Color Doppler ultrasound in the preoperative assessment of adnexal masses

Comparison of image features and diagnostic value of color Doppler ultrasound and two-dimensional ultrasound in the diagnosis of ovarian sex cord-stromal tumors

Clinical value of color Doppler ultrasound and two-dimensional ultrasound in the diagnosis of ovarian sex cord-stromal tumors (OSCSTs) were explored. A total of 91 patients with positive OSCSTs admitted to Sichuan Provincial Hospital for Women and Children from May 2014 to June 2018 were selected as research objects. There were 48 patients diagnosed by color Doppler ultrasound technology as the color Doppler group and 43 patients diagnosed by two-dimensional ultrasound technology as the two-dimensional ultrasound group. Results of ultrasound images in the two groups were compared, and the diagnostic value of two ultrasound techniques combined with detection of CA125 and CA199 for OSCSTs was compared. The real internal echo of color Doppler ultrasound was significantly higher than that of two-dimensional ultrasound (P<0.05). The blood flow signal of color Doppler ultrasound was significantly higher than that of two-dimensional ultrasound (P<0.05). The diagnostic sensitivity and diagnostic coincidence rate of color Doppler ultrasound for lymph node metastasis of OSCSTs were significantly higher than those of two-dimensional ultrasound (P<0.05). Color Doppler ultrasound combined with CA125 and CA199 detection has higher accuracy than two-dimensional ultrasound combination. In conclusion, both color Doppler ultrasound and two-dimensional ultrasound are used to observe OSCSTs for early diagnosis, but the sensitivity and diagnostic coincidence rate of color Doppler ultrasound for clinical diagnosis of OSCSTs are higher than those of two-dimensional ultrasound, so color Doppler ultrasound has higher diagnostic value in OSCSTs.

Management of a suspicious adnexal mass: a clinical practice guideline

QUESTIONS

What is the optimal strategy for preoperative identification of the adnexal mass suspicious for ovarian cancer? What is the most appropriate surgical procedure for a woman who presents with an adnexal mass suspicious for malignancy?

PERSPECTIVES

In Canada in 2010, 2600 new cases of ovarian cancer were estimated to have been diagnosed, and of those patients, 1750 were estimated to have died, making ovarian cancer the 7th most prevalent form of cancer and the 5th leading cause of cancer death in Canadian women. Women with ovarian cancer typically have subtle, nonspecific symptoms such as abdominal pain, bloating, changes in bowel frequency, and urinary or pelvic symptoms, making early detection difficult. Thus, most ovarian cancer cases are diagnosed at an advanced stage, when the cancer has spread outside the pelvis. Because of late diagnosis, the 5-year relative survival ratio for ovarian cancer in Canada is only 40%. Unfortunately, because of the low positive predictive value of potential screening tests (cancer antigen 125 and ultrasonography), there is currently no screening strategy for ovarian cancer. The purpose of this document is to identify evidence that would inform optimal recommended protocols for the identification and surgical management of adnexal masses suspicious for malignancy.

OUTCOMES

Outcomes of interest for the identification question included sensitivity and specificity. Outcomes of interest for the surgical question included optimal surgery, overall survival, progression-free or disease-free survival, reduction in the number of surgeries, morbidity, adverse events, and quality of life.

METHODOLOGY

After a systematic review, a practice guideline containing clinical recommendations relevant to patients in Ontario was drafted. The practice guideline was reviewed and approved by the Gynecology Disease Site Group and the Report Approval Panel of the Program in Evidence-based Care. External review by Ontario practitioners was obtained through a survey, the results of which were incorporated into the practice guideline.

PRACTICE GUIDELINE

These recommendations apply to adult women presenting with a suspicious adnexal mass, either symptomatic or asymptomatic. IDENTIFICATION OF AN ADNEXAL MASS SUSPICIOUS FOR OVARIAN CANCER: Sonography (particularly 3-dimensional sonography), magnetic resonance imaging (mri), and computed tomography (ct) imaging are each recommended for differentiating malignant from benign ovarian masses. However, the working group offers the following further recommendations, based on their expert consensus opinion and a consideration of availability, access, and harm: Where technically feasible, transvaginal sonography should be the modality of first choice in patients with a suspicious isolated ovarian mass.To help clarify malignant potential in patients in whom ultrasonography may be unreliable, mri is the most appropriate test.In cases in which extra-ovarian disease is suspected or needs to be ruled out, ct is the most useful technique.Evaluation of an adnexal mass by Doppler technology alone is not recommended. Doppler technology should be combined with a morphology assessment.Ultrasonography-based morphology scoring systems can be used to differentiate benign from malignant adnexal masses. These scoring systems are based on specific ultrasound parameters, each with several scores base on determined features. All evaluated scoring systems were found to have an acceptable level of sensitivity and specificity; the choice of scoring system may therefore be made based on clinician preference.As a standalone modality, serum cancer antigen 125 is not recommended for distinguishing between benign and malignant adnexal masses.Frozen sections for the intraoperative diagnosis of a suspicious adnexal mass is recommended in settings in which availability and patient preference allow. SURGICAL PROCEDURES FOR AN ADNEXAL MASS SUSPICIOUS FOR MALIGNANCY: To improve survival, comprehensive surgical staging with lymphadenectomy is recommended for the surgical management of patients with early-stage ovarian cancer. Laparoscopy is a reasonable alternative to laparotomy, provided that appropriate surgery and staging can be done. The choice between laparoscopy and laparotomy should be based on patient and clinician preference. Discussion with a gynecologic oncologist is recommended. Fertility-preserving surgery is an acceptable alternative to more extensive surgery in patients with low-malignant-potential tumours and those with well-differentiated surgical stage i ovarian cancer. Discussion with a gynecologic oncologist is recommended.

