1. Sonography and Ovarian Tumors Professor Galal Lotfi Obstetrics & Gynecology Suez Canal University. Egypt

2. Introduction The incidence of ovarian carcinoma has increased and is now the commonest malignancy of the female genital tract in much of the western world( William's 1992). Ovarian cancer presents in its late stages, (75% of ovarian cancer); Killing more women than does cancer of the cervix and uterine body combined (Silverberg et al l990).

3. Introduction… Ovarian cancer screening tests are the subject of endless debate. Some say it may progress to a late stage so quickly as to make screening impractical. This could be minimized by decreasing the time between follow up tests especially in women with family history of ovarian cancer. Again, this criticism could be said to any other screening programs. The screening tests tried for ovarian cancer included variety of techniques. Clinical examination, culdocentesis, immunoscintigraphy, tumor marker but all are insensitive.

4. Aim of Our Work Ultrasound has been an efficient tool for studying structural changes associated with human follicular development and ovulation, it was therefore a logical step to use the same technology for morphological changes in the ovary that may suggest the presence of early ovarian cancer. The use of ultrasound as a screening device for ovarian cancer was first proposed by Campbell et al (1982). The aim of that work was to implement a screening test to decrease the incidence of advancing ovarian carcinoma.

5. Material And Methods. 198 women who were postmenopausal. TVS for all women. Ovaries were classified with a score according to morphological and structural ultrasonic appearance on both sides. The TVS score (combined to both ovaries) was added to the clinical score, according to the woman's history, to get the total score. Another scan after a year was carried out for all women.

6. AppearanceScore Atrophic0 Volume >8cm.1 Simple anechoic <3cm1 Simple anechoic <5cm2 Simple anechoic >5cm3 Multilocular <5cm2 Multilocular >5cm3 Complex, cyst with echoic shadows.4 Solid cyst (solid areas >50%)5 Table (1) Scoring for US appearance of ovaries

7. Table (2), Score for Women’s History HistoryScore Family history of ovarian carcinoma2 Past or family history of genital, breast or colon 1 Negative history of oral contraceptive1 Nulligravida1

8. Table(3), Scoring of women, 1 st Scan Result TVS finding TVS score Other Ovary Family History Malignant History OCP History Total Score Simple cyst < 3cm (Persistent) 1$02014 Simple cyst < 5cm 110103 Simple cyst =>5cm 100001 Multiloc < 5cm 110013 Multiloc =>5cm 2$22017 Complex 2$00103 Solid 200002

9. Table (4): Surgical Results of Cases Operated Upon After the First Examination (N=198). TVS resultNo.Result Volume > 8Cm31Not operated Simple cyst < 3cm (persistent)41 Malignant 3 Benign Simple cyst < 5cm52 Malignant 1 inflammatory 2Benign Simple cyst =>5cm33 simple serous Multilocucyst < 5cm1Inflammatory Multilocular cyst =>5cm21 malignant 1 inflammatory Complex cyst1Malignant Solid cyst1Malignant Total18

10. Table (5): cases with proved malignancy. TVSSurgical stage Path. Grade Pathology Simple cyst < 3cm 1aiICystadenocarcinoma Simple <5cm1aiIMucinous carcinoma Simple <5cm1aiiICystadenocarcinoma Multiloc. >5cm1biIIEndometroid Complex1aiICystadenocarcinoma Solid cyst1cIEndometroid

11. Table (6): Surgical results after one year (N 185) TVS Result No.Surgical result Volume >8cm31Not operated Simple Cyst < 3cm (persistent) 2Simple serous Simple < 5cm2Simple serous Simple cyst => 5cm0 Multilocular cyst <5cm0 Multilocular cyst =>5cm0 Complex cyst0 Solid cyst0 Total5

12. Table(7), Scoring of women after one year, N (185) TVS findingTVS score Other Ovary Family History Malignant History OCP History Total Score Simple cyst < 3cm (Persistent) 102014 Simple cyst < 5cm 2222 0000 0000 0000 1111 3

13. Table (8): Comparison Between Cases With Proved Malignancy and Cases With Benign Lesions (first Scan). LesionNo.Min Score Max score MeanSD Malignant63126.333.1 Benign15142.930.88

14. Mean and SD of total score of Benign and malignant lesions (first scan)

15. Detection of abnormal, benign and malignant lesion (first Scan) in 1 st scan

16. Detection of Abnormal, Benign and malignant lesion in 2 nd scan.

17. Conclusion Abnormal ovarian conditions detection rate was 9. 1% and 2.2% of cases in initial examination and subsequent year follow up. Malignant detection rate was 3%.

18. Conclusion Andolf & Jorgensen (1989) found no malignancy in 58 anechoic lesions less than 5cm as detected by ultrasound. Rodrigenz et al (1988) reported 3 cancers detected in simple cystic lesions with a diameter greater than 5cm. In the present study, small cysts were found to be not immune for malignancy, 3 cases with cyst diameter less than 3cmwere found to be malignant.

19. Epilog. With small cyst and in situations where we are in doubt, the implemented score could help in deciding up. For big, multilocular, complex or solid cysts, the answer is straight forward, surgical intervention. TVS, cheap compared to other imaging techniques, non invasive, seems to provide a simple screening technique for early ovarian cancer.

20. Epilog. Its strength resides in its high sensitivity 62.5%, however we cannot deny the false positive rates which is present in any diagnostic tool. Till we find another test with the least false positive results, TVS should be appreciated as a screening tool for such a lethal disease not only for susceptible women with family history or history of other malignancies but for the whole population.

21. Epilog.. Application of the suggested scoring system could help in differentiating between benign and malignant lesions.. The new advances in ultrasonography may enable us to better understand and recognize the earliest stages of oncogenesis with the ovary.