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PubMed2005

Power Doppler vascularity index for predicting malignancy of adnexal masses.

OBJECTIVE: To assess the performance of a power Doppler vascularity index in the preoperative diagnosis of ovarian malignancy. METHODS: Adnexal masses (n = 101) were examined prospectively with power Doppler ultrasonography before surgical treatment. The tumor vascularity index (power Doppler index, PDI) was determined by quantification of the number of pixels in a defined region of interest according to the formula: number of colored pixels/(total number of pixels minus the number of pixels in the fluid or avascular areas). It was estimated on selected frames of the tumors using an in-house color-quantifying program added to MATLAB 6.0 software. Inter- and intraobserver reproducibilities of PDI assessment were evaluated. Intratumoral blood flow velocity waveforms were obtained to determine the lowest resistance index (RI). A subjective visual score of power Doppler signals in the tumor was used to classify it as having low, moderate or high vascularity. The discriminatory ability of this score was compared to that of RI and PDI measurement. RESULTS: Histology identified 23 malignant and 78 benign lesions. The PDI was considerably higher in malignant than in benign lesions (0.34 +/- 0.04 vs. 0.12 +/- 0.06; P < 0.001). The intra- and interobserver variabilities of PDI were low (intraclass correlation coefficients of 0.99 and 0.97, respectively). The PDI cut-off value to differentiate malignant from benign tumors was set at 0.265 (26.5% of the tumor being colored). Using this cut-off, sensitivity and specificity were 100% (95% CI, 87.8-100.0) and 97.4% (95% CI, 91.0-99.7) compared to 78.3% (95% CI, 56.3-92.5) and 83.1% (95% CI, 72.9-90.7) for RI (cut-off value of 0.53) and 78.3% (95% CI, 56.3-92.5) and 94.9% (95% CI, 87.4-98.6) for visual scoring. Logistic regression demonstrated that PDI was the best parameter for differentiating between malignant and benign tumors. CONCLUSION: The power Doppler vascularity index obtained using customized color quantifying software has high diagnostic value in discriminating between benign and malignant adnexal masses.

Adnexa Uteri↗
PubMed1994

Management of the adnexal mass.

The methods for preoperative diagnosis and evaluation of the woman with a suspected ovarian neoplasm have evolved significantly with little or no impact on the surgical treatment, which remains removal of the abnormal ovary. Although most adnexal masses are benign, the primary goal of the diagnostic evaluation is the exclusion of malignancy. A complete history, physical examination, and ultrasonic imaging are vital in evaluating a suspected ovarian mass. In postmenopausal women, serum CA-125 determinations further improve sensitivity and specificity. Once the presence of an ovarian mass is established, the crucial decision is whether to observe the patient or proceed with surgical removal. If surgical removal is indicated, the proper procedure is important for staging and initiation of effective therapy. While many surgeons are now using the less invasive laparoscopic approach, the standard of care continues to be a laparotomy with either an ovarian cystectomy or oophorectomy. Future clinical research in the management of adnexal masses should focus on decreasing the number of patients undergoing a surgical procedure, and in patients who require surgery, further evaluation of laparoscopy as a safe, cost-effective means of treatment. Improved imaging techniques may allow for nonoperative management of probably benign ovarian neoplasms.

Adnexal Diseases↗
PubMed1996

Differential diagnosis of adnexal masses with transvaginal sonography, color flow imaging, and serum CA 125 assay in pre- and postmenopausal women.

The aim of the present study was to compare the diagnostic accuracy of transvaginal sonography, color flow imaging, and serum CA 125 assay in pre- and postmenopausal women undergoing laparotomy for a clinical diagnosis of an adnexal mass. In 109 consecutive women, the morphology of the mass was evaluated with transvaginal sonography, the pulsatility index (PI) was computed on the arteries detected with color flow imaging, and blood samples were obtained for CA125 assay. Descriptive statistics were performed for the whole series and according to the menopausal status. The diagnostic accuracy of transvaginal sonography was significantly higher in premenopause than in postmenopause (97 versus 85%, P<0.05). In premenopause, the three tests showed a similar diagnostic accuracy (85, 82, and 79%, respectively). In conclusion, the addition of further tests besides transvaginal sonography is not warranted in premenopausal women with an adnexal mass, but they seem to be useful in postmenopause.

