Ultrasound to Differentiate Benign From Malignant Ovarian Tumors—Are We There Yet?

Adnexal (ovarian) tumors present a complex problem. Ovarian cancer (Ovca) is the second most common gynecologic cancer in the United States with the highest mortality rate of all gynecologic cancer, 7th among all cancers, and with a general survival rate of 50%.1 Thus, missing Ovca when performing any kind of test (false negative) will have grave consequences but suspecting it when not present (false positive) can have almost as critical results with morbidity and mortality secondary to (unnecessary) intervention.

The purpose of this post is not to review the differential diagnosis of ovarian tumors nor to discuss chemical markers such as CA125 or cancer-specific signal found on cell-free DNA (cfDNA) but to concentrate on ultrasound. Some tumors are relatively easy to recognize because of defined ultrasound characteristics: corpus luteum with the classic “ring of fire” or endometrioma with the ground-glass appearance content, for instance (image 1a and b). Conversely, a large, multilocular lesion with solid components and profuse internal Doppler blood flow leaves little doubt about its malignant nature (image 2).

Image 2: A large, multilocular lesion with solid components.

What are the ultrasound characteristics we look at?

  1. Size: Unilocular cystic ovarian tumor < 10 cm in diameter or simple septated cystic ovarian tumor < 10 cm in diameter rarely, if ever, are neoplastic.2
  2. Volume: Normal volume for premenopausal and postmenopausal ovaries are < 20 cm3 and 10 cm3, respectively.
  3. Appearance: Risk of malignancy in simple, unilocular anechoic cyst, less than 5 cm is < 1% in premenopause and about 2.8% in postmenopause.3
  4. Blood flow criteria: The rationale is that arteries formed by neovascularization in malignant tumors lack tunica media, resulting in lowered impedance (= less resistance to blood flow). Thus, resistance indices will be lower in cancer than in benign tumors. Malignancy was suspected with Doppler indices: pulsatility index (PI)<1 and/or resistive index (RI)<0.4.4 However, too much overlap makes reliance on only Doppler unjustified.

A very important point is that the expert performs very well when analyzing the ultrasound images of an ovarian mass, with a sensitivity of 92–98% and a specificity of 89%. The issue is how to help the non-expert decide whether he/she can continue the care of the patient or needs to refer her to a specialist. Based on several ultrasound criteria, scoring systems were implemented. The first one, in 1990, included appearance (unilocular, unilocular solid, multilocular, multilocular solid, or solid cyst) and presence of papillae (graded according to their number: 0 [none], 1 [one to five], or 2 [more than five]). This method had a sensitivity (true positive rate, or chance that person testing positive actually has Ovca) for malignancy of 82% with a specificity (true negative rate or chance that person with a negative test does not have Ovca) of 92%.5 Two important additional scoring systems were described later: the Morphology Index (MI) combining tumor volume, wall structure, and septal structure and the Risk of Malignancy Index (RMI), the product of ultrasound morphology score, CA 125 level, and menopausal status.6 Additional systems included the Logistic Regression 1 (LR1) and 2 (LR2). None of the published scoring systems were superior to image assessment by an expert, including in a meta-analysis of 47 articles, including over 19000 adnexal masses7 and, in reality, were not used widely in clinical practice.

The International Ovarian Tumor Analysis (IOTA) models

In 2000, a large group of European experts (gynecologists, radiologists, statisticians, biology, and computer experts) published a standardized terminology for the characterization of adnexal masses.8

The two important systems are the Simple Rules (SR) and the Assessment of Different NEoplasias in the adneXa (ADNEX) model. These were externally validated in numerous centers across the world but not in the USA.9 Recently, however, validation on the largest hitherto US population was published.10 This study showed for the first time that the models were effective in this population, regardless of menopausal status or race. These models are easy to learn and are geared towards non-experts.11 It is important to note that the IOTA group was one of the first to incorporate acoustic shadow as a key feature, and the acoustic shadow has been shown to be an important sonographic feature to consider.12

  1. Simple Rules: The IOTA Simple-Rules consist of 2 sets of 5 elements each: benign and malignant.13 Three simple rules are applied: if only benign characteristics are present, the mass is classified as benign. If only malignant features are present, the mass is considered malignant. If no features or both are, the findings are inconclusive. This model works well in about 80% of cases. The other 20% should be referred to an expert.
  2. ADNEX model14: This is a multiclass prediction model to differentiate between benign and malignant tumors and allows automatic calculation of sub-classification of malignant tumors into borderline tumors, Stage I, and Stage II–IV primary cancers, and secondary metastatic tumors. “The advantage of this model is that it gives a personalized risk score for each patient, based on age, whether the patient is seen at an oncology center or not, maximal diameters of the lesion and the solid parts, number of cysts and papillary projections, whether acoustic shadows are present, whether ascites is present and CA125 value (if available, not mandatory for calculation). With a cut-off value for malignancy risk set at 10%, the ADNEX model (with CA125) had a sensitivity of 94.3%, with a specificity of 74%, positive predictive value of 76%, and negative predictive value of 93.6%.”14

The O-RADS model

In 2020, the American College of Radiology convened an international multidisciplinary committee that developed an ultrasound model based on an MRI model used in mammography (the BI-RADS atlas), the O-RADS model (the Ovarian-Adnexal Reporting and Data System) to facilitate differentiation between benign and malignant ovarian tumors.15 It relies on the sonographic nomenclature developed by the IOTA group, but it classifies tumors into 1 of 6 categories (O-RADS 0–5), from normal to high risk of malignancy. O-RADS also includes guidelines for the management of the findings. It should be noted that the O-RADS first model did not take into account the presence or absence of an acoustic shadow, although this has now been amended.

A description of the most recent common ultrasound scoring systems (SR, ADNEX, and O-RADS) is available in the Journal of Ultrasound in Medicine (JUM): Yoeli-Bik R, Lengyel E, Mills KA, Abramowicz JS. Ovarian masses: The value of acoustic shadowing on ultrasound examination. J Ultrasound Med 2023; 42:935–945.    

