Metastasis of colorectal cancer to the uterine body and fallopian tube: case report and literature review

Colorectal cancer typically metastasizes to the peritoneum, liver, and lungs. However, metastases to the fallopian tube and uterus are uncommon. This case report delves into this rare occurrence of metastasis and discusses its characteristics, diagnostic methods, and treatments based on an extensive literature review. We present the case of a 61-year-old female patient who underwent her initial hospitalization for da Vinci robotic surgery to address colorectal cancer, stage pT3N0M0. However, during routine postoperative follow-up 6 months later, a localized rectal recurrence was detected. The patient commenced chemoradiotherapy with full response. Subsequently, the patient was readmitted due to pelvic pain again, and a magnetic resonance imaging scan revealed an abnormal mass in the patient's left fallopian tube and uterine corpus, infiltrating the myometrium. Consequently, total hysterectomy with bilateral adnexectomy was performed, along with omentectomy, which confirmed metastatic involvement from rectal cancer upon postoperative pathological examination. This case may inform further diagnosis and treatment of colorectal cancer metastasis to the fallopian tube.

Comparative Study of the Efficacy of the Ovarian-Adnexa Reporting and Data System Ultrasound Combined With Contrast-Enhanced Ultrasound and the ADNEX MR Scoring System in the Diagnosis of Adnexal Masses

OBJECTIVE

The aims of this study were to develop the Ovarian-Adnexa Reporting and Data System (O-RADS) and O-RADS + contrast-enhanced ultrasound (O-RADS CEUS) scoring system to distinguish adnexal masses (AMs) and to compare the diagnostic efficacy of these systems with that of a magnetic resonance imaging scoring system (ADNEX MR).

METHODS

We retrospectively evaluated 278 ovarian masses from 240 patients between May 2017 and July 2022. Pathology and adequate follow-up were used as reference standards for comparing the validity of O-RADS, O-RADS CEUS and ADNEX MR scoring to diagnose AMs. Area under the curve (AUC), sensitivity and specificity were calculated. The inter-class correlation coefficient (ICC) was calculated to evaluate inter-reader agreement (IRA) between the two sonographers and two radiologists who analyzed the findings with the three modalities.

RESULTS

The AUCs of O-RADS, O-RADS CEUS and ADNEX MR scores were 0.928 (95% confidence interval [CI]: 0.895-0.956), 0.951(95% CI: 0.919-0.973) and 0.964 (95% CI: 0.935-0.983), respectively. Their sensitivities were 95.7%, 94.3 and 91.4%, and their specificities were 81.3%, 92.3% and 97.1%, respectively. The three modalities had accuracies of 84.9%, 92.8% and 95.7%, respectively. O-RADS had the highest sensitivity but significantly lower specificity (p < 0.001), whereas the ADNEX MR scoring had the highest specificity (p < 0.001) but lower sensitivity (p < 0.001). O-RADS CEUS had intermediate sensitivity and specificity (p < 0.001).

CONCLUSION

The addition of CEUS significantly improves the efficacy of O-RADS in diagnosing AMs. The diagnostic efficacy of the combination is comparable to that of the ADNEX MR scoring system.

Imaging of pediatric ovarian tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper

Ovarian tumors in children are uncommon. Like those arising in the adult population, they may be broadly divided into germ cell, sex cord, and surface epithelium subtypes; however, germ cell tumors comprise the majority of lesions in children, whereas tumors of surface epithelial origin predominate in adults. Diagnostic workup, including the use of imaging, requires an approach that often differs from that required in an adult. This paper offers consensus recommendations for imaging of pediatric patients with a known or suspected primary ovarian malignancy at diagnosis and during follow-up.

O-RADS MRI Risk Stratification System: Guide for Assessing Adnexal Lesions from the ACR O-RADS Committee

MRI plays an important role as a secondary test or problem-solving modality in the evaluation of adnexal lesions depicted at US. MRI has increased specificity compared with US, decreasing the number of false-positive diagnoses for malignancy and thereby avoiding unnecessary or over-extensive surgery in patients with benign lesions or borderline tumors, while women with possible malignancies can be expeditiously referred for oncologic surgical evaluation. The Ovarian-Adnexal Reporting and Data System (O-RADS) MRI Committee is an international collaborative effort formed under the direction of the American College of Radiology and includes a diverse group of experts on adnexal imaging and management who developed the O-RADS MRI risk stratification system. This scoring system assigns a probability of malignancy based on the MRI features of an adnexal lesion and provides information to facilitate optimal patient management. The widespread implementation of a codified reporting system will lead to improved interpretation agreement and standardized communication between radiologists and referring physicians. In addition, it will allow for high-quality multi-institutional collaborations-an important unmet need that has hampered the performance of high-quality research in this area in the past. This article provides guidelines on using the O-RADS MRI risk stratification system in clinical practice, as well as in the educational and research settings.

Application of Deep Convolutional Neural Networks for Discriminating Benign, Borderline, and Malignant Serous Ovarian Tumors From Ultrasound Images

Objective

This study aimed to evaluate the performance of the deep convolutional neural network (DCNN) to discriminate between benign, borderline, and malignant serous ovarian tumors (SOTs) on ultrasound(US) images.

Material and Methods

This retrospective study included 279 pathology-confirmed SOTs US images from 265 patients from March 2013 to December 2016. Two- and three-class classification task based on US images were proposed to classify benign, borderline, and malignant SOTs using a DCNN. The 2-class classification task was divided into two subtasks: benign vs. borderline & malignant (task A), borderline vs. malignant (task B). Five DCNN architectures, namely VGG16, GoogLeNet, ResNet34, MobileNet, and DenseNet, were trained and model performance before and after transfer learning was tested. Model performance was analyzed using accuracy, sensitivity, specificity, and the area under the receiver operating characteristic curve (AUC).

