Transvaginal colour flow imaging: a possible new screening technique for ovarian cancer

Prognostic significance of ultrasound derived intratumoral peak systolic velocity in epithelial ovarian cancer

OBJECTIVE

To evaluate the prognostic significance of ultrasound derived intratumoral peak systolic velocity in epithelial ovarian cancer.

DESIGN

Color Doppler imaging and pulsed Doppler spectral analysis were used in the investigation of 49 patients with epithelial ovarian cancer (19 serous, 15 mucinous, eight endometrioid, four clear cell and three Brenner cell) immediately before laparotomy. Twenty-two were stage I, six were stage II, 17 were stage III and four were stage IV. Sections of malignant tumors were analyzed for the cellular expression of thymidine phosphorylase and the intratumoral density of microvessels by immunohistochemistry using antibodies to thymidine phosphorylase and factor VIII-related antigen, respectively. Moreover, the apoptotic index was evaluated by the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling method. Intratumoral peak systolic velocity was tested for correlation with patients' age at diagnosis, stage of disease, presence of a residual tumor, histological subtype and grade, thymidine phosphorylase expression, apoptotic index, microvessel count and patient survival.

RESULTS

Histological grade (P = 0.025), thymidine phosphorylase expression (P = 0.044), apoptotic index (P = 0.039) and microvessel count (P = 0.014) were all significantly associated with peak systolic velocity. Stage of disease (P = 0.002), presence of residual disease (P = 0.0002) and peak systolic velocity (P = 0.041) were found by univariate Cox regression analysis to be significantly associated with a poor prognosis. Multivariate Cox regression analysis revealed that stage of disease (P = 0.006) and peak systolic velocity (P = 0.008) are independent prognostic factors.

CONCLUSIONS

Intratumoral peak systolic velocity could be a preoperatively pertinent prognostic predictor of survival in patients with epithelial ovarian cancer.

Evaluation of endometrial polyps

OBJECTIVE

Endometrial polyps are relatively common in all groups of women. More polyps are being diagnosed with the widespread use of transvaginal ultrasound scanning and sonohysterography. The reported incidence of malignancy is low. The potential benefit of a noninvasive technique to distinguish benign from malignant polyps is obvious. This study was undertaken to evaluate endometrial polyps by color flow Doppler ultrasound scanning and histopathologic examination.

STUDY DESIGN

This was an observational study of patients with an endometrial polyp on sonohysterography who underwent interrogation of their polyp with color Doppler ultrasound scanning and subsequently polypectomy. Polyp volume, resistive index, pulsatility index, indication for scan (bleeding vs incidental), and patient age were correlated with histopathologic type of the polyp (nonfunctional, proliferative, secretory, hyperplastic, or malignant).

RESULTS

Of 61 patients studied, 42 patients (68.9%) were scanned for abnormal bleeding, and 19 patients (31.1%) had their polyps discovered incidentally. There were no statistically significant differences between histologic categories and the resistive index, pulsatility index, or size of the polyp. The age of patients with nonfunctional polyps was significantly greater than any other group (P <.001). Ninety-four percent of the functional polyps were discovered because of abnormal bleeding; 38% of the nonfunctional polyps were discovered incidentally (P <.001).

CONCLUSION

The data suggest that the objective assessment of blood flow impedance (resistive index, pulsatility index) in endometrial polyps and the size of these polyps cannot replace surgical removal and pathologic evaluation to predict histologic type. Patients with nonfunctional polyps were older and less likely to have vaginal bleeding.

Clinical usefulness of color Doppler ultrasound in patients with endometrial hyperplasia and carcinoma

BACKGROUND

The objective of this study was to examine the usefulness of transvaginal color Doppler ultrasound (TV-CDU) in differentiating between endometrial hyperplasia (EH) and endometrial carcinoma (EC) and in predicting tumor spread in patients with EC.

METHODS

Seventy-one postmenopausal patients were enrolled with either EH or EC that had been diagnosed by endometrial biopsy. The presence or absence of intratumoral blood flow was assessed by TV-CDU. The intratumoral blood flow characteristics were analyzed using the resistance index (RI), pulsatility index (PI), and peak systolic velocity (PSV). The endometrial thickness also was measured in all patients by gray-scale sonography. The correlation of these sonographic findings with histologic type, tumor grade, surgical stage, myometrial invasion, or the presence or absence of pelvic lymph node metastasis was then evaluated in patients with EC.

RESULTS

Although there were no patients with EC with endometrial thickness measuring < 5 mm, no significant difference was found in the mean value of endometrial thickness between patients with EH (n = 18 patients; 16.2 mm +/- 15.9 mm) and patients with EC (n = 53 patients; 18.7 mm +/- 17.1 mm). Intratumoral blood flow was detected in significant numbers of patients who had EC (71.7%; 38 of 53 patients) compared with patients who had EH (5.6%; 1 of 18 patients; P < 0.0001). Thus, no patients with EH showed any blood flow in the endometrial lesions, except for one patient who had EH complicated by pyometra. In patients with EC, the positive rate of intratumoral blood flow was correlated significantly with myometrial invasion, tumor grade, and pelvic lymph node metastasis (P < 0.05; Cochran-Armitage trend test). No associations were found between RI, PI, or PSV and the clinicopathologic parameters examined, including surgical stage.

CONCLUSIONS

TV-CDU may be more useful in differentiating between EH and EC than measuring endometrial thickness by transvaginal gray-scale sonography. For patients with EC, the detection of intratumoral blood flow may be helpful in distinguishing between low-grade and high-grade tumors and predicting myometrial invasion. However, intratumoral blood flow analysis using RI, PI, or PSV may not be useful for predicting tumor spread before surgery.

Gynecologic ultrasound

For most women, pelvic sonography using a transvaginal probe is the imaging modality of choice for evaluating the uterus and adnexae. It is reliable for detecting ovarian cysts and other adnexal masses, and it can often determine if a lesion can be observed on serial examinations or if it requires more urgent attention. Uterine ultrasound is reliable for evaluating both the normal and abnormal endometrium and myometrium. In cases that are technically limited, or in those that are difficult to interpret, a tailored MR imaging examination often can be helpful.

Approaching the adnexal mass in the new millennium

Adnexal masses are common dilemmas faced by practicing gynecologists. They affect women from before birth throughout life, yet considerable disagreement exists regarding their optimal management. Traditional management focused on avoiding undertreatment of a potentially malignant process. Advances in detection, diagnosis, and minimally invasive management make it necessary to review this practice to avoid unnecessary morbidity and mortality. The literature emphasizes a minimally invasive approach to the treatment of benign lesions without sacrificing the principles of oncologic surgery.

