MR imaging of ovarian masses: classification and differential diagnosis

Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis-part II: uterine emergencies and pelvic inflammatory disease

Due to the growing use of cross-sectional imaging in emergency departments, acute gynaecologic disorders are increasingly diagnosed on urgent multidetector computed tomography (CT) studies, often requested under alternative presumptive diagnoses in reproductive-age women. If clinical conditions and state-of-the-art scanner availability permit, magnetic resonance imaging (MRI) is superior to CT due to its more in-depth characterisationof abnormal or inconclusive gynaecological findings, owing to excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation.

This pictorial review aims to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their CT and MRI appearances, in order to provide a timely and correct imaging diagnosis. Specifically, this second instalment reviews with examples and emphasis on differential diagnosis the main non-pregnancy-related uterine emergencies (including endometrial polyps, degenerated leiomyomas and uterine inversion) and the spectrum of pelvic inflammatory disease.

Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis-part I: corpus luteum and haemorrhagic ovarian cysts, genital causes of haemoperitoneum and adnexal torsion

Acute gynaecologic disorders are commonly encountered in daily clinical practice of emergency departments (ED) and predominantly occur in reproductive-age women. Since clinical presentation may be nonspecific and physical findings are often inconclusive, imaging is required for a timely and accurate diagnosis. Although ultrasound is the ideal non-invasive first-line technique, nowadays multidetector computed tomography (CT) is extensively used in the ED, particularly when a non-gynaecologic disorder is suspected and differential diagnosis from gastrointestinal and urologic diseases is needed. As a result, CT often provides the first diagnosis of female genital emergencies. If clinical conditions and scanner availability permit, magnetic resonance imaging (MRI) is superior to CT for further characterisation of gynaecologic abnormalities, due to the excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation.

The purpose of this pictorial review is to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their cross-sectional imaging appearances. The present first section will review the CT and MRI findings of corpus luteum and haemorrhagic ovarian cysts, gynaecologic haemoperitoneum (from either ruptured corpus luteum or ectopic pregnancy) and adnexal torsion, with an emphasis on differential diagnosis. Additionally, comprehensive and time-efficient MRI acquisition protocols are provided.

Functional MRI in the pre-operative assessment of GI-RADS 3, 4, and 5 ovarian masses

Background

Characterization of an ovarian lesion is a diagnostic challenge. A correct preoperative assessment is of great importance so as to arrange adequate therapeutic procedures. The aim of the current study is to evaluate the diagnostic performance of functional MRI in differentiation between malignant, borderline, and benign ovarian masses.

Results

This study included 56 adnexal lesions. Bilateral synchronous ovarian lesions are detected in 16 cases. Postoperative histologically proved to be benign in 17 (30%), borderline (low potential malignancy) in 12 (22%), and malignant in 27 (48%). The overall diagnostic performance of conventional MRI in the diagnosis of adenexal lesion was a sensitivity of 74%, specificity of 47%, positive predictive value (PPV) of 76%, negative predictive value (NPV) of 44%, and an accuracy of 66%. Functional pelvic MRI examination showed an increase in overall diagnostic performance compared to conventional values with the highest sensitivity of 90% and NPV of 67% using DWI, and the highest specificity of 88%, PPV of 94%, and an accuracy of 82% using DCE MRI.

Conclusion

Functional MRI in conjugation with conventional MRI plays a key role in the ovarian lesion detection, characterization, and staging. Functional MRI is currently being evaluated as possible predictive and prognostic biomarkers in ovarian lesions.

Value of magnetic resonance spectroscopy in assessment of adnexal lesions

Background

The purpose of this study is to investigate the role of proton MR spectroscopy (1H-MRS) in the characterization and diagnosis of ovarian lesions.

