Differential Diagnosis Of Adnexal Masses Research Articles

Differential diagnosis of adnexal masses: risk of malignancy index, ultrasonography, magnetic resonance imaging, and radioimmunoscintigraphy

A risk of malignancy index (RMI), based on menopausal status, ultrasound (US) findings, and serum CA125, has previously been described and validated in the primary evaluation of women with adnexal masses and is widely used in selective referral of women from local cancer units to specialized cancer centers. Additional imaging modalities could be useful for further characterization of adnexal masses in this group of women. A prospective cohort study was conducted of 196 women with an adnexal mass referred to a teaching hospital for diagnosis and management. Follow-up data was obtained for 180 women; 119 women had benign and 61 women malignant adnexal masses. The sensitivity and specificity of specialist US, magnetic resonance imaging (MRI), radioimmunoscintigraphy (RS), and the RMI were determined. We identified a subgroup of women with RMI values of 25-1000 where the value of further specialist imaging was evaluated. Sensitivity and specificity for specialist US were 100% and 57%, for MRI 92% and 86%, and for RS 76% and 87%, respectively. Analysis of 123 patients managed sequentially, using RMI cutoff values of > or =25 and <1000 and then US and MRI provided a sensitivity of 94% and a specificity of 90%. Using this RMI cutoff followed by specialist US and MRI, as opposed to the traditional RMI cutoff value of 250, can increase the proportion of patients with cancer appropriately referred in to a cancer center, with no change in the proportion of patients with benign disease being managed in a local unit.

Using logistic regression analysis in preliminary differential diagnosis of adnexal masses

Using logistic regression analysis in preliminary differential diagnosis of adnexal masses

Using logistic regression analysis in preliminary differential diagnosis of adnexal masses

The aim of our study was to generate predictive model, which would allow to estimate the influence of analyzed parameters on predictive accuracy of differential diagnosis of adnexal masses and to evaluate prospectively diagnostic efficacy of the statistic model in the new set of patients. A total of 686 women diagnosed and surgically treated in the Gynecological and Obstetrical Teaching Hospital of University of Medical Sciences in Poznan, Poland, were recruited into the study. Preoperative diagnostics included gynecological examination, ultrasonographic evaluation, tumor Doppler blood flow analysis, and serum levels of CA125 and TPS. In order to find the best combination of features and to calculate the individual probability of the malignancy, stepwise logistic regression analysis with quasi-Newton estimation was applied. The essential part of the best prognostic model, described by foregoing variables, is as follows: [z = -6.005 + 0.058 x age + 1.174 x septa + 1.317 x tumor localization + 1.185 x ascites + 2.28 x solid element + 2.429 x vessels localization -2.386 x PI + 0.084 x MEDV]. The highest sensitivity and specificity for the obtained model were 87.84% and 93.74%, respectively. Prognostic model, constructed with the use of logistic regression analysis, is characterized by higher sensitivity and specificity than individually applied diagnostic tests. Prospective evaluation of this model application in a larger group of patients with adnexal masses will enable precise assessment of its objective clinical usefulness.

Multiloculated peritoneal inclusion cyst treated successfully with laparoscopic surgery

Background: Multiloculated peritoneal inclusion cysts or benign cystic mesotheliomas are most commonly found in women of reproductive years; the disease involves the abdomen, pelvis and retroperitoneum. Case: A 33-year-old, para 3-0-0-3, Thai woman presented to the hospital upon an incidental finding of left ovarian cyst and a mild pelvic pain for three months. Her pelvic examination revealed left ovarian cyst. Transvaginal ultrasonogram demonstrated a multiloculated cyst size 61×40×55 mm3 adherent to the normal left ovary. Laparoscopic surgery was performed. There was a multiloculated cyst 6 cm in diameter in the left pelvic cavity. The cyst was excised and the histopathology revealed inclusion cysts. She was well at discharge and throughout the four-week and six-month follow-up periods. Conclusion: Although multiloculated peritoneal inclusion cyst is uncommon, it should be included in the differential diagnosis of adnexal masses. Surgical excision remains the current recommended treatment for symptomatic disease. Surgical excision by laparoscopy might be an alternative method for successful management.

