Gynecologic Imaging and Reporting Data System for classifying adnexal masses.

INTRODUCTION: To perform a systematic review and meta-analysis of the diagnostic performance of the so-called Gynecologic Imaging and Report Data System (GI-RADS) for classifying adnexal masses. EVIDENCE ACQUISITION: A search for studies reporting about the use of GI-RADS system for classifying adnexal masses from January 2009 to December 2021 was performed in Medline (Pubmed), Google Scholar, Scopus, Cochrane, and Web of Science databases. Pooled sensitivity, specificity, positive and negative likelihood ratios and diagnostic odd ratio (DOR) were calculated. Studies' quality was evaluated using QUADAS-2. EVIDENCE SYNTHESIS: We identified 510 citations. Ultimately, 26 studies comprising 7350 masses were included. Mean prevalence of ovarian malignancy was 26%. The risk of bias was high in eight studies for domain "patient selection" and low for "index test," "reference test" domains for all studies. Overall, pooled estimated sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio and DOR of GI-RADS system for classifying adnexal masses were 94% (95% confidence interval [CI]=91-96%), 90% (95% CI=87-92%), 9.1 (95% CI=7.0-11.9), and 0.07 (95% CI=0.05-0.11), and 132 (95% CI=78-221), respectively. Heterogeneity was high for both sensitivity and specificity. Meta-regression showed that multiple observers and study's design explained this heterogeneity among studies. CONCLUSIONS: GI-RADS system has a good diagnostic performance for classifying adnexal masses.

External Validation of the Ovarian-Adnexal Reporting and Data System (O-RADS) Lexicon and the International Ovarian Tumor Analysis 2-Step Strategy to Stratify Ovarian Tumors Into O-RADS Risk Groups.

Importance: Correct diagnosis of ovarian cancer results in better prognosis. Adnexal lesions can be stratified into the Ovarian-Adnexal Reporting and Data System (O-RADS) risk of malignancy categories with either the O-RADS lexicon, proposed by the American College of Radiology, or the International Ovarian Tumor Analysis (IOTA) 2-step strategy. Objective: To investigate the diagnostic performance of the O-RADS lexicon and the IOTA 2-step strategy. Design, Setting, and Participants: Retrospective external diagnostic validation study based on interim data of IOTA5, a prospective international multicenter cohort study, in 36 oncology referral centers or other types of centers. A total of 8519 consecutive adult patients presenting with an adnexal mass between January 1, 2012, and March 1, 2015, and treated either with surgery or conservatively were included in this diagnostic study. Twenty-five patients were excluded for withdrawal of consent, 2777 were excluded from 19 centers that did not meet predefined data quality criteria, and 812 were excluded because they were already in follow-up at recruitment. The analysis included 4905 patients with a newly detected adnexal mass in 17 centers that met predefined data quality criteria. Data were analyzed from January 31 to March 1, 2022. Exposures: Stratification into O-RADS categories (malignancy risk <1%, 1% to <10%, 10% to <50%, and ≥50%). For the IOTA 2-step strategy, the stratification is based on the individual risk of malignancy calculated with the IOTA 2-step strategy. Main Outcomes and Measures: Observed prevalence of malignancy in each O-RADS risk category, as well as sensitivity and specificity. The reference standard was the status of the tumor at inclusion, determined by histology or clinical and ultrasonographic follow-up for 1 year. Multiple imputation was used for uncertain outcomes owing to inconclusive follow-up information. Results: Median age of the 4905 patients was 48 years (IQR, 36-62 years). Data on race and ethnicity were not collected. A total of 3441 tumors (70%) were benign, 978 (20%) were malignant, and 486 (10%) had uncertain classification. Using the O-RADS lexicon resulted in 1.1% (24 of 2196) observed prevalence of malignancy in O-RADS 2, 4% (34 of 857) in O-RADS 3, 27% (246 of 904) in O-RADS 4, and 78% (732 of 939) in O-RADS 5; the corresponding results for the IOTA 2-step strategy were 0.9% (18 of 1984), 4% (58 of 1304), 30% (206 of 690), and 82% (756 of 927). At the 10% risk threshold (O-RADS 4-5), the O-RADS lexicon had 92% sensitivity (95% CI, 87%-96%) and 80% specificity (95% CI, 74%-85%), and the IOTA 2-step strategy had 91% sensitivity (95% CI, 84%-95%) and 85% specificity (95% CI, 80%-88%). Conclusions and Relevance: The findings of this external diagnostic validation study suggest that both the O-RADS lexicon and the IOTA 2-step strategy can be used to stratify patients into risk groups. However, the observed malignancy rate in O-RADS 2 was not clearly below 1%.

