Daniela Fischerova

Patient satisfaction with ultrasound, whole-body CT and whole-body diffusion-weighted MRI for pre-operative ovarian cancer staging: a multicenter prospective cross-sectional survey

In addition to the diagnostic accuracy of imaging methods, patient-reported satisfaction with imaging methods is important. To report a secondary outcome of the prospective international multicenter Imaging Study in Advanced ovArian Cancer (ISAAC Study), detailing patients' experience with abdomino-pelvic ultrasound, whole-body contrast-enhanced computed tomography (CT), and whole-body diffusion-weighted magnetic resonance imaging (WB-DWI/MRI) for pre-operative ovarian cancer work-up. In total, 144 patients with suspected ovarian cancer at four institutions in two countries (Italy, Czech Republic) underwent ultrasound, CT, and WB-DWI/MRI for pre-operative work-up between January 2020 and November 2022. After having undergone all three examinations, the patients filled in a questionnaire evaluating their overall experience and experience in five domains: preparation before the examination, duration of examination, noise during the procedure, radiation load of CT, and surrounding space. Pain perception, examination-related patient-perceived unexpected, unpleasant, or dangerous events ('adverse events'), and preferred method were also noted. Ultrasound was the preferred method by 49% (70/144) of responders, followed by CT (38%, 55/144), and WB-DWI/MRI (13%, 19/144) (p7 of 10) during the ultrasound examination. We did not identify any factors related to patients' preferred method. Ultrasound was the imaging method preferred by most patients despite being associated with more pain during the examination in comparison with CT and WB-DWI/MRI. NCT03808792.

Added value of cell‐free DNA over clinical and ultrasound information for diagnosing ovarian cancer

ABSTRACT Objective We previously proposed two cell‐free (cf) DNA‐based scores (genome‐wide Z ‐score and nucleosome score) as candidate non‐invasive biomarkers to further improve the presurgical diagnosis of ovarian malignancy. We aimed to investigate the added value of these cfDNA‐based scores in combination with the clinical and ultrasound predictors of the Assessment of Different NEoplasias in the adneXa (ADNEX) model to estimate the risk of ovarian malignancy. Methods In this prospective cohort study, 526 patients with an adnexal mass scheduled for surgery were recruited consecutively in three oncology referral centers. All patients underwent a transvaginal ultrasound examination, and adnexal masses were described according to the International Ovarian Tumor Analysis terms and definitions. cfDNA was extracted from preoperative plasma samples and genome‐wide Z ‐scores and nucleosome scores were calculated. Logistic regression models were fitted for ADNEX predictors alone and after inclusion of the cfDNA‐based scores. We report likelihood ratios, area under the receiver‐operating‐characteristics curve (AUC), sensitivity, specificity and net benefit for thresholds between 5% and 40%, to assess the diagnostic performance of the models in discriminating between benign and malignant ovarian masses. Results The study included 272 benign, 86 borderline, 36 Stage‐I invasive, 113 Stage‐II–IV invasive, and 19 secondary metastatic tumors. The likelihood ratios for adding the cfDNA‐based scores to the ADNEX model were statistically significant ( P  < 0.001 for ADNEX without CA 125; P  = 0.001 for ADNEX including CA 125). The accompanying increases in AUC were 0.013 when the cfDNA biomarkers were added to the ADNEX model without CA 125, and 0.003 when added to the ADNEX model including CA 125. Net benefit, sensitivity and specificity were similar for all models. The increase in net benefit at the recommended 10% threshold estimated risk of malignancy when adding the cfDNA‐based scores was 0.0017 and 0.0020, respectively, for the ADNEX model without CA 125 and the ADNEX model with CA 125. According to these results, adding cfDNA markers would require at least 453 patients per additional true‐positive test result at the 10% risk threshold. Conclusion Although statistically significant, cfDNA‐based biomarker scores have limited clinical utility in addition to established clinical and ultrasound‐based ADNEX predictors for discriminating between benign and malignant ovarian masses. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound‐based risk model for preoperative prediction of lymph‐node metastases in women with endometrial cancer: model‐development study

ABSTRACTObjectiveTo develop a preoperative risk model, using endometrial biopsy results and clinical and ultrasound variables, to predict the individual risk of lymph‐node metastases in women with endometrial cancer.MethodsA mixed‐effects logistic regression model for prediction of lymph‐node metastases was developed in 1501 prospectively included women with endometrial cancer undergoing transvaginal ultrasound examination before surgery, from 16 European centers. Missing data, including missing lymph‐node status, were imputed. Discrimination, calibration and clinical utility of the model were evaluated using leave‐center‐out cross validation. The predictive performance of the model was compared with that of risk classification from endometrial biopsy alone (high‐risk defined as endometrioid cancer Grade 3/non‐endometrioid cancer) or combined endometrial biopsy and ultrasound (high‐risk defined as endometrioid cancer Grade 3/non‐endometrioid cancer/deep myometrial invasion/cervical stromal invasion/extrauterine spread).ResultsLymphadenectomy was performed in 691 women, of whom 127 had lymph‐node metastases. The model for prediction of lymph‐node metastases included the predictors age, duration of abnormal bleeding, endometrial biopsy result, tumor extension and tumor size according to ultrasound and undefined tumor with an unmeasurable endometrium. The model's area under the curve was 0.73 (95% CI, 0.68–0.78), the calibration slope was 1.06 (95% CI, 0.79–1.34) and the calibration intercept was 0.06 (95% CI, –0.15 to 0.27). Using a risk threshold for lymph‐node metastases of 5% compared with 20%, the model had, respectively, a sensitivity of 98% vs 48% and specificity of 11% vs 80%. The model had higher sensitivity and specificity than did classification as high‐risk, according to endometrial biopsy alone (50% vs 35% and 80% vs 77%, respectively) or combined endometrial biopsy and ultrasound (80% vs 75% and 53% vs 52%, respectively). The model's clinical utility was higher than that of endometrial biopsy alone or combined endometrial biopsy and ultrasound at any given risk threshold.ConclusionsBased on endometrial biopsy results and clinical and ultrasound characteristics, the individual risk of lymph‐node metastases in women with endometrial cancer can be estimated reliably before surgery. The model is superior to risk classification by endometrial biopsy alone or in combination with ultrasound. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Validation of ultrasound strategies to assess tumor extension and to predict high‐risk endometrial cancer in women from the prospective IETA (International Endometrial Tumor Analysis)‐4 cohort

