Imaging in gynecology

Abnormal Uterine Bleeding: A Pictorial Review on Differential Diagnosis and Not-So-Common Cases of Interventional Radiology Management

Abnormal uterine bleeding (AUB) poses a multifaceted challenge in women's health, necessitating an integrated approach that addresses its diverse etiologies and clinical presentations. The International Federation of Gynecology and Obstetrics PALM-COEIN classification system provides a systematic approach to the diagnosis of AUB in non-pregnant women, based on clinical and imaging-based categorization of causes into structural (Polyps, Adenomyosis, Leiomyomas and Malignancy; PALM), and non-structural causes (Coagulopathies, Ovulatory disorders, primary Endometrial disorders, Iatrogenic and Not otherwise classified; COEIN). On the other hand, placental disorders, uterine rupture, ectopic pregnancy and retained products of conceptions are the main causes of uterine bleeding during pregnancy and in the peripartum period. Ultrasound is usually the first-line imaging technique for the differential diagnosis of causes of AUB. Computed Tomography may be useful if ultrasound findings are unclear, especially in emergency settings. Magnetic resonance imaging, when indicated, is an excellent second-line diagnostic tool for a better non-invasive characterization of the underlying cause of AUB. This pictorial review aims to illustrate the main causes of AUB from the point of view of diagnostic imaging and to show not-so-common cases that can be treated by means of interventional radiology.

Endometriosis at all ages: diagnostic ultrasound

Endometriosis is a gynecological disease affecting about 10% of the female population. The multifactorial hormonal, inflammatory, genetic, mental and behavior pathogenesis can result in chronic pelvic pain, blooding disorders and infertility causing disruption of quality of life. Correct diagnosis of the extension and topography is substantial in defining the adequate therapeutic strategy. In an increasing proportion of the cases, endometriosis is being managed medically and para-medically; diagnostic or therapeutic surgery can often be avoided or delayed. Transvaginal sonography is considered being the first-line imaging method in the diagnosis of pelvic endometriosis. The paradigm shift from the belief that endometriosis only affects women of reproductive age has drawn attention to endometriosis in both premenarchal and postmenopausal patients. This review resumes the actually recommended ultrasound signs in the case of patients in menstrual age. Specific diagnostic approaches in adolescent and menopausal patients are highlighted.

A Review and Case Study of 3D Imaging Modalities for Female Amniote Reproductive Anatomy

Recent advances in non-invasive imaging methods have revitalised the field of comparative anatomy, and reproductive anatomy has been no exception. The reproductive systems of female amniotes present specific challenges, namely their often internal "hidden" anatomy. Quantifying female reproductive systems is crucial to recognising reproductive pathologies, monitoring menstrual cycles, and understanding copulatory mechanics. Here we conduct a review of the application of non-invasive imaging techniques to female amniote reproductive anatomy. We introduce the commonly used imaging modalities of computed tomography (CT) and magnetic resonance imaging (MRI), highlighting their advantages and limitations when applied to female reproductive tissues, and make suggestions for future advances. We also include a case study of micro CT and MRI, along with their associated staining protocols, applied to cadavers of female adult stoats (Mustela erminea). In doing so, we will progress the discussion surrounding the imaging of female reproductive anatomy, whilst also impacting the fields of sexual selection research and comparative anatomy more broadly.

Two-Step Strategy for Optimizing the Preoperative Classification of Adnexal Masses in a University Hospital, Using International Ovarian Tumor Analysis Models: Simple Rules and Assessment of Different NEoplasias in the adneXa Model

OBJECTIVES

To evaluate the performance of a two-step strategy compared with the International Ovarian Tumor Analysis (IOTA) - Assessment of Different NEoplasias in the adneXa (ADNEX) model for preoperative classification of adnexal masses.

METHODS

An ambispective diagnostic accuracy study based on ultrasound data collected at one university hospital between 2012 and 2018. Two ultrasonographers classified the adnexal masses using IOTA Simple Rules (first step). Not classifiable masses were evaluated using the IOTA ADNEX model (second step). Also, all masses were classified using the IOTA ADNEX model. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-), and receiver operating characteristic (ROC) curve were estimated. A P value of <.05 was used to determine statistical significance.

