Sonographic evaluation of ovarian masses and its therapeutical implications

High impact of FDG-PET/CT in diagnostic strategies for ovarian cancer

BACKGROUND

Ovarian cancer has the highest mortality of all gynecologic malignancies. FDG-PET/CT was proven to be accurate for identification of primary ovarian tumors, regional lymph nodes, and distant metastases.

PURPOSE

To evaluate ovarian masses at FDG-PET/CT in correlation with histopathologic findings.

MATERIAL AND METHODS

Ninety-eight patients underwent whole body FDG-PET/CT examination. Eighty-six patients with primary ovarian cancer and 12 patients with metastatic disease to the ovaries were included.

RESULTS

PET/CT imaging was true-positive in 87/94 patients with malignant tumors. In 4/4 patients with benign tumors, PET/CT results were true-negative, with sensitivity of 92.6%, specificity 100%, total test accuracy 92.9%. Fifty-seven patients were diagnosed as stage IV ovarian cancer with distant metastasis.

CONCLUSION

The anatomical/functional examination by FDG-PET/CT was proven to be valuable in increasing the diagnostic accuracy that can help improve patient management.

Comparison of four malignancy risk indices in the detection of malignant ovarian masses

Objective

The aim of this study was to evaluate the ability of four risk of malignancy indices (RMI) to detect malignant ovarian tumors.

Methods

This is a prospective study of 100 women admitted to the Department of Obstetrics and Gynecology of Gulhane Military Medicine Academy for surgical exploration of pelvic masses. To diagnose malignant ovarian tumors, the sensitivity, specificity, negative and positive predictive values and diagnostic accuracy of four RMIs (RMI 1, RMI 2, RMI 3, and RMI 4) were obtained.

Results

In our study we found that there is no statistically significant difference in the performance of four different RMIs in discriminating malignancy. We think that malignancy risk indices is more reliable than the menopausal status, serum CA-125 levels, ultrasound features and tumor size separately in detecting malignancy.

Conclusion

We concluded that any of the four malignancy risk indices described can be used for selection of cases for optimal therapy. These methods are simple techniques that can be used even in less-specialized gynecology clinics to facilitate the selection of cases for referral to an oncological unit.

Intravenous contrast ultrasound examination using contrast-tuned imaging (CnTI) and the contrast medium SonoVue for discrimination between benign and malignant adnexal masses with solid components

OBJECTIVE

To determine whether intravenous contrast ultrasound examination is superior to gray-scale or power Doppler ultrasound for discrimination between benign and malignant adnexal masses with complex ultrasound morphology.

METHODS

In an international multicenter study, 134 patients with an ovarian mass with solid components or a multilocular cyst with more than 10 cyst locules, underwent a standardized transvaginal ultrasound examination followed by contrast examination using the contrast-tuned imaging technique and intravenous injection of the contrast medium SonoVue(R). Time intensity curves were constructed, and peak intensity, area under the intensity curve, time to peak, sharpness and half wash-out time were calculated. The sensitivity and specificity with regard to malignancy were calculated and receiver-operating characteristics (ROC) curves were drawn for gray-scale, power Doppler and contrast variables and for pattern recognition (subjective assignment of a certainly benign, probably benign, uncertain or malignant diagnosis, using gray-scale and power Doppler ultrasound findings). The gold standard was the histological diagnosis of the surgically removed tumors.

RESULTS

After exclusions (surgical removal of the mass > 3 months after the ultrasound examination, technical problems), 72 adnexal masses with solid components were used in our statistical analyses. The values for peak contrast signal intensity and area under the contrast signal intensity curve in malignant tumors were significantly higher than those in borderline tumors and benign tumors, while those for the benign and borderline tumors were similar. The area under the ROC curve of the best contrast variable with regard to diagnosing borderline or invasive malignancy (0.84) was larger than that of the best gray-scale (0.75) and power Doppler ultrasound variable (0.79) but smaller than that of pattern recognition (0.93).

