Three-dimensional power Doppler vascular sonographic sampling for predicting ovarian cancer in cystic-solid and solid vascularized masses

OBJECTIVE

The purpose of this study was to explore the role of 3-dimensional (3D) power Doppler (PD) sonography to discriminate between benign and malignant cystic-solid and solid vascularized adnexal masses and to define cutoff values for 3D PD indices to be used in a clinical setting.

METHODS

A total of 143 consecutive women (mean age, 50.4 years; range, 17-82 years) with diagnoses of cystic-solid or solid vascularized adnexal masses on B-mode and 2-dimensional PD sonography were evaluated by 3D PD sonography before surgery. Three-dimensional PD sonography was used to assess vascularization within papillary projections and solid areas with a virtual organ computer-aided analysis program. Three-dimensional PD vascular indices (vascularization index [VI], flow index [FI], and vascularization-flow index [VFI]) were automatically calculated. A definitive histologic diagnosis was obtained in each case.

RESULTS

A total of 113 masses (74%) were malignant, and 39 (26%) were benign. Morphologic evaluation revealed 30 unilocular solid masses (19.7%), 43 multilocular solid masses (28.3%), and 79 mostly solid masses (52%). The mean VI (9.365% versus 3.3%; P< .001), FI (34.318 versus 28.794; P< .001), and VFI (3.233 versus 1.15; P<0.01) were significantly higher in malignant tumors. No differences were found in the resistive index, pulsatility index, and peak systolic velocity. Receiver operating characteristic analysis revealed an area under the curve of 0.77 (95% confidence interval, 0.69-0.85), 0.71 (0.60-0.81), and 0.75 (0.66-0.83) for the VI, FI and VFI, respectively. For reducing the false-positive rate by almost one-third, sensitivity values for the VI (cutoff, 1.556%), FI (25.212), and VFI (0.323) were 92%, 95%, and 93%, respectively.

CONCLUSIONS

Three-dimensional PD vascular indices could be helpful for reducing the false-positive rate in cystic-solid and solid vascularized adnexal masses.

Two-dimensional power Doppler-three-dimensional ultrasound imaging of a cesarean section dehiscence with utero-peritoneal fistula: a case report

Introduction

An imaging diagnosis after an iterative cesarean delivery is reviewed demonstrating a fine ultrasound-pathologic correlation.

Case presentation

A 33-year-old woman (G3, P3) presented referring intense dysmenorrhea and intermenstrual spotting since her third cesarean delivery, 1 year before. A cesarean section dehiscence with utero-peritoneal fistula was diagnosed by transvaginal ultrasound.

Conclusion

We can conclude that transvaginal two-dimensional power Doppler and three-dimensional ultrasound are highly accurate in detecting cesarean section dehiscence and uterine fistula.

Assessment of ovarian vascularization in the polycystic ovary by three-dimensional power Doppler ultrasonography

OBJECTIVE

To assess whether there are differences in ovarian echogenicity and vascularization as assessed by three-dimensional power Doppler angiography (3D-PDA) between women with polycystic ovaries (PCO) and women with normal ovaries (NO).

METHODS

Eighty-three women were classified into two groups according to the 2003 Rotterdam consensus criteria. The NO group comprised women (n = 45) with regular menstrual cycles and proven fertility, whereas the PCO group comprised women (n = 38) with oligo-anovulation, clinical and/or biochemical features of hyperandrogenism, and polycystic ovary morphology at two-dimensional ultrasound. All women were evaluated by means of 3D-PDA. The parameters studied in both groups were follicle number per ovary (FNPO), ovarian volume (OV), mean gray value (MG) and three vascular indices: vascularization index (VI), flow index (FI) and vascularization flow index (VFI).

RESULTS

The PCO group showed a higher mean OV as well as FNPO. No differences in MG, VI, FI and VFI were found between the groups.

CONCLUSIONS

3D-PDA indices are not useful for discriminating between normal and polycystic ovaries.

