Preoperative assessment of unilocular adnexal cysts by transvaginal ultrasonography: a comparison between ultrasonographic morphologic imaging and histopathologic diagnosis

Imaging of a Pelvic Mass: Uterine

The most common origin of a non-uterine pelvic mass is from the ovary. Ultrasound is the initial imaging modality of choice, additional imaging with computed tomography (CT) and/or magnetic resonance imaging (MRI) is performed in selected cases. Adnexal masses are also encountered as incidental findings during ultrasound, CT or MRI. Many of the adnexal masses that are surgically removed are benign. For optimal outcome and cost effective management, noninvasive risk stratification of such adnexal masses is necessary when discovered incidentally or when identified in a patient with a clinically detected pelvic mass. The American College of Radiology Ovarian-Adnexal Reporting Data System is a pattern-based scoring system for adnexal masses imaged with ultrasound and MRI, which assists clinicians to guide in the appropriate management based on evidence-based risk categories. Non-ovarian and non-uterine pelvic masses include fallopian tube abnormalities, paraovarian cysts, peritoneal inclusion cysts, and rare causes include masses that arise from the gastrointestinal tract or the sacrum. To distinguish non-ovarian masses from an ovarian tumor, a critical step is to identify a normal appearing ovary separate from the pelvic mass. This may be challenging in the post-menopausal woman with an atrophic ovary. MRI is a useful adjunctive modality in such cases. Extraovarian masses typically displace pelvic side wall vasculature medially, compress, encase or medially displace the ureters.

Variables Associated With Resolution and Persistence of Ovarian Cysts

OBJECTIVE

To estimate surveillance intervals of incident ovarian cysts, and describe variables associated with cyst resolution times.

METHODS

The UK-OCST (University of Kentucky Ovarian Cancer Screening Trial) was a prospective cohort that enrolled 47,762 individuals over 30 years, including 2,638 individuals with incident cysts. Cyst diameter and structure and patient age, body mass index, use of hormone therapy (HT), family history of ovarian cancer, and menopausal status were examined as variables associated with cyst resolution using t tests, χ 2 test, Kaplan Meier, and Cox multiple regression.

RESULTS

Of 2,638 individuals with incident cysts, 1,667 experienced resolution (63.2%) within 1.2 years, and 971 experienced persistence (36.8%). Within 1 year, unilocular and septated cysts had similar resolution rates (35.4% and 36.7%, respectively, P >.05), but time to resolution was shorter for unilocular cysts compared with septated cysts (mean 1.89 years vs 2.58 years, respectively, P <.001). Both unilocular and septated cysts smaller than 3 cm resolved faster than cysts larger than 6 cm ( P <.001). Variables associated with percent resolution included being of younger age, premenopausal status (but not for synchronous bilateral cysts), and those reporting a family history of ovarian cancer ( P <.05). Variables associated with a faster cyst resolution rate included being older than age 70 years and not using hormone therapy. Body mass index and family history were not associated with cyst resolution time.

CONCLUSION

Different surveillance times may be appropriate depending on cyst structure and size and patient age and HT use.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT04473833.

Management of adnexal mass: A comparison of five national guidelines

OBJECTIVES

General gynecologists are often the first to face a newly diagnosed adnexal mass. Bothering mass symptoms, fertility issues, and the effect of a possible surgical intervention on fertility in term of mechanical factor and ovarian follicular reserve are all considerations that should be accounted for. This study summarizes and compares five different adnexal mass management guidelines, enabling clinicians to peruse consensus and controversy issues, thus choosing the optimal management method.

DESIGN

We retrieved, reviewed and compared the most recent national guidelines of adnexal mass management from the national societies of the United States (American College of Obstetricians and Gynecologists), England (the Royal College of Obstetricians and Gynecologists), Canada (the Society of Obstetricians and Gynaecologists of Canada), Australia (the Royal Australian College of General Practitioners), and France (French College of Gynaecologists and Obstetricians).

RESULTS

There is a broad consensus regarding the role of transvaginal ultrasound as part of the initial evaluation of an adnexal mass and the radiological characteristics suggesting it being malignant. The role of transabdominal ultrasound or doppler mode is controversial. The use of MRI in cases of indeterminate adnexal masses is widely accepted. Ultrasound-guided aspiration is generally not recommended. There is a broad consensus that CA-125 should not be used as an ovarian cancer disease screening tool, though its role in the initial evaluation of adnexal masses is controversial. Risk prediction models are generally accepted, particularly the 'International Ovarian Tumor Analysis simple rules' and the 'Risk of Malignancy Index'.

CONCLUSION

Adnexal mass management national guidelines, though similar, had noticeable variations in the content, references cited, and recommendations made. While this variation might raise a concern as to the reproducibility of synthesizing literature, it can help practitioners present all spectra of recommendations and available data.

Benign, Borderline, and Malignant Pediatric Adnexal Masses: A 10-Year Review

STUDY OBJECTIVE

To investigate the incidence, clinical features, tumor markers, radiologic findings, types of surgeries, and histologies for adnexal masses in female pediatric and adolescent patients.

DESIGN

Retrospective chart review.

SETTING

Children's Health in Dallas and Plano, Texas from 2009 to 2018.

PARTICIPANTS

Female patients younger than 19 years old who underwent surgical management of an adnexal mass.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Imaging characteristics, tumor markers, surgical procedures, and histopathology.

