Transvaginal ultrasound and computed tomography combined with clinical parameters and CA-125 determinations in the differential diagnosis of persistent ovarian cysts in premenopausal women

Adnexal Lesion Imaging: Past, Present, and Future

Currently, imaging is part of the standard of care for patients with adnexal lesions prior to definitive management. Imaging can identify a physiologic finding or classic benign lesion that can be followed up conservatively. When one of these entities is not present, imaging is used to determine the probability of ovarian cancer prior to surgical consultation. Since the inclusion of imaging in the evaluation of adnexal lesions in the 1970s, the rate of surgery for benign lesions has decreased. More recently, data-driven Ovarian-Adnexal Reporting and Data System (O-RADS) scoring systems for US and MRI with standardized lexicons have been developed to allow for assignment of a cancer risk score, with the goal of further decreasing unnecessary interventions while expediting the care of patients with ovarian cancer. US is used as the initial modality for the assessment of adnexal lesions, while MRI is used when there is a clinical need for increased specificity and positive predictive value for the diagnosis of cancer. This article will review how the treatment of adnexal lesions has changed due to imaging over the decades; the current data supporting the use of US, CT, and MRI to determine the likelihood of cancer; and future directions of adnexal imaging for the early detection of ovarian cancer.

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.

Construction and Verification of a Predictive Model for Risk Factors in Children With Severe Adenoviral Pneumonia

OBJECTIVE

To construct and validate a predictive model for risk factors in children with severe adenoviral pneumonia based on chest low-dose CT imaging and clinical features.

METHODS

A total of 177 patients with adenoviral pneumonia who underwent low-dose CT examination were collected between January 2019 and August 2019. The assessment criteria for severe pneumonia were divided into mild group (N = 125) and severe group (N = 52). All cases divided into training cohort (N = 125) and validation cohort (N = 52). We constructed a prediction model by drawing a nomogram and verified the predictive efficacy of the model through the ROC curve, calibration curve and decision curve analysis.

RESULTS

The difference was statistically significant (P < 0.05) between the mild adenovirus pneumonia group and the severe adenovirus pneumonia group in gender, age, weight, body temperature, L/N ratio, LDH, ALT, AST, CK-MB, ADV DNA, bronchial inflation sign, emphysema, ground glass sign, bronchial wall thickening, bronchiectasis, pleural effusion, consolidation score, and lobular inflammation score. Multivariate logistic regression analysis showed that gender, LDH value, emphysema, consolidation score, and lobular inflammation score were severe independent risk factors for adenovirus pneumonia in children. Logistic regression was employed to construct clinical model, imaging semantic feature model, and combined model. The AUC values of the training sets of the three models were 0.85 (0.77-0.94), 0.83 (0.75-0.91), and 0.91 (0.85-0.97). The AUC of the validation set was 0.77 (0.64-0.91), 0.83 (0.71-0.94), and 0.85 (0.73-0.96), respectively. The calibration curve fit good of the three models. The clinical decision curve analysis demonstrates the clinical application value of the nomogram prediction model.

CONCLUSION

The prediction model based on chest low-dose CT image characteristics and clinical characteristics has relatively clear predictive value in distinguishing mild adenovirus pneumonia from severe adenovirus pneumonia in children and might provide a new method for early clinical prediction of the outcome of adenovirus pneumonia in children.

Ovarian Collision Tumor, Massive Mucinous Cystadenoma, and Benign Mature Cystic Teratoma

Collision tumors are rare neoplasms defined by the presence of two distant tumors in the same organ without any histological intermixing. Ovarian tumors are often asymptomatic during the early stages and become symptomatic when increased in size causing vague abdominal pain, abdominal distention, vomiting, and frequent urination. We report here a case of a 28-year-old female who presented with a history of worsening abdominal pain and distension. An abdominopelvic ultrasound scan showed a huge complex mass occupying the pelvic area with non-visualization of the left ovary suggesting an ovarian origin; further characterization by cross-sectional imaging by both CT and MRI were performed confirming a left ovarian complex mass containing multiseptated cystic and fat component at the same time along with massive ascites. After surgical resection of the mass, histopathology revealed mucinous cystadenoma coexisting with cystic teratoma.

Paraneoplastic neurological syndromes: clinical presentations and management

We provide an overview of the varied presentations of paraneoplastic neurological syndromes. We also review the onconeural antibodies and their particular oncological and neurological associations. Recognition of these syndromes and their oncological associations is crucial, as early diagnosis and management has been associated with better patient outcomes. Specific management strategies and prognosis vary widely depending on the underlying etiology. An understanding of the relevant clinical details, imaging findings, and other diagnostic information can help tailor treatment approaches. We provide an outline of the diagnostic evaluation and treatment of various paraneoplastic neurological disorders, presenting with central and/or peripheral nervous system involvement. We briefly discuss neurologic immune checkpoint inhibitor-related adverse events, which can occasionally present with paraneoplastic neurological syndrome phenotypes.

A classic case suggestive of an unruptured ectopic pregnancy with unexpected finding of a unilateral dermoid cyst intraoperatively: A case report

Acute lower abdominal pain or pelvic pain is a common presenting complaint in women of reproductive age, which can be accounted for by numerous aetiologies. The presentation of lower abdominal pain with associated findings of an adnexal mass on transvaginal ultrasonography and positive beta-human chorionic gonadotropin (β-hCG) (serum and urine) in a sexually active woman of reproductive age is an ectopic pregnancy until proven otherwise. Here, we present a classic case suggestive of an unruptured ectopic pregnancy, with an unexpected finding of a unilateral dermoid cyst intraoperatively in a 33-year-old woman. Findings presented herein suggest that practitioners in our local setting should evaluate patients carefully, and consider neoplasms as a possible source of β-hCG production in sexually active women of reproductive age who present with subacute lower abdominal pain, identified adnexal mass on ultrasonography and positive serum or urine β-hCG readings.

