Step-by-step instructions for detecting whirlpool sign in adnexal torsion / Journal of Rural Medicine

Objective: Adnexal torsion is a common gynecological emergency whose prompt diagnosis is essential because a delay may lead to ovarian dysfunction. Although the whirlpool sign is reliable for diagnosing ovarian cyst torsion, technical difficulties hinder its use by sonographers. Here we developed a systematic approach to visualizing this sign by focusing on the fact that torsion arises from the space between the uterus and the pelvic wall. One must determine the origin of the torsion via transverse imaging of the uterus and follow the twisted ligaments to the ovarian cyst.Patients and Methods: Two women aged 56 (Case 1) and 28 years (Case 2) visited our hospital with lower abdominal pain. Transvaginal ultrasonography showed a 7-cm right ovarian cyst in Case 1 and a 5-cm cyst in the Douglas pouch in Case 2; normal bilateral ovaries and the whirlpool sign were detected in both cases. Under laparoscopic guidance in Cases 1 and 2, an ovarian cyst and a paraovarian cyst were confirmed and removed.Results: Our step-by-step method allowed us to identify the whirlpool sign and confirm adnexal torsion, leading to prompt surgery in both cases.Conclusion: Using a systematic procedure helps less experienced practitioners detect the whirlpool sign.

Massas anexiais: descrição e interpretação ultrassonográfica por IOTA / Adnexal masses: IOTA ultrasound description and interpretation

Este artigo visa apresentar ao médico ginecologista (clínico e/ou cirurgião), de forma prática, a normatização internacional da prática da ultrassonografia ginecológica para avaliação das massas anexiais. Desde 2000, o grupo europeu IOTA (International Ovarian Tumor Analysis) vem colhendo dados e difundindo conhecimento nessa área, de forma a padronizar o exame ultrassonográfico. Quais descritores ecográficos devem ser valorizados, como devem ser descritos e medidos, como aplicar o estudo Doppler e como interpretar a presença ou ausência desses descritores ecográficos na diferenciação das massas anexiais benignas de malignas, inferindo o risco de malignidade das massas, tudo isso está bem definido.(AU)

The main aim of this article is to present to gynecologists (clinicians and/or surgeons) the practical international gynecological ultrasound standardization for adnexal masses assessment. Since 2000, European group IOTA (International Ovarian Tumor Analysis) has been collecting data and disseminating knowledge in order to standardize ultrasound examination. It is already well-defined which ultrasound features should be described and measured, how power/color Doppler have to be applied and how the presence or absence of these features can differentiate benign from malign masses, inferring tumors malignancy risk.(AU)

Comparación de tres índices ecográficos para evaluación del riesgo de malignidad de los tumores anexiales / Comparison of three ultrasound index in evaluating the risk of malignancy of adnexal tumors

Resumen Objetivo: Determinar y comparar el rendimiento diagnóstico de las Reglas Ecográficas Simples (RES), Índice Morfológico Ecográfico (IME) e Índice de Riesgo de Malignidad de Jacobs (IRM) en el diagnóstico de benignidad o malignidad de un tumor anexial. Material y método: Estudio retrospectivo, transversal y analítico efectuado en el Hospital Militar de Especialidades de la Mujer y Neonatología de la Ciudad de México. Se incluyeron pacientes con diagnóstico ecográfico de tumor anexial intervenidas quirúrgicamente. Se estudió el rendimiento diagnóstico de los índices comparado con el diagnóstico histopatológico mediante tablas de contingencia. Resultados: Se analizaron 141 pacientes y 166 tumores; 22 casos fueron bilaterales. De la muestra analizada, 79 eran pacientes premenopáusicas y 62 posmenopáusicas. Los casos de neoplasia maligna fueron 43 (26%) y benigna 123 (74%). El Índice Morfológico Ecográfico tuvo sensibilidad de 98.8%, especificidad de 33.3%, valor predictivo positivo de 33.9% y valor predictivo negativo de 97.6%. Las Reglas Ecográficas Simples reportaron una sensibilidad de 97.2%, especificidad de 71.1%, valor predictivo positivo de 55.6% y valor predictivo positivo de 98.6%; y el Índice de Riesgo de Malignidad de Jacobs una sensibilidad de 72.7%, especificidad de 79.3%, valor predictivo positivo de 55.8% y valor predictivo positivo de 89.4%. Conclusiones: Las Reglas Ecográficas Simples son un modelo prequirúrgico que en 82% de los casos permitieron clasificar los tumores anexiales en benignos o malignos. Los casos indeterminados deben ser reevaluados por un ecografista experto. El método es reproducible por evaluadores de mediana experiencia y susceptible de aplicarse en instituciones hospitalarias de segundo y tercer nivel de atención.