Results

From October 2015 to October 2017, a total of 57 female patients (65 adnexal lesions; 8 cases were bilateral) were included. The examined lesions were classified according to their histopathological findings, (37 (57%) benign lesions, 4 (6%) borderline lesions, and 24 (37%) malignant lesions). The mean choline/creatinine (CHO/Cr) ratio was 1.29 ± 0.98 SD for malignant lesions, while the mean value in borderline lesions was 0.63 ± 0.15 SD, and the mean value for the benign lesions was 0.65 ± 0.34. Therefore, the mean CHO/Cr ratio was much higher in malignant than in benign lesions, which was statistically significant (P ≤ 0.001) as well as between the borderline and invasive lesions (P = 0.05), but not between the benign and borderline lesions. The diagnostic performance of conventional MRI in diagnosing adnexal lesions was 100%, specificity was 76%, and accuracy was 86%. However, MRS individual diagnostic performances are the following: sensitivity 89%, specificity, and 100% with an accuracy of 95%.

Conclusion

MRS proved to be an accurate and efficient method for the analysis of adnexal lesions and in differentiation between benign and malignant tumors.

Amide proton transfer imaging for differentiating benign ovarian cystic lesions: Potential of first time right

PURPOSE

To investigate whether amide proton transfer (APT) imaging is useful to differentiate benign ovarian cystic lesions.

MATERIALS AND METHODS

This prospective study enrolled a total of 19 lesions in 18 patients with benign ovarian cystic lesion: serous cystadenoma (SCA), n = 4; mucinous cystadenoma (MCA), n = 9; or functional cyst (FC), n = 6. APT imaging was performed with three different presaturation pulse durations: 0.5, 1.0 and 2.0 s. APT signal was defined as magnetization transfer ratio asymmetry at 3.5 ppm. The SI ratios of cyst to muscle calculated on T1- and T2-weighted images were defined as T1- and T2-ratios. Apparent diffusion coefficient (ADC) maps were also generated. We compared the three cystic lesion groups' APT signals, T1-ratio, T2-ratio, and ADC.

RESULTS

When using 2.0 s of presaturation, the APT signals were 1.41 ± 0.71% in SCA, 5.15 ± 1.92% in MCA and 8.52 ± 1.17% in FC. Significant differences were observed between SCA and MCA (p < .01) and MCA and FC (p < .05), as well as between SCA and FC (P <  .0001). When 1.0 s presaturation pulse was used, similar results were obtained. On the other hand, ADC value shows significance only between SCA (2.91±0.03×10-3 mm2/s) and MCA (2.59 ± 0.49 × 10-3 mm2/s, p < .05). Further, there was no significant difference in the T1-ratio, T2-ratio among the three groups.

CONCLUSIONS

APT imaging might be useful for the non-invasive diagnosis of benign ovarian cystic lesions. With the use of the longer presaturation pulse as possible, APT imaging may provide an early and correct diagnosis of ovarian cystic lesions without additional follow-up studies.

Diagnostic extended usefulness of RMI: comparison of four risk of malignancy index in preoperative differentiation of borderline ovarian tumors and benign ovarian tumors

Background

This study aimed to examine the performance of the four risk of malignancy index (RMI) in discriminating borderline ovarian tumors (BOTs) and benign ovarian masses in daily clinical practice.

Methods

A total of 162 women with BOTs and 379 women with benign ovarian tumors diagnosed at the Second Affiliated Hospital of Harbin Medical University from January 2012 to December 2016 were enrolled in this retrospective study. Also, we classified these patients into serous borderline ovarian tumor (SBOT) and mucinous borderline ovarian tumor (MBOT) subgroup. Preoperative ultrasound findings, cancer antigen 125 (CA125) and menopausal status were reviewed. The area under the curve (AUC) of receiver operator characteristic curves (ROC) and performance indices of RMI I, RMI II, RMI III and RMI IV were calculated and compared for discrimination between benign ovarian tumors and BOTs.

Results

RMI I had the highest AUC (0.825, 95% CI: 0.790–0.856) among the four RMIs in BOTs group. Similar results were found in SBOT (0.839, 95% CI: 0.804–0.871) and MBOT (0.791, 95% CI: 0.749–0.829) subgroups. RMI I had the highest specificity among the BOTs group (87.6, 95% CI: 83.9–90.7%), SBOT (87.6, 95% CI: 83.9–90.7%) and MBOT group (87.6, 95% CI: 83.9–90.7%). RMI II scored the highest overall in terms of sensitivity among the BOTs group (69.75, 95% CI: 62.1–76.7%), SBOT (74.34, 95% CI: 65.3–82.1%) and MBOT (59.18, 95% CI: 44.2–73.0%) group.

