Early detection of ovarian carcinoma with transvaginal color Doppler ultrasonography

Identification of two theranostic biomarker panels for epithelial ovarian cancer

BACKGROUND

Epithelial Ovarian cancer (EOC) is the leading cause of death associated with gynecologic tumors. Because the disease is asymptomatic in early-stage, the majority of patients are not diagnosed until late stages, highlighting the need for the development of novel diagnostic biomarkers. Mediators of tumoral microenvironment may affect EOC progression and resistance to treatment.

AIM OF THE STUDY

Analysis of serum proteins to identify a panel of theranostic biomarkers for EOC.

PATIENTS AND METHODS

Serum levels of 65 analytes were determined in EOC patients, and healthy controls with the ProcartaPlex Human Immune Monitoring 65-Plex Panel.

RESULTS

Twenty-one analytes: 7 cytokines (IFN-γ, IL-12p70, IL-13, IL-18 and TSLP), 7 chemokines (Eotaxin, eotaxin-2, IP-10, BLC, I-TAC, SDF-1α, and fractalkine), 2 growth factors (MMP-1, VEGF-α), and 5 soluble receptors (APRIL, CD40L, TWEAK, CD30 and TNFRII; were significantly differentially expressed between the two groups. ROC curves showed that only seven of them (IL-9, TNF-α, Eotaxin, IP-10, BLC, Fractalkine, and Tweak) had AUC values greater than 0.70 and thus had potential clinical utility. Moreover, five cytokines: IFN-γ, IL-1 β, IL-8, MIP-1β, and TNF-α are positively associated with patients who developed resistance to taxol-platinum-based chemotherapy (CT).

CONCLUSION

This study has revealed a first panel of 7 analytes (IL-9, TNF-α, Eotaxin, IP-10, BLC, Fractalkine and Tweak) that can be used for early detection of EOC and a second panel of five cytokines (IFN-γ, IL-1β, IL-8, MIP-1β, TNF-α) that can help clinicians to identify EOC patients who are at higher risk to develop resistance to CT of EOC.

Combination of 2- and 3-dimensional contrast-enhanced transvaginal sonography for diagnosis of small adnexal masses

OBJECTIVES

The purpose of this study was to evaluate the efficacy of the combination of 2-dimensional (2D) and 3-dimensional (3D) contrast-enhanced sonography in discriminating between benign and malignant small adnexal masses.

METHODS

Selected patients were evaluated with both 2D and 3D contrast-enhanced sonography after conventional sonography before undergoing any surgery. Time-intensity curves for 2D contrast-enhanced sonography were constructed by using contrast-enhanced sonographic software. A vascular perfusion characteristic analysis was achieved by 2D and 3D contrast-enhanced sonography. Results were finally verified by surgery.

RESULTS

Forty-seven cases of benign and 10 cases of malignant small adnexal masses were discovered. Significant differences in perfusion patterns, time-intensity curve shapes for 2D contrast-enhanced sonography, grayscale contrast-enhanced sonography, and blood flow imaging on 3D contrast-enhanced sonography were observed between benign and malignant masses (P< .05). Two-dimensional contrast-enhanced sonography, 3D contrast-enhanced sonography, parallel combination of 2D and 3D contrast-enhanced sonography, and serial combination of 2D and 3D contrast-enhanced sonography all reached diagnostic sensitivity of 100% for discriminating benign from malignant masses, whereas specificity values were 61.7%, 63.8%, 68.1%, and 57.4%, respectively. Areas under the receiver operating characteristic curves were 0.809, 0.819, 0.840, and 0.787.

CONCLUSIONS

Two-dimensional contrast-enhanced sonography is of high value in distinguishing malignant from benign small adnexal masses; 3D contrast-enhanced sonography provides richer and more useful information for evaluation of these masses. Diagnostic sensitivity of 100% can be achieved when using a serial combination of 2D and 3D contrast-enhanced sonography, although specificity needs further improvement.

Early detection of ovarian cancer with conventional and contrast-enhanced transvaginal sonography: recent advances and potential improvements

Recently, there have been several major technical advances in the sonographic diagnosis of ovarian cancer in its early stages. These include improved assessment of tumor morphology with transvaginal sonography (TVS), and detection and characterization of tumor neovascularity with transvaginal color Doppler sonography (TV-CDS) and contrast-enhanced transvaginal sonography (CE-TVS). This paper will discuss and illustrate these improvements and describe how they enhance detection of early-stage ovarian cancer. Our initial experience with parametric mapping of CE-TVS will also be mentioned.

