A modified CEUS risk stratification model for adnexal masses with solid components: prospective multicenter study and risk adjustment.

OBJECTIVES: To evaluate the additional advantages of integrating contrast-enhanced ultrasound (CEUS) into the Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) for the characterization of adnexal lesions with solid components. MATERIALS AND METHODS: This prospective multicenter study recruited women suspected of having adnexal lesions with solid components between September 2021 and December 2022. All patients scheduled for surgery underwent preoperative CEUS and US examinations. The lesions were categorized according to the O-RADS US system, and quantitative CEUS indexes were recorded. Pathological results served as the reference standard. Univariable and multivariable analyses were performed to identify risk factors for malignancy in adnexal lesions with solid components. Receiver operating characteristic (ROC) curve analysis was employed to assess diagnostic performance. RESULTS: A total of 180 lesions in 175 women were included in the study. Among these masses, 80 were malignant and 100 were benign. Multivariable analysis revealed that serum CA-125, the presence of acoustic shadowing, and peak intensity (PI) ratio (PImass/PIuterus) of solid components on CEUS were independently associated with adnexal malignancy. The modified CEUS risk stratification model demonstrated superior diagnostic value in assessing adnexal lesions with solid components compared to O-RADS US (AUC: 0.91 vs 0.78, p < 0.001) and exhibited comparable performance to the Assessment of Different NEoplasias in the adnexa (ADNEX) model (AUC 0.91 vs 0.86, p = 0.07). CONCLUSION: Our findings underscore the potential value of CEUS as an adjunctive tool for enhancing the precision of diagnostic evaluations of O-RADS US. CLINICAL RELEVANCE STATEMENT: The promising performance of the modified CEUS risk stratification model suggests its potential to mitigate unnecessary surgeries in the characterization of adnexal lesions with solid components. KEY POINTS: • The additional value of CEUS to O-RADS US in distinguishing between benign and malignant adnexal lesions with solid components requires further evaluation. • The modified CEUS risk stratification model displayed superior diagnostic value and specificity in characterizing adnexal lesions with solid components when compared to O-RADS US. • The inclusion of CEUS demonstrated potential in reducing the need for unnecessary surgeries in the characterization of adnexal lesions with solid components.

Ultrasound Microvessel Visualization in Cervical Cancer: Association Between Novel Ultrasound Techniques and Histologic Microvessel Densities.

OBJECTIVE: The aim of the work described here was to evaluate the feasibility of superb microvascular imaging (SMI) and vascular endothelial growth factor receptor 2 (VEGFR2)-targeted microbubble (MBVEGFR2)-based ultrasound molecular imaging (USMI) for visualizing microvessels in cervical cancer. METHODS: Hela cells were used to establish subcutaneous cervical cancer models. SMI and MBVEGFR2-based USMI were performed, and the results were compared with intratumoral microvessel density (MVD) in four groups based on tumor diameter (<3 mm, 3-5 mm, 5-7 mm and ≥7 mm). The vascularization index (VI, %) was evaluated for SMI, and the normalized intensity difference (NID) for USMI. RESULTS: Tumors with diameters ranging from 3 to 5 mm had the highest VI (39.07 ± 1.58) in SMI, and VI significantly decreased with increasing tumor size (all p values <0.001). The strongest signal intensity was observed in very early tumors (d < 3 mm: 43.80 ± 3.58%) after MBVEGFR2 administration; the NID gradually decreased with increasing diameter of tumors (all p values = 0.007). However, no significant differences were observed in NID after administration of non-targeted (control) microbubbles (MBCon) (all p values = 0.125). MBVEGFR2-based USMI had the strongest correlation with MVD in displaying microvessels of cervical cancer compared with SMI and MBCon (R2 = 0.78 vs. R2 = 0.40 and R2 = 0.38). CONCLUSION: These findings validate the superiority and accuracy of MBVEGFR2-based USMI for microvessel imaging and monitoring of angiogenesis in cervical cancer compared with SMI and MBCon. Nonetheless, SMI remains an alternative to microvessel imaging when ultrasonic contrast agent use is contraindicated.

VEGFR2 targeted microbubble-based ultrasound molecular imaging improving the diagnostic sensitivity of microinvasive cervical cancer.

BACKGROUND: The current diagnostic methods of microinvasive cervical cancer lesions are imaging diagnosis and pathological evaluation. Pathological evaluation is invasive and imaging approaches are of extremely low diagnostic performance. There is a paucity of effective and noninvasive imaging approaches for these extremely early cervical cancer during clinical practice. In recent years, ultrasound molecular imaging (USMI) with vascular endothelial growth factor receptor type 2 (VEGFR2) targeted microbubble (MBVEGFR2) has been reported to improve the early diagnosis rates of breast cancer (including ductal carcinoma in situ), pancreatic cancer and hepatic micrometastases. Herein, we aimed to assess the feasibility of MBVEGFR2-based USMI in extremely early cervical cancer detection to provide an accurate imaging modality for microinvasive cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) Stage IA1 and IA2). RESULTS: We found MBVEGFR2-based USMI could successfully distinguish extremely early lesions in diameter < 3 mm from surrounding normal tissues (all P < 0.05), and the sensitivity gradually decreased along with increasing tumor diameter. Moreover, normalized intensity difference (NID) values showed a good linear correlation with microvessel density (MVD) (R2 = 0.75). In addition, all tumors could not be identified from surrounding muscles in subtracted ultrasound images when mice were administered MBCon. CONCLUSIONS: Overall, MBVEGFR2-based USMI has huge potential for clinical application for the early detection of microinvasive cervical cancer (FIGO Stage IA1 and IA2), providing the foothold for future studies on the imaging screening of this patient population.

