Wouter Froyman

Correlation between ultrasound and gross pathology examination of malignant ovarian tumors: a pictorial review for pattern recognition

Added value of cell‐free DNA over clinical and ultrasound information for diagnosing ovarian cancer

ABSTRACT Objective We previously proposed two cell‐free (cf) DNA‐based scores (genome‐wide Z ‐score and nucleosome score) as candidate non‐invasive biomarkers to further improve the presurgical diagnosis of ovarian malignancy. We aimed to investigate the added value of these cfDNA‐based scores in combination with the clinical and ultrasound predictors of the Assessment of Different NEoplasias in the adneXa (ADNEX) model to estimate the risk of ovarian malignancy. Methods In this prospective cohort study, 526 patients with an adnexal mass scheduled for surgery were recruited consecutively in three oncology referral centers. All patients underwent a transvaginal ultrasound examination, and adnexal masses were described according to the International Ovarian Tumor Analysis terms and definitions. cfDNA was extracted from preoperative plasma samples and genome‐wide Z ‐scores and nucleosome scores were calculated. Logistic regression models were fitted for ADNEX predictors alone and after inclusion of the cfDNA‐based scores. We report likelihood ratios, area under the receiver‐operating‐characteristics curve (AUC), sensitivity, specificity and net benefit for thresholds between 5% and 40%, to assess the diagnostic performance of the models in discriminating between benign and malignant ovarian masses. Results The study included 272 benign, 86 borderline, 36 Stage‐I invasive, 113 Stage‐II–IV invasive, and 19 secondary metastatic tumors. The likelihood ratios for adding the cfDNA‐based scores to the ADNEX model were statistically significant ( P  < 0.001 for ADNEX without CA 125; P  = 0.001 for ADNEX including CA 125). The accompanying increases in AUC were 0.013 when the cfDNA biomarkers were added to the ADNEX model without CA 125, and 0.003 when added to the ADNEX model including CA 125. Net benefit, sensitivity and specificity were similar for all models. The increase in net benefit at the recommended 10% threshold estimated risk of malignancy when adding the cfDNA‐based scores was 0.0017 and 0.0020, respectively, for the ADNEX model without CA 125 and the ADNEX model with CA 125. According to these results, adding cfDNA markers would require at least 453 patients per additional true‐positive test result at the 10% risk threshold. Conclusion Although statistically significant, cfDNA‐based biomarker scores have limited clinical utility in addition to established clinical and ultrasound‐based ADNEX predictors for discriminating between benign and malignant ovarian masses. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Validation of ADNEX and IOTA two‐step strategy and estimation of risk of complications during follow‐up of adnexal masses in low‐risk population