Diagnostic value of contrast-enhanced ultrasonography in the characterization of ovarian tumors()

INTRODUCTION

Vascularity influences the characteristics of gynecologic tumors observed with direct imaging techniques that reveal the macrovascular component of these lesions (color and power Doppler) and with indirect imaging involving the administration of contrast agents to examine the microcirculation and interstitial perfusion (contrast-enhanced computed tomography [CT] and magnetic resonance [MR] imaging). The purpose of this study was to determine whether contrast-enhanced ultrasonography (CEUS) of ovarian lesions provides useful information that cannot be obtained with conventional US.

MATERIALS AND METHODS

We used CEUS to assess 72 nonspecific adnexal lesions in 61 patients. CEUS was performed with a 4.8-ml bolus of a second-generation ultrasonographic contrast agent and dedicated imaging algorithms. For each lesion, B-mode morphology, CEUS morphology, and time/intensity curves were evaluated.

RESULTS

In 8/61 cases (13.1%) CEUS offered no additional morphovascular information. In 38/61 cases (62.3%), it provided additional information that did not modify the management of the lesion, and in 15/61 cases (24.6%) it gave additional information that modified the management of the lesion. Malignant lesions were characterized by significantly shorter times to peak enhancement (11.9 ± 3.1 s vs 19.8 ± 4.0 s p < 0.01) and significantly higher peak intensity (24.7 ± 4.2 dB vs 17.8 ± 3.3 dB p < 0.01) compared with benign lesions.

CONCLUSIONS

CEUS improves diagnostic confidence in the characterization of liquid-corpuscular lesions where conventional US is inconclusive. CEUS can be proposed as a valid alternative to CT and MR. However, information obtained by CEUS influences the therapy in a limited percentage of cases (24.6%).

A critical analysis of Doppler velocimetry in the differential diagnosis of malignant and benign ovarian masses

OBJECTIVES

To evaluate the intratumoral reliability of color Doppler parameters and the contribution of Doppler sonography to the gray-scale differential diagnosis of ovarian masses.

METHODS

An observational study was performed including 67 patients, 15 (22.4%) with malignant ovarian neoplasm and 52 (77.6%) with benign ovarian diseases. We performed the Doppler evaluation in two distinct vessels selected after decreasing the Doppler gain to sample only vessels with higher velocity flow. Doppler measurements were obtained from each identified vessel, and resistive index (RI), pulsatility index (PI), peak systolic velocity (PSV), and end-diastolic velocity (EDV) were measured. Intraclass coefficient of correlation (ICC), sensitivity, specificity, and potential improvement in gray-scale ultrasound performance were calculated.

RESULTS

The general ICC were 0.60 (95% CI 0.42-0.73) for RI, 0.65 (95% CI 0.49-0.77) for PI, 0.07 (95% CI -0.17-0.30) for PSV, and 0.19 (95% CI -0.05-0.41) for EDV. The sensitivity and specificity were respectively 84.6% and 86.7% for RI, 69.2% and 93.3% for PI, 80.0% and 65.4% for gray-scale sonography, and 93.3% and 65.4% for gray-scale plus RI (p = 0.013).

CONCLUSIONS

Gynecologists must be careful in interpreting results from Doppler evaluation of ovarian masses because PSV and EDV present poor intratumoral reliability. The lower RI value, evaluated in at least two distinct sites of the tumor, was able to improve the performance of gray-scale ultrasound in differential diagnosis of ovarian masses.