Triage for surgical management of ovarian tumors in asymptomatic women: assessment of an ultrasound-based scoring system

OBJECTIVES

To prospectively evaluate an ultrasound-based scoring system as a method for triaging asymptomatic women presenting with an adnexal mass for surgical treatment.

METHODS

Two hundred and four adnexal masses in 189 asymptomatic women undergoing elective surgical treatment at our institution were included in this prospective study. Patients were evaluated by transvaginal power Doppler ultrasound imaging before surgery. Patients were classified as low risk or high risk for malignancy according to an ultrasound-based scoring system. Women with a low risk for malignancy were scheduled for laparoscopy and patients with a high risk for malignancy were scheduled for laparotomy. However, patients classified as low risk by the ultrasound scoring system, but with a tumor size >or= 10 cm or clinical suspicion of pelvic adhesions, were instead considered to be at intermediate risk and were scheduled for laparotomy. Some patients classified as high risk were scheduled for an operative laparoscopy by an expert in gynecological oncology.

RESULTS

One hundred and thirty-four (65.7%) masses were considered to be low risk and were treated by a laparoscopically guided procedure. All these tumors were benign. Forty-seven (23%) masses were classified as high risk, of which 39 tumors were malignant and eight benign. Twenty-three (11.3%) tumors were considered to be intermediate risk and were scheduled for primary laparotomy. In this group, 21 (91.3%) tumors proved to be benign and two (8.7%) were malignant.

CONCLUSIONS

Ultrasound-based triage of asymptomatic women diagnosed with a persistent adnexal mass is effective for selecting the surgical approach.

Three-dimensional power Doppler vascular network assessment of adnexal masses: intraobserver and interobserver agreement analysis

OBJECTIVE

The purpose of this study was to assess intraobserver and interobserver agreement for tumor vascular network evaluation as assessed by 3-dimensional (3D) power Doppler sonography for discriminating benign from malignant adnexal masses.

METHODS

Stored 3D power Doppler angiographic volume data from 39 women with a diagnosis of a vascularized adnexal mass who were evaluated and treated at our institution were retrieved from our database for analysis. Two different examiners (observer A, with 6 years of experience in 3D sonography; and observer B, with 1 year of experience) reviewed 3D sonograms blinded to each other. Three-dimensional vascular network reconstruction was done with surface rendering in the color mode. Malignancy was considered in the presence of at least 2 of the following: irregular branching, vessel caliber changes, microaneurysms, and vascular lakes. A definitive histologic diagnosis was obtained in all cases. Intraobserver and interobserver agreement rates were estimated by calculating the kappa index.

RESULTS

Twenty (51%) tumors were malignant, and 19 (49%) were benign. Intraobserver agreement was good for observer A (kappa = 0.69) and moderate for observer B (kappa = 0.54). Interobserver agreement was moderate (kappa = 0.49).

CONCLUSIONS

We found intraobserver and interobserver agreement to be moderate for 3D power Doppler assessment of the vascular network in adnexal masses.

Three-dimensional power Doppler assessment of uterine vascularization in women with primary dysmenorrhea

OBJECTIVE

The aim of this study was to assess myometrial vascularization with 3-dimensional (3D) power Doppler angiography (PDA) in women with different grades of primary dysmenorrhea at the moment of maximum menstrual pain in an effort to improve the pathophysiologic knowledge of one of the most common gynecologic conditions.

METHODS

This was a cross-sectional study involving 70 voluntary women that studied or worked at the Clinica Universitaria de Navarra between January 2006 and January 2008. All women underwent transvaginal sonographic 3D PDA on the day of maximum pain after the onset of menstruation or during the first 24 to 48 hours of the new cycle if no pain was present. Three groups were defined according to a visual analog scale: no pain to mild dysmenorrhea, moderate dysmenorrhea, and severe dysmenorrhea. Vascularity assessment was done on the basis of 3D vascularity indices: the vascularization index (VI), flow index (FI), and vascularization-flow index (VFI).

