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To analyze how well untrained examiners - without experience in the use of International Ovarian Tumor Analysis (IOTA) terminology or simple ultrasound-based rules (simple rules) - are able to apply IOTA terminology and simple rules and to assess the level of agreement between non-experts and an expert. This prospective multicenter cohort study enrolled women with ovarian masses. Ultrasound was performed by non-expert examiners and an expert. Ultrasound features were recorded using IOTA nomenclature, and used for classifying the mass by simple rules. Interobserver agreement was evaluated with Fleiss' kappa and percentage agreement between observers. 50 consecutive women were included. We observed 46 discrepancies in the description of ovarian masses when non-experts utilized IOTA terminology. Tumor type was misclassified often (n = 22), resulting in poor interobserver agreement between the non-experts and the expert (kappa = 0.39, 95 %-CI 0.244 - 0.529, percentage of agreement = 52.0 %). Misinterpretation of simple rules by non-experts was observed 57 times, resulting in an erroneous diagnosis in 15 patients (30 %). The agreement for classifying the mass as benign, malignant or inconclusive by simple rules was only moderate between the non-experts and the expert (kappa = 0.50, 95 %-CI 0.300 - 0.704, percentage of agreement = 70.0 %). The level of agreement for all 10 simple rules features varied greatly (kappa index range: -0.08 - 0.74, percentage of agreement 66 - 94 %). Although simple rules are useful to distinguish benign from malignant adnexal masses, they are not that simple for untrained examiners. Training with both IOTA terminology and simple rules is necessary before simple rules can be introduced into guidelines and daily clinical practice.ZIEL: Analyse, ob ungeübte Anwender – ohne Erfahrung mit der „International Ovarian Tumor Analysis“ (IOTA)- Terminologie oder einfache ultraschallbasierten Regeln („Simple Rules“) – in der Lage sind, IOTA-Kriterien und „Simple Rules“ anzuwenden. Auch wird der Grad der Übereinstimmung zwischen Nichtexperten und Experten bewertet.Diese prospektive multizentrische Kohortenstudie nahm Frauen mit ovarialen Raumforderungen auf. Die Sonografie wurde von Nichtexperten und einem Experten durchgeführt. Ultraschall-Kriterien wurden mittels IOTA-Nomenklatur dokumentiert und dann für die Klassifizierung der Raumforderung mittels „Simple Rules“ verwendet. Die Intraobserver-Übereinstimmung zwischen den Beobachtern wurde durch Fleiss-Kappa und prozentualer Übereinstimmung bewertet. Eingeschlossen wurden 50 aufeinander folgende Frauen. Wir beobachteten 46 Diskrepanzen bei der Beschreibung der ovarialen Raumforderungen, wenn Nichtexperten die IOTA-Terminologie benutzten. Der Tumortyp wurde häufig falsch klassifiziert (n = 22), was zu einer schlechten Interobserver-Übereinstimmung zwischen Nichtexperten und Experten führte (Kappa = 0,39; 95 %-CI 0,244 – 0,529; prozentuale Übereinstimmung = 52,0 %). Eine Falschinterpretation der „Simple Rules“ durch Nichtexperten wurde 57 Mal beobachtet und führte bei 15 Patienten (30 %) zu einer Falschdiagnose. Die Übereinstimmung bei der Klassifizierung einer Raumforderung als gutartig, maligne oder nicht eindeutig durch die „Simple Rules“ war zwischen Nichtexperten und Experten nur mittelmäßig (Kappa = 0,50; 95 %-CI 0,300 – 0,704; prozentuale Übereinstimmung = 70,0 %). Der Grad der Übereinstimmung bei allen 10 „Simple Rules“-Kriterien variierte enorm (Kappa-Index-Bereich: -0,08 – 0,74; prozentuale Übereinstimmung 66 – 94 %). Obwohl die „Simple Rules“ nützlich sind, um benigne und maligne adnexale Raumforderungen zu unterscheiden, sind diese für ungeübte Untersucher nicht so einfach zu handhaben. Schulungen die sowohl IOTA-Terminologie als auch „Simple Rules“, zum Inhalt haben sind notwendig, noch ehe „Simple Rules“ in Leitlinien und den Praxisalltag Eingang finden.