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.

Hereditary ovarian cancer

At least 10% of ovarian tumors are hereditary and associated with highly penetrant, autosomal, dominant genetic predisposition. Three clinical manifestations of hereditary ovarian cancer have been identified: site-specific ovarian cancer, hereditary breast and/or ovarian cancer (HBOC) and hereditary non-polyposis colorectal cancer (HNPCC) syndromes. BRCA germline mutations account for more than 90% of all hereditary epithelial ovarian tumors whereas most of the remaining 10% are caused by MLH1 and MSH2 mutations, which are susceptibility genes of HNPCC. Genetic testing is available for each of the three hereditary syndromes above mentioned. The recommendations for OC surveillance in high-risk women having a strong family history or BRCA mutation carriers include transvaginal pelvic ultrasound with color Doppler and serum CA125 every 6 months. Bilateral salpingo-oophorectomy appears to be effective to reduce the risk of ovarian cancer in BRCA mutation carriers. Hysterosalpingo-oophorectomy should be considered in HNPCC women who undergo surgery for colorectal carcinoma.

Doppler Evaluation of the Ovary: Clinical Applications and Challenges

Transvaginal sonography has been shown to be an accurate technique for discriminating between benign and malignant adnexal masses. Accurate preoperative differential diagnosis of adnexal masses is essential for optimizing patients’ treatment. The advancement and wider availability of therapies of assisted conception have occurred to a large extent as a result of developments in ultrasonography. Transvaginal color Doppler has opened up exciting new possibilities for the better understanding of the physiology and pathophysiology of ovarian blood flow, resulting in a number of completely new diagnostic parameters.

Early ovarian cancer: 3-D power Doppler

Transvaginal sonography plays an important role in the assessment of the morphology of ovarian lesions. However, the accuracy of the technique is limited due to the significant number of false-positive results. Color Doppler imaging and pulsed Doppler spectral analysis enable evaluation of ovarian tumor blood flow, analysis of the distribution of blood vessels, and quantitative measurement of blood flow velocity waveforms. These parameters increase the sensitivity and specificity of ultrasound evaluation of ovarian tumors. Unfortunately, there is no consensus as to which Doppler parameters and cutoff values are the most predictive of malignancy. Three-dimensional (3-D) power Doppler ultrasound provides a new tool to evaluate features of tumor vascularity. Three-dimensional ultrasound and 3-D power Doppler imaging in patients with "positive" findings on standard ultrasound tests, which encompass annual gray-scale transvaginal sonography followed by transvaginal color Doppler ultrasound in selected cases, represent a novel approach for early and accurate detection of ovarian cancer through screening. Combined evaluations of morphology and neovascularity by 3-D power Doppler ultrasound may improve early detection of ovarian carcinoma. Contrast-enhanced 3-D power Doppler sonography facilitates visualization of adnexal tumor vessels, which may aid in differentiating benign from malignant adnexal lesions.

Angiographic power 3-dimensional quantitative analysis in gynecologic solid tumors: feasibility and reproducibility

OBJECTIVE

To determine the reproducibility of a simplified method of power Doppler 3-dimensional (3D) sonographic examination.

METHODS

Twenty-nine patients with solid pelvic masses underwent transvaginal 3D power Doppler evaluation. The volume of interest was obtained by drawing the margins of the largest section of the mass in the 3 orthogonal planes. The 3D vascular parameters ("relative color," "average color," and "flow measure") obtained by our method were compared with those calculated by a manufacturer-suggested model based on several parallel section planes drawn on the longitudinal frames. The intraobserver variability was quantified on 5 different 3D images acquired by the same operator at 5-minute intervals for each patient. The intraobserver variability was also assayed in 10 patients at 24-hour intervals. Ten patients were scanned by a second sonographer for interobserver variability.

