Federica Sedda

IOTA simple rules for discriminating between benign and malignant adnexal masses: prospective external validation

To determine the diagnostic performance of International Ovarian Tumor Analysis (IOTA) ‘simple’ rules for discriminating between benign and malignant adnexal masses.

Dienogest. A possible conservative approach in bladder endometriosis. Results of a pilot study

Abstract Deep endometriosis involvement of the bladder is uncommon but it is symptomatic in most of the cases. Although laparoscopic excision is very effective, some patients with no pregnancy desire require a medical approach. We performed a pilot study on the effect of a new progestin dienogest on bladder endometriosis. Six patients were treated for 12 months with dienogest 2 mg/daily. Pain, urinary symptoms, quality of life, nodule volume and side effects were recorded. During treatment, symptoms improved very quickly and the nodules exhibit a remarkable reduction in size. Dienogest may be an alternative approach to bladder endometriosis.

Surgical technique of endometrioma excision impacts on the ovarian reserve. Single-port access laparoscopy versus multiport access laparoscopy: a case control study

Abstract Several recent studies report the detrimental effect of endometrioma excision on the ovarian reserve. Surgical technique and the excessive use of bipolar coagulation could be the key factors. Single-port access laparoscopy (SPAL) ovarian cystectomy has been reported as a comparable procedure to conventional laparoscopy in terms of operative outcomes. The aim of this study was to evaluate whether the single-port surgery affects the ovarian reserve whilst performing laparoscopic ovarian cystectomy for unilateral endometrioma. This was a prospective, case-control study of 99 women with unilateral endometrioma. Forty-nine women underwent single-port cystectomy and 50 women underwent multiport laparoscopic (MPL) conventional cystectomy. The primary outcome was the assessment of the ovarian reserve. We evaluated the serum anti-Mullerian hormone (AMH) levels before, 4–6 weeks and 3 months after surgery. At T2 we performed an ultrasound assessment of the antral follicular count (AFC). We have drawn attention to a statistically significant decrease of the mean AMH value and AFC in the SPAL group at the 4–6-week and 3-month follow-up compared to the conventional laparoscopy group. In conclusion, our results suggest that SPAL cystectomy should not be recommended to patients undergoing surgery for endometrioma excision who want to preserve their fertility.

Three-dimensional volume off-line analysis as compared to real-time ultrasound for assessing adnexal masses.

OBJECTIVE To assess the agreement between three-dimensional volume off-line analysis as compared to real-time ultrasound for assessing adnexal masses. STUDY DESIGN Ninety-nine non-consecutive women diagnosed as having an adnexal mass were assessed by transvaginal power Doppler ultrasound. One single examiner performed all ultrasound examinations. Based on the examiners subjective evaluation using gray scale and Doppler ultrasound findings a presumptive diagnosis (benign or malignant) was provided after real-time ultrasound was performed. Once real-time was done a 3D volume of the adnexal mass was acquired and stored by this examiner. Two examiners, unaware of the real-time ultrasound results, evaluated the 3D volumes using multiplanar display and virtual navigation and also had to provide a presumptive diagnosis (benign or malignant). These two examiners, like the first one, had information about patients age, menopausal status and complaints. All women underwent surgery or were followed-up until cyst resolution. Histologic diagnosis was used as gold standard. Cysts that resolved spontaneously were considered as benign for analytical purposes. The Kappa index was used to assess the agreement between real time ultrasound and 3D volume analysis. Sensitivity and specificity of both methods were calculated and compared using McNemar test. RESULTS Forty-one masses were malignant and 58 were benign. Agreement between real-time ultrasound and 3D volume analysis was good for both off-line examiners (Kappa index: 0.82, 95% CI: 0.70-0.93 and 0.78, 95% CI: 0.65-0.90). Sensitivities for real-time ultrasound and 3D volume analyses were 100%, 93% and 90%, respectively (p>0.05). Specificities for real-time ultrasound and 3D volume analyses were 91%, 84% and 86%, respectively (p>0.05). CONCLUSIONS Off-line 3D volume analysis may be a useful method for assessing adnexal masses, showing a good agreement with real-time ultrasound and having a similar diagnostic performance.

