Search

Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd. Objective: To describe the sonographic features of endometrial cancer in relation to tumor stage, grade and histological type, using the International Endometrial Tumor Analysis (IETA) terminology. Methods: This was a prospective multicenter study of 1714 women with biopsy-confirmed endometrial cancer undergoing standardized transvaginal grayscale and Doppler ultrasound examination according to the IETA study protocol, by experienced ultrasound examiners using high-end ultrasound equipment. Clinical and sonographic data were entered into a web-based database. We assessed how strongly sonographic characteristics, according to IETA, were associated with outcome at hysterectomy, i.e. tumor stage, grade and histological type, using univariable logistic regression and the c-statistic. Results: In total, 1538 women were included in the final analysis. Median age was 65 (range, 27–98) years, median body mass index was 28.4 (range 16–67) kg/m2, 1377 (89.5%) women were postmenopausal and 1296 (84.3%) reported abnormal vaginal bleeding. Grayscale and color Doppler features varied according to grade and stage of tumor. High-risk tumors, compared with low-risk tumors, were less likely to have regular endometrial–myometrial junction (difference of −23%; 95% CI, −27 to −18%), were larger (mean endometrial thickness; difference of +9%; 95% CI, +8 to +11%), and were more likely to have non-uniform echogenicity (difference of +7%; 95% CI, +1 to +13%), a multiple, multifocal vessel pattern (difference of +21%; 95% CI, +16 to +26%) and a moderate or high color score (difference of +22%; 95% CI, +18 to +27%). Conclusion: Grayscale and color Doppler sonographic features are associated with grade and stage of tumor, and differ between high- and low-risk endometrial cancer. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Objective To estimate intra- and interrater agreement and reliability with regard to describing ultrasound images of the endometrium using the International Endometrial Tumor Analysis (IETA) terminology. Methods Four expert and four non-expert raters assessed videoclips of transvaginal ultrasound examinations of the endometrium obtained from 99 women with postmenopausal bleeding and sonographic endometrial thickness ≥ 4.5 mm but without fluid in the uterine cavity. The following features were rated: endometrial echogenicity, endometrial midline, bright edge, endometrial-myometrial junction, color score, vascular pattern, irregularly branching vessels and color splashes. The color content of the endometrial scan was estimated using a visual analog scale graded from 0 to 100. To estimate intrarater agreement and reliability, the same videoclips were assessed twice with a minimum of 2 months' interval. The raters were blinded to their own results and to those of the other raters. Results Interrater differences in the described prevalence of most IETA variables were substantial, and some variable categories were observed rarely. Specific agreement was poor for variables with many categories. For binary variables, specific agreement was better for absence than for presence of a category. For variables with more than two outcome categories, specific agreement for expert and non-expert raters was best for not-defined endometrial midline (93% and 96%), regular endometrial-myometrial junction (72% and 70%) and three-layer endometrial pattern (67% and 56%). The grayscale ultrasound variable with the best reliability was uniform vs non-uniform echogenicity (multirater kappa (κ), 0.55 for expert and 0.52 for non-expert raters), and the variables with the lowest reliability were appearance of the endometrial-myometrial junction (κ, 0.25 and 0.16) and the nine-category endometrial echogenicity variable (κ, 0.29 and 0.28). The most reliable color Doppler variable was color score (mean weighted κ, 0.77 and 0.69). Intra- and interrater agreement and reliability were similar for experts and non-experts. Conclusions Inter- and intrarater agreement and reliability when using IETA terminology were limited. This may have implications when assessing the association between a particular ultrasound feature and a specific histological diagnosis, because lack of reproducibility reduces the reliability of the association between a feature and the outcome. Future studies should investigate whether using fewer categories of variable or offering practical training could improve agreement and reliability. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Objectives A uniform rationalized management protocol for pregnancies of unknown location (PUL) is lacking. We developed a two-step triage protocol to select PUL at high risk of ectopic pregnancy (EP), based on serum progesterone level at presentation (step 1) and the serum human chorionic gonadotropin (hCG) ratio, defined as the ratio of hCG at 48 h to hCG at presentation (step 2). Methods This was a cohort study of 2753 PUL (301 EP), involving a secondary analysis of prospectively and consecutively collected PUL data from two London-based university teaching hospitals. Using a chronological split we used 1449 PUL for development and 1304 for validation. We aimed to assign PUL as low risk with high confidence (high negative predictive value (NPV)) while classifying most EP as high risk (high sensitivity). The first triage step assigned PUL as low risk using a threshold of serum progesterone at presentation. The remaining PUL were triaged using a novel logistic regression risk model based on hCG ratio and initial serum progesterone (second step), defining low risk as an estimated EP risk of

