CAN TV U/S REDUCE THE

Transcription

1 CAN TV U/S REDUCE THE NEED FOR SURGERY IN GYNECOLOGY? Steven R. Goldstein, M.D. Professor of Obstetrics & Gynecology New York University it School of fmedicine i Director of Gynecologic Ultrasound Co-Director of Bone Densitometry New York University Medical Center

2 WHERE CAN WE AVOID SURGICAL INTERVENTION? BENIGN OVARIAN LESIONS (SOME SELF LIMITED, SOME BEST TREATED MEDICALLY) POSTMENOPAUSAL SIMPLE CYSTS (EXPECTANT MANAGEMENT)

3 WHERE CAN WE AVOID SURGICAL INTERVENTION? PREMENOPAUSAL BLEEDING THAT IS ANOVULATORY POST MENOPAUSAL BLEEDING THAT IS ATROPHIC POSTMENOPAUSAL ENDOMETRIAL FLUID COLLECTIONS SOME CYSTADENOFIBROMAS (?)

4 REALIZE THAT THE FIELD HAS A LEARNING CURVE JUST LIKE INDIVIDUALS HAVE A LEARNING CURVE

5 THUS A DIFFERENTIAL Dx ON AN ADNEXAL MASS YEARS AGO THAT SAID COMPLEX MASS COMPATIBLE WITH HEMORRHAGIC CORPUS LUTEUM, DERMOID,ENDOMETRIOMA NEOPL ASIA CANNOT BE RULED OUT IS ALMOST NEVER APPLICABLE TODAY

6 Vaginal sonography can often definitively distinguish endometriomas from hemorrhagic corpora lutea from masses more suspicious for neoplasia.

7 ENDOMETRIOMAS Diffuse uniform internal echoes with vaginal probe Variable appearance on transabdominal ultrasound (such internal echoes may appear sonolucent) Should not be confused for a solid mass (will demonstrate some acoustic enhancement) Increasingly handled with endoscopic surgery (or even non surgically)

8 HEMORRHAGIC CORPORA LUTEA Functional, bleeding into site of ovulation As blood organizes sonographic appearance depends where along the maturation process it is viewed Begins as diffuse echogencity (less uniform then endometriomas), becomes a reticular cobweb pattern, finally from clot retraction can even mimic papillary projections

9 HEMORRHAGIC CORPORA LUTEA Invariably y self-limited If so recognized any operative intervention ti (diagnostic or therapeutic) can be avoided

10 NEOPLASIA (ESPECIALLY MALIGNANCY) Role of color Doppler Morphologic characteristics can result in very high h negative predictive value

11 VARIOUS SCORING SYSTEMS UTILIZE MORPHOLOGIC FEATURES (Granberg 1990, Sassone 1991, DePriest 1993, Lerner 1994) Unilocular vs. septated Inner wall structure (thick vs. thin) Presence of wall papillations or irregularities Echogenicity Solid components

12 META ANALYSIS SSOF THESE SCORING SYSTEMS (Ferrazzi, 1997 Ultrasound Obstet Gynecol) Positive predictive valve 36% Negative predictive valve 97%

13 In addition,very small findings WHOLLY contained within the ovary may often be managed non surgically with medication (endometriomas) or observation (dermoids)

14 WHAT ABOUT POST MENOPAUSAL OVARIES vs. CYSTIC MASSES

15 HOW DID WE GET WHEREWEARE WE TODAY?

16 IN THE BEGINNING

17 1971 THE PALPABLE POSTMENOPAUSAL OVARY SYNDROME

18 PPMO (Palpable Post Menopausal Ovary) Syndrome Barber and Graber Obstet Gynecol 1971;38:921 An ovary that would be considered normal sized in a premenopausal women should be considered abnormal in a postmenopausal women

19 PPMO (Palpable Post Menopausal Ovary) Syndrome Barber and Graber Obstet Gynecol 1971;38:921 and probably harbors a tumor not necessarily malignant but not functional or dysfunctional.

