Gupta A, Jha P, Baran TM, et al. Ovarian cancer detection in average-risk women: classic- versus nonclassic-appearing adnexal lesions at US. Radiology. 2022;212338. doi: 10.1148/radiol.212338.
Expert commentary
Gupta and colleagues conducted a multicenter, retrospective review of 970 adnexal lesions among 878 women—75% were premenopausal and 25% were postmenopausal.
Imaging details
The lesions were characterized by pattern recognition as “classic” (simple cysts, endometriomas, hemorrhagic cysts, or dermoids) or “nonclassic.” Out of 673 classic lesions, there were 4 malignancies (0.6%), of which 1 was an endometrioma and 3 were classified as simple cysts. However, out of 297 nonclassic lesions (multilocular, unilocular with solid areas or wall irregularity, or mostly solid), 32% (33/103) were malignant when vascularity was present, while 8% (16/184) were malignant when no intralesional vascularity was appreciated.
The authors pointed out that, especially because their study was retrospective, there was no standardization of scan technique or equipment employed. However, this point adds credibility to the “real world” nature of such imaging.
Other data corroborate findings
Other studies have looked at pattern recognition in efforts to optimize a conservative approach to benign masses and referral to oncology for suspected malignant masses, as described above. This was the main cornerstone of the International Consensus Conference,2 which also identified next steps for indeterminate masses, including evidence-based risk assessment algorithms and referral (to an expert imager or gynecologic oncologist). A multicenter trial in Europe3 found that ultrasound experience substantially impacts on diagnostic performance when adnexal masses are classified using pattern recognition. This occurred in a stepwise fashion with increasing accuracy directly related to the level of expertise. Shetty and colleagues4 found that pattern recognition performed better than the risk of malignancy index (sensitivities of 95% and 79%, respectively). ●
WHAT THIS EVIDENCE MEANS FOR PRACTICE
While the concept of pattern recognition for some “classic” benign ovarian masses has been around for some time, this is the first time a large United States–based study (albeit retrospective) has corroborated that when ultrasonography reveals a classic, or “almost certainly benign” finding, patients can be reassured that the lesion is benign, thereby avoiding extensive further workup. When a lesion is “nonclassic” in appearance and without any blood flow, further imaging with follow-up magnetic resonance imaging or repeat ultrasound could be considered. In women with a nonclassic lesion with blood flow, particularly in older women, referral to a gynecologic oncologic surgeon will help ensure expeditious treatment of possible ovarian cancer.
While the concept of pattern recognition for some “classic” benign ovarian masses has been around for some time, this is the first time a large United States–based study (albeit retrospective) has corroborated that when ultrasonography reveals a classic, or “almost certainly benign” finding, patients can be reassured that the lesion is benign, thereby avoiding extensive further workup. When a lesion is “nonclassic” in appearance and without any blood flow, further imaging with follow-up magnetic resonance imaging or repeat ultrasound could be considered. In women with a nonclassic lesion with blood flow, particularly in older women, referral to a gynecologic oncologic surgeon will help ensure expeditious treatment of possible ovarian cancer.