RESULTS

In total, 752 patients (mean age, 13.7 years) underwent 756 surgical procedures for 781 adnexal masses. Of these, 732/781 (93.7%) were benign, 7/781 (0.9%) were borderline, and 42/781 (5.4%) were malignant. Of all 781 masses, 520/781 (66.6%) were ovarian and 261/781 (33.4%) were paratubal or tubal. Benign masses were associated with Hispanic race, pain, simple or cystic characteristics on imaging, and negative tumor markers. Borderline and malignant masses were associated with white race, pain, mass or distension, larger size, and heterogeneous appearance on imaging. Borderline masses were associated with negative tumor markers. Malignant masses were associated with elevated alpha fetoprotein, beta human chorionic gonadotropin, cancer antigen 125, and lactate dehydrogenase.

CONCLUSION

Most adnexal masses in the pediatric and adolescent population are benign. Benign masses were significantly smaller, more likely to have negative tumor markers, and appear simple or cystic. There is little standardization with respect to preoperative tumor markers for adnexal masses. High-yield tumor markers for malignancy include alpha fetoprotein, beta human chorionic gonadotropin, cancer antigen 125, and lactate dehydrogenase. Low-yield tumor markers include inhibin A and B. Gynecologists performed more fertility-preserving surgeries including mini-laparotomies and fewer laparotomies for benign masses than pediatric surgeons.

Comparison of the four malignancy risk indices in the discrimination of malignant ovarian masses: A cross-sectional study

OBJECTIVE

To evaluate the accuracy of the four malignancy risk indices to distinguish benign from malignant ovarian masses MATERIALS AND METHODS: This was an observational cross-sectional study conducted on 155 patients between January 2016 and January 2019. Women with ovarian masses planned for surgical management were recruited from the outpatient Gynecology clinic of the hospital. The risk of malignancy index (RMI 1-4) was calculated for all women with ovarian masses. Biopsies obtained from the ovarian masses after the surgical intervention was sent to the pathology lab for histopathological examination. The histopathologic diagnosis of the ovarian masses was considered the gold standard for diagnosis.

RESULTS

The participants' mean age in the group of patients with benign masses was 33.50 ± 14.53 years versus 45.09 ± 13.67 years in the malignant group. The two most prominent features in the malignant group were solid areas in 85.3 % of malignant masses and about 91.2 % of malignant masses showing size <7 cm in their largest diameter. The RMI's most sensitive individual parameter was the CA-125 level, while the lowest sensitivity was for the menopausal status. RMI 2 had the highest sensitivity of 76.47 %, while RMI 1 and 3 had the highest specificity, 92.56 %. RMI 2 had the highest AUC, 0.83.

CONCLUSIONS

RMI 2 is a simple and reliable tool and had the best performance among all RMIs in benign discrimination from malignant ovarian masses with high sensitivity and accuracy.

Radiologic-Histopathologic Correlation of Transvaginal US and Risk-reducing Salpingo-oophorectomy for Women at High Risk for Tubo-ovarian Carcinoma

Purpose

To examine radiologic-histopathologic correlation and the diagnostic performance of transvaginal US prior to risk-reducing salpingo-oophorectomy (RRSO) in women at high risk for tubo-ovarian carcinoma (TOC).

Materials and Methods

This retrospective study included 147 women (mean age, 49 years; age range, 28-75 years) at high risk for TOC who underwent transvaginal US within 6 months of planned RRSO between May 1, 2007, and March 14, 2018. Histopathologic results were reviewed. Fellowship-trained abdominal radiologists reinterpreted transvaginal US findings by using standardized descriptors. Descriptive statistical analysis and multiple logistic regression were performed.

Results

Of the 147 women, 136 had mutations in BRCA1, BRCA2, Lynch syndrome, BRIP1, and RAD51D genes, and 11 had a family history of TOC. Histopathologic reports showed 130 (88.4%) benign nonneoplastic results, 10 (6.8%) benign neoplasms, five (3.4%) malignant neoplasms, and two (1.4%) isolated p53 signature lesions. Transvaginal US results showed benign findings in 95 (64.6%) women and abnormal findings in 11 (7.5%) women; one or both ovaries were not visualized in 41 (27.9%) women. Hydrosalpinx was absent in all TOC and p53 signature lesions at transvaginal US. Transvaginal US had 20% sensitivity (one of five), 93% specificity (132 of 142), 9% positive predictive value (one of 11), and 97% negative predictive value (132 of 136) for TOC. Cancer was detected in one of five women at transvaginal US, and three of five false-negative lesions were microscopic or very small.

Conclusion

Preoperative transvaginal US had low sensitivity for detecting TOC in women at high risk for TOC. Clinically relevant precursors and early cancers were too small to be detected.Keywords: Genital/Reproductive, UltrasoundSupplemental material is available for this article.© RSNA, 2020.

Size threshold for follow-up of postmenopausal adnexal cysts: 1 cm versus 3 cm

OBJECTIVES

To assess 3 cm size threshold for follow-up of simple cysts in postmenopausal women.

