Endometriomas: diagnostic performance of US

A Case Presentation: Decidualized Endometrioma Mimicking Ovarian Cancer during Pregnancy

During pregnancy, masses that are larger than 5 cm and appearing in the Doppler ultrasonography as having increased blood flow, echoes of heterogeneous density, and containing solid components are suspicious for malignancy; however, differential diagnosis of decidualized endometriomas should also be considered. The patient was an 8 weeks pregnant primigravida. The ultrasonographic evaluation showed a cystic mass of size 65 × 57 mm in the left ovary that was well circumscribed, heterogeneous, with highly dense internal echo, and containing a solid component of size 8 × 14 mm. In the 12th week, the ultrasonographic examination revealed an increase in the size of the mass and increased arterial blood flow in the mass. The patient underwent surgery. It was observed that both ovaries were adherent in the Douglas pouch and that the left ovary contained an endometrioma of size 8cm. While the capsule was being peeled, lesions of soft density, with irregular surfaces, and with adhesion in the Douglas pouch were observed. The results of the frozen section revealed decidualized endometrioma and decidual structures. Even in pregnant women when adnexal masses are encountered and the ultrasonography, Doppler, MRI, and CA 125 level analysis still do not favor endometriosis, decidualized endometrioma should be considered in the differential diagnosis.

Do endometriomas induce an inflammatory reaction in nearby follicles?

STUDY QUESTION

Do endometriomas induce an inflammatory reaction with increased cytokine concentrations in nearby follicles and thereby affect follicular development during controlled ovarian stimulation for in vitro fertilization (IVF)?

SUMMARY ANSWER

With most endometriomas, there is no evidence of increased cytokine concentrations in the ipsilateral leading follicle. Infrequently, the concentration of inflammatory cytokines is increased in the follicular fluid (FF) and associated with diminished ovarian response.

WHAT IS KNOWN ALREADY

The link between peritoneal endometriosis, inflammation and infertility is well established; however, the association between intraovarian inflammation and endometrioma is unknown.

STUDY DESIGN, SIZE, DURATION

This prospective cohort study included 117 infertile women undergoing IVF in a tertiary infertility clinic at Oslo University Hospital Rikshospitalet, Norway, during the period May 2009 to September 2011.

PARTICIPANTS, SETTING, METHODS

There were 47 patients with unilateral endometrioma and 17 patients with bilateral endometrioma, while the 53 control patients had unexplained or male factor infertility. Concentrations of IL-1β, IL-6, IL-8, IL-10, IL-12 and TNF-α were measured in serum and in the fluid of the largest pre-ovulatory follicles from each ovary of each participant.

MAIN RESULTS AND THE ROLE OF CHANCE

Cytokine levels in the follicular fluid from the two ovaries in women with unilateral endometriomas were comparable, and were not significantly altered compared with that of control groups with male factor infertility, unexplained infertility or bilateral endometriomas. Compared with serum levels, the follicular fluid levels of IL-8 and IL-6 were higher, suggesting a local production or recruitment. The follicular fluid IL-8 level varied considerably and showed an inverse relationship with IL-12, IL-10 and TNF-∝, suggesting a complex interaction between various immune cells. A small group of patients (n = 3) had increased levels of all follicular fluid cytokines combined with moderately to slightly elevated serum levels and these patients had a significantly lower ovarian response.

LIMITATIONS, REASONS FOR CAUTION

For ethical reasons, the endometriomas were diagnosed indirectly by ultrasound rather than by histology.

WIDER IMPLICATIONS OF THE FINDINGS

This paper reveals that endometriomas seldom induce inflammation in nearby follicles during IVF; therefore, routine cystectomy prior to IVF may not be necessary. Cytokine levels in the follicular fluid, nonetheless, show distinctive patterns and increased levels may be linked to reduced ovarian response independent of the cause of infertility.

