 (52%) patients in the level II group, and the authors hypothesise that this could have led to more minimally invasive procedures in the level III group (27%) than in the level II group (6%) which contributed to the significant decrease in the length of hospital stay in the level III group.
The authors conclude: "In the UK, the number of examiners who specialise in gynaecological ultrasonography is low...To achieve a high diagnostic accuracy, ultrasonography imaging needs to be combined with clinical history and physical examination. This method has been recognised by the Royal College of Obstetricians and Gynaecologists who have integrated gynaecological ultrasonography training into core and advanced specialty training in gynaecology; [but] until the number of highly trained gynaecological ultrasonographers is increased, efforts should be made to provide expert ultrasonography at least in tertiary referral units."
Dr Joseph Yazbek, King's College Hospital NHS Foundation Trust, London, UK. T) +44(0)203 299 3299/1702 Mobile) +44(0)78 0118 9868 joseph.yazbek@gmail.com
Mr Davor Jurkovic, King's College Hospital NHS Foundation Trust, London, UK. T) +44(0)203 299 1702 davor.jurkovic@kcl.ac.uk
Notes to Editors
* Adnexal abnormalities are ovarian tumours.
**Level III examiners had more than 10 years' experience in gynaecological ultrasonography; worked in a tertiary referral unit; had been continuously involved in research in the field of in gynaecological ultrasonography; and were recognised preceptors for the training of gynaecological ultrasonography by the Royal College of Obstetrics and Gynaecologists.
***Level II ultrasonography was done by ultrasonographers who were trained in gynaecological ultrasonography and all routinely and independently assessed patients with adnexal tumours who were referred for a second opinion from other units.
The paper associated with this release can be viewed at http://www.eurekalert.org/jrnls/lance/TLOultrasoundfinal.pdf.
Journal
The Lancet Oncology