Guerriero, S. (Stefano)
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- Superficial endometriosis at ultrasound examination - a diagnostic criteria proposal(2023) Vieira-de-Oliveira, Y. (Ygor); Alcazar, J.L. (Juan Luis); Guerriero, S. (Stefano); Graupera, B. (Betlem); Podgaec, S. (Sergio); Pagliuca, M. (Mariachiara); Chesa-Pascual, M.A. (María Ángeles); Camargos, E. (Esdras); Pedrassani, M. (Marcelo); Ajossa, S. (Silvia)The actual prevalence of superficial endometriosis is not known. However, it is considered the most common subtype of endometriosis. The diagnosis of superficial endometriosis remains difficult. In fact, little is known about the ultrasound features of superficial endometriotic lesions. In this study, we aimed to describe the appearance of superficial endometriosis lesions at ultrasound examination, with laparoscopic and/or histologic correlation. This is a prospective study on a series of 52 women with clinical suspicion of pelvic endometriosis who underwent preoperative transvaginal ultrasound and received a confirmed diagnosis of superficial endometriosis via laparoscopy. Women with ultrasound or laparoscopic findings of deep endometriosis were not included. We observed that superficial endometriotic lesions may appear as a solitary lesions, multiple separate lesions, and cluster lesions. The lesions may exhibit the presence of hypoechogenic associated tissue, hyperechoic foci, and/or velamentous (filmy) adhesions. The lesion may be convex, protruding from the peritoneal surface, or it may appear as a concave defect in the peritoneum. Most lesions exhibited several features. We conclude that transvaginal ultrasound may be useful for diagnosing superficial endometriosis, as these lesions may exhibit different ultrasound features.
- Ultrasound and clinical preoperative characteristics for discrimination between ovarian metastatic colorectal cancer and primary ovarian cancer: A case-control study(MDPI AG, 2019) Epstein, E. (Elizabeth); Fischerova, D. (Daniela); Pietrzak-Stukan, M. (Malgorzata); Alcazar, J.L. (Juan Luis); Guerriero, S. (Stefano); Szubert, S. (Sebastian); Braicu, E.I. (Elena Ioana); Szajewski, M. (Mariusz); Stukan, M. (Maciej); Sufliarska, A. (Alexandra); Gebicki, J. (Jacek); Liro, M. (Marcin)The aim of this study was to describe the clinical and sonographic features of ovarian metastases originating from colorectal cancer (mCRC), and to discriminate mCRC from primary ovarian cancer (OC). We conducted a multi-institutional, retrospective study of consecutive patients with ovarian mCRC who had undergone ultrasound examination using the International Ovarian Tumor Analysis (IOTA) terminology, with the addition of evaluating signs of necrosis and abdominal staging. A control group included patients with primary OC. Clinical and ultrasound data, subjective assessment (SA), and an assessment of different neoplasias in the adnexa (ADNEX) model were evaluated. Fisher’s exact and Student’s t-tests, the area under the receiver–operating characteristic curve (AUC), and classification and regression trees (CART) were used to conduct statistical analyses. In total, 162 patients (81 with OC and 81 with ovarian mCRC) were included. None of the patients with OC had undergone chemotherapy for CRC in the past, compared with 40% of patients with ovarian mCRC (p < 0.001). The ovarian mCRC tumors were significantly larger, a necrosis sign was more frequently present, and tumors had an irregular wall or were fixed less frequently; ascites, omental cake, and carcinomatosis were less common in mCRC than in primary OC. In a subgroup of patients with ovarian mCRC who had not undergone treatment for CRC in anamnesis, tumors were larger, and had fewer papillations and more locules compared with primary OC. The highest AUC for the discrimination of ovarian mCRC from primary OC was for CART (0.768), followed by SA (0.735) and ADNEX calculated with CA-125 (0.680). Ovarian mCRC and primary OC can be distinguished based on patient anamnesis, ultrasound pattern recognition, a proposed decision tree model, and an ADNEX model with CA-125 levels.
