Three-dimensional power Doppler sonography: imaging and quantifying blood flow and vascularization

OBJECTIVES

To assess the feasibility of imaging low-velocity blood flow in adnexal masses by transvaginal three-dimensional power Doppler sonography, to analyze three-dimensional power Doppler sonography data sets with a new computer-assisted method and to test the reproducibility of the technique.

METHODS

A commercially available 5-MHz Combison 530 ultrasound system was used to perform three-dimensional power Doppler sonography transvaginally. A cube (= volume of interest) was defined enclosing the vessels of the cyst and the Cartesian characteristics were stored on a hard disk. This cube was analyzed using specially designed software. Five indices representing vascularization (the vascularization index (VI) or blood flow (the flow index (FI)) or both (the vascularization-flow index (VFI)) were calculated. The intraobserver repeatability of cube definition and scan repetition was assessed using Hartley's test for homogeneous variances. Interobserver agreement was assessed by the Pearson correlation coefficient.

RESULTS

Imaging of vessels with low-velocity blood flow by three-dimensional power Doppler sonography and cube definition was possible in all adnexal massed studied. In some cases even induced non-vascular flow related to endometriosis was detected. The calculated F value with intraobserver repeated Cartesian file-saving ranged from 0 to 18.8, with intraobserver scan repetition from 4.74 to 24.8 for VI, FI 1, FI 2 and VFI 1; for VFI 2 the calculated F value was 64. The interobserver correlation coefficient ranged between 0.83 and 0.92 for VI, FI 1, FI 2 and VFI 1; for VFI 2 the correlation coefficient was less than 0.75.

CONCLUSION

Vessels with low-velocity blood flow can be imaged using three-dimensional power Doppler sonography. Induced non-vascular flow was detected in endometriotic cyst fluid. Three-dimensional power Doppler sonography combined with the cube method gave reproducible information for all indices except VFI 2. These indices might prove to be a new predictor in all fields of neoangiogenesis. The clinical relevance remains to be determined.

Benign and malignant ovarian masses: selection of the most discriminating gray-scale and Doppler sonographic features

PURPOSE

To determine the gray-scale and Doppler sonographic features that best enable discrimination between malignant and benign ovarian masses and develop a scoring system for accurate diagnosis with these features.

MATERIALS AND METHODS

Gray-scale and Doppler sonographic features of 211 adnexal masses were correlated with the final diagnosis; the most discriminating features for malignancy were selected with stepwise logistic regression.

RESULTS

Twenty-eight masses were malignant and 183 benign. All masses with a markedly hyperechoic solid component or no solid component were benign. For masses with a nonhyperechoic solid component, additional features that allowed statistically significant discrimination of benignity from malignancy were, in decreasing order of importance, (a) location of flow at conventional color Doppler imaging, (b) amount of free intraperitoneal fluid, and (c) presence and thickness of septations. A scoring formula that made use of values based on the logistic regression equation had an area under the receiver operating characteristic curve of 0.98 +/- 0.01. The cutoff score with the highest accuracy had a sensitivity of 93% and specificity of 93%.

CONCLUSION

A solid component is the most statistically significant predictor of a malignant ovarian mass. A multiparameter scoring system that uses three gray-scale and one Doppler feature, developed by means of stepwise logistic regression, has high sensitivity and specificity for predicting malignancy.

Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle

The purpose of this study was to assess the diagnostic value of ultrasonography for the detection of twisted vascular pedicle in ovarian torsion and to verify whether the blood flow alterations in the twisted vascular pedicle on color Doppler sonography can predict the viability of adnexal structures. In 28 of 32 patients with surgically proved torsion, the twisted vascular pedicle was detected preoperatively by ultrasonography, which shows a diagnostic accuracy of 87%. Arterial and venous flows were present in the twisted vessels on color Doppler sonography in 16 of 28 patients with a visible twisted vascular pedicle. In 11 patients who underwent adnexectomy, the pathologic findings revealed nonnecrotic ovaries in 10 patients. Untwisting of the twisted vascular pedicle was performed in five patients, and follow-up ultrasonography showed normal follicular development and ovulation. All 12 patients who showed no blood flow within the twisted vascular pedicle had necrotic ovaries. In conclusion, identification of the twisted vascular pedicle through ultrasonography is suggestive of ovarian torsion, and color Doppler sonography could be helpful in predicting the viability of adnexal structures by depicting blood flow within the twisted vascular pedicle.