Conclusion

Compared to other RMIs, RMI I was the best-performed method for differentiation of BOTs from benign ovarian tumors. At the same time, RMI I also performed best in the discrimination SBOT from benign ovarian tumors.

MR imaging in discriminating between benign and malignant paediatric ovarian masses: a systematic review

OBJECTIVES

The use of magnetic resonance (MR) imaging in differentiation between benign and malignant adnexal masses in children and adolescents might be of great value in the diagnostic workup of sonographically indeterminate masses, since preserving fertility is of particular importance in this population. This systematic review evaluates the diagnostic value of MR imaging in children with an ovarian mass.

METHODS

The review was made according to the PRISMA Statement. PubMed and EMBASE were systematically searched for studies on the use of MR imaging in differential diagnosis of ovarian masses in both adult women and children from 2008 to 2018.

RESULTS

Sixteen paediatric and 18 adult studies were included. In the included studies, MR imaging has shown good diagnostic performance in differentiating between benign and malignant ovarian masses. MR imaging techniques including diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) imaging seem to further improve the diagnostic performance.

CONCLUSION

The addition of DWI with apparent diffusion coefficient (ADC) values measured in enhancing components of solid lesions and DCE imaging may further increase the good diagnostic performance of MR imaging in the pre-operative differentiation between benign and malignant ovarian masses by increasing specificity. Prospective age-specific studies are needed to confirm the high diagnostic performance of MR imaging in children and adolescents with a sonographically indeterminate ovarian mass.

KEY POINTS

• MR imaging, based on several morphological features, is of good diagnostic performance in differentiating between benign and malignant ovarian masses. Sensitivity and specificity varied between 84.8 to 100% and 20.0 to 98.4%, respectively. • MR imaging techniques like diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) imaging seem to improve the diagnostic performance. • Specific studies in children and adolescents with ovarian masses are required to confirm the suggested increased diagnostic performance of DWI and DCE in this population.

Systematic radiological approach to utero-ovarian pathologies

Ultrasound is the first-line imaging modality for the evaluation of suspected adnexal masses, endometriosis and uterine tumors, whereas MRI is used as a secondary diagnostic tool to better characterize these lesions. The aim of this review is to summarize the latest advances in the imaging of these utero-ovarian pathologies.

[Management of tubo-ovarian abscesses and complicated pelvic inflammatory disease: CNGOF and SPILF Pelvic Inflammatory Diseases Guidelines]

A tubo-ovarian abscess (ATO) should be suspected in a context of pelvic inflammatory disease (PID) in case of severe pain associated with the presence of general signs and palpation of an adnexal mass at pelvic examination. Imaging allows most often a rapid diagnosis, by ultrasound or CT, the latter being irradiant but also allowing to consider the differential diagnoses (digestive or urinary diseases) in case of pelvic pain. MRI, non-irradiating examination, whenever it is feasible, provides relevant information, more efficient, guiding quickly the diagnosis. The diagnosis of tubo-ovarian abscess should lead to the hospitalization of the patient, the collection of bacteriological samples, the initiation of a probabilistic antibiotherapy associated with drainage of the purulent collection. In severe septic forms (generalized peritonitis, septic shock), surgery (laparoscopy or laparotomy) keeps its place. In other situations, ultrasound-guided trans-vaginal puncture in the absence of major hemostasis disorders or severe sepsis is a less morbid alternative to surgery and provides high rates of cure. Today, ultrasound-guided trans-vaginal puncture has been satisfactory evaluated in the literature and is part of a logic of therapeutic de-escalation. Randomized trials evaluating laparoscopic drainage versus radiological drainage should be able to answer, in the coming years, questions that are still outstanding (impact on chronic pelvic pain, fertility). The recommendations for the management of ATO published in 2012 by the CNGOF remain valid, legitimizing the place of radiological drainage associated with antibiotic therapy.

