Ultrasound in Obstetrics & 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.

Clinical utility of ultrasonography in pediatric and adolescent gynecology: retrospective review of 1313 ultrasound examinations

ABSTRACTObjectivesUltrasound is the first‐line imaging modality of the pelvis in the pediatric and adolescent gynecology (PAG) population. Ultrasound findings in pre‐ and postpubertal PAG patients differ from those in adults. Diagnostic models for adnexal pathology have not been validated in this cohort. The primary aim of this study was to evaluate normative findings and the incidence of pathology in this cohort. The secondary aim was to assess the performance of expert opinion alone, as well as using retrospective application of the International Ovarian Tumor Analysis (IOTA) simple rules (SRs) and benign descriptors (BDs) in those found to have an adnexal mass.MethodsThis was a retrospective review of pelvic ultrasound examinations performed in patients < 18 years of age from January 2017 to July 2021 in one expert center in the UK. Analysis was performed on three age groups: neonatal (aged < 1 year), premenarchal (aged ≥ 1 year) and postmenarchal. The study was locally approved as an audit (GRM_082). Expert review of images of ovarian masses was performed using retrospective application of the IOTA‐SRs and IOTA‐BDs.ResultsIn total, data on 1429 pelvic ultrasound examinations were retrieved, of which 116 were excluded, resulting in the inclusion of 1313 ultrasound images (1145 patients). The median age at the first ultrasound scan was 2 days after birth in the neonatal group (n = 20), 8.8 years in the premenarchal group (n = 124) and 16.1 years in the postmenarchal group (n = 961). The status of menarche was unknown in a further 40 patients. Normative ultrasound findings were in keeping with those in the existing literature. Uterine anomalies were seen in 14 (1.2%) patients. Endometrial pathology was rare, with five cases of gestational trophoblastic disease. The most frequent indication for ultrasound scan for each group were a known medical condition in neonates (n = 11 (55.0%)), suspected precocious puberty in premenarchal girls (n = 38 (30.6%)) and abnormal vaginal bleeding in postmenarchal girls (n = 504 (52.4%)). Polycystic ovarian appearances were described in 150 (15.6%) postmenarchal girls. Adnexal pathology was identified in 102 (8.9%) participants on initial ultrasound: four neonates, three premenarchal and 95 postmenarchal patients. Benign cystadenomas and hemorrhagic cysts were the most common adnexal mass type in all groups. Final outcomes were available for 79/95 masses in the postmenarchal group, none of which were malignant. The IOTA‐SRs, IOTA‐BDs, expert opinion and standard ultrasound reporting could characterize as benign 96.2%, 87.3%, 98.7% and 77.2% of the masses, respectively, all with a specificity of 100%. Eleven patients underwent 12 surgeries overall (three oophorectomies, six cystectomies and three cyst aspirations), with 11 out of 12 masses classified as benign based on retrospective expert assessment.ConclusionsUltrasound is effective for assessment of the female pelvis in the PAG population. Adnexal masses are common, but few require surgical intervention and most resolve expectantly. The IOTA‐BDs and IOTA‐SRs maintain their performance in this population. Larger studies are required for the prospective validation of diagnostic models which may aid a fertility‐sparing approach to care. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Evaluating use of two‐step International Ovarian Tumor Analysis strategy to classify adnexal masses identified in pregnancy: pilot study

ABSTRACTObjectivesThe primary aim was to validate the International Ovarian Tumor Analysis (IOTA) benign simple descriptors (BDs) followed by the Assessment of Different NEoplasias in the adneXa (ADNEX) model, if BDs cannot be applied, in a two‐step strategy to classify adnexal masses identified during pregnancy. The secondary aim was to describe the natural history of adnexal masses during pregnancy.MethodsThis was a retrospective analysis of prospectively collected data from women with an adnexal mass identified on ultrasonography during pregnancy between 2017 and 2022 at Queen Charlotte's and Chelsea Hospital, London, UK. Clinical and ultrasound data were extracted from medical records and ultrasound software. Adnexal masses were classified and managed according to expert subjective assessment (SA). Borderline ovarian tumors (BOTs) were classified as malignant. BDs were applied retrospectively to classify adnexal masses, and if BDs were not applicable, the ADNEX model (using a risk‐ of‐malignancy threshold ≥ 10%) was used, in a two‐step strategy. The reference standard was histology (where available) or expert SA at the postnatal ultrasound scan.ResultsA total of 291 women with a median age of 33 (interquartile range (IQR), 29–36) years presented with an adnexal mass during pregnancy, at a median gestational age of 12 (IQR, 8–17) weeks. Of those, 267 (91.8%) were followed up to the postnatal period. Based on the reference standard, 4.1% (11/267) of adnexal masses were classified as malignant (all BOTs) and 95.9% (256/267) as benign. BDs were applicable in 68.9% (184/267) of adnexal masses; of these, only one (0.5%) BOT was misclassified as benign. The ADNEX model was used to classify the 83 residual masses and misclassified 3/10 (30.0%) BOTs as benign and 25/73 (34.2%) benign masses as malignant, of which 13/25 (52.0%) were classified as decidualized endometrioma on expert SA. The two‐step strategy had a specificity of 90.2%, sensitivity of 63.6%, negative predictive value of 98.3% and positive predictive value of 21.9%. A total of 56 (21.0%) women underwent surgical intervention: four (1.5%) as an emergency during pregnancy, four (1.5%) electively during Cesarean section and 48 (18.0%) postnatally. During follow‐up, 64 (24.0%) adnexal masses resolved spontaneously. Cyst‐related complications occurred in four (1.5%) women during pregnancy (ovarian torsion, n = 2; cyst rupture, n = 2) and six (2.2%) women in the postnatal period (all ovarian torsion). Overall, 196/267 (73.4%) women had a persistent adnexal mass at postnatal ultrasound. Presumed decidualization occurred in 31.1% (19/61) of endometriomas and had resolved in 89.5% (17/19) by the first postnatal ultrasound scan.ConclusionsBDs apply to most adnexal masses during pregnancy. However, the small number of malignant tumors in this cohort (4.1%) restricted the evaluation of the ADNEX model, so expert SA should be used to classify adnexal masses during pregnancy when BDs do not apply. A larger multicenter prospective study is required to evaluate the use of the ADNEX model to classify adnexal masses during pregnancy. Our data suggest that most adnexal masses can be managed expectantly during pregnancy, given the high rate of spontaneous resolution and low risk of complications. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Combination of Proactive Molecular Risk Classifier for Endometrial cancer (ProMisE) with sonographic and demographic characteristics in preoperative prediction of recurrence or progression of endometrial cancer

ABSTRACTObjectiveTo evaluate the ability of demographic and sonographic variables and the Proactive Molecular Risk Classifier for Endometrial cancer (ProMisE) classification to predict preoperatively tumor recurrence or progression in women with endometrial cancer.MethodsThe study included 339 women with histologically confirmed endometrial cancer who underwent expert transvaginal ultrasound in a single center before surgery as part of the prospective International Endometrial Tumor Analysis 4 study or who were evaluated using the same protocol. The tumors were classified according to histotype, FIGO (International Federation of Gynecology and Obstetrics) grade and FIGO stage. In addition, molecular analysis was performed for classification into the four ProMisE subtypes: polymerase‐ϵ exonuclease domain mutations (POLE EDM), mismatch repair proteins deficiency (MMR‐D), protein 53 wild type (p53 wt) and protein 53 abnormal (p53 abn). Demographic and preoperative sonographic characteristics, tumor recurrence or progression and survival were compared between the ProMisE subgroups. Cox regression analysis was used to identify prognostic factors associated with recurrence or progression, using univariable models to study crude associations and multivariable models to study adjusted associations. Logistic regression and receiver‐operating‐characteristics (ROC)‐curve analysis were used to assess the predictive ability of the preoperative prognostic factors regarding recurrence or progression of cancer within 3 years after surgery, and to compare their predictive ability to that of the European Society for Medical Oncology (ESMO) preoperative (based on depth of myometrial invasion, histotype and grade) and postoperative (based on histotype, grade, surgical stage and lymphovascular space invasion) risk classifications. In a separate subanalysis, cases were stratified according to ProMisE p53 abn status (present vs absent) and sonographic tumor size (anteroposterior (AP) diameter < 2 cm vs ≥ 2 cm).ResultsMedian follow‐up time from surgery was 58 months (interquartile range, 48–71 months; range, 0–102 months). Recurrence or progression of cancer occurred in 51/339 (15%) women, comprising 14% of those with MMR‐D, 8% of those with POLE EDM, 9% of those with p53 wt and 45% of those with p53 abn ProMisE subtype. On multivariable analysis, age, waist circumference, ProMisE subtype and tumor extension and AP diameter on ultrasound were associated with tumor recurrence or progression. A multivariable model comprising ProMisE subtype, age, waist circumference and sonographic tumor extension and size (area under the ROC curve (AUC), 0.89 (95% CI, 0.85–0.93)) had comparable ability to predict tumor recurrence/progression to that of a multivariable model comprising histotype, grade, age, waist circumference and sonographic tumor extension and size (AUC, 0.88 (95% CI, 0.83–0.92)), and better predictive ability than both the preoperative (AUC, 0.74 (95% CI, 0.67–0.82); P < 0.01) and postoperative (AUC, 0.79 (95% CI, 0.72–0.86); P < 0.01) ESMO risk classifications. Women with a combination of non‐p53 abn subtype and tumor size < 2 cm (164/339 (48%)) had a very low risk (1.8%) of tumor recurrence or progression.ConclusionsThe combination of demographic characteristics, sonographic findings and ProMisE subtype had better preoperative predictive ability for tumor recurrence or progression than did the ESMO classification, supporting their use in the preoperative risk stratification of women with endometrial cancer. The combination of p53 status with ultrasound tumor size has the potential to identify preoperatively a large group of women with a very low risk of recurrence or progression. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. ‐ Legal Statement: This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Ultrasound examiners' ability to describe ovarian cancer spread using preacquired ultrasound videoclips from a selected patient sample with high prevalence of cancer spread

ABSTRACTObjectivesTo assess the ability, as well as factors affecting the ability, of ultrasound examiners with different levels of ultrasound experience to detect correctly infiltration of ovarian cancer in predefined anatomical locations, and to evaluate the inter‐rater agreement regarding the presence or absence of cancer infiltration, using preacquired ultrasound videoclips obtained in a selected patient sample with a high prevalence of cancer spread.MethodsThis study forms part of the Imaging Study in Advanced ovArian Cancer multicenter observational study (NCT03808792). Ultrasound videoclips showing assessment of infiltration of ovarian cancer were obtained by the principal investigator (an ultrasound expert, who did not participate in rating) at 19 predefined anatomical sites in the abdomen and pelvis, including five sites that, if infiltrated, would indicate tumor non‐resectability. For each site, there were 10 videoclips showing cancer infiltration and 10 showing no cancer infiltration. The reference standard was either findings at surgery with histological confirmation or response to chemotherapy. For statistical analysis, the 19 sites were grouped into four anatomical regions: pelvis, middle abdomen, upper abdomen and lymph nodes. The videoclips were assessed by raters comprising both senior gynecologists (mainly self‐trained expert ultrasound examiners who perform preoperative ultrasound assessment of ovarian cancer spread almost daily) and gynecologists who had undergone a minimum of 6 months' supervised training in the preoperative ultrasound assessment of ovarian cancer spread in a gynecological oncology center. The raters were classified as highly experienced or less experienced based on annual individual caseload and the number of years that they had been performing ultrasound evaluation of ovarian cancer spread. Raters were aware that for each site there would be 10 videoclips with and 10 without cancer infiltration. Each rater independently classified every videoclip as showing or not showing cancer infiltration and rated the image quality (on a scale from 0 to 10) and their diagnostic confidence (on a scale from 0 to 10). A generalized linear mixed model with random effects was used to estimate which factors (including level of experience, image quality, diagnostic confidence and anatomical region) affected the likelihood of a correct classification of cancer infiltration. We assessed the observed percentage of videoclips classified correctly, the expected percentage of videoclips classified correctly based on the generalized linear mixed model and inter‐rater agreement (reliability) in classifying anatomical sites as being infiltrated by cancer.ResultsTwenty‐five raters participated in the study, of whom 13 were highly experienced and 12 were less experienced. The observed percentage of correct classification of cancer infiltration ranged from 70% to 100% depending on rater and anatomical site, and the median percentage of correct classification for the 25 raters ranged from 90% to 100%. The probability of correct classification of all 380 videoclips ranged from 0.956 to 0.975 and was not affected by the rater's level of ultrasound experience. The likelihood of correct classification increased with increased image quality and diagnostic confidence and was affected by anatomical region. It was highest for sites in the pelvis, second highest for those in the middle abdomen, third highest for lymph nodes and lowest for sites in the upper abdomen. The inter‐rater agreement of all 25 raters regarding the presence of cancer infiltration ranged from substantial (Fleiss kappa, 0.68 (95% CI, 0.66–0.71)) to very good (Fleiss kappa, 0.99 (95% CI, 0.97–1.00)) depending on the anatomical site. It was lowest for sites in the upper abdomen (Fleiss kappa, 0.68 (95% CI, 0.66–0.71) to 0.97 (95% CI, 0.94–0.99)) and highest for sites in the pelvis (Fleiss kappa, 0.94 (95% CI, 0.92–0.97) to 0.99 (95% CI, 0.97–1.00)).ConclusionsUltrasound examiners with different levels of ultrasound experience can classify correctly predefined anatomical sites as being infiltrated or not infiltrated by ovarian cancer based on video recordings obtained by an experienced ultrasound examiner, and the inter‐rater agreement is substantial. The likelihood of correct classification as well as the inter‐rater agreement is highest for sites in the pelvis and lowest for sites in the upper abdomen. However, owing to the study design, our results regarding diagnostic accuracy and inter‐rater agreement are likely to be overoptimistic. © 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.