- Imaging in gynecological disease (17): ultrasound features of malignant ovarian yolk sac tumors (endodermal sinus tumors)(2020) Epstein, E. (E.); Alcazar, J.L. (Juan Luis); Fruscio, R. (Robert); Guerriero, S. (Stefano); Mascillini, F. (F.); Sibal, M. (M); Savelli, L. (L.); Testa, A.C. (Antonia Carla); Timmerman, D. (Dirk); Pascual, M.A. (Maria Angela); Chiappa, V. (Valentina); Froyman, W. (Wouter); Anfelter, P. (P.); Zannoni, G.F. (G.F.)Objective To describe the clinical and sonographic characteristics of malignant ovarian yolk sac tumors (YSTs). Methods In this retrospective multicenter study, we included 21 patients with a histological diagnosis of ovarian YST and available transvaginal ultrasound images and/or videoclips and/or a detailed ultrasound report. Ten patients identified from the International Results All cases were pure YSTs, except for one that was a mixed tumor (80% YST and 20% embryonal carcinoma). Median age at diagnosis was 25 (interquartile range (IQR), 19.5–30.5) years. Seventy-six percent (16/21) of women had an International Federation of Gynecology and Obstetrics (FIGO) Stage I–II tumor at diagnosis. Fifty-eight percent (11/19) of women felt pain during the ultrasound examination and one presented with ovarian torsion. Median serum α-fetoprotein (S-AFP) level was 4755 (IQR, 1071–25 303) μg/L and median serum CA 125 level was 126 (IQR, 35–227) kU/L. On ultrasound assessment, 95% (20/21) of tumors were unilateral. The median maximum tumor diameter was 157 (IQR, 107–181) mm and the largest solid component was 110 (IQR, 66–159) mm. Tumors were classified as either multilocular-solid (10/21; 48%) or solid (11/21; 52%). Papillary projections were found in 10% (2/21) of cases. Most (20/21; 95%) tumors were well vascularized (color score, 3–4) and none had acoustic shadowing. Malignancy was suspected in all cases, except in the patient with ovarian torsion, who presented a tumor with a color score of 1, which was classified as probably benign. Image and videoclip quality was considered as adequate in 18/21 cases. On review of the images and videoclips, we found that all tumors contained both solid components and cystic spaces, and that 89% (16/18) had irregular, still fine-textured and slightly hyperechoic solid tissue, giving them a characteristic appearance. Conclusion Malignant ovarian YSTs are often detected at an early stage, in young women usually in the second or third decade of life, presenting with pain and markedly elevated S-AFP. On ultrasound, malignant ovarian YSTs are mostly unilateral, large and multilocular-solid or solid, with fine-textured slightly hyperechoic solid tissue and rich vascularization. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
- How frequently benign uterine myomas appear suspicious for sarcoma as assessed by transvaginal ultrasound?(2023) Redondo, A. (Ana); Cabezas, N. (Nieves); Rodríguez, M.J. (María José); Díaz-de la Noval, B. (Begoña); Alcazar, J.L. (Juan Luis); Díaz, P. (Patricia); Guerriero, S. (Stefano); Lopez-Picazo, A. (Ana); Pascual, M.A. (Maria Angela); Ajossa, S. (Silvia); Valero, B. (Beatriz)Background: Uterine myomas may resemble uterine sarcomas in some cases. However, the rate of benign myomas appearing as sarcomas at an ultrasound examination is not known. The objective of this study is to determine the percentage of benign myomas that appear suspicious for uterine sarcoma on ultrasound examination. This is a prospective observational multicenter study (June 2019-December 2021) comprising a consecutive series of patients with histologically proven uterine myoma after hysterectomy or myomectomy who underwent transvaginal and/or transabdominal ultrasound prior to surgery. All ultrasound examinations were performed by expert examiners. MUSA criteria were used to describe the lesions (1). Suspicion of sarcoma was established when three or more sonographic features, described by Ludovisi et al. as frequently seen in uterine sarcoma, were present (2). These features are no visible myometrium, irregular cystic areas, non-uniform echogenicity, irregular contour, cooked appearance, and a Doppler color score of 3-4. In addition, the examiners had to classify the lesion as suspicious based on her/his impression, independent of the number of features present. Eight hundred and ten women were included. The median maximum diameter of the myomas was 58.7 mm (range: 10.0-263.0 mm). Three hundred and forty-nine (43.1%) of the patients had more than one myoma. Using the criterion of >3 suspicious features, 40 (4.9%) of the myomas had suspicious appearance. By subjective impression, the examiners considered 40 (4.9%) cases suspicious. The cases were not exactly the same. We conclude that approximately 5% of benign uterine myomas may exhibit sonographic suspicion of sarcoma. Although it is a small percentage, it is not negligible.