RESULTS

The study included 548 patients and 606 masses. Patients' median age was 41 years with an interquartile range between 32 and 51 years. In the first step, 89 (14%) masses were not classifiable. In the second step, 55 (61.8%) masses were classified as malignant. Furthermore, for the totality of 606 masses, the IOTA ADNEX model estimated the probability that 126 (20.8%) masses were malignant. The two-step strategy had a sensitivity, specificity, PPV, NPV, LR+, LR-, and ROC curve of 86.8%, 91.01%, 51.9%, 98.4%, 9.7, 0.1, and 0.889, respectively; compared to IOTA ADNEX model that had values of 91.8%, 87.16%, 44.4%, 99%, 7.1, 0.09, and 0.895, respectively.

CONCLUSION

The two-step strategy shows a similar diagnostic performance when compared to the IOTA ADNEX model. The IOTA ADNEX model involves only one step and can be more practical, and thus would be recommended to use.

Vessel morphology depicted by three-dimensional power Doppler ultrasound as second-stage test in adnexal tumors that are difficult to classify: prospective diagnostic accuracy study

OBJECTIVES

To assess whether vessel morphology depicted by three-dimensional (3D) power Doppler ultrasound improves discrimination between benignity and malignancy if used as a second-stage test in adnexal masses that are difficult to classify.

METHODS

This was a prospective observational international multicenter diagnostic accuracy study. Consecutive patients with an adnexal mass underwent standardized transvaginal two-dimensional (2D) grayscale and color or power Doppler and 3D power Doppler ultrasound examination by an experienced examiner, and those with a 'difficult' tumor were included in the current analysis. A difficult tumor was defined as one in which the International Ovarian Tumor Analysis (IOTA) logistic regression model-1 (LR-1) yielded an ambiguous result (risk of malignancy, 8.3% to 25.5%), or as one in which the ultrasound examiner was uncertain regarding classification as benign or malignant when using subjective assessment. Even when the ultrasound examiner was uncertain, he/she was obliged to classify the tumor as most probably benign or most probably malignant. For each difficult tumor, one researcher created a 360° rotating 3D power Doppler image of the vessel tree in the whole tumor and another of the vessel tree in a 5-cm³ spherical volume selected from the most vascularized part of the tumor. Two other researchers, blinded to the patient's history, 2D ultrasound findings and histological diagnosis, independently described the vessel tree using predetermined vessel features. Their agreed classification was used. The reference standard was the histological diagnosis of the mass. The sensitivity of each test for discriminating between benign and malignant difficult tumors was plotted against 1 - specificity on a receiver-operating-characteristics diagram, and the test with the point furthest from the reference line was considered to have the best diagnostic ability.

RESULTS

Of 2403 women with an adnexal mass, 376 (16%) had a difficult mass. Ultrasound volumes were available for 138 of these cases. In 79/138 masses, the ultrasound examiner was uncertain about the diagnosis based on subjective assessment, in 87/138, IOTA LR-1 yielded an ambiguous result and, in 28/138, both methods gave an uncertain result. Of the masses, 38/138 (28%) were malignant. Among tumors that were difficult to classify as benign or malignant by subjective assessment, the vessel feature 'densely packed vessels' had the best discriminative ability (sensitivity 67% (18/27), specificity 83% (43/52)) and was slightly superior to subjective assessment (sensitivity 74% (20/27), specificity 60% (31/52)). In tumors in which IOTA LR-1 yielded an ambiguous result, subjective assessment (sensitivity 82% (14/17), specificity 79% (55/70)) was superior to the best vascular feature, i.e. changes in the diameter of vessels in the whole tumor volume (sensitivity 71% (12/17), specificity 69% (48/70)).

