Three-dimensional ultrasound and power doppler improve the diagnosis of ovarian lesions

Is three-dimensional ultrasonography a valuable diagnostic tool for patients with ovarian cancer? Systematic review and meta-analysis

Introduction

This paper was to assess the diagnostic performance and clinical value of three-dimensional ultrasonography (3DUS), three-dimensional ultrasonography power Doppler (3DPD), and 3DUS combined with 3DPD in ovarian cancer (OC).

Methods

The study was registered with PROSPERO (CRD 42023405765). PubMed and Web of Science were searched from inception to 25 January 2022, and reference lists of potentially eligible studies were also manually searched. Patient and study characteristics were extracted by two independent reviewers. Any discrepancies were addressed through discussion. The sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR, respectively), and the area under the receiver operating characteristic curve (AUC) were pooled separately.

Results

We retrieved 2,566 studies, of which 18 were finally enrolled, with 2,548 cases. The pooled sensitivity, specificity, PLR, NLR, and AUC for 3DUS were 0.89 (95% CI: 0.85-0.93), 0.93 (95% CI: 0.88-0.96), 13.1 (95% CI: 7.3-23.4), 0.11 (95% CI: 0.08-0.16), and 0.90 (95% CI: 0.87-0.93), respectively. The pooled sensitivity, specificity, PLR, NLR, and AUC for 3DPD were 0.90 (95% CI: 0.80-0.95), 0.85 (95% CI: 0.71-0.92), 5.8 (95% CI: 3.0-11.2), 0.12 (95% CI: 0.06-0.24), and 0.94 (95% CI: 0.91-0.96), respectively. The pooled sensitivity, specificity, PLR, NLR, and AUC for 3DUS combined with 3DPD were 0.99 (95% CI: 0.73-1.00), 0.95 (95% CI: 0.85-0.99), 21.9 (95% CI: 6.1-78.9), 0.01 (95% CI: 0.00-0.37), and 0.99 (95% CI: 0.98-1.00), respectively.

Conclusions

3DUS, 3DPD, and 3DUS combined with 3DPD are promising diagnostic tools for OC, alongside elevated sensitivity and specificity. However, the combination of 3DUS and 3DPD techniques has higher diagnostic efficiency.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD 42023405765.

Comparison Between 360° 3-D Transvaginal Ultrasound and Magnetic Resonance Imaging for Assessment of Vaginal Invasion in Cervical Cancer: A Preliminary Report

Our goal was to estimate the agreement between 360° 3-D transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) of the vaginal invasion in cervical cancer and to discuss the clinical value of 360° 3-D TVUS. A total of 72 patients with untreated cervical cancer were included in the work. The percentage agreement between 2-D TVUS and MRI in assessing vaginal invasion (yes or no) was 77.8% (kappa, 0.400) and that between 360° 3-D TVUS and MRI was 97.2% (kappa, 0.873). The results of 2-D TVUS demonstrated the following agreement with those of MRI: 77.8% for the upper two-thirds of the vagina (kappa, 0.538), 83.3% for the lower third of the vagina (kappa, 0.471). The results of 360° 3-D TVUS demonstrated the following agreement with those of MRI: 95.8% for the upper two-thirds of the vagina (kappa, 0.907), 98.6% for the lower third of the vagina (kappa, 0.961). The results of 360° 3-D TVUS demonstrated good agreement with MRI, which is less costly and more readily available than MRI and should be considered in the pre-treatment work-up for cervical cancer.

Diagnostic value of ultrasound score, color Doppler ultrasound RI and spiral CT for ovarian tumors

Diagnostic value of ultrasound score, color Doppler ultrasound resistance index (RI) and spiral computed tomography (CT) for ovarian tumors was investigated. In total 224 patients pathologically diagnosed with ovarian tumor after operation in Cangzhou Central Hospital were selected, including 120 patients with benign ovarian tumor and 104 patients with malignant ovarian tumor. Patients with benign and malignant tumors were scored according to the ultrasound scoring criteria. The color Doppler ultrasound examination was performed and the corresponding RI was recorded. At the same time, 64-slice spiral CT was performed, and results were compared with the postoperative pathological diagnosis. Also, the sensitivity, specificity and accuracy of the combined application of the three methods were detected. The RI value of benign ovarian tumor was higher than that of malignant ovarian tumor, displaying statistically significant difference (P<0.05). The sensitivity, specificity and accuracy of the combined application of the three methods were 96.49, 90.91 and 93.75%, respectively. Ultrasound scoring, color Doppler ultrasound RI and 64-slice spiral CT have good diagnostic value for ovarian tumor, and the diagnostic accuracy rate of the combined application is higher. Therefore, different examination methods can be selected in clinic according to the different situations.

Past, present and future ultrasonographic techniques for analyzing ovarian masses

Ultrasonography is today the method of choice for distinguishing between benign and malignant adnexal pathologies. Using pattern recognition several types of tumors can be recognized according to their characteristic appearance on gray-scale imaging. Color Doppler imaging should be used only to perform a semiquantitative color score or evaluate the flow location. International Ovarian Tumor Analysis group had standardized definitions characterizing adnexal masses and suggested the use of 'simple rules' in premenopausal women. Recently, the use of 3D vascular indices has been proposed but its potential use in clinical practice is debated. Also computerized aided diagnosis algorithms showed encouraging results to be confirmed in the future.

Application of Combined Two-Dimensional and Three-Dimensional Transvaginal Contrast Enhanced Ultrasound in the Diagnosis of Endometrial Carcinoma

Objective. The goal of this study was to explore the clinical value of combining two-dimensional (2D) and three-dimensional (3D) transvaginal contrast-enhanced ultrasounds (CEUS) in diagnosis of endometrial carcinoma (EC). Methods. In this prospective diagnostic study, transvaginal 2D and 3D CEUS were performed on 68 patients with suspected EC, and the results of the obtained 2D-CEUS and 3D-CEUS images were compared with the gold standard for statistical analysis. Results. 2D-CEUS benign endometrial lesions showed the normal uterine perfusion phase while EC cases showed early arrival and early washout of the contrast agent and nonuniform enhancement. The 3D-CEUS images differed in central blood vessel manifestation, blood vessel shape, and vascular pattern between benign and malignant endometrial lesions (P < 0.05). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of transvaginal 2D-CEUS and 2D-CEUS combined with 3D-CEUS for diagnosis of benign and malignant endometrial lesions were 76.9%, 73.8%, 64.5%, 83.8%, and 75.0% and 84.6%, 83.3%, 75.9%, 89.7%, and 83.8%, respectively. Conclusion. 3D-CEUS is a useful supplement to 2D-CEUS and can clearly reveal the angioarchitecture spatial relationships between vessels and depth of myometrial invasion in EC. The combined use of 2D and 3D-CEUS can offer direct, accurate, and comprehensive diagnosis of early EC.

