Diagnostic parameters to differentiate benign from malignant ovarian masses with contrast-enhanced transvaginal sonography

Added Value of Contrast-enhanced US for Evaluation of Female Pelvic Disease

Since the first application of contrast-enhanced US (CEUS) in the late 1960s, the use of US contrast agents has grown tremendously, and this examination has proved to be a valuable adjunct to diagnostic US for detection and characterization of disease. Also, CEUS has emerged as an excellent option for evaluation of indeterminate lesions that require additional imaging, given its excellent safety profile, including that in patients with end-stage renal disease or allergies to contrast material who are unable to undergo contrast-enhanced CT or MRI. US traditionally has been considered the imaging modality of choice for evaluation of the female pelvis, followed by MRI and rarely fluoroscopy, CT, PET, or angiography. CEUS has the potential to add significant value in imaging gynecologic disease, and indications for its use in the female pelvis are expected to continue evolving. It can aid in evaluation of nonvascular structures, such as assessment of tubal patency, uterine cavity morphology, and pelvic fistulas. CEUS can help characterize poorly vascularized gynecologic tumors or tissues with slow flow by using qualitative and quantitative parameters and aid in image-guided interventions or biopsies by facilitating visualization of lesions that are difficult to see with other imaging modalities. The authors provide an overview of current applications of US contrast agents in the female pelvis and discuss associated factors such as technique, interpretation, and image optimization. They also discuss the limitations of CEUS and describe its utility in the evaluation of female pelvic disease by using an organ system case-based approach. © RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Comparative Study of the Efficacy of the Ovarian-Adnexa Reporting and Data System Ultrasound Combined With Contrast-Enhanced Ultrasound and the ADNEX MR Scoring System in the Diagnosis of Adnexal Masses

OBJECTIVE

The aims of this study were to develop the Ovarian-Adnexa Reporting and Data System (O-RADS) and O-RADS + contrast-enhanced ultrasound (O-RADS CEUS) scoring system to distinguish adnexal masses (AMs) and to compare the diagnostic efficacy of these systems with that of a magnetic resonance imaging scoring system (ADNEX MR).

METHODS

We retrospectively evaluated 278 ovarian masses from 240 patients between May 2017 and July 2022. Pathology and adequate follow-up were used as reference standards for comparing the validity of O-RADS, O-RADS CEUS and ADNEX MR scoring to diagnose AMs. Area under the curve (AUC), sensitivity and specificity were calculated. The inter-class correlation coefficient (ICC) was calculated to evaluate inter-reader agreement (IRA) between the two sonographers and two radiologists who analyzed the findings with the three modalities.

RESULTS

The AUCs of O-RADS, O-RADS CEUS and ADNEX MR scores were 0.928 (95% confidence interval [CI]: 0.895-0.956), 0.951(95% CI: 0.919-0.973) and 0.964 (95% CI: 0.935-0.983), respectively. Their sensitivities were 95.7%, 94.3 and 91.4%, and their specificities were 81.3%, 92.3% and 97.1%, respectively. The three modalities had accuracies of 84.9%, 92.8% and 95.7%, respectively. O-RADS had the highest sensitivity but significantly lower specificity (p < 0.001), whereas the ADNEX MR scoring had the highest specificity (p < 0.001) but lower sensitivity (p < 0.001). O-RADS CEUS had intermediate sensitivity and specificity (p < 0.001).

CONCLUSION

The addition of CEUS significantly improves the efficacy of O-RADS in diagnosing AMs. The diagnostic efficacy of the combination is comparable to that of the ADNEX MR scoring system.

Adnexal masses: Diagnostic performance of contrast-enhanced ultrasound using the simple rules from the International Ovarian Tumor Analysis group

OBJECTIVE

To evaluate the role of the Simple Rules (SR) from the International Ovarian Tumor Analysis group in contrast-enhanced ultrasound (CEUS) of for the differential diagnosis of benign and malignant adnexal tumors.

METHODS

A total of 180 patients with suspected malignant adnexal masses admitted to Lanzhou University Second Hospital were included, all of whom received conventional ultrasound (US) and CEUS examination before surgery. All masses were assessed using SR in US and SR in CEUS. To compare the diagnostic performance, the sensitivity, specificity, negative and positive predictive values, Youden index, and area under the curves values of SR in US and SR in CEUS were obtained.

