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1
oriGinal scientific PaPer oriGinalni naUČni rad oriGinal scientific PaPer
Corresponding author: Qays Ahmed Hassan,
University of Baghdad, Al-Kindy College of Medicine, Al-Nahdha square
Postal address: 10071 University of Baghdad, Baghdad, Iraq, E-mail: qtimeme@yahoo.com, Cell phone: 9647722604163
Ser J Exp Clin Res 2017; 1-1
DOI: 10.2478/SJECR20180069
aBstract
e aim of this study was to evaluate ovarian masses with
conventional grey scale ultrasonography and colour Doppler fl ow
imaging and to assess the diagnostic reliability of these methods in
diff erentiating benign and malignant ovarian masses.
We assessed 56 patients with an ovarian mass. Morpho-
logical characterisation of the mass was performed utilising
the Sassone score. Colour Doppler parameters were recorded
for each patient, and the Caruso vascular score was also ap-
plied. e results were compared with surgical/pathological
and/or follow-up scans.
Using the Sassone score, overall reliability in diff erentiat-
ing ovarian masses had a sensitivity of 89.5% and a specifi c-
ity of 78.4%. Using the Caruso score alone, we found a sensi-
tivity of 89.5% and a specifi city of 86.5%. Using the Sassone
and Caruso scores together, we found a sensitivity of 94.7%
and a specifi city of 89.1%.
Combining both morphological and colour Doppler
scores in the evaluation of ovarian masses obtained higher
specifi city, sensitivity, and accuracy than was obtained using
a single score only.
Keywords: Ovarian mass, Ultrasonography, Vascular
score, Malignant, Benign.
role of coMBininG coloUr doPPler and GreY scale
UltrasoUnd in differentiatinG BeniGn
froM MaliGnant oVarian Masses
Muna Abid Al-Ghani Zghair1, Qays Ahmed Hassan2, Rana Ahmed Mahdi3
1Assistant Professor, Section of Radiology, Department of Medicine, College of Medicine, Al-Mustansiriyah University, Baghdad, Iraq.
2Assistant Professor, Division of Radiology, Department of Surgery, Al-Kindy College of Medicine, University of Baghdad, Baghdad, Iraq.
3Radiologist Specialist, Department of Radiology, Al-Yarmook Teaching Hospital, Baghdad, Iraq.
UloGa KoMBinoVane color-doPPler i GraY-scale
UltraZVUČne Metode U diferenciJaciJi BeniGnih
od MaliGnih oVariJalnih ProMena
Muna Abid Al-Ghani Zghair1, Qays Ahmed Hassan2, Rana Ahmed Mahdi3
1Odsek za radiologiju, Katedra za medicinu, Medicinski fakultet, Al-Mustansiriyah Univerzitet, Bagdad, Irak
2Odsek za radiologiju, Katedra za hirurgiju, Al-Kindy medicinski fakultet, Univerzitet u Bagdadu, Bagdad, Irak
3Katedra za radiologiju, Al-Yarmook univerzitetska bolnica, Bagdad, Irak
Received / Primljen: 16. 03. 2018. Accepted / Prihvaćen: 17. 07. 2018.
introdUction
The diagnosis of ovarian masses is a frequent dilemma
in clinical work. Most ovarian masses are benign (1,2).
The most crucial step following identification of the ovar-
ian mass is the perception of a level of malignancy; deter-
mining the level of malignancy will have a great impact on
patient survival. It is the danger of malignancy that drives
us to reliable and immediate diagnosis to decrease mor-
bidity and mortality. Ovarian cancer represents a prin-
ciple surgical difficulty in that it requires exhaustive and
usually complicated therapies, and it greatly affects the
patient’s psychological and physical state. It has the great-
est case fatality rate of all the gynaecological malignan-
saŽetaK
Cilj ove studije bila je evaluacija ovarijalnih tumora
konvencionalnom crno-belom ultrasonografi jom kao i ko-
lor-dopler metodom sa ciljem diferentovanja benignih i ma-
lignih osobina tumora.
Uključili smo 56 pacijenata sa tumorima ovarijuma.
Morfološka karakterizacija tumora je urađena pomoću
Sasson skora. Za svakog pacijenta određeni su parametri
pomoću kolor-dopler metode kao i Karuzo vaskularni skor.