Ultrasonography, computed tomography and magnetic resonance imaging for diagnosis of ovarian carcinoma

Our objective was to compare US, CT, and MR imaging in differentiation of malignant from benign ovarian tumors. Through an electronic literature search and manual review of bibliographies (January 1990 to June 2006), relevant studies on the diagnostic performance of US, CT, and MR imaging in the differentiation between benign and malignant ovarian tumours were identified. Sixty-nine articles were included, yielding 143 studies. Data on the accuracy of the different imaging modalities were analyzed and compared by constructing summary receiver-operating characteristic (ROC) curves. Our results suggest that US techniques seems to be similar with CT and MRI in differentiation of malignant from benign ovarian tumors. The results also revealed that color Doppler flow imaging alone is significantly inferior to combined US techniques, morphologic assessment alone and contrast enhanced US in diagnosis of ovarian cancer. In conclusion, US morphologic assessment still is the most important and common modality in detect ovarian cancer.

Conventional and color Doppler sonography in preoperative assessment of ovarian tumors

OBJECTIVE

To study the vascular patterns of ovarian tumors by color Doppler imaging (CDI) and compare the findings of conventional sonographic studies and CDI with histopathologic findings for the same tumors.

METHODS

Fifty nonpregnant women scheduled for elective surgery for ovarian tumors were examined by sonographic scanning and CDI by the same physician. Sonographic morphology scores [SMSs] were used, and the pulsatility index (PI) and resistance index (RI) were calculated after locating vessels in and around the tumors by CDI.

RESULTS

It was possible to obtain CDI results in 26 of the 50 women. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 100%, 71.43%, 73.33%, and 100%, respectively, for SMS. With CDI, the sensitivity, specificity, PPV, and NPV were 100%, 85.72%, 95%, and 100% for PI and 100%, 71.43%, 90.48%, and 100% for RI. RI sensitivity and specificity were identical to those of SMS, i.e., 100% and 71.43%, respectively, but PI specificity was better (85.72%).

CONCLUSION

In this study, CDI was definitely better than SMS when color flow could be obtained through the tumors. The overall efficiency in diagnosing the nature of tumors is very high if SMS and CDI are both used in patients having ovarian tumors.

Differentiation of small adnexal masses based on morphologic characteristics of transvaginal sonographic imaging: a multicenter study

OBJECTIVE

The purpose of this study was to assess the diagnostic accuracy of transvaginal sonographic examination of small adnexal masses by simple descriptive sonographic scoring.

METHODS

In a prospective multicenter study, 4 teaching hospitals and 2 regional hospitals with homogeneous standard sonographic equipment and operator experience recruited 677 consecutive patients with small adnexal masses of less than 5 cm. Morphologic scoring was obtained for each mass and recorded. The management of the mass was based on local protocols. The minimal requirement was that surgery had to be performed for complex masses scoring 8 or higher, and follow-up of at least 12 months had to be performed and recorded for patients not admitted to surgery. Sonographic results were compared with pathologic reports and follow-up findings.

RESULTS

Fifty-two malignant tumors (19 borderline, 15 stage I-II, 15 stage III-IV, 2 tubal carcinomas, and 1 ovarian lymphoma), 243 benign tumors at pathologic examination, and 382 masses defined as benign according to follow-up findings were observed. Malignant tumors had a significantly higher mean +/- SD morphologic score (11.2 +/- 2.7) than benign masses (6.2 +/- 2.5) (P = .001). No difference was observed in the scoring assignment of malignant masses in different centers (P = .56). With a score of 8 or higher, the likelihood ratio was 3.61 (95% confidence interval, 3.09-4.21); sensitivity, 92%; specificity, 76.9%; and positive predictive value, 25.6%.

CONCLUSIONS

Our results provide evidence that descriptive morphologic scoring may overcome the subjectivity of interpretation of morphologic characteristics in small masses, and, at the same time, it can incorporate criteria to avoid simplistic description of a complex mass.

Selected adnexal cystic masses in postmenopausal women can be safely managed by laparoscopy

The aim of this study was to assess the efficacy and safety of laparoscopic treatment for adnexal cystic masses that were predicted to be benign in postmenopausal women. Postmenopausal women found to have an adnexal cystic mass were retrospectively evaluated with transvaginal ultrasonography, and serum CA-125 levels. The selection criteria were adnexal cystic masses greater than 3 cm but less than 10 cm, the masses were in the benign range (4-8) of Sassone's scoring system for transvaginal ultrasonography, and the patients had serum CA-125 levels less than 65 IU/mL. Two hundred nineteen women fulfilled the criteria and underwent operative laparoscopy. Almost all the masses (99.5%) were accurately predicted to be benign except for one borderline ovarian tumor. Two hundreds thirteen (97.3%) women were successfully managed by operative laparoscopy and six (2.7%) required laparotomy. For the patients managed by laparoscopy, the mean operative time was 51.3 min; the mean hospital stay was 2.5 days. There was no significant morbidity and surgery-related mortality. The combination of the Sassone's scoring system for transvaginal ultrasonography and serum CA-125 level can accurately predict benign cystic masses, and operative laparoscopy is technically feasible and safe for the management of adnexal mass in postmenopausal women.

