Adding cancer antigen 125 screening to gray scale sonography for predicting specific diagnosis of benign adnexal masses in premenopausal women: is it worthwhile?

OBJECTIVES

The purpose of this study was to assess whether a single determination of the serum cancer antigen 125 (CA-125) level provides additional information to sonography for specific diagnosis of benign adnexal masses in premenopausal women.

METHODS

We conducted a retrospective study comprising 1058 premenopausal women (mean age, 34.8 years) with histologically proven benign adnexal masses. All women had undergone transvaginal sonography and serum CA-125 determination within 1 week before surgery and tumor removal. According to "pattern recognition" analysis, a presumptive diagnosis was provided on gray scale transvaginal sonography for all masses. Positive and negative likelihood ratios were calculated for gray scale sonography and gray scale sonography plus CA-125.

RESULTS

Eighty-five women had bilateral masses (1143 masses analyzed). In 7 women with bilateral masses, the histologic diagnoses of the masses were discordant and were excluded. Histologic diagnoses were as follows: endometrioma, n = 452; dermoid cyst, n = 180; serous cyst, n = 158; hemorrhagic cyst, n = 119; mucinous cyst, n = 54; hydrosalpinx, n = 37; and other, n = 109. The median CA-125 level was significantly higher in endometrioma (71.9 IU/mL; range: 5-2620 IU/mL) and hydrosalpinx (59.2 IU/mL; range, 5-601 IU/mL) compared to all other tumor types (P < .001). The CA-125 level was 35 IU/mL or higher in 74% of endometriomas, 58% of hydrosalpinges, 34% of hemorrhagic cysts, 18% of mucinous cysts, 14% of dermoid cysts, and 8% of serous cysts. The positive and negative likelihood ratios for sonography and sonography plus CA-125 (335 IU/mL) for each kind of tumor were not statistically different except for endometrioma, for which the positive likelihood ratio for sonography plus CA-125 (55.0; 95% confidence interval, 27.5-109.9) was significantly higher than for sonography alone (19.2; 95% confidence interval, 13.6-27.1).

CONCLUSIONS

Cancer antigen 125 screening does not add useful information for specific diagnosis of benign adnexal tumors, except for endometrioma. An elevated CA-125 level significantly increases the probability of such a lesion.

GI-RADS reporting system for ultrasound evaluation of adnexal masses in clinical practice: a prospective multicenter study

OBJECTIVE

To assess the clinical usefulness of a structured reporting system based on ultrasound findings for management of adnexal masses.

METHODS

This was a prospective multicenter study comprising 432 adnexal masses in 372 women (mean age, 44.0 (range, 13-78) years) over a 36-month period. Ninety-three (25%) women were postmenopausal and 279 (75%) women were premenopausal. Patients were evaluated with transvaginal ultrasound by one of three examiners expert in gynecological ultrasound. Reporting was provided to referring clinicians according to the Gynecologic Imaging Report and Data System (GI-RADS) classification. A predetermined management protocol was offered to referral clinicians. It was suggested that patients classified as GI-RADS 2 be managed with follow-up scan, patients classified as GI-RADS 3 undergo laparoscopic surgery and patients classified as GI-RADS 4 or 5 be referred to a gynecologic oncologist. Definitive histologic diagnosis was available in 370 cases and 62 additional cases were considered as benign because of spontaneous resolution during follow-up. These outcomes were used as the gold standard for calculating the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-) of GI-RADS classification for identifying adnexal masses at high risk of malignancy, considering GI-RADS 4 and 5 as being malignant.

RESULTS

Of the 432 tumors, 112 were malignant and 320 benign. The GI-RADS classification rate was as follows: GI-RADS 2, 92 (21%) cases; GI-RADS 3, 184 (43%) cases; GI-RADS 4, 40 (9%) cases; GI-RADS 5, (27%) 116 cases. Sensitivity for this system was 99.1% (95% CI, 95.1-99.8%), specificity was 85.9% (95% CI, 81.7-89.3%), LR+ was 7.05 (95% CI, 5.37-9.45) and LR- was 0.01 (95% CI, 0.001-0.07). PPV and NPV were 71.1% and 99.6%, respectively.