Multiple pregnancy with complete hydatidiform mole and coexisting normal fetus: systematic review and meta‐analysis of clinical outcomes from non‐randomized studies

ABSTRACT Objective Complete hydatidiform mole and coexisting normal fetus (CHMCF) is a rare condition for which there is significant heterogeneity in diagnosis, counseling and management of complications. The objective of this study was to summarize the prevalence of clinical outcomes in reported cases of CHMCF. Methods A systematic literature search was conducted in PubMed, Embase and Scopus databases from inception until 1 October 2024. Case series and cohort studies including at least three cases of histologically confirmed CHMCF were included. A random‐effects model was used for meta‐analysis of proportions and heterogeneity was estimated using Higgins' I 2 index. The Newcastle–Ottawa scale and the Joanna Briggs Institute critical appraisal checklist were used to assess study quality, while certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The study was registered in the PROSPERO database (CRD42023431734). Results Quantitative synthesis included 19 studies and 417 cases of CHMCF. Diagnosis was made using ultrasound in 76.0% (95% CI, 58.5–90.6%) of cases and occurred in the first trimester in 52.7% (95% CI, 34.0–71.0%). Symptoms at diagnosis were present in 80.5% (95% CI, 66.1–92.3%) of cases, with vaginal bleeding being the most common symptom both at diagnosis and later in pregnancy. The pooled proportion of elective pregnancy termination was 48.8% (95% CI, 32.7–65.1%), with 6.2% (95% CI, 1.0–13.9%) due to maternal complications. The pooled proportion of live births was 46.5% (95% CI, 36.1–57.1%), with most being delivered by Cesarean section (71.2% (95% CI, 42.4–94.4%)). Preterm birth (< 37 weeks) occurred in 67.8% (95% CI, 44.7–88.1%) of cases, very preterm birth (< 32 weeks) in 12.4% (95% CI, 0.2–33.9%) and miscarriage (fetal death < 24 weeks) in 32.7% (95% CI, 26.1–39.6%). Pre‐eclampsia was present in 17.8% (95% CI, 5.9–32.7%) of cases and postpartum hemorrhage occurred in 42.7% (95% CI, 5.1–84.8%). A small‐for‐gestational‐age neonate (birth weight < 10 th percentile) was delivered in 40.6% (95% CI, 12.9–70.8%) of cases. Rates of neonatal and maternal mortality were negligible. The pooled proportion of gestational trophoblastic neoplasia was 33.8% (95% CI, 25.6–42.5%); among elective terminations, continued pregnancies and live births, the rates were 14.1% (95% CI, 5.4–24.9%), 20.3% (95% CI, 12.0–29.9%) and 5.9% (95% CI, 1.9–11.2%), respectively. The evidence level according to GRADE was low to very low. Conclusions Pregnancies with CHMCF present a high risk of maternal, obstetric and neonatal complications, including miscarriage, pre‐eclampsia, small‐for‐gestational age, postpartum hemorrhage and preterm birth. The risk of developing gestational trophoblastic neoplasia was not clearly mitigated by early pregnancy termination. Early diagnosis, referral to a maternal–fetal medicine unit with expertise in trophoblastic disorders and extensive implementation of screening protocols for preterm birth and pre‐eclampsia are recommended to facilitate timely intervention aimed at outcome improvement. © 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.

Magnetic resonance imaging and ultrasound examination in preoperative pelvic staging of early‐stage cervical cancer: post‐hoc analysis of SENTIX study

ABSTRACTObjectivesSENTIX was a prospective, single‐arm, international multicenter study that evaluated sentinel lymph node biopsy without pelvic lymph node dissection in patients with early‐stage cervical cancer. We aimed to evaluate the concordance between preoperative imaging modalities (magnetic resonance imaging (MRI) and ultrasound) and final pathology in the clinical staging of early‐stage cervical cancer by post‐hoc analysis of the SENTIX study data.MethodsIn total, 47 sites across 18 countries participated in the SENTIX study. Patients with Stage IA1/lymphovascular space invasion‐positive to IB2 (International Federation of Gynecology and Obstetrics (FIGO) classification (2018)) cervical cancer, with usual histological types and no suspicious lymph nodes on imaging, were prospectively enrolled between May 2016 and October 2020. Preoperative pelvic clinical staging on either pelvic MRI or ultrasound examination was mandatory. Tumor size discrepancy (< 10 mm vs ≥ 10 mm) between imaging and pathology, as well as the negative predictive value (NPV) of MRI and ultrasound for parametrial involvement and lymph node macrometastasis, were analyzed.ResultsAmong 690 eligible prospectively enrolled patients, MRI and ultrasound were used as the staging imaging modality in 322 (46.7%) and 298 (43.2%) patients, respectively. A discrepancy of tumor size ≥ 10 mm was reported between ultrasound and final pathology in 39/298 (13.1%) patients and between MRI and pathology in 53/322 (16.5%), with no significant difference in the accuracy of tumor measurement between the two imaging modalities. The NPV of ultrasound in assessing parametrial infiltration and lymph node involvement was 97.0% (95% CI, 0.95–0.99%) and 94.0% (95% CI, 0.91–0.97%), respectively, and that of MRI was 95.3% (95% CI, 0.93–0.98%) and 94.1% (95% CI, 0.92–0.97%), respectively, with no significant differences between the parameters. Ultrasound and MRI were comparable regarding the tumor size measurement (P = 0.452), failure to detect parametrial involvement (P = 0.624) and failure to detect macrometastases in sentinel lymph node (P = 0.876).ConclusionsPelvic ultrasound examination and MRI had similar concordance with histology in the assessment of tumor size and of parametrial and lymph node invasion in early‐stage cervical cancer. Ultrasound examination should be considered part of preoperative pelvic clinical staging in early‐stage cervical cancer, especially in limited‐resource regions where MRI is unavailable. © 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.

Radiomics analysis of ultrasound images to discriminate between benign and malignant adnexal masses with solid morphology on ultrasound

ABSTRACT Objective The primary aim was to identify radiomics ultrasound features that can distinguish between benign and malignant adnexal masses with solid ultrasound morphology, and between primary malignant (including borderline and primary invasive) and metastatic solid ovarian masses, and to develop ultrasound‐based machine learning models that include radiomics features to discriminate between benign and malignant solid adnexal masses. The secondary aim was to compare the discrimination performance of our newly developed radiomics models with that of the Assessment of Different NEoplasias in the adneXa (ADNEX) model and that of subjective assessment by an experienced ultrasound examiner. Methods This was a retrospective, observational single‐center study conducted at Fondazione Policlinico Universitario A. Gemelli IRCC, in Rome, Italy. Included were patients with a histological diagnosis of an adnexal tumor with solid morphology according to International Ovarian Tumor Analysis (IOTA) terminology at preoperative ultrasound examination performed in 2014–2020, who were managed with surgery. The patient cohort was split randomly into training and validation sets at a ratio of 70:30 and with the same proportion of benign and malignant tumors in the two subsets, with malignant tumors including borderline, primary invasive and metastatic tumors. We extracted 68 radiomics features, belonging to two different families: intensity‐based statistical features and textural features. Models to predict malignancy were built based on a random forest classifier, fine‐tuned using 5‐fold cross‐validation over the training set, and tested on the held‐out validation set. The variables used in model‐building were patient age and radiomics features that were statistically significantly different between benign and malignant adnexal masses and assessed as not redundant based on the Pearson correlation coefficient. We evaluated the discriminative ability of the models and compared it to that of the ADNEX model and that of subjective assessment by an experienced ultrasound examiner using the area under the receiver‐operating‐characteristics curve (AUC) and classification performance by calculating sensitivity and specificity. Results In total, 326 patients were included and 775 preoperative ultrasound images were analyzed. Of the 68 radiomics features extracted, 52 differed statistically significantly between benign and malignant tumors in the training set, and 18 uncorrelated features were selected for inclusion in model‐building. The same 52 radiomics features differed significantly between benign, primary malignant and metastatic tumors. However, the values of the features manifested overlapped between primary malignant and metastatic tumors and did not differ significantly between them. In the validation set, 25/98 (25.5%) tumors were benign and 73/98 (74.5%) were malignant (6 borderline, 57 primary invasive, 10 metastatic). In the validation set, a model including only radiomics features had an AUC of 0.80, sensitivity of 0.78 and specificity of 0.76 at an optimal cut‐off for risk of malignancy of 68%, based on Youden's index. The corresponding results for a model including age and radiomics features were AUC of 0.79, sensitivity of 0.86 and specificity of 0.56 (cut‐off 60%, based on Youden's index), while those of the ADNEX model were AUC of 0.88, sensitivity of 0.99 and specificity of 0.64 (at a 20% risk‐of‐malignancy cut‐off). Subjective assessment had a sensitivity of 0.99 and specificity of 0.72. Conclusions Our radiomics model had moderate discriminative ability on internal validation and the addition of age to this model did not improve its performance. Even though our radiomics models had discriminative ability inferior to that of the ADNEX model, our results are sufficiently promising to justify continued development of radiomics analysis of ultrasound images of adnexal masses. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Uterine fibroids and non‐informative cell‐free DNA screening results

ABSTRACTObjectiveUterine fibroids are monoclonal tumors, which are often genetically abnormal and associated with false‐positive genome‐wide cell‐free DNA (cfDNA) screening results, particularly when large. It is plausible that fibroids may also increase the risk of cfDNA failure by affecting fetal fraction or due to their genetic anomalies confounding cfDNA algorithms. We aimed to investigate a possible association between fibroids and cfDNA non‐informative results.MethodsThis was a retrospective cohort study of women undergoing cfDNA screening for fetal chromosomal abnormalities between 2013 and 2020, comparing pregnancies with vs without uterine fibroids recorded on any obstetric ultrasound before 24 weeks' gestation. Univariable and multivariable logistic regression models were used to investigate the association between fibroids and cfDNA failure, adjusting for gestational age, maternal age, weight and height at blood sampling, mode of conception, multiple gestation and test platform (chromosome‐selective or genome‐wide). Analyses were stratified according to the number of fibroids and total fibroid volume. The impact of fibroids on fetal fraction was assessed using linear regression, adjusting for the same covariates.ResultsAmong 19 818 pregnancies undergoing cfDNA screening, fibroids were reported in 2038 (10.28%) and cfDNA failure at the first screening attempt occurred in 228 (1.15%) pregnancies. Non‐informative results occurred in 1.96% of pregnancies with fibroids and 1.06% of pregnancies without fibroids (adjusted odds ratio (aOR), 2.40 (95% CI, 1.65–3.48)). The risk of failure in the first screening attempt increased progressively with the number of fibroids (aOR, 5.05 (95% CI, 2.29–11.13) in women with four or more fibroids) and total fibroid volume, with greater than a 5‐fold and 14‐fold increase in risk among women with fibroid volumes of 100.1–400 mL (aOR, 5.52 (95% CI, 2.30–13.25)) and > 400 mL (aOR, 14.80 (95% CI, 4.50–48.69)), respectively. Although test failure was more common with chromosome‐selective than genome‐wide screening, fibroids similarly increased the risk of failure of both screening platforms. Compared to pregnancies without fibroids, those with fibroids had a fetal fraction on average 0.61% lower (adjusted mean difference, −0.61% (95% CI, −0.77% to −0.45%)).ConclusionUterine fibroids are associated with lower fetal fraction and an increased risk of cfDNA screening failure. The strength of this association increases with increasing fibroid number and volume. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Whole‐genome paternal uniparental disomy identified through prenatal single‐nucleotide polymorphism‐based cell‐free DNA screening

ABSTRACT Objective Prenatal single‐nucleotide polymorphism (SNP)‐based cell‐free DNA (cfDNA) screening can identify genome‐wide paternal uniparental disomy (GW‐UPDpat), including cases with complete hydatidiform mole with a coexisting fetus (CHMCF), those with placental mesenchymal dysplasia (PMD) and those with a mosaic/chimeric GW‐UPDpat syndrome. Our objective was to review laboratory data and pregnancy outcome for SNP‐based cfDNA screening tests with results compatible with GW‐UPDpat and a normal cell line. Methods This was a retrospective study of all cfDNA screening results from a single commercial laboratory between June 2014 and November 2023 that were reported as twins or triploidy, with apparent GW‐UPDpat. Two‐dimensional representations of the relative ratios of SNP alleles (SNP plots) were used to identify and quantify the proportion of cfDNA from the mole (‘molar fraction’) and that from the coexisting non‐molar pregnancy (‘fetal fraction’). Test referral and follow‐up information, including ultrasound findings, laboratory testing and pregnancy outcome, were reviewed. Results Of 5 699 009 tests reviewed, 89 were reported as twins or triploidy, with apparent GW‐UPDpat. Retrospective review of SNP plots excluded 12 cases that were reinterpreted as triploidy with an extra set of paternal chromosomes. Of the remaining 77 cases, 24 had follow‐up pregnancy information available, and of these, 21 (87.5%) had ultrasound and/or pathology findings that were consistent with CHMCF. The fetal cfDNA fraction was often very low (≤ 2% in 28 cases). The molar cfDNA fraction was in the range of 10–58%. Fetal sex was male in 35 cases, female in 40 cases and uncertain in two cases. No case showed clear evidence of a Y‐chromosome in the GW‐UPDpat line. All 77 cases had isodisomy; none showed clear evidence of regions of heterodisomy. Conclusions SNP‐based cfDNA screening can help to identify CHMCF and distinguish between CHMCF and triploidy. For CHMCF, early detection is important for evaluating the risk of adverse outcome and gestational trophoblastic neoplasia. Some of our test‐positive cases could have included unrecognized PMD or mosaic/chimeric GW‐UPDpat syndrome. These preliminary observations do not allow assessment of the sensitivity or positive predictive value of this test. © 2025 Natera, Inc. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prospective external validation of IOTA methods for classifying adnexal masses and retrospective assessment of two‐step strategy using benign descriptors and ADNEX model: Portuguese multicenter study