Does three-dimensional power Doppler ultrasound predict histopathological findings of uterine fibroids? A preliminary study

OBJECTIVES

To compare three-dimensional (3D) power Doppler sonographic characteristics of fibroids with histopathological parameters.

METHODS

We evaluated sonographically 73 fibroids before myomectomy or hysterectomy. For each, the total fibroid volume, a shell of 3 mm and a 1-cm(3) spherical sample from the most vascularized area on subjective assessment were captured. 3D power Doppler vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were generated in the acquired volumes. The degree of cellularity, ischemic necrosis and fibrosclerosis, as well as CD31 and Ki-67 staining for vascular density and proliferation index, respectively, were estimated using the surgical sample. Pathological data were considered as dependent variables and ultrasound data as independent variables in multivariable logistic regression models including patients' characteristics.

RESULTS

A high histological 'cellular activity score', combining hypercellularity, a fibrosclerosis rate < 25% and positive Ki-67 staining, was statistically related in multivariate analyses to high 3D power Doppler VI in spherical samples (odds ratio (OR), 1.1 (95% CI, 1.0-1.3), P < 0.05) and VFI (OR, 1.3 (95% CI, 1.0-1.8), P < 0.05). Positive CD31 staining was statistically related to high 3D power Doppler VI in spherical samples (OR, 1.1 (95% CI, 1.0-1.3), P < 0.05). In contrast, ischemic necrosis was statistically related to low 3D power Doppler VI in the total volume (OR, 0.6 (95% CI, 0.4-1.0), P < 0.05) and VFI (OR, 0.4 (95% CI, 0.1-1.1), P < 0.05).

CONCLUSION

Vascular density, ischemic necrosis and histological cellular activity score are statistically significantly associated with some 3D power Doppler indices.

Preoperative evaluation and triage of women with suspicious adnexal masses using risk of malignancy index

AIMS

To test the accuracy of risk of malignancy index (RMI) in preoperative prediction of malignancy and treatment of adnexal masses.

METHODS

A total of 302 women with ultrasound diagnosed adnexal masses, and serum measurement of cancer-associated antigen CA-125 levels, were studied. They all had surgical exploration between October 2001 and September 2005 at the Friedrich-Alexander University Women's Hospital, Erlangen, Germany. The RMI was based on menopausal status, ultrasound morphology of adnexal masses and absolute level of serum CA-125. A cut-off of 250 was chosen as the threshold for determining the type of surgical operations (laparotomy versus laparoscopy) and the skill of the surgeons (gynecological oncologist versus general gynecologist). The data obtained were analyzed for baseline characteristics using chi(2) test and analysis of variance (ANOVA). P < 0.05 were statistically significant. The various testing methods were evaluated for sensitivity, specificity, positive and negative predictive values.

RESULTS

The best individual performance was found in RMI at a cut-off of 250 with a sensitivity of 88.2%, specificity of 74.3%, positive predictive value of 71.3% and negative predictive value of 90%. When RMI was used to triage patient treatment, 81.5% of patients who had laparoscopy had histological diagnosis of benign ovarian tumor and 7.5% had malignant tumor. In contrast, 74.4% of patients who had laparotomy had histological diagnosis of malignant ovarian tumor and 16% had benign tumor.

CONCLUSION

Risk of malignant index is a reliable, cheap, readily available and cost-effective method of preoperative discrimination of benign from malignant adnexal masses. It is also helpful in triaging patients to different treatment groups.

Primary Care in Obstetrics and Gynecology — A Place for Advanced Ultrasound?

The evaluation of adnexal masses based on transvaginal sonography (TVS) and when their size is too big- transabdominal US can be facilitated and refined by using color Doppler (CD), power Doppler (PD), and pulsed Doppler(PW), including three-dimensional ultrasound (3D US). With these modes, we obtain information about vascularity and flow indices, and their distribution within a mass. Considering the fact that neoangiogenesis is a main feature of malignancy, this is essential information. Thus, we are able to assume the benign or malignant character of an adnexal mass, make the right choice of additional imaging or biochemical tests, and then channel the treatment appropriately. This is subsequently demonstrated for simple cyst, hemorrhagic cysts, endometrioma, dermoid, serous papillary cystoma, ectopic pregnancy, and ovarian carcinoma.

Abnormal uterine bleeding (AUB) is a common problem in primary care. Compared to transabdominal approach, TVS improves the detection rate of underlying uterine pathology. In conditions like endometrial hyperplasia, polyps, submucous leiomyoma, and endometrial cancer, CD, PD, PW and contrast enhanced transvaginal ultrasound may optimize sonographic evaluation. Saline infusion sonohysterography (SISH) in out patient department (OPD) is an alternative to invasive diagnostic hysteroscopy in patients with AUB.

Care for maternal and fetal well-being during pregnancy is a main task in OPD. The assessment of fetal pathology is almost entirely based on Ultrasound. Several illustrations of fetal anomalies detected during 1st trimester and 2nd trimester screening, of abnormal findings in feto-maternal Doppler ultrasound, and fetal pathology demonstrated in 3D/4D ultrasound mode, conclude this review of advanced ultrasound in primary care.

Three-dimensional power Doppler vascular network assessment of adnexal masses: intraobserver and interobserver agreement analysis

OBJECTIVE

The purpose of this study was to assess intraobserver and interobserver agreement for tumor vascular network evaluation as assessed by 3-dimensional (3D) power Doppler sonography for discriminating benign from malignant adnexal masses.