CONCLUSIONS

The GI-RADS reporting system performed well in identifying adnexal masses at high risk of malignancy and seems to be useful for clinical decision-making.

Intra- and interobserver variability of 2D and 3D transvaginal sonography in the diagnosis of benign versus malignant adnexal masses

PURPOSE

The purpose of this study was to investigate the intraobserver and interobserver agreements in the diagnosis of malignant versus benign adnexal masses using two-dimensional ultrasonography (2D US) and three-dimensional ultrasonography (3D US).

METHODS

Two experienced sonographers performed a retrospective review of digitally stored 2D images and 3D data from a sample of 41 consecutive patients with a diagnosis of adnexal mass. Each observer independently, and blinded to each other, evaluated the 2D static images of each adnexal mass and then the 3D volumes 1 week later. The observers were required to classify the adnexal lesion as benign or malignant according to pattern recognition analysis. Intraobserver and interobserver agreement were assessed by calculating the kappa index (κ).

RESULTS

Intraobserver agreement between 2D US and 3D US for the observer A was 1.00 and for the observer B was 0.69. Interobserver agreement was 0.69 for 2D US and 1.00 for 3D US (p > 0.05)

CONCLUSIONS

Although 3D US in the diagnosis of adnexal masses appeared more reproducible than 2D US, the difference was not statistically significant.

Contribution of power Doppler blood flow mapping to gray-scale ultrasound for predicting malignancy of adnexal masses in symptomatic and asymptomatic women

OBJECTIVE

To determine the contribution of power Doppler blood flow mapping to gray-scale ultrasound for predicting malignancy of adnexal masses in symptomatic and asymptomatic women.

STUDY DESIGN

One thousand and ninety-four women with adnexal mass were included. Patients were divided into three groups according to clinical complaints: asymptomatic (group A), patients with symptoms non-suspicious of ovarian cancer (group B) and patients with symptoms suspicious of ovarian cancer (group C). All patients underwent transvaginal power Doppler ultrasound prior to surgery. Any mass in which the echo architecture at B-mode ultrasound was not highly suggestive of benign histology was categorized as questionable. In these cases power Doppler was performed as the second step. Definitive histological diagnosis was used as the standard reference. Sensitivity, specificity, positive likelihood ratio (+LR) and negative likelihood ratio (-LR) were calculated for B-mode diagnosis and B-mode plus Doppler in each group.

RESULTS

In group A, B-mode was significantly more sensitive (98.1%) than Doppler ultrasound (91.3%) (p<0.01). In group B Doppler ultrasound (97.0%) was more specific than B-mode ultrasound (92.2%) (p<0.001). In group C Doppler ultrasound (84.0%) was more specific than B-mode ultrasound (68.0%) (p<0.001). Positive LR was significantly higher after Doppler evaluation in all groups (30.5 vs 12.8 in group A, 33.2 vs 12.8 in group B and 6.0 vs 3.1 in group C).

CONCLUSIONS

The diagnostic performance of B-mode and power Doppler ultrasound is different depending on patients' complaints.

Spatiotemporal image correlation using high-definition flow: a new method for assessing ovarian vascularization

OBJECTIVE

The purpose of this study was to describe a new method for assessing ovarian vascularization using spatiotemporal image correlation (STIC)-high-definition flow (HDF).

METHODS

Thirty healthy premenopausal fertile women were assessed in the follicular part of the menstrual cycle by transvaginal sonography. A 4-dimensional STIC-HDF volume was obtained from the nondominant ovary to assess 3-dimensional (3D) vascular indices (vascularization index [VI] and flow index [FI]) during one cardiac cycle in each women. Using 1-cm(3) spherical sampling, we calculated the VI and FI from the most vascularized part of the ovarian stroma at two different moments of the cardiac cycle (systole and diastole). System settings were kept constant for all of the patients (pulse repetition frequency, 0.9 kHz; gain, 0.8; and depth, 40 mm). We calculated the VI and FI ratios between systole and diastole.