- O-RADS classification for ultrasound assessment of adnexal masses: agreement between IOTA lexicon and ADNEX model for assigning risk group(2023) Yakcich, J. (Javiera); Alcazar, J.L. (Juan Luis); Guerriero, S. (Stefano); Springer, S. (Serena); González de Canales-Díaz, J. (Juan); Brotóns-Almandoz, I. (Isabel); Pagliuca, M. (Mariachiara); Vara-García, J. (Julio); Pascual, M.A. (Maria Angela); Ajossa, S. (Silvia)Background: The O-RADS system is a new proposal for establishing the risk of malignancy of adnexal masses using ultrasound. The objective of this study is to assess the agreement and diagnostic performance of O-RADS when using the IOTA lexicon or ADNEX model for assigning the O-RADS risk group. Methods: Retrospective analysis of prospectively collected data. All women diagnosed as having an adnexal mass underwent transvaginal/transabdominal ultrasound. Adnexal masses were classified according to the O-RADS classification, using the criterion of the IOTA lexicon and according to the risk of malignancy determined by the ADNEX model. The agreement between both methods for assigning the O-RADS group was estimated using weighted Kappa and the percentage of agreement. The sensitivity and specificity of both approaches were calculated. Results: 454 adnexal masses in 412 women were evaluated during the study period. There were 64 malignant masses. The agreement between the two approaches was moderate (Kappa: 0.47), and the percentage of agreement was 46%. Most disagreements occurred for the groups O-RADS 2 and 3 and for groups O-RADS 3 and 4. The sensitivity and specificity for O-RADS using the IOTA lexicon and O-RADS using the ADNEX model were 92.2% and 86.1%, and 85.9% and 87.4%, respectively. Conclusion: The diagnostic performance of O-RADS classification using the IOTA lexicon as opposed to the IOTA ADNEX model is similar. However, O-RADS group assignment varies significantly, depending on the use of the IOTA lexicon or the risk estimation using the ADNEX model. This fact might be clinically relevant and deserves further research.
- External validation of the ovarian-adnexal reporting and data system (O-RADS) lexicon and the international ovarian tumor analysis 2-step strategy to stratify ovarian tumors into O-RADS risk groups(2023) Jokubkiene, L. (Ligita); Epstein, E. (Elizabeth); Deo, N. (Nandita); Landolfo, C. (Chiara); Timmerman, S. (Stefan); Sladkevicius, P. (Povilas); Alcazar, J.L. (Juan Luis); Fruscio, R. (Robert); Kaijser, J. (Jeroen); Guerriero, S. (Stefano); Andreotti, R. (Rochelle); Scambia, G. (Giovanni); Calster, B. (Ben) van; Domali, E. (Ekaterine); Ceusters, J. (Jolien); Testa, A.C. (Antonia Carla); Franchi, D. (Dorella); Buonomo, F. (Francesca); Timmerman, D. (Dirk); Kudla, M.J. (Marek J.); Bourne, T. (Tom); Leone, F.P.G. (Francesco Paolo Giuseppe); Holsbeke, C. (Caroline) van; Chiappa, V. (Valentina); Coccia, M.E. (Maria Elisabetta); Froyman, W. (Wouter); Valentin, L. (Lil)IMPORTANCE Correct diagnosis of ovarian cancer results in better prognosis. Adnexal lesions can be stratified into the Ovarian-Adnexal Reporting and Data System (O-RADS) risk of malignancy categories with either the O-RADS lexicon, proposed by the American College of Radiology, or the International Ovarian Tumor Analysis (IOTA) 2-step strategy. OBJECTIVE To investigate the diagnostic performance of the O-RADS lexicon and the IOTA 2-step strategy. DESIGN, SETTING, AND PARTICIPANTS Retrospective external diagnostic validation study based on interim data of IOTA5, a prospective international multicenter cohort study, in 36 oncology referral centers or other types of centers. A total of 8519 consecutive adult patients presenting with an adnexal mass between January 1, 2012, and March 1, 2015, and treated either with surgery or conservatively were included in this diagnostic study. Twenty-five patients were excluded