Doppler and gray-scale sonographic classification of adnexal torsion

Is color Doppler ultrasonography reliable in diagnosing adnexal torsion? A large cohort analysis

INTRODUCTION

Color Doppler ultrasonography (CDU) is widely used to diagnose adnexal torsion (AT). However, its validity remains questionable due to its low sensitivity. Our study aimed to evaluate the accuracy of CDU for the preoperative diagnosis of AT.

MATERIAL AND METHODS

The electronic medical records of patients who were taken to the operating room with the diagnosis of suspected AT were reviewed. Patients having surgically/pathologically-proven AT were compared with patients who were found to have a different pathology at the time of surgery. CDU validity was assessed using a 2 × 2 table and compared with a diagnostic model that consists of the Doppler findings, patient's age, and previous surgical history.

RESULTS

AT was diagnosed correctly in 74.6% of cases. Absent Doppler flow was seen in only 18.6% of cases. Although its specificity and positive predictive value were high, CDU had very low sensitivity and negative predictive value. The combined diagnostic model exceeded CDU alone in terms of diagnostic accuracy.

CONCLUSIONS

The use of CDU alone is not a reliable modality to exclude AT. Absent Doppler flow is a sign of ovarian necrosis. Clinical correlation between CDU findings and the patient's symptoms makes the diagnosis of AT more timely and accurate.

The Diagnostic Accuracy of Magnetic Resonance Imaging for Maternal Acute Adnexal Torsion during Pregnancy: Single-Institution Clinical Performance Review

Background: For acute adnexal torsion of pregnant women, appropriate treatment based on an accurate diagnosis is especially important for fertility preservation and timely treatment. The 2017 American College of Obstetricians and Gynecologists (ACOG) Committee Opinion No. 723 announced its practice-changing guidelines to ensure that diagnostic magnetic resonance imaging (MRI) conducted during the first trimester and gadolinium exposure at any time during pregnancy are safe for fetal stability. Unfortunately, few studies have been performed to evaluate the usefulness of the diagnostic accuracy of MRI for acute adnexal torsion during pregnancy. Objective: We sought to determine the efficacy of diagnostic MRI modality using multiparameter for maternal adnexal torsion during pregnancy. Methods: From 1 January 2007 to 31 January 2019, 131 pregnant with MRI tests were reviewed. In this retrospective cohort study, 94 women were excluded due to conditions other than an adnexal mass, and 37 were identified through MRI analyses conducted before surgery for suspected adnexal torsion. The primary outcome was the diagnostic accuracy of sonography and MRI, and the secondary outcome was the usefulness of Apparent diffusion coefficient (ADC) values for predicting the severity of hemorrhagic infarction between the medulla and cortex of the torsed ovarian parenchyma. Results: Our study demonstrates that in the diagnosis of adnexal torsion during pregnancy, the sensitivity, specificity, positive predictive value, and negative predictive value are 62.5%, 83.3%, 90.9%, and 45.5% for sonography and 100%, 77.8%, 90.5%, and 100% for MRI. MRI results in surgical-proven adnexal torsion patients revealed unilocular ovarian cysts (36.8% (7/19)), multilocular ovarian cysts (31.6% (6/19)), and near normal-appearing ovaries (31.6% (6/19)). Pathology in adnexal torsion revealed a corpus luteal ovarian cyst (63.2% (12/19)) and underlying adnexal pathology (46.8% (7/19)). Maternal adnexal torsion during pregnancy was more likely to occur in corpus luteal ovarian cysts than in underlying adnexal masses (odds ratio, 2.14; 95% confidence interval (CI), 0.428–10.738). MRI features for adnexal torsion were as follows: tubal wall thickness, 100% (19/19); ovarian stromal (medullary) edema, 100% (19/19); symmetrical or asymmetrical ovarian cystic wall, 100%(19/19); prominent follicles in the ovarian parenchyma periphery, 57.9% (11/19); periadenxal fat stranding, 84.2% (16/19); uterine deviation to the twisted side, 21.1% (4/19); and peritoneal fluid, 42.1% (8/19). The signal intensity of the ADC values of the ovarian medulla and cortex were compared between the cystectomy and detorsion (CD) and salpingo-oophorectomy (SO) groups. The ADC values of the CD and SO groups were 1.81 ± 0.09 × 10⁻³ mm²/s and 1.91 ± 0.18 × 10⁻³ mm²/s, respectively (P = 0.209), in the ovarian medulla and 1.37 ± 0.32 × 10⁻³ mm²/s and 0.96 ± 0.36 × 10⁻³ mm²/s, respectively (P = 0.022), in the ovarian cortex. The optimal cut-off value of ADC values for predictable total necrosis in the torsed ovarian cortex was ≤ 1.31 × 10⁻³ mm²/s (area under the curve (AUC) = 0.81; 95% CI 0.611–1.0; P = 0.028). Conclusion: Our data showed that maternal adnexal torsion during pregnancy occurred in most corpus luteal cystic ovary cases and some normal-appearing ovary during the 1st and 2nd trimesters of gestation. Therefore, this study is the first study to elaborate on the existence or usefulness of the diagnostic MRI for acute maternal adnexal torsion during pregnancy and to provide a predictive diagnosis of the severity of hemorrhagic infarction for deciding surgical radicality.