METHODS

Stored 3D power Doppler angiographic volume data from 39 women with a diagnosis of a vascularized adnexal mass who were evaluated and treated at our institution were retrieved from our database for analysis. Two different examiners (observer A, with 6 years of experience in 3D sonography; and observer B, with 1 year of experience) reviewed 3D sonograms blinded to each other. Three-dimensional vascular network reconstruction was done with surface rendering in the color mode. Malignancy was considered in the presence of at least 2 of the following: irregular branching, vessel caliber changes, microaneurysms, and vascular lakes. A definitive histologic diagnosis was obtained in all cases. Intraobserver and interobserver agreement rates were estimated by calculating the kappa index.

RESULTS

Twenty (51%) tumors were malignant, and 19 (49%) were benign. Intraobserver agreement was good for observer A (kappa = 0.69) and moderate for observer B (kappa = 0.54). Interobserver agreement was moderate (kappa = 0.49).

CONCLUSIONS

We found intraobserver and interobserver agreement to be moderate for 3D power Doppler assessment of the vascular network in adnexal masses.

A critical analysis of Doppler velocimetry in the differential diagnosis of malignant and benign ovarian masses

OBJECTIVES

To evaluate the intratumoral reliability of color Doppler parameters and the contribution of Doppler sonography to the gray-scale differential diagnosis of ovarian masses.

METHODS

An observational study was performed including 67 patients, 15 (22.4%) with malignant ovarian neoplasm and 52 (77.6%) with benign ovarian diseases. We performed the Doppler evaluation in two distinct vessels selected after decreasing the Doppler gain to sample only vessels with higher velocity flow. Doppler measurements were obtained from each identified vessel, and resistive index (RI), pulsatility index (PI), peak systolic velocity (PSV), and end-diastolic velocity (EDV) were measured. Intraclass coefficient of correlation (ICC), sensitivity, specificity, and potential improvement in gray-scale ultrasound performance were calculated.

RESULTS

The general ICC were 0.60 (95% CI 0.42-0.73) for RI, 0.65 (95% CI 0.49-0.77) for PI, 0.07 (95% CI -0.17-0.30) for PSV, and 0.19 (95% CI -0.05-0.41) for EDV. The sensitivity and specificity were respectively 84.6% and 86.7% for RI, 69.2% and 93.3% for PI, 80.0% and 65.4% for gray-scale sonography, and 93.3% and 65.4% for gray-scale plus RI (p = 0.013).

CONCLUSIONS

Gynecologists must be careful in interpreting results from Doppler evaluation of ovarian masses because PSV and EDV present poor intratumoral reliability. The lower RI value, evaluated in at least two distinct sites of the tumor, was able to improve the performance of gray-scale ultrasound in differential diagnosis of ovarian masses.

Early detection of ovarian cancer

Ovarian cancer is associated with an overall mortality of 75%, but can be cured in up to 90% of cases if diagnosed while still limited to the ovaries. Given the low prevalence of ovarian cancer in the general population, an effective screening strategy must not only have a high sensitivity for early-stage disease (>75%), but must also have a very high specificity (99.6%) to prompt no more than ten operations for each case of ovarian cancer diagnosed (positive predictive value [PPV] of 10%). Attempts to develop an effective screening strategy for ovarian cancer have utilized ultrasonography and serum tumor markers. Transvaginal sonography (TVS) and the serum marker CA125 have received the most attention to date. Used individually on a single occasion, neither of these approaches provides an adequate PPV and the cost of annual TVS is significant. Recent clinical trials have focused on serial monitoring of CA125 and the sequential use of a rising CA125 to prompt TVS in a limited number of women screened. Sequential monitoring of CA125 has significantly improved specificity of the assay in women over 50 years of age. The limited sensitivity of CA125 has, however, prompted a search for multiple serum markers that, in combination, would detect more than 90% of early-stage disease. Recent developments in genomic and proteomic research have identified a number of candidate biomarkers. Platforms have been developed that can assay more than 50 analytes in a few hundred microliters of serum. Panels of biomarkers have been discovered with high sensitivity and specificity for early-stage disease, but these require prospective validation. Several biomarkers have also been detected in urine, raising the possibility of a less expensive, more convenient screening test. Imaging techniques have been improved and mathematical methods developed that, in aggregate, promise to provide an effective screening strategy for ovarian cancer. In this review, we will assess the current status and describe future directions in ovarian cancer screening.

Three-dimensional quantification of tumor vascularity as a tertiary test after B-mode and power Doppler evaluation for detection of ovarian cancer

OBJECTIVE

The purpose of this study was to investigate the role of 3-dimensional (3D) quantification of tumor vascularity in the differential diagnosis of pelvic indeterminate masses with a solid appearance or unilocular or multilocular cysts with a solid component showing central vascularization on 2-dimensional power Doppler sonography.

METHODS

One hundred fifty-seven consecutive pelvic masses in 153 patients were included in this study and underwent sonography before surgery. Masses that showed a typical benign pattern on B-mode sonography (n = 112) and indeterminate masses with peripheral or absent flow on power Doppler sonography (n = 10) were not evaluated by 3D sonography. Only masses with central vascularization were submitted to 3D power Doppler imaging (n = 35). The following 3D vascular parameters were calculated: relative color and flow measure (similar to the vascularization flow index obtained with other systems).

RESULTS

With receiver operating characteristic curve analysis, the best cutoff values for relative color and flow measure were 4.4 and 2.7, respectively. Flow measure had sensitivity of 68% and specificity of 40% in the overall population submitted to 3D power Doppler sonography. Accuracy slightly increased when masses with small papillary projections (<10 mL) were excluded. In this group (n = 22), sensitivity was 83%, and specificity was 50%.

CONCLUSIONS

In masses with central vascularization on 2-dimensional power Doppler sonography, the use of 3D quantification of tumor vascularity had low diagnostic accuracy in the detection of adnexal malignancies, although an increase in accuracy in masses with a solid portion of greater than 10 mL was reported.

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.

Tele-virtual sonography

OBJECTIVES

3D-Ultrasound reconstruction, routinely available since 1994, has brought new technical capabilities such as virtual sonography that can be tele-consulted. Our experience is summarized in the present paper.

METHODS

During one year, 73 3D-US volumetric images coming from 34 patients were acquired and 68 were consulted at distance. Acquisitions were carried out through an existing 2D device adding a magnetic tracking system on the US-probe. Probe positioning and video output was introduced into a PC running software that allows the generation of 2D-orthogonal and 3D volume images, as well as tele-consultation. Several image analysis techniques for 3D-reconstruction were evaluated.