RESULTS

The mean VI and VFI for the inner 5 mm of the myometrium and the total myometrium were significantly higher in the women with severe dysmenorrhea than in those with no pain to mild dysmenorrhea (P < .05). The VI, FI, and VFI in the women with moderate dysmenorrhea did not differ significantly from those in the women with severe dysmenorrhea.

CONCLUSIONS

This study evaluated the use of 3D PDA for assessing uterine and specifically myometrial vascularization. Our data indicate that women with severe dysmenorrhea have increased myometrial vascularization during the early menstrual phase compared with women without pain.

Postpartum ovarian vein thrombosis after cesarean delivery: a case report

Introduction

Postpartum ovarian vein thrombosis is an uncommon complication; incidence varies between 0.002% and 0.05%. It most often occurs during the 2–15 days following delivery.

Case presentation

A 22-year-old pregnant woman at term presented to hospital with uterine contractions, abdominal pain, nausea and vomiting. After delivery an ovarian vein thrombosis was diagnosed.

Conclusion

Low-molecular weight heparin with broad-spectrum antibiotics are the accepted therapy in non-complicated cases of postpartum ovarian vein thrombosis.

Intraobserver and interobserver reproducibility of 3-dimensional power Doppler vascular indices in assessment of solid and cystic-solid adnexal masses

OBJECTIVE

The purpose of this study was to assess the intraobserver and interobserver reproducibility of 3-dimensional (3D) power Doppler angiography-derived vascular indices in evaluation of vascularized solid and cystic-solid adnexal masses.

METHODS

Stored 3D power Doppler angiographic volume data from 12 consecutive women with a diagnosis of a complex adnexal mass (6 cystic-solid and 6 solid) evaluated and treated at our institution were retrieved from our database for analysis. Two examiners performed the calculations blinded to each other. Calculations were performed offline in a computer using Virtual Organ Computer-Aided Analysis software (plane A, 9 degrees rotation step) to assess volume and vascularization (vascularization index, flow index, and vascularization-flow index) from solid areas within the tumor. In all cases, a definitive histologic diagnosis was obtained. Intraobserver and interobserver reproducibility was assessed by calculating the intraclass and interclass correlation coefficients for each index.

RESULTS

All tumors proved to be malignant after surgical removal. Intraobserver reproducibility for both examiners and interobserver reproducibility were high for all indices (interclass correlation coefficient > 0.95).

CONCLUSIONS

Three-dimensional power Doppler angiography is a reproducible technique for offline assessment of stored 3D volume data of vascularized adnexal masses.

Three-dimensional sonographic morphologic assessment of adnexal masses: a reproducibility study

OBJECTIVE

The purpose of this study was to assess the reproducibility of 3-dimensional (3D) sonography for classifying adnexal masses.

METHODS

Eighty-two consecutive women with the diagnosis of an adnexal mass on 2-dimensional transvaginal sonography were reevaluated by 3D sonography, and 3D volume data from each mass were stored. Two different examiners (6 years and 1 year of experience in 3D sonography, respectively) reviewed 3D sonograms 1 month after the last patient was recruited and then 1 week later again. Masses had to be classified as benign or malignant. Criteria suggestive of malignancy were the presence of a thick wall, gross papillary projections, solid areas, and solid echogenicity. A definitive histologic diagnosis was obtained in every case. Intraobserver and interobserver agreement was estimated by calculating the Cohen kappa index.

RESULTS

Twenty-seven (33%) tumors were malignant, and 55 (67%) were benign. Intraobserver agreement for both examiners was good (kappa = 0.78 and 0.72, respectively). Interobserver agreement was also good (kappa = 0.70).

CONCLUSIONS

Three-dimensional sonography is a reproducible technique for morphologic assessment of adnexal masses.

