Transvaginal ultrasonography in the diagnosis of cystic teratoma

Laparoscopic management of ovarian cysts during pregnancy under urgent situations

BACKGROUND

Majority of adnexal masses are incidental findings during pregnancy and resolve spontaneously. They may complicate pregnancy due to haemorrhage, cyst rupture and ovarian torsion. Laparoscopy is the preferred surgical intervention owing to shorter operative time, quicker recovery and lower post-operative pain. However, safety and feasibility of laparoscopic surgery in the management of ovarian cysts in pregnant women is challenging especially at advanced gestational ages and in urgent situations.

METHODS

In this retrospective study, a total of 48 cases of urgent laparoscopic surgeries were evaluated in the first and second trimesters of pregnancy between March 2018 and March 2021 in Al-Zahra Hospital, Tabriz, Iran.

RESULTS

The operations were ended in all patients successfully. The mean operation time was 45 min. There were no foetal maternal complications. All pregnancies had been terminated after 37 weeks of gestation. Oophorectomy had been performed in six patients and six other patients needed blood transfusion. Ovarian torsion was the most common reason for emergency surgery and mature teratoma was the most commonly reported pathology. Tocolytic therapy was required in six patients, and all of the patients were prescribed 50 mg of injectable progesterone twice daily for 10 days after surgery. The mean intra-abdominal pressure was equal to 15 mmHg and the mean end-expiratory carbon dioxide (CO 2 ) pressure was 36 mmHg. Intravenous paracetamol was used to relieve post-operative pain. The mean hospitalisation time was 1.63 days.

CONCLUSION

Most of the ovarian cysts can be managed laparoscopically with ensured safety and lower morbidity even in emergency situations at advanced gestational ages.

The Leading Role of Brain and Abdominal Radiological Features in the Work-Up of Anti-NMDAR Encephalitis in Children: An Up-To-Date Review

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis (NMDARe) is the most common cause of nonviral encephalitis, mostly affecting young women and adolescents with a strong female predominance (F/M ratio of around 4:1). NMDARe is characterized by the presence of cerebrospinal fluid (CSF) antibodies against NMDARs, even though its pathophysiological mechanisms have not totally been clarified. The clinical phenotype of NMDARe is composed of both severe neurological and neuropsychiatric symptoms, including generalized seizures with desaturations, behavioral abnormalities, and movement disorders. NMDARe is often a paraneoplastic illness, mainly due to the common presence of concomitant ovarian teratomas in young women. Abdominal ultrasonography (US) is a key imaging technique that should always be performed in suspected patients. The timely use of abdominal US and the peculiar radiological features observed in NMDARe may allow for a quick diagnosis and a good prognosis, with rapid improvement after the resection of the tumor and the correct drug therapy.

Multi-Institutional Review of the Preoperative Diagnostic Accuracy for Pediatric Ovarian Mature Cystic Teratomas

STUDY OBJECTIVE

To assess the preoperative imaging impression and surgeon diagnostic accuracy for pediatric ovarian mature cystic teratomas (MCTs) DESIGN: Retrospective review SETTING: Eleven pediatric hospitals PARTICIPANTS: Patients ages 2 to 21 who underwent surgical management of an ovarian neoplasm or adnexal torsion with an associated ovarian lesion INTERVENTION: None MAIN OUTCOME MEASURES: Preoperative imaging impression, surgeon diagnosis, tumor markers, and pathology RESULTS: Our cohort included 946 females. Final pathology identified 422 (45%) MCTs, 405 (43%) other benign pathologies, and 119 (12%) malignancies. Preoperative imaging impression for MCTs had a 70% sensitivity, 92% specificity, 88% positive predictive value (PPV), and 79% negative predictive value (NPV). For the preoperative surgeon diagnosis, sensitivity was 59%, specificity 96%, PPV 92%, and NPV 74%. Some measures of diagnostic accuracy were affected by the presence of torsion, size of the lesion on imaging, imaging modality, and surgeon specialty. Of the 352 masses preoperatively thought to be MCTs, 14 were malignancies (4%). Eleven patients with inaccurately diagnosed malignancies had tumor markers evaluated and 82% had at least 1 elevated tumor marker, compared with 49% of those with MCTs.

CONCLUSIONS

Diagnostic accuracy for the preoperative imaging impression and surgeon diagnosis is lower than expected for pediatric ovarian MCTs. For all ovarian neoplasms, preoperative risk assessment including a panel of tumor markers and a multidisciplinary review is recommended. This process could minimize the risk of misdiagnosis and improve operative planning to maximize the use of ovarian-sparing surgery for benign lesions and allow for appropriate resection and staging for lesions suspected to be malignant.

Research progress in teratoma-associated anti-N-methyl-D-aspartate receptor encephalitis: The gynecological perspective

AIM

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is one of the autoimmune encephalitis, which often occurs in children and young adults, especially in young women. In addition to viral infection, teratoma is an important causative factor. Anti-NMDAR encephalitis is well known to neurologist. However, this is less well known to gynecologists, who may have a decisive role in etiological management. Therefore, from the perspective of gynecologists, we provide an overview of the relationship between the encephalitis and ovarian teratoma, the clinical features and treatment of this disease, and prognosis of pregnant women with this encephalitis.

