Evaluation of Adnexal Masses With Transvaginal Color Ultrasound Asim Kurjak, lvica Zalud, Zarko Alfirevic
We evaluated 14,317 asymptomatic or minimally symptomatic women for ovarian carcinoma with transvaginal color Doppler ultrasound. The resistance index was calculated for at least five separate cardiac cycles in each case, and the mean was calculated. We discovered 624 benign adnexal masses: in every case except one the resistance index was >0.40. There were 56 malignant adnexal masses, 16 of which were stage I ovarian cancers. Neovascularization was found in six
0
varian carcinoma is the major lethal gynecological neoplasm in Western countries. 1 Yugoslavia is no exception. The poor prognosis of this neoplasm is generally due to its late presentation. Symptoms do not appear in most cases until the primary lesion has spread. Diagnosis of ovarian carcinoma at an early stage was very unusual before we introduced color Doppler ultrasound in 1987 for examination of the pelvic organs. 1 Color Doppler detects blood flow in small low-resistance vessels1·3 that form in neoplastic tissue. 4 Pulsed Doppler is then used to quantify such color-coded flow using Pourcelot's resistance index." Ovarian malignancy is thus differentiated from other lesions that produce similar but not identical patterns of flow. 2•3 •6 We present 14,317 asymptomatic or minimally symptomatic women evaluated for ovarian carcinoma with color Doppler ultrasound and followed up with this technique.
Received from the Ultrasonic Institute, University of Zagreb, Zagreb, Yugoslavia. Address correspondence and reprint requests to Dr. Asim Kurjak: Ultrasonic Institute, University of Zagreb, Pa v\eka Mis kine 64, 41 .000 Zagreb, Yugoslavia.
of the seven stage I primary neoplasms and in all of the nine stage I secondary ovarian cancers. In all, the RI was :s:0.40. There were 40 advanced ovarian cancers revealed (stage III or IV); 39 showed abnormal color ~ flow pattern with the resistance index 0.40 (Fig. 1) with one exception: a chronic appendicitis with hydrosalpinx in which the RI was 0.39. Seven primary and nine secondary stage I ovarian neoplasms were discovered. Five of the primary ovarian neoplasms were found in women known to have an adnexal mass, and two were in the asymptomatic group. Each of these tumors was stage IA, and their diameters were between 3.5 and 4 cm. Neovascularization was found in six of seven primary neoplasms. In these six the RI was 0.32- 0.40 (mean 0.36) (Fig. 2). The seventh tumour was stage IA; it was missed with color Doppler. In this patient, a 5.3-cm cyst was found in the other ovary with normal flow pattern. At laparotomy the enlarged ovary was found to be benign, but the other, which was ultrasonically normal with diameter of only 3.6 cm, contained the stage IA ovarian neoplasm. Nine secondary ovarian neoplasms were found. The primary growths were in the breast, thyroid, and rec·
tum. Their mean diameter was 4.6 cm (range 3.8- 5.1 cm). In each the RI was S0.40 (mean 0.38; range 0.280.40), and the color was not so prominent as in primary neoplasms (Fig. 3). In five of these nine cases, clinical examination, transabdominal, or transvaginal ultrasound did not reveal any pelvic abnormality. The remaining 40 malignant neoplasms were stage III and IV ovarian cancers with characteristic abnormal flow patterns in 39 cases (Fig. 4). Three of them were found in the asyptomati.c group. A secondary tumor from an endometrial cancer was not detected by means of color Doppler. However, sensitivity, specificity, and accuracy of this diagnostic method are acceptably high (Table 1). Repeat examinations have been carried out 12- 18 months after the first in 362 women. Benign adnexal masses were found in 16 of these, but no malignant masses have been found.
Figure 1 Benign adnexal mass. Typical color and pulsedDoppler finding.
Figure 3 Bilocular cystic structure represents secondary ovarian cancer at stage IA Weak color signal and very-low· impedance pulsed Doppler finding are shown.
JUltrasound Med 10:295- 297, 1991
KURJAK ET AL
Figure 4 Ovarian cancer at stage IV. Color and pulsed Doppler indicated malignant nature of the huge adnexal mass.