SUCCOR Risk: Design and Validation of a Recurrence Prediction Index for Early-Stage Cervical Cancer.

OBJECTIVE: Based on the SUCCOR study database, our primary objective was to identify the independent clinical pathological variables associated with the risk of relapse in patients with stage IB1 cervical cancer who underwent a radical hysterectomy. Our secondary goal was to design and validate a risk predictive index (RPI) for classifying patients depending on the risk of recurrence. METHODS: Overall, 1116 women were included from January 2013 to December 2014. We randomly divided our sample into two cohorts: discovery and validation cohorts. The test group was used to identify the independent variables associated with relapse, and with these variables, we designed our RPI. The index was applied to calculate a relapse risk score for each participant in the validation group. RESULTS: A previous cone biopsy was the most significant independent variable that lowered the rate of relapse (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.17-0.60). Additionally, patients with a tumor diameter >2 cm on preoperative imaging assessment (OR 2.15, 95% CI 1.33-3.5) and operated by the minimally invasive approach (OR 1.61, 95% CI 1.00-2.57) were more likely to have a recurrence. Based on these findings, patients in the validation cohort were classified according to the RPI of low, medium, or high risk of relapse, with rates of 3.4%, 9.8%, and 21.3% observed in each group, respectively. With a median follow-up of 58 months, the 5-year disease-free survival rates were 97.2% for the low-risk group, 88.0% for the medium-risk group, and 80.5% for the high-risk group (p < 0.001). CONCLUSION: Previous conization to radical hysterectomy was the most powerful protective variable of relapse. Our risk predictor index was validated to identify patients at risk of recurrence.

Transvaginal Ultrasound Versus Magnetic Resonance Imaging for Assessing Myometrial Infiltration in Endometrioid Low Grade Endometrial Cancer: A Prospective Study.

OBJECTIVE: To compare the diagnostic accuracy of transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) for assessing myometrial infiltration (MI) in patients with low grade endometrioid endometrial cancer. METHODS: Observational prospective study performed at a single tertiary care center from 2016 to 2020, comprising 156 consecutive patients diagnosed by endometrial sampling as having an endometrioid grade 1/grade 2 endometrial cancer. TVS and MRI were performed prior to surgical staging for assessing MI, which was estimated using subjective examiner's impression and Karlsson's method for both TVS and MRI. During surgery, intraoperative assessment of MI was also performed. Definitive pathological study considered as reference standard. Diagnostic accuracy for ultrasound, MRI, and intraoperative biopsy was estimated and compared. RESULTS: Sensitivity and specificity of TVS for detecting deep MI were 75 and 73.5% for subjective impression and 65 and 70% for Karlsson method, respectively (P = .54). Sensitivity and specificity of MRI for detecting deep MI were 80 and 87% for subjective impression and 70 and 71.3% for Karlsson method. MRI subjective impression showed a significant better specificity than MRI Karlsson method (P = .03). MRI showed better specificity than TVS when subjective impression was considered (P <.05), but not for Karlsson method. Sensitivity and specificity of intraoperative were 75 and 97%, respectively. Intraoperative biopsy showed better specificity than ultrasound and MRI either using examiner's impression or Karlsson method (P <.05). CONCLUSIONS: MRI revealed a significant higher specificity than TVS when assessing deep myometrial infiltration. However, the intraoperative biopsy offers a significant better diagnostic accuracy than preoperative imaging techniques.

