The Value of Expert Ultrasonography

Abstract & Commentary

By Robert L. Coleman, MD, Associate Professor, University of Texas; M.D. Anderson Cancer Center, Houston, is Associate Editor for OB/GYN Clinical Alert.

Dr. Coleman reports no financial relationship to this field of study.

Synopsis: Gynecologic sonographic expertise, represented as Level III scans, led to fewer major staging procedures in this first randomized clinical study of ovarian masses referred for further investigation.

Source: Yazbek J, et al. Effect of quality of gynaecological ultrasonography on management of patients with suspected ovarian cancer: a randomised controlled trial. Lancet Oncol. 2008;9:124-131.

Diagnostic ultrasonography is one of the most frequently utilized adjuvant tools clinicians rely upon to make treatment recommendations for suspect adnexal pathology. Intuitively and bolstered by some clinical information, studies conducted by experienced gynecological sonographers appear to provide better diagnostic accuracy in identifying significant pathology. However, proof of this observation has not been rigorously investigated. To address whether more sophisticated (Level III) ultrasonography could reduce the number of major surgical staging procedures over routine (Level II) ultrasonography, a randomized clinical trial of women referred with adnexal masses was conducted. One hundred fifty women were randomized on referral to either of the two procedures. A Level II sonogram is a routine morphological abdominal and transvaginal study performed by a technician trained in gynecologic sonography; a Level III sonogram is a similar procedure performed by a gynecologist with more than 10 years experience in gynecologic sonography. These clinicians often served as trainee preceptors in tertiary referral centers. Addressing the primary endpoint, significantly fewer major surgical staging procedures were performed in women getting Level III scans (37% vs 22%, p = 0.049). The total number of surgical procedures was similar between the two groups; however, the median number of hospital days was shorter for those receiving Level III scans due in large part to the more frequent use of laparoscopy. Ovarian cancer was ultimately diagnosed in 18 (12%) women. A likely histological diagnosis was opined significantly more often following Level III scans (99% vs 52%, P < 0.0001). Both sensitivity and specificity was improved with Level III scans. The authors conclude that improved quality of ultrasonography has a measurable effect on the management of suspected ovarian cancer in tertiary referral gynecologic cancer centers.

Gynecologic sonographic expertise, represented as Level III scans, led to fewer major staging procedures in this first randomized clinical study of ovarian masses referred for further investigation.


The value of ultrasonography in gynecology is hard to overstate. It is used as a diagnostic tool, a surveillance tool, a therapeutic adjuvant for tissue acquisition and is the foundation in many treatment and screening algorithms. The popularity of the imaging tool is rooted in both its availability and its technological features providing ever more detail to the uterus and adnexa. An unprecedented level of improved imagery in this regard is an annual occurrence and improvement is the continual goal of investigators and device makers. Nevertheless, its utility is operator dependent. The level of skill clearly impacts the inference potential; however, the degree to which this occurs has, heretofore, not been formally evaluated. The study, in the context of the UK health system, demonstrates the utility of more expert sonographers in evaluating referrals for adnexal abnormalities. An important economical impact was not reported in this current study but is planned in a future report. Based on this Level I evidence data, a review of the programmatic referral system is underway—a remarkable feat. The impact on the US health system is harder to ascertain as physician sonographic experts are a mixture of gynecologists and radiologists with special expertise in gynecologic imaging, extending beyond sonography to other modalities such as CT, FDG-PET, and MR. Nevertheless, on an individual basis our trust is naturally linked to those in whom confirmation of pathological outcomes is made. This study provides real evidence to support that bias.

Additional reading:

  1. Timmerman D, et al. Subjective assessment of adnexal masses with the use of ultrasonography: an analysis of interobserver variability and experience. Ultrasound Obstet Gynecol. 1999;13:11-16.
  2. Valentin L. Pattern recognition of pelvic masses by gray-scale ultrasound imaging: the contribution of Doppler ultrasound. Ultrasound Obstet Gynecol. 1999;14:338-347.
  3. Valentin L, et al. Ultrasound characteristics of different types of adnexal malignancies. Gynecol Oncol. 2006;102:41-48.
  4. Henrich W, et al. Value of preoperative transvaginal sonography (TVS) in the description of tumor pattern in ovarian cancer patients: results of a prospective study. Anticancer Res. 2007;27:4289-4294.