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.

Endometriomas: diagnostic performance of US

PURPOSE

To determine the diagnostic performance of specific ultrasonographic (US) features in discriminating endometriomas from other adnexal masses.

MATERIALS AND METHODS

Two sonologists independently reviewed the sonograms of 252 adnexal masses in 226 women and recorded US features by using a standardized checklist. The diagnostic performance of specific US features and overall reviewer impression in discriminating endometriomas from other adnexal masses were evaluated.

RESULTS

There were 40 endometriomas. Diffuse low-level internal echoes were present in 38 (95%) endometriomas and 40 (19%) nonendometriomas (positive likelihood ratio, 5). The positive likelihood ratio for the diagnosis of endometrioma increased to 8 if masses with neoplastic features at gray-scale US were excluded, allowing identification of 30 endometriomas (75%). The presence of multilocularity or hyperechoic wall foci further increased the positive likelihood ratio to 48, allowing the identification of 18 endometriomas (45%).

CONCLUSION

An adnexal mass with diffuse low-level internal echoes and absence of particular neoplastic features is highly likely to be an endometrioma if multilocularity or hyperechoic wall foci are present. A patient with a mass with diffuse low-level internal echoes and other US features may benefit from additional imaging.

Scanning the future--ultrasonography as a reproductive management tool for dairy cattle

Application of transrectal real-time ultrasonography as a research tool to study bovine reproduction represents a technological breakthrough that has revolutionized our understanding of reproductive biology in cattle. The widespread adoption and use of ultrasonography for routine reproductive examinations of dairy cattle by bovine practitioners is the next contribution this technology will make to the dairy industry. Assessment of pregnancy status and fetal viability early postbreeding to identify cows that fail to conceive improves reproductive efficiency by decreasing the interval between artificial insemination services and increasing artificial insemination service rate. Early identification of cows carrying twin fetuses will allow for implementation of differential management strategies to abrogate negative effects of twinning during the periparturient period once such strategies have been developed. Ovarian and uterine pathologies not accurately detected via rectal palpation can easily be visualized by ultrasound, and appropriate therapies can be implemented. Determination of fetal sex in utero is useful when coupled with a management decision that justifies the expense of fetal sexing. Development of integrated reproductive management systems that combine ultrasound with new and existing reproductive technologies will further enhance the practical applications of ultrasonography. Development of Extension education programs to train bovine practitioners to use ultrasound for routine reproductive examinations is a critical step toward rapid implementation of this technology into the dairy industry.

Diagnosis of acute appendicitis in pregnant women: value of sonography

OBJECTIVE

The diagnosis of acute appendicitis in pregnant women often is difficult to make on the basis of clinical findings, and radiologic examination is limited because of the potentially hazardous effects of radiation. This study was done to assess the value of sonography in the diagnosis of acute appendicitis in pregnant women.

SUBJECTS AND METHODS

We obtained sonograms in 45 pregnant women with clinically suspected acute appendicitis. Our sonographic technique included graded-compression scanning. The left lateral decubitus position was used in the third trimester of gestation. The sonographic criterion for the diagnosis of acute appendicitis was visualization of an incompressible appendix with a maximal diameter greater than 7 mm. We correlated the sonographic findings with the surgical findings in 22 cases and with the results of clinical follow-up in 23 cases.

RESULTS

Sonography could not be used to make the diagnosis in three (7%) of 45 patients because the size of the gravid uterus prevented use of the graded-compression technique. These three patients were in the third trimester of pregnancy (greater than 35 weeks' gestation). Sonographic findings were used as a basis for diagnosis in 42 cases. Acute appendicitis was diagnosed on the basis of sonograms in 16 patients, and in all but one of these patients, acute appendicitis was confirmed by surgical and pathologic findings. In the 42 cases in which the imaging findings indicated the diagnosis, the overall sensitivity of sonography was 100%, the specificity was 96%, and the accuracy was 98%.