Pattern of relapse in patients with stage IB1 cervical cancer after radical hysterectomy as primary treatment. Minimally invasive surgery vs. open approach. Systematic review and meta-analysis.

BACKGROUND: After the LACC trial, the SUCCOR study, and other studies, we know that patients who have undergone minimally invasive surgery for cervical cancer have worse outcomes, but today, we do not know if the surgical approach can be a reason to change the pattern of relapses on these patients. We evaluated the relapse pattern in patients with stage IB1 cervical cancer (FIGO, 2009) who underwent radical hysterectomy with different surgical approaches. METHODS: A systematic review of literature was performed in PubMed, Cochrane Library, Clinicaltrials.gov, and Web of science. Inclusion criteria were prospective or retrospective comparative studies of different surgical approaches that described patterns or locations of relapse in patients with stage IB1 cervical cancer. Heterogeneity was assessed by calculating I2. RESULTS: The research resulted in 782 eligible citations from January 2010 to October 2020. After filtering, nine articles that met all inclusion criteria were analyzed, comprising data from 1663 patients who underwent radical hysterectomy for IB1 cervical cancer, and the incidence of relapse was 10.6%. When we compared the pattern of relapse (local, distant, and both) of each group (open surgery and minimally invasive surgery), we did not see statistically significant differences, (OR 0.963; 95% CI, 0.602-1.541; p = 0.898), (OR 0.788; 95% CI, 0.467-1.330; p = 0.542), and (OR 0.683; 95% CI, 0.331-1.407; p = 0.630), respectively. CONCLUSION: There are no differences in patterns of relapse across surgical approaches in patients with stage IB1 cervical cancer undergoing radical hysterectomy as primary treatment.

Validation of models to diagnose ovarian cancer in patients managed surgically or conservatively: multicentre cohort study.

OBJECTIVE: To evaluate the performance of diagnostic prediction models for ovarian malignancy in all patients with an ovarian mass managed surgically or conservatively. DESIGN: Multicentre cohort study. SETTING: 36 oncology referral centres (tertiary centres with a specific gynaecological oncology unit) or other types of centre. PARTICIPANTS: Consecutive adult patients presenting with an adnexal mass between January 2012 and March 2015 and managed by surgery or follow-up. MAIN OUTCOME MEASURES: Overall and centre specific discrimination, calibration, and clinical utility of six prediction models for ovarian malignancy (risk of malignancy index (RMI), logistic regression model 2 (LR2), simple rules, simple rules risk model (SRRisk), assessment of different neoplasias in the adnexa (ADNEX) with or without CA125). ADNEX allows the risk of malignancy to be subdivided into risks of a borderline, stage I primary, stage II-IV primary, or secondary metastatic malignancy. The outcome was based on histology if patients underwent surgery, or on results of clinical and ultrasound follow-up at 12 (±2) months. Multiple imputation was used when outcome based on follow-up was uncertain. RESULTS: The primary analysis included 17 centres that met strict quality criteria for surgical and follow-up data (5717 of all 8519 patients). 812 patients (14%) had a mass that was already in follow-up at study recruitment, therefore 4905 patients were included in the statistical analysis. The outcome was benign in 3441 (70%) patients and malignant in 978 (20%). Uncertain outcomes (486, 10%) were most often explained by limited follow-up information. The overall area under the receiver operating characteristic curve was highest for ADNEX with CA125 (0.94, 95% confidence interval 0.92 to 0.96), ADNEX without CA125 (0.94, 0.91 to 0.95) and SRRisk (0.94, 0.91 to 0.95), and lowest for RMI (0.89, 0.85 to 0.92). Calibration varied among centres for all models, however the ADNEX models and SRRisk were the best calibrated. Calibration of the estimated risks for the tumour subtypes was good for ADNEX irrespective of whether or not CA125 was included as a predictor. Overall clinical utility (net benefit) was highest for the ADNEX models and SRRisk, and lowest for RMI. For patients who received at least one follow-up scan (n=1958), overall area under the receiver operating characteristic curve ranged from 0.76 (95% confidence interval 0.66 to 0.84) for RMI to 0.89 (0.81 to 0.94) for ADNEX with CA125. CONCLUSIONS: Our study found the ADNEX models and SRRisk are the best models to distinguish between benign and malignant masses in all patients presenting with an adnexal mass, including those managed conservatively. TRIAL REGISTRATION: ClinicalTrials.gov NCT01698632.

