UOG Journal Club August 2013 Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results J. L. Alcázar, L. Díaz, P. Flórez, S. Guerriero and M. Jurado Link to the article (open access): onlinelibrary.wiley.com/doi/10.1002/uog.12440/abstract

1. 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)
UOG Journal Club: August 2013

2. 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

3. 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

4. • 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

5. 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 results
Alcazar et al., UOG 2013

6. 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%.
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and
preliminary results
Alcazar et al., UOG 2013
Methods

7. 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
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and
preliminary results
Alcazar et al., UOG 2013
Trainee 1
Trainee 2

8. 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 1
1-day theoretical course
Phase 2
4 weeks real-time training
Phase 3
Half-day course
4 weeks offline training:
100 3D volumes
100 3D volumes
100 3D volumes
100 3D volumes
100 3D volumes

9. Training program: Phase 1
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and
preliminary results
Alcazar et al., UOG 2013
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:
•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
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and
preliminary results
Alcazar et al., UOG 2013

11. 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)
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and
preliminary results
Alcazar et al., UOG 2013

12. Training program: Phase 3
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and
preliminary results
Alcazar et al., UOG 2013
Analysis of 3D ultrasound volumes:

13. 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.

14. 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
Training program: Phase 3
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and
preliminary results
Alcazar et al., UOG 2013

15. 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
Intensive training program for ultrasound diagnosis of adnexal masses: protocol and
preliminary results
Alcazar et al., UOG 2013
Acceptable failure rate: 15%
Unacceptable failure rate: 25%

16. 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

17. 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

18. • 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
Limitations of the training program

19. 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
Conclusions

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?