for withdrawal of consent, 2777 were excluded from 19 centers that did not meet predefined data quality criteria, and 812 were excluded because they were already in follow-up at recruitment. The analysis included 4905 patients with a newly detected adnexal mass in 17 centers that met predefined data quality criteria. Data were analyzed from January 31 to March 1, 2022. EXPOSURES Stratification into O-RADS categories (malignancy risk < 1%, 1% to < 10%, 10% to < 50%, and-50%). For the IOTA 2-step strategy, the stratification is based on the individual risk of malignancy calculated with the IOTA 2-step strategy. MAIN OUTCOMES AND MEASURES Observed prevalence of malignancy in each O-RADS risk category, as well as sensitivity and specificity. The reference standard was the status of the tumor at inclusion, determined by histology or clinical and ultrasonographic follow-up for 1 year. Multiple imputation was used for uncertain outcomes owing to inconclusive follow-up information. RESULTS Median age of the 4905 patients was 48 years (IQR, 36-62 years). Data on race and ethnicity were not collected. A total of 3441 tumors (70%) were benign, 978 (20%) were malignant, and 486 (10%) had uncertain classification. Using the O-RADS lexicon resulted in 1.1% (24 of 2196) observed prevalence of malignancy in O-RADS 2, 4% (34 of 857) in O-RADS 3, 27% (246 of 904) in O-RADS 4, and 78% (732 of 939) in O-RADS 5; the corresponding results for the IOTA 2-step strategy were 0.9% (18 of 1984), 4% (58 of 1304), 30% (206 of 690), and 82% (756 of 927). At the 10% risk threshold (O-RADS 4-5), the O-RADS lexicon had 92% sensitivity (95% CI, 87%-96%) and 80% specificity (95% CI, 74%-85%), and the IOTA 2-step strategy had 91% sensitivity (95% CI, 84%-95%) and 85% specificity (95% CI, 80%-88%). CONCLUSIONS AND RELEVANCE The findings of this external diagnostic validation study suggest that both the O-RADS lexicon and the IOTA 2-step strategy can be used to stratify patients into risk groups. However, the observed malignancy rate in O-RADS 2 was not clearly below 1%.
- Ultrasonography and atypical sites of endometriosis(MDPI AG, 2020) Musa, E. (Eleonora); Conway, F. (Francesca); Neri, M. (Manuela); Alcazar, J.L. (Juan Luis); Guerriero, S. (Stefano); Graupera, B. (Betlem); Pascual, M.A. (Maria Angela); Pedrassani, M. (Marcelo); Ajossa, S. (Silvia)In the present pictorial we show the ultrasonographic appearances of endometriosis in atypical sites. Scar endometriosis may present as a hypoechoic solid nodule with hyperechoic spots while umbilical endometriosis may appear as solid or partially cystic areas with ill-defined margins. In the case of endometriosis of the rectus muscle, ultrasonography usually demonstrates a heterogeneous hypoechogenic formation with indistinct edges. Inguinal endometriosis is quite variable in its ultrasonographic presentation showing a completely solid mass or a mixed solid and cystic mass. The typical ultrasonographic finding associated with perineal endometriosis is the presence of a solid lesion near to the episiotomy scar. Under ultrasonography, appendiceal endometriosis is characterized by a solid lesion in the wall of the small bowel, usually well defined. Superficial hepatic endometriosis is characterized by a small hypoechoic lesion interrupting the hepatic capsula, usually hyperechoic. Ultrasound endometriosis of the pancreas is characterized by a small hypoechoic lesion while endometriosis of the kidney is characterized by a hyperechoic small nodule. Diaphragmatic endometriosis showed typically small hypoechoic lesions. Only peripheral nerves can be investigated using ultrasound, with a typical solid appearance. In conclusion, ultrasonography seems to have a fundamental role in the majority of endometriosis cases in “atypical” sites, in all the cases where “typical” clinical findings are present.