The relation of pelvic pain and dense adhesions to Doppler ultrasound findings in patients with ovarian endometriomas

PURPOSE

To study the relation of pelvic pain symptoms and pelvic adhesions to Doppler ultrasound findings in patients with ovarian endometriomas.

METHODS

62 patients who underwent laparoscopic surgery for endometrioma were divided into two groups according to their pelvic pain symptoms. Group 1 (n = 27) included patients with pelvic pain, group 2 (n = 35) asymptomatic patients. Patients were evaluated for the vascularization of endometrioma by transvaginal color and power Doppler ultrasonography before the surgery. The presence and amount of blood flow reported in terms of a color scale, pulsed Doppler indices, and dense pelvic adhesions were compared between the groups. The relation of Doppler ultrasound findings to the dense pelvic adhesions was also analyzed.

RESULTS

Blood flow was present in 74.1 % (n = 20) of patients in group 1 and 68.6 % (n = 24) in group 2 (p = 0.63). The volume and vascularization of the endometriomas, pulsed Doppler indices, stage of endometriosis, and the presence of dense pelvic adhesions were also similar. Patients with dense pelvic adhesions had significantly higher amount of blood flow compared to patients without adhesions (p = 0.006), but the mean pulsatility index and resistance index were not different between the groups (p = 0.55 and 0.59, respectively).

CONCLUSIONS

Pelvic pain symptoms were not found to be related to endometrioma vascularization. On the other hand, we observed an association between higher vascularized endometrioma and the presence of dense pelvic adhesions.

Adnexal masses in pregnancy

Adnexal masses are often seen in the gravid patient. With current advances in technology, an increased number of adnexal masses are incidentally discovered on antenatal screening ultrasonography examinations. Sonography is the first-line imaging modality for any adnexal mass. However, further evaluation with magnetic resonance imaging (MRI) may be critical for diagnosis. For example, MRI can determine whether a mass contains fat, which can be useful in the diagnosis of a teratoma. Characteristic features of nonneoplastic and neoplastic ovarian lesions seen on sonography and MRI will be discussed. Radiologic features that help distinguish benign from malignant neoplasms will be described. Additional lesions specific to the gravid state must be considered in the differential diagnosis when appropriate, such as hyperstimulated ovaries, hyperreactio luteinalis, theca lutein cyst, and luteomas.

Analysis of follicular fluid and serum markers of oxidative stress in women with infertility related to endometriosis

OBJECTIVE

To study the levels of four markers of oxidative stress in follicular fluid (FF) and plasma of patients with infertility related to endometriosis and controls.

DESIGN

Experimental study.

SETTING

University-affiliated hospital and infertility center.

PATIENT(S)

Ninety-one infertile women were included in the study (23 infertile women with endometriosis and 68 controls including infertile women due to tubal factor, male factor, or healthy egg donors).

INTERVENTION(S)

Blood was obtained at the time of egg retrieval, and FF from the mature follicles of each ovary was centrifuged and frozen until analysis.

MAIN OUTCOME MEASURE(S)

Vitamin C and E, malondialdehyde, and superoxide dismutase concentrations in plasma and follicular fluid.

RESULT(S)

Women with endometriosis showed a lower vitamin C concentration in FF (12.7 ± 5.9 vs. 9.7 ± 6.9 μg/mL) and lower superoxide dismutase concentration in plasma (0.9 ± 1.4 vs. 0.5 ± 0.7 U/mL) compared with controls. Vitamin E plasma levels were significantly higher in women with endometriosis (8.1 ± 3.8 vs. 5.2 ± 3.2 μg/mL). A nonsignificant trend toward a lower plasma concentration of malondialdehyde was found in women with endometriosis.

CONCLUSION(S)

These findings suggest a lower antioxidant capacity in infertile women with endometriosis. Although a certain level of reactive oxygen species is required under physiological conditions, an altered balance between pro-oxidant and antioxidant activities may have an impact on folliculogenesis and adequate embryo development.

