• 1.
  

  a) F b) T c) F d) T e) F

In women with regular menstrual periods, cardiac activity can be visualised at a gestational age of at least 46 days. Because of possible variation in the menstrual cycle and rate of fetal growth, however, gestational age alone should not be used for the determination of pregnancy viability. Cardiac activity can be seen by transvaginal ultrasonography in embryos measuring 3–5 mm in length. Taking into account variations in the sonographers’ experience and equipment quality, a safety margin has been proposed stipulating that fetal demise should not be diagnosed in a single visit when the embryo measures less than 7 mm in length. Miscarriage can be diagnosed in a single visit when an empty gestational sac measuring 25 mm or more is seen on ultrasound. Complete miscarriage is diagnosed when ultrasound fails to identify any signs of pregnancy tissue within the uterine cavity. One should bear in mind that this diagnosis can only be made when an intrauterine pregnancy was visualised on a previous scan. While falling βHCG levels indicate a failing pregnancy, they do not identify its location.

• 2.
  

  a) F b) F c) T d) F e) F

Clinical findings suggestive of torsion should always take precedence over ultrasound findings in diagnosing ovarian torsion and sudden onset pain associated with nausea and vomiting are the most common. Ultrasound findings typical of torsion are not always present, and their absence should not influence the clinical management of a cystic ovary and acute pain. In ovarian torsion, arterial blood flow is typically maintained and, therefore, Doppler ultrasound studies are not particularly helpful. Ovarian enlargement and evidence of oedema are more helpful than findings of blood-flow studies. The ‘Whirlpool’ sign is a useful feature, as the twisted torted pedicle can often be visualised using colour Doppler ultrasound. Endometriomas tend to be adherent to the surrounding pelvic structures and therefore they are less likely to tort compared to dermoid cysts which are typically free of adhesions. Pain that resolves in suspected torsion is usually due to de-torsion of the pedicle. In the presence of a cyst this should still be surgically managed to prevent it happening again and loss of the ovary.

• 3.
  

  a) F b) F c) F d) F e) F

Chorionicity can be determined when two gestational sacs are seen on the ultrasound examination. Gestational sacs can clearly be visualised at about 5 weeks’ gestation. Monozygotic twins develop from a single fertilised oocyte. The chorionicity depends upon the time at which the developing embryo divides. If it divides before implantation, the resulting twins are dichorionic. In the first trimester, amniotic and chorionic membranes are not fused, and amnionicity can be determined by counting the number of amniotic cavities within a gestational sac. Once pregnancy progresses beyond the first trimester, the membranes become fused, and determination of chorionicity and amnionicity is more difficult. In that situation the ‘T’ sign and ‘lambda’ sign are helpful in making the diagnosis. The number of yolk sacs can be predictive of amnionicity; however, in a small proportion of women, this can be misleading as a single yolk sac does not definitely indicate monoamniotic pregnancy. Because of this phenomenon, the visualisation of amniotic membranes at 7–9 weeks gestation is the appropriate tool for assessment of amnionicity. The early first trimester CRL measurements are not significantly different between singleton and twin pregnancies.

• 4.
  

  a) T b) T c) F d) T e) F

Only M-mode ultrasound should be used for heart rate assessment, as Doppler ultrasound produces high-energy output and should not be routinely used in early pregnancy. Three-dimensional ultrasound techniques use serial two-dimensional image sampling to reproduce a three-dimensional image. Hence, it does not exert higher energy impact on the embryo compared with standard two-dimensional ultrasound. Modern ultrasound machines always display mechanical and thermal indices. These should be presented to the examiner. They remind him to adjust the ultrasound settings to the lowest possible energy output. Tissue temperature rises of up to 1 °C are considered to be safe for the embryo.