CONCLUSION

Our experience suggests that graded-compression sonography is a valuable procedure for detecting acute appendicitis in pregnant women despite technical difficulty in performing it during the third trimester of pregnancy.

The polycystic ovary post-rotterdam: a common, age-dependent finding in ovulatory women without metabolic significance

INTRODUCTION

The age-specific prevalence of polycystic ovaries (PCO), as defined by the Rotterdam criteria, among normal ovulatory women, has not yet been reported. It is also uncertain whether these women differ from their peers in the hormonal or metabolic profile.

METHODS

A total of 262 ovulatory Caucasian women aged 25-45 yr, enrolled in a community-based ovarian aging study (OVA), underwent transvaginal ultrasound assessment of ovarian volume and antral follicle count (AFC) in the early follicular phase and were categorized as to whether they met the Rotterdam definition of PCO by AFC (≥12 in one ovary) and/or by volume (>10 cm(3) for one ovary). The effect of age on prevalence of PCO was assessed. Serum hormones and metabolic measures were compared between women meeting each element of the Rotterdam criterion and those without PCO using age-adjusted linear regressions.

RESULTS

The prevalence of PCO by AFC was 32% and decreased with age. Those with PCO by AFC had lower FSH; higher anti-Müllerian hormone, estrone, dehydroepiandrostenedione sulfate, and free androgen index; and slightly higher total testosterone than those without PCO. However, slightly higher body mass index and waist circumference were the only metabolic differences. Women with PCO by volume had higher anti-Müllerian hormone and free androgen index but did not differ in any other hormonal or metabolic parameter.

DISCUSSION

PCO is a common, age-dependent finding among ovulatory women. These women lack the metabolic abnormalities seen in PCO syndrome. Isolated PCO in an ovulatory woman is not an indication for metabolic evaluation.

Serum vascular endothelial growth factor concentrations and ovarian stromal blood flow are increased in women with polycystic ovaries

The aim of this study was to determine basal serum vascular endothelial growth factor (VEGF) concentrations and Doppler blood flow changes within the ovarian stroma of women with polycystic ovaries (PCO) and women with normal ovaries. Pulsed and colour Doppler blood flows within the ovarian stroma were recorded, and serum VEGF concentrations measured, in the early follicular phase (days 2-3 of a menstrual cycle) in 60 women undergoing ovarian stimulation for in-vitro fertilization. 36 women had normal ovaries, 14 women had PCO as seen on pelvic ultrasound examination and 10 had polycystic ovarian syndrome (PCOS). Mean+/-SD serum VEGF concentrations were significantly higher (P < 0.001) in women with PCO and PCOS (3.4+/-0.7 and 3.2+/-0.66 ng/ml respectively) compared with women with normal ovaries (2.3+/-0.5 ng/ml). Mean peak systolic blood flow velocity (PSV) and time-averaged maximum flow velocity (TAMXV) were significantly higher (P < 0.001) in women with PCO and PCOS compared with women with normal ovaries. The mean PSV were 15+/-4 and 16+/-4 cm/s in women with PCO and PCOS respectively, compared with 9+/-2 cm/s in women with normal ovaries. The TAMXV were 9+/-3 and 11+/-3 cm/s in women with PCO and PCOS respectively compared with women with normal ovaries (5.8+/-1.5 cm/s). Serum VEGF concentrations were positively correlated with PSV (r=0.44, P=0.001) and TAMXV (r=0.45, P < 0.000) in all three groups of women. Higher serum concentrations of VEGF in women with PCO and PCOS may relate to the increased vascularity that underlies the increased blood flow demonstrated by Doppler blood flow velocity measurements in these women. The results may explain the higher risk of ovarian hyperstimulation syndrome in programmes of ovarian stimulation in patients with PCO compared with those with normal ovaries.

Sonographic whirlpool sign in ovarian torsion

OBJECTIVE

To describe an additional maneuver during sonography for ovarian torsion and to assess its diagnostic value.

