Ultrasonography in the diagnosis of ovarian and endometrial carcinoma

Transvaginal sonography has become a crucial part of the routine gynecologic examination. It offers now a great help in the diagnosis of almost all gynecological diseases. Transvaginal ultrasound means the first step in the diagnosis of the first two most common gynecological malignancies, and in many cases we are able to set up a diagnosis of its own. The purpose of this article is to emphasize the significant role of transvaginal ultrasonography in the diagnosis of these two dieseases mentioned above, with summarizing the latest developments regarding the capabilities of sonography (Doppler-technique, three-dimensional ultrasonograpy). Orv. Hetil., 2011, 152, 1887–1893.

Three-dimensional power Doppler angiography in endometrial cancer: correlation with tumor characteristics

OBJECTIVE

To assess the correlation between intratumoral vascularization using three-dimensional power Doppler angiography (3D-PDA) and several histological tumor characteristics in a series of patients with endometrial carcinoma.

METHODS

Ninety-nine women (mean age, 61.7 (range, 31-84) years) diagnosed as having endometrial cancer were assessed by transvaginal 3D-PDA before surgical staging. Endometrial volume (EV) and 3D-PDA vascular indices (vascularization index (VI), flow index (FI) and vascularization flow index (VFI)) were calculated using the Virtual Organ Computer-aided AnaLysis (VOCAL) method. All patients were surgically staged. Individual tumor features such as histological type, tumor grade, myometrial infiltration depth, lymph-vascular space involvement, cervical involvement, lymph node metastases and tumor stage were considered for analysis. Multivariate logistic regression (MLR) analysis was used to determine which 3D-PDA parameters were independently associated with each histological characteristic.

RESULTS

MLR analysis showed that only EV and VI were independently associated with myometrial infiltration (EV: odds ratio (OR), 1.119 (95% CI, 1.025-1.221), P = 0.012; VI: OR, 1.127 (95% CI, 1.063-1.195), P = 0.001) and tumor stage (EV: OR, 1.103 (95% CI, 1.012-1.202), P = 0.025; VI: OR, 1.120 (95% CI, 1.057-1.187), P = 0.001), only VI was independently associated with tumor grade (OR, 1.056 (95% CI, 1.023-1.091), P = 0.001) and only EV was independently associated with lymph node metastases (OR, 1.086 (95% CI, 1.017-1.161), P = 0.001).

CONCLUSION

3D-PDA analysis of tumor vascularization in endometrial cancer correlates with some prognostic histological characteristics.

Assessment of Myometrial Invasion in Endometrial Cancer by Transvaginal Sonography, Doppler Ultrasonography, Magnetic Resonance Imaging and Frozen Section

Objective:

We aimed to compare the diagnostic performance of transvaginal sonography (TVS), magnetic resonance imaging (MRI), and intraoperative frozen section in the assessment of myometrial invasion and to evaluate intratumoral blood flow in any myometrial invasion with transvaginal Color Doppler ultrasonography (TV-CDU).

Methods:

This prospective study included 64 women consecutively diagnosed with endometrial carcinoma. The subjects were evaluated by TVS, MRI, and TV-CDU by 2 radiologists with a special training in gynecology. Intraoperatively, a frozen section was obtained and processed for interpretation by a blinded pathologist. Sensitivity, specificity, negative, and positive predictive values were calculated for each imaging modality and frozen section with regard to assessment of myometrial invasion. The intratumoral blood flow was evaluated by TV-CDU.

Results:

Transvaginal sonography, MRI, and frozen section showed no statistical significant differences in overall diagnostic performance for the preoperative and intraoperative assessment of any myometrial invasion, although frozen section seemed to be slightly superior to the imaging techniques. The positive rate of intratumoral blood flow was higher in deep myometrial invasion, but statistical significance was not obtained. The mean value of resistance index was significantly lower in the cases with deep myometrial invasion.

Conclusions:

Transvaginal sonography with concomitant TV-UCD is low-cost, easily performed, and repeated technique for particularly deep myometrial invasion. Because of its high costs and time-consuming, MRI may be recommended in the cases with poor quality of TVS. Because depending solely on imaging methods could lead to insufficient treatment schedules, intraoperative frozen section should also be performed for myometrial assessment.