Perioperative high-dose-rate brachytherapy in locally advanced and recurrent gynecological cancer: Final results of a Phase II trial.

PURPOSE: To determine the long-term results of a Phase II trial of perioperative high-dose-rate brachytherapy (PHDRB) in primary advanced or recurrent gynecological cancer. METHODS AND MATERIALS: Fifty patients with locally advanced and recurrent gynecological cancer suitable for salvage surgery were included. Unirradiated patients (n = 25) received preoperative chemoradiation followed by surgery and PHDRB (16-24 Gy). Previously irradiated patients (n = 25) received surgery and PHDRB alone (32-40 Gy). RESULTS: Median followup was 11.5 years. Eight unirradiated patients (32%) developed Grade ≥3 toxic events including two fatal events. Local and locoregional control rates at 16 years were 87.3% and 78.9%, respectively. Sixteen-year disease-free and overall survival rates were 42.9% and 46.4%, respectively. Ten previously irradiated patients (40.0%) developed Grade ≥3 adverse events, including four fatal events. Local and locoregional control rates at 14 years were 59.6% and 42.6%, respectively. Fourteen-year disease-free and overall survival rates were 16.0% and 19.2%, respectively. CONCLUSIONS: PHDRB allows effective salvage of a subset of unfavorable gynecological tumors with high-risk surgical margins. Toxicity was unacceptable at the initial dose levels but deescalation resulted in the absence of severe toxicity without a negative impact on locoregional control. A substantial percentage of patients remain alive and controlled at >10 years including a few previously irradiated cases with positive margins.

Applying a statistical method in transvaginal ultrasound training: lessons from the learning curve cumulative summation test (LC-CUSUM) for endometriosis mapping.

BACKGROUND: Methods available for assessing the learning curve, such as a predefined number of procedures or direct mentoring are lacking. Our aim was to describe the use of a statistical method to identify the minimal training length of an experienced sonographer, newly trained in deep infiltrating endometriosis (DIE) mapping by evaluating the learning curve of transvaginal ultrasound (TVUS) in the preoperative assessment of endometriosis. METHODS: A retrospective study in a tertiary referral center for endometriosis. Reports and stored data from TVUS scans performed by one operator with training in general gynecological ultrasound, but not in endometriosis mapping, were analyzed retrospectively for patients who subsequently underwent laparoscopy, which served as a reference standard. The performance of TVUS was assessed for the following sites: endometriomas, bladder, vagina, pouch of Douglas, bowel and uterosacral ligaments, and correlated with laparoscopic findings. Sensitivity, specificity, PPV, NPV, and accuracy were calculated, and the operator's diagnostic performance was assessed using the learning curve cumulative summation test (LC-CUSUM). RESULTS: Data from 94 women were available for analysis. The learning curve using the LC-CUSUM graph showed that the sonographer reached the predefined level of proficiency in detecting endometriosis lesions after 20, 26, 32, 31, 38, and 44 examinations for endometriomas, bladder nodules, vaginal nodules, pouch of Douglas obliteration, bowel nodules, and uterosacral ligament nodules, respectively. CONCLUSIONS: LC-CUSUM allows monitoring of individual performance during the learning process of new methodologies. This study shows that a sonographer trained in general gynecologic ultrasonography, who devotes time to learn TVUS for DIE mapping, can achieve proficiency for diagnosing the major types of endometriotic lesions after examining less than 50 patients who subsequently undergo surgery in a training setting.