CA 125 measurement and ultrasonography in borderline tumors of the ovary

OBJECTIVES

Our goal was to perform an analysis of ultrasonographic characteristics and CA 125 levels in ovarian tumors of borderline malignancy.

STUDY DESIGN

We performed a retrospective analysis of CA 125 levels and ultrasonographic parameters in 91 patients with borderline tumors.

RESULTS

Serous tumors of borderline malignancy were associated with elevated CA 125 levels in 75% of patients before surgery (mean, 156 IU/mL) compared with 30% of mucinous tumors (mean, 28 IU/mL; P =.004). CA 125 was elevated in 35% of stage IA serous tumors (mean, 67 IU/mL) compared with 89% of tumors with spread beyond the ovary (mean, 259 IU/mL; P =.001). Mucinous tumors tended to be bigger (13.1 +/- 7 cm) on ultrasonography than serous tumors (9.3 +/- 6.2 cm, P =.016). Mucinous tumors were multilocular in half the patients and contained papillations in 40% of the patients. Serous tumors were multilocular in 30% of the patients but presented with solid or papillary patterns in 78% of the patients (P =.001). A resistance index of <0.4 was found in 36% of mucinous tumors and half the cases of serous tumors. In 13% of patients, ultrasonographic characteristics were compatible with a simple cyst only, including 1 patient with microinvasion and 1 patient with stage IIIB disease. Sensitivity of gray-scale ultrasonography was 87%, that of CA 125 measurement was 62%, and that of flow was 55%. At least 1 diagnostic test result was abnormal in 93% of patients, 2 were abnormal in 69% of patients, and all 3 were abnormal in 21% of patients.

CONCLUSIONS

A high proportion of borderline tumors of the ovary, particularly of the serous type, were associated with elevated CA 125 levels and abnormal ultrasonographic characteristics, although some tumors presented as simple cysts.

Transvaginal color Doppler ultrasonic characterization of benign and malignant ovarian cystic teratomas and comparison with serum squamous cell carcinoma antigen

BACKGROUND

The preoperative diagnosis of squamous cell carcinoma (SCC) arising in mature cystic teratoma of the ovary remains difficult. The purpose of this study is to examine the usefulness of transvaginal color Doppler ultrasound (TV-CDU) in differentiating malignant (SCC) from benign cystic teratoma of the ovary.

METHODS

Eighty-eight patients with an ovarian tumor showing gray scale sonographic appearances of mature cystic teratoma were preoperatively evaluated for the presence or absence of intratumoral blood flow by TV-CDU. The blood flow characteristics of the tumor vessels were analyzed using the resistance index (RI), pulsatility index (PI), and peak systolic velocity (PSV). The serum levels of SCC antigen were also randomly examined preoperatively in 50 patients.

RESULTS

Intratumoral blood flow was significantly detected in malignant teratomas (SCCs) (80.0%; 4 of 5) compared with benign teratomas (20.5%; 17 of 83) (P < 0.01). All malignant teratomas with intratumoral blood flow showed both RI less than 0.4 and PI less than 0.6, whereas no benign teratomas showed any such value except for 1 case with struma ovarii. In addition, both the mean RI and the mean PI values in the tumor vessels were significantly lower in the malignant teratomas (RI: 0.31 +/- 0.07; PI: 0.40 +/- 0.16) than in the benign teratomas (RI: 0.62 +/- 0.13; PI: 1.06 +/- 0.44) (P < 0.001). However, the mean PSV value of the malignant teratomas (PSV: 20.6 +/- 8.33) was not significantly different from the benign teratomas (PSV: 18.1 +/- 9.9). Elevation of serum SCC was found in 4 of 5 patients (80%) with malignant teratomas, whereas the elevation was found in 11 of 45 patients (24.4%) with benign teratomas (P < 0.05). The diagnostic accuracy using the RI (cutoff value 0.4) as well as the PI (cutoff value 0.6) was thus 95.2%, which was significantly superior to that obtained by using the serum SCC (76%) (cutoff value, 1.5 ng/mL).

CONCLUSIONS

Evaluating the presence or absence of intratumoral blood flow, together with blood flow resistance, in tumor vessels using TV-CDU thus may be more useful to differentiate malignant (SCC) from benign cystic teratomas of the ovary than by measuring serum SCC levels.

Is color Doppler ultrasound useful in diagnosing ovarian cancer?

In summary, the emergence of CDUS presented an interesting new technical approach to the study of neovascularization in ovarian cancers. Techniques for CDUS are technically difficult and plagued with artifacts making correct interpretation difficult. Measures of blood flow (such as the resistive index) overlap significantly between ovarian cancers and benign ovarian tumors. Wide differences in estimates of the sensitivity and specificity of CDUS have been published, and fundamental norms such as resistive index also vary greatly among studies. Explanations for these differences are lacking. Most studies were performed in academic centers with referrals of high risk patients. This limits the ability to generalize results to the community. Data are insufficient to include CDUS in diagnostic protocols for ovarian cancer.

Surgical management of ovarian cancer

Ovarian cancer affects over 25,000 women each year in the United States. The performance of appropriate surgery for ovarian cancer is critical in directing further therapies and improving survival. Systematic surgical staging must be performed in patients who appear to have early stage ovarian cancer because a significant proportion of these women have occult metastases. A marked improvement in survival has been demonstrated in patients with bulky disease if all masses larger than 2 cm can be surgically removed. Despite the dramatic effect of surgery on the subsequent course of the disease, recent studies show that only a minority of women with ovarian cancer receive appropriate initial surgery. We review the evidence and rationale for systematic surgical treatment of ovarian cancer.

Pelvic Doppler

This article reviews gray-scale and Doppler evaluation of the adexae and endometrium. Color Doppler is useful in distinguishing between cystic and solid masses. However, spectral Doppler is of limited utility in improving the gray-scale morphologic impression of a mass being either benign or malignant.

