Three-dimensional ultrasound for assessing women with gynecological cancer: A systematic review

A Review of the Role of the S-Detect Computer-Aided Diagnostic Ultrasound System in the Evaluation of Benign and Malignant Breast and Thyroid Masses

Computer-aided diagnosis (CAD) systems have attracted extensive attention owing to their performance in the field of image diagnosis and are rapidly becoming a promising auxiliary tool in medical imaging tasks. These systems can quantitatively evaluate complex medical imaging features and achieve efficient and high-diagnostic accuracy. Deep learning is a representation learning method. As a major branch of artificial intelligence technology, it can directly process original image data by simulating the structure of the human brain neural network, thus independently completing the task of image recognition. S-Detect is a novel and interactive CAD system based on a deep learning algorithm, which has been integrated into ultrasound equipment and can help radiologists identify benign and malignant nodules, reduce physician workload, and optimize the ultrasound clinical workflow. S-Detect is becoming one of the most commonly used CAD systems for ultrasound evaluation of breast and thyroid nodules. In this review, we describe the S-Detect workflow and outline its application in breast and thyroid nodule detection. Finally, we discuss the difficulties and challenges faced by S-Detect as a precision medical tool in clinical practice and its prospects.

4D Doppler Ultrasound in High Grade Serous Ovarian Cancer Vascularity Evaluation-Preliminary Study

The aim of the study was to evaluate the usefulness of 4D Power Doppler tissue evaluation to discriminate between normal ovaries and ovarian cancer tumors. This was a prospective observational study. Twenty-three cases of surgically confirmed ovarian High Grade Serous Carcinoma (HGSC) were analyzed. The control group consisted of 23 healthy patients, each matching their study-group counterpart age wise (±3 years) and according to their menopausal status. Transvaginal Doppler 4D ultrasound scans were done on every patient and analyzed with 3D/4D software. Two 4D indices-volumetric Systolic/Diastolic Index (vS/D) and volumetric Pulsatility Index (vPI)-were calculated. To keep results standardized and due to technical limitations, virtual 1cc spherical tissue samples taken from the part with highest vascularization as detected by bi-directional Power Doppler were analyzed for both groups of ovaries. Values of volumetric S/D indices and volumetric PI indices were statistically lower in ovarian malignant tumors compared to normal ovaries: 1.096 vs. 1.794 and 0.092 vs. 0.558, respectively (p < 0.001). The 4D bi-directional Power Doppler vascular indices were statistically different between malignant tumors and normal ovaries. These findings could support the rationale for future studies for assessing this technology to discriminate between malignant and benign tumors.

Multimodality Imaging of Uterine Cervical Malignancies

OBJECTIVE. In this article, we provide an updated review on the role of imaging in initial staging, treatment monitoring, and follow-up of cervical cancer with a focus on the role of MRI and FDG PET/CT. In addition, the 2018 International Federation of Gynecology and Obstetrics staging system and its implication on management of cervical cancer are explored. CONCLUSION. Imaging plays a major role in treatment planning and as a prognostic indicator in patients with cervical cancer. MRI and PET/CT have complementary roles: MRI is essential for the local staging of the primary tumor, and PET/CT is the most useful modality for detecting regional nodal and distant metastases.

Endometrial cancer: an overview of novelties in treatment and related imaging keypoints for local staging

Endometrial cancer is the most common gynaecologic malignancy in developed countries and its incidence is increasing. First-level treatment, if no contraindicated, is based on surgery. Pre-operative imaging is needed for evaluation of local extent and detection of distant metastases in order to guide treatment planning. Radiological evaluation, based on transvaginal ultrasound, MR and CT, can make the difference in disease management, paying special attention to assessment of entity of myometrial invasion, cervical stromal extension, and assessment of lymph nodal involvement and distant metastases.

Intrauterine photoacoustic and ultrasound imaging probe

Intrauterine photoacoustic and ultrasound imaging are probe-based imaging modalities with translational potential for use in detecting endometrial diseases. This deep-tissue imaging probe design allows for the retrofitting of commercially available endometrial sampling curettes. The imaging probe presented here has a 2.92-mm diameter and approximate length of 26 cm, which allows for entry into the human endometrial cavity, making it possible to use photoacoustic imaging and high-resolution ultrasound to characterize the uterus. We demonstrate the imaging probes' ability to provide structural information of an excised pig uterus using ultrasound imaging and detect photoacoustic signals at a radial depth of 1 cm.