References

  1. https://www.cancer.org/cancer/types/ovarian-cancer/about/key-statistics.html
  2. Saunders et al. Risk of malignancy in sonographically confirmed septated cystic ovarian tumors. Gynecol Oncol 2010; 118:278–282.
  3. Valentin et al. Risk of malignancy in unilocular cysts: a study of 1148 adnexal masses classified as unilocular cysts at transvaginal ultrasound and review of the literature. Ultrasound Obstet Gynecol 2013; 41:80–89.
  4. Bourne et al. Transvaginal colour flow imaging: a possible new screening technique for ovarian cancer. BMJ 1989; 299:1367–370.
  5. Granberg S et al. Tumors in the lower pelvis as imaged by vaginal sonography. Gynecol Oncol 1990; 37: 224–229.
  6. Yamamoto Y, Yamada R, Oguri H, Maeda N, Fukaya T. Comparison of four malignancy risk indices in the preoperative evaluation of patients with pelvic masses. Eur J Obstet Gynecol Reprod Biol 2009; 144:163–167.
  7. Meys EM et al. Subjective assessment versus ultrasound models to diagnose ovarian cancer: A systematic review and meta-analysis. Eur J Cancer 2016; 58:17–29.
  8. Timmerman D, Van Calster B, Testa A, et al. Predicting the risk of malignancy in adnexal masses based on the simple rules from the international ovarian tumor analysis group. Am J Obstet Gynecol 2016; 214:424–437.
  9. Abramowicz JS, Timmerman D. Ovarian mass-differentiating benign from malignant: the value of the International Ovarian Tumor Analysis ultrasound rules. Am J Obstet Gynecol 2017; 217:652–660.
  10. Yoeli-Bik R, Longman RE, Wroblewski K, Weigert M, Abramowicz JS, Lengyel E. Diagnostic performance of ultrasonography-based risk models in differentiating between benign and malignant ovarian tumors in a US cohort. JAMA Netw Open 2023; 6:e2323289.
  11. Valentin L, Ameye L, Jurkovic D, et al. Which extrauterine pelvic masses are difficult to correctly classify as benign or malignant on the basis of ultrasound findings and is there a way of making a correct diagnosis? Ultrasound Obstet Gynecol 2006; 27:438–444.
  12. Yoeli-Bik R, Lengyel E, Mills KA, Abramowicz JS. Ovarian masses: The value of acoustic shadowing on ultrasound examination. J Ultrasound Med 2023; 42:935–945.
  13. Timmerman D, Testa AC, Bourne T, et al. Simple ultrasound-based rules for the diagnosis of ovarian cancer. Ultrasound Obstet Gynecol 2008; 31:681–90.
  14. Van Calster B, et al. Evaluating the risk of ovarian cancer before surgery using the ADNEX model to differentiate between benign, borderline, early and advanced stage invasive, and secondary metastatic tumours: prospective multicentre diagnostic study. BMJ 2014; 349:g5920.
  15. Andreotti RF, Timmerman D, Strachowski LM, et al. O-RADS US risk stratification and management system: a consensus guide-line from the ACR ovarian-adnexal reporting and data system committee. Radiology 2020; 294:168–185.

Appendix

Classification of primary ovarian tumors

  1. Ovulatory: functional or corpus luteum cyst; theca lutein cyst; polycystic ovary
  2. Infectious or inflammatory: tubo-ovarian abscess; hydrosalpinx
  3. Benign: serous or mucinous cystadenoma; endometrioma; mature cystic teratoma (most common primary benign tumor of the ovary); paraovarian/paratubal cysts
  4. Borderline: serous, mucinous
  5. Malignant
  6. Epithelial: high-grade serous carcinoma (HGSC; 70 to 80%); endometrioid carcinoma (10%); clear cell carcinomas (10%); mucinous carcinoma (3%); Low-grade serous carcinoma (LGSC; <5%); Brenner tumor; carcinosarcoma or malignant mixed müllerian tumor (MMMT); undifferentiated,
  7. Germ cell (20%): teratoma: immature, specialized teratomas of the ovary (struma ovarii, carcinoid tumor); dysgerminoma; yolk sac tumor: endodermal sinus tumor; embryonal carcinoma; choriocarcinoma: <1% of ovarian tumors; malignant mixed germ cell tumor
  8. Sex cord / stromal ovarian tumors (8–10%): fibrothecoma (fibroma, thecoma); Sertoli-Leydig cell tumor; granulosa cell tumor (juvenile or adult); small cell carcinoma

Jacques S. Abramowicz, MD, is a professor in the Department of Obstetrics and Gynecology at the University of Chicago.

Interested in learning more about gynecologic ultrasound? Check out the following posts from the Scan:

Mastering Ovarian Tumor Analysis: Join the AIUM-IOTA Partnership Course for Advanced Gynecologic Ultrasound

Ovarian lesions are a common finding among women, with etiologies ranging from ovarian changes related to normal hormonal function to aggressive malignancies. Therefore, the proper diagnosis and management of ovarian lesions are critical to women’s health. Here, I’ll give a brief description of ovarian tumor analysis, including descriptors, pattern recognition, and the application of the International Ovarian Tumor Analysis (IOTA) group’s Simple Rules, the IOTA ADNEX model, and O-RADS ultrasound characterization.

An ultrasound image of ovarian lesions.

Descriptive Analysis of Ovarian Tumors

The first step in the diagnosis of ovarian tumors is descriptive analysis. This step involves a detailed examination of the tumor’s characteristics, including its size, shape, texture, and location. This information is obtained through various imaging techniques, such as ultrasound, MRI, and CT scans. The following descriptors are used in descriptive analysis:

  • Size: The size of the tumor is measured in centimeters and is one of the critical factors in determining the type of tumor.
  • Shape: The shape of the tumor is described as either round or irregular. An irregular shape is often associated with malignant tumors.
  • Texture: The texture of the tumor is classified as either solid, cystic, or mixed.
  • Location: The location of the tumor is described as either unilateral or bilateral. Unilateral tumors are located on one ovary, while bilateral tumors are located on both ovaries.