• 5.
  

  a) T b) F c) T d) T e) F

The risk of finding endometrial cancer in a woman with postmenopausal bleeding and endometrial thickness as measured by ultrasound 4 mm or less is low. Prospective observational follow-up studies show that it is safe to refrain from endometrial sampling in these women. If the endometrial thickness is 5 mm or more, a representative endometrial sample must always be obtained. Regular endometrial echogenicity at grey scale ultrasound and poor vascularisation at colour or power Doppler decrease the risk of malignancy, but this information should be used mainly for prioritising women for a diagnostic procedure, not to decide whether or not a diagnostic procedure is needed (unless the woman is at extremely high operative risk and surgery is necessary to obtain a histological diagnosis). Almost all endometrial pathology grows focally in the uterine cavity. Therefore, a smooth endometrium with no signs of focal pathology at saline contrast sono-hysterography (or hysteroscopy) is a strong sign of normality. Because 87% of focal lesions cannot be removed at all or only partially removed if a blind endometrial sampling technique is used they must be resected under direct visual control to ensure their complete removal. Malignancy is sometimes rarely found in benign polyps. Therefore, it is important to remove focal lesions in toto. An endometrium that cannot be seen at ultrasound cannot be measured and cannot have its echogenicity or vascularity evaluated. Indeed, endometrial cancer is sometimes diagnosed in women with an invisible endometrium at ultrasound. To clarify the situation, saline-contrast sono-hysterography should be carried out. If it fails, the woman should be referred for hysteroscopy and endometrial sampling.

• 6.
  

  a) F b) F c) F d) T e) F

Endometrial thickness measurements with transvaginal ultrasound have no role in the triage of women with irregular bleeding before the menopause, because the endometrial thickness changes during the menstrual cycle. Immediately after menstruation, the endometrium is thin, during the proliferative phase it increases in thickness, and it remains thick in the secretory phase. The ultrasound appearance of the endometrium in the case of endometritis is not well known. No published high-quality ultrasound images exist of more common types of endometritis or of tuberculous endometritis. Indeed, endometritis in women with clinical signs of pelvic inflammatory disease does not seem to manifest any specific ultrasound features. Benign polyps may regress spontaneously in women before the menopause. Whether this is explained by misdiagnosis or by true polyps regression is unknown. Polyps are characterised by the presence of a feeding vessel at colour or power Doppler ultrasound examination (i.e. one big vessel entering into the endometrial echo from the surrounding myometrium) whereas submucous myomas are reported to be surrounded by a ring of colour.

• 7.
  

  a) F b) T c) F d) F e) F

In three studies in which women underwent both ultrasound and magnetic resonance imaging before hysterectomy, ultrasound was as good as magnetic resonance imaging for diagnosing adenomyosis provided that the uterus was not very large (>400 ml) and did not also contain myomas. In a meticulously designed prospective study in which women underwent both transvaginal ultrasound and magnetic resonance imaging before hysterectomy, the two methods had equal ability to detect uterine leiomyomas (magnetic resonance imaging sensitivity 99%, specificity 86%; transvaginal ultrasonography sensitivity 99%, specificity 91%). Magnetic resonance imaging, however, was superior to transvaginal ultrasound for myoma mapping (determination of the exact number, location and size of the myomas) if the uterus was greater than 375 ml or contained five or more myomas. In typical cases, benign leiomyomas are solid tumours characterised by regular internal echogenicity and stripy shadows at ultrasound examination, whereas leiomyosarcomas are solid tumours that often contain areas of necrosis and, therefore, have a more irregular internal echogenicity. Insufficient data are available on the typical ultrasound appearance of malignant uterine leiomyosarcomas to determine the extent to which the ultrasound features of uterine leiomyosarcomas and leiomyomas overlap. Unfortunately, no studies have been published that are large enough to estimate with any precision the ability of either ultrasound or magnetic resonance imaging to discriminate between benign uterine leiomyomas and leiomyosarcomas. It is not known if the ultrasound appearance of endometrial hyperplasia is the same in pre- and post-menopausal women.