Deep Infiltrating Endometriosis: Imaging Features and Laparoscopic Correlation

Endometriosis usually affects reproductive-aged women and can be responsible for pain symptoms and infertility. Deep infiltrating endometriosis may involve the uterine ligaments (utero-sacral and/or round ligaments), the retrocervical area, the rectovaginal septum, the rectum, the vagina, and the bladder. The pre-operative assessment of such lesions is required to plan full surgical excision of the disease. Endometriotic lesions have some typical imaging patterns on transvaginal ultrasound and magnetic resonance imaging enabling pre-operative mapping of the disease. In this paper the authors report the imaging features of deep infiltrating endometriosis and the laparoscopic correlation of such lesions.

Subjective assessment of ovarian masses using pattern recognition: the impact of experience on diagnostic performance and interobserver variability

PURPOSE

To compare diagnostic performance and interobserver variability in a group of 36 examiners, with four different levels of experience.

METHODS

Nine junior trainees, eight level I senior trainees, 11 level II senior gynecologists, and eight level III expert sonologists classified 105 ultrasound images of adnexal masses into three subgroups of ovarian lesions (malignancies, functional cysts, and dermoid cysts).

RESULTS

The level III sonologists obtained the best diagnostic results together with the lowest interobserver variability (κ = 0.70, SD = 0.04). They achieved significantly better results in comparison with the junior trainees and also the senior trainees (κ = 0.51, SD = 0.12, p < 0.001; and κ = 0.51, SD = 0.09, p < 0.001). Differences between level III sonologists and the group of level II observers did not reach statistical significance (κ = 0.65, SD = 0.09, p = 0.70). There were no significant differences between senior and junior trainees (p = 1.0) and both groups achieved a significantly poorer diagnostic performance in comparison with the level II observers (p < 0.01 and p < 0.01). For all observers, the largest differences were seen for classifying malignancies, the best results for classifying functional cysts, and the poorest for evaluating dermoid cysts.

CONCLUSIONS

Diagnostic performance of pattern recognition significantly improves with an increasing level of experience, emphasizing the importance of standardized ultrasound training programs with supervision by experts.

Doppler imaging in the diagnosis of ovarian disease

INTRODUCTION

Pelvic ultrasonography remains the non-invasive imaging modality of choice for detecting and characterising adnexal masses. The use of Doppler ultrasound has improved the differential diagnosis of ovarian disease and helped to widen the understanding of the aetiology and possible pathophysiology of the various underlying conditions with an aim of improved diagnosis and management.

AREAS COVERED

This review describes the basis of different Doppler techniques and their application in ovarian disease. The present evidence is critically analysed in an attempt to define the current role of Doppler ultrasound of the ovaries. The technique holds promise in certain ovarian diseases but remains controversial in others.

EXPERT OPINION

Doppler ultrasound has a role in both the clinical and research settings. Clinically, it can be used to differentiate benign and malignant disease and help confirm diagnoses suggested on grey-scale imaging giving the user more confidence. Its use here, however, is generally restricted to a subjective impression of colour flow rather than a quantitative analysis of vascularity or blood flow velocity. These measures are more relevant in the research setting where quantitative Doppler is being used to clarify the possible underlying aetiology of various ovarian diseases such as polycystic ovarian syndrome and benign cysts. Doppler ultrasound has also been used in various models to evaluate the response to ovarian stimulation and the effect of surgery on the ovary.

Recurrent chest pain, as a presenting sign of ovarian endometrioma

Chest pain is a rare sign of thoracal endometriosis associated with endometrioma of the tubo-ovarian endometrioma. We report the case periodic episodes of chest pain concurrent with menstruation in a 35-year-old female, in which ovarian endometrioma was diagnosed and left-sided oophorectomy was performed. After surgery, patient underwent medical treatment which included a Gn-RH agonist and a combined oral contraceptive. In the follow-up period, there was no evidence of chest pain.

