Journal of Ultrasound in Medicine

Contrast‐Enhanced Ultrasound of the Ovary Technique and Lexicon Recommendations

Diagnosis of ovarian malignancy in radiology is challenging, as there is significant overlap in imaging appearances along the spectrum of benign to malignant disease. In 2021, the American College of Radiology introduced the Ovarian‐Adnexal Reporting and Data System (O‐RADS) to standardize lesion description and improve consistency of interpretation and management of suspicious masses based on standard greyscale and Doppler ultrasound. Although endovaginal ultrasound (EVS) is well‐established as a first‐line investigation for ovarian lesions, it previously lacked the ability to show blood flow at the capillary level, severely limiting its contribution to patient care. The introduction of microbubble contrast agents and the subsequent development of contrast‐enhanced ultrasound (CEUS) software techniques for endovaginal probes have allowed ultrasound to characterize perfusion‐level vascularity of ovarian masses comparable to magnetic resonance (MR) and computed tomography (CT) scans. Today, there is limited North American literature addressing the utilization of CEUS in ovarian cancer. Given the advantages of EVS and CEUS, we propose a lexicon to standardize the description of qualitative and quantitative CEUS parameters with respect to ovarian masses. We emphasize the need for future development of specific CEUS criteria, including quantitative thresholds to aid in the differentiation of benign and malignant blood flow criteria. Our recommendation includes a safe, non‐invasive, readily available technique, which provides high accuracy for diagnosis.

Establishment of a Predictive Model for the Efficacy of High‐Intensity Focused Ultrasound in the Treatment of Uterine Fibroids

ObjectivesHigh‐intensity focused ultrasound (HIFU) has demonstrated efficacy as a non‐invasive treatment for uterine fibroids, though individual variability exists. This study aims to develop a risk scoring model using clinical and biochemical features to predict HIFU treatment outcomes.MethodsThis study collected clinical data from patients receiving HIFU treatment, including demographic characteristics, clinical symptoms, treatment information, and biochemical indicators. A risk scoring model was constructed using the random forest analysis method, and its performance was evaluated. Meanwhile, the impact of risk models and other factors on the efficacy of HIFU was evaluated. Furthermore, the interrelationships between the risk model and other factors were explored through interaction analysis. Finally, a nomogram was developed to evaluate its clinical utility.ResultsThe risk model, 4 or more treatments, age, and tumor necrosis factor levels were identified as independent influencing factors, with the risk model demonstrating the best performance (area under the curve (AUC) = 0.693). Interaction analysis revealed a significant synergistic effect between the risk model and receiving 4 or more treatments. The nomogram analysis indicated that lower risk scores and fewer treatment sessions were associated with better HIFU treatment outcomes. The receiver operating characteristic curves and calibration curves in both the training and validation sets demonstrated good performance of the nomogram.ConclusionsThis study successfully constructed a risk scoring model based on clinical features and biochemical indicators, which can effectively predict the efficacy of HIFU treatment for uterine fibroids. There is a significant interaction between the risk model and 4 or more treatments. The constructed nomogram provides strong support for individualized treatment.

Ultrasound Appearance of the Endometrium Post‐Radiofrequency Ablation

ObjectiveTo describe the ultrasonographic appearance of the post‐ablative endometrium to improve knowledge of its sonographic findings.MethodsThis was an Institutional Review Board approved prospective study of patients who underwent second‐generation endometrial ablation from 2016 to 2019 at a single health system. Patients had postoperative transvaginal ultrasounds at 2, 6, and 12 months. Ultrasound reports were analyzed for endometrial thickness, description of the endometrium and myometrium, presence of uterine fibroids, and uterine size. Statistical tests for repeated measures were utilized.ResultsThere were 68 patients with the average age of 42 (SD 6) years and a BMI of 33 (SD 8). Preoperatively the average endometrial thickness was 10 mm, uterine length was 9.7 cm, and 38.2% had leiomyoma. The average endometrial thickness decreased at each ultrasound: 8.4 mm (SD 3.4), 7.2 mm (SD 3.0), and 5.8 mm (SD 2.5) at 2, 6, and 12 months, respectively. When comparing endometrial thickness postoperatively there was a significant difference at 2 and 12 months (P = .041), and 6 and 12 months (P = .031). There was no change during the postoperative period in the presence of leiomyoma, hyperechoic endometrium, hypoechoic endometrium, heterogeneous endometrium, and cystic endometrium on the ultrasounds.ConclusionAfter ablation with a second‐generation device, the endometrial thickness on ultrasound decreases with time following surgery. Additional studies correlating these findings to clinical outcomes would be useful.

Ultrasound Findings andO‐RADSMalignancy Risk Stratification of Ovarian Collision Tumors

ObjectivesTo describe the ultrasonographic signs of ovarian collision tumors and evaluate the malignancy risk using the O‐RADS system.MethodsThis was a retrospective analysis of 25 ovarian collision tumors from 8739 patients between May 2010 and January 2020. All clinical characteristics, ultrasound images, and histological findings were collected and analyzed. Using the O‐RADS lexicon descriptors, the O‐RADS score was determined by two senior doctors. Lesions with O‐RADS scores of 1 to 3 were classified as benign tumors, and lesions with O‐RADS scores of 4 to 5 were classified as malignant tumors.ResultsThe mean age of the 25 patients was 30.4 years. Histological findings showed that all tumors were a combination of mature cystic teratomas and cystadenomas/cystadenocarcinomas. There were 11 benign tumors of O‐RADS 2 or 3, including 3 uniocular cysts, 3 dermoid cysts, and 5 dermoid cysts with an anechoic fluid cavity. There were 12 benign tumors of O‐RADS 4, including 3 uniocular–multilocular cysts with solid components, 2 multilocular cysts with irregular walls, and 8 multilocular cysts with dermoid sacs. One borderline tumor of O‐RADS 4 was a multilocular cyst with irregular septation. One malignant tumor of O‐RADS 5 was a multilocular cystic tumor with solid components and ascites.ConclusionsThe most common ovarian collision tumor was the coexistence of a mature cystic teratoma and a cystadenoma. The O‐RADS system was able to sensitively detect malignant tumors in this series. A typical dermoid cyst with an anechoic cavity or a multilocular cyst with a dermoid sac may signify a benign collision tumor.

