Ultrasound Image Discrimination between Benign and Malignant Adnexal Masses Based on a Neural Network Approach

The discrimination between benign and malignant adnexal masses in ultrasound images represents one of the most challenging problems in gynecologic practice. In the study described here, a new method for automatic discrimination of adnexal masses based on a neural networks approach was tested. The proposed method first calculates seven different types of characteristics (local binary pattern, fractal dimension, entropy, invariant moments, gray level co-occurrence matrix, law texture energy and Gabor wavelet) from ultrasound images of the ovary, from which several features are extracted and collected together with the clinical patient age. The proposed technique was validated using 106 benign and 39 malignant images obtained from 145 patients, corresponding to its probability of appearance in general population. On evaluation of the classifier, an accuracy of 98.78%, sensitivity of 98.50%, specificity of 98.90% and area under the curve of 0.997 were calculated.

Agreement between preoperative transvaginal ultrasound and intraoperative macroscopic examination for assessing myometrial infiltration in low-risk endometrioid carcinoma

OBJECTIVE

To compare diagnostic performance of preoperative transvaginal ultrasound (TVS) and intraoperative macroscopic examination for determining myometrial infiltration in women with low-risk endometrial cancer, and to estimate the agreement between the two methods.

METHODS

This was a single-center observational study comprising women with preoperative diagnosis of well- or moderately differentiated endometrioid carcinoma of the endometrium. All women underwent preoperative TVS by a single examiner. According to the examiner's subjective impression, myometrial infiltration was stated as ≥ 50% or < 50%. Surgical staging was performed in all cases. Intraoperative macroscopic examination of the removed uterus was performed by pathologists who were unaware of the ultrasound findings, and myometrial infiltration was stated as ≥ 50% or < 50%. Definitive histological diagnosis of myometrial infiltration was made by frozen section analysis and was used as the gold standard. Sensitivity and specificity with 95% CIs were calculated for TVS and intraoperative macroscopic inspection and compared using McNemar's test. Agreement between TVS and intraoperative macroscopic inspection was estimated using Cohen's kappa index (κ) and percentage of agreement.

RESULTS

Of 209 eligible women, 152 were ultimately included. Mean (± SD) age was 60.9 ± 10.2 years, with a range of 32-91 years. Definitive histological diagnosis revealed that myometrial infiltration was < 50% in 114 women and ≥ 50% in 38 women. Sensitivity and specificity of TVS for detecting deep myometrial infiltration were 81.6% and 89.5%, respectively, whereas the respective values for intraoperative macroscopic examination were 78.9% and 90.4% (McNemar's test, P > 0.05 when comparing TVS and intraoperative macroscopic examination). Agreement between methods was moderate with κ = 0.54 (95% CI, 0.39-0.69) and percentage of agreement of 82%.

CONCLUSIONS

Although the agreement between preoperative TVS and intraoperative macroscopic examination for detecting deep myometrial infiltration was only moderate, both methods had similar accuracy when compared with frozen section histology. Preoperative TVS might reasonably be proposed as a method for assessing myometrial infiltration as an alternative to intraoperative macroscopic examination, especially when performed by an experienced examiner and image quality is not poor. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Transvaginal/transrectal ultrasound for preoperative identification of high-risk cases in well- or moderately differentiated endometrioid carcinoma

OBJECTIVE

To evaluate the role of transvaginal/transrectal ultrasound for preoperative identification of high-risk cases among women with well-differentiated (G1) or moderately differentiated (G2) endometrioid carcinoma of the endometrium.

METHODS

This was a single-center prospective observational cohort study comprising a consecutive series of women with a preoperative diagnosis of G1/G2 endometrioid carcinoma of the endometrium. All women underwent transvaginal or transrectal ultrasound examination by a single examiner. According to the examiner's subjective impression, patients were considered high risk if myometrial infiltration was ≥ 50% and/or involvement of the cervix and/or adnexa was suspected. FIGO surgical staging was performed in all cases. According to definitive histological data regarding myometrial infiltration, cervical involvement and adnexal involvement, women were classified as low risk (no myometrial infiltration, no cervical involvement and no adnexal involvement) or high risk (myometrial infiltration ≥ 50% and/or cervical involvement and/or adnexal involvement). Sensitivity, specificity and positive (LR+) and negative (LR-) likelihood ratios, with 95% CIs, of transvaginal/transrectal ultrasound for detecting stage ≥ IB were calculated. Agreement between risk determined by transvaginal/transrectal ultrasound and postoperative definitive histology was calculated.