Results

The best overall performance was for the ResNet34 model, which also achieved the better performance after transfer learning. When classifying benign and non-benign tumors, the AUC was 0.96, the sensitivity was 0.91, and the specificity was 0.91. When predicting malignancy and borderline tumors, the AUC was 0.91, the sensitivity was 0.98, and the specificity was 0.74. The model had an overall accuracy of 0.75 for in directly classifying the three categories of benign, malignant and borderline SOTs, and a sensitivity of 0.89 for malignant, which was better than the overall diagnostic accuracy of 0.67 and sensitivity of 0.75 for malignant of the senior ultrasonographer.

Conclusion

DCNN model analysis of US images can provide complementary clinical diagnostic information and is thus a promising technique for effective differentiation of benign, borderline, and malignant SOTs.

Magnetic resonance imaging of pure ovarian dysgerminoma: a series of eight cases

BACKGROUND

Imaging findings have a prominent role in early and correct identification of ovarian dysgerminoma, the most common ovarian malignant germ cell tumor (OMGCT). Despite Computed Tomography (CT) is widely used, Magnetic Resonance Imaging (MRI) has proved to be superior in adnexal masses characterization. Limited data and small series are available concerning MRI aspects of dysgerminoma.

CASE PRESENTATION

From January 2012 to December 2018, a database of solid ovarian masses was retrospectively reviewed. Eight patients with histologically proven pure ovarian dysgerminoma and complete imaging available were identified and analyzed. Imaging findings were evaluated separately by two radiologists expert in female genito-urinary MRI.

CONCLUSIONS

MRI findings of a lobulated, purely solid, encapsulated mass with hyper-intensity of lobules and hypo-intensity of septa on T2w images contribute to differentiate dysgerminomas from other ovarian neoplasms.

Evaluating the added benefit of CT texture analysis on conventional CT analysis to differentiate benign ovarian cysts

PURPOSE

We aimed to evaluate the benefit of adding CT texture analysis on conventional CT features of benign adnexal cystic lesions, especially in identifying mucinous cystadenoma.

METHODS

This retrospective study included patients who underwent surgical removal of benign ovarian cysts (44 mucinous cystadenomas, 32 serous cystadenomas, 16 follicular/simple cysts and 43 endometriotic cysts) at our institution between January 2015 and November 2017. The CT images were independently reviewed by an abdominal radiologist (reviewer 1) and a resident (reviewer 2). Both reviewers recorded the conventional characteristics and performed texture analysis. Based on reviewer 1's results, two decision trees for differential diagnosis were developed. Reviewer 2's results were then applied to the decision trees. The diagnostic performances of each reviewer with and without the decision trees were compared.

RESULTS

Several conventional features and texture analysis parameters showed significant differences between mucinous cystadenomas and other benign adnexal cysts. The first decision tree selected septum number and thickness as significant features, whereas the second decision tree selected septum number and the mean values at spatial scaling factor (SSF) 0. Reviewer 1's performance did not change significantly with or without the use of the decision trees. Reviewer 2's interpretations were significantly less sensitive than reviewer 1's interpretations (p = 0.001). However, when aided by the first and second decision trees, Reviewer 2's interpretations were significantly more sensitive than reviewer 1's interpretations (86.4%, p < 0.001; 72.7%, p = 0.001).

CONCLUSION

This study suggests the benefit of CT texture analysis on conventional images to differentiate mucinous cystadenoma from other benign adnexal cysts, particularly for less experienced radiologists.

Adnexal Masses in Pregnancy

Importance

Adnexal masses are identified in approximately 0.05% to 2.4% of pregnancies, and more recent data note a higher incidence due to widespread use of antenatal ultrasound. Whereas most adnexal masses are benign, approximately 1% to 6% are malignant. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

Objective

The aim of this study was to review imaging modalities for evaluating adnexal masses in pregnancy and imaging characteristics that differentiate benign and malignant masses, examine various types of adnexal masses, and understand complications of and explore management options for adnexal masses in pregnancy.

Evidence Acquisition

This was a literature review using primarily PubMed and Google Scholar.

Results

Ultrasound can distinguish between simple-appearing benign ovarian cysts and masses with more complex features that can be associated with malignancy. Radiologic information can help guide physicians toward recommending conservative management with observation or surgical removal during pregnancy to facilitate diagnosis and treatment. The risks of expectant management of an adnexal mass during pregnancy include rupture, torsion, need for emergent surgery, labor obstruction, and progression of malignancy. Historically, surgical removal was performed more routinely to avoid such complications in pregnancy; however, increasing knowledge has directed management toward conservative measures for benign masses. Surgical removal of adnexal masses is increasingly performed via minimally invasive techniques including laparoscopy and robotic surgery due to a decreased risk of surgical complications compared with laparotomy.

Conclusions and Relevance

Adnexal masses are increasingly identified in pregnancy because of the use of antenatal ultrasound. Clear and specific guidelines exist to help differentiate between benign and malignant masses. This is important for management as benign masses can usually be conservatively managed, whereas malignant masses require excision for diagnosis and treatment. A multidisciplinary approach, including referral to gynecologic oncology, should be used for masses with complex features associated with malignancy. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

Management of Large Pediatric and Adolescent Ovarian Neoplasms with a Leak-Proof Extracorporeal Drainage Technique: Our Experience Using a Hybrid Minimally Invasive Approach

STUDY OBJECTIVE

In a pediatric setting, laparoscopic management of large cystic ovarian neoplasms with low malignancy probability is not suitable, because of the mass size; nevertheless, an effort should be made to be as minimally invasive as possible, without violating the principles of oncologic surgery. We describe our experience in managing these neoplasms with leak-proof extracorporeal drainage through mini laparotomy, followed by cyst excision or oophorectomy.