Ultrasound evaluation of gynecologic causes of pelvic pain

Ultrasound should be considered the first-line imaging modality of choice in women presenting with acute or chronic pelvic pain of suspected gynecologic or obstetric origin because many, if not most, gynecologic/obstetric causes of pelvic pain are easily diagnosed on ultrasound examination. Since the clinical presentation of gynecologic causes of pelvic pain overlaps with gastrointestinal and genitourinary pathology, referral to CT or MRI, especially in pregnant patients, should be considered if the US examination is nondiagnostic.

The impact of endometrioma and laparoscopic cystectomy on serum anti-Müllerian hormone levels

BACKGROUND

Serum anti-Müllerian hormone (AMH) had been proposed as a marker of ovarian reserve. The aim of this study was to evaluate the impact of endometrioma and laparoscopic cystectomy on ovarian reserve as measured by serum AMH levels.

METHODS

A total of 1,642 patients were recruited in this retrospective analysis. Control group (group 1) included 1,323 infertility patients without endometrioma. Endometrioma group (group 2) included 141 patients with ovarian endometrioma. Previous cystectomy group (group 3) included 147 patients who underwent unilateral or bilateral laparoscopic cystectomy due to ovarian endometrioma more than 6 months before enrollment. Current cystectomy group (group 4) included 31 patients who underwent cystectomy during study period. Serum anti-müllerian hormone (AMH) levels were measured upon enrollment with all patients. For patients in group 4, AMH levels were measured before and 3 months after cystectomy.

RESULTS

Mean AMH level of patients in control group was significantly higher than that of endometrioma group or previous cystectomy group in each age subgroup, while the mean serum AMH level of the endometrioma group was also significantly higher than that of the previous cystectomy group in each age subgroup. The mean AMH level was significantly lower in patients with previous bilateral cystectomy compared to that of patients with unilateral cystectomy. The mean serum AMH level was also significantly lower in patients with bilateral endometrioma compared to that of patients with unilateral endometrioma. In group 4, mean AMH level significantly decreased from 3.95 +/- 0.42 preoperation to 2.01 +/- 0.21 ng/ml at 3-month postoperation.

CONCLUSIONS

Both ovarian endometrioma and cystectomy are associated with a significant reduction on ovarian reserve. Bilateral endometrioma exerts a more profound negative impact on ovarian reserve than unilateral endometrioma, regardless of either conservative or surgical intervention.

Sonovaginography: redefining the concept of a "normal pelvis" on transvaginal ultrasound pre-laparoscopic intervention for suspected endometriosis

Office sonovaginography (SVG) challenges the concept of the "normal" pelvic ultrasound in women with chronic pelvic pain and suspected endometriosis. When positive for posterior compartment deep infiltrating endometriosis, with or without Pouch of Douglas obliteration, office SVG allows for triaging of women to the appropriately trained advanced laparoscopic gynaecological and colorectal surgical team. We advocate that all women with suspected endometriosis undergo office SVG prior to laparoscopy to ensure an accurate pre-operative mapping of endometriosis disease location and extension.

Echogenic foci in the ovary: are they predictive of endometriosis?

OBJECTIVES

The purpose of this study was to determine whether sonographically depicted echogenic foci are more common in the ovaries of women with endometriosis when compared to the ovaries of women who do not have endometriosis.

METHODS

Two radiologists blinded to the pathologic results reviewed the preoperative pelvic sonograms of consecutive women with a surgical diagnosis of endometriosis between June 2006 and October 2007. Results were compared with the preoperative sonograms of a control group of women without surgical evidence of endometriosis. The presence of echogenic foci in the ovaries and ovarian masses was recorded.

RESULTS

Echogenic foci were present in the ovaries of 33 of 70 women (47%) with endometriosis and in the ovaries of 21 of 76 women (28%) without endometriosis (P = 0.015). When only patients with sonographically normal ovaries were evaluated by excluding endometriomas and other ovarian masses, echogenic foci were present in 8 of 23 women (35%) with endometriosis and in 10 of 42 women (24%) without endometriosis (P = .344).