Computer Tomography in the Diagnosis of Ovarian Cysts: The Role of Fluid Attenuation Values

Pathological analysis of ovarian cysts shows specific fluid characteristics that cannot be standardly evaluated on computer tomography (CT) examinations. This study aimed to assess the ovarian cysts’ fluid attenuation values on the native (Np), arterial (Ap), and venous (Vp) contrast phases of seventy patients with ovarian cysts who underwent CT examinations and were retrospectively included in this study. Patients were divided according to their final diagnosis into the benign group (n = 32) and malignant group (n = 38; of which 27 were primary and 11 were secondary lesions). Two radiologists measured the fluid attenuation values on each contrast phase, and the average values were used to discriminate between benign and malignant groups and primary tumors and metastases via univariate, multivariate, multiple regression, and receiver operating characteristics analyses. The Ap densities (p = 0.0002) were independently associated with malignant cysts. Based on the densities measured on all three phases, neoplastic lesions could be diagnosed with 89.47% sensitivity and 62.5% specificity. The Np densities (p = 0.0005) were able to identify metastases with 90.91% sensitivity and 70.37% specificity, while the combined densities of all three phases diagnosed secondary lesions with 72.73% sensitivity and 92.59% specificity. The ovarian cysts’ fluid densities could function as an adjuvant criterion to the classic CT evaluation of ovarian cysts.

A Nomogram Combined Radiomic and Semantic Features as Imaging Biomarker for Classification of Ovarian Cystadenomas

Objective: To construct and validate a combined Nomogram model based on radiomic and semantic features to preoperatively classify serous and mucinous pathological types in patients with ovarian cystadenoma.

Methods: A total of 103 patients with pathology-confirmed ovarian cystadenoma who underwent CT examination were collected from two institutions. All cases divided into training cohort (N = 73) and external validation cohort (N = 30). The CT semantic features were identified by two abdominal radiologists. The preprocessed initial CT images were used for CT radiomic features extraction. The LASSO regression were applied to identify optimal radiomic features and construct the Radscore. A Nomogram model was constructed combining the Radscore and the optimal semantic feature. The model performance was evaluated by ROC analysis, calibration curve and decision curve analysis (DCA).

Result: Five optimal features were ultimately selected and contributed to the Radscore construction. Unilocular/multilocular identification was significant difference from semantic features. The Nomogram model showed a better performance in both training cohort (AUC = 0.94, 95%CI 0.86–0.98) and external validation cohort (AUC = 0.92, 95%CI 0.76–0.98). The calibration curve and DCA analysis indicated a better accuracy of the Nomogram model for classification than either Radscore or the loculus alone.

Conclusion: The Nomogram model combined radiomic and semantic features could be used as imaging biomarker for classification of serous and mucinous types of ovarian cystadenomas.

Combination of the non-invasive tests for the diagnosis of endometriosis

BACKGROUND

About 10% of women of reproductive age suffer from endometriosis, a costly chronic disease causing pelvic pain and subfertility. Laparoscopy is the gold standard diagnostic test for endometriosis, but is expensive and carries surgical risks. Currently, there are no non-invasive tests available in clinical practice to accurately diagnose endometriosis. This review assessed the diagnostic accuracy of combinations of different non-invasive testing modalities for endometriosis and provided a summary of all the reviews in the non-invasive tests for endometriosis series.

OBJECTIVES

To estimate the diagnostic accuracy of any combination of non-invasive tests for the diagnosis of pelvic endometriosis (peritoneal and/or ovarian or deep infiltrating) compared to surgical diagnosis as a reference standard. The combined tests were evaluated as replacement tests for diagnostic surgery and triage tests to assist decision-making to undertake diagnostic surgery for endometriosis.

SEARCH METHODS

We did not restrict the searches to particular study designs, language or publication dates. We searched CENTRAL to July 2015, MEDLINE and EMBASE to May 2015, as well as the following databases to April 2015: CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, DARE and PubMed.

SELECTION CRITERIA

We considered published, peer-reviewed, randomised controlled or cross-sectional studies of any size, including prospectively collected samples from any population of women of reproductive age suspected of having one or more of the following target conditions: ovarian, peritoneal or deep infiltrating endometriosis (DIE). We included studies comparing the diagnostic test accuracy of a combination of several testing modalities with the findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Three review authors independently collected and performed a quality assessment of the data from each study by using the QUADAS-2 tool. For each test, the data were classified as positive or negative for the surgical detection of endometriosis and sensitivity and specificity estimates were calculated. The bivariate model was planned to obtain pooled estimates of sensitivity and specificity whenever sufficient data were available. The predetermined criteria for a clinically useful test to replace diagnostic surgery were a sensitivity of 0.94 and a specificity of 0.79 to detect endometriosis. We set the criteria for triage tests at a sensitivity of 0.95 and above and a specificity of 0.50 and above, which 'rules out' the diagnosis with high accuracy if there is a negative test result (SnOUT test), or a sensitivity of 0.50 and above and a specificity of 0.95 and above, which 'rules in' the diagnosis with high accuracy if there is a positive result (SpIN test).

MAIN RESULTS

Eleven eligible studies included 1339 participants. All the studies were of poor methodological quality. Seven studies evaluated pelvic endometriosis, one study considered DIE and/or ovarian endometrioma, two studies differentiated endometrioma from other ovarian cysts and one study addressed mapping DIE at specific anatomical sites. Fifteen different diagnostic combinations were assessed, including blood, urinary or endometrial biomarkers, transvaginal ultrasound (TVUS) and clinical history or examination. We did not pool estimates of sensitivity and specificity, as each study analysed independent combinations of the non-invasive tests.Tests that met the criteria for a replacement test were: a combination of serum IL-6 (cut-off >15.4 pg/ml) and endometrial PGP 9.5 for pelvic endometriosis (sensitivity 1.00 (95% confidence interval (CI) 0.91 to 1.00), specificity 0.93 (95% CI, 0.80, 0.98) and the combination of vaginal examination and transvaginal ultrasound (TVUS) for rectal endometriosis (sensitivity 0.96 (95% CI 0.86 to 0.99), specificity 0.98 (95% CI 0.94 to 1.00)). Tests that met the criteria for SpIN triage tests for pelvic endometriosis were: 1. a multiplication of urine vitamin-D-binding protein (VDBP) and serum CA-125 (cut-off >2755) (sensitivity 0.74 (95% CI 0.60 to 0.84), specificity 0.97 (95% CI 0.86 to 1.00)) and 2. a combination of history (length of menses), serum CA-125 (cut-off >35 U/ml) and endometrial leukocytes (sensitivity 0.61 (95% CI 0.54 to 0.69), specificity 0.95 (95% CI 0.91 to 0.98)). For endometrioma, the following combinations qualified as SpIN test: 1. TVUS and either serum CA-125 (cut-off ≥25 U/ml) or CA 19.9 (cut-off ≥12 U/ml) (sensitivity 0.79 (95% CI 0.64 to 0.91), specificity 0.97 (95% CI 0.91 to 1.00)); 2. TVUS and serum CA 19.9 (cut-off ≥12 U/ml) (sensitivity 0.54 (95% CI 0.37 to 0.70), specificity 0.97 (95% CI 0.91 to 1.0)); 3-4. TVUS and serum CA-125 (cut-off ≥20 U/ml or cut-off ≥25 U/ml) (sensitivity 0.69 (95% CI 0.49 to 0.85), specificity 0.96 (95% CI 0.88 to 0.99)); 5. TVUS and serum CA-125 (cut-off ≥35 U/ml) (sensitivity 0.52 (95% CI 0.33 to 0.71), specificity 0.97 (95% CI 0.90 to 1.00)). A combination of vaginal examination and TVUS reached the threshold for a SpIN test for obliterated pouch of Douglas (sensitivity 0.87 (95% CI 0.69 to 0.96), specificity 0.98 (95% CI 0.95 to 1.00)), vaginal wall endometriosis (sensitivity 0.82 (95% CI 0.60 to 0.95), specificity 0.99 (95% CI 0.97 to 1.0)) and rectovaginal septum endometriosis (sensitivity 0.88 (95% CI 0.47 to 1.00), specificity 0.99 (95% CI 0.96 to 1.00)).All the tests were evaluated in individual studies and displayed wide CIs. Due to the heterogeneity and high risk of bias of the included studies, the clinical utility of the studied combination diagnostic tests for endometriosis remains unclear.

