Preoperative Transvaginal Sonography Research Articles

Clinical and ultrasound characteristics of deep endometriosis affecting sacral plexus.

To describe the sonomorphological changes and appearance of deep endometriosis (DE) affecting the nervous tissue of the sacral plexus (SP). This was a retrospective study of symptomatic patients who underwent radical resection of histologically confirmed DE affecting the SP and who had undergone preoperative transvaginal sonography (TVS) between 2019 and 2023. Lesions were described based on the terms and definitions of the International Deep Endometriosis Analysis (IDEA), International Ovarian Tumor Analysis (IOTA) and Morphological Uterus Sonographic Assessment (MUSA) groups. A diagnosis of DE affecting the SP on TVS was made when the sonographic criteria of DE were visualized in conjunction with fibers of the SP and the presence of related symptoms corresponding to sacral radiculopathy. Clinical symptoms, ultrasound features and histological confirmation were analyzed for each patient included. Twenty-seven patients with DE infiltrating the SP were identified in two contributing tertiary referral centers. Median age was 37 (range, 29-45) years and all patients were symptomatic and presented one or more of the following neurological symptoms: dysesthesia in the ipsilateral lower extremity (n = 17); paresthesia in the ipsilateral lower extremity (n = 10); chronic pelvic pain radiating in the ipsilateral lower extremity (n = 9); chronic pain radiating in the pudendal region (n = 8); and motor weakness in the ipsilateral lower extremities (n = 3). All DE lesions affecting the SP were purely solid tumors in the posterior parametrium in direct contact with, or infiltrating, the S1, S2, S3 and/or S4 roots of the SP. The median of the largest diameter recorded for each of the DE nodules was 35 (range, 18-50) mm. Echogenicity was non-uniform in 23 (85%) of the DE nodules, with all but one of these nodules containing hyperechogenic areas. The shape of the lesions was irregular in 24 (89%) cases. Only one lesion exhibited a lobulated form, with all other irregular lesions showing a spiculated appearance. An acoustic shadow was produced in 20 (74%) of the nodules, all of which were internal. On color- or power-Doppler examination, 21 (78%) of the nodules showed no signal (color score of 1). The remaining six (22%) of the lesions showed a minimal color content (color score of 2). According to pattern recognition, most DE nodules were purely solid, non-uniform, hypoechogenic nodules containing hyperechogenic areas, with internal shadows and irregular spiculated contours, and were poorly vascularized on color/power-Doppler examination. The ultrasound finding of a parametrial, unilateral, solid, non-uniform, hypoechogenic nodule with hyperechogenic areas and possible internal shadowing, as well as irregular spiculated contours, demonstrating poor vascularization on Doppler examination in proximity to or involving the structures of the SP, indicates DE affecting the SP. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prediction of preterm birth by measurement of cervical length on transvaginal ultrasound and magnetic resonance imaging in pregnancies complicated by twin-twin transfusion syndrome and treated with laser surgery.

Twin pregnancies complicated by twin-twin transfusion syndrome (TTTS) are at particularly high risk of preterm birth. Cervical length (CL) measurement on transvaginal ultrasound (TVS) is a powerful predictor of preterm birth, but the predictive accuracy of CL measurement on magnetic resonance imaging (MRI) has not yet been established. We sought to investigate the correlation between CL measurements obtained on preoperative TVS and on MRI and to quantify their predictive accuracy for preterm birth among pregnancies complicated by TTTS that underwent selective fetoscopic laser photocoagulation (SFLP), to identify whether MRI is a useful adjunct to TVS. This was a retrospective cohort study of pregnancies that were treated for TTTS with SFLP at a single center between April 2010 and June 2019 and that underwent TVS and MRI evaluation. Correlation was estimated using Pearson's coefficient, mean CL measurements were compared using the two-tailed paired t-test and the frequency at which a short cervix was detected by the two imaging modalities was compared using the χ-square test. Generalized linear models were used to estimate relative risk and receiver-operating-characteristics (ROC)-curve analysis was used to estimate the predictive accuracy of CL for preterm birth. Among 626 pregnancies complicated by TTTS that underwent SFLP, CL measurements were obtained on preoperative TVS in 579 cases and on preoperative MRI in 434. CL ≤ 2.5 cm was recorded in 39 (6.7%) patients on TVS and 47 (10.8%) patients on MRI (P = 0.0001). Measurements of CL made on MRI correlated well with those obtained on TVS overall (r = 0.63), but correlation was weak at the shortest CLs (r < 0.20). MRI failed to detect two (40.0%), three (18.8%), nine (32.1%) and 13 (28.9%) cases diagnosed as having a short cervix on TVS at cut-offs of ≤ 1.5 cm, ≤ 2.0 cm, ≤ 2.5 cm and ≤ 2.8 cm, respectively. Over half of the pregnancies with a preoperative CL of ≤ 2.5 cm delivered by 28 weeks' gestation, regardless of imaging modality. CL measurement on TVS was superior to that on MRI to predict preterm birth, the latter performing poorly at all CL cut-offs. A CL measurement of ≤ 2.0 cm on preoperative TVS had the highest predictive ability for preterm birth, with an area under the ROC curve for delivery before 32 weeks of 0.82. Although measurement of CL on MRI correlates well with that on TVS overall, it performs poorly at accurately detecting a short cervix. TVS outperforms MRI in evaluation of the cervix and remains the optimal modality for CL measurement in pregnancies at high risk for preterm birth, such as those undergoing SFLP for TTTS. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasonography, macroscopy, and frozen section: whıch is better for predicting deep myometrial invasıon in endometrial cancer?