Clinical usefulness of 3-dimensional sonography and power Doppler angiography for diagnosis of endometrial carcinoma

OBJECTIVE

The purpose of this study was to assess whether endometrial volume (EV) and 3-dimensional (3D) power Doppler indices can discriminate between hyperplasia and endometrial carcinoma and can predict extension of the endometrial carcinoma.

METHODS

Eighty-four women with uterine bleeding and a histopathologic diagnosis of endometrial hyperplasia (n = 29) or carcinoma (n = 55) were preoperatively examined by transvaginal 3D sonography and power Doppler angiography. Endometrial thickness (ET), EV, the vascularization index (VI), the flow index (FI), the vascularization-flow index (VFI), and the intratumoral resistive index (RI) were measured. A histopathologic diagnosis was made after endometrial biopsy was performed by hysteroscopy or curettage.

RESULTS

The EV and 3D power Doppler indices (VI, FI, and VFI) were significantly higher in endometrial carcinoma than endometrial hyperplasia, whereas the intratumoral RI was significantly lower (P < .05). A VFI of 2.07 was the best cutoff for predicting endometrial carcinoma, with sensitivity of 76.5% and specificity of 80.8%. No significant differences were noticed for ET. The endometrial VI was significantly higher when the tumor stage was greater than I. All the 3D power Doppler indices were significantly higher when the carcinoma infiltrated more than 50% of the myometrium. The intratumoral RI was significantly lower in cases with a high histologic grade, myometrial infiltration of more than 50%, and lymph node metastases.

CONCLUSIONS

The VI, 3D power Doppler indices, and the intratumoral RI are more useful than ET for differentiating between hyperplasia and endometrial carcinoma. Intratumoral blood flow evaluated by pulsed Doppler sonography and 3D power Doppler angiography can predict the spread of endometrial carcinoma.

Histochemical evaluation of angiogenesis in endometrial adenocarcinoma

The formation of new vessels from endothelial cells, termed angiogenesis, is a complex process that is controlled by numerous paracrine factors. Vacularization of tumor tissue is a prerequsite for tumor growth and enables the dissemination of tumor cells throughout the body. Angiogenesis is classically assessed by counting the vessels or clusters of endothelial cells after selective immunohistochemical staining. In this study, vascularization of tumor tissue was evaluated quantitatively in 36 cases of stage I endometrial adenocarcinoma. The goal of this study was to evaluate whether the microvessel density correlates with the invasion potential of endometrial adenocarcinoma. The results show an increase in the number of endothelial cells at different stages in endometrial adenocarcinoma stage I and a strong positive correlation between the endothelial-to-stromal ratio and tumor grading.

Imaging hypoxia and angiogenesis in tumors

There is a clear need in cancer treatment for a noninvasive imaging assay that evaluates the oxygenation status and heterogeneity of hypoxia and angiogenesis in individual patients. Such an assay could be used to select alternative treatments and to monitor the effects of treatment. Of the several methods available, each imaging procedure has at least one disadvantage. The limited quantitative potential of single-photon emission CT and MR imaging always limits tracer imaging based on these detection systems. PET imaging with FMISO and Cu-ATSM is ready for coordinated multicenter trials, however, that should move aggressively forward to resolve the debate over the importance of hypoxia in limiting response to cancer therapy. Advances in radiation treatment planning, such as intensity-modulated radiotherapy, provide the ability to customize radiation delivery based on physical conformity. With incorporation of regional biologic information, such as hypoxia and proliferating vascular density in treatment planning, imaging can create a biologic profile of the tumor to direct radiation therapy. Presence of widespread hypoxia in the tumor benefits from a systemic hypoxic cell cytotoxin. Angiogenesis is also an important therapeutic target. Imaging hypoxia and angiogenesis complements the efforts in development of antiangiogenesis and hypoxia-targeted drugs. The complementary use of hypoxia and angiogenesis imaging methods should provide the impetus for development and clinical evaluation of novel drugs targeted at angiogenesis and hypoxia. Hypoxia imaging brings in information different from that of FDG-PET but it will play an important niche role in oncologic imaging in the near future. FMISO, radioiodinated azamycin arabinosides, and Cu-ATSM are all being evaluated in patients. The Cu-ATSM images show the best contrast early after injection but these images are confounded by blood flow and their mechanism of localization is one step removed from the intracellular O2 concentration. FMISO has been criticized as inadequate because of its clearance characteristics, but its uptake after 2 hours is probably the most purely reflective of regional PO2 at the time the radiopharmaceutical is used. The FMISO images show less contrast than those of Cu-ATSM because of the lipophilicity and slower clearance of FMISO but attempts to increase the rate of clearance led to tracers whose distribution is contaminated by blood flow effects. For single-photon emission CT the only option is radioiodinated azamycin arabinosides, because the technetium agents are not yet ready for clinical evaluation. Rather than develop new and improved hypoxia agents, or even quibbling about the pros and cons of alternative agents, the nuclear medicine community needs to convince the oncology community that imaging hypoxia is an important procedure that can lead to improved treatment outcome.