METHODS

We searched the PubMed database using the search terms in various combinations "teratoma," "dermoid cyst," "ovary," "ovarian," "anti-NMDAR encephalitis," and "N-methyl-D-aspartate receptor."

RESULTS

According to the current literature, the mechanism of anti-NMDAR encephalitis is probably due to the ectopic expression of the NMDAR in the teratomas tissue. The disease has a high mortality rate if not treated promptly and effectively. An important way to improve patients' outcome is to remove the ovarian tumor in time. Pregnant women are also at risk of developing anti-NMDAR encephalitis during pregnancy. The fetal outcome is usually better in patients with mid- to late-pregnancy onset than in early pregnancy, and patients are often able to maintain their pregnancies into late pregnancy.

CONCLUSION

Young women with sudden onset of abnormal psychiatric behavior should be actively screened for ovarian tumors and, if confirmed to be teratoma-associated anti-NMDAR encephalitis, should undergo gynecologic surgery as early as possible, which can help improve their prognosis.

Ovarian teratomas: clinical features, imaging findings and management

Ovarian teratomas are the most common type of germ cell tumors. There are three major subtypes of ovarian teratomas including mature, immature, and monodermal teratomas. Ultrasound, computed tomography and magnetic resonance imaging can demonstrate specific imaging findings for mature teratoma. Imaging features of immature and monodermal teratomas are less specific, but a combination of clinical features and imaging findings can help in the diagnosis. Imaging is also very helpful in guiding management. In this article, we review the epidemiology, histopathology, clinical presentation, imaging features and management of ovarian teratomas.

Pre-operative diagnosis of a primary uterine mature teratoma

OBJECTIVE

Mature cystic teratoma is a common benign ovarian tumor. But extragonadal teratomas are very rare. They mainly occur in the midline structure of the body. Uterine teratomas are extremely rare with only few reports. The diagnosis was mainly based on the operative findings. We report a case of uterine mature teratoma in a 37 year-old woman who was diagnosed before the operation. We also review the literature about this exceptional presentation.

CASE REPORT

We report a case of uterine teratoma that was initially diagnosed as a uterine tumor under ultrasound examination. But teratoma was highly suspected preoperatively by the abdominal CT scan. She underwent tumor excision via laparotomy. The operative finding and the histological examination confirms the diagnosis of primary uterine teratoma.

CONCLUSION

Preoperatively diagnosis of uterine teratoma was difficult. Although there are no gold standard to treat the uterine teratoma, the majority of the treatment choice is surgery. The prognosis of this unusual disease is relatively good in benign lesions.

Multimodality imaging review of complex pelvic lesions in female pelvis

Complex pelvic lesions can originate from various anatomical structures in the pelvis and pose a diagnostic dilemma due to a wide range of possible diagnoses. Accurate characterisation of these lesions would often require an algorithmic approach, which incorporates clinical findings, sequential use of multiple imaging modalities and a multiparametric approach. This approach usually aims at identifying key imaging features, which aid in anatomical localisation, morphology and tissue characterisation. There have been various attempts to standardise the lexicon used for describing adnexal masses in female patients; stratify their risk of cancer and suggest appropriate next steps in the management pathway. Through this review, we extend this approach to complex pelvic masses in female pelvis in general and will focus on optimal use of different imaging modalities to arrive at definitive diagnosis or meaningful differential diagnosis. We will also discuss potential pitfalls of imaging diagnosis and common mimics.

Effects of laparoscopic cystectomy on ovarian reserve in patients with endometrioma and dermoid cyst

Objective:

To compare the effects of laparoscopic cystectomy on ovarian reserve between women with endometrioma and dermoid cyst.

Materials and Methods:

Thirty-six patients were diagnosed as having endometrioma (group A) and 32 patients with dermoid cyst (group B) using ultrasonography. Preoperative anti-mullerian hormone (AMH) levels were measured and unilateral antral follicle counts (AFC) were calculated for the ovary side containing the cyst. Laparoscopic cystectomy was performed using the stripping technique for all participants. After 3 months, all participants were re-evaluated between the third and sixth day of their menstrual cycle to determine AFC and AMH levels.

Results:

The mean serum preoperative AMH level and AFC level were significantly lower in group A than in group B (p=0.001, p=0.002), respectively. At 3 months after the surgery, serum AMH levels decreased significantly in group A from 2.04±0.68 to 1.47±0.55 (p=0.001), and from 2.60±0.57 to 2.17±0.56 in group B (p=0.001). In group A, unilateral (operated side) AFC levels decreased significantly from 4.05±1.24 to 2.16±0.94 (p=0.001), and in group B, it decreased significantly from 4.93±0.94 to 3.40±0.87 (p=0.001). The decrease in AMH levels was significantly higher in group A than in group B (p=0.033). The decrease in AFC levels was also significantly higher in group A than in group B (p=0.044).

