A Practical Approach to the Ultrasound Characterization of Adnexal Masses

EANM guideline on the role of 2-[18F]FDG PET/CT in diagnosis, staging, prognostic value, therapy assessment and restaging of ovarian cancer, endorsed by the American College of Nuclear Medicine (ACNM), the Society of Nuclear Medicine and Molecular Imaging (SNMMI) and the International Atomic Energy Agency (IAEA)

In most patients with ovarian carcinoma, the diagnosis is reached when the disease is long past the initial stages, presenting already an advanced stage, and they usually have a very bad prognosis. Cytoreductive or debulking surgical procedures, platinum-based chemotherapy and targeted agents are key therapeutic elements. However, around 7 out of 10 patients present recurrent disease within 36 months from the initial diagnosis. The metastatic spread in ovarian cancer follows three pathways: contiguous dissemination across the peritoneum, dissemination through the lymphatic drainage and, although less importantly in this case, through the bloodstream. Radiological imaging, including ultrasound, CT and MRI, are the main imaging techniques in which management decisions are supported, CT being considered the best available technique for presurgical evaluation and staging purposes. Regarding 2-[¹⁸F]FDG PET/CT, the evidence available in the literature demonstrates efficacy in primary detection, disease staging and establishing the prognosis and especially for relapse detection. There is limited evidence when considering the evaluation of therapeutic response. This guideline summarizes the level of evidence and grade of recommendation for the clinical indications of 2-[¹⁸F]FDG PET/CT in each disease stage of ovarian carcinoma.

Algorithmic Approach to Sonography of Adnexal Masses: An Evolving Paradigm

BACKGROUND

Pelvic US remains the workhorse for detection and characterization of adnexal masses in most centers worldwide. While the differentiation of benign from malignant masses remains the foremost concern, it is imperative to narrow the differential diagnosis for management of benign masses as well as prognostication of malignant masses. The IOTA group as well as ACR have described a five category classification system for adnexal lesions based on morphological patterns. In addition, a six category risk stratification has been proposed, incorporating the probability of malignancy as well as management recommendations.

LEARNING OBJECTIVES

1) Understand pattern based approach to adnexal lesion classification and the possible entities fitting into each pattern with the help of illustrations. 2) Classify lesions into appropriate risk categories based on diagnostic algorithms provided at the end of each section.

Diagnostic accuracy of gynecology imaging reporting and data system in evaluation of adnexal lesions

Background:

Considering the increasing incidence rate of ovarian cancer in worldwide and the utility of Gynecologic Imaging Reporting and Data System (GI-RADS) in diagnosing malignant adnexal lesions such as ovarian cancer, we aimed to evaluate the diagnostic performance of this reporting system in differentiating between malignant and benign adnexal lesions.

Materials and Methods:

In this cross-sectional study, women with suspected adnexal lesions were enrolled. For differentiating of malignant adnexal lesions, Grade II and III of GI-RADS system were classified as low risk for malignancy and Grades IV and V as high risk. Results of histopathologic diagnosis were compared with the results of the mentioned GI-RADS system classification, and the diagnosed accuracy of the system was determined. Patients who did not have histopathologic diagnosis were followed up.

Results:

In this study, 197 women with suspected adnexal lesions were evaluated. Frequency of GI-RADS II, III, IV, and V were 34.5% (69 cases), 38.0% (76 cases), 19.5% (39 cases), and 6.5% (13 cases), respectively. According to the low- and high-risk classification of GI-RADS, 72.5% were classified as GI-RADS II and III and 26% as GI-RADS IV and V, respectively. Definitive histopathologic diagnosis was reported for 158 cases. Histopathologic evaluation indicated that 12 (7.6%) of the masses were malignant and 146 (92.6%) were benign. Comparing with the histopathologic diagnosis, the GI-RADS system sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio (LR), and negative LR were 91.6%, 80.82%, 28.2%, 99.1%, 4.77, and 0.10, respectively. The accuracy of the scoring system was 81.64%.

Conclusion:

Our findings indicated that using GI-RADS, we could quantify the risk of malignancy by such a structured as well as simple reporting system so that the system could be useful for clinicians for performing an appropriate clinical management.

