Adnexal arteriovenous malformation presenting with spontaneous massive haemoperitoneum.

Arteriovenous malformations (AVMs) are vascular anomalies composed of a tangle of abnormal vessels in which one or more feeding arteries are directly connected to one or more draining veins via a nidus with no intervening capillary bed. The adnexa are particularly rare sites for the formation of such malformations. Here, we present the case of a middle-aged woman who presented with spontaneous massive haemoperitoneum occurring as a result of a ruptured adnexal AVM. The diagnosis was suspected on transabdominal sonography and confirmed on CT angiography. The patient was shifted to the interventional radiology suite for an urgent angioembolisation following which she improved haemodynamically and her symptoms resolved. The case highlights the fact that although exceedingly rare, gonadal AVMs are an important cause of spontaneous intraperitoneal bleeding. Diagnostic and interventional radiology play an important role in the early and accurate diagnosis of this entity, and angioembolisation can be lifesaving in such patients.

Neurovascular and lymphatic vessels distribution in uterine ligaments based on a 3D reconstruction of histological study: to determine the optimal plane for nerve-sparing radical hysterectomy.

OBJECTIVE: To present the distribution of neurovascular and lymphatic vessels in uterine ligaments using 3D models based on the pathological staining of serial 2D sections of postoperative specimens. METHODS: Serial transverse sections of fresh uterine ligaments from a patient with stage IB1 cervical squamous cell carcinoma were studied using the computer-assisted anatomic dissection (CAAD) technique. The sections were stained with hematoxylin and eosin, Weigert elastic fibers, D2-40 and immunostainings (sheep anti-tyrosine hydroxylase and rabbit anti-vasoactive intestinal peptide). The sections were then digitalized, registered and reconstructed three-dimensionally. Then, the 3D models were analyzed and measured. RESULTS: The 3D models of the neurovascular and lymphatic vessels in uterine ligaments were created, depicting their precise location and distribution. The vessels were primarily located in the upper part of the ligaments model, while the pelvic autonomic nerves were primarily in the lower part; the lymphatic vessels were scattered in the uterine ligaments, without obvious regularity. CONCLUSION: CAAD is an effective anatomical method to study the precise distribution of neurovascular and lymphatic vessels in uterine ligaments. It can present detailed anatomical information about female pelvic autonomic innervation and the spatial relationship between nerves and vessels and may provide a better understanding of nerve-sparing radical hysterectomy.

Can adnexal torsion be predicted by measuring plasma heat shock protein 70 level? An experimental study.

OBJECTIVE: To investigate the effect of adnexal torsion on the plasma heat shock protein 70 level and to determine whether plasma heat shock protein 70 can be used in the adnexal torsion diagnosis. MATERIALS AND METHODS: Twenty-one nulligravid 3-month-old female Wistar albino rats were randomly and equally allocated into three groups: study group (ovarian torsion) (n = 7), laparotomy group (sham operation) (n = 7) and control group (received no special treatment) (n = 7). Ovarian torsion model was created by twisting the right adnexa two times around its pedicle and fixing over the lateral pelvis with 6.0 polyglactin absorbable surgical suture. Blood was sampled before and 12 h after operation to assess plasma heat shock protein 70 level. RESULTS: In the study group, the mean plasma heat shock protein 70 level was significantly higher than that in the laparotomy and control groups (1.75 ± 0.25), (1.16 ± 0.99), (1.19 ± 0.11) ng/ml, respectively, P = 0.001), following 12 h of ovarian torsion. CONCLUSION: A significant increase in plasma heat shock protein 70 level in the study group indicates that plasma heat shock protein 70 level could be used as a serum marker in the early detection of adnexal torsion. However, further clinical and experimental studies of a larger size are required.

Quantifying tumor vascular heterogeneity with DCE-MRI in complex adnexal masses: A preliminary study.