DESIGN

Case series study, describing interventions and outcomes.

SETTING

Department of pediatric surgery in a tertiary pediatric and adult university hospital.

PARTICIPANTS

Pediatric patients affected by large cystic ovarian mass.

INTERVENTIONS

Hybrid minimally invasive approach using leak-proof extracorporeal drainage.

MAIN OUTCOME MEASURES

Data on demographic characteristics, tumor marker values, and imaging findings were collected and analyzed. Outcome of surgical technique was evaluated and reported.

RESULTS

Between 2011 and 2018, 17 patients (mean age, 10.2 years; range, 2-14 years) affected by large cystic ovarian mass, were eligible for this technique. All patients had negative preoperative tumor markers. Of the seventeen subjects, 13/17 girls (76%) underwent pelvic magnetic resonance imaging. No sign of lymphadenopathy or metastasis was found. Surgery was successful in all patients, with ovarian preservation in 5/17 cases (29.4%). Mean surgical time was 98 minutes; no intra-abdominal leakage of neoplasm content or postoperative complications occurred. Mature cystic teratoma was the most frequent histopathological diagnosis (71%).

CONCLUSION

After a thorough patient selection, the management of large cystic ovarian neoplasms with leak-proof extracorporeal drainage performed through a mini laparotomy is a feasible and safe approach, with excellent cosmetic results. When achievable, ovarian-sparing surgery has to be considered.

Multimodality Imaging Approach to Ovarian Neoplasms with Pathologic Correlation

Ovarian neoplasms can be categorized on the basis of histopathologic features into epithelial surface cell tumors, germ cell tumors, sex cord-stromal tumors, and metastases. While their imaging appearance is often nonspecific, it closely parallels the gross pathologic appearance, and radiologic-pathologic correlation is helpful to aid in a deeper understanding of the subtypes. Epithelial cell neoplasms are the most common category, and they can be benign, borderline, or malignant. Specific subtypes include serous (most common), mucinous, seromucinous, endometrioid, clear cell, Brenner, and undifferentiated. High-grade serous cystadenocarcinoma accounts for the majority of malignant ovarian tumors and the most ovarian cancer deaths. While serous neoplasms are often unilocular and bilateral, mucinous neoplasms are larger, unilateral, and multilocular. Solid components, thickened septa, and papillary projections, particularly with vascularity, indicate borderline or malignant varieties. Endometrioid and clear cell carcinomas can arise within endometriomas. Fibrous tumors (cystadenofibroma, adenofibroma, fibroma or fibrothecoma, and Brenner tumors) demonstrate low T2-weighted signal intensity of their solid components, while teratomas contain lipid. The nonspecific imaging appearance of additional malignant ovarian germ cell tumors can be narrowed with tumor marker profiles. Sex cord-stromal tumors are often solid, and secondary signs from their hormonal secretion can be a clue to their diagnosis. The authors review the anatomy of the ovary and distal fallopian tube, the proposed origins of the histologic subtypes of tumors, the clinical features and epidemiology of ovarian neoplasms, and the applications of US, CT, and MRI in imaging ovarian neoplasms. The main focus is on the radiologic and pathologic features of the multiple ovarian neoplasm subtypes. An algorithmic approach to the diagnosis of ovarian neoplasms is presented. Online supplemental material is available for this article. ^©RSNA, 2020.

Radiomics derived from dynamic contrast-enhanced MRI pharmacokinetic protocol features: the value of precision diagnosis ovarian neoplasms

OBJECTIVES

To evaluate the efficiency of 2- and 3-class classification predictive tasks constructed from radiomics features extracted from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) pharmacokinetic (PK) protocol in discriminating among benign, borderline, and malignant ovarian tumors.

METHODS

One hundred and four ovarian lesions were evaluated using preoperative DCE-MRI. Radiomics features were extracted from 7 types of DCE-MR images. To explore the differential ability of radiomics between three types of ovarian tumors, two- and three-class classification tasks were established. The 2-class classification task was divided into three subtasks: benign vs. borderline (task A), benign vs. malignant (task B), and borderline vs. malignant (task C). For the 3-class classification task, 104 lesions were randomly divided into training (72 lesions) and validation (32 lesions) cohorts. The discrimination abilities of the radiomics signatures were established with the training cohort and tested with the independent validation cohort. The predictive performance of the task was evaluated by receiver operating characteristic (ROC) curve, calibration curve analysis, and decision curve analysis (DCA).

RESULTS

For the 2-class classification task, the combination of PK radiomics signatures model (PK model) showed a good diagnostic ability with the highest area under the ROC curves (AUCs) of 0.899, 0.865, and 0.893 for tasks A, B, and C, respectively. Additionally, the 3-class classification task demonstrated a good discrimination performance with AUCs of 0.893, 0.944, and 0.891 for the benign, borderline, and malignant groups, respectively.

CONCLUSIONS

Radiomics analysis based on the DCE-MRI PK protocol showed promise for discriminating among benign, borderline, and malignant ovarian tumors.

KEY POINTS

• Two-class classification predictive task of DCE-MRI PK protocol enabled the classification of 3 categories of ovarian tumors through the pairwise comparison strategy with a perfect diagnostic ability. • Three-class classification predictive task maintained good performance to effectively judge each category of ovarian tumors directly.

