Background: Preoperative assessment of adnexal masses is an important but complex clinical challenge. Lesions that are likely to be benign may be adequately managed with laparoscopy, thus avoiding any surgical complications. Several parameters have been tested alone or in combination as prospective indicators of malignancy. The most common in current use are tumor size (diameter or volume), echogenicity, presence of papillary projections, presence of free fluid, and tumor blood flow. Ovarian tumor blood flow is assessed by B-mode color Doppler ultrasonography. The resistance to blood flow can be measured by several parameters and is generally lower in malignant than in benign lesions. Nevertheless, no models that perform well in clinical practice have been developed to differentiate benign from malignant masses. The introduction of three-dimensional ultrasonography provides substantial data on adnexal masses in three planes. This can be combined with three-dimensional power Doppler imaging showing vascularity to substantially improve information for surgical decision making. Geomini and colleagues assessed the ability of this new combined technique to prospectively identify malignant adnexal masses.

The Study: The study included 181 women scheduled to undergo surgery for adnexal masses at a Dutch subspecialist center. In the week before the surgery, participants underwent two- and three-dimensional gray-scale ultrasonography and two- and three-dimensional power Doppler ultrasonography. The data from these investigations were stored and were analyzed by a blinded researcher when the histopathologic diagnosis had been made.

Results: At surgery, 144 masses (80 percent) were benign, 26 (14 percent) were malignant, and 11 (6 percent) were borderline. The 26 malignant masses included 16 serous adenocarcinomas, three clear cell carcinomas, and two mucinous adenocarcinomas. Median laparotomy was performed on 29 women who were found to have benign lesions. Benign, borderline, and malignant masses did not differ significantly in volume. Malignant masses had significantly higher density, as measured by mean gray index, and significantly higher flow index. The most striking difference between malignant and other masses was in central vessels, which were present in 69 percent of malignant masses and 15 percent of benign masses.

Conclusion: The authors conclude that the best parameters to distinguish benign from malignant adnexal masses are detection of central blood vessels, density (mean gray index), and flow index. They call for large studies to better clarify and quantify predictors of malignancy in adnexal masses.