The differential diagnosis of benign and malignant adnexial masses
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Current approach for distinguishing between benign and malignant adnexal masses before surgery
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The differential diagnosis of benign and malignant adnexial masses
- 1. 10.10.2015 1 Adneksial kitlelerde malignite araştırması Dr. Tevfik Yoldemir Marmara Üniversitesi Kadın Hastalıkları ve Doğum A.D. tevfik@yoldemir.com Kistin iç duvarı kistin içeriği Uniloküler kist / uniloküler solid kist Multiloküler kist/ multiloküler solid kist Solid tumor (tüm kitlenin >%80) Septum / papiller çıkıntı
- 2. 10.10.2015 2 Douglas boşluğunda sıvı Siyah beyaz skala - morfoloji Ultrasound Obstet Gynecol 2007; 30: 874–882 Siyah beyaz + Doppler Ultrasound Obstet Gynecol 2007; 30: 874–882 Damar yapısı Ultrasound Obstet Gynecol 2007; 30: 874–882 Cut-off değerler Gynecologic Oncology 127 (2012) 379–383 Risk of Malignancy Index (RMI) • RMI = U x M x serum CA125 U = 0, görüntüleme skoru 0 ise U = 1, görüntüleme skoru 1 ise U = 3, görüntüleme skoru 2-5 ise M = 1 eğer premehayırpausal ise M = 3 eğer postmehayırpausal ise 1 puan : multilokular kist, solid hayırdul, bilateral kist, asit, ve uzak metastaz. http://www.hutchon.net/RMIcalc2.htm Am J Obstet Gynecol 2010;203:228.e1-6.
- 3. 10.10.2015 3 Risk of Ovarian Malignancy Algorithm (ROMA) • Premenapozal: Öngörü indeksi PI = -12.0+2.38 x LN(HE4)+0.0626 x LN(CA125) • Postmenapozal: PI = -8.09+1.04 x LN(HE4)+0.732 x LN(CA125) • Tahmin edilen olasılık = exp(PI) ⁄ [1+exp(PI)] http://xema-medica.com/eng/calc/ Am J Obstet Gynecol 2010;203:228.e1-6. ROMA v RMI - Selim v Malign Am J Obstet Gynecol 2010;203:228.e1-6. ROMA v RMI Am J Obstet Gynecol 2010;203:228.e1-6. multivariate index assay (MIA, OVA1) • CA125II, transferin, transthyretin (prealbumin), apolipoprotein A1, beta-2- microglobulin. • OvaCalc software (Vermillion, Inc., Austin, TX) • Yüksek risk – MIA skoru ≥5.0 (premenapozal) – ≥4.4 (postmenapozal) Am J Obstet Gynecol 2013;209:581.e1-8. Dearking modifiye-ACOG kılavuz rehberi (Jinekolog onkolog danışmak için) • Premenapozal – 1. Yüksek CA125 (>67 unite/mL) – 2. Asit – 3. Abdominal veya uzak metastaz • Postmenopozal – 1. Yüksek CA125 (>35 unite/mL) – 2. nodular veya fikse pelvik kitle – 3. Asit – 4. Abdominal veya uzak metastaz Am J Obstet Gynecol 2013;209:581.e1-8. Klinik v CA125 v mACOGg v MIA Am J Obstet Gynecol 2013;209:581.e1-8.
- 4. 10.10.2015 4 OVA1 + Klinik Am J Obstet Gynecol 2014;210:78.e1-9. OVA1 + Klinik - premenapoz Am J Obstet Gynecol 2014;210:78.e1-9. OVA1 + Klinik - postmenapoz Am J Obstet Gynecol 2014;210:78.e1-9. Copenhagen Index • CPH-I = −14.0647 + 1.0649 x log2 (HE4) + 0.6050 log2(CA125) + 0.2672 x yaş/10 • Tahmin edilen olasılık (PP) : PP = e(CPH-I) / ( 1 + e (CPH-I ) ) Gynecologic Oncology 138 (2015) 640–646 CPH-I v ROMA v RMI Gynecologic Oncology 138 (2015) 640–646 SP / SN Gynecologic Oncology 138 (2015) 640–646
- 5. 10.10.2015 5 Değerlendirme v RMI v ROMA European Journal of Cancer (2012) 48, 1649– 1656 Değerlendirme v RMI v ROMA European Journal of Cancer (2012) 48, 1649– 1656 Model development and internal validation (n = 1066) Role of CA 125 in diagnosing ovarian cancer Long-term behavior of ovarian masses managed expectantly Propose an evidence-based clinical management protocol for all adnexal masses Performance of main IOTA approaches in the hands of examiners with different levels of ultrasound experience Evaluation of impact on referral patterns using LR2 instead of RMI Assessment of second-stage tests (3D power Doppler, intravenous contrast, proteomics, new tumor markers) External validation of main IOTA models and direct comparison with RMI and established non-IOTA models (n = 997) Role of CA 125 in diagnosing ovarian cancer Temporal validation (n = 507) of main IOTA approaches(LR1, LR2, simple rules) IOTA 1 1999–2002 IOTA 1b 2002–2005 IOTA 2 2005–2007 IOTA 3 2009–2012 IOTA 4 2012–2013 IOTA 5 2012–2017 Ultrasound Obstet Gynecol 2013; 41: 9–20 Selim v Malign / LR modeli Selim v Malign / LR modeli J Clin Oncol 2005;23:8794-8801 Selim v Malign / LR modeli J Clin Oncol 2005;23:8794-8801