CONCLUSION

Vessel morphology depicted by 3D power Doppler ultrasound may slightly improve discrimination between benign and malignant adnexal tumors that are difficult to classify by subjective ultrasound assessment. For tumors in which the IOTA LR-1 model yields an ambiguous result, subjective assessment is superior to vessel morphology as a second-stage test. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Hemorrhagic corpus luteum: Clinical management update

Hemorrhagic corpus luteum (HCL) is an ovarian cyst formed after ovulation and caused by spontaneous bleeding into a corpus luteum (CL) cyst. When HCL rupture happens, a hemoperitoneum results. Clinical symptoms are mainly due to peritoneal irritation by the blood effusion. The differential diagnosis is extensive and standard management is not defined. The authors elaborated a comparison of the differential diagnosis and therapeutic modalities from the laparoscopic approach to nonsurgical, medical options because hemorrhage from HCL is often self-limiting. The authors reviewed all data implicated with the development of HCL, trying to give homogeneity to literature data. The authors analyzed extensive literature data and subdivided the medical approach into many topics. The wait-and-see attitude avoids unnecessary laparoscopic surgery using supportive therapies (antifibrinolytic, analgesics, liquid infusion, transfusions and antibiotic prophylaxis). Surgical therapy: operative management should be laparoscopic, with surgical options such as luteumectomy, ovarian wedge-shaped excision or oophorectomy. Prevention: the possibility to preserve fertility is essential, mainly in patients with bleeding disorders or undergoing anticoagulant therapy; therefore, they need estro-progestinics or GnRH analogues to prevent ovulation and avoid further episodes of HCL. This review will aid physicians in making an early diagnosis of HCL, to avoid unnecessary surgery, and use the most effective treatment.

Effect of the subdose of human chorionic gonadotropin applied in the Hou Hai acupoint on ovulation induction in mares

ABSTRACT The objective of this study was to evaluate the effects of an hCG sub dose applied at the Hou Hai acupoint on corpus luteum (CL) quality and ovulation induction in mares. Fifteen crossbred mares were distributed in randomized blocks and used in three periods with each period employed as the blocking factor in three treatments: T1 = 1500 IU of hCG via intravenous (IV); T2 = 450 IU of hCG applied at the false acupoint (IV); and T3 = 450 IU of hCG applied at the Hou Hai acupoint. Mean diameter of the CL, serum concentration of progesterone (P4), vascularization of the pre-ovulatory follicle and CL were evaluated. Females administered 450 IU of hCG at the Hou Hai acupoint exhibited greater ovulation rates (33.33%) 48h after induction; The minimum number of colored pixel (NCP) of the pre-ovulatory follicle of control females was superior (40.33) to that of mares administered 450 IU of hCG IV at the false acupoint (36.84) and similar to that of those administered hCG at the Hou Hai acupoint (39.31). Further, moderately positive correlations were found between the CL diameter and the P4 concentration on D8 (P<0.05). IV administration of 450 IU of hCG or at the Hou Hai acupoint was efficient at inducing ovulation and ensuring the quality of CL in mares.

Non-invasive tools for the diagnosis of potentially life-threatening gynaecological emergencies: a systematic review

OBJECTIVE

To identify non-invasive tools for diagnosis of the major potentially life-threatening gynaecological emergencies (G-PLEs) reported in previous studies, and to assess their diagnostic accuracy.

METHODS

MEDLINE; EMBASE; Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library) were searched to identify all eligible studies published in English or French between January 1990 and December 2012. Studies were considered eligible if they were primary diagnostic studies of any designs, with a gold standard and with sufficient information for construction of a 2 × 2 contingency table, concerning at least one of the following G-PLEs: complicated ectopic pregnancy, complicated pelvic inflammatory disease, adnexal torsion and haemoperitoneum of any gynaecological origin. Extraction of data and assessment of study quality were conducted by two independent reviewers. We set the thresholds for the diagnostic value of signs retrieved at Sensibility ≥ 95% and LR-≤ 0.25, or Specificity ≥ 90% and LR+ ≥ 4.

RESULTS

We identified 8288 reports of diagnostic studies for the selected G-PLEs, 45 of which met the inclusion criteria. The methodological quality of the included studies was generally low. The most common diagnostic tools evaluated were transvaginal ultrasound (20/45), followed by medical history (18/45), clinical examination (15/45) and laboratory tests (14/45). Standardised questioning about symptoms, systolic blood pressure<110 mmHg, shock index>0.85, identification of a mass by abdominal palpation or vaginal examination, haemoglobin concentration <10 g/dl and six ultrasound and Doppler signs presented high performances for the diagnosis of G-PLEs. Transvaginal ultrasound was the diagnostic tool with the best individual performance for the diagnosis of all G-PLEs.