RESULTS

Final volumes were small (1.5 Mb) and required about 4+/-2 min to be transmitted over one ISDN channel (64 Kbs). Good correlation (k = 0.7) was found between local and distant diagnoses. In 30%, images were considered of low quality and in 29% of good quality; diagnosis could be done with confidence in all except 7 cases. Virtual sonography, by means of oblique cuts in all space directions, improved distant diagnostic confidence. Limitations were linked to incomplete sampling due to the short acquisition time periods (26 s) and difficulties on hand-free probe movement. 3D reconstructions were time consuming (20 min to 4 h) and of limited indication.

CONCLUSIONS

3D reconstruction could reduce multiple explorations due to image constrains such as suboptimal fetal positioning, among others. Virtual sonography was important to reach confidence on distant diagnosis; it was also considered a tool for off-line local review of non-trained sonographer acquisitions.

Screening for ovarian cancer in the general population

Screening for ovarian cancer in the general population presents several unique challenges. Without a clearly identified premalignant state, efforts have focused on detection of early stage disease. Towards this end, investigators have focused on the use of serum markers and transvaginal ultrasound. CA125 determination is the most reliable serum marker in use, and utilization of serial measurements to calculate risk of cancer appears to have greater utility than evaluation of a single value. Multimodality screening focuses on combining serial CA125 measurement with transvaginal ultrasound follow-up for those with abnormal values. Large prospective trials, such as the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS), are currently underway to assess the impact of various screening strategies on mortality, and to evaluate feasibility, acceptability, and morbidity of screening. Future research efforts will undoubtedly focus on promising techniques to examine the serum proteosome for patterns to identify early ovarian cancer.

Outcome of surveillance and prophylactic salpingo-oophorectomy in asymptomatic women at high risk for ovarian cancer

OBJECTIVE

Women at high risk of ovarian cancer are currently offered two options: either surveillance or prophylactic bilateral salpingo-oophorectomy. The efficacy and outcome of surveillance remain unclear.

METHODS

We performed a retrospective study. Between 1994 and 2000, we screened 383 high-risk women, of which 152 were BRCA1/2 mutation carriers. Surveillance consisted of annual gynecological examination, transvaginal ultrasound, and serum CA125 measurement. Exploratory or prophylactic surgery was performed in selected cases.

RESULTS

There were no screen-detected primary ovarian cancers. Abnormal results at surveillance were observed in 74 (19.3%) of women; in 47 (63.5%), the abnormalities disappeared spontaneously. Exploratory surgery was performed in 20 (27.0%) women in whom one malignancy was found (metastatic breast cancer in the ovary). A rising CA125 value prompted further (non-surgical) evaluation in three women with a history of breast cancer: recurrent breast cancer was diagnosed in two women; in the third, a chondrosarcoma was found. 133 women opted for prophylactic bilateral salpingo-oophorectomy, whereby two unexpected malignancies were found (fallopian tube cancer and metastatic breast cancer). One interval primary ovarian cancer occurred, presenting as papillary serous carcinoma of the peritoneum 14 months after prophylactic bilateral salpingo-oophorectomy. Complications of prophylactic surgery were encountered in 15 (11.5%) women.

CONCLUSIONS

Ovarian cancer surveillance has limited sensitivity, and a high number of false positive findings. This can lead to unnecessary surgical interventions, possibly resulting in surgery-related complications. It is important to inform high-risk women of these limitations. For now, prophylactic bilateral salpingo-oophorectomy remains the optimal risk-reducing strategy for women at high risk.

Does quantitative analysis of three-dimensional power Doppler angiography have a role in the diagnosis of malignant pelvic solid tumors? A preliminary study

OBJECTIVE

To investigate the role of a simplified method for the three-dimensional (3D) quantification of tumor vascularity in the differential diagnosis of solid pelvic masses.

METHODS

Twenty-four patients with a solid pelvic mass on B-mode ultrasound evaluation underwent 3D power Doppler evaluation before surgery. The volume of interest was obtained by drawing the largest section of the mass in three orthogonal planes. The following 3D vascular parameters were calculated for all patients: relative color, average color and flow measure. Receiver-operating characteristics curve analysis was used to choose the best cut-off value. The overall agreement between the test result and the actual outcome was calculated using kappa statistics.

RESULTS

Fifteen of 24 subjects were found to have pelvic malignancy. The relative color and the flow measure were significantly higher in malignant (9.7 (8.98) and 8.95 (8.78) (median (interquartile range (IQR)), respectively) than in benign masses (2 (4.42) and 1.79 (4.71), respectively; P < 0.05) but there was no difference in the average color. The best cut-off values of relative color and flow measure were 3.2 and 2.8, respectively. The use of relative color showed a sensitivity of 80% with a specificity of 67% with an overall agreement that was higher, though only marginally so, than that of qualitative 3D power Doppler (kappa = 0.47 and 0.44, respectively).

CONCLUSIONS

In a small group of pelvic masses that appear malignant on B-mode ultrasonography, the use of 3D quantification of tumor vascularity yields a diagnostic accuracy that is similar to that of subjective evaluation of vascularity. We suspect, however, that the quantitative method will produce more consistent results between operators.

Three-dimensional ultrasound to assess the response to treatment in gynecological malignancies

OBJECTIVE

To report the potential role of 3D ultrasound to assess the response to treatment in gynecological malignancies.

METHODS

The volumes and three 3D power Doppler indices are measured in one case of cervix carcinoma and in one case of ovarian carcinoma with primary radio- and/or chemotherapy before and after treatment.

RESULTS

After treatment, tumor volume, vascularization index (VI), flow index (FI), and vascularization-flow index (VFI) were reduced in both two cases.

CONCLUSION

3D ultrasound may provide a new method to assess the response to treatment in gynecological malignancies.

The role of ultrasound evaluation in the detection of early-stage epithelial ovarian cancer

OBJECTIVE

Epithelial ovarian cancer kills more women than all other gynecologic malignancies combined because of our inability to detect early-stage disease. Ultrasonography has demonstrated usefulness in the detection of ovarian cancer in asymptomatic women, but its value for the detection of early-stage epithelial ovarian cancer in women of increased risk is uncertain. We examined the usefulness of sonography in the detection of early-stage epithelial ovarian cancer in asymptomatic high-risk women who participated in the National Ovarian Cancer Early Detection Program.