Combination of Sonographic Morphology Score and Tumor Markers for Detecting Postoperative Recurrent Pelvic Ovarian Carcinoma: Compared With MRI Assessment

To assess the efficacy of the combination of sonographic morphology score (SMS) with CA125 and HE4 for detecting recurrent pelvic ovarian carcinoma (OC). Data of 58 OC patients treated in our hospital between 2014 and 2016 were analyzed. After cytoreductive surgery and routine chemotherapy, all patients were followed up by transvaginal ultrasound examination (SMS for pelvic masses based on volume and structure scores) and tumor marker (serum CA125 and HE4) detection. Clinical diagnosis of recurrent OC was based on physical examination, magnetic resonance imaging, and punctured pathology for pelvic masses. Receiver operating characteristic (ROC) curves of SMS and the tumor markers were generated, and areas under the curve (AUC) values were assessed. There were 26 patients with tumor recurrence and 32 cases with no recurrence. Magnetic resonance imaging had 100% sensitivity and specificity. The areas under the ROC curves of SMS, CA125, HE4, and SMS-CA125-HE4 were 0.816, 0.825, 0.737, and 0.903, respectively. There was no significant difference in AUC values between SMS and CA125 or HE4. There were significant differences in AUC values between SMS-CA125-HE4 and SMS (Z = 2.48, P = 0.042), CA125 (Z = 2.38, P = 0.046), and HE4 (Z = 6.48, P = 0.016), respectively. With a cutoff value of SMS, 5; CA125, 35 U/mL; HE4, 105 pmol/L, the sensitivity, specificity, positive prognostic value, and negative prognostic value of SMS-CA125-HE4 for recurrent OC assessment were 0.9231, 0.8438, 0.8276, and 0.931, respectively. SMS-CA125-HE4 was correlated with recurrent OC (χ = 30.7428, P < 0.0001). Ultrasound combined with tumor markers may improve the diagnostic efficiency of recurrent OC.

The value of MR-detectable ipsilateral ovaries in characterizing the origin and malignancy of an adnexal tumors

OBJECTIVE

To investigate the magnetic resonance (MR) imaging morphological relationship between adnexal tumors and the ipsilateral ovaries to characterize the origin and malignancy of tumors.

MATERIAL AND METHODS

Clinical and MR imaging data of 496 adnexal tumors confirmed by histology (ovary tumors, n = 400, non-ovarian tumors, n = 96; benign tumors, n = 183, borderline tumors, n = 120, and malignant tumors, n = 193) were retrospectively analyzed. The presence and shape of the ipsilateral ovaries within the context of adnexal tumors of different origins, malignancies and configurations were evaluated. The relationships between the presence of the ipsilateral ovary and patient age, menstrual status and tumor size were also analyzed.

RESULT

The ipsilateral ovary was detected on MRI in 23% (90/400) of ovarian tumors and in 45% (43/96) of non-ovarian tumors (p < 0.001). A normal ovoid morphology of the ipsilateral ovary was found in only 7% (26/400) of ovarian tumors and in 26% (25/96) of non-ovarian tumors (p < 0.001). The ipsilateral ovary was detectable in 38% (69/183) of benign tumors, 35% (42/120) of borderline tumors, and 11% (22/193) of malignant tumors (p <  0.001); in 24% (24/101) of cystic tumors, 27% (49/179) of mixed cystic-solid tumors and 28% (60/216) of solid tumors (p = 0.737); and in 40% (120/303) of adnexal tumors in premenopausal patients and 7% (13/193) of adnexal tumors in postmenopausal patients (p < 0.001).

CONCLUSION

Detection of the ipsilateral ovary contributes to the localization and characterization of adnexal tumors. The ipsilateral ovary can be detected more frequently in non-ovarian tumors and in benign or borderline ovarian tumors.

Fludeoxyglucose F 18 PET/CT Assessment of Ovarian Cancer

Ovarian cancer is one of the most common gynecologic cancers and one of the leading causes of cancer death in women. It is often asymptomatic in early stages, and thus most patients are diagnosed when it is of advanced stage. For these reasons, the role of biomarkers and tomographic imaging is crucial. Fludeoxyglucose F 18 PET/CT is a useful imaging modality in different clinical settings of the disease, overcoming some limits of conventional imaging and influencing prognosis and therapeutic approaches. PET/MR imaging is an emerging modality, and its potential role remains to be explored.

Ovarian Cancer, the Revised FIGO Staging System, and the Role of Imaging

OBJECTIVE

It is now recognized that ovarian cancer includes a heterogeneous group of malignant epithelial tumors originating from the ovaries, fallopian tubes, or peritoneum. This development has prompted the International Federation of Gynecology and Obstetrics (FIGO) to issue a revised staging system that can provide prognostic information and guidance on personalized management of ovarian cancer.

CONCLUSION

We review the epidemiology of ovarian cancer, the new FIGO staging system, and the role of imaging in the assessment, staging, and follow-up of ovarian cancer.