RESULTS

Of 209 eligible women, 169 were included in the study. Mean (± SD) age of the study cohort was 60.7 ± 10.3 years, with a range of 32-91 years. Sensitivity, specificity, LR+ and LR- of transvaginal/transrectal ultrasound identifying high-risk cases according to myometrial infiltration, cervical involvement and adnexal involvement were 78.0% (95% CI, 63.7-88.0%), 89.1% (95% CI, 81.7-93.8%), 7.14 (95% CI, 4.19-12.18) and 0.25 (95% CI, 0.15-0.42), respectively.

CONCLUSIONS

Preoperative transvaginal/transrectal ultrasound may play a significant role in identifying high-risk cases among those with G1/G2 endometrioid carcinoma of the endometrium according to preoperative biopsy, and could be a useful test in this clinical setting. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

[First trimester screening of late-onset preeclampsia in a low risk and low volume obstetrical setting: external validation of a predictive model]

BACKGROUND

The external validation of predictive model of late preeclampsia in a low volume and low risk obstetrical setting.

METHODS

A cohort was created of 174 singleton pregnancies of 11+0-13+6 gestational weeks at Clinica Universidad Navarra from September 2011 to March 2013, which was considered as a validation cohort of a previously described model for late PE (Hospital Clinic, Barcelona).

RESULTS

A total of 7 (4%) women developed late PE. In the validation cohort the area under the curve of the model was 0.69 (95% CI 0.45-0.93). Detection rates for a 5, 10 and 15% of false positive rates were 21.9, 31.4% and 38.6% respec-tively. When comparing the areas under the curve of the validation cohort with the construction cohort, no statistical differences were found (p=0.68).

CONCLUSION

The combination of maternal history, pregnancy associated plasma protein-A and mean arterial pressure is moderately useful to predict preeclampsia in a low risk and low volume obstetrical setting. The predictive model of the Clinic Hospital of Barcelona is a valid tool in predicting late preeclampsia in this setting.

Transvaginal ultrasound for preoperative assessment of myometrial invasion in patients with endometrial cancer: a systematic review and meta-analysis

OBJECTIVE

To review the diagnostic accuracy of transvaginal ultrasound (TVS) in the preoperative detection of deep myometrial infiltration in patients with endometrial cancer, comparing subjective and objective methods.

METHODS

An extensive search was performed in MEDLINE (PubMed) and EMBASE for studies published between January 1989 and December 2014. The eligibility criterion was use of TVS for preoperative assessment of myometrial infiltration by subjective evaluation and/or objective measurements. Objective measurements included, specifically, the approaches of Gordon (ratio of the distance between endometrium-myometrium interface and maximum tumor depth to the total myometrial thickness) and Karlsson (endometrial tumor thickness/anteroposterior uterine diameter ratio), in women with endometrial cancer, using the surgical pathological data as a reference standard. Study quality was assessed using the QUADAS-2 tool.

RESULTS

Our extended search identified a total of 184 citations, among which we examined the full text of 24 articles. Overall pooled sensitivity, specificity, positive likelihood ratio (LR+) and negative likelihood ratio (LR-) of TVS for detecting deep myometrial infiltration were 82% (95% CI, 76-87%), 81% (95% CI, 76-85%), 4.3 (95% CI, 3.6-5.3) and 0.22 (95% CI, 0.16-0.30), respectively. We did not observe differences among the three methods in terms of diagnostic performance. Significant heterogeneity was found for sensitivity and specificity of all three methods (I(2) range, 60.6-95.0). The main limitation was that very few studies compared different approaches in the same set of patients.

CONCLUSION

Diagnostic performance of TVS for detecting deep myometrial infiltration in women with endometrial cancer is moderate.

Performance of three-dimensional power Doppler angiography as third-step assessment in differential diagnosis of adnexal masses

OBJECTIVE

To evaluate the contribution of three-dimensional (3D) power Doppler angiography (3D-PDA) to the differential diagnosis of adnexal masses.