Pattern Recognition of Ovarian Tumors

An essential aspect of ovarian tumor analysis is pattern recognition. It involves identifying specific patterns associated with malignant and benign tumors. The following patterns are commonly observed in ovarian tumors:

  • Solid: Solid tumors are characterized by the absence of cystic components and are often associated with malignancy.
  • Cystic: Cystic tumors are characterized by the presence of fluid-filled spaces and are typically benign.
  • Mixed: Mixed tumors have both solid and cystic components and can be either benign or malignant.

Application of the Simple Rules, the IOTA ADNEX Model, and O-RADS Ultrasound Characterization

The Simple Rules, the IOTA ADNEX Model, and O-RADS ultrasound characterization are 3 widely used methods for differentiating ovarian tumors.

  • The Simple Rules: The Simple Rules are a set of guidelines that assist in the diagnosis of ovarian tumors. The rules are based on the tumor’s size, shape, texture, and location. According to the Simple Rules, a tumor is considered benign if it meets all 3 of the following criteria: 1) it is purely cystic, 2) it is less than 10 cm in size, and 3) it has a thin, smooth wall.
  • IOTA ADNEX Model: The IOTA ADNEX Model is a predictive model that uses a combination of clinical and ultrasound findings to diagnose ovarian tumors. The model considers the tumor’s size, shape, texture, location, and other factors, such as the patient’s age and menopausal status. Then, the model provides a probability score for each tumor, indicating the likelihood of malignancy.
  • O-RADS Ultrasound Characterization: O-RADS is a standardized ultrasound reporting system that categorizes ovarian tumors based on their likelihood of malignancy. The system uses a 5-point scale, ranging from 1 (very low risk) to 5 (very high risk). The O-RADS system considers the tumor’s size, shape, texture, location, and vascularity.

The proper diagnosis and management of ovarian lesions are critical to women’s health. Descriptive analysis, pattern recognition, and the application of the Simple Rules, the IOTA ADNEX Model, and O-RADS ultrasound characterization are essential aspects of ovarian tumor analysis. These methods aid in accurately diagnosing and differentiating ovarian tumors and can guide appropriate treatment decisions.

Are you a healthcare professional looking to enhance your skills in gynecologic ultrasound and ovarian tumor analysis? Look no further than the Advanced Gynecologic Ultrasound course offered by the American Institute of Ultrasound in Medicine (AIUM) in partnership with the International Ovarian Tumor Analysis (IOTA) group.

This course offers a unique and valuable opportunity for healthcare professionals looking to enhance their skills in gynecologic ultrasound and ovarian tumor analysis. The comprehensive curriculum, hands-on training, and networking opportunities make it a worthwhile investment for healthcare professionals looking to improve patient outcomes and advance their careers. Register now for the course, taking place this June, at the AIUM Headquarters in Laurel, Maryland.

Sources
https://www.cancer.org/cancer/types/ovarian-cancer/about/what-is-ovarian-cancer.html
https://acsjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/cncr.11339
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5620878/
https://pubmed.ncbi.nlm.nih.gov/18504770/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4402441/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9728190/
https://www.mdpi.com/2075-4418/13/5/885

Arian Tyler, BS, is the Digital Media and Communications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

SLOW DOWN: Take Your Time in Diagnosing PCOS in Adolescents

Polycystic ovarian syndrome (PCOS) is the most common ovulation disorder among adult reproductive-age women. This blog post will discuss the latest recommendations, which state that we should wait about 8 years after menarche to make this diagnosis in adolescents!

PCOS is defined by the Rotterdam Criteria as 2 of the following: irregular menstrual cycles (or absent cycles), hirsutism (clinically as acne or male-patterned hair growth or elevated androgens), and polycystic-appearing ovaries on ultrasound, also known as PCO morphology. In addition, other disorders that may look like PCOS need to be ruled out (thyroid disease, hyperprolactinemia, adrenal disorders). The two main areas where patients or providers have difficulty are how cycle lengths are determined and PCO morphology.

In gynecology and infertility, we see a number of women with irregular menstrual cycles. Irregular menstrual cycles are defined as cycles occurring more frequently than every 21 days or less frequently than every 35 days from the beginning of one cycle to the beginning of the next cycle (cycle day 1 to cycle day 1). Some patients get confused and count from the last day of bleeding to the first day of the next period, which artificially makes the cycle seem short. It is good to keep a menstrual calendar (a regular calendar where each day of bleeding is marked with an “X” and review it over a couple of months). It is easy to count the number of days from the beginning of one menstrual cycle to the beginning of the next when counting from the first “X” of one cycle to the first “X” of the next.

One manner of identifying polycystic ovaries is by the volume: If one or both ovaries has a volume of more than 10 cm3 then that meets the criteria for a polycystic ovary on ultrasound.

The other method of identification is counting and measuring follicles. Counting antral follicles, which are follicles that measure as less than 10 mm in diameter, in a polycystic-appearing ovary can be difficult. First, check to see if there are any cysts in the ovary (any large, space-occupying mass greater than 10 mm). If cysts larger than 10 mm are present, then the antral follicle counts and the ovarian volumes will be distorted. Typically, it is easiest to measure the antral follicles and ovarian volume in the early follicular phase, or cycle days 1–5 (where cycle day 1 is the first day of the menstrual period). In this early part of the menstrual cycle, there should not be a dominant follicle growing yet so the ovary commonly has only small antral follicles at this time in the cycle.

Originally, polycystic-appearing ovaries were described as having antral follicles lined up in the periphery of the ovary or a “pearl necklace” sign. In PCOS, the stroma of the ovary produces the androgens, and patients with PCOS tend to have a greater stromal area. However, the Rotterdam criteria did not use these descriptions in defining a polycystic-appearing ovary. Instead, the Rotterdam criteria state a volume or an antral follicle count when there are no cysts. The antral follicle count was initially described in the Rotterdam criteria as either ovary with more than 12 follicles (2–9 mm).

Unfortunately, with this number, a number of adolescents were being misdiagnosed with PCOS. Why would that be?

There are two reasons: one, when girls have menarche, the hypothalamic pituitary ovary axis is not mature and they will have irregular cycles—sometimes this irregularity lasts a couple of years. So, many adolescents were noted to have met the “irregular cycles” criterion. Second, adolescents have an excellent ovarian reserve. They should have a lot of antral follicles because they have a lot of eggs in the early part of their reproductive years. These ovaries are sometimes referred to as multi-follicular ovaries. This is a normal finding.  

