Value of three-dimensional contrast-enhanced power Doppler ultrasound for characterizing adnexal masses

ACR Appropriateness Criteria® Clinically Suspected Adnexal Mass, No Acute Symptoms: 2023 Update

Asymptomatic adnexal masses are commonly encountered in daily radiology practice. Although the vast majority of these masses are benign, a small subset have a risk of malignancy, which require gynecologic oncology referral for best treatment outcomes. Ultrasound, using a combination of both transabdominal, transvaginal, and duplex Doppler technique can accurately characterize the majority of these lesions. MRI with and without contrast is a useful complementary modality that can help characterize indeterminate lesions and assess the risk of malignancy is those that are suspicious. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Comparison of conventional, doppler and contrast-enhanced ultrasonography in differential diagnosis of ovarian masses: a systematic review and meta-analysis

OBJECTIVES

To assess the value of conventional, Doppler and contrast-enhanced ultrasonography (CEUS) (conventional ultrasonography (US), Doppler US and CEUS) for diagnosing ovarian cancer.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase and the Cochrane Library were conducted for studies published until October 2021.

ELIGIBILITY CRITERIA

Studies assessed the diagnostic value of conventional US, Doppler US or CEUS for detecting ovarian cancer, with no restrictions placed on published language and status.

DATA EXTRACTION AND SYNTHESIS

The study selection and data extraction were performed by two independent authors. The sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR), diagnostic OR (DOR) and area under the receiver operating characteristic curve (AUC) were pooled using the bivariate generalised linear mixed model and random effects model.

RESULTS

The meta-analysis included 72 studies and involved 9296 women who presented with ovarian masses. The pooled sensitivity, specificity, PLR, NLR, DOR and AUC for conventional US were 0.91 (95% CI: 0.87 to 0.94) and 0.87 (95% CI: 0.82 to 0.91), 6.87 (95% CI: 4.98 to 9.49) and 0.10 (95% CI: 0.07 to 0.15), 57.52 (95% CI: 36.64 to 90.28) and 0.95 (95% CI: 0.93 to 0.97), respectively. The sensitivity, specificity, PLR, NLR, DOR and AUC for Doppler US were 0.93 (95% CI: 0.91 to 0.95) and 0.85 (95% CI: 0.80 to 0.89), 6.10 (95% CI: 4.59 to 8.11) and 0.08 (95% CI: 0.06 to 0.11), 61.76 (95% CI: 39.99 to 95.37) and 0.96 (95% CI: 0.94 to 0.97), respectively. The pooled sensitivity, specificity, PLR, NLR, DOR and AUC for CEUS were 0.97 (95% CI: 0.92 to 0.99) and 0.92 (95% CI: 0.85 to 0.95), 11.47 (95% CI: 6.52 to 20.17) and 0.03 (95% CI: 0.01 to 0.09), 152.11 (95% CI: 77.77 to 297.51) and 0.99 (95% CI: 0.97 to 0.99), respectively. Moreover, the AUC values for conventional US (p=0.002) and Doppler US (p=0.005) were inferior to those of CEUS.

CONCLUSIONS

Conventional US, Doppler US and CEUS have a relatively high differential diagnostic value for differentiating between benign and malignant ovarian masses. The diagnostic performance of CEUS was superior to that of conventional US and Doppler US.

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.

New sonographic marker of borderline ovarian tumor: microcystic pattern of papillae and solid components

OBJECTIVE

To describe and evaluate the utility of a new sonographic microcystic pattern, which is typical of borderline ovarian tumor (BOT) papillary projections, solid component(s) and/or septa, as a new ultrasound marker that is capable of distinguishing BOT from other adnexal masses, and to present/obtain histologic confirmation.

METHODS

In this retrospective study, we identified women with a histologic diagnosis of BOT following surgical resection who had undergone preoperative transvaginal ultrasound (TVS) examination. All images were reviewed for presence or absence of thin-walled, fluid-filled cluster(s) of 1-3-mm cystic formations, associated with solid component(s), papillary projections and/or septa. From the same cases, histopathologic slides of each BOT were examined for presence of any of these microcystic features which had been identified on TVS. To confirm that the microcystic TVS pattern is unique to BOTs, we also selected randomly from our ultrasound and surgical database 20 cases of epithelial ovarian cancer and 20 cases of benign cystadenoma, for review by the same pathologists. To confirm the novelty of our findings, we searched PubMed for literature published in the English language between 2010 and 2018 to determine whether the association between microcystic tissue pattern and BOT has been described previously.