Color Doppler velocimetry and three-dimensional color power angiography of cervical carcinoma

OBJECTIVES

To investigate the blood flow within invasive cervical carcinoma by transvaginal two-dimensional (2D) color spectral Doppler and three-dimensional (3D) color power angiography and to correlate these parameters with the clinicopathological characteristics.

METHODS

Seventy-four patients with invasive cervical carcinoma were enrolled for the analysis. Squamous cell carcinoma serum antigen levels (SCC) were obtained for all the patients. Sections of all malignant tissues were analyzed for tumor expression of cyclooxygenase-2 (COX-2). All patients underwent color and spectral Doppler examination and 44 patients had 3D color power angiography. Color spectral Doppler parameters (color score, lowest resistance index (RI), highest peak systolic velocity (PSV)) and 3D color power angiography indices (relative color, average color, flow measure) of FIGO I/II cervical cancers were compared with those obtained in a control group of 24 patients with a normal uterine cervix. Pulsed Doppler parameters and the 3D vascular indices were compared with clinicopathological parameters, SCC serum antigen levels and tumor COX-2 expression.

RESULTS

At color Doppler analysis 72 patients (97%) showed intralesional detectable vessels. Color spectral Doppler and 3D-derived parameters were significantly different in FIGO I/II cervical cancers compared with those in women with a normal cervix. A significantly higher color score (P = 0.0008), lower RI (P = 0.032) and higher PSV (P = 0.004) were associated with a tumor diameter > or =4 cm compared with smaller tumors. The highest PSV was significantly higher in patients with FIGO stage III/IV compared with FIGO stage I/II (P = 0.0069). There was a direct correlation between PSV and SCC (r = +0.44, P = 0.003). The median relative color was significantly higher in patients with a higher color score (P = 0.0006). No statistically significant correlations were found between 3D color power angiography parameters and the clinicopathological characteristics or between the 3D vascular parameters and biological factors.

CONCLUSIONS

Alterations of 3D ultrasound-derived vascular indices were found in patients with cervical cancer compared with those with a normal cervix. Moreover, some vascular indices proved to be associated with tumor size. The assessment of a possible clinical role of 2D and 3D ultrasound-derived vascular indices in cervical cancer deserves further investigation.

Power Doppler vascularity index for predicting the response of neoadjuvant chemotherapy in cervical carcinoma

BACKGROUND

To evaluate whether the power Doppler vascularity index (PDVI) can predict the response to neoadjuvant chemotherapy (NACT) in cervical carcinoma.

METHODS

Twenty-five women with bulky early stage cervical carcinoma treated by NACT followed by surgery were enrolled. Their response to NACT was evaluated. Clinical characteristics and pathologic data were recorded. Transvaginal power Doppler was performed before, during and after NACT. PDVI was detected using power Doppler and a quantitative image processing system. Factors that can potentially correlate with the response to NACT were analyzed.

RESULTS

Twelve (48%) patients showed a response (responders) to NACT and 13 (52%) were unchanged or had progressive disease (nonresponders) after NACT. Higher PDVI values were noted in tumors with lymphovascular emboli and pelvic lymph node metastasis both before and after NACT. The mean values of the PDVI of the nonresponders before (19.27 +/- 6.01 vs. 12.28 +/- 7.06, p = 0.014), during (20.2 +/- 1.5 vs. 12.9 +/- 2.1, p = 0.009) and after NACT (18.1 +/- 6.0 vs. 9.3 +/- 5.4, p = 0.001) were significantly higher than those of the responders. When the cutoff point for predicting nonresponders to NACT was set at a PDVI value of 15%, the sensitivity was 92.3% and the specificity 66.7%.