METHODS

During a period of about 2 years 6 months, 21 patients with acute or intermittent lower abdominal pain who had an ovarian mass and an extraovarian mass suggestive of a twisted vascular pedicle on sonography were studied. The gray scale features of the ovarian mass were recorded. The presence of a twisted vascular pedicle was evaluated. Its location and gray scale features were noted. The probe was moved to and fro along the axis of the pedicle, and the presence of a whirlpool sign was evaluated. The same procedure was repeated on a color Doppler study.

RESULTS

A twisted pedicle with a whirlpool sign was seen in all 21 patients. Ovarian torsion was confirmed in all 20 patients who underwent surgery. The last patient was pregnant and did well with conservative treatment. Hemorrhagic infarction or early hemorrhage of the ovary or ovarian mass was seen in all 8 patients who did not show flow in the twisted pedicle on the color Doppler study and in 2 patients who showed flow in the artery in the proximal part of the pedicle. Of the 6 patients who showed flow in the artery alone, the ovary was removed in 4, and all had hemorrhagic infarction or early hemorrhage. The ovary was viable in all 5 patients in whom flow was seen in both the artery and vein.

CONCLUSIONS

A positive whirlpool sign in the twisted vascular pedicle of the ovary is the most definitive sign of ovarian torsion. Absence of blood flow in the twisted pedicle and visualization of the flow in the artery alone are predictive of nonviability of the ovary.

Surgical indications in antenatally diagnosed ovarian cysts

The antenatal diagnosis of ovarian cysts poses a therapeutic dilemma because the natural history of these lesions is not well known. A retrospective review from 1980 to 1989 showed 29 ovarian cysts in 27 patients diagnosed by prenatal ultrasonography performed between 28 and 36 weeks of gestation. Nineteen cysts were initially observed. Eleven cysts resolved (diameter less than 2 cm), three are decreasing, three were lost to follow-up, and two underwent resection. Eight patients underwent surgical exploration immediately following birth. The diagnosis of benign ovarian cyst was confirmed histologically in all cases. A review of the literature showed an additional 230 cases of antenatally diagnosed ovarian cysts. Simple cysts of the ovary tend to resolve spontaneously and, therefore, may be treated conservatively. Serial ultrasonography allows accurate diagnosis and long-term assessment of ovarian cysts in the neonate and may prevent unnecessary oophorectomy. Patients with cysts larger than 4 cm may be candidates for percutaneous aspiration, or should undergo removal of the cyst because of a significant risk of torsion. Complex cystic masses, symptomatic ovarian cysts, and cysts that do not resolve should be removed.

Adnexal Masses in Pregnancy: Surgery Compared With Observation

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The malignant potential of small cystic ovarian tumors in women over 50 years of age

OBJECTIVE

The aim of this study was to determine the risk of malignancy in cystic ovarian tumors < 10 cm in diameter in asymptomatic postmenopausal women or women >or =50 years of age.

METHODS

All cystic ovarian tumors detected by transvaginal sonography screening in asymptomatic postmenopausal women or women > or =50 years of age were evaluated with respect to size and morphology. Histology was recorded on all tumors removed surgically. Follow-up data were available both on patients undergoing surgery and on those who elected to be followed without operative intervention.

RESULTS

Unilocular cystic tumors were detected in 256 of 7705 patients (3.3%). All tumors were < 10 cm in diameter and 90% were < 5 cm in diameter. One hundred twenty-five of these cysts (49%) resolved spontaneously within 60 days and 131 (51%) persisted. Forty-five patients with persisting ovarian cysts underwent operative removal of these tumors. Thirty-two patients had ovarian serous cystadenomas, and the remainder had a variety of benign lesions. There were no cases of ovarian carcinoma in this group. Eighty-six patients with unilocular cystic ovarian tumors were followed at 3- to 6-month intervals without surgery, and none have developed ovarian cancer. Complex cystic ovarian tumors were detected in 250 patients (3.2%). All tumors were < 10 cm in diameter and 89% were < 5 cm in diameter. One hundred thirty-five (55%) resolved spontaneously within 60 days, and 115 (45%) persisted. One hundred fourteen of these patients underwent operative tumor removal. Seven patients had ovarian carcinoma, 1 had primary peritoneal cancer, and 1 had metastatic breast cancer to the ovary.