RESULTS

Sensitivity, negative predictive values, Youden index, and area under the curves were better for SR in CEUS than SR in US. The specificity and negative predictive value of SR in CEUS were lower than that of SR in US. Compared with SR in US, SR in CEUS significantly reduced the number of uncertain masses (21, 36.7% vs. 66, 11.7%).

CONCLUSION

We concluded that SR in CEUS performed well in the diagnosis of malignant adnexal masses. SR in CEUS is a supplement to SR in US.

Ovarian Cancer Targeted Theranostics

Ovarian cancer is a leading cause of death from gynecological malignancies. Although the prognosis is quite favorable if detected at an early stage, the vast majority of cases are diagnosed at an advanced stage, when 5-year survival rates are only 30–40%. Most recurrent ovarian tumors are resistant to traditional therapies underscoring the need for new therapeutic options. Theranostic agents, that combine diagnostic and therapeutic capabilities, are being explored to better detect, diagnose and treat ovarian cancer. To minimize morbidity, improve survival rates, and eventually cure patients, new strategies are needed for early detection and for delivering specifically anticancer therapies to tumor sites. In this review we will discuss various molecular imaging modalities and targets that can be used for imaging, therapeutic and theranostic agent development for improved diagnosis and treatment of ovarian cancer.

The Sonographic Spectrum of Pelvic Endometriosis: Pearls, Pitfalls, and Mimics

Endometriosis is a common disease of reproductive-age women that is often first encountered with ultrasound. Therefore, familiarity with the variety of manifestations of endometriosis is important for appropriate diagnosis and management. The aim of this article is to review the spectrum of appearance of pelvic endometriosis and to discuss potential mimics on ultrasound. Given that magnetic resonance imaging is an important problem-solving tool in female pelvic imaging, magnetic resonance imaging correlation is also provided.

Ultrasound molecular imaging of ovarian cancer with CA-125 targeted nanobubble contrast agents

Ultrasound is frequently utilized in diagnosis of gynecologic malignancies such as ovarian cancer. Because epithelial ovarian cancer (EOC) is often characterized by overexpression of cancer antigen 125 (CA-125), ultrasound contrast agents able to target this molecular signature could be a promising complementary strategy. In this work, we demonstrate application of CA-125-targeted echogenic lipid and surfactant-stabilized nanobubbles imaged with standard clinical contrast harmonic ultrasound for imaging of CA-125 positive OVCAR-3 tumors in mice. Surface functionalization of the nanobubbles with a CA-125 antibody achieved rapid significantly (P < 0.05) enhanced tumor accumulation, higher peak ultrasound signal intensity and slower wash out rates in OVCAR-3 tumors compared to CA-125 negative SKOV-3 tumors. Targeted nanobubbles also exhibited increased tumor retention and prolonged echogenicity compared to untargeted nanobubbles. Data suggest that ultrasound molecular imaging using CA-125 antibody-conjugated nanobubbles may contribute to improved diagnosis of EOC.

Quantitative contrast-enhanced ultrasonography for the differential diagnosis of endometrial hyperplasia and endometrial neoplasms

The present study aimed to investigate the feasibility of applying contrast-enhanced ultrasonography (CEUS) imaging technology for distinguishing between benign and malignant endometrial lesions, and to screen markers that could be correlated with the pathological results. In this study, endometrial diseases were diagnosed by biopsy under hysteroscopy and CEUS examinations. The intensity and time parameters of the time-intensity curve (TIC) were analyzed. The mean arrival time (AT), time-to-peak (TTP), rise time (RT), washout half-time and clearance half-time of malignant lesions were shorter than those of benign lesions (P<0.05), whereas the average peak intensity (PI) and enhancement intensity (EI) of malignant lesions were higher than those of benign lesions (P<0.05). The receiver operating characteristic curve showed the following cut-off values: PI, 29.2 dB; EI, 21.35 dB; AT, 12.75 sec; TTP, 26.75 sec; RT, 13.2 sec; clearance half-time, 89.3 sec; and washout half-time, 75.45 sec. The lesions with PI, an EI higher than that of the cut-off and lesions with an AT, TTP, RT, half clearing time and washout half-time shorter than the cut-off were considered malignant. The TTP, RT and half clearing time were negatively correlated with microvessel density (MVD), i.e., MVD was higher when the TTP, RT and half clearing time were shorter. Overall, changes in the enhancement and clearing of lesions could be quantitatively analyzed by CEUS TIC and further discriminate benign from malignant lesions. In the present study, CEUS appeared to indirectly reflect blood vessel changes inside the lesions and provided a pre-operative non-invasive fast imaging method for the diagnosis of endometrial disease.

