The Validity of Doppler-Ultrasound in Distinguishing of Malignant and Benign Masses in Ovaries Using Cutoff Values
Abstract
Some studies have concluded that PI and RI play an inadequate role in distinguishing benign tumors from malignant ones; however, later studies have reported different results, showing that Doppler ultrasound is effective in differentiating malignant from non‑malignant ovarian masses by using specific threshold values for both RI and PI. The presence of such conflicting data justifies our study. The purpose of this project was to use color Doppler and ultrasound imaging to differentiate between malignant and benign ovarian tumors and to verify the findings by comparing them with histopathology. Over the course of two years, 86 patients with ovarian masses were evaluated for morphologic features, pulsatility indices (PI), and resistance indices (RI) using Doppler ultrasound. Histopathologic confirmation served as the basis for the final diagnosis. The cutoff value for RI was ≤0.39 and for PI was ≤1.1, as shown in figures 1 and 2 and table 1. The sensitivity, specificity, and positive and negative predictive values were all 100%. Doppler ultrasound provides effective tools, including resistive and pulsatility indices, that can be used to differentiate between benign and malignant ovarian masses.
1 Mahale N, Kumar N, Mahale A, Ullal S, Fernandes M, Prabhu S. Validity of ultrasound with color Doppler to differentiate between benign and malignant ovarian tumours. Obstet Gynecol Sci. 2024 Mar;67(2):227-234. doi: 10.5468/ogs.23072. Epub 2024 Feb 20. PMID: 38374696; PMCID: PMC10948212.
2 Carley ME, Klingele CJ, Gebhart JB, Webb MJ, Wilson TO. Laparoscopy versus laparotomy in the management of benign unilateral adnexal masses. J Am Assoc Gynecol Laparosc. 2002 Aug;9(3):321-6. doi: 10.1016/s1074-3804(05)60411-2. PMID: 12101329.
3 Sayasneh A, Ekechi C, Ferrara L, Kaijser J, Stalder C, Sur S, Timmerman D, Bourne T. The characteristic ultrasound features of specific types of ovarian pathology (review). Int J Oncol. 2015 Feb;46(2):445-58. doi: 10.3892/ijo.2014.2764. Epub 2014 Nov 18. PMID: 25406094; PMCID: PMC4277251.
4 Basha MAA, Refaat R, Ibrahim SA, Madkour NM, Awad AM, Mohamed EM, El Sammak AA, Zaitoun MMA, Dawoud HA, Khamis MEM, Mohamed HAE, El-Maghraby AM, Abdalla AAEM, Assy MM, Nada MG, Obaya AA, Abdelbary EH. Gynecology Imaging Reporting and Data System (GI-RADS): diagnostic performance and inter-reviewer agreement. Eur Radiol. 2019 Nov;29(11):5981-5990. doi: 10.1007/s00330-019-06181-0. Epub 2019 Apr 16. PMID: 30993433.
5 Mundhra R, Bahadur A, Kashibhatla J, Kishore S, Chaturvedi J. Comparing Four Different Risk Malignancy Indices in Differentiating Benign and Malignant Ovarian Masses. J Midlife Health. 2024 Apr-Jun;15(2):75-80. doi: 10.4103/jmh.jmh_192_23. Epub 2024 Jul 5. PMID: 39145276; PMCID: PMC11321511.
6 Timmerman D, Testa AC, Bourne T, Ameye L, Jurkovic D, Van Holsbeke C, Paladini D, Van Calster B, Vergote I, Van Huffel S, Valentin L. Simple ultrasound-based rules for the diagnosis of ovarian cancer. Ultrasound Obstet Gynecol. 2008 Jun;31(6):681-90. doi: 10.1002/uog.5365. PMID: 18504770.
7 Nunes N, Ambler G, Foo X, Widschwendter M, Jurkovic D. Prospective evaluation of IOTA logistic regression models LR1 and LR2 in comparison with subjective pattern recognition for diagnosis of ovarian cancer in an outpatient setting. Ultrasound Obstet Gynecol. 2018 Jun;51(6):829-835. doi: 10.1002/uog.18918. Epub 2018 Jun 4. PMID: 28976616.
8 Jung SI. Ultrasonography of ovarian masses using a pattern recognition approach. Ultrasonography. 2015 Jul;34(3):173-82. doi: 10.14366/usg.15003. Epub 2015 Feb 7. PMID: 25797108; PMCID: PMC4484293.
9 Salem S, White LM, Lai J. Doppler sonography of adnexal masses: the predictive value of the pulsatility index in benign and malignant disease. AJR Am J Roentgenol. 1994 Nov;163(5):1147-50. doi: 10.2214/ajr.163.5.7976891. PMID: 7976891.
10 Carter JR, Lau M, Fowler JM, Carlson JW, Carson LF, Twiggs LB. Blood flow characteristics of ovarian tumors: implications for ovarian cancer screening. Am J Obstet Gynecol. 1995 Mar;172(3):901-7. doi: 10.1016/0002-9378(95)90019-5. PMID: 7892883.