Solitary fibrous tumor arising in the fallopian tube

Background Solitary fibrous tumor (SFT) is an uncommon neoplasm that usually arises in the pleura. Although this tumor has been described at other sites, in the female genital tract it is extremely uncommon. Case We present a case of solitary fibrous tumor arising in the fallopian tube. A 32-year-old woman who presented with acute flank pain had a presumptive diagnosis of leiomyoma of the fallopian tube after abdominopelvic ultrasound. The adnexal mass was excised laparoscopically. Histologic examination showed the characteristic features of a solitary fibrous tumor. Conclusion Although rare, the diagnosis of solitary fibrous tumor can be considered in the differential diagnosis of adnexal masses.

The value of detection of normal ovarian tissue (the ‘ovarian crescent sign’) in the differential diagnosis of adnexal masses

The aim of the study was to evaluate whether the presence of normal ovarian tissue adjacent to an adnexal tumor (the 'ovarian crescent sign') could assist in the preoperative differential diagnosis of adnexal lesions. This was a prospective observational study including 100 women with a preoperative diagnosis of an adnexal mass. Demographic and biochemical data were collected and all women underwent a detailed transvaginal ultrasound scan. Tumor volume, morphological characteristics and Doppler features were recorded in each case. In addition, the tissue adjacent to the cyst was systematically examined for the presence of normal ovarian tissue. All the findings were compared to the final histological diagnosis. Sixty-seven (67%) of the cysts removed were benign, nine (9%) were borderline and 24 (24%) women had invasive malignant lesions. Normal ovarian tissue was seen in 58/76 (76%) women with non-invasive lesions, and in one woman (4%) with an invasive malignancy. In the absence of normal ovarian tissue, ovarian cancer was diagnosed with a sensitivity of 96% and specificity of 76%. The presence of normal ovarian tissue adjacent to an ovarian cyst is a useful morphological feature that may be used to help exclude an invasive ovarian malignancy in women with adnexal masses detected on ultrasound scan.

Ovarian cancer: the clinical role of US, CT, and MRI.

This article presents an overview of ovarian cancer, which addresses the clinical roles of imaging studies, including US, CT, and MR imaging in the course of diagnosis and treatment of this important disease. US is the modality of choice in the evaluation of patients with suspected adnexal masses. Although its accuracy is not sufficient to avert surgery, morphological analysis of adnexal masses with US helps narrow the differential diagnosis, determining the degree of suspicion for malignancy, usually in concert with a serum CA-125 level. Combined morphological and vascular imaging obtained by US appear to further improve the preoperative assessment of adnexal masses. For uncertain or problematic cases, MR imaging helps to distinguish benign from malignant, with an overall accuracy for the diagnosis of malignancy of 93%. The accuracy of MR imaging in the confident diagnosis of mature cystic teratoma, endometrial cysts, and leiomayomas is very high. CT is not indicated for differential diagnosis of adnexal masses because of poor soft tissue discrimination, except for fatty tissue and for calcification, and the disadvantages of irradiation. In the staging of ovarian cancer, CT, US, and MR imaging all have a similarly high accuracy. Although it is difficult to suggest a simple algorithm for evaluating the state of women with adnexal masses, the correct preoperative diagnosis and staging of ovarian cancer with the use of any of these imaging studies will lead to an appropriate referral to a specialist in gynecologic oncology and offer a significant survival advantage for patients with ovarian cancer.

Radioimmunoscintigraphy with Tc-99m-labelled SM3 in differentiating malignant from benign adnexal masses

Objective Ultrasound scanning, serum CA125 and menopausal status have previously been combined in a risk of malignancy index for the differential diagnosis of adnexal masses. Although this approach has greater accuracy than either individual tests or clinical assessment, it has a significant false positive and false negative rate. Efforts have been directed at refining differential diagnosis and this study assessed the role of radioimmunoscintigraphy using the stripped mucin 3 (SM3) antibody that has a 17-fold greater uptake in malignant than benign ovarian tumours in vitro. Design Prospective study of patients with a pelvic mass using radioimmunoscintigraphy. Setting Department of Nuclear Medicine of St Bartholomew's Hospital in collaboration with Cancer Network. Population A total of 93 patients with pelvic masses were recruited for this study of which 32 had ovarian cancer and 61 had benign lesions. Methods Radioimmunoscintigraphy was performed with Tc-99m-labelled SM3 (600 MBq), anterior and posterior pelvis imaged at 10 minutes and at 4 and 24 hours and evaluated with change detection analysis and probability mapping. Main outcome measures Sensitivity and specificity of radioimmunoscintigraphy for ovarian cancer. Results Radioimmunoscintigraphy had a sensitivity for ovarian cancer of 84% (27 true positive and 5 false negatives) and a specificity of 87% (53 true negatives and 8 false positives) giving a negative predictive value of 91%. Conclusion These results suggest that radioimmunoscintigraphy could be used to reduce the number of false positive findings in a strategy to refine differential diagnosis of the pelvic mass.

