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Year : 2004  |  Volume : 14  |  Issue : 4  |  Page : 365-372
Sonomorphological and color doppler flow imaging evaluation of adnexal masses

Department of Radiology, Lady Hardinge Medical College & Associated Smt. Sucheta Kriplani Hospital, New Delhi 110001, India

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Objective: Evaluation of adnexal masses with conventional gray scale and Color Doppler flow imaging to assess the diagnostic reliability of sonographic and Doppler findings to differentiate malignant and benign ovarian masses. Materials and Methods: Sonomorphologic indexing of 74 adnexal masses in 52 patients was done to designate a mass as benign or malignant .The findings of color flow imaging and spectral Doppler were further added to differentiate malignant from benign lesions. The results were correlated with surgery/laparoscopy/FNAC/ follow up scans. Results: Sonomorphology has the highest sensitivity (92.5 percent) and negative predictive value (92.8 percent). Evaluation of vessel morphology and arrangement has the highest specificity (96.8 percent) with a positive predictive value of 95.2 percent. Peak systolic velocity is a better discriminator of malignant versus benign adnexal masses showing lesser degree of overlap as compared to resistive and pulsatility indices. Combined sonomorphologic and vascular scoring increased both the positive predictive value (54.36 percent to 76.6 percent) and diagnostic accuracy (68.9 percent to 80.4 percent) in predicting malignancy. Conclusion: There is considerable overlap in the morphologic patternsof various adnexal masses and hence a multiparameter analysis incorporating morphologic scoring, vessel location, vessel arrangement and spectral waveform analysis is helpful in determining those patients in whom early intervention is necessary.

Keywords: Adnexal masses, transvaginal color Doppler

How to cite this article:
Madan R, Narula M K, Chitra R, Bajaj P. Sonomorphological and color doppler flow imaging evaluation of adnexal masses. Indian J Radiol Imaging 2004;14:365-72

How to cite this URL:
Madan R, Narula M K, Chitra R, Bajaj P. Sonomorphological and color doppler flow imaging evaluation of adnexal masses. Indian J Radiol Imaging [serial online] 2004 [cited 2021 Mar 1];14:365-72. Available from:

   Introduction Top

Determination of a degree of suspicion for malignancy in an adnexal mass is the most critical step after identification of the mass and has a profound effect on patient survival. Color flow imaging and spectral Doppler have a promising role in the evaluation of adnexal masses.

Morphologic analysis of adnexal masses is done to classify them as either low risk or high risk. The most ominous features are non-fatty solid vascularised tissue identified by Color Doppler US. Spectral Doppler waveform characteristics -RI, PI and PSV correlate well with malignancy and are based on the fact that tumor vessels are morphologically abnormal.

   Materials and Methods Top

The subjects for this study were 52 patients with 74 adnexal masses. The inclusion criteria were clinical or sonographic diagnosis of a pelvic mass of probable adnexal origin (patients with ectopic pregnancy were excluded.) After eliciting detailed history, clinical examination and routine laboratory investigations were carried out; CA-125 levels were evaluated whenever possible.

All adnexal masses were subjected to sonomorphological evaluation followed by blood flow analysis using color, pulsed and three-dimensional power Doppler sonography. The examination was performed during the follicular proliferative phase of the menstrual cycle in premenopausal women.

Morphologic indexing of the adnexal masses was done using the Sassone score based on the visualization of inner wall structure and wall thickness, septae, solid parts and echogenicity. A mass with a score of = 9 was classified as a high risk mass (suspicious for malignancy)[1]. Subsequently, color and pulsed Doppler flow imaging and spectral analysis was performed (using ATL HDI 5000 unit with 2-5 MHz convex broad band transducer and 5-9 MHz transvaginal probe.) Doppler parameters were optimized for detection of flow and calculation of impedance indices. Flow results were recorded as being absent or present and further characterized as normal or increased .Normal flow was characterized by fine branching vessels, no evidence of "hot-spots"/aliasing and presence of peripheral flow. Flow was classified as increased if dilated prominent parenchymal vessels, "hot-spots" and aliasing was seen on color flow mapping [2]. The vessel location (peripheral, central, septal), arrangement (regular/random) and morphology (normal-fine tapering vessels versus abnormal dilated prominent vessels, focal stenosis, aneurysms, blind ending lakes and dichotomous branching) was also noted [3].