Cervical tumor characterization by transvaginal color flow Doppler ultrasound

The aim of the study was to investigate the blood flow characteristics of benign cervical lesions and invasive cervical tumors and to determine if invasive cervical tumors can be predicted by transvaginal sonography (TVS) and color flow Doppler (CFD). The study design incorporated an open prospective collection of data from patients attending the Women's Cancer Center, University of Minnesota and the Sydney Women's Cancer Center. Inclusion criteria included patients with known benign or malignant cervical pathology. The study group of 66 patients comprised 32 patients with invasive cervical cancer and 34 patients with benign cervical lesions. Benign cervixes were significantly more likely to have absent or normal flow whereas malignant lesions were significantly more likely to have abnormal or increased flow (P < 0.0001). No differences in the uterine or intratumor systolic, diastolic, or mean velocity were found between the two groups. A reduction in the uterine artery pulsatility index (PI) and resistance index (RI) from 1.84 to 1.55 and 0.73 to 0.71, respectively, and also in the intracervical PI from 1.5 to 1.1, in the benign compared to invasive group was found, none of which reached statistical significance. However the intracervical RI was statistically lower (0.62) in malignant tumors compared to patients with benign lesions (0.71) (P = 0.03). The effect of menopause on blood flow characteristics was variable and overall not significant. While the uterine artery systolic velocity was significantly higher in premenopausal women, no such effect was found for the diastolic or mean velocity or the PI and RI. In postmenopausal women, the intratumor PI and RI were higher compared to premenopausal women. In conclusion, transvaginal CFD analysis of the uterine arterial or intratumor bed does not appear to be beneficial in attempting to distinguish benign from malignant cervical tumors.

Diagnosis and staging of ovarian cancer: comparative values of Doppler and conventional US, CT, and MR imaging correlated with surgery and histopathologic analysis--report of the Radiology Diagnostic Oncology Group

PURPOSE

To determine the optimal imaging modality for diagnosis and staging of ovarian cancer.

MATERIALS AND METHODS

Two hundred eighty women suspected to have ovarian cancer were enrolled in a prospective study before surgery. Doppler ultrasonography (US), computed tomography (CT), and magnetic resonance (MR) imaging were used to evaluate the mass; conventional US, CT, and MR imaging were used to stage spread.

RESULTS

All three modalities had high accuracy (0.91) for the overall diagnosis of malignancy. In the ovaries, the accuracy of MR imaging (0.91) was higher than that of CT and significantly higher than that of Doppler US (0.78). In the extraovarian pelvis and in the abdomen, conventional US, CT, and MR imaging had similar accuracies (0.87-0.95). In differentiation of disease confined to the pelvis from abdominal spread, the specificity of conventional US (96%) was higher than that of CT and significantly higher than that of MR imaging (88%), whereas the sensitivities of MR imaging (98%) and CT (92%) were significantly higher than that of conventional US (75%).

CONCLUSION

MR imaging is superior to Doppler US and CT in diagnosis of malignant ovarian masses. There is little variation among conventional US, CT, and MR imaging as regards staging.

Estimation of blood perfusion using ultrasound

Ways to measure blood perfusion using ultrasound techniques such as continuous-wave Doppler, pulsed Doppler, colour Doppler and power Doppler will be reviewed. From a certain standpoint, blood perfusion may be defined as the difference between arterial inflow and arterial outflow from a considered volume, i.e. capillary flow. The low velocities and small blood volumes involved make the signal-to-noise ratio, dynamic range and frequency resolution critical factors in the detection system. Another limiting factor is tissue motion which obscures the blood signal. Perfusion may still under certain conditions be estimated with the first moment of the Doppler power spectrum, as obtained with any Doppler ultrasound method. Modern flow mapping techniques also make it possible to estimate perfusion by counting the number of pixels that indicate flow, but low flow velocities cannot be included in the estimate. Future high-frequency systems may, however, provide very detailed images of minute flow distributions in superficial layers. Contrast agents are widely used today to enhance the blood signal, and a technique named harmonic imaging can suppress movement artefacts from surrounding tissue. Transient signals from disrupting contrast agent particles in an ultrasound field can potentially be used for perfusion quantification. Future developments to extract the blood flow signal from its noisy environment, aside from contrast agents, may be multiple sample volumes, frequency compounding and/or improved signal processing. The lack of an adequate perfusion phantom for verification of measurements of microcirculatory flow becomes, however, more apparent with improved detectability of slow flows.

Screening for ovarian cancer: a pilot randomised controlled trial

BACKGROUND

The value of screening for ovarian cancer is uncertain. We did a pilot randomised trial to assess multimodal screening with sequential CA 125 antigen and ultrasonography.

METHODS

Postmenopausal women aged 45 years or older were randomised to a control group (n=10,977) or screened group (n=10,958). Women randomised to screening were offered three annual screens that involved measurement of serum CA 125, pelvic ultrasonography if CA 125 was 30 U/mL or more, and referral for gynaecological opinion if ovarian volume was 8.8 mL or more on ultrasonography. All women were followed up to see whether they developed invasive epithelial cancers of the ovary or fallopian tube (index cancers).

FINDINGS

Of 468 women in the screened group with a raised CA 125, 29 were referred for a gynaecological opinion; screening detected an index cancer in six and 23 had false-positive screening results. The positive predictive value was 20.7%. During 7-year follow-up, ten further women with index cancers were identified in the screened group and 20 in the control group. Median survival of women with index cancers in the screened group was 72.9 months and in the control group was 41.8 months (p=0.0112). The number of deaths from an index cancer did not differ significantly between the control and screened groups (18 of 10,977 vs nine of 10,958, relative risk 2.0 [95% CI 0.78-5.13]).

INTERPRETATION

These results show that a multimodal approach to ovarian cancer screening in a randomised trial is feasible and justify a larger randomised trial to see whether screening affects mortality.

Ultrasound evaluation of pelvic masses: predictors of malignancy for the general gynecologist

Recent data indicate that assessment of sonographically determined tumor volume and morphology is the most accurate means to differentiate benign from malignant ovarian tumors. Doppler flow studies generally have shown a lower impedance to flow in vessels supplying ovarian malignancies than in those associated with benign tumors. However, the overlap in pulsatility index and resistive index values of benign and malignant ovarian tumors, and the cost of this procedure, make its routine use impractical. In a postmenopausal woman with a sonographically confirmed ovarian tumor, a progressively rising serum Ca-125 is highly suspicious for malignancy.

Predicting ovarian malignancy: application of artificial neural networks to transvaginal and color Doppler flow US

PURPOSE

To compare the performance of artificial neural networks (ANNs) with that of multiple logistic regression (MLR) models for predicting ovarian malignancy in patients with adnexal masses by using transvaginal B-mode and color Doppler flow ultrasonography (US).