CONCLUSION

This systematic review suggests that blood pressure measurement, haemoglobin tests and transvaginal ultrasound are cornerstone examinations for the diagnosis of G-PLEs that should be available in all gynaecological emergency care services. Standardised questioning about symptoms could be used for triage of patients.

Classification of images acquired with colposcopy using artificial neural networks

OBJECTIVE

To explore the advantages of using artificial neural networks (ANNs) to recognize patterns in colposcopy to classify images in colposcopy.

PURPOSE

Transversal, descriptive, and analytical study of a quantitative approach with an emphasis on diagnosis. The training test e validation set was composed of images collected from patients who underwent colposcopy. These images were provided by a gynecology clinic located in the city of Criciúma (Brazil). The image database (n = 170) was divided; 48 images were used for the training process, 58 images were used for the tests, and 64 images were used for the validation. A hybrid neural network based on Kohonen self-organizing maps and multilayer perceptron (MLP) networks was used.

RESULTS

After 126 cycles, the validation was performed. The best results reached an accuracy of 72.15%, a sensibility of 69.78%, and a specificity of 68%.

CONCLUSION

Although the preliminary results still exhibit an average efficiency, the present approach is an innovative and promising technique that should be deeply explored in the context of the present study.

In vivo high-resolution magnetic resonance elastography of the uterine corpus and cervix

OBJECTIVES

To apply 3D multifrequency MR elastography (3DMMRE) to the uterus and analyse the viscoelasticity of the uterine tissue in healthy volunteers considering individual variations and variations over the menstrual cycle.

METHODS

Sixteen healthy volunteers participated in the study, one of whom was examined 12 times over two menstrual cycles. Pelvic 3DMMRE was performed on a 1.5-T scanner with seven vibration frequencies (30-60 Hz) using a piezoelectric driver. Two mechanical parameter maps were obtained corresponding to the magnitude (|G (*) |) and the phase angle (φ) of the complex shear modulus.

RESULTS

On average, the uterine corpus had higher elasticity, but similar viscosity compared with the cervix, reflected by |G (*) |uterine corpus = 2.58 ± 0.52 kPa vs. |G (*) |cervix = 2.00 ± 0.34 kPa (p < 0.0001) and φ uterine corpus = 0.54 ± 0.08, φ cervix = 0.57 ± 0.12 (p = 0.428). With 2.23 ± 0.26 kPa, |G (*) | of the myometrium was lower in the secretory phase (SP) compared with that of the proliferative phase (PP, |G (*) | = 3.01 ± 0.26 kPa). For the endometrium, the value of |G (*) | in SP was 68% lower than during PP (PP, |G (*) | = 3.34 ± 0.42 kPa; SP, |G (*) | = 1.97 ± 0.34 kPa; p = 0.0061).

CONCLUSION

3DMMRE produces high-resolution mechanical parameter maps of the uterus and cervix and shows sensitivity to structural and functional changes of the endometrium and myometrium during the menstrual cycle.

KEY POINTS

MR elastography provided for the first time spatially resolved viscoelasticity maps of uterus. Uterine corpus had a higher elasticity, but similar viscosity compared with cervix. The stiffness of both endometrium and myometrium decreases during the menstrual cycle.

Tissue characterization using mean gray value analysis in deep infiltrating endometriosis

OBJECTIVES

To investigate differences in tissue characterization using three-dimensional sonographic mean gray value (MGV) between retrocervical and rectosigmoid deeply infiltrating endometriosis, and to assess intra- and interobserver concordance in MGV quantification.

METHODS

In this retrospective study, stored ultrasound volumes from 50 premenopausal women (mean age, 32 years) with 57 histologically confirmed nodules of deep endometriosis were retrieved from our database for analysis. A single experienced operator had acquired all volumes. For each nodule, the MGV was evaluated using virtual organ computer-aided analysis (VOCAL) software with semiautomated sphere-sampling (1 cm3) from the central part of the nodule. In these patients the MGV was also quantified from the myometrium of the fundal part of the uterus. In addition, two observers calculated the MGV in a subset of 24 volumes in order to quantify inter- and intraobserver agreement using intraclass correlation coefficients (ICC).

RESULTS

Mean MGV was significantly higher in rectosigmoid nodules (n = 34) than in nodules with a retrocervical location (n = 23) (23.863 vs. 17.705; P < 0.001). MGV of the myometrium was significantly higher in comparison with that of nodules in both locations (P < 0.001 for both). Intra- and interobserver measurement reproducibility was excellent (ICC > 0.95).