Contrast-enhanced sonography helps in discrimination of benign from malignant adnexal masses

OBJECTIVE

To investigate the potential efficacy of real-time contrast-enhanced power Doppler sonography in the differentiation of benign and malignant adnexal masses in a pilot study.

METHODS

Before surgical treatment, adnexal masses were prospectively evaluated with power Doppler sonography before and after injection of a contrast agent. Real-time postinjection sequences were computerized with time-intensity analysis software to determine an enhancement curve and contrast parameters. The intraobserver and interobserver reproducibilities of these criteria were assessed on a subsample. These contrast parameters were compared between benign and malignant tumors using logistic regression. Sensitivity and specificity were used to compare contrast parameters with sonographic and Doppler variables.

RESULTS

Ninety-nine women were included, for a total of 101 adnexal masses. There were 23 cases of ovarian malignancies and 78 benign adnexal lesions. Our procedure had excellent intraobserver and interobserver reproducibility, with an average intraclass correlation coefficient of 0.92. The time before enhancement and intensity ratio did not reliably differentiate between the benign and malignant masses. Washout times and areas under the curves were significantly greater in ovarian malignancies than in other benign tumors (P < .001), leading to sensitivity estimates between 96% and 100% and specificity estimates between 83 and 98%. Contrast parameters had slightly higher sensitivity and slightly lower specificity when compared with transvaginal sonographic variables of the resistive index and serum cancer antigen 125 levels.

CONCLUSIONS

Contrast-enhanced power Doppler imaging may easily and precisely discriminate benign from malignant adnexal lesions. Larger studies are needed to determine the appropriate use and benefits of this new procedure.

A new scoring system to differentiate benign from malignant adnexal masses

OBJECTIVE

The purpose of this study was to develop and cross-validate a new sonographic scoring system for differentiation between benign and malignant adnexal masses.

STUDY DESIGN

This study was conducted in a tertiary care university hospital. In the first part of the study, we used a multivariate logistic regression analysis to develop a scoring system that was based on morphologic and Doppler sonographic data for 705 adnexal masses in 665 patients who were diagnosed and treated at our institution from January 1995 to June 2001. The scoring system was designed to use only those parameters that are found to be independent predictors of malignancy. In the second part of the study, we prospectively cross-validated this scoring system in a series of 90 adnexal masses in 86 patients between July 2001 and March 2002. With the use of the area under the curve of the respective ROC curves, we compared the new scoring system with other scoring systems.

RESULTS

Multivariate logistic regression analysis revealed that the only independent predictor parameters were thick papillary projections, solid areas, central flow, and velocimetric features of high velocity and low resistance. In the prospective cross-validation study, our scoring system had the best diagnostic performance (area under the curve, 0.98) compared with Sassone (area under the curve, 0.89; P =.017), De Priest (area under the curve, 0.92; P =.048), and Ferrazzi (area under the curve, 0.90; P =.013) scoring systems.

CONCLUSION

Our new sonographic scoring system had a better diagnostic performance than three previously published scoring systems.

Color Doppler energy prediction of malignancy in adnexal masses using logistic regression models

OBJECTIVE

The aim of this study was to assess the usefulness of color Doppler energy in the preoperative diagnosis of ovarian malignancy using multivariate logistic regression analysis.

METHODS

One hundred and thirty adnexal masses were studied with transvaginal B-mode, color energy, and pulsed Doppler ultrasonography before surgery in order to develop a model that could be used to determine malignancy. Each ultrasonographic variable (tumor size, wall thickness, septal structure, echogenicity, papillary projection, density (solid or not)) was included individually or combined together as part of the Sassone ultrasound score. Intratumoral blood flow velocity waveforms were obtained to determine pulsatility index and resistance index and a more subjective parameter, location of tumor vascularity, was also assessed. Menopausal status and serum CA 125 levels were also entered as categorical variables. Sonographic parameters were entered alone, then associated with menopausal status and CA 125 serum levels, and finally with Doppler energy measurements. Our model was then validated in a group of 68 adnexal masses and compared to the model of Alcazar.

RESULTS

Eighteen adnexal masses (13.8%) were malignant or of low malignant potential. Multivariate analysis showed that papillary projection of the tumor wall, cyst with solid parts, resistance index with a cut-off value of 0.53, CA 125, and central blood flow location, were the only factors to be independent predictors of malignancy. Menopausal status was not an independent factor. For the final model including the Doppler energy parameter the best sensitivity and specificity were 83% and 93%, respectively, at a cut-off value of 10% probability of malignancy compared to 83% and 87% for the morphological variables alone. Validation of the model showed its diagnostic performance to be as good as that reported in the original population and better than the model of Alcazar.

CONCLUSION

Sonographic analysis of adnexal masses including color Doppler energy shows the best predictive properties according to histological diagnosis, and improves preoperative diagnosis of malignancy.