MATERIALS AND METHODS

Radiology information system was retrospectively queried for "US pelvis complete" over 8 years in women > 50 years, with keywords ovarian cyst, adnexal cyst, ovarian mass, cystic mass, cystic neoplasm, ovarian neoplasm, and ovarian mass. Premenopausal women were excluded. Cysts, were classified as ≤ 1 cm, 1-3 cm, 3-5 cm, and ≥ 7 cm. Largest cysts on each ovary was recorded. EMR and imaging archives were reviewed for assessing size, stability duration, and surgical records. Descriptive statistics and confidence interval were performed.

RESULTS

4388 patients met the initial search criteria. 919 cysts in 896 women (age: 50-91 years, mean: 61.5 years) were identified. We found 162 cysts ≤ 1 cm, 352 1-3 cm, 296 3-7 cm , and 51 ≥ 7 cm cysts. 127 patients with 1-3 cm cysts had no follow-up. Final analysis of 225 1-3 cm cysts included 203 ovarian and 22 paraovarian cysts (average size = 1.95 cm (1.1-3.0 cm)). 103 ovarian cysts had less than 2 years, and 100 cysts had more than 2 years follow-up. All except one ovarian cyst were stable for the entire duration of their follow-up (Mean duration of follow-up 5.4 years) (0.3%, 95% CI 0.0-0.05). 40 cysts resolved. One simple cyst increased in size (followed over 3.25 years) without suspicious imaging features and benign on surgery.

CONCLUSION

1-3 cm cysts represented the most common size range (> 40%) in postmenopausal women, majority of which are stable over follow-up with benign outcome. 3 cm size threshold is appropriate for simple cyst follow-up in postmenopausal women.

Algorithmic Approach to Sonography of Adnexal Masses: An Evolving Paradigm

BACKGROUND

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

LEARNING OBJECTIVES

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

Imaging of Benign Adnexal Disease

This article provides an overview of the imaging evaluation of benign ovarian and adnexal masses in premenopausal and postmenopausal women and lesions discovered during pregnancy. Current imaging techniques are discussed, including pitfalls and differential diagnosis when necessary, as well as management. It also reviews the now well-established American College of Radiology (ACR)/Society of Radiologists in Ultrasound consensus guidelines and covers the more recently introduced Ovarian-Adnexal Reporting and Data System by the ACR and the recently published ADNEx Scoring System.

Preoperative Risk Stratification of Adnexal Masses in the Pediatric and Adolescent Population: Evaluating the Decision Tree System

STUDY OBJECTIVE

To evaluate the diagnostic performance of the Decision Tree System (DTS) rules 2 and 3 for surgically managed adnexal masses in the North American population and to compare it with the risk stratification criteria used at The Hospital for Sick Children (≥8 cm and complex/solid).

DESIGN

A retrospective cohort study of patients who presented with adnexal masses and were surgically treated between April 2011 and March 2016.

SETTING

The Hospital for Sick Children (Toronto, Ontario, Canada).

PARTICIPANTS

Patients 1-18 years of age with adnexal masses who underwent surgical treatment.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Main outcome measures included diagnostic performance (preoperative sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV] for malignancy) of the DTS rules 2 and 3 and ≥8 cm and complex/solid criteria.

RESULTS

The malignancy rate was 10.4%. The DTS rules 2 and 3 had a sensitivity of 84% (95% confidence interval [CI], 79-90), specificity of 77% (95% CI, 71-83), PPV of 30% (95% CI, 17-42), and NPV of 98% (95% CI, 94-100). The 8 cm or larger and complex/solid criteria had a sensitivity of 89% (95% CI, 85-94), specificity of 71% (95% CI, 64-77), PPV of 27% (95% CI, 16-38), and NPV of 98% (95% CI, 96-100).

CONCLUSION

Our study showed that DTS rules 2 and 3 had similar diagnostic performance as the 8 cm or larger and complex/solid criteria in the same population, with a very high NPV and a low PPV. Future prospective investigations should be conducted to further assess how DTS components can be incorporated into future algorithms for the management of adnexal masses in the pediatric population.

BRCA Mutation Carriers: Breast and Ovarian Cancer Screening Guidelines and Imaging Considerations

Patients who carry the BRCA1 and BRCA2 gene mutations have an underlying genetic predisposition for breast and ovarian cancers. These deleterious genetic mutations are the most common genes implicated in hereditary breast and ovarian cancers. This monograph summarizes the evidence behind current screening recommendations, reviews imaging protocols specific to this patient population, and illustrates some of the imaging nuances of breast and ovarian cancers in this clinical setting.

Imaging and Differential Diagnosis of Ovarian Cancer

Ovarian cancer is the seventh most common cancer affecting women. Despite advances in cancer control and healthcare in general, mortality from ovarian cancer remains unacceptably high due to diagnosis at an advanced stage of the disease. The 5-year survival rate is 47.4% because a majority of ovarian cancers are diagnosed when advanced. Only 14.9% of ovarian cancers are diagnosed when localized where the survival rate is 92.3%. Mortality rate reduction by screening has not been proven in women at an average risk for ovarian cancer. Ultrasound remains the primary modality for assessment of ovarian tumors. The need for standardizing terminology is critical for optimal assessment of the risk of malignancy in an ovarian tumor. The international ovarian tumor analysis group and more recently the American College of Radiology Ovarian - Adnexal Reporting and Data System Committee have published standardized lexicon for ovarian lesions and encourage ultrasound imagers to adopt this standardized terminology. The aim is to apply the lexicon for risk stratification to allow for consistent follow-up and management. Various methodologies have been tested for characterization of adnexal tumors and to assess risk of malignancy preoperatively. Risk assessment models have been studied against the gold standard of a pattern recognition approach and subjective assessment by an experienced imager. The morphologic patterns of ovarian tumors are detailed and features that are more discriminatory than others in suggesting an ovarian malignancy are described. The imaging pathologic correlation for different tumor types is presented. A brief summary of the ovarian cancer pathologic types and staging of cancer is presented. Finally, the current role of transvaginal sonography as a screening modality for ovarian cancer is discussed. Recently published data show encouraging results, that a multimodal approach of screening for ovarian cancer using transvaginal sonography in women with an elevated CA-125 may prove beneficial and cost effective.

