B. Virgilio

Diagnostic value of transvaginal ‘tenderness-guided’ ultrasonography for the prediction of location of deep endometriosis

BACKGROUND The aim was to evaluate the diagnostic accuracy of transvaginal tenderness-guided ultrasonography in the identification of location of deep endometriosis. METHODS Consecutive women scheduled for surgery in our Department for clinically suspected endometriosis were included in this prospective study. All women underwent modified transvaginal ultrasonography using a stand-off in the week before surgery, which also evaluated the painful sites evocated by a gentle pressure of the probe. Five locations of deep endometriosis were considered: vaginal walls, rectovaginal septum, rectosigmoid involvement, uterosacral ligaments and anterior compartment (anterior pouch and/or bladder). Sensitivity, specificity and likelihood ratios (LR+/-) were calculated with 95% confidence intervals (CIs). RESULTS We included 88 women; surgery associated with histopathological evaluation revealed deep endometriosis in different pelvic locations in 72 patients. With respect to the vaginal walls, transvaginal ultrasonography had a sensitivity of 91% (95% CI, 79-97%), specificity of 89% (95% CI, 81-93%), an LR+ of 8.2 and an LR- of 0.09. For endometriosis of rectovaginal septum, transvaginal ultrasonography had a sensitivity of 74% (95% CI, 64-80%), specificity of 88% (95% CI, 4-8%), an LR+ of 6.2 and an LR- of 0.3. For other locations, the sensitivity was lower (ranging from 67% to 33%) with a comparable specificity. CONCLUSIONS This technique shows a high specificity and sensitivity in the detection of vaginal and rectovaginal endometriosis. Good specificity associated with a lower sensitivity was obtained in the diagnosis of deep endometriosis of uterosacral ligaments, rectosigmoid involvement or anterior deep endometriosis.

Mature and immature ovarian teratomas: CT, US and MR imaging characteristics

Ovarian teratomas (OTs) are the most common germ cell neoplasm. They include mature cystic teratomas, monodermal teratomas (neural tumors, struma ovarii, carcinoid tumors) and immature teratomas. Teratomas are the most common benign ovarian neoplasms in women less than 45 years old. OTs are usually characterized by ultrasound (US) and magnetic resonance (MR) whereas they are usually an incidental finding on CT. The purpose of this paper is to review the most common types of teratomas and to describe CT, US and MR imaging features of the various types of mature and immature OTs.

Diagnosis of the Most Frequent Benign Ovarian Cysts: Is Ultrasonography Accurate and Reproducible?

OBJECTIVE To evaluate the reproducibility and the accuracy of B-mode ultrasonographic features of three different kinds of benign ovarian cysts: ovarian endometrioma, mature teratoma, and serous cyst. METHODS Digitally stored B-mode sonographic images of 98 women submitted to surgery for the presence of an adnexal mass were evaluated by five different examiners with different degrees of experience. The histological type of each mass was predicted on the basis of the B-mode typical benign findings, as in the case of endometrioma (groundglass endocystic pattern), cystic teratoma (echogenic pattern with or without acoustic shadow), and serous cyst (anechoic cyst without endocystic vegetations). To assess the reproducibility of the B-mode findings, intraobserver and interobserver agreements were calculated using the kappa index. RESULTS The intraobserver agreement was good or very good for all examiners and for all patterns (kappa = 0.71-1) except for the dermoid cyst, which showed moderate agreement (kappa = 0.42) for the highly experienced operator. The interobserver agreement was good for all experts for endometrioma (kappa = 0.66-0.78) and for serous cyst (kappa = 0.82-1), whereas it was moderate or good for cystic teratoma (kappa = 0.51-0.72). Interobserver agreement between experts and highly experienced operators was fair (kappa = 0.33-0.36) for teratoma and good or very good for endometrioma (kappa = 0.70-0.83) and serous cyst (kappa = 0.76-0.82). For different kinds of cysts, the accuracy was comparable among different operators. CONCLUSIONS Typical features of benign masses using grayscale transvaginal ultrasonography are reproducible even in moderately experienced examiners, although more experience was associated with better interobserver agreement. The diagnostic performance of different operators with different degrees of experience is similar.

