Prevalence and histologic diagnosis of adnexal cysts in postmenopausal women: an autopsy study

Practical Tips for Reporting Adnexal Lesions Using O-RADS MRI

The Ovarian-Adnexal Reporting and Data System (O-RADS) MRI risk stratification system provides a standardized lexicon and evidence-based risk score for evaluation of adnexal lesions. The goals of the lexicon and risk score are to improve report quality and communication between radiologists and clinicians, reduce variability in the reporting language, and optimize management of adnexal lesions. The O-RADS MRI risk score is based on the presence or absence of specific imaging features, including the lipid content, enhancing solid tissue, number of loculi, and fluid type. The probability of malignancy ranges from less than 0.5% when there are benign features to approximately 90% when there is solid tissue with a high-risk time-intensity curve. This information can aid in optimizing management of patients with adnexal lesions. The authors present an algorithmic approach to the O-RADS MRI risk stratification system and highlight key teaching points and common pitfalls. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Evaluation of IOTA-ADNEX Model and Simple Rules for Identifying Adnexal Masses by Operators with Varying Levels of Expertise: A Single-Center Diagnostic Accuracy Study

Objectives The discrimination of ovarian lesions presents a significant problem in everyday clinical practice with ultrasonography appearing to be the most effective diagnostic technique. The aim of our study was to externally evaluate the performance of different diagnostic models when applied by examiners with various levels of experience. Methods This was a diagnostic accuracy study including women who were admitted for adnexal masses, between July 2018 and April 2021, to a Greek tertiary oncology center. Preoperatively sonographic data were evaluated by an expert gynecologist, a 6 th and a 1 st year gynecology resident, who applied the International Ovarian Tumor Analysis (IOTA) Simple Rules (SR) and Assessment of Different NEoplasias in the adneXa (ADNEX) model to discriminate between benign and malignant ovarian tumors. The explant pathology report was used as the reference diagnosis. Kappa statistics were used for the investigation of the level of agreement between the examined systems and the raters. Results We included 66 women, 39 with benign and 27 with malignant ovarian tumors. ADNEX (with and without "CA-125") had high sensitivity (96-100%) when applied by all raters but a rather low specificity (36%) when applied by the 1st year resident. SR could not be applied in 6% to 17% of the cases. It had slightly lower sensitivity, higher specificity, and higher overall accuracy, especially when applied by the 1st year resident (61% vs. 92%), compared to ADNEX. Conclusion Both ADNEX and SR can be utilized for screening in non-oncology centers since they offer high sensitivity even when used by less experienced examiners. In the hands of inexperienced examiners, SR appears to be the best model for assessing ovarian lesions.

Anatomic Distribution of Benign Ovarian Tumors in Perimenopausal and Postmenopausal Women

Introduction We aim to report the histotypes and reassess the anatomic distribution of benign ovarian tumors in perimenopausal and postmenopausal women. Methods Medical and pathology reports of women with histologically confirmed benign ovarian pathology were investigated. Data were collected, retrospectively between 2000 and 2020, and analyzed from perimenopausal and postmenopausal women with benign ovarian tumors, after bilateral salpingo-oophorectomy (BSO) with or without total abdominal hysterectomy (TAH). The ovarian masses histology and the distribution of locations were further evaluated. Results The total sample consisted of 1,355 women with benign ovarian tumors; 929 (68.6%) of the perimenopausal and 426 (31.4%) of the postmenopausal age. A dermoid cyst was prominent in the right ovary (52.8%), compared to the left side (41%) (p<0.01). Conversely, in patients with endometriomas and cysts of Morgagni, the observed proportion was more prominent in the left-sided ovary (61.8% vs 27%; p<0.001 and 52.3% vs 36.4%; p<0.01, respectively). Moreover, in the perimenopausal women, we mostly detected endometrioma (18.3%), dermoid cyst (15.5%) and cyst of Morgagni (4%) compared to postmenopausal women, where serous cysts (29.8%) and ovarian fibroids (8%) were the most common tumors. Conclusions Benign ovarian tumors are frequently seen in perimenopausal women and most histotypes present anatomical differences between the left and right ovaries. Serous cysts, followed by paraovarian, dermoid cysts and endometrioma present the commonest ovarian benign masses. Gynecologists should pay special attention to adnexal tumors in the postmenopausal period to choose the right operating setting for women at risk for ovarian cancer.

Giant Paratubal Cyst Mimicking Mesenteric Cyst

Paratubal cysts are adnexal masses located in the broad ligament; whenever the size of the cyst is >20 cm, it is considered a giant cyst and can present with complications including ovarian torsion and perforation. Diagnosis can be made clinically with the help of radiological investigations, although the gold standard diagnostic tool is diagnostic laparoscopy. Managing this condition relies mainly on surgical intervention (open or laparoscopic). Giant paratubal cysts carry challenges in their surgical excision as they carry a higher risk of spillage. We present a case of giant paratubal cyst in a 26-year-old Bahraini female who presented with abdominal distension and pain for 3 years.