Pathognomonic imaging signs in abdominal radiology

The imaging evaluation of the abdomen is of crucial importance for every radiologist. In addition to ultrasound, conventional radiographs and contrast-enhanced computed tomography (CT) are the most common imaging procedures in the abdominal region. Numerous pathognomonic signs should be known in this context by every radiologist. Radiographs of the abdomen are an often used first step in radiologic imaging, while CT examinations are carried out for further differentiation, in oncological settings and in time-critical emergency situations. A fast and clear assignment of these signs to a specific disease is the basis for a correct diagnosis. This pictorial review describes the most common pathognomonic signs in abdominal imaging. The knowledge of these pictograms is therefore essential for radiologists interested in abdominal medicine and should also be addressed in training and further education.

Systematic radiological approach to utero-ovarian pathologies

Ultrasound is the first-line imaging modality for the evaluation of suspected adnexal masses, endometriosis and uterine tumors, whereas MRI is used as a secondary diagnostic tool to better characterize these lesions. The aim of this review is to summarize the latest advances in the imaging of these utero-ovarian pathologies.

BRCA Mutation Carriers: Breast and Ovarian Cancer Screening Guidelines and Imaging Considerations

Patients who carry the BRCA1 and BRCA2 gene mutations have an underlying genetic predisposition for breast and ovarian cancers. These deleterious genetic mutations are the most common genes implicated in hereditary breast and ovarian cancers. This monograph summarizes the evidence behind current screening recommendations, reviews imaging protocols specific to this patient population, and illustrates some of the imaging nuances of breast and ovarian cancers in this clinical setting.

The Sonographic Spectrum of Pelvic Endometriosis: Pearls, Pitfalls, and Mimics

Endometriosis is a common disease of reproductive-age women that is often first encountered with ultrasound. Therefore, familiarity with the variety of manifestations of endometriosis is important for appropriate diagnosis and management. The aim of this article is to review the spectrum of appearance of pelvic endometriosis and to discuss potential mimics on ultrasound. Given that magnetic resonance imaging is an important problem-solving tool in female pelvic imaging, magnetic resonance imaging correlation is also provided.

Accuracy of the ADNEX MR scoring system based on a simplified MRI protocol for the assessment of adnexal masses

PURPOSE

We aimed to evaluate the ADNEX MR scoring system for the prediction of adnexal mass malignancy, using a simplified magnetic resonance imaging (MRI) protocol.

METHODS

In this prospective study, 200 patients with 237 adnexal masses underwent MRI between February 2014 and February 2016 and were followed until February 2017. Two radiologists calculated ADNEX MR scores using an MRI protocol with a simplified dynamic study, not a high temporal resolution study, as originally proposed. Sensitivity, specificity, positive and negative predictive values, likelihood ratios, and the area under the receiver operating characteristic curve were calculated (cutoff for malignancy, score ≥ 4). The reference standard was histopathologic diagnosis or imaging findings during >12 months of follow-up.

RESULTS

Of 237 lesions, 79 (33.3%) were malignant. The ADNEX MR scoring system, using a simplified MRI protocol, showed 94.9% (95% confidence interval [CI], 87.5%-98.6%) sensitivity and 97.5% (95% CI, 93.6%-99.3%) specificity in malignancy prediction; it was thus highly accurate, like the original system. The level of interobserver agreement on simplified scoring was high (κ = 0.91).

CONCLUSION

In a tertiary cancer center, the ADNEX MR scoring system, even based on a simplified MRI protocol, performed well in the prediction of malignant adnexal masses. This scoring system may enable the standardization of MRI reporting on adnexal masses, thereby improving communication between radiologists and gynecologists.

The utility of magnetic resonance imaging in the diagnosis and management of pediatric benign ovarian lesions

BACKGROUND

The utility of magnetic resonance imaging (MRI) in the diagnosis and management of pediatric ovarian lesions has not been well defined.

METHODS

A retrospective review of all girls who underwent MRI evaluation of ovarian masses during the period 2009-2015 was performed. The accuracy of MRI was evaluated by comparing results with surgical findings, pathology reports, and subsequent imaging. The influence of the MRI on the treatment plan was specifically explored.

RESULTS

Eighteen girls, 12-17years of age, underwent 27 MRIs, subsequent to ultrasound identification of ovarian lesions. Of 9 neoplastic lesions diagnosed on MRI, 8 (89%) were confirmed by surgical and pathological findings. Of 18 functional lesions, 17 (94.4%) were confirmed pathologically or by resolution on subsequent imaging. Twenty MRI exams (74%) directly influenced the treatment plan, by leading to appropriate operative intervention in 9 and appropriate observation in 11. The extent of ovarian resection was guided by MRI findings in 8 of 9 (89%) neoplastic lesions. For characterizing lesions as neoplastic, the sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of MRI were 89%, 94%, 94%, 89%, and 93% respectively.

CONCLUSIONS

MRI can differentiate functional from neoplastic pediatric ovarian masses, and guide ovarian resection in appropriate cases.

LEVEL OF STUDY

II.

Adnexal lesions: Imaging strategies for ultrasound and MR imaging

Adnexal lesions are routinely encountered in general practice. Ultrasound is the first line of investigation in determining the benign or malignant potential of an adnexal lesion. In the cases of classic simple cysts, hemorrhagic cysts, endometriomas, dermoids and obviously malignant lesions, ultrasound may be sufficient for management recommendations. In cases where there is an isolated adnexal lesion, without peritoneal disease or serum CA-125 elevation, and in lesions considered indeterminate on ultrasound, MR imaging with incorporation of the ADNEx MR score can increase the specificity for the diagnosis of benignity or malignancy. This article will review the imaging evaluation of adnexal lesions and how to incorporate the ADNEx MR score to help guide clinical management.