Two‐Step Strategy for Optimizing the Preoperative Classification of Adnexal Masses in a University Hospital, Using International Ovarian Tumor Analysis Models

ObjectivesTo evaluate the performance of a two‐step strategy compared with the International Ovarian Tumor Analysis (IOTA) ‐ Assessment of Different NEoplasias in the adneXa (ADNEX) model for preoperative classification of adnexal masses.MethodsAn ambispective diagnostic accuracy study based on ultrasound data collected at one university hospital between 2012 and 2018. Two ultrasonographers classified the adnexal masses using IOTA Simple Rules (first step). Not classifiable masses were evaluated using the IOTA ADNEX model (second step). Also, all masses were classified using the IOTA ADNEX model. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR−), and receiver operating characteristic (ROC) curve were estimated. A P value of <.05 was used to determine statistical significance.ResultsThe study included 548 patients and 606 masses. Patients' median age was 41 years with an interquartile range between 32 and 51 years. In the first step, 89 (14%) masses were not classifiable. In the second step, 55 (61.8%) masses were classified as malignant. Furthermore, for the totality of 606 masses, the IOTA ADNEX model estimated the probability that 126 (20.8%) masses were malignant. The two‐step strategy had a sensitivity, specificity, PPV, NPV, LR+, LR−, and ROC curve of 86.8%, 91.01%, 51.9%, 98.4%, 9.7, 0.1, and 0.889, respectively; compared to IOTA ADNEX model that had values of 91.8%, 87.16%, 44.4%, 99%, 7.1, 0.09, and 0.895, respectively.ConclusionThe two‐step strategy shows a similar diagnostic performance when compared to the IOTA ADNEX model. The IOTA ADNEX model involves only one step and can be more practical, and thus would be recommended to use.

Does Combing O‐RADS US and CA‐125 Improve Diagnostic Accuracy in Assessing Adnexal Malignancy Risk in Women With Different Menopausal Status?

ObjectivesTo evaluate the individual and combined performances of the Ovarian‐adnexal Reporting and Data System Ultrasound (O‐RADS US) and serum cancer antigen 125 (CA‐125) in assessing adnexal malignancy risk in women with different menopausal status.MethodsThis retrospective study included patients with adnexal masses scheduled for surgery based on their preoperative US and histopathology results between January 2018 and January 2020. O‐RADS were used to assess adnexal malignancy by two experienced radiologists. The area under the receiver operating characteristic curves (AUCs) were used to compare the accuracy of O‐RADS and a combination of O‐RADS and CA‐125. The weighted κ index was used to evaluate the inter‐reviewer agreement.ResultsOverall, the data of 443 lesions in 443 patients were included, involving 312 benign lesions and 131 malignant lesions. There were 361 premenopausal and 82 postmenopausal patients. The inter‐reviewer agreement for the two radiologists was very good (weighted κ: 0.833). Combing O‐RADS US and CA‐125 significantly increased diagnostic accuracy for classifying malignant from benign adnexal masses, compared with O‐RADS US alone (AUC: 0.97 vs 0.95, P < .001 for premenopausal population and AUC: 0.93 vs 0.85, P < .001 for postmenopausal population). The AUCs of O‐RADS with and without CA‐125 ranged from 0.50 to 0.99 for different adnexal pathology subtypes (ie, benign, borderline, Stage I–IV, and metastatic tumors).ConclusionThe addition of CA‐125 helps improve discrimination of O‐RADS US between benign and malignant adnexal masses, especially in postmenopausal women.

Three‐Dimensional Ultrasound Evaluation of Pelvic Floor Muscle Contraction in Women Affected by Deep Infiltrating Endometriosis: Application of a Quick Contraction Scale

ObjectivesUsing transperineal 3D/4D ultrasound, we evaluated the prevalence of the various categories of a 4‐point pelvic contraction scale among women affected by ovarian endometriosis (OE), deep infiltrating endometriosis (DIE), and healthy controls.MethodsThis prospective study was conducted on nulliparous women scheduled for surgery to remove endometriosis, and nulliparous healthy volunteers who did not show any clinical or sonographic signs of endometriosis, who served as controls. Patients were subjected to 3D/4D transperineal ultrasound obtaining measurements of the antero‐posterior diameter (APD), both at rest and during maximal pelvic floor muscle (PFM) contraction (PFMC). The difference of APD from rest to maximal PFMC was then calculated as percent change from baseline (ΔAPD) and patients were thus categorized using the 4‐point pelvic contraction scale.ResultsOne hundred sixty‐four patients were considered for the study. Mean difference in APD between relaxed state and maximal PFMC was 23.3 ± 7.9% (range 2.4–40.0) in controls, 20.5 ± 9.0% (range 0.0–37.3) in patients with OE, and 14.6 ± 10.4% (range 0.0–37.1) in patients with DIE (F‐test = 19.5, P‐value < .001). A significant negative correlation was found between the contraction scale and dyspareunia (rs = −0.17, P = .032), and it appeared to be stronger among patients with DIE (rs = −0.20, P = .076).ConclusionsPFM function in endometriotic patients could be assessed reliably through this 4‐point scale. The rapid identification of women suffering from PFM dysfunction, along with deep dyspareunia, could enable gynecologists to offer them additional therapies, such as PFM rehabilitation.