STUDY DESIGN

Only asymptomatic women of increased risk for the development of ovarian cancer with initial normal gynecologic and ultrasound examinations were eligible to participate in the institutional review board-approved National Ovarian Cancer Early Detection Program. Participants underwent comprehensive gynecologic and ultrasound examinations every 6 months. Increased risk includes women with at least 1 affected first-degree relative with ovarian cancer; a personal history of breast, ovarian, or colon cancer; > or =1 affected first- and second-degree relatives with breast and or ovarian cancer; inheritance of a breast cancer mutation from an affected family member, or membership within a recognized cancer syndrome.

RESULTS

The average age of the 4526 women who were evaluated was 46 years; 2610 women were premenopausal, and 1916 women were postmenopausal. A total of 12,709 scans have been performed since 1990. Visualization of both ovaries was noted in 98% of premenopausal and in 94% of postmenopausal women. Fourteen women had undergone unilateral salpingo-oophorectomy. Recall rates at less than the routine 6-month interval were 0.4% in the premenopausal and 0.3% in postmenopausal women. A total of 98 women with persistent adnexal masses were identified, and 49 invasive surgical procedures were performed that diagnosed 37 benign ovarian tumors and 12 gynecologic malignancies. All cancers were detected in asymptomatic women who had normal ultrasound and physical examinations 12 and 6 months before the cancer diagnosis. The detected malignancies were fallopian tube carcinoma (stage IIIC; n = 4 women), primary peritoneal carcinoma (n = 4 women; stage IIIA, 1 woman; stage IIIB, 2 women; stage IIIC, 1 woman), epithelial ovarian cancer (stages IIIA and IIIB; n = 2 women), and endometrial adenocarcinoma (stage IA; n = 2 women). Additionally 37 primary and 12 recurrent breast carcinomas were detected by physical examination. A total of 184 women with genetic predisposition (breast cancer positive) have undergone a prophylactic bilateral salpingo-oophorectomy; 23% of these procedures found atypical hyperplasia, and unexpectedly, 2 women (1%) were found to have stage III (A and B) primary peritoneal carcinoma.

CONCLUSION

This study demonstrates the limited value of diagnostic ultrasound examination as an independent modality for the detection of early-stage epithelial ovarian cancer in asymptomatic women who are at increased risk for disease.

Comparison of 2-dimensional and 3-dimensional power-Doppler imaging in complex adnexal masses for the prediction of ovarian cancer

OBJECTIVE

The purpose of this study was to compare 2-dimensional and 3-dimensional power-Doppler imaging diagnostic performance for the prediction of ovarian cancer in complex adnexal masses.

STUDY DESIGN

Sixty-nine complex adnexal masses in 60 women (mean age, 48.4 years [range, 17-82 years]) were evaluated by 2-dimensional and 3-dimensional power-Doppler imaging for differentiating benign from malignant masses. Complex adnexal mass was defined in the presence of at least 1 of the following features: solid areas, thick papillary projections, thick septa, or purely solid echogenicity. One examiner performed 2-dimensional power-Doppler imaging, and a second examiner performed 3-dimensional power-Doppler imaging. All masses were removed surgically, and definitive diagnosis was obtained. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for both techniques.

RESULTS

Forty-five tumors (65.2%) were proved to be malignant, and 24 tumors (34.8%) were proved to be benign. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for 2-dimensional power-Doppler imaging were 97.8%, 87.5%, 93.6%, 95.5%, and 94.2%, respectively. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for 3-dimensional power-Doppler imaging were 97.8%, 79.2%, 89.9%, 95%, and 91.3 % respectively. There were no statistical differences in sensitivity and specificity (McNemar test: P = .250)

CONCLUSION

Three-dimensional power-Doppler imaging did not have a better diagnostic performance than 2-dimensional power-Doppler imaging for the discrimination of benign from malignant complex adnexal masses.

Three-dimensional power Doppler imaging of early-stage cervical cancer

OBJECTIVES

To characterize intratumoral vascularization in early-stage cervical cancer by three-dimensional (3D) power Doppler ultrasound.

METHODS

One hundred and forty-one patients with carcinoma of the uterine cervix and 30 normal controls were studied by transvaginal 3D power Doppler ultrasound. The tumor volume of the cervical cancer was determined. The blood flow within the tumor or normal cervix was measured and expressed as the vascularization index (VI), flow index (FI) and vascularization flow index (VFI).

RESULTS

Of the 141 patients with cervical cancer, 44 patients had undergone prior cervical conization. Eighty-seven patients had measurable cervical tumors, of whom five had had prior conization. Abundant intratumoral power Doppler signals could be detected, and the VI, FI and VFI were significantly elevated in cervical cancer patients compared with women with a normal cervix and patients in whom no cervical tumor could be detected (P < 0.05, one-way ANOVA). We observed four types of intratumoral vascularity patterns, which did not significantly differ in VI, FI and VFI: localized, peripheral, scattered and single-vessel types. Cervical tumor volume was positively correlated with FI (linear regression, r = 0.373, P = 0.001), but not with VI or VFI.

CONCLUSIONS

3D power Doppler ultrasound provides a useful tool to investigate intratumoral vascularization and volume of cervical cancer.

Three-Dimensional Ultrasound in Small Parts

For longer than 40 years, ultrasound (US) has been a widely used imaging tool in medical practice, which has proved helpful for the diagnosis and staging of diseases. Although three-dimensional ultrasound (3D) US has been available for more than 10 years, it was only through the development of the most recent computer technologies and its adaptation to ultrasound systems, that 3D US has become able to achieve the high level of sensitivity and performance necessary to be considered seriously in clinical practice. 3D US is rapidly turning into a technology with an ever-increasing range of applications in numerous fields because, among other reasons, it helps overcome some of the key limitations related to two-dimensional imaging. 3D US can be used in ultrasonography for small parts, among other medical areas. The assessment of the testicle, parotid, thyroid and parathyroid glands is properly achieved. The multiplanar presentation and niche mode are quite useful to determine the extension--inside or outside the organs-, of nodules, cysts or tumors. The volume measurement is better assessed with 3D US and given this, we can perform studies that follow growth in order to decide medical or surgical treatment. The VOCAL makes it possible to obtain a proper after-treatment follow-up of focal disorders in these small organs. Neovascularization is clearly viewed with 3D US and probably can suggest malignant origin of a neoplasm. 3D US offers a more comprehensive image of anatomical structures and pathological conditions and also permits to observe the exact spatial relationships. We are aware more studies are needed to demonstrate specificity and sensibility of 3D US in particular clinical conditions, not only in small parts but also is some other non-Ob/Gyn applications.