ABSTRACTObjectivesTo evaluate the ability of the Assessment of Different NEoplasias in the adneXa (ADNEX) model and the International Ovarian Tumour Analysis (IOTA) two‐step strategy to predict malignancy in adnexal masses detected in an outpatient low‐risk setting, and to estimate the risk of complications in masses with benign ultrasound morphology managed using clinical and ultrasound follow‐up.MethodsThis single‐center study was performed at Hospital Universitari Dexeus, Barcelona, Spain, using interim data from the ongoing prospective observational IOTA Phase‐5 (IOTA5) study. The primary aim of the IOTA5 study is to describe the cumulative incidence of complications during follow‐up of adnexal masses classified as benign on ultrasound examination. Consecutive patients with an adnexal mass detected between June 2012 and September 2016 in a private center offering screening for gynecological cancer were included and followed up until February 2020. Tumors were classified as benign or malignant based on histology (if patients underwent surgery) or the outcome of clinical and ultrasound follow‐up at 12 (range, 10–14) months. Multiple imputation was used when outcomes were uncertain. The ability of the ADNEX model without CA125 and of the IOTA two‐step strategy to distinguish benign from malignant masses was evaluated retrospectively using the prospectively collected data. We assessed performance with regard to discrimination (area under the receiver‐operating‐characteristics curve (AUC)), calibration, classification (sensitivity and specificity) and clinical utility (Net Benefit). In the group of patients with a mass judged to be benign who were selected for conservative management, we evaluated the occurrence of spontaneous resolution or any mass complication during the first 5 years of follow‐up by assessing the cumulative incidence of malignancy, torsion, cyst rupture and minor mass complications (inflammation, infection or adhesions) and the time to occurrence of an event.ResultsA total of 2654 patients were recruited to the study. After application of exclusion criteria, 2039 patients with a newly detected mass were included for the model validation. Of those, 1684 (83%) masses were benign, 49 (2%) masses were malignant and, for 306 (15%) masses, the outcome was uncertain and therefore imputed. The AUC was 0.95 (95% CI, 0.89–0.98) for ADNEX without CA125 and 0.94 (95% CI, 0.88–0.97) for the two‐step strategy. Calibration performance could not be meaningfully interpreted because the small number of malignancies resulted in very wide confidence intervals. The two‐step strategy had better clinical utility than did the ADNEX model at malignancy risk thresholds < 3%. There were 1472 (72%) patients whose mass was judged to be benign based on pattern recognition by an experienced ultrasound examiner and were managed with clinical and ultrasound follow‐up. In this group, the 5‐year cumulative incidence was 66% (95% CI, 63–69%) for spontaneous resolution of the mass, 0% (95% CI, 0–0.2%) for torsion, 0.1% (95% CI, < 0.1–0.4%) for cyst rupture, 0.2% (95% CI, 0.1–0.6%) for a borderline tumor and 0.2% (95% CI, 0.1–0.6%) for invasive malignancy.ConclusionsThe ADNEX model and IOTA two‐step strategy performed well to distinguish benign from malignant adnexal masses detected in a low‐risk population. Conservative management is safe for masses with a benign ultrasound appearance in this population. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Imaging in gynecological disease (22): clinical and ultrasound characteristics of ovarian embryonal carcinomas, non‐gestational choriocarcinomas and malignant mixed germ cell tumors

ABSTRACTObjectiveTo describe the clinical and ultrasound characteristics of three types of rare malignant ovarian germ cell tumor: embryonal carcinoma, non‐gestational choriocarcinoma and malignant mixed germ cell tumor.MethodsThis was a retrospective multicenter study. From the International Ovarian Tumor Analysis (IOTA) database, we identified patients with a histological diagnosis of ovarian embryonal carcinoma, non‐gestational choriocarcinoma or malignant mixed germ cell tumor, who had undergone preoperative ultrasound examination by an experienced ultrasound examiner between 2000 and 2020. Additional patients with the same histology were identified from the databases of the departments of gynecological oncology in the participating centers. All tumors were described using IOTA terminology. Three examiners reviewed all available ultrasound images and described them using pattern recognition.ResultsOne patient with embryonal carcinoma, five patients with non‐gestational ovarian choriocarcinoma and seven patients with ovarian malignant mixed germ cell tumor (six primary tumors and one recurrence) were identified. Seven patients were included in the IOTA studies and six patients were examined outside of the IOTA studies. The median age at diagnosis was 26 (range, 14–77) years. Beta‐human chorionic gonadotropin levels were highest in non‐gestational choriocarcinomas and alpha‐fetoprotein levels were highest in malignant mixed germ cell tumors. Most tumors were International Federation of Gynecology and Obstetrics (FIGO) Stage I (9/12 (75.0%)). All tumors were unilateral, and the median largest diameter was 129 (range, 38–216) mm. Of the tumors, 11/13 (84.6%) were solid and 2/13 (15.4%) were multilocular‐solid; 9/13 (69.2%) manifested abundant vascularization on color Doppler examination. Using pattern recognition, the typical ultrasound appearance was a large solid tumor with inhomogeneous echogenicity of the solid tissue and often dispersed cysts which, in most cases, were small and irregular. Some tumors had smooth contours while others had irregular contours.ConclusionsA unilateral, large solid tumor with inhomogeneous echogenicity of the solid tissue and with dispersed small cystic areas in a young woman should raise the suspicion of a rare malignant germ cell tumor. This suspicion can guide the clinician to test tumor markers specific for malignant germ cell tumors. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

Imaging in gynecological disease (17): ultrasound features of malignant ovarian yolk sac tumors (endodermal sinus tumors)

