Marta Gerada

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.

Complex pelvic mass as a target of evaluation of vessel distribution by color Doppler sonography for the diagnosis of adnexal malignancies: results of a multicenter European study.

Objective. To compare the diagnostic accuracy of gray scale sonography and color Doppler imaging in the differential diagnosis of adnexal malignancies from benign complex pelvic masses in a multicenter prospective study. Methods. The study was performed as a collaborative work at 3 European university departments of obstetrics and gynecology. A total of 826 complex pelvic masses on which transvaginal sonography and evaluation of cancer antigen 125 plasma concentrations were performed before surgical exploration were included in the study. The scanning procedure was the same in the 3 institutions. An adnexal mass was first studied in gray scale sonography, and a probable histologic type was predicted. Second, solid excrescences or solid portions of the tumor were evaluated for vascular flow with color Doppler sonography (conventional or power). A mass was graded malignant if flow was shown within the excrescences or solid areas and benign if there was no flow. The overall agreement between the test result and the actual outcome was calculated by κ statistics. Results. Color Doppler evaluation was more accurate in the diagnosis of adnexal malignancies in comparison with gray scale sonography (κ = 0.82 and 0.65, respectively) because of significantly higher specificity (0.94 versus 0.84; P < .001). The evaluation of the cancer antigen 125 plasma concentration did not seem to increase the accuracy of either method. Conclusions. The evaluation of vessel distribution by color Doppler sonography in complex adnexal cysts seems to increase the diagnostic accuracy of gray scale sonography in the detection of adnexal malignancies in a large study population.

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.

Three-Dimensional Quantification of Tumor Vascularity as a Tertiary Test After B-Mode and Power Doppler Evaluation for Detection of Ovarian Cancer

The purpose of this study was to investigate the role of 3‐dimensional (3D) quantification of tumor vascularity in the differential diagnosis of pelvic indeterminate masses with a solid appearance or unilocular or multilocular cysts with a solid component showing central vascularization on 2‐dimensional power Doppler sonography.

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.

Reproducibility of Endometrial Vascular Patterns in Endometrial Disease as Assessed by Transvaginal Power Doppler Sonography in Women With Postmenopausal Bleeding

Objective. The purpose of this study was to assess the intraobserver and interobserver agreement for identifying different endometrial vascular patterns using power Doppler sonography in women with postmenopausal bleeding and a thickened endometrium. Methods. Digitally stored sonographic images from a random sample of 65 patients with postmenopausal bleeding and a thick endometrium (>5 mm) on B‐mode sonography and evaluated by transvaginal power Doppler sonography for assessment of endometrial blood flow mapping were evaluated by 5 different examiners with different levels of expertise in Doppler sonography. Intraobserver and interobserver agreement according to the level of experience were assessed by calculating the κ index. Results. Intraobserver agreement was good or very good for all experienced examiners (κ = 0.78–0.96) and moderate (κ = 0.52) for the inexperienced examiner. Interobserver agreement was moderate among all experienced examiners (κ = 0.45–0.80). The inexperienced examiner showed fair or moderate interobserver agreement (κ = 0.32–0.45). Conclusions. Our results indicate that endometrial blood flow mapping using transvaginal power Doppler sonography is acceptably reproducible. More experience was associated with better intraobserver and 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.

OC176: Three‐dimensional (3D) quantification of tumor vascularity as third step after B‐mode and power Doppler evaluation for detection of ovarian cancer

gadolinium injection. For the myometrial invasion, we used the FIGO classification: 1a (without myometrial invasion), 1b (< 50% myometrial invasion), 1c (> 50% myometrial invasion). Results: The pathological analysis showed that 15% of women were stage 1a, 31%, stage 1b and 54%, stage 1c. As far as the myometrial involvement is concerned, the sonographic report was correct in 9 out of 13 patients (69%). The MRI conclusion was concordant with the histology in 9 patients out of 11 (82%). The sonography found more overestimations, but recognized all stage 1c diseases. The MRI gave one overestimation and one underestimation, but was inaccessible for two patients (no place). Conclusion: In the extension staging of an early endometrial carcinoma, the endovaginal sonography, with all its potentialities, seems to be promising, as it seems to give nearly equivalent results has the MRI, with a lower cost and an easier access. This preliminary study stimulates us to extend the study on a larger scale.

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