Parasitic leiomyoma presenting as an inguinal hernia in a postmenopausal woman

Uterine leiomyomas are one of the most common tumors affecting reproductive-age women. Leiomyomas can present as an intrauterine mass or rarely as an extrauterine tumor. Depending on its location, the diagnosis of extrauterine leiomyoma can be challenging, and multiple imaging modalities may be needed for correct identification and differentiation from malignant entities. We report the case of a 48-year-old-postmenopausal female who presented with a painful left inguinal mass, which was clinically diagnosed as inguinal hernia. Ultrasound, computed tomography, magnetic resonance imaging, and percutaneous biopsy were used to characterize the mass. Surgical resection and histopathological analysis revealed the mass to be a parasitic leiomyoma, a very rare cause of inguinal hernia, especially in a postmenopausal woman.

A systematic approach to adnexal masses discovered on ultrasound: the ADNEx MR scoring system

Adnexal lesions are a common occurrence in radiology practice and imaging plays a crucial role in triaging women appropriately. Current trends toward early detection and characterization have increased the need for accurate imaging assessment of adnexal lesions prior to treatment. Ultrasound is the first-line imaging modality for assessing adnexal lesions; however, approximately 20% of lesions are incompletely characterized after ultrasound evaluation. Secondary assessment with MR imaging using the ADNEx MR Scoring System has been demonstrated as highly accurate in the characterization of adnexal lesions and in excluding ovarian cancer. This review will address the role of MR imaging in further assessment of adnexal lesions discovered on US, and the utility of the ADNEx MR Scoring System.

The Complementary Role of Imaging and Tumor Biomarkers in Gynecological Cancers: An Update of the Literature

Gynecological tumors, including endometrial, cervical and ovarian cancer, have increased in incidence over time. The widespread introduction of screening programs and advances in diagnostic imaging methods has lead to a progressive increase in gynecological cancer detection. Accurate diagnosis and proper monitoring of disease remain the primary target for a successful treatment. In the last years, knowledge about cancer biomarkers has considerably increased providing great opportunities for improving cancer detection and treatment. In addition, in the last few years there has been an important development of imaging techniques. Nowadays, a multimodal approach including the evaluation of serum tumor biomarkers combined with imaging techniques, seems to be the best strategy for assessing tumor presence, spread, recurrence, and/or the response to treatment in female cancer patients In this review we provide an overview of the application of biomarkers combined with novel imaging methods and highlight their roles in female cancer diagnosis and follow-up.

Indeterminate Adnexal Cysts at US: Prevalence and Characteristics of Ovarian Cancer

Purpose To assess the prevalence of indeterminate adnexal cysts in women presenting to academic medical centers for pelvic ultrasonography (US), determine the incidence of malignancy, and identify cyst and patient characteristics that are predictive of malignancy. Materials and Methods A multicenter study of US-detected adnexal cysts with appropriate follow-up (surgical pathologic examination, imaging and/or clinical examination) was conducted from January 2008 to June 2012. Indeterminate cysts were classified as category 1 (typical benign appearing cysts >5 cm) or category 2 (cysts with avascular solid components) on the basis of a combination of definitions in the existing literature. The incidence of neoplasms and malignant tumors was calculated. Patient and cyst characteristics associated with neoplasm and malignant tumors were evaluated with the χ² test or Fisher exact test for categorical variables and the t test for continuous variables. A backward stepwise logistic regression model was performed for two outcomes: (a) the presence of any neoplasm (benign or malignant) and (b) the presence of a malignant tumor. Results There were 1637 women with an adnexal cyst at US; 391 (mean age = 41.8 years ± 13.5.1; range = 17-91 years) had an indeterminate adnexal cyst at US. The prevalence of indeterminate adnexal cysts was 23.9% (391 of 1637; 95% confidence interval [CI]: 0.22, 0.26). Three hundred three indeterminate cysts in 280 women (mean age = 42.9 years ± 14.1; range = 17-88 years) had adequate follow-up. The incidence of ovarian neoplasms (benign and malignant) was 24.8% (75 of 303 cysts; 95% CI: 0.20, 0.30), and the incidence of malignant tumors was 3.6% (11 of 303 cysts; 95% CI: 0.02, 0.06). The proportion of ovarian neoplasms differed between category 1 and category 2 cysts (17.5% [25 of 143 cysts; 95% CI: 0.12, 0.25] vs 31.3% [50 of 160 cysts; 95% CI: 0.24, 0.39], respectively; P = .001). The proportion of malignant tumors differed between categories 1 and 2 cysts (0% [0 of 143 cysts] vs 6.9% [11 of 160 cysts; 95% CI: 0.03, 0.12]; P < .001). The presence of an avascular nodular component was a significant predictor of malignancy at stepwise logistic regression analysis (odds ratio = 2.83; P ≤ .0001; 95% CI: 1.69, 4.70). Conclusion The presence of an avascular nodular component was the most significant predictor of the presence of malignancy in indeterminate adnexal cysts. The risk of malignancy is higher with category 2 cysts than with category 1 cysts. ^© RSNA, 2018.