The Value of IOTA Simple Rules Combined With CEUS Scoring System in the Diagnosis of Benign and Malignant Ovarian Masses and Its Correlation With MVD and VEGF: A Preliminary Study

ObjectivesTo investigate the diagnostic value of International Ovarian Tumor Analysis (IOTA) simple rules combined with contrast‐enhanced ultrasound (CEUS) scoring system in the differential diagnosis of ovarian tumors, and the correlations of the scoring system with microvessel density (MVD) and vascular endothelial growth factor (VEGF).MethodsOne hundred eighty‐nine patients with ovarian tumors were examined by routine ultrasound and CEUS. The enhanced characteristics of CEUS were observed, and the masses were classified by IOTA simple rules. To compare the diagnostic value of IOTA simple rules combined with CEUS scoring system and IOTA simple rules in the diagnosis of ovarian tumors. Immunohistochemistry was used to detect the expression of MVD and VEGF in postoperative tissue samples. The correlations between the new scoring system with MVD and VEGF were analyzed.ResultsThe sensitivity (93.98%), specificity (94.34%), positive predictive value (92.86%), negative predictive value (95.24%), and accuracy (94.18%) of IOTA simple rules combined with CEUS scoring system in the diagnosis of ovarian tumors were higher than those of IOTA simple rules alone (all P < .05). The score system was significantly positively correlated with MVD and VEGF, and the r values were 0.77 and 0.63, respectively (P < .001).ConclusionsIOTA simple rules combined with CEUS scoring system was helpful to improve the accuracy of ultrasound diagnosis of ovarian tumors, which was significantly correlated with MVD and VEGF. It could provide important reference information for treatment scheme formulation and prognosis evaluation.

Clinical Application of Ultrasound Guidance for Parametrial Treatment of Advanced Cervical Cancer

ObjectivesTo evaluate the accuracy of ultrasound (US) in determining the positions of parametrial implants by comparing US with magnetic resonance imaging (MRI) for advanced cervical cancer.MethodsPatients undergoing brachytherapy with parametrial implantation for cervical cancer from February 2017 to February 2019 were involved in the study. The transverse section of the cervix (surface S1) and the transverse section 1 cm above the external cervix (surface S2) were selected from MRI and US images as the observation planes. In the MRI observation plane, the distances between the uterine titanium needles and the uterine tube/implanter were set as M1 to M4; in the US observation plane, the distances between the uterine titanium needles and the uterine tube/implanter were set as D1 to D4. The differences and consistency in M and D of each group were then compared.ResultsThere were no significant differences between M and D in each group (P = .058; P = .821; P = .870; and P = .936, respectively). The intraclass correlation coefficients of M and D in each group were 0.970, 0.968, 0.952, and 0.956. A regression analysis showed that the relationships between M and D in each group were as follows: M1 = 0.9449D1 + 0.1812; M2 = 0.9463D2 + 0.0965; M3 = 0.9176D3 + 0.1233; and M4 = 0.9253D4 + 0.1224.ConclusionsIn parametrial brachytherapy for cervical cancer, US can accurately determine the positions of parametrial implantation needles, which is already applicable on MRI, and can provide assistance in parametrial brachytherapy for advanced cervical cancer.

Quantitative Evaluation of the Normal Cervix, Cervical Cancer, and Cervical Precancerous Changes Via Real‐Time Shear Wave Elastography

ObjectivesThe present study aims to evaluate the clinical application values of ultrasound real‐time shear wave elastography (SWE) in the diagnosis and differential diagnosis of cervical cancer (CC).MethodsA total of 285 married female patients were screened and divided into three groups according to the results of the pathological examination and the cervical ThinPrep cytologic test: 1) the CC group (n = 94); 2) the cervical intraepithelial neoplasia (CIN) group (n = 91); and 3) the normal control group (n = 100). The maximum Young's modulus (Emax), mean Young's modulus (Emean), minimum Young's modulus (Emin), and Young's modulus stability (Esd) in each group were measured and statistically analyzed.ResultsThere were no statistically significant differences in Emax, Emean, Emin, and Esd values between the anterior and posterior cervical walls, premenopausal and postmenopausal women, and nonparturient and parturient women in the normal control group. The Emax, Emean, Emin, and Esd values in the CIN group showed no statistically significant differences in different periods when compared with the control group. The differences between the normal control group and the CC group were statistically significant; the CC group showed no statistically significant differences in Emax, Emean, Emin, and Esd values at different clinical stages and in different pathological types. The cutoff value of Emax for CC diagnosis, which was of the highest accuracy (89.7%), was 43.48 kpa.ConclusionUltrasound real‐time SWE can be applied to CC diagnosis.

Comparative Diagnostic Performance of IOTA Simple Rules, O‐ RADS US , and Subjective Assessment in Differentiating Benign from Malignant Adnexal Masses

Objectives To compare the diagnostic performance of International Ovarian Tumor Analysis (IOTA) Simple Rules, Ovarian‐Adnexal Reporting and Data System for Ultrasound (O‐RADS US), and Subjective Assessment in differentiating benign from malignant adnexal masses. Methods This prospective study included 249 women evaluated between May 2021 and June 2025 at a tertiary oncology center. Participants underwent standardized transvaginal ultrasound classified according to IOTA Simple Rules, O‐RADS US, and Subjective Assessment by examiners blinded to biomarker and imaging results. Most examinations (78%) were performed by a level 2 radiologist, 11% by a level 3 gynecologist, and 11% by level 2 gynecologist sonographers. Final diagnosis was established by histopathology ( n  = 243) or ≥2 years of follow‐up ( n  = 6). Diagnostic performance was assessed using sensitivity, specificity, predictive values, accuracy, likelihood ratios, and diagnostic odds ratios (DOR), with pairwise comparisons performed by McNemar's test. Results Malignant lesions were associated with older age, larger size, complex morphology, ascites, and higher CA125 ( p  < .05). O‐RADS US achieved the highest sensitivity (98.2%) and negative predictive value (95.9%) but the lowest specificity (33.8%). Subjective Assessment had the highest specificity (75.2%) and accuracy (79.6%) but lower sensitivity (85.6%). Simple Rules demonstrated balanced performance (sensitivity 94.6%, specificity 56.8%). DORs were comparable (17.9–27.6). In terms of accuracy, Simple Rules and Subjective Assessment outperformed O‐RADS US, while no statistically significant difference was observed between Simple Rules and Subjective Assessment. Inter‐method agreement was highest between Simple Rules and Subjective Assessment ( κ  = 0.69), followed by Simple Rules and O‐RADS US ( κ  = 0.62), and O‐RADS US and Subjective Assessment ( κ  = 0.41). Conclusion O‐RADS US maximized sensitivity for malignancy detection, Simple Rules provided balanced accuracy, and Subjective Assessment offered superior specificity. Their complementary use may optimize adnexal mass characterization across clinical settings.

