Surgical management of a suspicious adnexal mass: a systematic review.

OBJECTIVE: To systematically review the existing literature in order to determine the optimal recommended protocols for the surgical management of adnexal masses suspicious for apparent early stage malignancy. METHODS: A review of all systematic reviews and guidelines published between 1999 and 2009 was conducted as a first step. After the identification of two systematic reviews on the topic, searches of MEDLINE for studies published since 2004 were also conducted to update and supplement the evidentiary base. RESULTS: The updated literature search identified 31 studies that met the inclusion criteria. A bivariate random effects analysis of 15 frozen section diagnosis studies yielded an overall sensitivity of 89.2% (95% CI, 86.3 to 91.5%) and specificity of 97.9% (95% CI, 96.6 to 98.7%). The surgical evidence suggests that systematic lymphadenectomy and proper surgical staging improve survival. Conservative fertility-preserving surgical approaches are an acceptable option in women with low malignant potential tumours. The accuracy and the adequacy of surgical staging by laparotomy or laparoscopic approaches appear to be comparable, with neither approach conferring a survival advantage. Intraoperative tumour rupture was indeed reported to occur more frequently in patients undergoing laparoscopy versus laparotomy in two retrospective cohort studies. CONCLUSIONS: The best available evidence was collected and included in this rigorous systematic review. The abundant evidentiary base provided the context and direction for the surgical management of adnexal masses suspicious for apparent early stage malignancy.

Preoperative identification of a suspicious adnexal mass: a systematic review and meta-analysis.

OBJECTIVE: To systematically review the existing literature in order to determine the optimal strategy for preoperative identification of the adnexal mass suspicious for ovarian cancer. METHODS: A review of all systematic reviews and guidelines published between 1999 and 2009 was conducted as a first step. After the identification of a 2004 AHRQ systematic review on the topic, searches of MEDLINE for studies published since 2004 was also conducted to update and supplement the evidentiary base. A bivariate, random-effects meta-regression model was used to produce summary estimates of sensitivity and specificity and to plot summary ROC curves with 95% confidence regions. RESULTS: Four meta-analyses and 53 primary studies were included in this review. The diagnostic performance of each technology was compared and contrasted based on the summary data on sensitivity and specificity obtained from the meta-analysis. Results suggest that 3D ultrasonography has both a higher sensitivity and specificity when compared to 2D ultrasound. Established morphological scoring systems also performed with respectable sensitivity and specificity, each with equivalent diagnostic competence. Explicit scoring systems did not perform as well as other diagnostic testing methods. Assessment of an adnexal mass by colour Doppler technology was neither as sensitive nor as specific as simple ultrasonography. Of the three imaging modalities considered, MRI appeared to perform the best, although results were not statistically different from CT. PET did not perform as well as either MRI or CT. The measurement of the CA-125 tumour marker appears to be less reliable than do other available assessment methods. CONCLUSION: The best available evidence was collected and included in this rigorous systematic review and meta-analysis. The abundant evidentiary base provided the context and direction for the diagnosis of early-staged ovarian cancer.

Multicentre study on factors affecting the gynaecologic oncology career choice of canadian residents in obstetrics and gynaecology.

INTRODUCTION: The provision of optimal care for women with gynaecologic cancer may be threatened due to the changing demographics of patients and the projected increasing shortage of gynaecologic oncologists in Canada. We evaluated the career plans of Canadian residents in obstetrics and gynaecology to determine the proportion of residents currently considering a career in gynaecologic oncology (GO) and to explore factors that may affect their career decisions. METHODS: Following institutional ethics approval, all residents at 13 participating Canadian obstetrics and gynaecology residency training programs were contacted by email to complete a 20-item confidential questionnaire examining career plans. Quantitative data were analyzed using SAS v9.1. Qualitative data were coded by theme and grouped into various domains. RESULTS: Of 293 residents, 105 (36%) participated. More than half of these were considering at least one obstetrics and gynaecology subspecialty, but 53% indicated that their most appealing career path was general obstetrics and gynaecology. Although 50% of residents had ever considered a career in GO, only 17% were considering a GO career at the time of the survey. When rated as positive influences, medical school exposure, resident exposure, role models within GO, colleagues, other health care professionals, "my individual life circumstances," "my personal attributes," the clinical, research, and educational components of GO, the GO patient population, and relation with gynaecologic oncologists and other specialists were significant predictors of current GO interest. Themes that emerged from qualitative analysis revealed that the clinical, professional, and research domains were predominant influences among residents currently considering a career in GO. CONCLUSIONS: GO is an infrequent career choice for Canadian residents in obstetrics and gynaecology, and a number of factors significantly affect GO career decisions. Modifying factors such as educational experiences, work environment, and current practice models may lead to improved recruitment to the subspecialty, which is crucial for meeting the future needs of women with gynaecologic malignancies in Canada.

Identifying educationally influential specialists: issues arising from the use of "classic" criteria.

INTRODUCTION: Educationally influential physicians (EIPs) are identified by their colleagues as people who (1) encourage learning and enjoy sharing their knowledge, (2) are clinical experts and always seem up to date, and (3) treat others as equals. We aimed to identify surgical and pathologist EIPs for colorectal cancer (CRC) in Ontario as part of a blended knowledge transfer program. METHODS: A population-based cohort of surgeons (n = 794) and pathologists (n = 449) were sent surveys modeled on the Hiss method for identifying EIPs. Four formal mailings (including incentives) and telephone calls and faxes were completed. This labor-intensive process identified "general" EIPs and surgery or pathology EIPs for CRC. The characteristics of EIPs in these groups were studied. RESULTS: The response rate was 41% for surgeons and 42% for pathologists. One hundred eighteen general EIPs were identified and substantially more surgical EIPs for CRC (n = 63) than pathology EIPs for CRC (n = 6) were recognized. Forty-two of 81 medical centers in Ontario identified an EIP We also identified a cohort of "domain experts, " physicians whose opinion was valued for CRC but who did not meet the Hiss EIP criteria. This cohort of "domain experts" was larger than the cohort of ElPs for CRC for both surgeons (63 vs. 154) and pathologists (6 vs. 154). DISCUSSION: In this population study, we identified EIPs for CRC using the Hiss method, although significantly more surgical than pathology EIPs for CRC were recognized. The educational influence of domain experts who do not fulfill the Hiss characteristics compared with EIPs for CRC remains to be determined.