11 Angeid-Backman E, Coleman BG, Arger PH, Jacobs JE, Langer JE, Horii S. Comparison of resistive index versus pulsatility index in assessing the benign etiology of adnexal masses. Clin Imaging. 1998 Jul-Aug;22(4):284-91. doi: 10.1016/s0899-7071(98)00013-8. PMID: 9699050.
12 Tongsong T, Wanapirak C, Neeyalavira V, Khunamornpong S, Sukpan K. E-flow doppler indices for prediction of benign and malignant ovarian tumors. Asian Pac J Cancer Prev. 2009 Jan 1;10(1):139-42.
13 Chen CY, Wu YC, Yen MS, Hung JH, Yuan CC, Chao KC. The power Doppler velocity index, pulsatility index, and resistive index can assist in making a differential diagnosis of primary ovarian carcinoma and Krukenberg tumors: a preliminary study. J Ultrasound Med. 2007 Jul;26(7):921-6; quiz 927-9. doi: 10.7863/jum.2007.26.7.921. PMID: 17592055.
14 Liberto JM, Chen SY, Shih IM, Wang TH, Wang TL, Pisanic TR 2nd. Current and Emerging Methods for Ovarian Cancer Screening and Diagnostics: A Comprehensive Review. Cancers (Basel). 2022 Jun 11;14(12):2885. doi: 10.3390/cancers14122885. PMID: 35740550; PMCID: PMC9221480.
15. Lee SJ, Oh HR, Na S, Hwang HS, Lee SM. Ultrasonographic ovarian mass scoring system for predicting malignancy in pregnant women with ovarian mass. Obstet Gynecol Sci 2022;65:1-13.
16 Das TS, Choudhury SS, Dutta P, Ahmed RS. The Role of Colour Doppler Ultrasound in Differentiation of Benign from Malignant Ovarian Masses. J Obstet Gynaecol India. 2025 Apr;75(2):155-159. doi: 10.1007/s13224-024-02013-4. Epub 2024 Jul 4. PMID: 40353272; PMCID: PMC12064477.
17. Shah D, Shah S, Parikh J, Bhatt CJ, Vaishnav K, Bala DV. Doppler ultrasound: a good and reliable predictor of ovarian malignancy. J Obstet Gynaecol India 2013;63:186-9.
18. Tekay A, Jouppila P. Validity of pulsatility and resistance indices in classification of adnexal tumors with transvaginal color Doppler ultrasound. Ultrasound Obstet Gynecol 1992;2:338-44.
19. Mallari RGO, Coloma MLB. Comparison of SASSONE scoring and ADNEX model in differentiating benign and malignant ovarian neoplasm in a university hospital. JMUST 2018;2:192-200.
20. Günakan E, Tohma YA, Tunç M, Akıllı H, Şahin H, Ayhan A. Factors associated with surgical morbidity of primary debulking in epithelial ovarian cancer. Obstet Gynecol Sci 2020;63:64-71.
2 Carley ME, Klingele CJ, Gebhart JB, Webb MJ, Wilson TO. Laparoscopy versus laparotomy in the management of benign unilateral adnexal masses. J Am Assoc Gynecol Laparosc. 2002 Aug;9(3):321-6. doi: 10.1016/s1074-3804(05)60411-2. PMID: 12101329.
3 Sayasneh A, Ekechi C, Ferrara L, Kaijser J, Stalder C, Sur S, Timmerman D, Bourne T. The characteristic ultrasound features of specific types of ovarian pathology (review). Int J Oncol. 2015 Feb;46(2):445-58. doi: 10.3892/ijo.2014.2764. Epub 2014 Nov 18. PMID: 25406094; PMCID: PMC4277251.
4 Basha MAA, Refaat R, Ibrahim SA, Madkour NM, Awad AM, Mohamed EM, El Sammak AA, Zaitoun MMA, Dawoud HA, Khamis MEM, Mohamed HAE, El-Maghraby AM, Abdalla AAEM, Assy MM, Nada MG, Obaya AA, Abdelbary EH. Gynecology Imaging Reporting and Data System (GI-RADS): diagnostic performance and inter-reviewer agreement. Eur Radiol. 2019 Nov;29(11):5981-5990. doi: 10.1007/s00330-019-06181-0. Epub 2019 Apr 16. PMID: 30993433.
5 Mundhra R, Bahadur A, Kashibhatla J, Kishore S, Chaturvedi J. Comparing Four Different Risk Malignancy Indices in Differentiating Benign and Malignant Ovarian Masses. J Midlife Health. 2024 Apr-Jun;15(2):75-80. doi: 10.4103/jmh.jmh_192_23. Epub 2024 Jul 5. PMID: 39145276; PMCID: PMC11321511.