CONCLUSION

Unilocular ovarian cysts < 10 cm in diameter in asymptomatic postmenopausal women or women > or =50 years of age are associated with minimal risk for ovarian cancer. In contrast, complex ovarian cysts with wall abnormalities or solid areas are associated with a significant risk for malignancy. These data are important in determining optimal strategies for operative intervention in these patients.

Preoperative assessment of unilocular adnexal cysts by transvaginal ultrasonography: a comparison between ultrasonographic morphologic imaging and histopathologic diagnosis

OBJECTIVE

Our purpose was to evaluate the risk of malignancy in surgically removed ovarian cysts that were characterized before the operation as unilocular according to transvaginal ultrasonography.

STUDY DESIGN

This prospective analysis included 927 premenopausal women and 377 postmenopausal women operated on at 2 European university hospitals between January 1992 and December 1997. On the basis of ultrasonographic findings the cysts were characterized either as echo-free, without solid parts or papillary formations (group 1), or as having echogenic cyst content, with solid parts or papillary formations (group 2). Ultrasonographic and macroscopic appearances of the cysts were compared with histopathologic diagnosis.

RESULTS

In group 1, in premenopausal women 3 of 413 cysts (0.73%) proved to be borderline or malignant, and in postmenopausal women 4 of 247 cysts (1.6%) proved to be borderline or malignant. The figures for cysts in group 2 were 11 of 514 cysts (2.1%) and 13 of 130 cysts (10.0%), respectively. It was not possible to differentiate by transvaginal ultrasonography between benign, borderline, and malignant cysts when solid parts or papillary formations were visualized.

CONCLUSIONS

This study confirmed that the risk of malignancy associated with unilocular echo-free cysts (group 1) was low. Serial ultrasonographic follow-up should therefore be the standard procedure with unilocular echo-free cysts <50 mm in diameter. In cysts with a mean diameter of >50 mm, papillary formations or solid parts may be missed by transvaginal ultrasonography. The risk for malignancy in cysts containing papillary formations or solid parts (group 2) was 3 to 6 times higher than that in unilocular echo-free cysts.

The management of fetal ovarian cysts

BACKGROUND/PURPOSE

Ovarian torsion causing the loss of an ovary represents the most common complication of fetal ovarian cysts and occurs more frequently before than after birth. Thus, treatment of fetal simple ovarian cysts should be performed antenatally; however, criteria for prenatal decompression still need to be evaluated. Previous experience of the authors showed that large simple cysts have a poor outcome, whereas preliminary attempts of their "in utero" aspiration were all successful and uneventful. The authors evaluated the outcome of fetal simple ovarian cysts after prenatal aspiration and considered criteria for this procedure. The outcome of cysts showing a prenatal ultrasound pattern of torsion also was studied.

METHODS

This prospective study includes 73 ovarian cysts (48 simple, 25 showing torsion) diagnosed in 72 fetuses from June 1992 to June 1999, and followed up until spontaneous resolution or surgery. Prenatal aspiration was performed in the case of simple cysts >/=5 cm in diameter. The outcome of these cysts was compared with that of similar cysts not aspirated in the authors previous study (X(2). Cysts with an US pattern of torsion persisting at birth were operated on. The outcome of simple cysts less than 5 cm and cysts with a prenatal ultrasound appearance of torsion also was evaluated.