CONCLUSION

Findings on ultrasound contrast examination differed between benign and malignant tumors but there was a substantial overlap in contrast findings between benign and borderline tumors. It appears that ultrasound contrast examination is not superior to conventional ultrasound techniques, which also have difficulty in distinguishing between benign and borderline tumors, but can easily differentiate invasive malignancies from other tumors.

Adnexal Masses in Pregnancy: Diagnosis and Management

The widespread use of ultrasound in obstetrics has led to an increase in the diagnosis of asymptomatic adnexal masses in pregnancy. Ultrasound is an accurate and safe method for diagnosing the etiology of an adnexal mass and distinguishing benign from malignant pathology. The management of an adnexal mass in pregnancy is controversial. Historically, it was recommended that any adnexal mass be removed electively in the second trimester to exclude malignancy and prevent complications such as torsion, rupture, and obstruction of labor. More recent recommendations have limited surgical intervention in pregnancy to symptomatic adnexal masses and those that are highly suggestive of malignancy. Surgery in pregnancy is associated with an increased risk of adverse pregnancy outcomes. However, laparoscopy appears to be a safe alternative to laparotomy for benign masses when performed by experienced surgeons.

Learning objectives

To list the differential diagnoses of adnexal masses in pregnancy

To interpret ultrasound images of adnexal masses and distinguish benign from malignant masses

To describe the management options for adnexal masses in pregnancy, including the indications and options for surgical intervention.

Ultrasound features of different histopathological subtypes of borderline ovarian tumors

OBJECTIVE

To describe the gray-scale sonographic and color Doppler imaging features of the most common histopathological subtypes of borderline ovarian tumors.

METHODS

We analyzed retrospectively the preoperative transvaginal sonographic reports of patients with a histological diagnosis of borderline ovarian tumor. All patients were scanned consecutively by two of the investigators using transabdominal and transvaginal gray-scale imaging to assess the morphology and color Doppler to obtain indices of the blood flow. Sonographic findings were compared to histopathological data.

RESULTS

A total of 113 consecutive cases were reviewed from two referral centers for gynecological oncology. At histological examination 50 tumors (44%) were classified as being serous borderline ovarian tumors (SBOT), 61 (54%) were mucinous borderline ovarian tumors (MBOT) (42 intestinal type and 19 endocervical type), and two patients (2%) presented with borderline endometrioid tumors. SBOTs and endocervical-type MBOTs had very similar sonographic features and a smaller diameter, fewer locules (usually unilocular-solid lesions) and a higher color score than intestinal-type MBOTs. Intestinal-type MBOTs were characterized by a significantly higher percentage of lesions with > 10 locules when compared with the endocervical-type MBOTs.

CONCLUSION

Intestinal-type MBOTs have different sonographic features from other common borderline ovarian tumors.

Adnexal Masses in Pregnancy: Surgery Compared With Observation

OBJECTIVE

To estimate whether the delay of surgery impacts the risk of adverse maternal and fetal outcomes in patients diagnosed with an adnexal mass during pregnancy.

METHODS

A review was performed of pregnant patients diagnosed with an adnexal mass 5 cm or greater in diameter. Data collected included age, gravity/parity, gestational age at diagnosis, and presenting symptoms. Ultrasound examinations were evaluated for mass size and complexity. Pregnancy outcome, complications, and surgical pathology were reviewed.

RESULTS

Between 1990 and 2003, 127,177 deliveries were performed at our institution. An adnexal mass 5 cm in diameter or greater was diagnosed in 63 (0.05%) patients. Pathologic diagnosis was available for 59 (94%) patients. The remaining 4 patients were lost to follow-up and excluded from the analysis. Antepartum surgery was performed in 17 patients (29%): 13 because of ultrasound findings that suggested malignancy and 4 secondary to ovarian torsion. The remaining patients were observed, with surgery performed in the postpartum period or at time of cesarean delivery. The majority of masses were dermoid cysts (42%). Four patients were diagnosed with ovarian cancer (6.8% of masses, 0.0032% of deliveries), and one patient (1.7%) had a tumor of low malignant potential. Antepartum surgery due to ultrasound findings that caused concern was performed on all 5 women diagnosed with a malignancy or borderline tumor, compared with 12 (22%) of the patients with benign tumors (P < .01).

