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)

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

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

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

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.

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%.

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

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

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)

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

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)

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

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

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

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%

Diagnostic performance of trainees A and B Results Diagnostic performance of trainees A and B Sensitivity (%) Specificity (%) LR+ LR- Set 1 74 83 4.4 0.31 Set 3 97 95 21.7 0.03 Set 5 100 92 12.6 - Trainee A Set 1 76 88 6.5 0.27 Set 3 91 89 8.6 0.1 Set 5 100 90 8.9 - Trainee B

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

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

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.

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?