Risk of Malignant Ovarian Cancer Based on Ultrasonography Findings in a Large Unselected Population

IMPORTANCE

The risk of malignant ovarian cancer associated with simple cysts is unknown.

OBJECTIVE

To quantify the risk of ovarian cancer based on ultrasonographic characteristics of ovarian masses, including simple cysts, in a large unselected population.

DESIGN, SETTING, AND PARTICIPANTS

This was a nested case-control study of patients enrolled in Kaiser Permanente Washington, a large integrated health care system in Washington State. Participants were 72 093 women who underwent pelvic ultrasonography between January 1, 1997, and December 31, 2008. Analysis was completed in April 2017.

EXPOSURES

Ultrasonographic characteristics of ovarian masses measured in 1043 women, and also, using weights derived from the sampling strategy, estimated frequencies for the entire cohort.

MAIN OUTCOMES AND MEASURES

Malignant ovarian cancer, identified through December 31, 2011, by cancer registry linkage.

RESULTS

Among 210 women who were diagnosed as having ovarian cancer, 49 were younger than 50 years, and 161 were 50 years or older. Ultrasonography findings were predictive of cancer (C statistic, 0.89). The risk of cancer was significantly elevated in women with complex cysts or solid masses, with likelihood ratios relative to women with normal ovaries ranging from 8 to 74 and the 3-year risk of cancer ranging from 9 to 430 cases per 1000 women based on patient age and ultrasonography findings. In contrast, the 23.8% of women younger than 50 years and the 13.4% of women 50 years or older with simple cysts were not at a significantly increased risk of ovarian cancer compared with women with normal ovaries. Likelihood ratios associated with the detection of a simple cyst were 0.00 in women younger than 50 years (no cancers were identified) and 0.10 (95% CI, 0.01-0.48) in women 50 years or older, and the absolute 3-year risk of cancer ranged from 0 to 0.5 cases per 1000 women.

CONCLUSIONS AND RELEVANCE

According to this study, the ultrasonographic appearance of ovarian masses is strongly associated with a woman's risk of ovarian cancer. Simple cysts are not associated with an increased risk of ovarian cancer, whereas complex cysts or solid masses are associated with a significantly increased risk of ovarian cancer.

Adnexal lesions: Imaging strategies for ultrasound and MR imaging

Adnexal lesions are routinely encountered in general practice. Ultrasound is the first line of investigation in determining the benign or malignant potential of an adnexal lesion. In the cases of classic simple cysts, hemorrhagic cysts, endometriomas, dermoids and obviously malignant lesions, ultrasound may be sufficient for management recommendations. In cases where there is an isolated adnexal lesion, without peritoneal disease or serum CA-125 elevation, and in lesions considered indeterminate on ultrasound, MR imaging with incorporation of the ADNEx MR score can increase the specificity for the diagnosis of benignity or malignancy. This article will review the imaging evaluation of adnexal lesions and how to incorporate the ADNEx MR score to help guide clinical management.

A systematic approach to adnexal masses discovered on ultrasound: the ADNEx MR scoring system

Adnexal lesions are a common occurrence in radiology practice and imaging plays a crucial role in triaging women appropriately. Current trends toward early detection and characterization have increased the need for accurate imaging assessment of adnexal lesions prior to treatment. Ultrasound is the first-line imaging modality for assessing adnexal lesions; however, approximately 20% of lesions are incompletely characterized after ultrasound evaluation. Secondary assessment with MR imaging using the ADNEx MR Scoring System has been demonstrated as highly accurate in the characterization of adnexal lesions and in excluding ovarian cancer. This review will address the role of MR imaging in further assessment of adnexal lesions discovered on US, and the utility of the ADNEx MR Scoring System.

Indeterminate Adnexal Cysts at US: Prevalence and Characteristics of Ovarian Cancer