CONCLUSIONS

The power Doppler vascularity index can predict the response to neoadjuvant chemotherapy in cervical cancer, and might be useful for the evaluation of response to chemotherapy in cancer patients in the future.

[Preoperative endovaginal ultrasound in the assessment of myometrial invasion of endometrial adenocarcinoma]

OBJECTIVE

To determine, according to histological tumor grade, the reliability of preoperative endovaginal ultrasound in the detection of myometrial invasion in patients with stage I endometrial cancer.

PATIENTS AND METHODS

Sixty-one patients with stage I endometrial carcinoma were evaluated with preoperative endovaginal ultrasound compared to postoperative results of pathologic examination, in a six-year retrospective study.

RESULTS

Twenty-nine patients had a deep myometrial invasion (stage IC). The mean endometrial thickness was 9.5 mm in stage IA, 17.0 mm in stage IB and 20.0 mm in stage IC disease (P = 0.01). The sensitivity and the specificity of the ultrasound in the assessment of myometrial invasion in grade 1 tumors were 100% and 93.7%, respectively. They fell to 69.2% and 88.9% for high-grade tumors. The global accuracy of ultrasound was 82%.

DISCUSSION AND CONCLUSIONS

The performance of preoperative ultrasound varies according to the literature. The association of morphological and morphometric criteria enables an increase in the sensitivity of the exam. In grade 1 tumors, the preoperative endovaginal ultrasound could help in identifying a group of patients at low risk of lymph node metastasis for which a pelvic lymphadenectomy would be avoidable.

Intratumoral color Doppler analysis in endometrial carcinoma: is it clinically useful?

OBJECTIVE

The aim was to study the effectiveness of subjective color Doppler evaluation and spectral Doppler parameters in preoperative characterization of endometrial carcinomas.

METHODS

Seventy-six patients with endometrial carcinoma were preoperatively analyzed by color Doppler ultrasound in order to subjectively evaluate the amount of intratumoral blood flow (color score) and to analyze the lowest resistance index (RI), the highest peak systolic velocity (PV), and the highest time averaged maximum velocity (TAMVX). These parameters were analyzed according to clinico-pathological characteristics.

RESULTS

In 13 patients no intratumoral arterial vessels were detected by color Doppler examination. No lymph node metastases were found in this group of patients. Positive nodes were found in 24% of patients with detectable arterial vessels, although the difference did not reach the statistical significance. No differences were found in spectral Doppler parameters (RI, PV, TAMVX) according to tumor characteristics or nodal involvement. A higher percentage of cases with a color score of 3 was found in stage >I than in stage I patients (69 vs 42%, P < 0.05), and in patients with myometrial invasion greater than 50% than in those with less than 50% invasion (72 vs 38%; P = 0.05).

CONCLUSIONS

Nodal metastases were found in 24% of patients with detectable vessels at color Doppler examination. Subjective analysis of vessel density correlated >50%, myometrial invasion, but spectral Doppler analysis was not predictive of surgical stage, tumor grade, myometrial invasion, or lymph node metastases. These results do not support the use of preoperative intratumoral blood flow analysis as a clinical test in evaluating tumor characteristics or in predicting lymph node metastases.

Correlation among intratumoral blood flow in breast cancer, clinicopathological findings and Nottingham Prognostic Index

BACKGROUND

The purpose of this study was to evaluate the correlation among intratumoral blood flow as assessed by color Doppler ultrasonography, clinicopathological findings and the Nottingham Prognostic Index (NPI).

METHODS

Twenty-seven patients with breast cancer were examined. All patients received surgical treatment. Color Doppler ultrasonography was performed prior to surgery to detect arterial blood flow signals within the tumors. The lowest resistance index (RI) was recorded. Formalin-fixed, paraffin-embedded slides were reviewed by senior pathologists to evaluate the size of tumor, histological size, lymph node status and histological grade. Estrogen and progesterone receptor levels were measured by enzyme immunoassay. The Nottingham Prognostic Index was calculated using the equation NPI = 0.2 x tumor size (cm) + grade (I-III) + lymph node score (1-3).

RESULTS

The lowest RI correlated well with NPI and histological grade (grade II:III = RI 1.037:0.816, P = 0.0035). Regression analysis revealed a linear relationship between the lowest RI and NPI (correlation coefficient = 0.475; P = 0.0153).

