Suspicious Ovarian Masses Research Articles

Recurrent endometriosis and IVF: is it still an enigma?

The recurrence of endometriosis varies between 6% and 67%. If the patient is infertile and has recurrent endometriosis, she could be managed by repeat surgery or assisted reproduction. Given the increasing number of patients with recurrent endometriosis applying for IVF procedure, the aim of this study was to compare IVF outcome in patients who underwent one or more surgeries for endometriosis for the purpose of offering proper counseling to the infertile patients. The authors compared IVF outcome measures between 50 patients once operated for endometriosis with no signs of the disease at the time of IVF procedure, 29 patients also once operated for endometriosis with signs of the disease at the time of IVF procedure, and 47 patience more than once operated for endometriosis. Each group was also compared with a control group of 157 patients with tubal factor infertility. Outcome measures included number of follicles, number of oocytes, mean number of ampoules of gonadotropins, cumulative pregnancy, and live birth rates The rate of cancelled cycles was higher in all three groups of patients with endometriosis compared to the control group, and in addition, significantly higher in patients who underwent two or more endometriosis surgeries. The same applied for the number of oocytes retrieved by puncture and the number of the obtained embryos. The rate of implantation, clinical and multifetal pregnancies, as well as the birth rate per embryo transfer was significantly lower in patients who underwent endometriosis surgery two or more times, compared to all other groups of patients. When it comes to recurrent endometriosis, repeat surgery worsens the IVF outcome and therefore should be avoided. Except in cases of patients experiencing unbearable pain and suspicious ovarian mass findings, a patient with recurrent endometriosis should be immediately included in the IVF procedure without repetitive surgery.

Role of Diffusion Weighted MRI in Characterization of Ovarian Tumors

Background: Ovarian masses present a special diagnostic challenge when imaging findings cannot be categorized into benign or malignant pathology. Ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) are currently used to evaluate ovarian tumors.Functional imaging by means of diffusion weighted magnetic resonance imaging (DW-MRI) is now part of the standard imaging protocols for evaluation of the female pelvis. DW-MRI is important MR imaging technique which enable the radiologist to move from morphological to functional assessment of diseases of the female pelvis. Aim of the Study: The aim of the current study is to evaluate the diffusion-weighted MR imaging in prediction of the nature of suspicious ovarian masses which are detected previously by conventional ultrasound. Patients and Methods: MRI Unit, radiodiagnosis department, Ain Shams University hospital. The study is prospective, included thirty women who presented with suspicious adnexal masses on previous ultrasound examination and referred for further assessment and characterization by DW-MRI. Patients with contraindications to MRI (e.g. claustrophobia, cardiac prosthesis and metallic plates) are excluded. Results: The study included 30 women ranging in age between 24 and 61 years with mean age 43.22±11.15. Out of 30 cases, 12 had of benign ovarian tumors while 18 had malignant tumors. Conclusion: Thus, combination of DWI and conventional MRI implies using a completely noninvasive technique with no radiation exposure. It is cost effective (no additional cost to MRI examination), and easily added to the MR study protocols with no marked lengthening of examination time. It improves the specificity of MRI and thus increasing radiologist’s confidence in image interpretation which will finally reflect on patient’s outcome and prognosis.

Laparoscopic Minimally Invasive Approach to Sentinel Lymph Node Mapping of the Ovary Using the Near-infrared Fluorescent S1 HD Pinpoint System with Indocyanine Green Dye