METHODS

This was a prospective study in women diagnosed with a persistent adnexal mass and subsequently scheduled for surgery in a tertiary university hospital. All women were evaluated by transvaginal/transrectal ultrasound according to a predetermined three-step protocol, with transabdominal ultrasound being performed in some cases. First, morphological evaluation of the mass was performed using gray-scale 'pattern recognition' (first step). Lesions diagnosed as having a benign pattern were considered as being at low risk of malignancy whereas tumors with solid components, ascites and/or signs of carcinomatosis were considered as being at high risk of malignancy. In both cases no further test was performed and a decision regarding clinical management, either for follow-up or surgery, was taken. Tumors with solid components but without signs of ascites or carcinomatosis were considered as being at intermediate risk of malignancy. These lesions were assessed by two-dimensional (2D) PDA to evaluate tumor vascularity (color score) (second step). Solid tumors with a color score of 1 or 2 were considered as benign and no further test was performed, while tumors with a color score of 2, 3 or 4 within solid components or a color score of 3 or 4 in the case of a solid tumor were considered as malignant. The latter group underwent 3D-PDA assessment (third step). Vascularization index (VI) was calculated in a 1-mL sphere of the most vascularized area of the tumor. When a VI ≥ 24.015% was found, the tumor was considered as malignant. All masses were removed surgically and definitive histological diagnosis was used as the gold standard. Sensitivity and specificity for each strategy were calculated and compared. In the case of bilateral tumors, only the more suspicious one was used for analysis.

RESULTS

A total of 367 adnexal masses diagnosed in 367 women (mean age, 46.5 (range, 18-80) years) were evaluated during the study period. Of these, 86 masses were malignant and 281 were benign. The sensitivity and specificity for each assessment strategy were as follows: one-step, 97.7% and 78.6%; two-step, 94.2% and 97.9% (P < 0.001 for specificity when compared with that of one-step); three-step, 90.7% and 98.9% (not statistically significant when compared with that of two-step).

CONCLUSIONS

The addition of 2D-PDA in the differential diagnosis of an adnexal mass significantly increases specificity while sensitivity remains high; however performing subsequent 3D-PDA does not provide additional information or further improve diagnostic performance subsequent to 2D-PDA.

Interobserver agreement in assigning IOTA color score to adnexal masses using three-dimensional volumes or digital videoclips: potential implications for training

OBJECTIVE

To estimate the interobserver agreement between a trainer and trainees in assigning the International Ovarian Tumor Analysis (IOTA) color score to adnexal masses using three-dimensional (3D) volumes and videoclips.

METHODS

Fifty-one digital videoclips and 3D volumes of a non-consecutive series of adnexal masses were used for this study. One trainer and four trainees evaluated first the 3D volume and 1 week later a videoclip from the same mass. They had to assign IOTA color scores according to their impression of the amount of color content in each case. Interobserver agreement between trainer and trainees was assessed using Cohen's weighted kappa index with 95% CIs and percentage of agreement.

RESULTS

When using 3D volumes, interobserver agreement was good for three out of four pairs of comparisons and very good for one (kappa values of 0.70, 0.68, 0.81 and 0.71 for trainees A, B, C and D, respectively). When using videoclips, interobserver agreement was very good for two out of four pairs of comparisons and good for two (kappa values of 0.84, 0.80, 0.68 and 0.86 for Trainees A, B, C and D, respectively).

CONCLUSION

Evaluation of IOTA color scores in adnexal masses using either videoclips or 3D volumes is reproducible even in the hands of trainees after a short training program.

[Motor behavior of human fetuses during the second trimester of gestation: a longitudinal ultrasound study]

INTRODUCTION

The aim of this research is to contribute to knowledge of the normal spontaneous motor behavior of the human fetus during the second trimester of pregnancy. This study focuses on five patterns of spontaneous fetal movement: startle (S), axo-rhizomelic rhythmia (ARR), axial stretching (AS), general movement (GM), and diaphragmatic contraction (DC).

METHODS

A cohort of 13 subjects was followed up using 2D obstetrical ultrasound images at 12, 16, 20, and 24 weeks of gestation. As inclusion criteria, neonatal neurological examination and general movements after eutocic delivery at term were normal in all of the subjects, and their neuromotor and cognitive development until the end of pre-school age were also normal.