The aim of this study was to compare the power of preoperative transvaginal ultrasonography, intraoperative macroscopic examination, and frozen section for predicting deep myometrial invasion in endometrial cancer. This is a retrospective review involving 68 patients who underwent surgical staging for endometrial cancer from 2014 to 2017. Patients with grade 3 endometrial cancer and non-endometrioid tumors were excluded. The findings related to preoperative transvaginal ultrasonography, intraoperative macroscopic examination, and frozen section were compared with definitive histopathological diagnosis. The mean age, gravidity, and body mass index of the patients were 58.1±8.9 years (range: 30-80 years), 3.2±2.1 (range: 0-9), and 33.5±6.6 kg/m2 (range: 20-52 kg/m2), respectively. Only 11 (16.2%) patients were in the premenopausal period, while 57 (83.8%) were in the postmenopausal period. Grade 1 endometrial cancer was found in 29 patients (42.6%) and grade 2 tumors were specified in 39 patients (57.4%). Stage IA disease was found in 45 (66.2%) patients, while stage IB disease was observed in 23 (33.8%) patients. The 5-year survival rate was 91.2%. The sensitivity of preoperative transvaginal ultrasonography, intraoperative macroscopic examination, and frozen section were 56, 34, and 52%, respectively, for predicting deep myometrial invasion. In contrast, the specificity of preoperative ultrasonography, intraoperative macroscopic examination, and frozen section were 86, 100, and 100%, respectively. Transvaginal ultrasonography and intraoperative frozen section were found to have similar sensitivity and specificity for predicting deep myometrial invasion. Preoperative transvaginal ultrasonography appears as an efficient approach for predicting endometrial cancers with deep myometrial invasion.

Assessing The Role and Accuracy of Ultrasonographic Imaging in The Diagnosis of Deep Infiltrating Endometriosis: A Cross-Sectional Study.

Deep infiltrating endometriosis (DIE) is described as an endometriotic tissue that penetrates more than 5 mm under the peritoneal surface. It's suggested that trans vaginal sonography (TVS) is 79% sensitive and 94% specific in the assessment of intestinal DIE. Considering the possibility that DIE ultrasonography (rectal and\or vaginal ultrasonography) might be more accurate, we designed this study to assess this study to evaluate the accuracy of DIE ultrasonography. In this retrospective cross-sectional study, we designed and conducted this study from 2019 to 2020 on patients suspected of severe endometriosis. Our patients underwent ultrasonographic imaging and based on the results became candidates for surgery. We compared histopathological results with sonographic findings using crosstabulation and chi-square tests were used to measure accuracy. P<0.05 were considered statistically significant. Following pathological assessments of 109 cases, 97 cases had ovarian endometrioma, 42 cases had intestinal involvement and 56 cases had uterosacral DIE. The results for accuracy were as the following; uterosacral ligament (USL) involvement SE: 96.4% and SP: 59.1%; intestinal involvement SE: 97.6% and SP: 73.8%; and Cul de sac involvement with SE: 100% and SP: 50.8%. With regards to ovarian endometrioma, ultrasonographic imaging was 99.0% sensitive and 84.6% specific. With regards to intestinal involvement, ultrasonography performed a reliable overall diagnosis (97.6% sensitive and 73.8% specific). However, the results showed lower accuracy regarding the level of intestinal involvement. The accuracy for other sites and cavities was low except for ovarian endometrioma. The results of the present study demonstrated that pre-operative TVS and Transrectal ultrasound (TRUS) can be a helpful paraclinical tool in the assessment and diagnosis of DIE and endometriosis in general and particularly with adnexal and bowel lesions, it can have some shortcomings with respect to cul de sac and USLs.

Comparison Between Sonography-Based and Surgical Evaluation of Endometriotic Lesions Using the #Enzian Classification - A Retrospective Data Analysis.