On spectral Doppler, the lowest RI, PI and maximum PSV detected at any point in the mass was used for analysis. The Doppler findings were considered as being suggestive of malignancy when: RI = 0.40[4]; PI = 1.0[5]; and PSVmax = 15cm/sec [6].

The "vascular" score as described by Caruso et al [7] was also used for further characterization of the mass. The parameters used were: presence or absence of vessels; vessel location (peripheral, septal, central); arrangement of vessels (regular or random); waveform pattern; and the lowest values of RI (=0.43). Adnexal masses were considered suspicious when the total score was =5.

The sonographic findings were compared with intraoperative observations / gross and cytohistopathological analysis / follow up scans.

   Results Top

Out of 52 patients included in the study- 37 were premenopausal and 15 were postmenopausal ranging in age from 17 to 75 years. Thirty six patients had benign lesions (69.23%), while 16 had malignant lesions (30.70%). Ten patients (19.2%) were nulliparous (6 patients with ovarian neoplasms, 2 cases with endometriomas and 2 patients with inflammatory lesions). Majority of the patients with malignant adnexal lesions (11/16 -i.e. 68.75%) had bilateral masses. All the hemorrhagic cysts in the study were unilateral, while 50% of the endometriomas were bilateral [Table - 1].

The sonomorphologic evaluation following Sassone scoring system. [1] had a sensitivity of 92.3%, specificity 55.3%, PPV 54.3%, NPV 92.8% and a diagnostic accuracy of 68.9%). Forty six out of 74 masses were considered suspicious of malignancy (Sassone score = 9) of which 25 were malignant and 21 were benign. High scoring (= 9) benign lesions were inflammatory adnexal masses, endometriomas, cystic teratomas, mucinous cystadenomas, and thecoma. Non-suspicious sonomorphology (score<9) was noted in 28 mass lesions- 26 were benign and 2 were malignant (1 immature teratoma and 1 serous cystadenocarcinoma). [Table - 1]

Color flow was detected in 77.02% masses- - 92.5%(25/27 masses) malignant masses were vascularised as compared to 68.08%(32/47 masses) benign adnexal masses ; increased flow was noted in 92% malignant lesions and only 21.87% benign masses( 5 inflammatory masses, one broad ligament fibroid and one thecoma). Vascularisation in benign lesions tended to be peripheral [Figure - 1] and in malignant lesions it was central (p<0.001) [Figure - 2],[Figure - 3],[Figure - 4][Figure - 5]. Random vessel arrangement and abnormal vessel morphology was seen in 20 malignant masses and only 1 benign ovarian thecoma [Figure - 6] [Table - 2]

On pulsed Doppler, the average value of RI in malignant ovarian neoplasms amounted to 0.40 0.15 and was higher in benign masses [0.51 0.11]. The mean PI of 0.61 0.19 in malignant adnexal masses was lower than 0.89 0.32 in benign lesions. The mean PSV in benign masses (12.74 8.4cm/sec) was lower than that in malignant adnexal masses (23.92 13.6 cm/sec) [Figure - 3],[Figure - 4]. The mean vascular score (Caruso et al) was higher in malignant ovarian neoplasms (7.64 2.64) as compared to benign lesions (2.34 2.23).

Using Sassone scoring system 46/74 masses had suspicious sonomorphologic features - but in only 30/46 masses, Caruso's vascular score was = 5 and of these 23 were malignant .Thus, PPV increased from 54.3% to 76.6% and diagnostic accuracy increased from 68.9% to 80.4%. Two malignant ovarian masses with Sassone score <9 (1 serous cystadenocarcinoma and 1 immature teratoma) had a vascular score within normal range (<5) and were missed by applying vascular score.[Table - 3]

   Discussion Top

Benign cystic teratomas were the commonest benign ovarian neoplasms. These were high scoring lesions having characteristic imaging features- "Tip-of-the-iceberg" sign [8]; mobile hyper echoic fat balls [9]; halo-like peripheral hypoechogenicity in solid appearing dermoids [10] and a dermoid plug [11]. Isoechoic branching elements were seen in a case of immature teratoma. This has been described as suggestive of malignancy by Milkotic et al. [12].[Figure - 7] Color flow signals were absent in 81.8% dermoids as opposed to only 33.3% endometriomas thus further increasing the confidence level in distinguishing between these adnexal masses. Kurjak et al [13] too have previously noted that a greater percentage of dermoids (72%) are avascular compared to endometriomas (13%). A long vascular pedicle was identified in 3 benign cystic teratomas and one immature teratoma. A mass with a target appearance compatible with a twisted vascular pedicle was seen in a case of torsion of dermoid cyst; high resistance arterial waveforms were identified in the pedicle and no blood flow (arterial or venous) could be detected in the mass [14]