RESULTS

All these five motor patterns are present at the beginning of the 2(nd) gestational trimester, but their quantitative and qualitative traits are diverse according to gestational ages. The phasic, isolated or rhythmically repeated movements, S and ARR, are prominent at 12 and 16 weeks of gestation, and then their presence gradually diminishes. By contrast, tonic and complex AS and GM movements increase their presence and quality at 20 and 24 weeks. RAR constitute a particular periodic motor pattern not described in previous literature. Moreover, the incidence of DC is progressive throughout the trimester, in clusters of 2-6 arrhythmic and irregular beats. Fetal heart rate increases during fetal motor active periods.

CONCLUSIONS

All five normal behavioral patterns observed in the ultrasounds reflect the progressive tuning of motor generators in human nervous system during mid-pregnancy.

Interobserver agreement in describing adnexal masses using the International Ovarian Tumor Analysis simple rules in a real-time setting and using three-dimensional ultrasound volumes and digital clips

OBJECTIVE

To estimate the agreement between an expert and a non-expert examiner using the International Ovarian Tumor Analysis (IOTA) simple rules for classifying adnexal masses on real-time ultrasound and when using three-dimensional (3D) ultrasound volumes and digital clips.

METHODS

Forty-two non-consecutive women diagnosed as having an adnexal mass were evaluated by transvaginal power Doppler ultrasound as part of their diagnostic work-up. In each woman, examination was first performed by a non-expert examiner (a trainee) and immediately afterwards by an expert examiner. Both used the IOTA simple rules to describe the mass, blinded to each other's results. After finishing the examination, each examiner classified the mass as benign, malignant or inconclusive, according to the IOTA simple rules. Additionally, the expert recorded a short videoclip and acquired a static 3D volume of each mass, which were subsequently assessed by four trainees in obstetrics and gynecology with different levels of training, who also classified the mass as benign, malignant or inconclusive according to the IOTA simple rules. Agreement was assessed by calculating weighted and standard kappa index values with 95% CI and the percentage of agreement between observers.

RESULTS

Agreement between the observers who performed real-time ultrasound examination was good (weighted kappa = 0.76; 95% CI, 0.61-0.90; agreement = 78.6%). Agreement between trainees using videoclips plus 3D volumes was moderate (kappa values ranged from 0.45 to 0.58, depending on pair comparison).

CONCLUSION

Interobserver agreement of the IOTA simple rules for classifying adnexal masses as benign, malignant or inconclusive using real-time ultrasound, between an expert and a non-expert examiner, might be considered good. Agreement using a videoclip plus a 3D volume was moderate for trainees with different degrees of training.

Extended transvaginal sonography in deep infiltrating endometriosis: use of bowel preparation and an acoustic window with intravaginal gel: preliminary results

OBJECTIVES

The purpose of this study was to assess the diagnostic performance of extended transvaginal sonography for diagnosing deep infiltrating endometriosis.

METHODS

A prospective study was conducted comprising 51 women (mean age, 32.9 years; range, 23-43 years) with suspected deep infiltrating endometriosis based on clinical symptoms. All women underwent extended transvaginal sonography, which included assessment of 2 pelvic compartments (anterior compartment: bladder and distal ureters; and posterior compartment: posterior vaginal fornix, retrocervical area, pouch of Douglas, and rectosigmoid). The sliding sign for detecting pouch of Douglas obliteration was also assessed. All patients received bowel preparation before sonographic examinations. A single examiner performed all examinations. All women underwent laparoscopic surgery, and histologic confirmation of endometriosis was done. The sensitivity, specificity, positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were calculated.

RESULTS

Some women had more than 1 lesion, giving a total of 55 histologically confirmed lesions (rectosigmoid, n = 13; vagina, n = 5; retrocervical, n = 32; bladder, n = 5). The sensitivity, specificity, and LR+ for rectosigmoid involvement were 100%, 93%, and 14.0, respectively. The sensitivity, specificity, LR+, and LR- for vaginal involvement were 60%, 98%, 30.0, and 0.41. The sensitivity, specificity, LR+, and LR- for retrocervical involvement were 84%, 96%, 19.4, and 0.16. The sensitivity, specificity, and LR- for bladder involvement were 20%, 100%, and 0.80. The sensitivity, specificity, LR+, and LR- of the sliding sign for diagnosing pouch of Douglas obliteration were 89%, 92%, 10.7, and 0.12.