To compare the location and sizes of deep endometriosis (DE) lesions evaluated by preoperative transvaginal sonography (TVS) in different #Enzian compartments with intraoperatively assessed DE location and size. Retrospective data analysis of 93 women undergoing TVS and surgery for DE in 2019 at a tertiary referral center for endometriosis. #Enzian compartment C (rectum) showed the highest rate of exact concordance with 74% of cases, which increased to 87% when a tolerance margin of a maximum of 3mm for TVS measurements was taken into account. For compartment B (uterosacral ligaments, parametria) and compartment A (vagina, rectovaginal space), the rates of exact concordance were slightly lower. In compartment O (ovary), high exact concordance rates similar to those observed for compartment C were observed. In compartment T (tubo-ovarian unit), most reliable estimations were seen for slight (TVS T1) and severe adhesions (TVS T3). There were only a few cases of missed lesions as well as false positives on TVS: Sensitivity was 100% for all compartments except for A and B left (97%) and FB (urinary bladder, 86%); specificity was 100% for FB, FI (other intestinal locations), FU (ureters) and O right, 86%-98% for A, B right, C, O left and FO (other extragenital lesions) and 70% for B left. The preoperative evaluation of the location and size of DE lesions by TVS in different #Enzian compartments is accurate, providing a detailed presurgical description of the extent of ovarian and deep endometriosis and associated minor or severe adhesions.

A Comparative Study of Transvaginal Sonography and Pelvic MRI in Patients with Endometrial Cancer

Background: The most prevalent type of gynecological cancer is endometrial cancer. Accurate surgical staging is the most important aspect in the management of endometrial cancer. Preoperative evaluation of myometrial invasion and appropriate management could be achieved by transvaginal sonography and pelvic MRI. Methods: A total of 53 patients with endometrial cancer, who were referred to a gynecology oncology department of an academic hospital in Mashhad University of Medical Sciences from 2018 to 2020, were evaluated in this study. Data were collected using a questionnaire on endometrial cancer. All the patients underwent preoperative transvaginal sonography and pelvic MRI to evaluate myometrial invasion. The involvement of myometrium thickness and histological findings were compared between two imaging modalities, and SPSS 23.0 was used to analyze the data. Results: Junctional irregularity was the most prevalent finding on transvaginal sonography. Based on transvaginal sonography, myometrial invasion of less than 50% was found in 73% of patients, while invasion of more than 50% was observed in 26.31%. In 57.44% of MRIs, there was less than 50% myometrial invasion, while in 42.55% of MRIs, there was more than 50% myometrial invasion. In both modalities, the most common finding was myometrial invasion of less than 50%. The accuracy, sensitivity, and specificity of transvaginal sonography were 0.47, 0.27, and 0.75, respectively, whereas the accuracy, sensitivity, and specificity of MRI were 0.54, 0.45, and 0.61, respectively. Conclusion: MRI can be the modality of choice for evaluating myometrial invasion and optimizing endometrial cancer treatment planning, as well as reducing the complications of non-indicated lymphadenectomy.

Transvaginal sonography determines accurately extent of infiltration of rectosigmoid deep endometriosis.

To investigate the agreement of measurements of the three diameters of rectosigmoid deep endometriosis (DE) lesions between presurgical evaluation using transvaginal sonography (TVS) and postsurgical specimen measurement (PSM). This was a prospective observational multicenter study including symptomatic women undergoing surgical treatment for DE involving the rectosigmoid, by either discoid or segmental resection, from April 2017 to December 2019. TVS was performed presurgically to evaluate lesion size (craniocaudal-midsagittal length, anteroposterior thickness and transverse diameter), in accordance with the International Deep Endometriosis Analysis (IDEA) group consensus statement, and was compared with PSM. The agreement of lesion dimensions between the two methods was assessed by Bland-Altman plots and limits of agreement and additionally by the intraclass correlation coefficient (ICC) and Pearson's correlation coefficient. Systematic and proportional bias was assessed using the paired t-test. A total of 207 consecutive women were eligible for inclusion. Forty-one women were excluded, leaving 166 women for final analysis. A total of 123 segmental resections and 46 discoid resections were performed (both procedures were performed in three women). The mean difference between TVS and PSM was 0.90 (95% CI, 0.85-0.95)mm for lesion length measurements, 1.03 (95% CI, 0.98-1.09)mm for lesion thickness measurements and 0.84 (95% CI, 0.79-0.89)mm for transverse diameter measurements. Bland-Altman analysis demonstrated good agreement between the two methods for measurements of lesion length. Furthermore, there was good reliability and correlation between TVS and PSM for lesion length measurements, as demonstrated by an ICC of 0.82 (95% CI, 0.75-0.87) and Pearson's correlation coefficient of 0.72 (95% CI, 0.62-0.80), moderate-to-good reliability and correlation for lesion thickness measurements, with an ICC of 0.76 (95% CI, 0.67-0.82) and Pearson's correlation coefficient of 0.61 (95% CI, 0.51-0.70), and poor-to-moderate reliability and correlation for transverse diameter measurements, with an ICC of 0.58 (95% CI, 0.39-0.71) and Pearson's correlation coefficient of 0.46 (95% CI, 0.33-0.58). Preoperative TVS determines accurately rectosigmoid DE lesion length. TVS can thereby contribute to optimal planning of surgical treatment options in women with rectosigmoid DE. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Targeted Ultrasound for Deep Bowel Endometriosis

