Ultrasound Obstet Gynecol 2012; 39: 215–225 Published online 9 January 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.10068 Ultrasonographic appearance of metastatic non-gynecological pelvic tumors M. ZIKAN*, D. FISCHEROVA*, I. PINKAVOVA*, P. DUNDR† and D. CIBULA* *Gynecologic Oncology Center, Department of Obstetrics and Gynecology, Charles University, Prague, First Medical Faculty and General Teaching Hospital, Prague, Czech Republic; †Department of Pathology, Charles University, Prague, First Medical Faculty and General Teaching Hospital, Prague, Czech Republic KEYWORDS: metastatic ovarian tumors; metastatic pelvic tumors; ultrasound diagnostics ABSTRACT examination due to suspected gynecologic cancer. Sonography is the first method of choice for identifying Objective To describe the ultrasound (sonomorpho- the location of a tumor and its origin, and to distinguish logic and vascular) characteristics of metastatic non- between benign and malignant tumors; the ultrasound gynecological pelvic tumors, and to identify ultra- probe can get close to the tumor and Doppler can sound characteristics typical of the most common non- be used to assess parameters of vascularization10. gynecological pelvic tumors. However, the pelvis, and the ovaries in particular, is Methods In 92 patients with a pelvic mass who had often the site of metastases from extragenital (i.e. non- undergone ultrasound examination with subsequent gynecological) malignant tumors. Metastatic extragenital 1–4 surgery or tru-cut biopsy revealing a metastatic non- tumors constitute 5–20% of all ovarian tumors ; gynecological tumor origin, we analyzed retrospectively according to the literature, they are most commonly 4,5 the sonomorphologic and vascular parameters. All derived from gastric or breast cancer . The recognition parameters were evaluated for the whole group of non- preoperatively of a potential extragenital origin of a gynecological tumors as well as separately for each specific tumor can significantly change the management of the tumor type. The findings were compared with those from patient and allow for early initiation of appropriate 8,9 100 women with epithelial ovarian cancer. treatment of the primary disease . Yet, only a few studies have evaluated the accuracy of ultrasound examination Results We found that CA 125, size of tumor, echogenic- in determining the extragenital origin of tumors5–7. ity, homogeneity of solid portion, mobility, and presence According to their conclusions, a large proportion of of ovarian crescent sign, parenchymal metastases and sus- metastatic ovarian tumors are misinterpreted as being picious necrosis were individual statistically significant primary ovarian epithelial cancer. discriminators (P < 0.01) between the metastatic non- The aim of this retrospective study was to analyze gynecological tumor group and the epithelial ovarian sonomorphological and vascular parameters of non- cancer group. gynecological metastatic pelvic tumors and to assess Conclusions Metastatic non-gynecological tumors in the the presentation of all tumor types and their typical pelvis have a significantly different sonomorphologic ultrasound features in comparison to those of ovarian pattern compared with primary epithelial ovarian cancer. epithelial cancer. This pattern is dependent on the primary origin of the tumor. Doppler parameters, however, cannot differentiate between primary ovarian cancer and metastatic non- METHODS gynecological tumors. Copyright 2012 ISUOG. Patients Published by John Wiley & Sons, Ltd. The study population included 92 patients referred to the INTRODUCTION Gynecologic Oncology Center from 2005 to 2009 who underwent expert ultrasound examination and in whom Patients with a pelvic mass are commonly referred to a pelvic mass of non-gynecologic origin was subsequently a gynecologic oncology center for expert ultrasound confirmed and identified by histology (open surgery, Correspondence to: Dr M. Zikan, Gynecologic Oncology Center, Department of Obstetrics and Gynecology, Charles University, Prague, First Medical Faculty and General Teaching Hospital, Apolinarska 18, 128 00 Prague 2, Czech Republic (e-mail: [email protected]) Accepted: 22 July 2011 Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd. ORIGINAL PAPER 216 Zikan et al. laparoscopy or tru-cut biopsy). Patients in whom a non- Table 1 Scan protocol: summary of characteristics examined gynecologic origin of the pelvic tumor had been assumed during routine scanning of pelvic masses on the basis of computed tomography or magnetic resonance imaging findings, were not enrolled into the Characteristic study. Primary peritoneal serous tumors are classified as genital tumors, so these patients were not included in the Location