Conclusion:

Laparoscopic stripping has destructive effects on serum AMH levels and the operated side AFC levels after surgery for patients with endometrioma and dermoid cysts, and laparoscopic excision of endometrioma has more destructive effects on ovarian reserve than dermoid cysts.

Adnexal Masses in Adolescents

Adnexal masses in adolescents, such as functional cysts, are often benign and can usually be managed expectantly since they typically regress on their own. The most common ovarian neoplasm in adolescents is a benign cystic teratoma. Both functional cysts and benign cystic teratomas are associated with ovarian torsion. Of concern, ovarian torsion requires a high level of suspicion when adolescents present with acute abdominal pain, as almost one-half of cases have no associated adnexal masses. The most common malignant adnexal masses in this age group include germ cell tumors, followed by epithelial cell tumors. Finally, ectopic pregnancy and tubo-ovarian abscesses must be considered in the differential diagnosis of adnexal mass, as delays in treatment may seriously affect an adolescent's health and future fertility. Obtaining an accurate history, including a sexual history, requires reviewing this history with the adolescent privately. Management of adnexal mases should prioritize fertility preservation. [Pediatr Ann. 2020;49(4):e183-e187.].

Ovarian neoplasms of childhood

Ovarian neoplasms are rare in children. Although usually asymptomatic, they sometimes present with abdominal pain, abdominal distension or palpable mass. The distribution of neoplasms in the pediatric population is different from in adults; benign mature cystic teratoma is the most common ovarian tumor in children. Radiologists should be familiar with the variable sonographic, CT and MRI findings of ovarian neoplasms. Although the less frequently encountered ovarian malignancies cannot be reliably distinguished by imaging alone, it does play an important role in workup. This review discusses the imaging and relevant clinical manifestations of the more commonly encountered pediatric ovarian neoplasms.

Ultrasonographically diagnosed dermoid cysts do not influence ovarian stimulation response in an in vitro fertilization cycle

To determine if patients with a DC respond similarly to ovarian stimulation when compared to patients without a DC. Infertility patients with a DC that underwent IVF between January 2009 and December 2016 were included. A cystic mass with mixed echogenicity, internal echoes similar to thick bands, fatty-fluid level, or an echogenic tubercle with acoustic shadow (Rokitansky nodule) within two years of the cycle characterized the diagnosis. The z-score compared the standard deviations (SDs) in patients with/without a DC and were compared to a nomogram (expected oocytes minus oocytes obtained divided by the SD), adjusted for age and number of oocytes retrieved, built utilizing cycles from noninfertile female patients. Thirty-nine patients with DC and 7839 patients without DC were identified. The mean number of oocytes (8.6 ± 5.8 vs. 8.5 ± 7.7, p = .43) and MIIs (6.7 ± 4.7 vs. 7.0 ± 6.7, p = .74) retrieved were similar. When cycles with and without a DC were compared to the nomogram (z-score of 0), cycles with a DC presented a z-score for ovarian response of 0.1921 SDs from the mean, and patients without DC presented a z-score of -0.2065 SDs from the mean (similar and less than -1.0). After building a population 'normal' response as a template, patients with and without a DC responded similar to COS.

Anti–NMDAR encephalitis complicating pregnancy

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis was first reported in 2005 in four patients with ovarian teratomas; there have been many further cases reported since the antigen for the NMDAR antibody was confirmed in 2007. Patients characteristically have a well-defined set of features, characterised by psychiatric disturbance, seizures and cognitive disturbance, followed by movement disorders, disorders of consciousness and dysautonomia. To date, 14 cases of NMDAR encephalitis have been described in the context of pregnancy. We report a case of NMDAR encephalitis in a 34-year-old woman at 8 weeks’ gestation. She had a turbulent clinical course and was initially admitted to a psychiatric unit. She was successfully treated with first-line immunomodulatory therapies and surgical resection of an ovarian teratoma. Following discharge she delivered a healthy baby and made a complete clinical recovery.

Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses

Adnexal masses (ie, masses of the ovary, fallopian tube, or surrounding tissues) commonly are encountered by obstetrician-gynecologists and often present diagnostic and management dilemmas. Most adnexal masses are detected incidentally on physical examination or at the time of pelvic imaging. Less commonly, a mass may present with symptoms of acute or intermittent pain. Management decisions often are influenced by the age and family history of the patient. Although most adnexal masses are benign, the main goal of the diagnostic evaluation is to exclude malignancy. The purpose of this document is to provide guidelines for the evaluation and management of adnexal masses in adolescents, pregnant women, and nonpregnant women and to outline criteria for the identification of adnexal masses that are likely to be malignant and may warrant referral to or consultation with a gynecologic oncologist.

Mature Cystitic Teratoma of the Bladder Masquerading as a Distal Ureteral Stone

A 27-year woman presented with irritative lower urinary tract symptoms and alleged small right distal ureteric stone that had been diagnosed with KUB and non-contrast spiral CT.

Patient was scheduled for ureteroscopic lithotripsy, revealing absence of the presumed stone, while cystoscopy showed unexpected 2 cm pedunculated grayish white lesion, situated on the right lateral wall of the bladder with sparse hairs covering it.