RESULTS

There was high agreement between the 3D parameters obtained with the 2 methods. The 3D indices were similar in repeated observations at 5-minute intervals (median coefficients of variation for relative color, average color, and flow measure, 10.9, 4.5, and 13.0, respectively) and at 24-hour intervals (intraclass correlation coefficients for relative color, average color, and flow measure, 0.920, 0.978, and 0.978) and by the second sonographer (interclass correlation coefficients for relative color, average color, and flow measure, 0.978, 0.966, and 0.997).

CONCLUSIONS

The acceptable rates of intraobserver and interobserver variability make this approach potentially suitable for research protocols.

The detection of stage I ovarian cancer by three-dimensional sonography and power Doppler

OBJECTIVE

The objective was to determine the diagnostic accuracy of three-dimensional (3D) sonography and 3D power Doppler imaging, used together with standard 2D transvaginal grayscale and color/power Doppler modalities, for preoperative sonographic assessment of suspected ovarian lesions.

METHODS

Five-year retrospective analysis was performed by our experts on ultrasonography and surgery on the reports from 43 referred patients with suspected stage I ovarian cancer. All patients were evaluated during the week prior to surgery at our department. Preoperative sonographic assessment included careful examination of ovarian volume, morphology, and vascularity by four complementary sonographic methods. Scoring systems combining morphological and Doppler parameters were adopted for 2D and 3D sonographic examinations. Final diagnosis was confirmed by a histopathologist.

RESULTS

Out of the 43 stage I ovarian cancers, 42 cases were successfully detected preoperatively by four complementary sonographic methods. Only 30 (69.8%) and 37 (86.1%) cases of stage I ovarian cancer were detected by 2D grayscale and combined 2D grayscale and color Doppler sonography, respectively. Morphological analysis obtained by 3D sonography alone detected 32 of 43 ovarian malignancies, reaching a diagnostic rate of 74.4%. Qualitative analysis of tumor vascularity architecture by 3D power Doppler significantly improved the sonographic management process and successfully detected 41 cases of stage I ovarian cancer (95.4%). When morphological features obtained by 3D sonography were added to 3D power Doppler findings, we achieved an even higher diagnostic accuracy of 97.7%. We found a statistically significant difference (P </= 0.01) in diagnostic rates of 3D power Doppler, and especially the combined use of 3D sonography and 3D power Doppler in comparison to those obtained with transvaginal 2D grayscale (P </= 0.002 and P </= 0.001, respectively) or 3D sonography (P </= 0.006 and P </= 0.002, respectively).

CONCLUSIONS

In comparison to transvaginal 2D grayscale or 3D sonography, 3D power Doppler and especially the combined use of 3D sonography and power Doppler imaging significantly improve diagnostic accuracy in preoperative sonographic assessment of suspected ovarian lesions.

Sonographic assessment of the morphology and vascularity of ovarian masses

This review describes sonographic assessment of the morphology and vascularity of ovarian masses. It emphasizes the evaluation of wall regularity and the detection of papillary excrescences as well as the vascularity of lesions as depicted with color Doppler sonography.

Ultrasonic assessment of the peri- and postmenopausal ovary

OBJECTIVE

To analyze the role of B-mode ultrasound, color and power Doppler examination and three-dimensional ultrasound with and without power Doppler facilities in evaluation of the peri- and postmenopausal ovaries.

METHODS

Review of the literature on ultrasonic assessment of the ovaries in postmenopausal patients.

RESULTS

Ultrasound has assumed an increasing role in the evaluation of the peri- and postmenopausal ovaries. Ovarian lesions are a cause of great concern because of their malignant potential and the limited ability to distinguish accurately between benign and malignant lesions using morphological sonographic criteria alone. Superimposed color Doppler imaging enables the visualization of vascularization and blood flow characteristics of the ovaries and/or ovarian lesions. It becomes possible to detect normal, suspicious and pathologic blood flow characteristics even in small blood vessels. Owing to superb quality of the images, three-dimensional sonography enables precise assessment of the ovarian lesions. Three-dimensional power Doppler ultrasound permits effective targeting and rendering of ovarian tumor vasculature, thus providing new diagnostic possibilities for early detection of ovarian malignancy and differentiation of benign from malignant ovarian pathology.

CONCLUSIONS

Further technological development will contribute to more objective evaluation of ovarian tumor morphology and vasculature which will give us tremendous support in clinical decision making and planning the management.