Value of Contrast-Enhanced Ultrasound Parameters in the Evaluation of Adnexal Masses with Ovarian-Adnexal Reporting and Data System Ultrasound.

OBJECTIVE: The aim of this study was to determine whether incorporating qualitative parameters of contrast-enhanced ultrasound (CEUS) can increase the accuracy of adnexal lesion assessments with Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound category 4 or 5. METHODS: Retrospective analysis of patients with adnexal masses who underwent conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS) examinations between January and August of 2020. The study investigators reviewed and analyzed the morphological features of each mass before categorizing the US images independently according to the O-RADS system published by the American College of Radiology. In the CEUS analysis, the initial time and intensity of enhancement involving the wall and/or septation of the mass were compared with the uterine myometrium. Internal components of each mass were observed for signs of enhancement. The sensitivity, specificity, and Youden's index were calculated as the contrast variables and O-RADS. RESULTS: Receiver operating characteristic curve analysis revealed that the best cutoff value was higher than O-RADS 4. When information on the extent of enhancement was applied to selectively upgrade O-RADS category 4 and selectively downgrade O-RADS category 5, the overall sensitivity increased to 90.2%, while the level of specificity (91.3%) remained the same. CONCLUSION: Incorporating additional information from CEUS with respect to the extent of enhancement helped to improve the sensitivity of O-RADS category 4 and 5 masses without loss of specificity.

Predictive accuracy and reproducibility of the O-RADS US scoring system among sonologists with different training levels.

PURPOSE: To investigate the predictive performance and reproducibility of Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) system in evaluating adnexal masses between sonologists with varying levels of expertise. METHODS: This was a single-center retrospective study conducted between May 2019 and May 2020, which included 147 adnexal mases with pathological results. Four sonologists with varying experiences independently assigned an O-RADS US category to each adnexal mass twice. The intra- and inter-observer agreement was assessed using weighted kappa values. The area under the curve (AUC), sensitivity, specificity, positive and negative predictive value (PPV and NPV) were assessed for each sonologist. RESULTS: Of the 147 adnexal mases, 115 (78.2%) lesions were benign and 32 (21.8%) lesions were malignant. Considering O-RADS > 3 as a predictor for adnexal malignancy, the predictive accuracies of the four sonologists were excellent, with AUCs ranging from 0.831 to 0.926. The predictive accuracies of O-RADS US by experienced sonologists were significantly higher compared to inexperienced sonologists (all P values < 0.005). The O-RADS US presented high sensitivity and NPV value for each sonologist. With regard to the reproducibility of O-RADS, the intra- and inter-observer agreement among experienced sonologists performed better than inexperienced sonologists. CONCLUSION: O-RADS showed difference in the predictive accuracy and reproducibility in the evaluation of adnexal masses among sonologists with different levels of expertise. Training is required for inexperienced sonologists before the generalization of O-RADS classification system in clinical practice.

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

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

Imaging algorithm and multimodality evaluation of spinal osteoblastoma.

BACKGROUND: To analyze the features of CT, MRI and PET/CT and their diagnostic value for spinal osteoblastomas (OBs). METHODS: The radiological and clinical data of 21 patients with histopathologically-confirmed spinal OBs were analyzed retrospectively. RESULTS: Sixteen of the 21 cases were benign and 5 were aggressive OBs. Tumors were located in the lumbar (n = 11), cervical (n = 4), thoracic (n = 5), and sacral (n = 1) spinal regions. Nineteen cases were centered in the posterior elements of the spine, 13 of which extended into the vertebral body. Punctate or nodular calcifications were found in all cases on CT with a complete sclerotic rim (n = 12) or incomplete sclerotic rim (n = 8). The flare phenomenon (indicative of surrounding tissue inflammation) was found in 17/21 cases on CT, thin in 11 cases and thick in 6 cases, and in 19/19 cases on MRI, thin in 1 case and thick in 18 cases. On 18F-FDG PET/CT, all cases (8/8) were metabolically active with the SUVmax of 12.3-16.0; the flare sign was observed in 8 cases, including 7 cases of hypometabolism and 1 case of coexistence of hypermetabolism and hypometabolism. Based on CT, 3, 12, and 6 cases were classified as Enneking stage 1, 2 and 3, respectively. Of 19 cases with MRI, 1 and 18 cases were classified as Enneking stage 2 and 3, respectively. CONCLUSIONS: Spinal OB has multiple unique characteristic radiological features. Although a larger sample size is needed, combining CT, MRI and PET may be beneficial to optimize preoperative diagnosis and care of patients with OBs.