Abstract Objective: To determine and compare the diagnostic performance of the Simple Ultrasound-Based Rules (SUR), Sonographic Morphology Index (SMI) and the Jacob´s Risk Malignancy Index (RMI) in the diagnosis of benignity or malignancy to an adnexal tumor. Materials and methods: Retrospective, cross-sectional and analytical study at the at the Hospital Militar de Especialidades de la Mujer y Neonatología of Mexico City. Patients with ultrasound diagnosis of adnexal tumor who underwent surgery were included. The diagnostic performance of the indices compared to histopathological diagnosis was studied using contingency tables. Results: 141 women and 166 tumors were included for analysis, 22 cases were bilateral. Of the sample analyzed, 79 were premenopausal and 62 postmenopausal. Cases of malignant neoplasm were 43 (25.9%) and benign 123 (74.1%). The SMI had a sensitivity of 98.8%, specificity of 33.3%, positive predictive value (PPV) of 33.9%, and negative predictive value (NPV) of 97.6%. SUR showed a sensitivity of 97.2%, specificity of 71.1%, PPV of 55.6% and NPV of 98.6%; And RMI had a sensitivity of 72.7%, specificity of 79.3%, PPV of 55.8% and NPV of 89.4%. Conclusions: The simple ultrasonographic rules are a presurgical model that in 82% of the cases allowed to classify the adnexal tumors in benign or malignant. Indeterminate cases should be reevaluated by an expert sonographer. The method is reproducible by evaluators of medium experience and susceptible of being applied in hospital institutions of the second and third level of care.

Telarca precoz / Precocious thelarche

Introducción: telarca precoz está definida por la presencia de desarrollo mamario antes de los ocho años de edad, en ausencia de otros signos clínicos de maduración sexual. Material y métodos: se estudiaron a las niñas menores de ocho años de edad, atendidas en el consultorio de endocrinología pediátrica del Hospital Santa Cruz, durante cinco años, que acudieron a consulta por presentar telarca precoz. Resultados: se atendieron 119 niñas; el 70% de ellas era menor de dos años; la mayoría (86% del total) presentaba talla adecuada para la edad; se diagnosticó sobrepeso en el 33% de las pacientes (n=39) y obesidad en el 10% de los casos (n=12); la edad ósea se encontró acorde a la edad cronológica en 108 niñas (91% del total), siendo la ecografía ginecológica normal al igual que los niveles plasmáticos de LH y FSH (rango prepuberal), prolactina, estradiol y TSH, en 116 pacientes (97% de los casos). Se diagnosticó pubertad precoz en tres niñas y 116 pacientes (97%) presentaron telarca precoz. Conclusión: la telarca precoz no siempre es una condición autolimitada; es importante controlar periódicamente a las niñas afectadas.

Introduction: the precocious thelarche is defined by the presence of breast development before eight years of age, in the absence of other clinical signs of sexual maturation. Methods: we studied girls under eight years old, attended at the pediatric endocrinology clinic of the Hospital Santa Cruz, during five years, who went to the doctor because of thelarche. Results: we attended 119 girls, 70% of them were younger had two years, most (86% of total) had age appropriate stature, overweight was diagnosed in 33% of patients (n=39) and obesity in 10% of the cases (n=12), bone age was found according to chronological age in 108 girls (91% of total), with normal gynecological ultrasound as plasma levels of LH and FSH (prepubertal range), prolactin, estradiol and TSH in 116 patients (97% of cases). Precocious puberty was diagnosed in three girls; 116 patients (97% of the total) had precocious thelarche. Conclusions: the precocious thelarche is not always a self-limited condition, so it is important to periodically check the girls affected.