Parametric mapping of contrasted ovarian transvaginal sonography

The purpose of this study was to assess the accuracy of parametric analysis of transvaginal contrast-enhanced ultrasound (TV-CEUS) for distinguishing benign versus malignant ovarian masses. A total of 48 ovarian masses (37 benign and 11 borderline/malignant) were examined with TV-CEUS (Definity; Lantheus, North Billerica, MA; Philips iU22; Philips Medical Systems, Bothell, WA). Parametric images were created offline with a quantification software (Bracco Suisse SA, Geneva, Switzerland) with map color scales adjusted such that abnormal hemodynamics were represented by the color red and the presence of any red color could be used to differentiate benign and malignant tumors. Using these map color scales, low values of the perfusion parameter were coded in blue, and intermediate values of the perfusion parameter were coded in yellow. Additionally, for each individual color (red, blue, or yellow), a darker shade of that color indicated a higher intensity value. Our study found that the parametric mapping method was considerably more sensitive than standard region of interest (ROI) analysis for the detection of malignant tumors but was also less specific than standard ROI analysis. Parametric mapping allows for stricter cutoff criteria, as hemodynamics are visualized on a finer scale than ROI analyses, and as such, parametric maps are a useful addition to TV-CEUS analysis by allowing ROIs to be limited to areas of the highest malignant potential.

Differentiating between benign and malignant adnexal lesions with contrast-enhanced transvaginal ultrasonography

OBJECTIVE

To analyze the relationship between contrast kinetics in tumorous vessels and lesion histologic type in an attempt to differentiate between malignant and benign disease.

METHODS

In a single-center prospective study, patients who had been referred for elective surgery because of a diagnosis of unilateral and/or bilateral adnexal masses were enrolled at Dr Jan Biziel University Hospital, Bydgoszcz, Poland, between January 2012 and September 2013. Participants underwent contrast-enhanced ultrasonography examination (CEUS). Contrast kinetics were obtained and compared with the neovascularization of the tumor. Accuracy, and positive and negative predictive values were calculated.

RESULTS

Among 160 enrolled patients, 84 underwent CEUS examination and 51 lesions were studied. Baseline and maximum color Doppler intensities were significantly higher in malignant than in benign tumors (P < 0.001 for both). Similarly, the absolute and relative increases in color Doppler intensity were significantly higher in malignant tumors (P < 0.001). The estimated positive predictive value was 97.1%, the negative predictive value was 100%, and the accuracy was 100%. Peak enhanced intensity of fractional color Doppler Area and area under the time-intensity curve (S-parameter) correlated significantly with the histology of the lesion (P < 0.001). Probability curves demonstrated that higher S-parameter values were correlated with a higher risk of malignancy.

CONCLUSION

Transvaginal CEUS is a reliable and reproducible way to differentiate between benign and malignant adnexal lesions.

VEGFR2-Targeted Ultrasound Imaging Agent Enhances the Detection of Ovarian Tumors at Early Stage in Laying Hens, a Preclinical Model of Spontaneous Ovarian Cancer

