Diagnosis of pelvic masses with transabdominal color Doppler, CA 125 and ultrasonography

Management of a suspicious adnexal mass: a clinical practice guideline

QUESTIONS

What is the optimal strategy for preoperative identification of the adnexal mass suspicious for ovarian cancer? What is the most appropriate surgical procedure for a woman who presents with an adnexal mass suspicious for malignancy?

PERSPECTIVES

In Canada in 2010, 2600 new cases of ovarian cancer were estimated to have been diagnosed, and of those patients, 1750 were estimated to have died, making ovarian cancer the 7th most prevalent form of cancer and the 5th leading cause of cancer death in Canadian women. Women with ovarian cancer typically have subtle, nonspecific symptoms such as abdominal pain, bloating, changes in bowel frequency, and urinary or pelvic symptoms, making early detection difficult. Thus, most ovarian cancer cases are diagnosed at an advanced stage, when the cancer has spread outside the pelvis. Because of late diagnosis, the 5-year relative survival ratio for ovarian cancer in Canada is only 40%. Unfortunately, because of the low positive predictive value of potential screening tests (cancer antigen 125 and ultrasonography), there is currently no screening strategy for ovarian cancer. The purpose of this document is to identify evidence that would inform optimal recommended protocols for the identification and surgical management of adnexal masses suspicious for malignancy.

OUTCOMES

Outcomes of interest for the identification question included sensitivity and specificity. Outcomes of interest for the surgical question included optimal surgery, overall survival, progression-free or disease-free survival, reduction in the number of surgeries, morbidity, adverse events, and quality of life.

METHODOLOGY

After a systematic review, a practice guideline containing clinical recommendations relevant to patients in Ontario was drafted. The practice guideline was reviewed and approved by the Gynecology Disease Site Group and the Report Approval Panel of the Program in Evidence-based Care. External review by Ontario practitioners was obtained through a survey, the results of which were incorporated into the practice guideline.

PRACTICE GUIDELINE

These recommendations apply to adult women presenting with a suspicious adnexal mass, either symptomatic or asymptomatic. IDENTIFICATION OF AN ADNEXAL MASS SUSPICIOUS FOR OVARIAN CANCER: Sonography (particularly 3-dimensional sonography), magnetic resonance imaging (mri), and computed tomography (ct) imaging are each recommended for differentiating malignant from benign ovarian masses. However, the working group offers the following further recommendations, based on their expert consensus opinion and a consideration of availability, access, and harm: Where technically feasible, transvaginal sonography should be the modality of first choice in patients with a suspicious isolated ovarian mass.To help clarify malignant potential in patients in whom ultrasonography may be unreliable, mri is the most appropriate test.In cases in which extra-ovarian disease is suspected or needs to be ruled out, ct is the most useful technique.Evaluation of an adnexal mass by Doppler technology alone is not recommended. Doppler technology should be combined with a morphology assessment.Ultrasonography-based morphology scoring systems can be used to differentiate benign from malignant adnexal masses. These scoring systems are based on specific ultrasound parameters, each with several scores base on determined features. All evaluated scoring systems were found to have an acceptable level of sensitivity and specificity; the choice of scoring system may therefore be made based on clinician preference.As a standalone modality, serum cancer antigen 125 is not recommended for distinguishing between benign and malignant adnexal masses.Frozen sections for the intraoperative diagnosis of a suspicious adnexal mass is recommended in settings in which availability and patient preference allow. SURGICAL PROCEDURES FOR AN ADNEXAL MASS SUSPICIOUS FOR MALIGNANCY: To improve survival, comprehensive surgical staging with lymphadenectomy is recommended for the surgical management of patients with early-stage ovarian cancer. Laparoscopy is a reasonable alternative to laparotomy, provided that appropriate surgery and staging can be done. The choice between laparoscopy and laparotomy should be based on patient and clinician preference. Discussion with a gynecologic oncologist is recommended. Fertility-preserving surgery is an acceptable alternative to more extensive surgery in patients with low-malignant-potential tumours and those with well-differentiated surgical stage i ovarian cancer. Discussion with a gynecologic oncologist is recommended.

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.

