Imaging of gynecological disease (3): clinical and ultrasound characteristics of granulosa cell tumors of the ovary

Sonographic features of ovarian malignancies in children and young adults - A case control study

AIM

To investigate whether ovarian cancer in children and young adults, display the same accepted sonographic features that raise suspicious of ovarian malignancy among adults, and whether sonographic features predict clinical behavior.

METHODS

A matched case-control study. The study group comprised all youngsters < 25 years of age diagnosed with ovarian cancer in a tertiary university hospital between the years 1995-2023. A control group with benign ovarian masses was matched according to age and year of diagnosis in a 2:1 ratio. Clinical data, sonographic features and disease outcomes were compared.

RESULTS

The study group included 30 youngsters, 24 (80 %) of them had germ cell tumors, 4 (13.3 %) sex-cord tumors and two (6.7 %) were epithelial tumors. The control group included 60 youngsters, of them 27 (45 %) with mature teratomas, 25 (41.6 %) serous cystadenomas and 8 (13.4 %) with other benign ovarian tumors. In a univariate analysis, Palpation of mass (43.3 % vs. 15 %, p < 0.01), vomiting (33.3 % vs. 13.3 %, p = 0.02) and elevated tumor markers (79.3 % vs.21.6 %, p < 0.01) were more common in the study group. Malignant masses were larger (mean of maximal diameter 159 mm vs. 88 mm, p < 0.01), were more likely to contain a solid component (60 % vs. 21.7 %, P < 0.01), to have ascites (33.3 % vs. 3.3 %, P < 0.01) and to have a high color content on Doppler examination (50 % vs. 11.7 %, p < 0.01). These features remained significant also in a multivariable analysis. Disease recurrence was not associated with any sonographic parameters.

CONCLUSION

sonographic features suspicious for ovarian mass malignancy among adult women are valid also among the young population. However, none of these features are associated with a worse clinical course.

Radiomics analysis of ultrasound images to discriminate between benign and malignant adnexal masses with solid morphology on ultrasound

OBJECTIVE

The primary aim was to identify radiomics ultrasound features that can distinguish between benign and malignant adnexal masses with solid ultrasound morphology, and between primary malignant (including borderline and primary invasive) and metastatic solid ovarian masses, and to develop ultrasound-based machine learning models that include radiomics features to discriminate between benign and malignant solid adnexal masses. The secondary aim was to compare the discrimination performance of our newly developed radiomics models with that of the Assessment of Different NEoplasias in the adneXa (ADNEX) model and that of subjective assessment by an experienced ultrasound examiner.

METHODS

This was a retrospective, observational single-center study conducted at Fondazione Policlinico Universitario A. Gemelli IRCC, in Rome, Italy. Included were patients with a histological diagnosis of an adnexal tumor with solid morphology according to International Ovarian Tumor Analysis (IOTA) terminology at preoperative ultrasound examination performed in 2014-2020, who were managed with surgery. The patient cohort was split randomly into training and validation sets at a ratio of 70:30 and with the same proportion of benign and malignant tumors in the two subsets, with malignant tumors including borderline, primary invasive and metastatic tumors. We extracted 68 radiomics features, belonging to two different families: intensity-based statistical features and textural features. Models to predict malignancy were built based on a random forest classifier, fine-tuned using 5-fold cross-validation over the training set, and tested on the held-out validation set. The variables used in model-building were patient age and radiomics features that were statistically significantly different between benign and malignant adnexal masses and assessed as not redundant based on the Pearson correlation coefficient. We evaluated the discriminative ability of the models and compared it to that of the ADNEX model and that of subjective assessment by an experienced ultrasound examiner using the area under the receiver-operating-characteristics curve (AUC) and classification performance by calculating sensitivity and specificity.

RESULTS

In total, 326 patients were included and 775 preoperative ultrasound images were analyzed. Of the 68 radiomics features extracted, 52 differed statistically significantly between benign and malignant tumors in the training set, and 18 uncorrelated features were selected for inclusion in model-building. The same 52 radiomics features differed significantly between benign, primary malignant and metastatic tumors. However, the values of the features manifested overlapped between primary malignant and metastatic tumors and did not differ significantly between them. In the validation set, 25/98 (25.5%) tumors were benign and 73/98 (74.5%) were malignant (6 borderline, 57 primary invasive, 10 metastatic). In the validation set, a model including only radiomics features had an AUC of 0.80, sensitivity of 0.78 and specificity of 0.76 at an optimal cut-off for risk of malignancy of 68%, based on Youden's index. The corresponding results for a model including age and radiomics features were AUC of 0.79, sensitivity of 0.86 and specificity of 0.56 (cut-off 60%, based on Youden's index), while those of the ADNEX model were AUC of 0.88, sensitivity of 0.99 and specificity of 0.64 (at a 20% risk-of-malignancy cut-off). Subjective assessment had a sensitivity of 0.99 and specificity of 0.72.

CONCLUSIONS

Our radiomics model had moderate discriminative ability on internal validation and the addition of age to this model did not improve its performance. Even though our radiomics models had discriminative ability inferior to that of the ADNEX model, our results are sufficiently promising to justify continued development of radiomics analysis of ultrasound images of adnexal masses. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Unusual radiologic imaging in juvenile granulosa cell tumor with precocious puberty: A unilocular cyst

Juvenile Granulosa Cell Tumor (JGCT) represents 5% of all granulosa cell cancers. Precocious puberty is a frequent feature of this tumor. A 2-year and 2-month-old girl was referred with a diagnosis of suspected ovarian cancer, dysfunctional uterine bleeding, and precocious puberty. Radiologic examination revealed the following: Abdominal ultrasonography showed a solitary anechoic cystic lesion in the pelvic cavity. MRI confirmed the existence of solid components on its walls. JGCT was then confirmed using immunohistochemistry (IHC) markers. JGCT, along with adult granulosa cell tumors (AGCT) are subgroups of granulosa cell tumors (GCTs), which are part of pure sex cord tumors. The 2 forms share imaging findings due to their comparable gross appearance. GCTs require diagnostic imaging tests to distinguish them from other ovarian tumors. Two ultrasound patterns can be identified GCTs, and MRI showed that GCTs are more heterogeneous than other sex-cord stromal tumors (OSCs). In our case, the imaging characteristics for juvenile granulosa cell tumors were nonspecific and these tumors cannot be reliably distinguished from other ovarian neoplasms based on imaging alone. Although GCTs have imaging characteristics that can help to distinguish them from other tumors, confirmation by histopathology and IHC is still mandatory, especially in cases with nonspecific radiological features.

