Improving diagnostic performance of differentiating ocular adnexal lymphoma and idiopathic orbital inflammation using intravoxel incoherent motion diffusion-weighted MRI.

PURPOSE: To investigate the utility of intravoxel incoherent motion diffusion-weighted MRI (IVIM-DWI) derived diffusion and perfusion parameters in differentiating ocular adnexal lymphoma (OAL) from idiopathic orbital inflammation (IOI), and to assess whether IVIM-DWI provides improved diagnostic performance for the distinction. METHOD: Twenty-one patients with OAL and 24 patients with IOI underwent IVIM-DWI. Apparent diffusion coefficient (ADC) and IVIM-DWI parameters including true diffusion coefficient (D), pseudo-diffusion coefficient (D*), and perfusion fraction (f) were measured in lesions by two independent radiologists. The MRI parameter differences between OAL and IOI were tested using two-sample t-test. The receiver operating characteristic (ROC) analysis curves were used to determine the diagnostic performance of significant parameters for differentiation between OAL and IOI. RESULTS: The ADC, D, and f were lower in OAL than those in IOI (ADC = 0.78 ± 0.12 vs. 0.99 ± 0.16 × 10-3 mm2/s, P < 0.001; D = 0.34 ± 0.15 vs. 0.76 ± 0.25 × 10-3 mm2/s, P < 0.001; f = 0.31 ± 0.06 vs. 0.41 ± 0.08 × 100 %, P < 0.001). There was no significant difference in D* between OAL and IOI (P = 0.235). The optimal cut-off values of ADC, D, and f in differentiating OAL from IOI were 0.83 × 10-3 mm2/s, 0.56 × 10-3 mm2/s, and 0.36 × 100 %, respectively. No significant differences were found in areas under the curve (AUCs) among ADC, D and f (all P > 0.05). The combination of D and f provided significantly higher AUC than ADC (AUC = 0.984 vs. 0.838, Z = 2.128, P = 0.033), and had higher sensitivity of 95.24 %, specificity of 95.83 %, and accuracy of 95.56 %. CONCLUSIONS: IVIM-DWI is valuable in differentiating OAL from IOI, and D combined f can improve the performance of differential diagnosis.

Multifocal Recurrent Microcystic Adnexal Carcinoma.

Microcystic adnexal carcinoma (MAC) is a rare and locally aggressive neoplasm with preponderance for local recurrence but rarely nodal or distant metastasis. A 38-year-old male was referred to our clinic for definitive treatment of known recurrent and concern for multifocal MAC from previous biopsy. The patient was treated with modified Mohs and reconstruction with an anterolateral thigh (ALT) free flap for tissue coverage. This case highlights the rare nature of multifocal MAC, treatment challenges of Mohs clearance versus wide local excision, and reconstructive challenge associated with large post treatment defects.

Usefulness of 18F-FDG PET/CT for evaluating response of ocular adnexal lymphoma to treatment.

The purpose of this study was to investigate the efficacy of F-fluoro-deoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for evaluating the ocular adnexal lymphoma treatment responses.We retrospectively reviewed data for 9 histologically confirmed cases of malignant lymphoma. All patients had at least one ocular adnexal tumor site and underwent FDG PET/CT before and after treatment. Patients' histological disease subtypes included diffuse large B-cell lymphoma (n = 3), mucosa-associated lymphoid tissue lymphoma (n = 2), follicular lymphoma (n = 1), NK/T-cell lymphoma (n = 1), lymphoplasmacytic lymphoma (n = 1), and Hodgkin lymphoma (n = 1). The highest FDG uptake by the ocular adnexal lesions was calculated as the maximum standardized uptake value (SUVmax). FDG uptake at ocular adnexal sites and sites of systemic disease after treatment were also assessed using the 5-point Deauville scale.In 1 of the 9 patients, a conjunctival lesion could not be detected by either pre- or posttreatment PET/CT. For 8 of the 9 patients, the SUVmax value at the ocular adnexal site significantly decreased after treatment (7.1 ±â€Š5.1 vs 1.6 ±â€Š0.58; P = .0196). For 7 of the 9 patients, the first posttreatment FDG uptake at the ocular adnexal site was considered a complete metabolic response, and these patients showed an improved clinical ophthalmic presentation with no relapse at ocular adnexal sites during follow-up.FDG PET/CT is useful for evaluation of the response of ocular adnexal lymphoma to treatment, although its usefulness may depend on the histological subtype and site of the lesion.