Three-dimensional ultrasonographic and power Doppler characterization of ovarian lesions

OBJECTIVE

To determine whether three-dimensional ultrasound (3D US) and 3D power Doppler can improve the ability to differentiate benign from malignant ovarian lesions.

METHODS

Transvaginal ultrasound, transvaginal color Doppler, 3D US and 3D power Doppler were performed on 90 patients with ovarian lesions during the week prior to surgery. Four independent sonographers were blinded to the results of other ultrasound studies.

RESULTS

Color Doppler studies added to transvaginal gray-scale characterization of ovarian lesions resulted in sensitivity of 88.89% and specificity of 97.53% in diagnosing ovarian malignancy. Qualitative analysis of tumor vascularity by 3D power Doppler added to morphological features obtained by 3D US is clinical pertinent and reached sensitivity and specificity of 100 and 98.76%, respectively.

CONCLUSION

Three-dimensional ultrasound and power Doppler can enhance and facilitate the morphologic and functional evaluation of both benign and malignant ovarian lesions. Introduction of the 3D quantitative technique for measurements of blood flow and vascularization may increase clinical relevance of these studies.

Combined transvaginal B-mode and color Doppler sonography for differential diagnosis of ovarian tumors: results of a multivariate logistic regression analysis

OBJECTIVE

Transvaginal sonography is limited in its ability to assess early stage cancers of the ovary as well as in distinguishing benign processes. As a method for characterization of tumor vascularization, color-coded Doppler sonography may be able to improve the diagnostic accuracy of B-mode sonography.

METHODS

Preoperative transvaginal B-mode and Doppler sonography was performed in 63 patients with unclear adnexal lesions prior to operation. Using multiple logistic regression, the independent variables of each procedure were selected and combined to yield a diagnostic flow chart. The diagnostic accuracy of this decision matrix was tested on 257 patients with unclear adnexal tumors.

RESULTS

In the 63 adnexal tumors investigated, the diagnostic impact of isolated sonomorphological assessment with evidence of a "solid area" was 78%. Using Doppler sonography, the best discrimination was achieved by displaying the vascular distribution ("central vascularization"). Combining these independent significant variables of the two procedures raised the diagnostic accuracy to 90% (sensitivity 86%, specificity 93%). The validity achieved by this combination was confirmed by the independent application of this method to the 257 adnexal tumors with unclear malignancy status (diagnostic accuracy 93%, sensitivity 92%, specificity 94%).

CONCLUSIONS

The combination of sonography and Doppler sonography achieves high and reproducible diagnostic accuracy in preoperative malignancy status assessment of adnexal tumors. The additional use of Doppler sonography can thus provide significant aid both for differential diagnostics of adnexal lesions and for the choice of surgical route in the case of an existing indication for operative therapy.

Three-dimensional ultrasound and power doppler improve the diagnosis of ovarian lesions

OBJECTIVE

The aim of this study was to determine whether three-dimensional power Doppler can improve the ability to differentiate benign from malignant ovarian masses.

METHODS

Transvaginal color Doppler and three-dimensional power Doppler were performed on 120 patients with ovarian lesions. All patients underwent both ultrasound examinations during the day prior to laparotomy or laparoscopy. Scoring systems combining morphological and Doppler parameters were adopted for two- and three-dimensional ultrasound examinations.

RESULTS

In each of 11 ovarian malignancies, preoperative diagnosis by three-dimensional power Doppler was confirmed by histopathology. Transvaginal color Doppler missed 1 case of serous cystadenocarcinoma, while 3 benign lesions were considered false positive. In 1 case of cystadenofibroma both transvaginal color Doppler and three-dimensional power Doppler were falsely positive. Qualitative analysis of the tumor vascularity architecture added to morphological parameters had a sensitivity and specificity of 100 and 99.08%, respectively.

CONCLUSIONS

Better results achieved by three-dimensional ultrasound can be explained by improved recognition of the ovarian mass anatomy, characterization of the surface features, detection of the tumor infiltration, and precise depiction of the size and volume. Three-dimensional power Doppler imaging can detect structural abnormalities of malignant tumor vessels, such as arteriovenous shunts, microaneurysms, tumoral lakes, disproportional calibration, coiling, and dichotomous branching. Three-dimensional power Doppler can enhance and facilitate the morphologic and functional evaluation of both benign and malignant ovarian masses.

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.