Ovi rezultati su upoređivani sa hirurškim i/ili patološkim
nalazima.
Korišćenjem Sasson skora, opšta pouzdanost u proceni
vrste ovarijalnih tumora ima senzitivnost od 89,5% i speci-
fi čnost od 78,4%. Korišćenjem Karuzo skora, pronašli smo
senzitivnost od 89,5% i specifi čnost od 86,5%. Upotrebom
oba skora, Sassone i Karuzo, senzitivnost je bila 94,7% a
specifi čnost čak 89,1%.
Kombinovanjem morfoloških i kolor-dopler skorova u
evaluaciji i dijagnostici ovarijalnih tumora dobijamo veću
specifi čnost, senzitivnost i tačnost dijagnoze u odnosu na po-
jedinačno upotrebljene metode.
Ključne reči: Ovarijalni tumor, ultrasonografi ja, vasku-
larni skor, maligni, benigni
2
cies (3). Therefore, it is necessary to have a diagnostic tool
for its immediate discovery and conventional treatment
and to increase survival. Therefore, we want diagnostic
means that allow proper classification of ovarian masses
before surgery; hence, it is essential to identify the nature
of the tumour before surgery. Ultrasonography (USG) is
regarded as the basic imaging modality for recognising
the nature of the ovarian mass as benign or malignant
(4). USG morphologic assessment is still the most com-
mon modality for detecting ovarian cancer (5). USG re-
lates morphologic images with gross macroscopic patho-
logic characteristics of ovarian masses. However, when
morphologic characteristics only are used to predict the
ovarian malignancy, there is a tendency to over-diagnose
malignant tumours because of a large overlap between
malignant and benign masses. Accordingly, the addition
of colour Doppler imaging with pulsed Doppler spectral
analysis enhances the characterisation of ovarian masses
by means of quantitative blood flow measurements ob-
tained from tumour vessels and thus improves sensitivity
and specificity of the characterisation of ovarian masses
(1-4). High operator dependence and extreme variability
in the characteristics of ovarian tumours make a definite
diagnosis still difficult. To overcome these limitations, ap-
plying scoring systems has been promoted. These scoring
systems, joining various parameters of USG and colour
Doppler, raise the sensitivity and specificity of diagnosis
with excellent accuracy (6).
The purpose of this study was to evaluate the ovar-
ian masses with conventional grey scale and colour Dop-
pler flow imaging and to assess the diagnostic reliability
of these methods in differentiating benign and malignant
ovarian masses.
Materials and Methods
This prospective study was carried out between Au-
gust 2015 and January 2017. The study included 56 pa-
tients who were clinically suspected to have ovarian neo-
plasm and referred for USG and Doppler examinations.
Ethical clearance for the study was obtained from our lo-
cal institutional scientific and ethics committee with ap-
proval number 32 / 2015 before the commencement of the
study. Informed consent for all participating patients was
obtained. All patients were examined on GE Voluson E6
Color Doppler Machine with 3.5–5 MHz convex and 7.5
MHz transvaginal transducers and with grey scale, power,
and spectral Doppler. The detailed history of all patients
was studied, and complete examination was performed.
USG preferably was performed during the proliferative
phase of the menstrual cycle in premenopausal women.
The same radiologist evaluated all the cases. Scanning
was performed in the supine position. The whole of the
abdominal cavity was scanned in longitudinal and axial
plane with particular reference to the pelvic cavity. The
ovaries were recognised. Ovarian masses in either ova-
ry, if seen, were assessed. In uncertain cases of ovarian
masses on transabdominal USG, transvaginal USG was
done to exclude extra-ovarian masses. The Sassone scor-
ing system on the basis of morphological parameters was
applied where a score ≥9 is considered to be probably ma-
lignant. Table 1 shows the Sassone scoring system, which
is based on the visualisation of the inner wall structure,
wall thickness, septae and solid part echogenicity. Sub-
sequently, power and Doppler flow imaging and spectral
analysis were performed. Doppler parameters were opti-
mised for detection of flow and calculation of impedance
indices. Flow results were recorded as being absent or
present and further characterised as normal or increased.