INTRAOBSERVER AND INTEROBSERVER AGREEMENT OF GRAYSCALE TYPICAL ULTRASONOGRAPHIC PATTERNS FOR THE DIAGNOSIS OF OVARIAN CANCER

The purpose of this study was to evaluate the intraobserver and interobserver agreement for identifying ovarian malignancy using typical grayscale ultrasonographic patterns. Digitally stored grayscale sonographic images from a random sample of 98 women with an adnexal mass submitted to surgery after a grayscale transvaginal sonography were evaluated by five different examiners with different degrees of experience in three European university departments of obstetrics and gynecology. Masses in which the echo features were highly characteristic of a benign pathology were categorized as benign. Any cystic mass containing excrescences, thick septations, multiple irregular septations or solid component in which the echo architecture was not highly suggestive of benign histology was categorized as malignant. Intraobserver and interobserver agreement according to the level of experience were assessed by calculating the kappa index. Of the 98 cases randomly selected, 28 (29%) were malignant masses and 70 (71%) were benign. Intraobserver agreement was good or very good for all examiners with different degrees of experience (kappa = 0.72 to 1). Interobserver agreement was good for all expert operators (kappa = 0.69 to 0.75). Interobserver agreement between experts and highly experienced operators was moderate or good (kappa = 0.51 to 0.63). Interobserver agreement between the moderately experienced operator and experts was fair to moderate (kappa = 0.29 to 0.46). Interobserver agreement between moderately and highly experienced operators was fair (kappa = 0.33). Our results indicate that ultrasonographic malignant patterns are reproducible, even in moderately experienced examiners, although more experience is associated with better interobserver agreement.

Transvaginal ultrasonography in the diagnosis of extrauterine pelvic diseases

Extrauterine pelvic diseases include several kinds of adnexal masses. In addition, pelvic adhesions and deep endometriosis can be considered extrauterine pelvic diseases. In this article we will review a practical approach to adnexal pathologies using simple transvaginal ultrasonographic findings of several benign masses. Moreover, we will investigate the additional role of color Doppler and explain a simplified presurgical triage of adnexal masses that uses color Doppler as a secondary test for the detection of ovarian cancer, already confirmed by several studies. We will also evaluate the new insight of transvaginal ultrasonography in the detection of pelvic adhesions and deep endometriosis. A possible improvement in the field of the preoperative diagnosis of ovarian cancer in the next years comes from the constitution of the International Ovarian Tumor Analysis Group and from the introduction into clinical practice of 3D color Doppler sonography.

OC21.01: Biomarkers and transvaginal ultrasonography in the detection of ovarian cancer

Objective: To compare the diagnostic value of the simultaneous evaluation of osteopontin (OPN), insulin-growth factor II (IGF II), leptin, prolactin with the use of transvaginal ultrasonography and CA 125 determination for detection of ovarian cancer. Material and methods: Eighty-three patients with an adnexal mass were included in this study and underwent sonography and ELISA assays of the four serum protein markers before surgery, associated also with the determination of CA125. For the evaluation of diagnostic performance of bio-markers we also used split-point analysis to produce a score-based classification method in which a score of 1 or below is required for benign mass, whereas a score of 2 or above indicates cancer. Results: Ten patients with ovarian cancer and 73 patients with benign ovarian neoplasm were included in the study. The median concentrations of OPN, IGF II, leptin and prolactin were not significantly different in the two groups of patients. With receiver operating characteristic curve analysis, the area under the curve was respectively 0.384 for OPN, 0.395 for IGF II, 0.570 for leptin, 0.453 for prolactin and 0.838 for CA125. Using split-point scoring methods, the simultaneous evaluation of the four new serum markers had sensitivity of 80% and specificity of 10%. With the use of only CA125 a sensitivity of 68% and specificity of 40% were obtained. The ultrasonography showed a sensitivity of 80% but a specificity of 92%. Conclusions: Although previously proposed with encouraging results in the screening of ovarian cancer, the simultaneous evaluation of these new biomarkers not seems to be useful in the preoperative evaluation of patients with an adnexal mass when compared with CA125 and transvaginal ultrasonography. This study was supported by Assessorato Igiene e Sanità, Regione Autonoma della Sardegna.