Adnexal Diseases↗
PubMed1997

Adenocarcinoma of the ileum with an enterotubal fistula presenting as an adnexal mass.

Small bowel adenocarcinomas account for 3% of gastrointestinal malignancies, and 20 to 25% of these arise in the ileum. Clinical presentation is variable, and early diagnosis is difficult. A 56-year-old postmenopausal woman presented with crampy abdominal pain, anorexia, and weight loss. Pelvic examination and ultrasound revealed a 6 x 8-cm complex right adnexal mass. At laparotomy, en bloc resection of the right adnexa and the densely adherent ileal segment was performed along with a hysterectomy and a left salpingo-oophorectomy. The final pathology showed a moderately differentiated invasive adenocarcinoma of the ileum with a malignant enterotubal fistula. This is the first case reported in the literature of an ileal adenocarcinoma with a tubal fistula masquerading as an adnexal mass.

Adenocarcinoma↗
PubMed1990

Management of selected cystic adnexal masses in postmenopausal women by operative laparoscopy: a pilot study.

Twenty-five postmenopausal patients were predicted to have benign masses by screening criteria that included ultrasonographic findings of a cystic adnexal mass less than 10 cm with distinct borders and no evidence of irregular solid parts, thick septa, ascites, or matted bowel, and a normal serum CA 125 value (less than 35 U/ml). All 25 masses were accurately predicted to be benign. The size of the cysts on ultrasonography ranged from 3 to 9 cm with a mean of 5 cm. Twenty-two patients (88%) were successfully managed by operative laparoscopy and adnexectomy. Mean operative time was 70 minutes and mean postoperative hospital stay was 12 hours. Mean time of return to normal activity was 5 days. Three patients required laparotomy. We conclude that removal of these cystic adnexal masses by operative laparoscopy is an acceptable alternative in carefully selected postmenopausal women.

Adnexal Diseases↗
PubMed1990

Pure primary osteosarcoma of the ovary presenting as an extensively calcified adnexal mass: a case report and review of the literature.

A case of primary ovarian osteosarcoma is reported with a review of the literature. A perimenopausal woman presented with a calcific adnexal mass seen on abdominal radiography, surgical exploration revealed no gross evidence of metastatic disease. Adjuvant chemotherapy was administered due to the reported aggressiveness of this rare tumor. Following eight courses of cisplatin-doxorubicin combination chemotherapy, the patient is without evidence of disease. A differential diagnosis for extensively calcified adnexal masses is provided. Additionally, a rationale for adjuvant chemotherapy is discussed.

Adnexal Diseases↗
PubMed1990

Pretreatment serum levels of CA-125, carcinoembryonic antigen, tissue polypeptide antigen, and placental alkaline phosphatase, in patients with ovarian carcinoma, borderline tumors, or benign adnexal masses: relevance for differential diagnosis.

Pretreatment serum levels of the antigens CA-125, tissue polypeptide Antigen (TPA), carcinoembryonic antigen (CEA), and placental alkaline phosphatase (PLAP) were determined in samples from 295 women with adnexal masses. At laparotomy 48% of patients had epithelial ovarian carcinoma, 9% had tumors of low malignant potential, and 8% suffered from malignancies of other kinds. The sensitivity of CA-125 with 35 U/ml as the cutoff was 88% in women with ovarian carcinoma, but 74% among those with limited disease and 58% in borderline malignancy. Only 6 of 17 mucinous ovarian carcinomas were detected. Specificity was 83%. CEA was elevated above 5.0 micrograms/liter in 15 of 17 patients with mucinous ovarian cancer. TPA detected advanced stages of malignancy, but the sensitivity was low, 53%, in cases with limited disease. PLAP was elevated in 46% of ovarian carcinoma patients. For detecting malignancy overall, the use of a parallel combination of the CA-125 and CEA assays was more sensitive than use of CA-125 as a single marker. This test combination may be of value in the diagnosis of adnexal masses. The predictive value of a positive result was 90%, and that of a negative result, 76%.