Study ObjectiveTo show a novel minimally invasive approach to sentinel lymph node (SLN) detection of the ovary with near-infrared–guided surgery using indocyanine green (ICG). DesignA step by step description of the technique with video and figures (educational video). SettingThe standard surgical staging of early-stage I-II ovarian cancer includes systematic pelvic and aortic lymphadenectomy even in the absence of clear evidence regarding the survival benefits associated with comprehensive retroperitoneal staging. The ideal candidates are all women undergoing a surgical approach with frozen section analysis for highly suspicious ovarian masses or patients in whom an adnexal mass has been removed that appeared to be malignant and an open or laparoscopic surgical staging procedure is planned. PatientA 31-year-old woman with occult ovarian cancer after simple left ovarian cystectomy. InterventionsLaparoscopic surgical staging including simple hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and aortic bilateral lymphadenectomy, and sentinel node biopsy from the left ovary. Measurements and Main ResultsThe surgical intervention was performed with the PinPoint 0 degree HD S1 SPY fluorescence camera (PinPoint Endoscopic Fluorescence Imaging System; NOVADAQ, Mississauga, ON, Canada). After the induction of the pneumoperitoneum, ICG was injected with 2 separate injections in the proper ovarian ligament and the infundibulopelvic ligament, just below the peritoneum, at a concentration of 1.25 mg/mL. A total amount of 0.4 mL ICG solution was injected using a percutaneous abdominal approach with a 12-cm-long 22-G spinal needle. SLN mapping should be preceded by the exposure of the aortic region with a gentle dissection on both sides along the Toldt fascia up to the left renal vein. Two SLNs were identified in the left inframesenteric para-aortic and superficial left common areas. Both SLNs were negative. ConclusionThe minimally invasive approach in combination with the ICG near-infrared fluorescence S1 PinPoint fluorescence system seems feasible, and, in our opinion, even if preliminary, this approach can further extend the range of indications of SLN mapping. In the future, this combined approach can prospectively involve ovarian SLN detection.

Comparative Study of USG and CT in the Evaluation of Suspicious Ovarian Masses

Comparative Study of USG and CT in the Evaluation of Suspicious Ovarian Masses

Retrospective analysis of suspicious pelvic masses using the Pelvic Mass Index (PMI) scoring system from 2007 to 2014

ObjectivesThis study aims to validate the accuracy of the Pelvic Mass Index (PMI) by comparing it with Risk of Malignancy Index (RMI) in a large patient cohort. Study designThis retrospective study used data of women with ovarian masses collected from 2007 to 2014, referred to the Pelvic Mass Clinic (PMC) at University Hospital of Wales in Cardiff. The locally developed PMI was used to triage patients for surgery, surveillance or discharge. Performance measures for PMI, RMI and CA125 are reported as sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), receiver operating characteristic (ROC) curves and area under the curve (AUC) for premenopausal and postmenopausal women alike. ResultsPMI was calculated on 1468 patients of whom 497 underwent surgery, 176 (71.0%) were in the high risk group, 63 (68.0%) intermediate and 258 (23%) amongst low risk women. Compared to RMI, PMI had a higher sensitivity (90.4%) and NPV (96.9%) for the entire cohort, as well as in the premenopausal (88.9%; 97.6%) and postmenopausal (91.5%; 95.6%) subcategories. ROC curves indicated better performance in the total group (AUC 0.823 vs. 0.770) and the premenopausal group (AUC 0.847 vs. 0.728), though AUC in the postmenopausal group was similar (0.779 vs. 0.791) – likely due to increased specificity of CA125 after menopause. Histology revealed PMI significantly outperforms RMI in diagnosing malignancy, missing only 1 compared to 20 cancers. ConclusionsThe high sensitivity and NPV of PMI makes it a useful tool in triaging patients with suspicious ovarian masses.

Intraoperative frozen section analysis for the diagnosis of early stage ovarian cancer in suspicious pelvic masses.

Intraoperative frozen section analysis for the diagnosis of early stage ovarian cancer in suspicious pelvic masses.

Assessment of the Value of a Modified Risk of Malignancy Index (RMI) in Preoperative Discrimination Between Benign and Malignant Ovarian Masses