PURPOSE: To evaluate the value of quantifying dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) heterogeneity to characterize adnexal masses. MATERIALS AND METHODS: Our database was retrospectively queried to identify all surgically proven adnexal masses characterized with a 1.5T DCE-MRI between January 1st 2008 and February 28th 2010 (n = 113 masses, including 52 benign, 11 borderline, and 50 invasive malignant tumors). The solid component of the adnexal mass was segmented. Quantitative analysis with a compartmental model was performed to calculate microvascular parameters, including tissue blood flow (FT ), blood volume fraction (Vb ), lag time (DAT ), interstitial volume fraction (Ve ), permeability-surface area product (PS), and relative area under curve (r AUC), were calculated. Then heterogeneity parameters were evaluated using the analysis of the evolution of the standard deviation (SD) of signal intensities on DCE-MRI series. The area under the receiver operating characteristic (AUROC) curve was calculated to assess the overall discrimination of parameters. RESULTS: Malignant tumors displayed higher FT , Vb , and r AUC and lower DAT than benign tumors (P = 0.01, P < 0.0001, and P < 0.0001, respectively). Invasive malignant tumors displayed lower Vb and r AUC than borderline tumors (P < 0.01). After injection, whenever the heterogeneity parameter was considered, malignant tumors were more heterogeneous than benign tumors, invasive tumors were more heterogeneous than borderline ovarian tumors, and malignant tumors with carcinomatosis were more heterogeneous than tumors without carcinomatosis (P < 0.001). The most discriminant parameter was the SD during the 90 seconds after injection related to arterial input function (ΔSDEARLY/AIF ) with an AUROC between 0.715 and 0.808. CONCLUSION: This study proposes heterogeneity parameters as a new tool with a potential for clinical application, given that the technique uses routine imaging sequences. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;46:1776-1785.

The biochemical and histologic effects of adnexal torsion and early surgical intervention to unwind detorsion on ovarian reserve: an experimental study.

OBJECTIVE: The aim of the present study was to determine to what extent ovarian reserves are affected by ischemia-reperfusion injury, evaluating the number of growing follicles and the serum levels of the ovarian hormones. STUDY DESIGN: Thirty female fertile adult Wistar albino rats, weighing 200 to 220 g, were previously numbered to randomization, and then randomly divided into 3 equal groups (n = 10): sham, torsion, and detorsion groups. In torsion and detorsion groups, bilateral adnexal torsion (3-hour ischemia) was carried out. Bilateral adnexal detorsion (3-hour reperfusion) was performed in the detorsion group. RESULTS: The mean number of preantral and small antral follicles in detorsion group were lower than those of the sham group (P < .01). After torsion, anti-Müllerian hormone (AMH), estradiol, and inhibin B levels decreased significantly compared to the preoperative and postoperative periods (P = .003, P = .032, and P = .014, respectively). In detorsion group, only AMH levels were found to decrease significantly following the 3-hour ischemia and 3-hour reperfusion (P < .05). CONCLUSION: After adnexal torsion, a significant decrease in ovarian reserve has been detected for the first time in this study. Additionally, the results of this study suggest that conservative surgery alone is insufficient to protect ovarian reserve.

Spleno-parametrial ectopic varices: an unusual porto-systemic shunt in portal hypertension.

BACKGROUND: Cirrhotic liver disease commonly is complicated by portal hypertension, and the resultant porto-systemic shunts are an important cause of morbidity and mortality in cirrhotic patients. Identification of these shunts and their management is an important part of the medical care provided to this population. CASE: We present the case of a patient with nonalcoholic steatohepatitis or nonalcoholic fatty liver disease and resultant portal hypertension who developed an unusual porto-systemic shunt, which at first was thought to represent a highly vascular gynecologic mass. The splanchnic blood was shunted through a recanalized vein interconnecting the splenic vein with the parametrial venous plexus. CONCLUSION: Unrecognized portal hypertension and resultant porto-systemic shunts may mask themselves as vascular masses and result in catastrophic surgical outcomes if not fully characterized preoperatively.

Adnexal torsion: a literature review.