ABSTRACTObjectivesTo compare the performance of ultrasound measurements and subjective ultrasound assessment (SA) in detecting deep myometrial invasion (MI) and cervical stromal invasion (CSI) in women with endometrial cancer, overall and according to whether they had low‐ or high‐grade disease separately, and to validate published measurement cut‐offs and prediction models to identify MI, CSI and high‐risk disease (Grade‐3 endometrioid or non‐endometrioid cancer and/or deep MI and/or CSI).MethodsThe study comprised 1538 patients with endometrial cancer from the International Endometrial Tumor Analysis (IETA)‐4 prospective multicenter study, who underwent standardized expert transvaginal ultrasound examination. SA and ultrasound measurements were used to predict deep MI and CSI. We assessed the diagnostic accuracy of the tumor/uterine anteroposterior (AP) diameter ratio for detecting deep MI and that of the distance from the lower margin of the tumor to the outer cervical os (Dist‐OCO) for detecting CSI. We also validated two two‐step strategies for the prediction of high‐risk cancer; in the first step, biopsy‐confirmed Grade‐3 endometrioid or mucinous or non‐endometrioid cancers were classified as high‐risk cancer, while the second step encompassed the application of a mathematical model to classify the remaining tumors. The ‘subjective prediction model’ included biopsy grade (Grade 1 vs Grade 2) and subjective assessment of deep MI or CSI (presence or absence) as variables, while the ‘objective prediction model’ included biopsy grade (Grade 1 vs Grade 2) and minimal tumor‐free margin. The predictive performance of the two two‐step strategies was compared with that of simply classifying patients as high risk if either deep MI or CSI was suspected based on SA or if biopsy showed Grade‐3 endometrioid or mucinous or non‐endometrioid histotype (i.e. combining SA with biopsy grade). Histological assessment from hysterectomy was considered the reference standard.ResultsIn 1275 patients with measurable lesions, the sensitivity and specificity of SA for detecting deep MI was 70% and 80%, respectively, in patients with a Grade‐1 or ‐2 endometrioid or mucinous tumor vs 76% and 64% in patients with a Grade‐3 endometrioid or mucinous or a non‐endometrioid tumor. The corresponding values for the detection of CSI were 51% and 94% vs 50% and 91%. Tumor AP diameter and tumor/uterine AP diameter ratio showed the best performance for predicting deep MI (area under the receiver–operating characteristics curve (AUC) of 0.76 and 0.77, respectively), and Dist‐OCO had the best performance for predicting CSI (AUC, 0.72). The proportion of patients classified correctly as having high‐risk cancer was 80% when simply combining SA with biopsy grade vs 80% and 74% when using the subjective and objective two‐step strategies, respectively. The subjective and objective models had an AUC of 0.76 and 0.75, respectively, when applied to Grade‐1 and ‐2 endometrioid tumors.ConclusionsIn the hands of experienced ultrasound examiners, SA was superior to ultrasound measurements for the prediction of deep MI and CSI of endometrial cancer, especially in patients with a Grade‐1 or ‐2 tumor. The mathematical models for the prediction of high‐risk cancer performed as expected. The best strategies for predicting high‐risk endometrial cancer were combining SA with biopsy grade and the subjective two‐step strategy, both having an accuracy of 80%. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Ultrasound examiners' ability to describe ovarian cancer spread using preacquired ultrasound videoclips from a selected patient sample with high prevalence of cancer spread

ABSTRACTObjectivesTo assess the ability, as well as factors affecting the ability, of ultrasound examiners with different levels of ultrasound experience to detect correctly infiltration of ovarian cancer in predefined anatomical locations, and to evaluate the inter‐rater agreement regarding the presence or absence of cancer infiltration, using preacquired ultrasound videoclips obtained in a selected patient sample with a high prevalence of cancer spread.MethodsThis study forms part of the Imaging Study in Advanced ovArian Cancer multicenter observational study (NCT03808792). Ultrasound videoclips showing assessment of infiltration of ovarian cancer were obtained by the principal investigator (an ultrasound expert, who did not participate in rating) at 19 predefined anatomical sites in the abdomen and pelvis, including five sites that, if infiltrated, would indicate tumor non‐resectability. For each site, there were 10 videoclips showing cancer infiltration and 10 showing no cancer infiltration. The reference standard was either findings at surgery with histological confirmation or response to chemotherapy. For statistical analysis, the 19 sites were grouped into four anatomical regions: pelvis, middle abdomen, upper abdomen and lymph nodes. The videoclips were assessed by raters comprising both senior gynecologists (mainly self‐trained expert ultrasound examiners who perform preoperative ultrasound assessment of ovarian cancer spread almost daily) and gynecologists who had undergone a minimum of 6 months' supervised training in the preoperative ultrasound assessment of ovarian cancer spread in a gynecological oncology center. The raters were classified as highly experienced or less experienced based on annual individual caseload and the number of years that they had been performing ultrasound evaluation of ovarian cancer spread. Raters were aware that for each site there would be 10 videoclips with and 10 without cancer infiltration. Each rater independently classified every videoclip as showing or not showing cancer infiltration and rated the image quality (on a scale from 0 to 10) and their diagnostic confidence (on a scale from 0 to 10). A generalized linear mixed model with random effects was used to estimate which factors (including level of experience, image quality, diagnostic confidence and anatomical region) affected the likelihood of a correct classification of cancer infiltration. We assessed the observed percentage of videoclips classified correctly, the expected percentage of videoclips classified correctly based on the generalized linear mixed model and inter‐rater agreement (reliability) in classifying anatomical sites as being infiltrated by cancer.ResultsTwenty‐five raters participated in the study, of whom 13 were highly experienced and 12 were less experienced. The observed percentage of correct classification of cancer infiltration ranged from 70% to 100% depending on rater and anatomical site, and the median percentage of correct classification for the 25 raters ranged from 90% to 100%. The probability of correct classification of all 380 videoclips ranged from 0.956 to 0.975 and was not affected by the rater's level of ultrasound experience. The likelihood of correct classification increased with increased image quality and diagnostic confidence and was affected by anatomical region. It was highest for sites in the pelvis, second highest for those in the middle abdomen, third highest for lymph nodes and lowest for sites in the upper abdomen. The inter‐rater agreement of all 25 raters regarding the presence of cancer infiltration ranged from substantial (Fleiss kappa, 0.68 (95% CI, 0.66–0.71)) to very good (Fleiss kappa, 0.99 (95% CI, 0.97–1.00)) depending on the anatomical site. It was lowest for sites in the upper abdomen (Fleiss kappa, 0.68 (95% CI, 0.66–0.71) to 0.97 (95% CI, 0.94–0.99)) and highest for sites in the pelvis (Fleiss kappa, 0.94 (95% CI, 0.92–0.97) to 0.99 (95% CI, 0.97–1.00)).ConclusionsUltrasound examiners with different levels of ultrasound experience can classify correctly predefined anatomical sites as being infiltrated or not infiltrated by ovarian cancer based on video recordings obtained by an experienced ultrasound examiner, and the inter‐rater agreement is substantial. The likelihood of correct classification as well as the inter‐rater agreement is highest for sites in the pelvis and lowest for sites in the upper abdomen. However, owing to the study design, our results regarding diagnostic accuracy and inter‐rater agreement are likely to be overoptimistic. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Diagnostic performance of ultrasonography in pre-operative assessment of lymph nodes in patients with cervical cancer