Testosterone elevation in ovarian adult granulosa cell tumor: A case report and review of the literature

RATIONALE

Adult granulosa cell tumors (AGCT) mainly secret estrogen, but few androgens. It is rarer to have amenorrhea and hyperandrogenemia as clinical features. Here, we report a rare case of right side AGCTs with amenorrhea and hyperandrogenemia in a 19-year-old female.

PATIENT CONCERNS

The 19-year-old patient was admitted to our hospital due to amenorrhea for more than 1 year, and discovery of pelvic mass for 4 months. The gynecological ultrasound and computed tomography (CT) cannot define the nature of the mass. Surprisingly, an elevation in testosterone levels was also measured.

DIAGNOSIS AND INTERVENTIONS

The present patient underwent laparoscopic right salpingo-oophorectomy and partial omentectomy and biopsy of the peritoneum.

OUTCOMES

After the surgery, the testosterone value was down to normal. The patient menstrual cramps on August 13, 2021. Her clitoris is smaller than the front. Up to August 1, 2022, there was no obvious sign of recurrence.

LESSONS

Androgen-secreting AGCT is rare. We hope that this case can strengthen gynecologists' early diagnosis and treatment of this disease and improve the prognosis.

Clinical and paraclinical features, outcome, and prognosis of ovarian granulosa cell tumor: A retrospective study of 28 Vietnamese women

Background: Granulosa cell tumor of the ovary is a rare disease and presents with two clinically and molecularly distinct subtypes: the juvenile and the adult type. GCT is considered as a malignant tumor with an indolent course and a tendency toward late recurrence. Purpose: To assess the clinical and paraclinical features, treatment findings, survival outcomes, and explored the prognostic factors in the granulosa cell tumor. Methods: The current study was conducted on 28 GCT patients who had surgical operations and adjuvant chemotherapy (stage IC-IV) by applying a retrospective cohort analysis. The clinical and paraclinical characteristics were recorded. Recurrent status was evaluated for analysis with clinical and paraclinical features and survival. All GCT patients' survival were analyzed by using Kaplan-Meier and Log-Rank models. Results: 17.9% of patients experienced a relapse and two patients died due to disease. The mean time from initial diagnose to recurrence was 40.21 months. The 5-year OS and DFS of stage I-II were 100% and 80.8%, and of stage III were 50% and 25%, respectively. In survival analyses, using the log-rank test, age ≥50 years, irregular menstruation, stage I-II, and absence of residual lesion were all significant predictors for the improved DFS. Stage I-II and absence of residual lesion were associated significantly with better OS. Mean of age, FIGO stage, and residual lesion during surgery had significant differences to recurrent rate (p < <0.05). The multivariate model revealed that these factors didn't remain as an independent prognostic variable. Conclusion: FIGO stage and residual lesion during surgery had significant differences in survival and recurrent rate.

From diagnosis to treatment of androgen-secreting ovarian tumors: a practical approach

About 5% of all ovarian tumors develop some form of hormonal activity. Only 1% of ovarian tumors will secrete androgens causing clinical hyperandrogenism. Most androgen-secreting neoplasms (ASN) derive from sex cord or stroma cells of the ovary and may affect both premenopausal and postmenopausal women. Typically, a patient will present reporting symptoms of rapidly increasing hyperandrogenization such as: hirsutism, acne, frontal/male pattern balding, and in severe cases even virilization. Sertoli-Leydig Cell Tumors are the most frequent ASN and constitute about 0.5% of all ovarian neoplasms. Typically affecting women under 30 years of age, these tumors are usually unilateral and benign. They are also the most common tumor in postmenopausal women suffering with hyperandrogenism. Other tumors originating from the sex-cord stroma are also known to develop in this population, but the incidence of these is much lower. Approaching suspected hyperandrogenemia and its related symptoms in a clinical setting can be a significant diagnostic challenge. When evaluating a patient for hyperandrogenism, it is important to assess the severity of symptoms but most of all it is critical to assess the time of onset and dynamics of symptom progression. Diagnostic tools including laboratory tests and imaging studies should also be engaged. When deriving a differential diagnosis for androgen-secreting ovarian tumors, adrenal gland tumors should be considered as well as typical endocrine pathologies including polycystic ovary syndrome, congenital adrenal hyperplasia, Cushing's disease, and acromegaly. Treatment options for an androgen-secreting ovarian tumors is mainly surgical, but in exceptional cases can involve pharmacotherapy alone.

Imaging in gynecological disease (23): clinical and ultrasound characteristics of ovarian carcinosarcoma

OBJECTIVE

To describe the clinical and ultrasound characteristics of ovarian carcinosarcoma.

METHODS

This was a retrospective multicenter study. Patients with a histological diagnosis of ovarian carcinosarcoma, who had undergone preoperative ultrasound examination between 2010 and 2019, were identified from the International Ovarian Tumor Analysis (IOTA) database. Additional patients who were examined outside of the IOTA study were identified from the databases of the participating centers. The masses were described using the terms and definitions of the IOTA group. Additionally, two experienced ultrasound examiners reviewed all available images to identify typical ultrasound features using pattern recognition.