Three-dimensional ultrasound assessment of endometrial receptivity: a review

Three-dimensional ultrasound (3D US) is a new imaging modality, which is being introduced into clinical practice. Although this technique will not probably replace two-dimensional ultrasound, it is being increasingly used. It has been reported that 3D US is a very high reproducible technique. The endometrium has been paid special attention when using this technique. The aim of this paper is to address some technical aspects of 3D US and to review critically its current status in evaluating endometrial function with special focus in its role in predicting pregnancy in assisted reproductive techniques. In spontaneous cycles endometrial volume grows during follicular phase remaining constant through the luteal phase. Endometrial vascularization increases during follicular phase peaking 2-3 days before ovulation, decreasing thereafter and increasing again during mid and late luteal phase. Data from studies analysing the role of 3D US for predicting IVF outcome are controversial. An explanation for these controversial findings might be different design of reported studies, specially the timing of ultrasound evaluation.

Tumor angiogenesis assessed by three-dimensional power Doppler ultrasound in early, advanced and metastatic ovarian cancer: A preliminary study

OBJECTIVE

To evaluate tumor vascularity by three-dimensional power Doppler ultrasound (3D-PDU) in early and advanced stage primary ovarian cancers and in metastatic tumors to the ovary.

PATIENTS AND METHODS

This was a retrospective analysis of clinical and sonographic data from 49 women with primary ovarian cancers or metastatic tumors to the ovary. All women underwent 3D-PDU prior to surgery. Vascularization index (VI), flow index (FI) and vascularization flow index (VFI) from solid portions or papillary projections in the tumors were calculated using the Virtual Organ Computer-aided AnaLysis (VOCAL(trade mark)) program. Definitive histological diagnosis was obtained in each case.

RESULTS

Among the 49 women, 10 had stage I primary cancers (five low-malignant potential tumors and five invasive tumors), 26 had advanced stage primary ovarian cancers and 13 had metastatic tumors to the ovary. Mean VI and VFI were significantly higher in advanced stage tumors and metastatic tumors as compared with early stage tumors. No differences in 3D-PDU indices were found between advanced stage and metastatic cancers.

CONCLUSIONS

Vascular indices derived from 3D-PDU tend to be higher in advanced stage and metastatic ovarian cancers as compared with early stage ovarian tumors.

Reproducibility of endometrial vascular patterns in endometrial disease as assessed by transvaginal power Doppler sonography in women with postmenopausal bleeding

OBJECTIVE

The purpose of this study was to assess the intraobserver and interobserver agreement for identifying different endometrial vascular patterns using power Doppler sonography in women with postmenopausal bleeding and a thickened endometrium.

METHODS

Digitally stored sonographic images from a random sample of 65 patients with postmenopausal bleeding and a thick endometrium (>5 mm) on B-mode sonography and evaluated by transvaginal power Doppler sonography for assessment of endometrial blood flow mapping were evaluated by 5 different examiners with different levels of expertise in Doppler sonography. Intraobserver and interobserver agreement according to the level of experience were assessed by calculating the kappa index.

RESULTS

Intraobserver agreement was good or very good for all experienced examiners (kappa = 0.78-0.96) and moderate (kappa = 0.52) for the inexperienced examiner. Interobserver agreement was moderate among all experienced examiners (kappa = 0.45-0.80). The inexperienced examiner showed fair or moderate interobserver agreement (kappa = 0.32-0.45).

CONCLUSIONS

Our results indicate that endometrial blood flow mapping using transvaginal power Doppler sonography is acceptably reproducible. More experience was associated with better intraobserver and interobserver agreement.

Endometrial volume and vascularity measurements by transvaginal 3-dimensional ultrasonography and power Doppler angiography in stimulated and tumoral endometria: an interobserver reproducibility study

OBJECTIVE

The purpose of this study was to evaluate interobserver reproducibility of endometrial volume and vascular indices of the endometrium and subendometrial area estimated by 3-dimensional power Doppler angiography (3D-PDA) using the Virtual Organ Computer-Aided Analysis program, determining the influence of the endometrial growth etiology on measurements.