RESULTS

Included in the final analysis were 62 patients (67 ovaries) with preoperative TVS and surgically confirmed BOT on pathologic examination. The mean patient age at surgery was 39.8 years. The mean BOT size at TVS was 60.7 mm. Of the 67 BOTs, 47 (70.1%) were serous, 15 (22.4%) were mucinous and five (7.5%) were seromucinous. We observed on TVS a microcystic pattern in the papillary projections, solid component(s) and/or septa in 60 (89.6%) of the 67 BOTs, including 46 (97.9%) of the 47 serous BOTs, 11 (73.3%) of the 15 mucinous BOTs and three (60.0%) of the five seromucinous BOTs. On microscopic evaluation, 60 (89.6%) of the 67 samples had characteristic 1-3-mm fluid-filled cysts similar to those seen on TVS. In seven cases there was a discrepancy between sonographic and histologic observation of a microcystic pattern. The 20 cystadenomas were mostly unilocular and/or multilocular and largely avascular. None of them or the 20 epithelial ovarian malignancies displayed microcystic characteristics, either on TVS or at histology. On review of 23 published articles in the English medical literature, containing 163 sonographic images of BOT, we found that, while all images contained it, there was no description of the microcystic tissue pattern.

CONCLUSION

We report herein a novel sonographic marker of BOT, a 'microcystic pattern' of BOT papillary projections, solid component(s) and/or septa. This was seen in the majority of both serous and mucinous BOT cases. Importantly, based on comparison of sonographic images and histopathology of benign entities and malignancies, the microcystic appearance seems to be unique to BOTs. No similar description has been published previously. Utilization of this new marker should help to identify BOT correctly, discriminating it from ovarian cancer and benign ovarian pathology, and should ensure appropriate clinical and surgical management. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Combination of GI-RADS and 3D-CEUS for differential diagnosis of ovarian masses

OBJECTIVE

The purpose of this study is to evaluate the efficacy of the combination of gynecologic imaging reporting and data system (GI-RADS) ultrasonographic stratification and three-dimensional contrast-enhanced ultrasonography (3D-CEUS) in order to distinguish malignant from benign ovarian masses.

METHODS

In this study, 102 patients with ovarian masses were examined by both two-dimensional ultrasound(2D-US) and 3D-CEUS. Sonographic features of ovarian masses obtained from 3D-CEUS were analyzed and compared with 2D-US. All patients with ovarian masses were confirmed by operational pathology or long-term follow-up results.

RESULTS

(1)The Chi-square test and multiple Logistic regression analysis confirmed that there were only eight independent predictors of malignant masses, including thick septa (≥3mm), thick papillary projections(≥7mm), solid areas, presence of ascites, central vascularization, contrast enhancement, distribution of contrast agent, and vascular characteristics of the solid part and their odds ratios which were 5.52, 5.39, 4.94, 4.34, 5.92, 7.44, 6.09, and 7.67, respectively (P<0.05). (2)These eight signs were used to combine the GI-RADS with 3D-CEUS scoring system in which the corresponding value of the area under the curve (AUC) was 0.969, which was superior to using GI-RADS lonely (Z-value=1.64, P<0.025). Using 4 points as the cut-off, the scoring system showed the performance was clearly better than using GI-RADS alone (P<0.05). (3) The Kappa value was 0.872 for two different clinicians with equal experience.

CONCLUSIONS

The combination of GI-RADS and 3D-CEUS scoring system would be a more effective method to distinguish malignant from benign ovarian masses.

Value of Transvaginal Two-Dimensional Contrast-Enhanced Ultrasonography in Diagnosing Atypical Ovarian Corpus Luteum Hematoma

Objective

To evaluate the value of transvaginal two-dimensional contrast-enhanced ultrasonography (2D-CEUS) in the diagnosis of atypical ovarian corpus luteum hematoma (AT-OCLH).

Methods

A prospective study was performed on 53 consecutive patients with suspected AT-OCLH, and the diagnostic results by transvaginal 2D-CEUS were statistically compared with the gold standard. The gold standard results were confirmed by surgical pathology or long-term follow-up.