Transvaginal color Doppler assessment of venous flow in adnexal masses

OBJECTIVE

To analyze the usefulness of transvaginal color Doppler assessment of venous flow in the differential diagnosis of adnexal masses.

MATERIAL AND METHODS

Ninety-one consecutive patients (mean age: 46.6 years, range: 16-81 years) diagnosed as having an adnexal mass were evaluated by transvaginal color Doppler sonography prior to surgery. Color Doppler was used to detect and analyze the flow velocity waveform from arterial and venous blood flow within the tumor. For arterial signals the resistance index and peak systolic velocity, and for veins the maximum venous flow velocity, were calculated. Receiver operator characteristic curves were plotted to determine the best venous flow velocity cut-off. According to our previous study using arterial Doppler, a tumor was considered as malignant when flow was detected and the lowest resistance index was < or = 0.45. Using venous Doppler a mass was considered as malignant when flow was detected and the venous flow velocity was > or = the best cut-off found on the receiver operator characteristic curve. Definitive histopathological diagnosis was obtained in all cases. Sensitivity, specificity, positive predictive value and negative predictive value for B-mode morphology (evaluation performed according to Sassone's scoring system), arterial Doppler, venous Doppler, and a combination of both arterial and venous Doppler were calculated.

RESULTS

Twenty-five masses (27.5%) were malignant and 66 (72.5%) benign. Arterial and venous flow was found more frequently in malignant than in benign masses (92% vs. 41% (P < 0.001) and 72% vs. 21% (P < 0.001), respectively). The resistance index was significantly lower in malignant tumors (0.42 vs. 0.60, P = 0.0003). No differences were found in peak systolic velocity. Venous flow velocity was significantly higher in malignant masses (18.1 cm/s vs. 8.9 cm/s, P = 0.0006). The best cut-off of venous flow velocity was 10 cm/s. Sensitivity, specificity, positive predictive value and negative predictive value for morphology, arterial Doppler, venous Doppler, and the combination of both arterial and venous Doppler were 92%, 71%, 45%, 96%; 76%, 95%, 87%, 91%; 68%, 94%, 81%, 89%; and 88%, 91%, 79%, 95%, respectively.

CONCLUSIONS

Our results indicate that preoperative evaluation by venous flow assessment of adnexal masses may be useful to discriminate between malignant and benign tumors.

Does anybody know how we should measure Doppler parameters in lymph nodes?

AIM

To show how currently described techniques confuse interpretation of Doppler indices in lymph node characterization.

MATERIALS AND METHODS

The Doppler indices [resistivity index (RI) and pulsatility index (PI)] were obtained in 35 malignant lymph nodes by colour duplex sonography. Each node was sampled at eight different sites. Data were analysed using our own method, and methods employed in six previous studies.

RESULTS

Restistivity index values varied between 0.69 and 0.88 and PI values ranged from 1.28 to 2.34. All but two methods produced different resistance indices (P < 0.05).

CONCLUSION

Conflicting results are obtained analysing the same data using different methods. Standardized techniques should be agreed and employed in future studies.

US characterization of ovarian masses: a meta-analysis

PURPOSE

To compare the effectiveness of current ultrasonographic (US) techniques for characterizing ovarian masses.

MATERIALS AND METHODS

Through a MEDLINE literature search, articles with imaging-histopathologic correlation and data that allowed calculation of contingency tables were identified. Results of morphologic assessment, Doppler US, color Doppler flow imaging, and combined techniques were compared.

RESULTS

Among 89 data sets from 46 included studies (5,159 subjects), 35 sets used morphologic information, 36 measured Doppler US indexes, 10 assessed tumor vascularity with color Doppler flow imaging, and eight used combined techniques. Summary receiver operating characteristic curves revealed significantly higher performance for combined techniques than for morphologic information (P: =.003), Doppler US indexes (P: =.003), or color Doppler flow imaging alone (P: =.001). The Q* point (and 95% CI) for combined techniques was 0.92 (0.87, 0.96) versus 0. 85 (0.83, 0.88) for morphology, 0.82 (0.78, 0.86) for Doppler US, and 0.73 (0.58, 0.87) for color Doppler flow imaging. Morphologic assessment showed a trend toward better performance than color Doppler flow imaging (P: =.09) or Doppler US indexes (P: =.07). Doppler US index results were better in earlier studies (P: =.005).

CONCLUSION

Combined US techniques and a diagnostic algorithm perform significantly better than morphologic assessment, color Doppler flow imaging, or Doppler US indexes alone in characterizing ovarian masses.

CA 125 measurement and ultrasonography in borderline tumors of the ovary

OBJECTIVES

Our goal was to perform an analysis of ultrasonographic characteristics and CA 125 levels in ovarian tumors of borderline malignancy.

STUDY DESIGN

We performed a retrospective analysis of CA 125 levels and ultrasonographic parameters in 91 patients with borderline tumors.