MATERIALS AND METHODS

A total of 226 adnexal masses were examined before surgery: Fifty-one were malignant and 175 were benign. The data were divided into training and testing subsets by using a "leave n out method." The training subsets were used to compute the optimum MLR equations and to train the ANNs. The cross-validation subsets were used to estimate the performance of each of the two models in predicting ovarian malignancy.

RESULTS

At testing, three-layer back-propagation networks, based on the same input variables selected by using MLR (i.e., women's ages, papillary projections, random echogenicity, peak systolic velocity, and resistance index), had a significantly higher sensitivity than did MLR (96% vs 84%; McNemar test, p = .04). The Brier scores for ANNs were significantly lower than those calculated for MLR (Student t test for paired samples, P = .004).

CONCLUSION

ANNs might have potential for categorizing adnexal masses as either malignant or benign on the basis of multiple variables related to demographic and US features.

Sonographic prediction of malignancy in adnexal masses using an artificial neural network

OBJECTIVE

To generate a neural network algorithm which computes a probability of malignancy score for pre-operative discrimination between malignant and benign adnexal tumours.

DESIGN

A retrospective analysis of previously collected data. Information from 75% of the study group was used to train an artificial neural network and the remainder was used for validation.

SETTING

The Gynaecological Ultrasound Research Unit at King's College Hospital, London.

POPULATION

Sixty-seven women with known adnexal mass who had been examined using transvaginal B-mode ultrasonography and colour Doppler imaging with pulse spectral analysis immediately before surgery. The excised masses were classified histologically as benign (n = 52) or malignant (n = 15), of which three were borderline.

METHODS

The variables that were put into the artificial neural network were: age, menopausal status, maximum tumour diameter, tumour volume, locularity, the presence of papillary projections, the presence of random echogenicity, the presence of analysable blood flow velocity waveforms, the peak systolic velocity, time-averaged maximum velocity, the pulsatility index, and resistance index. Histological classification, categorised as benign or malignant, was the output result.

RESULTS

A variant of the back propagation method was selected to train the network. The overall architecture of the network with the best performance contained an input layer with four variables (age, time-averaged maximum velocity, papillary projection score and maximum tumour diameter), a hidden layer with three units and an output layer with one. The sensitivity and specificity at the optimum diagnostic decision value for the artificial neural network output (0.45) were 100% (95% CI 78.2%-100%) and 98.1% (95% CI 89.5%-100%), respectively. These values were significantly better than those obtained from the independent use of the resistance index, pulsatility index, time-averaged maximum velocity or peak systolic velocity at their optimum decision values (P < 0.01).

CONCLUSION

Artificial neural networks may be used on clinical and ultrasound derived end-points to accurately predict ovarian malignancy. There is a need for a prospective evaluation of this technique using a larger number of patients.

The blood flow characteristics in borderline ovarian tumors based on both color Doppler ultrasound and histopathological analyses

To clarify the tumor behavior in borderline ovarian tumors, we examined the characteristics of neovascularization in these tumors by using a transvaginal color Doppler ultrasound (TV-CDU). Twelve patients with borderline ovarian tumors were preoperatively evaluated for the characteristics of intratumoral blood flow by TV-CDU, using both the resistance index (RI) and pulsatility index (PI). As a control group, 100 patients with benign ovarian tumors and 31 patients with malignant ovarian tumors were also examined by TV-CDU. An intratumoral blood flow was significantly detected in both borderline (91.6%; 11/12) and malignant ovarian tumors (90.3%; 28/31), but not in benign ovarian tumors (53%; 53/100) (P < 0.01). In addition, both the mean RI and mean PI values were significantly lower in the borderline (RI; 0.45, PI; 0.67) and malignant ovarian tumors (RI; 0.39, PI; 0.58) than those in the benign ovarian tumors (RI; 0.61, PI; 1.05) (P < 0.01). In mucinous tumors, the borderline tumors showed a significantly high intratumoral vascularity (P < 0. 01) and both borderline and malignant tumors significantly demonstrated a low-resistance blood flow (P < 0.01), in comparison to those of the benign tumors. Mucinous borderline tumors of the intestinal type also tended to have a lower RI as well as a lower PI value than müllerian type. Regarding neovascularization as represented by intratumoral blood flow characteristics, this study thus suggests that a close relationship exists in the tumor behavior between borderline and malignant ovarian tumors, especially in mucinous epithelial tumors.

Comparison of resistive index versus pulsatility index in assessing the benign etiology of adnexal masses

Retrospective analysis of pelvic sonograms with colorguided spectral Doppler evaluation of 189 adnexal masses yielded four malignancies, 20 benign neoplasms, 32 cysts, and 14 endometriomas. Fifty-eight masses were presumed benign on additional imaging. Pulsatility index (PI) < 1.0 was seen in 70% neoplasms, 63% benign cysts and 50% endometriomas. Thirteen percent of benign cysts and no neoplasms had resistive index (RI) < 0.4. Fifty percent malignancies had PI < 1.0. None had RI < 0.4. Both thresholds lack sufficient sensitivity and specificity for distinguishing benign and malignant lesions.

Ultrasonographic appearance of ovarian tumors in 10 dogs

Signalment, clinical history, physical examination, clinicopathologic, radiographic and ultrasonographic findings of 10 female dogs with histologically confirmed ovarian neoplasms were reviewed. Ultrasonographic images and reports were reviewed for (1) location, size, outer margins, and echogenicity of the mass(es), (2) presence of free abdominal fluid, (3) evidence of uterine abnormalities, and (4) signs of metastatic disease. The masses were classified according to their ultrasonographic pattern in solid, solid with cystic component, and cystic. The masses were ultrasonographically reported as being of ovarian origin in eight dogs, and this origin was included in the list of differentials in the remaining two dogs. When present, abdominal effusions and uterine abnormalities were diagnosed by means of ultrasound.

Contrast-enhanced sonography of tumor neovascularity in a rabbit model

This project was designed to detect the development of tumor neovascularity and determine if intravenous microbubble contrast improves visualization of otherwise undetectable tumors in an animal model. VX-2 carcinoma was implanted into one thigh of 10 New Zealand white rabbits. Tumors were assessed without and with contrast at 1- to 4-day intervals from day 3-19 postimplantation, using gray scale, color flow, pulse Doppler and power Doppler imaging. Tumor vascularity was compared with the contralateral thigh muscle, so each animal was its own control. Contrast injection improved visualization of tumor neovascularity. Early tumors had homogeneous vasculature but, with time, the centers became less vascular, while the periphery increased. Following contrast injection, color gain was decreased by 40% without compromising color intensity. Neovascularity was detected by contrast injection before the tumor could be palpated or visualized by gray scale. Based on these data, we conclude that enhancement of neovascularity by intravenous contrast permits earlier detection and improved visualization of soft tissue tumors in rabbits.