RESULTS

The mean VI during systole (11.485%; SD, 6.7%) was significantly higher than during diastole (8.653%; SD, 5.6%; P < .0001). The mean FI values during systole (47.799 [unitless]; SD, 5.8) and diastole (47.791; SD, 6.0) were nearly identical (P = .993). The VI ratio was 1.35 (95% confidence interval, 1.28-1.42), which means that the mean VI was 35% higher during systole compared to diastole, whereas the FI during systole and diastole remained constant (FI ratio, 1.00; 95% confidence interval, 0.96-1.04). There was a high correlation between VI values during systole and diastole (r(2) = 0.94), whereas this correlation was weaker for the FI (r(2) = 0.45).

CONCLUSIONS

The STIC-HDF method allows assessment of 3D vascular indices throughout the cardiac cycle. Vascularization index calculation is affected by the moment of the cardiac cycle during which the measurement is taken. However, it seems that FI calculation is not affected by the cardiac cycle in the normal nondominant ovary.

Three-dimensional power Doppler angiography in endometrial cancer: correlation with tumor characteristics

OBJECTIVE

To assess the correlation between intratumoral vascularization using three-dimensional power Doppler angiography (3D-PDA) and several histological tumor characteristics in a series of patients with endometrial carcinoma.

METHODS

Ninety-nine women (mean age, 61.7 (range, 31-84) years) diagnosed as having endometrial cancer were assessed by transvaginal 3D-PDA before surgical staging. Endometrial volume (EV) and 3D-PDA vascular indices (vascularization index (VI), flow index (FI) and vascularization flow index (VFI)) were calculated using the Virtual Organ Computer-aided AnaLysis (VOCAL) method. All patients were surgically staged. Individual tumor features such as histological type, tumor grade, myometrial infiltration depth, lymph-vascular space involvement, cervical involvement, lymph node metastases and tumor stage were considered for analysis. Multivariate logistic regression (MLR) analysis was used to determine which 3D-PDA parameters were independently associated with each histological characteristic.

RESULTS

MLR analysis showed that only EV and VI were independently associated with myometrial infiltration (EV: odds ratio (OR), 1.119 (95% CI, 1.025-1.221), P = 0.012; VI: OR, 1.127 (95% CI, 1.063-1.195), P = 0.001) and tumor stage (EV: OR, 1.103 (95% CI, 1.012-1.202), P = 0.025; VI: OR, 1.120 (95% CI, 1.057-1.187), P = 0.001), only VI was independently associated with tumor grade (OR, 1.056 (95% CI, 1.023-1.091), P = 0.001) and only EV was independently associated with lymph node metastases (OR, 1.086 (95% CI, 1.017-1.161), P = 0.001).

CONCLUSION

3D-PDA analysis of tumor vascularization in endometrial cancer correlates with some prognostic histological characteristics.

Does sphere volume affect the performance of three-dimensional power Doppler virtual vascular sampling for predicting malignancy in vascularized solid or cystic-solid adnexal masses?

OBJECTIVE

To assess whether, when using spherical sampling with Virtual Organ Computer-Aided Analysis (VOCAL) for calculating three-dimensional (3D) power Doppler angiography (PDA) indices, the sphere volume affects performance in the prediction of malignancy in vascularized cystic-solid or solid adnexal masses.

METHODS

One hundred and thirty-eight women (mean +/- SD age, 51.8 +/- 14.1 years) diagnosed as having vascularized cystic-solid or solid adnexal masses on B-mode and two-dimensional (2D) power Doppler ultrasound were evaluated by 3D-PDA prior to surgery. Five women had bilateral masses, giving a total number of 143 masses analyzed. Vascularization was assessed using VOCAL software. 3D-PDA vascular indices (vascularization index (VI), flow index (FI) and vascularization flow index (VFI)) from the most vascularized area within papillary projections and solid areas were calculated automatically using spherical sampling. Five different volumes of sphere were used (1 cm(3), 2 cm(3), 3 cm(3), 4 cm(3) and 5 cm(3)) in each case. A definitive histological diagnosis was obtained in each case after surgical tumor removal.