Risk of malignancy index in the preoperative evaluation of pelvic masses

OBJECTIVES

To assess the ability of a risk malignancy index (RMI) based on serum levels of CA 125, ultrasound findings, and menopausal status to discriminate between benign and malignant pelvic masses in a particular population.

METHODS

A retrospective study was conducted of 100 women with pelvic masses admitted for laparotomy. The sensitivity and specificity of serum levels of CA 125, ultrasound findings, and menopausal status were calculated both separately and combined into a RMI to diagnose malignancy.

RESULTS

The RMI was more accurate than any single criterion in diagnosing malignancy. Using a cut-off level of 200 to indicate malignancy, the RMI gave a sensitivity of 90%, specificity of 89%, positive predictive value of 96%, and negative predictive value of 78%.

CONCLUSION

The RMI is able to correctly discriminate between malignant and benign pelvic masses. It is a simple scoring system that can be introduced easily into clinical practice to facilitate the selection of patients who would benefit from primary surgery.

Transvaginal three-dimensional ultrasonography combined with serum CA 125 level for the diagnosis of pelvic adhesions before laparoscopic surgery

STUDY OBJECTIVE

To investigate the role of transvaginal three-dimensional ultrasonography combined with serum CA 125 level in diagnosing pelvic adhesions before scheduled laparoscopic surgery.

DESIGN

Prospective study (Canadian Task Force classification II-1).

SETTING

Tertiary care academic hospital.

PATIENTS

Fifty-nine women with an adnexal mass diagnosed by two-dimensional transvaginal ultrasonography.

INTERVENTION

Preoperative transvaginal three-dimensional ultrasonography and serum CA 125 level, followed by laparoscopy or laparotomy.

MEASUREMENTS AND MAIN RESULTS

Pelvic adhesions were correctly identified by transvaginal three-dimensional ultrasonography in 26 of 32 women in whom the lesions were confirmed at laparoscopy or laparotomy. Mean serum CA125 level in women with adhesions was 70 +/- 73.7 U/ml, which was significantly higher than that in women without adhesions (24 +/- 16.16 U/ml, p = 0.004). The sensitivity of combined transvaginal three-dimensional ultrasonography and serum CA 125 level was 90%, specificity was 100%, positive predictive value was 100%, and negative predictive value was 89%. The two methods showed strong agreement with surgical results (kappa = 0.889). Eight scheduled laparoscopies (13.6%) were converted to laparotomy due to severe adhesions. One patient (1.7%) experienced colon injury during laparoscopic adhesiolysis.

CONCLUSION

Transvaginal three-dimensional ultrasonography combined with serum CA 125 level is sensitive in detecting pelvic adhesions before laparoscopic surgery. Patients with suspected severe pelvic adhesions should have preoperative bowel preparation to reduce the risk of intraoperative injury.

The detection of stage I ovarian cancer by three-dimensional sonography and power Doppler

OBJECTIVE

The objective was to determine the diagnostic accuracy of three-dimensional (3D) sonography and 3D power Doppler imaging, used together with standard 2D transvaginal grayscale and color/power Doppler modalities, for preoperative sonographic assessment of suspected ovarian lesions.

METHODS

Five-year retrospective analysis was performed by our experts on ultrasonography and surgery on the reports from 43 referred patients with suspected stage I ovarian cancer. All patients were evaluated during the week prior to surgery at our department. Preoperative sonographic assessment included careful examination of ovarian volume, morphology, and vascularity by four complementary sonographic methods. Scoring systems combining morphological and Doppler parameters were adopted for 2D and 3D sonographic examinations. Final diagnosis was confirmed by a histopathologist.

RESULTS

Out of the 43 stage I ovarian cancers, 42 cases were successfully detected preoperatively by four complementary sonographic methods. Only 30 (69.8%) and 37 (86.1%) cases of stage I ovarian cancer were detected by 2D grayscale and combined 2D grayscale and color Doppler sonography, respectively. Morphological analysis obtained by 3D sonography alone detected 32 of 43 ovarian malignancies, reaching a diagnostic rate of 74.4%. Qualitative analysis of tumor vascularity architecture by 3D power Doppler significantly improved the sonographic management process and successfully detected 41 cases of stage I ovarian cancer (95.4%). When morphological features obtained by 3D sonography were added to 3D power Doppler findings, we achieved an even higher diagnostic accuracy of 97.7%. We found a statistically significant difference (P </= 0.01) in diagnostic rates of 3D power Doppler, and especially the combined use of 3D sonography and 3D power Doppler in comparison to those obtained with transvaginal 2D grayscale (P </= 0.002 and P </= 0.001, respectively) or 3D sonography (P </= 0.006 and P </= 0.002, respectively).

CONCLUSIONS

In comparison to transvaginal 2D grayscale or 3D sonography, 3D power Doppler and especially the combined use of 3D sonography and power Doppler imaging significantly improve diagnostic accuracy in preoperative sonographic assessment of suspected ovarian lesions.

Toward understanding the natural history of ovarian carcinoma development: a clinicopathological approach

OBJECTIVE

The natural history of the development of ovarian carcinoma is not known. It also remains undetermined whether ovarian carcinomas develop from benign and/or borderline malignant tumors or arise de novo from the ovarian surface epithelium.

METHODS

To address these issues clinicopathologically, we reviewed the clinical charts of 543 patients with epithelial ovarian carcinoma and 252 patients with borderline tumors who underwent laparotomy at seven hospitals and collected patients whose clinical and transvaginal ultrasonography (USG) findings for adnexal regions 12 months or fewer prior to the surgery were available. Histological slides of the resected specimens were reexamined concerning the diagnosis and histological grade, as well as the presence or absence of benign- or borderline-like lesions adjacent to the carcinoma.