Ultrasound-guided transvaginal thrombin injection of uterine arteries pseudoaneurysms.

OBJECTIVE: To evaluate the utility of transvaginal ultrasound-guided thrombin injection (UGTI) to treat uterine artery pseudoaneurysms (UAPs) as an alternative to emergency arterial embolization. METHODS: Two females presenting with heavy vaginal bleeding were diagnosed with UAPs by pelvic CT scan. After UAP identification by transvaginal ultrasound, 2 cm3 of thrombin (Tissucol®; Baxter Healthcare Corporation, Munich, Germany) was slowly injected into the UAPs using a 30-cm long 22-gauge needle through a needle guide attached to the vaginal probe. The same procedure was performed in both cases, and the Doppler sign disappeared immediately and the bleeding stopped. RESULTS: We describe two cases of UAPs treated with transvaginal UGTI: one after intrauterine tandem and vaginal colpostat insertion for brachytherapy after diagnosis of cervical cancer (Case 1) and the other after the insertion of a levonorgestrel-releasing intrauterine device (Case 2). CONCLUSION: Transvaginal UGTI could be a minimally invasive tool to treat selected cases of UAPs with severe vaginal bleeding. Advances in knowledge: Transvaginal UGTI could avoid the need for uterine embolization and emergency hysterectomy in selected cases of UAPs diagnosed by CT scan.

Use of the Learning Curve-Cumulative Summation Test for Leopold Maneuvers Assessment in a Simulator: A Pilot Study.

INTRODUCTION: Simulation enables medical students to practice clinical skills in a safe environment. Graduates in medicine must be able to correctly perform an examination on a pregnant woman using Leopold maneuvers. Learning curves-cumulative summation (LC-CUSUM) may help determine when the student has achieved a specific skill. Our objective was to perform the LC-CUSUM test regarding the ability of students to correctly carry out Leopold maneuvers; a pregnancy simulator was used, transferring the results to a clinical setting. METHODS: Five medical students were trained to carry out Leopold maneuvers using the simulator. Each student performed maneuvers for 50 cases of different fetus positions; a LC-CUSUM was plotted for each student. Afterward, the students performed the Leopold maneuvers on 5 pregnant women. RESULTS: Of the 5 students, 3 achieved a level of proficiency; the attempts needed for reaching this level were 13, 13, and 37, respectively. The other 2 students did not reach proficiency level. Of the students who became successfully proficient with the simulator, one of them attained a 100% success rate in pregnant patients, whereas the other two had success rates of 80%. The students who did not achieve a level of competency with the simulator had only a 60% success rate with patients. CONCLUSIONS: Because of the differences observed between students in the number of attempts needed for achieving proficiency in Leopold maneuvers, we believe that each student should build his/her own learning curve. Achieving competency in carrying out Leopold maneuvers using the simulator could be transferable to patients.

Intervillous and uteroplacental circulation in normal early pregnancy and early pregnancy loss assessed by 3-dimensional power Doppler angiography.

OBJECTIVE: To assess intervillous and uteroplacental circulation in early normal pregnancies and miscarriages. STUDY DESIGN: One hundred normal pregnancies and 46 delayed miscarriages were evaluated by 3-dimensional vaginal ultrasound and power Doppler angiography. Volumes of the early placenta and the subplacental area were obtained between 5 and 12.6 weeks' gestation. The placental volume, vascularization index, flow index, and vascularization flow index was calculated. RESULTS: Intraclass correlation coefficients ranged from 0.961 for placental volume to 0.885 for intervillous flow index. Intervillous power Doppler signals were not detected before the sixth week. Placental volume (R(2) = 0.68), intervillous vascularization index (R(2) = 0.30), flow index (R(2) = 0.33) and vascularization flow index (R(2) = 0.35), uteroplacental flow index (R(2) = 0.34), and vascularization flow index (R(2) = 0.17) increase significantly (P < .001) throughout the first trimester of normal pregnancies. Uteroplacental vascularization index was not significantly related to gestational age. Intervillous vasculariztion index, flow index, and vascularization flow index were significantly raised in miscarriages, but there were no significant differences for uteroplacental vascularization index, flow index, or vascularization flow index. CONCLUSION: Intervillous and uteroplacental blood flow increases throughout the first trimester of normal pregnancies. Intervillous circulation is abnormally increased when a miscarriage is diagnosed.

