Medical Ultrasonography

Embryonal rhabdomyosarcoma of the uterine cervix

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A rare case of ovarian hypercalcemia type small cell carcinoma

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Logistic models and artificial intelligence in the sonographic assessment of adnexal masses – a systematic review of the literature

Adnexal masses are common, yet challenging, in gynecological practice. Making the differential diagnosis between their benign and malignant condition is essential for optimal surgical management, but reliable pre-surgical differentiation is sometimes difficult using clinical features, ultrasound examination, or tumor markers alone. A possible way to improve the diagnosis is using artificial intelligence (AI) or logistic models developed based on compiling and processing clinical, ultrasound, and tumor marker data together. Ample research has already been conducted in this regard that medical practitioners could benefit from. In this systematic review, we present logistic models and methods using AI, chosen based on their demonstrated high performance in clinical practice. Although some external validation of these models has been performed, further prospective studies are needed in order to select the best model or to create a new, more efficient, one for the pre-surgical evaluation of ovarian masses.

Magnetic resonance imaging and ultrasound for assessing parametrial infiltration in cervical cancer. A systematic review and meta-analysis

Aims: To provide information on the current evidence regarding the diagnostic performance of ultrasound and MRI for assessing parametrial involvement in cervical cancer using the histological report as the reference standard.Material and methods: Meta-analysis. An extensive search of papers comparing ultrasound and MRI in assessing parametrial infiltration in cervical cancer using pathologic analysis as a reference standard was performed in Medline (Pubmed) and Web of Science from January 1990 to September 2019. Quality was assessed using the QUADAS-2 tool.Results: Our extended search identified 205 citations but after exclusions we finally included 9 articles in the meta-analysis. The risk of bias for most studies was low for four domains were assessed in QUADAS-2. Overall, for ultrasound pooled estimated sensitivity and specificity for diagnosing parametrial infiltration was 78% (95% confidence interval [CI]:48%–93%) and 96% (95% CI=89%–99%), respectively. For MRI these figures were 68% (95% CI=54%–80%) and 91% (95% CI=84%–95%), respectively. No statistical differences were found when comparing both methods (p=0.548). Heterogeneity was low/moderate for MRI and high for ultrasound.Conclusion: Ultrasound and MRI have similar diagnostic performance for detecting parametrial infiltration in women with cervical cancer. This might have relevance from the clinical point of view, since ultrasound is cheaper than MRI

Transvaginal three-dimensional ultrasound for preoperative assessment of myometrial invasion in patients with endometrial cancer: a systematic review and meta-analysis

Aim: The aim of this meta-analysis is to evaluate the diagnostic accuracy of three-dimensional transvaginal ultrasound subjective assessment (3D-TVS) in the preoperative detection of deep myometrial invasion (MI) in patients with endometrial cancer, using definitive frozen section diagnosis after surgery as the reference standard. Material and methods: A search for studies evaluating the role of 3D-TVS for assessing myometrial invasion in endometrial cancer from January 1990 to Novem-ber 2020 was performed in PubMed/MEDLINE and Web of Science. The Quality Assessment of Diagnostic Accuracy Studies 2 evaluated the quality of the studies (QUADAS-2). All analyses were performed using MIDAS and METANDI commands. Results: Nine studies comprising 581 women were included. The mean prevalence of deep MI was 39.8%. QUADAS as-sessment showed that most studies had a high risk for the patient selection domain. Overall, the pooled estimated sensitivity, specificity, positive likelihood and negative likelihood ratio of 3D-TVS for detecting deep MI were 84% (95% CI, 73-90%), 82% (95% CI, 75-88%), 5 (95% CI, 3.1-7.1) and 0.20 95% CI, 0.11-0.35). respectively. Conclusions: 3D-TVS has an accept-able diagnostic performance for detecting MI in women with endometrial cancer.

Comparison of IOTA three-step strategy and logistic regression model LR2 for discriminating between benign and malignant adnexal masses

Aims: To compare the diagnostic performance of two ultrasound-based diagnostic systems for the classification of benign or malignant adnexal masses, the three-step strategy and the predictive logistic regression model LR2, both proposed by the International Ovarian Tumour Analysis (IOTA) Group. Material and methods: Prospective observational study at a single centre that included patients diagnosed with a persistent adnexal mass by transvaginal ultrasound over a period of two years. They were evaluated by a non-expert sonographer by applying the three-step diagnostic strategy and the LR2 predictive model to classify the masses as benign or malignant. Patients were treated surgically or followed up for at least one year, taking as the standard reference for benignity or malignancy the histological diagnosis of the lesion or ultrasound changes suggestive of malignancy during the follow-up period. Sensitivity, specificity, positive and negative likelihood ratios and overall accuracy of both systems was calculated and compared. Results: One hundred patients were included, with a mean age of 50.6 years (range 18-87). Surgery was performed on 62 (62%) patients and 38 (38%) were managed expectantly. Eighty-three (83%) lesions were benign and 17 (17%) were malignant. The IOTA three-step strategy presented sensitivity of 94.1% (95%CI, 86.7-98.3%) and specificity 97.6% (95%CI, 94.8-99%). The LR2 logistic regression model showed sensitivity 94.1% (95%CI, 73-98.9%) and specificity 81.9% (95%CI 72.3-88.7%). Comparison of the two systems showed a statistically significant dif-ference in specificity in favour of the three-step strategy. Conclusions: The IOTA three-step strategy, in addition to being sim-ple to use in clinical practice, has a high diagnostic accuracy for the classification of benignity and malignancy of the adnexal masses, overtaking that of other predictive models such as the LR2 logistic regression model.