Isolated fallopian tube metastasis from colorectal cancer: ultrasonographic features

We present here the first-reported case of tubal metastasis from colorectal cancer diagnosed by a preoperative pelvic ultrasound. A 53-year-old woman suffering from vaginal discharge was referred to us 2 years after she underwent a partial colectomy for adenocarcinoma. The pelvic ultrasound examination revealed a right pelvic mass of 52 × 24 × 38 mm, independent of the right ovary, which was apparently unaffected. A right salpingo-oophorectomy was performed and the definitive histopathology examination showed a recurrence of the initial adenocarcinoma with a right tubal metastasis. The eventuality of such an unusual site of metastasis should be remembered.

Fertility-sparing for young patients with gynecologic cancer: How MRI can guide patient selection prior to conservative management

Historically, cancer treatment has emphasized measures for the "cure" regardless of the long-term consequences. Advances in cancer detection and treatment have resulted in improved outcomes bringing to the fore various quality of life considerations including future fertility. For many young cancer patients, fertility preservation is now an integral component of clinical decision-making and treatment design. Optimal fertility-sparing options for young patients with gynecologic cancer are influenced by patient age, primary cancer, treatment regimens, and patient preferences. Possible approaches include embryo or oocyte cryopreservation, ovarian transposition, conservative surgery, and conservative medical treatment to delay radical surgery. These may be used alone or in combination to maximize fertility preservation. Awareness of the various fertility-sparing options, eligibility criteria, and the central role of magnetic resonance imaging in the proper selection of patients will enable radiologists to produce complete clinically relevant imaging reports and serve as effective consultants to referring clinicians. Knowledge of the potential imaging pitfalls is essential to avoid misinterpretation and guide appropriate management.

ADC-derived spatial features can accurately classify adnexal lesions

BACKGROUND

The role of quantitative apparent diffusion coefficient (ADC) maps in differentiating adnexal masses is unresolved.

PURPOSE/HYPOTHESIS

To propose an objective diagnostic method devised based on spatial features for predicting benignity/malignancy of adnexal masses in ADC maps.

STUDY TYPE

Prospective.

POPULATION

In all, 70 women with sonographically indeterminate and histopathologically confirmed adnexal masses (38 benign, 3 borderline, and 29 malignant) were considered for this study.

FIELD STRENGTH/SEQUENCE

Conventional and diffusion-weighted magnetic resonance (MR) images (b-values = 50, 400, 1000 s/mm² ) were acquired on a 3T scanner.

ASSESSMENT

For each patient, two radiologists in consensus manually delineated lesion borders in whole ADC map volumes, which were consequently analyzed using spatial models (first-order histogram [FOH], gray-level co-occurrence matrix [GLCM], run-length matrix [RLM], and Gabor filters). Two independent radiologists were asked to identify the attributed (benign/malignant) classes of adnexal masses based on morphological features on conventional MRI.

STATISTICAL TESTS

Leave-one-out cross-validated feature selection followed by cross-validated classification were applied to the feature space to choose the spatial models that best discriminate benign from malignant adnexal lesions. Two schemes of feature selection/classification were evaluated: 1) including all benign and malignant masses, and 2) scheme 1 after excluding endometrioma, hemorrhagic cysts, and teratoma (14 benign, 29 malignant masses). The constructed feature subspaces for benign/malignant lesion differentiation were tested for classification of benign/borderline/malignant and also borderline/malignant adnexal lesions.

RESULTS

The selected feature subspace consisting of RLM features differentiated benign from malignant adnexal masses with a classification accuracy of ∼92%. The same model discriminated benign, borderline, and malignant lesions with 87% and borderline from malignant with 100% accuracy. Qualitative assessment of the radiologists based on conventional MRI features reached an accuracy of 80%.

DATA CONCLUSION

The spatial quantification methodology proposed in this study, which works based on cellular distributions within ADC maps of adnexal masses, may provide a helpful computer-aided strategy for objective characterization of adnexal masses.

LEVEL OF EVIDENCE

1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1061-1071.

Mature cystic teratoma with high proportion of solid thyroid tissue: a controversial case with unusual imaging findings

We describe a case of a mature cystic teratoma of the ovary with high proportion of solid thyroid tissue (< 50% of the entire tumor) in a childbearing woman. The patient presented with non-specific abdominal bloating. Pelvic ultrasound and magnetic resonance imaging revealed a complex cystic-solid tumor confined to the left ovary with an anterior fat-containing locus compatible with mature cystic teratoma and a posterior predominantly solid component with low signal intensity on T2-weighted images that was histopatologically diagnosed as benign thyroid tissue. Thyroglobulin levels were in normal range. Although thyroid tissue is present in up to 20% of mature cystic teratomas, with exception of struma ovarii, it is not usually macroscopically nor radiologically identified. The differential diagnosis should include T2-hypointense adnexal lesions associated with mature cystic teratoma, malignant transformation of mature teratoma, and immature teratoma.

Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses

Adnexal masses (ie, masses of the ovary, fallopian tube, or surrounding tissues) commonly are encountered by obstetrician-gynecologists and often present diagnostic and management dilemmas. Most adnexal masses are detected incidentally on physical examination or at the time of pelvic imaging. Less commonly, a mass may present with symptoms of acute or intermittent pain. Management decisions often are influenced by the age and family history of the patient. Although most adnexal masses are benign, the main goal of the diagnostic evaluation is to exclude malignancy. The purpose of this document is to provide guidelines for the evaluation and management of adnexal masses in adolescents, pregnant women, and nonpregnant women and to outline criteria for the identification of adnexal masses that are likely to be malignant and may warrant referral to or consultation with a gynecologic oncologist.

MR Imaging-Pathologic Correlation in Ovarian Cancer

There are many ovarian cancer subtypes, giving rise to a range of appearances at gross pathology and magnetic resonance (MR) imaging. Certain fundamental concepts at MR, arising from underlying tissue characteristics, can provide guidance to radiologists in suggesting a diagnosis. The ability of multiparametric MR to risk stratify ovarian masses can contribute substantially to clinical decision making and patient management.