Role of MRI in staging and follow-up of endometrial and cervical cancer: pitfalls and mimickers

MRI plays important roles in endometrial and cervical cancer assessment, from detection to recurrent disease evaluation. Endometrial cancer (EC) is the most common malignant tumor of the female genital tract in Western countries. EC patients are divided into risk categories based on histopathological tumor type, grade, and myometrial invasion depth. EC is surgically staged using the International Federation of Gynecology and Obstetrics (FIGO) system. Since FIGO (2009) stage correlates with prognosis, preoperative staging is essential for tailored treatment. MRI reveals myometrial invasion depth, which correlates with tumor grade and lymph node metastases, and thus correlates with prognosis. Cervical cancer (CC) is the second most common cancer, and the third leading cause of cancer-related death among females in developing countries. The FIGO Gynecologic Oncology Committee recently revised its CC staging guidelines, allowing staging based on imaging and pathological findings when available. The revised FIGO (2018) staging includes node involvement and thus enables both therapy selection and evaluation, prognosis estimation, and calculation of end results. MRI can accurately assess prognostic indicators, e.g., tumor size, parametrial invasion, pelvic sidewall, and lymph node invasion. Despite these important roles of MRI, radiologists still face challenges due to the technical and interpretation pitfalls of MRI during all phases of endometrial and cervical cancer evaluation. Awareness of mimics that can simulate both cancers is critical. With careful application, functional MRI with DWI and DCE sequences can help establish a correct diagnosis, although it is sometimes necessary to perform biopsy and histopathological analysis.

Imaging in the pre-operative staging of ovarian cancer

The main prognostic factor in ovarian cancer is the stage of disease at diagnosis. The staging system in use (FIGO classification, updated in 2014) is based on the surgical-pathological findings. Although surgical staging is the gold standard in ovarian cancer, the initial patient management depends on the imaging-based pre-surgical staging assessment, in order to identify unresectable or difficult to resect disease. Radiologists need to be aware of the strengths of the available imaging modalities, as well as the imaging pitfalls. Clear understanding of pattern of disease spread and review areas are critical for accurate staging and treatment planning. The current standard of care for pre-surgical staging is CT of the thorax, abdomen, and pelvis. This allows a rapid evaluation of disease extent and is fairly accurate in identifying bulky disease but has definite limitations in assessing the extent of small volume disease and in the confirmation of certain sites of disease beyond the abdomen. Functional MRI has been reported to be superior in detecting small peritoneal deposits. PET/CT may be used as a problem-solving tool in some patients where determination remains unclear, particularly in confirmation of advanced stage beyond the abdomen.

The value of MR-detectable ipsilateral ovaries in characterizing the origin and malignancy of an adnexal tumors

OBJECTIVE

To investigate the magnetic resonance (MR) imaging morphological relationship between adnexal tumors and the ipsilateral ovaries to characterize the origin and malignancy of tumors.

MATERIAL AND METHODS

Clinical and MR imaging data of 496 adnexal tumors confirmed by histology (ovary tumors, n = 400, non-ovarian tumors, n = 96; benign tumors, n = 183, borderline tumors, n = 120, and malignant tumors, n = 193) were retrospectively analyzed. The presence and shape of the ipsilateral ovaries within the context of adnexal tumors of different origins, malignancies and configurations were evaluated. The relationships between the presence of the ipsilateral ovary and patient age, menstrual status and tumor size were also analyzed.

RESULT

The ipsilateral ovary was detected on MRI in 23% (90/400) of ovarian tumors and in 45% (43/96) of non-ovarian tumors (p < 0.001). A normal ovoid morphology of the ipsilateral ovary was found in only 7% (26/400) of ovarian tumors and in 26% (25/96) of non-ovarian tumors (p < 0.001). The ipsilateral ovary was detectable in 38% (69/183) of benign tumors, 35% (42/120) of borderline tumors, and 11% (22/193) of malignant tumors (p <  0.001); in 24% (24/101) of cystic tumors, 27% (49/179) of mixed cystic-solid tumors and 28% (60/216) of solid tumors (p = 0.737); and in 40% (120/303) of adnexal tumors in premenopausal patients and 7% (13/193) of adnexal tumors in postmenopausal patients (p < 0.001).

CONCLUSION

Detection of the ipsilateral ovary contributes to the localization and characterization of adnexal tumors. The ipsilateral ovary can be detected more frequently in non-ovarian tumors and in benign or borderline ovarian tumors.

External validation of ADNEX MR SCORING system: a single-centre retrospective study

AIM

To evaluate the accuracy of the ADNEX MR SCORING system for characterising adnexal masses.