AUTHORS' CONCLUSIONS

None of the biomarkers evaluated in this review could be evaluated in a meaningful way and there was insufficient or poor-quality evidence. Laparoscopy remains the gold standard for the diagnosis of endometriosis and using any non-invasive tests should only be undertaken in a research setting.

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.

Blood biomarkers for the non-invasive diagnosis of endometriosis

BACKGROUND

About 10% of reproductive-aged women suffer from endometriosis, a costly chronic disease causing pelvic pain and subfertility. Laparoscopy is the gold standard diagnostic test for endometriosis, but is expensive and carries surgical risks. Currently, there are no non-invasive or minimally invasive tests available in clinical practice to accurately diagnose endometriosis. Although other reviews have assessed the ability of blood tests to diagnose endometriosis, this is the first review to use Cochrane methods, providing an update on the rapidly expanding literature in this field.

OBJECTIVES

To evaluate blood biomarkers as replacement tests for diagnostic surgery and as triage tests to inform decisions on surgery for endometriosis. Specific objectives include:1. To provide summary estimates of the diagnostic accuracy of blood biomarkers for the diagnosis of peritoneal, ovarian and deep infiltrating pelvic endometriosis, compared to surgical diagnosis as a reference standard.2. To assess the diagnostic utility of biomarkers that could differentiate ovarian endometrioma from other ovarian masses.

SEARCH METHODS

We did not restrict the searches to particular study designs, language or publication dates. We searched CENTRAL to July 2015, MEDLINE and EMBASE to May 2015, as well as these databases to 20 April 2015: CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, DARE and PubMed.

SELECTION CRITERIA

We considered published, peer-reviewed, randomised controlled or cross-sectional studies of any size, including prospectively collected samples from any population of reproductive-aged women suspected of having one or more of the following target conditions: ovarian, peritoneal or deep infiltrating endometriosis (DIE). We included studies comparing the diagnostic test accuracy of one or more blood biomarkers with the findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Two authors independently collected and performed a quality assessment of data from each study. For each diagnostic test, we classified the data as positive or negative for the surgical detection of endometriosis, and we calculated sensitivity and specificity estimates. We used the bivariate model to obtain pooled estimates of sensitivity and specificity whenever sufficient datasets were available. The predetermined criteria for a clinically useful blood test to replace diagnostic surgery were a sensitivity of 0.94 and a specificity of 0.79 to detect endometriosis. We set the criteria for triage tests at a sensitivity of ≥ 0.95 and a specificity of ≥ 0.50, which 'rules out' the diagnosis with high accuracy if there is a negative test result (SnOUT test), or a sensitivity of ≥ 0.50 and a specificity of ≥ 0.95, which 'rules in' the diagnosis with high accuracy if there is a positive result (SpIN test).

MAIN RESULTS

We included 141 studies that involved 15,141 participants and evaluated 122 blood biomarkers. All the studies were of poor methodological quality. Studies evaluated the blood biomarkers either in a specific phase of the menstrual cycle or irrespective of the cycle phase, and they tested for them in serum, plasma or whole blood. Included women were a selected population with a high frequency of endometriosis (10% to 85%), in which surgery was indicated for endometriosis, infertility work-up or ovarian mass. Seventy studies evaluated the diagnostic performance of 47 blood biomarkers for endometriosis (44 single-marker tests and 30 combined tests of two to six blood biomarkers). These were angiogenesis/growth factors, apoptosis markers, cell adhesion molecules, high-throughput markers, hormonal markers, immune system/inflammatory markers, oxidative stress markers, microRNAs, tumour markers and other proteins. Most of these biomarkers were assessed in small individual studies, often using different cut-off thresholds, and we could only perform meta-analyses on the data sets for anti-endometrial antibodies, interleukin-6 (IL-6), cancer antigen-19.9 (CA-19.9) and CA-125. Diagnostic estimates varied significantly between studies for each of these biomarkers, and CA-125 was the only marker with sufficient data to reliably assess sources of heterogeneity.The mean sensitivities and specificities of anti-endometrial antibodies (4 studies, 759 women) were 0.81 (95% confidence interval (CI) 0.76 to 0.87) and 0.75 (95% CI 0.46 to 1.00). For IL-6, with a cut-off value of > 1.90 to 2.00 pg/ml (3 studies, 309 women), sensitivity was 0.63 (95% CI 0.52 to 0.75) and specificity was 0.69 (95% CI 0.57 to 0.82). For CA-19.9, with a cut-off value of > 37.0 IU/ml (3 studies, 330 women), sensitivity was 0.36 (95% CI 0.26 to 0.45) and specificity was 0.87 (95% CI 0.75 to 0.99).Studies assessed CA-125 at different thresholds, demonstrating the following mean sensitivities and specificities: for cut-off > 10.0 to 14.7 U/ml: 0.70 (95% CI 0.63 to 0.77) and 0.64 (95% CI 0.47 to 0.82); for cut-off > 16.0 to 17.6 U/ml: 0.56 (95% CI 0.24, 0.88) and 0.91 (95% CI 0.75, 1.00); for cut-off > 20.0 U/ml: 0.67 (95% CI 0.50 to 0.85) and 0.69 (95% CI 0.58 to 0.80); for cut-off > 25.0 to 26.0 U/ml: 0.73 (95% CI 0.67 to 0.79) and 0.70 (95% CI 0.63 to 0.77); for cut-off > 30.0 to 33.0 U/ml: 0.62 (95% CI 0.45 to 0.79) and 0.76 (95% CI 0.53 to 1.00); and for cut-off > 35.0 to 36.0 U/ml: 0.40 (95% CI 0.32 to 0.49) and 0.91 (95% CI 0.88 to 0.94).We could not statistically evaluate other biomarkers meaningfully, including biomarkers that were assessed for their ability to differentiate endometrioma from other benign ovarian cysts.Eighty-two studies evaluated 97 biomarkers that did not differentiate women with endometriosis from disease-free controls. Of these, 22 biomarkers demonstrated conflicting results, with some studies showing differential expression and others no evidence of a difference between the endometriosis and control groups.

