Sonographic features of ovarian cystadenofibromas: spectrum of findings

A Case Report of Comprehensive Diagnostic Approach on a Complex Left Adnexal Mass in a Young Female: Endometrioma or Complicated Ovarian Serous Cystadenofibroma

This case report presents a young female who was clinically, radiologically, and intraoperatively misdiagnosed as an ovarian endometrioma and was only diagnosed by histopathological biopsy as complicated serous cystadenofibroma, a rare benign tumor composed of both glandular and fibrous tissue. The diagnosis of adenofibroma typically involves a combination of imaging studies, such as ultrasound or magnetic resonance imaging (MRI) scan, and a histopathological biopsy to confirm the presence of the tumor. This case underscores the significance of utilizing various diagnostic methods and histopathological biopsies to diagnose and treat complex adnexal masses in females accurately.

Application of Ultrasound Scores (Subjective Assessment, Simple Rules Risk Assessment, ADNEX Model, O-RADS) to Adnexal Masses of Difficult Classification

BACKGROUND

Ultrasound features help to differentiate benign from malignant masses, and some of them are included in the ultrasound (US) scores. The main aim of this work is to describe the ultrasound features of certain adnexal masses of difficult classification and to analyse them according to the most frequently used US scores.

METHODS

Retrospective studies of adnexal lesions are difficult to classify by US scores in women undergoing surgery. Ultrasound characteristics were analysed, and masses were classified according to the Subjective Assessment of the ultrasonographer (SA) and other US scores (IOTA Simple Rules Risk Assessment-SRRA, ADNEX model with and without CA125 and O-RADS).

RESULTS

A total of 133 adnexal masses were studied (benign: 66.2%, n:88; malignant: 33.8%, n:45) in a sample of women with mean age 56.5 ± 7.8 years. Malignant lesions were identified by SA in all cases. Borderline ovarian tumors (n:13) were not always detected by some US scores (SRRA: 76.9%, ADNEX model without and with CA125: 76.9% and 84.6%) nor were serous carcinoma (n:19) (SRRA: 89.5%), clear cell carcinoma (n:9) (SRRA: 66.7%) or endometrioid carcinoma (n:4) (ADNEX model without CA125: 75.0%). While most teratomas and serous cystadenomas have been correctly differentiated, other benign lesions were misclassified because of the presence of solid areas or papillae. Fibromas (n:13) were better identified by SA (23.1% malignancy), but worse with the other US scores (SRRA: 69.2%, ADNEX model without and with CA125: 84.6% and 69.2%, O-RADS: 53.8%). Cystoadenofibromas (n:10) were difficult to distinguish from malignant masses via all scores except SRRA (SA: 70.0%, SRRA: 20.0%, ADNEX model without and with CA125: 60.0% and 50.0%, O-RADS: 90.0%). Mucinous cystadenomas (n:12) were misdiagnosed as malignant in more than 15% of the cases in all US scores (SA: 33.3%, SRRA: 16.7%, ADNEX model without and with CA125: 16.7% and 16.7%, O-RADS:41.7%). Brenner tumors are also difficult to classify using all scores.

CONCLUSION

Some malignant masses (borderline ovarian tumors, serous carcinoma, clear cell carcinoma, endometrioid carcinomas) are not always detected by US scores. Fibromas, cystoadenofibromas, some mucinous cystadenomas and Brenner tumors may present solid components/papillae that may induce confusion with malignant lesions. Most teratomas and serous cystadenomas are usually correctly classified.

Ultrasound Features and Ultrasound Scores in the Differentiation between Benign and Malignant Adnexal Masses

BACKGROUND

Several ultrasound (US) features help ultrasound experts in the classification of benign vs. malignant adnexal masses. US scores serve in this differentiation, but they all have misdiagnoses. The main objective of this study is to evaluate what ultrasound characteristics are associated with malignancy influencing ultrasound scores.