• 8.
  

  a) T b) T c) T d) T e) T

These are the typical intramyometrial sonographic signs of adenomyotic foci. They are located below the endometrium (e.g. sub-endometrium or junctional zone) or in the outer myometrium, and are associated with hyperechoic fibrotic reaction of the myometrium. Asymmetric myometrial walls are also a sonographic sign of adenomyosis, owing to fibrotic thickening of the myometrium of one uterine wall, unrelated to leiomyoma, in which the presence of adenomyosis is increased (e.g. anterior wall is thicker than the posterior wall or vice versa). Hypoechoic linear striations are related to fibrosis associated with adenomyosis and can also be present in fibroids. The presence of diffuse vascularity inside the myometrium affected by adenomyosis is seen as diffusely spread small vessels, which do not follow the normal course of the arcuate and radial arteries inside the myometrium. Uterine leiomyomas show a circular flow along the myoma capsule, whereas localised adenomyosis and adenomyomas are characterised by a few diffusely spread vessels inside the lesions.

• 9.
  

  a) F b) T c) F d) F e) F

This is the typical ultrasound appearance of an endometrioma and not of deep infiltrating endometriosis, which is retroperitoneal fibrotic endometriotic tissue. b is the typical ultrasound appearance of rectal deep infiltrating endometriosis, which is retroperitoneal fibrotic tissue attached and infiltrating the rectal wall. Deep infiltrating endometriosis appears at transvaginal ultrasound as hypoechoic and not hyperechoic. Deep infiltrating endometriosis shows very few vessels. Deep infiltrating endometriosis never has a cystic aspect with papillae (typical for borderline or malignant ovarian lesions).

• 10.
  

  a) F b) F c) T d) F e) F

The pouch of Douglas is posterior to the uterus. Obliteration is not caused by anterior bladder endometriosis, which obliterates the vesico-uterine pouch. Adhesions to the uterus, the broad ligaments, and also the pouch of Douglas are common in endometriomas, but generally they do not completely obliterate the pouch. Only in the case of large and bilateral cysts, and in the presence of extended adhesions (kissing ovaries) can the pouch of Douglas be obliterated. Rectal endometriosis often causes pouch of Douglas obliteration, as deep infiltrating endometriosis attaches to the uterus and the cervix. Very seldom, the retroperitoneal fibrotic endometriotic nodules are isolated and do not adhere to other pelvic organs.

Adenomyosis is localised in the myometrium and does not obliterate the pouch of Douglas if unassociated with rectal endometriosis. Hydrosalpinx can cause adhesions to the uterus and broad ligaments, and is often associated with endometriomas. It generally does not obliterate the Pouch of Douglas if unassociated with deep infiltrating endometriosis or bilateral adnexal lesions.

• 11.
  

  a) F b) F c) T d) F e) F

The normal junctional zone is visualised as a sub-endometrial hypoechoic halo and not as a hyperechoic zone. Hyperechoic areas inside the hypoechoic junctional zone are caused by infiltration on endometrial tissues in the inner myometrium called adenomyosis. The normal junctional zone does not have cystic fluid. Small sub-endometrial cystic areas or myometrial cystic areas can be observed only in cases of adenomyosis. Despite the apparent lack of histological distinction between the junctional zone and the outer myometrium on light microscopy, these two zones are in reality structurally and biologically different. The different orientation of the circular myometrial fibres of the junctional zone compared with the outer myometrium probably causes the hypoechoic ultrasound appearance of this zone. The normal junctional zone shows normal, regular myometrial vascularisation by radial vessels. The normal junctional zone does not have myometrial hypoechoic striations. These hypoechoic striations are associated with alterations of the myometrium by fibrotic tissue, as in case of adenomyosis or leiomyoma.

• 12.
  

  a) F b) F c) F d) F e) F

Difficult masses for expert examiners mainly comprise serous and mucinous cystadenomas and cystadenofibromas, fibromas, rare benign tumours, and borderline malignancies. Measurement of serum CA125 is not reliable as a second-line test with these histological subtypes. Levels are normal in one-half of all borderline tumours, and stage I invasive disease and there are frequently false-positive elevations in numerous benign tumours or conditions that irritate the pelvic peritoneum. Although serum HE4 is less frequently elevated in benign tumours that are commonly difficult to differentiate from ovarian cancer, test performance is also poor in borderline or stage I invasive tumours. Combining the tests is similarly unhelpful. Also, algorithms (Risk of Malignancy Index and Risk of Ovarian Malignancy Algorithm) that depend heavily upon these biomarkers did not improve test performance when used after subjective assessment by an expert examiner.

