A practical approach to the ultrasound characterization of adnexal masses

Because pelvic ultrasound is commonly used to evaluate adnexal masses, it is important to understand the most useful sonographic features for predicting benign and malignant masses. Determining whether an adnexal mass is of ovarian or extraovarian origin is key in arriving at the most likely diagnosis. Most adnexal masses are benign, and each of the most common benign ovarian lesions has a typical sonographic appearance. Additionally, most malignant ovarian neoplasms have a solid component with detectable flow by Doppler ultrasound, allowing one to strongly suggest the diagnosis. We will review an approach to the ultrasound diagnosis of adnexal masses that progresses through a series of 4 questions to help lead one to the most likely diagnosis.     

超声造影对附件区不同回声类型肿块良恶性鉴别中的应用价值

目的探讨超声造影对附件区不同回声类型肿块良恶性鉴别的临床应用价值。方法选取36例附件区肿块的患者,先行常规经阴道超声检查,根据二维超声声像图表现分为单纯性囊性肿块组、囊性为主混合性肿块组、实性肿块组及实性为主混合性肿块组,再行超声造影成像并分析其增强特点及时间-强度曲线,主要指标包括充盈起始时间(AT)、达峰时间(TTP)、廓清时间(WT)、造影曲线总时间(OT)、起始强度(AI)、峰值强度(PI)及曲线下面积(AUC)等。结果所有病例均获得病理诊断,其中单纯性囊性肿块组及囊性为主混合性肿块组均为良性;研究显示AT在囊性为主混合性肿块组及实性为主混合性肿块组晚于实性肿块组(P<0.01);AI及PI在囊性为主混合性肿块组低于实性肿块组(P<0.05,P<0.01)。在实性肿块组中,恶性组AT早于良性组(P<0.05),AI及PI高于良性组(P<0.01)。在实性为主混合性肿块组中,恶性组AT早于良性组(P<0.05),TTP晚于良性组(P<0.05)。结论超声造影对附件区不同回声类型肿块的良、恶性鉴别有一定的临床应用价值。     

Magnetic resonance imaging of adnexal masses

Adnexal masses are common in women of all ages. A range of physiological and benign ovarian conditions that develop in women, especially in the reproductive age, and adnexal malignancies can be evaluated with magnetic resonance imaging (MRI). Management of women with adnexal masses is frequently guided by imaging findings; therefore, precise characterization of adnexal pathology should be performed whenever possible. Magnetic resonance imaging is useful in characterization of adnexal masses that are not completely evaluated by ultrasound because it can provide additional information on soft tissue composition of adnexal masses based on specific tissue relaxation times and allows multiplanar imaging at large field of view to define the origin and extent of pelvic pathology. The patients most likely to benefit from MRI are pregnant women and those who are premenopausal and have masses that have complex features on ultrasound but do not have raised cancer antigen 125 tumor marker levels. The overlap in imaging appearance among different cell type malignancies makes it difficult to predict exact histology based on MRI appearance; however, MRI has a high accuracy in differentiating benign from malignant masses. Teratomas, endometriomas, simple and hemorrhagic cysts, fibromas, exophytic or extrauterine fibroids, and hydrosalpinges can be diagnosed with high confidence.In this article, the authors review the histopathologic background and MRI features of adnexal masses and discuss the role of MRI in the differentiation of benign from malignant adnexal pathologies.     

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 kappa statistics. RESULTS: Color Doppler evaluation was more accurate in the diagnosis of adnexal malignancies in comparison with gray scale sonography (kappa = 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.     

Computed tomographic and magnetic resonance features of gynecologic abnormalities in women presenting with acute or chronic abdominal pain