Assessing the reproducibility of the IOTA simple ultrasound rules for classifying adnexal masses as benign or malignant using stored 3D volumes

OBJECTIVE To analyze the reproducibility of the IOTA simple ultrasound rules for classifying adnexal masses as benign or malignant among examiners with different level of expertise using stored 3D volumes of adnexal masses. STUDY DESIGN Five examiners, with different levels of experience and blinded to each other, evaluated 100 stored 3D volumes from adnexal masses and looked for the presence or absence of malignant or benign features according to the IOTA definitions. Multiplanar view and virtual navigation were used. All examiners had to assess the 3D volume of each adnexal mass and classify it as benign or malignant. To analyze intra-observer agreement each examiner performed the assessment twice with a two-week interval between the first and second assessments. To analyze the inter-observer agreement, the second assessment from each examiner was used. Reproducibility was assessed calculating the weighted Kappa index. RESULTS Intra-observer reproducibility was moderate or good for all observers (Kappa index ranging from 0.59 to 0.74). Inter-observer reproducibility was moderate to good (Kappa index range: 0.46-0.67). CONCLUSIONS The simple rules are reasonably reproducible among observers with different level of expertise when assessed in stored 3D volumes.

Single-port versus conventional multiport access prophylactic laparoscopic bilateral salpingo-oophorectomy in high-risk patients for ovarian cancer: A comparison of surgical outcomes

Bilateral salpingo-oophorectomy (BSO) in carriers of BRCA1 and BRCA2 mutations is widely recommended as part of a risk-reduction strategy for ovarian or breast cancer due to an underlying genetic predisposition. BSO is also performed as a therapeutic intervention for patients with hormone-positive premenopausal breast cancer. BSO may be performed via a minimally invasive approach with the use of three to four 5 mm and/or 12 mm ports inserted through a skin incision. To further reduce the morbidity associated with the placement of multiple port sites and to improve cosmetic outcomes, single-port laparoscopy has been developed with a single access point from the umbilicus. The purpose of this study was to evaluate the surgical outcomes associated with reducing the risks of salpingo-oophorectomy performed in a single port, while comparing multiport laparoscopy in women with a high risk for ovarian cancer. Single-port laparoscopy–BSO is feasible and safe, with favorable surgical and cosmetic outcomes when compared to conventional laparoscopy.

Focusing on surgery results in infertile patients with deep endometriosis

Abstract Infertility is a common problem in patients with endometriosis and the involved mechanisms are still not completely known. The management of infertility in endometriosis patients includes surgery as well as assisted reproductive technology. Laparoscopic surgery has shown better results in infertility patients with endometriosis in comparison to laparotomy procedures. Laparoscopic surgery has proposed benefits in both minimal to moderate diseases. However, while there may be some benefits with severe diseases, there is still not enough evidence to recommend laparoscopic surgery as the recommended surgery when the main goal is to obtain fertility. We performed a MEDLINE search for articles on fertility in women with deep infiltrating endometriosis (DIE) published between 1990 and April 2015 using the following keywords: “endometriosis”, “deep infiltrative endometriosis”, “infertility”, “fertility after surgery”, “laparoscopy surgery”, “laparotomy”, “pregnancy”, “fertility outcome”, “bladder endometriosis”, and “ureteral endometriosis”. The aim of this review was to analyze the results of available clinical studies (randomized controlled or not controlled studies; retrospective cohort studies; or case–control and prospective studies) and guidelines on surgical treatment of infertile endometriosis patients, and pregnancy outcomes after surgery. Chinese abstract 不孕症是子宫内膜异位症患者很常见的问题，其涉及到的机制并没有被完全了解。子宫内膜异位中的不孕患者的治疗方法包括手术和辅助生殖技术。在子宫内膜异位导致的不孕患者中，腹腔镜手术比开腹手术越来越显示出更好的结局。腹腔镜手术在某些最小及中度疾病中有优势而被推荐。虽然，腹腔镜手术在某些疾病的治疗中有优势，然而当主要目标是使患者获得生育时，依旧没有足够的证据使得腹腔镜作为推荐的标准治疗方式。我们实施了一项文献检索，搜索了1990年-2015年4月间发表的以“子宫内膜异位症”“深浸润子宫内膜异位症”、“不孕症”、“手术后生育”、“腹腔镜手术”、“开腹手术”、“妊娠”、“生育结局”、“膀胱子宫内膜异位症”、“输尿管子宫内膜异位症”为关键词的与女性生育能力和深浸润子宫内膜异位的相关的文章。这篇综述的目的是分析现有的临床研究的结果（随机对照研究和非随机情况下的对照研究；回归性队列研究；病例对照和前瞻性研究）、子宫内膜异位症所致不孕症的外科治疗的指南以及手术后的妊娠结局。