Purpose To assess the prevalence of indeterminate adnexal cysts in women presenting to academic medical centers for pelvic ultrasonography (US), determine the incidence of malignancy, and identify cyst and patient characteristics that are predictive of malignancy. Materials and Methods A multicenter study of US-detected adnexal cysts with appropriate follow-up (surgical pathologic examination, imaging and/or clinical examination) was conducted from January 2008 to June 2012. Indeterminate cysts were classified as category 1 (typical benign appearing cysts >5 cm) or category 2 (cysts with avascular solid components) on the basis of a combination of definitions in the existing literature. The incidence of neoplasms and malignant tumors was calculated. Patient and cyst characteristics associated with neoplasm and malignant tumors were evaluated with the χ² test or Fisher exact test for categorical variables and the t test for continuous variables. A backward stepwise logistic regression model was performed for two outcomes: (a) the presence of any neoplasm (benign or malignant) and (b) the presence of a malignant tumor. Results There were 1637 women with an adnexal cyst at US; 391 (mean age = 41.8 years ± 13.5.1; range = 17-91 years) had an indeterminate adnexal cyst at US. The prevalence of indeterminate adnexal cysts was 23.9% (391 of 1637; 95% confidence interval [CI]: 0.22, 0.26). Three hundred three indeterminate cysts in 280 women (mean age = 42.9 years ± 14.1; range = 17-88 years) had adequate follow-up. The incidence of ovarian neoplasms (benign and malignant) was 24.8% (75 of 303 cysts; 95% CI: 0.20, 0.30), and the incidence of malignant tumors was 3.6% (11 of 303 cysts; 95% CI: 0.02, 0.06). The proportion of ovarian neoplasms differed between category 1 and category 2 cysts (17.5% [25 of 143 cysts; 95% CI: 0.12, 0.25] vs 31.3% [50 of 160 cysts; 95% CI: 0.24, 0.39], respectively; P = .001). The proportion of malignant tumors differed between categories 1 and 2 cysts (0% [0 of 143 cysts] vs 6.9% [11 of 160 cysts; 95% CI: 0.03, 0.12]; P < .001). The presence of an avascular nodular component was a significant predictor of malignancy at stepwise logistic regression analysis (odds ratio = 2.83; P ≤ .0001; 95% CI: 1.69, 4.70). Conclusion The presence of an avascular nodular component was the most significant predictor of the presence of malignancy in indeterminate adnexal cysts. The risk of malignancy is higher with category 2 cysts than with category 1 cysts. ^© RSNA, 2018.

The Usefulness of Ultrasound Imaging in Gynecologic Oncology

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

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.

Single port access laparoscopic surgery for large adnexal tumors: Initial 51 cases of a single institute

OBJECTIVE

Investigation of initial 51 cases of single port access (SPA) laparoscopic surgery for large adnexal tumors and evaluation of safety and feasibility of the surgical technique.

METHODS

We retrospectively reviewed the medical records of the first 51 patients who received SPA laparoscopic surgery for large adnexal tumors greater than 10 cm, from July 2010 to February 2015.

RESULTS

SPA adnexal surgeries were successfully completed in 51 patients (100%). The mean age, body mass index of the patients were 43.1 years and 22.83 kg/m², respectively. The median operative time, median blood loss were 73.5 (range, 20 to 185) minutes, 54 (range, 5 to 500) mL, and the median tumor diameter was 13.6 (range, 10 to 30) cm. The procedures included bilateral salpingo-oophorectomy (n=18, 36.0%), unilateral salpingo-oophorectomy (n=14, 27.45%), and paratubal cystectomy (n=1, 1.96%). There were no cases of malignancy and none were insertion of additional ports or conversion to laparotomy. The cases with intraoperative spillage were 3 (5.88%) and benign cystic tumors. No other intraoperative and postoperative complications were observed during hospital days and 6-weeks follow-up period after discharge.

CONCLUSION

Our results suggest that SPA laparoscopic surgery for large adnexal tumors may be a safe and feasible alternative to conventional laparoscopic surgery.

Gynecological pelvic pain as emergency pathology

Acute pelvic pain is a common condition in emergency. The sources of acute pelvic pain are multifactorial, so it is important to be familiar with this type of pathologies. The purpose of this article is review the main causes of gynecological acute pelvic pain and their radiologic appearances to be able to make an accurate diagnosis and provide objective criteria for patient management.

Retrospective analysis of suspicious pelvic masses using the Pelvic Mass Index (PMI) scoring system from 2007 to 2014

OBJECTIVES

This study aims to validate the accuracy of the Pelvic Mass Index (PMI) by comparing it with Risk of Malignancy Index (RMI) in a large patient cohort.

STUDY DESIGN

This retrospective study used data of women with ovarian masses collected from 2007 to 2014, referred to the Pelvic Mass Clinic (PMC) at University Hospital of Wales in Cardiff. The locally developed PMI was used to triage patients for surgery, surveillance or discharge. Performance measures for PMI, RMI and CA125 are reported as sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), receiver operating characteristic (ROC) curves and area under the curve (AUC) for premenopausal and postmenopausal women alike.

RESULTS

PMI was calculated on 1468 patients of whom 497 underwent surgery, 176 (71.0%) were in the high risk group, 63 (68.0%) intermediate and 258 (23%) amongst low risk women. Compared to RMI, PMI had a higher sensitivity (90.4%) and NPV (96.9%) for the entire cohort, as well as in the premenopausal (88.9%; 97.6%) and postmenopausal (91.5%; 95.6%) subcategories. ROC curves indicated better performance in the total group (AUC 0.823 vs. 0.770) and the premenopausal group (AUC 0.847 vs. 0.728), though AUC in the postmenopausal group was similar (0.779 vs. 0.791) - likely due to increased specificity of CA125 after menopause. Histology revealed PMI significantly outperforms RMI in diagnosing malignancy, missing only 1 compared to 20 cancers.