Normal flow was characterised by fine branching vessels,
no evidence of “hot-spots”/aliasing, and presence of pe-
ripheral flow. The flow was classified as increased if di-
Table 1. Criteria used in Sassone score for sonomorphological characterisation (7)
Inner wall
structure Smooth Irregularity
less than 3 mm
Papillarities
more than 3 mm Not applicable -
Septae No septa in less than
3 mm
ick more
than 3 mm - -
Wall thickness in less than
3 mm
ick more
than 3 mm
Not applicable
mostly solid - -
Echogenicity Sonolucent Low echogenic
Low echogenic
with echogenic
core
Mixed
echogenicity
High
echogenicity
Benign: <9; Malignant: ≥ 9
Table 2. Criteria used in Caruso score (8)
Vessels location
Absent 0
Present 1
Peripheral 0
Septal 1
Central 2
Arrangement of vessels
Regular 0
Random 2
Waveform pattern
Sharp with diastolic notch 0
Smooth without notch 2
Lowest RI More than 0.43 0
Less than 0.43 2
*Benign: <5; Malignant: ≥ 5. RI: Resistive index
3
lated prominent parenchyma vessels were present; “hot-
spots” and aliasing were seen in colour flow mapping.
The vessel location (peripheral, central, and septal), ar-
rangement (regular/random) and morphology (normal-
fine tapering vessels versus abnormal dilated prominent
vessels, focal stenosis, aneurysms, blind-ending lakes and
dichotomous branching) were also noted. Spectral Dop-
pler study including RI (Resistivity index), PI (Pulsatil-
ity index), PSV (Peak systolic velocity) and presence or
absence of dicrotic notch were recorded in each patient.
Caruso score (Table 2) was applied for further characteri-
sation of the mass where a score ≥5 was supposed indica-
tive of malignancy. Benign and malignant classification
of the ovarian masses was done depending upon the grey
scale and colour Doppler USG. The results were corre-
lated with the histopathological findings.
Statistical analysis
Statistical Package for the Social Sciences version 20
(SPSS 20) was used for both data entry and data analysis.
Discrete variables were displayed as a number (%). Chi-
square test (or Fisher’s exact test when appropriate) was
used to test the significance of the relationship for the dis-
crete variable. P-value of < 0.05 was regarded as significant.
RESULTS
Fifty-six patients were included in this study. Thirty-
eight (68%) patients were pre-menopausal, and 18 (32%)
were postmenopausal women. The mean (± SD) age of pa-
tients included in the study was 45.0 ±15.5 years (range 20-
67 years) for malignant masses and 38.2±12.2 years (range
20-67 years) for benign masses. In correlation with the
parity, the malignant masses were significantly noted more
among nulliparous and para 3 women, while the benign
masses were more among para 1 women. Table 3 shows
the distribution of the ovarian masses according to age and
parity. Table 4 summarises the histopathological diagnosis
of 56 ovarian masses studied where 37 (66.07%) were be-
nign and 19 (33.93%) were malignant.
Table 5 shows the distribution of 56 patients accord-
ing to the Sassone, Caruso and combined scoring systems
and its correlation to the finally confirmed histopathologi-
cal diagnosis. Out of 37 benign cases, the Sassone scoring
system alone was able to diagnose 29 (78.3%) cases, the Ca-
ruso scoring system alone was able to identify 32 (86.4%)
cases, and the combined scoring system was able to identi-
fy 33 (89.1%) cases. Out of 19 malignant cases, the Sassone
scoring system alone was able to diagnose 17 (89.4%) cases,
the Caruso scoring system alone was able to diagnose 17
(89.4%) cases, and the combined scoring system was able
to diagnose 18 (94.7%) cases. These findings, regarding the
Sassone scoring system alone, had a sensitivity of 89.5%,
a specificity of 78.4%, a positive predictive value (PPV) of
Table 3. Distribution of ovarian masses according to age and parity.
Histopathology
Malignant
%
Benign
%
P value
Age
<30 21.1 29.7 0.287
30---39 15.8 32.4
40---49 15.8 13.5
=>50 47.4 24.3
Mean±SD (Range) 45.0±15.5(20-67) 38.2±12.2(20-67)
Parity
Nulliparous 26.3 16.2 0.016
P1 10.5 37.8
P2 10.5 29.7
P3 26.3 10.8
P4 & more 26.3 5.4
Mean±SD (Range) 2.3±1.8(0-5) 1.5±1.1(0-4)
SD: Standard deviation, P: Para.