Female adnexal tumors of probable Wolffian origin (FATWO) are rare tumors, which are mostly localized in the broad ligament or the mesosalpinx. They show high intratumor and intertumor variability of histological patterns (e.g. solid, tubular, cribriform and cystic) with usually unremarkable cellular and nuclear morphology and a lower mitotic rate. In general, they behave in a benign fashion but there are rare cases with malignant transformation, so that careful examination and surveillance are necessary. Differential diagnoses include Sertoli-Leydig cell tumors, metastasized endometrioid carcinoma and the FATWO-like variant of the endometrioid carcinoma of the fallopian tubes. The FATWOs express pancytokeratin, CD10, vimentin, calretinin and inhibin A. Estrogen and progesterone receptors are expressed in a minority of cases, whereas epithelial membrane antigen (EMA) is not detectable.

Adnexal tumors of the skin are epithelial skin tumors with differentiation towards the adnexal epithelial structures of the skin, namely, hair follicle, sebaceous gland, apocrine gland, and eccrine gland. Adnexal tumors include hamartomas, benign and malignant neoplasms, and hyperplasias. The specific diagnosis of adnexal tumors is important because some lesions such as sebaceous neoplasms, cylindromas, or fibrofolliculomas are herald lesions of hereditary tumor syndromes (e.g., Muir-Torre syndrome, familial cylindromatosis, Birt-Hogg-Dubé syndrome). In this article, the classification of adnexal tumors of the skin is explained on the basis of embryology and histology and the main features of tumor-associated syndromes are summarized. Moreover, some conceptual controversies and problems in differential diagnosis of cutaneous adnexal tumors are discussed.

Confirmation and clarification of an adnexal mass is a domain of transvaginal ultrasound. The highest hit ratio is achieved by experienced sonographers relying on a dedicated set of sonomorphologic criteria. Less experienced may consult validated scores, colour doppler findings and the tumor marker CA125. The assignment to one of the three groups simple cyst, benign tumor, malign tumor should lead to an adequate procedure (control, laparoscopy, laparotomy). Whenever possible to avoid unnecessary surgical interventions, simple cysts should be treated conservatively. Also in postmenopausal woman 50% of them resolve spontaneously in 60 days. Ovarian cancer screening is still an unsolved problem. Nearly all established methods fail because of the low prevalence of ovarian cancer at around 0.4%.

The most important diagnostic test for clarification of an adnexal mass is ultrasonographic evaluation. The prognostic value of an ultrasonographic examination is higher in combination with the patient history and clinical findings. In order to achieve high diagnostic accuracy certain requirements are mandatory. Firstly a high level of expertise, meticulousness and patience of the examiner is crucial. Secondly the use of a high-end ultrasound machine is essential. Thirdly a thorough evaluation and interpretation of sonomorphologic findings are necessary. Furthermore, these skills have to be trained continuously. This is fundamental for subjective, sonographic pattern recognition and the successful use of tumor scores resulting in a correct classification of adnexal tumors. Most adnexal tumors (approximately 75%) can be correctly (sensitivity 95% and specificity 91%) classified as benign or malignant using a set of simple rules. Tumors which cannot be classified (approximately 25%) can be differentiated by ultrasound examination by an expert examiner on the basis of subjective evaluation in about 90% of cases.

MRI has proved beneficial in characterizing ovarian masses that are indeterminate by sonographic criteria. MRI can distinguish between benign and malignant ovarian tumors with high sensitivity and specificity and is capable of characterizing many adnexal masses. MRI should be therefore included in the preoperative diagnostic of adnexal masses.

Magnetic resonance imaging (MRI) is an accepted imaging method for diagnosing diseases of the female pelvis. This review article describes the role of MR imaging for the diagnosis of benign and malignant pelvic tumors. Sagittal T2-weighted fast spin echo sequences can be effectively applied to diagnose leiomyomas of the uterus and provide exact pretreatment measurements of size and localization. In the diagnostic work-up of endometrial carcinoma, fat-saturated, T1-weighted gradient echo sequences make it possible to determine precisely how deep myometrial infiltration extends and what tissue should be included in preoperative treatment planning. In cervical cancer staging, MRI permits both assessment of local tumor extent and determination of tumor volume for planning and monitoring radiotherapy. The usefulness of MRI in cervical cancer staging is, however, limited since not all early-stage cancer (FIGO stage IA and small stage IB tumors) can be detected. Hence, it appears that the use of MRI as a screening method for cervical cancer cannot be recommended. MRI can distinguish between benign and malignant ovarian tumors with high sensitivity and specificity. Standard and fat-saturated T1-weighted sequences usually can diagnose teratomas with a specificity of 100 %. Axial fat-saturated, contrast enhanced T1-weighted spin echo sequences are useful in the staging of malignant ovarian tumors since they facilitate evaluation of their internal structure and will disclose peritoneal metastases. Besides staging of ovarian cancer, MRI can be applied for localization and for monitoring treatment response.