Validation of the IOTA ADNEX Model Among Japanese Women Performed by Gynecology Trainees and Ultrasound Specialists

ObjectivesThis study aimed to validate the diagnostic accuracy of the International Ovarian Tumor Analysis (IOTA) Assessment of Different NEoplasias in the adneXa (ADNEX) model in Japanese women, population with a distinct adnexal mass distribution compared with European women, and to evaluate the model's utility by gynecology trainees and ultrasound specialists.MethodsThis single‐center, retrospective study analyzed ultrasound data from January 2017 to March 2020 of 206 women with adnexal masses. Patients who underwent ultrasonography and serum CA‐125 measurement and received postsurgery histological diagnosis were included. The ADNEX model's diagnostic performance was evaluated by two trainees and two specialists using the area under the receiver operating characteristic curve (AUC) and measures of accuracy, sensitivity, specificity, and predictive values for overall performance and each examiner.ResultsOf the 206 included Japanese women, the prevalence of malignancy was 30.1%, including borderline cases. The overall AUC for distinguishing malignancy was 0.848 (95% confidence interval [CI]: 0.817–0.880). The AUC for each examiner ranged from 0.791 to 0.898, with Specialist 2 showing the highest accuracy and sensitivity varying between 0.677 and 0.839. A moderate degree of agreement was noted among the four examiners (Fleiss' kappa was 0.586). The performance of trainees and specialists differed significantly in evaluating the solid tissue and the papillary projections in both malignant and benign groups (P < .001).ConclusionsThe IOTA ADNEX model effectively differentiates benign and malignant adnexal masses in Japanese women. Although the accuracy matched up moderately among the four examiners, better accuracy is expected with training in evaluating solid tissue and papillary projections.

Ultrasound Scoring to Predict High‐Risk Endometrial Cancer

Objectives To evaluate a scoring system using transvaginal ultrasound (TVS) to predict high‐risk endometrial cancer. Methods Consecutive patients with endometrial cancer/atypical hyperplasia (n = 266) were preoperatively examined by residents using TVS. Clinical parameters, endometrial morphology and Doppler scores were recorded using a gray scale and Doppler TVS and related to final histopathology at hysterectomy. Multivariate logistic regression was used to correlate imaging and clinical parameters to the presence of high‐risk endometrial cancer (defined as FIGO stage Ib‐IV or high‐grade tumors [grade 3/non‐endometroid]) to develop the High‐Risk Endometrial Cancer (HIREC) score. Results High‐risk endometrial cancer (n = 128) and lympho‐vascular space invasion (LVSI) (n = 43) were predicted by increased endometrial thickness (ET), age, and Doppler score. The HIREC scoring system, based on age, Doppler score, and ET performed well with an AUC of 78.5% (CI 95%: 73–84) to predict high‐risk cancer. By using a 2‐step strategy of (1) Preoperative identification of high‐grade tumors by biopsy, (2) Assessing the HIREC score, high‐risk endometrial cancer could be predicted at a HIREC score of ≥7 with sensitivity, specificity, and accuracy of 72.7, 88.4, and 80.8%. Low‐risk endometrial cancer was predicted at HIREC scores of <5 with sensitivity, specificity, and accuracy values of 91.4, 46.4 and 68.1%, respectively. Conclusions Low and high HIREC scores effectively predicted low‐ and high‐risk endometrial cancer. The score is a simple point system suitable for the first ultrasound assessment. It may be used in preoperative work‐up to select treatment and additional imaging, but it needs to be validated in further studies.

Development of a High‐Performance Ultrasound Prediction Model for the Diagnosis of Endometrial Cancer

Objectives To develop and validate an ultrasonography‐based machine learning (ML) model for predicting malignant endometrial and cavitary lesions. Methods This retrospective study was conducted on patients with pathologically confirmed results following transvaginal or transrectal ultrasound from 2021 to 2023. Endometrial ultrasound features were characterized using the International Endometrial Tumor Analysis (IETA) terminology. The dataset was ranomly divided (7:3) into training and validation sets. LASSO (least absolute shrinkage and selection operator) regression was applied for feature selection, and an extreme gradient boosting (XGBoost) model was developed. Performance was assessed via receiver operating characteristic (ROC) analysis, calibration, decision curve analysis, sensitivity, specificity, and accuracy. Results Among 1080 patients, 6 had a non‐measurable endometrium. Of the remaining 1074 cases, 641 were premenopausal and 433 postmenopausal. Performance of the XGBoost model on the test set: The area under the curve (AUC) for the premenopausal group was 0.845 (0.781–0.909), with a relatively low sensitivity (0.588, 0.442–0.722) and a relatively high specificity (0.923, 0.863–0.959); the AUC for the postmenopausal group was 0.968 (0.944–0.992), with both sensitivity (0.895, 0.778–0.956) and specificity (0.931, 0.839–0.974) being relatively high. SHapley Additive exPlanations (SHAP) analysis identified key predictors: endometrial–myometrial junction, endometrial thickness, endometrial echogenicity, color Doppler flow score, and vascular pattern in premenopausal women; endometrial thickness, endometrial–myometrial junction, endometrial echogenicity, and color Doppler flow score in postmenopausal women. Conclusion The XGBoost‐based model exhibited excellent predictive performance, particularly in postmenopausal patients. SHAP analysis further enhances interpretability by identifying key ultrasonographic predictors of malignancy.