An incomplete TURBT was done; the histological findings correlated with the gross picture seen on cystoscopy.

Following CT urography, the patient went an open partial cystectomy and right oophorectomy; the histopathology was consistent with mature bladder teratoma.

An Evaluation of the Incidence of Right-Sided Ovarian Cystic Teratoma Visualized on Sonograms

This study set out to determine the incidence of right-sided ovarian cystic teratoma. The author examined 270 cases of ovarian cystic teratoma. In this series, ovarian dermoids were more frequently found on the right ovary than the left ovary. The primary data were obtained over two decades and include both retrospective and prospective review. The data included the clinical history of each patient, pelvic sonography examination, and microscopic and/or surgical findings reports. Data used were limited to proven cases of ovarian cystic teratoma shown by sonography and confirmed by histology. Results demonstrate that 195 dermoids (72.22%) were located on the right ovary, 47 dermoids were found on the left side (17.41%), and 28 dermoids were found bilaterally (10.37%). The results indicate that the incidence of unilateral dermoids occurs more often on the right side.

Past, present and future ultrasonographic techniques for analyzing ovarian masses

Ultrasonography is today the method of choice for distinguishing between benign and malignant adnexal pathologies. Using pattern recognition several types of tumors can be recognized according to their characteristic appearance on gray-scale imaging. Color Doppler imaging should be used only to perform a semiquantitative color score or evaluate the flow location. International Ovarian Tumor Analysis group had standardized definitions characterizing adnexal masses and suggested the use of 'simple rules' in premenopausal women. Recently, the use of 3D vascular indices has been proposed but its potential use in clinical practice is debated. Also computerized aided diagnosis algorithms showed encouraging results to be confirmed in the future.

Anti-NMDA Receptor Encephalitis in a Pregnant Woman

Anti N-methyl-D-aspartate (NMDA) receptor encephalitis is one of the most common types of autoimmune synaptic encephalitis. Anti-NMDA receptor encephalitis commonly occurs in young women with ovarian teratoma. It has variable clinical manifestations and treatment responses. Sometimes it is misdiagnosed as a psychiatric disorder or viral encephalitis. To the best of our knowledge, anti-NMDA receptor encephalitis is a rare condition in pregnant women. We report a case of anti-NMDA receptor encephalitis in a pregnant woman who presented with abnormal behavior, epileptic seizure, and hypoventilation.

An unexpected mass of the urachus: a case report

The urachus is a remnant of the urogenital sinus and allantois, which persists after antenatal involution. Despite its rudimentary postnatal presence, it can undergo metaplasia and tumor formation. Malignant transformation of the urachus is rare. However, these tumors can recur and develop pseudomyxoma peritonei. Thus, they should remain on the differential for any female patient with a pelvic mass. A 28-year old G9P2062 presented at 8 weeks' gestation requesting pregnancy termination. On ultrasound, a single live intrauterine pregnancy was visualized. Also identified was a left-sided 8- × 7- × 6-cm complex echogenic mass with thickened septations, heterogeneous appearance, and fluid-fluid levels suspicious for a mature cystic teratoma. Surgical termination of pregnancy and diagnostic laparoscopy was planned. Intraoperatively a multiloculated midline mass was identified and excised. Final pathology identified a mucinous urachal neoplasm of low malignant potential. The patient followed up with urology and underwent surgical staging. Midline location is a key feature that helps distinguish ovarian masses from urachal or bladder masses. Many urachal and bladder neoplasms are managed with complete surgical excision and staging, illustrating the importance of preoperative identification. If laterality of a mass is unclear, further imaging is recommended to characterize the mass preoperatively. This case also reveals the feasibility of a minimally invasive abdominal wall mass resection.

Assessment of adnexal masses using ultrasound: a practical review

Pelvic ultrasound is commonly used as part of the routine gynecologic exams, resulting in diagnosis of adnexal masses, the majority of which are functional or benign. However, due to the possible complications involving benign adnexal cysts (ie, adnexal torsion, pelvic pain) and the utmost importance of early diagnosis and treatment of ovarian cancer, the correct ultrasound diagnosis of adnexal masses is essential in clinical practice. This review will describe the typical ultrasound appearance of the common physiologic, benign, and malignant adnexal masses with the aim of aiding the clinician to reach the correct diagnosis.

CA19-9 elevation in ovarian mature cystic teratoma: discrimination from ovarian cancer - CA19-9 level in teratoma

Background

We aimed to identify clinical characteristics of ovarian mature cystic teratoma (MCT) in association with CA19-9 elevation, and to determine if CA19-9 is a useful marker in discrimination of MCT from ovarian cancer (OC).

Material/Methods

Medical records of 322 women with pathologically-confirmed MCT or OC (stage 1 or 2) were reviewed retrospectively. The relationships between the characteristics of MCT (mean diameter, bilaterality, and pathologic components) and elevated CA19-9 were evaluated. Tumor markers in MCT were compared to those in OC.