Objectives: To assess the diagnostic accuracy of different risk of malignancy index (RMI) scores and to evaluate the role of a modified RMI (RMI 5) in pre-operative discrimination between benign and malignant ovarian masses. Study Design: Prospective observational study. Patients and methods: Women with a suspicious ovarian mass scheduled for laparotomy or laparoscopy were potentially eligible for inclusion in the current study. Trans-abdominal and trans-vaginal ultrasound with Doppler assessment of the adnexal masses was done. Calculation of the RMI 1, RMI2, RMI 3, RMI 4, and RMI5 was done. We compared RMI to histopathological outcome. In the current study, a new RMI score was created by adding Doppler blood flow of the ovarian mass to the calculation of the previous RMI1. Results: One hundred and fifty women with ovarian masses were included in the current study. Ninety six women (64%) had benign ovarian masses while, malignant ovarian masses were found in 54 women (36%). Comparison between benign and malignant ovarian masses regarding to the risk of malignancy indices revealed that that there was a statistically significant difference between the two groups regarding to the risk of malignancy indices with Pvalue< 0.001. Receiver operator characteristic curve analysis of the 5 RMI indices shows that the best method for prediction of malignant ovarian tumor was RMI 1. Also there was no statistically significant difference between the five methods in prediction of malignant ovarian tumors. RMI5 with cut off value of 250 is reliable tool at a tertiarycenter to discriminate between ovarian cancer and benign ovarian masses with a sensitivity of 90.38% and specificity of 93.88%. There was statistically significant difference between the different stages of ovarian cancer and RMI 5 with (P<0.05). Conclusion: The RMI 1 is the gold standard for preoperative discrimination between benign and malignant ovarian masses. Adding Doppler flow to the parameters of RMI 1 (RMI 5) increased specificity of RMI 1 in detecting malignant ovarian masses.

P10.03: Decidualisation: a case report of a suspicious ovarian mass in pregnant woman

P10.03: Decidualisation: a case report of a suspicious ovarian mass in pregnant woman

Diffusion-weighted magnetic resonance imaging in the assessment of ovarian masses with suspicious features: Strengths and challenges

ObjectiveTo evaluate diagnostic performance of diffusion weighted imaging (DWI) in evaluating ovarian masses with suspicious features on magnetic resonance imaging (MRI). Patients and methodsPelvic MRI and DWI assessed 235 complex and solid ovarian masses of suspicious MRI features. On DWI, scanning acquired by b values: 0, 500, 1000 and 1500. Analysis considered signal intensity (SI) at b1000 and the mean ADC values for the solid components of the masses. ResultsIncluded masses proved benign in 75(32%), borderline (low potential malignancy) in 55(23.4%) and malignant in 105(44.6%). Restricted diffusion was observed in all of the invasive malignancy (57.1%, n=105/184). Benign and borderline tumors with high DWI SI presented 15.2% and 27.7% respectively (P<0.05). The mean ADC value was 1.2+0.34×10−3mm2/s, 1.1+0.06×10−3mm2/s, and 0.83+0.15×10−3mm2/s for benign, borderline and malignant masses respectively. The ADC values of malignant masses and benign masses with fibrous components showed no significant difference (P=0.333). Significant difference was detected in those with fatty tissue (P=0.002). ConclusionDWI supported by conventional MRI data can confirm or exclude malignancy in suspicious ovarian masses. The combined analysis of quantitative and qualitative criteria and knowledge of the sequence pitfalls are required.

Frozen Section in Postmenopausal Women Presented with Suspicious Ovarian Masses, Does It Have a Role?

Background: Frozen section (FS) has a valuable role in the diagnosis of ovarian tumors. It is considered a pivotal point in guiding the surgical therapy, particularly in premenopausal women. In postmenopausal women, it may be required as well to avoid unnecessary surgical staging in benign ovarian tumors. Aim: This study aims to evaluate the accuracy of intraoperative frozen section in ovarian neoplasms in postmenopausal women. Materials and Methods: A retrospective analysis was done for intraoperative FS for suspected ovarian neoplasms. The study was conducted in Oncology Center, Mansoura University from March 2008 to December 2014. The frozen and paraffin section reports were compared, and overall accuracy, sensitivity, specificity, positive and negative predictive values were determined. Results: The study included 105 patients and the overall accuracy of FS in determining malignancy was 81.7%. The sensitivity for malignant tumors was 75.32% with specificity of 100%. For benign tumors, the sensitivity and specificity were 100% and 93%, respectively. Borderline tumors had the lowest sensitivity of 100% with specificity of 95.19%. Conclusion: The present study concurs that frozen section is an accurate test for diagnosis of benign and malignant tumors in postmenopausal women thus determining the extent of surgery done for them. On the other hand, accuracy rates for borderline tumors are low.

