Clinical and ultrasound characteristics of surgically removed adnexal lesions with largest diameter ≤ 2.5 cm: a pictorial essay.

OBJECTIVES: To describe the ultrasound characteristics, indications for surgery and histological diagnoses of surgically removed adnexal masses with a largest diameter of ≤ 2.5 cm (very small tumors), to estimate the sensitivity and specificity of diagnosis of malignancy by subjective assessment of ultrasound images of very small tumors and to present a collection of ultrasound images of surgically removed very small tumors, with emphasis on those causing diagnostic difficulty. METHODS: Information on surgically removed adnexal tumors with a largest diameter of ≤ 2.5 cm was retrieved from the ultrasound databases of seven participating centers. The ultrasound images were described using the International Ovarian Tumor Analysis terminology. The original diagnosis, based on subjective assessment of the ultrasound images by the ultrasound examiner, was used to calculate the sensitivity and specificity of diagnosis of malignancy. RESULTS: Of the 129 identified adnexal masses with largest diameter ≤ 2.5 cm, 104 (81%) were benign, 15 (12%) borderline malignant and 10 (8%) invasive tumors. The main indication for performing surgery was suspicion of malignancy in 22% (23/104) of the benign tumors and in all 25 malignant tumors. None of the malignant tumors was a unilocular cyst (vs 50% of the benign tumors), all malignancies contained solid components (vs 43% of the benign tumors), 80% of the borderline tumors had papillary projections (vs 21% of the benign tumors and 20% of the invasive malignancies) and all invasive tumors and 80% of the borderline tumors were vascularized on color/power Doppler examination (vs 44% of the benign tumors). The ovarian crescent sign was present in 85% of the benign tumors, 80% of the borderline tumors and 50% of the invasive malignancies. The sensitivity of diagnosis of malignancy by subjective assessment of ultrasound images was 100% (25/25) and the specificity was 86% (89/104). Excluding unilocular cysts, the specificity was 71% (37/52). Analysis of images illustrated the difficulty in distinguishing benign from borderline very small cysts with papillations and benign from malignant very small well vascularized (color score 3 or 4) solid adnexal tumors. CONCLUSIONS: Very small malignant tumors manifest generally accepted ultrasound signs of malignancy. Small unilocular cysts are usually benign, while small non-unilocular masses, particularly ones with solid components, incur a risk of malignancy and pose a clinical dilemma. © 2016 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Diagnostic accuracy and potential limitations of transvaginal sonography for bladder endometriosis.

OBJECTIVES: To evaluate the accuracy and the potential limitations of transvaginal sonography (TVS) in the preoperative evaluation of women with clinically suspected bladder endometriosis and to describe the sonographic features of the pathological condition in cases in which it was confirmed. METHODS: In the period between 2001 and 2006, we operated on 490 patients with clinically/sonographically suspected endometriosis. In 41 cases, bladder endometriosis was diagnosed at surgery and confirmed at histopathological examination. All patients underwent TVS in a standardized manner not more than 1 month before surgery. Findings at preoperative TVS were described and compared with those at laparoscopy in order to evaluate the sensitivity, specificity, and positive and negative predictive values of TVS. RESULTS: Bladder endometriosis was correctly identified at TVS in 18/41 cases (43.9%) while 23/41 (56.1%) patients had a negative preoperative sonogram. The sensitivity, specificity and positive and negative predictive values of TVS for bladder endometriosis were 44% (18/41), 100% (449/449), 100% (18/18) and 95% (449/472), respectively, and the total accuracy was 95% (467/490). The detection rate was strongly related to mean lesion diameter as measured by the pathologist (mean +/- SD, 42.5 +/- 22.1 mm in the nodules detected vs. 28.9 +/- 14.8 mm in the nodules missed; P = 0.029) and to a history of previous surgery for endometriosis (70.6% vs. 25.0%; P = 0.005). At TVS, the nodule was hypoechogenic, its morphology was either elongated ('comma-shaped': 12/18, 66.7%) or spherical (6/18, 33.3%), and the site involved was the dome (11/18, 61.1%) or the base (7/18, 38.9%) of the bladder. Small anechogenic cystic areas within the nodule were seen in five of the 18 patients (27.8%) and a bright hyperechogenic rim was seen in 10 (55.6%). CONCLUSIONS: The detection rate of bladder endometriosis by TVS depends on the size of the endometriotic nodules, with detected nodules being larger than those that were missed. A history of previous surgery for endometriosis increases the likelihood of bladder endometriosis being detected on ultrasound examination.

Imaging patterns in elastofibroma dorsi.

INTRODUCTION: Elastofibroma dorsi is a rare pseudotumor of the soft tissues. Its clinico-radiologic characteristics lead to a correct diagnosis. MATERIAL AND METHODS: We followed 43 patients with elastofibroma dorsi with a confirmed histological diagnosis or on the basis of typical imaging pattern (ultrasound, CT, MR) confirmed by evolution. RESULTS: Elastofibroma is prevalent in females, its onset occurs around 60 years of age and is most frequently localized in the deep subscapular region (93%), bilateral in 54% of cases. In 7% it was found in an atypical isolated suprascapular region, in 7% it was synchronous to that in the subscapular region. Four ultrasound patterns were detected: Type I (54%) inhomogeneous fasciculated, Type II (22%) inhomogeneous aspecific, Type III (15%) hyperechogeneous, Type IV (9%) hypoechogeneous. Three patterns were detected at CT and MR: Type A (84%) inhomogeneous fasciculated corresponding to Types I and III and partially to Type II ultrasound pattern, Type B (8%) inhomogeneous aspecific corresponding to Type II ultrasound pattern; Type C (8%) homogeneous isodense or isointense to the muscle corresponding to Type IV ultrasound pattern. CONCLUSION: A solid, slow-growing lesion, in the deep periscapular region in females aged between 50 and 60 years, with a typical fasciculated pattern is pathognomonic of elastofibroma dorsi and bilateral location convalidates diagnosis. Ultrasound is sufficient to orientate diagnosis. CT and/or MR are reserved only for non-fasciculated ultrasound patterns, when site is atypical or in candidates for surgery. Biopsy is reserved only in cases where integrated imaging shows a non-fasciculated pattern to differentiate it from other malignant lesions.

The role of ultrasound-guided needle biopsy in the diagnosis of soft-tissue tumors.

Soft-tissue tumors are not very common, but their diagnosis can be very difficult. In the final analysis, their diagnosis requires a biopsy, which must furnish a sufficient amount of material to allow a reliable histological diagnosis. The authors evaluated the diagnostic efficacy of ultrasound-guided needle biopsy in the diagnosis of soft-tissue tumors of the musculoskeletal system. The aim of the study was to optimize the biopsy procedure, with particular emphasis on the choice of the biopsy needle (large-gauge manual versus semiautomatic) based on the characteristics of the neoplastic mass (consistency, depth, size, location). The results of the study showed that appropriate needle selection significantly reduced the frequency of biopsies that were insufficient for histological diagnosis. The method proved to be highly reliable for diagnosis of soft-tissue tumors but strongly related to the proper selection of the needle to be used.