CONCLUSIONS

Echogenic foci are more commonly seen on sonography in the ovaries of women with endometriosis than in those without endometriosis, but this result seems largely due to ovarian endometriomas with echogenic foci in the walls. Echogenic foci are not predictive of endometriosis in women with otherwise sonographically normal ovaries.

Tumors and pseudotumors of the secondary müllerian system: review with emphasis on cross-sectional imaging findings

OBJECTIVE

Microscopic structures lined by müllerian epithelium are frequently seen outside the uterus and fallopian tubes and are termed "müllerian rests" or "secondary müllerian system." Varied entities ranging from benign endosalpingosis to highly malignant ovarian tumors are thought to be derived from the secondary müllerian system. Cross-sectional imaging findings of diseases and disorders of the secondary müllerian system are presented here.

CONCLUSION

Familiarity with a wide spectrum of diseases and disorders of the secondary müllerian system allows accurate diagnosis and management.

CT imaging findings of ruptured ovarian endometriotic cysts: emphasis on the differential diagnosis with ruptured ovarian functional cysts

Objective

The purpose of this study is to assess the prevalence of abnormal CT findings in patients with surgically proven ruptured endometriotic cysts, as compared with those abnormal CT findings of ruptured ovarian functional cysts.

Materials and Methods

This study included 13 retrospectively identified patients with surgically confirmed ruptured ovarian endometriotic cysts and who had also undergone preoperative CT scanning during the previous seven years. As a comparative group, 25 cases of surgically confirmed ruptured ovarian functional cysts were included. We assessed the morphologic features of the cysts and the ancillary findings based on CT.

Results

For the endometriotic cysts, the mean maximum cyst diameter was significantly larger than that of the functional cysts (70.1 mm versus 36.4 mm, respectively, p < 0.05). The endometriotic cysts frequently had a multilocular shape and a thicker cyst wall, as compared to that of functional cysts, and these differences were statistically significant. Among the ancillary findings, endometriotic cysts showed a significantly higher prevalence of loculated ascites, ascites confined to the pelvic cavity without extension to the upper abdomen, and peritoneal strandings and infiltrations (p < 0.05). Although 11 of the 25 cases of functional cysts showed active extravasation of contrast material at the ovarian bleeding site, only one of 13 cases of endometriotic cysts showed active extravasation.

Conclusion

The diagnosis of ruptured endometriotic cyst should be suspected for a woman in whom CT reveals the presence of multilocular or bilateral ovarian cysts with a thick wall and loculated ascites confined to the pelvic cavity with pelvic fat infiltrations.

Management of deep endometriosis

Deep endometriosis is still a challenging disease in terms of diagnosis and treatment. About 10-12% of women of reproductive age will have a form of endometriosis. This can affect pelvic as well as extra pelvic locations. Risk of malignant transformation has been studied over a long period of time. Medical and surgical treatments can be proposed to patients for endometriosis-associated pain depending on the severity of symptoms and location of the disease. Results and outcomes are different according to different publications. Understanding of the benefit of surgical treatment on fertility is increasing. The place of medical and surgical treatment in recurrent symptoms or disease is also of interest. Presented here is a review on the management of endometriosis in the light of recent data. Further investigations in many fields of endometriosis are still required.

Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement

The Society of Radiologists in Ultrasound convened a panel of specialists from gynecology, radiology, and pathology to arrive at a consensus regarding the management of ovarian and other adnexal cysts imaged sonographically in asymptomatic women. The panel met in Chicago, Ill, on October 27-28, 2009, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies, and are thought to represent a reasonable approach to asymptomatic ovarian and other adnexal cysts imaged at ultrasonography.

A new quantitative method to evaluate adnexal tumors

OBJECTIVE

The purpose of this study was to assess endometriomas and follicular cysts using a new quantitative method provided by the picture archiving and communication system.