METHODS

This is a retrospective analysis of ultrasound features of adnexal lesions of women managed surgically. Ultrasound characteristics were analyzed, and masses were classified by subjective assessment of the ultrasonographer (SA) and other ultrasound scores (IOTA Simple Rules Risk Assessment SRRA, ADNEX model, and O-RADS).

RESULTS

Of a total of 187 adnexal masses studied, 134 were benign (71.7%) and 53 were malignant (28.3%). SA, IOTA SRRA, ADNEX model with or without CA125 and O-RADS had high levels of sensitivity (93.9%, 81.1%, 94.3%, 88.7%, 98.1%) but lower specificity (80.2%, 82.1%, 82.8%, 77.6%, 73.1%) with similar AUC (0.87, 0.87, 0.92, 0.90, 0.86). Ultrasound features significantly related with malignancy were the presence of irregular contour, absence of acoustic shadowing, vascularized solid areas, ≥1 papillae, vascularized septum, and moderate-severe ascites.

CONCLUSION

IOTA SRRA, ADNEX model, and O-RADS can help in the classification of benign and malignant masses. Certain ultrasound characteristics studied in ultrasound scores are associated with malignancy.

Ultrasound Characteristics of Cystadenofibromas: A Retrospective Multicenter Study

ABSTRACT

Cystadenofibromas (CAFs) are relatively rare benign ovarian tumors. This study was to describe the ultrasound (US) findings of CAFs. Preoperative US information of 86 CAFs was retrospectively collected. To better illustrate their characteristic, 173 cystadenomas (CADs), 103 borderline ovarian tumors (BOTs), and 129 cystadenocarcinomas (CACs) were recruited as match groups. Besides morphology evaluation, tumors were categorized by the Ovarian-Adnexal Reporting and Data System US system. Higher-risk stratification in CAFs was more often being seen than CADs (63% of CAFs classified as Ovarian-Adnexal Reporting and Data System 4 or 5 vs 35% in CADs). Cystadenofibromas more commonly appeared as unilocular or multilocular solid than CADs. Solid components presented in 59% of CAFs and papillary projections presented in 45%. More CAFs contained solid components and papillary projections than CADs (P < 0.0001). When compared with BOTs and CACs, less CAFs contained solid components (P < 0.017 and P < 0.0001). However, no significant difference was found in CAFs versus BOTs or CACs about the presence of papillary projections. Shadowing was identified in 58% of CAFs; however, in CADs, BOTs, and CACs, the proportion was 2%, 11%, and 11%, respectively. Presence of shadowing in CAFs was noticeably more than CADs, BOTs, and CACs (P < 0.017 or P < 0.0001). Similar to CADs, most CAFs were avascular (76%) and without ascites (99%), which were significantly different from BOTs and CACs. We concluded that the sonographic markers for CAFs that differ from malignant were presence of shadowing, avascular, and absence of ascites.

Sonographic Evaluation of Serous Cystadenofibroma With Evidence of Intermittent Torsion

Serous cystadenofibromas are benign surface epithelial stromal tumors of the ovary. Many of the sonographic features of serous cystadenofibromas mimic what are traditionally considered possible characteristics of malignancy. Depending on the size of the ovarian neoplasm, there can be increased risk for ovarian torsion. Meticulous sonographic evaluation and appropriate optimization are critical for establishing the risk for malignancy and likelihood of torsion. This case describes how sonography was used to help identify a serous cystadenofibroma in a postmenopausal woman.

Tumor-to-Tumor Metastasis of Colorectal Adenocarcinoma to Ovarian Cystadenofibroma: A Case Report and Review of the Literature

Tumor-to-tumor metastasis is being described in different types of tumors and in increasing amount of cases. Being aware of this phenomenon is important, as it affects disease stage and treatment approach. In this report, we descried an incidental histopathologic finding of metastatic adenocarcinoma to an ovarian cystadenofibroma and review cases published previously in the literature.

Microcystic pattern and shadowing are independent predictors of ovarian borderline tumors and cystadenofibromas in ultrasound

OBJECTIVES

To determine the sonographic characteristics of borderline tumors (BoTs) and cystadenofibromas (CAFs).