CONCLUSIONS

Except for bladder involvement, extended transvaginal sonography has good diagnostic performance for deep infiltrating endometriosis.

Comparison of two methods for calculating the mean vascularization index of ovarian stroma on the basis of spatio-temporal image correlation high-definition flow technology

The aim of our study was to determine the agreement between two different methods for calculating the mean vascularization index (VI) of ovarian stroma using spatio-temporal image correlation-high definition flow (STIC-HDF) technology. Stored 4-D STIC-HDF volume data for ovaries of 34 premenopausal women were assessed retrospectively. We calculated the mean VI from the VI values derived for each 3-D volume within the STIC sequence. Then, the examiner subjectively selected the two volumes with the highest and lowest color signals, respectively. We averaged these two values. Agreement between VI measurements was estimated by calculating intra-class correlation coefficients. The intra-class correlation coefficient for the VI was 0.999 (95% confidence interval: 0.999-1.000). The mean time needed to calculate the mean VI using the entire 4-D STIC sequence was significantly longer than the mean time needed to calculate the average value from the volumes with the highest and lowest color signals determined by the operator (p < 0001). We conclude that there is significant agreement between the two methods. Calculating the average VI from the highest and lowest values is less time consuming than calculating the mean VI from the complete STIC sequence.

IOTA simple rules for discriminating between benign and malignant adnexal masses: prospective external validation

OBJECTIVE

To determine the diagnostic performance of International Ovarian Tumor Analysis (IOTA) 'simple' rules for discriminating between benign and malignant adnexal masses.

METHODS

A prospective study was performed between January 2011 and June 2012. Eligible patients were women diagnosed with a persistent adnexal mass who presented to the participating centers. Four trainees evaluated the adnexal mass by transvaginal ultrasound under the supervision of an expert examiner. The trainee analyzed the mass according to IOTA simple rules and provided a diagnosis of benign, malignant or inconclusive. All women included in the study underwent surgery and tumor removal in the center of recruitment. Diagnostic performance was assessed by calculating sensitivity, specificity and positive (LR+) and negative (LR-) likelihood ratios.

RESULTS

A total of 340 women were included (mean patient age, 42.1 (range, 13-79) years). Of the tumors, 55 (16.2%) were malignant and 285 (83.8%) were benign. The IOTA simple rules could be applied in 270 (79.4%) cases. In these cases, sensitivity was 87.9% (95% CI, 72.4-95.2), specificity 97.5% (95% CI, 94.6-98.8), LR+ 34.7 (95% CI, 15.6-77.3) and LR- 0.12 (95% CI, 0.05-0.31).

CONCLUSIONS

Application of the IOTA simple rules yielded acceptable results in terms of specificity in the hands of non-expert examiners. However, with non-expert examiners there was a 12% false-negative rate, which is relatively high.

Intensive training program for ultrasound diagnosis of adnexal masses: protocol and preliminary results

OBJECTIVE

To assess the feasibility of a specific training program for ultrasound diagnosis of adnexal masses.

METHODS

A 2-month intensive training program was developed. The program protocol consisted of a 1-day intensive theoretical course focused on clinical and sonographic issues related to adnexal masses and ovarian cancer, followed by a 4-week real-time ultrasound training program in a tertiary center (25-30 adnexal masses evaluated per month) and a final 4-week period for offline assessment of three-dimensional (3D) volumes from adnexal masses. In this final period, each trainee evaluated five sets of 100 3D volumes. 3D volumes contained gray-scale and power Doppler information, and the trainee was provided with clinical data for each case (patient age, menopausal status and reported symptoms). 3D volumes were obtained from surgically removed masses that had undergone histological diagnosis or from masses that had been followed up until resolution. After assessment of each set, the trainee's diagnostic performance was calculated (sensitivity and specificity) and each incorrectly classified mass was evaluated with the trainer. The objective was to achieve a sensitivity of > 95% and a specificity of > 90%. Learning curve cumulative summation (LC-CUSUM) graphs were plotted to assess the learning curve for the trainees.