Consequently, the international guideline, which has been adopted by the ESHRE (European Society of Human Reproduction and Embryology) and the ASRM (American Society of Reproductive Medicine) has concluded that the number of follicles needed to meet the PCO-appearing criteria should be 20 or more antral follicles (2–9 mm) in either ovary and others recommend 25 or more antral follicles.

They all accept that an ovary larger than 10 mL would meet the criterion. In addition, they have stated that we should NOT make the diagnosis of PCOS in adolescents within 8 years of their menarche because the reproductive axis is not mature early after menarche. Others have recommended NOT using the ultrasound criteria as an independent marker in diagnosing adolescents.

In other words, adolescents will need to have evidence of hirsutism and anovulation to meet the criteria of PCOS. The general consensus is that we do not want to inappropriately place a label of PCOS on these young women. PCOS has a lot of medical sequelae such as infertility, increased risk for insulin resistance, metabolic syndrome, diabetes, hypertension, and many others that could unnecessarily worry the young women.

Take home message: Be SLOW to diagnose PCOS in Adolescents! 

References:

Teede HJ, Misso ML, Costello MF, Dokras A, Laven J, Moran L, Piltonen T, Norman RJ and International PCOS Network. Recommendations form the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Hum Reprod 2018; 1–17. Doi:10.1093/humrep/dey256

Al Wattar BH, Fisher M, Bevington L, Talaulikar V, Davies M, Conway G, Yasmin E. Clinical practice guidelines on the diagnosis and management of polycystic ovary syndrome: a systematic review and quality assessment study. J Clin Endocrinol Metab 2021; 106(8):2436–2446.

Dumesic DA, Oberfield SE, Stener-Victorin E, Marshall JC, Laven JS, Legro RS. Scientific statement on the diagnostic criteria, epidemiology and pathophysiology, and molecular genetic of polycystic ovary syndrome. Endocrine Reviews 2015; 36(5):487–525. https://doi.org/10.1210/er.2015-2018

https://www.endocrine.org/advancing-research/scientific-statements/polycystic-ovary-syndrome

Elizabeth E. Puscheck, MD, MS, MBA, FACOG, FAIUM, is a board-certified Reproductive Endocrinologist practicing with InVia Ferility and a tenured Professor at Wayne State University School of Medicine.

O-RADS: Standardizing the way we assess adnexal lesions (and an app to make it easy!)

“When a word has many meanings, it has no meaning at all”. (Anonymous)

Let’s face it: ovarian lesions seen on ultrasound can be some of the most challenging to assess and describe. When not a simple cyst, generic terms such as “complex” are commonly used providing limited insight to the provider and patient regarding the level of concern for risk of malignancy. For instance, shown here are 3 different lesions that could all be described as “complex” or “heterogeneous”, yet range from nonneoplastic to malignant.

Figure 1. Hemorrhagic cyst
Figure 2. Benign dermoid cyst
Figure 3. Endometriod carcinoma

Compound the ambiguity of nonspecific descriptors in the imaging report with the angst of possibly missing an ovarian cancer, a rare but deadly disease, and the result is “over treatment”. Too often, surgery or additional imaging are performed for physiologic and benign findings with the added unintended consequences of associated morbidity and patient anxiety.

Enter O-RADS, an acronym for the Ovarian/Adnexal Reporting and Data System.

Similar to other American College of Radiology (ACR) “RADS” systems (ie, BI-RADS for breast imaging), O-RADS gets everyone speaking the same language AND provides a risk of malignancy using a numeric scale of 0 to 5 (Table 1).

Table 1. Risk of malignancy (ROM) associated with O-RADS Risk Stratification and Scoring System for US and MRI. (NOTE: US systems allow for greater sensitivity at the expense of specificity to avoid not missing a cancer.)

In O-RADS, there are two arms: 1) ultrasound (US), the primary imaging modality for the adnexa used by practitioners from many disciplines; and 2) magnetic resonance imaging (MRI), considered a problem-solving tool for radiologists. With O-RADS ultrasound, management guidance is also provided on triaging lesions to follow-up (clinical or imaging surveillance), additional characterization (by a specialist in US or with an MRI exam), or surgery. For the latter group, this is further divided into those lesions that can be excised by a general gynecologist, and those best managed by a gynecologic-oncologist, an important factor in improving long-term survival in the setting of ovarian malignancy.

Using the available descriptors in the O-RADS lexicon and an algorithmic approach, characterizing adnexal lesions is simplified. First, determine whether a finding in a menstruating patient meets criteria for a physiologic finding (follicle or corpus luteum). If it does not, or the patient is postmenopausal, assess for a “classic benign lesion”, a phrase coined for fairly common lesions that are almost certainly benign when typical features are seen (hemorrhagic cyst, endometrioma, dermoid cyst, paraovarian cyst, hydrosalpinx or peritoneal inclusion cyst). The remainder of lesions are assigned to 1 of 5 categories based on their solid or cystic appearance, and if cystic, the presence of septations and solid components as follows: solid lesion, unilocular cystic ± solid component(s), multilocular cystic ± solid component(s). Subsequently, features such as degree of internal vascularity, lesion size, ascites, and peritoneal nodules may come into play.

To score a lesion, color-coded O-RADS risk stratification tables are readily available and a useful resource. I personally find the O-RADS smartphone app to be an efficient and handy tool to quickly obtain a score and management recommendations. On average, I can reach a score in under 30 seconds and all the information I need for the imaging report is literally at my fingertips.

Since we started using O-RADS, our referring clinicians are asking for an O-RADS score whenever we describe an adnexal lesion as it gives them so much more useful information to counsel their patients. For instance, the patient in figure 1 with a hemorrhagic cyst did not require any imaging follow-up, the patient in figure 2 with a dermoid cyst has safely elected to undergo US surveillance in 1 year, and the patient in figure 3 with endometrioid cancer is doing well under the care of her gynecologic-oncologist.

For me, replacing vague terms (with many meanings) with standardized reporting systems not only makes sense, it’s truly meaningful.