Laparoscopic guided minilaparotomy: a modified technique for management of benign large ovarian cysts

BACKGROUND

The aim of the study is to evaluate the efficiency and safety of a novel technique to treat large benign ovarian cysts combining benefits of laparoscopic management along with mini-laparotomy without affection of the ovarian reserve.

METHODS

The study included 112 women with large benign ovarian cyst candidate for ovarian cystectomy. The technique started with laparoscopy followed by guided cyst aspiration followed by exteriorization of the ovary through minilaprotomy and completion of cystectomy through microsurgical technique. The primary outcome was ipsilateral recurrence of the cyst. Other outcomes included ovarian reserve assessment and postoperative pain.

RESULTS

The number of women with recurrence in the ipsilateral ovary after 12, 18 and 24 months were 5 (4.5%),16 (14.3%),20 (17.85%) respectively. Assessment of ovarian reserve revealed a significant decrease in the level of serum AMH (2.82 ± 0.44 vs. 2.50 ± 0.42) and a significant increase in AFC (3.5 ± 1.7 vs. 4.9 ± 1.3) after our novel technique in surgical treatment of ovarian cysts (P value < 0.001). The operative time was 50 ± 7 and 62 ± 7 min in unilateral and bilateral cysts respectively.

CONCLUSIONS

Laparoscopic guided minilaparotomy is a safe and effective technique for the management of large benign ovarian cysts with minimal recurrence rate, ovarian reserve affection and adhesions.

TRIAL REGISTRATION

clinical trial registry no. NCT03370952. Registered 13 December 2017, https://clinicaltrials.gov/ct2/show/NCT03370952.

[Rare Incidental Finding during a Student Ultrasonography Course - A Case Report]

Rare Incidental Finding during a Student Ultrasonography Course - A Case Report Abstract. During a sonography class in medical school, a large fluid-filled mass was discovered in the center of the lower abdomen in a healthy, asymptomatic female student; an overflow bladder was suspected. Despite various interdisciplinary investigations, the etiology of the cystic formation could not be clarified. Three months after discovery of the incidental finding, the increasingly symptomatic patient was diagnosed with a cystic tumor in the lower abdomen with secondary urinary retention, and surgical cyst excision was performed. A large, serous Paratubular cyst was found on the left side with torsion of the tube without signs of ischemia and without malignancy. Incidental findings in ultrasound teaching are not uncommon. Course participants, tutors, and course instructors must be aware of this and have a clear procedure at hand in order to deal with it.

Incidental Ovarian and Uterine Findings on Cross-sectional Imaging

Incidental adnexal masses and uterine findings occur with a high frequency on cross-sectional imaging examinations, particularly in postmenopausal women in whom imaging is performed for a different reason. These incidentalomas encompass a gamut of potential pelvic gynecologic disorders. Most are benign ovarian cysts; however, other less commonly encountered disorders and improperly positioned gynecologic devices may be seen. A knowledge of the management recommendations for such pelvic incidental findings is critical to avoid unnecessary imaging and surgical interventions, as well as to avoid failure in diagnosis and management of some of these conditions.

Adnexal torsion with paraovarian cysts in pediatric and adolescent populations: A retrospective study

BACKGROUND

Determination of the clinical characteristics associated with adnexal torsion involving paraovarian cysts in pediatric and adolescent populations.

METHODS

Retrospective review of all cases of paraovarian cysts operated on in our department between 2007 and 2019. Demographic characteristics, clinical and sonographic findings were reviewed.

RESULTS

The cohort was composed of 39 pediatric and adolescent patients with an operative diagnosis of adnexal masses located in the paraovarian area. The patients were classified into two groups: 19 girls (48.7%) with a confirmed operative diagnosis of adnexal torsion and 20 girls (51.3%) without torsion. The preoperative diagnosis of adnexal torsion was correct in ≈70% of the cases. The mean BMI were similar in both groups. The preoperative sonographic detection rate of paraovarian cysts was also similar (11/19 [57.9%] vs. 14/20 [70.0%]; P = 0.514). The mean cyst diameter did not differ between groups, nor did the classification into cyst size groups (≤50 mm, 51-99 mm and ≥100 mm).

CONCLUSION

Adnexal torsion is a common complication diagnosed in girls undergoing surgery for paraovarian cysts, and is not associated with sonographic appearance or cyst diameter. In order to prevent torsion, surgical removal of paraovarian cysts should thus be considered in young girls undergoing surgery for paraovarian cysts.

TYPE OF STUDY

Retrospective case series.

LEVEL OF EVIDENCE

IV.