Analysis of Clinical and Ultrasound Determinants of Adnexal Torsion in Children and Adolescents

STUDY OBJECTIVE

We aimed to assess the performance of transabdominal ultrasonography (US) for diagnosis of adnexal torsion (AT) in children and adolescents and evaluate its clinical and US determinants. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We retrospectively (2004-2014) studied data for children referred for acute or subacute pelvic pain who underwent US and included children 3 months to 18 years old who underwent surgical exploration and/or clinical and radiological follow-up for at least 3 months. The evaluation of US diagnostic performance was on the basis of the proposed diagnosis after US: AT or no AT with or without mass. Clinical and US predictors of AT were identified using regression analysis.

RESULTS

Among 65 girls included (mean age 11.75 ± 4.49 years), 33 (50.8%) had AT. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of US for AT were 90.9%, 68.7%, 75%, 88%, and 80%, respectively. Overall, 20 of 33 (60.6%) AT patients had a mass, including 33% with mature teratomas. Patients with AT versus no AT more frequently showed vomiting (64% vs 28%; P = .008), ovarian edematous stroma with a peripheral distribution of follicles (45.5% vs 9.4%; P = .002) and a mass of pluritissular aspect (40% vs 0%; P < .0001). The quantitative US predictors of AT were total area ratio (ovary and mass)/area of the contralateral ovary 4.9 or greater (P = .0002) and surface area 18.5 cm² or greater (P = .0003).

CONCLUSION

US has high sensitivity but low specificity for the diagnosis of AT in children. The predictive criteria are vomiting, presence of a pluritissular mass, 4.9 area ratio or greater, or surface area 18.5 cm² or greater.

Are Ultrasonographic Findings Suggestive of Ovarian Stromal Edema Associated with Ischemic Adnexal Torsion?

OBJECTIVE

To study whether sonographic findings suggestive of ovarian stromal edema are associated with tissue ischemia in patients with adnexal torsion.

METHODS

A study of 79 patients with adnexal torsion was performed. Patients were divided into an ischemic group, in which the twisted adnexa were seen as blue or black, and a non-ischemic group, in which the adnexa retained normal color and appeared viable. Clinical and ultrasonographic findings, specifically the presence of ultrasonographic signs suggestive of ovarian stromal edema, were compared between the two groups.