20 PPMO Revisited: 1984 Patients with palpable postmenopausal ovary syndrome should not be followed up or reevaluated but must be investigated t promptly for the presence or absence of an ovarian tumor

21 PPMO Revisited: 1984 the only method of diminishing the mortality from ovarian cancer is the acceptance of more liberal indications of surgery. Barber, 1984

22 When first introduced ultrasound showed cystic changes so easily ypeople p applied this technology to the old concept of this PPMO Syndrome

23 WHAT DO THESE STRUCTURES LOOK LIKE?

24 1989

25

26 CONCLUSIONS (1989) We concluded that small (<5 cm) unilocular, unilateral postmenopausal adnexal cystic masses, with no septations or ascites will have a very low incidence of malignant disease

27 CONCLUSIONS (1989) therefore serial ultrasound follow-up without surgical intervention ti may play a role in clinical management of such patients.

28 1992

29 ADNEXAL CYSTS in Postmenopausal women Levine, Gosink, Wolf et al, (Radiology, 1992;184:653) 184 asx. women scanned with TV U/S 17.3% had simple adnexal cysts

30 1998

31 Cysts < 10 cm in asymptomatic ti post menopausal women > 50 years 7705 women scanned, 236 (3.3%) had unilocular cystic adnexal masses 49% resolved in 60 days, 51% persisted 45 women operated, none malignant (32 cystadenomas) Bailey CL, et al, Gyncol Oncol 1998; 69:1-2

32 CRUCIAL Take Home Message Unlike cervix (dysplasia), breast (DCIS,LCIS), and endometrium (hyperplasias) where I spend much of my day as a clinician looking for precancers BEFORE they become malignant.

33 CRUCIAL Take Home Message there is no evidence that this is true in epithelial ovarian cancer In other words benign cystadenomas do not BECOME cystadenocarcinomas If they did we would have to remove all of these simple cystic structures since 2/3 are consistently shown to be cystadenomas

34 2003

35 UNILOCULAR OVARIAN CYSTS (University of Kentucky Ovarian Cancer Screening Program) 15,106 asx. women > 50 years of age screened with transvaginal ultrasound yearly from (18%) had unilocular cysts Modesitt SC, et al. Obstet Gynecol. 2003;102:594-9.

36 UNILOCULAR OVARIAN CYSTS (Con t). Of 2763 women with cysts ultimately 10 (0.3%) were later diagnosed with cancer But none of those 10 cancers arose IN the unilocular cysts!! Modesitt SC, et al. Obstet Gynecol. 2003;102:594-9.

37 2010

38 Prevalence, incidence, and natural history of simple ovarian cysts among women >55 years old Greenlee RT, et al. AJOG April 2010 PLCO (Prostate, Lung, Colorectal, and Ovarian) cancer screening program 15,735 women aged underwent TV U/S Scanned initially and then yearly for 3 additional years

39 Prevalence, incidence, and natural history of simple ovarian cysts among women >55 years old Greenlee RT, et al. AJOG April % of women had a simple cyst. 32% resolved the following year (presumably few were functional) In previous cyst free women 8% developed a cyst per year for 3 years, equally distributed through all age groups

40 Prevalence, incidence, and natural history of simple ovarian cysts among women >55 years old Greenlee RT, et al. AJOG April 2010 Women whose initial U/S had a cyst did not have any increased risk of SUBSEQUENT ovarian cancer (9/2217 or 0.41%) compared with their counterparts with no cysts (55/12,638 or 0.44%; p=0.85) This is almost identical to the University of Kentucky screening program data.