MATERIALS AND METHODS

An institutional review board approved this retrospective study. The study population comprised 663 women who underwent magnetic resonance imaging (MRI) from January 2007 to December 2014 to characterise 778 adnexal masses that were indeterminate under ultrasonography (590 benign and 188 malignant). Two radiologists independently reviewed the MRI images. The masses were scored from 1 to 5 according to the ADNEX MR SCORING system. The diagnostic performance of the system was evaluated by receiver operating characteristic (ROC) analysis. Masses scored 4 or greater were considered malignant (including tumours of borderline malignancy or low malignant potential).

RESULTS

The malignancy rates of masses with scores of 2, 3, 4 and 5 were 1.9% (8/419), 12.8% (19/149), 62.6% (57/91) and 87.4% (104/119) for reader 1 and 2.1% (9/424), 13.6% (20/147), 67.6% (71/105) and 86.3% (88/102) for reader 2, respectively. The areas under the ROC curves for the differentiation of benign and malignant masses were 0.929 and 0.923, respectively; the sensitivity, specificity and accuracy of diagnosis were 85.6% (161/188), 91.7% (541/590), and 90.2% (702/778) for reader 1 and 84.6% (159/188), 91.9% (542/590), and 90.1% (701/778) for reader 2, respectively. Tumours of borderline malignancy or low malignant potential had a higher rate of misclassification (46.1%) than other malignant tumours (6-7.4%).

CONCLUSION

The ADNEX MR SCORING system was highly accurate in differentiating benign and malignant adnexal masses, although it may be less accurate for tumours of borderline malignancy or low malignant potential.

Sertoli-Leydig cell tumors of ovary: A case series

INTRODUCTION

The purpose of this study was to report the clinical features, computed tomography (CT) and magnetic resonance imaging (MRI) findings, clinical management, and prognoses of 7 patients with Sertoli-Leydig cell tumors (SLCT) of ovary, and to review the literature of this rare condition.

METHODS

Seven patients with pathologically confirmed ovarian SLCT were included. Their clinical, CT and MRI characteristics (CT images obtained from 6 patients and MR images from 4 patients), clinical management, and prognoses of 7 patients were retrospectively analyzed.

RESULTS

Patients symptoms included irregular menstruation (n = 3), infertile (n = 1), vaginal bleeding after 7 years of menopause (n = 1), a palpable abdominal mass (n = 1), and abdominal pain (n = 1). Three patients had elevated alpha-fetoprotein (AFP), 1 had elevated cancer antigen 125 (CA125), and 2 had elevated Testosterone (T). The 7 tumors of 7 patients were solid or mixed solid-cystic mass with clear boundaries. The solid components of the tumors showed iso-dense on CT. On MRI, the solid components showed iso- or slightly low signal intensity (SI) on T1-weighted imaging (T1WI), high or slightly high SI on T2WI, and high on diffusion-weighted imaging (DWI) with low apparent diffusion coefficient (ADC) value. On contrast-enhanced CT and MRI, 1 tumor exhibited heterogeneous enhancement consisting of multiple nodules with relatively marked homogeneous enhancement, and other 6 tumors showed moderate or marked and constantly heterogeneous enhancements. All patients were treated with surgical excision. Only 3 had received postoperative chemotherapy. With the exception of 1 patient lost to follow-up, the other 6 patients exhibited tumor-free survival with a median follow-up time of 13.5 months, the longest follow-up time being 24 months.

CONCLUSION

The patients of SLCT can present with hormonal magnification and manifest high AFP, CA125, and T levels. SLCT is characterized by a solid or mixed solid-cystic mass on CT/MR scans, and shows marked or moderated heterogeneous and constantly enhancement upon postcontrast study. The clinical characteristics and imaging findings are features and appropriated imaging should be performed whenever an SLCT is suspected.

Endometriosis: clinical features, MR imaging findings and pathologic correlation

Objective

We illustrate the magnetic resonance imaging (MRI) features of endometriosis.