RESULTS

Serous tumors of borderline malignancy were associated with elevated CA 125 levels in 75% of patients before surgery (mean, 156 IU/mL) compared with 30% of mucinous tumors (mean, 28 IU/mL; P =.004). CA 125 was elevated in 35% of stage IA serous tumors (mean, 67 IU/mL) compared with 89% of tumors with spread beyond the ovary (mean, 259 IU/mL; P =.001). Mucinous tumors tended to be bigger (13.1 +/- 7 cm) on ultrasonography than serous tumors (9.3 +/- 6.2 cm, P =.016). Mucinous tumors were multilocular in half the patients and contained papillations in 40% of the patients. Serous tumors were multilocular in 30% of the patients but presented with solid or papillary patterns in 78% of the patients (P =.001). A resistance index of <0.4 was found in 36% of mucinous tumors and half the cases of serous tumors. In 13% of patients, ultrasonographic characteristics were compatible with a simple cyst only, including 1 patient with microinvasion and 1 patient with stage IIIB disease. Sensitivity of gray-scale ultrasonography was 87%, that of CA 125 measurement was 62%, and that of flow was 55%. At least 1 diagnostic test result was abnormal in 93% of patients, 2 were abnormal in 69% of patients, and all 3 were abnormal in 21% of patients.

CONCLUSIONS

A high proportion of borderline tumors of the ovary, particularly of the serous type, were associated with elevated CA 125 levels and abnormal ultrasonographic characteristics, although some tumors presented as simple cysts.

Transvaginal color Doppler ultrasonic characterization of benign and malignant ovarian cystic teratomas and comparison with serum squamous cell carcinoma antigen

BACKGROUND

The preoperative diagnosis of squamous cell carcinoma (SCC) arising in mature cystic teratoma of the ovary remains difficult. The purpose of this study is to examine the usefulness of transvaginal color Doppler ultrasound (TV-CDU) in differentiating malignant (SCC) from benign cystic teratoma of the ovary.

METHODS

Eighty-eight patients with an ovarian tumor showing gray scale sonographic appearances of mature cystic teratoma were preoperatively evaluated for the presence or absence of intratumoral blood flow by TV-CDU. The blood flow characteristics of the tumor vessels were analyzed using the resistance index (RI), pulsatility index (PI), and peak systolic velocity (PSV). The serum levels of SCC antigen were also randomly examined preoperatively in 50 patients.

RESULTS

Intratumoral blood flow was significantly detected in malignant teratomas (SCCs) (80.0%; 4 of 5) compared with benign teratomas (20.5%; 17 of 83) (P < 0.01). All malignant teratomas with intratumoral blood flow showed both RI less than 0.4 and PI less than 0.6, whereas no benign teratomas showed any such value except for 1 case with struma ovarii. In addition, both the mean RI and the mean PI values in the tumor vessels were significantly lower in the malignant teratomas (RI: 0.31 +/- 0.07; PI: 0.40 +/- 0.16) than in the benign teratomas (RI: 0.62 +/- 0.13; PI: 1.06 +/- 0.44) (P < 0.001). However, the mean PSV value of the malignant teratomas (PSV: 20.6 +/- 8.33) was not significantly different from the benign teratomas (PSV: 18.1 +/- 9.9). Elevation of serum SCC was found in 4 of 5 patients (80%) with malignant teratomas, whereas the elevation was found in 11 of 45 patients (24.4%) with benign teratomas (P < 0.05). The diagnostic accuracy using the RI (cutoff value 0.4) as well as the PI (cutoff value 0.6) was thus 95.2%, which was significantly superior to that obtained by using the serum SCC (76%) (cutoff value, 1.5 ng/mL).

CONCLUSIONS

Evaluating the presence or absence of intratumoral blood flow, together with blood flow resistance, in tumor vessels using TV-CDU thus may be more useful to differentiate malignant (SCC) from benign cystic teratomas of the ovary than by measuring serum SCC levels.

Neural networks in the diagnosis of malignant ovarian tumours

OBJECTIVE

To assess the role of neural networks in predicting the likelihood of malignancy in women presenting with ovarian tumours.

DESIGN

Retrospective case study.

SETTING

University Department of Obstetrics and Gynaecology, St James's Hospital, Leeds.

METHODS

Information from 217 cases with histologically proven benign, borderline or malignant tumours was extracted for study. Four variables (age, ultrasound findings with and without colour Doppler imaging and CA125) were entered in the neural network classifier. The neural network results were compared with logistic regression analysis.

RESULTS

When used in the neural network the variables of age, CA125 and ultrasound score produced the best result with a sensitivity of 95% and a corresponding specificity of 78% in predicting malignancy. Logistic regression gave a sensitivity or 82% for a specificity of 51%.