ABSTRACTObjectiveTo describe the clinical and sonographic characteristics of malignant ovarian yolk sac tumors (YSTs).MethodsIn this retrospective multicenter study, we included 21 patients with a histological diagnosis of ovarian YST and available transvaginal ultrasound images and/or videoclips and/or a detailed ultrasound report. Ten patients identified from the International Ovarian Tumor Analysis (IOTA) studies had undergone a standardized preoperative ultrasound examination, by an experienced ultrasound examiner, between 1999 and 2016. A further 11 patients were identified through medical files, for whom ultrasound images were retrieved from local image workstations and picture archiving and communication systems. All tumors were described using IOTA terminology. The collected ultrasound images and videoclips were used by two observers for additional characterization of the tumors.ResultsAll cases were pure YSTs, except for one that was a mixed tumor (80% YST and 20% embryonal carcinoma). Median age at diagnosis was 25 (interquartile range (IQR), 19.5–30.5) years. Seventy‐six percent (16/21) of women had an International Federation of Gynecology and Obstetrics (FIGO) Stage I–II tumor at diagnosis. Fifty‐eight percent (11/19) of women felt pain during the ultrasound examination and one presented with ovarian torsion. Median serum α‐fetoprotein (S‐AFP) level was 4755 (IQR, 1071–25 303) µg/L and median serum CA 125 level was 126 (IQR, 35–227) kU/L. On ultrasound assessment, 95% (20/21) of tumors were unilateral. The median maximum tumor diameter was 157 (IQR, 107–181) mm and the largest solid component was 110 (IQR, 66–159) mm. Tumors were classified as either multilocular‐solid (10/21; 48%) or solid (11/21; 52%). Papillary projections were found in 10% (2/21) of cases. Most (20/21; 95%) tumors were well vascularized (color score, 3–4) and none had acoustic shadowing. Malignancy was suspected in all cases, except in the patient with ovarian torsion, who presented a tumor with a color score of 1, which was classified as probably benign. Image and videoclip quality was considered as adequate in 18/21 cases. On review of the images and videoclips, we found that all tumors contained both solid components and cystic spaces, and that 89% (16/18) had irregular, still fine‐textured and slightly hyperechoic solid tissue, giving them a characteristic appearance.ConclusionMalignant ovarian YSTs are often detected at an early stage, in young women usually in the second or third decade of life, presenting with pain and markedly elevated S‐AFP. On ultrasound, malignant ovarian YSTs are mostly unilateral, large and multilocular‐solid or solid, with fine‐textured slightly hyperechoic solid tissue and rich vascularization. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology..

ESGO/ISUOG/IOTA/ESGE Consensus Statement on pre-operative diagnosis of ovarian tumors

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group, and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the pre-operative diagnosis of ovarian tumors, including imaging techniques, biomarkers, and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the pre-operative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when a consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the pre-operative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumors

ABSTRACTThe European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence‐based statements on the preoperative diagnosis of ovarian tumors, including imaging techniques, biomarkers and prediction models.ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the preoperative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence‐based, the current literature was reviewed and critically appraised.Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements.This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the preoperative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

Imaging in gynecological disease (24): clinical and ultrasound characteristics of ovarian mature cystic teratomas

ABSTRACTObjectiveTo describe the clinical and ultrasound features of ovarian mature cystic teratomas (MCTs).MethodsThis was a retrospective study. From the International Ovarian Tumor Analysis (IOTA) database, we identified patients with a histologically confirmed diagnosis of MCT who had undergone transvaginal ultrasound examination between 1999 and 2016 (IOTA phases 1, 2, 3 and 5) in one of five centers. Ultrasound was performed by an experienced examiner who used the standardized IOTA examination technique and terminology. In addition to extracting data from the IOTA database, available two‐dimensional grayscale and color or power Doppler images were reviewed retrospectively to identify typical ultrasound features of MCT described previously and detect possible new features using pattern recognition. All images were reviewed by two independent examiners and further discussed with two ultrasound experts to reach consensus.ResultsIncluded in the study were 454 patients with histologically confirmed MCT. Median age was 33 (range, 8–90)  years and 66 (14.5%) patients were postmenopausal. Most MCTs were described by the original ultrasound examiner as unilocular (262/454 (57.7%)) or multilocular (70/454 (15.4%)) cysts with mixed echogenicity of cystic fluid (368/454 (81.1%)), acoustic shadowing (328/454 (72.2%)) and no or little vascularization on color Doppler (color score 1, 240/454 (52.9%); color score 2, 123/454 (27.1%)). The median largest lesion diameter was 66 (range, 15–310)  mm. A correct preoperative diagnosis of MCT was suggested by the original ultrasound examiner in 372/454 (81.9%) cases. On retrospective review of ultrasound images of 334 MCTs that had quality sufficient for assessment, ‘dots and/or lines’ and/or ‘echogenic white ball’ (typical features according to the literature) were present in 271/334 (81.1%) masses. We identified four new ultrasound features characteristic of MCT: ‘cotton wool tufts’, ‘mushroom cap sign’, ‘completely hyperechogenic lesion’ and ‘starry sky sign’. At least one classical or novel ultrasound feature was present in 315/334 (94.3%) MCTs. Twenty‐nine (8.7%) MCTs manifested vascularized solid tissue, of which seven exhibited no typical features.ConclusionWe provide a comprehensive overview of conventional and newly described ultrasound features of MCTs. Only a small proportion of MCTs did not manifest any of the typical features. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Imaging in gynecological disease (23): clinical and ultrasound characteristics of ovarian carcinosarcoma

