Diagnosis of Gynecologic Ultrasonography: Analysis

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THOMAS

Pelvic Masses of Specificity

L. LAWSON’

AND

bowel.

small

lesions

(2 cm or less in diameter).

This gray of

study scale

was undertaken ultrasonography

gynecologic

diagnostic

pelvic

All female patients sound for evaluation

masses for a period cases

after

with

6 month

and

and

to

determine

No mass: Normal Early intrauterine Ascites, no pelvic

its

of 18 months

a diagnosis

clinical

Serial

follow-up

were

were

(sagittal)

obtained

masses were localized

analyzed.

by surgery.

autopsy.

at

and consistency

98 (94) masses:

transverse

1 cm

intervals.

determined

Identified both

A- and B-mode ultrasonography at high and low gain (sensitivity). Masses were classified as solid, cystic, or complex using the classic ultrasonic criteria . Ultrasonography was considered correct when the pelvic mass was properly characterized and localized and the proven diagnosis suggested.

Ovarian

fibroma

Ovarian Ovarian Total

granulosa dermoid

tissue

cell tumor tumor .

Complex pelvic Abscess Ectopic

4 4 4 3

adenocarcinoma of colon

Adhesions/inflammatory Endometriosis

B-mode

utilizing

22 (20)

Extrauterine: Ovarian Carcinoma

included.

and

19

Total

or

examined, 251 were deemed proven and study (table 1 ). Ultrasound correctly identified the presence or absence of a mass as well as its consistency and location in 229 cases, for an overall accuracy rate of approximately 91%. The 22 errors were primarily the result of oveninterpretation of loops of bowel, technically poor examinations, misinterpretation of ectopic pregnancy. or small lesions at the lower limit of resolution. There were 98 patients with suspected pelvic masses on pelvic examination who were subsequently found to be without mass or with a normal intrauterine pregnancy. Of this group, 94 were correctly diagnosed by ultrasound. The

in

four

loops

errors

were

caused

by misinterpretation

November

1976;

accepted

after

Am

J Roentgenol

128:1003-1006,

June

1977

March

Roentgen University

4.

46 (40) masses:t retention

49 10 4 2 2

cyst

pregnancy

cyst

Hydrosalpinx

Total .

of bowel

revision

2 adhesions

Endometrial

rectly

67 (59)

Numbers in determined

TAll

3,

2 tumor

Abscess Ectopic

18(16)

2

Total Cystic pelvic Functional

su9gested

Presented at the annual meeting of the American 1 Department of Radiology. George Washington

Brenner

Endometriosis Small bowel

as masses.

Received

carcinoma:

Malignant

this

.

9 5

Adenocarcinoma Cystadenocarcinoma

Of the patients

included

.

24

pregnancy

Ovarian

.

masses:t

Dermoid

Results

parentheses existence.

the correct

represent total for which ultrasonography size. location. and consistency of the mass

diagnosis

extrauterine

1977.

Ray Society. Medical

Center.

1003

Washington. Washington.

Cases

57 40

pregnancy tumor

Leiomyomas Sarcoma, mixed mesodermal Endometrial carcinoma Retained products of conception

ultrapelvic

were obtained with a full urinary available gray scale ultrasono-

longitudinal

ultrasonograms

were retrospectively

confirmed

No

Total

Methods of diagnostic or palpable

1

Diagnosis in Patients with Suspected Pelvic Masses

Type Mass and Diagnosis

Solid pelvic Uterine:

referred to the section of clinically suspected

All pelvic ultrasonograms bladder using a commercially

scope.

only made

specificity. Materials

Only

TABLE

or poor

are nonspecific. diagnosis be

40 solid pelvic masses: 22 uterine Solid extrauterine masses could not from the uterus ultrasonically in

Proven Clinically

to evaluate the accuracy of in the detection and diagnosis masses

N. ALBARELLI’

The series included and 18 extrauterine. be cleanly separated

A retrospective analysis of 251 proven cases of gynecologic masses was undertaken. Accuracy of gray scale sonography in determining the existence. size. location. and consistency of pelvic masses was approximately 91%. This is slightly higher than previously reported and could reflect increased accuracy of gray scale ultrasonography. Errors were primarily due to misinterpretation of loops of technique. Since ultrasonograms rarely could a specific histologic without accurate clinical information.

JUDITH

by Gray Scale and Accuracy

D.C., D.C

September 20037.