Table 4. e histopathological diagnosis of the studied ovarian masses.
Histopathological diagnosis No. (%)
Serous cystadenoma 8 (14.29)
Mucinous cystadenoma 4 (7.14)
Mature teratoma 13 (23.21)
Haemorrhagic cyst 5 (8.93)
Benign Fibrothecoma 2 (3.57)
Serous cystadenofibroma 2 (3.57)
Endometriosis 2 (3.57)
Epidermoid cyst 1 (1.79)
Total 37(66.07)
Serous cystadenocarcinoma 5 (8.93)
Mucinous cystadenocarcinoma 3 (5.35)
Endometroid adenocarcinoma 2 (3.57)
Malignant Immature teratoma 7 (12.50)
Brenner cell 1(1.79)
Fibrosarcoma 1(1.79)
Total 19 (33.93)
4
86.0%, a negative predictive value (NPV) of 93.5% and an
accuracy of 82.1%; the findings of the Caruso scoring sys-
tem alone had a sensitivity of 89.5%, a specificity of 86.5%, a
PPV of 77.3%, an NPV 94.1% and an accuracy of 87.5%. Us-
ing both the Sassone and Caruso scores together, we found
a sensitivity of 94.7%, a specificity of 89.1%, a PPV of 81.8%,
an NPV of 97.0% and an accuracy of 91.0%.
Table 6 gives comparative efficacy of Sassone, Caruso,
and combined scoring systems in differentiating benign
from malignant ovarian masses and shows that the com-
bined scoring system is a better performing scoring system.
DISCUSSION
Today, the commonly applied means for distinguishing
between malignant and benign ovarian masses are the phys-
ical examination, serum tumour markers, and grey scale and
colour Doppler USG (9). Colour and pulsed Doppler can
improve preoperative diagnosis of ovarian tumours when
compared to transvaginal sonography alone or tumour
marker assessment (10). Although grey scale USG is sensi-
tive in identifying ovarian carcinoma, its reliability has not
been enough to preclude further invasive methods, such as
laparoscopy and laparotomy. Colour Doppler imaging and
spectral Doppler imaging have been reviewed as potential
means of increasing the specificity of grey-scale USG in dif-
ferentiating benign from malignant masses (11,12).
Timmerman D et al.(13) in their prospective valida-
tion study, which was conducted in 19 USG centres in
eight countries, concluded that the use of the simple USG
rules (shape, size, solidity, and results of colour Doppler
examination) to distinguish benign from malignant ovar-
ian masses has the potential to improve the management
of women with an ovarian mass.
Characteristics that raise the suspicion of malignan-
cy in USG include the presence of thick septa, papillary
projections, heterogeneous echotexture, and septa great-
er than 3 mm in thickness or which have flow on colour
Doppler USG (14,15). Neovascularisation in the tumour
always offers lower resistance to blood flow in malignant
neoplasms (Fig 1).
Benign tumours have been characterised as being uni-
locular, with thin septae, homogenous iso echogenicity
and thin wall capsule (16).
In our study, using only a grey scale Sassone scoring
system, out of 37 benign tumours, 29 were correctly di-
agnosed and 8 were misdiagnosed. Out of 19 malignant
tumours, 17 were correctly diagnosed as malignant and 2
were misdiagnosed as benign. Using Caruso scoring sys-
tem, out of 19 malignant masses, 17 were correctly diag-
nosed. Using the combination of both scoring systems, out
of 19 malignant cases 18 were correctly diagnosed. The
only case, which was not diagnosed, was of immature tera-
toma. In this case, the tumour was of mixed echogenicity
without solid mass or vascularisation. Accordingly, out of
37 benign masses, 33 were correctly diagnosed as benign
and 4 were misdiagnosed as malignant; these were 2 cases
of fibrothecoma and 2 cases of serous cystadenofibroma.
In these cases, the tumours were encountered as unilocu-
lar cysts with solid areas and central flow.
In our study, Colour Doppler results showed predomi-
nantly peripheral localisation of vessels in benign masses
(65%) and predominantly central or septal vessel locali-
sation (81.8%) in malignant masses. This agrees with the
results of Jokubkiene et al. (17) who found that 57% of be-
nign masses showed peripheral vascularisation versus 70%
of malignant masses that showed central vascularisation.