Advances in technology and improved availability have led to increased use of computed tomography (CT) and magnetic resonance imaging (MRI) to evaluate women presenting to the emergency department or to their primary care provider with abdominal and/or pelvic pain. Computed tomographic examinations are often performed to evaluate the presence of appendicitis or renal stone disease. However, gynecologic abnormalities are frequently identified on these examinations. Although ultrasound remains the primary modality by which complaints specific to the pelvis are evaluated, in many instances, CT and MRI imaging occurs before sonographic evaluation.Historically, because of cost, radiation exposure, and relative ease of use, ultrasound examinations have preceded all other imaging modalities when evaluating pelvic disorders. However, as CT and MRI technology have improved, their use in diagnosing causes of pelvic pain has become equal to that of ultrasound. In some cases, primarily because of historic comfort with sonographic evaluation, gynecologic abnormalities originally diagnosed on CT or MRI may be immediately and unnecessarily reevaluated by ultrasound.For a woman in her reproductive years, the most common adnexal masses are physiological cysts, endometriomas, and cystic teratomas. Although lesions are often asymptomatic and incidentally detected, they can present with pain, and they increase the risk of ovarian torsion. Common causes of chronic pelvic pain in this population include leiomyomata and adenomyosis. In postmenopausal women, ovarian carcinoma, which often does not present clinically until a late stage, has to be included in the differential diagnosis of adnexal masses.If a gynecologic pathology is discovered on CT or MRI, an immediate follow-up ultrasound need not be pursued if the lesion can be characterized as benign, needing immediate surgical intervention, or a variant of normal anatomy. If, on the other hand, findings demonstrate a mass that either is uncharacteristic of a benign lesion, has an indeterminate risk for malignancy, or demonstrates suspicious characteristics for malignancy (such as enhancing mural nodules), further evaluation by serial ultrasound, biochemical marker, and/or CT or MRI is warranted.The purpose of this review is to present a series of commonly encountered gynecologic abnormalities with either CT or MR to make radiologists more familiar with gynecologic pathology on CT and MRI.     

超声国际卵巢肿瘤研究组简单法则与妇科影像报告与数据系统分类诊断卵巢肿瘤的比较

目的 比较超声国际卵巢肿瘤研究组（IOTA）简单法则与妇科影像报告与数据系统（GI-RADS）诊断卵巢肿瘤的价值。方法 由高年资医师运用IOTA简单法则对463例卵巢肿瘤进行分类,将诊断为良性和恶性的卵巢肿瘤纳入研究。然后,由低年资和高年资医师在互不知道检查结果的情况下分别运用IOTA简单法则和GI-RADS分类进行诊断,定义低年资医师采用IOTA简单法则诊断为A1组,高年资医师采用IOTA简单法则诊断为B1组,低年资医师采用GI-RADS诊断为A2组,高年资医师采用GI-RADS诊断为B2组,比较两种方法的诊断效能。结果 463例病例中,高年资医师IOTA确认良性及恶性的卵巢肿瘤共411例（411/463,88.77%）,不能确定性质的52例（52/463,11.23%）。A2与B2组间、A1与A2组间特异度、阳性预测值和诊断正确率差异均有统计学意义（P均<0.05）,敏感度与阴性预测值差异无统计学意义（P均>0.05）。诊断效能各指标在A1与B1组间、B1与B2组间差异均无统计学意义（P均>0.05）。结论 IOTA简单法则和GI-RADS分类对卵巢良恶性肿瘤的诊断效能相当且均较高。IOTA简单法则不存在经验依赖性,但不适合全部卵巢肿瘤的评价。     

超声卵巢-附件影像报告和数据系统与国际卵巢肿瘤研究组简单法则诊断卵巢肿块的对比研究

目的 比较超声卵巢-附件影像报告和数据系统（O-RADS）与国际卵巢肿瘤研究组（IOTA）简单法则诊断卵巢良恶性肿块的价值。方法 选取我院经手术病理证实的卵巢肿块患者129例,共计159个病灶,分别使用O-RADS和IOTA简单法则进行分类评价;绘制受试者工作特征曲线分析并比较二者对卵巢良恶性肿块的诊断效能。结果 O-RADS与IOTA简单法则鉴别卵巢良恶性肿块的曲线下面积分别为0.863、0.823,差异有统计学意义（P=0.015）。O-RADS鉴别卵巢良恶性肿块的灵敏度为95.1%,特异度为77.6%;IOTA简单法则鉴别卵巢良恶性肿块的灵敏度为90.2%,特异度为74.5%。结论 O-RADS鉴别卵巢良恶性肿块的诊断效能较IOTA简单法则更高。     