Background

Endometriosis is a chronic gynaecological condition affecting women of reproductive age and may cause pelvic pain and infertility. It is characterized by the growth of functional ectopic endometrial glands and stroma outside the uterus and includes three different manifestations: ovarian endometriomas, peritoneal implants, deep pelvic endometriosis. The primary locations are in the pelvis; extrapelvic endometriosis may rarely occur. Diagnosis requires a combination of clinical history, invasive and non-invasive techniques. The definitive diagnosis is based on laparoscopy with histological confirmation. Diagnostic imaging is necessary for treatment planning. MRI is as a second-line technique after ultrasound. The MRI appearance of endometriotic lesions is variable and depends on the quantity and age of haemorrhage, the amount of endometrial cells, stroma, smooth muscle proliferation and fibrosis. The purpose of surgery is to achieve complete resection of all endometriotic lesions in the same operation.

Conclusion

Owing to the possibility to perform a complete assessment of all pelvic compartments at one time, MRI represents the best imaging technique for preoperative staging of endometriosis, in order to choose the more appropriate surgical approach and to plan a multidisciplinary team work.

Teaching Points

• Endometriosis includes ovarian endometriomas, peritoneal implants and deep pelvic endometriosis.

• MRI is a second-line imaging technique after US.

• Deep pelvic endometriosis is associated with chronic pelvic pain and infertility.

• Endometriosis is characterized by considerable diagnostic delay.

• MRI is the best imaging technique for preoperative staging of endometriosis.

Magnetic Resonance Imaging (MRI) and Transvaginal Ultrasonography (TVU) at Ovarian Pain Caused by Benign Ovarian Lesions

Research goal

The aim of the research is to define the possibilities of TVU and the MRI in the diagnosis of the most common benign ovarian lesions which cause pelvic pain.

Patients and methods

In study were included n=74 patients with pelvic pain, who were examined with TVU and then with an MRI of pelvis. Diagnostic results of all patients (n=74) divided into two groups according to the modality that was performed (TVU results n=74 and MRI results n=74 MRI ). We compared the results of TVU and MRI, and with a pathohistological finding after surgery. TVU test sensitivity and MRI test sensitivity has been made for each pathological entity in particular. The overall sensitivity test of TVU was performed for all pathological entities together. The overall sensitivity test of MRI was performed for all pathological entities together.

Results

TVU demonstrated sensitivity of 83.3% for ectopic pregnancy, 83.3% for ovarian torsion, 84% for endometriotic cyst, 88.2% for hemorrhagic cysts, 58.3% for tubo-ovarian abscesses, 62.5% for dermoid cysts. Overall sensitivity of TVU for all these pathological entities was 78.4%. MRI showed a sensitivity of 100% for ovarian ectopic pregnancy, 83.3% for ovarian torsion, 100% for endometriotic cyst, 100% of hemorrhagic cysts, 83.3% tubo-ovarian abscess, and 87.5% for dermoid cysts. Overall sensitivity of MRI in all of these pathological entities was 94.6%. The analysis using the chi square test shows that there is a significant difference in the sensitivity between the US and MRI in favor of greater overall MRI sensitivity in diagnosing ovarian pain caused by benign lesions. (χ2 = 14.352, df = 9, p = 0.0021).

Conclusion

TVU is the first choice method for ovarian analysis due to the convenience and absence of radiation, and MRI is a very useful modality when TVU's results are confusing and unspecific.

Applying Quantitative CT Image Feature Analysis to Predict Response of Ovarian Cancer Patients to Chemotherapy

RATIONALE AND OBJECTIVES

The study aimed to investigate the role of applying quantitative image features computed from computed tomography (CT) images for early prediction of tumor response to chemotherapy in the clinical trials for treating ovarian cancer patients.

MATERIALS AND METHODS

A dataset involving 91 patients was retrospectively assembled. Each patient had two sets of pre- and post-therapy CT images. A computer-aided detection scheme was applied to segment metastatic tumors previously tracked by radiologists on CT images and computed image features. Two initial feature pools were built using image features computed from pre-therapy CT images only and image feature difference computed from both pre- and post-therapy images. A feature selection method was applied to select optimal features, and an equal-weighted fusion method was used to generate a new quantitative imaging marker from each pool to predict 6-month progression-free survival. The prediction accuracy between quantitative imaging markers and the Response Evaluation Criteria in Solid Tumors (RECIST) criteria was also compared.