DISCUSSION Discovering asymptomatic ovarian carcinomas of only 3.5-6.0 cm in diameter was only a chance occurrence at laparotomy, until now. Detecting the carcinoma as early as stage IA in a tumor of any size is also unusual since such tumors rarely produce symptoms. With color Doppler ultrasound it is now possible to diagnose ovarian carcinoma noninvasively because of the characteristic patterns of flow in the newly formed vessels within the tumour. 2 -v .s As we have shown, it is real· istic to be able to do so as early as stage IA. Any diagnostic program is likely to have both false positive and false negative results, particularly if new technology is involved. We had one false positive and two false negative observations. In one of the false negative observations, an enlarged ovary containing a 5.3-cm cyst was found to be normal, whereas the apparently healthy ovary had stage IA ovarian cancer. This could be partially explained by thorough exami-
nation of the •abnormal· ovary and inadequate assessment of the ·healthy• contralateral ovary. The other false negative result was due to failure to detect neo· vascularization in secondary endometrial carcinoma. Primary endometrial carcinoma can be diagnosed with color Doppler: 2 the secondary deposit may have been necrotic and lacked flow in new vessels, or the pattern of flow may have been different from the primary and not recognized. Other ovarian carcinomas may be discovered in annual review scans, but they are likely to be new lesions. In an ultrasound screening program, Campbell et al 9 discovered lesions in 3 of 5000 women 16-18 months after a negative scan. Even with our two false negatives, the sensitivity of our method was 96.4%, specificity was 99.8%, and positive predictive value was 98.2%. To have discovered seven stage IA primary carcinomas among 640 pelvic masses found in 14,317 women who did not have symptoms suggesting ovarian pathology is rewarding since tumors treated at this early stage have an excellent prognosis. Our experience also stresses the importance of thorough ex· amination of ovaries with color Doppler regardless of their B-mode ultrasound appearance or size.
REFERENCES 1. Beral V: The epidemiology of ovarian cancer. In: Sharp
2. 3. 4. 5.
Table 1: Transvaginal Color Doppler in Detection of Adnexal Tumor Malignancy Color Flow Present Histopathology - - - - - - Total Malignant Benign and RI
We evaluated 14,317 asymptomatic or minimally symptomatic women for ovarian carcinoma with transvaginal color Doppler ultrasound. The resistance index was calculated for at least five separate cardiac cycles in each case, and the mean was calculated. We discovered 624 benign adnexal masses: in every case except one the resistance index was >0.40. There were 56 malignant adnexal masses, 16 of which were stage I ovarian cancers. Neovascularization was found in six
0
varian carcinoma is the major lethal gynecological neoplasm in Western countries. 1 Yugoslavia is no exception. The poor prognosis of this neoplasm is generally due to its late presentation. Symptoms do not appear in most cases until the primary lesion has spread. Diagnosis of ovarian carcinoma at an early stage was very unusual before we introduced color Doppler ultrasound in 1987 for examination of the pelvic organs. 1 Color Doppler detects blood flow in small low-resistance vessels1·3 that form in neoplastic tissue. 4 Pulsed Doppler is then used to quantify such color-coded flow using Pourcelot's resistance index." Ovarian malignancy is thus differentiated from other lesions that produce similar but not identical patterns of flow. 2•3 •6 We present 14,317 asymptomatic or minimally symptomatic women evaluated for ovarian carcinoma with color Doppler ultrasound and followed up with this technique.
Received from the Ultrasonic Institute, University of Zagreb, Zagreb, Yugoslavia. Address correspondence and reprint requests to Dr. Asim Kurjak: Ultrasonic Institute, University of Zagreb, Pa v\eka Mis kine 64, 41 .000 Zagreb, Yugoslavia.
