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Transvaginal Sonography and
Postmenopausal Ovarian Screening:
I mplementation I s Essential

Professor Galal Lotfi
Obstetrics & Gynecology
Suez Canal University.
Egypt

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I ntroduction
The incidence of ovarian carcinoma has
increased and is now the commonest
malignancy of the female genital tract in
much of the western world( William's
1992).
Ovarian cancer presents in its late stages,
(75% of ovarian cancer); Killing more
women than does cancer of the cervix
and uterine body combined (Silverberg et
al l990).

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Introduction
Ovarian cancer screening tests are the subject of endless
debate. Some say it may progress to a late stage so
quickly as to make screening impractical. This could be
minimized by decreasing the time between follow up tests
especially in women with family history of ovarian
cancer. Again, this criticism could be said to any other
screening programs.
The screening tests tried for ovarian cancer included
variety of techniques. Clinical examination,
culdocentesis, immunoscintigraphy, tumor marker but
all are insensitive.

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Aim of Our Work
Ultrasound has been an efficient tool for studying
structural changes associated with human follicular
development and ovulation, it was therefore a logical step
to use the same technology for morphological changes in
the ovary that may suggest the presence of early ovarian
cancer. The use of ultrasound as a screening device for
ovarian cancer was first proposed by Campbell et al
(1982).
The aim of that work was to implement a screening test
to decrease the incidence of advancing ovarian
carcinoma.

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Material And Methods.
198 women who were postmenopausal.
TVS for all women.
Ovaries were classified with a score according
to morphological and structural ultrasonic
appearance on both sides.
The TVS score (combined to both ovaries) was
added to the clinical score, according to the
woman's history, to get the total score.
Another scan after a year was carried out for
all women.


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Appearance Score
Atrophic 0
Volume >8cm. 1
Simple anechoic <3cm 1
Simple anechoic <5cm 2
Simple anechoic >5cm 3
Multilocular <5cm 2
Multilocular >5cm 3
Complex, cyst with echoic shadows. 4
Solid cyst (solid areas >50%) 5
Table (1) Scoring for US appearance of ovaries
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Table (2), Score for Womens History







History

Score
Family history of ovarian carcinoma 2
Past or family history of genital, breast or
colon
1
Negative history of oral contraceptive 1
Nulligravida 1
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Table(3), Scoring of women, 1
st
Scan Result
TVS finding
TVS
score
Other
Ovary
Family
History
Malignant
History
OCP
History
Total
Score
Simple cyst < 3cm
(Persistent)
1$ 0 2 0 1 4
Simple cyst < 5cm
1 1 0 1 0 3
Simple cyst =>5cm
1 0 0 0 0 1
Multiloc < 5cm
1 1 0 0 1 3
Multiloc =>5cm
2$ 2 2 0 1 7
Complex
2$ 0 0 1 0 3
Solid
2 0 0 0 0 2
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Table (4): Surgical Results of Cases Operated Upon
After the First Examination (N=198).
TVS result No. Result
Volume > 8Cm3 1 Not operated
Simple cyst < 3cm (persistent) 4 1 Malignant 3 Benign
Simple cyst < 5cm 5 2 Malignant
1 inflammatory 2Benign
Simple cyst =>5cm 3 3 simple serous
Multilocucyst < 5cm 1 Inflammatory
Multilocular cyst =>5cm 2 1 malignant
1 inflammatory
Complex cyst 1 Malignant
Solid cyst 1 Malignant
Total 18
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Table (5): cases with proved malignancy.
TVS Surgical
stage
Path.
Grade
Pathology
Simple cyst <
3cm
1ai I Cystadenocarcinoma
Simple <5cm 1ai I Mucinous carcinoma
Simple <5cm 1aii I Cystadenocarcinoma
Multiloc. >5cm 1bi II Endometroid
Complex 1ai I Cystadenocarcinoma
Solid cyst 1c I Endometroid
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Table (6): Surgical results after one year (N 185)
TVS Result No. Surgical result
Volume >8cm3 1 Not operated
Simple Cyst < 3cm
(persistent)
2 Simple serous
Simple < 5cm 2 Simple serous
Simple cyst => 5cm 0
Multilocular cyst <5cm 0
Multilocular cyst =>5cm 0
Complex cyst 0
Solid cyst 0
Total 5
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Table(7), Scoring of women after one year, N (185)
TVS finding TVS
score
Other
Ovary
Family
History
Malignant
History
OCP
History
Total
Score
Simple cyst <
3cm (Persistent)
1 0 2 0 1 4
Simple cyst <
5cm
2
2
0
0
0
0
0
0
1
1
3
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Table (8): Comparison Between Cases With
Proved Malignancy and Cases With Benign
Lesions (first Scan).
Lesion No. Min
Score
Max
score
Mean SD
Malignant 6 3 12 6.33 3.1
Benign 15 1 4 2.93 0.88
0
1
2
3
4
5
6
7
Malignant Benign
Mean
SD
Mean and SD of total score of Benign and malignant
lesions (first scan)
0
2
4
6
8
10
Abn Ben Mal
Detection Rate
Detection of abnormal, benign and malignant
lesion (first Scan) in 1
st
scan
0
0,5
1
1,5
2
2,5
3
Abnormal Benign Malignant
Detection Rate
Detection of Abnormal, Benign and malignant
lesion in 2
nd
scan.
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Conclusion
Abnormal ovarian conditions detection
rate was 9. 1% and 2.2% of cases in
initial examination and subsequent year
follow up.
Malignant detection rate was 3%.


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Conclusion
Andolf & Jorgensen (1989) found no
malignancy in 58 anechoic lesions less than 5cm
as detected by ultrasound.
Rodrigenz et al (1988) reported 3 cancers
detected in simple cystic lesions with a diameter
greater than 5cm.
In the present study, small cysts were found to
be not immune for malignancy, 3 cases with cyst
diameter less than 3cmwere found to be
malignant.


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Epilog.
With small cyst and in situations where we are in
doubt, the implemented score could help in deciding
up. For big, multilocular, complex or solid cysts, the
answer is straight forward, surgical intervention.
TVS, cheap compared to other imaging techniques,
non invasive, seems to provide a simple screening
technique for early ovarian cancer.
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Epilog.
Its strength resides in its high sensitivity 62.5%,
however we cannot deny the false positive rates which
is present in any diagnostic tool.
Till we find another test with the least false positive
results, TVS should be appreciated as a screening
tool for such a lethal disease not only for susceptible
women with family history or history of other
malignancies but for the whole population.

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Epilog..
Application of the suggested scoring system
could help in differentiating between benign
and malignant lesions.
. The new advances in ultrasonography may
enable us to better understand and recognize
the earliest stages of oncogenesis with the ovary.