三维超声造影诊断附件小肿块的初步研究

目的 探讨三维超声造影诊断附件小肿块的价值。方法 对47枚附件小肿块进行二维及三维超声造影检查,对比分析附件良恶性小肿块二维及三维超声造影的图像表现,所有病例均经手术病理或长期随访证实。结果 良性小肿块40枚,二维超声造影多表现由周边向实质内、分隔或乳头状增强;恶性小肿块7枚,二维超声造影呈现为多中心由实质内向周边增强。良恶性小肿块三维超声造影的包膜血管、分隔及内部增强间差异有统计学意义(P＜0.05)。良性实性小肿块内部血管稀疏平直,囊性小肿块的囊壁可见增强,囊内无增强;恶性小肿块表现为实质内血管分布无序扭曲、密集杂乱,形成血管球,呈显著增强,6枚周边可见粗大的供养血管进入。结论三维超声造影显示复杂血管空间结构具有优势,有望成为一种研究附件良恶性小肿块血管真实构筑的新方法。     

Prospective cross-validation of Doppler ultrasound examination and gray-scale ultrasound imaging for discrimination of benign and malignant pelvic masses.

OBJECTIVE: To cross-validate, prospectively, the diagnostic performance of established ultrasound methods for discrimination of benign and malignant pelvic masses. METHODS: A total of 173 consecutive women with a pelvic mass judged clinically to be of adnexal origin underwent preoperative ultrasound examination including color and spectral Doppler techniques. A total of 149 tumors were benign, and 24 were malignant. The sensitivity and false-positive rate with regard to malignancy were calculated for the following methods, using cut-off values recommended in previous publications: Lerner score; ultrasound morphology, i.e. tumors without solid components being classified as benign and tumors with solid components as malignant; tumor color score; pulsatility index; resistance index; time-averaged maximum velocity; peak systolic velocity; the combined use of ultrasound morphology and tumor color score and the combined use of ultrasound morphology and peak systolic velocity. Sensitivity and false-positive rate were also calculated for subjective evaluation of the gray-scale ultrasound image and for subjective evaluation of the gray-scale ultrasound image supplemented with subjective evaluation of color Doppler ultrasound examination. The confidence with which the diagnosis was made, based on subjective evaluation, was rated on a visual analog scale. RESULTS: Subjective evaluation of the gray-scale ultrasound image was by far the best method for distinguishing benign from malignant tumors (sensitivity 88%, false-positive rate 4%), followed in descending order by subjective evaluation of the gray-scale ultrasound image supplemented with color Doppler examination, the Lerner score and the time-averaged maximum velocity. Adding Doppler examination to subjective evaluation of the gray-scale image did not increase the number of correct diagnoses, but it increased the confidence with which a correct diagnosis was made in 14% of tumors. In 11 tumors (6% of the series as a whole), the addition of Doppler examination changed the diagnosis based on subjective evaluation of the gray-scale ultrasound image from an incorrect (n = 1) or uncertain (n = 10) diagnosis to a correct and confident diagnosis. CONCLUSION: In experienced hands, subjective evaluation of the gray-scale ultrasound image is the best ultrasound method for discriminating between benign and malignant adnexal masses. The main advantage of adding Doppler examination to subjective evaluation of the gray-scale image is an increase in the confidence with which a correct diagnosis is made.     

经阴道超声造影诊断附件肿块的价值

目的 探讨经阴道超声造影技术在附件肿块诊断中的应用价值.方法 对30例附件包块(良性21例,恶性9例)患者行二维超声及超声造影匹配成像检查,并与术后病理对照,总结其声像图表现.结果 超声造影增强可区分实质部分与囊性部分;良性肿瘤内微血管不丰富,仅囊壁可见血管;而恶性肿瘤微血管极丰富,且血管形态异常,可见粗大不规则的肿瘤血管.造影剂在部分恶性肿瘤具有特征性的动态增强与消退过程.结论 经阴道超声造影有助于提高对附件包块的良、恶性病变鉴别诊断能力.     