To assess the diagnostic performance of ultrasonography in pre-operative assessment of lymph nodes in patients with cervical cancer, to compare the outcomes for pelvic and para-aortic regions, and to detect macrometastases and micrometastases separately. Patients were retrospectively included if they met the following inclusion criteria: pathologically verified cervical cancer; ultrasonography performed by one of four experienced sonographers; surgical lymph node staging, at least in the pelvic region-sentinel lymph node biopsy or systematic pelvic lymphadenectomy or debulking. The final pathological examination was the reference standard. 390 patients met the inclusion criteria between 2009 and 2019. Pelvic node macrometastases (≥2 mm) were confirmed in 54 patients (13.8%), and micrometastases (≥0.2 mm and <2 mm) in another 21 patients (5.4%). Ultrasonography had sensitivity 72.2%, specificity 94.0%, and area under the curve (AUC) 0.831 to detect pelvic macrometastases, while sensitivity 53.3%, specificity 94.0%, and AUC 0.737 to detect both pelvic macrometastases and micrometastases (pN1). Ultrasonography failed to detect pelvic micrometastases, with sensitivity 19.2%, specificity 85.2%, and AUC 0.522. There was no significant impact of body mass index on diagnostic accuracy. Metastases in para-aortic nodes (macrometastases only) were confirmed in 16 of 71 patients who underwent para-aortic lymphadenectomy. Ultrasonography yielded sensitivity 56.3%, specificity 98.2%, and AUC 0.772 to identify para-aortic node macrometastases. Ultrasonography performed by an experienced sonographer can be considered a sufficient diagnostic tool for pre-operative assessment of lymph nodes in patients with cervical cancer, showing similar diagnostic accuracy in detection of pelvic macrometastases as reported for other imaging methods (18F-fluorodeoxyglucose positron emission tomography/CT or diffusion-weighted imaging/MRI). It had low sensitivity for detection of small-volume macrometastases (largest diameter <5 mm) and micrometastases. The accuracy of para-aortic assessment was comparable to that for pelvic lymph nodes, and assessment of the para-aortic region should be an inseparable part of the examination protocol.

Imaging in gynecological disease (22): clinical and ultrasound characteristics of ovarian embryonal carcinomas, non‐gestational choriocarcinomas and malignant mixed germ cell tumors

ABSTRACTObjectiveTo describe the clinical and ultrasound characteristics of three types of rare malignant ovarian germ cell tumor: embryonal carcinoma, non‐gestational choriocarcinoma and malignant mixed germ cell tumor.MethodsThis was a retrospective multicenter study. From the International Ovarian Tumor Analysis (IOTA) database, we identified patients with a histological diagnosis of ovarian embryonal carcinoma, non‐gestational choriocarcinoma or malignant mixed germ cell tumor, who had undergone preoperative ultrasound examination by an experienced ultrasound examiner between 2000 and 2020. Additional patients with the same histology were identified from the databases of the departments of gynecological oncology in the participating centers. All tumors were described using IOTA terminology. Three examiners reviewed all available ultrasound images and described them using pattern recognition.ResultsOne patient with embryonal carcinoma, five patients with non‐gestational ovarian choriocarcinoma and seven patients with ovarian malignant mixed germ cell tumor (six primary tumors and one recurrence) were identified. Seven patients were included in the IOTA studies and six patients were examined outside of the IOTA studies. The median age at diagnosis was 26 (range, 14–77) years. Beta‐human chorionic gonadotropin levels were highest in non‐gestational choriocarcinomas and alpha‐fetoprotein levels were highest in malignant mixed germ cell tumors. Most tumors were International Federation of Gynecology and Obstetrics (FIGO) Stage I (9/12 (75.0%)). All tumors were unilateral, and the median largest diameter was 129 (range, 38–216) mm. Of the tumors, 11/13 (84.6%) were solid and 2/13 (15.4%) were multilocular‐solid; 9/13 (69.2%) manifested abundant vascularization on color Doppler examination. Using pattern recognition, the typical ultrasound appearance was a large solid tumor with inhomogeneous echogenicity of the solid tissue and often dispersed cysts which, in most cases, were small and irregular. Some tumors had smooth contours while others had irregular contours.ConclusionsA unilateral, large solid tumor with inhomogeneous echogenicity of the solid tissue and with dispersed small cystic areas in a young woman should raise the suspicion of a rare malignant germ cell tumor. This suspicion can guide the clinician to test tumor markers specific for malignant germ cell tumors. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