ABSTRACTObjectivesTo externally and prospectively validate the International Ovarian Tumor Analysis (IOTA) Simple Rules (SRs), Logistic Regression model 2 (LR2) and Assessment of Different NEoplasias in the adneXa (ADNEX) model in a Portuguese population, comparing these approaches with subjective assessment and the risk‐of‐malignancy index (RMI), as well as with each other. This study also aimed to retrospectively validate the IOTA two‐step strategy, using modified benign simple descriptors (MBDs) followed by the ADNEX model in cases in which MBDs were not applicable.MethodsThis was a prospective multicenter diagnostic accuracy study conducted between January 2016 and December 2021 of consecutive patients with an ultrasound diagnosis of at least one adnexal tumor, who underwent surgery at one of three tertiary referral centers in Lisbon, Portugal. All ultrasound assessments were performed by Level‐II or ‐III sonologists with IOTA certification. Patient clinical data and serum CA 125 levels were collected from hospital databases. Each adnexal mass was classified as benign or malignant using subjective assessment, RMI, IOTA SRs, LR2 and the ADNEX model (with and without CA 125). The reference standard was histopathological diagnosis. In the second phase, all adnexal tumors were classified retrospectively using the two‐step strategy (MBDs + ADNEX). Sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios and overall accuracy were determined for all methods. Receiver‐operating‐characteristics curves were constructed and corresponding areas under the curve (AUC) were determined for RMI, LR2, the ADNEX model and the two‐step strategy. The ADNEX model calibration plots were constructed using locally estimated scatterplot smoothing (LOESS).ResultsOf the 571 patients included in the study, 428 had benign disease and 143 had malignant disease (prevalence of malignancy, 25.0%), of which 42 had borderline ovarian tumor, 93 had primary invasive adnexal cancer and eight had metastatic tumors in the adnexa. Subjective assessment had an overall sensitivity of 97.9% and a specificity of 83.6% for distinguishing between benign and malignant lesions. RMI showed high specificity (95.6%) but very low sensitivity (58.7%), with an AUC of 0.913. The IOTA SRs were applicable in 80.0% of patients, with a sensitivity of 94.8% and specificity of 98.6%. The IOTA LR2 had a sensitivity of 84.6%, specificity of 86.9% and an AUC of 0.939, at a malignancy risk cut‐off of 10%. At the same cut‐off, the sensitivity, specificity and AUC for the ADNEX model with vs without CA 125 were 95.8% vs 98.6%, 82.5% vs 79.7% and 0.962 vs 0.960, respectively. The ADNEX model gave heterogeneous results for distinguishing between benign masses and different subtypes of malignancy, with the highest AUC (0.991) for discriminating benign masses from primary invasive adnexal cancer Stages II–IV, and the lowest AUC (0.696) for discriminating primary invasive adnexal cancer Stage I from metastatic lesion in the adnexa. The calibration plot suggested underestimation of the risk by the ADNEX model compared with the observed proportion of malignancy. The MBDs were applicable in 26.3% (150/571) of cases, of which none was malignant. The two‐step strategy using the ADNEX model in the second step only, with and without CA 125, had AUCs of 0.964 and 0.961, respectively, which was similar to applying the ADNEX model in all patients.ConclusionsThe IOTA methods showed good‐to‐excellent performance in the Portuguese population, outperforming RMI. The ADNEX model was superior to other methods in terms of accuracy, but interpretation of its ability to distinguish between malignant subtypes was limited by sample size and large differences in the prevalence of tumor subtypes. The IOTA MBDs are reliable in identifying benign disease. The two‐step strategy comprising application of MBDs followed by the ADNEX model if MBDs are not applicable, is suitable for daily clinical practice, circumventing the need to calculate the risk of malignancy in all patients. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Estimating risk of endometrial malignancy and other intracavitary uterine pathology in women without abnormal uterine bleeding using IETA‐1 multinomial regression model: validation study

ABSTRACTObjectivesTo assess the ability of the International Endometrial Tumor Analysis (IETA)‐1 polynomial regression model to estimate the risk of endometrial cancer (EC) and other intracavitary uterine pathology in women without abnormal uterine bleeding.MethodsThis was a retrospective study, in which we validated the IETA‐1 model on the IETA‐3 study cohort (n = 1745). The IETA‐3 study is a prospective observational multicenter study. It includes women without vaginal bleeding who underwent a standardized transvaginal ultrasound examination in one of seven ultrasound centers between January 2011 and December 2018. The ultrasonography was performed either as part of a routine gynecological examination, during follow‐up of non‐endometrial pathology, in the work‐up before fertility treatment or before treatment for uterine prolapse or ovarian pathology. Ultrasonographic findings were described using IETA terminology and were compared with histology, or with results of clinical and ultrasound follow‐up of at least 1 year if endometrial sampling was not performed. The IETA‐1 model, which was created using data from patients with abnormal uterine bleeding, predicts four histological outcomes: (1) EC or endometrial intraepithelial neoplasia (EIN); (2) endometrial polyp or intracavitary myoma; (3) proliferative or secretory endometrium, endometritis, or endometrial hyperplasia without atypia; and (4) endometrial atrophy. The predictors in the model are age, body mass index and seven ultrasound variables (visibility of the endometrium, endometrial thickness, color score, cysts in the endometrium, non‐uniform echogenicity of the endometrium, presence of a bright edge, presence of a single dominant vessel). We analyzed the discriminative ability of the model (area under the receiver‐operating‐characteristics curve (AUC); polytomous discrimination index (PDI)) and evaluated calibration of its risk estimates (observed/expected ratio).ResultsThe median age of the women in the IETA‐3 cohort was 51 (range, 20–85) years and 51% (887/1745) of the women were postmenopausal. Histology showed EC or EIN in 29 (2%) women, endometrial polyps or intracavitary myomas in 1094 (63%), proliferative or secretory endometrium, endometritis, or hyperplasia without atypia in 144 (8%) and endometrial atrophy in 265 (15%) women. The endometrial sample had insufficient material in five (0.3%) cases. In 208 (12%) women who did not undergo endometrial sampling but were followed up for at least 1 year without clinical or ultrasound signs of endometrial malignancy, the outcome was classified as benign. The IETA‐1 model had an AUC of 0.81 (95% CI, 0.73–0.89, n = 1745) for discrimination between malignant (EC or EIN) and benign endometrium, and the observed/expected ratio for EC or EIN was 0.51 (95% CI, 0.32–0.82). The model was able to categorize the four histological outcomes with considerable accuracy: the PDI of the model was 0.68 (95% CI, 0.62–0.73) (n = 1532). The IETA‐1 model discriminated very well between endometrial atrophy and all other intracavitary uterine conditions, with an AUC of 0.96 (95% CI, 0.95–0.98). Including only patients in whom the endometrium was measurable (n = 1689), the model's AUC was 0.83 (95% CI, 0.75–0.91), compared with 0.62 (95% CI, 0.52–0.73) when using endometrial thickness alone to predict malignancy (difference in AUC, 0.21; 95% CI, 0.08–0.32). In postmenopausal women with measurable endometrial thickness (n = 848), the IETA‐1 model gave an AUC of 0.81 (95% CI, 0.71–0.91), while endometrial thickness alone gave an AUC of 0.70 (95% CI, 0.60–0.81) (difference in AUC, 0.11; 95% CI, 0.01–0.20).ConclusionThe IETA‐1 model discriminates well between benign and malignant conditions in the uterine cavity in patients without abnormal bleeding, but it overestimates the risk of malignancy. It also discriminates well between the four histological outcome categories. © 2023 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.

Ultrasound features of chromophobe renal cell carcinoma metastasized to ovary

Fusion imaging in preoperative assessment of extent of disease in patients with advanced ovarian cancer: feasibility and agreement with laparoscopic findings

ABSTRACTObjectivesFusion imaging is an emerging technique that combines real‐time ultrasound examination with images acquired previously using other modalities, such as computed tomography (CT), magnetic resonance imaging and positron emission tomography. The primary aim of this study was to evaluate the feasibility of fusion imaging in patients with suspicion of ovarian or peritoneal cancer. Secondary aims were: to compare the agreement of findings on fusion imaging, CT alone and ultrasound imaging alone with laparoscopic findings, in the assessment of extent of intra‐abdominal disease; and to evaluate the time required for the fusion imaging technique.MethodsPatients with clinical and/or radiographic suspicion of advanced ovarian or peritoneal cancer who were candidates for surgery were enrolled prospectively between December 2019 and September 2020. All patients underwent a CT scan and ultrasound and fusion imaging to evaluate the presence or absence of the following abdominal‐cancer features according to the laparoscopy‐based scoring model (predictive index value (PIV)): supracolic omental disease, visceral carcinomatosis on the liver, lesser omental carcinomatosis and/or visceral carcinomatosis on the lesser curvature of the stomach and/or spleen, involvement of the paracolic gutter(s) and/or anterior abdominal wall, involvement of the diaphragm and visceral carcinomatosis on the small and/or large bowel (regardless of rectosigmoid involvement). The feasibility of the fusion examination in these patients was evaluated. Agreement of each imaging method (ultrasound, CT and fusion imaging) with laparoscopy (considered as reference standard) was calculated using Cohen's kappa coefficient.ResultsFifty‐two patients were enrolled into the study. Fusion imaging was feasible in 51 (98%) of these patients (in one patient, it was not possible for technical reasons). Two patients were excluded because laparoscopy was not performed, leaving 49 women in the final analysis. Kappa values for CT, ultrasound and fusion imaging, using laparoscopy as the reference standard, in assessing the PIV parameters were, respectively: 0.781, 0.845 and 0.896 for the great omentum; 0.329, 0.608 and 0.847 for the liver surface; 0.472, 0.549 and 0.756 for the lesser omentum and/or stomach and/or spleen; 0.385, 0.588 and 0.795 for the paracolic gutter(s) and/or anterior abdominal wall; 0.385, 0.497 and 0.657 for the diaphragm; and 0.336, 0.410 and 0.469 for the bowel. The median time needed to perform the fusion examination was 20 (range, 10–40) min.ConclusionFusion of CT images and real‐time ultrasound imaging is feasible in patients with suspicion of ovarian or peritoneal cancer and improves the agreement with surgical findings when compared with ultrasound or CT scan alone. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Ovarian cancer as imitator of severe pre‐eclampsia: role of angiogenic factors

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

Ultrasound features of appendiceal adenoneuroendocrine carcinoma metastatic to ovaries

Ultrasound features of ovarian recurrence of medullary thyroid carcinoma

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.

Reaffirming microcystic ultrasound appearance of borderline ovarian tumors using three‐dimensional ‘silhouette’ rendering

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.

Performance of IOTA Simple Rules, Simple Rules risk assessment, ADNEX model and O‐RADS in differentiating between benign and malignant adnexal lesions in North American women

ABSTRACTObjectivesTo apply the International Ovarian Tumor Analysis (IOTA) Simple Rules (SR), the IOTA Simple Rules risk assessment (SRR), the IOTA Assessment of Different NEoplasias in the adneXa (ADNEX) model and the Ovarian‐Adnexal Reporting and Data System (O‐RADS) in the same cohort of North American patients and to compare their performance in preoperative discrimination between benign and malignant adnexal lesions.MethodsThis was a single‐center diagnostic accuracy study, performed between March 2018 and February 2021, which included 150 women with an adnexal lesion. Using the ADNEX model, lesions were classified prospectively, whereas the SR, SRR assessment and O‐RADS were applied retrospectively. Surgery with histological analysis was performed within 6 months of the ultrasound exam. Sensitivity and specificity were determined for each testing modality and the performance of the different modalities was compared.ResultsOf the 150 women, 110 (73.3%) had a benign ovarian tumor and 40 (26.7%) had a malignant tumor. The mean risk of malignancy generated by the ADNEX model without CA 125 was significantly higher in malignant vs benign lesions (63.3% vs 11.8%) and the area under the receiver‐operating‐characteristics curve (AUC) of the ADNEX model for differentiating between benign and malignant adnexal masses at the time of ultrasound examination was 0.937. The mean risk of malignancy generated by SRR assessment was also significantly higher in malignant vs benign lesions (74.1% vs 15.9%) and the AUC was 0.941. To compare the ADNEX model, SRR assessment and O‐RADS, the malignancy risk threshold was set at ≥ 10%. This cut‐off differentiates O‐RADS low‐risk categories (Category ≤ 3) from intermediate‐to‐high‐risk categories (Categories 4 and 5). At this cut‐off, the sensitivity of the ADNEX model was 97.5% (95% CI, 85.3%–99.9%) and the specificity was 63.6% (95% CI, 53.9%–72.4%), and, for the SRR model, the sensitivity was 100% (95% CI, 89.1%–100%) and the specificity was 51.8% (95% CI, 42.1%–61.4%). In the 113 cases to which the SR could be applied, the sensitivity was 100% (95% CI, 81.5%–100%) and the specificity was 95.6% (95% CI, 88.5%–98.6%). If the remaining 37 cases, which were inconclusive under SR, were designated ‘malignant’, the sensitivity remained at 100% but the specificity was reduced to 79.1% (95% CI, 70.1%–86.0%). The 150 cases fell into the following O‐RADS categories: 17 (11.3%) lesions in Category 2, 34 (22.7%) in Category 3, 66 (44.0%) in Category 4 and 33 (22.0%) in Category 5. There were no histologically proven malignant lesions in Category 2 or 3. There were 14 malignant lesions in Category 4 and 26 in Category 5. The sensitivity of O‐RADS using a malignancy risk threshold of ≥ 10% was 100% (95% CI, 89.1%–100.0%) and the specificity was 46.4% (95% CI, 36.9%–56.1%).ConclusionsWhen IOTA terms and techniques are used, the performance of IOTA models in a North American patient population is in line with published IOTA results in other populations. The IOTA SR, SRR assessment and ADNEX model and O‐RADS have similar sensitivity in the preoperative discrimination of malignant from benign pelvic tumors; however, the IOTA models have higher specificity and the algorithm does not require the use of magnetic resonance imaging. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Blue mass in pelvis: serous cystadenofibroma of peritoneum

Preoperative staging of ovarian cancer: comparison between ultrasound, CT and whole‐body diffusion‐weighted MRI (ISAAC study)

AbstractObjectivesTo compare the performance of transvaginal and transabdominal ultrasound with that of the first‐line staging method (contrast‐enhanced computed tomography (CT)) and a novel technique, whole‐body magnetic resonance imaging with diffusion‐weighted sequence (WB‐DWI/MRI), in the assessment of peritoneal involvement (carcinomatosis), lymph‐node staging and prediction of non‐resectability in patients with suspected ovarian cancer.MethodsBetween March 2016 and October 2017, all consecutive patients with suspicion of ovarian cancer and surgery planned at a gynecological oncology center underwent preoperative staging and prediction of non‐resectability with ultrasound, CT and WB‐DWI/MRI. The evaluation followed a single, predefined protocol, assessing peritoneal spread at 19 sites and lymph‐node metastasis at eight sites. The prediction of non‐resectability was based on abdominal markers. Findings were compared to the reference standard (surgical findings and outcome and histopathological evaluation).ResultsSixty‐seven patients with confirmed ovarian cancer were analyzed. Among them, 51 (76%) had advanced‐stage and 16 (24%) had early‐stage ovarian cancer. Diagnostic laparoscopy only was performed in 16% (11/67) of the cases and laparotomy in 84% (56/67), with no residual disease at the end of surgery in 68% (38/56), residual disease ≤ 1 cm in 16% (9/56) and residual disease > 1 cm in 16% (9/56). Ultrasound and WB‐DWI/MRI performed better than did CT in the assessment of overall peritoneal carcinomatosis (area under the receiver‐operating‐characteristics curve (AUC), 0.87, 0.86 and 0.77, respectively). Ultrasound was not inferior to CT (P = 0.002). For assessment of retroperitoneal lymph‐node staging (AUC, 0.72–0.76) and prediction of non‐resectability in the abdomen (AUC, 0.74–0.80), all three methods performed similarly. In general, ultrasound had higher or identical specificity to WB‐DWI/MRI and CT at each of the 19 peritoneal sites evaluated, but lower or equal sensitivity in the abdomen. Compared with WB‐DWI/MRI and CT, transvaginal ultrasound had higher accuracy (94% vs 91% and 85%, respectively) and sensitivity (94% vs 91% and 89%, respectively) in the detection of carcinomatosis in the pelvis. Better accuracy and sensitivity of ultrasound (93% and 100%) than WB‐DWI/MRI (83% and 75%) and CT (84% and 88%) in the evaluation of deep rectosigmoid wall infiltration, in particular, supports the potential role of ultrasound in planning rectosigmoid resection. In contrast, for the bowel serosal and mesenterial assessment, abdominal ultrasound had the lowest accuracy (70%, 78% and 79%, respectively) and sensitivity (42%, 65% and 65%, respectively).ConclusionsThis is the first prospective study to document that, in experienced hands, ultrasound may be an alternative to WB‐DWI/MRI and CT in ovarian cancer staging, including peritoneal and lymph‐node evaluation and prediction of non‐resectability based on abdominal markers of non‐resectability. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Terms, definitions and measurements to describe sonographic features of lymph nodes: consensus opinion from the Vulvar International Tumor Analysis (VITA) group

ABSTRACTIn centers with access to high‐end ultrasound machines and expert sonologists, ultrasound is used to detect metastases in regional lymph nodes from melanoma, breast cancer and vulvar cancer. There is, as yet, no international consensus on ultrasound assessment of lymph nodes in any disease or medical condition. The lack of standardized ultrasound nomenclature to describe lymph nodes makes it difficult to compare results from different ultrasound studies and to find reliable ultrasound features for distinguishing non‐infiltrated lymph nodes from lymph nodes infiltrated by cancer or lymphoma cells. The Vulvar International Tumor Analysis (VITA) collaborative group consists of gynecologists, gynecologic oncologists and radiologists with expertise in gynecologic cancer, particularly in the ultrasound staging and treatment of vulvar cancer. The work herein is a consensus opinion on terms, definitions and measurements which may be used to describe inguinal lymph nodes on grayscale and color/power Doppler ultrasound. The proposed nomenclature need not be limited to the description of inguinal lymph nodes as part of vulvar cancer staging; it can be used to describe peripheral lymph nodes in general, as well as non‐peripheral (i.e. parietal or visceral) lymph nodes if these can be visualized clearly. The association between the ultrasound features described here and histopathological diagnosis has not yet been established. VITA terms and definitions lay the foundations for prospective studies aiming to identify ultrasound features typical of metastases and other pathology in lymph nodes and studies to elucidate the role of ultrasound in staging of vulvar and other malignancies. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Influence of uterine fibroids on cell‐free DNA screening: important but not definitive

Linked article: This Correspondence comments on Rolnik et al. Click here to view the article.