41 CONCLUSIONS: SIMPLE ADNEXAL CYSTS IN PM WOMEN 1) NOT ALL CYSTIC ADNEXAL STRUCTURES ARE OVARIAN IN ORIGIN 2) VAGINAL PROBE WILL IDENTIFY MANY SMALL SONOLUCENCES (AS MANY AS 18% OF WOMEN) 3) STUDIES WITH SURGICAL CONFIRMATION INDICATE THAT THE INCIDENCE OF SUCH SIMPLE CYSTS BEING MALIGNANT APPROACHES ZERO

42 CONCLUSIONS: SIMPLE ADNEXAL CYSTS IN PM WOMEN Of those with pathologic confirmation about 2/3 are benign cystadenomas No evidence that BENIGN epithelial ovarian tumors TRANSFORM into malignant (in other words cystadenomas do not become cystadenocarcinomas)

43 SRU CONSENSUS PANEL (OCTOBER,2009) 14 radiologists, i gynecologists, pathologists, t gyn oncs, REIs met for 1 1/2 days in Chicago Panel concluded that in PM women: -simple cysts <1cm are clinically inconsequential,may or may not be reported at MDs discretion, and need no F/U -simple cysts >1, but <7cm should be described but statement added that they are almost certainly benign Yearly F/U at least initially is recommended -simple cysts >7cm may be difficult to assess completely with U/S and therefore surgical exploration or further imaging (MRI) should be considered

44 AN U/S APPROACH TO ABNORMAL UTERINE BLEEDING

45 Ultrasonography-based triage for perimenopausal patients with abnormal uterine bleeding Ste en R Goldstein MD Ilana Zeltser BS Camile K Steven R. Goldstein, MD, Ilana Zeltser, BS, Camile K. Horan, RDMS, Jon R. Snyder, MD, and Lisa B. Schwartz, MD. Am J Obstet Gynecol 1997;177:102-8

46 OF 433 PATIENTS: 342 (78.9%) had dysfunctional bleeding 23 (5.3%) had submucous myomas 58 (13.4%) had polyps of which 3 were endocervical 15 (3.5%) had hyperplasia (of which 5 were symmetrical, 4 were focal, and 6 were in polyps

47 THUS IF 79% OF PREMENOPAUSAL WOMEN WITH AUB HAVE DYSFUNCTIONAL /ANOVULATORY BLEEDING SUCH AN U/S BASED APPROACH CAN AVOID ANY SURGICAL INTERVENTION

48 ADD ACOG REC ABOUT NO BIOPSY SHOW VALIDATION SHOW 1 IN 917 STUDIES SHOW ONLY (MOST 3-7%) OF PMB WILL HAVE CANCER WHEN US CAN REVEAL LACK OF TISSUE THESE WOMEN CAN AVOID ANY INTERVENTION

49 HOW ABOUT PATIENTS WITH POSTMENOPAUSAL BLEEDING? 1-14% HAVE ENDOMETRIAL CANCER (MOST STUDIES ARE 3-7%) THUS 93-97% DO NOT!!!

50 WHEN US CAN REVEAL LACK OF TISSUE THESE WOMEN CAN AVOID ANY INTERVENTION

51 ACOG Committee Opinion (2/09) When transvaginal ultrasound is performed for patients with postmenopausal bleeding and an EM thickness < 4mm is found EM sampling is not required

52 WHAT IS THIS BASED ON?

53 Endometrial Thickness and Cancer Findings in Postmenopausal Women With Bleeding Reference Endometrial thickness* Number of women Number of cancers Negative Predictive Value Karlsson mm 1, % Ferrazzi mm % < 5 mm % Gull mm % Epstein 2001 < 5mm % Gull mm %

54 TRANSVAGINAL U/S VALIDATION OF EARLY STUDIES For EM < 4mm incidence of malignancy 1 in 917

55 SO WHY IS ENDOMETRIAL BIOPSY NOT NECESSARY? False negative rate of TV U/S < 4mm significantly less than a negative suction piston biopsy When EM biopsy IS done on patients with EM < 5mm: only 82% of the time is it successfully performed, and of those only 27% gave a sample adequate for diagnosis!!!