Vessel morphology depicted by three‐dimensional power Doppler ultrasound as second‐stage test in adnexal tumors that are difficult to classify: prospective diagnostic accuracy study

ABSTRACTObjectivesTo assess whether vessel morphology depicted by three‐dimensional (3D) power Doppler ultrasound improves discrimination between benignity and malignancy if used as a second‐stage test in adnexal masses that are difficult to classify.MethodsThis was a prospective observational international multicenter diagnostic accuracy study. Consecutive patients with an adnexal mass underwent standardized transvaginal two‐dimensional (2D) grayscale and color or power Doppler and 3D power Doppler ultrasound examination by an experienced examiner, and those with a ‘difficult’ tumor were included in the current analysis. A difficult tumor was defined as one in which the International Ovarian Tumor Analysis (IOTA) logistic regression model‐1 (LR‐1) yielded an ambiguous result (risk of malignancy, 8.3% to 25.5%), or as one in which the ultrasound examiner was uncertain regarding classification as benign or malignant when using subjective assessment. Even when the ultrasound examiner was uncertain, he/she was obliged to classify the tumor as most probably benign or most probably malignant. For each difficult tumor, one researcher created a 360° rotating 3D power Doppler image of the vessel tree in the whole tumor and another of the vessel tree in a 5‐cm3 spherical volume selected from the most vascularized part of the tumor. Two other researchers, blinded to the patient's history, 2D ultrasound findings and histological diagnosis, independently described the vessel tree using predetermined vessel features. Their agreed classification was used. The reference standard was the histological diagnosis of the mass. The sensitivity of each test for discriminating between benign and malignant difficult tumors was plotted against 1 – specificity on a receiver‐operating‐characteristics diagram, and the test with the point furthest from the reference line was considered to have the best diagnostic ability.ResultsOf 2403 women with an adnexal mass, 376 (16%) had a difficult mass. Ultrasound volumes were available for 138 of these cases. In 79/138 masses, the ultrasound examiner was uncertain about the diagnosis based on subjective assessment, in 87/138, IOTA LR‐1 yielded an ambiguous result and, in 28/138, both methods gave an uncertain result. Of the masses, 38/138 (28%) were malignant. Among tumors that were difficult to classify as benign or malignant by subjective assessment, the vessel feature ‘densely packed vessels’ had the best discriminative ability (sensitivity 67% (18/27), specificity 83% (43/52)) and was slightly superior to subjective assessment (sensitivity 74% (20/27), specificity 60% (31/52)). In tumors in which IOTA LR‐1 yielded an ambiguous result, subjective assessment (sensitivity 82% (14/17), specificity 79% (55/70)) was superior to the best vascular feature, i.e. changes in the diameter of vessels in the whole tumor volume (sensitivity 71% (12/17), specificity 69% (48/70)).ConclusionVessel morphology depicted by 3D power Doppler ultrasound may slightly improve discrimination between benign and malignant adnexal tumors that are difficult to classify by subjective ultrasound assessment. For tumors in which the IOTA LR‐1 model yields an ambiguous result, subjective assessment is superior to vessel morphology as a second‐stage test. © 2020 The Authors. Ultrasound in Obstetrics &amp; Gynecology published by John Wiley &amp; Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on pre-operative diagnosis of ovarian tumors

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group, and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the pre-operative diagnosis of ovarian tumors, including imaging techniques, biomarkers, and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the pre-operative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when a consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the pre-operative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumors

ABSTRACTThe European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence‐based statements on the preoperative diagnosis of ovarian tumors, including imaging techniques, biomarkers and prediction models.ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the preoperative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence‐based, the current literature was reviewed and critically appraised.Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements.This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the preoperative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

Imaging in gynecological disease (23): clinical and ultrasound characteristics of ovarian carcinosarcoma

ABSTRACTObjectiveTo describe the clinical and ultrasound characteristics of ovarian carcinosarcoma.MethodsThis was a retrospective multicenter study. Patients with a histological diagnosis of ovarian carcinosarcoma, who had undergone preoperative ultrasound examination between 2010 and 2019, were identified from the International Ovarian Tumor Analysis (IOTA) database. Additional patients who were examined outside of the IOTA study were identified from the databases of the participating centers. The masses were described using the terms and definitions of the IOTA group. Additionally, two experienced ultrasound examiners reviewed all available images to identify typical ultrasound features using pattern recognition.ResultsNinety‐one patients with ovarian carcinosarcoma who had undergone ultrasound examination were identified, of whom 24 were examined within the IOTA studies and 67 were examined outside of the IOTA studies. Median age at diagnosis was 66 (range, 33–91) years and 84/91 (92.3%) patients were postmenopausal. Most patients (67/91, 73.6%) were symptomatic, with the most common complaint being pain (51/91, 56.0%). Most tumors (67/91, 73.6%) were International Federation of Gynecology and Obstetrics (FIGO) Stage III or IV. Bilateral lesions were observed on ultrasound in 46/91 (50.5%) patients. Ascites was present in 38/91 (41.8%) patients. The median largest tumor diameter was 100 (range, 18–260) mm. All ovarian carcinosarcomas contained solid components, and most were described as solid (66/91, 72.5%) or multilocular‐solid (22/91, 24.2%). The median diameter of the largest solid component was 77.5 (range, 11–238) mm. Moderate or rich vascularization was found in 78/91 (85.7%) cases. Retrospective analysis of ultrasound images and videoclips using pattern recognition in 73 cases revealed that all tumors had irregular margins and inhomogeneous echogenicity of the solid components. Forty‐seven of 73 (64.4%) masses appeared as a solid tumor with cystic areas. Cooked appearance of the solid tissue was identified in 28/73 (38.4%) tumors. No pathognomonic ultrasound sign of ovarian carcinosarcoma was found.ConclusionsOvarian carcinosarcomas are usually diagnosed in postmenopausal women and at an advanced stage. The most common ultrasound appearance is a large solid tumor with irregular margins, inhomogeneous echogenicity of the solid tissue and cystic areas. The second most common pattern is a large multilocular‐solid mass with inhomogeneous echogenicity of the solid tissue. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Preoperative staging of ovarian cancer: comparison between ultrasound, CT and whole‐body diffusion‐weighted MRI (ISAAC study)