Utilization of ultrasound as a diagnostic tool in the preoperative assessment of patients with adnexal masses.

PURPOSE: To evaluate the reliability of ultrasound scan (US) findings in the preoperative assessment of the nature of adnexal masses in females. METHODS: After detailed history, a preoperative US examination was performed in all women. Tumor diameter, localization, the presence of solid, cystic and multilocular components, excrescences, metastasis and free fluid were assessed. Doppler scan was done and pulsatility (PI) and resistance indices (RI) were determined. These data were compared with postoperatively obtained histopathological findings and statistically analyzed. RESULTS: The study included 609 women out of which 20.7% had malignant, 73.7% benign, and 5.6% border-line tumors. Patients with malignant tumors were oldest (p<0.001). There were significantly more positive US parameters in malignant than in benign tumors (p<0.001). Also, there were significant differences (p<0.001) between malignant, benign and borderline tumors regarding all examined US and Doppler parameters except tumor multilocularity. RI had sensitivity 75%, specificity 61.2%, positive predictive value (PPV) 42.70% and negative predictive value (NPV) 96.16%. PI had sensitivity 50%, specificity 35.3%, PPV 8.37% and NPV 25.93%. Sensitivity of US characteristics was 94.34%, specificity 30.62%, PPV 22.27% and NPV 96.25%. CONCLUSIONS: US pattern characteristics and Doppler parameters were found to be moderately reliable in discriminating malignant, benign and borderline adnexal tumors. Tumor of solid or mixed consistency, presence of ascites and excrescences were the best predictors of malignancy.

Risk of malignancy index validity assessment in premenopausal and postmenopausal women with adnexal tumors.

OBJECTIVE: The aim of this study was to investigate the validity of the risk of malignancy index (RMI) in premenopausal and postmenopausal patients with adnexal masses. MATERIALS AND METHODS: The study involved all women treated for adnexal tumors throughout an 18-month period in the Clinic for Gynecology and Obstetrics, Clinical Center of Serbia (Belgrade, Serbia). On admission, detailed anamnestic and laboratory data were obtained and an expert ultrasound scan was performed. The RMI was calculated for all patients and the obtained data were related to histopathological findings of the tumors. For statistical analysis, we used descriptive and analytical statistics methods and an SPSS computer program. RESULTS: From a total number of 540 women, 85 women had malignant tumors; 20 women, borderline tumors; and 435 women, benign adnexal tumors. The RMI was reliable in 84.6% of all patients; in 77% of premenopausal patients, and in 81.1% of postmenopausal patients. The sensitivity of the RMI in the overall population was 83.81%; the specificity was 77.24%; the positive predictive value (PPV) was 47.06%, and the negative predictive value (NPV) was 95.18%. In premenopausal women, the RMI sensitivity was 83.87%; specificity, 80.31%; PPV, 28.89%; and NPV, 98.12%. In postmenopausal women the RMI sensitivity was 83.78%; specificity, 68.18%; PPV, 63.92%; and NPV, 74.71%. CONCLUSION: The RMI was a reliable factor for differentiating benign from malignant adnexal masses in premenopausal and postmenopausal patients.

Estimation of yttrium-90 Zevalin tumor-absorbed dose in ocular adnexal lymphoma using quantitative indium-111 Zevalin radionuclide imaging.