This review of the literature focuses on the diagnosis and surgical management of adnexal torsion. Diagnosis of adnexal torsion is difficult and is based on a range of elements obtained by questioning, clinical examination and additional investigations. Pelvic and Doppler ultrasonography are often incapable of revealing this pathology. When adnexal torsion is suspected and diagnosis can only be achieved by surgery, arrangements should be made for laparoscopy as soon as possible. Treatment consists essentially of untwisting the adnexa, even when necrosed, and completed as required by treatment of any cyst present and/or ligamentopexy.

Construction and clinical significance of normal uterine arterial vascular network models.

AIMS: To construct in vitro models of normal uterine arterial vascular network through vascular corrosion casting and explore their characteristics and clinical significances. METHODS: Three sets of uterus, vagina and bilateral adnexa were perfused and cast via uterine artery and ovarian artery, using 25, 20 and 15% chlorinated poly vinyl chloride, respectively, and constructed into models one, two and three of the uterine arterial network correspondingly, followed by observing their characteristics. RESULTS: There existed important similarities and differences among the three models in displaying uterine arterial network: in model one, the uterine arterial trunk, its branches and partial spiral arteries were sharply demonstrated except the tiny ones; model two further displayed the communicating branches between bilateral spiral arteries, the arterial vascular network of ovarian artery and the anastomoses between the arterial blood supply of uterus and ovaries; model three presented the tiny branches, especially the obvious communicating branches, the complete arterial vascular network of ovary and fallopian tube and anastomoses between them. CONCLUSIONS: A panorama of the uterine arterial vascular network is obtained under organic combination of the three models, which is surely promising for clinical teaching, selections of different approaches and interventional therapy in obstetrics and gynecology.

Three-dimensional power Doppler vascular network assessment of adnexal masses: intraobserver and interobserver agreement analysis.

OBJECTIVE: The purpose of this study was to assess intraobserver and interobserver agreement for tumor vascular network evaluation as assessed by 3-dimensional (3D) power Doppler sonography for discriminating benign from malignant adnexal masses. METHODS: Stored 3D power Doppler angiographic volume data from 39 women with a diagnosis of a vascularized adnexal mass who were evaluated and treated at our institution were retrieved from our database for analysis. Two different examiners (observer A, with 6 years of experience in 3D sonography; and observer B, with 1 year of experience) reviewed 3D sonograms blinded to each other. Three-dimensional vascular network reconstruction was done with surface rendering in the color mode. Malignancy was considered in the presence of at least 2 of the following: irregular branching, vessel caliber changes, microaneurysms, and vascular lakes. A definitive histologic diagnosis was obtained in all cases. Intraobserver and interobserver agreement rates were estimated by calculating the kappa index. RESULTS: Twenty (51%) tumors were malignant, and 19 (49%) were benign. Intraobserver agreement was good for observer A (kappa = 0.69) and moderate for observer B (kappa = 0.54). Interobserver agreement was moderate (kappa = 0.49). CONCLUSIONS: We found intraobserver and interobserver agreement to be moderate for 3D power Doppler assessment of the vascular network in adnexal masses.

Intraobserver and interobserver reproducibility of 3-dimensional power Doppler vascular indices in assessment of solid and cystic-solid adnexal masses.

OBJECTIVE: The purpose of this study was to assess the intraobserver and interobserver reproducibility of 3-dimensional (3D) power Doppler angiography-derived vascular indices in evaluation of vascularized solid and cystic-solid adnexal masses. METHODS: Stored 3D power Doppler angiographic volume data from 12 consecutive women with a diagnosis of a complex adnexal mass (6 cystic-solid and 6 solid) evaluated and treated at our institution were retrieved from our database for analysis. Two examiners performed the calculations blinded to each other. Calculations were performed offline in a computer using Virtual Organ Computer-Aided Analysis software (plane A, 9 degrees rotation step) to assess volume and vascularization (vascularization index, flow index, and vascularization-flow index) from solid areas within the tumor. In all cases, a definitive histologic diagnosis was obtained. Intraobserver and interobserver reproducibility was assessed by calculating the intraclass and interclass correlation coefficients for each index. RESULTS: All tumors proved to be malignant after surgical removal. Intraobserver reproducibility for both examiners and interobserver reproducibility were high for all indices (interclass correlation coefficient > 0.95). CONCLUSIONS: Three-dimensional power Doppler angiography is a reproducible technique for offline assessment of stored 3D volume data of vascularized adnexal masses.