METHODS

Preoperative sonograms from consecutive patients who had at least one primary epithelial tumor in the adnexa were retrospectively collected. All tumors were described using the International Ovarian Tumor Analysis terminology. Ultrasound variables were tested using multinomial logistic regression after univariate analysis.

RESULTS

A total of 650 patients were included in this study. Of these, 110 had a CAF, 128 had a BoT, 249 had a cystadenoma (CAD), and 163 had a cystadenocarcinoma (CAC). Nearly half of CAFs and more than half of BoTs and CACs appeared to be unilocular and multilocular solid on the ultrasound images, while CADs were predominantly uni- or multilocular (p < 0.001). Overall, shadowing was identified in 82/650 cases. Sixty-five of 110 (59.1%) CAFs exhibited an acoustic shadow, compared with only 4/249 (1.6%) in CADs, 7/128 (5.5%) in BoTs, and 6/163 (3.7%) in CACs (p < 0.001). Furthermore, 112/650 cases demonstrated microcystic pattern (MCP). Sixty-eight of 128 (53.1%) BoTs exhibited MCP, compared with only 5/249 (2.0%) in CADs, 19/163 (11.7%) in CACs, and 20/110 (18.2%) in CAFs (p < 0.001). Logistic regression analysis revealed that shadowing is an independent predictor of CAFs, while MCP is an independent predictor of BoTs.

CONCLUSIONS

Sonographic findings for CAFs and BoTs were complex and partly overlapped with those for CACs. However, proper recognition and utilization of shadowing or MCP may help to correctly discriminate CAFs and BoTs.

KEY POINTS

• Sonographic findings for borderline tumors and cystadenofibromas are complex and mimic malignancy. • Microcystic pattern and shadowing are independent predictors of borderline tumors and cystadenofibromas respectively.

Coexistence of ovarian serous papillary cystadenofibroma and type A insulin resistance syndrome in a 14-year-old girl: A case report

BACKGROUND

Type A insulin resistance syndrome is a rare disorder caused by mutations in the gene encoding the insulin receptor. Its coexistence with ovarian serous papillary cystadenofibroma is even rarer.

CASE SUMMARY

A 14-year-old girl developed type A insulin resistance syndrome and showed high fasting insulin, glucose, and hemoglobin A1c (HbA1c) levels. The girl suffered from ovarian serous papillary cystadenofibroma. The laboratory results were as follows: fasting insulin was 2624.90 pmol/L and HbA1c was 8.5%. A heterozygous missense mutation on exon 20 of the insulin receptor gene (c.3601C>T, Arg1201Trp) was observed. The histopathological diagnosis was a cystic lesion that extended to the upper right uterus, indicating a right ovarian serous papillary cystadefibroma accompanied by focal interstitial hyperplasia. The patient was treated with metformin for over 6 mo. Additionally, laparoscopic resection (bilateral) of the ovarian lesion and laparoscopic intestinal adhesiolysis were performed under general anesthesia. Diet therapy combined with exercise was then initiated. The patient had an uneventful recovery. The patient also showed improved blood glucose control, with reduced levels of fasting insulin (857.84 pmol/L) and HbA1c (7.0%).

CONCLUSION

Insulin resistance may play a significant role in the induction of tumors. It is important to investigate further the association between insulin resistance and tumors and the underlying mechanism.

Borderline serous ovarian neoplasm: case report of a diagnostic challenge in intraoperative frozen sections

Surface epithelial tumors of the ovary account for 25% of all ovarian neoplasms. When composed predominantly of fibrous stroma, with glands and cysts forming a minor component, their appearance on imaging is often complex; cystic- to solid-appearing masses often raise suspicion of a malignant tumor. An accurate frozen histopathological diagnosis of a benign cystadenofibroma of this tumor can facilitate appropriate surgical management. However, it is equally important to diagnose areas of borderline changes/malignancy arising in these tumors, particularly when large or complex surface and inner papillary areas with multilayering or stratification are seen microscopically. We present here a case of bilateral complex ovarian mass in a 68-year-old woman, which was equivocal for malignancy on radiology, per operative gross examination as well as on frozen section evaluation. It was finally diagnosed as a borderline serous tumor (BOT) in a cystadenofibroma on histopathological examination.