56 POSTMENOPAUSAL ENDOMETRIAL FLUID COLLECTION REVISITED: LOOK AT THE DOUGHNUT NOT AT THE HOLE

57 ENDOMETRIAL FLUID COLLECTIONS In the 1980 s EM fluid collection (on transabdominal U/S) was felt to be an ominous sign, very highly associated with malignancy (75%!!)

58

59 ISOLATED MURAL NODULE WITH ISOLATED MURAL NODULE WITH NO FLOW

60 UNILOCULAR OVARIAN CYSTS As already discussed now well established that t UNILOCULAR Ovarian cysts in Post menopausal women (and CERTAINLY in premenopausal e women) are felt to be benign and NO LONGER come to routine surgical exploration

61 HOWEVER Solid components and/or mural nodules (especially if papillary) contained within cystic structures have been felt to be an ominous sonographic finding and have virtually always resulted in surgical removal

62 CYSTADENOFIBROMAS Benign g ovarian neoplasms that originate from the surface epithelium as well as underlying cortical connective tissue of the ovary

63 CYSTADENOFIBROMAS Often have solid areas that appear to be papillations coming off the cyst wall ( mural nodules ) and thus have almost always been removed to exclude malignancy

64 METHODS AND MATERIALS Over a 6 year period 58 cases of pathologically proven cystadenofibromas were identified from our pathology department database Of these 32 had TV U/S with color flow Doppler in our Ob/Gyn ultrasound unit. Images were analyzed for presence of features beyond simple cystic appearance, and presence or absence of blood flow

65 RESULTS 22/32 (69%) of these cystadenofibromas presented as unilocular cystic structures with one or more solid mural nodules projecting from the cyst wall. None of these displayed any discernable blood flow within the solid area.

66 RESULTS 10/32 (31%) were multilocular with variable solid areas and did not follow this more typical appearance

67 THE OTHER 31% HAD A VARIABLE APPEARANCE THAT WAS MULTILOCULAR AND EXHIBITED FLOW AND WERE SUSPICIOUS IN NATURE

68 CONCLUSIONS 1. Not all cystadenofibromas will look the same on TV U/S and color flow Doppler 2. The majority (69% in our series) presented as unilocular cysts with a solid non vascular projection(s) from the cyst wall. Of these 2 (9%) were mucinous,20 (91%) serous 3. This particular presentation ti was virtually pathognomonic and when present seemed to have reliability for benign cystadenofibroma that was 100% in this small series

69 CONCLUSIONS (cont) 31% of them had avariable non typical appearance.in fact of these 2 had surface areas of borderline serous tumors Further study to corroborate this observation is necessary but the potential exists to extend the U/S dx of benign

70 IN SUMMARY ULTRASOUND CAN BE INSTRUMENTAL IN HELPING US IDENTIFY PATIENTS WHOSE 1)ADNEXAL MASS IS CLEARLY BENIGN AND EITHER BEST TREATED MEDICALLY, EXPECTANTLY OR WILL RESOLVE, BUT CAN AVOID SURGERY

71 IN SUMMARY ULTRASOUND CAN EVALUATE THE ENDOMETRIAL CAVITY AND ALLOW PREMENOPAUSAL WOMEN WITH AUB ON A HORMONAL BASIS OR PMB ASSOCIATED WITH ATROPHY TO AVOID ANY FURTHER WORK UP, INVASION, OR SURGERY

72 IN SUMMARY ULTRASOUND CAN SEE WHEN ENDOMETRIAL FLUID COLLECTIONS ARE ASSOOCIATED WITH EM ATROPHY AND CAN AVOID INTERVENTION

73 IN SUMMARY SOME CYSTADENOFIBROMAS WILL HAVE A CLASSIC APPEARANCE OF A UNILOCULAR CYST WITH ONE OR MORE SMALL AVASCULAR MURAL NODULES AND ARE INVARIABLY BENIGN AND MAY POSSIBLY BE FOLLOWED UP AND NOT REMOVED