Ultrasound morphometric and cytologic preoperative assessment of inguinal lymph‐node status in women with vulvar cancer: MorphoNode study

ABSTRACTObjectiveTo assess the accuracy of preoperative ultrasound examination for predicting lymph‐node (LN) status in patients with vulvar cancer.MethodsThis was a single‐institution retrospective observational study of all women with a histological diagnosis of vulvar cancer triaged to inguinal surgery within 30 days following ultrasound evaluation between December 2010 and January 2016. For each groin examined, 15 morphological and dimensional sonographic parameters associated with suspicion for LN involvement were examined. A morphometric ultrasound pattern (MUP) was expressed for each groin, classifying the inguinal LN status into five groups (normal; reactive‐but‐negative; minimally suspicious/probably negative; moderately suspicious; and highly suspicious/positive) according to subjective judgment, followed by stratification as positive or negative for metastasis according to morphometric binomial assessment (MBA). In cases of positive MBA, fine‐needle aspiration cytology was performed. Combining the information obtained from MUP and cytologic results, a binomial final overall assessment (FOA) was assigned for each groin. The final histology was considered as the reference standard. Comparison was performed between patients with negative and those with positive LNs on histology, and receiver‐operating‐characteristics curves were generated for statistically significant variables on univariate analysis, to evaluate their diagnostic ability to predict negative LN status.ResultsOf 144 patients included in the analysis, 87 had negative inguinal LNs and 57 had positive LNs on histology. A total of 256 groins were analyzed, of which 171 were negative and 85 showed at least one metastatic LN on histology. The following parameters showed the greatest accuracy, with the best balance between specificity and sensitivity, in predicting negative LN status: cortical (C) thickness of the dominant LN (cut‐off, 2.5 mm; sensitivity, 90.0%; specificity, 77.9%); short‐axis (S) length of the dominant LN (cut‐off, 8.4 mm; sensitivity, 63.9%; specificity, 90.6%); C/medulla (M) thickness ratio of the dominant LN (cut‐off, 1.2 mm; sensitivity, 70.4%; specificity, 91.5%), the combination of S length and C/M thickness ratio (sensitivity, 88.9%; specificity, 82.4%); and the FOA analysis (sensitivity, 85.9%; specificity, 84.2%).ConclusionsPreoperative ultrasound assessment, with or without the addition of cytology, has a high accuracy in assessing inguinal LN status in patients with vulvar cancer. In particular, the combination of two ultrasound parameters (S length and C/M thickness ratio) provided the greatest accuracy in discriminating between negative and positive LNs. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Association of uterine fibroids with late miscarriage: multicenter cohort study

ABSTRACTObjectiveTo investigate the correlation between the number, location and size of uterine fibroids and the incidence of late miscarriage during pregnancy.MethodsThis was a retrospective, multicenter cohort study of singleton pregnancies, with a live fetus at the first‐trimester ultrasound examination, without known genetic anomalies or major fetal defects, from January 2012 to December 2022. We assessed the impact of fibroids and their characteristics, identified on ultrasound imaging at 11 + 0 to 13 + 6 weeks, on the risk of late miscarriage occurring at 11 + 0 to 21 + 6 weeks. Fibroid number, location and size were investigated, and adjusted odds ratios (aORs) with 95% CIs were calculated using multiple logistic regression and propensity score analysis via inverse probability of treatment weighting (IPTW) to minimize confounding. Singleton pregnancies without uterine fibroids comprised the control group. We further calculated the adjusted absolute risk (aAR) for the control group and the adjusted risk differences (aRD) for the study groups.ResultsIn total, 31 355 singleton pregnancies were analyzed, of which 942 (3.0%) had uterine fibroids. Multiple logistic regression analysis showed that pregnancies with a single fibroid did not have higher odds for late miscarriage compared to those without fibroids (aOR, 1.2 (95% CI, 0.6–2.4)), but women with multiple fibroids did have higher odds of late miscarriage (aOR, 2.5 (95% CI, 1.0–6.2)). Similarly, multiple logistic regression analysis after IPTW did not find higher odds of late miscarriage in pregnancies with a single fibroid (aOR, 1.7 (95% CI, 0.9–3.0) and aRD, 0.7% (95% CI, −0.2 to 2.1%)) but revealed increased odds of late miscarriage in women with multiple fibroids (aOR, 2.9 (95% CI, 1.1–7.3) and aRD, 2.0% (95% CI, −0.6 to 9.7%)). Analysis of the location of single fibroids revealed that submucosal fibroids significantly increased the odds of late miscarriage by 4.7 times, while the presence of fibroids in other locations did not have a statistically significant association with late miscarriage. When we limited our study population to cases with submucosal and intramural fibroids, logistic regression showed no significant increase in the odds of miscarriage for a single fibroid (aOR, 1.8 (95% CI, 0.9–3.5) and aRD, 1.2% (95% CI, −0.1 to 3.1%)), but revealed significantly higher odds for multiple fibroids (aOR, 3.8 (95% CI, 1.4–10.6) and aRD, 5.1% (95% CI, 0.6–22.0%)) compared with controls. IPTW analysis found a 2.3‐fold increase in the odds of late miscarriage for a single fibroid (aOR, 2.3 (95% CI, 1.2–4.2)) and an even larger increase in the odds of late miscarriage for multiple fibroids (aOR, 5.7 (95% CI, 2.2–15.1)).ConclusionUterine fibroids are associated with increased odds of late miscarriage, particularly when they are multiple and submucosal. © 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.

Role of ultrasound in detection of lymph‐node metastasis in gynecological cancer: systematic review and meta‐analysis

ABSTRACTObjectiveTo assess the diagnostic performance of transvaginal sonography (TVS) for the preoperative evaluation of lymph‐node metastasis in gynecological cancer.MethodsThis was a systematic review and meta‐analysis of studies published between January 1990 and May 2023 evaluating the role of ultrasound in detecting pelvic lymph‐node metastasis (index test) in gynecological cancer, using histopathological analysis as the reference standard. The quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies‐2 tool. Pooled sensitivity, specificity and diagnostic odds ratio were estimated.ResultsThe literature search identified 2638 citations. Eight studies reporting on a total of 967 women were included. The mean prevalence of pelvic lymph‐node metastasis was 24.2% (range, 14.0–65.6%). The risk of bias was low for most domains assessed. Pooled sensitivity, specificity and diagnostic odds ratio of TVS were 41% (95% CI, 26–58%), 98% (95% CI, 93–99%) and 32 (95% CI, 14–72), respectively. High heterogeneity was found between studies for both sensitivity and specificity.ConclusionTVS showed a high pooled specificity for the detection of pelvic lymph‐node metastasis in gynecological cancer, but pooled sensitivity was low. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

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.

Radiomics‐based ultrasOund Model for differentiating Uterine Sarcomas from leiomyomas ( ROMUS ): a retrospective pilot Multicenter Italian Trials in Ovarian Cancer ( MITO ) study

ABSTRACT Objective To develop machine‐learning models that incorporate clinical information and radiomics features extracted from ultrasound images to distinguish uterine sarcomas from leiomyomas. Methods This retrospective, multicenter, pilot case–control study included 200 patients (100 with a uterine sarcoma and 100 with a usual‐type leiomyoma, i.e. including no benign leiomyoma variants) who underwent preoperative ultrasound examination between January 2010 and June 2022. The patient cohort was split (70:30) into training and validation sets, with the same proportion of leiomyomas and sarcomas in each subset. We extracted radiomics features belonging to different families: intensity‐based statistical features and textural features. The variables used in model building were patient age and the radiomics features that differed statistically significantly between sarcomas and leiomyomas and that were not redundant based on Spearman's correlation coefficient. Logistic regression, random forest, extreme gradient boosting (XGBoost) and support vector machine models were tested in the model development process. We evaluated the performance of the models in differentiating between sarcomas and leiomyomas using the area under the receiver‐operating‐characteristics curve (AUC), accuracy, sensitivity and specificity. We compared these results to those of subjective assessment by the original ultrasound examiner and to those of two independent expert ultrasound examiners who, blinded to clinical history, reviewed the same grayscale ultrasound images as those used for the radiomics analysis. Results Sixty‐three radiomics features were extracted. Of these, eight differed statistically significantly between sarcomas and leiomyomas and were not correlated, so were selected for inclusion in model building. In the validation set, the model that performed best in differentiating between sarcomas and leiomyomas was an XGBoost model integrating patient age and radiomics features. In the validation set, this model had an AUC of 0.93, sensitivity of 0.93 and specificity of 0.83, at a risk‐of‐malignancy cut‐off of 47% (the cut‐off that yielded the highest number of correct classifications based on Youden's index in the training set). The corresponding results for the model integrating only the radiomics features were: AUC of 0.87, sensitivity of 0.87 and specificity of 0.83. Subjective assessment by the original ultrasound examiner had a sensitivity of 0.87 and specificity of 1 in the validation set, while retrospective review of grayscale ultrasound images by ultrasound experts had a sensitivity of 0.87 and specificity of 0.80 (same results for both reviewers). Conclusion A model including eight radiomics features and patient age demonstrated reasonably good discriminative and classification performance for distinguishing uterine sarcomas from leiomyomas. Its classification ability was similar to that of subjective assessment by the original ultrasound examiner, being more sensitive but less specific. To confirm the role of radiomics for discriminating between uterine sarcomas and leiomyomas, large prospective studies including benign leiomyoma variants are needed. If good performance of radiomics models can be confirmed, integrating automated radiomics analysis into ultrasound machine software may help ultrasound examiners to discriminate between sarcomas and benign leiomyomas. © 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.

Ultrasound appearance of decidualized non‐ovarian endometriotic lesions during pregnancy and after delivery

ABSTRACT Objective To evaluate the changes in the ultrasound characteristics of decidualized non‐ovarian endometriotic lesions that occur during pregnancy and after delivery. Methods This was a prospective observational cohort study carried out at a single tertiary center between December 2018 and October 2021. Pregnant women with endometriosis underwent a standardized transvaginal ultrasound examination with color Doppler imaging once in every trimester and after delivery. Non‐ovarian endometriotic lesions were measured and evaluated by subjective semiquantitative assessment of blood flow. Lesions with moderate‐to‐marked blood flow were considered decidualized. The size and vascularization of decidualized and non‐decidualized lesions were compared between the gravid state and after delivery. Only patients with non‐ovarian endometriotic lesion(s) who underwent postpartum examination were included in the final analysis. Results Overall, 26 pregnant women with a surgical or sonographic diagnosis of endometriosis made prior to conception were invited to participate in the study, of whom 24 were recruited. Of those, 13 women with non‐ovarian endometriosis who attended the postpartum examination were included. In 7/13 (54%) cases, the lesion(s) were decidualized. In 4/7 (57%) women with decidualized lesion(s), the size of the largest lesion increased during pregnancy, while in 3/7 (43%), the size was unchanged. The size of non‐decidualized lesions did not change during pregnancy. On postpartum examination, only seven lesions were observed, of which three were formerly decidualized and four were formerly non‐decidualized. Lesions that were detected after delivery appeared as typical endometriotic nodules and were smaller compared with during pregnancy. The difference in maximum diameter between the gravid and postpartum states was statistically significant in decidualized lesions ( P  < 0.01), but not in non‐decidualized lesions ( P  = 0.09). The reduction in mean diameter was greater in decidualized compared with non‐decidualized lesions ( P  = 0.03). Conclusions Decidualization was observed in 54% of women with non‐ovarian endometriotic lesion(s) and resolved after delivery. Our findings suggest that the sonographic features of decidualization, which might mimic malignancy, are pregnancy‐related and that expectant management and careful monitoring should be applied in these cases. Clinicians should be aware of the changes observed during pregnancy to avoid misdiagnosing decidualized lesions as malignancy and performing unnecessary surgery. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of 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.