1976 Address

reprint

requests

to

T. L. Lawson

corand

LAWSON

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1004

three

of four

noma with

of the colon, inflammatory

cases

of endometniosis. Among the sound

tumors,

Small

adhesions

one

ovarian

of one

tumors,

was

extrauterine and

carcinoma

cases and

were

was (fig.

were

were

two

an

adnexal

interpreted 1 ). Of the

ultrasound

interpreted

carcinoma

ultra-

sonolucent, as

sarcoma Ieiomyoma

canci-

two

relatively

misinterpreted

there

and

missed

as solid

errors.

as a pelvic

was

ALBARELLI

pelvic adhesions of three cases

there

pedunculated,

and the uterine a calcified uterine bowel

ovarian

uterine

One

Ieiomyoma

abscess, simply

both all four disease,

solid

errors.

uterine

of

AND

for

mass,

technical

reasons. All were

46

complex

the

most

pelvic

masses

inflammatory

postoperative disease. separated cases ovarian

and

Of the complex ultrasonically

pelvic from

In one

adhesions

were

other

cases,

cystic

denmoid

the

exceptions

two

secondary

loops

cystic tumor

were of

not

cysts

not

be nine

as

ovarian were

bound an

the

adnexal

carcinomas

and

by

mass.

and

misinterpreted

ovary;

by ultratogether

In

a bilateral

erroneously

Two patients with as having functional

ectopic

pregnancy

was

considered. In general,

tenistics to

of

four

Cnohn’s

misdiagnosed

bowel

diagnosed as simple ovarian cysts. ectopic pregnancy were interpreted retention

were to

masses, 37% could the uterus, including

misinterpreted

two

to gonococcal

five ectopic pregnancies, three one case of pelvic endometniosis.

masses

case,

Abscesses

secondary

disease;

abscesses

Six of the complex

extrauterine.

usually

of pelvic abscesses, carcinomas, and

sound.

were

common,

noted

definite

be observed

a specific that

solid

complex

histologic masses

distinguishing

ultrasonic

charac-

in the

solid

or complex

masses

diagnosis.

However,

with

a prominent

focal

wheel, tumor

it was area

of

tissue

diagnosed surgery were

no

could

allow

Fig. 2.-Longitudinal ultrasonogram 3 cm right of midline and lateral to uterus and bladder in patient with proven cystic right ovarian dermoid tumor. Note focal area of solid tissue (arrow) within complex mass. Pattern also seen in patients with ectopic pregnancy. Although not specific. this diagnostic sign may be helpful. U level of umbilicus.

ovarian

surrounded as

(fig.

cystic

by

but

with

prominent

which may be a clue (fig. 3). Ascites was adenocarcinoma

cystadenocarcinoma

a cystic

denmoid tumors or 2). The two mucinous

area

frequently

septations, to the present but

on malignant

were

ectopic pregnancy cystadenocarcinomas like

spokes

correct diagnosis in four of six not

in

Brenner

the tumor

at of a

of this cases of cases (fig.

of 4).

ACCURACY

OF ULTRASOUND

IN PELVIC

1005

MASSES

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.r

I

1

Q Fig. 3. - Midline longitudinal ultrasonogram of lower abdomen and pelvis in patient with ovarian cystadenocarcinoma. Note large complex pelvic mass with central area of solid tissue and prominent septations suggesting spokes of wheel (arrows).

All 73%

67

cystic

were

masses

simple

were

extrauterine.

functional

ovarian

Fig.

4. -Transverse

1

ultrasonogram

-

through

pelvis

demonstrating

uterus (u) in center of loculated area of malignant ascitic fluid. seen as anechoic region Note multiple solid masses along periphery of pelvic wall reflecting areas of tumor metastases and tethered loops of bowel (arrows)

Approximately retention

cysts.

Pelvic abscesses accounted for 20% of cystic masses: three occurred postoperatively, one secondary to appendicitis, one secondary to Crohn’s disease involving the terminal ileum, and one was a tuberculosis salpingitis. Eight diagnostic errors were pelvic masses. Two functional preted

as ectopic

made in interpreting retention cysts were

pregnancies,

two

ectopic

cystic inter-

pregnancies

were erroneously diagnosed as simple cysts, and four small cystic ovarian masses 1 cm in diameter were interpreted as small solid lesions. All lesions in this group, except two ectopic pregnancies. were easily separated from the uterus. Of the 13 patients with proven ectopic pregnancies, ultrasound suggested the correct diagnosis in nine. Analysis of the proven cases of ectopic pregnancy demonstrated the uterus to be either of normal size or slightly enlarged with an extrauterine mass present in all cases. The mass was complex in nine cases and cystic in four. In five cases of complex masses and two of cystic masses, the

mass

was

adjacent

to

the

uterus

but

could

not

be

distinctly separated from it (fig. 5). In the other four complex and two cystic masses, the mass could easily be separated from the uterus. The masses were located posteniorly in the cul-de-sac in three cases, in a lateral adnexal location in eight, above the uterine fundus in one case, and in a combined cul-de-sac and adnexal position in one. In only two of 13 cases was what was interpreted to be the gestational sac seen (fig. 6). Discussion Diagnostic mining

the

ultrasound existence,

is an accurate size,

location,

method and

of deter-

consistency

of

Fig. 5. -Transverse pelvic ultrasonogram 4 cm above pubic symphysis and above urinary bladder in patient with ectopic pregnancy. Scan demonstrates slightly enlarged uterus (ul and complex left adnexal mass (arrows) with focal area of echogenic solid tissue. Mass is adjacent to uterus but inseparable from it; no gestational sac seen. This complex of abnormalities

was

most

common

finding

in ectopic

pregnancies.