Tumor-associated neoangiogenesis (TAN) is an early event in ovarian cancer (OVCA) development. Increased expression of vascular endothelial growth factor receptor 2 (VEGFR2) by TAN vessels presents a potential target for early detection by ultrasound imaging. The goal of this study was to examine the suitability of VEGFR2-targeted ultrasound contrast agents in detecting spontaneous OVCA in laying hens. Effects of VEGFR2-targeted contrast agents in enhancing the intensity of ultrasound imaging from spontaneous ovarian tumors in hens were examined in a cross-sectional study. Enhancement in the intensity of ultrasound imaging was determined before and after injection of VEGFR2-targeted contrast agents. All ultrasound images were digitally stored and analyzed off-line. Following scanning, ovarian tissues were collected and processed for histology and detection of VEGFR2-expressing microvessels. Enhancement in visualization of ovarian morphology was detected by gray-scale imaging following injection of VEGFR2-targeted contrast agents. Compared with pre-contrast, contrast imaging enhanced the intensities of ultrasound imaging significantly (p < 0.0001) irrespective of the pathological status of ovaries. In contrast to normal hens, the intensity of ultrasound imaging was significantly (p < 0.0001) higher in hens with early stage OVCA and increased further in hens with late stage OVCA. Higher intensities of ultrasound imaging in hens with OVCA were positively correlated with increased (p < 0.0001) frequencies of VEGFR2-expressing microvessels. The results of this study suggest that VEGFR2-targeted contrast agents enhance the visualization of spontaneous ovarian tumors in hens at early and late stages of OVCA. The laying hen may be a suitable model to test new imaging agents and develop targeted therapeutics.

Interleukin 16- (IL-16-) Targeted Ultrasound Imaging Agent Improves Detection of Ovarian Tumors in Laying Hens, a Preclinical Model of Spontaneous Ovarian Cancer

Limited resolution of transvaginal ultrasound (TVUS) scanning is a significant barrier to early detection of ovarian cancer (OVCA). Contrast agents have been suggested to improve the resolution of TVUS scanning. Emerging evidence suggests that expression of interleukin 16 (IL-16) by the tumor epithelium and microvessels increases in association with OVCA development and offers a potential target for early OVCA detection. The goal of this study was to examine the feasibility of IL-16-targeted contrast agents in enhancing the intensity of ultrasound imaging from ovarian tumors in hens, a model of spontaneous OVCA. Contrast agents were developed by conjugating biotinylated anti-IL-16 antibodies with streptavidin coated microbubbles. Enhancement of ultrasound signal intensity was determined before and after injection of contrast agents. Following scanning, ovarian tissues were processed for the detection of IL-16 expressing cells and microvessels. Compared with precontrast, contrast imaging enhanced ultrasound signal intensity significantly in OVCA hens at early (P < 0.05) and late stages (P < 0.001). Higher intensities of ultrasound signals in OVCA hens were associated with increased frequencies of IL-16 expressing cells and microvessels. These results suggest that IL-16-targeted contrast agents improve the visualization of ovarian tumors. The laying hen may be a suitable model to test new imaging agents and develop targeted anti-OVCA therapeutics.

Diagnostic performance of contrast-enhanced ultrasound for ovarian cancer: a meta-analysis

This meta-analysis is the first study aimed at assessing the overall diagnostic performance of contrast-enhanced ultrasound for ovarian cancer. PubMed, Embase and Medline databases were systematically searched for relevant articles published up to June 2014. Data were pooled to yield summary sensitivity, specificity, diagnostic odds ratio and receiver operating characteristic curves using Meta-Disc Version 1.4 software. Ten independent studies with 579 ovarian tumors were enrolled in this meta-analysis. The pooled sensitivity, specificity and diagnostic odds ratio statistics were 0.89 (0.83-0.94), 0.91 (0.88-0.93) and 91.70 (41.41-203.05), respectively, and the area under the summary receiver operating characteristic curve was 0.9619 (standard error: 0.0125), all indicating that contrast-enhanced ultrasound has high diagnostic accuracy in differentiation of malignant from benign ovarian tumors.

Contrast-enhanced ultrasonography in differential diagnosis of benign and malignant ovarian tumors

Objective

To evaluate the accuracy of contrast-enhanced ultrasonography (CEUS) in differential diagnosis of benign and malignant ovarian tumors.

Methods

The scientific literature databases PubMed, Cochrane Library and CNKI were comprehensively searched for studies relevant to the use of CEUS technique for differential diagnosis of benign and malignant ovarian cancer. Pooled summary statistics for specificity (Spe), sensitivity (Sen), positive and negative likelihood ratios (LR⁺/LR⁻), and diagnostic odds ratio (DOR) and their 95%CIs were calculated. Software for statistical analysis included STATA version 12.0 (Stata Corp, College Station, TX, USA) and Meta-Disc version 1.4 (Universidad Complutense, Madrid, Spain).