ABSTRACTObjectiveTo describe the clinical and ultrasound characteristics of ovarian carcinosarcoma.MethodsThis was a retrospective multicenter study. Patients with a histological diagnosis of ovarian carcinosarcoma, who had undergone preoperative ultrasound examination between 2010 and 2019, were identified from the International Ovarian Tumor Analysis (IOTA) database. Additional patients who were examined outside of the IOTA study were identified from the databases of the participating centers. The masses were described using the terms and definitions of the IOTA group. Additionally, two experienced ultrasound examiners reviewed all available images to identify typical ultrasound features using pattern recognition.ResultsNinety‐one patients with ovarian carcinosarcoma who had undergone ultrasound examination were identified, of whom 24 were examined within the IOTA studies and 67 were examined outside of the IOTA studies. Median age at diagnosis was 66 (range, 33–91) years and 84/91 (92.3%) patients were postmenopausal. Most patients (67/91, 73.6%) were symptomatic, with the most common complaint being pain (51/91, 56.0%). Most tumors (67/91, 73.6%) were International Federation of Gynecology and Obstetrics (FIGO) Stage III or IV. Bilateral lesions were observed on ultrasound in 46/91 (50.5%) patients. Ascites was present in 38/91 (41.8%) patients. The median largest tumor diameter was 100 (range, 18–260) mm. All ovarian carcinosarcomas contained solid components, and most were described as solid (66/91, 72.5%) or multilocular‐solid (22/91, 24.2%). The median diameter of the largest solid component was 77.5 (range, 11–238) mm. Moderate or rich vascularization was found in 78/91 (85.7%) cases. Retrospective analysis of ultrasound images and videoclips using pattern recognition in 73 cases revealed that all tumors had irregular margins and inhomogeneous echogenicity of the solid components. Forty‐seven of 73 (64.4%) masses appeared as a solid tumor with cystic areas. Cooked appearance of the solid tissue was identified in 28/73 (38.4%) tumors. No pathognomonic ultrasound sign of ovarian carcinosarcoma was found.ConclusionsOvarian carcinosarcomas are usually diagnosed in postmenopausal women and at an advanced stage. The most common ultrasound appearance is a large solid tumor with irregular margins, inhomogeneous echogenicity of the solid tissue and cystic areas. The second most common pattern is a large multilocular‐solid mass with inhomogeneous echogenicity of the solid tissue. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Imaging in gynecological disease (29): clinical and ultrasound features of primary ovarian immature teratoma