6 Timmerman D, Testa AC, Bourne T, Ameye L, Jurkovic D, Van Holsbeke C, Paladini D, Van Calster B, Vergote I, Van Huffel S, Valentin L. Simple ultrasound-based rules for the diagnosis of ovarian cancer. Ultrasound Obstet Gynecol. 2008 Jun;31(6):681-90. doi: 10.1002/uog.5365. PMID: 18504770.
7 Nunes N, Ambler G, Foo X, Widschwendter M, Jurkovic D. Prospective evaluation of IOTA logistic regression models LR1 and LR2 in comparison with subjective pattern recognition for diagnosis of ovarian cancer in an outpatient setting. Ultrasound Obstet Gynecol. 2018 Jun;51(6):829-835. doi: 10.1002/uog.18918. Epub 2018 Jun 4. PMID: 28976616.
8 Jung SI. Ultrasonography of ovarian masses using a pattern recognition approach. Ultrasonography. 2015 Jul;34(3):173-82. doi: 10.14366/usg.15003. Epub 2015 Feb 7. PMID: 25797108; PMCID: PMC4484293.
9 Salem S, White LM, Lai J. Doppler sonography of adnexal masses: the predictive value of the pulsatility index in benign and malignant disease. AJR Am J Roentgenol. 1994 Nov;163(5):1147-50. doi: 10.2214/ajr.163.5.7976891. PMID: 7976891.
10 Carter JR, Lau M, Fowler JM, Carlson JW, Carson LF, Twiggs LB. Blood flow characteristics of ovarian tumors: implications for ovarian cancer screening. Am J Obstet Gynecol. 1995 Mar;172(3):901-7. doi: 10.1016/0002-9378(95)90019-5. PMID: 7892883.
11 Angeid-Backman E, Coleman BG, Arger PH, Jacobs JE, Langer JE, Horii S. Comparison of resistive index versus pulsatility index in assessing the benign etiology of adnexal masses. Clin Imaging. 1998 Jul-Aug;22(4):284-91. doi: 10.1016/s0899-7071(98)00013-8. PMID: 9699050.
12 Tongsong T, Wanapirak C, Neeyalavira V, Khunamornpong S, Sukpan K. E-flow doppler indices for prediction of benign and malignant ovarian tumors. Asian Pac J Cancer Prev. 2009 Jan 1;10(1):139-42.
13 Chen CY, Wu YC, Yen MS, Hung JH, Yuan CC, Chao KC. The power Doppler velocity index, pulsatility index, and resistive index can assist in making a differential diagnosis of primary ovarian carcinoma and Krukenberg tumors: a preliminary study. J Ultrasound Med. 2007 Jul;26(7):921-6; quiz 927-9. doi: 10.7863/jum.2007.26.7.921. PMID: 17592055.
14 Liberto JM, Chen SY, Shih IM, Wang TH, Wang TL, Pisanic TR 2nd. Current and Emerging Methods for Ovarian Cancer Screening and Diagnostics: A Comprehensive Review. Cancers (Basel). 2022 Jun 11;14(12):2885. doi: 10.3390/cancers14122885. PMID: 35740550; PMCID: PMC9221480.
15. Lee SJ, Oh HR, Na S, Hwang HS, Lee SM. Ultrasonographic ovarian mass scoring system for predicting malignancy in pregnant women with ovarian mass. Obstet Gynecol Sci 2022;65:1-13.
16 Das TS, Choudhury SS, Dutta P, Ahmed RS. The Role of Colour Doppler Ultrasound in Differentiation of Benign from Malignant Ovarian Masses. J Obstet Gynaecol India. 2025 Apr;75(2):155-159. doi: 10.1007/s13224-024-02013-4. Epub 2024 Jul 4. PMID: 40353272; PMCID: PMC12064477.
17. Shah D, Shah S, Parikh J, Bhatt CJ, Vaishnav K, Bala DV. Doppler ultrasound: a good and reliable predictor of ovarian malignancy. J Obstet Gynaecol India 2013;63:186-9.
18. Tekay A, Jouppila P. Validity of pulsatility and resistance indices in classification of adnexal tumors with transvaginal color Doppler ultrasound. Ultrasound Obstet Gynecol 1992;2:338-44.
19. Mallari RGO, Coloma MLB. Comparison of SASSONE scoring and ADNEX model in differentiating benign and malignant ovarian neoplasm in a university hospital. JMUST 2018;2:192-200.
20. Günakan E, Tohma YA, Tunç M, Akıllı H, Şahin H, Ayhan A. Factors associated with surgical morbidity of primary debulking in epithelial ovarian cancer. Obstet Gynecol Sci 2020;63:64-71.
| Files | ||
| Issue | Articles in Press: Vol 64 No 03 (2026) | |
| Section | Original Articles | |
| Keywords | ||
| Pulsatility Resistive Index Ovarian mass | ||
| Rights and permissions | |
|
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Matrood Alkhazraji R. The Validity of Doppler-Ultrasound in Distinguishing of Malignant and Benign Masses in Ovaries Using Cutoff Values. Acta Med Iran. 2026;.
