W Collins

A comparison of methods for preoperative discrimination between malignant and benign adnexal masses: The development of a new logistic regression model☆☆☆★

OBJECTIVEnThe aim of this study was to assess the complementary use of ultrasonographic end points with the level of circulating CA 125 antigen by multivariate logistic regression analysis algorithms to distinguish malignant from benign adnexal masses before operation.nnnSTUDY DESIGNnOne hundred ninety-one patients aged 18 to 93 years with overt adnexal masses were examined by transvaginal ultrasonography with color Doppler imaging and 31 variables were recorded. The end points were the histologic classification of the tumor and the areas under the receiver-operator characteristic curves of alternative algorithms.nnnRESULTSnOne hundred forty patients had benign tumors and 51 (26.7%) had malignant tumors: 31 primary invasive tumors (37% International Federation of Gynecology and Obstetrics stage I), 5 tumors of borderline malignancy (100% International Federation of Gynecology and Obstetrics stage I), and 15 tumors were metastatic and invasive. The most useful variables for the logistic regression analysis were the menopausal status, the serum CA 125 level, the presence of >/=1 papillary growth (>3 mm in length), and a color score indicative of tumor vascularity and blood flow. The optimized procedure had a sensitivity of 95.9% and a specificity of 87.1%. The area under the receiver-operator characteristic curve was significantly higher (P <.01) than the corresponding values from the independent use of serum CA 125 levels or indexes of tumor form or vascularity.nnnCONCLUSIONnRegression analysis of a few complementary variables can be used to accurately discriminate between malignant and benign adnexal masses before operation.

A randomized trial on the use of ultrasonography or office hysteroscopy for endometrial assessment in postmenopausal patients with breast cancer who were treated with tamoxifen

OBJECTIVEnOur purpose was to compare the screening effectiveness and acceptability of transvaginal ultrasonography (with sonohysterography if endometrial thickness was >4 mm) with office hysteroscopy.nnnSTUDY DESIGNnThis randomized crossover study comprised 53 consecutive asymptomatic (without vaginal bleeding) postmenopausal patients with breast cancer who had taken tamoxifen (20 or 40 mg/day) for at least 6 months.nnnRESULTSnTwo patients had endometrial cancer (1 primary, 1 breast secondary), both detected only by transvaginal ultrasonography. Twenty-six patients had at least 1 polyp (total 47, all benign). The women who had polyps were not significantly different in their age, body mass, months of tamoxifen intake, or the cumulative dose. The sensitivity and specificity of transvaginal ultrasonography were 85% and 100%, respectively. The corresponding values for office hysteroscopy were 77% and 92%. It was significant that more patients preferred transvaginal ultrasonography to hysteroscopy (P < .001).nnnCONCLUSIONnTransvaginal ultrasonography (plus sonohysterography) may be more effective and acceptable than office hysteroscopy for detecting endometrial abnormalities in women taking tamoxifen.

Transabdominal ultrasound screening for early ovarian cancer: Authors' reply

the women concerned. Practically all of the potential benefits arise from the detection of five cases of curable malignant disease. The total life expectancy attributable to five women of the same ages as those diagnosed as having ovarian cancer is about 127 years,2 a mean of 25-4 years. Assuming that the women who had their primary cancers discovered on screening would without screening have died immediately, the screening and subsequent treatment of these cancers can have saved a maximum of 3-2 days of life expectancy per screening examination. The early malignancies detected might, however, have manifested themselves only after further symptom free years-indeed they might never have caused symptoms within the lifetime of the patients. There would thus have been a significant lag time before these malignancies produced symptoms. Furthermore, ovarian cancer, though a very serious disease, is not always immediately fatal after diagnosis: the mean survival is more than six years (Thames Cancer Registry, personal communication). The true figure would therefore have been much less than 3 2 days. A total of 115 screening ultrasound scans and 2 6 operations were done per year of life expectancy of the women whose primary cancers were removed. The authors provide no data on the costs in time, morbidity, money, or anxiety attributable to these procedures or on the adverse psychological consequences to the 321 women who had positive results on screening but did not have primary ovarian cancer. These costs of the screening programme are nevertheless important. Indeed, the time spent by the patients in obtaining the ultrasound examination alone may have been greater than the additional life expectancy resulting from entry into the total screening and treatment programme. It seems premature to advocate a programme of general population screening on the evidence of Professor Campbell and colleagues. To do so further data suggesting a higher ratio of benefit to human cost, preferably in a population based randomised controlled trial, would be needed.