Mitchell P. Wilson

Re-evaluating Endometrial Thickness in Symptomatic Postmenopausal Patients for Excluding Cancer: Systematic Review and Meta-Analysis

The current ACR and American College of Obstetricians and Gynecologists guidelines recommend a ≤4-mm endometrial thickness threshold for excluding endometrial cancer in symptomatic postmenopausal patients. This systematic review and meta-analysis aims to re-evaluate the optimal endometrial thickness threshold on imaging for excluding cancer in symptomatic postmenopausal patients. A systematic search of MEDLINE, EMBASE, Cochrane Library, and Scopus from inception to October 2023 was performed in addition to a gray literature search. Studies were included if they evaluated the diagnostic imaging accuracy of endometrial thickness thresholds for detecting endometrial cancer in symptomatic postmenopausal patients. The reference standard was histopathology. Full-text review and data extraction were performed independently by two reviewers. Risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Meta-analysis was performed using a bivariate mixed-effects regression model. Thirty-five studies with 6,302 patients met inclusion criteria. Mean age range was 51 to 68 years. The sensitivities and specificities with 95% confidence intervals for the 2- to 7-mm thresholds are 95% (84%-98%) and 22% (8%-49%) for ≤2 mm, 94% (82%-98%) and 35% (24%-47%) for ≤3 mm, 95% (86%-98%) and 45% (34%-56%) for ≤4 mm, 88% (75%-95%) and 56% (42%-68%) for ≤5 mm, 84% (63%-94%) and 60% (43%-74%) for ≤6 mm, and 85% (56%-96%) and 62% (49%-73%) for ≤7 mm. Studies were deemed predominantly low risk for bias across domains. This comprehensive meta-analysis supports the ≤4-mm endometrial thickness threshold for excluding endometrial cancer in symptomatic postmenopausal patients.

Diagnostic accuracy of contrast-enhanced CT versus PET/CT for advanced ovarian cancer staging: a comparative systematic review and meta-analysis

Accurate staging of ovarian cancer is critical to guide optimal management pathways. North American guidelines recommend contrast-enhanced CT as the primary work-up for staging ovarian cancer. This meta-analysis aims to compare the diagnostic accuracy of contrast-enhanced CT alone to PET/CT for detecting abdominal metastases in patients with a new or suspected diagnosis of ovarian cancer. A systematic review of MEDLINE, EMBASE, Scopus, the Cochrane Library, and the gray literature from inception to October 2022 was performed. Studies with a minimum of 5 patients evaluating the diagnostic accuracy of contrast-enhanced CT and/or PET/CT for detecting stage 3 ovarian cancer as defined by a surgical/histopathological reference standard ± clinical follow-up were included. Study, clinical, imaging, and accuracy data for eligible studies were independently acquired by two reviewers. Primary meta-analysis was performed in studies reporting accuracy on a per-patient basis using a bivariate mixed-effects regression model. Risk of bias was evaluated using QUADAS-2. From 3701 citations, 15 studies (918 patients with mean age ranging from 51 to 65 years) were included in the systematic review. Twelve studies evaluated contrast-enhanced CT (6 using a per-patient assessment and 6 using a per-region assessment) and 11 studies evaluated PET/CT (7 using a per-patient assessment and 4 using a per-region assessment). All but one reporting study used consensus reading. Respective sensitivity and specificity values on a per-patient basis were 82% (67-91%, 95% CI) and 72% (59-82%) for contrast-enhanced CT and 87% (75-94%) and 90% (82-95%) for PET/CT. There was no significant difference in sensitivities between modalities (p = 0.29), but PET/CT was significantly more specific than CT (p < 0.01). Presumed variability could not be assessed in any single category due to limited studies using per-patient assessment. Studies were almost entirely low risk for bias and applicability concerns using QUADAS-2. Contrast-enhanced CT demonstrates non-inferior sensitivity compared to PET/CT, although PET/CT may still serve as an alternative and/or supplement to CT alone prior to and/or in lieu of diagnostic laparoscopy in patients with ovarian cancer. Future revisions to existing guidelines should consider these results to further refine the individualized pretherapeutic diagnostic pathway.