Flow differences between endometrial polyps and cancer: a prospective study using intravenous contrast-enhanced transvaginal color flow Doppler and three-dimensional power Doppler ultrasound

Contrast-Enhanced Ultrasound Imaging of Uterine Disorders: A Systematic Review

Uterine disorders are often presented with overlapping symptoms. The microvasculature holds specific information important for diagnosing uterine disorders. Conventional sonography is an established diagnostic technique in gynecology, but is limited by its inability to image the microvasculature. Contrast-enhanced ultrasound (CEUS), is capable of imaging the microvasculature by means of intravascular contrast agents; that is, gas-filled microbubbles. We provide a literature overview on the use of CEUS in diagnosing myometrial and endometrial disorders, that is, fibroids, adenomyosis, leiomyosarcomas and endometrial carcinomas, as well as for monitoring and enhancing the effectiveness of minimally invasive therapies. A systematic literature search with quality assessment was performed until December 2020. In total 34 studies were included, published between 2007 and 2020.The results entail a description of contrast-enhancement patterns obtained from healthy tissue and from malignant and benign tissue; providing a first base for potential diagnostic differentiation in gynecology. In addition it is also possible to determine the degree of myometrial invasion in case of endometrial carcinoma using CEUS. The effectiveness of minimally invasive therapies for uterine disorders can safely and accurately be assessed with CEUS. In conclusion, the abovementioned applications of CEUS are promising and it is worth further exploring its full potential for gynecology by designing innovative and methodologically high-quality clinical studies.

Diagnostic Value of Quantitative Analysis by Contrast-Enhanced Ultrasound of Endometrial Lesions

OBJECTIVES

To explore the diagnostic value of time-intensity curve parameters from contrast-enhanced ultrasound (CEUS) examinations of endometrial lesions.

METHODS

Fifty-two patients with suspected endometrial lesions who received vaginal CEUS examinations were divided into a polyp group (n = 36), a malignant group (n = 11), and a normal control group (n = 5) based on the pathologic diagnosis. The midpoint of the myometrium at the same depth as the endometrial lesion was used as the reference point. The initial increase time, time to peak, area under the curve, and peak intensity were determined by the time-intensity curve. The relative parameters, namely, the initial increase time difference, peak time difference, area ratio, and peak intensity ratio, were also calculated and analyzed statistically.

RESULTS

The comparison results of the relative parameters among the groups showed that the differences in the time difference, intensity ratio, and area ratio were statistically significant. The differences in the intensity ratio and time difference between the malignant and normal groups were statistically significant (P < .001). The differences in the intensity ratio, area ratio, and time difference between the malignant and polyp groups were statistically significant (P < .001). The diagnostic value of the intensity ratio and area ratio was confirmed by a receiver operating characteristic curve. The sensitivity and specificity of the intensity ratio and area ratio in the groups were 100% and 77.5% and 85.7% and 85.0%, respectively.

CONCLUSIONS

The relative CEUS parameters in endometrial lesions provide more diagnostic value in differential diagnosis of benign and malignant lesions than the absolute parameters.

The Role of Contrast-Enhanced Ultrasound in Evaluating Gestational Trophoblastic Neoplasia: A Preliminary Study

Objective

We aimed to compare the imaging features of gestational trophoblastic neoplasias (GTNs) and benign pregnancy-related uterine diseases on contrast-enhanced ultrasound (CEUS) to explore the clinical value of CEUS in differentiating these two types of uterine lesions.

Materials and Methods

In this prospective study, patients with GTNs before and after chemotherapy and benign pregnancy-related uterine lesions received conventional US and CEUS. The imaging features and parameters of CEUS of the lesions were assessed.

Results

A total of 73 patients were enrolled in this study, including 48 with GTNs and 25 with benign lesions. The enhancement pattern of newly diagnosed GTNs was mainly diffuse enhancement (70.8%), with a non-enhanced area of less than 1/3 of the entire lesion. For the benign group, the enhancement pattern was mainly ring-shaped enhancement (72.0%), and the non-enhanced area was more than 1/2 (68.0%), significantly different from that of GTNs (P = 0.000 and 0.002, respectively). Forty-one lesions demonstrated unclear boundaries on greyscale US but clearly displayed on CEUS. In both the benign and malignant groups, the measurements of lesion size on CEUS were larger than those on greyscale US (P = 0.000). The measurement differences (ΔD: D2-D1) of the malignant cases were higher than those of the benign cases (P = 0.001).