RESULTS

One hundred and seventeen (82%) masses were malignant and 26 (18%) were benign. Morphological evaluation revealed 34 (24%) unilocular solid masses, 49 (34%) multilocular solid masses and 60 (42%) mostly solid masses. The 1-cm(3) sphere could be used in 100% of the cases, the 2-cm(3) sphere could be used in 98.2% of the cases and the 3-5-cm(3) spheres could be used in 97.2% of the cases. The median VI, FI and VFI for all sphere volumes were significantly higher in malignant compared with non-malignant tumors. Receiver-operating characteristics curve analysis showed that VI and VFI, independently of sphere volume, were better predictors of malignancy than was FI. The best cut-off values for the 3D-PDA indices differed depending on sphere volume. VI was significantly more specific than were VFI and FI.

CONCLUSIONS

Sphere volume does not affect the performance of 3D-PDA. We recommend the use of different cut-off values for 3D-PDA indices for discriminating between benign and malignant adnexal masses, depending on the sphere volume used. Use of VI is preferable due to its higher specificity.

Three-dimensional vascular indices calculated using conventional power Doppler and high-definition flow imaging: are there differences?

OBJECTIVE

The purpose of this study was to determine whether there are differences in 3-dimensional (3D) vascular indices when calculated using high-definition flow imaging (HDF) and power Doppler imaging (PD).

METHODS

Twenty-five consecutive asymptomatic premenopausal women (mean age, 31 years; range, 28-33 years) without a history of gynecologic disease who attended routine gynecologic checkups were included in the study. All women had regular menstrual cycles, and none had uterine or myometrial disease detected on basal transvaginal sonography. All women underwent 3D transvaginal sonography. In each patient, a first volume using conventional PD was obtained, immediately followed by a second volume using HDF. Volumes were stored and subsequently analyzed for calculating 3D vascular indices (vascularization index [VI], flow index [FI], and vascularization-flow index [VFI]) from the endometrium.

RESULTS

The median VI, FI, and VFI were significantly higher when calculated using HDF compared with conventional PD (P < .05).

CONCLUSIONS

Three-dimensional vascular indices calculated using HDF are higher than those calculated using conventional PD.

Assessment of cyst content using mean gray value for discriminating endometrioma from other unilocular cysts in premenopausal women

OBJECTIVE

To assess whether the analysis of cyst content using mean gray value (MGV) can discriminate ovarian endometriomas from other unilocular ovarian cysts in premenopausal women.

METHODS

Stored three-dimensional (3D) volumes from 54 unilocular ovarian cysts diagnosed in 50 premenopausal women (mean age, 37 (range, 22-50) years) were analyzed to calculate the MGV from cyst content. Cysts with solid components or septations were excluded. MGV was calculated in all cases with the Virtual Organ Computer-aided AnaLysis technique. The B-mode presumptive diagnosis based on the examiner's subjective impression was also recorded.

RESULTS

Sixteen of the cysts resolved spontaneously and were given a final clinical diagnosis of hemorrhagic functional cyst, while 38 cysts were removed surgically (diagnosed histologically as seven simple cysts, three hemorrhagic cysts, 20 endometriomas, five mucinous cysts and three paraovarian cysts). B-mode diagnoses were as follows: seven simple cysts, 18 hemorrhagic cysts, 24 endometriomas, three mucinous cysts and two paraovarian cysts. MGV was significantly higher in ovarian endometrioma when compared with all other kinds of cyst. The receiver-operating characteristics curve showed that using an MGV cut-off >or= 15.560 had a sensitivity of 85% and a specificity of 76.5% for diagnosing ovarian endometrioma (area under the curve, 0.831; 95% CI, 0.718-0.944). These figures were similar to those for B-mode diagnosis (sensitivity, 90%; specificity, 82%) (McNemar test, P = 1.000). Combining B-mode and MGV gave a sensitivity of 80% and a specificity of 91%.

