How successful is color flow mapping and pulsed Doppler studies in predicting histologically confirmed benign and malignant adnexal masses in perimenopausal women


  • Souptik Gangopadhyay Department of Obstetrics and Gynecology, SSKM Hospital, Kolkata, West Bengal, India
  • Partha Sarathi Chakraborty Department of Obstetrics and Gynecology, SSKM Hospital, Kolkata, West Bengal, India
  • Archana Singh Department of Radiodiagnosis, SSKM Hospital, Kolkata, West Bengal, India



Adnexal mass, Neovascularization, Pulsitility index, Resistivity index


Background: Adnexal masses in perimenopausal women presents a specific diagnostic challenge because benign masses outnumbers malignant masses. Majority of adnexal masses are benign but 25% are malignant. The objective of this study was to see the effectiveness of transvaginal colour Doppler in predicting malignancy in adnexal masses in perimenopausal women.

Methods: Clinically detected adnexal masses were subjected to transabdominal ultrasound scan (for basic characterization of mass into solid, cystic, mixed) then transvaginal scan and neovascularization, resistivity index (RI) was measured. Subsequently all patients underwent laparotomy. Histopathological reports obtained, and correlation done between USG and histopathology.

Results: Among cystic masses neovascularization was present in 4 cases, among them benign and malignant masses were equal in number. Among mixed masses neovascularization was present in 17 cases 9 were malignant 8 benign, among solid masses all cases where neovascularization was detected were malignant. Neovascularization was absent in 12 cystic masses and 11 mixed masses, and all were benign. Kappa value calculated for tumour status and neovascularization is 0.610 which is substantially agreement with neovascularization as predictor of malignancy. Sensitivity, specificity, positive predictive value and negative predictive value of neovascularization for cystic masses are 100, 85, 50, 100(%) respectively. Sensitivity, specificity, positive predictive value and negative predictive value of neovascularization for mixed masses are 100, 57.89, 52.94, 100(%) respectively. Sensitivity and positive predictive value of neovascularization for solid masses is 100(%). Sensitivity specificity positive predictive value and negative predictive value of RI for cystic masses: 100, 92.8, 66.6, 100 (%) respectively. Sensitivity specificity positive predictive value and negative predictive value of RI for mixed masses: 77.7, 89.4, 77.7, 89.4(%). Sensitivity positive predictive value of RI for solid masses 100%.ROC curve analysis shows cut off value for differentiating between benign and malignant masses is 0.4. Less than 0.4 has more chance of malignancy.

Conclusions: Transvaginal Doppler ultrasound must be done preoperatively for adnexal mass characterization.


Koonings PP, Campbell K, Mischell DR. Relative frequency of primary ovarian neoplasm: a 10 year review. Obstet Gynecol. 1989;74:921-6.

Andolf E, Jorgensen C. A prospective comparison of transvaginal and transabdominal ultrasound with surgical findings in gynecological disease. J Ultrasound Med. 1990;9:71-5.

Disantis DJ, Scatarige JC, Given FT, Kemp G, Cramer MS. A prospective evaluation of transvaginal sonography for detection of ovarian disease. Am J Roentgenol. 1993;161:91-4.

Leibman AJ, Kruse B, Mcsweeney MB. Transvaginal sonography: comparison with transabdominal sonography in the diagnosis of pelvic masses. Am J Roentgenol. 1988;151:89-92.

Andolf E, Jorgensen C. A prospective comparison of clinical ultrasound and operative examination of female pelvis. J Ultrasound Medicine. 1988;7:617-20.

Herrmann UJ Jr, Locher GW, Goldhirsch A. Sonographic patterns of ovarian tumors: prediction of malignancy. Obstet Gynecol. 1987;69(5):777-81.

Marret H. Doppler ultrasonography in the diagnosis of ovarian cysts: indications, pertinence and diagnostic criteria. J Obstet Gynecol Reprod Reprod Biol. 2001;30:20-33.

Kujrak A, Predanic M, Kupesik-Urek S, Jukie S. Transvaginal colour and pulsed Doppler assessment of adnexal tumour vascularity. Gynecol Oncol. 1993;50:3-9.

Dock W, Grabenwoger F, Metz V, Eibenberger K, Farres MT. Tumour vascularization: assessment with duplex sonography. Radiol. 1991;181:241-4.

Folkman J, Watson K, Ingber D, Hanahan D. Induction of angiogenesis from transition from hyperplasia to neoplasia. Nature. 1989;339:58-61.

Reles A, Wein U, Lichtenegger W. Transvaginal sonography and conventional sonography in preoperative assessment of adnexal masses. J Clin Ultrasound. 1997;25:217-25.

Emoto M, Iwasaki H, Mimura K, Kawarabayashi T Kikuchi M. Difference in angiogenesis in benign and malignant ovarian tumour, demonstrated by colour Doppler, immunohistochemistry and micro vessel density. 1997;80:899-907.

Maly Z, Riss P, Deutinger J. Localization of blood vessels and qualitative assessment of blood flow in ovarian tumors. Obstetric Gynecol. 1995:85(1):33-6.

Brustmann H, Naude S. Relevance of angiogenesis in benign and malignant tumours of ovary, a quantitative histologic study. Gynecol Oncol. 1997;67:20-6.