AbstractObjectivesTo compare the performance of transvaginal and transabdominal ultrasound with that of the first‐line staging method (contrast‐enhanced computed tomography (CT)) and a novel technique, whole‐body magnetic resonance imaging with diffusion‐weighted sequence (WB‐DWI/MRI), in the assessment of peritoneal involvement (carcinomatosis), lymph‐node staging and prediction of non‐resectability in patients with suspected ovarian cancer.MethodsBetween March 2016 and October 2017, all consecutive patients with suspicion of ovarian cancer and surgery planned at a gynecological oncology center underwent preoperative staging and prediction of non‐resectability with ultrasound, CT and WB‐DWI/MRI. The evaluation followed a single, predefined protocol, assessing peritoneal spread at 19 sites and lymph‐node metastasis at eight sites. The prediction of non‐resectability was based on abdominal markers. Findings were compared to the reference standard (surgical findings and outcome and histopathological evaluation).ResultsSixty‐seven patients with confirmed ovarian cancer were analyzed. Among them, 51 (76%) had advanced‐stage and 16 (24%) had early‐stage ovarian cancer. Diagnostic laparoscopy only was performed in 16% (11/67) of the cases and laparotomy in 84% (56/67), with no residual disease at the end of surgery in 68% (38/56), residual disease ≤ 1 cm in 16% (9/56) and residual disease &gt; 1 cm in 16% (9/56). Ultrasound and WB‐DWI/MRI performed better than did CT in the assessment of overall peritoneal carcinomatosis (area under the receiver‐operating‐characteristics curve (AUC), 0.87, 0.86 and 0.77, respectively). Ultrasound was not inferior to CT (P = 0.002). For assessment of retroperitoneal lymph‐node staging (AUC, 0.72–0.76) and prediction of non‐resectability in the abdomen (AUC, 0.74–0.80), all three methods performed similarly. In general, ultrasound had higher or identical specificity to WB‐DWI/MRI and CT at each of the 19 peritoneal sites evaluated, but lower or equal sensitivity in the abdomen. Compared with WB‐DWI/MRI and CT, transvaginal ultrasound had higher accuracy (94% vs 91% and 85%, respectively) and sensitivity (94% vs 91% and 89%, respectively) in the detection of carcinomatosis in the pelvis. Better accuracy and sensitivity of ultrasound (93% and 100%) than WB‐DWI/MRI (83% and 75%) and CT (84% and 88%) in the evaluation of deep rectosigmoid wall infiltration, in particular, supports the potential role of ultrasound in planning rectosigmoid resection. In contrast, for the bowel serosal and mesenterial assessment, abdominal ultrasound had the lowest accuracy (70%, 78% and 79%, respectively) and sensitivity (42%, 65% and 65%, respectively).ConclusionsThis is the first prospective study to document that, in experienced hands, ultrasound may be an alternative to WB‐DWI/MRI and CT in ovarian cancer staging, including peritoneal and lymph‐node evaluation and prediction of non‐resectability based on abdominal markers of non‐resectability. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

European Society of Gynaecological Oncology Guidelines for the Management of Patients with Vulvar Cancer - Update 2023

As part of its mission to improve the quality of care for women with gynecological cancers across Europe, the European Society of Gynaecological Oncology (ESGO) first published in 2017 evidence-based guidelines for the management of patients with vulvar cancer. To update the ESGO guidelines based on the new evidence addressing the management of vulvar cancer and to cover new topics in order to provide comprehensive guidelines on all relevant issues of diagnosis and treatment of vulvar cancer. The ESGO Council nominated an international development group comprised of practicing clinicians who provide care to vulvar cancer patients and have demonstrated leadership through their expertize in clinical care and research, national and international engagement and profile as well as dedication to the topics addressed to serve on the expert panel (18 experts across Europe). To ensure that the statements were evidence-based, new data identified from a systematic search were reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the international development group. Prior to publication, the guidelines were reviewed by 206 international practitioners in cancer care delivery and patient representatives. The updated guidelines cover comprehensively diagnosis and referral, staging, pathology, pre-operative investigations, surgical management (local treatment, groin treatment, sentinel lymph node procedure, reconstructive surgery), (chemo)radiotherapy, systemic treatment, treatment of recurrent disease (vulvar, inguinal, pelvic, and distant recurrences), and follow-up. Management algorithms are also defined.

Terms, definitions and measurements to describe sonographic features of lymph nodes: consensus opinion from the Vulvar International Tumor Analysis (VITA) group

ABSTRACTIn centers with access to high‐end ultrasound machines and expert sonologists, ultrasound is used to detect metastases in regional lymph nodes from melanoma, breast cancer and vulvar cancer. There is, as yet, no international consensus on ultrasound assessment of lymph nodes in any disease or medical condition. The lack of standardized ultrasound nomenclature to describe lymph nodes makes it difficult to compare results from different ultrasound studies and to find reliable ultrasound features for distinguishing non‐infiltrated lymph nodes from lymph nodes infiltrated by cancer or lymphoma cells. The Vulvar International Tumor Analysis (VITA) collaborative group consists of gynecologists, gynecologic oncologists and radiologists with expertise in gynecologic cancer, particularly in the ultrasound staging and treatment of vulvar cancer. The work herein is a consensus opinion on terms, definitions and measurements which may be used to describe inguinal lymph nodes on grayscale and color/power Doppler ultrasound. The proposed nomenclature need not be limited to the description of inguinal lymph nodes as part of vulvar cancer staging; it can be used to describe peripheral lymph nodes in general, as well as non‐peripheral (i.e. parietal or visceral) lymph nodes if these can be visualized clearly. The association between the ultrasound features described here and histopathological diagnosis has not yet been established. VITA terms and definitions lay the foundations for prospective studies aiming to identify ultrasound features typical of metastases and other pathology in lymph nodes and studies to elucidate the role of ultrasound in staging of vulvar and other malignancies. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Interobserver agreement of transvaginal ultrasound and magnetic resonance imaging in local staging of cervical cancer