ACR Appropriateness Criteria® Clinically Suspected Adnexal Mass, No Acute Symptoms

There are approximately 9.1 pelvic surgeries performed for every histologically confirmed adnexal malignancy in the United States, compared to 2.3 surgeries per malignancy (in oncology centers) and 5.9 surgeries per malignancy (in other centers) in Europe. An important prognostic factor in the long-term survival in patients with ovarian malignancy is the initial management by a gynecological oncologist. With high accuracy of imaging for adnexal mass characterization and consequent appropriate triage to subspecialty referral, the better use of gynecologic oncology can improve treatment outcomes. Ultrasound, including transabdominal, transvaginal, and duplex ultrasound, combined with MRI with contrast can diagnose adnexal masses as benign with specific features (ie, functional masses, dermoid, endometrioma, fibroma, pedunculated fibroid, hydrosalpinx, peritoneal inclusion cyst, Tarlov cyst), malignant, or indeterminate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Imaging of Benign Adnexal Disease

This article provides an overview of the imaging evaluation of benign ovarian and adnexal masses in premenopausal and postmenopausal women and lesions discovered during pregnancy. Current imaging techniques are discussed, including pitfalls and differential diagnosis when necessary, as well as management. It also reviews the now well-established American College of Radiology (ACR)/Society of Radiologists in Ultrasound consensus guidelines and covers the more recently introduced Ovarian-Adnexal Reporting and Data System by the ACR and the recently published ADNEx Scoring System.

Paratubal borderline serous tumor in a postmenopausal woman: a case report

Unlike borderline ovarian tumors, paratubal borderline tumors are extremely rare gynecologic tumors. They occur in reproductive-aged females at an earlier stage of disease and have a good prognosis. A 61-year-old woman, gravida 3 para 3, presented with progression of ovarian cyst. Computed tomography revealed a 6-cm simple cystic lesion without enhancing papillary projections. The patient underwent total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. Frozen specimens showed that the tumor was benign, thereby confirming a final diagnosis of paratubal borderline serous tumor. The patient refused comprehensive surgical staging and opted for close follow-up. The patient remains asymptomatic with no evidence of recurrence at the 24-month follow-up. To the best of our knowledge, this is the first reported case of paratubal borderline serous tumor in a postmenopausal patient. The findings of this study and those of other case reports can contribute to the understanding, diagnosis, treatment and prognosis of these rare tumors.

Nonovarian Mimics of Ovarian Malignancy

Once a pelvic mass is identified on an ultrasound examination, the first step in the differential diagnostic work up is to determine its origin. Most lateral pelvic masses in women are ovarian in origin, and the distinction between ovarian and nonovarian mimics of ovarian cancer is critical for appropriate clinical and surgical management. Adnexal masses detected on ultrasound can be further characterized by magnetic resonance imaging (MRI) when needed. Superior contrast resolution, multiplanar imaging, characteristic signal intensity of common pathology such as dermoid tumors or endometriomas allows one to accurately evaluate adnexal tumors with supplemental use of MRI. Commonly encountered extraovarian abnormalities that mimic ovarian malignancies are categorized as being either predominantly cystic or solid. The common causes of such extraovarian lesions that mimic ovarian pathology include fallopian tube diseases, paroaovarian cysts, peritoneal inclusion cysts, and a pedunculated or a broad ligament fibroid. Less common causes of cystic and solid nonovarian mimics of ovarian malignancy include mucocele of the appendix, lymphocele, spinal meningeal cysts, extraovarian endometriomas, extraovarian fibrothecomas, and gastrointestinal stromal tumors (Table 1). Identifying a normal appearing ovary is the key in distinguishing an extraovarian pelvic mass from an ovarian tumor. This becomes particularly challenging in postmenopausal women with atrophic ovaries. In this scenario, MRI comes into use by identifying small atrophic ovaries more often than ultrasound is able to. Extraovarian lesions typically displace the pelvic sidewall vasculature medially, ureters tend to be compressed, encased or medially displaced, enhancement matches pelvic arteries and may be associated with engorged mesenteric vessels compared to gonadal vessel engorgement seen with ovarian tumors.

Adnexal lesions detected on CT in postmenopausal females with non-ovarian malignancy: do simple cysts need follow-up?

PURPOSE

To assess whether CT morphology of adnexal lesions in postmenopausal women with history of non-ovarian cancer could be used to discriminate benign and malignant lesions, particularly focusing on applicability of the ACR criteria.

MATERIALS AND METHODS

This was an IRB-approved HIPAA-compliant retrospective review of contrast-enhanced CTs of 199 women, 55 years and older. Lesions were classified as simple cystic, complex cystic, solid-cystic, or solid based on CT morphology, and were diagnosed as benign, indeterminate, or malignant on follow-up imaging or pathology. Associated metastatic disease was noted, if present. Findings were analyzed to correlate CT morphology, primary tumor pathology, and metastatic disease pattern with eventual lesion diagnosis.

RESULTS

There were 223 adnexal lesions, including 123 (55%) simple cystic, 48 (22%) complex cystic, 40 (18%) solid-cystic, and 12 (5%) solid lesions. 186/223 (83%) lesions were benign, and 37/223 (17%) were malignant. Primary colorectal cancer was significantly associated with an increased likelihood of malignant adnexal lesions (OR 10.2, p < 0.001) compared to patients with other cancers. Adnexal malignancy was significantly associated with the presence of non-ovarian peritoneal metastases (p < 0.001). None of the simple cysts (including 85 cysts between 1-3 cm and 38 cysts > 3 cm) were found to be malignant (malignancy rate: 0.0%, 95% CI 0.0-3.0%). Complex cysts were more likely to be malignant than simple cysts (p = 0.002) and solid-cystic lesions were more likely to be malignant than complex cysts (p < 0.001).

