Three-dimensional power Doppler vascular sampling: a new method for predicting ovarian cancer in vascularized complex adnexal masses

OBJECTIVE

The purpose of this study was to explore the role of a new concept ("vascular sampling") as a third step to discriminate benign and malignant lesions in B-mode and color Doppler sonographically suggestive adnexal masses.

METHODS

Forty-five women (mean age, 52.3 years; range, 17-82 years) with the diagnosis of complex adnexal masses on B-mode sonography were evaluated using 3-dimensional power Doppler sonography. Four women had bilateral masses. After a morphologic reevaluation was done, color pulsed Doppler sonography was used to obtain flow velocity waveforms, and velocimetric indices were calculated (resistive index, pulsatility index, and peak systolic velocity). Thereafter, 3-dimensional power Doppler sonography was used to assess vascularization of highly suggestive areas (gross papillary projections, solid areas, and thick septations), meaning a focused assessment ("sampling") of a suggestive area of the tumor. With a virtual organ computer-aided analysis program, vascular indices (vascularization index, flow index, and vascular flow index) were automatically calculated. A definitive histologic diagnosis was obtained in each case.

RESULTS

Forty masses (82%) were malignant and 9 (18%) were benign. Morphologic evaluation revealed 10 (20%) unilocular solid masses, 20 (41%) multilocular solid masses, and 19 (39%) mostly solid masses. Blood flow was found in all cases. Median vascularization index (15.5% versus 8.2%; P = .002), flow index (33.6 versus 20.8; P = .007), and vascular flow index (5.2 versus 2.3; P = .001) were significantly higher in malignant tumors. No differences were found in resistive index (0.43 versus 0.45; P = .770), pulsatility index (0.62 versus 0.65; P = .694), and peak systolic velocity (15.6 versus 12 cm/s; P = .162).

CONCLUSIONS

Three-dimensional power Doppler vascular sampling seems to be a promising tool for predicting ovarian cancer in vascularized complex adnexal masses. It could be better than conventional color pulsed Doppler imaging.

Comparison of 2-dimensional and 3-dimensional power-Doppler imaging in complex adnexal masses for the prediction of ovarian cancer

OBJECTIVE

The purpose of this study was to compare 2-dimensional and 3-dimensional power-Doppler imaging diagnostic performance for the prediction of ovarian cancer in complex adnexal masses.

STUDY DESIGN

Sixty-nine complex adnexal masses in 60 women (mean age, 48.4 years [range, 17-82 years]) were evaluated by 2-dimensional and 3-dimensional power-Doppler imaging for differentiating benign from malignant masses. Complex adnexal mass was defined in the presence of at least 1 of the following features: solid areas, thick papillary projections, thick septa, or purely solid echogenicity. One examiner performed 2-dimensional power-Doppler imaging, and a second examiner performed 3-dimensional power-Doppler imaging. All masses were removed surgically, and definitive diagnosis was obtained. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for both techniques.

RESULTS

Forty-five tumors (65.2%) were proved to be malignant, and 24 tumors (34.8%) were proved to be benign. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for 2-dimensional power-Doppler imaging were 97.8%, 87.5%, 93.6%, 95.5%, and 94.2%, respectively. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for 3-dimensional power-Doppler imaging were 97.8%, 79.2%, 89.9%, 95%, and 91.3 % respectively. There were no statistical differences in sensitivity and specificity (McNemar test: P = .250)

CONCLUSION

Three-dimensional power-Doppler imaging did not have a better diagnostic performance than 2-dimensional power-Doppler imaging for the discrimination of benign from malignant complex adnexal masses.

Transvaginal color Doppler sonography for predicting response to concurrent chemoradiotherapy for locally advanced cervical carcinoma

PURPOSE

This study was conducted to evaluate the potential role of transvaginal color Doppler sonography (TVCD) in predicting response to concurrent chemoradiotherapy for locally advanced cervical cancer.

METHODS AND MATERIALS

Tumor vascularity was assessed using TVCD before the start of concurrent chemoradiotherapy in 21 patients (median age, 47 years; range, 31-75 years) with histologically proven locally advanced cervical cancer. The lowest resistance index (RI), lowest pulsatility index (PI), and highest peak systolic velocity (PSV) from central vessels within the tumor were recorded and used for analysis. All patients were clinically evaluated by physical examination and CT scanning after completing the chemoradiotherapy protocol. Complete clinical response (CR) was determined when no residual tumor was found. Partial clinical response (PR) was determined when the tumor volume had decreased more than 50%.