ABSTRACT Objective To describe the clinical and ultrasound characteristics at the time of diagnosis of primary ovarian immature teratoma with no other germ cell tumor components described on histopathology. Methods This was a retrospective study of women with a histological diagnosis of primary ovarian immature teratoma who had undergone a preoperative ultrasound examination between 1998 and 2024. Cases were identified from the databases of 17 contributing ultrasound centers and the International Ovarian Tumor Analysis (IOTA) database. The descriptions of the ultrasound images of the tumors made by the original ultrasound examiners using IOTA terminology were reported. In addition, grayscale and color or power Doppler ultrasound images or videoclips were retrieved for all tumors. Two independent ultrasound examiners reviewed the retrieved material and searched for specific ultrasound characteristics of immature teratomas using pattern recognition. We present their agreed description of the tumors. Results In total, 64 patients with ovarian immature teratoma were included, of which 38 (59.4%) were obtained from the IOTA database (IOTA studies phase 1, 1b, 2, 3, 5 and 7). The median age of the patients at diagnosis was 24.5 (interquartile range (IQR), 18.8–31.0; range, 12–50) years. The most common presenting symptoms were abdominal or pelvic pain (38/60, 63.3%) and abdominal swelling (30/60, 50.0%). All immature teratomas were unilateral. The median largest diameter of the tumor was 149.5 (IQR, 125.0–183.8; range, 27–400) mm. Using IOTA terminology, most tumors were described as multilocular‐solid (32/64, 50.0%) or solid lesions (22/64, 34.4%). When present, the solid component had a median largest diameter of 98.5 (IQR, 59.8–146.8; range 6–400) mm. Most masses showed minimal (19/63, 30.2%) or moderate (35/63, 55.6%) vascularization on color or power Doppler ultrasound examination. Using pattern recognition, the most typical ultrasound feature was heterogeneous, bizarre echogenicity of the solid components, with hyperechogenic areas, cystic spaces and acoustic shadows. This feature, which we consider pathognomonic, was present in 48/57 (84.2%) immature teratomas in which the solid components were adequately assessable. Conclusions The typical ultrasound appearance of an ovarian immature teratoma is a large unilateral adnexal mass with large solid components that is poorly or moderately vascularized. The pathognomonic feature is heterogeneous echogenicity of the solid components with hyperechogenic areas, cystic spaces and acoustic shadows. Preoperative suspicion of immature teratoma can guide treatment, such as offering fertility‐sparing surgery. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Imaging in gynecological disease (28): clinical and ultrasound characteristics of serous and mucinous cystadenomas in the adnexa

ABSTRACTObjectiveTo describe the clinical and ultrasound characteristics of serous and mucinous cystadenomas in the adnexa.MethodsThis was a retrospective international multicenter study. Using the International Ovarian Tumor Analysis (IOTA) database, patients with a histological diagnosis of serous or mucinous cystadenoma who had undergone preoperative ultrasound examination between 1999 and 2016 (IOTA studies phase 1, 1b, 2, 3 and 5) were identified. All masses were described using the standardized IOTA terminology. The diagnosis assigned by the original ultrasound examiner based on subjective assessment was recorded. Two reviewers assessed the available digital ultrasound images using pattern recognition to identify typical sonographic features of cystadenomas.ResultsA total of 1318 patients were included: 687 (52.1%) with serous cystadenomas and 631 (47.9%) with mucinous cystadenomas. Based on the data recorded prospectively in the IOTA database, for serous cystadenomas the median diameter of the largest tumor was 68 (range, 14–320) mm. Most serous cystadenomas were described as unilateral (588/687 (85.6%)), with unilocular (274/687 (39.9%)) or multilocular (221/687 (32.2%)) morphology, and most had anechoic cyst content (508/687 (73.9%)). Most serous cystadenomas were not vascularized (color score of 1; 327/687 (47.6%)) or were poorly vascularized (color score of  2; 253/687 (36.8%)) on color Doppler examination. The original ultrasound examiner correctly classified 91.1% (626/687) of serous cystadenomas as benign and suggested the correct specific diagnosis in 51.5% (354/687) of tumors. For mucinous cystadenomas, the median diameter of the largest tumor was 93 (range, 12–550) mm. Most mucinous cystadenomas were described as unilateral (594/631 (94.1%)) with multilocular morphology (357/631 (56.6%)), and most manifested low‐level echogenicity (334/631 (52.9%)). Most mucinous cystadenomas were poorly (color score of 2; 248/631 (39.3%)) or moderately (color score of 3; 194/631 (30.7%)) vascularized on color Doppler examination. The original ultrasound examiner correctly classified 87.5% (552/631) of mucinous cystadenomas as benign and suggested the correct specific diagnosis in 42.9% (271/631) of tumors. Based on pattern recognition (review of ultrasound images available for 433 tumors), the most typical sonographic features of serous cystadenomas were unilocular cyst (100/211 (47.4%)) or multilocular cyst with < 10 cyst locules (71/211 (33.6%)), whereas the typical features of mucinous cystadenomas were multilocular cyst with < 10 cyst locules (99/222 (44.6%)), unilocular cyst (78/222 (35.1%)) or multilocular cyst with > 10 cyst locules (31/222 (14.0%)). A honeycomb nodule was found in some mucinous cystadenomas (31/222 (14.0%)) but was not found in serous cystadenomas.ConclusionsSerous and mucinous cystadenomas exhibit typical sonographic features, allowing ultrasound examiners to assign a correct specific diagnosis to most tumors. Recognizing the ultrasound features of cystadenomas and avoiding misdiagnosing them as malignant can help prevent surgery for these benign tumors in asymptomatic patients. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound features using MUSA terms and definitions in uterine sarcoma and leiomyoma: cohort study