Standardized IETA criteria enhance accuracy of junior and intermediate ultrasound radiologists in diagnosing malignant endometrial and intrauterine lesions

ABSTRACTObjectivesTo transform the standardized descriptions of the ultrasound characteristics of endometrial and intrauterine lesions devised by the International Endometrial Tumor Analysis (IETA) group into a practical scoring method and to investigate whether application of this method enhances the diagnostic accuracy of ultrasound radiologists with different levels of experience in detecting malignancy compared with subjective assessment.MethodsThis was a retrospective study of 855 patients with endometrial and/or intrauterine lesions, who were divided into a training (n = 600) and a validation (n = 255) set. Ultrasound radiologists with varying levels of experience (expert, intermediate and junior) evaluated all lesions by subjective assessment and according to IETA rules. Using IETA rules, the experts identified signs of malignancy in the training set, assigned scores for each indicator and validated the scoring method in the validation set. The intermediate‐level and junior ultrasound radiologists reassessed the malignancy of the lesions using the IETA scoring method and compared their classifications with those made previously by subjective assessment. Postsurgical pathological evaluation was used as the reference standard.ResultsUsing subjective assessment, the experts demonstrated the highest level of diagnostic accuracy, with a sensitivity of 85.0%, specificity of 94.3% and an area under the receiver‐operating‐characteristics curve (AUC) of 0.897. Applying the IETA scoring method (comprising eight ultrasound characteristics that contributed to the total score) with a threshold of > 25 points for the diagnosis of malignancy achieved a sensitivity of 84.7%, specificity of 94.7% and AUC of 0.9533 in the training set, with similar performance in the validation set, when performed by experts. Using the IETA scoring method, both junior and intermediate ultrasound radiologists showed improvement in sensitivity (from 55.5% to 74.8% and from 70.2% to 77.1%, respectively), specificity (from 88.4% to 91.5% and from 87.4% to 92.2%, respectively) and AUC (from 0.704 to 0.827 and from 0.793 to 0.841, respectively) for diagnosing malignant lesions.ConclusionsThe IETA scoring method exhibits high diagnostic efficacy for malignant endometrial and intrauterine lesions. This method compensates for the lack of experience among junior and intermediate‐level ultrasound radiologists, enhancing their diagnostic skill to a level nearing that of experienced senior ultrasound radiologists. Further research is essential to validate the practicality of implementing this method and to confirm its clinical value. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Prospective geographical and temporal validation of three published mathematical models to calculate risk of endometrial malignancy in patients with postmenopausal bleeding

Diagnostic performance of transvaginal ultrasound and magnetic resonance imaging for preoperative evaluation of low‐grade endometrioid endometrial carcinoma: prospective comparative study

ABSTRACTObjectiveTo compare the diagnostic performance of transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) in the prediction of deep myometrial invasion (DMI) and cervical stromal invasion (CSI) in patients with low‐grade (Grade 1 or 2) endometrioid endometrial cancer (EEC).MethodsThis was a prospective study including all patients with low‐grade EEC diagnosed between October 2013 and July 2018 at the Vall d'Hebron Hospital in Barcelona, Spain. Preoperative staging was performed using TVS and MRI, followed by surgical staging. Final histology was considered as the reference standard. Sensitivity, specificity, likelihood ratios and diagnostic accuracy were calculated for both imaging techniques in the prediction of DMI and CSI, and the agreement index was calculated for both techniques. The STARD 2015 guidelines were followed.ResultsA total of 131 patients with low‐grade EEC were included consecutively. Sensitivity was higher for TVS than for MRI both for the prediction of DMI (69% (95% CI, 53–82%) vs 51% (95% CI, 36–66%), respectively) and CSI (43% (95% CI, 27–61%) vs 24% (95% CI, 12–41%), respectively). Specificity was similar for TVS and MRI in the prediction of DMI (87% (95% CI, 78–93%) vs 91% (95% CI, 82–96%)) and equal in the prediction of CSI (97% (95% CI, 91–99%) for both). The agreement index between TVS and MRI was 0.84 (95% CI, 0.76–0.90) for DMI and 0.92 (95% CI, 0.85–0.96) for CSI.ConclusionsThe diagnostic performance of TVS is similar to that of MRI for the prediction of DMI and CSI in low‐grade EEC, and TVS can play a role as a first‐line imaging technique in the preoperative evaluation of low‐grade EEC. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound‐based radiomics features: a gain or loss for risk stratification in patients with endometrial cancer

Linked article: This Correspondence comments on Moro et al. Click here to view the article.

Efficacy of transrectal ultrasound in assessing endometrium of postmenopausal women with axial uterus

ABSTRACTObjectiveTo evaluate the acceptance and efficacy of transrectal ultrasound (TRS) in assessing the endometrium in postmenopausal women with an axial uterus.MethodsThis was a prospective cross‐sectional study conducted between October 2015 and October 2018 of consecutive postmenopausal women with an axial uterus on transvaginal ultrasound (TVS). Women with a known diagnosis of gynecological malignancy were excluded. TRS was offered immediately after TVS without prior bowel preparation. A single operator determined subjectively whether the endometrium was visualized satisfactorily on TVS and TRS. In women with postmenopausal bleeding (PMB), endometrial thickness (ET) was measured and endometrial morphology was categorized as atrophic, uniformly thickened, benign endometrial polyp or endometrial cancer, based on subjective pattern recognition. All women with PMB and a non‐atrophic endometrium underwent outpatient endometrial biopsy, hysteroscopy or hysterectomy. The success rate of TRS in assessing satisfactorily the endometrium was compared with that of TVS. In patients with PMB, ET measurements and subjective diagnosis of endometrial cancer on TVS vs TRS were compared.ResultsOf the 1553 women who underwent TVS examination, 103 (6.6%) had an axial uterus, of whom 76 (73.8%) presented with PMB. TRS was accepted by 66/103 (64.1%) women with an axial uterus. TRS assessed satisfactorily a significantly higher proportion of endometria compared with TVS (90.9% vs 62.1%; χ2 = 14.1, P < 0.001). In 50 women with PMB and an axial uterus who underwent both TVS and TRS, TVS failed to visualize the endometrium satisfactorily in 15 (30.0%) women, whilst TRS provided satisfactory images in all cases. Among the 35 women with PMB and a satisfactory endometrial assessment on TVS and TRS, measurements of ET on TRS were significantly lower compared to those on TVS (median difference, −1.2 (interquartile range, −3.0 to −0.4) mm). The overall agreement of TVS and TRS on the presence or absence of endometrial cancer using subjective pattern recognition was 30/35 (85.7%; 95% CI, 74.1–97.3%). While all seven cases of histologically confirmed endometrial cancer were diagnosed correctly on TRS, four were misdiagnosed on TVS as benign polyps or uniformly thickened endometrium.ConclusionsTRS is an acceptable and effective way to assess the endometrium in postmenopausal women with an axial uterus. Among women presenting additionally with PMB, TRS is associated with a higher proportion of satisfactory endometrial assessments and fewer misdiagnoses of endometrial cancer by subjective pattern recognition compared with TVS. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Developing and validating ultrasound‐based radiomics models for predicting high‐risk endometrial cancer

AbstractObjectivesThe primary aim of this study was to develop and validate radiomics models, applied to ultrasound images, capable of differentiating from other cancers high‐risk endometrial cancer, as defined jointly by the European Society for Medical Oncology, European Society of Gynaecological Oncology and European Society for Radiotherapy & Oncology (ESMO‐ESGO‐ESTRO) in 2016. The secondary aim was to develop and validate radiomics models for differentiating low‐risk endometrial cancer from other endometrial cancers.MethodsThis was a multicenter, retrospective, observational study. From two participating centers, we identified consecutive patients with histologically confirmed diagnosis of endometrial cancer who had undergone preoperative ultrasound examination by an experienced examiner between 2016 and 2019. Patients recruited in Center 1 (Rome) were included as the training set and patients enrolled in Center 2 (Milan) formed the external validation set. Radiomics analysis (extraction of a high number of quantitative features from medical images) was applied to the ultrasound images. Clinical (including preoperative biopsy), ultrasound and radiomics features that were statistically significantly different in the high‐risk group vs the other groups and in the low‐risk group vs the other groups on univariate analysis in the training set were considered for multivariate analysis and for developing ultrasound‐based machine‐learning risk‐prediction models. For discriminating between the high‐risk group and the other groups, a random forest model from the radiomics features (radiomics model), a binary logistic regression model from clinical and ultrasound features (clinical‐ultrasound model) and another binary logistic regression model from clinical, ultrasound and previously selected radiomics features (mixed model) were created. Similar models were created for discriminating between the low‐risk group and the other groups. The models developed in the training set were tested in the validation set. The performance of the models in discriminating between the high‐risk group and the other groups, and between the low‐risk group and the other risk groups for both validation and training sets was compared.ResultsThe training set comprised 396 patients and the validation set 102 patients. In the validation set, for predicting high‐risk endometrial cancer, the radiomics model had an area under the receiver‐operating‐characteristics curve (AUC) of 0.80, sensitivity of 58.7% and specificity of 85.7% (using the optimal risk cut‐off of 0.41); the clinical‐ultrasound model had an AUC of 0.90, sensitivity of 80.4% and specificity of 83.9% (using the optimal cut‐off of 0.32); and the mixed model had an AUC of 0.88, sensitivity of 67.3% and specificity of 91.0% (using the optimal cut‐off of 0.42). For the prediction of low‐risk endometrial cancer, the radiomics model had an AUC of 0.71, sensitivity of 65.0% and specificity of 64.5% (using the optimal cut‐off of 0.38); the clinical‐ultrasound model had an AUC of 0.85, sensitivity of 70.0% and specificity of 80.6% (using the optimal cut‐off of 0.46); and the mixed model had an AUC of 0.85, sensitivity of 87.5% and specificity of 72.5% (using the optimal cut‐off of 0.36).ConclusionsRadiomics seems to have some ability to discriminate between low‐risk endometrial cancer and other endometrial cancers and better ability to discriminate between high‐risk endometrial cancer and other endometrial cancers. However, the addition of radiomics features to the clinical‐ultrasound models did not result in any notable increase in performance. Other efficacy studies and further effectiveness studies are needed to validate the performance of the models. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Two‐dimensional transvaginal sonography vs saline contrast sonohysterography for diagnosing endometrial polyps: systematic review and meta‐analysis

ABSTRACTObjectiveTo compare the diagnostic performance of two‐dimensional transvaginal sonography (TVS) and saline contrast sonohysterography (SCSH) for the diagnosis of endometrial polyps in studies that used both tests in the same group of patients.MethodsThis was a systematic review and meta‐analysis. An extensive search was conducted of Medline (PubMed), Cochrane Library and Web of Science, for studies comparing the diagnostic performance of TVS and SCSH for identifying endometrial polyps, published between January 1990 and December 2019, that reported a definition of endometrial polyp on TVS and SCSH and used pathologic analysis as the reference standard. Quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies‐2 (QUADAS‐2) tool. A random‐effects model was used to determine pooled sensitivity, specificity and positive and negative likelihood ratios of TVS and SCSH in the detection of endometrial polyps. Subanalysis according to menopausal status was performed.ResultsIn total, 1278 citations were identified; after exclusions, 25 studies were included in the meta‐analysis. In the included studies, the risk of bias evaluated using QUADAS‐2 was low for most of the four domains, except for flow and timing, which had an unclear risk of bias in 13 studies. Pooled sensitivity, specificity and positive and negative likelihood ratios for TVS in the detection of endometrial polyps were 55.0% (95% CI, 46.0–64.0%), 91.0% (95% CI, 86.0–94.0%), 5.8 (95% CI, 3.9–8.7) and 0.5 (95% CI, 0.41–0.61), respectively. The corresponding values for SCSH were 92.0% (95% CI, 87.0–95.0%), 93.0% (95% CI, 91.0–95.0%), 13.9 (95% CI, 9.9–19.5) and 0.08 (95% CI, 0.05–0.14), respectively. Significant differences were found when comparing the methods in terms of sensitivity (P < 0.001), but not for specificity (P = 0.0918). Heterogeneity was high for TVS and moderate for SCSH. On subanalysis according to menopausal status, SCSH was found to have higher diagnostic accuracy in both pre‐ and postmenopausal women; sensitivity and specificity did not differ significantly between the groups for either TVS or SCSH.ConclusionGiven that SCSH has better diagnostic positive and negative likelihood ratios than does TVS in both pre‐ and postmenopausal women, those with clinical suspicion of endometrial polyps should undergo SCSH if TVS findings are inconclusive. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

Ultrasound diagnosis of endometrial cancer by subjective pattern recognition in women with postmenopausal bleeding: prospective inter‐rater agreement and reliability study

ABSTRACTObjectivesTo assess the inter‐rater agreement and reliability of using subjective pattern recognition for diagnosing endometrial cancer (EC) on ultrasound in women with postmenopausal bleeding (PMB).MethodsThis was a prospective cross‐sectional study conducted at a gynecological rapid‐access clinic, between October 2016 and December 2017, in which consecutive women with PMB and endometrial thickness of ≥ 4.5 mm on transvaginal ultrasound examination were included. Women on hormone replacement therapy or tamoxifen and those with a history of primary gynecological malignancy were excluded. Two raters independently performed ultrasound examinations, blinded to each other's findings, and classified women as having uniformly thickened endometrium, benign endometrial polyp or EC, using subjective pattern recognition. Inter‐rater reliability of ultrasound diagnosis was assessed using Cohen's kappa (κ) statistic. All women subsequently underwent either outpatient endometrial biopsy, hysteroscopy or hysterectomy.ResultsForty women were included in the study, with a median age of 61 (interquartile range (IQR), 57–69) years and a median endometrial thickness of 11.0 (IQR, 6.2–20.3) mm. Final histological analysis confirmed 16 (40%) women with EC, 16 (40%) with benign endometrial polyp, four (10%) with atrophic endometrium, three (8%) with proliferative endometrium and one (3%) with endometrial hyperplasia. Inter‐rater agreement for the ultrasound diagnoses of uniformly thickened endometrium, benign endometrial polyp and EC was 14/16 (87.5%), 22/30 (73.3%) and 28/34 (82.4%), respectively; inter‐rater reliability was good (κ = 0.69; 95% CI, 0.49–0.88). When the ultrasound diagnoses were grouped as either cancer or no cancer, inter‐rater agreement was 85% and inter‐rater reliability was good (κ = 0.78; 95% CI, 0.61–0.95). Rater A correctly identified 14/16 cases of EC and Rater B identified 15/16. EC was misdiagnosed as benign polyps on ultrasound in two women by Rater A and in one woman by Rater B. The overall accuracies of Rater A and Rater B in differentiating between benign endometrial pathologies and malignancy were 90% and 90%, respectively.ConclusionsOur results show good inter‐rater reliability of subjective pattern recognition in diagnosing uniformly thickened endometrium, benign endometrial polyp and EC on ultrasound in women with PMB. Our findings should facilitate wider use of subjective pattern recognition in routine clinical practice. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound‐based risk model for preoperative prediction of lymph‐node metastases in women with endometrial cancer: model‐development study