pelvic masses. Previous reports demonstrated an accuracy of 82% in diagnosis of pelvic masses 11-31. Overall accuracy in this study was approximately 91%. This slight improvement

may

of gray

ultrasonography.

scale

Ultrasound

nosis

can

be a reflection

is nonspecific,

be given

according

of the and

only

to clinical

improved a differential

history,

technique diag-

location,

LAWSON

1006

AND

cysts, including follicular and lutein cysts, were the most common. A significant number of pelvic abscesses and a few cases of ectopic pregnancy and endometnial cysts were also found to be cystic, mimicking the ultrasonic findings of a simple ovarian cyst. A correct ultrasound diagnosis was made in nine of 13 patients (69%) with proven ectopic pregnancy. This is approximately the same accuracy as previously reported

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ALBARELLI

[4].

I S

kt

I

b’

S

False

internal

Fig.

6.

-

Midline

longitudinal

ultrasonogram

demonstrating

uterus (u) behind bladder (b) in patient with ectopic pregnancy. Complex mass is adjacent to fundus of uterus (arrows). Note small cystic area with appearance of gestational sac. S = level of pubic symphysis.

and consistency of the mass in question. Solid uterine masses are most likely to be uterine Ieiomyomas. However, the possibility of a malignant uterine tumor cannot be excluded by ultrasound alone. Our case of a rare uterine sarcoma of the mixed mesodermal type with osseous cornponents. which mimicked a calcified leiomyoma on both and

radiographs,

or colon

and

could

not

masses,

endometniosis

a carcinoma

were

the

most

of the common

lesions. These lesions may be bound to the uterus by adhesions or in close proximity so they cannot be separated from the uterus by ultrasound, and a specific diagnosis cannot be made. However, if an irregular extrauterine pelvic mass is identified with ascites present. a diagnosis of ovarian adenocancinoma is suggested. The malignant ascites noted in these patients had the characteristic pattern

of

tethered

The ectopic ultrasonic

being loops

relatively of bowel

loculated fixed

with

along

the

nodular lateral

masses pelvic

approximately

3.5%,

a

echoes

[4]

was

not

commonly

seen

most

commonly

observed

our

series

of

pregnancy

was

to, but inseparable

from,

ectopic

enlarged

uterus,

within

with

or outside

no

the

triad

of

gestational

uterus.

in this

study.

abnormalities

a complex

a normal sac

A good

in

adnexal

or slightly

identified

clinical

either

history

with

ectopic pregnancy suspected was the single most important factor in making a correct diagnosis. Ultrasound errors were made in several cases when loops of bowel or adhesions were misinterpreted and overzealously diagnosed as a pelvic mass. Care should be taken when analyzing these vague, nonspecific “masses”; a mass should not be diagnosed if it is not easily reproducible.

If in doubt,

repeat

or follow-up

sonography

should

were

noted

which

would

diagnosis

was

when

Ultrasound

masses

were

cm or greater

cystic

masses

are

ameter

of the

2-3 less

beam

than

easier

and

2 cm,

width,

and

they

cannot

more

accurate

in diameter.

When

approach

the

di-

be discriminated

from surrounding tissues. Many of these masses are misinterpreted as solid because artifactual echoes and diffuse

nelfections small cysts.

are

recorded

or

as

arising

from

inside

these

REFERENCES

walls.

most common complex mass was pelvic abscess; pregnancy was the next most common. No specific characteristics

was

be performed.

be diagnosed preoperatively. Of the solid extrauterine ovary

probably

diagnosis

The

mass adjacent

slightly

enlarged

ultrasound

positive

marked improvement from earlier reports. Criteria for diagnosis in our study was a strong clinical suspicion, a pelvic mass, and a normal or slightly enlarged uterus, without an intrauterine gestational sac. The previously reported sign of uterine enlargement with prominent

allow

a histologic diagnosis, although cystadenocancinomas were found to have prominent septations like spokes of a wheel, while complex masses with a focal solid area surrounded by a cystic zone were usually dermoid tumors on ectopic pregnancy. Of the purely cystic pelvic masses, functional retention

1 . Cochrane

WJ,

Thomas

MA:

Ultrasound

diagnosis

of

gyne-

Radiology 1 10:649-654, 1974 2. Cochrane WJ: Ultrasound in gynecology. Radiol Clin North Am 13:457-466, 1975 3. Levi 5, Delval R: Value of ultrasonic diagnosis of gynecologic tumors in 370 surgical cases. Obstet Gynecol Scand 55: cologic

pelvic

261-266.

4. Kobayashi the

diagnosis

1131-1140.

masses.

1976

M. Hellman of ectopic 1969

LM,

Fillisti

pregnancy.

LP: Am

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an aid in 103:

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