CONCLUSION

Cyst content MGV is higher in ovarian endometrioma than it is in other unilocular ovarian cysts. The diagnostic performance of MGV is similar to that of the examiner's subjective impression. The combination of both criteria achieves the highest specificity.

Endometriosis in a postmenopausal woman without previous hormonal therapy: a case report

INTRODUCTION

The prevalence of pelvic endometriosis is high, affecting approximately 6% to 10% of women of reproductive age. Although endometriosis has been associated with the occurrence of menstrual cycles, it can affect between 2% to 5% of postmenopausal women.

CASE PRESENTATION

We present a case of ovarian endometriosis in a 62-year-old Spanish Caucasian woman with no previous use of hormonal therapy and no history of endometriosis or infertility.

CONCLUSION

ALTHOUGH THE REPORTED SITUATION IS RARE, IT IS IMPORTANT TO BE AWARE OF ENDOMETRIOSIS AFTER THE MENOPAUSE: post-menopausal endometriosis confers a risk of recurrence and malignant transformation.

Thrombospondin-1 serum levels do not correlate with pelvic pain in patients with ovarian endometriosis

Objetive

Thrombospondin-1 serum levels is correlate with pelvic pain in patients with ovarian endometriosis.

Patients

Thrombospondin-1 serum levels were prospectively analysed in 51 patients (group A asymptomatic patients or patients presenting mild dysmenorrhea and women comprised group B severe dysmenorrhea and/or chronic pelvic pain and/or dyspareunia) who underwent surgery for cystic ovarian endometriosis to asses whether a correlation exists among thrombospondin-1 serum levels and pelvic pain.

Results

From 56 patients, five cases were ultimateley excluded, because the histological diagnosis was other than cystic ovarian endometriosis (2 teratomas and 3 haemorragic cysts). The mean thrombospondin-1 serum levels in group A was 256,69 pg/ml_+37,07 and in group B was 291,41 pg/ml + 35,59.

Conclusion

Pain symptoms in ovarian endometriosis is not correlated with thrombospondin-1 serum levels.

Resectability rates of previously irradiated recurrent cervical cancer (PIRCC) treated with pelvic exenteration: is still the clinical involvement of the pelvis wall a real contraindication? a twenty-year experience

OBJECTIVE

(1) To determine the accuracy of a standard clinical and radiological assessment of resectability in patients with previously irradiated recurrent cervical cancer (PIRCC), and (2) to report the outcome and prognostic factors in this high-risk population treated with an exenterative procedure.

METHODS

Forty-eight patients with centrally located (n=20, 41.7%) or lateralized (n=28, 58.3%) PIRCC treated with exenterative procedures were analyzed. All patients underwent standard assessment of resectability with pelvic exam and radiological studies. Patients with centrally located tumors were considered as resectable and lateralized tumors were deemed unresectable.

RESULTS

Complete surgical resection with negative margins (R0) was achieved in 28.6% of the patients with lateral recurrences and in 65.0% of the patients with central recurrences (p<0.019). After a median follow-up of 114.6 months (3.0-244.9 months), the 10-year local control rate for the whole group was 36.3%, 43.1% in the central PIRCC group and 31.5% in the lateral PIRCC group, respectively (p=0.290). Multivariate analysis showed that improved local control was significantly associated with the presence of negative margins (p=0.004). The 10-year distant failure rate was 69%, 56.6% in the central PIRCC group and 83.2% in the lateral PIRCC group (p=0.178), respectively. Multivariate analysis showed that the development of distant metastases was significantly correlated with the absence of local control (p=0.01). The 10-year disease-specific survival (DSS) for central and lateral PIRCC was 27.2% and 14.9%, respectively (p=0.239). Multivariate analysis showed that negative margins (p=0.001), local control (p=0.001) and distant control (p=0.006) were all significantly associated with improved DSS. Location of PIRCC (central vs. lateral) was irrelevant for DSS in completely resected (R0) patients. Overall morbidity rate was 65.0% and 73.3% for central and lateral PIRCC patients, respectively (p=0.528).