Bowel endometriosis is a complex gynecologic condition that requires targeted investigation and multidisciplinary care by an experienced team [1]. Here, we demonstrate the value of the preoperative transvaginal sonography in the assessment of deep endometriosis involving the bowel. We present a resected rectal segment containing the deep bowel nodule previously identified on the dedicated transvaginal ultrasound. A preoperative pelvic ultrasound helps characterize the extent of disease to help plan a multidisciplinary surgical approach for the patient.

Transvaginal Sonography Accurately Determines Infiltration Length of Rectosigmoid Deep Endometriosis.

<h3>Study Objective</h3> Investigate agreement of the three diameters of the rectosigmoid deep endometriosis (DE) lesion size between pre-surgical evaluation with transvaginal sonography (TVS) and post-surgical specimen measurements (PSM). <h3>Design</h3> A prospective observational study. TVS was performed pre-surgically to evaluate lesion size compared to PSM in accordance with the International Deep Endometriosis Analysis (IDEA) group consensus statement. The agreement between the two methods regarding lesion dimensions were assessed by Bland-Altman plots, limits of agreement, and intraclass correlation coefficient (ICC) for additional analysis. Systematic and proportional bias was assessed with paired t-test. <h3>Setting</h3> Three tertiary referral centers for endometriosis. <h3>Patients or Participants</h3> Consecutive symptomatic women undergoing surgical treatment for DE of the rectosigmoid by either discoid or segmental resection. <h3>Interventions</h3> Surgical treatment for rectosigmoid deep endometriosis by either discoid or segmental resection. TVS was performed pre-surgically to evaluate lesion size i.e., length, thickness and transverse measurement and was compared to PSM on the fresh bowel specimen. <h3>Measurements and Main Results</h3> A total of 207 consecutive women were eligible for inclusion from April 2017 to December 2019. Forty-one were excluded, leaving 166 women for final analysis. A total of 123 segmental resections and 46 discoid excisions were performed. The limits of agreement for lesion length were 0.44 mm (95% CI 0.44-0.49 mm) to 1.82 mm (95% CI 1.67-1.99 mm), lesion thickness 0.53 mm (95% CI 0.48-0.58 mm) to 2.01 mm (95% CI 1.84-2.20 mm), and lesion transverse measurement 0.37 mm (95% CI 0.33-0.41 mm) to 1.90 mm (95% CI 1.7-2.12 mm). Our study found good reliability between TVS and PSM for lesion length with ICC 0.82 (95% CI: 0.75-0.87). There was moderate reliability for lesion thickness with ICC 0.76 (95% CI: 0.67-0.82), and moderate-to-poor for transverse diameter with ICC 0.58 (95% CI: 0.39-0.71). <h3>Conclusion</h3> Pre-operative TVS accurately determines rectosigmoid DE lesion length. TVS can contribute to improved planning of surgical treatment of women with rectosigmoid DE.

Comparison between Sonography-based and Surgical Extent of Deep Endometriosis Using the Enzian Classification - A Prospective Diagnostic Accuracy Study

To compare a preoperative evaluation of deep endometriosis (DE) by transvaginal sonography (TVS) according to the Enzian classification with the intraoperatively assessed extent of DE using the Enzian system. Prospective diagnostic accuracy study. Tertiary referral center for endometriosis. Women undergoing TVS and surgery for DE between 2017 and 2019 (N = 195). Evaluation of DE lesion sizes according to the Enzian classification as evaluated by preoperative TVS compared with surgical findings. The rate of exact concordances between preoperative TVS-based predictions of DE lesion sizes and intraoperatively assessed lesion sizes according to the Enzian classification varied depending on anatomic localizations, that is, Enzian compartments, and evaluated lesion size. The highest rate of exact concordances was found in Enzian compartment C (rectosigmoid) in which 86% of all TVS C3 lesions were confirmed as such at surgery. Enzian compartment A (vagina, rectovaginal septum) showed similar results. The rates of exact concordances were slightly lower in Enzian compartment B (uterosacral ligaments, parametria), with confirmation at surgery of 71% of TVS B2 lesions. In most cases of discordant findings, an underestimation of the lesion size by 1 severity grade was observed compared with the intraoperative findings. In Enzian compartment FB (urinary bladder), 91% of the lesions seen at TVS and 98% of cases without any lesion at TVS were confirmed surgically. TVS could detect DE preoperatively in compartments A, B, C, and FB with an overall sensitivity of 84%, 91%, 92%, and 88%, respectively, and a specificity of 85%, 73%, 95%, and 99%, respectively. TVS provides a valuable preoperative estimation of DE localization and lesion size using the Enzian classification, especially for Enzian compartments A, C, and FB. For Enzian compartment B, the exact assessment of the lesion size using the Enzian system seems to be less precise than for the other compartments.