CONCLUSIONS

The high sensitivity and NPV of PMI makes it a useful tool in triaging patients with suspicious ovarian masses.

Adnexal masses in the premenopausal patient

Practitioners may frequently encounter adnexal masses in premenopausal women. Adnexal masses can represent a wide variety of etiologies, and therefore they can represent a diagnostic dilemma. When an adnexal mass is found the initial work up must focus on identifying acute pathology followed by determining the risk of a malignancy. Pelvic ultrasound remains the mainstay for evaluation of adnexal masses in premenopausal patients. If ultrasounds findings are indeterminate magnetic resonance imaging (MRI) is the next imaging modality of choice. The evaluation for malignancy should include serum marker screening. Aspiration of adnexal masses is generally avoided, due to the lack of therapeutic benefit and risk of seeding a tumor. When ultrasound findings are suggestive of benign disease, conservative management, including repeat imaging, should be considered. If the clinical suspicion for malignancy is high referral to a gynecologic oncologist is warranted. In other patients whom the evaluation of their adnexal mass remains unclear surgical excision with care not to disrupt the integrity of the mass should be performed for pathologic diagnosis.

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.

[Ovarian tumors in postmenopausal women: report of 100 cases and review of the literature]

Le but de notre travail est d’étudier les particularités de prise en charge des tumeurs de l'ovaire chez la femme ménopausée. L’étude rétrospective porte sur 100 patientes opérées pour des tumeurs ovariennes en post ménopause durant une période de 5 ans. L’âge moyen des patientes était de 61,3 ans (extrêmes: 47- 84 ans). L'aspect échographique était liquidien pur dans 40% des cas, mixte ou solide dans 30% des cas. Le dosage de CA 125 était élevé dans 25% des cas. Un traitement chirurgical a été pratiqué chez toutes les patientes: Laparotomie de première intention dans 43 cas,cœliochirurgie dans 51 cas, cœlioscopie puis laparotomie dans 6 cas. L'examen anatomopathologique définitif a révélé 22% de tumeurs malignes et 10% de kystes fonctionnels. Le geste chirurgical était une annexectomie bilatérale pour la majorité des tumeurs bénignes et carcinologique en cas de tumeurs malignes. La stratégie diagnostique des tumeurs ovariennes en post ménopause reste de nos jours basée sur la clinique, l’échographie et les marqueurs tumoraux. Les bénéfices de la cœlioscopie sont indiscutables. L'attitude à opérer systématiquement les kystes uniloculaires ayant les critères de bénignité est actuellement révisée.

[Sonographic diagnosis of presumed benign ovarian tumors]

To discriminate ovarian lesions is of particular importance in gynecological practice. Two main problems need answers: discrimination of benign and malignant adnexal masses and choice of the appropriate surgical treatment if necessary. Nearly 2% of the adnexal masses are ovarian carcinomas or borderline tumors. It is now, well established that ultrasonography is the gold standard for ovarian cyst diagnosis. The purpose of this data was to review the literature and to establish, with the evidence base medicine model, which parameters and existing diagnostic models using ultrasound and Doppler perform best in the evaluation of adnexal masses. Transvaginal sonography has demonstrated considerable advantage over conventional transabdominal sonography. However, transparietal sonography is still useful in large tumors. Definition of the nomenclature and classification was done and should be used. Unilocular ovarian cyst characterization seems easy using sonography and Doppler. In front of complication, discrimination of such functional cyst may be difficult but spontaneous regression confirms usually the expectative management. Dermoid cysts and endometriomas seem to be easier to discriminate from other adnexal masses. Ultrasound and morphologic parameters have a sensitivity of about 90% and a specificity of 80%; that makes this exam the gold standard for ovarian masses diagnosis. Only 50% of ovarian masses are characterized by sonography. Scoring systems help to differentiate benign from malignant masses (sensitivity of about 90%). Logistic regression and models are good methods especially for LR1 and 2 and RMI and may be useful for malignancy prediction but are difficult to use in current practice. Expert diagnosis is a subjective but most important performing parameter. Any suspicious ovarian mass or not easily diagnosed mass requires sonography by an expert, which can first use all the techniques and the different parameters to discriminate benign and malignant tumors. An explicit report will help the physician to define the right attitude for an appropriate management. Six to 16% of adnexial masses are complex or not classified and will result in MRI prescription or surgery.

Imaging strategy for early ovarian cancer: characterization of adnexal masses with conventional and advanced imaging techniques

Early detection of ovarian cancer remains crucial for improving patient survival rates. However, early-stage disease is often asymptomatic, and population screening is currently unproven. Adnexal masses may be incidentally detected, but most are identified at ultrasonography (US) in patients who are symptomatic, and most may be characterized as benign or malignant. Indices are available to estimate the risk of malignancy on the basis of clinical and US findings. However, adnexal masses remain indeterminate in some cases, with some benign lesions demonstrating features of malignancy at US. In these cases, use of magnetic resonance (MR) imaging improves the ability to characterize adnexal masses and reduces the number of indeterminate lesions. Establishing the likelihood of malignancy on the basis of imaging features is important to the preoperative detection of early ovarian cancer and profoundly influences referral and management pathways. Conventional and contrast material-enhanced MR imaging are used to evaluate morphologic features, including lesion complexity, signal intensity, and enhancement of solid areas. At dynamic contrast-enhanced MR imaging with semiquantitative analysis, early enhancement characteristics may help differentiate some complex benign and malignant lesions. Diffusion-weighted imaging has a limited but useful role in evaluating adnexal masses: Those with a hypointense solid area on both diffusion-weighted (b = 1000 sec/mm²) and T2-weighted images are likely benign, whereas those that are hyperintense on diffusion-weighted images (b = 1000 sec/mm²) with intermediate signal intensity on T2-weighted images are likely malignant.