Doppler color flow analysis of the uterine arteries before and after intrauterine device insertion: a prospective study

OBJECTIVE

An intrauterine device (IUD) is one of the most frequently used methods of birth control around the world. Although a relationship between its use and menstrual disorders has been well documented, only a few studies have tried to show whether there are any vascular modifications. The aim of our study was to evaluate the influence of an IUD on uterine artery blood flow using Doppler assessment.

METHODS

A total of 100 patients selected for IUD use were prospectively evaluated with Doppler analysis before and 30 days after insertion. The resistive index (RI) and pulsatility index (PI) were used to evaluate uterine artery vascular resistance. Patients were allocated in 2 groups according to whether they were (group 2) or were not (group 1) lactating.

RESULTS

The PI and RI of the patients in groups 1 and 2 before and after IUD insertion were not statistically significantly different (P = .298 and .23). When we compared uterine artery blood flow indices before and after IUD insertion for groups 1 and 2 separately, we observed in group 1 that the mean +/- SD PI values were 2.45 +/- 0.62 and 2.55 +/- 0.55 (P = .38) and the RI values were 0.87 +/- 0.08 and 0.87 +/- 0.06 (P = .88) before and after IUD insertion, respectively. In group 2, the PI values were 2.31 +/- 0.55 and 2.37 +/- 0.69 (P = .68) and the RI values were 0.85 +/- 0.07 and 0.86 +/- 0.07 (P = .44) before and after IUD insertion. Finally, we used the mean blood flow indices of the uterine arteries of all patients to compare the effect of IUD insertion. Results were also not statistically significant when we compared PI and RI before and after IUD insertion.

CONCLUSIONS

The presence of an IUD does not interfere with the vascular resistance of the uterine arteries that can be shown by Doppler flow assessments 1 month after insertion.

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.

Asymptomatic adnexal masses: correlation of FDG PET and histopathologic findings

PURPOSE

To analyze asymptomatic adnexal masses at positron emission tomography (PET) with fluorodeoxyglucose (FDG) in correlation with histopathologic findings and evaluate FDG PET for assessing malignancy in comparison with transvaginal B-mode and Doppler ultrasonography (US) and magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Ninety-nine patients underwent static FDG PET of the abdomen. US scans were evaluated according to sonomorphologic scoring systems. Resistance index of tumor blood vessels was calculated. Transverse and sagittal T1-weighted MR images obtained before and after intravenous administration of gadopentetate dimeglumine with a fat-saturation technique and T2-weighted MR images were acquired at 1.5 T. Adnexal mass malignancy was first assessed with each modality and then with a combination of the three techniques. Final diagnosis was made with histopathologic evaluation.

RESULTS

FDG PET depicted seven of 12 malignant and 66 of 87 benign asymptomatic adnexal tumors. False-negative PET results were obtained in five of seven stage pT1a cystadenocarcinomas and tumors of low malignant potential but not in advanced-stage ovarian carcinomas. Small moderately intense FDG accumulations in the lower pelvis were caused by benign adnexal tumors or gastrointestinal activity in 21 of 27 cases. The overall sensitivities and specificities were 58% (95% CI: 27.7, 84.8) and 76% (95% CI: 65.5, 84.4), respectively, for FDG PET; 92% (95% CI: 61.5, 99.8) and 60% (95% CI: 48.7, 70.1), respectively, for US; 83% (95% CI: 51.6, 97.7) and 84% (95% CI: 74.5, 90.9), respectively, for MR imaging; and 92% (95% CI: 61.5, 99.8) and 85% (95% CI: 75.8, 91.8), respectively, for the combination of three modalities.

CONCLUSION

Since the sensitivity of US is as high as that of PET, MR imaging, and the combination of three modalities, it remains the method of choice for diagnosis and assessment of asymptomatic adnexal masses.

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.