ABSTRACTObjectivesTimely and accurate preoperative diagnosis of uterine sarcoma will increase patient survival. The primary aim of this study was to describe the ultrasound features of uterine sarcoma compared with those of uterine leiomyoma based on the terms and definitions of the Morphological Uterus Sonographic Assessment (MUSA) group. A secondary aim was to assess the interobserver agreement for reporting on ultrasound features according to MUSA terminology.MethodsThis was a retrospective cohort study of patients with uterine sarcoma or uterine leiomyoma treated in a single tertiary center during the periods 1997–2019 and 2016–2019, respectively. Demographic characteristics, presenting symptoms and surgical outcomes were extracted from patients' files. Ultrasound images were re‐evaluated independently by two sonologists using MUSA terms and definitions. Descriptive statistics were calculated and interobserver agreement was assessed using Cohen's κ (with squared weights) or intraclass correlation coefficient, as appropriate.ResultsA total of 107 patients were included, of whom 16 had a uterine sarcoma and 91 had a uterine leiomyoma. Abnormal uterine bleeding was the most frequent presenting symptom (69/107 (64%)). Compared with leiomyoma cases, patients with uterine sarcoma were older (median age, 65 (interquartile range (IQR), 60–70) years vs 48 (IQR, 43–52) years) and more likely to be postmenopausal (13/16 (81%) vs 15/91 (16%)). In the uterine sarcoma cohort, leiomyosarcoma was the most frequent histological type (6/16 (38%)), followed by adenosarcoma (4/16 (25%)). On ultrasound evaluation, according to Observers 1 and 2, the tumor border was irregular in most sarcomas (11/16 (69%) and 13/16 (81%) cases, respectively), but regular in most leiomyomas (65/91 (71%) and 82/91 (90%) cases, respectively). Lesion echogenicity was classified as non‐uniform in 68/91 (75%) and 51/91 (56%) leiomyomas by Observers 1 and 2, respectively, and 15/16 (94%) uterine sarcomas by both observers. More than 60% of the uterine sarcomas showed acoustic shadows (11/16 (69%) and 10/16 (63%) cases by Observers 1 and 2, respectively), whereas calcifications were reported in a small minority (0/16 (0%) and 2/16 (13%) cases by Observers 1 and 2, respectively). In uterine sarcomas, intralesional vascularity was reported as moderate to abundant in 13/16 (81%) cases by Observer 1 and 15/16 (94%) cases by Observer 2, while circumferential vascularity was scored as moderate to abundant in 6/16 (38%) by both observers. Interobserver agreement for the presence of cystic areas, calcifications, acoustic shadow, central necrosis, color score (overall, intralesional and circumferential) and maximum diameter of the lesion was moderate. The agreement for shape of lesion, tumor border and echogenicity was fair.ConclusionsA postmenopausal patient presenting with abnormal uterine bleeding and a new or growing mesenchymal mass with irregular tumor borders, moderate‐to‐abundant intralesional vascularity, cystic areas and an absence of calcifications on ultrasonography is at a higher risk of having a uterine sarcoma. Interobserver agreement for most MUSA terms and definitions is moderate. Future studies should validate the abovementioned clinical and ultrasound findings on uterine mesenchymal tumors in a prospective multicenter fashion. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Developing and validating ultrasound‐based machine‐learning models incorporating radiomics features to predict malignancy in adnexal masses