AUTHORS' CONCLUSIONS

Of the biomarkers that were subjected to meta-analysis, none consistently met the criteria for a replacement or triage diagnostic test. A subset of blood biomarkers could prove useful either for detecting pelvic endometriosis or for differentiating ovarian endometrioma from other benign ovarian masses, but there was insufficient evidence to draw meaningful conclusions. Overall, none of the biomarkers displayed enough accuracy to be used clinically outside a research setting. We also identified blood biomarkers that demonstrated no diagnostic value in endometriosis and recommend focusing research resources on evaluating other more clinically useful biomarkers.

Imaging modalities for the non-invasive diagnosis of endometriosis

BACKGROUND

About 10% of women of reproductive age suffer from endometriosis. Endometriosis is a costly chronic disease that causes pelvic pain and subfertility. Laparoscopy, the gold standard diagnostic test for endometriosis, is expensive and carries surgical risks. Currently, no non-invasive tests that can be used to accurately diagnose endometriosis are available in clinical practice. This is the first review of diagnostic test accuracy of imaging tests for endometriosis that uses Cochrane methods to provide an update on the rapidly expanding literature in this field.

OBJECTIVES

• To provide estimates of the diagnostic accuracy of imaging modalities for the diagnosis of pelvic endometriosis, ovarian endometriosis and deeply infiltrating endometriosis (DIE) versus surgical diagnosis as a reference standard.• To describe performance of imaging tests for mapping of deep endometriotic lesions in the pelvis at specific anatomical sites.Imaging tests were evaluated as replacement tests for diagnostic surgery and as triage tests that would assist decision making regarding diagnostic surgery for endometriosis.

SEARCH METHODS

We searched the following databases to 20 April 2015: MEDLINE, CENTRAL, EMBASE, CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, MEDION, DARE, and PubMed. Searches were not restricted to a particular study design or language nor to specific publication dates. The search strategy incorporated words in the title, abstracts, text words across the record and medical subject headings (MeSH).

SELECTION CRITERIA

We considered published peer-reviewed cross-sectional studies and randomised controlled trials of any size that included prospectively recruited women of reproductive age suspected of having one or more of the following target conditions: endometrioma, pelvic endometriosis, DIE or endometriotic lesions at specific intrapelvic anatomical locations. We included studies that compared the diagnostic test accuracy of one or more imaging modalities versus findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Two review authors independently collected and performed a quality assessment of data from each study. For each imaging test, data were classified as positive or negative for surgical detection of endometriosis, and sensitivity and specificity estimates were calculated. If two or more tests were evaluated in the same cohort, each was considered as a separate data set. We used the bivariate model to obtain pooled estimates of sensitivity and specificity when sufficient data sets were available. Predetermined criteria for a clinically useful imaging test to replace diagnostic surgery included sensitivity ≥ 94% and specificity ≥ 79%. Criteria for triage tests were set at sensitivity ≥ 95% and specificity ≥ 50%, ruling out the diagnosis with a negative result (SnNout test - if sensitivity is high, a negative test rules out pathology) or at sensitivity ≥ 50% with specificity ≥ 95%, ruling in the diagnosis with a positive result (SpPin test - if specificity is high, a positive test rules in pathology).

MAIN RESULTS

We included 49 studies involving 4807 women: 13 studies evaluated pelvic endometriosis, 10 endometriomas and 15 DIE, and 33 studies addressed endometriosis at specific anatomical sites. Most studies were of poor methodological quality. The most studied modalities were transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), with outcome measures commonly demonstrating diversity in diagnostic estimates; however, sources of heterogeneity could not be reliably determined. No imaging test met the criteria for a replacement or triage test for detecting pelvic endometriosis, albeit TVUS approached the criteria for a SpPin triage test. For endometrioma, TVUS (eight studies, 765 participants; sensitivity 0.93 (95% confidence interval (CI) 0.87, 0.99), specificity 0.96 (95% CI 0.92, 0.99)) qualified as a SpPin triage test and approached the criteria for a replacement and SnNout triage test, whereas MRI (three studies, 179 participants; sensitivity 0.95 (95% CI 0.90, 1.00), specificity 0.91 (95% CI 0.86, 0.97)) met the criteria for a replacement and SnNout triage test and approached the criteria for a SpPin test. For DIE, TVUS (nine studies, 12 data sets, 934 participants; sensitivity 0.79 (95% CI 0.69, 0.89) and specificity 0.94 (95% CI 0.88, 1.00)) approached the criteria for a SpPin triage test, and MRI (six studies, seven data sets, 266 participants; sensitivity 0.94 (95% CI 0.90, 0.97), specificity 0.77 (95% CI 0.44, 1.00)) approached the criteria for a replacement and SnNout triage test. Other imaging tests assessed in small individual studies could not be statistically evaluated.TVUS met the criteria for a SpPin triage test in mapping DIE to uterosacral ligaments, rectovaginal septum, vaginal wall, pouch of Douglas (POD) and rectosigmoid. MRI met the criteria for a SpPin triage test for POD and vaginal and rectosigmoid endometriosis. Transrectal ultrasonography (TRUS) might qualify as a SpPin triage test for rectosigmoid involvement but could not be adequately assessed for other anatomical sites because heterogeneous data were scant. Multi-detector computerised tomography enema (MDCT-e) displayed the highest diagnostic performance for rectosigmoid and other bowel endometriosis and met the criteria for both SpPin and SnNout triage tests, but studies were too few to provide meaningful results.Diagnostic accuracies were higher for TVUS with bowel preparation (TVUS-BP) and rectal water contrast (RWC-TVS) and for 3.0TMRI than for conventional methods, although the paucity of studies precluded statistical evaluation.