•

Borderline tumors among surface epithelial tumors with a prominent stromal component are uncommon.

•

Adhesions & bilaterality with a prominent stromal component result in radiological interpretation of a complex ovarian mass.

•

The Risk of Malignancy Index is usually <200 if the CA125 is low.

•

Intraoperative surgical decisions are based on frozen section examination which are challenging.

•

A benign tumor diagnosis may results in inadequate surgery, additional interventions later and possible tumor spread.

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.

Imaging in gynecological disease (16): clinical and ultrasound characteristics of serous cystadenofibromas in adnexa

OBJECTIVE

To describe the clinical and ultrasound characteristics of serous cystadenofibromas in the adnexa.

METHODS

This was a retrospective study of patients identified in the International Ovarian Tumor Analysis (IOTA) database, who had a histological diagnosis of serous cystadenofibroma and had undergone preoperative ultrasound examination by an experienced ultrasound examiner, between 1999 and 2012. In the IOTA database, which contains data collected prospectively, the tumors were described using the terms and definitions of the IOTA group. In addition, three authors reviewed, first independently and then together, ultrasound images of serous cystadenofibromas and described them using pattern recognition.

RESULTS

We identified 233 women with a histological diagnosis of serous cystadenofibroma. In the IOTA database, most cystadenofibromas (67.4%; 157/233) were described as containing solid components but 19.3% (45/233) were described as multilocular cysts and 13.3% (31/233) as unilocular cysts. Papillary projections were described in 52.4% (122/233) of the cystadenofibromas. In 79.5% (97/122) of the cysts with papillary projections, color Doppler signals were absent in the papillary projections. Most cystadenofibromas (83.7%; 195/233) manifested no or minimal color Doppler signals. On retrospective analysis of 201 ultrasound images of serous cystadenofibromas, using pattern recognition, 10 major types of ultrasound appearance were identified. The most common pattern was a unilocular solid cyst with one or more papillary projections, but no other solid components (25.9%; 52/201). The second most common pattern was a multilocular solid mass with small solid component(s), but no papillary projections (19.4%; 39/201). The third and fourth most common patterns were multi- or bilocular cyst (16.9%; 34/201) and unilocular cyst (11.9%; 24/201). Using pattern recognition, shadowing was identified in 39.8% (80/201) of the tumors, and microcystic appearance of the papillary projections was observed in 34 (38.6%) of the 88 tumors containing papillary projections.

CONCLUSIONS

The ultrasound features of serous cystadenofibromas vary. The most common pattern is a unilocular solid cyst with one or more papillary projections but no other solid components, with absent color Doppler signals. Most serous cystadenofibromas were poorly vascularized on color Doppler examination and many manifested acoustic shadowing. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Ultrasound and Histopathologic Correlation of Ovarian Cystadenofibromas: Diagnostic Value of the "Shadow Sign"

OBJECTIVES

Cystadenofibromas (CAFs) are rare benign ovarian tumors without a widely accepted ultrasound (US) pattern. They are usually described by as thin-walled, unilocular or multilocular, and at times septated cysts with scant blood flow and no solid components. We describe a unique US feature, the "shadow sign," seen in prospectively diagnosed benign CAFs. We also provide the histopathologic basis for this typical US appearance.

METHODS

Ultrasound (US) examinations were performed in our obstetric and gynecologic US unit. Pathologic examinations were performed by a dedicated gynecologic pathology team. The US and pathology department's database was searched for the diagnosis of a CAF between 2010 and 2017.

RESULTS

We identified 20 patients who underwent transvaginal US examinations with a sole US diagnosis of a CAF, and the tumors were surgically removed. The common US feature across the 20 cases was the presence of hyperechoic avascular shadowing nodules. The correlating histologic features were unilocular or multilocular cysts with a smooth internal wall surface lined by a simple epithelium and occasional robust polypoid fibrous stroma.