Reliability of preoperative evaluation of postmenopausal ovarian tumors

Background

Preoperative evaluation of ovarian tumors is challenging. This study was undertaken to evaluate the performance of conventional two-dimensional (2D) ultrasound and CA125 in predicting malignant or benign nature of pelvic masses, and to investigate if three-dimensional power Doppler (3DPD) ultrasound provides any added value. Ninety-six postmenopausal and four perimenopausal women with supposed ovarian tumors were examined by standardized 2D and 3DPD ultrasounds preoperatively. The tumors were evaluated using the risk of malignancy index (RMI), International Ovarian Tumors Analysis (IOTA) group simple rules, expert opinion, IOTA logistic regression model 2 (LR2) and 3D vascular indices, and were postoperatively compared to histopathological results.

Results

Ninety-eight tumors turned out to be ovarian in origin. Of these, 66 were benign and 32 malignant. RMI (cut-off value 200), simple rules, expert opinion and LR2 (cut-off value 25) were used to predict malignant nature of the tumors and had sensitivities of 71.9, 90.6, 87.5 and 90.6%, and specificities of 80.3, 84.6, 92.4 and 77.3%, respectively. When the 3D vascularization flow index (VFI) was added to RMI and LR2, the accuracy of the test improved from 77.6 to 81.4% and from 81.6 to 86.5%, respectively, at the expense of sensitivity, while VFI gave no added benefit for simple rules and expert opinion. Agreement between two examiners using expert opinion was good (Cohen’s kappa = 0.89).

Conclusions

The subjective opinion of an expert seems to be the most reliable method in assessing ovarian tumors, and the 3DPD indices seem to provide no significant added value.

What Is the Best Preoperative Imaging for Endometrial Cancer?

Although endometrial cancer is surgicopathologically staged, preoperative imaging is recommended for diagnostic work-up to tailor surgery and adjuvant treatment. For preoperative staging, imaging by transvaginal ultrasound (TVU) and/or magnetic resonance imaging (MRI) is valuable to assess local tumor extent, and positron emission tomography-CT (PET-CT) and/or computed tomography (CT) to assess lymph node metastases and distant spread. Preoperative imaging may identify deep myometrial invasion, cervical stromal involvement, pelvic and/or paraaortic lymph node metastases, and distant spread, however, with reported limitations in accuracies and reproducibility. Novel structural and functional imaging techniques offer visualization of microstructural and functional tumor characteristics, reportedly linked to clinical phenotype, thus with a potential for improving risk stratification. In this review, we summarize the reported staging performances of conventional and novel preoperative imaging methods and provide an overview of promising novel imaging methods relevant for endometrial cancer care.

Three-Dimensional Transvaginal Sonography and Magnetic Resonance Imaging for Local Staging of Cervical Cancer: An Agreement Study

OBJECTIVES

To evaluate the agreement of clinical examination, 2-dimensional (2D) sonography, and 3-dimensional (3D) sonography with magnetic resonance imaging (MRI) for local staging of cervical cancer.

METHODS

We conducted a prospective study including women with a diagnosis of carcinoma of the cervix. All women were staged clinically and underwent 2D and 3D transvaginal sonography and MRI before treatment for assessing tumor size and parametrial, bladder, and rectal involvement using the examiner's subjective impression. Agreement between sonography and MRI was assessed by calculating the κ index and percentage of agreement.

RESULTS

Forty women were included (mean age ± SD, 46.6 ± 11.4 years). Eleven had early-stage (IA and IB1) disease, and 29 had advanced-stage (IB2-IVB) disease. A significant correlation for tumor size estimation was found between MRI and pelvic examination (r = 0.754; P < .001), MRI and 2D sonography (r = 0.649; P < .001), and MRI and 3D sonography (r = 0.657; P< .001). Agreement for parametrial infiltration between MRI and pelvic examination was fair (κ = 0.26; 95% confidence interval [CI], 0.10-0.54; 62.5% agreement), between MRI and 2D sonography was moderate (κ = 0.41; 95% CI, 0.15-0.66; 70.0% agreement), and between MRI and 3D sonography was good (κ = 0.60; 95% CI, 0.35-0.85; 80.0% agreement). Agreement for bladder involvement between MRI and pelvic examination was moderate (κ = 0.48; 95% CI, 0.10-0.99; 95.0% agreement), between MRI and 2D sonography was moderate (κ = 0.48; 95% CI, 0.10-0.99; 95.0% agreement), and between MRI and 3D sonography was very good (κ = 0.84; 95% CI, 0.55-1.0; 97.5% agreement). Agreement for rectal involvement was not calculated because of the very small number of cases.

