Sugandha Garg , Amarjit Kaur , Jaswinder kaur Mohi , Preet

Kanwal Sibia, Navkiran kaur

Introduction

Ovarian cancer is one of the common cancers in

women and is diagnosed at later stage in majority.

The 5-year survival rate associated with ovarian

cancer is less than 30%.

The limiting factor for early diagnosis of ovarian

tumour is lack of standardised terms and
procedures in gynaecological sonography.
Introduction
A standardized technique for
preoperative classification of adnexal
masses was defined by IOTA group.

Although large no. of studies are

available proving the efficacy of these
rules, however a prospective study
directly applying these diagnostic
rules to the patient was lacking
Objective

To evaluate the efficacy of IOTA simple

ultrasound rules in distinguishing benign
and malignant ovarian tumours and
establishing their use as a tool in early
diagnosis of ovarian malignancy.
50 women with suspected ovarian pathology attending
gynaecology clinic at department of Obstetrics and Gynaecology
during the period of December 2014 to October 2016

Criteria inclusion : Patient

Criteria exclusion : pregnant
with suspicion of adnexal
patient and patient not
mass on pelvic examination
willing for surgery in the
or discovered during previous
hospital
sonographic examination
Transvaginal sonography was done on all the patients. Examination was
limited to Transabdominal sonography in virgins and where it was not
possible to completely visualize the mass by a transvaginal probe.

Sonographic assessment of the given adnexal masses was done

using wide band intracavitary transducer having frequency 5-7.5 MHz
for transvaginal sonography and 2-5 MHz curved transducer for
transabdominal sonography

each patient were classified as benign or malignant on basis of IOTA

simple rules
most common was combination of Rules B1 and B5 (eight out
of 23 combinations) showing no risk of malignancy on final
histopathological analysis

B5 was the most common occurring factor in all
benign lesions, followed by B1. But B2 and B4
predicted the result most correctly (100%) followed
by B5 and B1
Kappa statistics showed high level of agreement
between USG and histopathological findings and it
was statistically significan
Rules M1, M2, M4 were all equally common factors
each present in eight patients with suspected
malignancy. Out of these best M factor was M2
(presence of ascites) which correctly predicted
malignancy in all the eight patients in which it was
found [Table/Fig-7].
The sensitivity for the detection of malignancy in
cases where IOTA simple rules were applicable was
91.66% and the specificity was 84.84%. Accuracy
was 88.88%
A total of 55 patients with
suspected ovarian pathology were
evaluated using transvaginal
ultrasonography and
transabdominal ultrasonography
when transvaginal approach was
not feasible.

The sensitivity and specificity of

present study most closely related
to study by Hartman CA et al.,
who reported a sensitivity and
specificity of 91% and 87%
respectively. The specificity of our
study was lower as compared to
these seven studies.
The rate of inconclusive result in this study was 10%. Using a strategy classifying the inconclusive cases as malignant
was adopted by many already published studies in this regard as shown in
The sensitivity for the detection of malignancy in cases
where IOTA simple rules were applicable was 91.66% and
the specificity was 84.84%. Accuracy was 88.88%.

Classifying inconclusive cases as malignant the sensitivity

and specificity were 93% and 80% respectively.
The most important factor in ovarian malignancy is time of detection. With early
detection, it is possible to improve the survival of patient significantly.

USG offers inherent advantages of easy availability, low cost and lack of radiation
exposure but being more subjective than other modalities.

IOTA simple ultrasound rules can eliminate this problem as they are highly sensitive and
specific in predicting ovarian malignancy yet being reproducible, easy to train and use.
CRITICAL APPRAISAL
 • women with suspected ovarian pathology attending
gynaecology clinic at department of Obstetrics and
POPULATION Gynaecology during the period of December 2014 to
October 2016

• Patient underwent Transvaginal and transabdominal

INTERVENTION sonography

• histopathological findings
COMPARISON

• evaluate the efficacy of IOTA simple ultrasound rules in

distinguishing benign and malignant ovarian tumours
OUTCOME
Is the aim clearly stated?

Yes, the authors To evaluate the efficacy of IOTA

simple ultrasound rules in
elaborated the distinguishing benign and malignant
objective clearly ovarian tumours
Were the basic data adequately
described?

Yes it is clearly described.

During the study 55 women were eligible but five were

excluded as they deny for surgery. Out of 50 patients eight
had bilateral masses (larger one was considered for study).
Was the sample size justified?

The writer doesn’t give any information.

Out of initial 55 patients, 50 patients were included in the final
analysis who underwent surgery. IOTA simple rules were
applicable in 45 out of these 50 patients (90%).
Was the statistical significance
assessed?

Collected data was statistically analysed using chi square test

and kappa statistical method.

Kappa statistics showed high level of agreement

between USG and histopathological findings and it
was statistically significant (K=0.323)
Are the statistical methods
described?

Yes, it is described

Collected data was statistically analysed using

chi square test and kappa statistical method.
Where are the biases?
experienced (experience of seven years
Selection bias  No
Criteria inclusion : Patient with suspicion of
adnexal mass on pelvic examination or
discovered during previous sonographic
examination
Criteria exclusion : pregnant patient and
patient not willing for surgery in the hospital
Information bias  No 
Ultrasound was done by both
or more in abdominopelvic
sonography) and new sonographers
and each patient were classified as
benign or malignant on basis of IOTA
simple rules.
In cases of bilateral mass, the larger
mass was considered. During the
sonographic examination both the
sonographers were blind folded for
their results as well as the
histopathological finding.
Did untoward events occur during the study?

No, Untoward events occurred

Out of total 50 cases studied, IOTA Rules classified 45 patients, 29 as

benign and 16 as malignant. Five cases where rules could not be
applied or where both B and M rules were applicable were labelled as
indeterminate or inconclusive cases
How do the results compare with previous
reports? (1)

Till date only few studies which applied this diagnostic test directly to patient have
been performed.

Our study overcomes this limitation by directly applying IOTA simple ultrasound rules
on the patients.

The sensitivity and specificity of present study most closely related to study by
Hartman CA et al., who reported a sensitivity and specificity of 91% and 87%
respectively. The specificity of our study was lower as compared to these seven studies.
How do the results compare with previous
reports? (2)

It shows that sensitivity was higher in premenopausal women (100%) than

in postmenopausal women (90.9%) while specificity was slightly lower
(86.2% and 75% respectively).

The increased sensitivity and specificity in premenopausal women

compared to the postmenopausal women in present study may be
explained by increased number of inconclusive cases in the premenopausal
patients in present study where the simple rules could not be applied (10%).
How do the results compare with previous
reports? (3)
The rate of inconclusive result in
this study was 10%. Using a Applying this strategy in present
strategy classifying the study the sensitivity of the index
inconclusive cases as malignant test increased from 92% to 93%
was adopted by many already whereas specificity decreased from
published studies in this regard as 85% to 80% respectively.
shown in [Table/Fig-13] [3-5,7-9].

This result correlated well with the

published data and the sensitivity
and specificity of present study
was close to sensitivity and
specificity as per study by
Timmerman et al., [3].
What implications does the study have for
your practice?

USG offers inherent advantages of easy availability, low

cost and lack of radiation exposure but being more
subjective than other modalities.

IOTA simple ultrasound rules can eliminate this problem as

they are highly sensitive and specific in predicting ovarian
malignancy yet being reproducible, easy to train and use.
Thank you