RESULTS

Of the 79 patients with torsion, in 44 (55.7%) the adnexa appeared ischemic at surgery. The presence of ischemia was not associated with age, pregnancy, duration of pain, vomiting or findings at physical examination. There was no significant difference between the ischemic and the non-ischemic group in the proportion of patients with signs of ovarian stromal edema (59 vs. 40%, p = 0.11), in the proportion of patients with absent/diminished stromal Doppler flow (36 vs. 28%, p = 0.12%) or in the proportion of patients with both signs of stroma edema and absent/diminished stromal Doppler flow (20 vs. 12%, p = 0.36).

CONCLUSION

Ultrasonographic signs of ovarian stromal edema do not assist in differentiating between ischemic and non-ischemic adnexal torsion.

Added Value of Using a CT Coronal Reformation to Diagnose Adnexal Torsion

Objective

To evaluate the increased value of using coronal reformation of a transverse computed tomography (CT) scan for detecting adnexal torsion.

Materials and Methods

This study included 106 woman suspected of having adnexal torsion who underwent CT with coronal reformations and subsequent surgical exploration. Two readers independently recorded the CT findings, such as the thickening of a fallopian tube, twisting of the adnexal pedicle, eccentric smooth wall thickening of the torsed adnexal mass, eccentric septal thickening of the torsed adnexal mass, eccentric poor enhancement of the torsed adnexal mass, uterine deviation to the twisted side, ascites or infiltration of pelvic fat, and the overall impression of adnexal torsion with a transverse scan alone or combined with coronal reformation and a transverse scan. The areas under the receiver operating characteristic curves (AUCs), sensitivity, specificity, and positive predictive value were used to compare diagnostic performance.

Results

Fifty-two patients were confirmed to have adnexal torsion. The addition of coronal reformations to the transverse scan improved AUCs for readers 1 and 2 from 0.74 and 0.75 to 0.92 and 0.87, respectively, for detecting adnexal torsion (p < 0.001 and p = 0.004, respectively). Sensitivity of CT for detecting twisting of the adnexal pedicle increased significantly for readers 1 and 2 from 0.27 and 0.29 with a transverse scan alone to 0.79 and 0.77 with a combined coronal reformation and a transverse scan, respectively (p < 0.001 and p < 0.001, respectively).

Conclusion

Use of a coronal reformation with transverse CT images improves detection of adnexal torsion.

[Complications of presumed benign ovarian tumors]

The main risk factor of adnexal torsion is a previous adnexal torsion (LE3). There is no clinical, biological or radiological sign that may exclude the diagnosis of adnexal torsion (LE3). The presence of flow at color Doppler imaging does not allow exclusion of the diagnosis (LE2). An emergent laparoscopy is recommended for adnexal untwisting (Grade B), except in postmenopausal women where oophorectomy is recommended (grade C). A persistent black color of the adnexa after untwisting is not an indication for systematic oophorectomy (grade C), since a functional recovery is possible (LE3). Ovariopexy is not routinely recommended following adnexal untwisting (grade C). The clinical signs of intra-cystic hemorrhage and those of rupture of the corpus luteum are not specific (LE4). MRI is not recommended to confirm the diagnosis of intra-cystic hemorrhage (grade C). Malignant transformation of an ovarian cyst is very rare. The presence of a benign ovarian cyst is not associated with an increased risk of ovarian cancer at long-term follow-up (LE2). For these women, an ultrasound follow-up is not recommended (grade C). Dermoid ovarian cyst containing nerve tissue can trigger the production of pathogenic auto-antibody-anti-NMDA, leading to encephalitis. A high proportion of thyroid tissue in a mature teratoma (struma ovarii) may cause hyperthyroidism.

Case report: ovarian torsion in pregnancy - diagnosis and management

BACKGROUND

Ovarian torsion (OT) is one of the most common gynecologic surgical emergencies. All age groups can be affected, but ovarian stimulation, as found during early pregnancy or infertility treatment, is a major risk factor.

OBJECTIVE

Diagnosing OT in early pregnancy can be challenging. Patients frequently present with abdominal pain and non-specific symptoms. Missed diagnosis of OT could lead not only to ovarian necrosis and sepsis, but also threaten the pregnancy. The objective of this article is to present a case of OT in early pregnancy and to review its epidemiology, diagnosis, and treatment.