OBJECTIVE: The purpose of this investigation was to estimate radiation-absorbed dose in orbital tumors from yttrium-90 ibritumomab tiuxetan (Zevalin) radioimmunotherapy of ocular adnexal lymphoma. METHODS: Three patients participating in a prospective research protocol involving treatment of ocular adnexal lymphoma with yttrium-90 Zevalin consented to quantitative radionuclide imaging to estimate tumor radiation-absorbed doses. Each patient received 185 MBq of indium-111 Zevalin, followed by serial planar whole-body scanning, to derive an activity versus time curve for the tumor. Single photon emission computed tomography (SPECT) and computed tomography (CT) imaging, including a calibration source, were performed at 24 h on a SPECT/CT scanner, to obtain a SPECT estimate of the radioactivity (in megabequerels) in the tumor and correct the planar curve, as well as estimate the tumor mass (M) from CT. The curve was then converted to that for yttrium-90 at the prescribed activity, and absorbed dose estimated from the area under the curve multiplied by the Medical Internal Radiation Dose S value (Gy per MBq-h) for a sphere of mass M. RESULTS: A right orbital tumor in one patient was visualized in both the planar and SPECT/CT images, with an estimated absorbed dose of 3.57 Gy. Tumor uptake in the other two patients was not visualized. CONCLUSION: The radiation dose to the orbit and ocular structures during radioimmunotherapy of ocular adnexal lymphoma is well below the threshold for significant radiation-induced ocular toxicity and about 10 times lower than that delivered during external beam radiotherapy.

Differential diagnosis of adnexal masses: risk of malignancy index, ultrasonography, magnetic resonance imaging, and radioimmunoscintigraphy.

A risk of malignancy index (RMI), based on menopausal status, ultrasound (US) findings, and serum CA125, has previously been described and validated in the primary evaluation of women with adnexal masses and is widely used in selective referral of women from local cancer units to specialized cancer centers. Additional imaging modalities could be useful for further characterization of adnexal masses in this group of women. A prospective cohort study was conducted of 196 women with an adnexal mass referred to a teaching hospital for diagnosis and management. Follow-up data was obtained for 180 women; 119 women had benign and 61 women malignant adnexal masses. The sensitivity and specificity of specialist US, magnetic resonance imaging (MRI), radioimmunoscintigraphy (RS), and the RMI were determined. We identified a subgroup of women with RMI values of 25-1000 where the value of further specialist imaging was evaluated. Sensitivity and specificity for specialist US were 100% and 57%, for MRI 92% and 86%, and for RS 76% and 87%, respectively. Analysis of 123 patients managed sequentially, using RMI cutoff values of > or =25 and <1000 and then US and MRI provided a sensitivity of 94% and a specificity of 90%. Using this RMI cutoff followed by specialist US and MRI, as opposed to the traditional RMI cutoff value of 250, can increase the proportion of patients with cancer appropriately referred in to a cancer center, with no change in the proportion of patients with benign disease being managed in a local unit.

[The use of 2-dimensional and 3-dimensional color and power-Doppler in the diagnosis of blood flow indices of adnexal tumors]. / Zastosowanie ultrasonografii Dopplerowskiej i sonoangiografii trójwymiarowej w badaniu unaczynienia i przeplywu krwi w guzach przydatków macicy u kobiet.