RESULTS

The highest areas under the receiver operating characteristic curve are 0.684 ± 0.056 and 0.771 ± 0.050 when using a single image feature computed from pre-therapy CT images and feature difference computed from pre- and post-therapy CT images, respectively. Using two corresponding fusion-based image markers, the areas under the receiver operating characteristic curve significantly increased to 0.810 ± 0.045 and 0.829 ± 0.043 (P < 0.05), respectively. Overall prediction accuracy levels are 71.4%, 80.2%, and 74.7% when using two imaging markers and RECIST, respectively.

CONCLUSIONS

This study demonstrated the feasibility of predicting patients' response to chemotherapy using quantitative imaging markers computed from pre-therapy CT images. However, using image feature difference computed between pre- and post-therapy CT images yielded higher prediction accuracy.

The value of dynamic contrast-enhanced MRI in characterizing complex ovarian tumors

BACKGROUND

The study aimed to investigate the utility of dynamic contrast enhanced MRI (DCE-MRI) in the differentiation of malignant, borderline, and benign complex ovarian tumors.

METHODS

DCE-MRI data of 102 consecutive complex ovarian tumors (benign 15, borderline 16, and malignant 71), confirmed by surgery and histopathology, were analyzed retrospectively. The patterns (I, II, and III) of time-signal intensity curve (TIC) and three semi-quantitative parameters, including enhancement amplitude (EA), maximal slope (MS), and time of half rising (THR), were evaluated and compared among benign, borderline, and malignant ovarian tumors. The types of TIC were compared by Pearson Chi-square χ ² between malignant and benign, borderline tumors. The mean values of EA, MS, and THR were compared using one-way ANOVA or nonparametric Kruskal-Wallis test.

RESULTS

Fifty-nine of 71 (83%) malignant tumors showed a type-III TIC; 9 of 16 (56%) borderline tumors showed a type-II TIC, and 10 of 15 (67%) benign tumors showed a type-II TIC, with a statistically significant difference between malignant and benign tumors (P < 0.001) and between malignant and borderline tumors (P < 0.001). MS was significantly higher in malignant tumors than in benign tumors and in borderline than in benign tumors (P < 0.001, P = 0.013, respectively). THR was significantly lower in malignant tumors than in benign tumors and in borderline than in benign tumors (P < 0.001, P = 0.007, respectively). There was no statistically significant difference between malignant and borderline tumors in MS and THR (P = 0.19, 0.153) or among malignant, borderline, and benign tumors in EA (all P > 0.05).

CONCLUSIONS

DCE-MRI is helpful for characterizing complex ovarian tumors; however, semi-quantitative parameters perform poorly when distinguishing malignant from borderline tumors.

MENOPAUSAL ANDROGEN EXCESS - ASSOCIATED CARDIO-METABOLIC RISK: CLUES FOR OVARIAN LEYDIG CELL TUMOUR (CASE REPORT AND MINI-REVIEW OF LITERATURE)

Background

Ovarian Leydig cell tumour is a very rare steroid hormones producing mass, causing clinical and biochemical hyperandrogenism. Even if the level of evidence is based on case studies, many authors (but not all) agree that raised androgens increase the cardio-metabolic risk thus early diagnosis and treatment are necessary On the other hand, the endocrine features pointing an ovarian tumour source of testosterone do not indicate the specific histological finding which needs a post-operative conformation.

Case presentation

We report a case of a 60-year-old woman with a 4-year history of progressive virilisation in association with hypertension, high number of red blood cells, impaired glucose tolerance and dyslipidemia. Total testosterone was 20 times above normal with suppressed gonadotropins, inadequate for menopause. Trans-vaginal ultrasound and pelvic and abdominal computerized axial tomography imaging revealed a right ovarian solid nodule, and no evidence of alteration in the adrenal glands. Total hysterectomy and bilateral salpingo-oophorectomy were performed. Histopathology and immunohistochemistry confirmed the diagnosis of Leydig cell tumour. After surgery, androgen levels returned to normal and the doses of anti-hypertensive drugs were reduced.