MATERIALS AND METHODS

We reviewed our computer ultrasound database of endometriomas and follicular cysts between November 2003 and July 2007. A total of 123 consecutive women diagnosed with an endometrioma or follicular cyst on two-dimensional sonography were re-evaluated using new parameters with the picture archiving and communication system. We chose quantitative tumor density and standard deviation on sonographic images as the new diagnostic parameters. Analysis of variance and Scheffé post hoc test were analyzed to compare the mean tumor density of the endometriomas and follicular cysts. The receiver operating characteristic curve was plotted to choose the cutoff value of the endometrioma tumor density with the best sensitivity and specificity.

RESULTS

There was a significant difference when the tumor density of the follicular cyst and endometrioma groups was compared using the vaginal, abdominal or endovaginal approach (p < 0.001). Based on the results of the receiver operating characteristic curve, endovaginal ultrasonography is an excellent diagnostic tool with which to evaluate endometriomas. With endovaginal ultrasonography examination, the best cutoff value of tumor density is 28 and the sensitivity and specificity are 64% and 100%, respectively.

CONCLUSION

The use of quantitative tumor density and standard deviation on sonographic images is a potential new diagnostic tool in the assessment of endometriomas and follicular cysts.

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.

Delayed diagnosis is associated with changes in the clinical and ultrasound features of subcutaneous endometriosis near cesarean section scars

INTRODUCTION

The aim of the present study was to highlight the sonographic and clinical characteristics of large (≥30 mm in diameter) scar endometriomas near Pfannenstiel incisions, assuming that large size is a marker of delayed diagnosis.

METHODS

We compared clinical, ultrasound (US) and color Doppler findings in 13 patients (mean age 31.3 years) with 13 large scar endometriomas (L-SEs) (mean lesion diameter 41.8 mm; range 30-60 mm) and 17 women (mean age 30.7 years) with 19 small scar endometriomas (S-SEs) (mean lesion size 18.3 mm; range 7-26 mm).

RESULTS

Compared with the S-SE group, the L-SE group had a significantly longer mean interval between the last cesarean section and hospital admission (5.5 vs. 3.3 years; p < 0.01) and longer mean duration of symptoms before admission (43 vs. 17.4 months; p < 0.01). The L-SE group also had a significantly higher percentage of patients who had undergone at least one inconclusive diagnostic examination (Computed Tomography, Magnetic Resonance Imaging, fine needle biopsy, or laparoscopy) (39% vs. 0%; p < 0.05). As for US findings, L-SEs more frequently displayed cystic regions and fistulous tracts (p < 0.05), loss of round/oval shape (p < 0.05), and increased vascularity (p < 0.05).

CONCLUSIONS

Delayed diagnosis of scar endometrioma reflected by a longer and more complex medical history results in larger than usual endometriomas with peculiar US findings, which are even more likely to be misinterpreted by physicians and radiologists.

Endometriomas in the region of a scar from Cesarean section: sonographic appearance and clinical presentation vary with the size of the lesion

PURPOSE

To describe the sonographic (US) appearances of endometriomas developed in the vicinity of a scar from Cesarean section and compare sonographic and clinical characteristics of large (> or =3 cm) scar endometriomas (LSEs) with small scar endometriomas (SSEs).

METHOD

Twenty-eight consecutive women (mean age, 31 years; range, 20-42) with 31 scar endometriomas (mean diameter, 2.7 cm; range, 0.7-6 cm) were examined by US, including color Doppler imaging prior to surgery. Clinical and US findings in women with LSE were compared with those of women with SSE.