AUTHORS' CONCLUSIONS

None of the evaluated imaging modalities were able to detect overall pelvic endometriosis with enough accuracy that they would be suggested to replace surgery. Specifically for endometrioma, TVUS qualified as a SpPin triage test. MRI displayed sufficient accuracy to suggest utility as a replacement test, but the data were too scant to permit meaningful conclusions. TVUS could be used clinically to identify additional anatomical sites of DIE compared with MRI, thus facilitating preoperative planning. Rectosigmoid endometriosis was the only site that could be accurately mapped by using TVUS, TRUS, MRI or MDCT-e. Studies evaluating recent advances in imaging modalities such as TVUS-BP, RWC-TVS, 3.0TMRI and MDCT-e were observed to have high diagnostic accuracies but were too few to allow prudent evaluation of their diagnostic role. In view of the low quality of most of the included studies, the findings of this review should be interpreted with caution. Future well-designed diagnostic studies undertaken to compare imaging tests for diagnostic test accuracy and costs are recommended.

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.

Management of giant ovarian teratoma: A case series and review of the literature

The management of ovarian teratomas in normal conditions is well established, but in rare giant cases (tumor diameter over 15 cm), the choice of management, such as laparotomic or laparoscopic approaches, are controversial and may be therapeutically challenging for surgeons. The aims of the current study were to analyze the clinical features of giant ovarian teratoma and to discuss its management. The clinical data of 330 patients with giant ovarian teratoma (of whom 1 patient was treated by the authors and 329 were admitted to the Second Affiliated Hospital of Zhejiang University Medical College between January 1st 2000 and December 31st 2010) were reviewed and analyzed. The patients had an age range of 6 to 83 years and a mean tumor size of 24.9±7.1 cm. Of the 330 patients, 102 (30.9%) were asymptomatic and the majority (69.1%, 228/330) reported symptoms. There were more patients in the laparotomic group than the laparoscopic group, especially for the emergency cases (5.5 vs. 0%, P<0.05). Accidental cyst rupture was more frequent when a laparoscopic approach was used (31.5 vs. 19.6%, P<0.05). These results suggest that laparotomic resection may be preferred for the en bloc mass removal, adequate abdominal cavity irrigation and avoidance of accidental mass rupture in the management of giant ovarian teratomas. Familiarity with the imaging features of giant ovarian teratomas effectively aids preoperative diagnosis and differentiation.

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.

Ovarian cancer arising in endometrioid cysts: ultrasound findings

OBJECTIVES

To describe sonographic characteristics of malignant transformation in endometrioid cysts.

METHODS

Women with a histological diagnosis of ovarian endometrioid cysts, borderline tumors arising in endometrioid cysts and carcinoma arising in endometrioid cysts, preoperatively examined sonographically, were included in this retrospective study. Gray-scale and Doppler ultrasound characteristics of the endometrioid cysts were compared with those of the borderline tumors and primary cancers arising in endometrioid cysts. The performance of an experienced examiner in classifying the masses was also assessed.

RESULTS

Of 324 cases collected for the study, 309 (95.3%) lesions were classified as endometrioid cysts, four (1.2%) as borderline tumors arising in endometrioid cysts and 11 (3.4%) as carcinoma arising in endometrioid cysts. Women with malignant findings (borderline ovarian tumors and cancers) were older (median age 52 (range, 28-79) years) than those with benign endometrioid cysts (median age 34 (range, 18-76) years) (P<0.0001), and the prevalence of postmenopausal status was significantly higher in malignant cases. All (15/15) malignant tumors vs. 16% (50/309) of benign tumors were characterized by the presence of solid tissue (P<0.0001). The prevalence of solid tissue with positive Doppler signals was higher in malignant tumors (100%) than in benign cysts (7.8%) (P<0.0001). Papillary projections were a more frequent sonographic feature among malignant lesions (86.7%) than among benign endometrioid cysts (11.3%) (P<0.0001); power Doppler signals were detected within the projections in 92.3% and 37.1% of malignant and benign lesions, respectively. The examiner correctly diagnosed 94.8% (293/309) of benign lesions as benign and 93.3% (14/15) of malignant lesions as malignant. The risk estimation of the examiner was 'uncertain' in three (20%) and 'probably/certainly malignant' in 12 (80%) of 15 malignant cases.

CONCLUSION

Borderline tumors and carcinomas arising in endometrioid cysts show a vascularized solid component at ultrasound examination.

The diagnosis of ovarian cancer: is color Doppler imaging reproducible and accurate in examiners with different degrees of experience?

OBJECTIVE

To evaluate the reproducibility and accuracy of color Doppler flow location in indeterminate masses after a gray-scale sonography in the diagnosis of ovarian malignancy.

METHODS

Digitally stored color Doppler sonographic images from a random sample of 130 women with an indeterminate adnexal mass submitted to surgery were evaluated by six different examiners with different degrees of experience. A mass was graded malignant if flow was shown within the excrescences or solid areas. Intraobserver agreement and interobserver agreement according to the level of experience were assessed by calculating the kappa index.

RESULTS

Intraobserver agreement was good for all examiners with different degrees of experience (kappa 0.72-0.89). Interobserver agreement was good to moderate for all operators (kappa 0.48-0.71) irrespective of degree of experience. The accuracy was comparable among different operators.

CONCLUSIONS

Our results indicate that color Doppler imaging for detection of adnexal malignancy seems to be a reproducible method even in moderately experienced examiners.

Screening for tumours in paraneoplastic syndromes: report of an EFNS task force

BACKGROUND

paraneoplastic neurological syndromes (PNS) almost invariably predate detection of the malignancy. Screening for tumours is important in PNS as the tumour directly affects prognosis and treatment and should be performed as soon as possible.