CONCLUSIONS

This US marker helps in differentiating CAFs from borderline ovarian tumors, which do not show this US feature. We hope that recognizing the suggested shadow sign as an additional descriptor of CAFs will lead to minimizing their unnecessary removal and eliminating additional and unnecessary imaging by computed tomography and magnetic resonance imaging.

Autoantibodies against HSF1 and CCDC155 as Biomarkers of Early-Stage, High-Grade Serous Ovarian Cancer

Background: Tumor-directed circulating autoantibodies (AAb) are a well-established feature of many solid tumor types, and are often observed prior to clinical disease manifestation. As such, they may provide a good indicator of early disease development. We have conducted a pilot study to identify novel AAbs as markers of early-stage HGSOCs.Methods: A rare cohort of patients with early (FIGO stage Ia-c) HGSOCs for IgG, IgA, and IgM-mediated AAb reactivity using high-content protein arrays (containing 9,184 individual proteins). AAb reactivity against selected antigens was validated by ELISA in a second, independent cohort of individual patients.Results: A total of 184 antigens were differentially detected in early-stage HGSOC patients compared with all other patient groups assessed. Among the six most highly detected "early-stage" antigens, anti-IgA AAbs against HSF1 and anti-IgG AAbs CCDC155 (KASH5; nesprin 5) were significantly elevated in patients with early-stage malignancy. Receiver operating characteristic (ROC) analysis suggested that AAbs against HSF1 provided better detection of early-stage malignancy than CA125 alone. Combined measurement of anti-HSF1, anti-CCDC155, and CA125 also improved efficacy at higher sensitivity.Conclusions: The combined measurement of anti-HSF1, anti-CCDC155, and CA125 may be useful for early-stage HGSOC detection.Impact: This is the first study to specifically identify AAbs associated with early-stage HGSOC. The presence and high frequency of specific AAbs in early-stage cancer patients warrants a larger scale examination to define their value for early disease detection at primary diagnosis and/or recurrence. Cancer Epidemiol Biomarkers Prev; 27(2); 183-92. ©2017 AACR.

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.

Cystadenofibromas: Can transvaginal ultrasound appearance reduce some surgical interventions?

PURPOSE

Cystadenofibromas are benign ovarian neoplasms. Their most typical features on sonography (US) are unilocular cysts with small, shadowing hyperechoic, solid papillae without internal vascularity. In the past, they were virtually always surgically removed to exclude malignancy. This study was undertaken to review the sonographic appearances of benign cystadenomas.

METHODS

We retrospectively reviewed the transvaginal US studies of 32 cases of pathologically proven ovarian cystadenofibromas.

RESULTS

Twenty-two of the tumors presented as unilocular cystic structures with one or more solid, hyperechoic, shadowing, mural nodules with no discernible blood flow projecting from the inner cyst wall. Ten lesions were multiloculated with multiple small solid areas, with scant or no blood vessels.

CONCLUSIONS

Cystadenofibromas do not always have a classic appearance on transvaginal US and color Doppler imaging. In our series, however, the majority (69%) presented as unilocular cysts with one or more small solid, avascular projections from the inner cyst wall. These features had 100% reliability for a diagnosis of benign cystadenofibroma in this small series. Further study is necessary to confirm the reliability of this finding for benign cystadenofibroma, thus possibly avoiding or minimizing any surgical exploration.

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.