CONCLUSIONS

Intratumoral blood flow analysis assessed by color Doppler ultrasonography correlates well with histological grade and NPI. Preoperative assessment using color Doppler ultrasonography provides useful information and may contribute to the determination of prognosis.

Association of color Doppler vascularity index and microvessel density with survival in patients with gastric cancer

OBJECTIVE

The purpose of this study was to investigate the clinical usefulness of microvessel density (MVD) and an in vivo angiogenesis parameter, color Doppler vascularity index (CDVI), in patients with gastric cancer.

SUMMARY BACKGROUND DATA

Many studies have reported a significant association between the degree of MVD-evaluated angiogenesis with the clinicopathologic factors and prognosis of patients with various solid tumors. All these studies were accomplished on tissue sections retrospectively obtained from surgical specimens. However, an in vivo method to assess tumor angiogenesis for human malignancies is highly desirable for diagnostic purpose, treatment planning, and follow-up. The CDVI is a new ultrasound parameter for evaluating in vivo angiogenesis, has a good correlation with status of lymph node metastasis in cervical carcinoma, and can predict distant metastasis and survival in colon cancer patients. Therefore, the CDVI may also be useful to assess in vivo angiogenesis in human gastric cancer.

METHODS

A total of 79 patients with gastric cancer were enrolled in this study, and microvessel density was evaluated by using immunohistochemical staining of surgical specimens with anti-CD-34 antibody. Tumors were sonographically visible in 31 patients. The CDVI of each tumor was determined using transabdominal color Doppler ultrasound. The CDVI was defined as the ratio of the number of the colored pixels within a tumor section to the number of total pixels in that specific tumor section, and was calculated by using Encomate software (Electronic Business Machine Co. Ltd., Taipei, Taiwan). Correlation between MVD, CDVI and clinicopathologic factors and patient survival was studied.

RESULTS

The MVD was significantly correlated with vascular invasion by multiple linear regression analysis. Although the survival of patients with high MVD (> 32) was significantly worse than those with low MVD (< 32) by univariate analysis, vascular invasion was an independent prognostic factor by Cox proportional hazard model. There was a linear correlation between CDVI and MVD (r =.495, P =.005). Moreover, in patients with a high CDVI (> 11%), the survival rate was significantly lower than that in those with low CDVI (< or = 11%, P =.005). None of the patients with high CDVI (> 11%) survived 2 years after curative resection. In addition to vascular invasion, the CDVI was another independent prognostic factor in the patients with stage III gastric cancer.

CONCLUSIONS

Vascular invasion was an important prognostic indicator in gastric cancer. The high CDVI was a good preoperative indicator of early death in stage III gastric cancer patients. Thus, the CDVI may be helpful in selecting patients with gastric cancer for neoadjuvant chemotherapy and/or anti-angiogenic therapy.

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.

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.

Preoperative assessment of vascularity by color Doppler ultrasonography in human rectal carcinoma

PURPOSE

Although angiogenesis assessed by immunostaining endothelial cells (microvessel density) is a well-known prognostic factor in a wide variety of human solid tumors, preoperative determination of microvessel density seems to be difficult in rectal carcinoma. Thus, we performed transanal color Doppler ultrasonography in 46 patients with rectal carcinoma to assess preoperative angiogenic status and compare it with microvessel density in surgical specimens.

METHODS

Time-averaged maximal velocity, peak systolic velocity, number of vascular points, and vascular point index were conducted by color Doppler ultrasonography in 46 patients with rectal carcinoma. Number of vascular points was defined as the number of vessels with pulsation in the section of tumor. Vascular point index was defined as the average number of vascular points divided by the area assessed by color Doppler ultrasonography in the section of tumor. The profiles of number of vascular points were similar to those assessed by microangiography in five rectal carcinomas.

RESULTS

Vascular point index significantly correlated with microvessel density (P < 0.0001). No significant correlation was found between microvessel density and time-averaged maximal velocity or peak systolic velocity. Vascular point index was also a better indicator of lymph node metastasis and venous invasion than microvessel density. In addition, 11 of 46 cases with postoperative hematogenous metastasis (23.9 percent) were observed prospectively. Vascular point index may be a best predictor for hematogenous metastasis from rectal carcinoma compared with peak systolic velocity, time-averaged maximal velocity, and microvessel density by receiver operating characteristic analysis.

CONCLUSION

These results suggest that preoperative quantification of angiogenesis using color Doppler ultrasonography will provide quick and useful information in the management of rectal carcinoma.