RESULTS

Ninety-one patients with ovarian carcinosarcoma who had undergone ultrasound examination were identified, of whom 24 were examined within the IOTA studies and 67 were examined outside of the IOTA studies. Median age at diagnosis was 66 (range, 33-91) years and 84/91 (92.3%) patients were postmenopausal. Most patients (67/91, 73.6%) were symptomatic, with the most common complaint being pain (51/91, 56.0%). Most tumors (67/91, 73.6%) were International Federation of Gynecology and Obstetrics (FIGO) Stage III or IV. Bilateral lesions were observed on ultrasound in 46/91 (50.5%) patients. Ascites was present in 38/91 (41.8%) patients. The median largest tumor diameter was 100 (range, 18-260) mm. All ovarian carcinosarcomas contained solid components, and most were described as solid (66/91, 72.5%) or multilocular-solid (22/91, 24.2%). The median diameter of the largest solid component was 77.5 (range, 11-238) mm. Moderate or rich vascularization was found in 78/91 (85.7%) cases. Retrospective analysis of ultrasound images and videoclips using pattern recognition in 73 cases revealed that all tumors had irregular margins and inhomogeneous echogenicity of the solid components. Forty-seven of 73 (64.4%) masses appeared as a solid tumor with cystic areas. Cooked appearance of the solid tissue was identified in 28/73 (38.4%) tumors. No pathognomonic ultrasound sign of ovarian carcinosarcoma was found.

CONCLUSIONS

Ovarian carcinosarcomas are usually diagnosed in postmenopausal women and at an advanced stage. The most common ultrasound appearance is a large solid tumor with irregular margins, inhomogeneous echogenicity of the solid tissue and cystic areas. The second most common pattern is a large multilocular-solid mass with inhomogeneous echogenicity of the solid tissue. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

A case report of ovarian granulosa cell tumor in patient with polycystic ovarian syndrome

RATIONALE

Granulosa cell tumors (GCTs) account for less than 2% of all ovarian malignancies and are the second most common ovarian sex cord stromal tumors after fibroma/thecomas.GCTs occur most frequently in postmenopausal women with a peak age of 50 to 55, are usually diagnosed in their early stages, and have a good prognosis. GCTs usually present with features of hyperestrogenism, with an average size is 10 to 15 cm.

PATIENT CONCERNS

A 31-year-old nulligravida diagnosed with polycystic ovarian syndrome (PCOS) 10 years prior, had a 20-mm mass in her right ovary found on ultrasonography 2 years ago. She had been taking dienogest 2 mg for 2 years for a misdiagnosed endometrioma, but over a 2-year course, the mass increased to 50 mm.

DIAGNOSES

An ultrasound scan revealed a 47 × 37-mm round solid mass in the right ovary with a spongiform appearance and little vascularity. The pathologic findings showed an adult-type granulosa cell tumor with necrosis and hemorrhage. The tissue stained positive for inhibin-α, Wilms' tumor-1, CD56, and negative for cytokeratin 7.

INTERVENTIONS

We finally performed right salpingo-oophorectomy, endometrial biopsy, peritoneal biopsy, and partial omentectomy. The pathological findings were adult-type granulosa cell tumor. The International Federation of Gynecology and Obstetrics staging was IA. The patient did not require additional treatment.

OUTCOMES

Surprisingly, her normal menstruation returned 2 weeks after the operation, and she had a normal pregnancy and parturition. The patient had been followed-up regularly for 3 years following the surgery. The patient has not experienced any complications and has remained disease-free.

LESSONS

GCTs should be considered in the differential diagnosis if a female patient with PCOS and amenorrhea shows a unilateral small solid mass. They are extremely rare malignant ovarian tumors that must be differentiated from other benign ovarian tumors, especially endometriomas and dermoid cysts. It was difficult for us to suspect a granulosa cell tumor because the patient already had PCOS symptoms such as mild hirsutism and amenorrhea. This case highlights the importance of physicians being aware of and suspicious for GCTs in similar cases, along with knowing their characteristics in considering possible differential diagnoses.

Algorithmic Approach to Sonography of Adnexal Masses: An Evolving Paradigm

BACKGROUND

Pelvic US remains the workhorse for detection and characterization of adnexal masses in most centers worldwide. While the differentiation of benign from malignant masses remains the foremost concern, it is imperative to narrow the differential diagnosis for management of benign masses as well as prognostication of malignant masses. The IOTA group as well as ACR have described a five category classification system for adnexal lesions based on morphological patterns. In addition, a six category risk stratification has been proposed, incorporating the probability of malignancy as well as management recommendations.

LEARNING OBJECTIVES

1) Understand pattern based approach to adnexal lesion classification and the possible entities fitting into each pattern with the help of illustrations. 2) Classify lesions into appropriate risk categories based on diagnostic algorithms provided at the end of each section.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumors

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the preoperative diagnosis of ovarian tumors, including imaging techniques, biomarkers and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the preoperative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the preoperative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on pre-operative diagnosis of ovarian tumors

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group, and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the pre-operative diagnosis of ovarian tumors, including imaging techniques, biomarkers, and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the pre-operative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when a consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the pre-operative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

Ultrasound evaluation of ovarian masses and assessment of the extension of ovarian malignancy

The current review sums up the literature on the diagnostic performance of models to predict malignancy in adnexal masses and the ability of ultrasound to make a specific diagnosis in adnexal masses. A summary of the role of ultrasound in assessing the extension of malignant ovarian disease is also provided.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumours

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the preoperative diagnosis of ovarian tumours, including imaging techniques, biomarkers and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the preoperative diagnosis of ovarian tumours and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when a consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the preoperative diagnosis of ovarian tumours and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

Imaging in gynecological disease (22): clinical and ultrasound characteristics of ovarian embryonal carcinomas, non-gestational choriocarcinomas and malignant mixed germ cell tumors

OBJECTIVE

To describe the clinical and ultrasound characteristics of three types of rare malignant ovarian germ cell tumor: embryonal carcinoma, non-gestational choriocarcinoma and malignant mixed germ cell tumor.