Objectives To compare subjective ultrasound assessment and the ADNEX model with ultrasound-guided tru-cut biopsy to differentiate disseminated primary ovarian cancer from metastatic non-ovarian cancer. Methods This was a prospective study including 143 consecutive women with disseminated malignancy of unknown primary origin, with a pelvic tumor/carcinosis. Women underwent either transvaginal or transrectal ultrasound as well as transabdominal ultrasound examination followed by tru-cut biopsy. The ultrasound examiner assessed tumor morphology, spread in the pelvis and abdomen, and predicted tumor origin as primary ovarian or metastatic using both subjective assessment and the ADNEX model. Histology from tru-cut biopsy served as the gold standard for assessment of diagnostic accuracy. Biopsy adequacy and the complication rate were assessed. Results Tru-cut biopsy was performed transvaginally in 131/143 (92%) women. Two women needed inpatient care (one had abdominal wall hematoma, and one infection). Biopsy resulted in a conclusive diagnosis in 126/143 (88%) women, amongst whom cytoreductive surgery was performed in 30/126 confirming the diagnosis in all cases. Non-ovarian metastatic cancer was found in 37/126 (29%) women and primary ovarian cancer in 89/126 (71%) women. Subjective ultrasound evaluation had a sensitivity of 82% (73/89) and a specificity of 70% (26/37) in predicting primary ovarian cancer. The ADNEX model had an area under the receiver–operating characteristics curve of 0.891 (95% CI, 0.794–0.946) (in women with an ovarian lesion, n = 104). Tumor origin was associated with age, CA 125, previous neoplasia, presence of omental cake and tumor mobility. Conclusions Subjective ultrasound assessment and the ADNEX model can both be used to predict whether a pelvic tumor is metastatic and of non-ovarian origin, indicating the need for tru-cut biopsy, which is associated with very few complications and will provide a conclusive diagnosis in nine out of 10 women. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Objectives To investigate the efficacy of collagen plugs at reducing the risk of preterm premature rupture of membranes (PPROM) after fetoscopic surgery for congenital diaphragmatic hernia (CDH). Methods This was a single-center cohort study on all consecutive cases undergoing fetoscopic endoluminal tracheal occlusion (FETO) for severe or moderate CDH, between April 2002 and May 2011 (n = 141). Cases either received a collagen plug for sealing the fetal membrane defect after FETO or did not, depending on the operating surgeon. The principal outcome measure was the time from fetal surgery to PPROM, further referred to as ‘latency’. A multivariable Cox regression model was used to investigate the association between collagen plug and latency while adjusting for risk factors for PPROM. Results Of the 141 cases, 54 (38%) received a collagen plug and 87 (62%) did not. Sixty cases experienced PPROM, 26 among cases with and 34 among cases without a plug (48 vs 39%). The hazard ratio of plug use was 1.29 (95% CI, 0.76–2.19), which does not exclude a potentially increased risk for PPROM when a collagen plug is used. For cases with a plug, 24% had PPROM before balloon removal and 24% had PPROM after elective balloon removal. For cases without a plug, these rates were 30 and 9%, respectively. Perinatal outcomes were similar in both groups. Conclusions No evidence was found that collagen plugs reduce the risk of PPROM after FETO for CDH. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Objective To determine whether serum human-epididymis protein-4 (HE4) levels or Risk of Ovarian Malignancy Algorithm (ROMA) scores are useful second-stage tests for tumors thought to be difficult to characterize as benign or malignant on the basis of ultrasound findings by experienced examiners, and to investigate whether adding information on serum HE4 levels or ROMA scores to ultrasound findings improves diagnostic performance. Methods This was a prospective cross-sectional diagnostic accuracy study conducted in a tertiary referral center that enrolled consecutive women with a known adnexal mass scheduled for surgery. Experienced level III examiners classified each mass as certainly or probably benign, difficult to classify, or probably or certainly malignant after preoperative ultrasound examination. Serum HE4 and CA 125 levels were measured before surgery. Results The final database comprised 360 women, of whom 216 (60%) had benign and 144 (40%) had malignant disease. Examiners were highly confident in 196 cases (54%), moderately confident in 135 (38%) and completely uncertain about their diagnosis in 29 (8%) cases. With a sensitivity of 67% and specificity of 70%, subjective assessment outperformed HE4 and ROMA in the subgroup of difficult tumors. Both tests had low discriminatory capacity with poor areas under the receiver–operating characteristics curve of 0.536 (95% CI, 0.302–0.771) and 0.565 (95% CI, 0.294–0.836), respectively. A strategy that incorporates sequential testing of serum HE4 or ROMA scores after transvaginal ultrasonography resulted in a deterioration in overall test performance. Conclusion Measurement of serum HE4 or calculating scores using the ROMA as secondary tests does not seem useful for classifying adnexal tumors after subjective assessment with transvaginal ultrasonography. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Objective To develop a model to predict the success of a trial of vaginal birth after Cesarean section (VBAC) based on sonographic measurements of Cesarean section (CS) scar features, demographic variables and previous obstetric history. Methods We used transvaginal sonography (TVS) to examine the CS scar of 320 consecutive pregnant women. TVS was carried out at 11–13, 19–21 and 34–36 weeks' gestation and prospective measurements of the scar were recorded at each visit according to a defined protocol. A logistic regression model to predict success of VBAC was developed for those patients with a visible scar on ultrasound and only one previous CS. The model was evaluated using bootstrap validation. Results There were 131 women with one previous CS and a visible scar, of whom 10 underwent CS prior to labor and were excluded from analysis. Successful VBAC was achieved in 74/121 (61%) of the remaining cases. The prediction model developed was based on patient age, previous history of VBAC, residual myometrial thickness (RMT) and the change in RMT from the first to the second trimester (ΔRMT). The internally validated area under the receiver–operating characteristics curve was 0.62 when measurements of RMT and ΔRMT were excluded, but 0.94 when scar information was incorporated into the model. Conclusion Ultrasound measurements of CS scar, namely RMT and the change in RMT from the first to the second trimester of pregnancy, when incorporated into a mathematical model, can predict accurately a successful trial of labor in patients with one previous CS. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Objectives To estimate the ability to discriminate between benign and malignant adnexal masses of different size using: subjective assessment, two International Ovarian Tumor Analysis (IOTA) logistic regression models (LR1 and LR2), the IOTA simple rules and the risk of malignancy index (RMI). Methods We used a multicenter IOTA database of 2445 patients with at least one adnexal mass, i.e. the database previously used to prospectively validate the diagnostic performance of LR1 and LR2. The masses were categorized into three subgroups according to their largest diameter: small tumors (diameter < 4 cm; n = 396), medium-sized tumors (diameter, 49.9 cm; n = 1457) and large tumors (diameter = 10 cm, n = 592). Subjective assessment, LR1 and LR2, IOTA 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 receiveroperating characteristics curve (AUC) were used to describe diagnostic performance. A moving window technique was applied to estimate the effect of tumor size as a continuous variable on the AUC. The reference standard was the histological diagnosis of the surgically removed adnexal mass. Results The frequency of invasive malignancy was 10% in small tumors, 19% in medium-sized tumors and 40% in large tumors; 11% of the large tumors were borderline tumors vs 3% and 4%, respectively, of the small and medium-sized tumors. The type of benign histology also differed among the three subgroups. For all methods, sensitivity with regard to malignancy was lowest in small tumors (5684% vs 6793% in medium-sized tumors and 7495% in large tumors) while specificity was lowest in large tumors (6087%vs 8395% in medium-sized tumors and 8396% in small tumors ). The DOR and the AUC value were highest in medium-sized tumors and the AUC was largest in tumors with a largest diameter of 711 cm. Conclusion Tumor size affects the performance of subjective assessment, LR1 and LR2, the IOTA simple rules and the RMI in discriminating correctly between benign and malignant adnexal masses. The likely explanation, at least in part, is the difference in histology among tumors of different size. Copyright (C) 2012 ISUOG. Published by John Wiley & Sons, Ltd. (Less)