Pelvic examination, transvaginal ultrasound and transvaginal color Doppler sonography as predictors of ovarian cancer

OBJECTIVE

To assess and compare the efficacy of pelvic examination, transvaginal ultrasound and transvaginal color Doppler imaging in differentiating benign and malignant ovarian tumors.

METHODS

34 patients with ovarian tumors scheduled for laparotomy underwent pelvic examination and a diagnosis of benign or malignant tumor was made. Transvaginal ultrasound was carried out to study the ovarian morphology followed by color Doppler imaging. A score of > or = 9 on Sassone scoring system or a pulsatility index < 1 was taken as suspicious for malignancy.

RESULTS

Of all the three indicators (pelvic examination, transvaginal sonography and Doppler) transvaginal sonography had the highest sensitivity (100%) and Doppler had maximum specificity (96.29%) for predicting malignancy. However, statistical analysis did not show any difference in the predicting ability of these three modalities.

CONCLUSION

Pelvic examination, transvaginal sonography and Doppler all had similar ability to predict malignancy in an adnexal mass.

Estimation of probability of malignancy using a logistic model combining physical examination, ultrasound, serum CA 125, and serum CA 72-4 in postmenopausal women with a pelvic mass: an international multicenter study

BACKGROUND

To assess the differential diagnostic potential of physical examination, ultrasound, the serum CA 125 assay, and serum CA 72-4 assay, and the contribution of each parameter to a logistic model predicting the probability of malignancy in postmenopausal patients presenting with a pelvic mass.

PATIENTS AND METHODS

In a multicenter, prospective study a total of 155 patients were evaluated preoperatively using a standard protocol for pelvic examination, transvaginal (occasionally additional abdominal) ultrasound, and serum CA 72-4 (cutoff level 3 U/ml) and CA 125 (cutoff level 35 U/ml).

RESULTS

Fifty-nine malignant (39%) and 92 benign (61%) pelvic tumors were found in addition to 4 borderline tumors (3%). Forty-three patients appeared to have ovarian carcinoma, FIGO Stage III or IV in 28 cases. Borderline tumors were excluded from the statistical calculations. The diagnostic accuracy of each single parameter, i.e., pelvic examination, ultrasound, and serum CA 125 and CA 72-4 in discriminating between benign and malignant pelvic masses gave highly similar results (81, 76, 78, and 81% respectively). Best sensitivity was found in pelvic examination (92%); best specificity was found in CA 72-4 (93%). Using logistic regression analysis the power of pelvic examination appeared to be the most relevant (adjusted odds ratio 12.1), followed by ultrasound (odds ratio 9.7), serum CA 125 (odds ratio 5.0), and serum CA 72-4 (odds ratio 4.9). Age appeared to be nonpredictive. The logistic model gives a correct prediction in 87% of all cases.

CONCLUSIONS

The addition of serum CA 72-4 to the combination of pelvic examination, ultrasound, and serum CA 125 leads to an improved discrimination between malignant and benign pelvic masses.

Evaluation of ovarian tumors in postmenopausal women by transvaginal sonography

OBJECTIVE

The aim of the present study was the evaluation of simple reproducible sonomorphological criteria for the preoperative evaluation of ovarian tumors in postmenopausal women by use of transvaginal sonography.

STUDY DESIGN

Postmenopausal women (> or =1 year of secondary amenorrhea) with ovarian tumors (n=378; tumors > or =3 cm and <3 cm but with solid parts) were examined in a prospective study by transvaginal sonography prior to surgery between 1987 and 1993. The sonomorphological criteria were correlated with the histological findings of the tumors.

RESULTS

Of all ovarian tumors in postmenopausal women, 6.3% were functional cysts (follicular or corpus luteum cysts). Almost all of them were detected within the first 5 years of postmenopause. The other ovarian tumors were diagnosed as retention cysts (17.5%), benign neoplasms (39.4%), and malignant tumors (36.8%). Simple ovarian cysts (monolocular, smooth inner wall) represented sonomorphologically the second most frequent type of ovarian tumors in postmenopausal women (35.7%). Of these tumors, 9.6% were diagnosed as malignant.

CONCLUSIONS

Simple reproducible sonomorphological criteria proved to be a useful clinical parameter in the preoperative evaluation of ovarian tumors.

Preoperative diagnosis of primary fallopian tube carcinoma

INTRODUCTION

Transvaginal color and pulsed Doppler can detect areas of neovascularization within the tubal carcinoma and can distinguish it from other benign adnexal pathology. SUBJECTS AND METHODS. During a 7-year period eight cases of Fallopian tube carcinoma were detected using transvaginal color and pulsed Doppler.

RESULTS

Transvaginal sonography revealed complex, sausage-shaped, and/or cystic structures in the adnexal region. Additional color Doppler examination depicted low vascular impedance (RI ranged from 0.29 to 0.40). Histopathology reported different types of Fallopian tube carcinoma.

CONCLUSION

Transvaginal color Doppler may aid in diagnosis of Fallopian tube malignancy more reliably than using other costly diagnostic procedures.

Use of colour and spectral Doppler ultrasound examination in gynaecology

Objective: To review and sum up the published literature on gynecological Doppler ultrasound examination. Methods: Publications on gynecological Doppler ultrasound examination already known by the author, publications found in the bibliographic database Medline, and publications found in the reference lists of available studies were read, and relevant information was extracted and summarized. Results: Reference data representative of normal findings at transvaginal color and spectral Doppler ultrasound examination of the uterine and ovarian arteries have been established in healthy pre- and post-menopausal women and in normal early pregnancies. Blood flow velocities in the uterine and ovarian arteries change during the normal menstrual cycle and are very different in pre- and post-menopausal women. Lower blood flow velocities and higher pulsatility index (PI) values have been recorded in the ovarian arteries after the menopause. Uterine artery blood flow velocities increase and uterine artery PI values and resistance index (RI) values decrease with gestational age in the first trimester. There is not yet an established role of the gynecological Doppler ultrasound examination in clinical practice. It remains unclear whether the gynecological Doppler ultrasound examination contributes substantially to the clinical management of early pregnancy complications or infertility problems, to the differential diagnosis of pelvic masses or uterine pathology. Conclusions: Large prospective studies-preferably randomized controled trials-are needed to determine the clinical value of the gynecological Doppler ultrasound examination. Copyright 1997 Elsevier Science Ireland Ltd.