METHODS

This was a retrospective multicenter study. From the International Ovarian Tumor Analysis (IOTA) database, we identified patients with a histological diagnosis of ovarian embryonal carcinoma, non-gestational choriocarcinoma or malignant mixed germ cell tumor, who had undergone preoperative ultrasound examination by an experienced ultrasound examiner between 2000 and 2020. Additional patients with the same histology were identified from the databases of the departments of gynecological oncology in the participating centers. All tumors were described using IOTA terminology. Three examiners reviewed all available ultrasound images and described them using pattern recognition.

RESULTS

One patient with embryonal carcinoma, five patients with non-gestational ovarian choriocarcinoma and seven patients with ovarian malignant mixed germ cell tumor (six primary tumors and one recurrence) were identified. Seven patients were included in the IOTA studies and six patients were examined outside of the IOTA studies. The median age at diagnosis was 26 (range, 14-77) years. Beta-human chorionic gonadotropin levels were highest in non-gestational choriocarcinomas and alpha-fetoprotein levels were highest in malignant mixed germ cell tumors. Most tumors were International Federation of Gynecology and Obstetrics (FIGO) Stage I (9/12 (75.0%)). All tumors were unilateral, and the median largest diameter was 129 (range, 38-216) mm. Of the tumors, 11/13 (84.6%) were solid and 2/13 (15.4%) were multilocular-solid; 9/13 (69.2%) manifested abundant vascularization on color Doppler examination. Using pattern recognition, the typical ultrasound appearance was a large solid tumor with inhomogeneous echogenicity of the solid tissue and often dispersed cysts which, in most cases, were small and irregular. Some tumors had smooth contours while others had irregular contours.

CONCLUSIONS

A unilateral, large solid tumor with inhomogeneous echogenicity of the solid tissue and with dispersed small cystic areas in a young woman should raise the suspicion of a rare malignant germ cell tumor. This suspicion can guide the clinician to test tumor markers specific for malignant germ cell tumors. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Comprehensive review of imaging features of sex cord-stromal tumors of the ovary

Sex cord-stromal tumors of the ovary (SCST) are uncommon ovarian tumors arising from sex cord and/or stromal cells of the ovaries. They may be nonfunctional and asymptomatic or functional presenting with hyperestrogenic, hyperandrogenic or cushingoid symptoms. They present in a wide age group of women, mostly in early stages and follow a nonaggressive clinical course after surgical resection. They differ from more prevalent epithelial ovarian tumors which tend to present in older women in advanced stages with poor prognosis. Some of SCSTs are associated with clinical syndromes. We will review imaging features on ultrasound, computed tomography and magnetic resonance imaging, epidemiology and clinical presentations of these tumors.

Transvaginal ultrasound in evaluation and follow-up of ovarian granulosa cell tumors

OBJECTIVE

Ultrasound features of granulosa cell tumors of the ovary are still poorly defined. The aim of this study is to widen current knowledge on the role of sonographic gray scale and pattern recognition in the characterization of these tumors and to compare the ultrasound characteristics of primary diagnosis and recurrences.

METHODS

Transvaginal ultrasound images of primary diagnosis or recurrences of histologically-confirmed granulosa cell tumors of the ovary were retrospectively retrieved from a dedicated database designed for the collection of clinical and ultrasound data from January 2001 to January 2019. All patients included were treated at San Raffaele and Santa Chiara Hospitals. Women with a concomitant diagnosis of another malignancy other than endometrial carcinoma were excluded from the study. All ultrasound images were described according to International Ovarian Tumor Analysis terminology and examined by experienced ultrasound examiners.

RESULTS

A total of 27 patients were included: 24 with adult and 3 with juvenile ovarian granulosa cell tumors. At primary diagnosis, mean ovarian mass size was 103.8 mm (range 30-200). On ultrasound evaluation at primary diagnosis, 12 patients presented with a multilocular solid lesion (48%), 9 with a solid lesion (36%), and 4 with a multilocular lesion(16%). The echogenicity of the cyst was low level or anechoic, mixed, or hemorrhagic in 56.3%, 31.2%, and 12.5% of cases, respectively. Most tumors (45.1%), including first diagnosis and relapses, had a moderate to high color score on doppler evaluation.

CONCLUSIONS

Our study showed that sonographic features and pattern recognition of relapses were comparable to those of tumors at primary diagnosis. In order to highlight the importance of transvaginal ultrasound evaluation during follow-up, further studies based on a standardized ultrasound characterization of ovarian masses are recommended.

Imaging in gynecological disease (17): ultrasound features of malignant ovarian yolk sac tumors (endodermal sinus tumors)

OBJECTIVE

To describe the clinical and sonographic characteristics of malignant ovarian yolk sac tumors (YSTs).

METHODS

In this retrospective multicenter study, we included 21 patients with a histological diagnosis of ovarian YST and available transvaginal ultrasound images and/or videoclips and/or a detailed ultrasound report. Ten patients identified from the International Ovarian Tumor Analysis (IOTA) studies had undergone a standardized preoperative ultrasound examination, by an experienced ultrasound examiner, between 1999 and 2016. A further 11 patients were identified through medical files, for whom ultrasound images were retrieved from local image workstations and picture archiving and communication systems. All tumors were described using IOTA terminology. The collected ultrasound images and videoclips were used by two observers for additional characterization of the tumors.