CONCLUSION

Simple adnexal lesions on CT in this cohort were unlikely to be malignant, supporting the ACR guidelines. A higher size threshold of 3 cm (vs. 1 cm) may be preferred in all cases of simple cysts for recommending further follow-up. However, more complex-appearing cysts need further evaluation as the risk of malignancy is increased. Peritoneal metastases have a significant correlation with malignant adnexal involvement.

MR Imaging for Incidental Adnexal Mass Characterization

Incidentally detected adnexal masses are common, and the overwhelming majority of them are benign. As many of these adnexal masses are considered indeterminate at CT or US, a large number of benign oophorectomies occur. Of the malignant adnexal masses, high-grade primary ovarian neoplasms with fast doubling times and early dissemination are the most common. Due to their aggressive behavior, diagnosis of malignancy by interval growth on surveillance imaging represents an undesirable option. Immediate MR characterization allows for a decreased rate of benign oophorectomies and expedited triage of patients to definitive treatment when malignancy is suspected.

Clinical, radiological, and histopathological analysis of paraovarian cysts

Introduction:

Paraovarian cyst arise from either mesothelium or from paramesonephric remnant. These present as either adneal mass or as an incidental finding. Diagnosis is usually established on ultrasound and it is important to differentiate these from ovarian cyst.

Material and Methods:

The present study is a retrospective analysis of 32 women with a confirmed diagnosis of paraovarian cyst after surgery. The clinical profile, symptoms and radiological findings of these patients were noted from the hospital records. A correlation was made with the surgical findings and the final histopathological diagnosis.

Results:

Only 2 patients were postmenopausal and one case was diagnosed during pregnancy. Ultrasound accurately diagnosed paraovarian cyst in 87.5% patients. 78% paraovarian cysts were found to be simple and none had any malignant change. We reported a higher incidence of cystic adenomatoid tumor in these paraovarian cysts.

Conclusion:

In our study, most paraovarian cysts occur in reproductive age group and present as an adnexal mass. Ultrasound is the diagnostic modality and a paraovarian cyst needs to be differentiated from ovarian cyst. Most of them were simple cysts on histopathology.

Impact of Simple Ovarian Cysts on the Interpretation of Endometrial Thickness in Women with Postmenopausal Bleeding

BACKGROUND

There is evidence that premenopausal hormones may persist for variable time after menopause. Histological specimens from postmenopausal women support the presence of follicular growth at that age. Residual ovarian function may explain postmenopausal bleeding (PMB), which is not associated with endometrial pathology. Our objective was to evaluate the effect of sonographic diagnosis of simple ovarian cysts on the association between thickened endometrium and endometrial pathology in women with PMB.

MATERIALS AND METHODS

Data were retrospectively collected from medical records of women who underwent office hysteroscopy for PMB between January 2007 and October 2011. Women with sonographic reports within 3 months of presentation were included. Endometrial thickness and the presence of a simple ovarian cyst (≤5 cm) were documented by reviewing sonographic reports. Diagnosis of endometrial pathology was abstracted according to pathology reports or hysteroscopic impression. Endometria with hyperplasia, cancer, or polyps were considered pathological.

RESULTS

Of 836 women with PMB, 356 had recent transvaginal sonography and were included in the analysis. Pathological endometrium was documented in 129 (36.2%) women, including 29 (8.2%) with endometrial cancer. In women with PMB and no evidence of a simple ovarian cyst, endometrial thickness was an independent predictor of endometrial pathology and endometrial cancer with adjusted OR = 1.13 (95% CI = 1.07-1.19) and 1.16 (95% CI = 1.07-1.25), respectively. In the presence of simple ovarian cysts, the adjusted ORs for endometrial thickness as a predictor of endometrial pathology were 1.06 (95% CI = 0.90-1.25) and 0.84 (95% CI = 0.62-1.14), respectively.

CONCLUSION

The presence of simple ovarian cysts (≤5 cm) tempers the value of endometrial thickness in predicting endometrial pathology in women with PMB.

The Value of Ultrasound Monitoring of Adnexal Masses for Early Detection of Ovarian Cancer

Although ultrasound has so far been found to be ineffective as a screening tool for ovarian cancer, it is commonly used as a means of evaluating or following ovarian or adnexal masses once they are detected. We review the use of serial ultrasound for the management of adnexal masses and propose an approach to monitoring based on an understanding of the overall risk of cancer among the population in question and an assessment of how the potential benefit of monitoring compares with potential risk. In our approach, masses that are symptomatic, large (>10 cm), associated with an elevated CA 125 level or overt signs of malignancy, or that are determined to have a worrisome appearance by stringent ultrasound criteria should be evaluated surgically. Women with masses that have none of these characteristics should be offered monitoring. Short-term initial ultrasound monitoring carries significant potential benefit in terms of aiding detection of early malignancy and avoidance of unnecessary surgery. However, if a mass remains stable but persistent, the potential benefit of ongoing monitoring wanes with time, whereas the potential harms, in terms of patient anxiety, cost, and the risk of incidental findings and unnecessary surgery increase. Therefore, monitoring of stable lesions should be limited in duration in order to limit potential harms from overtreatment and overdiagnosis.