CONCLUSION

The neural network is a good method of combining diagnostic variables and may be a useful predictor of malignancy in women presenting with ovarian tumours. A comparison of the performance of the neural network with conventional diagnostic methods would be warranted prior to use in clinical practice.

Using a logistic model to predict malignancy of adnexal masses based on menopausal status, ultrasound morphology, and color Doppler findings

In the present study we aimed to develop a formula for predicting adnexal malignancy based on menopausal status, ultrasound morphology, and color Doppler findings. Logistic regression analysis was performed retrospectively in 79 adnexal masses (59 benign and 20 malignant) in 73 unselected and consecutive patients. All these masses had been preoperatively evaluated using transvaginal color Doppler ultrasonography. In logistic analysis menopausal status (premenopausal vs postmenopausal), color Doppler findings (no flow or lowest resistance index >0.45 vs lowest resistance index </=0.45) and ultrasound morphology (nonsuspicious vs suspicious) were entered as categorical variables. Morphology and color Doppler were found to be independent predictors, whereas menopausal status was not. To assess the validity of the developed mathematical formula, this was applied prospectively in a second series of 58 consecutive and unselected patients diagnosed of adnexal mass and scheduled for surgery. The probability of malignancy was estimated in each case. Overall, 56 of 58 (96.5%) adnexal masses were correctly classified. We conclude that the formula developed in this study is easy to apply and could be useful to predict malignancy or benignity of adnexal masses.

Evaluation of ovarian tumors in postmenopausal women by transvaginal sonography

OBJECTIVE

The aim of the present study was the evaluation of simple reproducible sonomorphological criteria for the preoperative evaluation of ovarian tumors in postmenopausal women by use of transvaginal sonography.

STUDY DESIGN

Postmenopausal women (> or =1 year of secondary amenorrhea) with ovarian tumors (n=378; tumors > or =3 cm and <3 cm but with solid parts) were examined in a prospective study by transvaginal sonography prior to surgery between 1987 and 1993. The sonomorphological criteria were correlated with the histological findings of the tumors.

RESULTS

Of all ovarian tumors in postmenopausal women, 6.3% were functional cysts (follicular or corpus luteum cysts). Almost all of them were detected within the first 5 years of postmenopause. The other ovarian tumors were diagnosed as retention cysts (17.5%), benign neoplasms (39.4%), and malignant tumors (36.8%). Simple ovarian cysts (monolocular, smooth inner wall) represented sonomorphologically the second most frequent type of ovarian tumors in postmenopausal women (35.7%). Of these tumors, 9.6% were diagnosed as malignant.

CONCLUSIONS

Simple reproducible sonomorphological criteria proved to be a useful clinical parameter in the preoperative evaluation of ovarian tumors.

Transvaginal color Doppler sonography and conventional sonography in the preoperative assessment of adnexal masses

OBJECTIVE

This investigation was undertaken to evaluate the predictive value of the blood flow velocity as measured by transvaginal color Doppler sonography (CDS) and conventional sonographic criteria in the preoperative assessment of ovarian tumors.

METHODS

98 patients who were admitted for surgery with a suspicion of an adnexal mass (69 benign tumors, 4 borderline tumors, and 25 malignant tumors) were prospectively studied with transvaginal sonography (TVS) and CDS. Pulsatility index of blood flow velocity waveforms was evaluated by CDS and compared with established sonographic criteria for discriminating between benign and malignant ovarian tumors.

RESULTS

TVS had a sensitivity of 91% and a specificity of 84% in detecting malignant ovarian tumors compared with CDS with a sensitivity of 90% and a specificity of 74%, using 1.1 as a cut-off value for the pulsatility index. The specificity of CDS was higher in postmenopausal (88%) than in premenopausal (63%) patients. Using TVS and CDS combined, the sensitivity and specificity of diagnosing malignant ovarian tumors could be increased to 95% and 86%.

CONCLUSION

In premenopausal patients, TVS is clearly a more sensitive and more specific technique than CDS in correctly identifying benign and malignant ovarian tumors, whereas in postmenopausal patients, CDS gives useful additional information concerning blood vessel resistance. If CDS is used as an additional technique to TVS, it can increase the sensitivity and specificity of TVS in discriminating between benign and malignant ovarian tumors.

The role of transvaginal ultrasonography combined with color velocity imaging and pulsed Doppler in the diagnosis of endometrioma

OBJECTIVE

To assess the diagnostic accuracy of transvaginal ultrasonography alone and combined with color velocity imaging and pulsed Doppler in differentiating ovarian endometriomas from other nonendometriotic masses.

DESIGN

Prospective study with pathological confirmation of sonographic diagnosis.

SETTING

Department of Obstetrics and Gynecology at a university hospital.

PATIENT(S)

A series of 78 consecutive patients diagnosed as having an adnexal mass and scheduled for surgery, between January 1995 and March 1996.