Allograft en bloc vagino-utero-ovarian avascular transplant versus autograft implantation in rats.

OBJECTIVES: The aim of this study was to compare the results of an allograft en bloc vagino-uteroovarian avascular transplant with those of autograft implantation in rats. MATERIALS AND METHODS: Thirty-four inbred adult virgin female Albino rats (age range, 10 - 12 weeks) were divided into 2 groups: the control group (autograft, n=11) and the study group (en bloc vagino-utero-ovariectomy, n=23). In the study group, the uterus and adnexa and the ovaries of the donor rat were transplanted to the recipient animal. Twenty-five to 30 days after that procedure, all rats were killed, and the samples were assessed histopathologically. No immunosuppressive drugs were used. RESULTS: Ten rats died during the postoperative period. In 16 rats, the transplanted system had survived completely at the conclusion of the study. In each of the study groups, complete survival of the uterus and ovaries was noted in 8 rats (34.8% in the study group and 72.8% in the control group). In all rats except 1, histopathologic examination did not reveal any signs of the classic criteria for tissue rejection reaction. The lack of revascularization, nonspecific signs of inflammation, and the presence of large granular lymphocytes and natural killer cells were reported. CONCLUSIONS: Our data indicated that the outcome of both allograft and homograft avascular en bloc transplant of vagino-utero-ovariectomy in rats was successful, and that immunologic rejection did not seem to have an important role in those procedures.

[Power Doppler Index for preoperative ovarian tumors discrimination]. / Valeur de l'index de vascularisation (Power Doppler Index) pour la discrimination des masses ovariennes en préopératoire.

OBJECTIVE: To assess the performance of a power doppler vascularity index in the preoperative diagnosis of ovarian malignancy. PATIENTS AND METHODS: Two successive series of adnexal masses (N=101 and N=82) were examined prospectively with power Doppler before surgical treatment. A vascularity index, called Power Doppler Index (PDI), based on the number of colored pixels, was estimated on selected frames (defined region of interest covering the entire tumor) of the tumors using an in house color-quantifying program. The first study was monocentric to test the inter- and intraobserver reproducibilities and the availability of the parameter. The second was multicentric to validate the first results. The sensitivity and specificity of PDI, resistance index (RI) and subjective visual scoring were compared using receiver operating characteristic (ROC) curves. RESULTS: Histology identified 23 malignant and 78 benign lesions in the first study and 34 malignant and 48 benign tumors in the second. PDI was considerably higher in malignant than in benign lesions (0.34+/-0.04 vs 0.12+/-0.06 (P<0.001)). Intra-observer and interobserver variability of PDI was low (intraclass correlation coefficients estimated at 0.99 and 0.98, respectively). The PDI cut-off value for differential diagnosis was set at 0.265 (26.5% of the tumor is colored) in the first study and 0.107 in the second. Sensitivity and specificity were 100% (95% CI [87.8; 100.0]) and 97.4% (95% CI [91.0; 99.7]), respectively, for PDI in the first study compared to 75% (95% CI [72.9; 90.7]) and 60% (95% CI [56.3; 92.5]) in the second study. Using logistic regression, visual Doppler scoring performed best. DISCUSSION AND CONCLUSION: The Power Doppler Index obtained using our color quantifying software has discriminating power for adnexal masses but visual Doppler scoring performs best.

Sonographic findings of ovarian torsion in children.

