Rachel A. Ware

Predicting risk of malignancy in adnexal masses.

OBJECTIVE: To estimate the accuracy of preoperative ultrasonography, serum CA 125, and patient demographics as a means of predicting risk of malignancy in women with a ultrasonographically confirmed adnexal mass. METHODS: Tumor morphology derived from ultrasonographic images, tumor size, tumor bilaterality, serum CA 125, and patient demographics were evaluated preoperatively in 395 patients undergoing surgery from 2001 to 2008. Tumor morphology was classified as complex, solid, or cystic. Preoperative findings were compared with tumor histologic findings at the time of surgery. Multivariable classification and regression tree analysis were used to identify a group of patients at high risk of ovarian malignancy. RESULTS: One hundred eighteen patients had ovarian cancer, 13 patients had ovarian tumors of borderline malignancy, and 264 had benign ovarian tumors. Multivariable classification and regression tree analysis defined women at high risk of ovarian malignancy as those with an adnexal mass having complex or solid morphology and a serum CA 125 value greater than 35 units/mL. This definition had a positive predictive value of 84.7% and a negative predictive value of 92.4% and correctly identified 77.3% of patients with stage I and stage II ovarian cancer and 98.6% of patients with stage III and stage IV ovarian cancer. CONCLUSION: Patients with solid or complex ovarian tumors and an elevated serum CA 125 level (greater than 35 units/mL) are at high risk of ovarian malignancy. LEVEL OF EVIDENCE: II

Risk of malignancy in sonographically confirmed septated cystic ovarian tumors

OBJECTIVE To determine the risk of malignancy in septated cystic ovarian tumors. MATERIALS 1319 (4.4%) of 29,829 women were identified by transvaginal sonography (TVS) as having a complex cystic ovarian tumor with septations without solid areas or papillary projections and were placed on long-term ultrasound surveillance for ovarian malignancy. RESULTS These 1319 patients had a total of 2870 septated cystic ovarian tumors. 2288 tumors (79.7%) had a septal width <2 mm and 582 (20.3%) had a septal width >or=2 mm. 2286 tumors (79.6%) were <5 cm in diameter and 584 (20.4%) were>or=5 cm in diameter. 1114 septated cystic tumors (38.8%) resolved spontaneously (mean duration to resolution-12 months) and 1756 (61.2%) tumors persisted. 128 patients underwent surgical tumor removal within 3 months of ultrasound. Most common histopathology was: serous cystadenoma (75), mucinous cystadenoma (13), and endometrioma (10). One patient had an ovarian tumor of borderline malignancy (Stage IB). There were no cases of ovarian cancer. Patients were followed from 4 to 252 months (mean-77 months). One patient developed papillary morphology in the contralateral ovary 3.2 years after detection of a septated ovarian cyst and had epithelial ovarian cancer in that ovary and in the omentum (Stage IIIC disease). The remaining patients are all free of ovarian neoplasia after a total of 7642 follow-up years. CONCLUSIONS Septated cystic ovarian tumors without solid areas or papillary projections have a low risk of malignancy and can be followed sonographically without surgery.

The search for meaning—Symptoms and transvaginal sonography screening for ovarian cancer

The mortality rate of ovarian cancer is greater than that of all other major gynecologic malignancies. Detecting ovarian cancer at an early and curable stage long has been an objective of oncologists. Recently, it was reported that certain symptom patterns are informative for the presence of ovarian malignancy. In this article, the authors report on how symptoms and ultrasound predict ovarian malignancy.

Radical Hysterectomy with Pelvic Lymphadenectomy: Indications, Technique, and Complications

Radical hysterectomy with pelvic lymphadenectomy remains the treatment of choice for women with Stages IA2 and IB1 carcinoma of the cervix, and selected patients with Stage II endometrial cancer. Improvement in surgical techniqe, administration of prophylactic antibiotics, thromboemolic prophylaxis, and advances in critical care medicine have resulted in lower operative morbidity associated with this procedure. Major urinary tract complications such as ureteral injury or vesico-vaginal fistula are now extremely rare (<1%). Five-year survival rates following this procedure vary according to a number of clinical and histologic variables, and may be as high as 90% in women without lymph node metastases.