The Risk of Malignancy Index (Rmi) In Preoperative Prediction of Malignancy in a Clinically Suspicious Ovarian Mass

There is no satisfactory preoperative tools to differentiate a benign from malignant masses in pelvis. Serum CAl25 level, pelvic ultrasonogram and menopausal status are used individually to predict malignancy with poor outcome but the use of three in association RMI can improve diagnostic performance. Objective:- To evaluate RMI scoring system as method of choice for predicting whether or not an ovarian mass is likely to be malignant. Design:- Cross sectional study. Settings:- Chittagong medical college hospital and Chittagong metropolitan hospital. Duration: January 2011 to October 2014. Sample size:-175 patients admitted in January 2011 to October 2014. The risk malignancy index was calculated as UXMXCA 125 performed preoperatively. Ultrasound findings were scored depending on wall structure, wall thickness and echogenecity (1,4), Menopausal status pre and post menopausal scored as (1,4) and absolute level of CA 125 measured by radioimmunoassay. The individual performance were found in RMI (sen82%, spe 77%, +ve PV 81%, -vePV23, +veLR5.s6, -veL. 53, accuracy 78%), USG (sen86%, spe23%, +vePV87%, vePV32%, +veLR6.5%, veLR.84, accuracy 82%), CAl25 (sen72%, spe32%, +vePV87%, vePV32%, +veLR6.5, veLR. 84, accuracy 67%), Manupausal status (sen84%, spe50%, +vePV21%, -vePV2.4%, +veLR, -veLR, accuracy78%). The area under the ROC curve for risk malignancy index was (.8-.9), which was greater than the area for CAl25 (.6-.7), USG (.7-.8) score and menopausal status (.7-.8). The risk malignancy index using ultrasound morphological score, serum CAl25 level and menopausal status might be of value in the preoperative assessment of ovarian carcinoma.&#x0D; JCMCTA 2014 ; 25 (2) : 14-20

Value of Symptom-Triggered Diagnostic Evaluation for Ovarian Cancer

To evaluate the potential harms and ovarian cancer outcomes associated with symptom-triggered diagnostic evaluation of all women with symptoms of ovarian cancer. Five thousand twelve women older than age 40 years were prospectively enrolled in a cohort study of proactive symptom-triggered diagnostic evaluation. Women who tested positive on a symptom index were offered testing with CA 125 and transvaginal ultrasonography. Results of these tests and any subsequent procedures were recorded. Assessment of ovarian cancer outcomes for all participants through Surveillance, Epidemiology, and End Results was performed 1 year after enrollment was complete. A positive symptom index was found in 241 (4.8%) participating patients, and 211 (88%) underwent CA 125 testing, transvaginal ultrasound screening, or both. Twenty surgical procedures (laparoscopy, laparotomy, vaginal) were performed in the study population (0.4% of participating women). However, only six (0.12%) were performed for a suspicious ovarian mass and only four (0.08%) were performed solely as a result of study participation. A total of eight ovarian cancers were diagnosed, 31-843 days after symptom assessment (50% distant, 50% local or regional). Of the two cancers diagnosed within 6 months, one was symptom index-positive. Proactive symptom-triggered diagnostic evaluation for ovarian cancer results in minimal unindicated surgery. A small number of ovarian cancers was identified solely on the basis of symptom-triggered diagnostic testing. II.

Struma Ovarii Associated with Pseudo-Meigs’ Syndrome and Elevated Serum CA 125: A Case Report and Literature Review

The association of struma ovarii with Pseudo-Meigs’ syndrome and elevation of CA 125 has been reported in literature. Here we report a 55-year-old with benign struma ovarii who presented with ascites, small left pleural effusion, suspicious left ovarian mass and elevated serum CA 125 level. Repeated cytology tests were negative for malignancy. The radiologic appearance was highly suggestive of an ovarian malignancy and due to her overall state of illness the patient received 3 cycles of chemotherapy. Chemotherapy had no impact on the rate of accumulation of ascites, CA 125 level or the size of the ovarian mass highlighting the need to reconsider the initial diagnosis. Diagnostic left oophorectomy revealed struma ovarii and was followed by resolution of the ascites and normalization of the serum CA 125. No recurrence of the ascites or of the tumor has been observed during the 5 months follow-up. Struma ovarii or other dermoid variants should be considered in the differential diagnosis in patients with ascites, pleural effusions and elevated CA125 level but with negative cytology. Diagnostic laparoscopic oophorectomy should also be considered within the standard protocol for diagnosis of indeterminate adnexal masses.