ABSTRACTObjectiveTo develop a preoperative risk model, using endometrial biopsy results and clinical and ultrasound variables, to predict the individual risk of lymph‐node metastases in women with endometrial cancer.MethodsA mixed‐effects logistic regression model for prediction of lymph‐node metastases was developed in 1501 prospectively included women with endometrial cancer undergoing transvaginal ultrasound examination before surgery, from 16 European centers. Missing data, including missing lymph‐node status, were imputed. Discrimination, calibration and clinical utility of the model were evaluated using leave‐center‐out cross validation. The predictive performance of the model was compared with that of risk classification from endometrial biopsy alone (high‐risk defined as endometrioid cancer Grade 3/non‐endometrioid cancer) or combined endometrial biopsy and ultrasound (high‐risk defined as endometrioid cancer Grade 3/non‐endometrioid cancer/deep myometrial invasion/cervical stromal invasion/extrauterine spread).ResultsLymphadenectomy was performed in 691 women, of whom 127 had lymph‐node metastases. The model for prediction of lymph‐node metastases included the predictors age, duration of abnormal bleeding, endometrial biopsy result, tumor extension and tumor size according to ultrasound and undefined tumor with an unmeasurable endometrium. The model's area under the curve was 0.73 (95% CI, 0.68–0.78), the calibration slope was 1.06 (95% CI, 0.79–1.34) and the calibration intercept was 0.06 (95% CI, –0.15 to 0.27). Using a risk threshold for lymph‐node metastases of 5% compared with 20%, the model had, respectively, a sensitivity of 98% vs 48% and specificity of 11% vs 80%. The model had higher sensitivity and specificity than did classification as high‐risk, according to endometrial biopsy alone (50% vs 35% and 80% vs 77%, respectively) or combined endometrial biopsy and ultrasound (80% vs 75% and 53% vs 52%, respectively). The model's clinical utility was higher than that of endometrial biopsy alone or combined endometrial biopsy and ultrasound at any given risk threshold.ConclusionsBased on endometrial biopsy results and clinical and ultrasound characteristics, the individual risk of lymph‐node metastases in women with endometrial cancer can be estimated reliably before surgery. The model is superior to risk classification by endometrial biopsy alone or in combination with ultrasound. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Dynamic contrast‐enhanced ultrasound improves diagnostic performance in endometrial cancer staging

ABSTRACTObjectivesTo compare the sensitivity and specificity of conventional two‐dimensional transvaginal ultrasound/power Doppler (2D‐TVU/PD) alone and 2D‐TVU/PD combined with dynamic contrast‐enhanced ultrasound (DCE‐US) in diagnosing deep myometrial invasion (MI) and cervical stromal involvement (CSI) in women with endometrial cancer (EC), and to assess the association of DCE‐US semiquantitative and qualitative variables with International Federation of Gynecology and Obstetrics (FIGO) Stage ≥ IB and ‘high‐risk’ cancer.MethodsThis was a prospective study of 101 consecutive women with biopsy‐confirmed EC, undergoing expert ultrasound examination at Karolinska University Hospital, a tertiary referral center. All consenting women underwent DCE‐US using a 1.5–2.5‐mL intravenous bolus of SonoVue contrast agent, as well as conventional 2D‐TVU/PD examination. DCE‐US videoclips were analyzed with regard to filling (global or focal), wash‐in (prior, simultaneous or after) and wash‐out (global or focal) patterns of the contrast agent in the tumor compared with the surrounding tissue, as well as semiquantitative DCE‐US parameters (wash‐in slope, time‐to‐peak, peak intensity and area under the time–intensity curve (TIC)) obtained from a TIC. The study cohort was compared with a control cohort of women with EC examined at our center according to the International Endometrial Tumor Analysis protocol using 2D‐TVU/PD only, matched at a ratio of 3:1 for FIGO stage and grade. The sensitivity and specificity of 2D‐TVU/PD alone in the control cohort and in combination with DCE‐US in the study cohort in the diagnosis of deep MI, CSI and high‐risk cancer (defined as FIGO Stage ≥ IB and/or Grade 3 endometrioid and/or non‐endometrioid histology) were compared, using pathological evaluation after hysterectomy as the ‘gold standard’.ResultsAfter exclusions, 93 women were included in the study cohort and were matched to 279 women in the control cohort. The prevalence of FIGO Stage IA, Grade 1–2 EC was 52% in both cohorts. The sensitivity of 2D‐TVU/PD with DCE‐US in the study cohort was higher than that of 2D‐TVU/PD alone in the control cohort in diagnosing both deep MI (0.74 vs 0.62; P = 0.036) and CSI (0.75 vs 0.51; P < 0.001), whereas the specificity was not significantly different (0.87 vs 0.85 and 0.96 vs 0.95, respectively). Compared with 2D‐TVU/PD alone, the specificity of 2D‐TVU/PD with DCE‐US was higher in detecting high‐risk cancer (0.94 vs 0.85; P = 0.024) but the sensitivity did not differ (0.73 vs 0.71). High‐risk cancer and FIGO Stage ≥ IB were characterized by a ‘focal’ filling pattern, with a ‘prior’ wash‐in pattern and a ‘focal’ wash‐out pattern on subjective assessment of DCE‐US videoclips. All semiquantitative DCE‐US parameters were significantly predictive of FIGO Stage ≥ IB but not of high‐risk cancer, despite a clear trend.ConclusionsCompared with 2D‐TVU/PD alone, combining 2D‐TVU/PD with DCE‐US can significantly improve the detection of deep MI and CSI in women with EC, without increasing the false‐positive rate. It can also improve the correct classification of high‐risk disease, mainly by increasing specificity, thereby possibly reducing the number of unnecessarily extensive surgeries by almost 10%. Semiquantitative DCE‐US parameters, as well as a ‘focal’ filling pattern, endometrial wash‐in prior to the myometrium and a ‘focal’ wash‐out pattern, are all associated with more advanced disease. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Long‐term outcome of postmenopausal women with non‐atypical endometrial hyperplasia on endometrial sampling

ABSTRACTObjectiveTo assess the long‐term outcome of postmenopausal women diagnosed with non‐atypical endometrial hyperplasia (NEH).MethodsThis was a retrospective study of women aged 55 or older who underwent endometrial sampling in our academic medical center between 1997 and 2008. Women who had a current or recent (< 2 years) histological diagnosis of NEH were included in the study group and were compared with those diagnosed with atrophic endometrium (AE). Outcome data were obtained until February 2018. The main outcomes were risk of progression to endometrial carcinoma and risk of persistence, recurrence or new development of endometrial hyperplasia (EH) (‘persistent EH’). Logistic regression analysis was used to identify covariates that were independent risk factors for progression to endometrial cancer or persistent EH.ResultsDuring the study period, 1808 women aged 55 or older underwent endometrial sampling. The median surveillance time was 10.0 years. Seventy‐two women were found to have a current or recent diagnosis of NEH and were compared with 722 women with AE. When compared to women with AE, women with NEH had significantly higher body mass index (33.9 kg/m2 vs 30.6 kg/m2; P = 0.01), greater endometrial thickness (10.00 mm vs 6.00 mm; P = 0.01) and higher rates of progression to type‐1 endometrial cancer (8.3% vs 0.8%; P = 0.0003) and persistent NEH (22.2% vs 0.7%; P < 0.0001). They also had a higher rate of progression to any type of uterine cancer or persistent EH (33.3% vs 3.5%; P < 0.0001). Women with NEH had a significantly higher rate of future surgical intervention (51.4% vs 15.8%; P < 0.0001), including future hysterectomy (34.7% vs 9.8%; P < 0.0001). On multivariable logistic regression analysis, only NEH remained a significant risk factor for progression to endometrial cancer or persistence of EH.ConclusionsPostmenopausal women with NEH are at significant risk for persistent EH and progression to endometrial cancer, at rates higher than those reported previously. Guidelines for the appropriate management of postmenopausal women with NEH are needed in order to decrease the rate of persistent disease or progression to cancer. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Validation of ultrasound strategies to assess tumor extension and to predict high‐risk endometrial cancer in women from the prospective IETA (International Endometrial Tumor Analysis)‐4 cohort

ABSTRACTObjectivesTo compare the performance of ultrasound measurements and subjective ultrasound assessment (SA) in detecting deep myometrial invasion (MI) and cervical stromal invasion (CSI) in women with endometrial cancer, overall and according to whether they had low‐ or high‐grade disease separately, and to validate published measurement cut‐offs and prediction models to identify MI, CSI and high‐risk disease (Grade‐3 endometrioid or non‐endometrioid cancer and/or deep MI and/or CSI).MethodsThe study comprised 1538 patients with endometrial cancer from the International Endometrial Tumor Analysis (IETA)‐4 prospective multicenter study, who underwent standardized expert transvaginal ultrasound examination. SA and ultrasound measurements were used to predict deep MI and CSI. We assessed the diagnostic accuracy of the tumor/uterine anteroposterior (AP) diameter ratio for detecting deep MI and that of the distance from the lower margin of the tumor to the outer cervical os (Dist‐OCO) for detecting CSI. We also validated two two‐step strategies for the prediction of high‐risk cancer; in the first step, biopsy‐confirmed Grade‐3 endometrioid or mucinous or non‐endometrioid cancers were classified as high‐risk cancer, while the second step encompassed the application of a mathematical model to classify the remaining tumors. The ‘subjective prediction model’ included biopsy grade (Grade 1 vs Grade 2) and subjective assessment of deep MI or CSI (presence or absence) as variables, while the ‘objective prediction model’ included biopsy grade (Grade 1 vs Grade 2) and minimal tumor‐free margin. The predictive performance of the two two‐step strategies was compared with that of simply classifying patients as high risk if either deep MI or CSI was suspected based on SA or if biopsy showed Grade‐3 endometrioid or mucinous or non‐endometrioid histotype (i.e. combining SA with biopsy grade). Histological assessment from hysterectomy was considered the reference standard.ResultsIn 1275 patients with measurable lesions, the sensitivity and specificity of SA for detecting deep MI was 70% and 80%, respectively, in patients with a Grade‐1 or ‐2 endometrioid or mucinous tumor vs 76% and 64% in patients with a Grade‐3 endometrioid or mucinous or a non‐endometrioid tumor. The corresponding values for the detection of CSI were 51% and 94% vs 50% and 91%. Tumor AP diameter and tumor/uterine AP diameter ratio showed the best performance for predicting deep MI (area under the receiver–operating characteristics curve (AUC) of 0.76 and 0.77, respectively), and Dist‐OCO had the best performance for predicting CSI (AUC, 0.72). The proportion of patients classified correctly as having high‐risk cancer was 80% when simply combining SA with biopsy grade vs 80% and 74% when using the subjective and objective two‐step strategies, respectively. The subjective and objective models had an AUC of 0.76 and 0.75, respectively, when applied to Grade‐1 and ‐2 endometrioid tumors.ConclusionsIn the hands of experienced ultrasound examiners, SA was superior to ultrasound measurements for the prediction of deep MI and CSI of endometrial cancer, especially in patients with a Grade‐1 or ‐2 tumor. The mathematical models for the prediction of high‐risk cancer performed as expected. The best strategies for predicting high‐risk endometrial cancer were combining SA with biopsy grade and the subjective two‐step strategy, both having an accuracy of 80%. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Sonographic features of pelvic tuberculosis mimicking ovarian‐tubal‐peritoneal carcinoma

Imaging in gynecological disease (30): clinical and ultrasound characteristics of usual‐type and variants of leiomyoma

ABSTRACT Objective To characterize the clinical and ultrasound features of usual‐type leiomyoma and variants of leiomyoma. Methods This retrospective, single‐center study included patients with a histologically confirmed diagnosis of benign mesenchymal uterine tumor, prospectively collected between January 2019 and December 2021 in the MYometrial Lesion UltrasouNd And mRi (MYLUNAR) study. Tumors were classified according to the Morphological Uterus Sonographic Assessment criteria and grouped according to the 2020 World Health Organization (WHO) classification of female genital tumors into usual‐type and variant leiomyomas. The variants of leiomyoma were further classified into specific histological subtypes as defined in the WHO classification. Two ultrasound examiners independently reviewed all available ultrasound images to identify patterns associated with usual‐type leiomyoma and variants of leiomyoma. Results A total of 1766 patients were included, of whom 1383 (78.3%) had usual‐type leiomyoma and 383 (21.7%) had a variant of leiomyoma. The median age at diagnosis was 45 (range, 15–88) years, with no statistically significant difference between the two groups. Most patients were premenopausal, although the variant group had a higher proportion of postmenopausal patients compared with the usual‐type group (21.5% vs 12.6%; P  < 0.001). On ultrasound examination, leiomyoma variants were larger than usual‐type leiomyomas (median maximum diameter, 82.5 mm vs 70.0 mm; P  < 0.001) and more frequently exhibited cystic areas (33.2% vs 12.8%; P  < 0.001). Acoustic shadows were present in 79.1% of variants, compared with 90.4% in usual‐type leiomyomas (P  < 0.001). Some variant subtypes appeared only in premenopausal women and had distinct morphological characteristics. Epithelioid leiomyomas were the largest variant, with a median diameter of 139.5 mm. Mitotically active leiomyomas showed regular margins and uniform echostructure, and lacked cystic areas in almost all cases. Lipoleiomyomas contained calcifications in some cases. After reviewing the ultrasound images, 13 patterns were identified, some of which were distinctive of specific variant subtypes. Conclusion Patients with usual‐type vs variant leiomyomas presented with some distinct clinical and ultrasound characteristics. Among variants of leiomyomas, some histotypes exhibited distinctive clinical and ultrasound features. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Diagnostic accuracy of Ovarian‐Adnexal Reporting and Data System, IOTA Simple Rules and Pediatric Risk of Malignancy Index for pediatric adnexal lesions: comparative study

ABSTRACT Objective Many risk stratification models have been developed to improve the accuracy of sonographic evaluation of adnexal lesions. Although these models have been validated across various adult populations, their accuracy in the pediatric population remains underexplored. This study aimed to evaluate and compare the diagnostic accuracy of three sonography‐based risk models in assessing pediatric adnexal lesions. Methods This was a single‐center retrospective diagnostic accuracy study conducted at a tertiary hospital in China, which included consecutive patients aged 17 years or younger with adnexal lesions managed either surgically or conservatively between January 2015 and January 2024. Each adnexal lesion was assessed using the Ovarian‐Adnexal Reporting and Data System (O‐RADS) ultrasound risk stratification and management tool, the International Ovarian Tumor Analysis (IOTA) Simple Rules (SR) followed by expert assessment for inconclusive cases in a two‐step strategy and the Pediatric Risk of Malignancy Index (PRMI) model. The reference standard was either surgical intervention or conservative management with ultrasound surveillance. The accuracy of the different sonography‐based risk models was evaluated using the area under the receiver‐operating‐characteristics curve (AUC), sensitivity, specificity and positive and negative predictive values. The clinical utility of each model was evaluated using decision‐curve analysis. Results This study included 364 patients with a total of 375 adnexal lesions. The median age of the patients was 15.0 (interquartile range, 14.0–17.0) years, with a malignancy rate of 2.1% (8/375). The AUC for the O‐RADS tool, IOTA two‐step strategy and the PRMI model were 0.989 (95% CI, 0.980–0.999), 0.992 (95% CI, 0.985–0.998) and 0.806 (95% CI, 0.626–0.985), respectively. The IOTA two‐step strategy demonstrated the highest accuracy and provided the greatest net benefits at malignancy risk thresholds between 1% and 30% compared with the other two models. Conclusions In this retrospective pediatric cohort, the O‐RADS ultrasound model and the IOTA‐SR followed by expert assessment for inconclusive cases in a two‐step strategy exhibited high diagnostic accuracy in characterizing adnexal lesions, comparable to that observed in adults. These results support the applicability of both of these risk‐stratification methods to the pediatric population. The PRMI scoring system showed lower discriminative capacity compared with the other models; therefore, it is not recommended to serve as a standalone diagnostic tool. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Clinical and ultrasound features of uterine perivascular epithelioid cell tumors: case series and literature review

