Ultrasonography and color Doppler-based triage for adnexal masses to provide the most appropriate surgical approach

doi:10.1016/j.ajog.2004.09.002

American Journal of Obstetrics and Gynecology

Volume 192, Issue 2, February 2005, Pages 401-406

https://doi.org/10.1016/j.ajog.2004.09.002 Get rights and content

Objective

This study was undertaken to identify whether ultrasonography with color Doppler can identify and triage the patients with adnexal masses to the most appropriate surgical approach.

Study design

Four hundred fifty-three pelvic masses were included in the study and underwent ultrasonography before surgical treatment for adnexal masses. Masses that showed a typical benign pattern at B-mode ultrasonography (very low risk of malignancy) were treated by conventional laparoscopy without further evaluation. Masses that extended above the umbilicus were consider at very high risk and treated by laparotomy. All other adnexal masses were evaluated with power Doppler. Masses with central vascularization (high risk of malignancy) were submitted to laparotomy or laparoscopy with additional tools, whereas masses with peripheral or absent flow (low risk of malignancy) were submitted to conventional laparoscopy.

Results

Among 284 very low-risk, 32 low-risk, 46 high-risk, 91 very high-risk masses, the rate of malignant masses were 0%, 0%, 52%, and 78%, respectively. The use of color Doppler increases the diagnostic accuracy of B-mode ultrasonography in the diagnosis of adnexal malignancies because of a significantly higher specificity (0.91 vs 0.82, P < .001).

Conclusion

The evaluation of vessel distribution by color Doppler seems a safe diagnostic procedure, permitting to treat by laparoscopy 91% of benign masses.

Section snippets

Material and methods

The study, performed at Department of Obstetrics and Gynecology of University of Cagliari, Italy, included 424 women who underwent transvaginal ultrasonography before elective surgical treatment for adnexal masses. The study was approved by our Institutional Review Board and all participating patients gave their informed consent. The average ± SD age of the study population was 39 ± 15 years (range, 14-79 years). Three hundred twenty-three patients (76%) were premenopausal, and 101 (24%) were

Results

Four hundred fifty-three adnexal masses diagnosed in 424 patients were included in the study. Three hundred fifty-eight (79%) masses were benign and 95 (21%) were malignant. Thirty-four (36%) of the malignant masses were in the premenopausal group and 61 (64%) were in the postmenopausal group. Of the 95 ovarian carcinomas, 20 were low-malignancy potential tumors, 18 were stages I and II according the FIGO, and 38 were stages III and IV. Five masses were ovarian metastases of a carcinoma of the

Comment

The use of color Doppler to increase the specificity of B-mode ultrasonography in the diagnosis of ovarian cancer is a safe diagnostic procedure with a very low risk of false-negative cases.¹⁴ In the current study, we propose in a large study population a new algorithm for the preoperative assessment of adnexal masses that is based on the use of color Doppler as a secondary test after B-mode evaluation. This B-mode evaluation remains the key of this approach because masses with a typical benign