RESULTS

Twelve patients had 12 LSEs with a mean longest diameter of 4.1 cm (range, 3-6 cm); in 1 case, a large nodule was associated with a small lesion. Sixteen women had 18 SSEs with a mean lesion size of 1.8 cm (range, 0.7-2.6 cm).The mean time interval between the last Cesarean section and hospital admission was longer in patients with LSE (66 versus 40 months; p < 0.01) as was the mean duration of symptoms before admission (43 versus 17 months; p < 0.01); in addition, 41.6% of patients with LSE had undergone previous inconclusive diagnostic examinations (CT, MRI, fine needle aspiration, or laparoscopy) compared with 0% in patients with SSE (p < 0.05). LSEs more frequently showed cystic portions and fistulous tracts (p < 0.05), loss of round/oval shape (p < 0.05), and increased vascularity (p < 0.05) than SSEs did.

CONCLUSION

LSEs were associated with a delay in diagnosis and some US findings that could result in further diagnostic difficulties.

Characterising acute gynaecological pathology with ultrasound: an overview and case examples

This article summarises the ultrasound features of a number of gynaecological emergencies: ectopic pregnancy, haemorrhagic corpus luteum, twisted adnexa, pelvic inflammatory disease, acute myoma necrosis, haematocolpos and haematometra. The basis of all diagnosis in women with acute gynaecological conditions is history and clinical examination. An ultrasound examination should only be performed if it is likely to provide information that would change the likelihood of the diagnosis suspected on the basis of clinical data. If ultrasound findings are abnormal, then it is important to thoroughly evaluate if they do explain the woman's symptoms or if they are merely an incidental finding. If ultrasound findings are completely normal, then the risk of significant pelvic pathology is probably small.

Decidualized ovarian endometriosis in pregnancy: a challenging diagnostic entity

BACKGROUND

The hormonal milieu that characterizes pregnancy may determine profound modifications of ovarian endometriomas leading to lesions mimicking malignancy. In this study, we report on our experience and perform a review of the literature on this issue.

METHODS

Data from women evaluated at our referral center for prenatal diagnosis were reviewed in order to identify those who were detected with an ovarian endometrioma in pregnancy mimicking malignancy. A review of the literature on this issue (1990-2008) was also performed, using the PubMed database.

RESULTS

Three cases were identified at our center. The literature reports on a further 19 cases (11 studies). Sonographic and color Doppler examination consistently documented rapidly growing and abundantly vascularized intracystic excrescences. Conversely, the presence of septations or significant free fluid was never reported. The vast majority of cases underwent surgical removal. Interestingly, in our experience, in a woman who declined surgery and had spontaneous miscarriage at 10 weeks' gestation, the sonographic examination performed 6 weeks after dilatation and curettage revealed an unremarkable typical endometrioma, thus suggesting that it is a transitory transformation.

CONCLUSIONS

Pregnancy-related modifications of an ovarian endometrioma leading to the rapid development of vascularized intracystic excrescences are an uncommon but possible event. An expectant management and serial monitoring should first be envisaged in these cases provided that other features of malignancy, such as septations or free fluid, are absent.

[Imaging of chronic pelvis pain]

This is a review of different diseases implicated in chronic pelvic pain (endometriosis, adenomyosis, pelvic varices, and pelvic chronic inflammatory disease) assessed by different imaging modalities (US, CT, MRI).

Reimaging the female pelvis with ultrasound after CT: general principles

Ultrasound is the most appropriate first imaging test to perform when gynecologic pathology is suspected based on clinical history or physical examination, and imaging is required. However, as a practical matter, a woman's first imaging test evaluating her pelvis may be a computed tomographic (CT) scan; this is especially true when these women present to an acute care facility or emergency department with chronic or acute lower abdominal pain. Radiologists need to be able to recognize the CT features of a variety of gynecologic conditions. However, just as importantly, radiologists should have a firm understanding of general principles that help to clarify when reimaging the pelvis with ultrasound is indicated; furthermore, a clear understanding of these principles helps to focus the sonologist's attention on the sonographic features that will be most helpful in further characterization of abnormal CT findings. This pictorial essay discusses these general principles that clarify when ultrasound is and is not helpful in reimaging the female pelvis after CT.