Elastography of the uterine cervix in gynecology: normal appearance, cervical intraepithelial neoplasia and cancer. A systematic review

Aims: To revise the current literature about the usefulness of elastography in cervical cancer (CC) and cervical intraepithelial neoplasia (CIN), from methods and technical limitations, to diagnosis, staging and the ability of predicting the response to oncologic treatment.Methods: An electronic database search was performed (PubMed, EMBASE, Web of Science) with the data range from January 2000 until May 2020. All studies, fully-available in English, assessing elastography of the uterine cervix in CC and CIN were selected. Studies were reviewed and discussed according to the elastographic technique and to the purpose of the research.Results: Twenty-three articles were found: 11 articles regarding strain elastography, 4 articles assessing shear wave elastography and 8 papers with matter-related information. Elastography was used in the study of normal variants of the uterine cervix as well as: the positive diagnosis of CC and CIN, clinical staging and the prediction of therapeutic response in CC. Comparison of the elastographic techniques was also performed.Conclusions: Elastography has multiple applications in the gynecological pathology of the cervix. The methods used to assess the cervix are diverse, and none have become universally accepted. With regard to CC and CIN, elastography is still an ongoing research field.

Diagnostic accuracy of transvaginal ultrasound examination for local staging of cervical cancer: a systematic review and meta-analysis

Aim: Transvaginal ultrasonography (TVUS) has shown varying results in the staging of cervical cancer patients around the world. Hence, the current review was done to assess the diagnostic accuracy of TVUS for identifying parametrial, stromal invasion and lymph node metastasis among cervical cancer patients.Material and methods: We conducted a systematic search for all studies reporting the diagnostic accuracy of TVUS for staging of cervical cancer in the databases of PubMed Central, MEDLINE, EMBASE, MEDLINE, SCOPUS and Cochrane library from inception till March 2021. Meta-analysis was performed using STATA software “midas” package.Results: Eleven studies with 760 patients were included. The pooled sensitivity and specificity of TVUS for diagnosing parametrial invasion were 62% (95% CI, 40-80) and 91% (95% CI, 79-97), for stromal invasion were 84% (95% CI, 77-90) and 80% (95% CI, 61-91), for lymph node metastasis were 52% (95% CI, 8-93) and 95% (95% CI, 68-99). There was significant heterogeneity found with all the outcomes with significant chi-square test and I2 statistic >75%.Conclusion: TVUS has limited applicability and use as a screening or diagnostic tool for local staging of cervical cancer patients. Further reviews comparing multiple non-invasive imaging modalities are required to pick the best tool for local staging of cervical cancer.

Usefulness of real time elastography strain ratio in the assessment of cervical intraepithelial neoplasia and cervical cancer using a reference material

Aims: To assess the usefulness of real time elastography (RTE) strain ratio (SR) in diagnosing cervical cancer (CC) and cervical intraepithelial neoplasia (CIN), using a synthetic experimental device (ED) as reference material.Material and methods: Seventy-nine participants were enrolled, divided in three groups: Group 1 – benign cervix (n=39); Group 2 – CIN (n=32); Group 3 - CC (n=8). Transvaginal RTE was performed, with SR determination, as the ratio between the ED and the cervical tissue. Mean SR values of the groups were compared; diagnostic performance was assessed by tracing the receiver operating characteristic (ROC) curve. Area under the curve (AUC) was analyzed. Cut-off values were established. Pathological results were considered as reference for data interpretation.Results: SR means significantly differed in Group 1 as compared to Groups 2 and 3 (p=0.001). Excluding 2 aberrant values in Group 3, assigned to cases complicated by hemorrhagic necrosis, statistical difference was also noted between Groups 2 and 3 (p=0.02). For Groups 1 and 3, AUC was 0.966 with a 95%CI (0.914-1.000); the cut-off point of SR was 1.42, with a sensitivity of 100% and a specificity of 94.9%. AUC was 0.752 with a 95%CI (0.629-0.876) for Groups 1 and 2. For the cut-off value of 1.03, sensitivity and specificity were 75% and 74%, respectively.Conclusion: RTE SR, performed with a synthetic reference material, seems a reliable method for distinguishing between benign uterine cervix and malignancy, with promising results as a complementary investigation in diagnosing CIN. However, SR becomes inoperant in cases of cancer complicated with hemorrhagic necrosis.

An interesting mass: a case of abdominal teratoma from ovary complicated with torsion

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