BACKGROUND: The clinical diagnosis of ovarian torsion is challenging and findings on pelvic sonography can be pivotal in making the correct diagnosis. OBJECTIVE: To determine the sonographic characteristics in children of surgically and pathologically proven ovarian torsion. MATERIAL AND METHODS: We performed a retrospective review of the sonograms and medical records of 41 patients with surgically and pathologically proven ovarian torsion at a pediatric hospital between 1994 and 2005. All sonograms were reviewed retrospectively by two pediatric radiologists with attention to the size, echotexture, location, presence of peripheral round cysts, and evidence of flow on Doppler sonography within the torsed ovary. The amount of free pelvic fluid was also recorded. RESULTS: The most common sonographic finding of ovarian torsion was an enlarged ovary/adnexal mass. All torsed adnexa were larger than the normal contralateral ovary, with the median volume 12 times that of the normal contralateral side. The majority (61%, n = 25) of the torsions occurred on the right. Color flow, either venous or arterial, was present in 62% (n = 21/34) of the torsed ovaries for which flow on Doppler sonography was documented. In 63% of the torsed ovaries (n = 26), the torsed adnexa appeared heterogeneous. Ovarian or para-ovarian pathology that may have acted as a potential lead point was present in 55% (n = 24) of torsed ovaries. The volume ratio of the torsed to normal ovary can predict the presence of an ovarian mass within the torsed ovary. In 70% of torsed ovaries with a volume ratio greater than 20, an ovarian mass was present, and in approximately 90% of those with a volume ratio less than 20, an internal mass was absent. CONCLUSION: An enlarged heterogeneous appearing ovary is the most common finding in ovarian torsion. The presence or absence of flow by Doppler sonography is not helpful in the diagnosis. The volume ratio of the torsed to the normal ovary can predict the presence of an internal mass within the torsed adnexa.

Ultrasonido oncológico 3D y sus nuevas proyecciones / 3D gynecological ultrasound: new projections

Con el desarrollo de los equipos de alta resolución junto con mejorar la calidad de las imágenes cada vez es más complejo realizar un examen completo en especial en ginecología donde la imagen 2D como verán sigue siendo la base. Pero para avanzar en la orientación diagnóstica, cada vez más, se hace necesario utilizar el Power Doppler, la ultrasonografía 3D y el análisis de perfusión vascular mediante el programa de Vocal. Estas nuevas técnicas de ultrasonido se puede utilizar en la mayoría de las patologías por ejemplo en las masas anexiales donde su mayor utilidad esta dado en los tumores sólidos. A nivel endometrial ayuda a definir aquellas pacientes que es necesario complementar su estudio con biopsia de endometrio y/o histeroscopía y en el cuello uterino tiene utilidad en cáncer de cuello definiendo aquellas pacientes que van ha tener buena mala respuesta a la terapia cooayudante.

The author presents several applications and technologies for diagnosis of benign and malignant gynecological masses ultrasound new technology does not make histological diagnosis but new applications like 3D and 4D, vascular perfusion with Vocal program, and Power Doppler are useful in studies of solid and cystic tumors.

Power Doppler vascularity index for predicting malignancy of adnexal masses.

OBJECTIVE: To assess the performance of a power Doppler vascularity index in the preoperative diagnosis of ovarian malignancy. METHODS: Adnexal masses (n = 101) were examined prospectively with power Doppler ultrasonography before surgical treatment. The tumor vascularity index (power Doppler index, PDI) was determined by quantification of the number of pixels in a defined region of interest according to the formula: number of colored pixels/(total number of pixels minus the number of pixels in the fluid or avascular areas). It was estimated on selected frames of the tumors using an in-house color-quantifying program added to MATLAB 6.0 software. Inter- and intraobserver reproducibilities of PDI assessment were evaluated. Intratumoral blood flow velocity waveforms were obtained to determine the lowest resistance index (RI). A subjective visual score of power Doppler signals in the tumor was used to classify it as having low, moderate or high vascularity. The discriminatory ability of this score was compared to that of RI and PDI measurement. RESULTS: Histology identified 23 malignant and 78 benign lesions. The PDI was considerably higher in malignant than in benign lesions (0.34 +/- 0.04 vs. 0.12 +/- 0.06; P < 0.001). The intra- and interobserver variabilities of PDI were low (intraclass correlation coefficients of 0.99 and 0.97, respectively). The PDI cut-off value to differentiate malignant from benign tumors was set at 0.265 (26.5% of the tumor being colored). Using this cut-off, sensitivity and specificity were 100% (95% CI, 87.8-100.0) and 97.4% (95% CI, 91.0-99.7) compared to 78.3% (95% CI, 56.3-92.5) and 83.1% (95% CI, 72.9-90.7) for RI (cut-off value of 0.53) and 78.3% (95% CI, 56.3-92.5) and 94.9% (95% CI, 87.4-98.6) for visual scoring. Logistic regression demonstrated that PDI was the best parameter for differentiating between malignant and benign tumors. CONCLUSION: The power Doppler vascularity index obtained using customized color quantifying software has high diagnostic value in discriminating between benign and malignant adnexal masses.