The purpose of the study was to determine the feasibility and potential clinical value of laparoscopic intraoperative sonography in the female genital tract.Intraoperative ultrasound was performed in 20 consecutive premenopausal patients with adnexal masses during laparoscopy using a 7.5 MHz semiflexible transducer.Laparoscopic ultrasound of the female genital tract improves image resolution. Furthermore, this new method allows accurate localisation of early tubal pregnancy and may be helpful if laparoscopic evaluation of the inner genital tract is impaired by severe adhesions. In 7 out of 20 patients, the therapeutical procedure was clearly influenced by the laparoscopic ultrasound findings, resulting in a benefit for the patients in all seven cases.Intraoperative laparoscopic ultrasound may improve minimal invasive management of adnexal masses.

It is reported about the indication to operative therapy, therapy-shape and the going of cure of 30 patients suffering from tuboovarian abscesses. At the beginning there is the conservative therapy with general measures immediately dose of antibiotica without waiting for the germ and resistence determinations. However the well timed operative therapy under conditions as well as possible is deciding. As a rule the abdominal exstirpation of the uterus with both adnexe is practiced in order to come to a complete removal of the infection hearth. --The postoperative cours war only febril in one third of the treated women. In 86,7% the laparotomy scare healed per primam intentionem. We didn't observe an extension of the infection post operationem and there were not any complications with letal exit.

About complications in 2147 interruptions of pregnancy, carried out between February 15, 1974 and December 31, 1976 was reported.--48,4 per cent was nullipare or primipare. The rate of early complications was 5,28 per cent. During the period of report 7,03 per cent of patients became pregnant again. The fates from these pregnancy were following: 37,6 per cent interruptions of pregnancy once more. 15,2 per cent abortion and 18,4 per cent premature birth. Prenatal mortality was 3,1 per cent.A study of 2147 induced abortions was undertaken to determine the frequency of complications and to determine the effect of an abortion on a subsequent pregnancy. 9.4% of the patients were 17 years of age or younger, 36.5% were single, 25.1% were nulliparae. The overall complication rate was 5.28%. The most frequent complications were inflammations, e.g., adnexitis, endometritis, parametritis: 1.58%. There was a .79% incidence of cervical injuries, 76.4% of which were among primigravidae. 151 of the patients became pregnant during the 2 years following the abortion; 87 carried the pregnancy to term. The incidence of spontaneous abortion among these patients was 25.3%, of cervical insufficiency 20.7% and of premature birth 13.8%. Only 35.6% of the pregnancies proceeded without complication. Perinatal mortality was 3.1%. Steps must be taken to prevent the use of induced abortion as a contraceptive measure, especially among young primigravidae.

42 of 86 patients with suppurated ovaries had primary isolated ovarian abscesses (PIOA), 44 secondary tubo-ovarian abscesses (STOA). Parts of ectopic endometrium in the abscess wall could be identified by serial sections in 23 PIOA. With Berlin-blue-staining was a special phenomenon in 28 of 42 PIOA demonstrated: a basal layer of hemosiderophages underlying the abscess membrane. Thus in 36 of 42 PIOA the histogenesis out of cystic ovarian endometriosis or other pathologic ovarian hematomas is assured. The PIOA is a typical major complication of ovarian hematomas, especially in cases of ovarian endometriosis caused by vaginal aplasia (gynatresia). Concomitant salpingitis in PIOA is therefore often better explained as secondary descending infection from pelveoperitonitis. Before laparotomy it is extremely difficult to diagnose PIOA on a clinical basis only. More than laboratory data helps this special consideration if an inflammatory adnexal mass could be or not the result of an ascending infection and if an ovarian endometriosis could exist. Besides the abscesses out of cystic ovarian endometriosis PIOA were observed after hysterectomies and complicated appendectomies possible due to the infection of traumatic ovarian hematomas. The only curative therapy for PIOA is surgery--as soon as possible. Antibiotics are poorly helpful. However the inefficacy of antibiotics usually gives the final indication for laparotomy. Knowing the usual etiology of PIOA out of pathologic (endometriotic) ovarian hematomas we have new guidelines in other clinical problems also: Thus every ovarian endometriosis has to be cured--hormonally or surgically; evacuation of endometriotic cysts during pelvic endoscopy is not a sufficient therapy, for the endometrium would be left in the ovary. During operations provocation of traumatic hematomas of the adnexa should be avoided.