Acute Gynecologic Disorders

Premenopausal women with acute pelvic pain comprise a significant percentage of patients who present to the emergency room. Etiologies can be gynecologic, urologic, gastrointestinal, or vascular. Signs and symptoms are often nonspecific and overlapping. The choice of imaging modality is determined by the clinically suspected differential diagnosis. Ultrasound (US) is the preferred imaging modality for suspected obstetric or gynecologic disorders. CT is more useful when gastrointestinal or urinary tract pathology is likely. MR imaging is rarely used in the emergent setting, except to exclude appendicitis in pregnant women. This article presents a comprehensive review of imaging of acute gynecologic disorders.

Assessment of adnexal masses using ultrasound: a practical review

Pelvic ultrasound is commonly used as part of the routine gynecologic exams, resulting in diagnosis of adnexal masses, the majority of which are functional or benign. However, due to the possible complications involving benign adnexal cysts (ie, adnexal torsion, pelvic pain) and the utmost importance of early diagnosis and treatment of ovarian cancer, the correct ultrasound diagnosis of adnexal masses is essential in clinical practice. This review will describe the typical ultrasound appearance of the common physiologic, benign, and malignant adnexal masses with the aim of aiding the clinician to reach the correct diagnosis.

[Radiological diagnostics of ovarian cancer]

Ovarian cancer is diagnosed in stages FIGO III/IV in up to 75% of cases. Despite medical advances the 5-year survival rate has only been moderately increased to 44% during recent years. The initial evaluation is performed using transvaginal ultrasound (US) (sensitivity 90-96%, specificity 98-99% for detection of ovarian lesions). Probably benign findings will be followed-up sonographically or will be laparoscopically excised. Magnetic resonance imaging (MRI) allows a definitive diagnosis in more than 90% of sonographically indeterminate lesions. Malignant lesions require computer tomography (CT) staging and treatment in gynecology centers in a multidisciplinary setting. Peritoneal implants larger than 1 cm are detected equally by CT and MRI. Detection of ascites which is associated with peritoneal carcinomatosis in up to 80% of cases is equally feasible by US, CT and MRI.

Doppler imaging in the diagnosis of ovarian disease

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Clinical indications and utilization of 320-detector row CT in 2500 outpatients

Clinical indications and utilization patterns for 3963 CT scans on 2500 consecutive patents on a 320-detector row CT in an outpatient setting were retrospectively analyzed and compared with previously reported CT studies. The impact of the latest generation CT technology, including whole organ perfusion, on indications and utilization patterns during the study period was also assessed. The top five requested CT scan types were abdomen/pelvis, chest, head, sinuses, and coronary CT angiography. Indication and utilization rates were similar to prior studies for abdomen/pelvis, non-cardiac chest, and head CT scans. Abdominal pain and headaches were the most frequent indications for abdomen/pelvis and head CTs, respectively. The 7.3% cardiac CT scan utilization rate was not comparable to rates of up to 72% in self-referral outpatient settings. Whole organ volume CT imaging was utilized in 100% of coronary CT angiography and 22.7% of head CTs. The 320-row CT had fewer negative head and body CT findings as compared to prior reports. The availability of new technology, such as whole organ dynamic scans, appears to have influenced CT indications, utilization and finding rates with a decrease in negative brain and body results. Comparisons with previous outpatient CT studies were similar for multiple categories with the exception of cardiac CT utilization, which is heavily influenced by self-referral. Further study of outpatient imaging indications and utilization rates from multiple centers may benefit from a standardized categorization to improve understanding of the disparate outpatient imaging environment.

Ultrassonografia nas massas anexiais: aspectos de imagem

A ultrassonografia realizada por um habilidoso e experiente examinador é considerada, atualmente, método de elevada acurácia no diagnóstico diferencial das massas anexiais. Os autores expõem uma revisão baseada em imagens ultrassonográficas das principais apresentações das massas anexiais, descrevendo suas características e localizações.

The diagnosis of ovarian cancer: is color Doppler imaging reproducible and accurate in examiners with different degrees of experience?

OBJECTIVE

To evaluate the reproducibility and accuracy of color Doppler flow location in indeterminate masses after a gray-scale sonography in the diagnosis of ovarian malignancy.

METHODS

Digitally stored color Doppler sonographic images from a random sample of 130 women with an indeterminate adnexal mass submitted to surgery were evaluated by six different examiners with different degrees of experience. A mass was graded malignant if flow was shown within the excrescences or solid areas. Intraobserver agreement and interobserver agreement according to the level of experience were assessed by calculating the kappa index.

