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Ultrasonography

compared with magnetic


resonance imaging for the
diagnosis of adenomyosis:
correlation with
histopathology
Paulo P. Nakamaya
Case
A 32 year old G2P2 complained of vaginal
bleeding since 3 months ago. LNMP was on
February 16, 2016. Her menstruation was
described as moderate to profuse using 4-5
regular pads per day lasting for 10 days each
month.
Paulo B. Nakayama
Presentation of the
Journal
Objective:
Clinical Question
Is ultrasonography a more accurate diagnostic
exam in a 32 year old patient who presented with
symptoms suggestive of Adenomyosis over
magnetic resonance imaging?
Critical Appraisal
1. Evaluating Directness
2. Appraising Validity
3. Interpreting Results
4. Assessing Applicability
5. Individualizing the Results
Evaluating Directness
Does the study provide a direct enough answer to your
clinical question in terms of patient (P), examination (E)
used and disease or outcome (O) being diagnosed?

P: The Study population consisted of 120 women, with a


mean age of 51 years ranging from 30-88 years old.
E: All patients had Transabdominal ultrasound, Transvaginal
ultrasound, and Magnetic Resonance Imaging in correlation
with histopathology.
O: Accuracy in diagnosing Adenomyosis.
Clinical Question Research Question

Patient 32 year old G2P2 30-88 year old patients Match


complained of vaginal with indications for
bleeding surgery
Intervention All patients had
Transabdominal
ultrasound,
Transvaginal
ultrasound, and
Magnetic Resonance
Imaging in correlation
with histopathology

Comparison Patients referred for


hysterectomy
underwent TAS, TVS
and MRI
Histological
Evaluation

Outcome Accuracy in
diagnosing
Adenomyosis
Methods Prospective Study
Appraising Validity
Was the reference standard an acceptable one?

Yes, the reference standard is an acceptable one. In the


study they used histopathological criteria used for diagnosis
of adenomyosis. It is suggested that the diagnosis of
adenomyosis required the identification of hyperplasia
reaction. (p. 2431)
Appraising Validity
Was the reference standard interpreted independently from
the test question?

Yes, the reference standard interpreted independently from


the test question. Histopathological examinations were all
performed by the same pathologist, who was blinded to
sonographic and MRI data. Gross and microscopic
histopathological examinations were performed according
to Molitors method. (p. 2429)
Interpreting Results
What likelihood ratios were associated with the range of
possible test results?
Sensitivity Specificity Positive Negative
Predictive Predictive
Value Value
Transvaginal 76.4 % 92.8 % 73.8 % 88.8 %
Ultrasound
Transabdomi 32.5 % 65.0 % 95 % 97.5 %
nal
Ultrasound
Magnetic 77.5 % 92.5 % 83.8 % 89.2 %
Resonance
Imaging
Interpreting Results
What likelihood ratios were associated with the range of
possible test results?
Likelihood ration for Likelihood ratio for
positive test result negative test result
Transabdominal 0.96 1.08
Ultrasound

Transvaginal 10.61 0.25


Ultrasound

Magnetic Resonance 10.33 0.24


Imaging
Assessing Applicability
Are the biologic issues that may affect accuracy of the test? (Consider the
influence of sex, comorbidity, race, age, and pathology)
Clinical Case Research Case
Sex Female Female Matched
Comorbidity Women with
other other
associated
disorder
Race Filipino European Not Matched
Age 32 years old 30-88 years old Matched
Pathology
Assessing Applicability
Are there socio-economic issues that may affect accuracy of the test?

There were no socio-economic issues identified in the study.


Individualizing Results
Are the results applicable to the clinical scenario?

Yes
Individualizing the result
Does it add information beyond the available
data? Does it lead to a management that is
ultimately helpful to your patient?

Yes
Transabdominal Ultrasound
Estimated Pretest Probability 17/120

Pretest Odds 17/103 = 0.17

Posttest Odds (LR-)(0.17) = (1.08)(0.17) = 0.1836

Posttest Probability 0.1836/1+0.1836 = 0.16 = 16%


Transabdominal Ultrasound
Estimated Pretest Probability 17/120

Pretest Odds 17/103 = 0.17

Posttest Odds (LR+)(0.17) = (0.96)(0.17) = 0.1632

Posttest Probability 0.1632/1+0.1632 = 0.14 = 14%

There is a low probability that the disease is present in a positive test result.
Tranvaginal Ultrasound
Estimated Pretest Probability 28/120

Pretest Odds 28/92 = 0.30

Posttest Odds (LR-)(0.30) = (0.25)(0.30) = 0.075

Posttest Probability 0.075/1+0.075 = 0.07 = 7%


Tranvaginal Ultrasound
Estimated Pretest Probability 28/120

Pretest Odds 28/92 = 0.30

Posttest Odds (LR+)(0.30) = (10.61)(0.30) = 3.183

Posttest Probability 3.183/1+3.183 = 0.76 = 76%

There is a high probability that the disease is present in a positive test result.
Magnetic Resonance Imaging
Estimated Pretest Probability 105/120

Pretest Odds 105/15 = 7

Posttest Odds (LR-)(7) = (0.24)(7) = 1.68

Posttest Probability 1.68/1+1.68 = 0.63 = 63%


Magnetic Resonance Imaging
Estimated Pretest Probability 105/120

Pretest Odds 105/15 = 7

Posttest Odds (LR+)(7) = (10.33)(7) = 72.31

Posttest Probability 72.31/1+72.31 = 0.99 = 99%

There is a high probability that the disease is present in a positive test result.