Results

MCTs with CA19-9 elevation were correlated with a larger diameter (8.53±3.84 cm vs. 6.95±3.97 cm, p=0.002) and presence of fat component (67.1% vs. 32.9%, p<0.001), compared to those with normal CA 19-9. Although the incidence of CA19-9 elevation was not different between patients with MCT and OC (p=0.700), the mean value of CA19-9 was higher in those with OC (114.66±20.66 U/mL vs. 508.58±261.63 U/mL, p=0.013). In addition, simultaneous elevation of CA125 and CA19-9 was associated with a higher probability of malignant neoplasm (p<0.001; odds ratio: 23.7; 95% confidence interval: 8.863–63.576) than single elevation of CA 19-9.

Conclusions

CA19-9 could be an important tool in the diagnosis of ovarian mature cystic teratoma. CA19-9, in combination with CA125, might be a useful marker in discrimination of MCT from cancer.

Gastric teratoma in an infant: a rare case report and discussion

Gastric teratoma is a rare tumor, accounting for less than 1 % of all teratomas in infants & children. To date, only about 102 cases have been reported in the literature. A 10 month old infant was brought with a history of upper abdominal mass which was otherwise asymptomatic. On evaluation it was diagnosed as gastric teratoma. On laparotomy the mass was found to be originating from lesser curvature of stomach. Mass was excised and histopathologically it was a mature cystic teratoma. No recurrence after 18 months of follow-up.

Subjective assessment of ovarian masses using pattern recognition: the impact of experience on diagnostic performance and interobserver variability

PURPOSE

To compare diagnostic performance and interobserver variability in a group of 36 examiners, with four different levels of experience.

METHODS

Nine junior trainees, eight level I senior trainees, 11 level II senior gynecologists, and eight level III expert sonologists classified 105 ultrasound images of adnexal masses into three subgroups of ovarian lesions (malignancies, functional cysts, and dermoid cysts).

RESULTS

The level III sonologists obtained the best diagnostic results together with the lowest interobserver variability (κ = 0.70, SD = 0.04). They achieved significantly better results in comparison with the junior trainees and also the senior trainees (κ = 0.51, SD = 0.12, p < 0.001; and κ = 0.51, SD = 0.09, p < 0.001). Differences between level III sonologists and the group of level II observers did not reach statistical significance (κ = 0.65, SD = 0.09, p = 0.70). There were no significant differences between senior and junior trainees (p = 1.0) and both groups achieved a significantly poorer diagnostic performance in comparison with the level II observers (p < 0.01 and p < 0.01). For all observers, the largest differences were seen for classifying malignancies, the best results for classifying functional cysts, and the poorest for evaluating dermoid cysts.

CONCLUSIONS

Diagnostic performance of pattern recognition significantly improves with an increasing level of experience, emphasizing the importance of standardized ultrasound training programs with supervision by experts.

Expectant management of ultrasonically diagnosed ovarian dermoid cysts: is it possible to predict outcome?

OBJECTIVE

The aim of this study was to assess the natural history of ultrasonically diagnosed ovarian dermoid cysts in a large group of women who were managed expectantly, and to assess the factors that were associated with failure of expectant management.

METHODS

Our database was searched for dermoid cysts diagnosed on ultrasonography by a single expert operator between 2001 and 2007 in this retrospective study. In women who opted for expectant management, demographic data including age, gravidity and parity were recorded. Indications for scan, site of cysts, dimensions and the outcomes of expectant management were also recorded.

RESULTS

Two hundred and eighty-nine women were diagnosed with a total of 323 dermoid cysts by a single expert ultrasound operator. 93/289 (32.2%; 95% CI, 26.8-37.6%) women with 105/323 (32.5%; 95% CI, 27.4-37.6%) ovarian dermoid cysts were managed expectantly for longer than 3 months. The mean age at diagnosis was 33.8 (range, 13-79) years and the median duration of follow up was 12.6 (interquartile range, 7.6-29.3) months. The mean growth rate of dermoid cysts during follow up was 1.67 mm/year. There were no demographic or morphological features that could be used to predict the growth rate of dermoid cysts. After a period of expectant management, 24/93 (25.8%; 95% CI, 16.9-34.7%) women had surgical intervention. The risk of surgical intervention was significantly increased in younger women, those of parity > or = 2 and in women with bilateral cysts or larger-diameter cysts, and reduced in women with a past history of ovarian cyst.

CONCLUSIONS

The success rate of expectant management of dermoid cysts is high and this approach should be considered as a viable alternative to surgical management.

Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement

The Society of Radiologists in Ultrasound convened a panel of specialists from gynecology, radiology, and pathology to arrive at a consensus regarding the management of ovarian and other adnexal cysts imaged sonographically in asymptomatic women. The panel met in Chicago, Ill, on October 27-28, 2009, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies, and are thought to represent a reasonable approach to asymptomatic ovarian and other adnexal cysts imaged at ultrasonography.

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.

Diagnosis of the most frequent benign ovarian cysts: is ultrasonography accurate and reproducible?