ABSTRACTObjectiveTo evaluate interobserver agreement for the assessment of local tumor extension in women with cervical cancer, among experienced and less experienced observers, using transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI).MethodsThe TVS observers were all gynecologists and consultant ultrasound specialists, six with and seven without previous experience in cervical cancer imaging. The MRI observers were five radiologists experienced in pelvic MRI and four less experienced radiology residents without previous experience in MRI of the pelvis. The less experienced TVS observers and all MRI observers underwent a short basic training session in the assessment of cervical tumor extension, while the experienced TVS observers received only a written directive. All observers were assigned the same images from cervical cancer patients at all stages (n = 60) and performed offline evaluation to answer the following three questions: (1) Is there a visible primary tumor? (2) Does the tumor infiltrate &gt; ⅓ of the cervical stroma? and (3) Is there parametrial invasion? Interobserver agreement within the four groups of observers was assessed using Fleiss kappa (κ) with 95% CI.ResultsExperienced and less experienced TVS observers, respectively, had moderate interobserver agreement with respect to tumor detection (κ (95% CI), 0.46 (0.40–0.53) and 0.46 (0.41–0.52)), stromal invasion &gt; ⅓ (κ (95% CI), 0.45 (0.38–0.51) and 0.53 (0.40–0.58)) and parametrial invasion (κ (95% CI), 0.57 (0.51–0.64) and 0.44 (0.39–0.50)). Experienced MRI observers had good interobserver agreement with respect to tumor detection (κ (95% CI), 0.70 (0.62–0.78)), while less experienced MRI observers had moderate agreement (κ (95% CI), 0.51 (0.41–0.62)), and both experienced and less experienced MRI observers, respectively, had good interobserver agreement regarding stromal invasion (κ (95% CI), 0.80 (0.72–0.88) and 0.71 (0.61–0.81)) and parametrial invasion (κ (95% CI), 0.69 (0.61–0.77) and 0.71 (0.61–0.81)).ConclusionsWe found interobserver agreement for the assessment of local tumor extension in patients with cervical cancer to be moderate for TVS and moderate‐to‐good for MRI. The level of interobserver agreement was associated with experience among TVS observers only for parametrial invasion. © 2021 The Authors. Ultrasound in Obstetrics &amp; Gynecology published by John Wiley &amp; Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Imaging in gynecological disease (29): clinical and ultrasound features of primary ovarian immature teratoma

ABSTRACT Objective To describe the clinical and ultrasound characteristics at the time of diagnosis of primary ovarian immature teratoma with no other germ cell tumor components described on histopathology. Methods This was a retrospective study of women with a histological diagnosis of primary ovarian immature teratoma who had undergone a preoperative ultrasound examination between 1998 and 2024. Cases were identified from the databases of 17 contributing ultrasound centers and the International Ovarian Tumor Analysis (IOTA) database. The descriptions of the ultrasound images of the tumors made by the original ultrasound examiners using IOTA terminology were reported. In addition, grayscale and color or power Doppler ultrasound images or videoclips were retrieved for all tumors. Two independent ultrasound examiners reviewed the retrieved material and searched for specific ultrasound characteristics of immature teratomas using pattern recognition. We present their agreed description of the tumors. Results In total, 64 patients with ovarian immature teratoma were included, of which 38 (59.4%) were obtained from the IOTA database (IOTA studies phase 1, 1b, 2, 3, 5 and 7). The median age of the patients at diagnosis was 24.5 (interquartile range (IQR), 18.8–31.0; range, 12–50) years. The most common presenting symptoms were abdominal or pelvic pain (38/60, 63.3%) and abdominal swelling (30/60, 50.0%). All immature teratomas were unilateral. The median largest diameter of the tumor was 149.5 (IQR, 125.0–183.8; range, 27–400) mm. Using IOTA terminology, most tumors were described as multilocular‐solid (32/64, 50.0%) or solid lesions (22/64, 34.4%). When present, the solid component had a median largest diameter of 98.5 (IQR, 59.8–146.8; range 6–400) mm. Most masses showed minimal (19/63, 30.2%) or moderate (35/63, 55.6%) vascularization on color or power Doppler ultrasound examination. Using pattern recognition, the most typical ultrasound feature was heterogeneous, bizarre echogenicity of the solid components, with hyperechogenic areas, cystic spaces and acoustic shadows. This feature, which we consider pathognomonic, was present in 48/57 (84.2%) immature teratomas in which the solid components were adequately assessable. Conclusions The typical ultrasound appearance of an ovarian immature teratoma is a large unilateral adnexal mass with large solid components that is poorly or moderately vascularized. The pathognomonic feature is heterogeneous echogenicity of the solid components with hyperechogenic areas, cystic spaces and acoustic shadows. Preoperative suspicion of immature teratoma can guide treatment, such as offering fertility‐sparing surgery. © 2025 The Author(s). Ultrasound in Obstetrics &amp; Gynecology published by John Wiley &amp; Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

ISUOG/ESGO Consensus Statement on ultrasound‐guided biopsy in gynecological oncology

ABSTRACTThe International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) with the European Society of Gynaecological Oncology (ESGO) jointly developed clinically relevant and evidence‐based statements on performing ultrasound‐guided biopsies in gynecological oncology.The objective of this Consensus Statement is to assist clinicians, including gynecological sonographers, gynecological oncologists and radiologists, to achieve the best standards of practice in ultrasound‐guided biopsy procedures. ISUOG/ESGO nominated a multidisciplinary international group of 16 experts who have demonstrated leadership in the use of ultrasound‐guided biopsy in the clinical management of patients with gynecological cancer. In addition, two early‐career gynecological fellows were nominated to participate from the European Network of Young Gynae Oncologists (ENYGO) within ESGO and from ISUOG. The group also included a patient representative from the European Network of Gynaecological Cancer Advocacy Groups. The document is divided into six sections: (1) general recommendations; (2) image‐guided biopsy (imaging guidance, sampling methods); (3) indications and contraindications; (4) technique; (5) reporting; and (6) training and quality assurance. To ensure that the statements are evidence‐based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on this review of the literature. During a conference call, the whole group discussed each preliminary statement, and a first round of voting was carried out. The group achieved consensus on all 46 preliminary statements without the need for revision.These ISUOG/ESGO statements on ultrasound‐guided biopsy in gynecological oncology, together with a summary of the evidence supporting each statement, are presented herein. This Consensus Statement is supplemented by detailed narrated videoclips presenting different approaches and indications for ultrasound‐guided biopsy, a patient leaflet, and an extended version which includes a detailed review of the evidence. © 2025 The Authors. Published by John Wiley &amp; Sons Ltd on behalf of The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and by Elsevier Inc. on behalf of the European Society of Gynaecological Oncology and the International Gynecologic Cancer Society.