OBJECTIVES

an overview of the screening of tumours related to classical PNS is given. Small cell lung cancer, thymoma, breast cancer, ovarian carcinoma and teratoma and testicular tumours are described in relation to paraneoplastic limbic encephalitis, subacute sensory neuronopathy, subacute autonomic neuropathy, paraneoplastic cerebellar degeneration, paraneoplastic opsoclonus-myoclonus, Lambert-Eaton myasthenic syndrome (LEMS), myasthenia gravis and paraneoplastic peripheral nerve hyperexcitability.

METHODS

many studies with class IV evidence were available; one study reached level III evidence. No evidence-based recommendations grade A-C were possible, but good practice points were agreed by consensus.

RECOMMENDATIONS

the nature of antibody, and to a lesser extent the clinical syndrome, determines the risk and type of an underlying malignancy. For screening of the thoracic region, a CT-thorax is recommended, which if negative is followed by fluorodeoxyglucose-positron emission tomography (FDG-PET). Breast cancer is screened for by mammography, followed by MRI. For the pelvic region, ultrasound (US) is the investigation of first choice followed by CT. Dermatomyositis patients should have CT-thorax/abdomen, US of the pelvic region and mammography in women, US of testes in men under 50 years and colonoscopy in men and women over 50. If primary screening is negative, repeat screening after 3-6 months and screen every 6 months up till 4 years. In LEMS, screening for 2 years is sufficient. In syndromes where only a subgroup of patients have a malignancy, tumour markers have additional value to predict a probable malignancy.

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.

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.

Three-dimensional quantification of tumor vascularity as a tertiary test after B-mode and power Doppler evaluation for detection of ovarian cancer

OBJECTIVE

The purpose of this study was to investigate the role of 3-dimensional (3D) quantification of tumor vascularity in the differential diagnosis of pelvic indeterminate masses with a solid appearance or unilocular or multilocular cysts with a solid component showing central vascularization on 2-dimensional power Doppler sonography.

METHODS

One hundred fifty-seven consecutive pelvic masses in 153 patients were included in this study and underwent sonography before surgery. Masses that showed a typical benign pattern on B-mode sonography (n = 112) and indeterminate masses with peripheral or absent flow on power Doppler sonography (n = 10) were not evaluated by 3D sonography. Only masses with central vascularization were submitted to 3D power Doppler imaging (n = 35). The following 3D vascular parameters were calculated: relative color and flow measure (similar to the vascularization flow index obtained with other systems).

RESULTS

With receiver operating characteristic curve analysis, the best cutoff values for relative color and flow measure were 4.4 and 2.7, respectively. Flow measure had sensitivity of 68% and specificity of 40% in the overall population submitted to 3D power Doppler sonography. Accuracy slightly increased when masses with small papillary projections (<10 mL) were excluded. In this group (n = 22), sensitivity was 83%, and specificity was 50%.

CONCLUSIONS

In masses with central vascularization on 2-dimensional power Doppler sonography, the use of 3D quantification of tumor vascularity had low diagnostic accuracy in the detection of adnexal malignancies, although an increase in accuracy in masses with a solid portion of greater than 10 mL was reported.

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.

Ultrasonography, computed tomography and magnetic resonance imaging for diagnosis of ovarian carcinoma

Our objective was to compare US, CT, and MR imaging in differentiation of malignant from benign ovarian tumors. Through an electronic literature search and manual review of bibliographies (January 1990 to June 2006), relevant studies on the diagnostic performance of US, CT, and MR imaging in the differentiation between benign and malignant ovarian tumours were identified. Sixty-nine articles were included, yielding 143 studies. Data on the accuracy of the different imaging modalities were analyzed and compared by constructing summary receiver-operating characteristic (ROC) curves. Our results suggest that US techniques seems to be similar with CT and MRI in differentiation of malignant from benign ovarian tumors. The results also revealed that color Doppler flow imaging alone is significantly inferior to combined US techniques, morphologic assessment alone and contrast enhanced US in diagnosis of ovarian cancer. In conclusion, US morphologic assessment still is the most important and common modality in detect ovarian cancer.

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).

Indeterminate Ovarian Mass at US: Incremental Value of Second Imaging Test for Characterization—Meta-Analysis and Bayesian Analysis

PURPOSE

To compare value of current diagnostic strategies in assessment of changes in posttest probability of ovarian cancer when menopausal status and combination and sequence of diagnostic imaging tests are considered.

MATERIALS AND METHODS

Prevalence of ovarian cancer according to menopausal status in women with an ovarian mass and performance of combined gray-scale and Doppler ultrasonography (US), computed tomography (CT), and non-enhanced magnetic resonance (MR) imaging and contrast material-enhanced MR imaging after indeterminate results at gray-scale US were derived from meta-analysis by using MEDLINE database and institutional data. Study was approved by the institutional review board of University Hospital Geneva, Geneva, Switzerland; informed consent was waived. Posttest probability values were computed through Bayesian analysis and Monte Carlo simulation after initial gray-scale US and secondary combined gray-scale and Doppler US, CT, or MR imaging, while dependence of test results among imaging modalities was considered. Changes in posttest probability were compared among imaging modalities with summary receiver operating characteristic curves.

RESULTS

Prevalence of ovarian cancer was 8.75% in premenopausal women and 32.40% in postmenopausal women with an ovarian mass. After characterization with initial gray-scale US, posttest probability in pre- and postmenopausal women changed, respectively, to 25% and 63% for indeterminate results and to 2% and 7% for benign results. Subsequent use of combined gray-scale and Doppler US, CT, or MR imaging had significant higher positive and lower negative posttest probability than did use of gray-scale US alone. In women with an indeterminate initial US result, posttest probability decreased after secondary testing with benign results for all imaging modalities to 2% in premenopausal women and to 8%-10% in postmenopausal women. After secondary testing for suspicious lesions, posttest probability increased more after non-enhanced (premenopausal women, 70%; postmenopausal women, 92%) or contrast-enhanced MR imaging (premenopausal women, 80%; postmenopausal women, 95%) than it did after combined gray-scale and Doppler US (premenopausal women, 30%; postmenopausal women, 69%) or CT (premenopausal women, 38%; postmenopausal women, 76%) (P < .001).

CONCLUSION

In women with an indeterminate ovarian mass at gray-scale US, MR imaging results contributed to change in probability of ovarian cancer in both pre- and postmenopausal women more than did CT or combined gray-scale and Doppler US results.

Ultrasonography and color Doppler-based triage for adnexal masses to provide the most appropriate surgical approach

OBJECTIVE

This study was undertaken to identify whether ultrasonography with color Doppler can identify and triage the patients with adnexal masses to the most appropriate surgical approach.