METHODS

Forty women underwent 3D-PDA ultrasonography. Group A comprised 25 women scanned on the day after controlled ovarian stimulation with human chorionic gonadotropin. Group B comprised 15 patients who had uterine bleeding and questionable endometrial thickening. (Histologic evaluation revealed 10 endometrial cancers and 5 endometrial hyperplasias.) A single observer examined all patients and acquired all volume data sets. Forty volume data sets were then analyzed with the Virtual Organ Computer-Aided Analysis program by 2 different observers. Endometrial volume and vascularity indices (vascularization index [VI], flow index [FI], and vascularization flow index [VFI]) of the endometrium and subendometrium were manually calculated in the coronal plane with a 9 degrees rotation step. An intraclass correlation coefficient (ICC) was used to assess interobserver reliability.

RESULTS

Endometrial volume was more reproducible in group A (ICC = 0.98) than in group B (ICC = 0.58) (P < .05). Endometrial and subendometrial VI, FI, and VFI also presented good reproducibility with ICC greater than 0.84. The ICC was not statistically different for endometrial and subendometrial VI, FI, and VFI according to patient group, although subendometrial VFI was less reproducible in group B (ICC = 0.53) than in group A (ICC = 0.88).

CONCLUSIONS

Endometrial volume and endometrial and subendometrial 3D power Doppler indices have acceptable reproducibility. The interobserver reproducibility in tumoral endometrium was more similar than in stimulated endometrium. Our results indicate that 3D-PDA is a reliable method to evaluate physiologic and pathologic endometrial changes.

Is expectant management of sonographically benign adnexal cysts an option in selected asymptomatic premenopausal women?

BACKGROUND

The objective was to assess whether expectant management of sonographically benign ovarian cysts may be an option for selected asymptomatic premenopausal women.

METHODS

This is a prospective observational longitudinal study. Between January 1997 and December 2002, 323 asymptomatic premenopausal women (mean age: 40.6 years; range: 19-50 years) diagnosed as having a sonographically benign ovarian cyst measuring <6 cm were offered conservative management with periodic follow-up at 6-12 month intervals. In all cases, a first check was performed 3 months after diagnosis to confirm the 'persistent' nature of the cyst. A total of 120 women agreed to participate in this study and constitute the basis of the data presented.

RESULTS

Mean diameter at diagnosis for the most frequent lesions were as follows: endometrioma 3.3 cm (SD 1.5); simple cyst 4.1 cm (SD 1.6); dermoid cyst 3.2 cm (SD 1.4); haemorrhagic cyst 3.5 cm (SD 1.2); hydrosalpinx 2.9 cm (SD 1.0). With a median follow-up of 42 months (range: 18-94 months), most lesions remained unchanged, both in size and sonographic appearance. Ten cysts (8.3%) disappeared during follow-up, all of them after more than 2 years of follow-up. No patient has developed signs or symptoms suggesting ovarian cancer.

CONCLUSION

Most sonographically benign ovarian cysts remain unchanged during long-term follow-up. Our data would support conservative management in these cases.

Does nitric oxide play a role in maternal tolerance towards the foetus?

In pregnancy there occurs maternal tolerance to the foetus. Several mechanisms have been proposed to explain this phenomenon. The main immune population in the decidua are macrophages and natural killer cells, but with some "special" suppressor characteristics. There is also a predominant TH2 response. The non classical MCH type I HLA-G is expressed by trophoblasts and can suppress lymphomononuclear cytotoxicity. Other system to avoid the immune system is the expression of indoleamine-2,3-dioxygenase, that suppresses T cell activation by degrading tryptophan. Even though in the placenta there is a high production of nitric oxide, a well-known immune modulator, low attention has been paid to its role in maternal tolerance. There are many data showing that NO affects the IDO, CD95/CD95-L and the balance between TH1/TH2. Maybe NO could interact with several mechanisms at the same time, which could modify the tolerogenic activity depending on the concentration and the presence of other factors in the medium.