Adnexal Diseases↗
PubMed2004

Benign adnexal masses in the adolescent.

Adnexal masses are common in adolescents. Certain conditions will require immediate intervention, including possible torsion, medically refractory tuboovarian abscess, intra-abdominal hemorrhage with hemodynamic instability, or possible ectopic pregnancy. Further evaluation of other masses, including additional imaging or tumor markers may be indicated, especially if masses are complex, solid, or have features characteristic of benign or malignant neoplasms. Otherwise, expectant management and surveillance allow for spontaneous resolution of most masses, especially cystic masses, and prevents unnecessary surgical intervention with its potential risks and sequelae. Laparoscopy can be done in many patients, and conservative, adnexal-sparing surgery should be encouraged when possible. In addition, physicians should be familiar with signs and symptoms of postoperative complications to allow for early diagnosis and intervention.

Adnexal Diseases↗
PubMed2004

Use of morphology to characterize and manage common adnexal masses.

The use of grey-scale ultrasound morphology to characterize a pelvic mass may also be called 'pattern recognition'. The grey-scale ultrasound image provides us with the same information as that obtained by the surgeon or pathologist when he or she cuts a surgical specimen to see what it looks like inside. Many pelvic masses have such a typical macroscopic appearance that a fairly confident diagnosis can be made on the basis of their macroscopic appearance alone, i.e. on the basis of their grey-scale ultrasound image. This is true of most dermoid cysts, endometriomas, corpus luteum cysts, hydrosalpinges and peritoneal pseudocysts, and of many paraovarian cysts and benign solid ovarian tumours, for example, fibromas, fibrothecomas, thecofibromas, thecomas and Brenner tumours. A mass with irregularities should always evoke suspicion of malignancy. A mass that is completely smooth is almost certainly benign. Papillary projections--considered a strong sign of malignancy--are more common in borderline tumours than in invasive cancers but may also be seen in benign tumours, for example, in adenofibromas. They explain many false-positive ultrasound diagnoses of malignancy. Pattern recognition is superior to all other ultrasound methods (e.g. simple classification systems, scoring systems, mathematical models for calculating the risk of malignancy) for discrimination between benign and malignant extrauterine pelvic masses. Today's often too liberal use of transvaginal ultrasound gives clinicians problems. Many adnexal masses that probably would have remained undetected before the ultrasound era are now found incidentally at transvaginal ultrasound examination in women without symptoms of an adnexal tumour. The natural history of incidentally detected pelvic masses with benign ultrasound morphology is not known. Therefore, the optimal management of such tumours is also unknown.

Adnexal Diseases↗
PubMed2006

Novel serum inflammatory markers in patients with adnexal mass who had surgery for ovarian torsion.

OBJECTIVE: To determine the diagnostic value of preoperative levels of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), interleukin-8 (IL-8), and E-selectin in patients with an adnexal mass who had surgery for ovarian torsion. DESIGN: Prospective study. SETTING: University hospital. PATIENT(S): Fifty consecutive women with adnexal mass who were admitted with a diagnosis of ovarian torsion. INTERVENTION(S): All had a single preoperative measurement of IL-6, IL-8, TNF-alpha, and E-selectin by ELISA. MAIN OUTCOME MEASURE(S): To determine if a single preoperative serum sampling of IL-6, IL-8, TNF-alpha, and E-selectin by ELISA can diagnose ovarian torsion. RESULT(S): Thirteen patients had proven torsion of the ovary. Serum levels of IL-6 were significantly higher in the 13 patients with proven ovarian torsion compared with the 37 without ovarian torsion. Patients with IL-6 serum values > or =10.2 pg/mL had a 16 times higher risk of having ovarian torsion. No significant difference was found in TNF-alpha, IL-8, and E-selectin between the two groups. CONCLUSION(S): The IL-6 levels might assist in the prompt diagnosis of ovarian torsion and allow a timely surgical intervention.