Benign and Suspicious Ovarian Masses—MR Imaging Criteria for Characterization: Pictorial Review

Ovarian masses present a special diagnostic challenge when imaging findings cannot be categorized into benign or malignant pathology. Ultrasonography (US), Computed Tomography (CT), and Magnetic Resonance Imaging (MRI) are currently used to evaluate ovarian tumors. US is the first-line imaging investigation for suspected adnexal masses. Color Doppler US helps the diagnosis identifying vascularized components within the mass. CT is commonly performed in preoperative evaluation of a suspected ovarian malignancy, but it exposes patients to radiation. When US findings are nondiagnostic or equivocal, MRI can be a valuable problem solving tool, useful to give also surgical planning information. MRI is well known to provide accurate information about hemorrhage, fat, and collagen. It is able to identify different types of tissue contained in pelvic masses, distinguishing benign from malignant ovarian tumors. The knowledge of clinical syndromes and MRI features of these conditions is crucial in establishing an accurate diagnosis and determining appropriate treatment. The purpose of this paper is to illustrate MRI findings in neoplastic and non-neoplastic ovarian masses, which were assessed into three groups: cystic, solid, and solid/cystic lesions. MRI criteria for the correct diagnosis and characteristics for differentiating benign from malignant conditions are shown in this paper.

Involvement of Gynecologic Oncologists in the Treatment of Patients With a Suspicious Ovarian Mass

To identify the factors associated with inclusion of a gynecologic oncologist in managing the care of a woman with suspected ovarian cancer. A vignette-based survey was mailed to 3,200 physicians aged 64 and younger who were randomly sampled from family physician, general internist, and obstetrician-gynecologist (ob-gyn) lists from the American Medical Association Physician Masterfile. The vignette described a 57-year-old woman with pain, bloating, and a suspicious right adnexal mass with ascites. Using multivariable analysis we evaluated patient, physician, and practice characteristics associated with a self-reported referral or inclusion of a gynecologic oncologist in the patient's care. The response rate was 61.7%. After exclusions we included 569 ob-gyns, 591 family physicians, and 414 general internists. Gynecologic oncologist referral and consultation was self reported by 39.3% of family physicians and 51.0% of general internists (P=.01). Among ob-gyns, 33.7% indicated they would perform surgery and 66.3% recommended consultation or referral. Factors associated with not referring and consulting included patients having Medicaid insurance (family physicians), providers' weekly average number of patients being more than 91 (family physicians and general internists), male sex (family physicians), a rural practice location (general internists), and solo practice (general internists). Factors associated with primary surgical management for ob-gyns were small and remote rural practice locations and Census division. When presented with a patient with a suspicious ovarian mass, the majority of primary care physicians do not self-report direct referral to a gynecologic oncologist. This may contribute to the high rates of noncomprehensive surgery for ovarian cancer patients in the United States. II.

Extraovarian primary peritoneal carcinoma: staging with 18F-FDG PET/CT

A 69-year-old woman who presented with left lower quadrant abdominal pain and elevated serum cancer antigen 125 (CA-125) levels was referred for an MRI and an (18)F-FDG PET/CT to evaluate a suspicious abdominal mass seen on ultrasound. PET/CT showed extensive, intensely FDG-avid, omental and pelvic peritoneal thickening with no suspicious ovarian or colon masses. Based on the PET/CT results, the patient had extensive debulking surgery and histopathological evaluation revealed an extraovarian primary peritoneal carcinoma (EOPPC). (18)F-FDG PET/CT may be useful in differentiating EOPPC from other types of peritoneal carcinomatosis, and in determining the extent of the disease to better guide surgical management and improve long term outcomes.