RESULTS

All cases were pure YSTs, except for one that was a mixed tumor (80% YST and 20% embryonal carcinoma). Median age at diagnosis was 25 (interquartile range (IQR), 19.5-30.5) years. Seventy-six percent (16/21) of women had an International Federation of Gynecology and Obstetrics (FIGO) Stage I-II tumor at diagnosis. Fifty-eight percent (11/19) of women felt pain during the ultrasound examination and one presented with ovarian torsion. Median serum α-fetoprotein (S-AFP) level was 4755 (IQR, 1071-25 303) µg/L and median serum CA 125 level was 126 (IQR, 35-227) kU/L. On ultrasound assessment, 95% (20/21) of tumors were unilateral. The median maximum tumor diameter was 157 (IQR, 107-181) mm and the largest solid component was 110 (IQR, 66-159) mm. Tumors were classified as either multilocular-solid (10/21; 48%) or solid (11/21; 52%). Papillary projections were found in 10% (2/21) of cases. Most (20/21; 95%) tumors were well vascularized (color score, 3-4) and none had acoustic shadowing. Malignancy was suspected in all cases, except in the patient with ovarian torsion, who presented a tumor with a color score of 1, which was classified as probably benign. Image and videoclip quality was considered as adequate in 18/21 cases. On review of the images and videoclips, we found that all tumors contained both solid components and cystic spaces, and that 89% (16/18) had irregular, still fine-textured and slightly hyperechoic solid tissue, giving them a characteristic appearance.

CONCLUSION

Malignant ovarian YSTs are often detected at an early stage, in young women usually in the second or third decade of life, presenting with pain and markedly elevated S-AFP. On ultrasound, malignant ovarian YSTs are mostly unilateral, large and multilocular-solid or solid, with fine-textured slightly hyperechoic solid tissue and rich vascularization. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology..

Imaging in gynecological disease (14): clinical and ultrasound characteristics of ovarian clear cell carcinoma

OBJECTIVE

To describe the clinical and ultrasound characteristics of ovarian pure clear cell carcinoma.

METHODS

This was a retrospective study involving data from 11 ultrasound centers. From the International Ovarian Tumor Analysis (IOTA) database, 105 patients who had undergone preoperative ultrasound examination by an experienced ultrasound examiner between 1999 and 2016 were identified with a histologically confirmed pure clear cell carcinoma of the ovary. An additional 47 patients diagnosed with pure clear cell carcinoma between 1999 and 2016 and with available complete preoperative ultrasound reports were identified retrospectively from the databases of the departments of gynecological oncology in the participating centers. The ultrasound images of all tumors were described using IOTA terminology. Clinical and ultrasound characteristics were analyzed for the whole group, and separately, for patients with and those without histologically confirmed endometriosis, and for patients with evidence of tumor developing from endometriosis.

RESULTS

Median age of the 152 patients was 53.5 (range, 28-92) years and 92/152 (60.5%) tumors were FIGO Stage I. Most tumors (128/152, 84.2%) were unilateral. On ultrasound examination, all tumors contained solid components and 36/152 (23.7%) were completely solid masses. The median largest diameter of the lesion was 117 (range, 25-310) mm. Papillary projections were present in 58/152 (38.2%) masses and, in most of these (51/56, 91.1%), vascularized papillary projections were seen. Information regarding the presence, site and type of pelvic endometriosis at histology was available for 130/152 patients. Endometriosis was noted in 54 (41.5%) of these. In 24/130 (18.6%) patients, the tumor was judged to have developed from endometriosis. Patients with, compared to those without, evidence of tumor developing from endometriosis were younger (median 47.5 vs 55.0 years, respectively), and ground-glass echogenicity of cyst fluid was more common in pure clear cell cancers developing from endometriosis (10/20 vs 13/79 (50.0% vs 16.5%), respectively).

CONCLUSIONS

Ovarian pure clear cell carcinoma is usually diagnosed at an early stage and typically appears as a large unilateral mass with solid components. Patients with clear cell carcinoma developing from endometriosis are younger than other patients with clear cell carcinoma, and clear cell cancers developing from endometriosis more often manifest ground-glass echogenicity of cyst fluid. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Imaging in gynecological disease (13): clinical and ultrasound characteristics of endometrioid ovarian cancer

OBJECTIVE

To describe the clinical and ultrasound characteristics of ovarian pure endometrioid carcinomas.

METHODS

This was a retrospective multicenter study of patients with a histological diagnosis of pure endometrioid carcinoma. We identified 161 patients from the International Ovarian Tumor Analysis (IOTA) database who had undergone preoperative ultrasound examination by an experienced ultrasound examiner between 1999 and 2016, and another 78 patients from the databases of the departments of gynecological oncology in the participating centers. All tumors were described using IOTA terminology. In addition, one author reviewed all available ultrasound images and described them using pattern recognition.

RESULTS

Median age of the 239 patients was 55 years (range, 19-88 years). On ultrasound examination, two (0.8%) endometrioid carcinomas were described as unilocular cysts, three (1.3%) as multilocular cysts, 37 (15.5%) as unilocular-solid cysts, 115 (48.1%) as multilocular-solid cysts and 82 (34.3%) as solid masses. Median largest tumor diameter was 102.5 mm (range, 20-300 mm) and median largest diameter of the largest solid component was 63 mm (range, 9-300 mm). Papillary projections were present in 70 (29.3%) masses. Most cancers (188 (78.7%)) were unilateral. In 49 (20.5%) cases, the cancer was judged by the pathologist to develop from endometriosis. These cancers, compared with those without evidence of tumor developing from endometriosis, more often manifested papillary projections on ultrasound (46.9% (23/49) vs 24.7% (47/190)), were less often bilateral (8.2% (4/49) vs 24.7% (47/190)) and less often associated with ascites (6.1% (3/49) vs 28.4% (54/190)) and fluid in the pouch of Douglas (24.5% (12/49) vs 48.9% (93/190)). Retrospective analysis of available ultrasound images using pattern recognition revealed that many tumors without evidence of tumor developing from endometriosis (36.3% (41/113)) had a large central solid component entrapped within locules, giving the tumor a cockade-like appearance.

