S. Guerriero

Simple ultrasound rules to distinguish between benign and malignant adnexal masses before surgery: prospective validation by IOTA group

Objectives To prospectively assess the diagnostic performance of simple ultrasound rules to predict benignity/malignancy in an adnexal mass and to test the performance of the risk of malignancy index, two logistic regression models, and subjective assessment of ultrasonic findings by an experienced ultrasound examiner in adnexal masses for which the simple rules yield an inconclusive result. Design Prospective temporal and external validation of simple ultrasound rules to distinguish benign from malignant adnexal masses. The rules comprised five ultrasonic features (including shape, size, solidity, and results of colour Doppler examination) to predict a malignant tumour (M features) and five to predict a benign tumour (B features). If one or more M features were present in the absence of a B feature, the mass was classified as malignant. If one or more B features were present in the absence of an M feature, it was classified as benign. If both M features and B features were present, or if none of the features was present, the simple rules were inconclusive. Setting 19 ultrasound centres in eight countries. Participants 1938 women with an adnexal mass examined with ultrasound by the principal investigator at each centre with a standardised research protocol. Reference standard Histological classification of the excised adnexal mass as benign or malignant. Main outcome measures Diagnostic sensitivity and specificity. Results Of the 1938 patients with an adnexal mass, 1396 (72%) had benign tumours, 373 (19.2%) had primary invasive tumours, 111 (5.7%) had borderline malignant tumours, and 58 (3%) had metastatic tumours in the ovary. The simple rules yielded a conclusive result in 1501 (77%) masses, for which they resulted in a sensitivity of 92% (95% confidence interval 89% to 94%) and a specificity of 96% (94% to 97%). The corresponding sensitivity and specificity of subjective assessment were 91% (88% to 94%) and 96% (94% to 97%). In the 357 masses for which the simple rules yielded an inconclusive result and with available results of CA-125 measurements, the sensitivities were 89% (83% to 93%) for subjective assessment, 50% (42% to 58%) for the risk of malignancy index, 89% (83% to 93%) for logistic regression model 1, and 82% (75% to 87%) for logistic regression model 2; the corresponding specificities were 78% (72% to 83%), 84% (78% to 88%), 44% (38% to 51%), and 48% (42% to 55%). Use of the simple rules as a triage test and subjective assessment for those masses for which the simple rules yielded an inconclusive result gave a sensitivity of 91% (88% to 93%) and a specificity of 93% (91% to 94%), compared with a sensitivity of 90% (88% to 93%) and a specificity of 93% (91% to 94%) when subjective assessment was used in all masses. Conclusions The use of the simple rules has the potential to improve the management of women with adnexal masses. In adnexal masses for which the rules yielded an inconclusive result, subjective assessment of ultrasonic findings by an experienced ultrasound examiner was the most accurate diagnostic test; the risk of malignancy index and the two regression models were not useful.

Ovarian cancer prediction in adnexal masses using ultrasound‐based logistic regression models: a temporal and external validation study by the IOTA group

The aims of the study were to temporally and externally validate the diagnostic performance of two logistic regression models containing clinical and ultrasound variables in order to estimate the risk of malignancy in adnexal masses, and to compare the results with the subjective interpretation of ultrasound findings carried out by an experienced ultrasound examiner (‘subjective assessment’).

Endometriomas: their ultrasound characteristics

To describe the ultrasound characteristics of endometriomas in pre‐ and postmenopausal patients and to develop rules that characterize endometriomas.

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.

Transvaginal ultrasonography in the diagnosis of cystic teratoma

Objective To assess prospectively the role of transvaginal ultrasonography in screening for cystic teratoma and in differentiating cystic teratoma from other ovarian masses. Methods Three hundred seventy-six premenopausal non-pregnant women underwent transvaginal ultrasonography 1 week before undergoing laparotomy or laparoscopy. The visualization of localized or diffuse echogenicity was chosen as the characteristic ultrasonographic finding of cystic teratoma. Endosonographic diagnosis was compared with surgical and pathologic findings. Results Sensitivity and specificity for the ultrasonographic screening were 57.9 and 99.7%, respectively, calculated for each visualized overy (n = 659), and 84.6 and 98.2%, respectively, for differentiating cystic teratoma from other ovarian masses, calculated for each visualized cyst (n = 123). Conclusion Transvaginal ultrasonography has a better predictive ability for differentiating cystic teratoma from other ovarian masses (kappa value 0.84) than in screening for cystic teratomas (kappa value 0.69).