OC168: Transvaginal color Doppler in the detection of ovarian cancer in a large study population: Results of sardinia‐navarra (Sa.Na.) group

Echogenic ovarian foci (EOF) are common ultrasound findings of unclear significance. Objectives: to follow up natural course of EOF and to determine potential for malignant transformation. Materials and Methods: Sixty five patients with EOF in one or both ovaries were followed with yearly pelvic ultrasound for 10 years. Results: EOF were bilateral in 53 patients, unilateral in 12 patients. EOF had clustered pattern in 83 ovaries and were singular in 35 ovaries. EOF were peripheral in 67 ovaries, had central location in 18 and had mixed distribution in 33 ovaries. During longitudinal follow up EOF stayed unchanged in 99 ovaries, increased in size in 12, decreased or became undetectable in 7 ovaries. Ovarian specimens were obtained in 6 patients (total 9 ovaries) who had gynecologic surgery for reasons unrelated to EOF. Epithelial inclusion cysts were detected in 5 ovaries, simple calcifications in 4 ovaries. None of the patients developed ovarian malignancy over 10-year observation period. Conclusion: EOF are benign findings and their appearance changes over time. In our series EOF did not signify ovarian pathology and required no follow-up.

OP06.01: Transvaginal ultrasonography and pelvic adhesions in patients with cystic ovarian endometriosis

A. C. Testa1, M. Ludovisi2, R. Manfredi3, G. Zannoni4, B. Gui5, D. Basso1, A. Di Legge1, G. Scambia1, G. Ferrandina2 1Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy, 2Department of Oncology, Catholic University of the Sacred Heart, Campobasso, Italy, 3Department of Radiology, University of Verona, Verona, Italy, 4Institute of Human Pathology, Catholic University of Sacred Heart, Rome, Italy, 5Department of Radiology, Catholic University of Sacred Heart, Rome, Italy

OC165: Differential diagnosis of the most common benign ovarian cysts using transvaginal ultrasonography: Results of Sardinia-Navarra (Sa.Na.) group

A. C. Testa1, D. Timmerman2, E. Fruscella1, C. Van Holsbeke2, L. Savelli3, E. Ferrazzi4, F.P.G. Leone4, H. Marret5, C. Exacoustos6, G. De Placido7, D. Bokor8, G. Ferrandina1, V. Van Belle9, L. Valentin10 1Università Cattolica del Sacro Cuore, Rome, Italy, 2University Hospitals, Leuven, Belgium, 3Reproductive Medicine Unit, Bologna, Italy, 4DSC L. Sacco Università di Milano, Milano, Italy, 5Unité INSERM CHU Bretonneau, Tours, France, 6University of Tor Vergata, Rome, Italy, 7University of Naples, Naples, Italy, 8Bracco S.p.A., Milano, Italy, 9Dept Electrical Engineering (ESAT-SCD), Katholieke Universiteit Leuven, Leuven, Belgium, 10University Hospital, Malmo, Sweden

OC07: Diagnosis of location of deep infiltrating endometriosis by transvaginal tenderness‐guided ultrasonography

variables could improve ultrasound prediction of fetal macrosomia over prediction which relies on the commonly used formulas for the sonographic estimation of fetal weight. Methods: The δ SVM algorithm was used for binary classification between two categories of weight estimation: > 4000 g and < 4000 g. Clinical and sononographic input variables of 100 pregnancies suspected of having LGA fetuses were tested. Results: Thirteen of 38 features were selected as contributing variables that distinguish birth weights of below 4000 g and of 4000 g and above. Considering 4000 g as a cut-off weight the pattern recognition algorithm predicted macrosomia with a sensitivity of 81%, specificity of 73%, positive predictive value of 81% and negative predictive value of 73%. The comparative figures according to the combined criteria based on two commonly used formulae generated from regression analysis were 88.1%, 34%, 65.8% and 66.7%. Conclusions: The δ SVM algorithm provides a prediction of LGA fetuses comparable to that of other commonly used formulae generated from regression analysis. The better specificity and better positive predictive value suggest potential value for this method and further accumulation of data may improve the reliability of this approach.