Cambell S, Bourne T, Bradley E. Screening for ovarian cancer by trans vaginal sonography and colour Doppler. Eur J Obstet Gynecol Reprod Biol. 1993;49:33.

Folkman J, Merler E, Abernathy C, Williams G. Isolation of tumor factor responsible for angiogenesis. J Exp Med. 1971;133:275-88.

Brown DL, Frates MC, Laing FC. Ovarian masses. can benign and malignant masses be differentiated with color and pulsed Doppler US?. 1994;190:333-6.

Carter J, Saltzman A, Fowler J, Carson L, Twiggs LB. Flow characteristics in benign and malignant gynecological tumours using transvaginal colour flow Doppler. Obstet Gynecol. 1994;83:125-30.

Jain KA. Prospective evaluation of adnexal masses with endovaginal grey scale duplex and colour Doppler US: correlation with pathologic findings. Radiol. 1994;191:63-7.

Levine D, Feldstein VA, Filly RA, Babcook CJ. Sonography of oarian masses: poor sensitivity of resistance index for identifying malignant masses. Am J Roentgenol. 1994;162:1355-9.

Salem S, White LM ,Lai J. Doppler sonography of adnexal masses:The predictive value of pulsitility index in benign and malignant disease. Am J Roentgenol. 1994;163;1147-50.

Weiner Z, Thaler I, Levron J, Lewit N. Uterine artery flow velocity waveforms and color flow imaging in women with perimenopausal and postmenopausal bleeding: Correlation to endometrial histopathology. Acta Obstet Gynecol Scand. 1993;59:743-9.

Rehn M, Lohmann K, Rempen A. Transvaginal ultrasonography of pelvic masses: evaluation of B-mode technique and Doppler ultrasonography. Am J Obstetric Gynecol. 1996;175(1):97-104.

Sassone AM, Tritsch TIE. Transvaginal sonographic characterization of ovarian disease: evaluation of a new scoring system to predict ovarian malignancy Obstet Gynecol. 1991;78:70-6.

Lerner JP, Timor-Tritsch, Federman A, Abramovich G- Transvaginal characterization of ovarian masses with an improved weighted scoring system. Am J Obstet Gynecol. 1994;170:81-5.

Hata K, Hata T, Manabe A, Sugimura K, Kitao M. A critical evaluation of transvaginal Doppler studies MRI and CA -125 in detecting ovarian cancer. Obstet Gynecol. 1992;80:922-6.

Franchi M, Beretta P, Ghezzi F, Zanaboni F, Goddi A, Salvatore S. Diagnosis of pelvic masses with transabdominal color Doppler, CA 125 and ultrasonography. Acta Obstet Gynecol Scand. 1995;74(9):734-9.

Schutter EMJ, Kenemans P. Diagnostic value of pelvic examination, ultrasound, and serum CA 125 in postmenopausal women with a pelvic mass. An international multicenter study. Cancer. 1994;74(4):1398-406.

Bushong SC. The physics and biology of diagnostic ultrasound. In: Athey PA, Hadlock FD, eds. Ultrasound in obstetrics and gynecology, 2nd edition. St. Louis, CV Mosby; 1985:315-6.

Athey PA, Adnexa: Non-neoplastic cysts. In: Athey AP, Hadlock FD, eds. Ultrasound in Obstetrics and Gynecology, 2nd edition. St Louis, CV Mosby; 1985:206-7.

Ferazzi E, Zanetta G, Dordoni D, Berlanda N: Transvaginal ultrasonographic characterization of ovarian masses. Comparison of five scoring system in a multicenter study. US Obstet Gynecol. 1997;10:192-7.

Brown DL, Doubilet PM, Miller FH, Frates MC, Laing FC, DiSalvo DN, at al. Benign and malignant ovarian masses: selection of the most discriminating gray-scale and Doppler sonographic features. Radiol. 1998;208(1):103-10.

Weiner J, Brandes JM, Beck D. Transvaginal sonography, colour Doppler, computed tomography screening, CA-125 as a routine follow up of women with pelvic tumour. Detection of recurrent disease. J Ultrasound Medicine. 1994;13:37-41.

Kawai M, Kano T. Transvaginal Doppler Ultrasound with colour flow imaging in the diagnosis of ovarian cancer. Obstet Gynecol. 1992;79:163-7.

Zanetta G, Lissoni A, Vergani P. Colour Doppler ultrasound in preoperative assessment of adnexal masses. Acta Obstet Gynecol.1994;73(8):637-41.

Sawicki W, Spiewankiewicz B, Cendrowski K, Stelmachów J. Preoperative discrimination between malignant and benign adnexal masses with transvaginal ultrasonography and colour blood flow imaging. 2001;22(2):137-42.

Kurjak A, Schulman H, Sosic A, Zalud I, Shalan H. Transvaginal ultrasound, color flow, and Doppler waveform of the postmenopausal adnexal mass. Obstet Gynecol. 1992;80(6):917-21.

Pellerito JS, Troiano RN, Quedens-Case C, Taylor KJ. Common pitfalls of endovaginal colour Doppler flow imaging. Radiograph. 1995;15(1):37-47.

Czekierdowski A, Stachowicz N, Smoleń A, Kotarski J. The use of 2-dimensional and 3-dimensional color and power-Doppler in the diagnosis of blood flow indices of adnexal tumors. Gynecol Pol. 2006;77(4):296-306.






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