Tissue characterization using mean gray value analysis in deep infiltrating endometriosis

To investigate differences in tissue characterization using three‐dimensional sonographic mean gray value (MGV) between retrocervical and rectosigmoid deeply infiltrating endometriosis, and to assess intra‐ and interobserver concordance in MGV quantification.

OC11.01: Prevalence of deep endometriosis in patients of a second level ultrasound laboratory and tissue US characterization of nodules using VOCAL

Objectives: To generate physical fetal models using images obtained by 3-dimensional ultrasound (3DUS), magnetic resonance (MR) and computed tomography (CT) to guide additive manufacturing (AM) technology. Methods: Images from 45 fetuses, including 4 sets of twins, were used. Twenty-three fetuses were normal and evaluated only by 3DUS. Twenty-two cases had complications such as conjoined twins; tumors; aneuploidy; skeletal; central nervous system; facial or thoracic defects. Scans were performed using high-resolution 3DUS. In cases of abnormalities, MR and CT were performed on the same day as 3DUS. The images obtained with 3DUS, MR or CT, were exported to a workstation in Digital Imaging and Communications in Medicine format. A single observer performed slice-by-slice manual segmentation using a digital high definition screen. Software that converts medical images into numerical models was used to construct virtual 3D models, which were physically realised using AM technologies (SLA Viper, Objet Connex 350, ZCorp 510 or FDM Vantage). Results: The main outcomes presented were the possibility to create 3D virtual and physical models from 3DUS, MRI or CT both separately and also in various combinations. AM systems allow the conversion of a 3D virtual model to a physical model in a fast, easy and dimensionally accurate process. They were remarkably similar to the postnatal appearance of the aborted fetus or newborn baby. Conclusions: This study introduced the innovative use of AM models into fetal researches. The results suggest a new possibility for educational purposes or better interaction between parents and their unborn child during pregnancy. Normal fetus (29 weeks): Virtual and physical model built in a powder-based system.

OC21.05: Low rate of inconclusive findings in less expert operators using ultrasound simple rules for the diagnosis of ovarian cancer

and LR2, the simple rules and the RMI were applied to each of the three groups. Sensitivity, specificity, positive and negative likelihood ratio (LR+, LR−), Diagnostic Odds Ratio (DOR), and area under the receiver operating characteristic curve (AUC) were used to describe diagnostic performance. The gold standard was the histological diagnosis of the surgically removed adnexal mass. Results: The rate of invasive malignancy was 10% in the small tumors, 19% in the medium sized tumors and 40% in the large tumors; 11% of the large tumors were borderline tumors versus 3% and 4% of the small and medium sized tumors. The type of benign histology also differed between the three subgroups. For all methods, the sensitivity with regard to malignancy was lowest in the small tumors, while the specificity was lowest in the large tumors; the DOR and the AUC were highest in the medium sized tumors. The AUC was largest in tumors with a largest diameter 7–11 cm. Conclusions: Tumor size affects the ability of subjective assessment, LR1 and LR2, the IOTA simple rules and the RMI to correctly discriminate between benign and malignant adnexal masses.