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In addition, with the development of ultrasound technology, higher-resolution images can be obtained, which enables defining the characteristics of ovarian masses with higher accuracy. Considering the high predictive power of ultrasound for ovarian malignancy in non-pregnant patients [14–17], ovarian scoring systems using ultrasound may also be useful to determine the risk of malignancy in pregnant women. However, to our knowledge, there is a paucity of information regarding the accuracy of ultrasound-based ovarian mass scoring systems in pregnant women.
The purpose of this study is to compare ultrasonographic ovarian mass scoring systems in pregnant women.
This multicenter study included women with an ovarian mass during pregnancy who were evaluated using ultrasound and underwent surgery in 11 referral hospitals. The ovarian mass was evaluated and scored using three different scoring systems(International Ovarian Tumor Analysis Assessment of Different NEoplasias in the adnexa[IOTA ADNEX], Sassone, and Lerner). The final diagnosis was made histopathologically. Receiver operating characteristic(ROC) curves were generated for each scoring system.
During the study period, 236 pregnant women underwent surgery for an ovarian mass, including 223 women(94.5%) with a benign ovarian mass and 13 women(5.5%) with a malignant ovarian mass. Among 10 ultrasound image findings, six findings were different between benign and ovarian masses(maximal diameter of mass, maximal diameter of solid mass, wall thickness of mass, inner wall structure, thickness of septations, and papillarity). In all three scoring systems, the ovarian mass scores were significantly higher in malignant masses than in benign masses, with the highest area under the ROC curve(AUROC) in the Sassone scoring system(AUROC: 0.831 for Sassone, 0.710 for Lerner vs 0.709 for IOTA ADNEX; p < 0.05, between the Sassone and Lerner/ IOTA ADNEX). A combined model was developed with the six different ultrasound findings, and the AUROC of the combined model was 0.883(p = not significant between the combined model and Sassone).
In pregnant women, malignant ovarian tumors can be predicted with high accuracy using either the Sassone scoring system or the combined model.
Correlation of cytokines and inducible nitric oxide synthase expression with prognostic factors in ovarian cancer
2014, Immunology Letters
Citation Excerpt :
It also delivers important information regarding tumor size and content [3]. In addition, a transvaginal ultrasound image associated with color Doppler can increase ultrasound specificity, enabling an assessment of vascular tumor and blood flow conditions [4]. Notwithstanding these advantages, early diagnosis of ovarian cancer by ultrasound is uncommon due to their low prevalence in the general population.
The study related the immunohistochemical staining of cytokines (IL2, IL5, IL6, IL8, IL10, and TNF-alpha), and iNOS staining with clinical and pathological parameters of patients with primary ovarian malignancy. We prospectively evaluated 40 patients who underwent surgical treatment in accordance with pre-established criteria and later confirmed diagnosis of ovarian cancer. Immunohistochemistry study for cytokines (IL2, IL5, IL6, IL8, IL10, TNF-alpha) and iNOS was performed. The evaluation of prognostic factors was performed using the Fisher's exact test. The significance level was less than 0.05. Histological grade 1 was significantly correlated with strong intensity for TNF-α (p = 0.0028). In addition, early stages showed strong expression intensity of TNF-α, but this was at the limit of significance (p = 0.0525). Strong staining immunohistochemical IL5 was related to disease-free survival less than or equal to 24 months, suggesting that a factor of poor prognosis, but there was no statistical significance (p = 0.1771). There was no statistical significance in relation at other cytokines studied. Therefore, immunohistochemical staining in strong intensity for TNF-α was related to histological grade 1 and early stages of ovarian cancer in our sample of patients.
Pelvic Imaging in Reproductive Endocrinology
2013, Yen and Jaffe's Reproductive Endocrinology: Seventh Edition
Borderline ovarian tumors: Features and controversial aspects
2013, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Their absence certainly argues for a markedly benign cyst and leads us to prefer a laparoscopic approach. Finally we considered the values of tumor markers, whose negativity generally points to a benign cyst taking into account the relative sensitivity and specificity [13], especially if associated with color doppler ultrasound evaluation [14]. These factors suggest that the removal of a benign simple cyst is best achieved through a laparoscopy, which yields the same result as a laparotomy but requires smaller incisions, is less invasive, and allows a rapid recovery and better aesthetic results.
To investigate features and controversial aspects of the borderline ovarian tumor (BOT), a neoplasm with favorable prognosis representing 10–15% of epithelial ovarian tumors.
: We retrospectively studied all patients treated at our institution from 2000 to 2010 taking into account the age, the stage, the type of surgery, the tumor size, the symptoms, the pre- and post-intervention tumor marker levels (CA125, CA19.9, CA15.3 and CEA), the presence of recurrence, the overall survival (OS), the progression-free survival (PFS).