Ultrasound-based preoperative assessment for cervical cancer: a pragmatic staging and treatment-planning strategy adaptable to diverse resource settings.

Cervical cancer remains a major global health burden, particularly in low- and middle-income countries, where access to advanced imaging and treatment is often limited. While magnetic resonance imaging is considered the gold standard for loco-regional staging, recent evidence supports transvaginal/transrectal ultrasound as an accurate and cost-effective alternative when performed by trained sonographers and clinicians. Its portability and affordability make ultrasound particularly valuable in resource-constrained settings. In this paper, we present a pragmatic diagnostic and clinical strategy for managing cervical cancer in contexts where magnetic resonance imaging, sentinel lymph node mapping, and radiotherapy are not available. Building on a structured checklist of ultrasound-based parameters, we propose simple, tailored pathways to guide decisions regarding upfront surgery, neoadjuvant chemotherapy, pelvic exenteration, or palliative chemotherapy and supportive care. The approach emphasizes accurate staging through transvaginal/transrectal ultrasound combined with transabdominal scanning, allowing identification of tumor size, local extension, lymph node status, and clear contraindications to surgery. By promoting ultrasound as a reliable tool for loco-regional staging and treatment planning, we aim to improve access to cervical cancer care in low- and middle-income countries and to lay the groundwork for future prospective multi-center studies.

Comparison of ultrasound with computed tomography and whole‐body diffusion‐weighted MRI in prediction of surgical outcome using ESMO ‐ ESGO criteria in patients with tubo‐ovarian carcinoma: prospective ISAAC study

ABSTRACT Objective To test the non‐inferiority of extended abdominopelvic ultrasound examination compared with contrast‐enhanced computed tomography (CT) and whole‐body diffusion‐weighted magnetic resonance imaging (WB‐DWI/MRI) in discriminating preoperatively between resectable and non‐resectable disease based on the European Society for Medical Oncology (ESMO) and European Society of Gynecological Oncology (ESGO)‐defined criteria in patients with tubo‐ovarian carcinoma. Methods The Imaging Study on Advanced ovArian Cancer was a prospective multicenter observational study conducted in five European gynecological oncology centers. All centers had ESGO accreditation to perform advanced ovarian cancer surgery, and ultrasound examinations were performed by a European Federation of Societies for Ultrasound in Medicine and Biology level‐III examiner in a standardized manner. Included in the analysis were patients enrolled between 2020 and 2022 with suspected or histologically proven primary tubo‐ovarian (including peritoneal) carcinoma who, for the purposes of the study, underwent ultrasound and CT imaging, as well as WB‐DWI/MRI if available, prior to surgery. The index tests, which included the preoperative imaging modalities as well as intraoperative exploration at the start of surgery, supplemented by biopsy or follow‐up imaging for extra‐abdominal locations, evaluated the presence of disease at eight anatomical sites that, if infiltrated, would indicate non‐resectability of the tumor according to the ESMO‐ESGO criteria. Surgical outcome, described by the surgeons at the end of the procedure, was used as the reference standard and non‐resectability was defined as the presence of residual disease &gt; 1 cm or when debulking surgery was not feasible. The area under the receiver‐operating‐characteristics curve (AUC) and F 1  score were used to assess the performance of the preoperative imaging methods and surgical exploration in discriminating between patients with resectable and those with non‐resectable disease, based on the ESMO‐ESGO criteria. We also calculated the percentage agreement between imaging findings and surgical exploration findings at the start of surgery, supplemented when applicable by biopsy or follow‐up imaging for extra‐abdominal locations, regarding the presence of tumor infiltration at each of the eight anatomical sites associated with non‐resectability. Results Of 279 patients enrolled during the study period, 242 were included in the final analysis. In the subgroup of 167 patients who underwent surgery and had been examined by all three imaging methods, the AUC of the three imaging modalities and surgical exploration for discriminating between resectable and non‐resectable disease based on the ESMO‐ESGO criteria was 0.835 (95% CI, 0.756–0.915) for ultrasound, for CT it was 0.754 (95% CI, 0.664–0.843), for WB‐DWI/MRI it was 0.720 (95% CI, 0.626–0.814) and for surgical exploration it was 0.952 (95% CI, 0.915–0.988). Ultrasound was not inferior to CT or WB‐DWI/MRI, based on the AUC and F 1 score, in discriminating between patients with resectable and those with non‐resectable tubo‐ovarian carcinoma. At surgical exploration, at least one non‐resectability criterion was present in 32.2% cases. The criteria observed most frequently at surgical exploration were small‐bowel involvement (23.6% of cases), diffuse deep infiltration of the root of the small‐bowel mesentery (18.2% of cases) and hepatic hilum involvement (5.4% of cases). The percentage agreement between ultrasound and surgical exploration in assessing the presence of disease in at least one of the eight anatomical sites that, if infiltrated, would indicate non‐resectability of tumor, was 83.9%, surpassing the percentage agreement with surgical exploration of both CT (77.7%) and WB‐DWI/MRI (75.8%). Conclusion When performed by an experienced examiner, ultrasound is not inferior to either CT or WB‐DWI/MRI in discriminating between resectable and non‐resectable disease in patients with tubo‐ovarian carcinoma, based on evaluation of the presence of the disease in at least one of eight anatomical sites that, if infiltrated, would indicate non‐resectability of the tumor. © 2025 The Author(s). Ultrasound in Obstetrics &amp; Gynecology published by John Wiley &amp; Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

International multicenter validation of AI-driven ultrasound detection of ovarian cancer