Transperineal versus transvaginal color Doppler imaging of the uterine circulation

Transperineal sonography has been described as being useful in assessing patients in special clinical situations such as posterior placenta previa, preterm labor, stress incontinence, and vaginal atresia. We explored the feasibility of this approach in assessing the uterine circulation in 54 subjects, of whom 36 were postmenopausal. We found that visualization of the uterine artery by the transperineal approach was satisfactory in most patients. The uterine arterial Doppler indices obtained from this approach were compared with those obtained by the transvaginal route. Highly significant correlations were found (correlation coefficient tau for pulsatility index = 0.74, p < 0.0001). No significant differences in results between the two approaches were detected using the Wilcoxon Matched-Pairs Signed-Rank test. We conclude that transperineal Doppler studies of the uterine circulation are possible and may be useful in certain patient groups.

Preoperative evaluation of cystic teratoma: what does color Doppler add?

The aim of this prospective study lasting 4 years was to develop a scoring system using clinical parameters, sonographic findings, and transvaginal color and pulsed Doppler impedance values for the preoperative recognition of cystic teratoma. A total of 887 benign and malignant adnexal masses, among which 102 were histologically proved to be cystic teratomas, were evaluated. Using morphological criteria, cystic teratoma was successfully predicted in 95 patients. The sensitivity and specificity of a morphological scoring system were 93.1% and 99.4%, respectively, while positive and negative predictive values were 95.0% and 99.1%. A scoring system using both morphology and vascular assessment demonstrated higher sensitivity and specificity (99.02%, 99.75%). The application of a scoring system combining morphology and vascularity improves the accuracy of diagnosing cystic teratoma and of separating this entity preoperatively from other benign and malignant ovarian conditions.

Transvaginal color Doppler sonography and conventional sonography in the preoperative assessment of adnexal masses

OBJECTIVE

This investigation was undertaken to evaluate the predictive value of the blood flow velocity as measured by transvaginal color Doppler sonography (CDS) and conventional sonographic criteria in the preoperative assessment of ovarian tumors.

METHODS

98 patients who were admitted for surgery with a suspicion of an adnexal mass (69 benign tumors, 4 borderline tumors, and 25 malignant tumors) were prospectively studied with transvaginal sonography (TVS) and CDS. Pulsatility index of blood flow velocity waveforms was evaluated by CDS and compared with established sonographic criteria for discriminating between benign and malignant ovarian tumors.

RESULTS

TVS had a sensitivity of 91% and a specificity of 84% in detecting malignant ovarian tumors compared with CDS with a sensitivity of 90% and a specificity of 74%, using 1.1 as a cut-off value for the pulsatility index. The specificity of CDS was higher in postmenopausal (88%) than in premenopausal (63%) patients. Using TVS and CDS combined, the sensitivity and specificity of diagnosing malignant ovarian tumors could be increased to 95% and 86%.

CONCLUSION

In premenopausal patients, TVS is clearly a more sensitive and more specific technique than CDS in correctly identifying benign and malignant ovarian tumors, whereas in postmenopausal patients, CDS gives useful additional information concerning blood vessel resistance. If CDS is used as an additional technique to TVS, it can increase the sensitivity and specificity of TVS in discriminating between benign and malignant ovarian tumors.

Use of a stochastic simulation model to identify an efficient protocol for ovarian cancer screening

The intervention protocol for an ovarian cancer screening trial should be efficient as well as effective, because it may become the standard of care if the trial demonstrates mortality reduction. To identify an efficient ovarian cancer screening protocol, the effectiveness and cost-effectiveness of selected single modality and multimodal screening strategies were estimated using a stochastic simulation model. Screening was simulated over a 30-year period in a hypothetical cohort of 1 million women aged 50 at the beginning of the period. The net present value of the cost per year of life saved was estimated for six protocols involving transvaginal sonography (TVS) and/or the tumor antigen CA 125. Internal and external validation was performed, and sensitivity analyses were conducted to assess the robustness of the ranking of the strategies. A multimodal strategy involving CA 125 with a threshold for positivity of either elevation above 35 U/ml or doubling since the previous screen, followed by TVS only if CA 125 is positive, was found to be efficient in the sense that no other strategies saved as many years of life at lower cost per year of life saved. Used annually, this strategy cost under $100,000 per year of life saved over a range of assumptions. The model's predictions are consistent with results reported in the literature regarding the performance of TVS and CA 125. The multimodal strategy used annually or every six months was efficient compared to either ultrasound or CA 125 used alone, over a range of assumptions. Simulation of screening may be useful in selecting a screening protocol to be tested in a randomized controlled trial.

Transvaginal color Doppler and CA125 as tools in the differential diagnosis of postmenopausal ovarian masses

OBJECTIVE

To evaluate whether transvaginal color Doppler and CA125 are valid in differentiating malignant from benign postmenopausal ovarian masses.

METHODS

Sixty-two women with ovarian masses were studied with transvaginal color Doppler ultrasound before surgery. Serum CA125 levels were also measured. Resistance index (RI) and pulsatility index (PI) were calculated from the waveforms generated from blood flow within the ovary.

RESULTS

Benign tumors had a significantly higher pulsatility index (mean 1.23 +/- 1.02; range 0.65-2.99) and resistive index (mean 0.78 +/- 0.22; range 0.5-1.1) than did malignant tumors. However some overlap in individual values for benign and malignant lesions was found. RI and PI sensitivity were significantly higher than those with CA125 (P < 0.05). Blood flow was detectable by color Doppler imaging in 95% of cases with malignant masses.

CONCLUSION

Doppler sonographic evaluation of resistance and pulsatility indexes in the vessels of ovarian masses together with CA125 increased the sensitivity of prediction of malignancy for pelvic masses, but further work is needed before the validity of these factors is proved.

Gray scale sonography, subjective evaluation of the color Doppler image and measurement of blood flow velocity for distinguishing benign and malignant tumors of suspected adnexal origin

OBJECTIVE

To compare the capacity of transvaginal Doppler ultrasound examination with that of gray scale sonography as an aid in distinguishing benign and malignant pelvic tumors of suspected adnexal origin.