Imaging evaluation of ovarian masses

Adnexal masses present a special diagnostic challenge, in part because benign adnexal masses greatly outnumber malignant ones. Determination of a degree of suspicion for malignancy is critical and is based largely on imaging appearance. Endovaginal ultrasonography (US) is the most practical modality for assessment of ovarian tumors because it is readily available and has a high negative predictive value. Morphologic analysis of adnexal masses is accurate for identifying masses as either low risk or high risk. The most important morphologic features are non-fatty solid (vascularized) tissue, thick septations, and papillary projections. Color Doppler US helps identify solid, vascularized components in a mass. Spectral Doppler waveform characteristics (eg, resistive index, pulsatility index) correlate well with malignancy but generally add little information to morphologic considerations. Computed tomography can help assess the extent of disease in patients before and after primary cytoreductive surgery. Magnetic resonance (MR) imaging is better reserved for problem solving when US findings are nondiagnostic or equivocal because, although it is more accurate for diagnosis, it is also more expensive. The signal intensity characteristics of ovarian masses make possible a systematic approach to diagnosis. Mature cystic teratomas, cysts, endometriomas, leiomyomas, fibromas, and other lesions can be accurately diagnosed on the basis of T1-weighted, T2-weighted, and fat-saturated T1-weighted MR imaging findings.

Classification of asymptomatic adnexal masses by ultrasound, magnetic resonance imaging, and positron emission tomography

OBJECTIVE

The purpose of this study was to determine the diagnostic accuracy of sonography versus magnetic resonance imaging (MRI) and positron emission tomography (PET) in the characterization of adnexal masses.

METHODS

One hundred and one patients with asymptomatic adnexal masses, which were scheduled for laparoscopy, underwent preoperative transvaginal ultrasound, MRI, and 2-[(18)F]fluoro-2-deoxy-d-glucose PET. Two different sonomorphological scoring systems were used to distinguish malignant from benign lesions. In addition, transvaginal Doppler flow velocimetry was performed and the resistance index (RI) of ovarian blood vessels was calculated. RI values below 0.45 were considered to indicate malignancy. MRI was evaluated on the basis of signal intensity and morphologic features such as wall thickness, septations, fluid or solid components, and vascularity. PET imaging was used to determine 2-[(18)F]fluoro-2-deoxy-D-glucose uptake. Malignancy was suspected if radiotracer uptake equaled or exceeded that of the liver. Based on histologic findings, sensitivity, specificity, positive and negative predictive values, and accuracy were first calculated independently for each imaging technique. Finally, a second session resulted in a consensus diagnosis being made based on the findings of all three modalities.

RESULTS

Sonographic evaluation of adnexal masses resulted in correct classification of 11 of 12 ovarian malignancies (sensitivity 92%) but with a specificity of only 60%. With MRI and PET, specificities improved to 84 and 80% respectively, but sensitivities decreased. When all imaging modalities were combined, sensitivity and specificity were 92 and 85%, respectively, and accuracy was 86%.

CONCLUSION

Combination of ultrasound with MRI and PET may improve accuracy in differentiation of benign from malignant ovarian lesions. However, negative MRI or PET results do not rule out early-stage ovarian cancer or borderline malignancies.

Is color Doppler ultrasound useful in diagnosing ovarian cancer?

In summary, the emergence of CDUS presented an interesting new technical approach to the study of neovascularization in ovarian cancers. Techniques for CDUS are technically difficult and plagued with artifacts making correct interpretation difficult. Measures of blood flow (such as the resistive index) overlap significantly between ovarian cancers and benign ovarian tumors. Wide differences in estimates of the sensitivity and specificity of CDUS have been published, and fundamental norms such as resistive index also vary greatly among studies. Explanations for these differences are lacking. Most studies were performed in academic centers with referrals of high risk patients. This limits the ability to generalize results to the community. Data are insufficient to include CDUS in diagnostic protocols for ovarian cancer.

Pelvic examination, transvaginal ultrasound and transvaginal color Doppler sonography as predictors of ovarian cancer

OBJECTIVE

To assess and compare the efficacy of pelvic examination, transvaginal ultrasound and transvaginal color Doppler imaging in differentiating benign and malignant ovarian tumors.

METHODS

34 patients with ovarian tumors scheduled for laparotomy underwent pelvic examination and a diagnosis of benign or malignant tumor was made. Transvaginal ultrasound was carried out to study the ovarian morphology followed by color Doppler imaging. A score of > or = 9 on Sassone scoring system or a pulsatility index < 1 was taken as suspicious for malignancy.