- Transvaginal ultrasound versus magnetic resonance imaging for diagnosing adenomyosis: A systematic review and head-to-head meta-analysis(Wiley, 2022) Vara, J. (J.); Alcazar, J.L. (Juan Luis); Guerriero, S. (Stefano); Usandizaga, C. (Claudia); Pascual, M.A. (Maria Angela); Ajossa, S. (Silvia)Background: Transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) are used for the clinical diagnosis of adenomyosis. Objectives: To compare the diagnostic accuracy of TVS and MRI for the diagnosis of adenomyosis. Search strategy: A search of studies was performed in five databases comparing TVS and MRI for the diagnosis of adenomyosis from January 1990 to May 2022. Selection criteria: Studies were eligible if they reported on the use of TVS and MRI in the same set of patients. The reference standard must be pathology (hysterectomy). Data collection and analysis: The quality of studies was assessed using the QUADAS-2 tool. Pooled sensitivity and specificity of both techniques were estimated and compared. Main results: Six studies comprising 595 women were included. The risk of bias of patient selection was high in three studies. The risk of bias for index tests and reference test was low. Pooled estimated sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for TVS were 75%, 81%, 3.9, and 0.31, respectively. These figures for MRI were 69%, 80%, 3.5, and 0.39, respectively. No statistically significant differences were found (p = 0.7509). Heterogeneity was high. Conclusions: MRI and TVS have similar performances for the diagnosis of adenomyosis.
- Transvaginal ultrasound accuracy in the hydrosalpinx diagnosis: a systematic review and meta-analysis(2023) Nieto-Tous, M. (Mar); Alcazar, J.L. (Juan Luis); Guerriero, S. (Stefano); Delgado-Morell, A. (Aina); Andrada-Ripollés, C. (Cristina); Pascual, M.A. (Maria Angela); Ajossa, S. (Silvia)Hydrosalpinx is a condition with a crucial prognostic role in reproduction, and its diagnosis by a non-invasive technique such as ultrasound is key in achieving an adequate reproductive assessment while avoiding unnecessary laparoscopies. The aim of the present systematic review and meta-analysis is to synthetize and report the current evidence on transvaginal sonography (TVS) accuracy to diagnose hydrosalpinx. Articles on the topic published between January 1990 and December 2022 were searched in five electronic databases. Data from the six selected studies, comprising 4144 adnexal masses in 3974 women, 118 of which were hydrosalpinxes, were analyzed as follows: overall, TVS had a pooled estimated sensitivity for hydrosalpinx of 84% (95% confidence interval (CI) = 76-89%), specificity of 99% (95% CI = 98-100%), positive likelihood ratio of 80.7 (95% CI = 33.7-193.0), and negative likelihood ratio of 0.16 (95% CI = 0.11-0.25) and DOR of 496 (95% CI = 178-1381). The mean prevalence of hydrosalpinx was 4%. The quality of the studies and their risk of bias were assessed using QUADAS-2, evidencing an overall acceptable quality of the selected articles. We concluded that TVS has a good specificity and sensitivity for diagnosing hydrosalpinx.
- The diagnostic accuracy of transvaginal ultrasound for detection of ureteral involvement in deep infiltrating endometriosis(Wiley, 2023) Muñoz, M.D. (María Dolores); Alcazar, J.L. (Juan Luis); Guerriero, S. (Stefano); Florez, S. (Sandra); Chway, C. (Cizar)Objective—The aim of this study is to determine the accuracy of transvaginal ultrasound (TVU) for the diagnosis of ureteral involvement in women with deep infiltrating endometriosis (DIE). Methods—The meta-analysis included primary studies comparing the use of TVU for diagnosing endometriotic involvement of the ureter, using laparoscopic surgery and histological diagnosis as the reference standard. Search was performed in several databases (Scopus, Web of Science, and PubMed/ MEDLINE). The studies’ quality and bias risk were assessed using the Quality Assessment of Diagnostic Accuracy Study-2 (QUADAS-2). Diagnostic performance was estimated by assessing pooled sensitivity and specificity. Results—A total of 496 citations were found. Six articles were ultimately selected for this systematic review and meta-analysis after the inclusion and exclusion criteria were applied. Pooled sensitivity and specificity were 0.81 (95% CI: 0.42– 0.96), 1.00 (95% CI: 0.93–1.00). The heterogeneity observed was high for both sensitivity and specificity. Overall risk of bias was low. Conclusion—TVU is a valuable tool for the pre-operative identification of ureteral involvement by DIE.