ABSTRACTObjectiveTo describe the clinical and ultrasonographic features of uterine perivascular epithelioid cell tumor (PEComa) using standardized terminology.MethodsThis was a retrospective analysis of patients with uterine PEComa diagnosed and confirmed by pathology and immunohistochemistry at West China Second University Hospital, Sichuan University, Sichuan, China, between January 2010 and September 2023. The Morphological Uterus Sonographic Assessment (MUSA) consensus and the International Endometrial Tumor Analysis (IETA) consensus were utilized for the standardized description of the sonographic characteristics of uterine PEComa. We summarized the clinical and ultrasound features of uterine PEComa in cases from our center and those found in a review of the literature conducted using PubMed from 1 January 2013 to 30 September 2023 (inclusive).ResultsFive patients, aged 33–57 (median, 52) years, with a total of six uterine PEComa lesions were included in our cohort. All cases had complete ultrasonographic and pathological images. None of the patients had a history of tuberous sclerosis complex. Two patients had malignant PEComa (one patient had two lesions) and three had benign PEComa, originating from the cervix, myometrium or uterine cavity. Patients presented with symptoms including increased vaginal discharge, vaginal bleeding and pelvic or abdominal pain. The three patients with benign PEComa underwent total hysterectomy and bilateral adnexectomy, tumor excision and conservative management, respectively, while both malignant cases underwent total hysterectomy and bilateral adnexectomy followed by chemotherapy. Regular follow‐up (from 6 to 24 months) revealed recurrence in one case. Two lesions were misdiagnosed as uterine fibroids, two as cervical cancer, one as metastatic cervical cancer (with myometrial invasion) and one was indeterminate. Ultrasound examination showed that most lesions displayed regular round or ovoid shape (66.7%), uniform echoes (66.7%) and hypoechogenicity (66.7%), with one (16.7%) malignant PEComa showing cystic areas and one (16.7%) benign PEComa showing punctate calcifications. All lesions lacked shadowing and the majority showed moderate to abundant vascularity (color score of 3–4, 83.3%). The color score was 2–4 in the periphery in 100% of cases and internally in 83.3% of cases. The three benign PEComas showed similar characteristics in vascular distribution, with scattered internal vessels and peripheral vessels exhibiting a circular pattern. The literature search identified 11 articles describing the ultrasonographic appearance of 18 cases of uterine PEComa, with similar characteristics to those in our cohort.ConclusionsThe sonographic features of uterine PEComa include a uniform or non‐uniform hypoechogenic mass, typically round or ovoid with regular margins, occasionally containing cystic areas or calcifications, lacking shadowing and often showing moderate to abundant vascularity. Although the preoperative ultrasound diagnosis of uterine PEComa remains challenging, particularly given the non‐specific nature of the sonographic characteristics described here, dispersed intratumoral vessels and a peripheral circular vascular distribution may serve as diagnostic clues for uterine PEComa, but more cases are needed for confirmation. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Characterization of adnexal lesions using photoacoustic imaging to improve sonographic O‐RADS risk assessment

Abstract Objective To assess the impact of photoacoustic imaging (PAI) on the assessment of ovarian/adnexal lesion(s) of different risk categories using the sonographic ovarian‐adnexal imaging‐reporting‐data system (O‐RADS) in women undergoing planned oophorectomy. Method This prospective study enrolled women with ovarian/adnexal lesion(s) suggestive of malignancy referred for oophorectomy. Participants underwent clinical ultrasound (US) examination followed by coregistered US and PAI prior to oophorectomy. Each ovarian/adnexal lesion was graded by two radiologists using the US O‐RADS scale. PAI was used to compute relative total hemoglobin concentration (rHbT) and blood oxygenation saturation (%sO 2 ) colormaps in the region of interest. Lesions were categorized by histopathology into malignant ovarian/adnexal lesion, malignant Fallopian tube only and several benign categories, in order to assess the impact of incorporating PAI in the assessment of risk of malignancy with O‐RADS. Malignant and benign histologic groups were compared with respect to rHbT and %sO 2 and logistic regression models were developed based on tumor marker CA125 alone, US‐based O‐RADS alone, PAI‐based rHbT with %sO 2 , and the combination of CA125, O‐RADS, rHbT and %sO 2. Areas under the receiver‐operating‐characteristics curve (AUC) were used to compare the diagnostic performance of the models. Results There were 93 lesions identified on imaging among 68 women (mean age, 52 (range, 21–79) years). Surgical pathology revealed 14 patients with malignant ovarian/adnexal lesion, two with malignant Fallopian tube only and 52 with benign findings. rHbT was significantly higher in malignant compared with benign lesions. %sO 2 was lower in malignant lesions, but the difference was not statistically significant for all benign categories. Feature analysis revealed that rHbT, CA125, O‐RADS and %sO 2 were the most important predictors of malignancy. Logistic regression models revealed an AUC of 0.789 (95% CI, 0.626–0.953) for CA125 alone, AUC of 0.857 (95% CI, 0.733–0.981) for O‐RADS only, AUC of 0.883 (95% CI, 0.760–1) for CA125 and O‐RADS and an AUC of 0.900 (95% CI, 0.815–0.985) for rHbT and %sO 2 in the prediction of malignancy. A model utilizing all four predictors (CA125, O‐RADS, rHbT and %sO 2 ) achieved superior performance, with an AUC of 0.970 (95% CI, 0.932–1), sensitivity of 100% and specificity of 82%. Conclusions Incorporating the additional information provided by PAI‐derived rHbT and %sO 2 improves significantly the performance of US‐based O‐RADS in the diagnosis of adnexal lesions. © 2023 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.

Additional value of uterine artery Doppler pulsatility index for ultrasound diagnosis of placental site trophoblastic tumor: prospective cohort study

ABSTRACT Objectives The ultrasound diagnosis of placental site trophoblastic tumor (PSTT) is challenging owing to a lack of pathognomonic features. Differential diagnosis from other forms of gestational trophoblastic neoplasia (GTN) is critical owing to major differences in prognosis and treatment. Doppler measurement of uterine artery (UtA) pulsatility index (PI) has been proposed for the diagnosis and management of GTN. The aim of this study was to evaluate the added value of UtA‐PI Doppler measurement during the standard transvaginal ultrasound (TVS) assessment, in patients with PSTT as compared to those with other GTN. Methods This was a single‐center prospective cohort study involving ultrasound assessment of all GTN cases referred to and treated at the trophoblast unit of San Raffaele Hospital, Milan, Italy, between 2011 and 2023. TVS assessment included: grayscale analysis for the detection of myometrial or endometrial abnormalities, color and power Doppler assessment of lesions with scoring of vascularization, and spectral pulsed‐wave Doppler for measurement of mean UtA‐PI from the left and right UtAs. Sonographic findings were compared between patients with PSTT and those with other forms of GTN (postmolar, invasive mole or choriocarcinoma), using non‐parametric two‐tailed statistical analysis. Results A total of 73 GTN cases were recruited, comprising nine (12.3%) with PSTT and 64 (87.7%) with other GTN. A significant difference was detected between other‐GTN and PSTT cases when comparing rates of substantial endometrial vascularity on Doppler (50% vs 0%; P  = 0.013) and mean UtA‐PI measurements (median, 1.5 (interquartile range (IQR), 1.0–2.4) vs 2.2 (IQR, 1.5–2.7); P  = 0.014; area under the receiver‐operating‐characteristics curve, 0.768 (95% CI, 0.610–0.888)). Conclusions This study describes UtA‐PI as a novel and effective marker allowing for the ultrasound differentiation of PSTT from other forms of GTN. The significantly higher mean UtA‐PI and lower endometrial vascularity observed in PSTT as compared with other GTN suggests a unique vascularization pattern, with a potential role in differential diagnosis and management. © 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 (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..

Serial endometrial thickness and risk of non‐endometrial hormone‐dependent cancers in postmenopausal women in UK Collaborative Trial of Ovarian Cancer Screening

ABSTRACTObjectiveEstrogen is a well‐established risk factor for various cancers. It causes endometrial proliferation, which is assessed routinely as endometrial thickness (ET) using transvaginal ultrasound (TVS). Only one previous study, restricted to endometrial and breast cancer, has considered ET and the risk of non‐endometrial cancer. The aim of this study was to explore the association between baseline and serial ET measurements and nine non‐endometrial hormone‐sensitive cancers, in postmenopausal women, using contemporary statistical methodology that attempts to minimize the biases typical of endogenous serial data.MethodsThis was a cohort study nested within the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). In the ultrasound arm of UKCTOCS, 50639 postmenopausal women, aged 50–74, underwent annual TVS examination, of whom 38 105 had a valid ET measurement, no prior hysterectomy and complete covariate data, and were included in this study. All women were followed up through linkage to national cancer registries. The effect of ET on the risk of six estrogen‐dependent cancers (breast, ovarian, colorectal, bladder, lung and pancreatic) was assessed using joint models for longitudinal biomarker and time‐to‐event data, and Cox models were used to assess the association between baseline ET measurement and these six cancers in addition to liver cancer, gastric cancer and non‐Hodgkin's lymphoma (NHL). All models were adjusted for current hormone‐replacement therapy (HRT) use, body mass index, age at last menstrual period, parity and oral contraceptive pill use.ResultsThe 38 105 included women had a combined total of 267 567 (median, 8; interquartile range, 5–9) valid ET measurements. During a combined total of 407 838 (median, 10.9) years of follow‐up, 1398 breast, 351 endometrial, 381 lung, 495 colorectal, 222 ovarian, 94 pancreatic, 79 bladder, 62 gastric, 38 liver cancers and 52 NHLs were registered. Using joint models, a doubling of ET increased significantly the risk of breast (hazard ratio (HR), 1.21; 95% CI, 1.09–1.36; P = 0.001), ovarian (HR, 1.39; 95% CI, 1.06–1.82; P = 0.018) and lung (HR, 1.25; 95% CI, 1.02–1.54; P = 0.036) cancers. There were no statistically significant associations between ET and the remaining six cancers.ConclusionPostmenopausal women with high/increasing ET on TVS are at increased risk of breast, ovarian and lung cancer. It is important that clinicians are aware of these risks, as TVS is a common investigation. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

ISUOG/ESGO Consensus Statement on ultrasound‐guided biopsy in gynecological oncology

ABSTRACTThe International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) with the European Society of Gynaecological Oncology (ESGO) jointly developed clinically relevant and evidence‐based statements on performing ultrasound‐guided biopsies in gynecological oncology.The objective of this Consensus Statement is to assist clinicians, including gynecological sonographers, gynecological oncologists and radiologists, to achieve the best standards of practice in ultrasound‐guided biopsy procedures. ISUOG/ESGO nominated a multidisciplinary international group of 16 experts who have demonstrated leadership in the use of ultrasound‐guided biopsy in the clinical management of patients with gynecological cancer. In addition, two early‐career gynecological fellows were nominated to participate from the European Network of Young Gynae Oncologists (ENYGO) within ESGO and from ISUOG. The group also included a patient representative from the European Network of Gynaecological Cancer Advocacy Groups. The document is divided into six sections: (1) general recommendations; (2) image‐guided biopsy (imaging guidance, sampling methods); (3) indications and contraindications; (4) technique; (5) reporting; and (6) training and quality assurance. To ensure that the statements are evidence‐based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on this review of the literature. During a conference call, the whole group discussed each preliminary statement, and a first round of voting was carried out. The group achieved consensus on all 46 preliminary statements without the need for revision.These ISUOG/ESGO statements on ultrasound‐guided biopsy in gynecological oncology, together with a summary of the evidence supporting each statement, are presented herein. This Consensus Statement is supplemented by detailed narrated videoclips presenting different approaches and indications for ultrasound‐guided biopsy, a patient leaflet, and an extended version which includes a detailed review of the evidence. © 2025 The Authors. Published by John Wiley & Sons Ltd on behalf of The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and by Elsevier Inc. on behalf of the European Society of Gynaecological Oncology and the International Gynecologic Cancer Society.

Comparison of ultrasound with computed tomography and whole‐body diffusion‐weighted MRI in prediction of surgical outcome using ESMO ‐ ESGO criteria in patients with tubo‐ovarian carcinoma: prospective ISAAC study

ABSTRACT Objective To test the non‐inferiority of extended abdominopelvic ultrasound examination compared with contrast‐enhanced computed tomography (CT) and whole‐body diffusion‐weighted magnetic resonance imaging (WB‐DWI/MRI) in discriminating preoperatively between resectable and non‐resectable disease based on the European Society for Medical Oncology (ESMO) and European Society of Gynecological Oncology (ESGO)‐defined criteria in patients with tubo‐ovarian carcinoma. Methods The Imaging Study on Advanced ovArian Cancer was a prospective multicenter observational study conducted in five European gynecological oncology centers. All centers had ESGO accreditation to perform advanced ovarian cancer surgery, and ultrasound examinations were performed by a European Federation of Societies for Ultrasound in Medicine and Biology level‐III examiner in a standardized manner. Included in the analysis were patients enrolled between 2020 and 2022 with suspected or histologically proven primary tubo‐ovarian (including peritoneal) carcinoma who, for the purposes of the study, underwent ultrasound and CT imaging, as well as WB‐DWI/MRI if available, prior to surgery. The index tests, which included the preoperative imaging modalities as well as intraoperative exploration at the start of surgery, supplemented by biopsy or follow‐up imaging for extra‐abdominal locations, evaluated the presence of disease at eight anatomical sites that, if infiltrated, would indicate non‐resectability of the tumor according to the ESMO‐ESGO criteria. Surgical outcome, described by the surgeons at the end of the procedure, was used as the reference standard and non‐resectability was defined as the presence of residual disease > 1 cm or when debulking surgery was not feasible. The area under the receiver‐operating‐characteristics curve (AUC) and F 1  score were used to assess the performance of the preoperative imaging methods and surgical exploration in discriminating between patients with resectable and those with non‐resectable disease, based on the ESMO‐ESGO criteria. We also calculated the percentage agreement between imaging findings and surgical exploration findings at the start of surgery, supplemented when applicable by biopsy or follow‐up imaging for extra‐abdominal locations, regarding the presence of tumor infiltration at each of the eight anatomical sites associated with non‐resectability. Results Of 279 patients enrolled during the study period, 242 were included in the final analysis. In the subgroup of 167 patients who underwent surgery and had been examined by all three imaging methods, the AUC of the three imaging modalities and surgical exploration for discriminating between resectable and non‐resectable disease based on the ESMO‐ESGO criteria was 0.835 (95% CI, 0.756–0.915) for ultrasound, for CT it was 0.754 (95% CI, 0.664–0.843), for WB‐DWI/MRI it was 0.720 (95% CI, 0.626–0.814) and for surgical exploration it was 0.952 (95% CI, 0.915–0.988). Ultrasound was not inferior to CT or WB‐DWI/MRI, based on the AUC and F 1 score, in discriminating between patients with resectable and those with non‐resectable tubo‐ovarian carcinoma. At surgical exploration, at least one non‐resectability criterion was present in 32.2% cases. The criteria observed most frequently at surgical exploration were small‐bowel involvement (23.6% of cases), diffuse deep infiltration of the root of the small‐bowel mesentery (18.2% of cases) and hepatic hilum involvement (5.4% of cases). The percentage agreement between ultrasound and surgical exploration in assessing the presence of disease in at least one of the eight anatomical sites that, if infiltrated, would indicate non‐resectability of tumor, was 83.9%, surpassing the percentage agreement with surgical exploration of both CT (77.7%) and WB‐DWI/MRI (75.8%). Conclusion When performed by an experienced examiner, ultrasound is not inferior to either CT or WB‐DWI/MRI in discriminating between resectable and non‐resectable disease in patients with tubo‐ovarian carcinoma, based on evaluation of the presence of the disease in at least one of eight anatomical sites that, if infiltrated, would indicate non‐resectability of the tumor. © 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.