Adnexal mass in the postmenopausal patient

The adnexal mass in a postmenopausal patient poses an important diagnostic and management dilemma for primary care providers and gynecologists. Postmenopausal women are at a significantly increased risk of gynecologic malignancy; yet even in this population the majority of adnexal masses are benign. Evaluation and management of these lesions centers on the identification of malignancy, especially ovarian cancer, while avoiding unnecessary intervention in patients with benign lesions. Tumor markers and imaging can help in the evaluation of adnexal mass in postmenopausal women. Transvaginal ultrasound has long been considered the imaging modality of choice for the evaluation of adnexal masses. Particularly in the setting of high frequency utilization of transvaginal probes, which project high quality images allowing for detailed descriptions of the macroscopic appearance of the mass, and remains the least expensive of all imaging modalities currently available. For adnexal masses that are highly suspicious for cancer, women should be referred a gynecologic oncologist and facility for optimal care.

Cystadenofibromas: Can transvaginal ultrasound appearance reduce some surgical interventions?

PURPOSE

Cystadenofibromas are benign ovarian neoplasms. Their most typical features on sonography (US) are unilocular cysts with small, shadowing hyperechoic, solid papillae without internal vascularity. In the past, they were virtually always surgically removed to exclude malignancy. This study was undertaken to review the sonographic appearances of benign cystadenomas.

METHODS

We retrospectively reviewed the transvaginal US studies of 32 cases of pathologically proven ovarian cystadenofibromas.

RESULTS

Twenty-two of the tumors presented as unilocular cystic structures with one or more solid, hyperechoic, shadowing, mural nodules with no discernible blood flow projecting from the inner cyst wall. Ten lesions were multiloculated with multiple small solid areas, with scant or no blood vessels.

CONCLUSIONS

Cystadenofibromas do not always have a classic appearance on transvaginal US and color Doppler imaging. In our series, however, the majority (69%) presented as unilocular cysts with one or more small solid, avascular projections from the inner cyst wall. These features had 100% reliability for a diagnosis of benign cystadenofibroma in this small series. Further study is necessary to confirm the reliability of this finding for benign cystadenofibroma, thus possibly avoiding or minimizing any surgical exploration.

Outcomes from ultrasound follow-up of small complex adnexal masses in women over 50

OBJECTIVE

The discovery of a complex adnexal mass in an older woman often raises concern for cancer. We evaluate outcomes for a large population-based cohort of women older than age 50 years with a small complex adnexal mass reported on ultrasound, without elevated CA125 or other evidence of malignancy, including time to detection of malignancy and stage at diagnosis for those initially observed.

STUDY DESIGN

Women older than age 50 years who had an ultrasound during 2007-2011 reporting a complex adnexal mass 1-6 cm in size were identified. Previous or subsequent pelvic ultrasounds were reviewed to determine when the mass was first identified and whether there was change over time. Women with concurrent elevated CA125, evidence of metastatic disease, or less than 24 months of clinical follow-up were excluded. Surgical pathology from removal and diagnoses of ovarian cancer within 24 months of follow-up were identified.

RESULTS

Among 1363 complex masses identified, 18 cancers or borderline tumors (1.3%; 95% confidence interval, 0.8-2.1%) were found. Six cases were diagnosed among 204 women who had immediate surgery after initial ultrasound (15%), and 12 additional cases were found among 994 women with at least 1 repeat ultrasound (73%). Growth was apparent on ultrasound by 7 months for all borderline and epithelial ovarian cancers. Of the 12 cases diagnosed during follow-up, 10 were found to be stage 1 at surgery.

CONCLUSION

Among isolated adnexal masses reported as complex and 1-6 cm on pelvic ultrasound in women older than 50 years, the overall risk of malignancy is low. All cases of epithelial cancer and borderline tumor demonstrated growth by 7 months of observation.

The characteristic ultrasound features of specific types of ovarian pathology (review)

Characterizing ovarian masses enables patients with malignancy to be appropriately triaged for treatment by subspecialist gynecological oncologists, which has been shown to optimize care and improve survival. Furthermore, correctly classifying benign masses facilitates the selection of patients with ovarian pathology that may either not require intervention, or be suitable for minimal access surgery if intervention is required. However, predicting whether a mass is benign or malignant is not the only clinically relevant information that we need to know before deciding on appropriate treatment. Knowing the specific histology of a mass is becoming of increasing importance as management options become more tailored to the individual patient. For example predicting a mucinous borderline tumor gives the opportunity for fertility sparing surgery, and will highlight the need for further gastrointestinal assessment. For benign disease, predicting the presence of an endometrioma and possible deeply infiltrating endometriosis is important when considering both who should perform and the extent of surgery. An examiner’s subjective assessment of the morphological and vascular features of a mass using ultrasonography has been shown to be highly effective for predicting whether a mass is benign or malignant. Many masses also have features that enable a reliable diagnosis of the specific pathology of a particular mass to be made. In this narrative review we aim to describe the typical morphological features seen on ultrasound of different adnexal masses and illustrate these by showing representative ultrasound images.