OBJECTIVE

To evaluate the reproducibility and the accuracy of B-mode ultrasonographic features of three different kinds of benign ovarian cysts: ovarian endometrioma, mature teratoma, and serous cyst.

METHODS

Digitally stored B-mode sonographic images of 98 women submitted to surgery for the presence of an adnexal mass were evaluated by five different examiners with different degrees of experience. The histological type of each mass was predicted on the basis of the B-mode typical benign findings, as in the case of endometrioma (groundglass endocystic pattern), cystic teratoma (echogenic pattern with or without acoustic shadow), and serous cyst (anechoic cyst without endocystic vegetations). To assess the reproducibility of the B-mode findings, intraobserver and interobserver agreements were calculated using the kappa index.

RESULTS

The intraobserver agreement was good or very good for all examiners and for all patterns (kappa = 0.71-1) except for the dermoid cyst, which showed moderate agreement (kappa = 0.42) for the highly experienced operator. The interobserver agreement was good for all experts for endometrioma (kappa = 0.66-0.78) and for serous cyst (kappa = 0.82-1), whereas it was moderate or good for cystic teratoma (kappa = 0.51-0.72). Interobserver agreement between experts and highly experienced operators was fair (kappa = 0.33-0.36) for teratoma and good or very good for endometrioma (kappa = 0.70-0.83) and serous cyst (kappa = 0.76-0.82). For different kinds of cysts, the accuracy was comparable among different operators.

CONCLUSIONS

Typical features of benign masses using grayscale transvaginal ultrasonography are reproducible even in moderately experienced examiners, although more experience was associated with better interobserver agreement. The diagnostic performance of different operators with different degrees of experience is similar.

Laparoscopic resection of benign ovarian tumours in children with gonadal preservation

PURPOSE

Ovarian tumours are often regarded as an indication for open oophorectomy, especially following torsion. We wish to report our results of laparoscopic ovarian cystectomy with ovarian preservation.

METHODS

Retrospective review of clinical records of patients who where managed with laparoscopic ovarian cystectomy with ovarian preservation.

RESULTS

Twelve records were identified over a 3-year period. The average age was 11.8 years (9-15). Presentation was of a mass in nine patients and torsion in three patients. Average size of the mass was 8.2 cm (5-18). Two patients had bilateral lesions. All patients were noted to have normal tumour markers. Successful cystectomy with ovarian preservation was accomplished in all cases using 3-port laparoscopy. The bilateral lesions were addressed at the same surgery with no increased length of stay or morbidity. In the three patients with acute torsion, an initial laparoscopic detorsion was performed with delayed laparoscopic cystectomy and ovarian preservation 7-10 days later. There was one complication of a minor umbilical port site infection. Histology was of a mature teratoma in ten cases and simple cyst in two. Six patients underwent routine ultrasonographic follow-up at 2-5 months at which time the involved ovary assumed a size and shape and blood flow comparable to the contra-lateral ovary in five patients. In one patient the affected side was smaller, 8.6 ml compared to 10 ml on the contra-lateral ovary. The remaining patients have been followed up clinically and remain asymptomatic.

CONCLUSION

Laparoscopic cystectomy with ovarian preservation can be successfully applied to benign ovarian tumours. Acute ovarian torsion is not a contraindication to this technique where a two stage procedure still enables us to offer ovarian preservation.

The efficacy of sonographic morphology indexing and serum CA-125 for preoperative differentiation of malignant from benign ovarian tumors in patients after operation with ovarian tumors

OBJECTIVE

To evaluate the value of sonographic morphology indexing (MI) system and serum CA-125 levels in the assessment of the malignancy risk in patients with ovarian tumors.

METHODS

From September 2000 to July 2006, 202 patients who underwent surgery for ovarian tumors were reviewed retrospectively. In all patients, the MI score and serum CA-125 level were measured preoperatively. The association of the final pathologic diagnosis with the MI score and serum CA-125 level were examined.

RESULTS

There were 26 malignant tumors out of 141 ovarian tumors with a MI >/=5 (18%). With a cut-off value of 5, the sensitivity, specificity, PPV, and NPV of MI scores were 0.743, 0.293, 0.181, and 0.845, respectively. There were 22 malignant tumors out of 54 ovarian tumors with serum CA-125 >30 u/ml (41%). With a cut-off value of 30 u/ml, the sensitivity, specificity, PPV, and NPV of serum CA-125 level were 0.667, 0.808, 0.407, and NPV 0.925, respectively. On ROC curve, the optimal cut-off value of MI score was 6.5-7.5 and that of serum CA-125 level was 25.6-28.5 u/ml. With a cut-off value of 7, the sensitivity and 1-specificity of MI score were 0.875-0.917 and 0.023-0.203, respectively. After the exclusion of teratoma cases, the sensitivity and 1-specificity of MI score were 0.875-0.917 and 0.046-0.138, respectively. With a cut-off value of 25.6-28.5 u/ml, the sensitivity and 1-specificity of serum CA-125 level were 0.958 and 0.203-0.215, respectively.