RESULTS

CR was achieved in 11 patients (52%), whereas 10 (48%) had PR. The initial median tumor volume was not statistically different between those with CR (26 cm3) and those with PR (28 cm3) (p = 0.71). RI was higher in those tumors with CR (median, 0.47) than in those with PR (median, 0.29) (p < 0.01). Likewise, PI was higher in tumors with CR (median, 0.81) than in those with PR (median, 0.41) (p < 0.01). No differences were found in PSV. The likelihood ratio for CR for tumors with a lowest RI of 0.35 or more was 2.7 (95% confidence interval, 1.8-3.6) and the likelihood ratio for CR for tumors with a lowest PI of 0.45 or more was 3.3 (95% confidence interval, 2.1-4.5).

CONCLUSIONS

The results suggest that TVCD may be useful in predicting clinical response to concurrent chemoradiation in patients with locally advanced cervical cancer.

Transvaginal color Doppler sonography versus sonohysterography in the diagnosis of endometrial polyps

OBJECTIVE

To compare the diagnostic performance of transvaginal color Doppler sonography (TVCD) and sonohysterography (SHG) in the diagnosis of endometrial polyps.

METHODS

Fifty-one women (mean age, 51 years; range, 27-75 years) with clinical or B-mode sonographic suspicion of endometrial polyps were included in this prospective study. Transvaginal color Doppler sonography first and then SHG were performed in all patients. On TVCD, a polyp was suspected when a vascular pedicle penetrating the endometrium from the myometrium was identified. On SHG, a polyp was suspected when a focal polypoid lesion was seen within the endometrial cavity. All patients underwent hysteroscopy and endometrial biopsy, the findings of which were used as the criterion standard. Sensitivity and specificity for TVCD and SHG were calculated and compared by the McNemar test.

RESULTS

Hysteroscopy and endometrial biopsy findings were as follows: endometrial polyps, 41; endometrial hyperplasia, 3; cystic atrophy, 4; proliferative endometrium, 2; and endometritis, 1. Sensitivity and specificity for TVCD and SHG were 95% and 80% and 100% and 80%, respectively (McNemar test, P = .5)

CONCLUSIONS

Transvaginal color Doppler sonography and SHG had similar performance for diagnosing endometrial polyps.

Natural history of sonographically detected simple unilocular adnexal cysts in asymptomatic postmenopausal women

OBJECTIVE

To determine the natural history of simple unilocular adnexal cysts in asymptomatic postmenopausal women.

METHODS

Eight thousand seven hundred ninety-four asymptomatic postmenopausal women underwent transvaginal ultrasound as part of routine gynecological check-up at our institution between January 1995 and June 2002. All patients in whom a simple unilocular adnexal cyst was found out were offered surgical treatment or conservative follow-up with serial transvaginal ultrasound at 6-month intervals. In all these cases, serum CA-125 levels was determined.

RESULTS

Two hundred twenty-three simple adnexal cysts in 215 women were found out (prevalence: 2.5%). Annual incidence did not change significantly. Sixty-six (30.6%) women were lost after initial diagnosis. One hundred and forty-nine patients with 153 cysts were entered ultimately in the study. Forty-five (30%) underwent surgery (34 after initial diagnosis and 11 during follow-up). A total of 49 cysts were removed. The most frequent histological diagnosis was serous cystadenoma (84%). There was a case of a stage IA ovarian carcinoma (2% of the cysts removed, 0.6% of all the cysts included in the study). One hundred and four patients with 104 cysts underwent conservative follow-up throughout the study period. Forty-six (44%) of these cysts resolved spontaneously (74% of them within 2 years). In 14 (30%) of these women, a new cyst was diagnosed when follow-up went on. In 58 patients, cysts persisted during all study period (median follow-up: 48 months, range: 6-90 months), 69.6% of them remained unchanged, 17.2% increased, and 17.2% decreased. Patients in whom cysts resolved spontaneously had a shorter menopausal time (P=0.001) and tend to be younger (P=0.06). No differences were found regarding cysts' features.

CONCLUSION

The risk of malignancy of simple adnexal cysts in asymptomatic postmenopausal women is low. Almost half of them will resolve spontaneously during follow-up. Most of those that persist remain unchanged. Asymptomatic postmenopausal women having simple adnexal cysts can be managed conservatively with a very reasonable degree of reassurance.

Ultrasonographic and pathological endometrial findings in asymptomatic postmenopausal women taking antihypertensive drugs

OBJECTIVES

To assess whether abnormal sonographic endometrial findings are more frequent in asymptomatic postmenopausal women receiving anti-hypertensive drugs than in normotensive women.

METHODS

A prospective study on 187 postmenopausal asymptomatic normotensive (group A) and 182 postmenopausal asymptomatic women receiving anti-hypertensive drugs (group B) was performed. All patients were evaluated initially by transvaginal ultrasound and endometrial sampling (Pipelle device). Those women with abnormal sonographic findings (endometrial thickness > or =5 mm or heterogeneous echogenicity) or abnormal endometrial sampling results underwent hysteroscopy and guided biopsy.

