Obstetric imaging
From imaging to clinical diagnosis
Ovarian masses discovered in the ultrasound of the 1st quarter
Ovaries are listed in a short but precise line in the 1st trimester report: absence of a suspicious annex mass. This means the obligation to examine both ovaries as well as nucal clarity.
Precedents
In France, there are 130,000 pregnancies for 35 years and over, and those over 40 have tripled in twenty years! Ovarian cancer affects mostly women over the age of 60; however, it is diagnosed once in six in women under the age of 50. The frequency of ovarian cancer is estimated to be 1 per 18,000 pregnancies, including abortions, and the rate of cancer in relation to all ovarian tumors ranges from 2% to 5%, while outside pregnancy, the rate is estimated to be 18-20%.
A meta-analysis of Whitecar MP et al.(1) reproduces 22 series between 1954 and 1998: 1,532 masses were found during pregnancy. The frequency varies from one study to another from 1/79 to 1/2,400, with an incidence of malignancy ranging from 0.8% to 10%. Another study by Bernhard LM et al.(2) included a cohort of 18,391 patients and found 432 annexed masses (2.3%) including:
- 320 ovarian cysts < 5 cm;
- 102 complex masses or > 5 cm, of which: 18 unilocular cysts > 5 cm, 39 multilocular cysts and 45 complex masses.
The frequency of discovery has, of course, increased with the systematic ultrasound of the 1st quarter. The three most recent studies showed a significant percentage of malignant masses, including all masses above 4 cm (table). The endovaginal and transparent pelvic ultrasound is essential to reliably guide the clinician towards the diagnosis of ovarian tumor during pregnancy. About 10% of the masses are complex and deserve a second diagnostic test by a referent ultrasound designer. The ultrasound must specify the origin of the mass, its location, size, internal structure (the existence of vegetations or partitions) and classify the mass according to the criteria of the IOTA group (International Ovarian Tumor Analysis). The signs and symptoms of ovarian cancer during pregnancy do not offer any particularity. The discovery of a mass in emergency consultation for rupture, twisting, hemorrhage or infection should be differentiated from an annexational mass most often discovered in the first obstetric examination. It is therefore necessary to fully understand the criteria for analyzing an ovarian mass, in particular, by referring to the IOTA criteria before defining a surgical therapeutic conduct or abstention.
Diagnostic Strategy
Wait 14 weeks of amenorrhea (SA).
Recognize Reference Image : the yellow body (Figures 1a and b)
Figures 1a and 1b: The yellow bodies are characteristic by their shape: tissue, starfish, liquid, smooth; vascularization is peripheral, bordering a homogeneous tissue layer: the thèque. These are the basic images of the cyclic "ovarian mass" whose semiology has no tumor equivalent.
Three situations
• very likely and characteristic benign tumor:
- hemorrhagic or cystic yellow body (figures 2a and b);
- endometrioma (figures 3a and b);
- dermoid (figure 4).
Figures 2a and 2b: Yellow hemorrhagic cysts are also without tumor equivalents. The clot has a particular semiology and never vascular.
Figures 3a and 3b: Endometrioma is also a particular cyst, with no tumor equivalent. Hypoechogenic mass without loci or logettes, encapsulated, the contents of which are for hyperechogenic piquetas.
Figure 4: Ovarian-confined dermoid cyst also occupies a special place in the phenotypic analysis of ovarian masses: regular contours, internal tissue content, inhomogenous but dense, and especially vascular. In the 3D reconstructed front section, the end of the peripheral hypoechogenic edge is visualized.
• IOTA criteria for risk of malignancy
• Differential Diagnostics:
- hydrosalpinx;
- peritoneal cyst.
Surgery Square
- Wait 14 SA.
- Probable and Painful Bleeding Tumor (twist):
- example: Unilocular or dermoid tumor;
- surgery from the start. - IOTA criteria for malignity:
- carcinological orientation.
Place of surgery between 24 and 28 SA
• Abstention if the IOTA criteria are benign.
Figure 5: IOTA B1 criterion: single-eyed cyst in 2D and 3D.
Presence of solid elements, the largest of which has a diameter < 7 mm
Figure 6: IOTA B2.
Presence of Acoustic Shadow
Figure 7: IOTA B3.
Multilocular Smooth Tumor with Diameter < 100 mm
Figure 8: IOTA B4.
No blood flow (color score 1)
Figure 9: Criterion IOTA B5.
Irregular Solid Tumor
Figure 10: IOTA M1 criterion.
Presence of ascites
Figure 11: Criterion IOTA M2. Text in the papillary structure >=4
Figure 12: IOTA M3 criterion. Text in ImageMulti-locular solid tumor with maximum diameter >=100 mm
Figure 13: IOTA M4 criterion.
Very large blood flow (color score 4)
Figure 14: Criterion IOTA M5.
→ If one or more "M" characteristics apply in the absence of "B" characteristics, the mass is classified as malignant.
→ If one or more "B" characteristics apply in the absence of "M" characteristics, the mass is classified as benign.
→ If "M" and "B" characteristics apply, mass cannot be classified.
→ If none of the characteristics apply, mass cannot be classified.
** P. CAPMAS*, B. BENOIT***, H. FERNANDEZ*, A.-G. POURCELOT*
*CHU du Kremlin-Bicêtre,
**CHI de Créteil, CEFFE Créteil,
***Hôpital Princesse Grâce de Monaco
References
Click on the references and access the Abstracts on
1. Whitecar MP, Turner S, Higby MK. Adnexal masses in pregnancy: a review of 130 cases undergoing surgical management. Am J Obstet Gynecol 1999 ; 181(1) : 19-24. Search the abstract2. Bernhard LM, Klebba PK, Gray DL, Mutch DG. Predictors of persistence of adnexal masses in pregnancy. Obstet Gynecol 1999 ; 93(4) : 585-9. Search the abstract
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