Three-dimensional power Doppler vascular sampling: a new method for predicting ovarian cancer in vascularized complex adnexal masses.

OBJECTIVE: The purpose of this study was to explore the role of a new concept ("vascular sampling") as a third step to discriminate benign and malignant lesions in B-mode and color Doppler sonographically suggestive adnexal masses. METHODS: Forty-five women (mean age, 52.3 years; range, 17-82 years) with the diagnosis of complex adnexal masses on B-mode sonography were evaluated using 3-dimensional power Doppler sonography. Four women had bilateral masses. After a morphologic reevaluation was done, color pulsed Doppler sonography was used to obtain flow velocity waveforms, and velocimetric indices were calculated (resistive index, pulsatility index, and peak systolic velocity). Thereafter, 3-dimensional power Doppler sonography was used to assess vascularization of highly suggestive areas (gross papillary projections, solid areas, and thick septations), meaning a focused assessment ("sampling") of a suggestive area of the tumor. With a virtual organ computer-aided analysis program, vascular indices (vascularization index, flow index, and vascular flow index) were automatically calculated. A definitive histologic diagnosis was obtained in each case. RESULTS: Forty masses (82%) were malignant and 9 (18%) were benign. Morphologic evaluation revealed 10 (20%) unilocular solid masses, 20 (41%) multilocular solid masses, and 19 (39%) mostly solid masses. Blood flow was found in all cases. Median vascularization index (15.5% versus 8.2%; P = .002), flow index (33.6 versus 20.8; P = .007), and vascular flow index (5.2 versus 2.3; P = .001) were significantly higher in malignant tumors. No differences were found in resistive index (0.43 versus 0.45; P = .770), pulsatility index (0.62 versus 0.65; P = .694), and peak systolic velocity (15.6 versus 12 cm/s; P = .162). CONCLUSIONS: Three-dimensional power Doppler vascular sampling seems to be a promising tool for predicting ovarian cancer in vascularized complex adnexal masses. It could be better than conventional color pulsed Doppler imaging.

Transvaginal power Doppler ultrasound in pelvic congestion.

PURPOSE: Pelvic congestion is diagnosed by transuterine venography, an invasive procedure requiring sedation and irradiation. Ultrasound may be an alternative but is hindered by slow flow within pelvic veins. In an attempt to counter this, we investigated the possible role of transvaginal power Doppler ultrasound. MATERIAL AND METHODS: 42 women with a clinical suspicion of pelvic congestion underwent transvaginal ultrasound. Adnexal veins were examined and a congestion score established. Planimetric measurements of adnexal vessels were obtained using power Doppler ultrasound, and uterine and ovarian morphology noted. All women then underwent transuterine venography and agreement with the ultrasound congestion score and morphologic features was determined. RESULTS: There was a trend towards weak positive correlation between ultrasound and venography congestion scores (r = 0.29, p = 0.06). However, agreement between scores was poor on an individual basis (95% limits of agreement, -3.9 to +2.7). Planimetric power Doppler assessments of adnexal vascularity were unrelated to venographic congestion. Instead, there was correlation between the number and diameter of ovarian follicles and venographic congestion: women with congestion tended to have significantly more (0.04) and smaller follicles (p = 0.001). CONCLUSION: There was poor individual agreement between ultrasound and venographic estimates of congestion. However, there was a direct relationship between venographic congestion score and ovarian morphology.