CASE REPORT

A 30-year-old woman at 10 weeks gestational age presented to the Emergency Department (ED) with 2 h duration of abdominal pain, nausea, and vomiting. The patient was not on ovarian stimulation treatments. A bedside ED ultrasound showed an enlarged edematous right ovary with a large cyst, but without flow on color Doppler. Immediate obstetric consultation was initiated. Eventual radiology ultrasound showed decreased but present flow in the right ovary. The patient underwent emergent laparoscopic surgery, during which the necrotic right ovary was removed. She was placed on progesterone therapy upon hospital discharge and eventually delivered a healthy term infant.

CONCLUSIONS

Ovarian torsion in pregnancy is increasing in frequency due to the growing prevalence of ovarian stimulation treatment. Although diagnostic ultrasound is a frequently used imaging tool in patients with suspected OT, the mere presence of blood flow on Doppler ultrasonography of the adnexa has a poor negative predictive value. A high clinical suspicion and early laparoscopic management correlate with favorable maternal and fetal outcomes.

Acute abdomen due to ovarian congestion: a fallopian tube accompanied by a paratubal cyst, coiling tightly round the ovary

We experienced an unreported rare case with an adnexal mass causing severe acute abdomen during pregnancy. A 30-year-old Japanese pregnant woman was transported to our hospital for her right lower abdominal pain at 30 weeks of gestation. Magnetic resonance imaging and ultrasound demonstrated a cyst measuring 3-4 cm in diameter adjacent to the right ovary, and a parovarian cyst was considered to be the most probable diagnosis. We strongly suspected torsion of the ovarian pedicle or fallopian tube in conjunction with her clinical symptoms. Laparotomy revealed that the elongated right fallopian tube accompanied by a paratubal cyst was coiling tightly 2.5 times round the right ovary, causing apparent congestion and enlargement of the right ovary. Soon after we released the congested right ovary from the coiling of the fallopian tube, the congestion subsided. The postoperative course was favorable, and pregnancy and delivery were uneventful.

Added value of the gray-scale whirlpool sign in the diagnosis of adnexal torsion

OBJECTIVE

Adnexal torsion is a common gynecologic emergency affecting females of all ages. Expedient diagnosis and treatment are important, particularly in young fertile patients to preserve ovarian viability. Classical parameters for the clinical and sonographic diagnosis of adnexal torsion have very high false-positive rates, approaching 50%. The sonographic 'whirlpool' sign has been shown to be effective for visualizing the torsed part in the prenatal diagnosis of malrotation of the midgut with volvulus, as well as scrotal and ovarian torsion. We aimed to evaluate the efficacy of the whirlpool sign in the diagnosis of torsion, as compared to a protocol based on 'classic' sonographic signs of torsion alone.

METHODS

This was a retrospective chart review. Files of all patients who underwent laparoscopy for suspected torsion at our center between January 2006 and May 2009 were extracted and reviewed. Ultrasound reports were retrieved from our computerized database. Patients were assigned to the study group if the whirlpool sign had been investigated during pre-procedural evaluation or to the control group if only the standard protocol had been applied.

RESULTS

Eighty women were referred for laparoscopy for suspected adnexal torsion during the study period. In 22 women the ultrasound investigation had included the whirlpool sign (study group) while 58 had been examined by the standard protocol (control group). Twenty women in the study group had a positive whirlpool sign on ultrasound, 18 of whom (90.0%) had confirmed torsion on laparoscopy. In the control group 32 of 58 (55.2%) women had confirmed torsion on laparoscopy.

CONCLUSION

The addition of the sonographic whirlpool sign to the preoperative sonographic evaluation of patients with suspected torsion appears to improve the rate of true-positive diagnoses as confirmed by laparoscopy. Copyright © 2010 ISUOG. Published by John Wiley & Sons, Ltd.