RESULTS

Prenatal decompression was performed without any complications in 14 cases: 12 (86%; 95% CI: 0.68 to 1.00) regressed subsequently; 2 (14%; 95% CI: 0.00 to 0.32) showed torsion postnatally. This outcome is significantly better than that of similar cysts not aspirated in the authors' previous study(10) (P =.0002). Among the 34 simple cysts less than 5 cm, 26 (76%; 95% CI: 0.62 to 0.90) resolved spontaneously; 8 (24%; 95% CI: 0.10 to 0.38) had complications, 7 of which showing torsion (diameter at evidence of torsion, 4.4 cm [median]; range, 3.3 to 5.2 cm). Among the 34 cysts showing torsion (25 with initial US pattern of torsion + 9 subsequently complicated simple cysts), 24 (71%; 95% CI: 0.56 to 0.86) required oophorectomy; 9 (26%; 95% CI: 0.11 to 0.41) spontaneously disappeared at ultrasound, one of which required surgery for intestinal obstruction secondary to adhesion of a necrotic ovary; one patient (3%; 95% CI: 0.00 to 0.09) was lost to follow-up.

CONCLUSIONS

Prenatal aspiration of ovarian cysts appears effective and safe: a "cutoff" of 4 cm should be investigated. Cysts with ultrasound pattern of torsion persisting postnatally require surgery; options for their management, when sonographically disappearing and asymptomatic, need to be investigated.

The diagnosis of endometriomas using colour Doppler energy imaging

We studied the role of colour Doppler energy (CDE) (or power Doppler) imaging in the differentiation between endometriomas and other adnexal masses in premenopausal non-pregnant women. A total of 170 consecutive patients with persistent adnexal masses was submitted to B-mode transvaginal ultrasonography associated with CDE imaging evaluation. Plasma concentrations of CA125 were measured before surgery. Using CDE imaging evaluation of vessel distribution, the occurrence of one of the following findings was considered to indicate the likely presence of endometrioma: (i) a round-shaped homogeneous hypoechoic 'tissue' of low-level echoes without papillary proliferations associated with 'poor' vascularization; (ii) a round-shaped homogeneous hypoechoic 'tissue' of low-level echoes with an echogenic portion in which no flow was detected. The overall agreement between the test result and the actual outcome was calculated using the k index. The CDE imaging evaluation was more accurate in the diagnosis of endometriomas compared with B-mode ultrasonography alone (k = 0.88 and 0.80 respectively). According to the logistic regression equation obtained, the probability of the presence of endometrioma varied between a minimum of 1.4% for patients with no risk factors to a maximum of 95.6% for patients with two risk factors (CDE result and value of CA125 >25 IU/ml).

The management of a persistent adnexal mass in pregnancy

OBJECTIVE

Our purpose was to evaluate the pathologic features and outcome of pregnancy complicated by a persistent adnexal mass that was managed conservatively or with surgical intervention.

STUDY DESIGN

A review was performed of patients who were seen with an adnexal mass in pregnancy from January 1988 to June 1994. We included patients with simple or complex masses > or = 6 cm that were persistent on ultrasonographic evaluation. We excluded cysts that spontaneously resolved by 16 weeks' gestation and those diagnosed after delivery.

RESULTS

Thirty-one patients of 43,372 deliveries were identified with persistent adnexal masses that met the above criteria. Nineteen (59%) of these patients had operative intervention, whereas 12 (41%) were managed conservatively. Of the patients who had surgery, nine had functional cysts, six had mature cystic teratomas, and four had other benign cysts. Complications within 12 hours of surgery included one spontaneous abortion and one patient with rupture of membranes. Twelve patients were managed nonsurgically. Seven patients had conservative management, whereas five patients had percutaneous drainage of simple cysts (negative results on cytologic study) that were symptomatic.

CONCLUSIONS

Although the incidence of ovarian cancer in pregnancy is low, the incidental finding of an adnexal mass in pregnancy is becoming more common. Because complications of abdominal surgery are increased in pregnancy, surgical management of this prenatal complication needs to be reconsidered. Our data support a randomized clinical study to determine optimal management of an adnexal mass in pregnancy.

Sonographic pitfalls in the diagnosis of enteric duplication cysts

OBJECTIVE

The sonographic double wall sign has been well described in the literature and is often the cornerstone in suggesting the diagnosis of an enteric duplication cyst. We report two cases with this sign that were erroneously diagnosed as enteric cysts and a third case without this sonographic feature that proved to be a duplication cyst. Histologic analysis of the specimens helps explain the cause of the sonographic pitfalls.