CONCLUSION

The sonographic MI system is an accurate and simple method to differentiate a malignant tumor from a benign ovarian tumor. The accuracy of the sonographic MI system improved when the serum CA-125 level was considered and ovarian teratomas were excluded.

Intraobserver and interobserver agreement of grayscale typical ultrasonographic patterns for the diagnosis of ovarian cancer

The purpose of this study was to evaluate the intraobserver and interobserver agreement for identifying ovarian malignancy using typical grayscale ultrasonographic patterns. Digitally stored grayscale sonographic images from a random sample of 98 women with an adnexal mass submitted to surgery after a grayscale transvaginal sonography were evaluated by five different examiners with different degrees of experience in three European university departments of obstetrics and gynecology. Masses in which the echo features were highly characteristic of a benign pathology were categorized as benign. Any cystic mass containing excrescences, thick septations, multiple irregular septations or solid component in which the echo architecture was not highly suggestive of benign histology was categorized as malignant. Intraobserver and interobserver agreement according to the level of experience were assessed by calculating the kappa index. Of the 98 cases randomly selected, 28 (29%) were malignant masses and 70 (71%) were benign. Intraobserver agreement was good or very good for all examiners with different degrees of experience (kappa = 0.72 to 1). Interobserver agreement was good for all expert operators (kappa = 0.69 to 0.75). Interobserver agreement between experts and highly experienced operators was moderate or good (kappa = 0.51 to 0.63). Interobserver agreement between the moderately experienced operator and experts was fair to moderate (kappa = 0.29 to 0.46). Interobserver agreement between moderately and highly experienced operators was fair (kappa = 0.33). Our results indicate that ultrasonographic malignant patterns are reproducible, even in moderately experienced examiners, although more experience is associated with better interobserver agreement.

Mature and immature ovarian teratomas: CT, US and MR imaging characteristics

Ovarian teratomas (OTs) are the most common germ cell neoplasm. They include mature cystic teratomas, monodermal teratomas (neural tumors, struma ovarii, carcinoid tumors) and immature teratomas. Teratomas are the most common benign ovarian neoplasms in women less than 45 years old. OTs are usually characterized by ultrasound (US) and magnetic resonance (MR) whereas they are usually an incidental finding on CT. The purpose of this paper is to review the most common types of teratomas and to describe CT, US and MR imaging features of the various types of mature and immature OTs.

A Practical Approach to the Ultrasound Characterization of Adnexal Masses

Because pelvic ultrasound is commonly used to evaluate adnexal masses, it is important to understand the most useful sonographic features for predicting benign and malignant masses. Determining whether an adnexal mass is of ovarian or extraovarian origin is key in arriving at the most likely diagnosis. Most adnexal masses are benign, and each of the most common benign ovarian lesions has a typical sonographic appearance. Additionally, most malignant ovarian neoplasms have a solid component with detectable flow by Doppler ultrasound, allowing one to strongly suggest the diagnosis. We will review an approach to the ultrasound diagnosis of adnexal masses that progresses through a series of 4 questions to help lead one to the most likely diagnosis.

Prenatal and Neonatal MRI of Sacrococcygeal Teratoma With Surgical Correlation

We report a case in which a sacrococcygeal teratoma was identified and characterized on prenatal and postnatal MRI, and correlated with subsequent surgical resection.

Imaging in gynecology

This chapter summarizes the diagnostic performance (sensitivity, specificity, positive and negative likelihood ratios) of ultrasound, computer tomography, and magnetic resonance imaging in the diagnosis of various gynecological diseases and tumors. Positron emission tomography is not discussed. Imaging in infertility, in the diagnosis of Mullerian duct anomalies and in gynecological oncology (staging of gynecological cancers, diagnosis of recurrence of gynecological cancer, diagnosis of trophoblastic tumors) is not dealt with. Ultrasound is the first-line imaging method for discrimination between viable intrauterine pregnancy, miscarriage and tubal pregnancy in women with bleeding and/or pain in early pregnancy, for discrimination between benign and malignant adnexal masses and for making a specific diagnosis in adnexal tumors (e.g. dermoid cyst, endometrioma, hemorrhagic corpus luteum, etc.), for diagnosing intracavitary uterine pathology in women with bleeding problems, and for confirming or refuting pelvic pathology in women with pelvic pain. Magnetic resonance imaging can have a role as a secondary test in the diagnosis of adenomyosis, 'deep endometriosis' (e.g. endometriosis in the rectovaginal septum or in the uterosacral ligaments), and in the diagnosis of extremely rare types of ectopic pregnancy (e.g. in the spleen, liver or retroperitoneum).

Adnexal Masses in Pregnancy: Surgery Compared With Observation

OBJECTIVE

To estimate whether the delay of surgery impacts the risk of adverse maternal and fetal outcomes in patients diagnosed with an adnexal mass during pregnancy.

METHODS

A review was performed of pregnant patients diagnosed with an adnexal mass 5 cm or greater in diameter. Data collected included age, gravity/parity, gestational age at diagnosis, and presenting symptoms. Ultrasound examinations were evaluated for mass size and complexity. Pregnancy outcome, complications, and surgical pathology were reviewed.