[Ovarian tumors in postmenopausal women: report of 100 cases and review of the literature]

Le but de notre travail est d’étudier les particularités de prise en charge des tumeurs de l'ovaire chez la femme ménopausée. L’étude rétrospective porte sur 100 patientes opérées pour des tumeurs ovariennes en post ménopause durant une période de 5 ans. L’âge moyen des patientes était de 61,3 ans (extrêmes: 47- 84 ans). L'aspect échographique était liquidien pur dans 40% des cas, mixte ou solide dans 30% des cas. Le dosage de CA 125 était élevé dans 25% des cas. Un traitement chirurgical a été pratiqué chez toutes les patientes: Laparotomie de première intention dans 43 cas,cœliochirurgie dans 51 cas, cœlioscopie puis laparotomie dans 6 cas. L'examen anatomopathologique définitif a révélé 22% de tumeurs malignes et 10% de kystes fonctionnels. Le geste chirurgical était une annexectomie bilatérale pour la majorité des tumeurs bénignes et carcinologique en cas de tumeurs malignes. La stratégie diagnostique des tumeurs ovariennes en post ménopause reste de nos jours basée sur la clinique, l’échographie et les marqueurs tumoraux. Les bénéfices de la cœlioscopie sont indiscutables. L'attitude à opérer systématiquement les kystes uniloculaires ayant les critères de bénignité est actuellement révisée.

[Epidemiology of presumed benign ovarian tumors]

Ovarian cysts presumed benign can be organic or functional. Their prevalence is estimated between 14 and 18% in postmenopausal women and around 7% in asymptomatic women of childbearing age. Their incidence during pregnancy is between 0.2 and 5% and varies within the term of pregnancy. Ovarian cysts presumed benign have caused nearly 45,000 hospitalizations in France in 2012, bringing the annual risk of hospitalization for a woman residing in France to 1.3‰. Among the risk factors studied in the literature, tamoxifen increases the incidence of ovarian cysts in premenopausal patients and immunosuppressive treatments are associated with a high prevalence of benign ovarian cysts while estrogen contraception reduces the risk of developing functional cysts.

Two cases of paraovarian tumor of borderline malignancy

Paraovarian tumor of borderline malignancy is rare. Only 13 cases in Japan, including the present cases, and 40 cases overseas have been reported. We report two cases of paraovarian tumor of borderline malignancy. Case 1: A 38-year-old woman was found to have a right ovarian cyst. Transvaginal ultrasonography showed a unilocular cystic tumor and a solid part of 8 mm in diameter within the tumor. Malignancy could not be ruled out, therefore the laparotomy was performed. The tumor was paraovarian tumor. Intraoperative rapid histological diagnosis was made and the patient was diagnosed with a serous borderline tumor. There has been no recurrence 1 year after surgery. Case 2: A 30-year-old woman was found to have a right hydrosalpinx, or an ovarian cyst, with a solid part inside. Transvaginal ultrasonography showed the solid part within the tumor was 14 × 9 mm. Laparoscopic surgery was performed and we diagnosed the tumor as paraovarian cyst. Histological diagnosis was mucinous borderline tumor. There has been no recurrence 11 months after surgery.

Recurrent ovarian torsion due to paratubal cysts in an adolescent female

BACKGROUND

Though paratubal and paraovarian cysts are rare in adolescent females, the influence of post-menarchal hormonal stimulation on these tubal derivates can produce large and clinically significant adnexal pathology. Ovarian torsion secondary to paratubal cysts is rare due to the cyst's location and ipsilateral recurrence is uncommon.

CASE

We report a case of an 11-year-old female with a large right paratubal cyst causing ovarian torsion on two separate occasions within one year and our approach to surgical management.

CONCLUSION

Excision of a paratubal or paraovarian cyst that causes ovarian torsion is necessary to decrease the risk of cyst recurrence and ovarian torsion in the future. Timely diagnosis and treatment of ovarian torsion enables preservation of ovarian function and patient fertility.

Histology and prevalence of ovarian tumours in postmenopausal women: is follow-up required in all cases?

The objective of this study was to determine if follow-up is required for all ovarian tumours incidentally diagnosed in postmenopausal women, by studying the prevalence and histology of ovarian tumours in postmenopausal women undergoing hysterectomy. The histopathology of adnexa in 100 consecutive postmenopausal women who underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy for various indications, was reviewed. A total of 200 adnexa were examined. Ovarian pathology was found in 62/200 (31%). Of these 34/62 (53%) were unilocular cystic tumours, 9/62 (15%) were multilocular tumours, 11/62 (18%) were solid tumours and 8/62 (11%) were uni or multilocular with solid elements. The prevalence of borderline tumours was 4% and that of malignant tumours was 5%. All tumours < 2 cm were found to be benign. All unilocular cysts < 5 cm were benign. In conclusion, a vast majority of ovarian tumours in this group of women were benign. It may be reasonable not to follow-up women with unilocular ovarian tumours < 5 cm who have a normal CA125.