Additional resources:

Dr. Lori Strachowski is a Clinical Professor of Radiology at the University of California, San Francisco, where she holds an adjunct title in the department of Obstetrics, Gynecology and Reproductive Sciences. She is a member of the ACR O-RADS committee serving on the steering committee and chairs the education committee for O-RADS US.

Ultrasound-Guided Obstetric and Gynecologic Procedures in the Pelvis

Ultrasound guidance can be a safe and effective technique in obstetric and gynecologic procedures. Before beginning such a procedure, consider which approach will you take, transabdominal, transgluteal, or transvaginal. The approach that uses the shortest distance to the area of interest without transversing other structures is usually the best tolerated by the patient and will rarely result in complications, which are uncommon and usually minor, such as pain or self-limited bleeding. To select the shortest and safest path for access, review prior cross-sectional imaging and determine it on a case-by-case basis.

In cases of fluid management, such as benign adnexal cyst or peritoneal inclusion cyst fluid collection, note that you may need a larger needle gauge (18+) in those instances in which the fluid is thick. If you intend to test for malignancy, also take into account that fluid is generally less likely than solid tissue to give up the cells needed for a diagnosis.

Fine-needle aspiration in a case with mixed cyst and solid mass.

Ultrasound guidance can also enable delivery of vascular acting medications directly where it is needed, as well as to guide direct gestation sac injection of potassium chloride (KCl) and/or methotrexate for cervical, interstitial, or C-section ectopic or heterotopic pregnancies in appropriate patients.

In conclusion, transvaginal or percutaneous ultrasound guidance can be used in the search for a diagnosis, in fluid collections, and to treat obstetric and gynecologic pathology, such as delivering medications to treat ectopic pregnancy or vascular conditions in select cases.

To learn more about this topic and see examples of its use, watch the full on-demand webinar, “Ultrasound-Guided Interventions to Treat Obstetric and Gynecologic Disease” presented by Tara A. Morgan, MD. Members of the American Institute of Ultrasound in Medicine can access it for free. Join today!

Read more from Tara A. Morgan, MD, on ultrasound guidance in the Journal of Ultrasound in Medicine:

Clear Reporting About Adnexal Torsion

The Challenge: “Can you please rule out torsion?” is a common request ED teams have of their radiologists and gynecologists. Unfortunately, a straightforward answer to this question is rare. The diagnosis of adnexal torsion is full of uncertainty and to make matters worse, we humans are terrible at communicating uncertainty.

Indeed, there are pathognomonic sonographic findings of torsion– whirlpool sign and/or absent flow in the setting of an enlarged, edematous ovary. But certainty is rare. Thus, many reports hedge that “torsion cannot be ruled out.”

We acknowledge that the radiologist interpreting the images is not at fault for this uncertainty. The issue is that the tool itself is imperfect. Ultrasound, as a test, is great at “ruling things in,” but quite mediocre at “ruling things out.” And torsion, as we know, is a surgical diagnosis. However, going to the OR means subjecting a patient to the potential risks of surgical complications, “tying up” healthcare resources, and is expensive.

The Crux: Most imaging is helpful to “rule in,” NOT “rule out” a diagnosis. The complexity and uncertainty of pelvic ultrasonography in the evaluation of women with acute pelvic pain in and of itself is challenging. On top of that, how do we best communicate the uncertainty of NOT seeing something – like looking for a black cat in a dark room — is it even there?

The language we use in ultrasound reports can further complicate the situation. This is especially true when images are interpreted out of context, and a broad differential diagnosis offered. There are incidental findings in asymptomatic patients that warrant further evaluation in the outpatient setting, and there are others that require emergent evaluation in the correct clinical context. A cyst or mass may be an incidentaloma. Torsion is not.

The verbiage used in reports carries significant weight in clinical decision-making and management. When humans read “cannot rule out xyz,” they usually interpret this (for better or worse) as “xyz should be ruled out.” And so, we would love to start a conversation about the linguistics of report-writing for female pelvic ultrasonography.

Cases: Here are a couple of clinical scenarios that illustrate our concern:

  1. A 14-year-old female patient presents to the ED with right upper abdominal and flank pain. Her ultrasound was performed to evaluate the kidneys (area where pain was originating from), however, it also demonstrated an enlarged right ovary (4.9 cm in largest dimension). The report reads “intermittent torsion cannot be excluded.” We agree; it in fact cannot. However, now intermittent torsion MUST be excluded, and we are consulted.

The patient’s lower abdominal examination is benign. Our suspicion for torsion is exceedingly low. However, ultrasound cannot rule out torsion, only surgery can rule out torsion. Now this teenager has been given an additional, unrelated stressor (“your ovary can die”) that was unlikely to ever have significant medical repercussions. To top it off, the report recommends a follow-up scan at 8–12 weeks for what appears to be a physiologic hemorrhagic corpus luteum — an additional expense and time taken from the patient and her family to follow-up.

Final Diagnosis: Pyelonephritis

  1. A 43-year-old female patient scheduled for hysterectomy later in the month presents to the ED with persistent left lower quadrant pain that has been present for several weeks. She has a long-standing history of fibroids and was diagnosed with a 5-cm anechoic left ovarian cyst 2 months ago. Ultrasonography re-demonstrates a leiomyomatous uterus and the left ovary was not visualized.

The report reads “torsion of the left adnexa could not be excluded.” Agreed, it in fact cannot. However, the reason why it cannot be excluded is not that the ovary was not visualized. Additionally, torsion could not be excluded because ultrasound is NOT a test to exclude torsion.  

On examination, there was focal tenderness and point-of-care ultrasonography confirmed its location over a pedunculated fibroid (likely degenerating). An overnight, unscheduled diagnostic laparoscopy, in this case, would’ve resulted in a reassuring adnexal evaluation and possible myomectomy, not the procedure the patient truly needed (a laparoscopic hysterectomy).

Final Diagnosis: Degenerating fibroid (noted on hysterectomy later that week)

Why now?

Prior to COVID-19, healthcare overutilization and defensive medicine were problematic. Now, with limited resources and increased demand, the burden is even higher. ER providers, gynecologists, and radiologists must work in tandem to:

  1. prioritize imaging studies when relevant,
  2. report in clear, objective language in the context of the clinical scenario, and
  3. prioritize emergency and inpatient consultations.