Adnexal Diseases↗
PubMed2006

Genistein attenuates postischemic ovarian injury in a rat adnexal torsion-detorsion model.

OBJECTIVE: To investigate the effects of genistein on reperfusion injury in a rat ovarian torsion-detorsion model. DESIGN: Controlled experimental study. SETTING: University animal research laboratory. SUBJECT(S): Thirty-two Wistar-Albino rats. INTERVENTION(S): The rats were divided into four groups. Sham operation was performed in group I. In group II, 5 mg/kg genistein was given intraperitoneally (IP) during laparotomy, and right ovaries were removed 4 hours later. In group III, right ovaries were subjected to 4 hours of adnexal ischemia by use of vascular clips, and after ischemic insult, 4 hours of reperfusion was maintained by removing the clips. In group IV, after the ischemic period, 5 mg/kg genistein was given IP, and 4 hours of reperfusion was maintained. Right ovaries were surgically removed at the end of the procedure in each group. MAIN OUTCOME MEASURE(S): Ovarian histopathologic findings were scored and compared among study groups. Serum and ovarian tissue malondialdehyde (MDA), glutathione peroxidase, and superoxide dismutase, levels were measured. RESULT(S): Ovarian tissue damage scores were significantly different among groups and were seen to correlate with ovarian tissue MDA levels. Genistein significantly decreased the tissue damage scores, ovarian tissue MDA levels, and serum MDA levels. CONCLUSION(S): Genistein attenuates ischemia-reperfusion injury in rat adnexal torsion-detorsion model.

Adnexal Diseases↗
PubMed2005

Asynchronous bilateral adnexal torsion in a 13-year-old adolescent: our experience of a rare case with review of the literature.

Adnexal torsion is a serious condition and delay in surgical intervention may result in loss of the tube and/or ovary. Children and adolescents who have suffered from uterine adnexal torsion may be at risk for asynchronous torsion of the contralateral uterine adnexa. We report the case of sequential bilateral torsion of uterine adnexa in a 13-year-old girl, resulting in right and subsequently left salpingo-oophorectomy because of gross evidence of total necrosis in both uterine adnexa. After the castration the patient was started on hormone replacement therapy. Families of children who suffered from ovarian torsion and unilateral ovarian loss should be educated about the risk of the contralateral ovary for future torsion and should be encouraged to seek immediate medical help with the recurrence of abdominal pain.

Adnexal Diseases↗
PubMed2006

Hydrosalpinx with adnexal torsion in an adolescent virgin patient--A diagnostic dilemma: case report and review of the literature.

Hydrosalpinx is one of the predisposing factors of adnexal torsion. However, because the incidence of hydrosalpinx in adolescent virgin patients is very rare, it may cause diagnostic dilemma, leading sometimes to suboptimal treatment. We present the case of an 18-yr-old female, not sexually active, presenting with acute lower right abdominal pain. The working diagnosis was of a simple ovarian cyst, so aspiration was performed. Abdominal symptoms reoccurred and sonography revealed a large hemorrhagic cystic mass adjacent to an edematous right ovary. The patient was referred to immediate laparoscopy due to suspected right adnexal torsion. On laparoscopy, the right adnexa was twisted three times causing an edematous ovary with a hematosalpinx. Detorsion was performed. Five weeks later, transabdominal ultrasound reviled normal bilateral ovaries and the hematosalpinx disappeared. In conclusion, hydrosalpinx, although very rare in adolescence, must be considered in the differential diagnosis. Aspiration in such cases is not the treatment of choice and moreover, it may cause complications.

Abdominal Pain↗
PubMed2005

Diagnostic accuracy of frozen section diagnosis of the adnexal mass: a metaanalysis.

