Transvaginal ultrasound versus magnetic resonance imaging for diagnosing adenomyosis: A systematic review and head-to-head meta-analysis

Background: Transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) are used for the clinical diagnosis of adenomyosis. Objectives: To compare the diagnostic accuracy of TVS and MRI for the diagnosis of adenomyosis.Search Strategy: A search of studies was performed in five databases comparing TVS and MRI for the diagnosis of adenomyosis from January 1990 to May 2022.Selection Criteria: Studies were eligible if they reported on the use of TVS and MRI in the same set of patients. The reference standard must be pathology (hysterectomy). Data Collection and Analysis: The quality of studies was assessed using the QUADAS-2 tool. Pooled sensitivity and specificity of both techniques were estimated and compared. Main Results: Six studies comprising 595 women were included. The risk of bias of patient selection was high in three studies. The risk of bias for index tests and reference test was low. Pooled estimated sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for TVS were 75%, 81%, 3.9, and 0.31, respectively. These figures for MRI were 69%, 80%, 3.5, and 0.39, respectively. No statistically significant differences were found (p= 0.7509). Heterogeneity was high. Conclusions: MRI and TVS have similar performances for the diagnosis of adenomyosis

Extra-Gynecological Pelvic Pathology: A Challenge in the Differential Diagnosis of the Female Pelvis

Ultrasound technology with or without color Doppler allows a real-time evaluation of the entire female pelvis including gynecologic and non-gynecological organs, as well as their pathology. As ultrasound is an accurate tool for gynecological diagnosis and is less invasive and less expensive than other techniques, it should be the first imaging modality used in the evaluation of the female pelvis. We present a miscellany of non-gynecological pelvic images observed during the realization of gynecological ultrasound. Transvaginal and transabdominal ultrasound is the first choice among diagnostic techniques for the study of the female pelvis, providing information about gynecological and extra-gynecological organs, allowing for an orientation toward the pathology of a specific organ or system as well as for additional tests to be performed that are necessary for definitive diagnosis

O-RADS Classification for Ultrasound Assessment of Adnexal Masses: Agreement between IOTA Lexicon and ADNEX Model for Assigning Risk Group

Background: The O-RADS system is a new proposal for establishing the risk of malignancy of adnexal masses using ultrasound. The objective of this study is to assess the agreement and diagnostic performance of O-RADS when using the IOTA lexicon or ADNEX model for assigning the O-RADS risk group. Methods: Retrospective analysis of prospectively collected data. All women diagnosed as having an adnexal mass underwent transvaginal/transabdominal ultrasound. Adnexal masses were classified according to the O-RADS classification, using the criterion of the IOTA lexicon and according to the risk of malignancy determined by the ADNEX model. The agreement between both methods for assigning the O-RADS group was estimated using weighted Kappa and the percentage of agreement. The sensitivity and specificity of both approaches were calculated. Results: 454 adnexal masses in 412 women were evaluated during the study period. There were 64 malignant masses. The agreement between the two approaches was moderate (Kappa: 0.47), and the percentage of agreement was 46%. Most disagreements occurred for the groups O-RADS 2 and 3 and for groups O-RADS 3 and 4. The sensitivity and specificity for O-RADS using the IOTA lexicon and O-RADS using the ADNEX model were 92.2% and 86.1%, and 85.9% and 87.4%, respectively. Conclusion: The diagnostic performance of O-RADS classification using the IOTA lexicon as opposed to the IOTA ADNEX model is similar. However, O-RADS group assignment varies significantly, depending on the use of the IOTA lexicon or the risk estimation using the ADNEX model. This fact might be clinically relevant and deserves further research