RESULTS

Patients in group B had significantly higher percentage of endometrial thickness > or =5 mm (26.9 vs. 12.8%, P<0.001) and heterogeneous endometria (23.1 vs. 12.8%, P<0.001) than in group A. Patients in group B had a significantly higher incidence of endometrial polyps (17.6 vs. 9.6%, P<0.001) too. These findings were not associated with the type of anti-hypertensive drug taken and were independent of the body mass index.

CONCLUSIONS

Postmenopausal hypertensive asymptomatic women receiving pharmacological anti-hypertensive therapy show a higher percentage of abnormal sonographic endometrial findings than normotensive women.

Intratumoral blood flow in cervical cancer as assessed by transvaginal color doppler ultrasonography: Correlation with tumor characteristics

The objective of this study was to evaluate whether intratumoral blood flow as assessed by transvaginal color Doppler ultrasonography (TVCD) correlates with some tumor features in cervical cancer. Clinical, sonographic, and histologic data on 49 women (mean age: 50.3 years, range: 25-85 years) diagnosed as having a carcinoma from the uterine cervix were reviewed. Intratumoral blood flow was assessed by TVCD in all cases. Subjective impression of the amount of flow (scanty, moderate, or abundant) as well as the lowest resistance index (RI) and highest peak systolic velocity (PSV, cm/s) were used for analysis. These data were correlated with some tumoral features such as histologic type, histologic grade, tumor volume, and tumor stage. Intratumoral blood flow was found in all cases. Abundant blood flow was found more frequently in squamous carcinoma, moderately or poorly differentiated tumors, tumors with larger volume, and advanced stage tumors (P < 0.0001). Significantly lower RI was found in moderately or poorly differentiated tumors and advanced stage tumors (P < 0.01) and significantly higher PSV was found in moderately or poorly differentiated tumors, tumors with larger volume, and advanced stage tumors (P < 0.01). No correlation was found between RI and PSV and histologic type. Our data indicate that intratumoral blood flow as assessed by TVCD correlates well with some tumor features in cervical cancer.

Endometrial blood flow mapping using transvaginal power Doppler sonography in women with postmenopausal bleeding and thickened endometrium

OBJECTIVE

To evaluate the role of transvaginal power Doppler sonography to discriminate between benign and malignant endometrial conditions in women presenting with postmenopausal bleeding and thickened endometrium at baseline sonography.

METHODS

Ninety-one postmenopausal women (median age, 58 years; range, 47-83 years) presenting with uterine bleeding and a thickened endometrium (> or = 5-mm double-layer endometrial thickness) on transvaginal sonography were included in this prospective study. Endometrial blood flow distribution was assessed in all patients by power Doppler immediately after B-mode transvaginal sonography. Three different vascular patterns were defined: Pattern A: multiple-vessel pattern, Pattern B: single-vessel pattern and Pattern C: scattered-vessel pattern. Histological diagnoses were obtained in all cases. No patient taking tamoxifen citrate or receiving hormone replacement therapy was included.

RESULTS

Histological diagnoses were as follows: endometrial cancer: 33 (36%), endometrial polyp: 37 (41%), endometrial hyperplasia: 14 (15%), endometrial cystic atrophy: 7 (8%). Blood flow was found in 97%, 92%, 79% and 85% of cases of carcinoma, polyp, hyperplasia and endometrial cystic atrophy, respectively. A total of 81.3% of vascularized endometrial cancers showed Pattern A, 97.1% of vascularized polyps exhibited Pattern B and 72.7% of vascularized hyperplasias showed Pattern C. Sensitivity and specificity for endometrial cancer were 78.8% and 100%. For endometrial polyp these respective values were 89.2% and 87% and for hyperplasia they were 57.1% and 88.3%.

CONCLUSIONS

Transvaginal power Doppler blood flow mapping is useful to differentiate benign from malignant endometrial pathology in women presenting with postmenopausal bleeding and thickened endometrium at baseline sonography.

A new scoring system to differentiate benign from malignant adnexal masses

OBJECTIVE

The purpose of this study was to develop and cross-validate a new sonographic scoring system for differentiation between benign and malignant adnexal masses.

STUDY DESIGN

This study was conducted in a tertiary care university hospital. In the first part of the study, we used a multivariate logistic regression analysis to develop a scoring system that was based on morphologic and Doppler sonographic data for 705 adnexal masses in 665 patients who were diagnosed and treated at our institution from January 1995 to June 2001. The scoring system was designed to use only those parameters that are found to be independent predictors of malignancy. In the second part of the study, we prospectively cross-validated this scoring system in a series of 90 adnexal masses in 86 patients between July 2001 and March 2002. With the use of the area under the curve of the respective ROC curves, we compared the new scoring system with other scoring systems.