CONCLUSION

The potential sonographic visualization of the split hypoechoic muscularis propria layer or identification of all five layers will increase the specificity in making the sonographic diagnosis of duplication cyst.

Transvaginal sonographic ovarian findings in a random sample of women 25-40 years old

OBJECTIVE

To investigate the occurrence rate of adnexal lesions in premenopausal women.

METHODS

A random sample of women 25-40 years old was invited to undergo a transvaginal ultrasound examination, and 335 women were examined. The criteria used to define an adnexal lesion were either a cystic lesion with its largest diameter of at least 25 mm within the pelvic region, or the appearance of solid parts in any lesion regardless of size.

RESULTS

Adnexal lesions were found in 26/335 cases, (7.8%) (95% confidence interval (CI), +/- 2.9%). The occurrence rate of ovarian cysts was 22/335 (6.6%) (95% CI, +/- 2.7%). There were no differences between the women with or without ovarian cysts related to age, smoking habits, parity or body mass index. At follow-up 3 months later, 18 of the 22 (82%) cysts had disappeared (95% CI, +/- 16%). Women using progesterone contraception (either oral contraception or an intrauterine device with levonorgestrel) had a significantly higher relative risk of 2.7 (95% CI, 1.1-6.9) of functional cysts as compared to women with natural cycles. Polycystic ovaries were found in 10.2% (95% CI, +/- 4.2%) of the women not using any hormonal contraception. The mean volumes of the polycystic ovaries were significantly larger compared to those in natural cycles.

CONCLUSION

Adnexal lesions are common in asymptomatic women in the age group 25-40 years, but four out of five ovarian cysts disappeared spontaneously after 3 months. The ultrasound appearance of the cyst, the woman's family history and her own feelings must be considered if a persisting cyst is to be surgically removed or followed by repeated transvaginal ultrasound.

Chocolate cysts from ovarian follicles

OBJECTIVE

To study the development of chocolate cysts by serial transvaginal ultrasonographic tracking of ovarian follicles.

DESIGN

Retrospective study.

SETTING

Department of Obstetrics and Gynaecology, Sunderland Royal Hospital, Sunderland, United Kingdom.

PATIENT(S)

We reviewed case notes of all patients who underwent laparoscopy for diathermy to endometriosis/ovarian diathermy/aspiration of ovarian cysts from 1989 to 1998. Twelve women with histories of infertility and proven chocolate cysts with documented ultrasonographic findings were included in the study.

INTERVENTION(S)

Serial ultrasonographic tracking of ovarian follicles in the cycle leading to the development of the chocolate cysts, followed by ultrasonographic tracking of cysts for 3 months and laparoscopy.

MAIN OUTCOME MEASURE(S)

Development and formation of chocolate cysts.

RESULT(S)

The diagnosis of chocolate cysts was confirmed laparoscopically in all patients and histopathologically in four. Ultrasound confirmed that they had all developed from follicles.

CONCLUSION(S)

Chocolate cysts can develop from ovarian follicles.

Should we be examining the ovaries in pregnancy? Prevalence and natural history of adnexal pathology detected at first-trimester sonography

OBJECTIVE

To assess the prevalence and natural history of ovarian pathology in pregnancy.

METHODS

Three thousand consecutive pregnant women presenting before 14 weeks' gestation at the early pregnancy unit at St George's Hospital, London, underwent ultrasound examination during which both ovaries were visualized. Women found to have a simple ovarian cyst with a minimum diameter > or =25 mm or a complex ovarian cyst of any size were included in the study. They were followed up with ultrasound scans every 4-6 weeks until either resolution of the ovarian cyst occurred, intervention was required or the pregnancy was concluded. If the cyst persisted at 20 weeks' gestation, these women were rescanned 6 weeks after conclusion of the pregnancy. Women were managed expectantly throughout their pregnancy.

