1. UOG Journal Club: August 2013
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results
J. L. Alcazar, L. Diaz, P. Florez, S. Guerriero and M. Jurado
Volume 42, Issue 2, Date: August 2013, pages 218–223
Journal Club slides prepared by Dr Ligita Jokubkiene
(UOG Editor for Trainees)

2. Background
Ultrasound is a first-line imaging technique for discriminating between benign and malignant adnexal masses
BUT…..
Highly dependent on the expertise of the examiner
Poorer reproducibility, diagnostic performance and examiner’s confidence in providing diagnosis in non-expert examiners
Timmerman D et al., UOG 1999, Guerriero S et al., J womens Health 2009 et 2011 et Ultrasound Med Biol 2008, Van Holsbeke C et al., UOG 2009 et Gynecol Obstet Invest 2010

3. Background
Several programs for ultrasound training in obstetrics and gynecology and simulators for basic gynecological ultrasound training have been proposed
BUT…..
No specific training program for assessing adnexal masses
ISUOG Education Commitee UOG 1996, Di Renzo GC and Clerici G, ANN N Y Acad Sci 1998, Calhoun BC and Hume RF UOG 2000, Salvesen et al., UOG 2010,
Sidhu et al., J Ultrasound Med 2012, Tutschek et al., UOG 2012

4. Background
Theoretical ultrasound teaching does not improve the performance of pattern recognition in the hands of trainees
Practical training is important to optimize diagnostic performance
Van Holsbeke C et al., UOG 2009

5. Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results
Alcazar et al., UOG 2013
Objective
Objective:
To assess the feasibility of a specific training program for ultrasound diagnosis of adnexal masses.

6. Specific training program developed Offline evaluation of 3D volumes
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results
Alcazar et al., UOG 2013
Methods
Specific training program developed +
Real-time ultrasound
Offline evaluation of 3D volumes
Objective 1:
To train examiners with no or very little experience in ultrasound assessment of adnexal masses.
Objective 2:
For trainees to achieve diagnostic performance with sensitivity of > 95% and specificity of > 90%.

7. Two trainees included in specific training program:
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results
Alcazar et al., UOG 2013
Two trainees included in specific training program:
Specialist with experience in transabdominal obstetrical ultrasound but
with very little experience in gynecological ultrasound
3rd year resident in radiology with no experience in gynecological
ultrasound
Trainee 1
Trainee 2

8. Three phases of the training program
1-day theoretical course
clinical and ultrasound issues related to adnexal masses
Phase 2
4 weeks real-time training
25-30 adnexal masses evaluated
Phase 3
Half-day course
4 weeks offline training:
100 3D volumes
500 adnexal masses,
28-35% malignancies in each set

9. Training program: Phase 1 Theoretical lectures on:
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results
Alcazar et al., UOG 2013
Training program: Phase 1
Theoretical lectures on:
Epidemiology of ovarian cancer and adnexal masses
Surgical management of ovarian cancer and adnexal masses
Principles of gray-scale and color Doppler ultrasound
Use of ultrasound for assessing adnexal masses (pattern recognition)

10. Training program: Phase 2 Training in real-time ultrasound:
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results
Alcazar et al., UOG 2013
Training program: Phase 2
Training in real-time ultrasound:
Performing transabdominal and transvaginal ultrasound, principles of gray-scale and Doppler ultrasound
Assessment of adnexal masses by gray-scale and Doppler ultrasound, dynamic aspects as mobility and tenderness
Application of machine settings in gray-scale and Doppler ultrasound
Supervision by an ultrasound expert with > 20 years experience

11. Training program: Phase 3 Assessment of stored 3D ultrasound volumes :
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results
Alcazar et al., UOG 2013
Training program: Phase 3
Assessment of stored 3D ultrasound volumes :
Half-day course with training on the use of dedicated software for assessing 3D volumes
4 weeks for assessment of five sets of 100 3D volumes each
Excel file with clinical data of patient (age, menopausal status, symptoms)

12. Training program: Phase 3 Analysis of 3D ultrasound volumes:
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results
Alcazar et al., UOG 2013
Training program: Phase 3
Analysis of 3D ultrasound volumes:
Tumor diameter
Vessel location, distribution and amount
Size of solid components
Height of papillary projection
Echogenicity of cyst content
Thickness of cyst wall and septations
Acoustic shadowing
Tumor contour regularity

13. Cases 1–5 for which 3D volumes are provided in Supplementary Material.
Case 1. Unilocular cyst with internal wall irregularities
Case 2. Septated cyst
Case 3. Multilocular cyst
Case 4. Irregular solid tumor
Case 5. Cystic solid mass

14. Training program: Phase 3
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results
Alcazar et al., UOG 2013
Training program: Phase 3
Based on pattern recognition trainees had to:
Provide confidence level in classification:
Certainly benign
Probably benign
Uncertain
Probably malignant
Certainly malignant
Classify tumors as benign or malignant, despite uncertainty
Review cases with incorrect diagnosis with a trainer

15. Analysis of diagnostic performance of each trainee
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results
Alcazar et al., UOG 2013
Analysis of diagnostic performance of each trainee
Sensitivity, speificity, LRs for each 3D volume set
Learning curve cumulative summation (LC-CUSUM) test
to assess learning curve for each trainee
Acceptable failure rate: 15%
Unacceptable failure rate: 25%

16. Diagnostic performance of trainees A and B
Results
Diagnostic performance of trainees A and B
Sensitivity (%) Specificity (%) LR LR-
Set 1
Set 3
Set 5
Trainee A
Set 1
Set 3
Set 5
Trainee B

17. Results
Learning curve for discriminating between benign and malignant adnexal masses
Trainee A reached performance after case 170
Trainee B reached performance after case 185

18. Limitations of the training program
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results
Alcazar et al., UOG 2013
Limitations of the training program
Training is based on static 3D volumes
Limited training of dynamic aspects of real-time ultrasound
Difficult cases not addressed
Only one trainer and two trainees, no control group

19. Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results
Alcazar et al., UOG 2013
Conclusions
Proposed training program for ultrasound assessment of adnexal masses is feasible and renders good results.
A similar program could be implemented for training in ultrasound assessment for other gynecological conditions.

20. Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results
Alcazar et al., UOG 2013
Discussion points
•          Do we need distinct or separate ultrasound training in assessing adnexal masses?
•          What are the phases of the suggested training program?
•          How many adnexal masses cases are thought to be required on average during training to reach a satisfactory level of competence?
•          Was there any difference in diagnostic performance between experienced and not-experienced trainee in assessing adnexal masses?
•          What are the limitations of this training program?