Florian Frühauf

European training requirements for gynecological oncology: the European Society of Gynaecological Oncology Curriculum

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.

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.

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

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.