STUDY DESIGN

Four hundred fifty-three pelvic masses were included in the study and underwent ultrasonography before surgical treatment for adnexal masses. Masses that showed a typical benign pattern at B-mode ultrasonography (very low risk of malignancy) were treated by conventional laparoscopy without further evaluation. Masses that extended above the umbilicus were consider at very high risk and treated by laparotomy. All other adnexal masses were evaluated with power Doppler. Masses with central vascularization (high risk of malignancy) were submitted to laparotomy or laparoscopy with additional tools, whereas masses with peripheral or absent flow (low risk of malignancy) were submitted to conventional laparoscopy.

RESULTS

Among 284 very low-risk, 32 low-risk, 46 high-risk, 91 very high-risk masses, the rate of malignant masses were 0%, 0%, 52%, and 78%, respectively. The use of color Doppler increases the diagnostic accuracy of B-mode ultrasonography in the diagnosis of adnexal malignancies because of a significantly higher specificity (0.91 vs 0.82, P < .001).

CONCLUSION

The evaluation of vessel distribution by color Doppler seems a safe diagnostic procedure, permitting to treat by laparoscopy 91% of benign masses.

Management of ovarian cysts

BACKGROUND

The treatment of an ovarian cyst relies on its nature, and accurate preoperative discrimination of benign and malignant cysts is therefore of crucial importance. This study was undertaken to review the literature concerning the preoperative diagnosis and treatment of ovarian cysts.

METHODS

Articles concerning ovarian cysts from a medline literature search during the period 1985-2003 were included in addition to articles found as references in the initial publications.

RESULTS

Different methods for discriminating between benign and malignant ovarian cysts are discussed. The diagnosis and the treatment are assessed in relation to age, menopausal status, pregnancy, and whether the cyst is presumed to be benign or malignant. In general, expectant management is the choice in premenopausal and pregnant women with non-suspicious cysts and normal levels of CA-125. In postmenopausal women, unilocular, anechoic cysts less than 5 cm in diameter together with a normal CA-125 may be followed up. Operation is recommended in women with cysts larger than 5 cm and/or elevated levels of CA-125. Women with symptoms should be operated regardless of age, menopausal status, or ultrasound findings.

CONCLUSIONS

The preoperative discrimination between benign and malignant ovarian cysts is a challenge. Multimodal methods improve the results of single modalities, but we still need improved preoperative diagnostic tools. Furthermore, these methods should be validated in consecutive patient populations large enough to give a reliable estimate of the method's sensitivity and specificity.

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.

The diagnosis of functional ovarian cysts using transvaginal ultrasound combined with clinical parameters, CA125 determinations, and color Doppler

OBJECTIVES

To investigate the role of transvaginal ultrasound combined with clinical parameters, CA125 determinations, and color Doppler in the differentiation between functional cysts and other adnexal masses.

STUDY DESIGN

Two hundred and eighty-seven consecutive persistent adnexal masses were submitted to B-mode transvaginal ultrasonography associated with color and power Doppler imaging. Plasma CA125 concentrations were measured before surgery.

RESULTS

According to the obtained logistic regression equation, the presence of anechoic tumors without echogenic portions or septa and CA125 <25IU/ml was associated with a 75% probability of presence of follicular cysts. The visualization of fine trabecular jelly-like content or of a heterogeneous mass with hypoechoic content, absent or only peripheral arterial flow, and age <40 years was associated with a 56% probability of presence of luteal cysts.

CONCLUSIONS

Addition of findings to B-mode ultrasonography can help to differentiate functional cysts from other adnexal masses.

Complex pelvic mass as a target of evaluation of vessel distribution by color Doppler sonography for the diagnosis of adnexal malignancies: results of a multicenter European study

OBJECTIVE

To compare the diagnostic accuracy of gray scale sonography and color Doppler imaging in the differential diagnosis of adnexal malignancies from benign complex pelvic masses in a multicenter prospective study.

METHODS

The study was performed as a collaborative work at 3 European university departments of obstetrics and gynecology. A total of 826 complex pelvic masses on which transvaginal sonography and evaluation of cancer antigen 125 plasma concentrations were performed before surgical exploration were included in the study. The scanning procedure was the same in the 3 institutions. An adnexal mass was first studied in gray scale sonography, and a probable histologic type was predicted. Second, solid excrescences or solid portions of the tumor were evaluated for vascular flow with color Doppler sonography (conventional or power). A mass was graded malignant if flow was shown within the excrescences or solid areas and benign if there was no flow. The overall agreement between the test result and the actual outcome was calculated by kappa statistics.

RESULTS

Color Doppler evaluation was more accurate in the diagnosis of adnexal malignancies in comparison with gray scale sonography (kappa = 0.82 and 0.65, respectively) because of significantly higher specificity (0.94 versus 0.84; P < .001). The evaluation of the cancer antigen 125 plasma concentration did not seem to increase the accuracy of either method.

CONCLUSIONS

The evaluation of vessel distribution by color Doppler sonography in complex adnexal cysts seems to increase the diagnostic accuracy of gray scale sonography in the detection of adnexal malignancies in a large study population.

Borderline cystic tumors of the ovary: gray-scale and color Doppler sonographic findings

PURPOSE

The aim of the study was to determine the value of gray-scale and color Doppler sonography in distinguishing borderline cystic tumors (BCTs) from benign cysts and malignant tumors of the ovary.

METHODS

The gray-scale and color Doppler sonographic features of 383 ovarian lesions in 374 nonpregnant women were retrospectively studied. Sonography was performed transvaginally for all but 7 lesions, which were imaged suprapubically. All of the lesions were surgically resected via laparoscopy or laparotomy.

RESULTS

The histopathologic diagnoses were 27 BCTs, 35 ovarian carcinomas, and 321 benign cysts. Sonography diagnosed 24 (89%) of 27 BCTs as malignant lesions. Patients with BCTs, were younger than those with ovarian cancer (p < 0.001). BCTs showed intracystic papillae in 17 cases (63%), diffuse internal echoes in 11 (41%), intracystic septa in 8 (30%), a heterogeneous echo pattern in 7 (26%), and a solid pattern in 4 (15%). BCTs showed blood flow in 24 cases (89%) and lower pulsatility and resistance indices (RI) compared with benign lesions (p < 0.001 for both). Multivariate analysis revealed intracystic papillae as the only independent predictor of BCTs (p < 0.001).