CONCLUSIONS

Endometrioid cancers are usually large, unilateral, multilocular-solid or solid tumors. The ultrasound characteristics of endometrioid carcinomas developing from endometriosis differ from those without evidence of tumor developing from endometriosis, the former being more often unilateral cysts with papillary projections and no ascites. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

The Usefulness of Ultrasound Imaging in Gynecologic Oncology

Pelvic ultrasound examination is the primary imaging modality for evaluating a wide range of female pelvic symptomatology, and is often the first imaging test to detect a gynecologic malignancy. Ultrasound imaging is particularly useful for evaluating the thickness and appearance of the endometrium in patients with abnormal bleeding, and in detecting and characterizing ovarian lesions. This article reviews the ultrasound appearance of gynecologic neoplasms grouped by anatomic site of origin, the ultrasound appearance of select benign pelvic pathology not to be misinterpreted as malignancy, as well as available ultrasound imaging-based guidelines for managing potential gynecologic neoplasms.

The association of enchondromatosis with malignant transformed chondrosarcoma and ovarian juvenile granulosa cell tumor (Ollier disease)

OBJECTIVE

Ovarian juvenile granulosa cell tumor has an interesting association with multiple enchondromatosis (Ollier disease and Maffucci syndrome) and should be considered a leading diagnosis when an ovarian mass is found in young patients with these conditions. Besides the association with nonskeletal malignancies, there is a high risk of malignant transformation of enchondroma in chondrosarcoma as was also the case in this instance.

CASE REPORT

The report uses multiple images to document the representative and characteristic markers of multiple enchondromas in a 22-year-old patient with Ollier disease complicated by malignant transformation of chondrosarcoma and in whom the disease is associated with ovarian juvenile granulosa cell tumor of the right ovary.

CONCLUSION

It is important to recognize that when the female patient presents with enchondromatosis and a large unilateral multilocular-solid ovarian mass, the specific diagnosis of granulosa cell tumor can be made with high accuracy.

Imaging features of complex solid and multicystic ovarian lesions: proposed algorithm for differential diagnosis

Complex solid and multicystic ovarian lesions are broad-spectrum diseases, ranging from benign to malignant. This article describes the broad-spectrum and imaging features of complex solid and multicystic ovarian lesions and illustrates an algorithmic approach to such lesions, focusing on the ultrasonography and magnetic resonance imaging features that allow one to hone the differential diagnosis. Multimodality imaging workup plays an important role in the characterization and differential diagnosis of these diseases. Also, knowledge of the clinical setting and imaging features for the spectrum of complex solid and multicystic ovarian lesions can lead to appropriate management.

Ultrasonography of ovarian masses using a pattern recognition approach

As a primary imaging modality, ultrasonography (US) can provide diagnostic information for evaluating ovarian masses. Using a pattern recognition approach through gray-scale transvaginal US, ovarian masses can be diagnosed with high specificity and sensitivity. Doppler US may allow ovarian masses to be diagnosed as benign or malignant with even greater confidence. In order to differentiate benign and malignant ovarian masses, it is necessary to categorize ovarian masses into unilocular cyst, unilocular solid cyst, multilocular cyst, multilocular solid cyst, and solid tumor, and then to detect typical US features that demonstrate malignancy based on pattern recognition approach.

Ovarian metastasis of clear cell renal cell carcinoma: A case report

We report on a 61-year-old woman with a history of right-sided nephrectomy for clear cell renal cell carcinoma (RCC) occurring 21 years ago; she currently presented with a bilateral ovarian tumour. Histologically, the tumour of both ovaries was clear cell carcinoma. Immunohistochemically, the tumour cells were positive for vimentin, RCC marker, epithelial membrane antigen, cytokeratin AE1/3 and CD10. Cytokeratin 7, CA125, HMWCK, estrogen and progesterone receptors were all negative. Based on the morphology and immunophenotype of the tumour, we established a diagnosis of late metastasis of RCC in the ovaries. A postoperative abdominal computed tomography scan, however, revealed a tumour mass solely in the left kidney, which had not been visible in the preoperative ultrasound. The patient underwent nephron-sparing surgery and a biopsy showed the tumour to be clear cell RCC. Metastasis of RCC to the ovaries is rare, and to the best of our knowledge, only 24 cases have been reported to date. However, due to the different treatments and prognosis, the distinction between a primary ovarian tumour and metastasis of RCC is important.

[Granulosa cell tumor: difficulty of diagnosis and contribution of imaging]

Granulosa tumors (GT) are rare neoplasms, difficult to diagnose in a preoperative stage. We report a set of seven patients affected by GT admitted in Amiens University Hospital, collated with a review of the literature (n=379). Our aim was to report the clinical and radiological characteristics of GT, in order to improve preoperative diagnosis. The average age of the subjects was 50.8 years old among the bibliographical search, and 37years old for the observations reported in Amiens. The principal circumstances of diagnosis were vaginal bleeding, abdominal pain and infertility. Ultrasound was the most frequently investigation, revealing GT as a large unilateral solid and cystic mass. The computed tomodensitometry (CT) allowed to precise the locoregional extension. Magnetic Resonance Imaging (MRI) appeared to be interesting to clarify lesions, showing GT as a solid mass with a cystic component or as a multicystic mass. Hormonal assays (inhibin B and/or anti-Müllerian hormone) can provide valuable assistance in diagnosis, despite their cost and lack of availability. In view of the clinical and radiological presentation of the reported and literature review cases, we suggest hormonal assays among perimenopausal women presenting with an unusual radiological aspect of an annexial mass.

Pre-operative imaging with CA125 is a poor predictor for granulosa cell tumors

OBJECTIVE

To determine the radiographic characteristics of ovarian granulosa cell tumors (GCTs) and to evaluate the use of CA125 levels >35 in combination with imaging as an algorithm for preoperative diagnosis.

METHODS

A retrospective analysis of women from two academic medical centers who were diagnosed with ovarian GCT between January 1998 and August 2012 was conducted. Clinical data included tumor appearance on pre-operative imaging and CA125 levels. Ovarian cysts were defined as complex if imaging exhibited multicystic areas, hemorrhagic, solid, or cystic and solid components. A CA125 level >35 was abnormal.