OBJECTIVES: The purpose of this study was to compare 2-dimensional and 3-dimensional color and power-Doppler as measured with blood flow indices for the prediction of malignancy in complex adnexal masses. METHODS: Two hundred eighty women with complex adnexal masses (mean age, 46,3 years (range, 13-83 years) were evaluated by 2-dimensional and 3-dimensional power-Doppler imaging. Complex adnexal mass was defined as the presence of at least one of the following features: solid areas, thick papillary projections, thick septa, or purely solid echogenicity. Tumor volume, sonomorphology and Doppler indices (PI, RI), as well 3-dimensional power-Doppler assessment (VI, FI, VFI) were calculated. All tumors were surgically removed and definitive histological diagnosis was obtained in each case. Diagnostic accuracy and areas under ROC curve (AUROC's) were calculated for each test. RESULTS: Seventy one tumors (25.3%) were proved to be malignant, and 209 tumors (74.7%) were proved to be benign. Statistically significant differences between benign and malignant tumors were found for PI (1.06 vs 0.76; p = 0.001), RI (0.62 vs 0.51; p = 0.002), VI (0.55 vs 1.52; p = 0.002) oraz VFI (0.18 vs 0.49; p = 0.001). However, the highest sensitivity of 3D indices for malignant tumor detection was found for FI (42.9%). Specificity of 2D and 3D indices was between 93.6% for VI to 98.2% for RI. Accuracy and positive and negative predictive values were fund to be between 66.8% to 79.8%, respectively. AUROC's analysis indicated that the most useful test for the discrimination between benign and malignant tumors was VI followed by VFI and PI with RI. CONCLUSION: Three-dimensional power-Doppler imaging has diagnostic potential for the discrimination of benign and malignant complex adnexal masses, but specific, possibly most vascularised areas of each tumor have to be examined in detail to improve not yet satisfactory predictive values of this method.

Doppler flowmetry in the differentiation of biological characteristics of ovarian cancer.

On basis of ultrasonographic structural criteria and Doppler flowmetry in a group of 76 patients with ovarian cancer, benign lesions were discovered in 59 patients and malignant lesions in 17 patients (77.6% and 22.4%, respectively). Surgical intervention was indicated according to the clinical findings and following of the trend of organ-specific oncomarkers in 32 out of 76 patients (42.1%). The stratification involved 17 patients with sonomorphologically/Doppler-flowmetry - diagnosed malignancy as well as 15 patients with sonographically diagnosed benign ovarian tumor. The clinical findings were histologically verified in all 32 patients. Histology confirmed malignant tumor in 16 patients, 1 histologically borderline malignancy and 15 benign tumors. The Doppler-flowmetry showed 94.1% sensitivity, 93.3% specificity, 93.3% positive predictive value, and 93.75% accuracy.

[Preoperative assessment of asymptomatic adnexal tumors by positron emission tomography and F 18 fluorodeoxyglucose]. / Präoperative Dignitätsbeurteilung asymptomatischer Adnextumoren mittels Positronen-Emissions-Tomographie und F-18-Fluordeoxyglukose.

AIM: To evaluate use of F-18-FDG-PET in assessment of dignity of asymptomatic adnexal masses. METHODS: 85 asymptomatic patients with suspicious, asymptomatic adnexal masses were evaluated. Static FDG-PET (Exact HR+ or ECAT 931) imaging of the abdomen was performed following application of 222-555 MBq F-18-FDG. Iterative reconstruction was applied. PET data were analysed visually, at first without and second together with MRT images. Final diagnosis was made by histopathology. RESULTS: FDG-PET allowed correct identification of 4 of 8 malignant adnexal tumors. False negative results were obtained in 2 adenocarcinomas stage pT1a and 2 borderline-tumors. In 60 out of 77 benign adnexal masses malignancy could be excluded. False positive FDG-uptake, partly because of misinterpretation of gastrointestinal activity, was found in 3 inflammatory processes, 1 teratoma, 1 benign schwannoma, 1 dermoid cyst, 1 benign thecoma, 1 serous cyst, 1 serous cystadenoma, 2 mucinous cystadenomas, 2 corpus luteum cysts, 3 endometriosic cysts and 1 sactosalpinx. The overall sensitivity and specificity of FDG-PET alone were 50% and 78%. Evaluation together with MRT images showed a sensitivity of 50% and a specificity of 86%. CONCLUSION: Sensitivity of FDG-PET in detection of borderline-tumors and early stage ovarian cancer seems to be limited. Low incidence of malignant ovarian tumors requires for assessment of dignity a procedure of high specificity, that is not reached by FDG-PET neither without nor together with MRT images for topographic orientation. Therefore use of FDG-PET for assessment of dignity in suspicious, asymptomatic ovarian tumors is limited.