Results

The characteristic perfusion patterns of AT-OCLH in 2D-CEUS showed no contrast agent perfusion within the tumor mass, and the capsule wall showed rapid, annular, high enhancement perfusion; perfusion patterns could be classified into type Ia and type IIa. AT-OCLH can be distinguished from ovarian tumors based on perfusion characteristics and perfusion pattern type, which can be diagnosed based on the significantly stronger cystic wall perfusion intensity, earlier arrival time, and thicker cystic wall than nonluteal cystic foci (P<0.05). The sensitivity of 2D-CEUS for diagnosing AT-OCLH was 95.7%, with a specificity of 96.6%. A 2D-CEUS scoring system for AT-OCLH was established. Lesions with scores >17.5 were diagnosed as AT-OCLH.

Conclusion

2D-CEUS is an effective method for diagnosing AT-OCLH.

Role of Imaging Tools for the Diagnosis of Borderline Ovarian Tumors: A Systematic Review and Meta-Analysis

Borderline ovarian tumors (BOTs) have a low malignant potential and occur most often in young women. Its preoperative diagnosis can improve surgical strategy and reproductive approach. This study systematically reviews the literature for the accuracy of transvaginal ultrasound (TVUS), magnetic resonance (MRI), and computed tomography (CT) in the diagnostic of BOTs. We conducted a search in PubMed/Medline of articles in English from the last 5 years and included 14 studies for systematic review, 9 of them in the meta-analysis. The pooled sensibility and specificity was respectively 77.0% and 83.0% for TVUS (5 studies) and 85% and 74% for MRI (4 studies) in differentiating benign from malignant BOTs. CT and positron emission tomography (PET)-CT techniques were heterogeneous between studies, so a meta-analysis was not performed for the 4 studies on CT and PET-CT. However, these 4 studies have also shown a high accuracy in differentiating BOTs from malignant ovarian cancers.

Contrast-enhanced ultrasound for differential diagnosis of malignant and benign ovarian tumors: systematic review and meta-analysis

OBJECTIVE

To assess the performance of contrast-enhanced ultrasound (CE-US) in the differential diagnosis of malignant and benign ovarian tumors.

METHODS

We conducted a comprehensive literature search of PubMed and EMBASE to identify published articles evaluating the diagnostic potential of CE-US for the differentiation of benign and malignant ovarian tumors. Inclusion criteria were: (1) the study assessed the accuracy (or sensitivity and specificity) of CE-US for diagnosis of benign and malignant ovarian tumors; (2) it used surgery and histopathology as the reference standard for distinguishing between benign and malignant tumors; (3) it included data allowing construction of a 2×2 contingency table for true- and false-positives and negatives. We present summary sensitivity, specificity, diagnostic odds ratio (OR) and areas under the summary receiver-operating characteristics curves (AUCs).

RESULTS

Preliminary screening identified 103 papers, of which 11 fulfilled our predefined inclusion criteria and underwent final analysis. The pooled sensitivity and specificity of CE-US for diagnosis of benign and malignant ovarian tumors were 93% (95% CI, 89-96%) and 95% (95% CI, 92-96%), respectively. The pooled diagnostic OR was 171.2 (95% CI, 65.9-444.6) and the AUC was 0.98. I(2) values of sensitivity, specificity and diagnostic OR were 38.3%, 31.7% and 48.4%, respectively, all indicating moderate heterogeneity.

CONCLUSIONS

The evidence from available studies suggests CE-US is useful for discriminating between benign and malignant ovarian tumors; however, further studies are needed to examine whether CE-US has improved diagnostic test accuracy compared with that of standard two-dimensional Doppler sonography.

Performance of three-dimensional power Doppler angiography as third-step assessment in differential diagnosis of adnexal masses

OBJECTIVE

To evaluate the contribution of three-dimensional (3D) power Doppler angiography (3D-PDA) to the differential diagnosis of adnexal masses.