RESULTS

One hundred and fifteen women were diagnosed with GCTs, of whom 63 underwent pre-operative imaging. Median age at surgery was 46 years (12-87). Forty women had preoperative ultrasounds, 43 had CT scans and 20 underwent both modalities. GCTs were almost exclusively classified as complex cysts in 62 (98%) cases. The most common morphology was solid and cystic (n=44 (70%)). Forty-four (70%) patients had tumors >10 cm. Forty-two patients had a pre-operative CA125 performed. Eighteen (43%) patients had complex masses and CA125 >35. Twenty-three (55%) had CA125 <35 with a complex mass, and one (2%) had a unilocular cyst with a CA125 >35.

CONCLUSIONS

In this study, there was a near equal distribution of patients with complex masses and CA125 levels > or <35. If established strategies to predict malignancy are applied to GCTs, we will frequently fail to make the diagnosis pre-operatively. Additional research is necessary to generate an appropriate algorithm to guide pre-operative referral to a gynecologic oncologist.

Imaging in gynecological disease (7): clinical and ultrasound features of Brenner tumors of the ovary

OBJECTIVES

To describe clinical and ultrasound features of Brenner tumors of the ovary.

METHODS

In this retrospective study, the databases of the International Ovarian Tumor Analysis (IOTA) studies and one tertiary center were searched to identify patients who had undergone an ultrasound scan before surgery for an adnexal mass that proved to be a Brenner tumor. Twenty-eight patients with 29 Brenner tumors were included, most of which had been collected within the framework of the IOTA studies. An experienced ultrasound examiner reviewed available ultrasound images (available for 14 tumors), searching for a pattern specific to Brenner tumors.

RESULTS

Most patients were postmenopausal and asymptomatic. Twenty-four (83%) tumors were benign, two (7%) were borderline and three (10%) were malignant. Most benign tumors (17/24, 71%) contained solid components and manifested no or minimal blood flow on Doppler examination (19/24, 79%). Information about calcifications was available for 15 benign tumors, and in 13 (87%) calcifications were present. The five borderline and invasively malignant tumors contained solid components less often than did the benign ones (3/5, 60%) and were more richly vascularized on Doppler examination. Information about calcifications was available for four borderline or invasively malignant tumors, and in three (75%) calcifications were present.

CONCLUSION

We failed to demonstrate ultrasound features specific to Brenner tumors. A prospective study is needed to determine if ultrasound features of calcifications can discriminate between Brenner tumors and other types of ovarian tumor.

The multifaceted granulosa cell tumours-myths and realities: a review

Background. Granulosa cell tumors (GCTs), representing ~2% of ovarian tumours, are poorly understood neoplasms with unpredictable and undetermined biological behaviour. Design. 5 unusual presentations of GCT and a retrospective 14-year (1997–2011) surgical pathology review based on patient sex, age, tumour type and concurrent pathology findings are presented to discuss the “myths and realities” of GCTs in the context of relevant evidence-based literature. Results. The 5 index cases included (1) a 5 month-old boy with a left testicular mass, (2) a 7-day-old neonate with a large complex cystic mass in the abdomen, (3) a 76-year-old woman with an umbilical mass, (4) a 64-year-old woman with a complex solid-cystic pelvic mass, and (5) a 45 year-old woman with an acute abdomen. Pathological analysis confirmed the final diagnosis as (1) juvenile GCT, (2) macrofollicular GCT, (3) recurrent GCT 32 years later, (4) collision tumour: colonic adenocarcinoma and GCT, and (5) ruptured GCT. Conclusion. GCT is best considered as an unusual indolent neoplasm of low malignant potential with late recurrences that can arise in the ovaries and testicles in both the young and the old. Multifaceted clinical presentations coupled with the unpredictable biological behaviour with late relapses are diagnostic pitfalls necessitating a high degree of suspicion for accurate clinical and pathological diagnosis.

Clinical and sonographic features of uncommon primary ovarian malignancies

PURPOSE

To describe the gray-scale and color Doppler ultrasound features of uncommon (<5% prevalence) primary malignant ovarian tumors.

METHODS

Retrospective analysis of 98 masses in 89 patients (median age: 50.4 years old, ranging from 15 to 81 years) diagnosed as having an uncommon primary ovarian malignancy. All patients had undergone transvaginal color Doppler ultrasound according to a standardized protocol prior to surgical tumor removal. Ultrasound features analyzed were laterality, presence of ascites, tumor volume, morphologic appearance (unilocular, multilocular, unilocular-solid, multilocular-solid, and solid), and color Doppler score (subjective assessment of the amount of flow as absent, scanty, moderate, or abundant).

RESULTS

Pathological diagnoses included uncommon epithelial tumors (n = 59), germ cell tumors (n = 10), sex cord-stromal tumors (n = 11), sarcoma (n = 9), and lymphoma (n = 9). Germ cell tumors presented in younger women (p < 0.001). Germ cell tumors, sex cord-stromal tumors, sarcomas, and lymphomas were significantly more often solid as compared with epithelial malignancies, which appeared more frequently as complex (cystic-solid) tumors (p < 0.001). There were no differences in color Doppler score between the various types of tumors.

CONCLUSIONS

Germ cell tumors, sex cord-stromal tumors, sarcomas, and lymphomas tend to appear as unilateral solid tumors. Color Doppler score is not useful for discriminating among uncommon primary ovarian malignancies.

Imaging of gynecological disease (6): clinical and ultrasound characteristics of ovarian dysgerminoma

OBJECTIVES

To describe the clinical history and ultrasound findings in patients with ovarian dysgerminoma.