RESULTS

Multivariate logistic regression analysis revealed that the only independent predictor parameters were thick papillary projections, solid areas, central flow, and velocimetric features of high velocity and low resistance. In the prospective cross-validation study, our scoring system had the best diagnostic performance (area under the curve, 0.98) compared with Sassone (area under the curve, 0.89; P =.017), De Priest (area under the curve, 0.92; P =.048), and Ferrazzi (area under the curve, 0.90; P =.013) scoring systems.

CONCLUSION

Our new sonographic scoring system had a better diagnostic performance than three previously published scoring systems.

Transvaginal gray scale and color Doppler sonography in primary ovarian cancer and metastatic tumors to the ovary

OBJECTIVE

To compare gray scale and color Doppler features of primary and metastatic ovarian carcinomas.

METHODS

Clinical, sonographic (gray scale and color Doppler), and histopathologic data of 143 patients with primary (n = 127 adnexal masses) and metastatic (n = 34 adnexal masses) ovarian cancer were reviewed. Morphologic gray scale parameters assessed were bilaterality, tumor volume, echogenicity, and presence of septa, papillary projections, or solid areas. Color Doppler parameters were presence of blood flow, tumor blood flow location (central versus peripheral), subjective impression of blood flow amount (scanty, moderate, or abundant), lowest resistive index, lowest pulsatility index, and maximal peak systolic velocity (centimeters per second).

RESULTS

No statistical differences were found in bilaterality, tumor volume, presence of septa, papillary projections or solid areas, presence of blood flow, tumor blood flow location, subjective impression of blood flow amount, lowest resistive index, lowest pulsatility index, and maximal peak systolic velocity. Metastatic carcinomas were more frequently purely solid tumors (47% versus 26%; P = .001; likelihood ratio, 2.4; 95% confidence interval, 1.2-4.7).

CONCLUSIONS

The presence of a purely solid tumor indicates a higher probability of metastatic carcinoma than primary ovarian cancer. However, with the use of gray scale and color Doppler sonography, it is difficult to differentiate primary ovarian carcinomas from metastatic tumors to the ovary.

Three-dimensional sonographic morphologic assessment in complex adnexal masses: preliminary experience

OBJECTIVE

To evaluate the role of three-dimensional transvaginal sonography in assessing complex adnexal masses.

METHODS

Forty-one women (mean age, 49.5 years; range, 23-75 years) with the diagnosis of complex adnexal masses on the basis of two-dimensional transvaginal sonography were reevaluated by three-dimensional transvaginal sonography. Two different sonologists evaluated the two- and three-dimensional transvaginal sonograms. Criteria indicative of malignancy included the presence of gross papillary projections, solid areas, and solid echogenicity for both techniques. Three women (7%) had bilateral masses, giving a total of 44 masses that were ultimately assessed. A definitive histologic diagnosis was obtained in every case after surgical tumor removal.

RESULTS

Twenty-one tumors (47.7%) were proved malignant, and 23 (52.3%) were benign. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for two- and three-dimensional transvaginal sonography were 90%, 61%, 68%, 87%, and 75% and 100%, 78%, 81%, 100%, and 89%, respectively. There were no statistical differences between two- and three-dimensional transvaginal sonography (McNemar test, P = .687). The agreement between both examiners was high (kappa index = 0.71).

CONCLUSIONS

The use of three-dimensional transvaginal sonography does not significantly improve the two-dimensional transvaginal sonographic morphologic assessment of complex adnexal masses; however, we found it useful for reinforcing initial diagnostic impressions.

Transvaginal color Doppler ultrasonography in the management of first-trimester spontaneous abortion

OBJECTIVE

To evaluate the role of transvaginal color Doppler ultrasonography in the management of first-trimester spontaneous abortion, clinically thought to be complete.

STUDY DESIGN

A prospective interventional non-randomized study was performed in a tertiary care University hospital. Sixty-two women with suspected first-trimester spontaneous abortion, clinically thought to be complete were included in the study. All women were evaluated on admission by transvaginal color Doppler ultrasonography. The amount of blood flow within the myometrium or in the endometrium-myometrium interface was assessed. Those women with suspected retained tissue on color Doppler were scheduled to undergo dilatation and curettage (D&C). Those patients with no suspected retained tissue on color Doppler were scheduled for expectant management.

RESULTS

Eighteen women had suspected retained tissue and 44 women did not. A total of 16 out of 18 (88.9%) patients had retained trophoblastic tissue confirmed on histopathologic analysis. There were two false negative cases. Outcome of all patients managed expectantly was optimal with no complications.

CONCLUSIONS

Transvaginal color Doppler ultrasonography is useful to detect or to rule out the presence of retained trophoblastic tissue after first-trimester spontaneous abortion and to select patients for expectant management.

Intratumoral blood flow analysis in endometrial carcinoma: correlation with tumor characteristics and risk for recurrence

OBJECTIVE

The aim of this study was to correlate intratumoral blood flow as assessed by transvaginal color Doppler ultrasound with tumor histopathologic characteristics, tumoral stage, and risk for recurrence in endometrial carcinoma.