INTERVENTION(S)

Transvaginal ultrasonography and color velocity imaging and pulsed Doppler was performed before surgery in all patients. A total of 82 masses were diagnosed (four patients had bilateral masses). CA-125 plasma levels were measured in all patients. Ultrasound diagnosis was compared with definitive histopathological diagnosis.

MAIN OUTCOME MEASURE(S)

The presence of a round-shaped homogeneous cyst with low-level echoes was considered as sonographic diagnosis of ovarian endometrioma. The typical vascular pattern from endometrioma was considered as "pericystic flow at the level of the ovarian hilius." The sensitivity, specificity, and positive and negative predictive values were calculated for transvaginal ultrasonography alone and combined with color velocity imaging and pulsed Doppler.

RESULT(S)

Twenty-seven (32.9%) of the 82 masses were proven to be ovarian endometriomas. Morphological assessment diagnosed correctly 24 (88.9%) of 27 endometriomas (false-positive rate: 9%). Typical flow pattern was present in 90.5% of endometriomas (false-positive rate: 80%). CA-125 levels in patients with endometrioma (45.6 +/- 6.3 U/mL; mean +/- SEM) were significantly higher than in patients with nonendometriotic masses (26.5 +/- 5.5 U/mL). The sensitivity, specificity, and positive and negative predictive values of transvaginal ultrasonography alone and combined with color velocity imaging and pulsed Doppler were 88.9%, 91%, 84.2%, and 94.5%, and 76.2%, 88.9%, 82.4%, and 82.4%, respectively. For CA-125 levels, using a cutoff > or = 35 U/mL, these figures were 79.3%, 84.6%, 79.3%, and 84.6%, respectively.

CONCLUSION(S)

The use of color velocity imaging and pulsed Doppler does not improve the diagnostic accuracy of transvaginal ultrasonography alone in the diagnosis of ovarian endometrioma.

Transvaginal ultrasonography of pelvic masses: evaluation of B-mode technique and Doppler ultrasonography

OBJECTIVE

The purpose of this study was to evaluate pelvic masses by B-mode and Doppler ultrasonography for identification of ovarian malignancies.

STUDY DESIGN

A previously described scoring system for pelvic masses was applied in 310 women, and the lesions were classified into four groups according to the ultrasonographic structure. Pulsatility index values of vessels within the tumor and the contralateral ovary and of both uterine arteries were determined.

RESULTS

A total of 259 masses were benign and 51 were malignant. The scoring system and classification into morphologic groups revealed similar sensitivity, specificity, and positive and negative predictive values. Intratumoral and opposite ovarian blood flow and ipsilateral and contralateral uterine blood flow did not differ in benign and malignant masses except in cases of benign lesions in postmenopausal women. In malignant lesions a lower pulsatility index (0.94 +/- 0.4) was measured than in benign lesions (1.06 +/- 0.4, p < 0.05), although a remarkable overlap was found.

CONCLUSION

The results suggest that further refinement of assessment of pelvic masses with Doppler ultrasonography is needed.

A comparison of intratumoural indices of blood flow velocity and impedance for the diagnosis of ovarian cancer

The aim was to assess the value of blood flow velocity indices in an ultrasound-based test to discriminate between malignant and benign adnexal tumours. Fifty-one women (35 premenopausal and 16 postmenopausal) with persistent adnexal masses were scanned prior to surgery using transvaginal sonography with colour Doppler imaging. Intratumoural flow velocity waveforms obtained by pulsed Doppler sonography were used to determine the time averaged maximum velocity (TAMXV), peak systolic velocity (PSV), pulsatility index (PI) and resistance index (RI). The tumours were classified by histologic criteria (42 benign, 1 borderline and 8 malignant tumours). Two of the malignant and the single borderline tumour were stage I, five were stage III and one was stage IV. Detectable blood flow signals were found in all malignant and borderline tumours and in 33 of 42 (78.6%) of the benign tumours. TAMXV was the best parameter for discrimination of benign and malignant adnexal pathology and at a cut-off value of TAMXV > or = 12 cm/s to indicate malignancy, the sensitivity and specificity were 88.9% and 81.0%, respectively. At the same sensitivity level, this gave a better specificity than the PI < or = 0.90 (specificity 61.9%, P = 0.036), RI < or = 0.60 (specificity 54.8%, P = 0.010) and PSV > or = 16 cm/s (specificity 71.4%, P = 0.121). Discrimination between benign and malignant tumours was improved further by using two criteria rather than one. When the two criteria of a TAMXV of > or = 12 cm/s and a PI < or = 1.0 were applied simultaneously, the tumours could be characterised with a sensitivity of 88.9% and a specificity of 88.1%. Therefore, intratumoural PSV and TAMXV could be used to discriminate between benign and malignant adnexal tumours better than values for PI and RI. The best discrimination was achieved by using a combination of cut-off values for velocity and impedance parameters as two criteria to define malignancy.