uog journal club: intensive training program for ultrasound diagnosis of adnexal masses

Intensive training program for ultrasound diagnosis of adnexal masses: protocol and

preliminary resultsJ. 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)

UOG Journal Club: August 2013

Ultrasound is a first-line imaging technique for discriminating between benign and malignant adnexal masses

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

BUT…..

• Highly dependent on the expertise of the examiner

• Poorer reproducibility, diagnostic performance and examiner’s confidence in providing diagnosis in non-expert examiners

Background

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

BUT…..

Several programs for ultrasound training in obstetrics and gynecology and simulators for basic gynecological ultrasound training have been proposed

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

Background

Objective:To assess the feasibility of a specific training program for ultrasound diagnosis of adnexal masses.

Objective

Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary resultsAlcazar et al., UOG 2013

Real-time ultrasound

Specific training program developed

+ 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%.


Methods

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

clinical and ultrasound issues related to adnexal masses

25-30 adnexal masses evaluated

500 adnexal masses,28-35% malignancies in

each set

Phase 11-day theoretical course

Phase 24 weeks real-time training

Phase 3Half-day course

4 weeks offline training:

100 3D volumes

100 3D volumes

100 3D volumes

100 3D volumes

100 3D volumes

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 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



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)




Analysis of 3D ultrasound volumes:

Case 1. Unilocular cyst with internal wall irregularities Case 3. Multilocular cyst

Case 4. Irregular solid tumor Case 5. Cystic solid mass

Case 2. Septated cyst

Cases 1–5 for which 3D volumes are provided in Supplementary Material.

http://onlinelibrary.wiley.com/doi/10.1002/uog.12440/suppinfo

Provide confidence level in classification:

•Certainly benign

•Probably benign

•Uncertain

•Probably malignant

•Certainly malignant

Based on pattern recognition trainees had to:

Classify tumors as

benign or malignant,

despite uncertainty

Review cases with

incorrect diagnosis

with a trainer



Analysis of diagnostic performance of each traineeSensitivity, speificity, LRs for each 3D volume set

Learning curve cumulative summation (LC-CUSUM) testto assess learning curve for each trainee


Acceptable failure rate: 15%

Unacceptable failure rate: 25%

ResultsDiagnostic 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

Trainee A reached performance after case 170

Trainee B reached performance after case 185

Learning curve for discriminating between benign and malignant adnexal masses

Results

• 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


Limitations of the training program

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.


Conclusions


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?

uog journal club: intensive training program for ultrasound diagnosis of adnexal masses

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