METHODS

Forty-five patients (mean age: 58.2 years, range: 30 to 83 years) with surgically treated endometrial carcinoma preoperatively evaluated with transvaginal color Doppler ultrasound were included in this retrospective study. The lowest arterial resistance index (RI) and highest peak systolic velocity (PSV) were used for intratumoral blood flow analysis. Individual tumor characteristics evaluated were tumor growth pattern, tumor size, histologic type, tumor grade, myometrial infiltration depth, cervical involvement, lymph node metastasis, and lymph-vascular space invasion (LVSI). Tumoral stage and risk for recurrence were also evaluated.

RESULTS

Significantly lower RI was found in tumors with the following characteristics: infiltrative growth pattern (P = 0,013), grade 3 (P = 0.001), infiltrating >or=50% of the myometrium (P = 0.006), cervical involvement (P = 0.009), LVSI (P = 0.008), lymph-node metastasis (P = 0.049), stage >or=Ic (P = 0.004), and high risk for recurrence (P = 0.001). Significantly higher PSV was found in tumors that were grade 3 (P = 0.034), infiltrating >or=50% of the myometrium (P = 0.029), stage >or=Ic (P = 0.015), and with a high risk for recurrence (P = 0.002).

CONCLUSIONS

Our data indicate that a correlation between intratumoral blood flow features and histopathological characteristics, tumor stage, and risk for recurrence exists in endometrial cancer. Further prospective studies are needed to determine the clinical usefulness of preoperative assessment of tumor vascularization in these carcinomas.

Transvaginal colour Doppler in patients with ovarian endometriomas and pelvic pain

BACKGROUND

The aim of this investigation was to correlate ovarian endometrioma vascularization with the presence of pelvic pain.

METHODS

The presence of blood flow, peak systolic velocity (PSV, cm/s) and lowest pulsatility index (PI), assessed by transvaginal colour Doppler ultrasonography and CA-125 plasma concentrations, were retrospectively analysed in 74 patients who had undergone operations for cystic ovarian endometriosis. Fifty-two patients were asymptomatic (group A) and 22 presented with pelvic pain (group B). There were 56 endometriomas in group A and 26 in group B.

RESULTS

Blood flow was found in 66.1 and 88.5% of endometriomas in groups A and B respectively (P = 0.036). PI was significantly lower (P = 0.009) and CA-125 concentration higher (P = 0.0004) in group B. There were no differences in PSV.

CONCLUSIONS

We conclude that vascularization of ovarian endometriomas in patients presenting with pelvic pain is higher than in asymptomatic patients. This could be an indicator of endometriosis activity.

Assessment of a new logistic model in the preoperative evaluation of adnexal masses

OBJECTIVE

To assess a new logistic regression model developed to predict malignancy in adnexal masses.

METHODS

In the first part of this study, we developed a logistic model by applying logistic regression analysis in a series of 268 adnexal masses (203 benign and 65 malignant lesions) in 248 patients (mean age, 43.6 years; SD, 14.2 years) evaluated and treated at our institution. Eleven parameters were entered in the logistic regression analysis in a forward stepwise way. In the second part of the study, we evaluated the model's diagnostic performance in a further set of 135 adnexal masses (103 benign and 32 malignant tumors) in 129 patients (mean age, 44.4 years; SD, 14.6 years). This diagnostic performance was compared with that of age, tumor volume, Sassone's and Ferrazzi's B-mode ultrasonographic morphologic scoring systems, serum cancer antigen 125 level, and the tumor's lowest resistive index. Comparison was done by calculating the area under the receiver operating characteristic curve.

RESULTS

In logistic analysis, only menopausal status, the presence of papillary projections, the logarithm of the cancer antigen 125 value, tumor blood flow location, and the lowest resistive index were retained in the model. The model had the best area under the curve (0.97), significantly higher than patient age (area under the curve, 0.78; P = .001), tumor volume (area under the curve, 0.68; P < .0001), cancer antigen 125 (area under the curve, 0.88; P = .008), lowest resistive index (area under the curve, 0.85; P = .011), Ferrazzi's scoring system (area under the curve, 0.89; P = .01), and maximal peak systolic velocity (area under the curve, 0.71; P< .0001). Comparison with Sassone's scoring system (area under the curve, 0.91) did not reach statistical significance, but a clear trend was found (P = .116).

CONCLUSIONS

The model had the best diagnostic performance for discriminating between benign and malignant adnexal masses. A clinical prospective evaluation is needed to confirm its actual value.

Sonographic features of ovarian cystadenofibromas: spectrum of findings

OBJECTIVE

To describe the sonographic characteristics of ovarian cystadenofibromas.

METHODS

We conducted a retrospective study of 23 ovarian tumors histopathologically confirmed as ovarian cystadenofibromas that were preoperatively evaluated by transvaginal color Doppler sonography.