Why does this matter?

Most imaging is helpful to “rule in,” not “rule out” a diagnosis. Language and semantics may significantly affect management, especially in the context of less experienced providers. For patients, it may mean the difference between an unscheduled abdominal surgery or observation. In our prior commentary (1) we referenced the language used by our obstetrics colleagues wherein they acknowledge the limitations of the imaging modality and thus, we suggest the following modification to the current style of reporting:

“Ultrasound is not intended to rule out ovarian torsion.”

We understand that this suggestion, for some, is a change of established practice patterns and we would love to hear your thoughts. Please leave comments below or tweet at @StethoscopeOn and @Dmitry_Fridman to continue the conversation!

Reference

  1. Meljen V,  Fridman D. Gynecologist’s Perspective: Semantics of “Ruling Out” Ovarian Torsion. J Ultrasound Med 2020; 39:1013. Available at: https://onlinelibrary.wiley.com/doi/10.1002/jum.15175.

Vivienne Meljen, MD, is a resident, and Dmitry Fridman, MD, PhD, is an Assistant Professor of Obstetrics and Gynecology, in the Department of Obstetrics and Gynecology at  Duke University Health System in Durham, North Carolina, USA.

Interested in learning more about gynecologic ultrasound? Check out the following posts from the Scan:

The Development of a Reporting and Data System Using Ultrasound: My ACR O-RADS Journey

Supervising the development of the American College of Radiology Ovarian-Adnexal Imaging-Reporting and Data System for Ultrasound (ACR O-RADS US)1 has been a journey that has challenged and substantially improved my leadership and management skills.Rochelle F. Andreotti, MD

O-RADS is a quality assurance tool and clinical decision support system for the standardized description of ovarian/adnexal pathology and its management consisting of a lexicon and risk stratification system. It is 1 of 10 Reporting and Data Systems (RADS) sponsored by the American College of Radiology (ACR). The committee was formed in 2015 under the direction of the ACR Ultrasound Commission and Commissioner, Beverly Coleman. I was asked to Chair the committee with Dr. Phyllis Glanc from Toronto, Canada, as Vice-chair.

“The best and the brightest”

O-RADS is an international initiative that has involved extensive collaboration with competing national and international societies. We began in the summer of 2015 developing our mission and membership. Our membership was primarily derived from several major initiatives that prompted our formation. These included the SRU Consensus Statement, a North American initiative helpful in determining management of cystic lesions, the International Consensus, the first collaboration of European and North American management approaches promoting a more conservative, standardized approach while optimizing the referral pattern to a GYN-oncologist when malignancy is suspected and terms and risk stratification models developed by the International Ovarian Tumor Analysis Group (IOTA). It was also highly recommended that the committee consist of members representing national and international related societies who could contribute to and eventually help promote our system. As a result, from the beginning, I was facing highly opinionated, accomplished colleagues so that there would need to be lots of creative thinking to navigate the pathway going forward.

Lumper, not a splitter

I can see the overall picture and am an accomplished problem solver but concentrating on the smaller details is not my forte and I often find them cumbersome. In order to achieve group consensus, the next 2 years that we spent establishing the lexicon was a thought-provoking and prolonged experience in which both of these qualities were essential.

Ergo, I needed to step up my game.

Evaluating quality of evidence using a comprehensive scoring system was an early point of contention, but fairly quickly we were able to come to agreement that scoring articles for quality would not be of much concern in the lexicon phase, although evaluating the quality of the study would be useful if the article added support to the risk management phase.  The method chosen to develop the lexicon became a tedious process of culling evidence-based and frequently used terms from the literature using a survey, then through a consensus process, narrowing down the list to a workable group. Inevitably, since the IOTA terms were the most evidence-based, this became the foundation of the lexicon.

Looking back at other approaches, perhaps there may have been an easier, less time-intensive pathway that would also have led to the same results. Nevertheless, the process taught me that no matter how well thought out a strategy, always be prepared for others who, out of their own desire to work toward the greater good, will complicate the plan.

Let’s keep this as simple as possible

On a similar note to the “lumper” versus “splitter” mindset, we vigorously debated the specific modalities to be included in this system. There was no question that ultrasound (US) as the primary modality and magnetic resonance imaging (MRI) as a problem-solving tool were key. However, would it be prudent to add CT/PET, tools not recommended for these adnexal mass diagnoses, although occasionally demonstrating incidental findings?

Limiting our bandwidth to the two tracks was my recommendation. However, this high-spirited deliberation came close to splintering our fledgling committee, be it not for the ACR staff’s suggestion of a vote that finally put to bed the possibility of a third O-RADS track. The vote left us with the two original parallel US and MRI working groups, preventing much added unnecessary work and anxiety. From this encounter, I learned the value of highly polished social skills.

The European mathematical model and the North American pattern approach- the challenge of working internationally

The relationship of the Ultrasound Working Group of the ACR O-RADS Committee with the IOTA Group has been collaborative but, at times, complicated and contentious. The reasons for this were two-fold. Foremost, the IOTA Group had already developed a set of applicable terms that were evidence-based as well as validated mathematical models to risk stratify lesions and were most interested in expanding their influence. However, these European models, while highly accurate, were less accepted in North America where a pattern-recognition approach is generally more desirable. Since IOTA provided their cohort of over 5900 surgically proven lesions, to support our pattern approach, compromise needed to be reached regarding further incorporation into the O-RADS Ultrasound System.

In the early development of the risk stratification system at our 2017 meeting at ACR headquarters in Reston Virginia, Dr. Dirk Timmerman from Leuven, Belgium, our IOTA representative, first presented to the group a proposal of a dual approach with addition of the IOTA Simple Rules2. After further work using a more generalized pattern approach based upon IOTA data, this was not pursued.

However, later in 2019, we were confronted with the need to incorporate the more accurate, well-validated IOTA ADNEX mathematical model3 into the O-RADS system as an alternate approach. In this way, we were able to obtain acknowledgment from key players representing IOTA with the hope of allowing O-RADS US to be launched internationally in addition to North American acceptance.

With continued use of the system, I have found an extra advantage of incorporating the ADNEX model when evaluating higher risk lesions in that it adds additional specificity to the diagnosis, information greatly appreciated by the gynecologic oncologists.