BACKGROUND: Frozen section diagnosis is a diagnostic procedure for the assessment of the adnexal mass during surgery. The purpose of the present study was to perform a systematic review of the literature on the accuracy of frozen section diagnosis in the assessment of the adnexal mass. METHODS: We performed a computerized Medline and EMBASE search to identify all registered articles published between January 1966 and June 2003, comparing frozen section diagnosis of ovarian pathology to the final histopathological diagnosis. For each study, we calculated the prevalence of malignant and borderline tumors, and the sensitivity and specificity of the frozen section diagnosis using the final histopathological diagnosis as reference. We performed the calculations in two ways. In the first analysis, tumors that were found to be borderline were considered as malignant in the 2 x 2 table. In the second analysis, tumors that were found to be borderline were considered as benign in the 2 x 2 table. RESULTS: Eighteen studies were included for analysis. When the diagnosis borderline was classified as malignant, the sensitivity of frozen section diagnosis varied between 65% and 97%, and the specificity between 97% and 100%. When the diagnosis borderline was considered to be benign, the sensitivity varied between 71% and 100%, for a specificity varying between 98.3% and 100%. CONCLUSION: The accuracy of frozen section diagnosis for the assessment of the ovarian mass is good, with acceptable sensitivities for almost perfect specificities. Future studies on patient preferences for the different outcomes as well as economic analysis are needed for definite position of this diagnostic technique.

Adnexa Uteri↗
PubMed2005

Ultrasound characteristics of different types of adnexal malignancies.

OBJECTIVE: To describe ultrasound characteristics of adnexal malignancies, i.e., borderline ovarian tumors, primary invasive ovarian epithelial cancer stage 1, primary invasive ovarian epithelial cancer stages 2-4, rare types of malignancy, and metastatic tumors. METHODS: In a prospective international study involving nine European ultrasound centers, 1,066 women with a pelvic mass judged to be of adnexal origin underwent transvaginal gray scale and color Doppler ultrasound examination by a skilled examiner before surgery. A standardized examination technique and predefined definitions of ultrasound characteristics were used. RESULTS: Of 1,066 masses, 266 were malignant and are included: 55 ovarian borderline tumors, 144 primary invasive epithelial ovarian cancers (42 stage 1, 102 stages 2-4), 25 rare malignancies, and 42 metastatic tumors. Most (56%) metastatic tumors and most (60%) rare types of tumor were solid and richly vascularized at color Doppler ultrasound examination (on a scale ranging from 1 to 4, color score based on subjective evaluation was 3 or 4 in 88% and 86%, respectively). Borderline ovarian tumors and stage 1 primary invasive ovarian epithelial cancers differed from stages 2-4 primary invasive ovarian epithelial cancers: they were larger (median volume 375 ml and 695 ml vs. 209 ml; P = 0.0213 and 0.0001), a larger proportion contained papillary projections (64% and 67% vs. 41%; P = 0.0072 and 0.0054), they were more often multilocular cysts without solid components (18% and 14% vs. 2%; P < 0.0017 and 0.0204), but they were less often purely solid (5% and 7% vs. 38%; P <or= 0.0001 and 0.0005). With increasing degree of invasiveness - from borderline epithelial ovarian tumors via stage 1 invasive epithelial ovarian tumors to stages 2-4 invasive epithelial ovarian tumors - ascites became more common (9% vs. 31% vs. 61%; P = 0.0082, <0.0001, and 0.0017), and, among tumors with solid components (n = 179), the proportion of tumor consisting of solid tissue increased (median 2%-10%-34%; P = 0.0212, <0.0001, and 0.0003). CONCLUSION: Papillary projections are characteristic of borderline tumors and stage 1 primary invasive epithelial ovarian cancer. A small proportion of solid tissue at ultrasound examination makes a malignant mass more likely to be a borderline tumor or a stage 1 epithelial ovarian cancer than an advanced ovarian cancer, a metastasis, or a rare type of tumor.

Adnexal Diseases↗
PubMed1984

Patterns of adnexal inflammatory damage: Chlamydia, the intrauterine device, and history of pelvic inflammatory disease.