Ultrasonography and atypical sites of endometriosis

In the present pictorial we show the ultrasonographic appearances of endometriosis in atypical sites. Scar endometriosis may present as a hypoechoic solid nodule with hyperechoic spots while umbilical endometriosis may appear as solid or partially cystic areas with ill-defined margins. In the case of endometriosis of the rectus muscle, ultrasonography usually demonstrates a heterogeneous hypoechogenic formation with indistinct edges. Inguinal endometriosis is quite variable in its ultrasonographic presentation showing a completely solid mass or a mixed solid and cystic mass. The typical ultrasonographic finding associated with perineal endometriosis is the presence of a solid lesion near to the episiotomy scar. Under ultrasonography, appendiceal endometriosis is characterized by a solid lesion in the wall of the small bowel, usually well defined. Superficial hepatic endometriosis is characterized by a small hypoechoic lesion interrupting the hepatic capsula, usually hyperechoic. Ultrasound endometriosis of the pancreas is characterized by a small hypoechoic lesion while endometriosis of the kidney is characterized by a hyperechoic small nodule. Diaphragmatic endometriosis showed typically small hypoechoic lesions. Only peripheral nerves can be investigated using ultrasound, with a typical solid appearance. In conclusion, ultrasonography seems to have a fundamental role in the majority of endometriosis cases in “atypical” sites, in all the cases where “typical” clinical findings are present

How Frequently Benign Uterine Myomas Appear Suspicious for Sarcoma as Assessed by Transvaginal Ultrasound?

Uterine myomas may resemble uterine sarcomas in some cases. However, the rate of benign myomas appearing as sarcomas at an ultrasound examination is not known. The objective of this study is to determine the percentage of benign myomas that appear suspicious for uterine sarcoma on ultrasound examination. This is a prospective observational multicenter study (June 2019-December 2021) comprising a consecutive series of patients with histologically proven uterine myoma after hysterectomy or myomectomy who underwent transvaginal and/or transabdominal ultrasound prior to surgery. All ultrasound examinations were performed by expert examiners. MUSA criteria were used to describe the lesions (1). Suspicion of sarcoma was established when three or more sonographic features, described by Ludovisi et al. as "frequently seen in uterine sarcoma", were present (2). These features are no visible myometrium, irregular cystic areas, non-uniform echogenicity, irregular contour, "cooked" appearance, and a Doppler color score of 3-4. In addition, the examiners had to classify the lesion as suspicious based on her/his impression, independent of the number of features present. Eight hundred and ten women were included. The median maximum diameter of the myomas was 58.7 mm (range: 10.0-263.0 mm). Three hundred and forty-nine (43.1%) of the patients had more than one myoma. Using the criterion of >3 suspicious features, 40 (4.9%) of the myomas had suspicious appearance. By subjective impression, the examiners considered 40 (4.9%) cases suspicious. The cases were not exactly the same. We conclude that approximately 5% of benign uterine myomas may exhibit sonographic suspicion of sarcoma. Although it is a small percentage, it is not negligible

past present and future ultrasonographic techniques for analyzing ovarian masses

Ultrasonography is today the method of choice for distinguishing between benign and malignant adnexal pathologies. Using pattern recognition several types of tumors can be recognized according to their characteristic appearance on gray-scale imaging. Color Doppler imaging should be used only to perform a semiquantitative color score or evaluate the flow location. International Ovarian Tumor Analysis group had standardized definitions characterizing adnexal masses and suggested the use of 'simple rules' in premenopausal women. Recently, the use of 3D vascular indices has been proposed but its potential use in clinical practice is debated. Also computerized aided diagnosis algorithms showed encouraging results to be confirmed in the future

Diagnostic accuracy of ultrasound signs for detecting adnexal torsion: systematic review and meta-analysis