Ten-year relative survival for epithelial ovarian cancer

OBJECTIVE Most patients with epithelial ovarian cancer who are alive at 5 years have active disease. Thus, 10-year survival rather than 5-year survival may be a more appropriate endpoint. Relative survival adjusts for the general survival of the United States population for that race, sex, age, and date at which the diagnosis was coded. Our objective was to estimate relative survival in epithelial ovarian cancer over the course of 10 years. METHODS Using the Surveillance, Epidemiology and End Results 1995-2007 database, epithelial ovarian cancer cases were identified. Using the actuarial life table method, relative survival over the course of 10 years was calculated, stratified by stage, classification of residence, surgery as the first course of treatment, race, and age. RESULTS There were 40,692 patients who met inclusion criteria. The overall relative survival was 65%, 44%, and 36% at 2, 5, and 10 years, respectively. The slope of decline in relative survival was reduced for years 5-10 as compared with years 1-5 after diagnosis. Relative survival at 5 years was 89%, 70%, 36%, and 17%, and at 10 years relative survival was 84%, 59%, 23%, and 8% for stages I, II III, and IV, respectively. At all stages, patients with nonsurgical primary treatment and those with advanced age had reduced relative survival. CONCLUSIONS The 10-year relative survival for stage III is higher than expected. This information provides the physician and the patient with more accurate prognostic information.

Abstract 4816: OVA1: An in vitro diagnostic multivariate index assay for preoperative assessment of ovarian tumors

Objectives: We describe the development and validation of OVA1, an in vitro diagnostic multivariate index assay (IVDMIA) that has been recently approved by the FDA for preoperative assessment of the risk of ovarian cancer in women with ovarian tumors to help in deciding who should be referred to a gynecologic oncologist for surgery. Methods: The OVA1 test combines five immunoassays into a single numerical result, including CA125 II, transthyretin (prealbumin), apolipoprotein A1, beta 2microglobulin, and transferrin. The OVA1 algorithm was derived using prospectively collected samples from women with a pelvic mass who were surgically evaluated for ovarian cancer. OVA1 was then validated in women scheduled for surgery for a known ovarian tumor in a prospective, multi-institutional trial involving 27 primary care and specialty sites throughout the United States. Over half of the patients (52%) were enrolled by non-GO surgeons. The OVA1 results were correlated with the physician assessment (assigned by the enrolling physician after considering all available clinical information) and surgical pathology. Subjects were excluded from analysis if surgery was not performed, pathology report was not available, or the blood specimen was unusable. Results: The training sample set consisted of 274 samples from the University of Kentucky (including 63 epithelial ovarian cancer (EOC), 27 tumors of low malignant potential (LMP), 3 other ovarian malignancies, and 12 other cancers) and 125 samples from another multiple institution study (including 33 ovarian cancer). The independent validation study enrolled 590 women and 516 were evaluable with a pre-surgical assessment. There were 151 ovarian malignancies (29.3%), including: 96 EOC, 9 non-EOC, 28 LMP, and 18 malignancies metastatic to the ovary (met). The 235 premenopausal women enrolled (45.5%) accounted for 42 ovarian malignancies. The OVA1 test had a sensitivity of 92.5% and a specificity of 42.8% with corresponding PPV at 42.3% and NPV at 92.7%. OVA1 significantly improved the clinician9s pre-surgical assessment for both non-GO and GO physicians. Sensitivity improved from 72.2% to 91.7% (95% CI: 83.0-96.1) for non-GO, and 77.5% to 98.9% (95% CI: 93.9-99.8) for GO. The NPV improved from 89.1% to 93.2% (95% CI: 85.9-96.8) for non-GO, and 85.5% to 97.6% (95% CI: 87.7-99.6) for GO. OVA1 correctly identified 70% (non-GO) and 95% (GO) of malignancies missed by the preoperative physician assessment alone. The OVA1 sensitivity by histologic subtype was: EOC 99.0% (95/96), non-EOC 77.8% (7/9), LMP 75.0% (21/28), and met 94.4% (17/18). Conclusions: In the prospective, multi-institutional trial, the IDVMIA OVA1 correctly identified the majority of patients with ovarian malignancies that were missed by preoperative physician assessment alone, supporting the use of OVA1 to assist in surgical planning and decisions about referral to a gynecologic oncologist before surgery. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4816.