RESULTS

Forty-nine patients had had gynecological examination with transvaginal USG 12 months or fewer prior to laparotomy. Among them, 35 had carcinomas (11 serous, 6 mucinous, 8 clear cell, 10 endometrioid) and 14 had borderline tumors (8 serous, 6 mucinous). Of the 35 patients with carcinoma, 19 (54%) had been followed up for benign-appearing cysts or endometriotic cysts. In these cases, serial USG examinations revealed an increase in size and/or appearance of the solid part of the cyst. In the remaining 16 (46%), however, there had been no apparent abnormalities in USG, and such cases occurred most frequently for serous carcinomas.

CONCLUSIONS

Our findings suggest that approximately half of ovarian carcinomas develop secondarily from preexisting, benign-appearing cysts or endometriotic cysts, whereas the remaining half seem to develop suddenly from a normal-appearing ovary. This appears to be consistent with two possible pathways of ovarian carcinoma development; adenoma-carcinoma sequence and de novo carcinogenesis.

Risk-of-malignancy index in preoperative evaluation of clinically restricted ovarian cancer

CONTEXT

There is no adequate preoperative method for differentiating between benign and malignant pelvic masses. Evaluations of CA 125 serum levels, ultrasonography findings and menstrual state have been tested in isolation as diagnostic methods. The evaluation of these three methods in association with each other could improve diagnostic performance.

OBJECTIVE

To evaluate the risk-of-malignancy index by combining serum CA 125 levels, ultrasound score and menopausal status in preoperative diagnoses for women with pelvic masses clinically restricted to the ovaries and without clear evidence of malignancy.

DESIGN

Cross-sectional study.

SETTING

Centro de Atenção Integral à Saúde da Mulher, Universidade Estadual de Campinas, Campinas, São Paulo, Brazil.

PARTICIPANTS

158 women admitted between January 1996 and March 1998 for surgical exploration of pelvic masses.

PROCEDURES

The risk-of-malignancy index was calculated as US x M x CA 125, performed preoperatively. Ultrasound findings were classified according to the shape, size, multiplicity, presence of wall expansion involvement or ascites, using a score system (US). Menopausal status was considered as 1 for premenopausal and 3 for postmenopausal (M), and CA 125 serum levels were considered in absolute values.

STATISTICAL ANALYSIS

Most relevant variables were included in a logistic multiple regression model, fitted using the ultrasound score, the serum CA 125 level and the menopausal status. The model was used for evaluating the performance of each individual predictor in determining the malignancy of these tumors and identifying the risk-of-malignancy index.

RESULTS

The best individual performance was found in CA 125 levels (sensitivity of 78%, specificity of 75%), followed by ultrasound score (sensitivity of 75%, specificity of 73%) and menopausal status (sensitivity of 73%, specificity of 69%). The performance obtained for the risk-of-malignancy index at the cut-off point of 150 was a sensitivity and specificity of 79%. The area under the ROC curve for the risk-of-malignancy index was 0.90, which was greater than the area for CA 125 levels (0.83) or ultrasound score (0.79).

CONCLUSION

The risk-of-malignancy index using ultrasound morphological score, serum CA 125 levels and menopausal status might be of value in the preoperative assessment of ovarian carcinomas.

Detection and characterization of adnexal masses

The main challenge to the radiologist is to differentiate benign from malignant adnexal masses. Both US and MRI perform well for prediction of benignity. There is less specificity for diagnosis of malignancy but features, such as papillary projections, thickened septations, and internal vascularity within nodules, aid in this differentiation. The combination of morphology and Doppler characteristics provide the most accurate US diagnosis. For sonographically indeterminate masses, MRI is useful for additional lesion characterization. Analysis of T1- and T2-weighted signal intensities for benign-appearing lesions with the addition of fat saturation for high signal on T1-weighted sequences may lead to an exact diagnosis or a narrow differential. For cases considered suspicious by TVUS, more specific diagnosis by MRI may obviate the need for surgery or otherwise change management by identification of benign etiology.

Ultrasonic assessment of the peri- and postmenopausal ovary

OBJECTIVE

To analyze the role of B-mode ultrasound, color and power Doppler examination and three-dimensional ultrasound with and without power Doppler facilities in evaluation of the peri- and postmenopausal ovaries.

METHODS

Review of the literature on ultrasonic assessment of the ovaries in postmenopausal patients.

RESULTS

Ultrasound has assumed an increasing role in the evaluation of the peri- and postmenopausal ovaries. Ovarian lesions are a cause of great concern because of their malignant potential and the limited ability to distinguish accurately between benign and malignant lesions using morphological sonographic criteria alone. Superimposed color Doppler imaging enables the visualization of vascularization and blood flow characteristics of the ovaries and/or ovarian lesions. It becomes possible to detect normal, suspicious and pathologic blood flow characteristics even in small blood vessels. Owing to superb quality of the images, three-dimensional sonography enables precise assessment of the ovarian lesions. Three-dimensional power Doppler ultrasound permits effective targeting and rendering of ovarian tumor vasculature, thus providing new diagnostic possibilities for early detection of ovarian malignancy and differentiation of benign from malignant ovarian pathology.

CONCLUSIONS

Further technological development will contribute to more objective evaluation of ovarian tumor morphology and vasculature which will give us tremendous support in clinical decision making and planning the management.

Comparison of conventional color Doppler imaging and power doppler imaging for the diagnosis of ovarian cancer: results of a European study

OBJECTIVE

The purpose of this prospective study was to compare the diagnostic accuracy of conventional color Doppler (CCD) imaging and power Doppler (PD) imaging in the diagnosis of ovarian cancer.

METHODS

Six hundred fifty-six consecutive women with adnexal masses scheduled for surgery in two European university departments of obstetrics and gynecology underwent preoperative transvaginal ultrasound. The scanning procedure was the same in the two institutions: after B-mode sonography, a CCD/PD imaging scan was performed before pulsed Doppler evaluation. Using both modalities of color Doppler, malignancy was suspected when arterial flow was visualized in an echogenic portion defined as malignant by B-mode. To avoid the risk of bias due to the absence of blindness of the examiner after the first Doppler evaluation, at one institution 328 consecutive women with an adnexal mass were evaluated using only CCD imaging, whereas at the second institution the ultrasonographic evaluation of the same number of masses was performed using PD imaging, and the results were compared prospectively.