In our study, the RI alone was an insufficient discrimi-
nating parameter, as there was overlap between benign and
Table 5. Comparison between Sassone, Caruso and combined scoring
systems and histopathology
Benign Malignant Total
Sassone score
Benign (0-8) 29 2 31
Malignant (≥9) 8 17 25
Caruso score
Benign (<5)
Malignant (≥5)
Combined score
Benign
Malignant
37
32
5
37
33
4
37
19
2
17
19
1
18
19
34
22
34
22
Table 6. Statistical comparison between two scoring systems
Statistical
parameter
Sassone scoring
system %
Caruso scoring
system %
Combined
scoring
system %
Sensitivity 89.5 89.5 94.7
Specificity 78.4 86.5 89.1
PPV 68.0 77.3 81.8
NPV 93.5 94.1 97.0
Accuracy 82.1 87.5 91.0
PPV: Positive predictive value, NPV: Negative predictive value
Figure 1. Spectral Doppler USG of 47 year-old patient shows complex
ovarian mass with internal vascularity and low RI=0.37 diagnosed as se-
rous cyst adenocarcinoma on histopathology
5
malignant masses. The RI cut-off value of <0.43 used had
a significant p-value (<0.0005). Pulsatility index <1.0 had
a sensitivity of 73.6% and a specificity of 64.9%, and there
was a significant overlap between malignant and benign
masses. Ueland et al. (16) reported sensitivity and specific-
ity of 52.8% and 77.6%, respectively, using the cut-off value
of PI < 1. In spite of that, Abbas et al. (18) reported that PI <
1 was an important feature of malignancy (80.4%), but PI <
1 was also found in 15.7% of benign masses. Thus PI alone
cannot be a reliable parameter to detect malignancy. Shah
D et al. (19) reported sensitivity (97.5 %) and specificity
(84.1%) withPIandRIvalues of <1.0 and <0.6, respective-
ly, in their multi-parameter analysis utilising B-mode USG
along with Colour Doppler and Spectral Doppler to dif-
ferentiate between malignant and benign ovarian tumours.
These findings are correlated with our result.
In the present study, B mode USG along with Doppler
showed a sensitivity of 94.7%, a specificity of 89.1%, a PPV
of 81.8%, an NPV of 97.0% and an accuracy of 91.0%. These
results agreed with those of Abbas et al. (18) who were us-
ing a new scoring model (Assiut Scoring Model {ASM}),
in which they used two-dimensional USG and Doppler
features and showed a sensitivity of 93.5%, a specificity of
92.2%, a PPV of 82.7% and an NPV of 97.3%, with overall
accuracy of 92.6%. Our results also agree with the results
of Dhwani et al. (20), who conclude that using the combi-
nation of both grey scale and colour Doppler in differenti-
ating benign from malignant ovarian masses gives results
with more accuracy. Furthermore, our results agree with
those of Malhotra A et al. (21), who conclude that grey
scale USG combined with Colour and Spectral Doppler
is superior to grey scale USG alone in differentiating be-
nign and malignant adnexal masses. Gagandeep et al. (22)
evaluated 30 patients with ovarian mass in their study, and
they showed a sensitivity of 91.7% and a specificity of 77.7%
when using the Sassone score alone, a sensitivity of 83.3%
and a specificity of 88.9% when using Caruso score alone,
and a sensitivity of 90.9% and a specificity of 93.3% when
using both scores together. These findings are well corre-
lated with our results.
Based on the results of our study, patients with masses
score < 5 can be managed in the gynaecological unit by a
gynaecologist, either conservatively or surgically, accord-
ing to their features. Patients with masses score ≥ 8 must
be referred to a gynaecological oncologist and be managed
in specialised oncology centres. Patients with masses score
4-6 are suspicious with high possibility of malignancy if
score ≥ 6, so further investigations may be ordered such
as MRI.
CONCLUSION
There is significant overlap in the morphologic features
of different ovarian masses. The combination of grey scale
USG with colour and spectral Doppler is recommended as
the leading diagnostic modality in patients with an ovarian
tumour. This combination gives better diagnostic achieve-
ment than an individual method and accordingly will es-
tablish the definite diagnosis of malignancy early in the
course of the disease.
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