¿Puede la ecografía tridimensional cambiar la exploración ecográfica ginecológica en nuestro medio? / Can 3-dimensional ultrasonography change gynecological ultrasonographic examination in Spain?

Objetivo: Comprobar si la ecografía en 3D vaginal es tan fiable como la convencional y si aporta alguna ventaja al diagnóstico ecográfico ginecológico. Material y métodos: Estudio prospectivo en 46 mujeres a las que se realizó consecutivamente una ecografía vaginal en 2D y en 3D. Se obtuvieron tres volúmenes en 3D (útero y cada uno de los ovarios) y se estudiaron 4 meses más tarde en un ordenador personal. Se compararon ambas técnicas con respecto el diagnóstico y la biometría ecográfica y el tiempo empleado. Resultados: Se comprobó un acuerdo total entre los diagnósticos ecográficos realizados en modo 2D y 3D (31 exploraciones normales, 16 quistes anexiales y 7 miomas uterinos), excepto para la visualización y medida del cuello uterino. El tiempo medio ± desviación estándar por exploración fue de 3,29 ± 1,32 min para el modo 2D y de 2,96 ± 0,58 min para el modo 3D (p = 0,076). La adquisición de los volúmenes en 3D necesita sólo 1 h, lo que permite destinar el ecógrafo a otras exploraciones durante 1 h 32 min (AU)

Objective: To verify whether 3D transvaginal ultrasonography is as accurate as 2D conventional ultrasonography and whether it provides additional advantages in gynecologic diagnosis. Material and methods: We performed a prospective study in 46 women who underwent 2D and 3D transvaginal scans successively. Three 3D volumes (uterus and each ovary) were acquired and evaluated 4 months later on a personal computer. We compared 2D and 3D scans in relation to sonographic diagnosis and biometry and the time spent. Results: There was complete agreement between 2D and 3D techniques for sonographic diagnosis (31 normal exams, 16 adnexal cysts and seven myomas), except for the visualization and measurement of the uterine cervix. The mean time for 2D scans was 3.29 ± 1.32 minutes and was 2.96 ± 0.58 minutes for 3D examination (P=.076). The time required to acquire 3D volumes was only 1 hour, freeing 1 hour and 32 minutes for the performance of new scans. Conclusions: Transvaginal 3D ultrasonography can be more efficient than conventional 2D ultrasonography in gynecologic diagnosis (AU)

Clinical usefulness of 3-dimensional sonography and power Doppler angiography for diagnosis of endometrial carcinoma.

OBJECTIVE: The purpose of this study was to assess whether endometrial volume (EV) and 3-dimensional (3D) power Doppler indices can discriminate between hyperplasia and endometrial carcinoma and can predict extension of the endometrial carcinoma. METHODS: Eighty-four women with uterine bleeding and a histopathologic diagnosis of endometrial hyperplasia (n = 29) or carcinoma (n = 55) were preoperatively examined by transvaginal 3D sonography and power Doppler angiography. Endometrial thickness (ET), EV, the vascularization index (VI), the flow index (FI), the vascularization-flow index (VFI), and the intratumoral resistive index (RI) were measured. A histopathologic diagnosis was made after endometrial biopsy was performed by hysteroscopy or curettage. RESULTS: The EV and 3D power Doppler indices (VI, FI, and VFI) were significantly higher in endometrial carcinoma than endometrial hyperplasia, whereas the intratumoral RI was significantly lower (P < .05). A VFI of 2.07 was the best cutoff for predicting endometrial carcinoma, with sensitivity of 76.5% and specificity of 80.8%. No significant differences were noticed for ET. The endometrial VI was significantly higher when the tumor stage was greater than I. All the 3D power Doppler indices were significantly higher when the carcinoma infiltrated more than 50% of the myometrium. The intratumoral RI was significantly lower in cases with a high histologic grade, myometrial infiltration of more than 50%, and lymph node metastases. CONCLUSIONS: The VI, 3D power Doppler indices, and the intratumoral RI are more useful than ET for differentiating between hyperplasia and endometrial carcinoma. Intratumoral blood flow evaluated by pulsed Doppler sonography and 3D power Doppler angiography can predict the spread of endometrial carcinoma.