Results

Following a stringent selection process, seven high quality clinical trials were found suitable for inclusion in the present meta-analysis. The 7 studies contained a combined total of 375 ovarian cancer patients (198 malignant and 177 benign). Statistical analysis revealed that CEUS was associated with the following performance measures in differential diagnosis of ovarian tumors: pooled Sen was 0.96 (95%CI = 0.92∼0.98); the summary Spe was 0.91 (95%CI = 0.86∼0.94); the pooled LR⁺ was 10.63 (95%CI = 6.59∼17.17); the pooled LR− was 0.04 (95%CI = 0.02∼0.09); and the pooled DOR was 241.04 (95% CI = 92.61∼627.37). The area under the SROC curve was 0.98 (95% CI = 0.20∼1.00). Lastly, publication bias was not detected (t = −0.52, P = 0.626) in the meta-analysis.

Conclusions

Our results revealed the high clinical value of CEUS in differential diagnosis of benign and malignant ovarian tumors. Further, CEUS may also prove to be useful in differential diagnosis at early stages of this disease.

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.

Biomarkers for early detection of ovarian cancer

Ovarian cancer is the most lethal gynecological malignancy. However, effective screening strategies have not been established and continue to be elusive. A good screening test must adequately address validity, reliability, yield, cost, acceptance and follow-up services. An ideal screening test for ovarian cancer must have a high sensitivity in order to correctly diagnose all women with the disease and a high specificity to avoid false-positive results. The current screening modalities of bimanual examination, CA-125 and transvaginal ultrasonography together allow us to detect only 30-45% of women with early-stage disease. Recent developments in proteomic and genomic research have identified a number of potential biomarkers. Although panels of tumor markers and proteomic-based technologies may improve the positive predictive value, all markers require validation and interfacing with newly developed diagnostic imaging technologies. While a large amount of information on miRNAs has been promising, much remains to be elucidated. This review will examine the current status of biomarkers and technologies of interest in the effort of early detection of ovarian cancer.

Quantitative assessment of tumor angiogenesis using real-time motion-compensated contrast-enhanced ultrasound imaging

PURPOSE

To develop and test a real-time motion compensation algorithm for contrast-enhanced ultrasound imaging of tumor angiogenesis on a clinical ultrasound system.

MATERIALS AND METHODS

The Administrative Institutional Panel on Laboratory Animal Care approved all experiments. A new motion correction algorithm measuring the sum of absolute differences in pixel displacements within a designated tracking box was implemented in a clinical ultrasound machine. In vivo angiogenesis measurements (expressed as percent contrast area) with and without motion compensated maximum intensity persistence (MIP) ultrasound imaging were analyzed in human colon cancer xenografts (n = 64) in mice. Differences in MIP ultrasound imaging signal with and without motion compensation were compared and correlated with displacements in x- and y-directions. The algorithm was tested in an additional twelve colon cancer xenograft-bearing mice with (n = 6) and without (n = 6) anti-vascular therapy (ASA-404). In vivo MIP percent contrast area measurements were quantitatively correlated with ex vivo microvessel density (MVD) analysis.

RESULTS

MIP percent contrast area was significantly different (P < 0.001) with and without motion compensation. Differences in percent contrast area correlated significantly (P < 0.001) with x- and y-displacements. MIP percent contrast area measurements were more reproducible with motion compensation (ICC = 0.69) than without (ICC = 0.51) on two consecutive ultrasound scans. Following anti-vascular therapy, motion-compensated MIP percent contrast area significantly (P = 0.03) decreased by 39.4 ± 14.6 % compared to non-treated mice and correlated well with ex vivo MVD analysis (Rho = 0.70; P = 0.05).

CONCLUSION

Real-time motion-compensated MIP ultrasound imaging allows reliable and accurate quantification and monitoring of angiogenesis in tumors exposed to breathing-induced motion artifacts.