The Value of Shear Wave Elastography in Predicting the Risk of Endometrial Cancer and Atypical Endometrial Hyperplasia

ObjectivesTo evaluate shear wave elastography (SWE) technology diagnosis value of endometrial cancer (EC) and atypical endometrial hyperplasia (AEH), and to establish predictive logistic regression models for the diagnosis of EC and AEH.MethodsClinical information collection, transvaginal conventional ultrasonography, and SWE check were performed on 122 patients, who were perimenopausal or postmenopausal vaginal bleeding with ≥4.5 mm thick endometrium. The maximal (Emax) and mean (Emean) of Young's modulus for the endometrium were obtained. Using pathology as the gold standard, ROC curves were plotted to evaluate Young's modulus on the diagnostic effectiveness of EC and AEH. Single‐factor analysis and bivariate logistic regression methods were applied to assess the clinical variables, transuaginal conventional ultrasonography variables, and Young's modulus on the identification of EC and AEH.ResultsOut of 122 cases of endometrial lesions, 85 cases were benign lesions, and the remaining 37 cases were EC and AEH. The Emax and Emean for the benign group were 29.80 ± 11.40 and 17.96 ± 8.05 kPa, respectively. The Emax and Emean values for EC and AEH group were 59.49 ± 16.95 and 38.46 ± 17.10 kPa, respectively. Emax and Emean for both groups were statistically significant, with p <.001. In the logistical regression analysis, endometrial thickness, Color score, and Young's modulus were identified as independent risk factors for EC and AEH.ConclusionsSWE technology plays an important role in the diagnosis of EC and AEH, and the diagnostic effectiveness would be higher when combined with conventional ultrasonography.

The Sonographic Appearance of Endometrial Intraepithelial Neoplasia

ObjectivesTo describe the sonographic findings of endometrial intraepithelial neoplasia (EIN), a precursor of endometrial cancer.MethodsCases were found by word search of pathology database 1/2013 to 6/2019. One hundred and seventy‐eight patients with ultrasound <1 year prior to biopsy were included. Medical records were searched for patient data. Two radiologists blindly classified images. Differences of opinion were decided by clinical report. Univariate and multivariate analyses were performed.ResultsMedian time between ultrasound and first sampling procedure was 49 days. Median age was 55 (range 28–85) years. Endometrial thickness ranged from 2 to 90 mm. Mean endometrial thickness was 13 ± 6 mm in the noncancer group and 16 ± 11 mm in the cancer group (P = .02). The endometrium was almost always heterogeneous 175/178 (98%). Cysts were almost always multiple (89/109, 82%) and >1 mm (72/109, 66%). Masses were most often >5 mm (56/105, 55%) and ill‐defined (41/105, 39%). Vascularity was present in 93/178 examinations (52%) and always associated with cysts and/or mass. There were 92 cancers, 25 with invasion (including 4 with tumor extension into adenomyosis). In 47 cases, the endometrial‐myometrial interface was graded as ill‐defined, 39 of whom had hysterectomy. There was macroscopic cancer in 11, microscopic cancer in 4, and invasive carcinoma in 12 patients (P for invasive cancer versus other outcomes = .02). Depth of invasion was 5‐ >95%, with 6 cancers >50%. Multivariate analysis showed thickness, polyps, and type of bleeding as the best set of independent variables for cancer (area under the receiver operating characteristic (ROC) curve [AUC] = .75). Replacing type of bleeding with age or menopausal status had AUC of .73 and .74, respectively.ConclusionsEIN has a variety of sonographic appearances with thickened endometrium with cysts and masses being common. Ill‐definition of the endometrial‐myometrial interface is a poor prognostic finding when seen in the absence of adenomyosis.

Transvaginal Ultrasound Versus Magnetic Resonance Imaging for Assessing Myometrial Infiltration in Endometrioid Low Grade Endometrial Cancer

ObjectiveTo compare the diagnostic accuracy of transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) for assessing myometrial infiltration (MI) in patients with low grade endometrioid endometrial cancer.MethodsObservational prospective study performed at a single tertiary care center from 2016 to 2020, comprising 156 consecutive patients diagnosed by endometrial sampling as having an endometrioid grade 1/grade 2 endometrial cancer. TVS and MRI were performed prior to surgical staging for assessing MI, which was estimated using subjective examiner's impression and Karlsson's method for both TVS and MRI. During surgery, intraoperative assessment of MI was also performed. Definitive pathological study considered as reference standard. Diagnostic accuracy for ultrasound, MRI, and intraoperative biopsy was estimated and compared.ResultsSensitivity and specificity of TVS for detecting deep MI were 75 and 73.5% for subjective impression and 65 and 70% for Karlsson method, respectively (P = .54). Sensitivity and specificity of MRI for detecting deep MI were 80 and 87% for subjective impression and 70 and 71.3% for Karlsson method. MRI subjective impression showed a significant better specificity than MRI Karlsson method (P = .03). MRI showed better specificity than TVS when subjective impression was considered (P <.05), but not for Karlsson method. Sensitivity and specificity of intraoperative were 75 and 97%, respectively. Intraoperative biopsy showed better specificity than ultrasound and MRI either using examiner's impression or Karlsson method (P <.05).ConclusionsMRI revealed a significant higher specificity than TVS when assessing deep myometrial infiltration. However, the intraoperative biopsy offers a significant better diagnostic accuracy than preoperative imaging techniques.