Risk of malignancy in unilocular cysts: a study of 1148 adnexal masses classified as unilocular cysts at transvaginal ultrasound and review of the literature

OBJECTIVES

The aim of this study was to estimate the rate of malignancy in adnexal lesions described as unilocular cysts at transvaginal ultrasound examination and to investigate if there are differences in clinical and ultrasound characteristics between benign and malignant unilocular cysts.

METHODS

A total of 3511 patients with an adnexal mass underwent transvaginal ultrasound examination between 1999 and 2007. Sonologists used the International Ovarian Tumor Analysis terms and definitions to describe their ultrasound findings. Only masses operated on within 120  days after the ultrasound examination were included in the analysis and the histopathological diagnosis of the mass was used as the gold standard.

RESULTS

Of the 3511 masses, 1148 (33%) were classified as unilocular cysts on ultrasound. Of these, 11 (0.96% (95% CI, 0.48-1.71)) were malignant. The malignancy rate was lower in premenopausal than in postmenopausal women: 0.54% (5/931; 95% CI, 0.17-1.25) vs. 2.76% (6/217; 95% CI, 1.02-5.92); P = 0.009. More patients with malignant unilocular cysts had a personal history of breast cancer (18% vs. 2%; P = 0.02) or ovarian cancer (18% vs 0.6%; P = 0.003). Hemorrhagic cyst contents on ultrasound were more common in malignant than in benign unilocular cysts (18% vs. 2%; P = 0.03). In seven of the 11 malignancies judged to be unilocular cysts at scan, papillary projections or other solid components were seen at macroscopic inspection of the surgical specimen.

CONCLUSIONS

The malignancy rate in surgically removed adnexal lesions judged to be unilocular cysts at transvaginal scan is c 1%. Postmenopausal status, personal history of breast or ovarian cancer and hemorrhagic cyst contents on ultrasound increase the risk of malignancy. To avoid misclassifying adnexal lesions as unilocular cysts at scan, it is important to scrutinize unilocular cysts for the presence of solid components.

Role of sonography in the diagnostic workup of ovarian and adnexal masses except in pregnancy and during ovarian stimulation

The main role of imaging is to provide a description of the appearance, size, and location of adnexal lesions and associated abnormalities. In some circumstances, the aggressive potential of an adnexal lesion may be suggested on the basis of the imaging findings, the age of the patient, and the clinical data.

Risk of epithelial ovarian cancer in asymptomatic women with ultrasound-detected ovarian masses: a prospective cohort study within the UK collaborative trial of ovarian cancer screening (UKCTOCS)

OBJECTIVE

To estimate the risk of primary epithelial ovarian cancer (EOC) and slow growing borderline or Type I and aggressive Type II EOC in postmenopausal women with adnexal abnormalities on ultrasound.

METHODS

This was a prospective cohort study in the ultrasound group of the UK Collaborative Trial of Ovarian Cancer Screening of postmenopausal women with ultrasound-detected abnormal adnexal (unilocular, multilocular, unilocular solid and multilocular solid, solid) morphology on their first scan. Women were followed up through the national cancer registries and by postal questionnaires. Absolute risks of EOC and borderline, Type I and Type II EOC within 3 years of initial scan were calculated.

RESULTS

Of 48 053 women who underwent ultrasound examination and had complete scan data, 4367 (9.1% (95% CI, 8.8-9.3%)) had abnormal adnexal morphology. Median follow-up was 7.09 (25(th) -75(th) centiles, 6.03-7.92) years. Forty-seven (32 borderline or Type I, 15 Type II) were diagnosed with EOC. The overall absolute risk of EOC associated with abnormal adnexal morphology was 1.08% (95% CI, 0.79-1.43%); for borderline and Type I it was 0.73% (95% CI, 0.5-1.03%); and for Type II it was 0.34% (95% CI, 0.33-0.79%). In the subgroup (n = 741) with solid elements (unilocular solid, multilocular solid and solid) overall absolute risk was 4.45% (95% CI, 3.08-6.20%), for borderline and Type I it was 3.1% (95% CI, 1.9-4.6%) and for Type II it was 1.3% (95% CI, 0.6-2.4%). 11 982 women had both ovaries visualized and normal annual scans throughout the 3-year follow-up period. In this group, no borderline or Type I and eight Type II cancers were diagnosed.

CONCLUSION

Asymptomatic postmenopausal women with ultrasound-detected adnexal abnormalities with solid elements have a 1 in 22 risk for EOC. Despite the higher prevalence of Type II EOC, the risk of borderline or Type I cancer in women with ultrasound abnormalities seems to be higher than does the risk of Type II cancer. This has important immediate implications for patients with incidental adnexal findings as well as for any future ultrasound-based screening.