Ovarian study. Ovarian tumors with metastases to the uterus, Non-ovarian (intraperitoneal; retroperitoneal) tumors of the uterus with metastases to the ovaries Laterality and tumors growing from other pelvic structures and Unilateral penetrating the uterus and ovaries were also not included. Bilateral For comparison, we enrolled a group of 100 patients Solitary central Size (measured in three dimensions) suffering from epithelial ovarian cancer and examined Size of largest solid component (if applicable)(measured in three with ultrasound (four Stage IV, 72 Stage III, 17 Stage II dimensions) and seven Stage I) using the same scan protocol as for the Distribution study group. Eighty of them had serous histotype cancer, Pelvic 10 had clear cell cancer, six had endometrioid cancer and Pelvic and extrapelvic Structure four had mucinous cancer. All 100 underwent surgery. Solid Unilocular-solid Ultrasound examination Multilocular-solid Unilocular Each patient underwent both transabdominal and Multilocular Papillary projections (yes/no) transvaginal or transrectal ultrasound examination, Echogenicity performed by one of two oncogynecologists experienced Anechoic in the field of ultrasound diagnostics in gynecologic Low level oncology, using a GE Logiq 9 (GE Healthcare Ultrasound, Ground glass Milwaukee, WI, USA) machine equipped with a M7C Hemorrhagic Mixed matrix 3–8-MHz transducer and with both B-mode Homogeneity of solid portion (if applicable) (yes/no) and Doppler mode. The description and examination Vascular features of solid portion (if applicable) reports were based on the standard protocol for pelvic Subjective assessment of flow (1–4)11 mass evaluation applied by our center and using the Peak systolic velocity terminology described previously11 (Table 1). The still Pulsatility index Resistance index images and videoclips taken during the course of the Surface examination were stored in electronic form. Smooth Irregular Elasticity Evaluation of acquired data Compressible Rigid Our assessment was carried out retrospectively by Mobility reviewing the stored examination reports. In cases of Mobile uncertainty or lack of clarity in the report, stored Semi-fixed still images or videoclips were used to clarify, without Fixed Ovarian crescent sign (yes/no) knowledge of the histological diagnosis. Locularity (if applicable) There was no tumor duplicity. Tumors metastasizing Number of locules (1–5; 6–10; > 10) to the ovaries were designated as ovarian (there were Size of chambers no tumors affecting the corpus uteri or cervix uteri). Septa (if applicable) If the tumor was confined to the ovarian surface only, Width Regularity of width with unaffected ovarian stroma, it was classified as Subjective assessment of flow (level 1–4)11 non-ovarian with carcinomatosis. Tumors fixed to the Suspicious necrosis (yes/no) pelvic wall, supplied by external, internal or common Involvement of uterus (yes/no) iliac artery, or tumors clearly located below the Presence of carcinomatosis (yes/no) parietal peritoneum, were classified as retroperitoneal. Ascites (yes/no) Parenchymal metastases (yes/no) Heterogeneous, avascular areas of mixed echogenicity with blurred borders radiating to the adjacent vascularized Parameters were evaluated/measured in each patient (if applicable) tissue were classified as probable necrosis (Figure 1). and expressed in words according to the institute’s documentation The elasticity of tumors was assessed using pressure and also stored as images or videoclips. exerted by the vaginal probe with simultaneous abdominal wall palpation (in order to avoid moving the tumor) and classified as compressible or rigid. examiner’s hand was pressing on the abdominal wall with The mobility of tumors was assessed by their movement simultaneous scanning by transvaginal or transabdominal with respect to the adjacent structures when the ultrasound probe. A tumor was considered mobile when Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2012; 39: 215–225. Metastatic pelvic tumors 217 Table 2 Type and frequency of non-gynecological tumors in the study group Patients Tumor (n (%)) Colorectal cancer 32 (34.8) Upper gastrointestinal tract (pancreas, gallbladder) tumor 13 (14.1) Lymphoma 11 (11.9) Krukenberg tumor (metastatic gastric cancer) 9 (9.8) Breast cancer 6 (6.5) Gastrointestinal stromal tumor 4 (4.3) Urinary bladder cancer 3 (3.3) Neuroendocrine tumor 2 (2.2) Carcinoid tumor 2 (2.2) Malignant mesothelioma 1 (1.1) Malignant Schwannoma 1 (1.1) Primitive neuroectodermal tumor 1 (1.1) Liposarcoma 1 (1.1) Leiomyosarcoma 1 (1.1) Ewing’s sarcoma 1 (1.1) Figure 1 Necrosis: heterogeneous irregular avascular area (arrow) Thyroid cancer 1 (1.1) surrounded by vascularized tissue. Perimyocytoma* 1 (1.1) Atypical