CONCLUSION

About one-third of the patients with lateral PIRCC classified as unresectable with non-surgical means may ultimately undergo complete (R0) resections and about one-third of the patients with centrally located PIRCC and judged as resectable will undergo non-curative (R1) resections. A curative (R0) resection significantly impacts local control rates, distant metastases-free rates and DSS.

Three-dimensional sonographic characteristics of deep endometriosis

OBJECTIVE

The purpose of this presentation is to investigate the potential role of 3-dimensional (3D) sonography in the assessment of deep endometriosis.

METHODS

Cases of deep endometriosis are presented to illustrate the spectrum of appearances obtained with 3D sonography. In addition, we evaluate the possible role of other functions included in 3D equipment, such as the niche mode and tomographic ultrasound imaging (TUI).

RESULTS

Three-dimensional image rendering could allow a good analysis of the endometriotic nodule; in fact, in all presented cases, this reconstruction seems to clearly show the irregular shapes and borders of the lesions. This technique allows unrestricted access to an infinite number of viewing planes, which can be very useful for correctly locating lesions within the pelvis and evaluating the relationship with other organs. The stored 3D volumes can be reassessed and compared by the same or different examiners over time. This characteristic may be relevant for monitoring the effect of medical therapies over time. In the niche mode, sonographic imaging is represented as a "cut-open" view of the internal aspect of the nodule and its surrounding tissue. This additional function, which is associated with TUI, could be particularly useful for evaluation of the extension of a nodule in the rectovaginal septum, the depth of infiltration, and the relationship with the rectosigmoid junction or ureter.

CONCLUSIONS

In the near future, 3D sonography in deep infiltrating endometriosis could be an interesting mode of research with positive effects in everyday clinical practice.

[Diagnosis of endometriosis]

There are no sufficiently sensitive and specific signs and symptoms or diagnostic tests for the clinical diagnosis of endometriosis, and no diagnostic strategy is supported by evidence of effectiveness. Pelvic and rectal examinations should be performed, although the yield of the physical examination is low. Laboratory tests and radiological examinations are usually not warranted. Measurement of CA 125 levels may be useful for monitoring disease progress, and MRI has a high sensitivity in detecting endometrial cysts but poor diagnostic accuracy for endometriosis in general. Patients with persistent symptoms after empirical treatment should be referred for laparoscopy, the preferred method for diagnosis of endometriosis.

Ultrasound study of the myoendometrial border

Abnormal thickening of the Endometrial Subendometrial Myometrium Unit (ESEMy Unit, including basal endometrium and inner myometrium) has been detected on imaging and referred to as "diffuse adenomyosis" in infertile patients with proven endometriosis. However, no robust relationship exists between enlargement of the ESEMy Unit and adenomyosis proven on hysterectomy specimen examination; moreover, if any correlation exists, it lacks histological validation in women wishing to preserve fertility. While adenomyosis effects on fertility, if any, remain elusive, thickening of the ESEMy Unit have been consistently linked to fertility impairment in both experimental and clinical models. The hypothesis tested herein is that a novel condition exists, called "ESEMy Unit disruption disease"; it is epidemiologically different from adenomyosis, diagnosable on imaging and bears a clear impact on human fertility through various mechanisms. A new wave of good quality studies may be elicited by a clear distinction between adenomyosis and the "ESEMy Unit disruption disease".

The value of minilaparotomy for total hysterectomy for benign uterine disease: a comparative study with conventional Pfannenstiel and laparoscopic approaches

Background

The aim of this paper is to review and compare the results obtained using the Pfannenstiel, laparoscopy and minilaparotomy approaches for total hysterectomy procedure in relation to benign uterine diseases.