In a study of 204 consecutive infertile couples, 58 women with adnexal abnormalities consistent with prior pelvic infection were identified. The status of those 58 subjects with respect to prior pelvic infection, prior intrauterine device use, and serologic evidence of past chlamydial infection was correlated with the types of adnexal abnormalities identified. Women with serologic evidence of past chlamydial infection were more likely to exhibit severe adhesions and hydrosalpinx formation, and hydrosalpinx formation was related to a history of clinically detected pelvic infection.

Chlamydia Infections↗
PubMed1999

Transvaginal color Doppler ultrasonography and CA-125 in suspicious adnexal masses.

OBJECTIVE: To compare diagnostic performance of color Doppler ultrasound and CA-125 in suspicious adnexal masses on B-mode sonography. MATERIALS AND METHODS: Data on 94 patients (mean age: 47.4 years, range: 17-79 years. Fifty-two (55.3%) premenopausal and 42 (44.7%) postmenopausal women) managed in our institution because of a suspicious adnexal mass were reviewed. All patients were evaluated by transvaginal color Doppler ultrasonography (CD) and serum CA-125 level determination prior to surgery. Definitive histopathological diagnosis was obtained in each case. Sonographic morphology evaluation was suspicious in all cases. CD was considered as suspicious when flow was detected and the lowest RI found was < or = 0.45. CA-125 cut-off was > or = 35 UI/ml. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each method and compared. ROC analysis was performed for RI and CA-125. Areas under curve (AUC) were calculated and compared. RESULTS: Fifty-six (59.6%) tumors were found to be malignant and 38 (40.4%) benign. Sensitivity, specificity, PPV and NPV for CD were 87.5% (95% CIs: 75.3-94.4), 84.2% (95% CIs: 68.7-94), 89.1% (95% CIs: 77.7-95.9) and 82.1% (95% CIs: 66.5-92.5), respectively. Sensitivity, specificity, PPV and NPV for CA-125 were 83.9% (95% CIs: 71.7-92.4), 68.4% (95% CIs: 51.3-82.5), 79.7% (95% CIs: 66.2-89) and 74.3% (95% CIs: 56.7-87.5), respectively. Sensitivity, PPV and NPV were not statistically different. CD had higher specificity (P = 0.01). AUC curve for Doppler (0.75) was significantly higher than for CA-125 (0.61) (P = 0.0002). CONCLUSIONS: Our results indicate that color Doppler ultrasound has a better diagnostic performance as compared with CA-125, being significantly more specific.

Adnexal Diseases↗
PubMed1989

Adnexal torsion in children.

Adnexal torsion is rare in children and is usually reported as small series or case reports. We reviewed a series of 19 consecutive cases of children aged 3 to 19 years (mean, 9.6 years) who were treated in our institution between 1977 and 1988. Thirteen patients presented with torsion of a previously normal adnexa, while six presented with torsion of a diseased adnexa. The right adnexa was involved in 84% of cases. Detorsion with recovery of vascularization of the adnexa was possible in only four cases. All patients presented with lower abdominal pain, and onset was sudden in 78% of cases with an average of 5.2 days between the first symptom and hospital admission and a mean delay of 30.2 hours between consultation and surgical intervention. A previous history of abdominal pain was present in nine cases. Nausea or vomiting were present in 84% of cases. An abdominal mass was palpable in 42% of the patients and was associated with a delay in surgical intervention. Ultrasound confirmed the presence of a mass in 94% of cases. The preoperative diagnosis was accurate in 37% of cases, and the most common inaccurate diagnosis was appendicitis or appendiceal abcess. Our series confirms the predominance of right-sided lesions as reported in the literature. It is not clear whether this is an anatomic phenomenon or whether the suspicion of appendicitis leads to the more frequent diagnosis of right-sided lesions, whereas many left-sided adnexal torsions are being missed. We therefore advocate pelvic ultrasound in female patients who present with left lower quadrant pain.(ABSTRACT TRUNCATED AT 250 WORDS)

Adnexal Diseases↗