Objectives To assess intra- and interobserver agreement of routinely performed measurements – crown–rump length (CRL) and mean gestational sac diameter (MSD) – for assessing the likelihood of miscarriage in the first trimester of pregnancy using transvaginal sonography. Methods A cross-sectional study of CRL and gestational sac measurements in first-trimester pregnancies was conducted in a fetal medicine referral center with a predominantly Caucasian population. Gestational age ranged from 6 to 9 weeks. All patients underwent a transvaginal ultrasound examination using a highresolution ultrasound machine. Two measurements of CRL and measurements of three diameters of the gestational sac were obtained by two observers. Agreement within and between observers for CRL and between observers for MSD was analyzed using 95% prediction intervals, Bland–Altman plots with 95% limits of agreement and the intraclass correlation coefficient (ICC). Results In total 54 patients were included in the study, with measurements obtained by both observers in 44 of these. Intra- and interobserver ICCs were high for CRL measurements, with values of 0.992 and 0.993 for intraobserver agreement and 0.993 for interobserver agreement. For the MSD, the interobserver ICC was 0.952. Limits of agreement were ± 8.91 and ± 11.37% for intraobserver agreement of CRL and ± 14.64% for interobserver agreement of CRL. For MSD, the interobserver limits of agreement were ± 18.78%. For an MSD measurement of 20 mm by the first observer, the prediction interval for the second observer was 16.8–24.5 mm. For a CRL measurement of 6 mm, the prediction interval for the second observer was 5.4–6.7 mm. Conclusion For dating purposes, there is reasonable reproducibility of CRL measurements using transvaginal ultrasonography at 6–9 weeks’ gestation. When diagnosing miscarriage based on measurements of CRL care must be taken for values close to any decision boundary. The higher interobserver variability that we observed for MSD has implications for the diagnosis of miscarriage based on this measurement in the absence of a visible embryo or yolk sac. Copyright  2011 ISUOG. Published by John Wiley & Sons, Ltd.