RESULTS

In all cases the mass was predominantly cystic. Septations appeared in 30.4% of the tumors. Papillary projections or solid nodules appeared in 56.5% of the cases. The most frequent appearance was a unilocular complex cystic mass. In 47.8% of the tumors, vascularization was detected, having a typical pattern of peripheral vascularization with scattered vessels of high blood flow impedance.

CONCLUSIONS

We have described the sonographic spectrum of findings of ovarian cystadenofibromas. The most frequent appearance was a unilocular cystic mass with gross papillary projections or solid nodules. In almost half of the tumors, vascularization could be detected.

Transvaginal color Doppler assessment of venous flow in adnexal masses

OBJECTIVE

To analyze the usefulness of transvaginal color Doppler assessment of venous flow in the differential diagnosis of adnexal masses.

MATERIAL AND METHODS

Ninety-one consecutive patients (mean age: 46.6 years, range: 16-81 years) diagnosed as having an adnexal mass were evaluated by transvaginal color Doppler sonography prior to surgery. Color Doppler was used to detect and analyze the flow velocity waveform from arterial and venous blood flow within the tumor. For arterial signals the resistance index and peak systolic velocity, and for veins the maximum venous flow velocity, were calculated. Receiver operator characteristic curves were plotted to determine the best venous flow velocity cut-off. According to our previous study using arterial Doppler, a tumor was considered as malignant when flow was detected and the lowest resistance index was < or = 0.45. Using venous Doppler a mass was considered as malignant when flow was detected and the venous flow velocity was > or = the best cut-off found on the receiver operator characteristic curve. Definitive histopathological diagnosis was obtained in all cases. Sensitivity, specificity, positive predictive value and negative predictive value for B-mode morphology (evaluation performed according to Sassone's scoring system), arterial Doppler, venous Doppler, and a combination of both arterial and venous Doppler were calculated.

RESULTS

Twenty-five masses (27.5%) were malignant and 66 (72.5%) benign. Arterial and venous flow was found more frequently in malignant than in benign masses (92% vs. 41% (P < 0.001) and 72% vs. 21% (P < 0.001), respectively). The resistance index was significantly lower in malignant tumors (0.42 vs. 0.60, P = 0.0003). No differences were found in peak systolic velocity. Venous flow velocity was significantly higher in malignant masses (18.1 cm/s vs. 8.9 cm/s, P = 0.0006). The best cut-off of venous flow velocity was 10 cm/s. Sensitivity, specificity, positive predictive value and negative predictive value for morphology, arterial Doppler, venous Doppler, and the combination of both arterial and venous Doppler were 92%, 71%, 45%, 96%; 76%, 95%, 87%, 91%; 68%, 94%, 81%, 89%; and 88%, 91%, 79%, 95%, respectively.

CONCLUSIONS

Our results indicate that preoperative evaluation by venous flow assessment of adnexal masses may be useful to discriminate between malignant and benign tumors.

Primary vaginal and pelvic floor reconstruction at the time of pelvic exenteration: a study of morbidity

PURPOSE

The purpose of this study was to analyze our experience with the influence of reconstructive techniques at the time of pelvic exenteration on morbidity.

MATERIALS AND METHODS

Between June 1986 and December 1998, 60 pelvic exenterations for gynecologic malignancies were performed in our hospital. Forty-five were selected for this study because they met two criteria: they were performed by the same team (gynecologic oncologist), and they had similar primary tumors. There were 38 cervical, 2 vaginal, and 5 uterine malignancies. Sixteen patients underwent reconstructive surgery: 11 (68.8%) with placement of a myocutaneous flap with left rectus abdominis, 3 (18.8%) with gracilis muscle, and 2 (12.5%) with the Singapore fasciocutaneous flap. Twenty-nine patients had no reconstruction. Records were reviewed and statistical analysis was performed.

RESULTS

Attachment of the grafts was complete in 14 of 16 (87.5%), with a partial vulvovaginal dehiscence in 2 cases. Morbidities included secondary infection in 3 (18.8%), partial necrosis in 3 (18.8%), and partial stenosis in 5 (31.6%); the last was significantly associated with a gracilis flap (P = 0.015). There were no statistical differences between neovagina and nonneovagina groups with respect to the rate of fever, small bowel fistula, bowel obstruction, wound infection or dehiscence, hernia, colorectal leak, colostomy or urostomy prolapse, deep vein thrombosis, pulmonary embolism, intraoperative blood transfusions, or hospital stay. There were no pelvic abscesses in the neovagina group compared with 27% (6/29) in the other group (P = 0.050). Surgery was significantly longer (P = 0.019) for the reconstructive surgery group, with no statistical difference between different kinds of flaps. There were no deaths in either group.

