B-mode and Power Doppler Ultrasound in Adnexal Masses 31 B-mode and Power Doppler Ultrasound in Adnexal Masses Stefano Guerriero, Silvia Ajossa, Nicoletta Garau, Anna Maria Paoletti, Valerio Mais, Bruno Piras, Enrico Silvetti, Stefano Angioni, Marco Angiolucci, Monica Pilloni, Gian Benedetto Melis Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy Correspondence: Stefano Guerriero, Department of Obstetrics and Gynecology of the University of Cagliari, Ospedale San Giovanni di Dio, Via Ospedale 46, 09124, Cagliari, Italy Phone: +39-070-6092467, Fax: +39-070-668575, e-mail: gineca.sguerriero@tiscali.it Donald School Journal of Ultrasound in Obstetrics and Gynecology, January-March 2009;3(1):31-40 Abstract Adnexal masses can be classified in ovarian, paraovarian or tubal. In the present review we analyzed the diagnostic performance of transvaginal ultrasonography in identifying simple ultrasonographic findings of benign adnexal pathology but also the role of color Doppler in the differential diagnoses between benign and malignant masses and in the preoperative triage. Because of many kinds of adnexal masses have usually a typical ultrasound appearance, the results of the studies present in literature showed a good and sufficient diagnostic accuracy. Unfortunately some cases with uncertain findings are present and in these cases the addition of color Doppler can be useful as demonstrated by several authors. Using the location of flow evaluated using color Doppler as main parameter a mass should be graded as malignant if flow is shown centrally within the excrescences or solid areas. The same approach should be used to triage the patients with adnexal masses to the most appropriate surgical approach with an increase of less invasive surgery. Keywords: B-mode ultrasonography, power Doppler, adnexal masses, ovary, ovarian cancer, transvaginal ultrasonography. INTRODUCTION Adnexal masses can be classified in ovarian, paraovarian or tubal. Several papers have been published in these last 20 years about ultrasonographic differential diagnosis of the different kinds of pelvic masses and different authors have described simple findings at B-mode evaluation that characterize benign adnexal masses. 1-21 An improvement in the diagnosis of ovarian cancer can be obtained using Doppler evaluation in those masses suspected to be malignant at B-mode evaluation. We analyzed in the present review the diagnostic performance of transvaginal ultrasonography in identifying simple ultrasonographic findings of benign pelvic pathology but also the role of color Doppler in differential diagnoses between benign and malignant masses and in the preoperative triage. OVARIAN LOCALIZATION Functional or Simple Cyst At ultrasonographic evaluation the follicular cyst appears as unilocular, anechoic smooth walled cyst without endocystic vegetation (Fig. 1). 1 This morphology is not specific and similar sonographic findings may be found in serous cystadenomas. 2 Ninety-three percent of follicular cysts was anechoic and septa were present in 14% of the cases while a vegetation was present only in 3% of the cases. 3 When these B-mode findings are present and the CA125 value is lower than 25 IU/ml, the probability of the presence of functional follicular cysts is high (75%). 3 In addition, other authors correctly suggest that is necessary an observation over a period of 1 to 3 months to make a diagnosis of functional cyst. 4 Corpus-Luteum Cyst This kind of functional cyst, represent approximately 30% of all persistent ovarian masses in reproductive age submitted to surgery. 3 The sonographic appearance of a corpus luteum can mimic many other lesions, also malignant tumors. Brown 5 in a recent review describes hemorrhagic cysts as often having internal echoes with a pattern of fine interdigitating lines that have been variously described as “reticular”, “fishnet”, “lace- Fig. 1: The B-mode findings of follicular cysts: an unilocular, anechoic smooth walled cyst without endocystic vegetation