Objectives: Positive CMV IgM in the first trimester of pregnancy mandates IgG avidity assays to exclude or confirm primary infection in pregnancy. Methods: To correlate IgG avidity index actual values and trends with the risk of fetal infection. Sera were obtained from women in the first trimester of pregnancy. CMV serology was performed with the LIAISON CMV IgG kit and the LIAISON CMV IgM. Kit. Positive IgG (>0.6 UI/mL) and equivocal IgM (≥15 UA/mL and

Objectives: To study the correlation between characteristics of contrast-enhanced ultrasound and microvessel density (MVD) of ovarian tumors. Methods: Sixty-two patients with benign and malignant ovarian tumors were examined by contrast-enhanced transvaginal ultrasound, when they were diagnosed by a conventional ultrasound scan in which the diagnosis could not be differentiated. Data were analyzed by time-intensity curves (TIC). The MVD in ovarian tumor specimens from either biopsies or surgery was examined by CD34 immunohistochemical staining. The correlation between ultrasound PI and AUC and MVD in two groups was analyzed. Results: Ovarian tumors were diagnosed as malignant in 58% (36/62) patients and benign 42% (26/62) patients by surgery, laparoscopy and ultrasound-guided biopsy. The mean tumor diameter was 1.7–9.3 cm (4.6 ± 1.8) cm. Ultrasound examination showed that: (1) in benign and malignant tumors, PI values were (13.5 ± 8.3) dB and (20.3 ± 5.2) dB, respectively; and AUCs were (8.2 ± 5.9) and (17.5 ± 5.0), respectively. PI and AUC in malignant tumors were significantly higher than those in benign tumors (P < 0.05). (2) MVD of malignant tumors (65.3 ± 22.3) was higher than that benign tumors (43.1 ± 20.4) (P < 0.01). (3) In both groups, PI value and AUC were significantly correlated with MVD (r = 0.595, r = 0.533, P = 0.002). Conclusions: Ultrasound PI value and AUC were significantly correlated with ovarian tumor MVD. Contrast-enhanced ultrasound could be helpful in the preoperative diagnosis of ovarian tumor malignancy.

OR 1.16, CI OR: 1.03–1.33). Regression analysis revealed that the odds of failure increased as size of ectopic increased (P = 0.045, OR 1.85, CI OR 1.01–3.39). Conclusions: Similar results to previous studies were found regarding failure rate of methotrexate therapy. The odds of failure of methotrexate therapy and need for surgical intervention increased by 16% for every 500 iu increase noted in pretreatment βhCG level. Size of ectopic pregnancy also played an important role with failure of therapy almost doubling as size of ectopic increased. Cutoff levels for size and βhCG at which risk of failure was considered clinically significant were calculated.

pregnancy of uncertain viability (IPUVI) after a single visit at the primary transvaginal scan (TVS). Methods: Prospective observational study. Between Nov 2006 and Jan 2010, all pregnant women presenting to the EPU underwent a TVS. Data was collected from women with an IPUVI at primary TVS. These women were followed up until the outcome (viable or non-viable pregnancy at the end of the first trimester) was established. More than 40 historical, clinical and ultrasonographic (US) end points were recorded for analysis, at which US data included the crown–rump length (CRL) as well as gestational sac (GS) and yolk sac (YS) measurements in 3 planes. Variables for preliminary model development were determined by stepwise logistic regression. Results: 2048 pregnant women underwent TVS, out of which 268 (13.1%) were classified with an IPUVI. 237 women with an IPUVI on primary TVS (84%) returned for follow up until the outcome was established (52.3% viable, 47.7% non-viable). 185 of these data sets have been used for model building. The variables used in the model were maternal age, gestational age in days by LMP, CRL in mm, mean GS size in mm, and previous normal vaginal delivery. The predictive ability of our model was measured with an AUC of 0.91 and its sensitivity and specificity for viable was shown to be 81.1% and 85.3% respectively. Conclusions: We have developed a valid model to predict the likelihood of a viable pregnancy at the end of the first trimester in women, who present with an IPUVI on primary ultrasound. This may help to counsel women with this common condition. We aim to test this model prospectively to evaluate its performance.