STUDY DESIGN

One hundred and fifty-one women scheduled for laparotomy or laparoscopic surgery because of a pelvic mass of suspected adnexal origin underwent ultrasound examination including color and spectral Doppler techniques within 8 days preceding the operation. Based on the gray scale ultrasound image, each tumor was classified as being either a unilocular cyst, a multilocular cyst, a unilocular cyst with solid parts, a multilocular cyst with solid parts or a solid tumor. Tumor vascularization was visualized with the color Doppler technique, each tumor being characterized by the color content of the scan, as rated subjectively on a visual analogue scale ('tumor color score'). Blood flow velocity waveforms were obtained by placing the Doppler gate over the colored area with the tumor. The blood flow velocity waveform with the highest time averaged maximum velocity was used to characterize the tumor . The results of gray scale imaging and Doppler ultrasound examination were compared with the histology of the specimen.

RESULTS

Ultrasound morphology correctly identified all the malignant tumors, with a false-positive rate of 61%; none of the 49 unilocular or multilocular cysts without solid parts was malignant, whereas 24% (24/102) of the tumors with solid components were. Among multilocular cysts with solid parts, both tumor color scores and time average maximum blood flow velocities were significantly higher in malignant than in benign tumors, but among solid tumors there was complete overlap in Doppler results between the malignant and benign subgroups. Using Doppler examination to discriminate between benign and malignant multilocular cysts with solid parts and ultrasound morphology for differentiation of the remaining tumors, all the malignancies in the study were detected with a false-positive rate of 32 or 38% depending on which Doppler variable was used.

CONCLUSION

The present technique of Doppler ultrasound examination is helpful only in the differential diagnosis of multilocular cysts with solid parts. Therefore, the degree to which Doppler examination can contribute to the differential diagnosis of pelvic tumors will depend on the proportion of multilocular cysts with solid parts in the population studied: the greater this proportion, the greater the potential of the Doppler examination to improve diagnostic accuracy.

Decay constant of Doppler flow waveform as a possible indicator of ovarian malignancy

The objectives of this study were to analyze the decay constant (tau) of the Doppler flow waveform in ovarian tumors; to determine if differences in this constant can discriminate between malignant and benign ovarian tumors; and to compare the decay constant to the known resistive index (RI), in order to determine its potential prognostic application. Patients with ovarian masses (46) were evaluated in a retrospective study; 13 had malignant tumors, 7 showed tumors with low malignant potential (LMP), 11 had benign masses, 4 had secondary ovarian metastases and 11 had functional ovarian masses. Doppler flow waves measured in the ovary before operation were analyzed from archival videotapes. The RI was calculated preoperatively, and the decay constant of the flow waveform was analyzed retrospectively. We approximated the decaying portion of the flow waveform from the systolic peak to the diastolic level to an exponential curve. Then, the decay constant associated with the flow signal was compared for different types of ovarian pathology. Ovaries with malignancies showed significantly higher mean values for the decay constant (89.7; 95% confidence interval 60.0-119.3) than those with benign tumors (41.8; 25.7-57.9) (p < 0.007), where tau is provided in pixels (in this study each pixel equals approximately 11.4 ms). The mean RI value for malignant tumors was 0.44 +/- 0.12 whereas, in benign tumors, it was 0.622 +/- 0.11. For the benign tumors, both tau and RI did not differ significantly from the measured indices in LMP tumors, metastases and functional ovarian findings. In addition, when the cutoff value of tau was set at 48, 92.3% of all malignancies were identifiable using only tau. This preliminary study indicates that the decay constant of the Doppler flow waveform is able to discriminate between malignant and benign masses and may, thus, provide substantial assistance as an additional parameter in the diagnosis of malignant ovarian tumors in postmenopausal patients.

Postmenopausal adnexal cysts: how clinical management has evolved

It has been 25 years since the introduction of the palpable postmenopausal ovary syndrome. As diagnostic imaging techniques have improved, small findings imaged in the adnexa were often handled as if they had been palpated. Clinical management was not made on any scientific basis. New endovaginal probes afford a degree of image magnification that is as if we are doing ultrasonography through a low-power microscope ("sonomicroscopy"). More recent additions of CA 125 measurement, color flow Doppler, and advanced endoscopic surgical techniques have come into the picture. This report attempts to describe an approach to postmenopausal cystic adnexal masses that synthesizes available information and techniques. It is designed to prevent unnecessary surgery and to prevent undue anxiety but not to miss or, at the least, unduly delay the diagnosis of ovarian cancer when it is, in fact, present.

Diagnostic value of transvaginal color Doppler flow in ovarian torsion

OBJECTIVE

To evaluate the role of Doppler flow in the diagnostic process of ovarian torsion.

METHODS

Twenty-two patients who displayed the clinical symptoms of abdominal pain concomitant with an ovarian mass and were scheduled for explorative laparoscopy were enrolled in the study. The cohort was divided into 3 groups: (A) 8 patients with clinical and sonographic evidence of torsion; (B) 8 patients with abdominal pain and sonographic diagnosis of hemorrhagic cyst; and (C) 6 patients with a simple cystic mass who had undergone explorative surgery due to abdominal pain.

RESULTS

After Doppler flow imaging, Group A displayed no blood flow within the mass, and surgery confirmed the diagnosis of ovarian torsion. Seven of the 8 group B patients showed ovarian vascular flow (RI = 0.472 +/- 0.067). Only 2 of the 6 Group C patients displayed vascular flow (RI = 0.680 +/- 0.129) within an untwisted cyst, confirmed by laparoscopy.

CONCLUSIONS

The combination of Doppler flow imaging with the morphologic assessment improves the diagnostic accuracy of ovarian torsion.

Blood flow changes in the ovarian and uterine arteries during the normal menstrual cycle

OBJECTIVE

Our purpose was to study the hemodynamic changes in the uterine and intraovarian vessels during the normal menstrual cycle and to relate the vascular changes to hormonal index values.

STUDY DESIGN

Seven women who had bilateral tubal patency, a normal pelvis on laparoscopy, and regular ovulatory cycles underwent serial transvaginal ultrasonography on menstrual cycle day 2, daily from estimated day of ovulation-6, hourly from estimated day of ovulation-2, or when the mean follicular diameter was > 16 mm (whichever was earlier) until 6 hours after follicular rupture and once 7 days after follicular rupture. At each scan uterine and intraovarian blood flow was assessed with transvaginal color Doppler ultrasonography and serum concentrations of follicle-stimulating hormone, luteinizing hormone, estradiol, and progesterone assessed by fluoroimmunoassay.