Ovarian incidentaloma

Incidental adnexal masses occur with relatively high frequency in post-menopausal women, with a prevalence rate of 3.3-18% in asymptomatic patients. Unilocular, benign-appearing ovarian cysts represent the vast majority of abnormal findings at transvaginal ultrasonography. As many as 80% will resolve over a period of several months; if persistent, unchanged, less than 10 cm, and with normal CA-125 values, the likelihood of an invasive cancer is sufficiently low that observation should be offered. More recent investigations support the use of secondary imaging modalities such as MRI, which may help differentiate benign from malignant masses. Surgical management plays a key role when patients are symptomatic regardless of age, menopausal and have documented changes in cyst characteristics, experience elevations in tumor markers or have symptoms suggestive of a hormone-producing neoplasm. High level, evidence-based screening guidelines have yet to be developed.

Pathologic findings following false-positive screening tests for ovarian cancer in the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial

OBJECTIVE

In the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO), ovarian cancer screening with transvaginal ultrasound (TVU) and CA-125 produced a large number of false-positive tests. We examined relationships between histopathologic diagnoses, false-positive test group, and participant and screening test characteristics.

METHODS

The PLCO ovarian cancer screening arm included 39,105 women aged 55-74 years assigned to annual CA-125 and TVU. Histopathologic diagnoses from women with false-positive tests and subsequent surgery were reviewed in this analysis: all CA125+ (n=121); all CA125+/TVU+ (n=46); and a random sample of TVU+ (n=373). Demographic and ovarian cancer risk factor data were self-reported. Pathologic diagnoses were abstracted from surgical pathology reports. We compared participant characteristics and pathologic diagnoses by category of false-positive using Pearson χ2, Fisher's exact, or Wilcoxon-Mann-Whitney tests.

RESULTS

Women with a false-positive TVU were younger (P<0.001), heavier (P<0.001), and reported a higher frequency of prior hysterectomy (P<0.001). Serous cystadenoma, the most common benign ovarian diagnosis, was more frequent among women with TVU+ compared to CA-125+ and CA-125+/TVU+ (P<0.001). Benign non-ovarian findings were commonly associated with all false-positives, although more frequently with CA-125+ than TVU+ or CA-125+/TVU+ groups (P=0.019). Non-ovarian cancers were diagnosed most frequently among CA-125+ (P<0.001).

CONCLUSIONS

False-positive ovarian cancer screening tests were associated with a range of histopathologic diagnoses, some of which may be related to patient and screening test characteristics. Further research into the predictors of false-positive ovarian cancer screening tests may aid efforts to reduce false-positive results.

Peri- and post-menopausal incidental adnexal masses and the risk of sporadic ovarian malignancy: new insights and clinical management

Adnexal masses are common among peri- and post-menopausal women. Although ovarian cancer is a significant cause of mortality in menopausal women, large population-based studies demonstrate that the majority of adnexal masses are benign. Despite this, the appearance of an adnexal mass is a concern for the patient and an insight exercise for physicians. In most cases, an adnexal enlargement is an incidental finding, generally corresponding to a benign cyst and easily diagnosed by conventional ultrasound. Exceptionally an ovarian tumour may be malignant and should be treated as early as possible. When conventional ultrasound renders complex morphology other diagnostic tools must be used such as: colour Doppler and functional tumour vessel properties, serum CA 125 levels, nuclear magnetic resonance imaging and in some cases laparoscopy. Several new tumour markers are being studied for clinical application, although there are presently no clear recommendations. Adnexal masses with benign morphological and functional properties must be periodically monitored as an alternative to surgery since malignant transformation is exceptional.

Imaging of benign adnexal masses: characteristic presentations on ultrasound, computed tomography, and magnetic resonance imaging

Adnexal masses are common in the general population. Although ovarian cancer is a significant cause of mortality, large screening studies demonstrate that the majority of adnexal masses are benign. These benign masses include physiologic cysts, paraovarian masses, and benign ovarian lesions. It is important that gynecologists and radiologists appreciate the appearance of these lesions on multiple imaging modalities, including ultrasound, computed tomography, and magnetic resonance imaging to avoid unnecessary intervention.

Does retention of the ovaries improve long-term survival after hysterectomy? A gynecological oncological perspective

Ovarian cancer is, in most cases, a lethal disease as it is virtually impossible to diagnose at an early stage and almost impossible to treat successfully when detected at an advanced stage. In postmenopausal women, there is no prevention for ovarian cancer but oophorectomy. Therefore, from the gynecological oncological perspective, where benign gynecological pathology requires surgery in postmenopausal women, oophorectomy should be the preferred option.

Common Gynecologic Problems in Geriatric-aged Women

Gynecologic concerns in postmenopausal women are common. Although various conditions may affect all women in this age group, the prevalence of certain disorders, and also diagnostic approaches and treatment options, may vary significantly when considering very elderly women compared with those early in the sixth decade. The focus of this chapter is to address several commonly encountered gynecologic issues in postmenopausal women, with particular attention given to aspects that must be considered when caring for women in the geriatric age group.