RESULTS

Between 1990 and 2003, 127,177 deliveries were performed at our institution. An adnexal mass 5 cm in diameter or greater was diagnosed in 63 (0.05%) patients. Pathologic diagnosis was available for 59 (94%) patients. The remaining 4 patients were lost to follow-up and excluded from the analysis. Antepartum surgery was performed in 17 patients (29%): 13 because of ultrasound findings that suggested malignancy and 4 secondary to ovarian torsion. The remaining patients were observed, with surgery performed in the postpartum period or at time of cesarean delivery. The majority of masses were dermoid cysts (42%). Four patients were diagnosed with ovarian cancer (6.8% of masses, 0.0032% of deliveries), and one patient (1.7%) had a tumor of low malignant potential. Antepartum surgery due to ultrasound findings that caused concern was performed on all 5 women diagnosed with a malignancy or borderline tumor, compared with 12 (22%) of the patients with benign tumors (P < .01).

CONCLUSION

In select cases, close observation is a reasonable alternative to antepartum surgery in patients with an adnexal mass during pregnancy.

A case of a mature cystic teratoma of the uterosacral ligament successfully treated by laparoscopic surgery

An asymptomatic tumor was found in the pelvic cavity of a 49-year-old woman during a routine examination. With a diagnosis of mature cystic teratoma of the right ovary, laparoscopic surgery was performed. The intraoperative finding showed the presence of a cystic tumor firmly attached to the uterosacral ligament in a position distant from the bilateral ovaries. Laparoscopic excision was performed, and the diagnosis of mature cystic teratoma of the uterosacral ligament was made histopathologically. This is the first report in the literature of successful laparoscopic treatment for a mature cystic teratoma of the uterosacral ligament.

Laparoscopic Treatment of Ovarian Dermoid Cysts: Eleven Years' Experience

STUDY OBJECTIVE

To compare laparoscopic and open approaches in the management of benign ovarian teratomas (dermoid cysts) with regard to operative outcome, complications, and postoperative follow-up. Factors that predispose to rupture of dermoid cysts during laparoscopic removal and rates of adhesion formation in women with and without cyst rupture during laparoscopic surgery also were considered.

DESIGN

Review of cases of women with dermoid cysts who underwent cystectomy either by laparoscopy or laparotomy in our department from 1992 through 2002 (Canadian Task Force classification III).

SETTING

The Infertility and Operative Laparoscopy units of the First Department of Obstetrics and Gynecology of the University of Athens, Alexandra Maternity Hospital, Athens, Greece.

PATIENTS

Two hundred twenty-two women with an ovarian mass requiring surgical management. Of these, 187 women with benign cystic teratomas underwent laparoscopic cystectomy, and 35 underwent cystectomy by laparotomy.

INTERVENTIONS

Cystectomy either by laparoscopy or laparotomy.

MEASUREMENTS AND MAIN RESULTS

Potential benefits of operative laparoscopy include reduced blood loss, less postoperative pain, shorter hospital stay, fast recovery, and an excellent cosmetic result.

CONCLUSION

Laparoscopy should be considered the method of choice for the removal of benign ovarian cystic teratomas as it offers the advantages of fewer postoperative adhesions, reduced pain, shorter hospital stay, and better cosmetic result. It should be performed by surgeons with considerable experience in advanced laparoscopic surgery.

Use of morphology to characterize and manage common adnexal masses

The use of grey-scale ultrasound morphology to characterize a pelvic mass may also be called 'pattern recognition'. The grey-scale ultrasound image provides us with the same information as that obtained by the surgeon or pathologist when he or she cuts a surgical specimen to see what it looks like inside. Many pelvic masses have such a typical macroscopic appearance that a fairly confident diagnosis can be made on the basis of their macroscopic appearance alone, i.e. on the basis of their grey-scale ultrasound image. This is true of most dermoid cysts, endometriomas, corpus luteum cysts, hydrosalpinges and peritoneal pseudocysts, and of many paraovarian cysts and benign solid ovarian tumours, for example, fibromas, fibrothecomas, thecofibromas, thecomas and Brenner tumours. A mass with irregularities should always evoke suspicion of malignancy. A mass that is completely smooth is almost certainly benign. Papillary projections--considered a strong sign of malignancy--are more common in borderline tumours than in invasive cancers but may also be seen in benign tumours, for example, in adenofibromas. They explain many false-positive ultrasound diagnoses of malignancy. Pattern recognition is superior to all other ultrasound methods (e.g. simple classification systems, scoring systems, mathematical models for calculating the risk of malignancy) for discrimination between benign and malignant extrauterine pelvic masses. Today's often too liberal use of transvaginal ultrasound gives clinicians problems. Many adnexal masses that probably would have remained undetected before the ultrasound era are now found incidentally at transvaginal ultrasound examination in women without symptoms of an adnexal tumour. The natural history of incidentally detected pelvic masses with benign ultrasound morphology is not known. Therefore, the optimal management of such tumours is also unknown.