Conclusion

GTNs and benign pregnancy-related uterine diseases have different imaging characteristics on CEUS. The boundary and involved range of the lesion can be clearly demonstrated on CEUS. CEUS possesses clinical value in diagnosing and evaluating GTNs and benign pregnancy-related diseases.

Dynamic contrast-enhanced ultrasound improves diagnostic performance in endometrial cancer staging

OBJECTIVES

To compare the sensitivity and specificity of conventional two-dimensional transvaginal ultrasound/power Doppler (2D-TVU/PD) alone and 2D-TVU/PD combined with dynamic contrast-enhanced ultrasound (DCE-US) in diagnosing deep myometrial invasion (MI) and cervical stromal involvement (CSI) in women with endometrial cancer (EC), and to assess the association of DCE-US semiquantitative and qualitative variables with International Federation of Gynecology and Obstetrics (FIGO) Stage ≥ IB and 'high-risk' cancer.

METHODS

This was a prospective study of 101 consecutive women with biopsy-confirmed EC, undergoing expert ultrasound examination at Karolinska University Hospital, a tertiary referral center. All consenting women underwent DCE-US using a 1.5-2.5-mL intravenous bolus of SonoVue contrast agent, as well as conventional 2D-TVU/PD examination. DCE-US videoclips were analyzed with regard to filling (global or focal), wash-in (prior, simultaneous or after) and wash-out (global or focal) patterns of the contrast agent in the tumor compared with the surrounding tissue, as well as semiquantitative DCE-US parameters (wash-in slope, time-to-peak, peak intensity and area under the time-intensity curve (TIC)) obtained from a TIC. The study cohort was compared with a control cohort of women with EC examined at our center according to the International Endometrial Tumor Analysis protocol using 2D-TVU/PD only, matched at a ratio of 3:1 for FIGO stage and grade. The sensitivity and specificity of 2D-TVU/PD alone in the control cohort and in combination with DCE-US in the study cohort in the diagnosis of deep MI, CSI and high-risk cancer (defined as FIGO Stage ≥ IB and/or Grade 3 endometrioid and/or non-endometrioid histology) were compared, using pathological evaluation after hysterectomy as the 'gold standard'.

RESULTS

After exclusions, 93 women were included in the study cohort and were matched to 279 women in the control cohort. The prevalence of FIGO Stage IA, Grade 1-2 EC was 52% in both cohorts. The sensitivity of 2D-TVU/PD with DCE-US in the study cohort was higher than that of 2D-TVU/PD alone in the control cohort in diagnosing both deep MI (0.74 vs 0.62; P = 0.036) and CSI (0.75 vs 0.51; P < 0.001), whereas the specificity was not significantly different (0.87 vs 0.85 and 0.96 vs 0.95, respectively). Compared with 2D-TVU/PD alone, the specificity of 2D-TVU/PD with DCE-US was higher in detecting high-risk cancer (0.94 vs 0.85; P = 0.024) but the sensitivity did not differ (0.73 vs 0.71). High-risk cancer and FIGO Stage ≥ IB were characterized by a 'focal' filling pattern, with a 'prior' wash-in pattern and a 'focal' wash-out pattern on subjective assessment of DCE-US videoclips. All semiquantitative DCE-US parameters were significantly predictive of FIGO Stage ≥ IB but not of high-risk cancer, despite a clear trend.

CONCLUSIONS

Compared with 2D-TVU/PD alone, combining 2D-TVU/PD with DCE-US can significantly improve the detection of deep MI and CSI in women with EC, without increasing the false-positive rate. It can also improve the correct classification of high-risk disease, mainly by increasing specificity, thereby possibly reducing the number of unnecessarily extensive surgeries by almost 10%. Semiquantitative DCE-US parameters, as well as a 'focal' filling pattern, endometrial wash-in prior to the myometrium and a 'focal' wash-out pattern, are all associated with more advanced disease. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Antidiastole Value of Three-dimensional Ultrasonography and Power Doppler between Uterine Parenchyma Lumps and Endometrial Cancer: A Retrospective Study