RESULTS

The age, the rate of postmenopausal women, and the rate of ovarian cancer were similar in the two institutions. The false-positive rate of B-mode imaging was similar in the two institutions (17 versus 18%), while the false-positive rates of CCD and PD imaging were 4.6 and 7.4%, respectively. Although the overall diagnostic accuracy of two techniques seems comparable, with a similar value of K (0.81 versus 0.84), a significantly lower sensitivity in differentiation of benign from malignant ovarian lesions was found using CCD (87 versus 100%).

CONCLUSIONS

At least one of the two Doppler techniques should be used in conjunction with B-mode imaging in order to decrease the false-positive rate of B-mode used alone but CCD imaging showed a higher false-negative rate.

Common problems in pediatric and adolescent gynecologic surgery

Clinical studies on the myriad of problems that are encompassed by pediatric and adolescent gynecologic surgery are extremely difficult to carry out due to the low numbers of patients with these diagnoses in any one location or institution. Our current understanding of diagnosis, treatment, and outcome is drawn from case reports and the sharing of information. Frequently, clinical practice embraces technology long before the reports of such technology appear in the literature. As clinicians join together to study the various pathologies seen in this group of patients, we may see some impressive studies in the future. This review will focus on the current information available, which may contribute to the treatment and understanding of pediatric and adolescent gynecologic surgery.

Development of three-dimensional power Doppler ultrasound imaging of fetoplacental vasculature

To develop an off-line system for three-dimensional (3-D) ultrasound (US) reconstruction of fetoplacental vasculature using colour segmentation and reconstruction software and to determine sources of error in fully freehand ultrasound image acquisition. US images were acquired freehand with the Acuson Sequoia (5C 2-MHz transducer) using power Doppler. After digital transfer to a personal computer, CQ Analysis software (Kinetic Imaging Ltd, Liverpool, UK) was used to segment the colour information from these images, and the resulting 8-bit grey-scale images were used for 3-D rendering using commercial software (VoxBlast, Vaytek Inc., Fairfield, IA, USA). 2-D scanning, software and freehand acquisition accuracy were assessed using a linear test rig and distance and volume phantoms (Dansk Phantom Service Ltd); 2-D scanning accuracy was within 1.3%, and software reconstruction accuracy within 1% for x and y planes and up to 3% for the z plane. Fully freehand acquisition was associated with a 12% to 18% mean percentage error in distance measurement in the plane of acquisition. Volumetric reconstruction inaccuracy was between 1.5% and 19.7% for precisely separated images and between 16.2% and 39.2% for fully freehand image acquisition. Rendered 3-D US vascular images clearly delineated vascular anatomy within the placenta and cord. Fully freehand 3-D US does have a role in off-line reconstruction of vascular anatomy, although variability in the z plane precludes its use for volumetric measurement. (E-mail: a.welsh@ic.ac.uk)

Light-based imaging of green fluorescent protein-positive ovarian cancer xenografts during therapy

OBJECTIVE

The purpose of the study was to develop a sensitive, noninvasive imaging method for monitoring ovarian xenografts during therapeutic intervention.

METHODS

Human ovarian tumor cells (SKOV3.ip1) were infected with a replication-deficient adenoviral (Ad) vector encoding green fluorescent protein (GFP). The GFP-positive tumor cells were imaged in vitro and in vivo with a fluorescence stereomicroscope. Using appropriate filters, both GFP fluorescence and adriamycin were simultaneously detected. Nude mice implanted with GFP-positive cells were imaged repeatedly, in a noninvasive manner.

RESULTS

SKOV3.ip1 cells infected with Ad-GFP showed high GFP fluorescence, which was eliminated after treatment with adriamycin. Loss of GFP fluorescence was confirmed to be dead cells. For in vivo imaging, intraperitoneal tumors as small as 0.2 mm in diameter were detected externally. Adriamycin uptake was detected in tumors by in vivo imaging, and reduction in tumor size was concurrent with decrease in GFP fluorescence. These findings were confirmed at necropsy.

CONCLUSIONS

Fluorescence stereomicroscopy monitored the response of ovarian xenografts to adriamycin therapy. For the first time, GFP and adriamycin were imaged simultaneously.

Three-dimensional power Doppler ultrasound improves the diagnostic accuracy for ovarian cancer prediction

OBJECTIVE

The goal of this study was to determine if three-dimensional power Doppler ultrasound improves the specificity for ovarian cancer detection as compared with two-dimensional ultrasound.

METHODS

Seventy-one women with a known complex pelvic mass were referred for a preoperative ultrasound evaluation with both two-dimensional and three-dimensional gray-scale ultrasonography. The 3D studies were performed with the Kretz Voluson 530D using a mechanized transvaginal probe. Surface rendering and power Doppler imaging were performed by the same gynecologic sonologist, and reassigned to one of four echo patterns: cystic, multicystic, complex, or solid. Sonographic criteria used for diagnosing ovarian cancer were based on a system that included morphological characteristics, histological prediction, and power Doppler imaging.

RESULTS

Seventy-one women underwent surgical exploration: 14 (19.7%) had ovarian cancer (2 FIGO stage I, 2 stage II, 7 stage III, and 3 metastatic colon) and 2 had uterine cancer. Two-dimensional gray-scale ultrasound identified 40 masses as suspicious for cancer, including all 14 malignancies, yielding a sensitivity, specificity, and positive predictive value of 100, 54, and 35%, respectively. However, evaluation with 3D power Doppler identified only 28 cases as suspicious (including all 14 cancers), resulting in a sensitivity, specificity, and positive predictive value of 100, 75, and 50%, respectively.

CONCLUSIONS

Three-dimensional power Doppler imaging better defines the morphological and vascular characteristics of ovarian lesions. All malignancies were correctly identified by both 2D and 3D imaging; however, the specificity significantly improved with the addition of 3D power Doppler. This improved diagnostic accuracy may promote improved patient care by separating complex benign masses from ovarian cancer, therefore facilitating appropriate physician referral.