Cytokine response in the postoperative period after surgical treatment of benign adnexal masses: comparison between laparoscopy and laparotomy

BACKGROUND

Cytokines are the main mediators of the inflammation and the response to trauma. The purpose of the present study was the comparative assessment in sera of patients with benign adnexal masses treated by laparoscopy or laparotomy of the following proinflammatory and anti-inflammatory cytokines: interleukin (IL)-1beta, IL-6, IL-8, tumor necrosis factor-alpha (TNF-alpha), and IL-10 in the early postoperative period.

METHODS

A total of 40 patients with benign adnexal masses were studied; 25 of whom underwent laparoscopy and 15, laparotomy. Blood serum concentration of IL-1beta, IL-6, IL-8, TNF-alpha, and IL-10 were measured by commercially available ELISA assays before and 4 h, 24 h, and 48 h after the operation.

RESULTS

Concentrations of IL-6 were significantly increased in both groups at 4 h, 24 h, and 48 h after the surgery; levels of IL-10 showed a significant increase 4 h and 24 h after the operation; an increase in IL-1beta levels was observed only after laparotomy; no significant variations were observed in serum levels of IL-8; the postoperative increase of IL-1beta, IL-6, and IL-10 levels was more pronounced in patients undergoing laparotomy than in those treated laparoscopically; length of the surgical procedure, amount of CO2 used, tumor diameter, age, and body mass index (BMI) of the patients did not influence the postoperative patterns of the studied cytokines.

CONCLUSIONS

Systemic cytokine response after operations for benign adnexal masses depends on the degree of the surgical trauma, and is less pronounced in patients undergoing laparoscopy.

Practical Approach to the Adnexal Mass

Gynecologic sonography has matured into a highly effective and accurate tool enabling confident diagnosis of a variety of adnexal masses. Using a practical evidence-based approach, sonologists are well equipped to differentiate expected findings in the normal ovary from pathologic entities and can often generate specific conclusions regarding the cause of an adnexal mass. Mastery of the diagnostic strategies to use when an adnexal mass is identified and the sonographic patterns of various types of adnexal pathology contributes greatly to the proper and cost-effective care of a woman with an adnexal mass.

The incidental postmenopausal adnexal mass

The postmenopausal ovary continues to produce cysts; the prevalence in an ovarian cancer screening population approaches 18%. Yet 60% to 70% of unilocular cysts resolve spontaneously. Optimal management of an asymptomatic adnexal mass allows surveillance of women at low malignancy risk while triaging intermediate/high-risk women to surgery. Women with unilocular cysts on transvaginal ultrasound (TVS) and a normal CA-125 are monitored with repeat TVS at 3 to 6 months. Those with a complex mass <5 cm and normal CA-125 should have repeat TVS and CA-125 testing in 4 weeks. Surgery is recommended for any women with increasing morphologic complexity or a rising CA-125.

Paraovarian/paratubal cysts: comparison of transvaginal sonographic and pathological findings to establish diagnostic criteria

OBJECTIVES

To describe the sonographic features of paraovarian cysts and to compare these features with pathological findings in order to define the best treatment options (surgical vs. conservative).

METHODS

Fifty patients (mean age 48 (range, 14-68) years), each with a surgically proven paraovarian cyst, were retrospectively recruited. Preoperative transvaginal ultrasonographic B-mode and power Doppler observations were re-evaluated and histological reports were analyzed.

RESULTS

All cysts were correctly diagnosed as paraovarian at preoperative transvaginal sonography (TVS). Paraovarian cysts appeared as unilocular ('simple') cysts in 33 (66%) cases and multilocular in two (4%). In 15 patients (30%) the cyst showed a variable number of papillary projections growing from the cyst wall (unilocular-solid cysts). Power Doppler examination of the papillae showed the presence of blood vessels in four of these patients (27%). Histological analysis of the masses containing papillary projections diagnosed eight cystadenofibromas, five cystadenomas and two serous papillary borderline tumors, while analysis of paraovarian cysts without papillations revealed benign, serous cysts of paramesonephric or mesothelial origin.

CONCLUSIONS

Paraovarian cysts can show a wide range of sonographic features. Their risk of malignancy is low if no papillary projections are detected at transvaginal sonography, but when mural proliferations are present a borderline tumor can be found at pathological examination.

Diagnostic and therapeutic capabilities of ultrasound in the management of pelvic pain

PURPOSE OF REVIEW

This review discusses the current diagnostic and therapeutic role of ultrasound in the management of pelvic pain.

RECENT FINDINGS

Recent advances in ultrasound technology and expertise have facilitated the accurate diagnosis of common gynaecological and nongynaecological pathologies. Peritoneal and deep infiltrating endometriosis can now be diagnosed using hard and soft ultrasound-based markers. The combination of ultrasound-guided aspiration and instillation of a sclerosant is an alternative to surgery in the management of adnexal masses.

SUMMARY

Experience is a key factor in the ability of transvaginal ultrasound to characterize common gynaecological disorders with accuracy. Therapeutic ultrasound provides an alternative to surgery.