CONCLUSIONS

Three-dimensional sonography showed good agreement with MRI for assessing parametrial infiltration and bladder involvement in cervical cancer.

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.

Sonographic Detection of Cervical Carcinoma With Metastases

Cervical cancer is not considered to be a highly prevalent carcinoma, as there are more cases of pre-cancer detected than invasive cases. It is also on the decline due to the use of routine Papanicolaou (Pap) tests, and immunizations against Human Papilloma Virus (HPV) have also helped diminish the number of cases. A case is presented of a cervical mass with metastases into the bladder and hydronephrosis of the kidneys detected using computed tomography (CT) and further evaluated using sonography. These imaging modalities together were able to provide global visualization of the pathology, resulting in accurate diagnosis and plan for treatment.

Management of musculoskeletal tumors during pregnancy: a retrospective study

Background

In recent years, scientific research has increasingly focused on malignancies during pregnancy. However, the development of musculoskeletal tumors during pregnancy has only been the subject of a few studies so far. The primary aim of this study was to identify the incidence of sarcomas during pregnancy at our musculoskeletal tumor center (MSTC). Secondarily we intended to analyze these cases and discuss possible recommendations regarding diagnostic work-up as well as therapy on the basis of the literature.

Methods

All female patients who had been treated for soft tissue or bone sarcoma at our academic MSTC in the period between the years 2002 and 2010 were screened retrospectively for anamnestic annotations of pregnancy or records of pregnancy in the obstetrical database of our university hospital. The patients who met the criteria for inclusion (diagnosed sarcoma and pregnancy) were enrolled. For every pregnant patient two age-matched female control patients that suffered from tumors with the same histologic type were included.

Results

In the period between 2002 and 2010, 240 female patients between the age of 16 and 45 were treated for sarcoma. In eight out of the 240 cases the tumor disease developed or progressed during pregnancy. The delay in diagnosis was approximately eight months and turned out to be significantly higher for pregnant patients compared to non- pregnant controls. Each woman’s tumor was misdiagnosed at least once.

Conclusions

Diagnostic follow-up of pregnant women presenting with a growing or painful mass, which is suspected to be a musculoskeletal tumor, should be performed at a specialized tumor center. We recommend a multidisciplinary approach and discussing all possible consequences for mother and child intensively in accordance with the available literature.

Role of Three-Dimensional Ultrasound in Gynecology

Three-dimensional ultrasound (3D USG) is a fast-evolving imaging technique that holds a great potential for use in gynecology. Its sensitivity and specificity is reported to be close to 100 % for diagnosing congenital uterine anomalies, comparable with those of magnetic resonance imaging (MRI) and laparoscopy. With 3D USG, a coronal view of the uterus can be obtained, clearly outlining the external contour of the uterus and providing accurate information about the shape of the cavity. Although 3D USG may not perform well in thin endometria, combining it with saline infusion sonography (SIS) overcomes this problem. Research shows that 3D USG is more sensitive and specific than two-dimensional ultrasound (2D USG) in defining and mapping uterine lesions, such as fibroids, adenomyosis, and intrauterine synechia. In cases of suspected malignancy, 3D USG is mainly used in the initial evaluation of patients. Measuring various indices and mapping vascular architecture with 3D power Doppler have been proposed for evaluating adnexal masses. Although some studies raised hope, no consensus is reached about its use, success, and limitations. In urogynecology, translabial 3D USG is proved to be a valuable tool, as it provides instant access to the axial plane, which clearly depicts the relationship of the vagina, urethra, rectum, and the muscular pelvic floor. Studies report no significant differences between translabial 3D USG and MRI measurements for evaluation of the pelvic floor. In conclusion, adding 3D USG to routine gynecological workup can be beneficial for clinicians, as it provides fast and accurate results in a relatively cost-effective setting.