RESULTS

Intraobserver agreement was good for all examiners with different degrees of experience (kappa 0.72-0.89). Interobserver agreement was good to moderate for all operators (kappa 0.48-0.71) irrespective of degree of experience. The accuracy was comparable among different operators.

CONCLUSIONS

Our results indicate that color Doppler imaging for detection of adnexal malignancy seems to be a reproducible method even in moderately experienced examiners.

Pelvic incidentalomas

Recent advances in multi-detector computed tomography, magnetic resonance imaging, and ultrasound have led to the detection of incidental ovarian, uterine, vascular and pelvic nodal abnormalities in both the oncology and non-oncology patient population that in the past remained undiscovered. These incidental pelvic lesions have created a management dilemma for both clinicians and radiologists. Depending on the clinical setting, these lesions may require no further evaluation, additional immediate or serial follow-up imaging, or surgical intervention. In this review, guidelines concerning the diagnosis and management of some of the more common pelvic incidentalomas are presented.

Transvaginal Color Doppler Imaging in the Detection of Ovarian Cancer in a Large Study Population

Introduction:

The aim of the study was to compare the diagnostic accuracy of grayscale sonography and that of color Doppler imaging in the diagnosis of ovarian malignancy in a prospective study by the Sardinia-Navarra group.

Methods:

The study was performed as a collaborative work at the 2 European university departments of obstetrics and gynecology between 1997 and 2007. A total of 2148 pelvic masses in 1997 women on whom transvaginal sonography were performed before surgical exploration were included in the study. An adnexal mass was first studied in grayscale sonography, and any cystic mass in which the echo architecture was not suggestive of benign tumor was categorized as malignant. Second, any solid excrescences or solid portions of the tumor were evaluated with color/power Doppler sonography. A mass was graded malignant if flow was shown within the excrescences or the solid areas and benign if there was no flow or if flow was only peripheral.

Results:

Four hundred sixty-eight masses were malignant. Color Doppler evaluation was more accurate in the diagnosis of adnexal malignancies in comparison with grayscale sonography because of a significantly higher specificity (94% vs 89%, P = 0.001), with similar sensitivity (95% vs 98%, P = 0.44). The pretest probability of ovarian cancer was 22%, and this probability rose to 82% when the diagnosis was suggested by color Doppler evaluation. The diagnostic accuracy of the tests was also dependent on menopausal status.

Conclusions:

The evaluation of vessel distribution by color Doppler sonography in adnexal masses increases the diagnostic accuracy of grayscale sonography in the detection of adnexal malignancies in a large study population.

Intraobserver and interobserver agreement of grayscale typical ultrasonographic patterns for the diagnosis of ovarian cancer

The purpose of this study was to evaluate the intraobserver and interobserver agreement for identifying ovarian malignancy using typical grayscale ultrasonographic patterns. Digitally stored grayscale sonographic images from a random sample of 98 women with an adnexal mass submitted to surgery after a grayscale transvaginal sonography were evaluated by five different examiners with different degrees of experience in three European university departments of obstetrics and gynecology. Masses in which the echo features were highly characteristic of a benign pathology were categorized as benign. Any cystic mass containing excrescences, thick septations, multiple irregular septations or solid component in which the echo architecture was not highly suggestive of benign histology was categorized as malignant. Intraobserver and interobserver agreement according to the level of experience were assessed by calculating the kappa index. Of the 98 cases randomly selected, 28 (29%) were malignant masses and 70 (71%) were benign. Intraobserver agreement was good or very good for all examiners with different degrees of experience (kappa = 0.72 to 1). Interobserver agreement was good for all expert operators (kappa = 0.69 to 0.75). Interobserver agreement between experts and highly experienced operators was moderate or good (kappa = 0.51 to 0.63). Interobserver agreement between the moderately experienced operator and experts was fair to moderate (kappa = 0.29 to 0.46). Interobserver agreement between moderately and highly experienced operators was fair (kappa = 0.33). Our results indicate that ultrasonographic malignant patterns are reproducible, even in moderately experienced examiners, although more experience is associated with better interobserver agreement.

Pelvic masses

Pelvic masses develop commonly in women of all ages and states of health. Despite the variety of masses that exist, general guidelines for diagnosis and management allow most masses to be treated in a generalist setting. This article is intended to guide non-obstetric and non-gynecologic physicians through diagnosis and treatment of nonmalignant pelvic masses. It includes information on physical examination, appropriate imaging techniques, laboratory tests, and variations in treatment for adolescents and pre- and postmenopausal women. It also addresses referral guidelines for suspected malignant masses.