Objectives: Many fetuses with vascular ring have been screened recently. The range of symptoms after birth are very wide, from no symptom to severe dyspnea. The objective of this study was to evaluate the fetal tracheal stenosis of vascular ring by new methods. Methods: 20 fetuses with vascular ring, 3 with double aortic arch and 17 with right aortic arch and, as a control group, 100 cases without cardiovascular anomalies were included. 3DCT were performed after birth to evaluate the tracheal stenosis. 2 cases with severe tracheal stenosis by 3DCT and severe dyspnea were operated, division of the ring and tracheal repair. 5 cases with mild tracheal stenosis by 3DCT and no dyspnea were followed several months and operated, division of the ring, because of mild dyspnea. The other 13 cases have no tracheal stenosis by 3DCT and no symptom. We evaluated retrospectively the tracheal stenosis by these two methods. Method 1 to evaluate the tracheal size on the ring level. Group 1 with stenosis, Group 2 no stenosis. Method 2 to calculate the area inside the ring, AIR. Group 1 with narrow ring, AIR less than 0.6 cm2, Group 2 with wide ring, AIR more than 0.6 cm2. Results: In Method 1, 2 cases with sever tracheal stenosis belonged in Group 1. The other cases with mild and no tracheal stenosis and control group belonged in Group 2. In Method 2, 2 cases with severe tracheal stenosis and 1 case with mild stenosis and 1 case with no stenosis belonged in Group 1. The other cases with mild and no tracheal stenosis and control group belonged in Group 2. Conclusions: Method 1 and 2 are new evaluating methods of tracheal stenosis, which will make the accurate fetal evaluation of tracheal stenosis and poor outcome possible. In this study, the statistical analysis is not possible because of small number of cases, but multicenter study will be done in future.

B. Van Calster1,2, L. Valentin3, L. Ameye1,2, C. Van Holsbeke4,5, A. Testa6, I. Vergote4, S. Van Huffel1,2, T. Bourne7, D. Timmerman4 1Department of Electrical Engineering (ESAT), Katholieke Universiteit Leuven, Leuven, Belgium; 2IBBT-K.U.Leuven Future Health Department, Katholieke Universiteit Leuven, Leuven, Belgium; 3Department of Obstetrics and Gynecology, Skane University Hospital, Malmo, Sweden; 4Department of Obstetrics and Gynaecology, University Hospitals K.U. Leuven, Leuven, Belgium; 5Department of Obstetrics and Gynecology, Ziekenhuis Oost-Limburg, Genk, Belgium; 6Istituto di Clinica Ostetrica e Ginecologica, Universita Cattolica del Sacro Cuore, Rome, Italy; 7Department of Obstetrics and Gynecology, Imperial College London, Hammersmith Campus, London, United Kingdom

Objective: To predict neonatal outcome and unresponsive pulmonary hypertension (PHT) in fetuses with isolated congenital diaphragmatic hernia (iCDH) by fetal pulmonary arterial reactivity after maternal hyperoxygenation. Methods: 59 fetuses with iCDH were assessed ≥ 30 wks, either expectantly managed (n=27) or following removal of tracheal occlusion (n=32). Doppler measurements of pulsatility index (PI) in the 1st branch of the contralateral pulmonary artery were performed before and after maternal administration of 60% O2 by mask. Outcome measures included the decrease in PI after O2 (deltaPI), observed/expected lung-to-head-ratio (O/E LHR), neonatal survival at discharge, and unresponsive PHT, defined on the presence of a pre-/postductal O2 saturation gradient of > 20mmHg that did not respond to therapy. Results: Oxygen test was performed at 33.6 ± 1.6. Delivery took place at 37.1 ± 2.1 wks. In 25% we could not obtain echocardiography data, hence not assess severity of PHT. 36 (61%) neonates survived until discharge. Their O/E LHR and deltaPI values where significantly different from those who died. Only one of the survivors (2%) and 20/23 (87%) of those who eventually died after birth had unresponsive PHT, with different O/E LHR and delta PI as compared to those without or responsive PHT. Discriminant analysis shows that both prenatal measurements independently predict outcome. Conclusion: O/E LHR and Delta PI in the third trimester are both predictive parameters for neonatal survival and occurrence of severe PHT in CDH.