CONCLUSIONS

Reconstruction of the vagina and pelvic floor at the time of pelvic exenteration can be done safely. Although this increases surgical time, morbidity is not significantly increased. The rectus abdominis flap seems to be the preferable option for primary vaginal and pelvic floor reconstruction.

Endometrial sonographic findings in asymptomatic, hypertensive postmenopausal women

PURPOSE

In this retrospective study, the sonographically measured endometrial thickness in asymptomatic, hypertensive postmenopausal women was compared with that in normotensive postmenopausal women.

METHODS

We reviewed clinical and sonographic data on 511 consecutive, unselected, asymptomatic postmenopausal women who attended our hospital for routine gynecologic examinations during a 6-month period. Two hundred nineteen patients (mean age, 60.2 years; age range, 49-81 years) were included in the study. Reasons for exclusion were: clinical data about hypertension were not available (n = 159); the patient had received or was receiving hormonal treatment (n = 78); the patient had undergone a hysterectomy (n = 25); and endometrial thickness could not be determined (n = 30). All patients had been examined using transvaginal or transabdominal sonography. Endometrial thickness was measured at the level of its maximum thickness in the uterine sagittal plane.

RESULTS

Fifty-six (26%) of 219 patients were hypertensive. Of these 56 patients, 41 (73%) were receiving drug treatment. The mean endometrial thickness in the hypertensive patients receiving treatment [6.2 mm; 95% confidence interval (CI), 5.1-7.4 mm] was significantly greater than in both the untreated, hypertensive patients (4.3 mm; 95% CI, 3.1-5. 5 mm) (p = 0.008) and the normotensive patients (3.6 mm; 95% CI, 3. 4-3.8 mm) (p < 0.0001). Endometrial thickness was equal to or greater than 5 mm in 59% of the hypertensive patients receiving drug treatment compared with 40% of the untreated, hypertensive patients and 18% of the normotensive patients (p < 0.001). An endometrial stripe was sonographically detected in 22% of the hypertensive patients undergoing treatment, 7% of the hypertensive patients undergoing no treatment, and 1% of the normotensive patients (p < 0. 0001).

CONCLUSIONS

Our data indicate that endometrial thickness, which can be determined sonographically, is frequently greater in asymptomatic, hypertensive postmenopausal women receiving antihypertensive drugs than in untreated hypertensive and normotensive patients. This conclusion could have clinical relevance when interpreting endometrial sonographic findings in asymptomatic, hypertensive postmenopausal patients.

Saline infusion sonohysterography in endometrial cancer: assessment of malignant cells dissemination risk

BACKGROUND

To assess the risk of malignant cells dissemination in patients with endometrial cancer undergoing saline infusion sonohysterography (SIS).

METHODS

Fourteen consecutive patients (mean age: 58.1 years, range: 41-74 years) diagnosed as having a clinical stage I endometrial carcinoma and scheduled for surgical staging were entered in this study. SIS was performed at the time of laparotomy just when the abdomen was opened and prior to the start of the surgical procedure. 10-20 mL of saline was infused. All fluid spilled from the fimbrial ends of the fallopian tubes was collected and analyzed for the presence or absence of malignant endometrial cells. Samplings were also taken from ascites, if found, or cytological washings, prior to and after SIS.

RESULTS

SIS could be satisfactorily performed in all patients. There was no spillage from either tube in nine patients. Mean fluid volume obtained from the other five patients was 4.4 mL. Cytologic analysis revealed the presence of malignant cells in the spilled fluid in one case (7.1%, one out of fourteen).

CONCLUSIONS

Our data show that a small but real risk of malignant cell dissemination exists in patients with endometrial carcinoma who undergo SIS.

Uteroplacental circulation in patients with first-trimester threatened abortion

OBJECTIVE

To assess uteroplacental circulation in patients with first-trimester threatened abortion with a living embryo.

DESIGN

Prospective, cross-sectional study.

SETTING

Tertiary care university hospital.

PATIENT(S)

Forty-nine patients with first-trimester threatened abortion and a living embryo and 129 women with singleton, low-risk, normally developing first-trimester pregnancies recruited as controls.

INTERVENTION(S)

Transvaginal color Doppler ultrasound measurement of the peak systolic velocity and pulsatility index of the uterine arteries and the spiral arteries.

MAIN OUTCOME MEASURE(S)

Uteroplacental blood flow and pregnancy outcome.

RESULT(S)

There was a significant relation between gestational age and the peak systolic velocity and pulsatility index in the uterine arteries and between gestational age and the peak systolic velocity and pulsatility index in the spiral arteries in controls. There were no differences in any Doppler parameter assessed between the study group and the controls, even in those pregnancies that ended in spontaneous abortion.

CONCLUSION(S)

No apparent alteration occurs in the early uteroplacental circulation in patients with threatened abortion with a living embryo. The use of transvaginal color Doppler ultrasound is not helpful for predicting pregnancy outcome in these cases.