Application Value of Real‐Time Shear Wave Elastography in Diagnosing the Depth of Infiltrating Muscular Layer of Endometrial Cancer

ObjectiveTo explore the clinical value of real‐time shear wave ultrasonic elastography in diagnosing the depth of infiltrating muscularis of endometrial cancer.MethodsSeventy‐one patients with stage I endometrial cancer infiltrating the myometrium and 37 patients with normal physical examination were enrolled and divided into three groups: endometrial cancer superficial muscle infiltration group, endometrial cancer deep muscle infiltration group, and normal control group. After completing 2‐dimensional ultrasound examination, each patient switched to the real‐time shear wave elastography mode to measure the elasticity values Emax, Emean, and Esd.ResultsFor control group, comparison of elastic modulus values between superficial muscular layer near the intimal surface and the deep muscular layer near the serosa surface showed no difference (P > 0.05). For endometrial cancer superficial muscular infiltration group, significant difference was found regarding the elastic modulus values of infiltrated muscular layer and uninfiltrated muscular layer (Emax and Emean) without difference for Esd (P > 0.05). A significant difference of elastic modulus was observed between control group and deep myometrial infiltration group (P < 0.05) without difference of Emean or Emax but with difference of Esd. The accuracy in diagnosing muscular layer infiltration was 78.9% for Emax cutoff and 82.5% for Emean cutoff. The rate of using Emax ≥32.22 kPa or Emean ≥27.54 kPa as the ultrasound standard for diagnosing myometrium infiltration was 92.9%. The accuracy for the diagnosis of muscular layer infiltration was 96.1% for Emax cutoff, 94.1% for Emean cutoff and 86.3% for Esd cutoff.ConclusionReal‐time shear wave elastography is helpful to determine the depth of infiltrating myometrium of endometrial cancer.

Clinical Radiomics Nomogram Based on Ultrasound

Objectives This study aims to develop a noninvasive preoperative predictive model utilizing ultrasound radiomics combined with clinical characteristics to differentiate uterine sarcoma from leiomyoma. Methods This study included 212 patients with uterine mesenchymal lesions (102 sarcomas and 110 leiomyomas). Clinical characteristics were systematically selected through both univariate and multivariate logistic regression analyses. A clinical model was constructed using the selected clinical characteristics. Radiomics features were extracted from transvaginal ultrasound images, and 6 machine learning algorithms were used to construct radiomics models. Then, a clinical radiomics nomogram was developed integrating clinical characteristics with radiomics signature. The effectiveness of these models in predicting uterine sarcoma was thoroughly evaluated. The area under the curve (AUC) was used to compare the predictive efficacy of the different models. Results The AUC of the clinical model was 0.835 (95% confidence interval [CI]: 0.761–0.883) and 0.791 (95% CI: 0.652–0.869) in the training and testing sets, respectively. The logistic regression model performed best in the radiomics model construction, with AUC values of 0.878 (95% CI: 0.811–0.918) and 0.818 (95% CI: 0.681–0.895) in the training and testing sets, respectively. The clinical radiomics nomogram performed well in differentiation, with AUC values of 0.955 (95% CI: 0.911–0.973) and 0.882 (95% CI: 0.767–0.936) in the training and testing sets, respectively. Conclusions The clinical radiomics nomogram can provide more comprehensive and personalized diagnostic information, which is highly important for selecting treatment strategies and ultimately improving patient outcomes in the management of uterine mesenchymal tumors.

Comparison of Reintervention Rates for Type 1 and Type 2 Uterine Fibroids Treated With HIFU Ablation With Varying Non‐Perfused Volume Ratios to That With TCRM

Objectives The objective of this study is to investigate the correlation between long‐term reintervention rates following high‐intensity focused ultrasound (HIFU) ablation with varying non‐perfused volume ratios (NPVR) and hysteroscopic transcervical resection of myoma (TCRM) for type 1 and 2 fibroids. Additionally, the study aims to define the technical success criteria in this context. Methods This retrospective study included patients with type 1 and 2 fibroids who underwent treatment with HIFU or TCRM between January 2012 and December 2019. Follow‐up assessments were conducted to monitor reintervention rates. NPVR, assessed via magnetic resonance imaging (MRI) post‐HIFU treatment, served as a technical indicator for comparing reintervention outcomes between HIFU and TCRM. Logistic regression analysis was employed to identify factors influencing reintervention in patients. Results A total of 445 patients were enrolled, with successful follow‐up on 325 cases, including 181 cases in the HIFU group and 144 cases in the TCRM group, resulting in a follow‐up rate of 73%. When NPVR was ≥70% (n = 151), the long‐term reintervention rate following HIFU was comparable to that of TCRM. Binary logistic regression analysis revealed age and long‐term symptom relief as independent influencing factors influencing reintervention. The cut‐off value of age in patients from the HIFU group was determined as 41.5 using receiver operating characteristic curve (ROC) analysis. The reintervention rate was found to be 10.1% (n = 79) for patients aged over 41.5 years, compared to 34.7% (n = 72) for those aged below it. Conclusion HIFU emerges as an effective and reliable treatment modality for large type 1 and type 2 uterine fibroids, providing a viable non‐invasive alternative for their management. NPVR ≥70% can serve as a technical criterion for successful operation.

A New Insight on Exophytic Serous Borderline Adnexal Tumors: Specific Sonographic Features

ObjectivesTo characterize and compare the sonographic features of exophytic serous borderline ovarian tumors (ESBOT) with those of high‐grade serous carcinoma of the ovary (HGSC).MethodsSeven patients with histological diagnosis of ESBOT diagnosed between 2011 and 2019 and 10 consecutive cases of HGSC detected during 2019, both depicting an exophytic growth pattern, were identified retrospectively. The sonographic imaging of the masses was reassessed and characterized according to the International Ovarian Tumor Analysis terms.ResultsA unilateral irregular solid adnexal mass was demonstrated in all patients with ESBOT. The mass typically wrapped an apparently normal ovary, with a clear demarcation line depicted between them and it contained tiny cystic inclusions and calcifications. On color Doppler study of all the ESBOT cases, a unique vascular pattern could be demonstrated: an intratumoral vascular bundle originating from the ovarian vessels and supplying a rich radial blood flow to the tumor periphery. These characteristic morphological and color Doppler features could not be observed in any of the HGSC cases (P < .001). In 42.8% of the patients with ESBOT, additional unilocular‐solid components (ipsilateral or contralateral) could be detected, whereas all the HGSC patients presented with a multilocular‐solid tumor morphology (P < .001). The interface of the external mass border with the adjacent pelvic walls was regular in all the cases with ESBOT, whereas in 80% of HGSC patients, it was irregular, suggesting invasiveness (P = .002).ConclusionsESBOT can mimic HGSC. Our results suggest that ESBOT has specific B‐mode and color Doppler features, enabling differentiation from HGSC and planning appropriate intervention.