of the seven stage I primary neoplasms and in all of the nine stage I secondary ovarian cancers. In all, the RI was :s:0.40. There were 40 advanced ovarian cancers revealed (stage III or IV); 39 showed abnormal color ~ flow pattern with the resistance index 0.40 (Fig. 1) with one exception: a chronic appendicitis with hydrosalpinx in which the RI was 0.39. Seven primary and nine secondary stage I ovarian neoplasms were discovered. Five of the primary ovarian neoplasms were found in women known to have an adnexal mass, and two were in the asymptomatic group. Each of these tumors was stage IA, and their diameters were between 3.5 and 4 cm. Neovascularization was found in six of seven primary neoplasms. In these six the RI was 0.32- 0.40 (mean 0.36) (Fig. 2). The seventh tumour was stage IA; it was missed with color Doppler. In this patient, a 5.3-cm cyst was found in the other ovary with normal flow pattern. At laparotomy the enlarged ovary was found to be benign, but the other, which was ultrasonically normal with diameter of only 3.6 cm, contained the stage IA ovarian neoplasm. Nine secondary ovarian neoplasms were found. The primary growths were in the breast, thyroid, and rec·
tum. Their mean diameter was 4.6 cm (range 3.8- 5.1 cm). In each the RI was S0.40 (mean 0.38; range 0.280.40), and the color was not so prominent as in primary neoplasms (Fig. 3). In five of these nine cases, clinical examination, transabdominal, or transvaginal ultrasound did not reveal any pelvic abnormality. The remaining 40 malignant neoplasms were stage III and IV ovarian cancers with characteristic abnormal flow patterns in 39 cases (Fig. 4). Three of them were found in the asyptomati.c group. A secondary tumor from an endometrial cancer was not detected by means of color Doppler. However, sensitivity, specificity, and accuracy of this diagnostic method are acceptably high (Table 1). Repeat examinations have been carried out 12- 18 months after the first in 362 women. Benign adnexal masses were found in 16 of these, but no malignant masses have been found.
Figure 1 Benign adnexal mass. Typical color and pulsedDoppler finding.
Figure 3 Bilocular cystic structure represents secondary ovarian cancer at stage IA Weak color signal and very-low· impedance pulsed Doppler finding are shown.
JUltrasound Med 10:295- 297, 1991
KURJAK ET AL
Figure 4 Ovarian cancer at stage IV. Color and pulsed Doppler indicated malignant nature of the huge adnexal mass.
DISCUSSION Discovering asymptomatic ovarian carcinomas of only 3.5-6.0 cm in diameter was only a chance occurrence at laparotomy, until now. Detecting the carcinoma as early as stage IA in a tumor of any size is also unusual since such tumors rarely produce symptoms. With color Doppler ultrasound it is now possible to diagnose ovarian carcinoma noninvasively because of the characteristic patterns of flow in the newly formed vessels within the tumour. 2 -v .s As we have shown, it is real· istic to be able to do so as early as stage IA. Any diagnostic program is likely to have both false positive and false negative results, particularly if new technology is involved. We had one false positive and two false negative observations. In one of the false negative observations, an enlarged ovary containing a 5.3-cm cyst was found to be normal, whereas the apparently healthy ovary had stage IA ovarian cancer. This could be partially explained by thorough exami-
nation of the •abnormal· ovary and inadequate assessment of the ·healthy• contralateral ovary. The other false negative result was due to failure to detect neo· vascularization in secondary endometrial carcinoma. Primary endometrial carcinoma can be diagnosed with color Doppler: 2 the secondary deposit may have been necrotic and lacked flow in new vessels, or the pattern of flow may have been different from the primary and not recognized. Other ovarian carcinomas may be discovered in annual review scans, but they are likely to be new lesions. In an ultrasound screening program, Campbell et al 9 discovered lesions in 3 of 5000 women 16-18 months after a negative scan. Even with our two false negatives, the sensitivity of our method was 96.4%, specificity was 99.8%, and positive predictive value was 98.2%. To have discovered seven stage IA primary carcinomas among 640 pelvic masses found in 14,317 women who did not have symptoms suggesting ovarian pathology is rewarding since tumors treated at this early stage have an excellent prognosis. Our experience also stresses the importance of thorough ex· amination of ovaries with color Doppler regardless of their B-mode ultrasound appearance or size.
REFERENCES 1. Beral V: The epidemiology of ovarian cancer. In: Sharp
2. 3. 4. 5.
Table 1: Transvaginal Color Doppler in Detection of Adnexal Tumor Malignancy Color Flow Present Histopathology - - - - - - Total Malignant Benign and RI