ABSTRACT Objective The primary aim of this study was to develop and internally validate ultrasound‐based radiomics models to discriminate between all types of benign and malignant adnexal masses. The secondary aim was to compare the performance of the radiomics models with that of the Assessment of Different NEoplasias in the adneXa (ADNEX) model. Methods This was a retrospective, observational, single‐center study, for which all patients with an adnexal mass that were included in the ongoing International Ovarian Tumor Analysis phase‐5 and phase‐7 studies and were examined using ultrasound between January 2012 and December 2023 at Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy, were eligible for inclusion. Inclusion criteria were: adnexal mass detected by ultrasound; surgical removal of the adnexal mass within 180 days after the ultrasound examination; histological confirmation of an adnexal mass; and absence of a synchronous malignant tumor. Patients without digital ultrasound images saved in DICOM format were excluded. The patient cohort was split randomly into training and validation sets using a stratified split with a ratio of 70:30, to preserve the proportion of benign and malignant cases in the two sets. Two machine‐learning models for discriminating between benign and malignant adnexal masses were built using one image per tumor, with 5‐fold cross‐validation for hyperparameter tuning, and were tested on the validation set. The variables used in model building were patient age, serum CA 125 level and the radiomics features that differed significantly between benign and malignant tumors (determined using the Mann–Whitney U ‐test with Benjamini–Hochberg correction) and were not redundant based on Pearson correlation analysis. Histology was the reference standard. We assessed the discriminative performance of the radiomics models using the area under the receiver‐operating‐characteristics curve (AUC) and classification performance using sensitivity and specificity at the optimal cut‐off of each model to classify the mass as malignant, as determined by Youden's index. The diagnostic performance of the developed radiomics models was compared with that of the ADNEX model (AUC, sensitivity and specificity at the 10% risk‐of‐malignancy cut‐off, which is the recommended threshold for clinical use of the ADNEX model). Results In total, 4501 patients met the inclusion criteria. Among these, 2428 patients were excluded owing to an absence of ultrasound images or images unsuitable for radiomics analysis. Overall, a total of 2073 patients were included in the analysis, of whom 803 (38.7%) had a histologically confirmed malignant tumor. In the validation set ( n  = 622, including 254 malignancies), the clinical–radiomics model trained using the eXtreme Gradient Boosting algorithm, including age, serum CA 125 level and 14 selected radiomics features, achieved the highest performance, with an AUC of 0.89 (95% CI, 0.86–0.92), sensitivity of 0.83 (95% CI, 0.79–0.88) and specificity of 0.81 (95% CI, 0.77–0.85) at the optimal cut‐off (31% risk of malignancy, based on Youden's index). At a 10% risk‐of‐malignancy cut‐off, it had a sensitivity of 0.94 (95% CI, 0.91–0.97) and specificity of 0.48 (95% CI, 0.42–0.53). The ADNEX model had an AUC of 0.95 (95% CI, 0.93–0.97), sensitivity of 0.97 (95% CI, 0.95–0.99) and specificity of 0.72 (95% CI, 0.68–0.77) at the 10% risk‐of‐malignancy cut‐off in the validation set. Conclusions Our results support further exploration of radiomics analysis for distinguishing between benign and malignant adnexal masses in larger study populations. Future studies should consider using multiple images per tumor and testing alternative model‐building methods, and should perform external validation to assess the generalizability of the radiomics models. © 2026 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

International Ovarian Tumour Analysis (IOTA) Phase 5

The purpose of this study is to learn more about the appearance and behavior of benign-looking adnexal masses. * Benign-looking means that when viewed here by ultrasound it has the appearance of looking not harmful or not malignant. * Adnexal refers to the 'adnexa', the space in the female pelvis on either side of the uterus (or where the uterus used to be if you previously had a hysterectomy). The adnexa includes, but is not limited to, the ovaries and the fallopian tubes. * Masses refers to a variety of structures, including but not limited to: * ovarian cysts that are fluid filled sacs within or attached to an ovary * ovarian tumors that can be solid tissue or a combination of cysts and solid tissue * hydrosalpinges that are fluid collections in the fallopian tube Many women have what appear to be benign adnexal masses. Many times, removal of the masses with surgery is not necessary. Often surgery is performed unnecessarily, for fear that these masses could be cancer. There is not much information available for doctors to know how and when to follow these masses, or which ones will become cancer. This study will combine information from centers all around the world regarding the behavior of all types of benign adnexal masses. The aim of this study is to develop decision tools for doctors to know the best way to treat these masses in order to improve the detection of ovarian cancer while at the same time reduce the number of unnecessary operations.