CONCLUSIONS

Retrocervical and rectosigmoid endometriotic nodules display significantly different MGVs. Measurement of MGV is highly reproducible and its clinical value in the diagnosis and assessment of distribution of deep endometriosis should be assessed in future studies.

Contrast-enhanced ultrasonography using Sonazoid(®) is useful for diagnosis of malignant ovarian tumors: comparison with Doppler ultrasound

PURPOSE

The purpose of this study was to assess the usefulness of Sonazoid(®)-enhanced ultrasonography (US) in the diagnosis of ovarian cancer in comparison with Doppler US.

METHODS

Twenty-five ovarian tumor patients who were scheduled to undergo surgery were recruited for this study. The day before the operation, each patient was evaluated with color and power Doppler and baseline US during intravenous infusion of Sonazoid. Each lesion was classified as "benign" or "malignant" on the basis of specific criteria for a Doppler signal or Sonazoid-enhanced pattern. The reference standard was the histology of surgically removed adnexal tumors.

RESULTS

Twenty patients were diagnosed with malignant tumors (invasive cancer, n = 15; metastatic cancer, n = 1; borderline tumor, n = 4), and the remaining five were diagnosed with benign tumors. Sonazoid-enhanced US correctly depicted the presence or absence of intratumoral blood flow in all patients with an accuracy of 92 %. Color Doppler ultrasound depicted the malignancies with an accuracy of 64 %, and power Doppler ultrasound depicted them with an accuracy of 76 %.

CONCLUSION

Our study suggests that Sonazoid-enhanced US is superior to conventional color Doppler US for the diagnosis of malignant ovarian tumors, but not to power Doppler US. The data and their interpretation in our study should be taken with some degree of caution because of the small number of subjects. Further studies involving a larger sample size would be needed to confirm these findings.

Diagnosis, treatment, and follow-up of borderline ovarian tumors

Borderline ovarian tumors represent a heterogeneous group of noninvasive tumors of uncertain malignant potential with characteristic histology. They occur in younger women, are present at an early stage, and have a favorable prognosis, but symptomatic recurrence and death may be found as long as 20 years after therapy in some patients. The molecular changes in borderline ovarian tumors indicate linkage of this disease to type I ovarian tumors (low-grade ovarian carcinomas). The pathological stage of disease and subclassification of extraovarian disease into invasive and noninvasive implants, together with the presence of postoperative macroscopic residual disease, appear to be the major predictor of recurrence and survival. However, it should be emphasized that the most important negative prognostic factor for recurrence is just the use of conservative surgery, but without any impact on patient survival because most recurrent diseases are of the borderline type-easily curable and with an excellent prognosis. Borderline tumors are difficult masses to correctly preoperatively diagnose using imaging methods because their macroscopic features may overlap with invasive and benign ovarian tumors. Over the past several decades, surgical therapy has shifted from a radical approach to more conservative treatment; however, oncologic safety must always be balanced. Follow-up is essential using routine ultrasound imaging, with special attention paid to the remaining ovary in conservatively treated patients. Current literature on this topic leads to a number of controversies that will be discussed thoroughly in this article, with the aim to provide recommendations for the clinical management of these patients.