Radioimmunoscintigraphy with Tc‐99m‐labelled SM3 in differentiating malignant from benign adnexal masses

Ultrasound scanning, serum CA125 and menopausal status have previously been combined in a risk of malignancy index for the differential diagnosis of adnexal masses. Although this approach has greater accuracy than either individual tests or clinical assessment, it has a significant false positive and false negative rate. Efforts have been directed at refining differential diagnosis and this study assessed the role of radioimmunoscintigraphy using the stripped mucin 3 (SM3) antibody that has a 17-fold greater uptake in malignant than benign ovarian tumours in vitro. Prospective study of patients with a pelvic mass using radioimmunoscintigraphy. Department of Nuclear Medicine of St Bartholomew's Hospital in collaboration with Cancer Network. A total of 93 patients with pelvic masses were recruited for this study of which 32 had ovarian cancer and 61 had benign lesions. Radioimmunoscintigraphy was performed with Tc-99m-labelled SM3 (600 MBq), anterior and posterior pelvis imaged at 10 minutes and at 4 and 24 hours and evaluated with change detection analysis and probability mapping. Sensitivity and specificity of radioimmunoscintigraphy for ovarian cancer. Radioimmunoscintigraphy had a sensitivity for ovarian cancer of 84% (27 true positive and 5 false negatives) and a specificity of 87% (53 true negatives and 8 false positives) giving a negative predictive value of 91%. These results suggest that radioimmunoscintigraphy could be used to reduce the number of false positive findings in a strategy to refine differential diagnosis of the pelvic mass.

Ectopic pregnancy after cesarean hysterectomy

BACKGROUND: Ectopic pregnancy after a total abdominal hysterectomy is rare and, for this reason, delay in diagnosis may occur when such a patient presents with abdominal pain. CASE: A multiparous patient with a history of cesarean hysterectomy 12 years before presented to the emergency department with abdominal pain and incidental positive urine beta-human chorionic gonadotrophin (hCG). A computed tomography scan revealed a loculated left cystic mass in the pelvis. Laparotomy findings revealed a left adnexal mass; pathology revealed chorionic villi consistent with pregnancy. CONCLUSION: Ectopic pregnancy may occur after hysterectomy, but typically presents near the time of surgery and is more commonly associated with vaginal hysterectomy. However, because ectopic pregnancy is possible after hysterectomy, it should be considered in the differential diagnosis of adnexal mass in such a patient.

Brenner tumor of the ovary with extensive stromal luteinization presenting in pregnancy: report of a case and review of the literature

Brenner tumor in pregnancy is rare, with only two reported cases in association with intrauterine pregnancy. A 30-year-old woman, G1P0, was found to have an adnexal mass at 15 weeks of gestation. The masswas resected at Cesarean section and found to be a Brenner tumor with areas of stromal luteinization. Brenner tumor should be considered in the differential diagnosis of adnexal masses presenting duringpregnancy. The stromal luteinization was probably related to the hormonal environment of the pregnancy.

WS09‐04Ultrasound diagnosis of adnexal masses: computer modelling

The differential diagnosis of adnexal masses still represents a challenge. The main goal is to determine whether a given mass is malignant or benign, in order to establish the best therapautical approach. When a clinician face to a woman diagnosed as having an adnexal tumor several parameters may be used to determine the nature of the mass, such as patient's age, menopausal status, clinical complaints, physical examination, tumor's sonographic and Doppler features and serum tumor markers. When these data are collected may be difficult to interpret them all together and the clinician has to rely in one or two of them to predict the diagnosis and to decide the management strategy, guided many times by own experience or strict protocols.A possible solution to this question may be the use of computer modelling. This means the use of statistical or mathematical models developed, using computer aid, to predict adnexal malignancy.Currently, there are two methods that may be used: Multiple Logistic Regression Analysis (MLRA) and Artificial Neural Networks (ANN).Both techniques allow to calculate the probability of a particular event has occurred, in this case a mass to be malignant or benign.By computer modelling, actual independent predictors parameters are identified and may be used combined and simultaneously to predict malignancy. Each method has advantages and disadvantages, being MLRA the statistical technique of choice and ANN a potential newer alternative to MLRA.Several studies have been published using one or both technique to predict adnexal malignancy. The results of these studies are encouraging showing a high diagnostic performance. All studies comparing MLRA to ANN showed the latter seems to be superior. However, it should be taken into account that most of these models have not tested prospectively.