RESULTS

One trainer and two trainees with little experience in gynecological ultrasound (one gynecologist and one radiologist) participated in this study. LC-CUSUM graphs showed that competence was achieved after 170 or 185 examinations. The objectives for diagnostic performance were achieved after assessment of the second set of 3D volumes (200 cases) for each trainee.

CONCLUSIONS

The proposed training program appears to be feasible. High diagnostic performance can be achieved after analysis of 200 cases and maintained thereafter.

Expectant management of adnexal masses in selected premenopausal women: a prospective observational study

OBJECTIVE

To evaluate the results of expectant management of ovarian cysts with benign ultrasound morphology in selected asymptomatic premenopausal women.

METHODS

This was a prospective cohort study of premenopausal women diagnosed with a persistent adnexal cyst. Patients were selected according to symptoms (asymptomatic), the cyst's appearance on ultrasound (benign) and size (< 8 cm). Patients underwent a follow-up protocol with transvaginal ultrasound examination at 6-monthly intervals for 2 years and then annually for at least 3 years.

RESULTS

The study comprised 166 women (mean age, 40 years) with 192 masses present at inclusion. Twenty-two women (with 29 masses) were lost to follow-up. Seventy-four masses (38.5%) resolved spontaneously (median time from diagnosis to resolution, 40 months). Forty-nine masses (25.5%) persisted without change (median follow-up time, 88 (range, 36-192) months). Forty masses (20.8%) were surgically removed; 12 because of increase in size, four because a second lesion appeared during follow-up, three because of change in appearance and increase in size, five because of surgery for uterine benign or malignant disease, two because of change in appearance without increase in size, one because of clinical suspicion of ovarian torsion and 13 because of the patient's decision in spite of there being no change in the mass. Histology was benign in all but two cases (Stage Ia mucinous ovarian carcinoma and Stage Ia mucinous borderline tumor). During follow-up 40 new masses in 31 women were diagnosed, of which 21 resolved spontaneously, five (all with benign histology) were surgically removed and 14 were still present at the time of writing.

CONCLUSIONS

Expectant management of cysts with benign ultrasound morphology is a management option in selected asymptomatic premenopausal women.

Ovarian stromal vessels assessed by spatiotemporal image correlation-high definition flow in women with polycystic ovary syndrome: a case-control study

OBJECTIVE

To compare spatiotemporal image correlation-high definition flow (STIC-HDF) indices from spherical samples of ovary between women with polycystic ovary syndrome (PCOS) and normal women.

METHODS

This was a prospective case-control study of premenopausal women with a diagnosis of PCOS according to the Rotterdam criteria and of healthy, regularly menstruating, premenopausal women (controls) matched for age (< 35 years) and body mass index. Women were assessed in the follicular phase of the menstrual cycle by 4D STIC-HDF transvaginal ultrasound. Based on 1-cm(3) spherical sampling, we calculated for each woman the vascularization index (VI) for the most vascularized part of the ovarian stroma in all three-dimensional volumes of the 4D STIC-HDF sequence. The maximum (VI(sys)) and minimum (VI(diast)) values were assumed to represent systole and diastole, respectively, and the mean VI for all frames from one cardiac cycle was calculated. Based on these three VI values, we calculated the following indices: volumetric systolic/diastolic ratio (vS/D), volumetric resistance index (vRI) and volumetric pulsatility index (vPI), and compared them between study and control groups.

RESULTS

The study included 32 PCOS women (mean age, 29.6 years) and 32 controls (mean age, 30.4 years). Mean VI(sys) (26.246% vs 8.136%, P < 0.0001) and mean VI(diast) (22.242% vs 5.997%, P < 0.0001) were significantly higher in PCOS women compared with controls. Median vS/D (1.15 vs 1.33, P < 0.001), mean vRI (0.17 vs 0.30, P < 0.001) and median vPI (0.14 vs 0.28, P < 0.001) were significantly lower in PCOS women compared with controls.

CONCLUSION

4D STIC-HDF indices from 1-cm(3) spherical samples of the ovaries were different between PCOS women and controls, suggesting lower impedance to flow in ovarian stromal vessels in PCOS women.

Clinical and sonographic features of uncommon primary ovarian malignancies

PURPOSE

To describe the gray-scale and color Doppler ultrasound features of uncommon (<5% prevalence) primary malignant ovarian tumors.