Objective: To evaluate the diagnostic accuracy of different ultrasound signs for diagnosing adnexal torsion, using surgery as the reference standard. Methods: This was a systematic review and meta-analysis of studies published between January 1990 and November 2021 evaluating ovarian edema, adnexal mass, ovarian Doppler flow findings, the whirlpool sign and pelvic fluid as ultrasound signs (index tests) for detecting adnexal torsion, using surgical findings as the reference standard. The search for studies was performed in PubMed/MEDLINE, CINAHL, Scopus, The Cochrane Library, ClinicalTrials.gov and Web of Science databases. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to evaluate the quality of the studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios were calculated separately, and the post-test probability of adnexal torsion following a positive or negative test was also determined. Results: The search identified 1267 citations after excluding duplicates. Eighteen studies were ultimately included in the qualitative and quantitative syntheses. Eight studies (809 patients) analyzed the presence of ovarian edema, eight studies (1044 patients) analyzed the presence of an adnexal mass, 14 studies (1742 patients) analyzed ovarian Doppler flow, six studies (545 patients) analyzed the whirlpool sign and seven studies (981 patients) analyzed the presence of pelvic fluid as ultrasound signs of adnexal torsion. Overall, the quality of most studies was considered to be moderate or good. However, there was a high risk of bias in the patient-selection and index-text domains (with the exception of the whirlpool sign) in a significant proportion of studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios of each ultrasound sign were 58%, 86%, 4.0 and 0.49 for ovarian edema, 69%, 46%, 1.3 and 0.67 for adnexal mass, 65%, 91%, 7.6 and 0.38 for the whirlpool sign, 53%, 95%, 11.0 and 0.49 for ovarian Doppler findings and 55%, 69%, 1.7 and 0.66 for pelvic fluid. Heterogeneity was high for all analyses. Conclusions: The presence of an adnexal mass or pelvic fluid have poor diagnostic accuracy as ultrasound signs of adnexal torsion, while the presence of ovarian edema, the whirlpool sign and decreased or absent ovarian Doppler flow have good specificity but moderate sensitivity for detecting adnexal torsion. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.Objetivo.Evaluar la precision diagnostica de diferentes indicios ecograficos para el diagnostico de la torsion anexial,utilizando la cirugia como patron de referencia. Metodos. Se trata de una revision sistematica y un metaanalisis de los estudios publicados entre enero de 1990 y noviembre de 2021 que evaluaron el edema ovarico, la masa anexial, los resultados del flujo Doppler ovarico, el ‘‘signo del remolino’’ (torsion ovarica) y el liquido pelvico como indicios ecograficos (pruebas de referencia) para detectar la torsion anexial, utilizando los resultados quirurgicos como patron de referencia. La busqueda de estudios se realizo en las bases de datos PubMed/MEDLINE, CINAHL, Scopus, The Cochrane Library, ClinicalTrials.gov y Web of Science.Para evaluar la calidad de los estudios se utilizo la herramienta de Evaluacion de Calidad de los Estudios de Precision Diagnostica-2 (QUADAS-2, por sus siglas en ingles). Se calcularon por separado los valores combinados de sensibilidad,especificidad y cocientes de verosimilitud positivos y negativos, y se determino tambien la probabilidad posterior a la prueba de la torsion anexial tras una prueba positiva o negativa. Resultados. La busqueda identifico 1267 citas, una vez excluidas las duplicadas. Se incluyeron dieciocho estudios en las sıntesis cualitativa y cuantitativa. Ocho estudios (809 pacientes) analizaron la presencia de edema ovarico, ocho estudios(1044 pacientes) analizaron la presencia de una masa anexial, 14 estudios (1742 pacientes) analizaron el flujo Doppler ovarico, seis estudios (545 pacientes) analizaron el ‘‘signo del remolino’’ y siete estudios (981 pacientes) analizaron la presencia de lıquido pelvico como indicios ecograficos de torsion anexial. En general, la calidad de la mayorıa de los estudios se considero moderada o buena. Sin embargo, hubo un alto riesgo de sesgo en una proporcion significativa de estudios en las areas de seleccion de pacientes y texto de referencia (con la excepcion del ‘‘signo del remolino’’). Los valores combinados de la sensibilidad, la especificidad y los cocientes de probabilidad positivos y negativos de cada indicio ecografico fueron del 58%, 86%, 4,0 y 0,49 para el edema ovarico, del 69%, 46%, 1,3 y 0,67 para la masa anexial, del 65%, 91%, 7,6 y 0,38 para el ‘‘signo del remolino’’, del 53%, 95%, 11,0 y 0,49 para los resultados del Doppler ovarico y del 55%, 69%, 1,7 y 0,66 para el liquido pelvico. La heterogeneidad fue elevada en todos los analisis. Conclusion. La presencia de una masa anexial o de liquido pelvico apenas tienen precision diagnostica como indicios ecograficos de torsion anexial, mientras que la presencia de edema ovarico, el ‘‘signo del remolino’’ y la disminucion o ausencia de flujo Doppler ovarico tienen una buena especificidad, pero una sensibilidad moderada para detectar la torsion anexial