Impact factor

Any success that I have had in the field of medicine can be attributed to a desire to influence and leave this world, in some way, a little better for it. My hope is that this data system will prove to be something that will make a meaningful contribution and be my legacy to women’s healthcare.

References:

  1. Andreotti RF, Timmerman D, Strachowski LM, et al. O-RADS US risk stratification and management system: A consensus guideline from the ACR Ovarian-Adnexal reporting and data system committee. Radiology 2020;294:168–185.
  1. Timmerman D, Van Calster B, Testa A, et al. Predicting the risk of malignancy in adnexal masses based on the Simple Rules from the International Ovarian Tumor Analysis group. Am J Obstet Gynecol 2016;214(4):424–437.
  1. Van Calster B, Van Hoorde K, Valentin L, et al. Evaluating the risk of ovarian cancer before surgery using the ADNEX model to differentiate between benign, borderline, early and advanced stage invasive, and secondary metastatic tumours: prospective multicentre diagnostic study. BMJ 2014;349:g5920.

Rochelle F. Andreotti, MD, is a Professor of Clinical Radiology and Obstetrics and Gynecology at Vanderbilt University College of Medicine in Nashville, Tennessee.

https://connect.aium.org/home

The Best of the Scan, 5 Years in the Making

The Scan has been a home for all things ultrasound, from accreditation to zoos, since its debut 5 years ago, on February 6, 2015.MISC_SCAN_5_YR_ANN_DIGITAL_ASSETS_FB

In its first 5 years, the Scan has seen exponential growth, in large part due to the hard work of our 110 writers, who have volunteered their time to provide the 134 posts that are available on this anniversary. And it all began with Why Not Start? by Peter Magnuson, the AIUM’s Director of Communications and Member Services, who spearheaded the blog’s development.

In honor of this 5th Anniversary, here are some of your favorites:

Top 5 Most Viewed Posts

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1. Ultrasound Can Catch What NIPT Misses
by Simcha Yagel
(August 4, 2015)

Sonographer Stretches2. Sonographer Stretches for an ‘A’ Game
by Doug Wuebben and Mark Roozen
(January 31, 2017)

Keepsake3. The Issue with Keepsake Ultrasounds
by Peter Magnuson
(April 30, 2015)

Hip Flexor Stretch4. 3 Stretches All Sonographers Should Do
by Doug Wuebben and Mark Roozen
(January 19, 2016)

Anton5. From Sonographer to Ultrasound Practitioner: My Career Journey
by Tracy Anton
(October 23, 2018)

The Fastest Growing Posts
That Are Not Already in the Top 5

And we have plenty more great posts, such as:

Menstrual Pain: Is it Adenomyosis?

Frequently, during daily ultrasound consultations, female patients complain about certain symptoms during their menstrual period, whereas other women go through their monthly cycle without experiencing pain and might feel just a little discomfort associated with their period.Ticci

For those women who do suffer from various common menstrual disorders that can cause stress, pelvic ultrasound is commonly used to investigate any underlying medical problems in menstrual abnormalities.

For example, before speaking with her physician, Brianna didn’t know which symptoms were normal and which were not, since she always thought that a cycle that’s “regular” for her may be abnormal for someone else. She was just chilling at a regular doctor’s checkup when the physician advised her about a vaginal ultrasound after she told him about her symptoms during her menstrual period.

Brianna had never experienced a transvaginal ultrasound before and she thought that it was a little weird and awkward, although some of her friends had told her a while back that the procedure was not painful.

Brianna was referred to my office for the ultrasound exam. She complained about a persistent pelvic pain during her period and about heavy bleeding.

Ultrasound findings:

  • enlarged globular uterus with different densities within the myometrium
  • pockets of fluid within the muscle of the uterus (myometrial cysts)
  • linear acoustic shadowing without the presence of fibroids and echogenic linear striations, like stripes

That’s adenomyosis and it’s very common. And she’s probably never heard of it.

 

 

 

Adenomyosis

Adenomyosis is a common benign gynecologic disorder and its etiology and association with infertility are still unclear. It is a benign disorder previously associated with multiparity but recently, an association with infertility has emerged.

Adenomyosis can be asymptomatic or present with menorrhagia, dysmenorrhea, and metrorrhagia.

Other symptoms may be painful intercourse and/or persistent bladder pressure. These symptoms usually occur in patients aged 35 to 50, and the condition may affect 65% of women.

The patient looked at me while I tried to quell her fears, trying to explain that it is just an unusual thickening of the uterine wall, caused by glandular tissue being pushed into the muscle.

“It’s cancer?” That’s the first question.

“No, it’s not cancer.” I try to explain: it’s something I saw on the ultrasound called adenomyosis and it’s not going to turn into cancer.

The patient probably had never heard that word before and she’s asking how to spell it so she could go home and Google it.

“Is that a bad thing?” That’s the next question.

I answer, “no, it just doesn’t sound like a good thing. ”

 

Adenomyosis and Endometriosis

Brianna is actually very worried at this point. She’s heard the word “Endometriosis” before because some of her female friends have had it and they thought that, perhaps, that was the cause of their fertility problem.

That’s the next question.

“Is adenomyiosis similar to endometriosis?”

I try to explain that endometriosis happens when endometrial cells are outside the uterus. Adenomyosis is when these cells grow into the uterine wall.

This is my answer and I’m trying to reassure my patient that the two syndromes are quite different. Endometriosis is much more severe. Because Brianna remembers that her friends had pregnancy problems, she’s now scared to death.

Pregnancy and fertility, that’s the great issue.

 

Pregnancy and fertility

“Is it possible to get pregnant with Adenomyosis?”

“Don’t be too concerned, Madam” is my answer.

Evidence that links adenomyosis to fertility is limited to case reports and small case series. But there is a significant association between pelvic endometriosis and adenomyosis (54% to 90% of cases), and it is well known that endometriosis causes infertility. For this reason, findings of infertility were due to endometriosis rather than adenomyosis.

At this point in the conversation, I really think that it is very important to calm the patient.

“In most women, it’s not going to have a medical impact. Sometimes, doctors don’t even tell their findings because it’s not really clinically significant,” I say to her.