Magnetic Resonance Imaging of Pelvic Masses: A Compartmental Approach

Magnetic resonance imaging (MRI) is often "one stop shop" for evaluating female pelvic masses that helps in diagnosis, staging, and restaging of these tumors. A pelvic mass can arise from any tissue present within the pelvis. Although most masses in the female pelvis arise from the reproductive organs, masses may also arise from the gastrointestinal tract, urinary system, adjacent soft tissues, peritoneum, etc. It may not always be possible to determine the site of origin or distinguish these masses based on imaging characteristics. However, familiarity with the clinicopathologic and MRI features of most common pelvic masses helps in narrowing the differential diagnosis. Diagnosis of these masses needs a holistic approach as required for any tumor including clinical history, laboratory data, and imaging characteristics. We focus on MRI characteristics of commonly encountered pelvic masses. A compartmental imaging approach is discussed in this article that helps in identifying and characterizing these masses.

[Gynecological tumors of the true pelvis: Radiological diagnosis for pelvic tumors made simple]

Tumors of the reproductive organs are among the most common female tumors. Computed tomography (CT) and magnetic resonance imaging (MRI) are used for establishing the differential diagnosis, for staging and increasingly for treatment stratification. Sonography is the first line imaging modality for assessing benign and malignant tumors of the uterus as well as ovarian and adnexal lesions. In sonographically indeterminate masses MRI is used for clarification as it allows not only a prediction of the dignity but also in most cases a specific diagnosis. The MRI examination is also superior to CT in the assessment of tumors resembling benign pelvic lesions. Whereas MRI has become established as the modality of choice for local staging and treatment planning in cancers of the uterine cervix and endometrial cancer, CT is used for staging of ovarian cancer due to the propensity for peritoneal spread outside the pelvis at the time of initial diagnosis.

Endometrioid adenocarcinoma of the ovary: MRI findings with emphasis on diffusion-weighted imaging for the differentiation of ovarian tumors

BACKGROUND

Preoperative differentiation of ovarian malignant tumors still remains a challenge. Diffusion-weighted imaging (DWI) provides information about cellularity of the lesion and might facilitate discrimination between different malignant ovarian lesions.

PURPOSE

To evaluate magnetic resonance imaging (MRI) findings of endometrioid adenocarcinoma of the ovary and to determine the value of DWI in the differential diagnosis of malignant and benign adnexal tumors.

MATERIAL AND METHODS

The following MRI findings were reviewed in 162 patients (21 endometrioid adenocarcinoma, 103 other malignant tumors, 38 benign tumors): lesion size, morphological appearance, T2-weighted (T2W) signal intensity, T1-weighted (T1W) signal intensity, contrast-enhancement pattern, DWI signals with apparent diffusion coefficient (ADC) calculated for b = 800 s/mm(2) in solid tumor components.

RESULTS

The most common morphological appearance was predominantly cystic lesion, found in 90.3% of patients with endometriod adenocarcinoma. The solid parts were slightly hyperintense on T2W images in 19 patients with marked enhancement after contrast administration. No significant difference (P = 0.13) in conventional MRI features was found between endometrioid adenocarcinoma and other malignant ovarian tumors. Hyperintensity on DWI was more frequently observed in malignant tumors than in benign lesions (P < 0.001). ADC values were significantly lower in endometrioid adenocarcinoma than other malignant tumors (0.79 ± 0.21 vs. 0.90 ± 0.19; P = 0.04) and in all malignant lesions compared with benign tumors (0.88 ± 0.31 vs. 1.33 ± 0.17; P < 0.001).

CONCLUSION

DWI with ADC measurement could indicate the presence of endometrioid adenocarcinomas due to a slightly but significantly lower ADC values compared to other malignant ovarian lesions. Thus, DWI is beneficial and should be part of a standard protocol for the evaluation of indeterminate adnexal lesions.

Teratodermoid mimicking cholecystitis

An acute abdomen assessment in pregnancy is complicated. Pain can have obstetric and nonobstetric causes. Cholecystitis is a common cause of pain in pregnancy with significant morbidity if not managed promptly. We report a case of a ruptured, torted, right ovarian teratodermoid erroneously diagnosed as cholecystitis in pregnancy.

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.

[Ultrasonographic features in the preoperative diagnosis of primitive fallopian tube carcinoma]

OBJECTIVES

To review the characteristic ultrasound features of primary fallopian tube carcinoma (PFTC) and its relationship to the clinical history in order to establish specific findings useful for the preoperative diagnosis.

METHOD

An extensive review of the current literature was done on Medline via PubMed by using the following keywords: "primary fallopian tube cancer", "tubal cancer", "adnexal malignancy mass" and "ultrasound".

RESULTS

PFTC corresponds to complex, sausage-shaped structures or cystic adnexal masses. A thick and an irregular capsule are in favour of a malignant lesion. Three-dimensional ultrasound is superior to 2D ultrasound for the detection of tubal wall irregularities such as papillary projections or pseudosepta who were suggestive of tubal malignancy and allows a better assessment of the extent of tumor infiltration through the capsule. Neovascularization with low resistance indices are typical of tubal malignancy. Three-dimensional power Doppler sonography acutely detected structural abnormalities of the malignant tumor vessels which are randomly dispersed within the papillary projections. Intra-uterine collection and peritumoral fluid are often found but ascite could be also an indirect proof of peritoneal carcinosis.