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.

Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements : A consensus opinion from the International Deep Endometriosis Analysis (IDEA) group

The IDEA (International Deep Endometriosis Analysis group) statement is a consensus opinion on terms, definitions and measurements that may be used to describe the sonographic features of the different phenotypes of endometriosis. Currently, it is difficult to compare results between published studies because authors use different terms when describing the same structures and anatomical locations. We hope that the terms and definitions suggested herein will be adopted in centers around the world. This would result in consistent use of nomenclature when describing the ultrasound location and extent of endometriosis. We believe that the standardization of terminology will allow meaningful comparisons between future studies in women with an ultrasound diagnosis of endometriosis and should facilitate multicenter research. Copyright

Evaluating the risk of ovarian cancer before surgery using the ADNEX model to differentiate between benign, borderline, early and advanced stage invasive, and secondary metastatic tumours: prospective multicentre diagnostic study.

Objectives To develop a risk prediction model to preoperatively discriminate between benign, borderline, stage I invasive, stage II-IV invasive, and secondary metastatic ovarian tumours. Design Observational diagnostic study using prospectively collected clinical and ultrasound data. Setting 24 ultrasound centres in 10 countries. Participants Women with an ovarian (including para-ovarian and tubal) mass and who underwent a standardised ultrasound examination before surgery. The model was developed on 3506 patients recruited between 1999 and 2007, temporally validated on 2403 patients recruited between 2009 and 2012, and then updated on all 5909 patients. Main outcome measures Histological classification and surgical staging of the mass. Results The Assessment of Different NEoplasias in the adneXa (ADNEX) model contains three clinical and six ultrasound predictors: age, serum CA-125 level, type of centre (oncology centres v other hospitals), maximum diameter of lesion, proportion of solid tissue, more than 10 cyst locules, number of papillary projections, acoustic shadows, and ascites. The area under the receiver operating characteristic curve (AUC) for the classic discrimination between benign and malignant tumours was 0.94 (0.93 to 0.95) on temporal validation. The AUC was 0.85 for benign versus borderline, 0.92 for benign versus stage I cancer, 0.99 for benign versus stage II-IV cancer, and 0.95 for benign versus secondary metastatic. AUCs between malignant subtypes varied between 0.71 and 0.95, with an AUC of 0.75 for borderline versus stage I cancer and 0.82 for stage II-IV versus secondary metastatic. Calibration curves showed that the estimated risks were accurate. Conclusions The ADNEX model discriminates well between benign and malignant tumours and offers fair to excellent discrimination between four types of ovarian malignancy. The use of ADNEX has the potential to improve triage and management decisions and so reduce morbidity and mortality associated with adnexal pathology.

Transvaginal ultrasonography combined with CA-125 plasma levels in the diagnosis of endometrioma

OBJECTIVE To assess the role of transvaginal ultrasonography combined with CA-125 plasma levels in the diagnosis of endometrioma. DESIGN Prospective study with pathological confirmation of the diagnosis. SETTING Department of Obstetrics and Gynecology of the University of Cagliari, Italy. PATIENTS One hundred one consecutive premenopausal nonpregnant women submitted to laparoscopy or laparotomy, from November 1993 to October 1994, because of the presence of an adnexal mass. INTERVENTIONS Within 2 days before surgery all patients underwent transvaginal ultrasonography and evaluation of CA-125 plasma levels. The ultrasonographic impression and the CA-125 value were then compared with the histopathological diagnosis. MAIN OUTCOME MEASURE The overall agreement between the test result and the actual outcome was calculated using the kappa index for the transvaginal ultrasonography used alone and for the combination of transvaginal ultrasonography and CA-125 values, for each chosen cutoff and range. RESULTS Transvaginal ultrasonography has a strong agreement between test and surgery (kappa value 0.76) whereas the combined use of the two methods is associated with a lower kappa index, ranging from 0.40 to 0.69. CONCLUSION Transvaginal ultrasonography used alone has a better predictive capacity in differentiating endometrioma from other adnexal masses than combined methods.