METHODS

This was a prospective study in women diagnosed with a persistent adnexal mass and subsequently scheduled for surgery in a tertiary university hospital. All women were evaluated by transvaginal/transrectal ultrasound according to a predetermined three-step protocol, with transabdominal ultrasound being performed in some cases. First, morphological evaluation of the mass was performed using gray-scale 'pattern recognition' (first step). Lesions diagnosed as having a benign pattern were considered as being at low risk of malignancy whereas tumors with solid components, ascites and/or signs of carcinomatosis were considered as being at high risk of malignancy. In both cases no further test was performed and a decision regarding clinical management, either for follow-up or surgery, was taken. Tumors with solid components but without signs of ascites or carcinomatosis were considered as being at intermediate risk of malignancy. These lesions were assessed by two-dimensional (2D) PDA to evaluate tumor vascularity (color score) (second step). Solid tumors with a color score of 1 or 2 were considered as benign and no further test was performed, while tumors with a color score of 2, 3 or 4 within solid components or a color score of 3 or 4 in the case of a solid tumor were considered as malignant. The latter group underwent 3D-PDA assessment (third step). Vascularization index (VI) was calculated in a 1-mL sphere of the most vascularized area of the tumor. When a VI ≥ 24.015% was found, the tumor was considered as malignant. All masses were removed surgically and definitive histological diagnosis was used as the gold standard. Sensitivity and specificity for each strategy were calculated and compared. In the case of bilateral tumors, only the more suspicious one was used for analysis.

RESULTS

A total of 367 adnexal masses diagnosed in 367 women (mean age, 46.5 (range, 18-80) years) were evaluated during the study period. Of these, 86 masses were malignant and 281 were benign. The sensitivity and specificity for each assessment strategy were as follows: one-step, 97.7% and 78.6%; two-step, 94.2% and 97.9% (P < 0.001 for specificity when compared with that of one-step); three-step, 90.7% and 98.9% (not statistically significant when compared with that of two-step).

CONCLUSIONS

The addition of 2D-PDA in the differential diagnosis of an adnexal mass significantly increases specificity while sensitivity remains high; however performing subsequent 3D-PDA does not provide additional information or further improve diagnostic performance subsequent to 2D-PDA.

Diagnostic performance of contrast-enhanced ultrasound for ovarian cancer: a meta-analysis

This meta-analysis is the first study aimed at assessing the overall diagnostic performance of contrast-enhanced ultrasound for ovarian cancer. PubMed, Embase and Medline databases were systematically searched for relevant articles published up to June 2014. Data were pooled to yield summary sensitivity, specificity, diagnostic odds ratio and receiver operating characteristic curves using Meta-Disc Version 1.4 software. Ten independent studies with 579 ovarian tumors were enrolled in this meta-analysis. The pooled sensitivity, specificity and diagnostic odds ratio statistics were 0.89 (0.83-0.94), 0.91 (0.88-0.93) and 91.70 (41.41-203.05), respectively, and the area under the summary receiver operating characteristic curve was 0.9619 (standard error: 0.0125), all indicating that contrast-enhanced ultrasound has high diagnostic accuracy in differentiation of malignant from benign ovarian tumors.

[Sonographic diagnosis of presumed benign ovarian tumors]

To discriminate ovarian lesions is of particular importance in gynecological practice. Two main problems need answers: discrimination of benign and malignant adnexal masses and choice of the appropriate surgical treatment if necessary. Nearly 2% of the adnexal masses are ovarian carcinomas or borderline tumors. It is now, well established that ultrasonography is the gold standard for ovarian cyst diagnosis. The purpose of this data was to review the literature and to establish, with the evidence base medicine model, which parameters and existing diagnostic models using ultrasound and Doppler perform best in the evaluation of adnexal masses. Transvaginal sonography has demonstrated considerable advantage over conventional transabdominal sonography. However, transparietal sonography is still useful in large tumors. Definition of the nomenclature and classification was done and should be used. Unilocular ovarian cyst characterization seems easy using sonography and Doppler. In front of complication, discrimination of such functional cyst may be difficult but spontaneous regression confirms usually the expectative management. Dermoid cysts and endometriomas seem to be easier to discriminate from other adnexal masses. Ultrasound and morphologic parameters have a sensitivity of about 90% and a specificity of 80%; that makes this exam the gold standard for ovarian masses diagnosis. Only 50% of ovarian masses are characterized by sonography. Scoring systems help to differentiate benign from malignant masses (sensitivity of about 90%). Logistic regression and models are good methods especially for LR1 and 2 and RMI and may be useful for malignancy prediction but are difficult to use in current practice. Expert diagnosis is a subjective but most important performing parameter. Any suspicious ovarian mass or not easily diagnosed mass requires sonography by an expert, which can first use all the techniques and the different parameters to discriminate benign and malignant tumors. An explicit report will help the physician to define the right attitude for an appropriate management. Six to 16% of adnexial masses are complex or not classified and will result in MRI prescription or surgery.