Potential role of ultrasound imaging in interstitial image based cervical cancer brachytherapy

In 2012, more than 500,000 cases of cervical cancer were diagnosed worldwide. Over three quarters of these cases occur in less developed countries [1]. Advancements in image-guided brachytherapy are resulting in improved outcomes and reduced morbidity for women with this disease, but its worldwide adoption is hampered by lack of accessibility to advanced imaging techniques. Ultrasound is emerging as a potential option for tumor visualization, brachytherapy catheter placement, and treatment planning. While additional work is needed, ultrasound can potentially serve as the sole imaging modality for catheter insertion and planning. This paper will review our current knowledge on the use of ultrasound in interstitial brachytherapy treatment for cervical cancer.

Three-dimensional power Doppler ultrasound in cervical carcinoma: monitoring treatment response to radiotherapy

OBJECTIVES

To investigate, using three-dimensional power Doppler ultrasound (3D-PDU), alterations in cervical intratumoral vascularization during and after radiotherapy.

METHODS

Between 2004 and 2009 we enrolled into the study 37 patients with FIGO Stages IB1-IIB cervical carcinoma who were undergoing radiotherapy. Serial 3D-PDU scans were performed during treatment, providing ultrasonographic measurement of tumor size, vascularization index, flow index and vascularization flow index, as well as monthly for 3 months post-treatment and tri-monthly thereafter, until vascularity was undetectable on two consecutive occasions. Physical examination, cervical cytology and serum marker evaluation were performed every 3-6 months for the first 5 years following treatment. Patients evaluated after a 2-year tumor-free interval and those with clinically assessed positive findings at follow-up underwent 3D-PDU to detect possible local disease.

RESULTS

A total of 329 3D-PDU scans were performed in the 37 women. Cervical tumors and intratumoral vascularization disappeared within 3 months following radiotherapy, except in one patient with persistent disease. Nine patients had disease relapse, in four of whom the recurrence was local. In three of these four, there was recurrence of tumor and vascularization after a complete response. At follow-up, 3D-PDU detected local disease with 75.0% sensitivity and 98.5% specificity, while serum markers detected local disease among 34 patients with squamous cell carcinoma with 20.0% sensitivity and 77.3% specificity.

CONCLUSIONS

Compared with serum markers in cervical squamous cell carcinoma, 3D-PDU has higher sensitivity and specificity for detecting local recurrence or persistence in cervical carcinoma. Thus, 3D-PDU combined with clinical assessment may be a new and safe method for monitoring radiotherapy treatment response and detecting local recurrence.

Current Role of 3D/4D Sonography in Obstetrics and Gynecology

Modern 3D/4D sonography provides a routine method not only for storing single image planes as in 2D ultrasound but also for storing complete sets of volume data in the computer memory. Once acquisition is completed, all volumes can be accessed from the memory and normal and abnormal findings in both obstetrics and gynecology can be demonstrated in different display modes. Furthermore digital storage of volumes permits virtual examinations by reloading of volumes and navigating through them in the absence of the patient.

This review article would like to give an illustration of the latest technologies in 3D/4D ultrasound in obstetrics and gynecology.

How to cite this article

Merz E, Pashaj S. Current Role of 3D/ 4D Sonography in Obstetrics and Gynecology. Donald School J Ultrasound Obstet Gynecol 2013;7(4):400-408.

Diagnosis, treatment, and follow-up of borderline ovarian tumors

Borderline ovarian tumors represent a heterogeneous group of noninvasive tumors of uncertain malignant potential with characteristic histology. They occur in younger women, are present at an early stage, and have a favorable prognosis, but symptomatic recurrence and death may be found as long as 20 years after therapy in some patients. The molecular changes in borderline ovarian tumors indicate linkage of this disease to type I ovarian tumors (low-grade ovarian carcinomas). The pathological stage of disease and subclassification of extraovarian disease into invasive and noninvasive implants, together with the presence of postoperative macroscopic residual disease, appear to be the major predictor of recurrence and survival. However, it should be emphasized that the most important negative prognostic factor for recurrence is just the use of conservative surgery, but without any impact on patient survival because most recurrent diseases are of the borderline type-easily curable and with an excellent prognosis. Borderline tumors are difficult masses to correctly preoperatively diagnose using imaging methods because their macroscopic features may overlap with invasive and benign ovarian tumors. Over the past several decades, surgical therapy has shifted from a radical approach to more conservative treatment; however, oncologic safety must always be balanced. Follow-up is essential using routine ultrasound imaging, with special attention paid to the remaining ovary in conservatively treated patients. Current literature on this topic leads to a number of controversies that will be discussed thoroughly in this article, with the aim to provide recommendations for the clinical management of these patients.