The characteristic ultrasound features of specific types of ovarian pathology (review)

Characterizing ovarian masses enables patients with malignancy to be appropriately triaged for treatment by subspecialist gynecological oncologists, which has been shown to optimize care and improve survival. Furthermore, correctly classifying benign masses facilitates the selection of patients with ovarian pathology that may either not require intervention, or be suitable for minimal access surgery if intervention is required. However, predicting whether a mass is benign or malignant is not the only clinically relevant information that we need to know before deciding on appropriate treatment. Knowing the specific histology of a mass is becoming of increasing importance as management options become more tailored to the individual patient. For example predicting a mucinous borderline tumor gives the opportunity for fertility sparing surgery, and will highlight the need for further gastrointestinal assessment. For benign disease, predicting the presence of an endometrioma and possible deeply infiltrating endometriosis is important when considering both who should perform and the extent of surgery. An examiner’s subjective assessment of the morphological and vascular features of a mass using ultrasonography has been shown to be highly effective for predicting whether a mass is benign or malignant. Many masses also have features that enable a reliable diagnosis of the specific pathology of a particular mass to be made. In this narrative review we aim to describe the typical morphological features seen on ultrasound of different adnexal masses and illustrate these by showing representative ultrasound images.

Large functional benign endometroid cystadenofibroma of the ovary leading to endometrial cystic glandular hyperplasia and postmenopausal bleeding

Benign endometroid cystadenofibroma of the ovary is a rare tumour with few reported cases. The association of endometroid cystadenofibroma with endometrial cystic glandular hyperplasia has not been previously reported to authors' knowledge. We are reporting a 75-year-old postmenopausal woman who presented with a large abdominopelvic mass corresponding to 30 weeks size gravid uterus and postmenopausal bleeding. She has a well-oestrogenised vagina. Ultrasound pelvis revealed a large cystic mass extending from pelvis to epigastrium with no solid component and few incomplete septations and no internal echoes. MRI findings showed mainly cystic component with few moderately enhancing, fine, incomplete septa. Endometrial aspiration reported histopathology of cystic glandular hyperplasia without atypia. Serum oestrogen level reported to be high (210 pg/mL). Hysterectomy with bilateral salpingo-oophorectomy was performed. Histopathology of the specimen revealed benign endometroid cystadenofibroma. She remained asymptomatic and disease free during her 6-month follow-up.

Peri- and post-menopausal incidental adnexal masses and the risk of sporadic ovarian malignancy: new insights and clinical management

Adnexal masses are common among peri- and post-menopausal women. Although ovarian cancer is a significant cause of mortality in menopausal women, large population-based studies demonstrate that the majority of adnexal masses are benign. Despite this, the appearance of an adnexal mass is a concern for the patient and an insight exercise for physicians. In most cases, an adnexal enlargement is an incidental finding, generally corresponding to a benign cyst and easily diagnosed by conventional ultrasound. Exceptionally an ovarian tumour may be malignant and should be treated as early as possible. When conventional ultrasound renders complex morphology other diagnostic tools must be used such as: colour Doppler and functional tumour vessel properties, serum CA 125 levels, nuclear magnetic resonance imaging and in some cases laparoscopy. Several new tumour markers are being studied for clinical application, although there are presently no clear recommendations. Adnexal masses with benign morphological and functional properties must be periodically monitored as an alternative to surgery since malignant transformation is exceptional.

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.

Gynecologic imaging reporting and data system: a new proposal for classifying adnexal masses on the basis of sonographic findings

OBJECTIVE

The purpose of this study was to describe a new reporting system called the Gynecologic Imaging Reporting and Data System (GI-RADS) for reporting findings in adnexal masses based on transvaginal sonography.

METHODS

A total of 171 women (mean age, 39 years; range, 16-77 years) suspected of having an adnexal mass were evaluated by transvaginal sonography before treatment. Pattern recognition analysis and color Doppler blood flow location were used for determining the presumptive diagnosis. Then the GI-RADS was used, with the following classifications: GI-RADS 1, definitively benign; GI-RADS 2, very probably benign; GI-RADS 3, probably benign; GI-RADS 4, probably malignant; and GI-RADS 5, very probably malignant. Patients with GI-RADS 1 and 2 tumors were treated expectantly. All GI-RADS 3, 4, and 5 tumors were removed surgically, and a definitive histologic diagnosis was obtained. The GI-RADS classification was compared with final histologic diagnosis.