Ultrasonographic Imaging Features of Female Urethral and Peri-urethral Masses: A Retrospective Study of 95 Patients

The aim of this study was to assess the imaging features of urethral and peri-urethral masses on transvaginal or transperineal ultrasound (US) in a cohort of 95 women. In this retrospective study, medical records of 95 female patients with 98 asymptomatic or symptomatic urethral and peri-urethral masses were retrospectively reviewed. Data regarding patient demographic characteristics, symptoms, signs, imaging features on 2-D and 3-D transvaginal or transperineal US, diagnostic tests and physical and intra-operative findings were extracted. The US imaging features and clinicopathologic characteristics of each urethral or peri-urethral mass were compared. On ultrasound, 39 masses (in 39 patients) were diagnosed as urethral diverticula, which manifested mostly as complex cystic masses (24/39, 61.5%); 35 masses (in 33 patients) were diagnosed as para-urethral cysts, which manifested mostly as simple cystic masses (19/35, 54.3%); 13 hypo-echoic solid masses (in 12 patients) exhibiting blood flow signals on color Doppler imaging were diagnosed as urethral leiomyomas; hypo-echoic or heterogeneous solid masses (in 8 patients) exhibiting blood flow signals on color Doppler imaging were diagnosed as urethral caruncles, including one complicated by malignant transformation; solid masses with mixed echogenicity (in 2 patients) exhibiting blood flow signals on color Doppler imaging were diagnosed as urethral squamous cell carcinoma or adenocarcinoma, and a hypoechoic solid mass (in one patient) with blood-flow signals on color Doppler imaging was diagnosed as urethral condyloma associated with human papillomavirus infection. This study confirmed transvaginal or transperineal 2-D and 3-D ultrasonography to be a valid, non-invasive, cost-effective diagnostic modality for the differential diagnosis of urethral and periurethral masses.     

超声造影在乳腺囊实性复合肿块良恶性鉴别及活检决策中的作用

目的 探讨超声造影在鉴别乳腺囊实性复合肿块良恶性并是否行超声引导下活检指导中的应用。方法 回顾性研究2020年1月至2021年1月经超声诊断为乳腺囊实性复合肿块患者74例,结合病理及随访结果分析常规超声及超声造影声像图特征并对乳腺囊实性肿块恶性诊断效能进行评价;分别统计常规超声及超声造影后决定行组织穿刺活检的例数。结果 病理证实的60例患者中良性45例,恶性15例。超声造影乳腺囊实性复合肿块实性部分有无强化、强化范围是否增大及实性部分基底部突破特征对于区分肿块良、恶性差异有统计学意义(p<0.05)。超声造影可提高乳腺囊实性复合肿块恶性病变诊断的敏感性。超声造影后对乳腺囊实性肿块活检的决定被改变25.7%;而对于怀疑恶性乳腺囊实性复合肿块超声造影不会改变穿刺的决策。结论 超声造影在乳腺囊实性复合肿块的良恶性鉴别中有一定作用,为指导超声引导下乳腺穿刺活检决策提供新方法。     

Gynecologic applications of MRI

Gynecologic anatomy is consistently depicted with MRI. Abnormal developmental anatomy is also well assessed. In cases of complete or partial vaginal agenesis where ultrasound is equivocal, MRI can be definitive. The various subtypes of uterine anomalies are well delineated with MRI. MRI is the optimal technique in the therapeutic evaluation of leiomyomas, because the number, size, location, and degeneration can be documented. It is particularly useful in the identification of the ovaries in the presence of an enlarged leiomyomatous uterus. Adenomyosis, an often neglected diagnosis, is distinguishable from leiomyomas. In the setting of an equivocal ultrasound, MRI is useful in discerning whether a mass is ovarian or uterine in origin. Endometriosis, a disease routinely diagnosed and staged by laparoscopy, does have a typical MR appearance and therefore can usually be differentiated from other adnexal masses. Dermoids are readily diagnosed with MRI. Other adnexal masses do not have a specific MR appearance and morphologic criteria as used with ultrasound or CT must be relied upon in suggesting whether or not the mass is benign or malignant. MRI is the procedure of choice in the staging of cervical and endometrial cancer.     

Imaging of benign adnexal masses: characteristic presentations on ultrasound, computed tomography, and magnetic resonance imaging

Adnexal masses are common in the general population. Although ovarian cancer is a significant cause of mortality, large screening studies demonstrate that the majority of adnexal masses are benign. These benign masses include physiologic cysts, paraovarian masses, and benign ovarian lesions. It is important that gynecologists and radiologists appreciate the appearance of these lesions on multiple imaging modalities, including ultrasound, computed tomography, and magnetic resonance imaging to avoid unnecessary intervention.     