RESULTS

Of all the three indicators (pelvic examination, transvaginal sonography and Doppler) transvaginal sonography had the highest sensitivity (100%) and Doppler had maximum specificity (96.29%) for predicting malignancy. However, statistical analysis did not show any difference in the predicting ability of these three modalities.

CONCLUSION

Pelvic examination, transvaginal sonography and Doppler all had similar ability to predict malignancy in an adnexal mass.

Use of colour and spectral Doppler ultrasound examination in gynaecology

Objective: To review and sum up the published literature on gynecological Doppler ultrasound examination. Methods: Publications on gynecological Doppler ultrasound examination already known by the author, publications found in the bibliographic database Medline, and publications found in the reference lists of available studies were read, and relevant information was extracted and summarized. Results: Reference data representative of normal findings at transvaginal color and spectral Doppler ultrasound examination of the uterine and ovarian arteries have been established in healthy pre- and post-menopausal women and in normal early pregnancies. Blood flow velocities in the uterine and ovarian arteries change during the normal menstrual cycle and are very different in pre- and post-menopausal women. Lower blood flow velocities and higher pulsatility index (PI) values have been recorded in the ovarian arteries after the menopause. Uterine artery blood flow velocities increase and uterine artery PI values and resistance index (RI) values decrease with gestational age in the first trimester. There is not yet an established role of the gynecological Doppler ultrasound examination in clinical practice. It remains unclear whether the gynecological Doppler ultrasound examination contributes substantially to the clinical management of early pregnancy complications or infertility problems, to the differential diagnosis of pelvic masses or uterine pathology. Conclusions: Large prospective studies-preferably randomized controled trials-are needed to determine the clinical value of the gynecological Doppler ultrasound examination. Copyright 1997 Elsevier Science Ireland Ltd.

Ovarian vein vs peripheral blood CA125 serum levels: a comparative study

OBJECTIVE

Direct sampling from the ovarian vessels may be considered as a supplementary method of ovarian cancer diagnosis providing further clinical information for the staging and localization of ovarian carcinoma. This present multi-institutional study evaluates and compares the clinical values of CA125 serum levels sampled directly from the right and left ovarian veins to the peripheral blood supply in an effort to correlate CA125 values to tumor volume and location.

METHODS

Serum samples from 43 patients with primary ovarian carcinoma were evaluated for the presence of CA125. All patients underwent surgery for the primary tumor, and stage was defined according to the classification of the International Federation of Gynecology and Obstetrics. The measurement of CA125 was accomplished by radioimmunoassay.

RESULTS

Twenty of 20 patients with serous papillary adenocarcinoma, 8/12 patients with tumors of low malignant potential, 6/6 patients with endometrioid carcinoma, 2/4 patients with clear cell adenocarcinoma, and 1/1 patients with mucinous adenocarcinoma had elevated (>35 U/mL) peripheral CA125 levels. Peripheral blood CA125 values had Spearman correlation coefficients of 0.96 and 0.95 with left and right ovarian vein CA125 values, respectively. Similarly, left and right ovarian vein CA125 values had a correlation coefficient of 0.98. CA125 values were moderately correlated with tumor volume in this sample. Spearman correlation coefficients between left ovarian vein CA125 values and left and right tumor volume were 0.51 and 0.43, respectively. Spearman correlation coefficients between right ovarian vein CA125 levels and left and right tumor volume were 0.41 and 0.46, respectively. Those between peripheral CA125 values and left and right tumor volume were 0.56 and 0.36, respectively. Median CA125 values for stage I diseases were elevated (53.25, 101.5, and 74.50 for left, right, and peripheral, respectively).

DISCUSSION

Direct sampling from the ovarian veins compared to that from the peripheral veins did not appear to offer additional information regarding ovarian tumor volume and location.

Office management of ovarian cysts

Ovarian cysts are detected in female patients of all ages. The patient's age, the size of the cyst, and the ultrasound appearance are helpful in determining which ovarian cysts necessitate observation and which necessitate surgical excision. The cancer antigen 125 level alone does not help to distinguish between benign and malignant ovarian cysts. The combination of benign findings on pelvic examination, a benign ultrasound appearance, and a cancer antigen 125 level within normal limits indicates a benign origin in practically all cases.