Sometimes endometrial polyps, submucosal myomas, and endometrial cancer show similar findings under ultrasonography. The aim of this study was to assess the antidiastole value of blood flow parameters using three-dimensional (3D) power Doppler ultrasonography angiography (PDA) between endometrial cancer and uterine parenchyma lumps. The data of the blood flow indices in 3D-PDA including the vascularization index (VI), flow index (FI), and vascularization flow index (VFI) in 40 patients with endometrial cancer and 41 patients with uterine parenchyma lumps (endometrial polyps and submucosal myomas) were retrospectively analysed and compared utilizing Virtual Organ Computer-aided AnaLysis (VOCAL) software. The results showed that all the blood flow parameters (VI, FI, VFI) were significantly higher in women with endometrial cancer than in those with uterine parenchyma lumps (P<0.001). The area under the curve of ROC of VI, FI, and VFI was 0.98, 0.84, and 0.97, respectively. Thus, the best predictor of endometrial carcinoma was VI with a sensitivity of 97.0% and a specificity of 91.0%. The optimal cutoff value of VI was 4.06%. Our data demonstrated that all of the blood flow signal parameters (including VI, FI, and VFI) in 3D power Doppler ultrasonography had significant antidiastole values between endometrial cancer and uterine parenchyma lumps to assist clinicians in properly diagnosing patients.

Endometrial polyps: Pathogenesis, sequelae and treatment

Endometrial polyps are overgrowths of endometrial glands that typically protrude into the uterine cavity. Endometrial polyps are benign in nature and affect both reproductive age and postmenopausal women. Although endometrial polyps are relatively common and may be accompanied by abnormally heavy bleeding at menstruation. In asymptomatic women, endometrial polyps may regress spontaneously, in symptomatic women endometrial polyps can be treated safely and efficiently with hysteroscopic excision.

Risk of malignancies among asymptomatic postmenopausal women with thickened endometrium: A cohort study

The risk of malignancies and related factors among asymptomatic postmenopausal women with thickened endometrium in transvaginal sonography (TVS) are unclear.In this longitudinal study at a tertiary teaching hospital, all medical records of hysteroscopy were searched and retrospectively reviewed according to age, TVS results and diseases coded as International Classification of Diseases version 10. Asymptomatic postmenopausal women with endometrial thickness ≥5 mm from January 2006 to January 2016 were included. A follow-up was provided up to January 2017.Four hundred eighty-eight patients were included with a median endometrial thickness of 8 mm (range 5-30) in TVS. The most common pathologic findings were polyps (51.0%) and normal endometrium (34.2%). Fifteen (3.1%) and 10 cases (2.0%) had endometrial intraepithelial neoplasia (EIN) and carcinoma. Patients with carcinoma had significantly more abnormal serum CA125, thicker endometrium, and more lesions with positive Doppler flow signals. In receiver operating characteristic curve analysis, endometrial thickness of 12 mm had the best predictive ability for malignancies. In multivariate analysis, endometrial lesion with positive Doppler flow signals in TVS was the only independent factor for EIN/carcinoma (odds ratio [OR] 8.0, 95% confidence interval [CI] 1.4-45.1) and for carcinoma (OR 16.0, 95% CI 1.3-192.8). After a median follow-up of 45 months, carcinoma occurred in 1 of 35 (2.8%) women with repeated thickened endometrium.Among asymptomatic postmenopausal women with thickened endometrium, the risk of EIN and malignancy was minimal but worth of long-term follow-up. Endometrial lesions with positive Doppler flow signals in TVS suggested a high risk of malignancy.

Utility of three dimensional (3-D) ultrasound and power Doppler in identification of high risk endometrial cancer at a tertiary care hospital in southern India: A preliminary study

OBJECTIVE

The study was conducted to find the utility of three dimensional (3-D) ultrasound and Doppler sonography in differentiating benign and malignant endometrial lesions and to ascertain the association of sonology parameters with type, grade and stage of endometrial cancer.

MATERIALS AND METHODS

Women attending the gynaecology department of a tertiary care hospital, with a provisional diagnosis of carcinoma endometrium were subjected to three dimensional power Doppler ultrasound evaluation and assessment of vascular patterns. VOCAL (Virtual Organ Computer-aided Analysis) software was used to assess volume, Vascularisation Index (VI), Flow Index (FI) and Vascularisation Flow Index (VFI). Ultrasound parameters were compared with histologic diagnosis to evaluate the diagnostic performance using Receiver Operating Characteristic (ROC) Curve.