• 13.
  

  a) T b) T c) T d) F e) F

An important finding from the IOTA study is that almost one-half of ovarian masses have features that enable them to be characterised relatively easily. For example, ‘typical’ dermoid cysts, ‘typical’ endometriomas and late-stage ovarian cancer have characteristic ultrasound features that should be recognised almost instantly by any ultrasound examiner. Retrospectively, the IOTA study has defined six ‘easy descriptors’ that should enable an examiner to make an ‘instant’ diagnosis of an ovarian mass without needing to use second-stage tests: four described features of common benign tumours, whereas two described features of malignancies. Answer d and e correspond to clinical situations where these descriptors are applicable, whereas some unilocular-solid or multilocular-solid tumours, tumours with irregular walls and papillary projections, and tumours that contain over 10 locules, may be difficult to classify for expert examiners.

• 14.
  

  a) F b) F c) F d) T e) F

An ovarian mass is classified as malignant if at least one M-feature and no B-features are present and vice versa. When no B- or M-features are present, or if both B- and M-features are present, then simple rules are considered inconclusive (uncertain) and a different diagnostic method should be used. Both an M (M2) and B feature (B5) are present in this first tumour; thus, it cannot be classified using the simple rules. Again both an M (M2) and B (B5) feature are present in the second tumour; thus, it cannot be classified using the simple rules. The third tumour only contains B features (B2, B3), and thus should be classified as benign, and not malignant. This fourth tumour contains two M features (M2, M3) and no B features; thus, it is classified as malignant according to the rules. This final tumour contains both an M feature (M5) and B feature (B4); thus, it is not classifiable according to the rules.

• 15.
  

  a) T b) T c) T d) F e) F

Some studies suggest that conventional MRI is the best second-line imaging test for inconclusive tumours after TVS. These studies, however, have not compared MRI with subjective ultrasound assessment by experts for this group of ‘difficult’ tumours. In some studies, the addition of ultrafast dynamic contrast enhanced and diffusion-weighted imaging sequences to conventional MRI led to an improved test performance of MRI in the characterisation of difficult masses, and enabled the development of a new promising magnetic resonance scoring system. This scoring system, however, still needs to be externally validated before introducing it into daily clinical practice. Most non-classifiable masses are benign; therefore, the contribution of MRI is mainly to improve specificity. A drawback to most studies evaluating test performance of MRI in this group of difficult masses is that no information is provided that clearly defines what the characteristics are of the masses that have been defined as ‘difficult to classify’ compared with other masses where classification was more straightforward.

• 16.
  

  a) T b) T c) T d) F e) F

Ultrasound is a commonly available and a comparatively inexpensive imaging method. Its general utility in staging is limited by the need for expertise in interpreting transvaginal and transabdominal ultrasound. Another limitation might be restricted visibility of abdominal structures in obese women, in women who have had multiple laparotomies causing intestinal loops adhesions, or in the presence of large amount of ascites. On the other hand, the absence of ascites makes the detection of discrete peritoneal implants in the abdomen almost impossible. Futhermore, results of studies evaluating the reproducibility of ultrasound for ovarian cancer staging are not available.

• 17.
  

  a) T b) F c) F d) F e) T

The recommended preoperative staging consists of abdomino-pelvic computed tomography with contrast and chest X-ray. The latter serves to screen for pleural metastases. Magnetic resonance imaging is an equivalent alternative to computed tomography in tumour staging, but its applicability is limited. Positron emission tomography and computed tomography is not yet fully established in ovarian cancer staging. Radiographic studies, such as urography or contrast enema, have been replaced by computed tomography for staging of ovarian cancer.