P13.18: 3D power‐Doppler vascular biopsy as a second step in the correct diagnosis of suspicious ovarian masses by B mode ultrasonography

P13.18: 3D power‐Doppler vascular biopsy as a second step in the correct diagnosis of suspicious ovarian masses by B mode ultrasonography

Frozen Section in Laparoscopic Management of Macroscopically Suspicious Ovarian Masses

Study Objective To study the usefulness of and applications for frozen section in the laparoscopic management of adnexal masses. Design Historical prospective study (Canadian Task Force classification II-3). Setting Large tertiary care hospital with university affiliation. Patients One hundred forty-one women undergoing laparoscopy for a suspicious adnexal mass. Intervention Adnexal masses suspicious on ultrasound were managed by laparoscopy. After laparoscopic diagnosis, frozen sections were used to confirm a diagnosis of malignancy. Treatment was performed by laparoscopy whenever feasible. Measurements and Main Results The results of frozen section were compared with the results of permanent sections, and the consequences of the intraoperative diagnosis on the surgical management were evaluated. The frozen section diagnosis was correct in 125 of the 141 patients (88.7%). In one patient, the result was false negative. Specifically, frozen section diagnosis was correct in 96.8% of cases when a cyst or biopsy was sent for pathologic examination and in 86.4% when the whole adnexa was sent. It was correct in 93% of the cases involving tumors smaller than 100 mm and in 74% of larger tumors. It was correct in 92.3% of the women younger than 50 years and in 81.6% of women older than age 50. Intraoperative pathologic diagnosis was correct in 95.5% of benign tumors, 77.8% of low-malignancy tumors, and 75% of cancer cases. Conclusion Frozen section is a useful examination for surgical management decision making; however, the limitations and the difficulties should be taken into account.

Missed ovarian pregnancy in early laparoscopic management

ABSTRACTObjective To report a case of repeat hemoperitoneum which was later proved to be a missed ovarian pregnancy in early laparoscopic management.Design Case report.Setting University hospital.Subject and intervention A 31‐year‐old women who presented with haemoperitoneum was thought to have an ectopic pregnancy, but no substantial lesion was found at early laparoscopy. Haemoperitoneum recurred 10 days later, and repeat laparosopy revealed a ruptured ovarian pseudogestational sac at a site previously thought to be a corpus luteum.Main Outcome Measure intraoperative transvagianl doppler ultrasonography confirmed the presence of pseudogestational sac. Postoperative histopathology proved the diagnosis of ovarian pregnancy.Result and Conclusion The lesson learned from this case was the need to remove all suspicious ovarian masses, including the corpus luteum cysts, in early laparoscopic management in patients with otherwise ‘negative’ findings, in order to avoid missing an ovarian pregnancy.

Laparoscopic 'oophorectomy-in-a bag'an alternative to laparotomy for the evaluation of suspicious ovarian masses

A prospective observational study was performed to assess the feasibility of the technique of laparoscopic oophorectomy-ina bag for the safe removal of ovarian masses that do not meet the standard guidelines for laparoscopic management of adnexal pathology. Ovarian lesions were selected preoperatively by: age of the patient, ultrasound appearance, bilaterality and size. None of the women had ascites or matted bowel on ultrasound, and all had normal serum tumour markers. There were no stigmata of malignant disease in any of the cases at the time of surgery. Twenty women were recruited. Eighteen procedures (90·0%) were completed successfully laparoscopically. In two cases the bag could not be removed laparoscopically and minilaparotomy was performed. Nineteen of the tumours (95·0%) were removed without intra-abdominal spillage; the bag ruptured in one case. There were no major complications. One case of borderline ovarian tumour (stage Ia) was discovered. We conclude that laparoscopic oophorectomy-in-a bag allows for the safe removal of suspicious ovarian tumours. The advantages of this approach are that women can be treated locally, a laparotomy is avoided, and the subgroup with ovarian malignancy can be identified to be referred to an oncological centre.