CONCLUSION

Sausage-shaped structures or cystic adnexal masses associated with imaging findings such as papillary projections and neovascularization with low resistance indices are in favour of PFTC. A standardized terminology, high-frequency and 3D power Doppler could improve diagnostic performance by allowing a better assessment of tubal wall and chaotic vessels architecture of these tumors.

Correlation of Pelvic Magnetic Resonance Imaging Diagnosis With Pathology for Indeterminate Adnexal Masses

Objectives

The aim of this study was to determine the accuracy of pelvic magnetic resonance imaging (MRI) diagnoses compared with the final pathology diagnoses for a series of women with indeterminate adnexal masses.

Materials and Methods

We performed a retrospective cohort study of women who underwent pelvic MRI with a diagnosis of an adnexal mass between June 2009 and 2010 after indeterminate ultrasound at our tertiary care institution. Chart abstraction was performed for demographic information and radiologic interpretations (benign or malignant) and favored a specific histologic subtype on MRI reports. The radiologic diagnoses were compared with the diagnoses by surgical pathology.

Results

Data from 237 female patients who underwent pelvic MRI were included, and 41.35% underwent surgical intervention for the adnexal mass. Pelvic MRI (n = 88) was determined to have a sensitivity of 95.0% and specificity of 94.1%. The predicted specific histologic subtype by MRI (n = 84) was accurate in 56 (98.25%) of 57 women with an anticipated benign diagnosis and in 23 (85.19%) of 27 women with an anticipated malignancy. The agreement between a benign diagnosis from MRI and benign final surgical pathology was 0.85 (95% confidence interval, 0.716–0.976).

Conclusions

In our tertiary care center, MRI is used to further characterize indeterminate adnexal masses and can accurately differentiate benign versus malignant adnexal masses. The diagnosis on MRI was highly correlative with the final histopathology. The majority of the cohort (59%) were able to be managed expectantly based on reassuring results of the MRI. Magnetic resonance imaging offered diagnostic value, more detailed patient counseling, appropriate subspecialty referral, and surgical planning, as well as reassurance to pursue conservative management of benign masses by MRI.

Dynamic contrast-enhanced magnetic resonance imaging: applications in oncology

Dynamic contrast-enhanced magnetic resonance imaging (DCE MRI) allows functional characterisation of tissue perfusion characteristics and acts as a biomarker for tumour angiogenesis. It involves serial acquisition of MRI images before and after injection of contrast, as such, tissue perfusion and permeability can be assessed based on the signal enhancement kinetics. The ability to evaluate whole tumour volumes in a non-invasive manner makes DCE MRI especially attractive for potential oncological applications. Here we provide an overview of the current research involving DCE MRI as a biomarker for the diagnosis and characterisation of malignancies, prediction of the therapeutic response and survival outcomes, as well as radiation therapy planning.

Algorithmic approach to solid adnexal masses and their mimics: utilization of anatomic relationships and imaging features to facilitate diagnosis

Solid adnexal masses, while less common than their cystic counterparts, may present a challenge for radiologists given the wide range of histologic entities that occur in this region. Pelvic masses, especially when large, can seem overwhelming at first but application of an algorithmic approach allows for more confident assessment. This approach focuses first on the use of anatomic relationships and interactions of various pelvic structures to localize the mass' origin. For instance, the directionality of ureteral displacement can suggest if a mass is intra or extraperitoneal. Then, key discriminating imaging features, such as the presence of fat, hypervascularity, or low T2 signal on magnetic resonance imaging (MRI) can be applied to further narrow the list of diagnostic possibilities. Entities such as leiomyomas, nerve sheath tumors, congenital uterine anomalies, and vascular abnormalities (ovarian torsion or iliac vessel aneurysm) in particular are often accurately characterized with sonography and/or MRI. For solid adnexal masses in which a definitive diagnosis by imaging is not reached, information germane to clinicians regarding further management can still be provided, principally with regard to surgical vs. nonsurgical treatment.

Multidetector computed tomography for the assessment of adnexal mass: is unenhanced CT scan necessary?

OBJECTIVE

To compare the diagnostic performance and radiation dose between contrast-enhanced CT (ECT) alone, and combined unenhanced and contrast-enhanced CT (UE + ECT) for the assessment of adnexal mass.

MATERIALS AND METHODS

This retrospective study was approved by the Institutional Review Board. A total of 146 consecutive patients (mean age, 41.1 years) who underwent preoperative unenhanced and contrast-enhanced multidetector CT of the pelvis and had adnexal masses found at surgery were included. Two readers independently evaluated the likelihood of adnexal malignancy on a 5-point scale on two different imaging datasets (ECT alone and UE + ECT). The area under the receiver operating characteristic curve (AUC) was used to evaluate diagnostic performance. Radiation dose to patients was calculated by the volume CT dose index (CTDIvol) and the dose length products (DLP) on each dataset.

RESULTS

Of the total 178 adnexal masses, 133 masses were benign and 45 masses were malignant. For both readers, there is no significant difference of AUC values between ECT alone and UE + ECT for the detection of adnexal malignancy (reader 1, 0.93 vs. 0.95; reader 2, 0.92 vs. 0.91) (p > 0.05). The mean CTDIvol (12.6 ± 2.2 mGy) and DLP (641.2 ± 137.2 mGy) of ECT alone was significantly lower than the mean CTDIvol (21.5 ± 2.7 mGy) and DLP (923.6 ± 158.8 mGy) of UE + ECT (p < 0.0001).

CONCLUSION

The use of unenhanced CT scan in addition to contrast-enhanced CT scan does not improve the detection of adnexal malignancy, but increases radiation exposure.