• 18.
  

  a) T b) T c) T d) T e) F

Computed tomography provides all the required information in a short examination time. The most important limitation of computed tomography in the staging of ovarian cancer is its inability to detect reliably small bowel visceral (serosal), mesenteric, or parietal peritoneal implants, which lead to disease stage underestimation. Computed tomography with contrast cannot be carried out in cases of renal insufficiency or severe allergy to iodinated contrast agents. The ionising radiation exposure associated with computed tomography is contraindicated in women who are pregnant.

• 19.
  

  a) F b) T c) F d) F e) F

The International Federation of Gynecology and Obstetrics (FIGO) recommends a clinical staging system for cervical cancer. In 20–30% of cases of early stage disease (defined on the basis of clinical examination), a significant discrepancy was found between clinical staging and histological finding for tumour diameters and parametrial involvement. International recommendations, such as National Comprehensive Cancer Network and American College of Radiology, have suggested magnetic resonance imaging as the optimal modality for assessing the extent of cervical carcinoma FIGO stage IB1 or greater. Also, FIGO now encourages its use in the assessment of cervical cancer for detecting prognostic factors such as tumour size, parametrial, and pelvic side-wall invasion, adjacent organ invasion, and lymph-node metastases.

• 20.
  

  a) T b) T c) T d) T e) T

Compared with MRI, ultrasound examination has the advantage of providing a dynamic examination, which permits the operator to assess the mutual sliding of contiguous tissues against each other. This plays an important role in evaluating the local extent of a tumour. This makes it possible to clearly define the relations between the neoplasm and pelvic walls, and to recognise the presence of pelvic lymphadenopathy. Therefore, even if international recommendations, such as those provided by the National Comprehensive Cancer Network and the American College of Radiology, consider only MRI as the appropriate diagnostic method to assess cervical carcinoma, ultrasound examination, which is broadly available, fast, non-invasive, and cheap technique, should be considered as a first-line diagnostic method in the work up of cervical cancer.

• 21.
  

  a) F b) F c) T d) F e) T

In the past decade, the value of ultrasound examination in assessing cervical cancer was highlighted by some investigators who used transrectal or transvaginal ultrasound. At colour or power Doppler examination, cervical tumours usually appear richly vascularised. In the multicentre prospective studies, ultrasound examination was compared with MRI in women with early stage cervical cancer planned for surgery, and similar accuracy was obtained for assessing parametrial infiltration. MRI is considered better with more advanced disease.

• 22.
  

  a) T b) T c) F d) F e) F

Subjective assessment of cervical and myometrial invasion are the two most important aspects in the assessment of endometrial cancer, as these are the best predictors of high-risk endometrial cancer. The tumour size correlates to the risk of deep myometrial invasion, but the tumour size must be related to the uterine size. We know that vascular morphology correlates to tumour growth pattern and to high-risk cancer. The subjective gray scale assessment, however, has a higher predictive value when it comes to estimating the risk of deep myometrial and cervical stromal invasion.

• 23.
  

  a) F b) T c) T d) F e) T

Three-dimensional volume measurements (three-dimensional tumour–uterine volume ratio) confer no advantage over two-dimensional measurements (tumour–uterine anterio-posterior diameter ratio). Three-dimensional ultrasound may be used to detect the minimal margin, but this can be done as well using two-dimensional ultrasound. The three-dimensional volume-contrast imaging technique may be used to delineate the tumour, but the clinical value needs to be established in larger prospective studies. Tumor–uterine anterio–posterior diameter is a valuable objective measurement technique, but the optimal cut-off needs to be established. Using a dynamic examination technique can help to determine if the tumour is only bulging down in the cervical canal or truly invading the cervical stroma. Myometrial invasion is best assessed using transvaginal ultrasound with an empty bladder. The simplicity, availability, and low cost remain major advantages of ultrasound. One must not forget, however, that the accuracy of the assessment depends on proper equipment, good training, and patient constitution.