331 Correlation between MRI and transvaginal-ultrasound cervical length measurements in pregnancies complicated by twin-twin transfusion syndrome

Twin pregnancies are at high risk of preterm birth, especially when complicated by twin-twin transfusion syndrome (TTS). Pregnancies with TTTS that are candidates for selective fetoscopic laser photocoagulation (SFLP) at our institution undergo transvaginal ultrasound (TVUS) and MRI evaluation of cervical length (CL) to assess preterm birth risk during the perioperative period. There is a paucity of data on accuracy of MRI for cervical length screening in high-risk pregnancies. We sought to investigate the correlation of CL between the two imaging modalities Retrospective cohort study comparing TVUS to MRI measures of CL in pregnancies that underwent SFLP for TTTS at a single center, 4/2010-6/2019. Among 626 pregnancies, data on pre-operative TVUS (n=579), MRI (n=424), and post-op TVUS (n=596) CL measures were available for analysis. Correlation was estimated using Pearson’s coefficient, mean CL measurements were compared with two-tailed paired T-test, and frequency of short cervix detection by the two imaging modalities was compared with chi-square The mean pre-op CL by MRI was an average of 3 mm shorter than the TVUS CL, 39 vs 42mm, respectively (p=0.002). The frequency of short CL ≤25 mm was 39(6.7%) by TVUS and 47(10.8%) by MRI, p=0.0001. CL measures by MRI correlate with TVUS overall (r=0.64); however, the correlation is poor at the shortest cervical lengths (r<0.20), see figure. MRI missed n=2(40%), 3(18.8%), 9(32.1%), and 13(28.9%) of CL cases detected as short by TV US at cut-offs of ≤15, 20, 25 and 28 mm, respectively. Sensitivity analyses excluding or adjusting for cerclage and pessary did not alter these findings Although MRI measurement of CL correlates well with TVUS overall, it performs poorly to accurately detect short cervix. Although prenatal MRI has some fetal anatomic diagnostic advantages over ultrasound, TVUS remains the optimal screening modality for cervical length in pregnancies at high-risk of preterm birthView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Assessment of myometrial invasion of endometrial carcinoma with preoperative transvaginal sonography

Objective: Routine pelvic and para-aortic lymphadenectomy up to the level of the renal veins is controversial in endometrial cancer as the complication rate and prolonging the operation time is considerable. Intraoperative frozen section analysis of the uterus is the mainstay for the decision of performing a staging lymphadenectomy. Preoperative estimation of myometrial invasion may be useful for surgical planning. Our objective is to assess the accuracy of preoperative transvaginal ultrasound for identifying myometrial invasion. Methods: 80 consecutive patients operated between August 2017 and December 2019 with a histologically confirmed diagnosis of endometrial carcinoma evaluated within two weeks before surgery by transvaginal ultrasound are the subject of this study. Myometrial invasion estimation is documented and intraoperative frozen section analysis and final pathologic diagnosis as the reference standard was recorded. Results: Preoperative TVUS had 76.5% sensitivity, 91.3% specificity, whereas frozen section analysis had 85.3% sensitivity and 93.5% specificity, and they correlate well with each other (P &lt; 0.01). Agreement between these two methods was substantial according to Cohen’s kappa index (κ) = 0.74 (P &lt; 0.01) and percentage of agreement was 88%. Increasing tumor diameter decreased the prediction accuracy of preoperative ultrasound (P &lt; 0.01). Conclusion: There is good correlation of preoperative transvaginal ultrasound with intraoperative frozen section analysis and final pathology results. The subjective assessment of transvaginal ultrasound can guide surgeons as a useful preoperative tool for preparing surgery

Importance of pre-operative ultrasound examination and pathological tumour evaluation in the management of women with endometrial cancer

IntroductionEndometrial cancer (EC) is the most common gynaecological malignancy in developed countries. Early and accurate diagnostic assessment is crucial for appropriate treatment planning. Information obtained by pre-operative imaging with transvaginal ultrasound (TVUS) and histological endometrial biopsy assessment is often the cornerstone for further management planning. This study aimed to analyse the accuracy of this diagnostic approach for patient management decisions. Materials and methodsThis single-centre retrospective analysis included all patients with endometrial cancer treated between 2015 and 2019. Pre-operative TVUS staging assessment and histopathological endometrial biopsy examination were compared with the final surgical stage and histopathological diagnosis. ResultsPre-operative and surgical pathological assessment of Type I and Type II tumours was in agreement in 95 % (174/184) and 54 % (12/22) of cases, respectively. The sensitivity and specificity of TVUS assessment of myometrial invasion were 76 % [95 % confidence interval (CI) 66.3–84.2 %] and 81.7 % [95 % CI 73.0–88.6 %], respectively. Diagnostic accuracy was higher for Type I EC (95 %) than Type II EC (54 %). Only presumed ESMO/ESGO/ESTRO risk classification (p < 0.000) and deep myometrial invasion (p < 0.000) were significant for the prediction of lymph node involvement. ConclusionPre-operative TVUS examination and pathological endometrial biopsy evaluation enable moderately accurate assessment of the risk of EC. Efforts should be aimed towards the development of novel and more reproducible methods, such as molecular tumour characterization, to improve the pre-operative assessment of risk in patients with EC.