Methods

A retrospective data analysis was performed on 165 patients who underwent hysterectomy for benign uterine diseases at our centre during the period 2004 to 2006.

Findings

The minilaparotomy procedure was the fastest procedure with a mean time of 73.4 minutes (range: 67.85 to 78.94 minutes, p < 0.001). Hospital stay was shortest for laparosopic procedure (mean time: 3.24 days, range: 2.86 to 3.61 days) (p < 0.001). The rate of intraoperative and postoperative complications were not statistical different among three procedures.

Conclusion

The minilaparotomy procedure offers a minimally invasive option for total hysterectomy due to benign uterine disease.

[Angiogenesis and endometriosis]

Endometriosis is a common gynaecological disease of unknown aetiology. Angiogenesis appears to be one of the processes involved in its pathogenesis. Angiogenic factors are increased in the peritoneal fluid of patients with endometriosis (McLaren 1996 et al; Taylor et al, 2002), in peritoneal implants (Ferriani et al, 1993) and in ovarian endometriomas. On the other hand, some researchers have found that angiogenesis is related to pelvic pain. We speculated that ovarian endometriomas in patients presenting with pelvic pain would be more angiogenic than those in asymptomatic women and that their vascular features would therefore be different.

Evaluation of two different methods for vascular sampling by three-dimensional power Doppler angiography in solid and cystic-solid adnexal masses

OBJECTIVE

To analyze two different methods for performing three-dimensional power Doppler angiography (3D-PDA) vascular sampling in solid and cystic-solid adnexal masses.

METHODS

Twenty-one 3D-PDA volumes from 18 consecutive and unselected solid or cystic-solid adnexal masses (13 malignant and five benign) were analyzed. A single examiner (J. L. A.) acquired all the volumes according to a predetermined scanning protocol. Two different observers (one inexperienced and the other experienced) calculated 3D-PDA vascular indices (vascularization index (VI), flow index (FI) and vascularization flow index (VFI)) from solid tumor areas. First, manual sampling (Plane A, 15 degrees rotation-step) was performed, and 1 week later 5-cm(3) sphere sampling from the most vascularized area was carried out. The observers made a record of any difficulty that they encountered in delineating the solid areas of tumors or in distinguishing true tumor vessels from pre-existing vessels, the time spent performing each analysis was recorded and inter- and intraobserver reproducibility was evaluated for each method using intraclass correlation coefficients (ICC).

RESULTS

In four (19.0%) of the 21 volumes sphere sampling could not be performed because it was not possible to obtain a sphere smaller than 5.5 cm(3). This happened in cases in which image zooming was used when acquiring the 3D volume. The inexperienced observer encountered more difficulty, but not significantly more, than the experienced observer when analyzing 3D-PDA volumes both by manual sampling (29% vs. 14% of cases) and 5-cm(3) sphere sampling (35% vs. 18% of cases). The mean time spent by the inexperienced observer was significantly greater (P < 0.001) than that spent by the experienced observer both for manual sampling (6.11 min vs. 1.85 min) and 5-cm(3) sphere sampling (2.93 min vs. 2.15 min). Contrary to the findings for the experienced observer, the inexperienced observer required less time to perform sphere sampling than they did manual sampling. Interobserver agreement was high for both methods: ICC for manual volume, 0.993; manual VI, 0.908; manual FI, 0.913; manual VFI, 0.914; sphere volume, 0.949; sphere VI, 0.954; sphere FI 0.850; and sphere VFI, 0.953. Intraobserver reproducibility was also high, with all ICCs above 0.99.

CONCLUSIONS

Manual and 5-cm(3) sphere sampling are reproducible methods for 3D-PDA vascular sampling. Caution is required when image zoom is used at the time of acquiring the volume because this may prevent sphere sampling. Difficulties found in performing both manual and sphere sampling do not seem to significantly affect the reproducibility of Doppler index calculations.

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.