“Tenderness-guided” transvaginal ultrasonography: a new method for the detection of deep endometriosis in patients with chronic pelvic pain

OBJECTIVE

To determine the accuracy of transvaginal ultrasonography (TVUS) using a modified "tenderness-guided" approach in the diagnosis of deep endometriosis of the cul-de-sac, retrocervical region, and rectovaginal septum.

DESIGN

Prospective study.

SETTING

Academic department of obstetrics and gynecology.

PATIENT(S)

Fifty women scheduled for laparoscopy for chronic pelvic pain.

INTERVENTION(S)

All patients underwent TVUS. The modified tenderness-guided approach consisted of TVUS combined with the introduction of 12 mL of ultrasound transmission gel (instead of the usual 4 mL) in the probe cover to create a stand-off to visualize the near-field area. The posterior fornix was evaluated accurately with an up-and-down sliding movement of the probe. In addition, when the patient indicated that tenderness was evoked by the probe's pressure, the sliding movement was stopped, and particular attention was paid to the painful site for detection of endometriosis lesions.

MAIN OUTCOME MEASURE(S)

Sensitivity, specificity, and kappa values.

RESULT(S)

Using this approach, we obtained a specificity of 95% with a sensitivity of 90%, associated with a very high kappa value of 0.86 (95% CI, 0.56-0.91).

CONCLUSION(S)

Our new TVUS approach appears to be an accurate, inexpensive, and less invasive method for the diagnosis of deep endometriosis.

Variations in appearance of endometriomas

OBJECTIVE

Because of the range of patient ages with endometriosis, the persistence of endometriomas, and the degradation of internal blood products over time, the appearance of endometriomas is variable. The purpose of this study was to identify the prospective diagnoses in cases of surgically proven endometriomas and to illustrate the variety of appearances of endometriomas.

METHODS

Sonographic images from 325 women with histologic confirmation of an adnexal mass during a 16-month period were reviewed. Eighty-seven endometriomas in 71 women were found. Prospective diagnoses were scored as follows: 1, the diagnosis was endometrioma only; 2, the differential diagnosis listed endometrioma first; 3, the differential diagnosis listed endometrioma but not first; 4, the diagnosis did not include endometrioma but included a complex or hemorrhagic cyst; and 5, the diagnosis did not include endometrioma. Lesions with the classic appearance of an endometrioma (hypoechoic mass with diffuse low-level internal echoes) or an atypical appearance were chosen for illustration.

RESULTS

Thirty-five (60.3%) of 58 endometriomas measuring at least 2 cm in greatest dimension included endometrioma in the differential diagnosis at sonography. In 6 (10.3%) of 58, the lesions were described as complex or hemorrhagic cysts. Atypical endometriomas included cases with retracted clots that appeared solid but without blood flow, endometriomas in pregnant patients, and endometriomas in postmenopausal women with heterogeneous internal echoes and central calcification. A ruptured endometrioma was interpreted as pelvic inflammatory disease. Five endometriomas were suspected to be malignancies because of a solid appearance, blood flow, surrounding adhesions, and, in 1 pregnant patient, extensive decidualization.

CONCLUSIONS

Recognition of the varied appearance of endometriomas should aid the interpreting physician in giving an appropriate prospective diagnosis of endometriomas.

A Practical Approach to the Ultrasound Characterization of Adnexal Masses

Because pelvic ultrasound is commonly used to evaluate adnexal masses, it is important to understand the most useful sonographic features for predicting benign and malignant masses. Determining whether an adnexal mass is of ovarian or extraovarian origin is key in arriving at the most likely diagnosis. Most adnexal masses are benign, and each of the most common benign ovarian lesions has a typical sonographic appearance. Additionally, most malignant ovarian neoplasms have a solid component with detectable flow by Doppler ultrasound, allowing one to strongly suggest the diagnosis. We will review an approach to the ultrasound diagnosis of adnexal masses that progresses through a series of 4 questions to help lead one to the most likely diagnosis.