Diagnosis of Deep Infiltrating Endometriosis Using Transvaginal Ultrasonography.

Objective: To evaluate the performance of transvaginal ultrasonography (TVS) in diagnosis of deep infiltrating endometriosis (DIE).Methods: We retrospectively analyzed 198 patients with pathological diagnosis of DIE in our hospital from January 2017 to December 2019 and assessed the performances of pre-operative TVS diagnosis of DIE with regarding to sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV), using the pathological diagnosis as the ground truth. We also characterized the ultrasonographic features of the DIE lesions.Results: Among all the 198 cases, 170 cases were uterosacral ligament (USL) involvement, SE: 96.47% and SP: 85.71%; 79 cases were intestinal involvement, SE: 94.94% and SP: 94.96%; 57 cases were vaginal rectal septum (VRS) involvement, SE: 73.68% and SP: 94.33%; 20 cases were vaginal involvement, SE: 50% and SP: 97.21%; three cases were bladder involvement, SE: 66.7% and SP: 100%; nine cases were ureter involvement, SE: 55.56% and SP: 100%; and 10 cases were broad ligament involvement, SE: 10% and SP: 100%.Conclusion: TVS showed high accuracy in diagnosing DIE.

Comparison of Sensitivity and Specificity of Structured and Narrative Reports of Transvaginal Ultrasonogaphy for Adenomyosis

To compare the sensitivity and specificity of the transvaginal ultrasonography (TVUS) narrative report with those of the structured report for the diagnosis of adenomyosis. Retrospective study. A tertiary teaching hospital. One hundred ninety-two patients (45 with adenomyosis and 147 controls) who underwent hysterectomy between 2012 and 2016 and were aged 30 years to 55 years, with available preoperative TVUS images, were included. To compare preoperative TVUS with histologic analysis of the uterus after hysterectomy for the diagnostic of adenomyosis. Data regarding the presence of the ultrasonographic characteristics previously described for the diagnosis of adenomyosis were obtained from the original TVUS report (narrative report) and the structured report from 2 blinded radiologists (R1 and R2). Histologic analysis is defined as the gold standard for the diagnosis of adenomyosis. The mean age (45.4 ± 5.3 years vs 44.9 ± 4.8 years; p = .496) and clinical symptoms were similar between the adenomyosis and control groups, except for dyspareunia, which was more frequently reported in the patients with adenomyosis (25.6% vs 9.4%; p = .006). Most of TVUS characteristics were more frequently observed in the structured reports than in the narrative reports. The structured report presented higher sensitivity (R1: 84.4%, R2: 69.1%; narrative report: 31.1%; p <.05) and lower specificity (R1: 28.0%, R2: 31.2%; narrative report: 90.5%; p <.05) for adenomyosis. The structured report presented higher sensitivity and lower specificity for most of sonographic characteristics evaluated. After logistic regression analysis, no sonographic characteristics presented with statistical significance for the diagnosis of adenomyosis on R1's structured report, while globular uterus (odds ratio [OR] 0.276; p = .006; 95% CI, 0.11-0.697) and poorly defined junctional zone (OR 3.6; p = .007; 95% CI, 1.4-9.2) were significantly associated with adenomyosis. In the narrative report, a myometrial cyst was associated with a higher risk of adenomyosis (odds ratio 9.486, p =.002; CI, 2.359-38.149). The narrative reports were more specific, whereas the structured reports were more sensitive for the diagnosis of adenomyosis. In addition, the sensitivity of most of sonographic feature of adenomyosis was higher and the specificity was lower in the structured report. Future prospective studies comparing both reports are needed to validate the current findings.