METHODS

This was a retrospective study of patients with a histological diagnosis of ovarian dysgerminoma who had undergone preoperative ultrasound examination. The patients were identified from the databases of 11 ultrasound centers. The tumors were described by the principal investigator at each contributing center on the basis of ultrasound images, ultrasound reports and research protocols (when applicable) using the terms and definitions of the International Ovarian Tumor Analysis (IOTA) group. In addition, three authors reviewed all available electronic ultrasound images (gray-scale images and color/power Doppler images were available for 18 patients and 14 patients, respectively) and described them using subjective evaluation of gray-scale and color Doppler ultrasound findings (here called pattern recognition).

RESULTS

Twenty-one patients with ovarian dysgerminoma were identified (including one woman with bilateral masses). Twenty patients had a primary ovarian dysgerminoma (including the one with bilateral masses) and one patient had a recurrence of dysgerminoma in her retained ovary. One of the 21 patients was pregnant. All tumors except one were pure dysgerminomas, one being a mixed germinal cell tumor with 30% dysgerminoma component. Median age was 20 (range, 16-31) years. Information on clinical symptoms was available for 18 patients. In four patients, the tumor was detected incidentally, whereas 14 patients presented with one or more of the following symptoms: acute pain (n = 4), chronic pain (n = 8), bloating (n = 8), menstrual disorders (n = 5) and infertility problems (n = 1). One (5%) patient had ascites. Using the IOTA terms and definitions, all but one dysgerminoma were moderately (43%) or very well (50%) vascularized solid tumors. One tumor was multilocular-solid. According to pattern recognition, most dysgerminomas were highly vascularized, purely solid tumors with heterogeneous internal echogenicity divided into several lobules, had a smooth and sometimes lobulated contour and were well-defined relative to the surrounding organs.

CONCLUSION

The ultrasound finding of a highly vascularized, large, solid, lobulated adnexal mass with irregular internal echogenicity in a woman 20-30 years old should raise the suspicion of ovarian dysgerminoma.

Diagnostic value of contrast-enhanced ultrasonography in the characterization of ovarian tumors()

INTRODUCTION

Vascularity influences the characteristics of gynecologic tumors observed with direct imaging techniques that reveal the macrovascular component of these lesions (color and power Doppler) and with indirect imaging involving the administration of contrast agents to examine the microcirculation and interstitial perfusion (contrast-enhanced computed tomography [CT] and magnetic resonance [MR] imaging). The purpose of this study was to determine whether contrast-enhanced ultrasonography (CEUS) of ovarian lesions provides useful information that cannot be obtained with conventional US.

MATERIALS AND METHODS

We used CEUS to assess 72 nonspecific adnexal lesions in 61 patients. CEUS was performed with a 4.8-ml bolus of a second-generation ultrasonographic contrast agent and dedicated imaging algorithms. For each lesion, B-mode morphology, CEUS morphology, and time/intensity curves were evaluated.

RESULTS

In 8/61 cases (13.1%) CEUS offered no additional morphovascular information. In 38/61 cases (62.3%), it provided additional information that did not modify the management of the lesion, and in 15/61 cases (24.6%) it gave additional information that modified the management of the lesion. Malignant lesions were characterized by significantly shorter times to peak enhancement (11.9 ± 3.1 s vs 19.8 ± 4.0 s p < 0.01) and significantly higher peak intensity (24.7 ± 4.2 dB vs 17.8 ± 3.3 dB p < 0.01) compared with benign lesions.

CONCLUSIONS

CEUS improves diagnostic confidence in the characterization of liquid-corpuscular lesions where conventional US is inconclusive. CEUS can be proposed as a valid alternative to CT and MR. However, information obtained by CEUS influences the therapy in a limited percentage of cases (24.6%).

Diagnostic accuracy of transvaginal ultrasound examination for assigning a specific diagnosis to adnexal masses

OBJECTIVES

To determine the sensitivity and specificity of subjective evaluation of gray-scale and Doppler ultrasound findings (here called pattern recognition) when used by experienced ultrasound examiners with regard to making a specific diagnosis of adnexal masses.

METHODS

Within the framework of a European multicenter study, the International Ovarian Tumor Analysis study, comprising nine ultrasound centers, women with at least one adnexal mass were examined with gray-scale and color Doppler ultrasonography by experienced ultrasound examiners. A standardized examination technique, and standardized terms and definitions were used. Using pattern recognition the examiners classified each mass as benign or malignant and suggested a specific diagnosis (e.g. dermoid cyst or endometrioma). The reference standard was the histology of the surgically removed adnexal tumors.

RESULTS

A total of 1066 women were included, of whom 800 had a benign mass and 266 a malignant mass. A specific diagnosis based on ultrasound findings was suggested in 899 (84%) tumors. The specificity was high for all diagnoses (range, 94-100%). The sensitivity was highest for benign teratoma/dermoid cysts (86%, 100/116), hydrosalpinges (86%, 18/21), peritoneal pseudocysts (80%, 4/5) and endometriomas (77%, 153/199), and lowest for functional cysts (17%, 4/24), paraovarian/parasalpingeal cysts (14%, 3/21), benign rare tumors (11%, 1/9), adenofibromas (8%, 3/39), simple cysts (6%, 1/18) and struma ovarii (0%, 0/5). The positive and negative likelihood ratios of pattern recognition with regard to dermoid cysts, hydrosalpinges and endometriomas were 68.2 and 0.14, 38.9 and 0.15, and 33.3 and 0.24, respectively. Dermoid cysts, hydrosalpinges, functional cysts, paraovarian cysts, peritoneal pseudocysts, fibromas/fibrothecomas and simple cysts were never misdiagnosed as malignancies by the ultrasound examiner, whereas more than 10% of inflammatory processes, adenofibromas and rare benign tumors including struma ovarii were misdiagnosed as malignancies.

CONCLUSIONS

Using subjective evaluation of gray-scale and Doppler ultrasound findings it is possible to make an almost conclusive diagnosis of a dermoid cyst, endometrioma and hydrosalpinx. Many other adnexal pathologies can be recognized but not confidently confirmed or excluded.