• 24.
  

  a) T b) T c) T d) T e) T

Sagittal and axial planes are the standard most important ones for pelvic examination. For imaging of uterine cancer, it is beneficial if the sagittal plane is sagittal to the long axis of the uterus. In addition to these two planes, oblique imaging planes are used in tumours extending into the cervix for assessment of tumour relation to the vaginal fornices and parametria. If the tumour extends through the myometrium, coronal or frontal images may occasionally be useful to assess tumour relation to the urinary bladder and colon.

• 25.
  

  a) T b) F c) T d) F e) T

The M-features in IOTA are irregular solid tumour, at least 4 papillary structures, the presence of ascites, an irregular multilocular, solid tumour with largest diameter ≥100 mm and a very strong blood flow.

• 26.
  

  a) T b) T c) F d) F e) T

The B-features in IOTA are a unilocular tumour, the presence of solid components where the largest solid component has a largest diameter <7 mm, the presence of acoustic shadows, a smooth multilocular tumour with largest diameter <100 mm and no colour flow.

• 27.
  

  a) T b) F c) F d) T e) T

Subjective assessment of gray scale and colour Doppler ultrasound findings with TVS is indeed the first-line imaging technique for characterising adnexal masses.

The optimal approach using ultrasound to discriminate between the benign or malignant nature of an adnexal mass before surgery is the subjective assessment of gray-scale and Doppler ultrasound findings by an expert level III examiner with a special interest in gynaecological ultrasonography. In the International Ovarian Tumor Analysis (IOTA) six categories of diagnostic certainty have been proposed for the subjective assessment of adnexal masses (i.e. certainly malignant, probably malignant, uncertain but more likely to be malignant, uncertain but more likely to be benign, probably benign, or certainly benign). When expert examiners are highly or moderately confident about the histological nature of an adnexal mass, a large study on 3511 adnexal masses by the IOTA collaboration reported a sensitivity and specificity of 91% and 96% for malignancy.

• 28.
  

  a) T b) T c) F d) T e) F

Only a small proportion (6–8%) of masses cannot be confidently classified as benign or malignant when using subjective assessment by experienced ultrasound examiners and accuracy is limited to 68% in this group of tumours, with rather poor sensitivity ranging from 57–70%, and specificity of only 60–77%. The ability to characterise adnexal tumours correctly with TVS when using subjective assessment of gray scale and colour Doppler ultrasound findings clearly improves with the level of experience of the ultrasound operator. Therefore, investment in education and training in gynaecological ultrasound examination is pivotal to minimise the healthcare burden related to mis-classified adnexal tumours. The European Federation of Societies for Ultrasound in Medicine and Biology has published guidelines on how much training and education in gynaecological ultrasound imaging is needed to obtain competence at different levels.

• 29.
  

  a) F b) F c) T d) T e) T

An alternative approach to using subjective assessment is to use risk models or diagnostic rules to triage women as being at low or high risk of cancer. Such models and rules have been developed to assist clinicians with variable training backgrounds and levels of expertise. In the most recent systematic review and meta-analysis to address the performance of mathematical models and scoring systems, a total of 195 diagnostic accuracy studies were included. It considered 116 different prediction models for characterising adnexal masses. The meta-analysis focused on 19 different models that had been externally validated in 96 studies. The RMI was the most frequently validated model, with a pooled sensitivity of 72% (67–76%) and specificity of 92% (89–93%), using a cut-off level of 200. The IOTA logistic regression model LR2, with a risk cut off of 10% and simple rules, were superior to all other models included in the meta-analysis, with a pooled sensitivity and specificity of 92% (88–95%) and 83% (77–88%) for LR2, and 93% (89–95%) and 81% (76–85%) for simple rules.

• 30.
  

  a) F b) T c) T d) T e) T

The IOTA LR2 model uses six variables: (1) patient age (years); (2) presence of ascites (yes = 1, no = 0); (3) presence of blood flow within a papillary projection (yes = 1, no = 0); (4) maximum diameter of the solid component (expressed in millimeters and truncated at 50 mm); (5) irregular internal cyst walls (yes = 1, no = 0); and (6) presence of acoustic shadows (yes = 1, no = 0).