Ovarian Sliding Sign As a Predictor of Ureterolysis at Laparoscopy in Women with Endometriosis: Retrospective Observational Study

Study Objective To determine whether a negative ovarian “sliding sign” (i.e. fixed ovary) during pre-operative transvaginal ultrasound (TVU) is useful in predicting the need for ipsilateral ureterolysis, for women with suspected endometriosis undergoing laparoscopic surgery. Design Retrospective observational study. Setting Hospital based. Patients or Participants 66. Interventions All women undergoing laparoscopic surgery for suspected endometriosis were assessed for ovarian mobility at TVU using the ovarian “sliding sign” technique. Data was analysed to determine the diagnostic accuracy of a negative ovarian “sliding sign” for the prediction of ipsilateral ureterolysis. Measurements and Main Results Complete TVU and surgical data was available for 66 women. The age range was from 18-52 years (Mean =31.5 years). Incidence of right left and any fixed ovary at TVU was 22/66 (33%), 24/66 (36%) and 27/66 (41%) respectively. Incidence of ureterolysis (partial or complete) at surgery for right, left and either pelvic sidewall was 10/66, (15%), 18/66 (27%) and 22/66 (33%) respectively. The sensitivity/specificity/positive predictive value /negative predictive value for the ovarian “sliding sign” at TVU for the prediction of ipsilateral ureterolysis was:Right ovary 80%/75%/36%/95% and left ovary 44%/66%/33%/76%. The crosstab for relationship between a negative ovarian “sliding sign” of the left ovary and left ureterolysis was not significant (p =0.437) but was significant for the right ovary and right ureterolysis (p =0.002). Conclusion A negative right ovarian “sliding sign” (i.e. fixed right ovary) at pre-operative TVU was significantly associated with the need for right ureterolysis. In addition, a positive ovarian “sliding sign” (i.e. mobile ovaries) at TVU demonstrated a high NPV for the need for laparoscopic ureterolysis. The TVU ovarian “sliding sign” may therefore be a useful ultrasound soft marker for predicting which women are at increased risk of requiring ureterolysis at surgery, and thus, aid in the pre-operative planning and counselling for these women.

A case of primary ovarian signet-ring cell carcinoma treated with S-1/CDDP therapy

BackgroundPrimary ovarian signet-ring cell carcinoma is extremely rare, with only five recent case reports. Almost all reported cases of ovarian signet-ring cell carcinoma have been treated with TC therapy and none have reported regarding the use of S-1/CDDP therapy. We report a case of primary ovarian signet-ring cell carcinoma treated postoperatively with S-1/CDDP therapy.Case presentationWe describe a 55-year-old woman diagnosed with stage IB primary ovarian signet-ring cell carcinoma that was treated with S-1/CDDP therapy. Preoperative transvaginal ultrasonography and contrast-enhanced computed tomography (CT) revealed a solid tumor measuring 10 cm in diameter in the pelvis. The tumor marker levels were as follows: CA125, 41.6 U/mL; CA19–9, < 2.0 U/mL; and CEA, 2.2 ng/mL. Ovarian cancer was suspected, and total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy were performed. The left ovary was enlarged to greater than fist-sized, and there was a small amount of clear yellow ascites. Histological examination of the left ovary led to the diagnosis of signet-ring cell carcinoma. Histological examination of the right ovary also showed the presence of a signet-ring cell carcinoma. After surgery, upper and lower gastrointestinal endoscopy and positron-emission tomography-CT were performed to search for a possible primary lesion, but none was found. The patient was diagnosed with primary ovarian signet-ring cell carcinoma with FIGO Stage IB (PT1b, NX, M0). As postoperative adjuvant chemotherapy, S-1/CDDP therapy (S-1120 mg/day/body × 14 days, CDDP 50 mg/m2 day 8, q 21 days) was administered for six cycles. There was no recurrence 27 months after the initial treatment.ConclusionsWe considered S-1/CDDP therapy was effective for primary ovarian signet-ring cell carcinoma. This is the first case report of primary ovarian signet-ring cell carcinoma treated with S-1/CDDP therapy in the world.

Pre-operative classification of molar pregnancy: How good is ultrasound?

Histopathology is the reference standard for diagnosing hydatidiform molar pregnancy (HMP). To assess the performance of pre-operative transvaginal ultrasound (TVS) to predict HMP. A retrospective diagnostic accuracy study was performed on women who had both TVS and histopathological examination of uterine curettings between January 2011-February 2017. TVS diagnosis of partial MP (PMP) included assessment of fetal parts and/or empty gestational sac with small cystic spaces adjacent to gestational sac. TVS diagnosis of complete MP (CMP) included assessment of complex, echogenic intra-uterine mass(es) containing multiple small cystic areas. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratios (PLR/NLR) for TVS were reported. Reference standard was histology. There were 4917 consecutive women who underwent TVS; 1636 underwent surgical curettage for miscarriage. Forty out of 4917 (0.6%) had HMP histologically; 25/40 (62.5%) had suspected HMP and 15/40 (37.5%) did not; 24/40 (60.0%) had CMP of which 19/24 (79.1%) were suspected on TVS and 5/24 (20.8%) were not; 16/40 (40.0%) had PMP of which 6/16 (37.5%) were suspected on TVS and 10/16 (62.6%) were not. The sensitivity, specificity, PPV, NPV, PLR and NLR of pre-operative TVS to predict HMP were: 60.0, 99.1, 63.2, 99.0% 68.4, 0.4; for CMP: 79.2, 99.8, 86.3, 99.6%, 421.7, 0.2; for PMP: 37.5, 99.3, 35.3, 99.4%, 54.3, 0.6. Histology remains the gold standard for diagnosing HMP. TVS is an acceptable diagnostic tool for HMP. When there are no ultrasound features of HMP, almost all these women will not have an underlying HMP.