Serum miRNA Combined With Transvaginal Color Doppler Ultrasound Diagnosis Clinical Research on Cervical Cancer

ObjectivesTo explore clinical value of miRNA‐18a, miRNA‐130a, and miRNA‐92a combined with transvaginal color Doppler ultrasound (TVCDS) in the diagnosis of cervical cancer (CC).MethodsOne hundred patients with pathologically confirmed CC (CC group), 100 patients with cervical epithelial neoplasia (disease group), and 100 patients with benign uterine lesions (control group) were selected. TVCDS was performed, and the levels of serum miRNA‐18a, miRNA‐130a, and miRNA‐92a were detected.ResultsThe systolic blood velocity of the cancer group, the disease group, and the control group decreased sequentially, while the resistance index and pulsatility index increased sequentially. The serum miR‐18a, miR‐130a, miR‐92a, and expression levels of the patients' increased sequentially. Multivariate logistic regression analysis showed that age, high‐risk human papillomavirus (HR‐HPV) infection, menopause, blood flow RI, serum miRNA‐18a, miRNA‐92a, and miRNA‐130a were the influencing factors of CC. The receiver operating characteristic curve showed that the sensitivity, specificity, accuracy, and area under curve of transvaginal Doppler ultrasound in the diagnosis of CC were 86.43%, 88.01%, 84.32%, and 0.913; serum miR‐18a were, respectively, 76.56, 81.30, 80.36, and 0.839; serum miR‐130a were 77.88%, 76.97%, 78.32%, and 0.0.864; serum miR‐92a were 71.04%, 80.39%, 80.74%, and 0.894; 90.33%, 95.14%, 91.25%, and 0.947, the area under curve of the combined detection of the 3 was greater than that of the single detection.ConclusionsSerum miRNA combined with TVCDS has the advantages of it being noninvasive, and having high sensitivity and high specificity in the diagnosis of CC.

Ovarian Cystadenomas: Growth Rate and Reliability of Imaging Measurements

ObjectivesTo evaluate the growth rate of benign ovarian cystadenomas and the degree of variability in ultrasound measurements.MethodsTwo independent retrospective cohorts of women found to have benign cystadenomas at surgery were identified. To assess growth rate, ultrasounds on women in a community‐based health system were reviewed and the growth rate was determined based on the maximum reported size dimension using a mixed effect model. To assess measurement variability, two radiologists independently measured presurgical adnexal imaging findings for women in a tertiary care referral setting. Interobserver, intra‐observer, and intermodality (cine clip versus still images) variability in measurements was determined using correlation coefficients (CC) and Bland–Altman analysis, with the proportion of measurements varying by more than 1 cm calculated.ResultsFor growth rate assessment, 405 women with 1412 ultrasound examinations were identified. The median growth rate was 0.65 cm/year with mucinous cystadenomas growing faster at 0.83 cm/year compared to 0.51 cm/year for serous cystadenomas (median test P < .0001). To evaluate measurement variability, 75 women were identified with 176 ultrasound studies. The within‐subject standard deviations for ultrasound measurements were 0.74 cm for cine clip images and 0.41 cm for static images, with 11% of measurements overall differing by more than 1 cm.ConclusionsCystadenomas grow on average 0.65 cm/year, which is similar in magnitude to the inherent error observed in measurement on ultrasound, suggesting that repeat ultrasound at intervals of longer than a year will often be needed to accurately assess growth if a cyst represents a benign cystadenoma.

Comparison of O‐RADS, GI‐RADS, and ADNEX for Diagnosis of Adnexal Masses: An External Validation Study Conducted by Junior Sonologists

ObjectiveTo externally validate the Ovarian‐adnexal Reporting and Data System (O‐RADS) and evaluate its performance in differentiating benign from malignant adnexal masses (AMs) compared with the Gynecologic Imaging Reporting and Data System (GI‐RADS) and Assessment of Different NEoplasias in the adneXa (ADNEX).MethodsA retrospective analysis was performed on 734 cases from the Second Affiliated Hospital of Fujian Medical University. All patients underwent transvaginal or transabdominal ultrasound examination. Pathological diagnoses were obtained for all the included AMs. O‐RADS, GI‐RADS, and ADNEX were used to evaluate AMs by two sonologists, and the diagnostic efficacy of the three systems was analyzed and compared using pathology as the gold standard. We used the kappa index to evaluate the inter‐reviewer agreement (IRA).ResultsA total of 734 AMs, including 564 benign masses, 69 borderline masses, and 101 malignant masses were included in this study. O‐RADS (0.88) and GI‐RADS (0.90) had lower sensitivity than ADNEX (0.95) (P < .05), and the PPV of O‐RADS (0.98) was higher than that of ADNEX (0.96) (P < .05). These three systems showed good IRA.ConclusionO‐RADS, GI‐RADS, and ADNEX showed little difference in diagnostic performance among resident sonologists. These three systems have their own characteristics and can be selected according to the type of center, access to patients' clinical data, or personal comfort.