CYFRA 21-1 serum levels in women with adnexal masses and inflammatory diseases.

The aim of the present study was to evaluate the clinical usefulness of the cytokeratin marker CYFRA 21-1 as a screening marker for ovarian cancer, as a predictive marker in patients with adnexal masses and as a prognostic marker in women suffering from ovarian cancer. In order to determine the specificity of the CYFRA 21-1 test, we have investigated CYFRA 21-1 serum levels in several benign conditions. This retrospective study comprises 37 patients suffering from ovarian cancer FIGO stages Ia-III. Sera from patients with benign ovarian cysts, endometriosis, pelvic inflammatory disease, inflammatory bowel disease and liver cirrhosis were evaluated in 90, 10, 38, 10 and 20 cases respectively. With a sensitivity of 41% and a specificity of 95%, CYFRA 21-1 was not suitable as a screening marker for ovarian cancer. Although CYFRA 21-1 was able to discriminate between ovarian cancer and benign adnexal tumours (univariate regression model, P = 0.0001), CYFRA 21-1 did not reveal additional information to CA 125 in a multivariate regression analysis (P = 0.06). CYFRA 21-1 serum levels were elevated in benign conditions such as liver cirrhosis, but not in endometriosis and inflammatory diseases. In ovarian cancer patients, elevated CYFRA 21-1 serum levels before therapy were associated with a poor overall and disease-free survival (log-rank test, P = 0.02 and log-rank test, P = 0.005 respectively). CYFRA 21-1, while obviously not suitable for screening or differential diagnosis of adnexal masses, could be useful as an additional prognostic factor in ovarian cancer patients.

M3/M21 serum levels in women with adnexal masses and inflammatory diseases.

The aim of the present study was to evaluate the clinical usefulness of the cytokeratin tumor marker M3/M21 as a screening marker for ovarian cancer, as a predictive marker in patients with adnexal masses and as a prognostic factor in women with ovarian cancer. To determine the specificity of the M3/M21 test, we investigated M3/M21 serum levels in several benign conditions. This retrospective study comprises 37 patients with ovarian cancer FIGO stages Ia to III. Sera of patients with benign cysts, endometriosis, pelvic inflammatory disease, inflammatory bowel disease and liver cirrhosis were evaluated in 90, 10, 38, 10 and 20 cases, respectively. With a sensitivity of 57% and a specificity of 95%, M3/M21 is not suitable as a screening marker for ovarian cancer. Although M3/M21 is able to discriminate between ovarian cancer and benign adnexal tumors (univariate logistic regression, p = 0.0003), M3/M21 does not provide information additional to CA 125. M3/M21 serum levels are elevated in several benign conditions such as liver cirrhosis and inflammatory bowel disease. In ovarian cancer patients, elevated M3/M21 serum levels prior to therapy were associated with poor overall and disease-free survival (log-rank test, p = 0.03; log-rank test, p = 0.01, respectively). M3/M21, while obviously not suitable for screening or differential diagnosis of adnexal masses, could be useful as an additional prognostic factor in ovarian cancer patients.

Concentration of vascular endothelial growth factor (VEGF) in the serum of patients with suspected ovarian cancer.

As a promoter of angiogenesis, vascular endothelial growth factor (VEGF) is believed to play a pivotal role in tumour growth and metastasis. The aim of this study was to determine the value of preoperative serum VEGF levels in the early diagnosis of ovarian cancer and in the differential diagnosis of adnexal masses. We examined preoperative serum VEGF levels in healthy women (n = 131), patients with benign ovarian cysts (n = 81) and in ovarian cancer patients (n = 44) by using an ELISA (R&D Systems, Minneapolis, MN, USA). A logistic regression model was carried out to determine the influence of VEGF and CA 125 on the probability of malignancy. VEGF revealed a significant influence on the odds of presenting with malignancy vs healthy women (P = 0.001). At 363.7 pg ml(-1), VEGF achieved a sensitivity of 54% and a specificity of 77%. With respect to the differentiation between benign cysts and ovarian cancer, CA 125 (P < 0.0001) but not VEGF (P = 0.229) predicts the presence of malignancy in a multivariate model. In conclusion, VEGF does not appear to be a useful tool in the early diagnosis of ovarian cancer or for indicating the absence or presence of malignancy in patients with an adnexal mass.