RESULTS

A total of 187 masses were evaluated. The prevalence rate for malignant tumors was 13.4%. Overall GI-RADS classification rates were as follows: GI-RADS 1, 4 cases (2.1%); GI-RADS 2, 52 cases (27.8%); GI-RADS 3, 90 cases (48.1%); GI-RADS 4, 13 cases (7%); and GI-RADS 5, 28 cases (15%). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 92%, 97%, 85%, 99%, and 96%, respectively.

CONCLUSIONS

Our proposed reporting system showed good diagnostic performance. It is simple and could facilitate communication between sonographers/sonologists and clinicians.

Is expectant management of sonographically benign adnexal cysts an option in selected asymptomatic premenopausal women?

BACKGROUND

The objective was to assess whether expectant management of sonographically benign ovarian cysts may be an option for selected asymptomatic premenopausal women.

METHODS

This is a prospective observational longitudinal study. Between January 1997 and December 2002, 323 asymptomatic premenopausal women (mean age: 40.6 years; range: 19-50 years) diagnosed as having a sonographically benign ovarian cyst measuring <6 cm were offered conservative management with periodic follow-up at 6-12 month intervals. In all cases, a first check was performed 3 months after diagnosis to confirm the 'persistent' nature of the cyst. A total of 120 women agreed to participate in this study and constitute the basis of the data presented.

RESULTS

Mean diameter at diagnosis for the most frequent lesions were as follows: endometrioma 3.3 cm (SD 1.5); simple cyst 4.1 cm (SD 1.6); dermoid cyst 3.2 cm (SD 1.4); haemorrhagic cyst 3.5 cm (SD 1.2); hydrosalpinx 2.9 cm (SD 1.0). With a median follow-up of 42 months (range: 18-94 months), most lesions remained unchanged, both in size and sonographic appearance. Ten cysts (8.3%) disappeared during follow-up, all of them after more than 2 years of follow-up. No patient has developed signs or symptoms suggesting ovarian cancer.

CONCLUSION

Most sonographically benign ovarian cysts remain unchanged during long-term follow-up. Our data would support conservative management in these cases.

Three-dimensional power Doppler vascular sampling: a new method for predicting ovarian cancer in vascularized complex adnexal masses

OBJECTIVE

The purpose of this study was to explore the role of a new concept ("vascular sampling") as a third step to discriminate benign and malignant lesions in B-mode and color Doppler sonographically suggestive adnexal masses.

METHODS

Forty-five women (mean age, 52.3 years; range, 17-82 years) with the diagnosis of complex adnexal masses on B-mode sonography were evaluated using 3-dimensional power Doppler sonography. Four women had bilateral masses. After a morphologic reevaluation was done, color pulsed Doppler sonography was used to obtain flow velocity waveforms, and velocimetric indices were calculated (resistive index, pulsatility index, and peak systolic velocity). Thereafter, 3-dimensional power Doppler sonography was used to assess vascularization of highly suggestive areas (gross papillary projections, solid areas, and thick septations), meaning a focused assessment ("sampling") of a suggestive area of the tumor. With a virtual organ computer-aided analysis program, vascular indices (vascularization index, flow index, and vascular flow index) were automatically calculated. A definitive histologic diagnosis was obtained in each case.

RESULTS

Forty masses (82%) were malignant and 9 (18%) were benign. Morphologic evaluation revealed 10 (20%) unilocular solid masses, 20 (41%) multilocular solid masses, and 19 (39%) mostly solid masses. Blood flow was found in all cases. Median vascularization index (15.5% versus 8.2%; P = .002), flow index (33.6 versus 20.8; P = .007), and vascular flow index (5.2 versus 2.3; P = .001) were significantly higher in malignant tumors. No differences were found in resistive index (0.43 versus 0.45; P = .770), pulsatility index (0.62 versus 0.65; P = .694), and peak systolic velocity (15.6 versus 12 cm/s; P = .162).

CONCLUSIONS

Three-dimensional power Doppler vascular sampling seems to be a promising tool for predicting ovarian cancer in vascularized complex adnexal masses. It could be better than conventional color pulsed Doppler imaging.