Conclusions

The hyperandrogenic state with elevated plasma testosterone and progressive signs of virilization raises suspicion of an ovarian androgen-secreting tumor. For a postmenopausal patient with hyperandrogenism the diagnosis of Leydig cell tumour should be considered. However, the exact diagnosis is provided by post-operative histological exam. Prolonged exposure to hyperandrogenism may generate cardiovascular abnormalities and metabolic syndrome which after tumor excision and removal of the source of androgen hormones are expected to significantly improve.

Ovarian thecoma-fibroma groups: clinical and sonographic features with pathological comparison

Background

Ovarian thecoma-fibroma groups (OTFG) are uncommon sex cord-stromal neoplasms. The objective of the study was to demonstrate clinical and sonographic features of OTFG and compare with surgical histopathology.

Methods

A total of 61 patients with surgically proven OTFG were enrolled in this retrospective study to demonstrate its clinical and sonographic features and to compare with pathological findings. Gray scale and color Doppler sonography were performed presurgically with either transabdominal or transvaginal approach to image pelvic structures and lesions. The clinical findings and sonographic appearances were compared with the types of the OTFG tumors based on the histopathological diagnosis.

Results

The mean patient age was 53.57 (range, 26–86) years. There were 63.93% (39/61) patients in postmenopausal and 63.93% (39/61) patients with no clinical symptoms. Ultrasound findings of OTFG revealed as solid tumors with a typical feature of well-demarcated hypoechoic masses in 70.49% (43/61), among which 74.41% (32/43) tumors were smaller than 5 cm in diameter. There were 17 mixed echogenic masses with calcification, hemorrhage, or cyst, among which 70.59% (12/17) lesions were larger than 5 cm in diameter. Acoustic attenuation of the tumor was presented in 44.26% (27/61) of the cases. Doppler flow signals within the tumors were found in 20 cases (32.79%), in which 80% (16/20) had minimal or moderate flow signals. Ascites was detected in 32.79% (20/61) of the cases, Megi’s syndrome was found in 1 case. Final pathology revealed 41 (67.21%) thecoma-fibromas, 15 (24.59%) fibromas, 4 (6.56%) thecomas and 1 (1.64%) fibrosarcoma. There were 58 patients underwent cancer antigen 125 (CA125) test, and 20.69% (12/58) showed an elevated level. The diameter of tumors was found to be significantly correlated with CA125 level (p < 0.01) and the amount of ascites fluid (p < 0.05).

Conclusions

The typical sonographic features of OTFG include adnexal hypoechoic masses with clear border and acoustic attenuation as well as minimal Doppler flow signals. All the aforementioned features could make ultrasound imaging as a assistent tool improve the preoperative diagnostic accuracy.

Usefulness of transabdominal real-time sonoelastography in the evaluation of ovarian lesions: preliminary results

OBJECTIVE

We aim to evaluate and describe the tissue elasticity characteristics of various ovarian lesions with sonoelastography.

METHODS

35 patients (age range 16-85 years; mean age 40.8 years) underwent sonoelastography and later MRI. Histopathological confirmation of all lesions was carried out, except eight of endometriomas and six of septated cysts which were confirmed on MRI and follow-up ultrasonography. Strain ratios and elastogram patterns were recorded. Lesions were classified into three groups (Group 1: cystic lesions, Group 2: benign tumours and Group 3: malignant lesions) and findings were compared between groups for both observers. Interobserver agreement was analyzed. Optimal cut-off values for strain ratios were achieved with receiver operating characteristic curve analysis.

RESULTS

Ovarian endometriomas and complex cystic lesions were observed hard on elastograms with high strain ratios, and malignant lesions were observed mostly soft with very small strain ratios. Benign tumours had average tissue stiffness, observed harder than the malignant lesions, and strain ratios ranged from 4 to 14. The differences in patterns and strain ratios between groups were statistically significant (p < 0.05 for both observers).

CONCLUSION

Our study revealed that malignant ovarian lesions have softer tissue property than benign lesions and cystic lesions in terms of elastogram patterns and strain ratios.

ADVANCES IN KNOWLEDGE

Most ovarian lesions contain solid and cystic parts which make the malignant and benign lesions look similar on imaging modalities. Using real-time sonoelastography as an adjunct to other imaging modalities may improve the differentiation of malignant ovarian lesions from benign lesions.