Ultrasound evaluation of gynecologic causes of pelvic pain

Ultrasound should be considered the first-line imaging modality of choice in women presenting with acute or chronic pelvic pain of suspected gynecologic or obstetric origin because many, if not most, gynecologic/obstetric causes of pelvic pain are easily diagnosed on ultrasound examination. Since the clinical presentation of gynecologic causes of pelvic pain overlaps with gastrointestinal and genitourinary pathology, referral to CT or MRI, especially in pregnant patients, should be considered if the US examination is nondiagnostic.

Characterization of complex adnexal masses: value of adding perfusion- and diffusion-weighted MR imaging to conventional MR imaging

PURPOSE

To retrospectively determine the value of adding perfusion-weighted (PW) and diffusion-weighted (DW) sequences to a conventional magnetic resonance (MR) imaging protocol to differentiate benign from malignant tumors.

MATERIALS AND METHODS

The institutional ethics committee approved this retrospective study and waived the requirement to obtain informed consent. MR images in 87 women (age range, 25-87 years) who underwent imaging before surgery for complex adnexal masses-excluding endometriomas and cystic teratomas-were analyzed. Conventional morphologic, perfusion, and diffusion MR criteria of malignancy were recorded. Three independent observers reviewed images in four steps: conventional MR images alone, conventional MR images and PW images combined, conventional MR images and DW images combined, and conventional, PW, and DW MR images combined. Receiver operating characteristic curve analysis was performed to compare the results of the readings. A recursive partitioning model was built to establish a multivariate decision tree.

RESULTS

There was almost perfect agreement for lesion characterization regardless of the reader experiment or step considered (κ = 0.811-0.929). Area under the receiver operating characteristic curve values were higher for conventional and DW images combined, conventional and PW images combined, and conventional, DW, and PW images combined compared with conventional MR images alone (P < .05). For all readers, the accuracy of conventional, PW, and DW imaging combined was higher than that of conventional MR imaging alone for benign masses (P < .01) but not for malignant masses (P = .24). The addition of both PW and DW images led to a correct change in the diagnosis in 19% (11 of 57 patients), 23% (13 of 57 patients), and 24% (14 of 57 patients) of cases for readers 1, 2, and 3, respectively, with no incorrect changes. Conventional, PW, and DW MR imaging criteria were combined to generate a decision tree giving an accuracy of 95%.

CONCLUSION

The addition of PW and DW sequences to a conventional MR imaging protocol improved the diagnostic accuracy in the characterization of complex adnexal masses.

Simple ultrasound rules to distinguish between benign and malignant adnexal masses before surgery: prospective validation by IOTA group

OBJECTIVES

To prospectively assess the diagnostic performance of simple ultrasound rules to predict benignity/malignancy in an adnexal mass and to test the performance of the risk of malignancy index, two logistic regression models, and subjective assessment of ultrasonic findings by an experienced ultrasound examiner in adnexal masses for which the simple rules yield an inconclusive result.

DESIGN

Prospective temporal and external validation of simple ultrasound rules to distinguish benign from malignant adnexal masses. The rules comprised five ultrasonic features (including shape, size, solidity, and results of colour Doppler examination) to predict a malignant tumour (M features) and five to predict a benign tumour (B features). If one or more M features were present in the absence of a B feature, the mass was classified as malignant. If one or more B features were present in the absence of an M feature, it was classified as benign. If both M features and B features were present, or if none of the features was present, the simple rules were inconclusive.

SETTING

19 ultrasound centres in eight countries.

PARTICIPANTS

1938 women with an adnexal mass examined with ultrasound by the principal investigator at each centre with a standardised research protocol. Reference standard Histological classification of the excised adnexal mass as benign or malignant.

MAIN OUTCOME MEASURES

Diagnostic sensitivity and specificity.

RESULTS

Of the 1938 patients with an adnexal mass, 1396 (72%) had benign tumours, 373 (19.2%) had primary invasive tumours, 111 (5.7%) had borderline malignant tumours, and 58 (3%) had metastatic tumours in the ovary. The simple rules yielded a conclusive result in 1501 (77%) masses, for which they resulted in a sensitivity of 92% (95% confidence interval 89% to 94%) and a specificity of 96% (94% to 97%). The corresponding sensitivity and specificity of subjective assessment were 91% (88% to 94%) and 96% (94% to 97%). In the 357 masses for which the simple rules yielded an inconclusive result and with available results of CA-125 measurements, the sensitivities were 89% (83% to 93%) for subjective assessment, 50% (42% to 58%) for the risk of malignancy index, 89% (83% to 93%) for logistic regression model 1, and 82% (75% to 87%) for logistic regression model 2; the corresponding specificities were 78% (72% to 83%), 84% (78% to 88%), 44% (38% to 51%), and 48% (42% to 55%). Use of the simple rules as a triage test and subjective assessment for those masses for which the simple rules yielded an inconclusive result gave a sensitivity of 91% (88% to 93%) and a specificity of 93% (91% to 94%), compared with a sensitivity of 90% (88% to 93%) and a specificity of 93% (91% to 94%) when subjective assessment was used in all masses.

CONCLUSIONS

The use of the simple rules has the potential to improve the management of women with adnexal masses. In adnexal masses for which the rules yielded an inconclusive result, subjective assessment of ultrasonic findings by an experienced ultrasound examiner was the most accurate diagnostic test; the risk of malignancy index and the two regression models were not useful.