 

Treatment

Treatment requires a lifelong management plan as the disease has a negative impact on quality of life in terms of menstrual symptoms, fertility, and pregnancy outcome, including a high risk of miscarriage and obstetric complications.

The therapeutic choice depends on the woman’s age, reproductive status, and clinical symptoms. However, so far, few clinical studies focusing on medical or surgical treatment for adenomyosis have been performed, and no drugs labeled for adenomyosis are currently available. Nonetheless, the disease is increasingly diagnosed in young women with reproductive desire, and conservative treatments should be preferred.

Adenomyosis may be considered a sex steroid hormone-related disorder associated with an intense inflammatory process. An antiproliferative effect of progestins suggests their use for treating adenomyosis by reducing bleeding and pain. Continuous oral norethisterone acetate or medroxyprogesterone acetate may help to induce regression of adenomyosis by relieving pain and reducing bleeding.

There is evidence on several surgical approaches for the improvement of adenomyosis-related symptoms; however, there is no robust evidence that they are effective for infertility.

 

 Let’s go back to our office

After this long talk, Brianna realized she didn’t need to freak out.

One thing she really couldn’t understand is why she’d never heard the name of this condition.

She was also kind of upset because she spent her teenage years suffering so much from pelvic pain during periods and now that she’s ready to have a family and give birth, a doctor tells her about an annoying medical condition, gives her all this news that explains all her symptoms, which may cause fertility problems and she’d never heard of it before!

Any suggestions for getting the word out about adenomyosis?

 

Do you have any suggestions for getting the word out about adenomyosis? Do you have your own experience to share? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

connect_now_live_digital_graphics_e-newsletter-1 

Pietro Ticci, MD, is originally from Florence, Italy, and has been a medical doctor in the Florence Area (Tuscany) since 1995. Currently, he is an Ultrasound Physician at his private medical facilities in the Florence Area.

Exploring the Potential of Ultrasound for Endometriosis

Endometriosis is a benign and chronic condition that can cause women to experience pain and fertility problems. For a long time, and to an extent still today, surgery is required to diagnose the disease. However, in the hands of an expert, a transvaginal ultrasound can accurately map deep endometriotic nodules and identify pouch of Douglas obliteration in a noninvasive fashion (Figure 1). Though this statement exhibits optimism in the effort to minimize the use of invasive surgery for diagnostic purposes, there are a few limitations with ultrasound in this scenario.

Leonardi Fig 1

Figure 1: Ultrasound depiction of bowel deep endometriosis and negative sliding sign (can only be noted with dynamic movements) (left) and laparoscopic depiction of bowel deep endometriosis and obliterated pouch of Douglas.

This blog post will attempt to highlight a few key issues with ultrasound’s potential in the realm of endometriosis. We also encourage your comments below on how you feel about ultrasound for endometriosis. Ultimately, we must all be critical of what can and cannot be achieved with ultrasound to ensure appropriate day-to-day clinical practice. This then also allows us to pursue ongoing cutting-edge research endeavors.Leonardi

Our first limitation is in the definition of the word, “expert.”  Thus far, one might attach the term “expert” to those responsible for the bulk of the literature on ultrasound for endometriosis. Certainly, in the view of these academics, ultrasound can see much more endometriosis than previously thought. The belief in the value of ultrasound and expertise in scanning/interpreting scans may trickle down the typical training ladder to fellows, residents, and sonographers. But is there any formal teaching—didactic or tactile? Is there any formal assessment of skill to suggest a minimum level of competency? Is there, at this time, even an understanding of how to evaluate a trainees’ learning curve of endometriosis ultrasound? What is to there to stop an individual from claiming competency when ultrasound for endometriosis is still in its infancy? One concern with pseudo-experts is that they may actually impede the advancement of endometriosis ultrasound integration because surgeons do not verify their findings intraoperatively, leading to skepticism.

Another big problem with the current potential for noninvasive ultrasound diagnosis of endometriosis is the inability to visualize superficial endometriosis, the mildest form of the disease. In surgery, deposits of superficial endometriosis are generally small, only a few millimeters in width and depth, and discolored (Figure 2). They sometimes cause adhesions to form between structures, such as the ovaries and the pelvic sidewall or uterosacral ligament. Thus far, no one has been able to directly identify superficial endometriosis deposits on ultrasound. However, soft markers on ultrasound, such as ovarian immobility and site-specific tenderness (ie, the ability to elicit pain with the pressure of the transvaginal probe during the scan) may hold some secrets to the diagnosis of this enigmatic form of the disease. Until further research supports the routine use of these components in ultrasound for endometriosis, the superficial disease remains a surgical, and therefore invasive, diagnosis.

Condous and Leonardi Fig 2

Figure 2: Laparoscopic depiction of small superficial endometriosis deposit.

Despite these limitations and others not highlighted here, the ability to directly visualize the more severe forms of the disease (ie, ovarian endometriomas, deep endometriosis of the bowel, and pouch of Douglas obliteration) has led to two very clear and significant benefits. One, the patient may be able to receive a diagnosis of disease in a noninvasive fashion, which may guide treatment. Second, if surgery is elected as the treatment of choice, surgeons can prepare. If severe disease is noted on a scan, surgeons can anticipate advanced level surgery, which may necessitate skill from a minimally invasive gynecologic surgeon and/or colorectal surgeon. If no disease is identified on a scan, there will be superficial endometriosis or no disease at all in surgery.

Overall, we are at a much better place right now than we have ever been when it comes to ultrasound for endometriosis. There are still limits that must be addressed, many of which are actively being investigated by dedicated teams around the world. This blog commentary does not attempt to offer solutions to the obstacles highlighted. However, please feel free to comment below if you have any thoughts on an approach to these, or other, limitations.

Have you tried ultrasound for endometriosis? What is your experience with ultrasound and endometriosis? What are your thoughts on the limitations of ultrasound for endometriosis? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

Connect

Mathew Leonardi, MD, FRCSC, is an Honorary Lecturer in the Department of Obstetrics and Gynaecology and PhD student at the Nepean Clinical School, University of Sydney, under the supervision of Associate Professor George Condous. His Twitter handle is @mathewleonardi