Endometrial cancer

Endometrial cancer is the most common gynecologic malignancy in the United States, with 37,400 new cases and 6400 deaths estimated to occur in 1999. The epidemiology of endometrial cancer has been widely characterized; nevertheless, efforts continue to more precisely define risk factors for the disease. Accurate epidemiologic risk factor profiles or focused screening efforts may ultimately facilitate the primary prevention of endometrial cancer. Currently, standard management of women with endometrial cancer includes surgical exploration with total hysterectomy and bilateral salpingo-oophorectomy. Uterine histopathologic characteristics and intraoperative findings continue to provide the primary indications for surgical staging in endometrial cancer. The addition of serum CA125 and selected imaging techniques (eg, transvaginal sonography with color Doppler and MR imaging) to the preoperative assessment may ultimately improve the sensitivity and specificity with which patients are selected for pathologic nodal evaluation. Various clinicopathologic factors have been evaluated as predictors of the clinical course of endometrial cancer and as selection criteria for patients most likely to benefit from adjuvant therapy. Histologic measurement of the tumor microvessel density is a promising technique for identifying patients at high risk for recurrence. Although uterine papillary serous carcinoma of the endometrium represents only 3% to 4% of endometrial cancer cases, it is of particular interest because of the aggressive clinical course and poor prognosis associated with this disease.

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.

Vascularity index as a novel parameter for the in vivo assessment of angiogenesis in patients with cervical carcinoma

BACKGROUND

The importance of angiogenesis now is well recognized. Conventionally, tumor angiogenesis is assessed by determination of microvessel density (MVD) in the surgical specimen. This study examines tumor angiogenesis using power Doppler ultrasound and a quantitative image processing system. The authors hope to develop an in vivo and noninvasive method for quantitating tumor angiogenesis.

METHODS

Thirty-five patients with FIGO Stage IB-IIA cervical carcinoma exhibiting visible cervical tumors by transvaginal ultrasound were included in this study. All patients underwent radical abdominal hysterectomy and pelvic lymph node dissection. Transvaginal power Doppler ultrasound was performed before surgery to search for blood flow signals from the tumor. The intratumoral vascularity index (VI) and resistance index (RI) were calculated. The VI was defined as the number of colored pixels divided by the number of total pixels in the defined tumor section. Maximal VI and minimal RI of a certain tumor were used for analysis. Clinical and pathologic data also were recorded. The MVD of the excised tumor was assessed immunohistochemically using a monoclonal antibody against CD34.

RESULTS

Significantly higher VI values were noted in Stage II tumors compared with Stage 1 tumors (19.01+/-10.90% vs. 9.09+/-6.59%; P = 0.008), tumors invad-ing+/-50% of the cervical stroma compared with tumors invading < 50% of the cervical stroma (13.20+/-8.20% vs. 5.72+/-5.00%; P = 0.003), tumors with lymphovascular emboli compared with tumors without lymphovascular emboli (17.28+/-8.26% vs. 6.98 +/- 5.09%; P = 0.001), and tumors with pelvic lymph node metastases compared with tumors without pelvic lymph node metastases (26.16+/-7.88% vs. 8.00+/-4.95%; P = 0.021). None of the variables mentioned earlier showed a significant difference in terms of the RI values. No correlation was noted between intratumoral RI and VI in respective tumors (P = 0.53). Analysis of VI revealed linear regression with regard to tumor size (P < 0.001, correlation coefficient [r] = 0.586) and depth of stromal invasion (P = 0.002, r = 0.497). In addition, the MVD exhibited a linear relation with VI (P = 0.006, r = 0.454), tumor size (P = 0.005, r = 0.465), and depth of stromal invasion (P = 0.009, r = 0.436) using simple regression analysis. No correlation could be found between MVD and RI.

CONCLUSIONS

In cervical carcinoma, intratumoral VI assessment by power Doppler ultrasound and quantitative image processing system showed better correlation with tumor stage, tumor size, and pathologic findings including depth of stromal invasion, lymphovascular emboli, and pelvic lymph node metastases than intratumoral RI. The in vivo indicator of angiogenic activity (VI) is well correlated with the conventional indicator of tumor angiogenic activity (MVD). Thus, VI could be a useful parameter for the in vivo assessment of global tumor angiogenesis.