超声在乳腺分叶状肿瘤诊断中的应用

目的研究乳腺分叶状肿瘤(PTB)的超声表现以及与病理基础的关系,以提高超声的诊断水平。方法回顾性分析经手术病理证实的58例PTB超声表现,其中17例经超声弹性成像检查,并将其与病理结果对照。结果 58例PTB中30例为良性,15例为交界性,13例为恶性。大于30 mm的肿块中,良性的比例比小于30 mm的肿块少。按超声图像分型,呈明显分叶状的实性肿块26例,呈浅分叶状或表现为圆形、椭圆形的实性肿块20例,呈囊实混合性的12例。良性与恶性,良性与交界性PTB的血流分级差异有统计学意义。结论超声对PTB的诊断和鉴别诊断有重要的临床价值。     

常规超声联合超声造影对乳腺囊实性复合肿块良恶性的鉴别诊断价值

目的探讨常规超声联合超声造影（CEUS）在不同超声分组乳腺囊实性复合肿块良恶性鉴别中的应用价值。 方法回顾性选取2017年4月至2019年11月苏州大学附属第一医院收治的乳腺囊实性复合肿块患者111例,共计111个乳腺病灶。根据肿块内部囊实性成分比例及分布特点将其分为3组［A组：厚壁和（或）厚分隔;B组：囊性为主;C组：实性为主］。结合病理分析各组肿块的常规超声及超声造影声像图特征。 结果111个乳腺病灶中,A组病灶28个（良性24个,恶性4个）,B组病灶36个（良性28个,恶性8个）,C组病灶47个（良性29个,恶性18个）。B、C组恶性肿块的年龄及最大径均大于良性组,差异均有统计学意义（P均＜0.05）。A组肿块CEUS后恶性肿块多表现为边缘不光整、壁和（或）分隔增厚,与良性肿块比较差异均有统计学意义（P=0.004、0.016）。B、C组恶性肿块多表现为常规超声及CEUS后实性边缘不光整、实性成分增强范围超出基底部,与良性肿块比较差异均有统计学意义（P均＜0.05）。C组良性肿块与恶性肿块间形态、后方回声、有无钙化及血供情况比较,差异均有统计学意义（P均＜0.05）。 结论常规超声联合CEUS对乳腺囊实性复合肿块的良恶性鉴别具有重要意义,可为临床评估提供可靠的诊断依据。     

In search of the elusive benign cystic ovarian teratoma: application of the ultrasound "tip of the iceberg" sign.

The benign cystic ovarian teratoma (dermoid) has distinctive ultrasonic features that differentiate it from other adnexal masses. The most frequent sign is the presence of highly reflective irregular solid components within a fluid-containing adnexal mass. In vitro scans of surgical specimens have shown that the strongly reflective echo pattern is caused by the hair and sebum within the dermoid. Calcium is often sparse or absent. Acoustic shadowing from the hair may totally obscure the back wall of a large, clinically evident mass; hence the term "tip of the iceberg" sign. Recognition of this sign reduces the possibility of a false negative interpretation and confusion with a "bowel gas pattern."     

高频彩色多普勒超声诊断乳腺实性肿块的价值研究

目的 探讨高频彩色多普勒超声在乳腺实性肿块良恶性鉴别诊断中的价值。方法 对27例乳腺良性肿块和44例乳腺癌肿块进行彩色多普勒超声检查,分析病灶的声像图特点,并与病理结果进行对照。结果彩色多普勒超声对良、恶性肿块的诊断符合率分别为89％、93％。良、恶性肿块在二维灰阶声像图及彩色多普勒血流分级方面比较差异均有统计学意义（P〈0．05）。结论 二维灰阶声像图结合彩色血流成像的典型表现,可以判断其性质,对一些非典型病例,还应结合病史综合分析,以便做出正确判断。     

Sonography of malignant breast disease

The greatest utility for ultrasound of the breast is in the differentiation of cysts from solid masses. After complete, high quality x-ray mammography, a palpable mass or nonpalpable mammographic abnormality may remain indeterminate in etiology, and ultrasound may be useful as an adjunctive diagnostic modality. However, present ultrasound technology is poor for visualization of small solid masses, particularly in fatty breasts, and it cannot reliably detect microcalcifications. Therefore, sonography has no role in screening for breast cancer.