The presence of solid components though generally indicative of malignancy, was also observed in benign neoplasms [15]. The absence of flow on color Doppler in echogenic portions of mucinous tumors helped to confirm the presence of mucin pockets/hemorrhage [16] [Figure - 8] Nonetheless, benign mucinous tumors were still difficult to differentiate from malignant mucinous lesions with considerable overlap of resistive indices[17]

A solid hypo echoic mass lesion with Sassone score = 9, and Caruso score =5, prominent intratumoral lakes and low impedance flow (RI=0.26)was seen in a case of benign ovarian thecoma leading to an erroneous diagnosis of malignant neoplasm.[Figure - 6] These findings have been observed in benign ovarian thecomas by Valentin et al. [18]

Endometriomas showed diverse appearances on ultrasonography- ranging from anechoic cystic lesions to echogenic cysts to masses containing multiple septations and solid tissue. Both ovarian (50%) and extra-ovarian (50%) endometriomas were seen in this study .Cysts with diffuse low level internal echoes , multilocularity and hyper echoic wall foci which have been described as path gnomonic features of endometriomas by Patel et al . [24] were seen in 3 masses.

Sonomorphology has higher specificity in differentiating malignant from benign ovarian neoplasms if dermoids, inflammatory masses and endometriomas are excluded by recognizing their specific sonographic characteristics [1]. Morphologic assessment by three dimensional sonography yielded additional information, especially small papillary projections (<3mm), thick septae, and the relationship of the mass to surrounding structures. Papillary protrusions and abnormalities of the inner wall structure were the most reliable findings associated with ovarian carcinoma [1].

As elucidated previously by many authors [6],[25] absence of detectable flow did not exclude ovarian malignancy;

An incremental angiogenic intensity has been observed in going from benign-borderline-malignant with considerable overlap in RI & PI values [26]; hence various cut off points have been used for RI & PI to indicate malignancy [27]. The mean RI & PI of malignant adnexal masses was lower than that of benign masses though RI was a more useful parameter offering a specificity of 90.62% [Table - 4]. Although two cut-off levels for RI were used in the present study - = 0.40 (Kurjak et al.)[4] and = 0.43(Caruso et al.[7], no case was misdiagnosed using a higher cut off level of = 0.43. A statistically significant difference was seen between PSV of benign and malignant lesions (p<0.001) in close agreement to that observed by Valentin et al.(1997) Intratumoral PSV was high in malignant lesions & showed lesser degree of overlap than impedance indices [28].

Even though the combined approach of application of the vascular score to morphologic score increased the PPV from 54.3% to 76.6% and diagnostic accuracy from 68.9% to 80.4% [Table - 3].[, yet it is not infallible as 1 serous cystadenocarcinoma, 1 immature teratoma were misdiagnosed as benign lesions and 1 broad ligament fibroid with cystic degeneration, and 1 ovarian thecoma were misdiagnosed as malignant lesions using all modalities together.

The application of three-dimensional power Doppler sonography revealed a highly indicative vascular pattern with characteristic structural abnormalities such as micro aneurysms, tumoral lakes, disproportional calibration, elongation and coiling, and dichotomous branching.[Figure - 5] This technique is also relatively more sensitive to low-velocity, low-amplitude flow.

Comparing the accuracy of gray scale morphologic assessment with color Doppler imaging is inappropriate ; both modalities lack sufficient specificity and predictive values if used alone as a malignancy indicator. Thus a multi parameter analysis which incorporates morphologic scoring, vessel location, and arrangement and pulsed Doppler waveform characteristics is advocated in determining patients in whom early intervention is necessary versus those in whom an expectant management may be undertaken.

   References Top

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28.Prompeler HJ, Madjar H ,Latterman U. Quantitative flow measurements for classification of ovarian tumors by transvaginal color Doppler sonography in postmenopausal patients .Ultrasound Obstet Gynecol 1995;4:406-413.  Back to cited text no. 28    

Correspondence Address:
M K Narula
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9]


[Table - 1], [Table - 2], [Table - 3], [Table - 4]


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