RESULTS

Sixty-four women were included in the study, 33 with benign and 31 with malignant endometrial lesions. Larger endometrial volume and higher Doppler indices correlated with malignant lesions. The variables with good discriminatory potential between benign and malignant status were VI and VFI, having a sensitivity of 90.3% and specificity of around 80%. VFI (adjusted odds ratio of 40.4; (95% CI - 8.46-192.88), p value < 0.001) was the only significant variable identified by multivariate logistic regression, when adjusted for age and post-menopausal status. Multiple global and focal vessel pattern was seen predominantly in malignant cases (specificity 93.9%), although the sensitivity was low (61.2%). Higher stages and grades of tumour and non-endometrioid types had higher Doppler indices, and requires further evaluation.

CONCLUSIONS

3-D ultrasound has good discrimination potential between benign and malignant endometrial lesions and could be useful as a screening tool. However, utility of 3-D tool for differentiation between tumour characteristics needs further validation.

Current strategies in the diagnosis of endometrial cancer

PURPOSE

Endometrial cancer is the most common gynecological malignancy in developed countries. There are no uniform recommendations for endometrial cancer screening in the general population. Therefore, it is of paramount importance that the primary physician profoundly understands, and is familiar with the methods for prevention and early detection of endometrial cancer. The aim of this review is to provide the primary physician with a toolbox to reach these goals.

METHODS

We performed a systemic review to summarize the current strategies to diagnose and prevent endometrial cancer. Many published articles from the last years were identified and included.

RESULTS

A systematic review that summarizes the important subjects in the diagnosis and prevention of endometrial cancer.

CONCLUSION

Maintaining a high index of suspicion and obtaining endometrial biopsies from all suspected patients is the key for achieving a timely diagnosis.

Three-dimensional ultrasonography and power Doppler for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding

BACKGROUND

Ultrasonography has been extensively used in women suspected of having a gynecological malignancy. The aim of this study is to evaluate the efficacy of 3D ultrasonography and power Doppler for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding.

METHODS

This cross-sectional study included 78 premenopausal women with abnormal uterine bleeding scheduled for hysteroscopy and endometrial curettage. The endometrial thickness (ET), uterine artery pulsatility index (PI) and resistance index (RI), and endometrial volume (EV) and 3D power Doppler vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were measured and compared with hysteroscopic and histopathologic findings.

RESULTS

The ET (P <0.001), EV (P <0.001), and endometrial VI (P <0.001) and VFI (P = 0.043) were significantly increased in patients with atypical endometrial hyperplasia and endometrial carcinoma (n = 10) than those with benign endometrium (n = 68); whereas, the uterine artery PI and RI and endometrial FI were not significantly different between the two groups. The best marker for discrimination between benign and malignant endometrium was the VI with an area under the ROC curve of 0.88 at a cutoff value of 0.81%.

CONCLUSION

3D ultrasonography and power Doppler, especially endometrial VI, may be useful for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding.

Role of contrast-enhanced ultrasound (CEUS) in the diagnosis of endometrial pathology

Ultrasound is the reference imaging procedure used for the exploration of endometrial pathology. As medical procedures improve and the requirements of modern medicine become more demanding, gray-scale ultrasound is insufficient in establishing gynecological diagnosis. Thus, more complex examination techniques are required: Doppler ultrasound, contrast-enhanced ultrasound (CEUS), 3D ultrasound, etc. Contrast-enhanced ultrasound is a special examination technique that gains more and more ground. This allows a detailed real-time evaluation of microcirculation in a certain territory, which is impossible to perform by Doppler ultrasound. The aim of this review is to synthesize current knowledge regarding CEUS applications in endometrial pathology, to detail the technical aspects of endometrial CEUS and the physical properties of the equipment and contrast agents used, as well as to identify the limitations of the method.

Value of 3-dimensional and power Doppler sonography for diagnosis of endometrial polyps

OBJECTIVES

To investigate whether the endometrial thickness, endometrial volume, and endometrial and subendometrial vascularization index, flow index, and vascularization-flow index were useful for diagnosing endometrial polyps in infertility.

METHODS

Transvaginal and 3-dimesional power Doppler sonography was performed to calculate the endometrial echogenicity, endometrial thickness, endometrial volume, and endometrial and subendometrial vascularization index, flow index, and vascularization-flow index, followed by hysteroscopy in the follicular phase of the menstrual cycle (postmenstrual days 3-7). A total of 555 patients were selected, and 4 groups were defined according to the comparison of sonographic and hysteroscopic diagnoses: group A (sonographically positive but hysteroscopically negative), group B (sonographically and hysteroscopically negative), group C (sonographically negative but hysteroscopically positive), and group D (sonographically and hysteroscopically positive).