Unusual polypoid endometriosis mimicking multiple solid ovarian masses following ovarian drilling

Hydatidiform mole identification using non‐invasive single‐cell sequencing of fetal circulating extravillous trophoblasts isolated from maternal blood

Sonographic characteristics of ovarian Leydig cell tumor

Subjective assessment and IOTA ADNEX model in evaluation of adnexal masses in patients with history of breast cancer

ABSTRACTObjectiveTo evaluate the performance of subjective assessment and the Assessment of Different NEoplasias in the adneXa (ADNEX) model in discriminating between benign and malignant adnexal tumors and between metastatic and primary adnexal tumors in patients with a personal history of breast cancer.MethodsThis was a retrospective single‐center study including patients with a history of breast cancer who underwent surgery for an adnexal mass between 2013 and 2020. All patients had been examined with transvaginal or transrectal ultrasound using a standardized examination technique and all ultrasound reports had been stored and were retrieved for the purposes of this study. The specific diagnosis suggested by the original ultrasound examiner in the retrieved report was analyzed. For each mass, the ADNEX model risks were calculated prospectively and the highest relative risk was used to categorize each into one of five categories (benign, borderline, primary Stage I, primary Stages II–IV or metastatic ovarian cancer) for analysis of the ADNEX model in predicting the specific tumor type. The performance of subjective assessment and the ADNEX model in discriminating between benign and malignant adnexal tumors and between primary and metastatic adnexal tumors was evaluated, using final histology as the reference standard.ResultsIncluded in the study were 202 women with a history of breast cancer who underwent surgery for an adnexal mass. At histology, 93/202 (46.0%) masses were benign, 76/202 (37.6%) were primary malignancies (four borderline and 72 invasive tumors) and 33/202 (16.3%) were metastases. The original ultrasound examiner classified correctly 79/93 (84.9%) benign adnexal masses, 72/76 (94.7%) primary adnexal malignancies and 30/33 (90.9%) metastatic tumors. Subjective ultrasound evaluation had a sensitivity of 93.6%, specificity of 84.9% and accuracy of 89.6%, while the ADNEX model had higher sensitivity (98.2%) but lower specificity (78.5%), with similar accuracy (89.1%), in discriminating between benign and malignant ovarian masses. Subjective evaluation had a sensitivity of 51.5%, specificity of 88.8% and accuracy of 82.7% in distinguishing metastatic and primary tumors (including benign, borderline and invasive tumors), and the ADNEX model had a sensitivity of 63.6%, specificity of 84.6% and similar accuracy (81.2%).ConclusionsThe performance of subjective assessment and the ADNEX model in discriminating between benign and malignant adnexal masses in this series of patients with history of breast cancer was relatively similar. Both subjective assessment and the ADNEX model demonstrated good accuracy and specificity in discriminating between metastatic and primary tumors, but the sensitivity was low. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

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.

Ultrasound image analysis using deep neural networks for discriminating between benign and malignant ovarian tumors: comparison with expert subjective assessment

AbstractObjectivesTo develop and test the performance of computerized ultrasound image analysis using deep neural networks (DNNs) in discriminating between benign and malignant ovarian tumors and to compare its diagnostic accuracy with that of subjective assessment (SA) by an ultrasound expert.MethodsWe included 3077 (grayscale, n = 1927; power Doppler, n = 1150) ultrasound images from 758 women with ovarian tumors, who were classified prospectively by expert ultrasound examiners according to IOTA (International Ovarian Tumor Analysis) terms and definitions. Histological outcome from surgery (n = 634) or long‐term (≥ 3 years) follow‐up (n = 124) served as the gold standard. The dataset was split into a training set (n = 508; 314 benign and 194 malignant), a validation set (n = 100; 60 benign and 40 malignant) and a test set (n = 150; 75 benign and 75 malignant). We used transfer learning on three pre‐trained DNNs: VGG16, ResNet50 and MobileNet. Each model was trained, and the outputs calibrated, using temperature scaling. An ensemble of the three models was then used to estimate the probability of malignancy based on all images from a given case. The DNN ensemble classified the tumors as benign or malignant (Ovry‐Dx1 model); or as benign, inconclusive or malignant (Ovry‐Dx2 model). The diagnostic performance of the DNN models, in terms of sensitivity and specificity, was compared to that of SA for classifying ovarian tumors in the test set.ResultsAt a sensitivity of 96.0%, Ovry‐Dx1 had a specificity similar to that of SA (86.7% vs 88.0%; P = 1.0). Ovry‐Dx2 had a sensitivity of 97.1% and a specificity of 93.7%, when designating 12.7% of the lesions as inconclusive. By complimenting Ovry‐Dx2 with SA in inconclusive cases, the overall sensitivity (96.0%) and specificity (89.3%) were not significantly different from using SA in all cases (P = 1.0).ConclusionUltrasound image analysis using DNNs can predict ovarian malignancy with a diagnostic accuracy comparable to that of human expert examiners, indicating that these models may have a role in the triage of women with an ovarian tumor. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Vessel morphology depicted by three‐dimensional power Doppler ultrasound as second‐stage test in adnexal tumors that are difficult to classify: prospective diagnostic accuracy study

ABSTRACTObjectivesTo assess whether vessel morphology depicted by three‐dimensional (3D) power Doppler ultrasound improves discrimination between benignity and malignancy if used as a second‐stage test in adnexal masses that are difficult to classify.MethodsThis was a prospective observational international multicenter diagnostic accuracy study. Consecutive patients with an adnexal mass underwent standardized transvaginal two‐dimensional (2D) grayscale and color or power Doppler and 3D power Doppler ultrasound examination by an experienced examiner, and those with a ‘difficult’ tumor were included in the current analysis. A difficult tumor was defined as one in which the International Ovarian Tumor Analysis (IOTA) logistic regression model‐1 (LR‐1) yielded an ambiguous result (risk of malignancy, 8.3% to 25.5%), or as one in which the ultrasound examiner was uncertain regarding classification as benign or malignant when using subjective assessment. Even when the ultrasound examiner was uncertain, he/she was obliged to classify the tumor as most probably benign or most probably malignant. For each difficult tumor, one researcher created a 360° rotating 3D power Doppler image of the vessel tree in the whole tumor and another of the vessel tree in a 5‐cm3 spherical volume selected from the most vascularized part of the tumor. Two other researchers, blinded to the patient's history, 2D ultrasound findings and histological diagnosis, independently described the vessel tree using predetermined vessel features. Their agreed classification was used. The reference standard was the histological diagnosis of the mass. The sensitivity of each test for discriminating between benign and malignant difficult tumors was plotted against 1 – specificity on a receiver‐operating‐characteristics diagram, and the test with the point furthest from the reference line was considered to have the best diagnostic ability.ResultsOf 2403 women with an adnexal mass, 376 (16%) had a difficult mass. Ultrasound volumes were available for 138 of these cases. In 79/138 masses, the ultrasound examiner was uncertain about the diagnosis based on subjective assessment, in 87/138, IOTA LR‐1 yielded an ambiguous result and, in 28/138, both methods gave an uncertain result. Of the masses, 38/138 (28%) were malignant. Among tumors that were difficult to classify as benign or malignant by subjective assessment, the vessel feature ‘densely packed vessels’ had the best discriminative ability (sensitivity 67% (18/27), specificity 83% (43/52)) and was slightly superior to subjective assessment (sensitivity 74% (20/27), specificity 60% (31/52)). In tumors in which IOTA LR‐1 yielded an ambiguous result, subjective assessment (sensitivity 82% (14/17), specificity 79% (55/70)) was superior to the best vascular feature, i.e. changes in the diameter of vessels in the whole tumor volume (sensitivity 71% (12/17), specificity 69% (48/70)).ConclusionVessel morphology depicted by 3D power Doppler ultrasound may slightly improve discrimination between benign and malignant adnexal tumors that are difficult to classify by subjective ultrasound assessment. For tumors in which the IOTA LR‐1 model yields an ambiguous result, subjective assessment is superior to vessel morphology as a second‐stage test. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Longitudinal ultrasound evaluation of clear‐cell ovarian carcinoma

Imaging in gynecological disease (27): clinical and ultrasound characteristics of recurrent ovarian stromal cell tumors

ABSTRACTObjectiveTo describe the clinical and ultrasound characteristics of recurrent granulosa cell and Sertoli–Leydig cell tumors.MethodsThis was a retrospective observational study performed at Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, IRCCS, Rome (Gemelli center), Italy. Patients with a histological diagnosis of recurrent granulosa cell tumor or Sertoli–Leydig cell tumor were identified from the database of the Department of Gynecological Oncology. Those who had undergone a preoperative ultrasound examination at the Gemelli center between 2012 and 2020 were included, and the data retrieved from the original ultrasound reports. In all of these reports, the recurrent tumors were described using International Ovarian Tumor Analysis (IOTA) terminology. If a patient had more than one episode of relapse, information from all episodes was collected. If there was more than one recurrent tumor at the same ultrasound examination, all tumors were included. One expert sonographer also reviewed all available ultrasound images to identify typical ultrasound patterns using pattern recognition.ResultsWe identified 30 patients with a histological diagnosis of recurrent granulosa cell tumor (25 patients, 55 tumors) or Sertoli–Leydig cell tumor (five patients, seven tumors). All 30 had undergone at least one preoperative ultrasound examination at the Gemelli center and were included. These women had a total of 66 episodes of relapse, of which a preoperative ultrasound examination had been performed at the Gemelli center in 34, revealing 62 recurrent lesions: one in 22/34 (64.7%) episodes of relapse, two in 4/34 (11.8%) episodes and three or more in 8/34 (23.5%) episodes. Most recurrent granulosa cell tumors (38/55, 69.1%) and recurrent Sertoli–Leydig tumors (6/7, 85.7%) were classified as solid or multilocular‐solid tumors, while 8/55 (14.5%) recurrent granulosa cell tumors and 1/7 (14.3%) recurrent Sertoli–Leydig cell tumors were unilocular cysts and 9/55 (16.4%) recurrent granulosa cell tumors were multilocular cysts. The nine unilocular cysts had contents that were anechoic (n = 2) or had low‐level echogenicity (n = 7), had either smooth (n = 4) or irregular (n = 5) internal cyst walls, and ranged in largest diameter from 8 to 38 mm, with three being < 20 mm and five being 20–30 mm. On retrospective review of the images, two typical ultrasound patterns were described: small solid tumor measuring < 2 cm (15/62, 24.2%) and tumor with vascularized echogenic ground‐glass‐like content (12/62, 19.4%).ConclusionsSome granulosa cell and Sertoli–Leydig cell recurrences manifest one of two typical ultrasound patterns, while some appear as unilocular cysts. These are usually classified as benign, but in patients being followed up for a granulosa cell tumor or Sertoli–Leydig cell tumor, a unilocular cyst should be considered suspicious of recurrence. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Interobserver agreement of transvaginal ultrasound and magnetic resonance imaging in local staging of cervical cancer

ABSTRACTObjectiveTo evaluate interobserver agreement for the assessment of local tumor extension in women with cervical cancer, among experienced and less experienced observers, using transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI).MethodsThe TVS observers were all gynecologists and consultant ultrasound specialists, six with and seven without previous experience in cervical cancer imaging. The MRI observers were five radiologists experienced in pelvic MRI and four less experienced radiology residents without previous experience in MRI of the pelvis. The less experienced TVS observers and all MRI observers underwent a short basic training session in the assessment of cervical tumor extension, while the experienced TVS observers received only a written directive. All observers were assigned the same images from cervical cancer patients at all stages (n = 60) and performed offline evaluation to answer the following three questions: (1) Is there a visible primary tumor? (2) Does the tumor infiltrate > ⅓ of the cervical stroma? and (3) Is there parametrial invasion? Interobserver agreement within the four groups of observers was assessed using Fleiss kappa (κ) with 95% CI.ResultsExperienced and less experienced TVS observers, respectively, had moderate interobserver agreement with respect to tumor detection (κ (95% CI), 0.46 (0.40–0.53) and 0.46 (0.41–0.52)), stromal invasion > ⅓ (κ (95% CI), 0.45 (0.38–0.51) and 0.53 (0.40–0.58)) and parametrial invasion (κ (95% CI), 0.57 (0.51–0.64) and 0.44 (0.39–0.50)). Experienced MRI observers had good interobserver agreement with respect to tumor detection (κ (95% CI), 0.70 (0.62–0.78)), while less experienced MRI observers had moderate agreement (κ (95% CI), 0.51 (0.41–0.62)), and both experienced and less experienced MRI observers, respectively, had good interobserver agreement regarding stromal invasion (κ (95% CI), 0.80 (0.72–0.88) and 0.71 (0.61–0.81)) and parametrial invasion (κ (95% CI), 0.69 (0.61–0.77) and 0.71 (0.61–0.81)).ConclusionsWe found interobserver agreement for the assessment of local tumor extension in patients with cervical cancer to be moderate for TVS and moderate‐to‐good for MRI. The level of interobserver agreement was associated with experience among TVS observers only for parametrial invasion. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.