Perioperative high-dose-rate brachytherapy in locally advanced and recurrent gynecologic cancer: Initial results of a phase II trial.

BACKGROUND: This study was undertaken to determine the feasibility of perioperative high-dose-rate brachytherapy (PHDRB) as an adjunct to salvage surgery in primary advanced or recurrent gynecologic cancer. METHODS: Twenty-five patients with either locally advanced (n = 4) or recurrent (n = 21) gynecologic cancer suitable for salvage surgery were included. Unirradiated patients were treated with preoperative chemoradiation followed by salvage surgery and PHDRB (R0 and R1 resections receiving 16 or 24 Gy, respectively). Previously irradiated patients were treated with salvage surgery and PHDRB alone with 32 or 40 Gy for R0 or R1 resections, respectively. RESULTS: Resections were categorized as R0 in 9 patients (36.0%) and R1 in 16 (64.0%). Four previously irradiated patients suffered fatal pelvic bleeding between 8 and 13 months after surgery and PHDRB. After a median follow-up of 20 months (3-55+), the 4-year actuarial local and pelvic controls were 88.1% and 80.8%, respectively. The 4-year distant metastases-free survival was 40.9%. Four-year actuarial overall survival was 34.0%, with a median survival of 27.1 months (95% confidence interval: 17.5-36.8). CONCLUSIONS: Local and pelvic control results are excellent for this very high-risk-disease population. PHDRB dose in previously irradiated patients has been shifted to the closest lower level due to unacceptable vascular toxicity.

Endometrial volume and vascularity measurements by transvaginal three-dimensional ultrasonography and power Doppler angiography in stimulated and tumoral endometria: intraobserver reproducibility.

OBJECTIVES: To assess intraobserver reproducibility of the endometrial volume (EV) and 3D power Doppler indices (vascularization index, VI; flow index, FI; and vascularization flow index, VFI) of the endometrium and subendometrial area using three-dimensional power Doppler angiography (3D-PDA). METHODS: Twenty-five women on the hCG day after controlled ovarian stimulation and 15 patients presenting with uterine bleeding and suspicious endometrial thickening (10 endometrial cancers and 5 endometrial hyperplasias) were scanned. Eighty volume data sets were analyzed using the VOCAL imaging program. EV and VI, FI and VFI of the endometrium and subendometrium (5 mm shell) were manually calculated in the longitudinal and coronal planes with 15 degrees and 9 degrees rotation steps. Intraclass correlation coefficient (ICC) and 95% confidence intervals were used to assess reliability. RESULTS.: EV measurements were highly reproducible (ICC > or = 0.97) without significant differences between planes and rotation steps. Endometrial and subendometrial VI, FI, and VFI presented ICCs above 0.90 with the exception of the subendometrial FI (ICC > or = 0.80). There were no significant differences according to measurement plane and rotation step except for subendometrial VFI. Nevertheless, 3D power Doppler indices calculated in the coronal plane and 9 degrees rotation step obtained the highest ICC. ICCs for 3D-PDA indices from the tumoral endometria were significantly higher than those calculated from the stimulated endometria. CONCLUSIONS: Endometrial volume and endometrial and subendometrial 3D power Doppler indices have an acceptable reproducibility, significantly higher in tumoral endometria. The reliability of measurements does not seem to be significantly influenced by the rotation plane and degrees of rotation. These results support that 3D-PDA and VOCAL are reliable methods to evaluate the physiological and pathological changes of the endometrium.