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The Complexity of a “Complex Mass” and the Simplicity of a “Simple Cyst”

ynecologic sonography has made considerable strides in the last 20 years. Initially, the resolution of abdominal transducers increased. Then transvaginal probes were introduced, were perfected, and have become the principal tools for evaluating the female pelvis. Correlations of sonographic images with pathologic findings have led to a substantial understanding of adnexal abnormalities. In fact, you could say, the field collectively has a learning curve just as individuals have a learning curve. The development of scoring systems to characterize and define ovarian lesions first based on morphologic characteristic and later including color Doppler flow data brought us closer to a relatively reliable distinction between benign and malignant lesions or at least a negative predictive value in the range of 97% to 99%.1–3 Despite the above achievements, it is disheartening to see today some gynecologic sonographic reports that may have been appropriate 20 years ago when resolution was more limited, as was our field’s level of understanding. We frequently see, in reports of a gynecologic patient, the wording “a left adnexal complex mass measuring 4 × 5 × 4 cm was seen.” We desperately look for a more detailed description of the finding—in vain, because there is none. Then we search for the results of a Doppler study of the vessels in or around the finding. Again, none are reported. The most alarming message comes at the end of the report in the paragraph entitled “Impression,” where we see a long list of differential diagnoses, which invariably end with the statement, “. . . ovarian malignancy cannot be ruled out.” Looking at the pictures on which these reports are issued, we can often see benign-appearing adnexal lesions such as corpora lutea, cystic teratomas, endometriomas, and even simple cysts. Much of the time, however, the diagnosis can be made with a great deal more accuracy than the clinician is currently getting. We agree that not all hemorrhagic corpora lutea, endometriomas, or benign cystic teratomas are “classic” in their sonographic appearance, but most of them are distinctive enough. Therefore, this practice of giving a differential diagnosis that includes virtually every adnexal abnormality is no longer appropriate. As a field we can do better—most of the time. What should the referring provider do reading such a report? When the adnexal mass was detected at the palpatory examination, the gynecologist knew all too well the differential diagnoses pertaining to this mass, including the possibility of cancer. The patient was sent for the sonographic scan for help in the diagnostic process, not for the purpose of reading the list of diagnoses the gynecologist knew in the first place. Imaging laboratories can and should do better much of the time.