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 CA 125 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 diagnostic accuracy of transvaginal sonography was significantly higher than that of PI measurement (73%,P< 0.002) and serum CA 125 assay (87%,P< 0.05). In postmenopause, 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.

Imaging features of ovarian metastases from colonic adenocarcinoma in adolescents.

This paper describes the imaging features of ovarian metastases from adenocarcinoma of the colon in adolescent females. We reviewed retrospectively abdominal and pelvic computed tomographic and pelvic ultrasound examinations, histologic slices, and clinical charts of six adolescent females with ovarian metastases secondary to adenocarcinoma of the colon. One patient had ovarian metastasis at presentation and was presumed to have a primary ovarian tumor. The ovarian metastases were either solid (n = 3), complex with both solid and cystic components (n = 2), or multilocular cysts (n = 1). The ovarian lesions were large, ranging from 6 cm to 18 cm in diameter. Colorectal carcinoma in adolescent females is frequently associated with ovarian metastases. One imaging characteristic differs in adult and adolescent ovarian metastases, although they do have features in common: in adolescents, a smaller proportion of colorectal ovarian metastases are multicystic (17%) compared with the adult series (45%). These lesions are frequently large and may be complex, multicystic, or solid. Although it is a rare disease, the differential diagnosis of adnexal masses in adolescent females should include ovarian metastases from adenocarcinoma of the colon.

Surgically treated adnexal masses in infancy, childhood, and adolescence

OBJECTIVE: We retrospectively evaluated the clinical presentation and histopathologic findings of benign and malignant adnexal masses in infants, children, and adolescents. STUDY DESIGN: Between 1955 and 1992, 486 patients (aged 7 days through 20 years) with adnexal masses were surgically evaluated. RESULTS: Of 521 adnexal masses, 92% were benign, including 335 nonneoplastic and 144 of 186 (77%) neoplastic lesions. The frequency of ovarian malignancies correlated inversely with patient age. Germ cell, stromal, and epithelial malignancies accounted for 40%, 21%, and 33%, respectively, of the 42 cancers. Nonconcordance between preoperative and postoperative diagnoses was noted in 94 cases. The most common preoperative diagnosis necessitating reassignment was acute appendicitis. During the last decade of this study, ultrasonography and computed tomography missed no malignancies. CONCLUSION: Physicians who care for young girls must be familiar with the differential diagnosis of adnexal masses to advise conservative management when appropriate and surgical intervention when necessary. (AM J Obstet Gynecol 1994;170:1780-9.)

Surgically treated adnexal masses in infancy, childhood, and adolescence

We retrospectively evaluated the clinical presentation and histopathologic findings of benign and malignant adnexal masses in infants, children, and adolescents. Between 1955 and 1992, 486 patients (aged 7 days through 20 years) with adnexal masses were surgically evaluated. Of 521 adnexal masses, 92% were benign, including 335 nonneoplastic and 144 of 186 (77%) neoplastic lesions. The frequency of ovarian malignancies correlated inversely with patient age. Germ cell, stromal, and epithelial malignancies accounted for 40%, 21%, and 33%, respectively, of the 42 cancers. Nonconcordance between preoperative and postoperative diagnoses was noted in 94 cases. The most common preoperative diagnosis necessitating reassignment was acute appendicitis. During the last decade of this study, ultrasonography and computed tomography missed no malignancies. Physicians who care for young girls must be familiar with the differential diagnosis of adnexal masses to advise conservative management when appropriate and surgical intervention when necessary.

Accessory spleen presenting as adnexal mass

Pelvic splenic ectopia is a very rare entity, often unsuspected preoperatively. We report a case of an ectopic spleen presenting as an adnexal mass in a middle-aged woman. Diagnosis was achieved intraoperatively, and confirmed pathologically. Pelvic ectopic spleen should be considered in the differential diagnosis of adnexal masses.