The ADNEX model to triage adnexal masses: An external validation study and comparison with the IOTA two-step strategy and subjective assessment by an experienced ultrasound operator

ObjectivesThe ADNEX (Assessment of Different NEoplasias in the adneXa) model was developed using parameters collected by experienced (level III) ultrasound examiners. Our primary aim was to externally validate the ADNEX model. Then, the discriminatory performance of ADNEX was compared with the two-step strategy and subjective assessment by an experienced ultrasound operator. MethodsBetween February 2013 and January 2017, all patients who were scheduled for surgery for an adnexal mass at the Sant’Anna Hospital in Turin were enrolled in this study. Preoperative transvaginal sonography was performed, and the two-step strategy was applied for triage of the adnexal mass. Two ultrasound examiners, IOTA certified, applied the ADNEX model to all the collected masses based on the ultrasound reports. Finally, an experienced operator assigned the subjective assessment based on recorded ultrasound images. The discrimination and calibration performance of ADNEX were evaluated. The AUC was calculated for the basic discrimination between benign and malignant tumours. In addition, AUCs were computed for each pair of tumour types using the conditional risk method. ResultsA total of 577 patients were included in the analysis: the overall prevalence of malignancy was 25 %. With ADNEX, the AUC to differentiate between benign and malignant masses was 0.9111 (95 % CI 0. 8788-0.9389). At risk cut-offs of 1%, 10 % and 30 %, sensitivities were 100 %, 89.6 % and 79.2 %, respectively, and specificities were 2.8 %, 76.2 % and 89.6 %, respectively. Discrimination between benign and stage II–IV tumours was good (AUC 0.935). The model had the most difficulties discriminating between borderline and stage I tumours (AUC 0.666), and between stages II–IV invasive and secondary metastatic tumours (AUC 0.736). The polytomous discrimination index (PDI) was 0.61 for ADNEX, whereas PDI for random performance would be 0.25. ADNEX proved to be equally or more accurate than the subjective assessment or the two-step strategy in the discrimination between benign and malignant adnexal masses. Conclusionsthe ADNEX model could probably be successfully applied when an expert examiner is not available and, therefore both a subjective assessment and the two-step strategy cannot be performed.

Effect of morphological type of extrauterine ectopic pregnancy on accuracy of preoperative ultrasound diagnosis

To assess the overall accuracy of transvaginal ultrasound (TVS) for diagnosis of all types of extrauterine ectopic pregnancy (EUEP) in a large group of women who were managed surgically. We also aimed to assess the positive predictive value (PPV) of TVS for each of the different ultrasound morphological types of EUEP. This was a retrospective observational study of all pregnant women who underwent emergency surgery following ultrasound diagnosis of EUEP at a single early pregnancy unit between January 2009 and December 2017. The preoperative TVS findings were recorded, including the exact location and morphological type (Type I-V; defined using ultrasound criteria) of EUEP. TVS findings were compared with operative and histological findings. The performance of ultrasound in diagnosing EUEP overall and according to morphological type was assessed, using visual confirmation of ectopic pregnancy at surgery as the reference standard. A total of 26 401 women presented with early-pregnancy complications during the study period, including 1241 (4.7%; 95% CI, 4.5-5.0%) women with a conclusive diagnosis of EUEP on TVS or a presumed diagnosis based on severe pain and significant hemoperitoneum. Surgery was performed in 721/1241 (58.1%; 95% CI, 55.3-60.8%) cases, of which 710 (98.5%; 95% CI, 97.6-99.4%) had a conclusive diagnosis of EUEP on preoperative TVS. The remaining 11 women had severe pain and significant hemoperitoneum and were managed surgically on clinical grounds as an emergency, without an ectopic pregnancy having been identified on ultrasound examination. At laparoscopy, the diagnosis of EUEP was confirmed in 706/710 (99.4%; 95% CI, 98.6-99.8%) women with a positive ultrasound diagnosis and in all 11 women with a presumed ultrasound diagnosis of EUEP. The PPV of preoperative ultrasound for the diagnosis of EUEP was 99.4% (95% CI, 98.6-99.8%) with sensitivity of 98.5% (95% CI, 97.3-99.1%). There was no statistically significant difference in the accuracy of preoperative ultrasound diagnosis between the five morphological types (P = 0.76). The accuracy of preoperative ultrasound for diagnosis of EUEP is high. The morphological type of EUEP on TVS had no significant effect on the accuracy of preoperative diagnosis. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.