METHODS

Retrospective analysis of 98 masses in 89 patients (median age: 50.4 years old, ranging from 15 to 81 years) diagnosed as having an uncommon primary ovarian malignancy. All patients had undergone transvaginal color Doppler ultrasound according to a standardized protocol prior to surgical tumor removal. Ultrasound features analyzed were laterality, presence of ascites, tumor volume, morphologic appearance (unilocular, multilocular, unilocular-solid, multilocular-solid, and solid), and color Doppler score (subjective assessment of the amount of flow as absent, scanty, moderate, or abundant).

RESULTS

Pathological diagnoses included uncommon epithelial tumors (n = 59), germ cell tumors (n = 10), sex cord-stromal tumors (n = 11), sarcoma (n = 9), and lymphoma (n = 9). Germ cell tumors presented in younger women (p < 0.001). Germ cell tumors, sex cord-stromal tumors, sarcomas, and lymphomas were significantly more often solid as compared with epithelial malignancies, which appeared more frequently as complex (cystic-solid) tumors (p < 0.001). There were no differences in color Doppler score between the various types of tumors.

CONCLUSIONS

Germ cell tumors, sex cord-stromal tumors, sarcomas, and lymphomas tend to appear as unilateral solid tumors. Color Doppler score is not useful for discriminating among uncommon primary ovarian malignancies.

Extragenital endometrial stromal sarcoma arising in endometriosis

The diagnosis rate of deep pelvic endometriosis is increasing. Endometrial stromal sarcoma (ESS) is a rare neoplasm. Extragenital ESS is an extremely uncommon event. Very few cases of extragenital ESS have been reported to date. The diagnosis of this entity is very difficult in some instances. Knowledge about its management is also limited. In this paper, we review the current literature on the clinical management, histology, immunohistochemistry, treatment and outcome of ESS arising in pelvic endometriosis.

Spatiotemporal image correlation with spherical sampling and high-definition flow: new 4-dimensional method for assessment of tissue vascularization changes during the cardiac cycle: reproducibility analysis

OBJECTIVES

To describe and assess the interobserver reproducibility of a new method for evaluation of ovarian vascularization using spatiotemporal image correlation-high definition flow (STIC-HDF).

METHODS

Stored 4-dimensional (4D) STIC-HDF volume data from 39 healthy pre-menopausal fertile women (aged <35 years) examined in the follicular part of the menstrual cycle by transvaginal sonography were assessed by two different examiners blinded from each other (one in Spain the other in Poland). Using 1-cm(3) spherical sampling, the vascularization index (VI) from the most vascularized part of the ovarian stroma was calculated at two different moments of the cardiac cycle (systole and diastole). System settings were kept constant for all patients (pulse repetition frequency, 0.6 kHz; gain, 0.2) with a depth of 40 mm. Analysis was performed offline using 4D software on a personal computer. On the basis of VI and vascularization-flow index (VFI) values during systole and diastole, 4 new 4D indices were defined: 4D systolic/diastolic volumetric index (4D-SDVI = VI(syst)/VI(diast)), 4D hemodynamic volumetric index (4D-HVI = [VI(syst) + VI(diast)]/[VI(syst) - VI(diast)]), 4D systolic/diastolic vascularization-flow index (4D-SDVFI = VFI(syst)/VFI(diast)), and 4D hemodynamic vascularization-flow index (4D-HVFI = [VFI(syst) + VFI(diast)]/[VFI(syst)- VFI(diast)]). Reproducibility of measurements was estimated by calculating the intraclass correlation coefficient (ICC).

RESULTS

The systolic VI, diastolic VI, 4D-SDVI, 4D-HVI, systolic VFI, diastolic VFI, and 4D-HVFI showed good reproducibility (ICC, 0.992, 0.994, 0.879, 0.915, 0.995, 0.995, and 0.893, respectively). The 4D-SDVFI showed moderate reproducibility (ICC, 0.797).

CONCLUSIONS

We describe 4 new 4D vascular indices for assessing tissue vascularization using STIC-HDF technology. Assessment of ovarian vascularization using this STIC-HDF spherical sampling is reliable. The calculation of these new indices is reproducible between two different examiners.