CONCLUSIONS

When a cystic mass has papillae, this is the only abnormal finding detected by gray-scale transvaginal sonography, and color Doppler imaging shows low RI values within the mass, a BCT should be suspected.

Comparison of conventional color Doppler imaging and power doppler imaging for the diagnosis of ovarian cancer: results of a European study

OBJECTIVE

The purpose of this prospective study was to compare the diagnostic accuracy of conventional color Doppler (CCD) imaging and power Doppler (PD) imaging in the diagnosis of ovarian cancer.

METHODS

Six hundred fifty-six consecutive women with adnexal masses scheduled for surgery in two European university departments of obstetrics and gynecology underwent preoperative transvaginal ultrasound. The scanning procedure was the same in the two institutions: after B-mode sonography, a CCD/PD imaging scan was performed before pulsed Doppler evaluation. Using both modalities of color Doppler, malignancy was suspected when arterial flow was visualized in an echogenic portion defined as malignant by B-mode. To avoid the risk of bias due to the absence of blindness of the examiner after the first Doppler evaluation, at one institution 328 consecutive women with an adnexal mass were evaluated using only CCD imaging, whereas at the second institution the ultrasonographic evaluation of the same number of masses was performed using PD imaging, and the results were compared prospectively.

RESULTS

The age, the rate of postmenopausal women, and the rate of ovarian cancer were similar in the two institutions. The false-positive rate of B-mode imaging was similar in the two institutions (17 versus 18%), while the false-positive rates of CCD and PD imaging were 4.6 and 7.4%, respectively. Although the overall diagnostic accuracy of two techniques seems comparable, with a similar value of K (0.81 versus 0.84), a significantly lower sensitivity in differentiation of benign from malignant ovarian lesions was found using CCD (87 versus 100%).

CONCLUSIONS

At least one of the two Doppler techniques should be used in conjunction with B-mode imaging in order to decrease the false-positive rate of B-mode used alone but CCD imaging showed a higher false-negative rate.

Ovarian teratomas: tumor types and imaging characteristics

Ovarian teratomas include mature cystic teratomas (dermoid cysts), immature teratomas, and monodermal teratomas (eg, struma ovarii, carcinoid tumors, neural tumors). Most mature cystic teratomas can be diagnosed at ultrasonography (US) but may have a variety of appearances, characterized by echogenic sebaceous material and calcification. At computed tomography (CT), fat attenuation within a cyst is diagnostic. At magnetic resonance (MR) imaging, the sebaceous component is specifically identified with fat-saturation techniques. The US appearances of immature teratoma are nonspecific, although the tumors are typically heterogeneous, partially solid lesions, usually with scattered calcifications. At CT and MR imaging, immature teratomas characteristically have a large, irregular solid component containing coarse calcifications. Small foci of fat help identify these tumors. The US features of struma ovarii are also nonspecific, but a heterogeneous, predominantly solid mass may be seen. On T1- and T2-weighted images, the cystic spaces demonstrate both high and low signal intensity. Familiarity with the US, CT, and MR imaging features of ovarian teratomas can aid in differentiation and diagnosis.

Laparoscopic management of 641 adnexal tumors in Kiel, Germany

STUDY OBJECTIVE

To evaluate the effectiveness and safety of laparoscopic and laparotomic management of ovarian tumors.

DESIGN

Retrospective analysis (Canadian Task Force classification II-2).

SETTING

University-affiliated hospital.

PATIENTS

Six hundred forty-one women with benign and malignant ovarian tumors.

INTERVENTIONS

Laparoscopy and laparotomy.

MEASUREMENTS AND MAIN RESULTS

Between January 1997 and December 1998, 493 (76.9%) ovarian tumors were treated laparoscopically and 138 (21.5%) by laparotomy. Criteria for laparotomy were high suspicion of malignancy and tumors larger than 10 cm that were technically too difficult for the laparoscopic approach. The mean size of tumors treated laparoscopically was 4.5 cm (range 1.1-11 cm) and by laparotomy 8.2 cm (range 3-20 cm). Mean operating times were 75.7 minutes (range 30-200 min) and 126 minutes (range 30-235 min), respectively, and mean blood loss was 193 ml (range 50-1200 ml) and 431 ml (range 50-2500 ml), respectively. Twelve laparoscopies were converted to laparotomy, six because of technical reasons such as severe adhesions, bleeding, or tumor size, and six for intraoperative suspicion of malignancy. Of the latter, four (66.7%) turned out to be ovarian carcinoma and two (33.3%) borderline tumors. Histologic evaluation clearly revealed predominance of functional ovarian cysts, endometriomas, and dermoid cysts in the group treated by laparoscopy, whereas ovarian carcinomas, large endometriomas, and serous cysts prevailed in the laparotomy group.

CONCLUSION

With careful preoperative screening, the rate of laparoscopies for treatment of benign ovarian cysts can be increased. (J Am Assoc Gynecol Laparosc 8(1):74-82, 2001)

US characterization of ovarian masses: a meta-analysis

PURPOSE

To compare the effectiveness of current ultrasonographic (US) techniques for characterizing ovarian masses.

MATERIALS AND METHODS

Through a MEDLINE literature search, articles with imaging-histopathologic correlation and data that allowed calculation of contingency tables were identified. Results of morphologic assessment, Doppler US, color Doppler flow imaging, and combined techniques were compared.

RESULTS

Among 89 data sets from 46 included studies (5,159 subjects), 35 sets used morphologic information, 36 measured Doppler US indexes, 10 assessed tumor vascularity with color Doppler flow imaging, and eight used combined techniques. Summary receiver operating characteristic curves revealed significantly higher performance for combined techniques than for morphologic information (P: =.003), Doppler US indexes (P: =.003), or color Doppler flow imaging alone (P: =.001). The Q* point (and 95% CI) for combined techniques was 0.92 (0.87, 0.96) versus 0. 85 (0.83, 0.88) for morphology, 0.82 (0.78, 0.86) for Doppler US, and 0.73 (0.58, 0.87) for color Doppler flow imaging. Morphologic assessment showed a trend toward better performance than color Doppler flow imaging (P: =.09) or Doppler US indexes (P: =.07). Doppler US index results were better in earlier studies (P: =.005).

CONCLUSION

Combined US techniques and a diagnostic algorithm perform significantly better than morphologic assessment, color Doppler flow imaging, or Doppler US indexes alone in characterizing ovarian masses.