Adenomyosis reduces pregnancy rates in infertile women undergoing IVF

High-resolution transvaginal ultrasound has facilitated the diagnosis of adenomyosis. This study determined the prevalence of this finding in infertile women and its effect on the outcome of IVF/intracytoplasmic sperm injection (ICSI). This prospective study evaluated 275 consecutive women, commencing IVF/ICSI for the first time. Inclusion criteria were adequate ovarian reserve. Women with fibroids or a previous myomectomy were excluded. All women were screened for adenomyosis by transvaginal ultrasound on three separate occasions. The control group included 256 women and the adenomyosis group included 19 women. There was no significant difference in the ages of women, FSH, cause of infertility, body mass index, total dose of gonadotrophin used and number of oocytes collected between the two groups. However, women with adenomyosis had a higher mean antral follicle count (P=0.006). The clinical pregnancy rate (22.2% versus 47.2%) and ongoing pregnancy rate (11.1% versus 45.9%) were significantly lower in women with adenomyosis and the miscarriage rate (50.0% versus 2.8%) was significantly higher in women with adenomyosis (all P<0.001). Ultrasound evidence of adenomyosis is found in a significant number of women presenting with infertility and has a negative impact on the outcome of IVF/ICSI. This paper suggests that a common condition known as adenomyosis is associated with a reduced success following fertility treatment such as IVF. The diagnosis of adenomyosis has been greatly facilitated by the advent of high-resolution transvaginal ultrasound. This was a study including 275 consecutive women who were commencing IVF for the first time. Comparing women who did not have adenomyosis and those that did, the clinical and ongoing pregnancy rates were both lower in women with adenomyosis (22.2% versus 47.2% and 11.1% versus 45.9%, respectively). So, fewer women with adenomyosis became pregnant and had an ongoing pregnancy. The miscarriage rate was higher in women with adenomyosis compared with those without (50.0% versus 2.8%). We conclude that ultrasound evidence of adenomyosis is found in a significant number of women presenting with infertility and has a negative impact on the outcome of IVF.

Misdiagnosed uterine rupture of an advanced cornual pregnancy

Cornual pregnancy is a diagnostic and therapeutic challenge with potential severe consequences if uterine rupture occurs with following massive intraabdominal bleeding. We report a case of a misdiagnosed ruptured cornual pregnancy occurring at 21 weeks of gestation. Ultrasound examination and computer tomography revealed no sign of abnormal pregnancy. The correct diagnosis was first made at emergency laparotomy. Uterine rupture should be considered in pregnant women presenting with abdominal pain and haemodynamic instability.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

MRI of the female pelvis: a possible pitfall in the differentiation of haemorrhagic vs. fatty lesions using fat saturated sequences with inversion recovery

The use of fat-saturated techniques should be an integral part of the work-up of any T1-hyperintense structure in the female pelvis for tissue characterization and for differentiation of a fat-containing ovarian mature teratoma from a haemorrhagic lesion. Two cases with haematocolpos and haematometra are presented, respectively. The haemorrhagic content showed high signal both on T1- and T2-weighted images, whereas an unexpected signal decrease in the fat-saturated T2-weighted inversion-recovery sequence was encountered. This unspecific suppression of signal in tissues with similar T1 relaxation times as fat can lead to a diagnostic pitfall both in T1- and T2-weighted STIR pulse sequences. Furthermore, a loss of signal on T2-weighting may also be due to the phenomenon of "T2-shading" in T1-bright ovarian endometrioma. Therefore, the fat-specific spectral fat-saturation of T1-weighted images is strongly recommended for tissue characterization in gynaecological disease.

Clinical management of uterine sarcomas

Malignant pure mesenchymal uterine tumours encompass endometrial stromal sarcoma (ESS), uterine leiomyosarcoma, and undifferentiated sarcomas. This Review discusses pathology, preoperative diagnosis, and standard treatment of uterine leiomyosarcoma and low-grade ESS (distinct from undifferentiated uterine sarcomas), with an emphasis on targeted treatment. We show that several features on ultrasonography and MRI can raise suspicion of a uterine sarcoma; however, there are no pathognomonic features on any imaging technique. For both ESS and uterine leiomyosarcoma, hysterectomy with bilateral salpingo-oophorectomy, but without lymphadenectomy, is the standard surgical treatment for early stage disease. The clinical benefit of chemotherapy is limited, which underscores the importance of targeted therapy. ESS and uterine leiomyosarcoma are driven by different pathways, resulting in a different clinical behaviour. ESS typically is a hormone-sensitive tumour with indolent growth. Uterine leiomyosarcoma is notorious for its aggressive growth and poor outcome. Individualisation of treatment is mandatory, because randomised trials are almost non-existent. The progesterone and oestrogen receptors are clinically important targets for most primarily advanced or recurrent ESS and a subset of recurrent uterine leiomyosarcomas. Potential future targets and targeted treatments that are under investigation are presented for both entities.

Diagnostic accuracy of transvaginal ultrasound examination for assigning a specific diagnosis to adnexal masses

OBJECTIVES

To determine the sensitivity and specificity of subjective evaluation of gray-scale and Doppler ultrasound findings (here called pattern recognition) when used by experienced ultrasound examiners with regard to making a specific diagnosis of adnexal masses.