CONCLUSION

In select cases, close observation is a reasonable alternative to antepartum surgery in patients with an adnexal mass during pregnancy.

Asymptomatic adnexal masses: correlation of FDG PET and histopathologic findings

PURPOSE

To analyze asymptomatic adnexal masses at positron emission tomography (PET) with fluorodeoxyglucose (FDG) in correlation with histopathologic findings and evaluate FDG PET for assessing malignancy in comparison with transvaginal B-mode and Doppler ultrasonography (US) and magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Ninety-nine patients underwent static FDG PET of the abdomen. US scans were evaluated according to sonomorphologic scoring systems. Resistance index of tumor blood vessels was calculated. Transverse and sagittal T1-weighted MR images obtained before and after intravenous administration of gadopentetate dimeglumine with a fat-saturation technique and T2-weighted MR images were acquired at 1.5 T. Adnexal mass malignancy was first assessed with each modality and then with a combination of the three techniques. Final diagnosis was made with histopathologic evaluation.

RESULTS

FDG PET depicted seven of 12 malignant and 66 of 87 benign asymptomatic adnexal tumors. False-negative PET results were obtained in five of seven stage pT1a cystadenocarcinomas and tumors of low malignant potential but not in advanced-stage ovarian carcinomas. Small moderately intense FDG accumulations in the lower pelvis were caused by benign adnexal tumors or gastrointestinal activity in 21 of 27 cases. The overall sensitivities and specificities were 58% (95% CI: 27.7, 84.8) and 76% (95% CI: 65.5, 84.4), respectively, for FDG PET; 92% (95% CI: 61.5, 99.8) and 60% (95% CI: 48.7, 70.1), respectively, for US; 83% (95% CI: 51.6, 97.7) and 84% (95% CI: 74.5, 90.9), respectively, for MR imaging; and 92% (95% CI: 61.5, 99.8) and 85% (95% CI: 75.8, 91.8), respectively, for the combination of three modalities.

CONCLUSION

Since the sensitivity of US is as high as that of PET, MR imaging, and the combination of three modalities, it remains the method of choice for diagnosis and assessment of asymptomatic adnexal masses.

Comparison of three risk of malignancy indices in evaluation of pelvic masses

OBJECTIVES

The aims of this study were to validate the risk of malignancy index (RMI) incorporating menopausal status, serum CA 125 levels, and ultrasound features for discriminating benign from malignant pelvic masses and to evaluate the performance of the three different risk of malignancy indices (RMI 1, RMI 2, and RMI 3).

METHODS

This is a retrospective study of 152 women admitted at Kasturba Hospital, Manipal, between January 1997 and August 1999 for surgical exploration of pelvic masses. The sensitivity, specificity, and positive predictive value of serum CA 125 levels, ultrasound findings, and menopausal status were taken separately and combined into the RMI 1, RMI 2, and RMI 3 to diagnose ovarian cancer. The risk of malignancy index is the product of menopausal score, ultrasound score, and serum CA 125 levels.

RESULTS

The study confirms that the malignancy risk index is more accurate than the menopausal status, serum CA 125 levels, and ultrasound features separately in diagnosing malignancy. There was no statistically significant difference in the performance of these three different malignancy risk indices in identifying malignancy.

CONCLUSIONS

The risk of malignancy index is able to identify malignant and benign pelvic masses efficiently to optimize therapy. The risk of malignancy index is a simple scoring system which can be used in less specialized gynecology centers. We recommend the use of any of these risk of malignancy indices to facilitate the selection of cases for referral to an oncological unit for adequate staging and optimal debulking.