2000 laparoscopies were performed between 1968 and 1975. 253 from 493 patients with unexplained pelvic pain were followed up a half till 5 years after laparoscopy concerning the pains. The discrepancy of clinical diagnosis and laparoscopie statement is compared and discussed. The most clinical diagnosis were: chronic pelvic pain (149 cases) and unexplained pelvic pain (32 cases). Postlaparoscopic findings were: inconspicuous statements (27,3%), pelvic adhesions (27,3%), chronic disease of the fallopian tubes (21,1%), chronic appendix diseases (10,3%), ovary cysts (9,8%), endometriosis (4,3%).52,9% of the patients were cured by specific treatment a half till 5 years after laparoscopy. The laparoscopy is considered to be a diagnostic and therapeutic acurate method. 14,2% of the patients with little or inconspicuous statements were cured after instruction. The laparoscopy may be the base for acurate diagnostic and team-work of several branches of knowledge.

The morphological and clinical findings of a papillomatous cystic para-ovarian blastoma are reported. A 48-year old patient had a hysterectomy and partial right salpingectomy in 1974. In 1980 at now age 54 the remaining appendages right and left were removed. The histologic examination of the remaining right appendages showed in the mesorovarium a 17 x 15 x 12 mm diameter papillomatous cystic para-ovarian blastoma with abundant formation of psammoma bodies and numerous lymph follicles in the stroma. The left ovary showed a papillomatous, fibromatous, serous cystadenoma. The aetiology of the papillomatous cystic para-ovarian blastoma is unknown. A relationship to the prior right salpingectomy is unlikely. The concommitant findings of a papillomatous fibromatous serous cystadenoma of the left ovary is suggestive of a tumour diathesis of the mesonephric system in this case.

This report deals with the clinical and morphological findings in a rare case of Echinococcus granulosus of the female genital tract. The symptoms are not characteristic. A preoperative diagnosis can only be suspected on serological grounds. The diagnosis is confirmed by histological examination of the specimen. The therapy of choice is the surgical removal of the cyst. Care should be taken not to open the cyst during operation. The success of the operation should be confirmed by postoperative serological, ultrasonic, scintigraphic and x-ray controls.

The authors performed 2000 laparoscopies in females with chronic and acute pelvic pain. In 399 cases an appendectomy had been done before. Among 478 patients with acute pelvic pain an acute appendicitis was found in 26 women by laparoscopy.

A correct differential diagnosis of pelvic tumors is sophisticated in gynecology. The present effort concerns with introducing of computertomography in our diagnostic facilities. The ultrasound method being of value in detection of early developing ovarian tumors and showing their size as well as the extent of tissue transformation is however unprecise in comparison with CT-method which allows to evaluate the anatomical relations and tissue differences. The latter one allows differentiation of cystic tumor from dermoid cyst as well as from solid tumor. Density measurement scrutinizes with more precision endometriosis, lipomatosis and tubo-ovarial abscesses. The CT-diagnosis has been proving useful especially in differentiation between ovarian and intestinal tumors.

There is an inherent danger of infection or promoting the exacerbation of an as yet incompletely healed inflammatory process when retrograde perfusion of the Fallopian tubes is performed, as in the diagnosis of sterility by laparoscopy and chromopertubation. Hence, the intense-red tuberculostatic drug, rifamycin SV (Rifocin) was instilled by means of the Schultz Instillator, either alone or in combination with indigo carmine, in place of the conventional indicator solutions, to test tubal patency in all patients under investigation for sterility, whether there was a history of acute, subacute or chronic salpingitis or not. This procedure was not followed by exacerbation of preceeding infection in a single case, which is particularly noteworthy in two patients shown to have extensive tubal and peritoneal tuberculosis.

Reported is the rare case of an actinomycosis of the right Fallopian tube. The clinical picture is characterized by a comparatively sudden onset of abdominal pain, obstipation and feaver as well as a markedly increased ESR. Good co-operation between the various clinical disciplines (urology, surgery, internal medicine, gynecology) lead to an exact preoperative localization of the scaring and infiltrating process that is then verified by laparotomy. The right adnexae show massive inflammatory infiltrates and form a conglomerate tumor with the adjacent sigma and appendix. Characteristic actinomycetic druses are found histologically only in the right Fallopian tube. On the left side a florid non-specific salpingitis is antibiotics is withoug complications. Mode of infection, differential diagnosis and prognosis that is dependent on a correct diagnosis at an early stage are discussed.

30 patients with hepatitis, 50 patients with gynecological diseases, and 100 with urological diseases were investigated with regards to lumbago to find out whether there is a correlation between the internal disease and the signs of low back pain. The patients were compared with a control group of 33 healthy people. The vertebral localisation of the pain and its radiation were investigated and discussed in certain diseases as well as any correlation between lumbago and average age. The various possibilities of pain radiation are described and the importance of the vertebral column as secondary seat of low back pain is pointed out.