RESULTS

A total of 426 patients were enrolled in the final analysis. Significantly higher endometrial thickness and volume were found in groups C and D compared with groups A and B (P < .05). There were no significant differences among the 4 groups in terms of the endometrial and subendometrial vascularization index, flow index, and vascularization-flow index (P > .05). The sensitivity, specificity, and positive and negative predictive values of endometrial thickness and volume in predicting endometrial polyps were 62.7%, 69.8%, 26.9%, and 91.9% and 39.3%, 88.2%, 35.8%, and 89.7%, respectively. Combined sonographic evaluation (sonographic echogenicity, endometrial thickness, and endometrial volume) showed higher sensitivity, specificity, and positive and negative predictive values (65.6%, 89.0%, 50.0%, and 93.9%) compared with a single indicator.

CONCLUSIONS

A combination of endometrial echogenicity, thickness, and volume on sonography may be better than a single indicator for predicting endometrial polyps in infertility. However, the endometrial or subendometrial vascularization index, flow index, and vascularization-flow index are not useful for prediction.

Imaging of endometrial carcinoma using contrast-enhanced sonography

OBJECTIVES

The purpose of this study was to evaluate the utility of contrast-enhanced sonography as an adjunct to conventional transvaginal sonography for detecting endometrial carcinoma and defining the depth of myometrial invasion.

METHODS

A total of 35 patients with endometrial carcinoma diagnosed by endometrial sampling were examined with transvaginal sonography followed by contrast-enhanced sonography before treatment. The contrast enhancement phases (ie, early wash-in/out and late wash-in/out) were visually observed before comparison of tumors grouped by average diameter and histopathologic grade. We evaluated the effectiveness of contrast-enhanced sonography as an adjunct to transvaginal sonography in tumor imaging. We calculated the accuracy of contrast-enhanced sonography for diagnosing the depth of tumor invasion into the myometrium by using arcuate vascular plexus involvement as the sonographic standard for diagnosis of deep myometrial infiltration.

RESULTS

Of the 34 tumors identified by contrast-enhanced sonography, 28 (82.4%) showed early wash-in, and 6 (17.6%) showed late wash-in. Similar numbers of cases showed early and late wash-out. The enhancement phases did not differ significantly across groups with different average tumor diameters or histologic grades (P > .05). Contrast-enhanced sonography contributed the most to tumor imaging in patients with a thin endometrium after endometrial biopsy because it enhanced the contrast between the tumor and tissue. The diagnostic accuracy of contrast-enhanced sonography for determining the myometrium infiltration depth was 85.3%.

CONCLUSIONS

This study revealed diagnostically useful characteristics of the enhancement phase of endometrial carcinoma. The ability to enhance tumor-to-tissue contrast makes contrast-enhanced sonography a valuable adjunct to conventional sonography of endometrial carcinoma, especially for the thin endometrium found after endometrial biopsy. Contrast-enhanced sonography performed well in the diagnosis of the myometrial infiltration depth when using arcuate vascular plexus involvement as a marker of deep myometrial infiltration.

Effect of gel-instillation sonography on Doppler ultrasound findings in endometrial polyps

OBJECTIVE

Saline infusion sonohysterography has been reported to suppress the color signal within the endometrium at color or power Doppler evaluation. The aim of this study was to evaluate if gel-instillation sonography (GIS) affects the power Doppler signal in patients with endometrial polyps.

METHODS

Ultrasound volumes of the uterus, obtained by three-dimensional ultrasound imaging of 25 women with histologically confirmed endometrial polyps, were assessed offline by six gynecologists with a special interest in gynecological ultrasound. Each woman contributed four volumes: one gray-scale volume and one power Doppler volume before GIS, and one gray-scale volume and one power Doppler volume at GIS. Power Doppler features before and after gel infusion were compared.

RESULTS

At unenhanced ultrasound a pedicle artery was seen in 27-46% of cases, whereas, after gel infusion the examiners reported a pedicle artery in 30-46% of cases (Exact McNemar's test P-values ranged from 0.50 to 1.00). The level of agreement between unenhanced ultrasound and GIS ranged from 59 to 91% (Cohen's kappa values ranged from 0.17 to 0.79). There was no tendency for a pedicle artery to be identified less often at GIS than before gel instillation.

CONCLUSION

Gel infusion does not affect the power Doppler signal in patients with endometrial polyps.