METHODS

Within the framework of a European multicenter study, the International Ovarian Tumor Analysis study, comprising nine ultrasound centers, women with at least one adnexal mass were examined with gray-scale and color Doppler ultrasonography by experienced ultrasound examiners. A standardized examination technique, and standardized terms and definitions were used. Using pattern recognition the examiners classified each mass as benign or malignant and suggested a specific diagnosis (e.g. dermoid cyst or endometrioma). The reference standard was the histology of the surgically removed adnexal tumors.

RESULTS

A total of 1066 women were included, of whom 800 had a benign mass and 266 a malignant mass. A specific diagnosis based on ultrasound findings was suggested in 899 (84%) tumors. The specificity was high for all diagnoses (range, 94-100%). The sensitivity was highest for benign teratoma/dermoid cysts (86%, 100/116), hydrosalpinges (86%, 18/21), peritoneal pseudocysts (80%, 4/5) and endometriomas (77%, 153/199), and lowest for functional cysts (17%, 4/24), paraovarian/parasalpingeal cysts (14%, 3/21), benign rare tumors (11%, 1/9), adenofibromas (8%, 3/39), simple cysts (6%, 1/18) and struma ovarii (0%, 0/5). The positive and negative likelihood ratios of pattern recognition with regard to dermoid cysts, hydrosalpinges and endometriomas were 68.2 and 0.14, 38.9 and 0.15, and 33.3 and 0.24, respectively. Dermoid cysts, hydrosalpinges, functional cysts, paraovarian cysts, peritoneal pseudocysts, fibromas/fibrothecomas and simple cysts were never misdiagnosed as malignancies by the ultrasound examiner, whereas more than 10% of inflammatory processes, adenofibromas and rare benign tumors including struma ovarii were misdiagnosed as malignancies.

CONCLUSIONS

Using subjective evaluation of gray-scale and Doppler ultrasound findings it is possible to make an almost conclusive diagnosis of a dermoid cyst, endometrioma and hydrosalpinx. Many other adnexal pathologies can be recognized but not confidently confirmed or excluded.

Novel nanomedicine-based MRI contrast agents for gynecological malignancies

Gynecological cancers result in significant morbidity and mortality in women despite advances in treatment and diagnosis. This is due to detection of the disease in the late stages following metastatic spread in which treatment options become limited and may not result in positive outcomes. In addition, traditional contrast agents are not very effective in detecting primary metastatic tumors and cells due to a lack of specificity and sensitivity of the diagnostic tools, which limits their effectiveness. Recently, the field of nanomedicine-based contrast agents offers a great opportunity to develop highly sophisticated devices that can overcome many traditional hurdles of contrast agents including solubility, cell-specific targeting, toxicities, and immunological responses. These nanomedicine-based contrast agents including liposomes, micelles, dendrimers, multifunctional magnetic polymeric nanohybrids, fullerenes, and nanotubes represent improvements over their traditional counterparts, which can significantly advance the field of molecular imaging.

Functional ovarian lesions in children and adolescents: when to remove them

STUDY OBJECTIVE

Functional ovarian lesions represent 45% of all pediatric adnexal abnormalities. Their surgical management, even if frequent, is not clear, especially in pediatric age.

MATERIALS AND METHODS

We retrospectively reviewed 22 pediatric patients surgically treated for functional ovarian lesions from 2000 to 2006. The following characteristics were analysed: age, size of the lesion, ultrasound (US) aspect and clinical presentation.

RESULTS

The average age was 16.1 years of age (range: 6 months-18 years). Of the 22 functional lesions, 12 (55%) were follicular cysts and 10 (45%) corpus luteum ones. The average size was 6.7 cm (range: 5.1-33 cm). US scan showed simple lesions in 10 cases (45%) and complex ones in 12 cases (55%). In 16 girls (72.8%) the presenting symptom was abdominal pain while 2 patients (9%) presented abdominal distention. In the other 4 patients (16.2%) the lesion was found accidentally during US examination.

CONCLUSION

In pediatric subjects, functional ovarian cysts rarely required surgical intervention, though no complications or disorder recurrence were reported. To preserve ovarian function, conservative surgery has to be performed whenever feasible.