RESULTS

In one case there was evidence of a luteinized unruptured follicle and the patient was therefore excluded from analysis. In the other six women there was spontaneous ovulation at a mean of 39 hours after the onset of the luteinizing hormone surge. On the side with the dominant follicle, follicular and ovarian stromal peak systolic blood flow velocity rose significantly during the menstrual cycle with no significant change in pulsatility index. The changes in blood flow velocity correlated significantly with changes in serum follicle-stimulating hormone, luteinizing hormone and progesterone concentrations. There were no significant changes in either blood flow velocity or pulsatility index in the contralateral ovary. Uterine artery time-averaged maximum velocity on the side of the developing ovarian follicle increased during the menstrual cycle with no significant change in the contralateral vessel. Uterine artery pulsatility index on the side of the developing follicle declined during the midluteal phase and was significantly lower than on the contralateral side. The changes in time-averaged maximum velocity correlated with the changes in serum estradiol and progesterone concentrations.

CONCLUSION

The vascular changes in the wall of the dominant ovarian follicle and ovarian stroma during the menstrual cycle are consistent with activity of angiogenic-like factors. The decline in uterine artery resistance during the midluteal phase may reflect optimal vascularity for implantation of the blastocyst.

Evaluation of a risk of malignancy index based on serum CA125, ultrasound findings and menopausal status in the pre-operative diagnosis of pelvic masses

OBJECTIVE

To evaluate the ability of a risk of malignancy index (RMI), based on a serum CA125 level, ultrasound findings and menopausal status, to discriminate a benign from a malignant pelvic mass and to discriminate early stage (Figo Stage I) from Stages II, III and IV of ovarian cancer.

DESIGN

A prospective study.

SETTING

Department of Gynaecology, Trondheim University Hospital, Trondheim, Norway.

PARTICIPANTS

One hundred and seventy-three women, 30 years or older, consecutively admitted between February 1992 and February 1994 for primary laparotomy of a pelvic mass.

MAIN OUTCOME MEASURES

The sensitivity, specificity and positive predictive value of serum CA125 level, ultrasound findings and menopausal status, separately and combined into the RMI, to diagnose ovarian cancer.

RESULTS

The RMI was more accurate than any individual criterion in diagnosing cancer. Using a RMI cut-off level of 200 to indicate malignancy, the RMI derived from this dataset gave a sensitivity of 80%, specificity of 92% and positive predictive value of 83%. Applying RMI criteria developed by others, the following test performance was found: sensitivity 71%, specificity 96% and positive predictive value 89%. For the Stages II, III and IV of ovarian cancer the sensitivity increased to approximately 90% without any substantial loss in specificity.

CONCLUSIONS

The risk of malignancy index is able to correctly discriminate between malignant and benign pelvic masses. It is a scoring system which can be introduced easily into clinical practice to facilitate the selection of patients for primary surgery at an oncological unit.

Transvaginal ultrasonography of pelvic masses: evaluation of B-mode technique and Doppler ultrasonography

OBJECTIVE

The purpose of this study was to evaluate pelvic masses by B-mode and Doppler ultrasonography for identification of ovarian malignancies.

STUDY DESIGN

A previously described scoring system for pelvic masses was applied in 310 women, and the lesions were classified into four groups according to the ultrasonographic structure. Pulsatility index values of vessels within the tumor and the contralateral ovary and of both uterine arteries were determined.

RESULTS

A total of 259 masses were benign and 51 were malignant. The scoring system and classification into morphologic groups revealed similar sensitivity, specificity, and positive and negative predictive values. Intratumoral and opposite ovarian blood flow and ipsilateral and contralateral uterine blood flow did not differ in benign and malignant masses except in cases of benign lesions in postmenopausal women. In malignant lesions a lower pulsatility index (0.94 +/- 0.4) was measured than in benign lesions (1.06 +/- 0.4, p < 0.05), although a remarkable overlap was found.

CONCLUSION

The results suggest that further refinement of assessment of pelvic masses with Doppler ultrasonography is needed.

Conservative management of postmenopausal pelvic echo-free findings--preliminary results

OBJECTIVES

To develop a conservative protocol for the treatment of echo-free findings in the pelvis, diagnosed by sonography in post-menopausal women, in order to avoid unnecessary surgical intervention.

METHODS

A prospective study where each post-menopausal-patient underwent sonographic evaluation of the pelvic mass, serum Ca-125 levels, ambulatory aspiration of the cyst, and operative laparoscopy if necessary.

RESULTS

One hundred and eighty-two women were included in the 3 years of the study. Only two cases of malignancy were diagnosed. There were no false-negative results.

CONCLUSION

Although the results of our protocol of conservative management look promising, we cannot draw final conclusions because of the small sample size. Perhaps as our knowledge increases, physicians will feel more confident in handling adnexal findings conservatively.

Ultrasound diagnosis of polycystic ovary syndrome

The US diagnostic criteria of the PCO have been refined with each successive advance in US technology. Diagnostic accuracy has evolved from a mere appreciation of overall ovarian size to the recognition of characteristic follicular patterns of distribution and subtle textural changes in the ovarian stroma. The most consistent features are the presence of multiple small follicles arranged around, or scattered through, a dense echogenic ovarian stroma, although recognition of the latter is highly subjective. Sophisticated innovations such as 3D US, together with colour and pulsed Doppler US, should improve the objectivity of observations and allow quantitative analysis of the ovarian stroma, which is known to be the source of the characteristic hyperandrogenaemia in PCOS. Valid comparative studies of women with normal and polycystic ovaries should now be feasible and will hopefully bring us closer to understanding the pathogenesis of this fascinating condition.

Transvaginal Doppler examination of uteri with myomas

The uterine arteries and arteries in the wall and core of myomas were examined with transvaginal color and spectral Doppler ultrasound in 28 premenopausal and 17 postmenopausal women with uterine myomas. Eighteen premenopausal women and 100 postmenopausal women without myomas served as the controls for uterine artery Doppler measurements. The respective median time-averaged maximum velocity and pulsatility index (PI) values for the left uterine artery were 36.1 cm/s and 1.36 in premenopausal women with myomas vs. 17.6 cm/s and 2.58 in controls; p = 0.0001. The corresponding values in postmenopausal women were 13.9 cm/s and 1.93 vs. 11.0 cm/s and 2.33; p < 0.05. PI values < 1.0 were recorded from 92% (24/26) of the myomas in premenopausal women and from 69% (11/16) of those in postmenopausal women. We conclude that uterine myomas substantially affect blood flow velocity in the uterine arteries, and that PI values < 1.0 are common in uterine myomas and do not indicate malignancy.