Abstract Ovarian lesions are common and often incidentally detected. A critical shortage of expert ultrasound examiners has raised concerns of unnecessary interventions and delayed cancer diagnoses. Deep learning has shown promising results in the detection of ovarian cancer in ultrasound images; however, external validation is lacking. In this international multicenter retrospective study, we developed and validated transformer-based neural network models using a comprehensive dataset of 17,119 ultrasound images from 3,652 patients across 20 centers in eight countries. Using a leave-one-center-out cross-validation scheme, for each center in turn, we trained a model using data from the remaining centers. The models demonstrated robust performance across centers, ultrasound systems, histological diagnoses and patient age groups, significantly outperforming both expert and non-expert examiners on all evaluated metrics, namely F1 score, sensitivity, specificity, accuracy, Cohen’s kappa, Matthew’s correlation coefficient, diagnostic odds ratio and Youden’s J statistic. Furthermore, in a retrospective triage simulation, artificial intelligence (AI)-driven diagnostic support reduced referrals to experts by 63% while significantly surpassing the diagnostic performance of the current practice. These results show that transformer-based models exhibit strong generalization and above human expert-level diagnostic accuracy, with the potential to alleviate the shortage of expert ultrasound examiners and improve patient outcomes.

Preoperative discrimination between uterine myomas and sarcomas

The narrative review article is focused on the strengths and limitations of modern imaging methods in the preoperative differential diagnosis of uterine mesenchymal tumours. In order to tailor the surgical procedures, imaging methods, namely ultrasound and magnetic resonance imaging (MRI), should be taken into account as well as clinical symptoms, age, and fertility plans. On ultrasound scans, uterine sarcomas have the appearance of large, usually solitary tumours of non-homogenous structure with irregular cysts, ill-defined outline borders (interrupted capsule), absence of calcifications with acoustic shadowing, and moderate to rich internal vascularisation. Rapid growth between follow-ups or atypical growth in peri- or post-menopause is also a sign of malignancy. On MRI, uterine sarcomas are characterized by irregular borders, hyperintense areas on T1-weighted and T2-weighted images, and central non-enhancing necrotic areas. On diffusion-weighted imaging (DWI/MRI), sarcomas exhibit markedly restricted diffusion but there is a significant overlap with some variants of fibroids. Core-needle or hysteroscopic biopsy can be used preoperatively if suspicious features are detected on ultrasound or MRI scans, particularly before myomectomy if fertility preservation is required or when conservative management is considered in asymptomatic women. Other imaging methods, such as positron emission tomography fused with CT (PET-CT) or computed tomography (CT) have limited role to distinguish uterine sarcomas from myomas and are suitable only for staging purposes. The importance of tumour markers including lactate dehydrogenase in preoperative work-up have not been verified yet. Conclusion: Uterine sarcomas can be distinguished from much more common myomas based on a combination of malignant features on ultrasound or MR imaging. In these suspicious cases the type and extent of surgery should be adjusted, avoiding intraperitoneal morcellation, which could lead to iatrogenic tumour spread and worsening of the patient’s prognosis. Key words: myoma – uterine sarcoma – ultrasound – magnetic resonance imaging – biopsy – biomarkers

ESGO/EURACAN/GCIG guidelines for the management of patients with uterine sarcomas

Ultrasound-guided core needle biopsy: evaluating adequacy, accuracy, and safety in gynecologic oncology

Tissue biopsy is an important component of pre-surgical pathologic diagnosis of cancer for treatment planning and clinical research. Core needle biopsy, or Tru-Cut biopsy, was introduced in the 1960s and 1970s but has not yet become routine in gynecologic oncology, and few studies have examined its adequacy or accuracy in this setting. We report our experience of ultrasound-guided core needle biopsy in patients with gynecologic malignancies. We conducted a retrospective study of ultrasound-guided core needle biopsy at a single tertiary hospital in Prague, Czech Republic, using electronic medical records of cases between 2010 and 2022. We examined the adequacy of biopsy samples, accuracy relative to surgical pathology specimens, and safety. Ultrasound-guided core needle biopsy was performed using standardized procedures. A total of 690 core needle biopsy procedures were evaluated (456 in newly diagnosed cases and 234 in recurrent cases), including 16 repeat procedures, in 674 patients. The 3 most common biopsy sites were ovary (29.3%), carcinomatosis (17.4%), and indeterminate pelvic mass (10.2%). Most (85.9%) biopsies retrieved 3 tissue samples. Core needle biopsy was adequate to establish a diagnosis in 622 of 690 cases (90.1%), and repeat core needle biopsy yielded an additional 16 adequate samples (2.3%). The adequacy rate was highest for ovarian biopsies (96.6%) and lowest for uterine body biopsies (83.3%). Pathologic assessment of core needle biopsy agreed with surgical specimens in 263 of 273 patients who underwent surgery, with an accuracy rate of 96.3%. There was no clear correlation between inaccurate biopsy results and final histotypes. Complications occurred in 9 of 690 core needle biopsy procedures (1.3%), including 6 cases of intra-procedural bleeding (3 required hospitalization), 2 cases of infection, and 1 case of a psychogenic reaction (non-epileptic seizure). Ultrasound-guided core needle biopsy is an accurate, well-tolerated technique that provides reliable diagnostic tissue in gynecologic oncology and may be considered a preferred approach for initial evaluation and confirmation of disease.

In Vitro Study of [18F]F-FAPI-74 Feasibility in Vulvar Cancer

This study aims to investigate the expression of FAP by phosphor imaging in invasive vulvar squamous cell carcinoma specimens. This in vitro study will include all consecutive tumour specimens stored both in optimal cutting temperature (OCT) compound and formalin-fixed paraffin-embedded (FFPE) from patients with a first diagnosis of vulvar squamous cell carcinoma who underwent surgery at Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

Imaging Study in Advanced Ovarian Cancer

The aim of the study is the assessment of tumour sites critical for the achievement of optimal cytoreduction in patients with advanced ovarian cancer using Ultrasound, CT and WB-DWI/MRI. The study uses an equivalence design with a hypothesis that cases with non-resectable disease identified by Index test (Ultrasound, CT and WB-DWI MRI) are equivalent to a portion of cases identified during surgery.