Radiological assessment of gynecologic malignancies

Patients with gynecologic malignancies are evaluated with a combination of imaging modalities including ultrasonography (US), computed tomography (CT), and magnetic resonance (MR) imaging. US has a primary role in detecting and characterizing endometrial and adnexal pathology. CT is one of the primary modalities in staging malignancy and detecting recurrence. MR imaging is characterized by superior contrast resolution and specificity. This article reviews the role of radiologic imaging for the characterization of gynecologic masses and for staging, planning, and monitoring treatment, as well as for the assessment of tumor recurrence of the most common gynecologic malignancies.

Ultrasound and ovarian cancer screening: is there a future?

Ovarian cancer is a leading cause of death due to gynecologic malignant disease. Advances in ultrasound have improved the ability to identify the more subtle characteristics of adnexal masses, resulting in an increasing volume of research addressing its use to accurately predict whether masses are benign or malignant, and the inclusion of ultrasound in large-scale studies addressing screening for ovarian cancer. Herein, we explore some of the factors that make screening for ovarian cancer challenging, review the major trials addressing the effect of ovarian cancer screening, and examine data relating to more recent advances in ultrasound technology.

Study on the characteristics of contrast-enhanced ultrasound and its utility in assessing the microvessel density in ovarian tumors or tumor-like lesions

Angiogenesis is a critical factor in tumor growth and metastasis, and microvessel density (MVD) was an important parameter for assessing vessels in tumors. However, radiologic assessment of tumor vascularity is not yet well established. In our study, we aimed at investigating the efficacy of contrast-enhanced ultrasonography (CEUS) in exploring the vascularity of the ovarian tumors or tumor-like lesions to assess the relationship between the parameters of the peak intensity (PI) and area under curve (AUC) on CEUS and MVD in ovarian masses. Compared to the contrast-enhanced ultrasound technique, conventional ultrasound shows limitation in differentiating benign and malignant ovarian tumors. The former is promising in improving the sensitivity of detecting small vessels and blood flow in ovarian tumors. Our results showed clear differences in enhancement patterns between benign and malignant ovary tumors or tumor-like lesions. The PI and AUC in the malignant tumors were significantly higher than those in the benign tumors or tumor-like lesions (p=0.001 and =0.01, respectively). The MVD was 43.1 ± 20.4 in the benign tumors or tumor-like lesions and was 65.3 ± 22.3 in the malignant ones (p= 0.01). In both the benign and malignant groups, the PI and AUC were correlated significantly with the MVD (r=0.595, p = 0.001; r =0.533, p = 0.003, respectively). The PI and AUC in CEUS can reflect the MVD in ovarin tumors. The PI and AUC of the ovarian masses in the contrast transvaginal sonography show significant correlation with the angiogenesis and may help in assessing tumor vascularity in ovarian masses.

ACR appropriateness criteria© ovarian cancer screening

The majority of women with ovarian cancer have advanced stage disease at the time of diagnosis and a poor 5 year survival rate. Hence, screening has been investigated in the hopes of improving survival by diagnosing ovarian cancer at an earlier stage. Most screening methods thus far have included ultrasound and/or serum tumor markers. However, low prevalence of the disease, high false positive rate of current screening methods, and the probable rapid growth of most ovarian carcinomas from no defined precursor lesion, all contribute to difficulty in screening for ovarian cancer. While screening may be able to detect ovarian cancer at an earlier stage, adequate data is presently lacking on whether screening improves survival. The results of ongoing large clinical trials will be available in a few years and should provide critical information regarding the usefulness of screening. Pending results of those large clinical trials, screening is not currently recommended for women at average risk for ovarian cancer. Screening is most likely to be performed in women with an increased familial risk of ovarian cancer, but patients should be aware that even with this risk factor, there is currently insufficient evidence to know if screening is effective. New screening methods, including new or multiple serum markers and proteomics, are also being investigated.

Contrast-enhanced sonography depicts spontaneous ovarian cancer at early stages in a preclinical animal model

OBJECTIVE

Our goal was to examine the feasibility of using laying hens, a preclinical model of human spontaneous ovarian cancer, in determining the kinetics of an ultrasound contrast agent indicative of ovarian tumor-associated neoangiogenesis in early-stage ovarian cancer.