Preoperative sonographic features of borderline ovarian tumors

OBJECTIVE

To determine the sonographic findings that distinguish borderline ovarian tumors (BOT) from both benign and invasive malignant tumors, thus allowing conservative treatment and laparoscopic management of these tumors.

METHODS

We reviewed retrospectively transvaginal sonograms of 33 women who, when evaluated further by surgery and histology, were found to have BOT. Twenty-three were premenopausal and 10 were postmenopausal (mean age +/- SD, 45.8 +/- 15.7 years). For each mass, size and morphological features and power Doppler characteristics were evaluated. We compared these findings with those of 337 patients with benign ovarian tumors and those of 82 patients with invasive malignant ovarian tumors. Patients with dermoid cysts were not included in the study.

RESULTS

Of the 33 BOT, 15 were mucinous and 18 were serous cystadenomas. The presence of papillae, defined as a small number of solid tissue projections, 1-15 mm in height and 1-10 mm in width (base) and length (base), into the cyst cavity from the cyst wall, was significantly more frequent in BOT (48%) than it was in benign (4%) and invasive (4%) malignant tumors. Intracystic solid tissue (> 15 mm in height or > 10 mm in width or length) was observed in 48% of invasive malignant masses but in only 18% of BOT and in 7% of benign tumors (P < 0.001). No sonographically unilocular, hypoechoic, smooth-walled adnexal cysts were invasively malignant but three unilocular cysts with a diameter of > 6 cm were serous BOT. Although close attention was paid to the cyst wall at ultrasound examination we did not observe in these three cysts the very small papillae which were found at histological analysis.

CONCLUSIONS

The most frequent diagnostic feature on imaging BOT is the presence of papillae within the cyst. However, neither papillae nor other sonographic features constituted highly sensitive sonographic markers of BOT.

CT and MRI findings of cystadenofibromas of the ovary

The aim of this study was to assess imaging findings on CT or MR images of histologically proven ovarian cystadenofibromas. In the period 1995-2001, 32 histologically proven ovarian cystadenofibromas were identified in 28 women. Of the 32 ovarian cystadenofibromas, 16 tumors were purely cystic and the remaining 16 were complex cystic on CT or MR images. Solid components of 16 complex cystic tumors were seen as nodular ( n=8) or trabecular ( n=9) solid areas. One tumor had both nodular and trabecular solid components. Among 16 complex cystic tumors, 14 had thick or irregular septa; thus, half of ovarian cystadenofibromas had morphological imaging features of malignancy on CT or MR images. On histology, solid components in the cystic tumors were correlated with fibrous stromas that occasionally made a false-positive result for malignancy on imaging.

Three-dimensional sonographic morphologic assessment in complex adnexal masses: preliminary experience

OBJECTIVE

To evaluate the role of three-dimensional transvaginal sonography in assessing complex adnexal masses.

METHODS

Forty-one women (mean age, 49.5 years; range, 23-75 years) with the diagnosis of complex adnexal masses on the basis of two-dimensional transvaginal sonography were reevaluated by three-dimensional transvaginal sonography. Two different sonologists evaluated the two- and three-dimensional transvaginal sonograms. Criteria indicative of malignancy included the presence of gross papillary projections, solid areas, and solid echogenicity for both techniques. Three women (7%) had bilateral masses, giving a total of 44 masses that were ultimately assessed. A definitive histologic diagnosis was obtained in every case after surgical tumor removal.

RESULTS

Twenty-one tumors (47.7%) were proved malignant, and 23 (52.3%) were benign. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for two- and three-dimensional transvaginal sonography were 90%, 61%, 68%, 87%, and 75% and 100%, 78%, 81%, 100%, and 89%, respectively. There were no statistical differences between two- and three-dimensional transvaginal sonography (McNemar test, P = .687). The agreement between both examiners was high (kappa index = 0.71).

CONCLUSIONS

The use of three-dimensional transvaginal sonography does not significantly improve the two-dimensional transvaginal sonographic morphologic assessment of complex adnexal masses; however, we found it useful for reinforcing initial diagnostic impressions.