- 6. 10.10.2015 6 IOTA bölüm 1 deki 11 model Clin Cancer Res 2009;15(2) January 15, 2009 IOTA bölüm 1 deki 11 model Clin Cancer Res 2009;15(2) January 15, 2009 Non-IOTA v IOTA modelleri Clin Cancer Res 2011; 18(3); 815–25 Non-IOTA v IOTA modelleri Clin Cancer Res 2011; 18(3); 815–25 Non-IOTA v IOTA modelleri Clin Cancer Res 2011; 18(3); 815–25 Non-IOTA v IOTA modelleri Clin Cancer Res 2011; 18(3); 815–25
- 7. 10.10.2015 7 Non-IOTA v IOTA modelleri Clin Cancer Res 2011; 18(3); 815–25 Non-IOTA v IOTA modelleri Clin Cancer Res 2011; 18(3); 815–25 Int. Ovarian Tumor Analysis IOTA logistic regression model LR1 (a) Over kanseri öyküsü (evet=1, hayır=0); (b) Halen hormon tedavisi alma (evet=1, hayır=0); (c) Yaş (yıl); (d) Lezyonun max çapı (mm); (e) Ultrason muayenesinde ağrı (evet=1, hayır=0); (f) Asit (evet=1, hayır=0); (g) Solid papiller çıkıntıda kan akımı varlığı (evet=1, hayır=0); (h) Tümüyle solid tümör varlığı (evet=1, hayır=0); (i) Solid kısmın max çapı (mm, >50 mmden fazla değil); (j) Kist duvarlarının içlerinde düzensizlik (evet=1, hayır=0); (k) Akustik gölgelerin olması (evet=1, hayır=0); (l) Renk skoru (1, 2, 3, 4). LR1 Habis olma riski = 1/(1 + e−z) z = −6.7468 + 1.5985(a) − 0.9983(b) + 0.0326(c) + 0.00841(d) − 0.8577(e) + 1.5513(f) + 1.1737(g) + 0.9281(h) + 0.0496(i) + 1.1421(j) − 2.3550(k) +0.4916(l) http://www.iotagroup.org/index.php/software LB2 Habis olma riski = 1/(1 + e−z) z= −5.3718 + 0.0354(c) + 1.6159(f) + 1.1768(g) + 0.0697(i) + 0.9586(j) − 2.9486(k). http://www.iotagroup.org/index.php/software Ultrason özellikleri
- 8. 10.10.2015 8 Basit kurallar Ultrasound Obstet Gynecol 2013; 41: 9–20 Basit kurallar BMJ 2010;341:c6839 SR v SA v LR1 v LR2 BMJ 2010;341:c6839 SR v SA v LR1 v LR2 BMJ 2010;341:c6839 SR v SA v LR1 v LR2 BMJ 2010;341:c6839 Tm çapına göre SN / SP
- 9. 10.10.2015 9 AUC 6 tanımlayıcı Ultrasound Obstet Gynecol 2012; 40: 582–591 SR Ultrasound Obstet Gynecol 2012; 40: 582–591 Kombinasyonlar Ultrasound Obstet Gynecol 2012; 40: 582–591 Ultrasound Obstet Gynecol 2012; 40: 582–591 IOTA çalışması - bölüm 3 British Journal of Cancer (2014) 111, 680–688
- 10. 10.10.2015 10 Test performansı British Journal of Cancer (2014) 111, 680–688 Test performansı pre/postmenapoz British Journal of Cancer (2014) 111, 680–688 LR1 ve LR2 Değişkenleri British Journal of Cancer (2014) 111, 680–688 Basit kurallar değişkenleri British Journal of Cancer (2014) 111, 680–688 Assessment of Different NEoplasias in the adneXa (ADNEX) model – yaş, – serum CA-125 seviyesi (log transformed), – Merkez tipi, – Lezyonun maksimum çapı (log transformed), – Solid dokunun oranı (with quadratic term), – Papiller uzantıların sayısı, – 10dan fazla kistik lokül, – Akustik gölgelenme, – asit. http://www.iotagroup.org/adnexmodel/site%20iota.html BMJ 2014;349:g5920 ADNEX için seçilen US belirteçleri Facts Views Vis Obgyn, 2015, 7 (1): 32-41
- 11. 10.10.2015 11 ADNEX model BMJ 2014;349:g5920 ADNEX model BMJ 2014;349:g5920 ADNEX model BMJ 2014;349:g5920 Basit kurallar – Test performansı Facts Views Vis Obgyn, 2015, 7 (1): 42-59 LR2 ve RMI tanısal performansı Facts Views Vis Obgyn, 2015, 7 (1): 42-59 Ultrasound Obstet Gynecol 2011; 38: 456–465
- 12. 10.10.2015 12 Ultrasound Obstet Gynecol 2011; 38: 456–465 Sonuç Human Reproduction Update, Vol.20, No.3 pp. 449–462, 2014 Ultrasound Obstet Gynecol 2013; 41: 9–20 Dikkatiniz için teşekkür ederim. Dr. Tevfik Yoldemir tevfik@yoldemir.com http://www.slideshare.net/dryoldemir