Ovarian Masses: The Value of Acoustic Shadowing on Ultrasound Examination

Adnexal lesions are a common finding in women and pose a clinical challenge since ovarian cancer is a highly lethal disease. However, most adnexal masses are benign, benefiting from a more conservative approach. In preoperative assessment, transvaginal ultrasound plays a key role in evaluating morphologic features that correlate with the risk of malignancy. The acoustic shadow is the loss of echo behind sound‐absorbing components, such as calcifications or fibrous tissues, which are predominantly found in benign lesions. However, recognizing the acoustic shadow is a difficult skill to master, and its usefulness may be underappreciated.

Obstetrics and Gynecology Residents Can Accurately Classify Benign Ovarian Tumors Using the International Ovarian Tumor Analysis Rules

ObjectivesRecognition of benign versus malignant tumors is essential in gynecologic ultrasound (US). The International Ovarian Tumor Analysis (IOTA) rules have been proposed as part of resident US training. The objective of this study was to examine whether they could be accurately used by obstetrics and gynecology residents in Rwanda.MethodsPatients undergoing explorative laparotomy for adnexal masses at the University Teaching Hospital of Kigali were included. Before the study, a didactic lecture on the IOTA rules for classifying adnexal masses was performed. Preoperative transabdominal US examinations were performed by residents at different levels of training, who were blinded to the results of prior US examinations. The IOTA classification was compared to the final pathologic diagnosis.ResultsThere were 72 patients who underwent 116 US examinations. Only 15.5% of US examinations were considered inconclusive. First‐year residents (12) correctly diagnosed 18 of 20 masses (90%) as benign and 4 of 4 as malignant. Second‐year residents (9) classified 29 of 29 masses correctly. Third‐year residents (10) accurately identified 21 of 22 (95.5%) as benign and 5 of 5 as malignant. Fourth‐year residents (13) accurately identified 11 of 12 (91.7%) as benign and 6 of 6 as malignant. Therefore, 74 of 78 tumors (94.9%) considered benign by IOTA rules were confirmed by histologic results. Similarly, all 20 tumors classified as malignant were confirmed. Overall, the sensitivities to diagnose benign and malignant tumors by the IOTA rules were 83.3% and 100%, respectively. The positive and negative predictive values were 100% and 94.9%. There were no significant differences noted between residency years.ConclusionsAll levels of Rwandan obstetrics and gynecology residents were able to use the IOTA rules to accurately distinguish benign from malignant tumors.

Characterization of Adnexal Masses Using Contrast‐Enhanced Subharmonic Imaging: A Pilot Study

ObjectivesThis pilot study evaluated whether contrast‐enhanced subharmonic imaging (SHI) could be used to characterize adnexal masses before surgical intervention.MethodsTen women (with 12 lesions) scheduled for surgery of an ovarian mass underwent an SHI examination of their adnexal region using a modified LOGIQ E9 scanner (GE Healthcare, Waukesha, WI) with an endocavitary transducer, in which digital clips were acquired by pulse destruction‐replenishment SHI across the lesions. Time‐intensity curves were created offline to quantitatively evaluate SHI parameters (fractional tumor perfusion, peak contrast intensity, time to peak contrast enhancement, and area under the time‐intensity curve), which were compared to pathologic characterizations of the lesions.ResultsOf the 12 masses, 8 were benign, and 4 were malignant. A qualitative analysis of the SHI images by an experienced radiologist resulted in diagnostic accuracy of 70%, compared to 56% without contrast, whereas an inexperienced radiologist improved from 50% to 58% accuracy, demonstrating the benefit of SHI. A quantitative analysis of SHI parameters produced diagnostic accuracy as high as 81%. Peak contrast intensity was significantly greater in malignant than benign masses (mean ± SD, 0.109 ± 0.088 versus 0.046 ± 0.030 arbitrary units; P = .046). Malignant masses also showed significantly greater perfusion than benign masses (24.79% ± 25.34% versus 7.62% ± 6.50%; P = .045). When the radiologist reads were combined with the most predictive quantitative SHI parameter (percent perfusion), diagnostic accuracy improved to 84% for the experienced radiologist and 96% for the novice radiologist.ConclusionsResults indicate that SHI for presurgical characterization of adnexal masses may improve the determination of malignancy and diagnostic accuracy, albeit based on a small sample size.

Sonoelastographic Assessment of the Uterine Cervix in the Prediction of Imminent Delivery in Singleton Nulliparous Women Near Term

ObjectivesTo explore the role of newly developed software to assess cervical sonoelastography in predicting the onset of spontaneous delivery in singleton pregnancies at term and to compare its diagnostic performance with that provided by the cervical length (CL) and posterior cervical angle (PCA).MethodsThis work was a prospective study including nulliparous singleton pregnancies at gestational ages of 37 weeks to 38 weeks 6 days. The CL, PCA, hardness ratio (HR), and mean strain from the internal os and external os were obtained by a transvaginal ultrasound approach using semiautomatic software (E‐Cervix; Samsung Medison Co, Ltd, Seoul, Korea). Multivariate logistic regression and area under the curve analyses were used to test the strength of the association and the diagnostic performance of the variables considered in predicting delivery within 7 days.ResultsA total of 398 women were included, and 24.6% delivered within 7 days. The CL was shorter (19.5 versus 2 7 mm; P = .0001), PCA narrower (99° versus 102°; P = .02) HR lower (35.3 versus 40.7; P = .0001), mean strain from the external os higher (0.41 versus 0.35; P = .0001), and mean strain from the internal os higher (0.38 versus 0.33; P = .0001) higher in women who delivered within 7 days from the assessment. At the multivariable logistic regression analysis, the CL (adjusted odds ratio, 1.307) and HR (adjusted odds ratio, 1.227) were the only variables independently associated with delivery within 1 week. A model combining the CL and HR showed an area under the curve of 0.873 in predicting delivery within 7 days, higher than that obtained by using the CL and HR singularly (P ≤ .0001).ConclusionsThe HR assessed by sonoelastography improves the efficacy of the CL in predicting imminent delivery in nulliparous women close to term.