RESULTS

One hundred and sixty one women with a total of 166 cysts were included for analysis. At presentation, 43.7% of the women were asymptomatic and 56.3% had pain and/or vaginal bleeding. The mean gestational age at presentation was 53 (range, 28-98) days, the mean maternal age was 30 (range, 17-42) years, and the mean ovarian cyst diameter was 48 (range, 12-115) mm. The first-trimester pregnancy diagnoses were 106 intrauterine pregnancies, 40 miscarriages, five ectopic pregnancies, three pregnancies of unknown location and seven terminations of pregnancy. The sonographic features of the ovarian cysts included: 117 simple and anechoic, 21 hemorrhagic, 16 with mixed echogenicity, seven with a ground-glass appearance, three solid/cystic with papillary projections and two with low-level echoes. One hundred and nineteen (71.7%) of the cysts resolved spontaneously and were presumed to be physiological, 40 (24.1%) persisted and seven (4.2%) required intervention, four of these as an emergency because of pain. There was one case of borderline malignancy and no cases of malignancy. Five (3.0%) of the cysts underwent torsion. Only 0.13% (4/3000) of all women who initially presented to our unit required acute intervention during their pregnancy.

CONCLUSIONS

The majority of cysts detected in early pregnancy are physiological and resolve. Very few persist and intervention during the pregnancy is rarely indicated. The expectant management of ovarian cysts detected in the first trimester is safe and should be encouraged. Examining the ovaries in the first trimester is of limited value.

Prevalence of simple adnexal cysts in postmenopausal women

This prospective study was performed with ultrasound (US) to determine the prevalence of unilocular, nonseptated adnexal cysts ("simple cysts") in healthy postmenopausal women and the relationship between cyst occurrence and both hormone replacement and length of time since onset of menopause. Transabdominal and transvaginal US were performed on 149 volunteers aged 50 years or older. Patients were classified according to hormone regimens (no hormones, unopposed estrogen, continuous daily estrogen and progesterone, and sequential estrogen and progesterone) and time since onset of menopause (less than 5 years, 5-10 years, and greater than 10 years). Simple adnexal cysts were found in 22 women with the aid of transvaginal and/or transabdominal US, yielding a relative frequency of 14.8% +/- 5.7% and a prevalence of 14,800 patients with cysts per 100,000 patients. No statistical relationship was found between cyst frequency and type of hormone replacement or length of time since onset of menopause.

Prevalence, incidence, and natural history of simple ovarian cysts among women >55 years old in a large cancer screening trial

OBJECTIVE

The purpose of this study was to measure the occurrence and natural history of simple ovarian cysts in a cohort of older women.

STUDY DESIGN

Simple cysts were ascertained among a cohort of 15,735 women from the intervention arm of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial through 4 years of transvaginal ultrasound screening.

RESULTS

Simple cysts were seen in 14% of women the first time that their ovaries were visualized. The 1-year incidence of new simple cysts was 8%. Among ovaries with 1 simple cyst at the first screen, 54% retained 1 simple cyst, and 32% had no cyst 1 year later. Simple cysts did not increase risk of subsequent invasive ovarian cancer.

CONCLUSION

Simple ovarian cysts are fairly common among postmenopausal women, and most cysts appear stable or resolve by the next annual examination. These findings support recent recommendations to follow unilocular simple cysts in postmenopausal women without intervention.

Adnexal masses: MR imaging observations at 1.5 T, with US and CT correlation

To assess the role of 1.5-T magnetic resonance (MR) imaging in evaluation of the adnexa, 43 consecutive examinations that revealed 61 adnexal masses were retrospectively reviewed. T1- and T2-weighted images in coronal, axial, and/or sagittal planes were included. Available ultrasound (US) (n = 30) and/or computed tomographic (CT) (n = 9) scans were then correlated with the MR images. On T2-weighted images at least part of all adnexal masses was of higher signal intensity than surrounding muscle and adipose tissue, and therefore the adnexal masses were best seen with these sequences. T1-weighted imaging improved tissue characterization by revealing signal characteristics of fat in teratomas and characteristics of blood in endometriomas or hemorrhagic cysts, pelvic inflammatory disease, ovarian carcinomas, serous cystadenomas, and teratomas. MR imaging provided additional information or increased diagnostic confidence in 25 of 30 patients who underwent US or CT. MR imaging is a promising problem-solving modality after US in the study of adnexal abnormalities.