METHODS

Three-year-old White Leghorn laying hens with decreased ovarian function were scanned before and after intravenous injection of a human serum albumin-perflutren contrast agent at a dose of 5 μL/kg body weight. Gray scale morphologic characteristics, Doppler indices, the arrival time, peak intensity, and wash-out of the contrast agent were recorded and archived on still images and video clips. Hens were euthanized thereafter; sonographic predictions were compared at gross examination; and ovarian tissues were collected. Archived clips were analyzed to determine contrast parameters and Doppler intensities of vessels. A time-intensity curve per hen was drawn, and the area under the curve was derived. Tumor types and the density of ovarian microvessels were determined by histologic examination and immunohistochemistry and compared to sonographic predictions.

RESULTS

The contrast agent significantly (P < .05) enhanced the visualization of microvessels, which was confirmed by immunohistochemistry. Contrast parameters, including the time of wash-out and area under the curve, were significantly different (P < .05) between ovaries of normal hens and hens with ovarian cancer and correctly detected cancer at earlier stages than the time of peak intensity.

CONCLUSIONS

The laying hen may be a useful animal model for determining ovarian tumor-associated vascular kinetics diagnostic of early-stage ovarian cancer using a contrast agent. This model may also be useful for testing the efficacy of different contrast agents in a preclinical setting.

Preoperative diagnosis of ovarian tumors using pelvic contrast-enhanced sonography

OBJECTIVE

The purpose of this study was to assess the feasibility of using a contrast agent for the sonographic examination of adnexal tumors and identify discriminating parameters in the preoperative diagnosis of malignant tumors.

METHODS

We conducted a prospective descriptive monocenter study that analyzed validated echographic criteria and parameters of the enhancement curve obtained by sonographic contrast agent injection. Patients included were referred for a second opinion after the discovery of a suspicious ovarian image. The final diagnosis was reached after surgery and an anatomopathologic examination.

RESULTS

Fifty-two tumors were analyzed. Morphologic and Doppler criteria analyses were conducted as described in the literature. The significant parameters of the enhancement curve were the time-intensity curve total area and the duration of activity of the contrast agent during the first phase of decay (P < .002). The performance of the contrast agent was lower than that of the examiner's subjective diagnosis, with an area under the receiver operating characteristic curve (AUC) of 0.78 versus 0.80. When borderline tumors were eliminated, there was an inversion of this, with an AUC of 0.85 versus 0.73. The inclusion of contrast results in the examiner's diagnosis in the context of a bivariate model comparing malignant and borderline tumors with benign tumors provided an AUC of 0.88.

CONCLUSIONS

Contrast-enhanced sonography improves preoperative diagnosis of ovarian tumors parameters. The significant parameters of the enhancement curve were significantly different for malignant and benign tumors. Borderline tumors contribute to a reduction of the discriminating capacity of the contrast agent.

New frontiers for ovarian cancer risk evaluation: proteomics and contrast-enhanced ultrasound

OBJECTIVE

The grim ovarian cancer statistics are attributed to the fact that most women typically present with widespread disease at the time of initial diagnosis. Our current diagnostic tools, such as pelvic examination and standard ultrasound, are inadequate to detect early-stage epithelial ovarian cancer. In recent years there has been an explosion of important advances in biomedical engineering, proteomic technologies, and computational analyses that has led to the identification of hundreds of previously unknown proteins unique to the pathophysiology of ovarian cancer, some of which are currently under clinical validation. At present, no one biomarker exists with 100% specificity and sensitivity for the accurate detection of early-stage epithelial ovarian cancer.

CONCLUSION

As the search for a panel of biomarkers detecting cancer, let alone early-stage disease, progresses, diagnostic imaging will continue to play a critical role to confirm or refute these biomarker assays. Interestingly, recent studies using contrast-enhanced ultrasound have shown potential as an early-detection tool by detecting the aberrant vascularity required for tumor growth before the development of a mass. Thus, we propose that the use of proteomic-based biomarker discovery and contrast-enhanced ultrasound may serve as a promising combination to help accurately identify early-stage epithelial ovarian cancer to improve women's health care.