Prospective evaluation of a logistic model based on sonographic morphologic and color Doppler findings developed to predict adnexal malignancy

To assess prospectively a logistic model based on sonographic morphologic and color Doppler findings, which had been developed to predict adnexal malignancy, 167 consecutive and unselected patients (mean age, 45.7 yr; range, 17 to 81 yr; 113 [67.7%] premenopausal and 54 [32.3%] postmenopausal) diagnosed as having an adnexal mass and scheduled for surgery were prospectively included in this study. All patients were evaluated by transvaginal color Doppler ultrasonography. The probability of adnexal malignancy was estimated prior to surgery, applying a logistic model developed previously. A probability of malignancy greater than 75% was considered to assess model performance. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for the model. In all cases definitive histopathologic diagnosis was obtained. One hundred and twenty-five (74.9%) benign and 42 (25.1%) malignant tumors were found. The sensitivity, specificity, positive predictive value, and negative predictive value of the model were 85.7% (95% confidence intervals, 71.4% to 94.6%), 100% (95% confidence intervals, 97.1% to 100%), 100% (95% confidence intervals, 90.3% to 100%), and 95.4% (95% confidence intervals, 90.3% to 98.3%), respectively. Overall accuracy was 96.4% (95% confidence intervals, 91.3% to 98.7%). Our results confirm the validity of the proposed logistic model in predicting adnexal malignancy.

Transvaginal color Doppler ultrasonography and CA-125 in suspicious adnexal masses

OBJECTIVE

To compare diagnostic performance of color Doppler ultrasound and CA-125 in suspicious adnexal masses on B-mode sonography.

MATERIALS AND METHODS

Data on 94 patients (mean age: 47.4 years, range: 17-79 years. Fifty-two (55.3%) premenopausal and 42 (44.7%) postmenopausal women) managed in our institution because of a suspicious adnexal mass were reviewed. All patients were evaluated by transvaginal color Doppler ultrasonography (CD) and serum CA-125 level determination prior to surgery. Definitive histopathological diagnosis was obtained in each case. Sonographic morphology evaluation was suspicious in all cases. CD was considered as suspicious when flow was detected and the lowest RI found was < or = 0.45. CA-125 cut-off was > or = 35 UI/ml. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each method and compared. ROC analysis was performed for RI and CA-125. Areas under curve (AUC) were calculated and compared.

RESULTS

Fifty-six (59.6%) tumors were found to be malignant and 38 (40.4%) benign. Sensitivity, specificity, PPV and NPV for CD were 87.5% (95% CIs: 75.3-94.4), 84.2% (95% CIs: 68.7-94), 89.1% (95% CIs: 77.7-95.9) and 82.1% (95% CIs: 66.5-92.5), respectively. Sensitivity, specificity, PPV and NPV for CA-125 were 83.9% (95% CIs: 71.7-92.4), 68.4% (95% CIs: 51.3-82.5), 79.7% (95% CIs: 66.2-89) and 74.3% (95% CIs: 56.7-87.5), respectively. Sensitivity, PPV and NPV were not statistically different. CD had higher specificity (P = 0.01). AUC curve for Doppler (0.75) was significantly higher than for CA-125 (0.61) (P = 0.0002).

CONCLUSIONS

Our results indicate that color Doppler ultrasound has a better diagnostic performance as compared with CA-125, being significantly more specific.

Transvaginal color Doppler for predicting pathological response to preoperative chemoradiation in locally advanced cervical carcinoma: a preliminary study

To evaluate the role of transvaginal color Doppler ultrasonography (TCD) in predicting pathological response to preoperative chemoradiation in patients with locally advanced cervical cancer, 10 patients (mean age: 45.2 y, range: 31 to 75 y) with histologically proven locally advanced cervical cancer who were scheduled for preoperative chemoradiation were evaluated by TCD prior to beginning the treatment protocol. Tumor volume, number of vessels within the tumor, lowest resistance index (RI), maximum peak systolic velocity (PSV), and the ratio between the number of vessels and tumor volume (tumor vascular density, TVD) were calculated. All patients underwent preoperative chemoradiation and radical surgery. Complete pathological response (pathCR) was considered when no residual tumor was found on surgical specimens. Partial pathological response (pathPR) was considered when residual tumor was found. PathCR was achieved in three patients (30%), whereas 7 (70%) had pathPR. Mean tumoral volume was not statistically different between those with pathCR (33.2 cm3) and those with pathPR (20.3 cm3) (p = 0.305). Those tumors with pathCR had lower mean number of vessels (3.3 vs. 5.3, p = 0.01), lower TVD (0.1 vs. 1.1, p = 0.05) and higher RI (0.41 vs. 0.29, p = 0.03). No differences were found in PSV. Although these data are preliminary, our results suggest that TCD may be used to predict pathological response to preoperative chemoradiation in patients with locally advanced cervical cancer.