A total of 43 patients were identified. The median age was 49 years (range: 15–82 years). The most frequent FIGO stage was IA (74% of the cases) with a prevalence of serous histotype, and 49% of the patients were asymptomatic. The CA125 level was abnormal in 55% of the patients before surgery, returning to the normal range in all cases after tumor removal. The PFS was 96% and 77% at five and sixty months respectively.
The BOT is closer to a benign than to a malignant tumor in the early stages, when confined to the ovary (IA and IB). In these stages conservative surgery is safe and advisable for women seeking offspring. In the other stages the need for a careful and long-term follow-up arises. CA125, despite its modest sensitivity and specificity, has a role in the follow-up of BOT.
Imagery of the borderline epithelial ovarian tumors
2012, Imagerie de la Femme
Les tumeurs ovariennes épithéliales frontières représentent un groupe spécifique de tumeurs présentant des critères de malignité en règle localisés à l’ovaire. Elles sont essentiellement constituées par les tumeurs borderline séreuses et mucineuses et surviennent fréquemment chez des femmes en période d’activité génitale. Ces deux sous-groupes présentent des caractéristiques macroscopiques évocatrices permettant d’évoquer leur nature spécifique en préopératoire et d’adapter le geste opératoire. En échographie et IRM, kyste uni- ou biloculaire avec végétations endo- et/ou exokystiques hypervascularisées en Doppler énergie et en signal intermédiaire en séquences IRM pondérées T2, hypersignal en diffusion associé à une prise de contraste de type 2 évoque des tumeurs séreuses frontières. De même, kystes multiloculaires séparés par des cloisons épaisses et irrégulières avec loculi de signaux différents évoquent des tumeurs mucineuses frontières.
Borderline epithelial ovarian tumors represent a specific group of ovarian tumors with malignant features mainly localized within the ovaries. Serous and mucinous ovarian tumors are the most frequent subtypes of borderline ovarian tumors (BOT). These tumors are especially encountered in women during reproductive years. Suggestive macroscopic features are present allowing suspecting their nature preoperatively. At ultrasonography, the presence of uni- or bilocular cysts containing endocystic and/or exophytic vegetations displaying central vessels at power Doppler analysis is suggestive serous BOT. At MR imaging, these vegetations display intermediate signal intensity on T2- and high signal intensity on diffusion-weighted MR images, in association with curve type 2 on dynamic contrast-enhanced MRI. At ultrasonography and MRI, the presence of multilocular cysts containing loculi of different signal intensity and numerous tethered irregular septa are suggestive of mucinous BOT.
Contribution of power Doppler blood flow mapping to gray-scale ultrasound for predicting malignancy of adnexal masses in symptomatic and asymptomatic women
2011, European Journal of Obstetrics and Gynecology and Reproductive Biology
To determine the contribution of power Doppler blood flow mapping to gray-scale ultrasound for predicting malignancy of adnexal masses in symptomatic and asymptomatic women.
One thousand and ninety-four women with adnexal mass were included. Patients were divided into three groups according to clinical complaints: asymptomatic (group A), patients with symptoms non-suspicious of ovarian cancer (group B) and patients with symptoms suspicious of ovarian cancer (group C). All patients underwent transvaginal power Doppler ultrasound prior to surgery. Any mass in which the echo architecture at B-mode ultrasound was not highly suggestive of benign histology was categorized as questionable. In these cases power Doppler was performed as the second step. Definitive histological diagnosis was used as the standard reference. Sensitivity, specificity, positive likelihood ratio (+LR) and negative likelihood ratio (−LR) were calculated for B-mode diagnosis and B-mode plus Doppler in each group.
In group A, B-mode was significantly more sensitive (98.1%) than Doppler ultrasound (91.3%) (p < 0.01). In group B Doppler ultrasound (97.0%) was more specific than B-mode ultrasound (92.2%) (p < 0.001). In group C Doppler ultrasound (84.0%) was more specific than B-mode ultrasound (68.0%) (p < 0.001). Positive LR was significantly higher after Doppler evaluation in all groups (30.5 vs 12.8 in group A, 33.2 vs 12.8 in group B and 6.0 vs 3.1 in group C).
The diagnostic performance of B-mode and power Doppler ultrasound is different depending on patients’ complaints.

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: Supported in part by Assessorato Igiene e Sanità, Regione Autonoma della Sardegna.

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General Obstetrics and Gynecology: GynecologyUltrasonography and color Doppler-based triage for adnexal masses to provide the most appropriate surgical approach

Objective

Study design

Results

Conclusion

Section snippets

Material and methods

Results

Comment

Obstet Gynecol

Am J Obstet Gynecol

BJOG

Obstet Gynecol

Gynecol Oncol

Am J Obstet Gynecol

Am J Obstet Gynecol

Gynecol Oncol

Best Pract Res Clin Obstet Gynaecol

BJOG

Laparoscopic management of adnexal masses: a gold standard?

Curr Opin Obstet Gynecol

Management of adnexal masses: role and risk of laparoscopy

Semin Surg Oncol

General Obstetrics and Gynecology: Gynecology
Ultrasonography and color Doppler-based triage for adnexal masses to provide the most appropriate surgical approach