Three-dimensional power Doppler vascular sampling: a new method for predicting ovarian cancer in vascularized complex adnexal masses.

OBJECTIVE: The purpose of this study was to explore the role of a new concept ("vascular sampling") as a third step to discriminate benign and malignant lesions in B-mode and color Doppler sonographically suggestive adnexal masses. METHODS: Forty-five women (mean age, 52.3 years; range, 17-82 years) with the diagnosis of complex adnexal masses on B-mode sonography were evaluated using 3-dimensional power Doppler sonography. Four women had bilateral masses. After a morphologic reevaluation was done, color pulsed Doppler sonography was used to obtain flow velocity waveforms, and velocimetric indices were calculated (resistive index, pulsatility index, and peak systolic velocity). Thereafter, 3-dimensional power Doppler sonography was used to assess vascularization of highly suggestive areas (gross papillary projections, solid areas, and thick septations), meaning a focused assessment ("sampling") of a suggestive area of the tumor. With a virtual organ computer-aided analysis program, vascular indices (vascularization index, flow index, and vascular flow index) were automatically calculated. A definitive histologic diagnosis was obtained in each case. RESULTS: Forty masses (82%) were malignant and 9 (18%) were benign. Morphologic evaluation revealed 10 (20%) unilocular solid masses, 20 (41%) multilocular solid masses, and 19 (39%) mostly solid masses. Blood flow was found in all cases. Median vascularization index (15.5% versus 8.2%; P = .002), flow index (33.6 versus 20.8; P = .007), and vascular flow index (5.2 versus 2.3; P = .001) were significantly higher in malignant tumors. No differences were found in resistive index (0.43 versus 0.45; P = .770), pulsatility index (0.62 versus 0.65; P = .694), and peak systolic velocity (15.6 versus 12 cm/s; P = .162). CONCLUSIONS: Three-dimensional power Doppler vascular sampling seems to be a promising tool for predicting ovarian cancer in vascularized complex adnexal masses. It could be better than conventional color pulsed Doppler imaging.     

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.     

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

OBJECTIVE: The purpose of this study was to assess whether endometrial volume (EV) and 3-dimensional (3D) power Doppler indices can discriminate between hyperplasia and endometrial carcinoma and can predict extension of the endometrial carcinoma. METHODS: Eighty-four women with uterine bleeding and a histopathologic diagnosis of endometrial hyperplasia (n = 29) or carcinoma (n = 55) were preoperatively examined by transvaginal 3D sonography and power Doppler angiography. Endometrial thickness (ET), EV, the vascularization index (VI), the flow index (FI), the vascularization-flow index (VFI), and the intratumoral resistive index (RI) were measured. A histopathologic diagnosis was made after endometrial biopsy was performed by hysteroscopy or curettage. RESULTS: The EV and 3D power Doppler indices (VI, FI, and VFI) were significantly higher in endometrial carcinoma than endometrial hyperplasia, whereas the intratumoral RI was significantly lower (P < .05). A VFI of 2.07 was the best cutoff for predicting endometrial carcinoma, with sensitivity of 76.5% and specificity of 80.8%. No significant differences were noticed for ET. The endometrial VI was significantly higher when the tumor stage was greater than I. All the 3D power Doppler indices were significantly higher when the carcinoma infiltrated more than 50% of the myometrium. The intratumoral RI was significantly lower in cases with a high histologic grade, myometrial infiltration of more than 50%, and lymph node metastases. CONCLUSIONS: The VI, 3D power Doppler indices, and the intratumoral RI are more useful than ET for differentiating between hyperplasia and endometrial carcinoma. Intratumoral blood flow evaluated by pulsed Doppler sonography and 3D power Doppler angiography can predict the spread of endometrial carcinoma.     

Sonographic depiction of intratumoral vascularity with 2- and 3-dimensional color Doppler techniques.

OBJECTIVE: The purpose of this study was to describe patterns seen on 2- and 3-dimensional color Doppler sonographic depiction of intratumoral vessels and to correlate these patterns to histopathologic findings in an attempt to assess their clinical importance. METHODS: We conducted a retrospective analysis of 26 patients with ovarian masses and intratumoral abnormalities in whom standard 2- and 3-dimensional color Doppler sonography was performed. RESULTS: Two- and 3-dimensional color Doppler sonography depicted several patterns of vascularity within ovarian masses. These included masses with vascularity confined to the wall or loculus and those with central versus peripheral vascularity. The presence of central intratumoral vascularity had a high positive predictive value (90%) for malignancy. Conversely, the absence of intratumoral vascularity had a high negative predictive value (96%). CONCLUSIONS: Three-dimensional color Doppler sonography is helpful in depicting overall vessel density and branching patterns within an intratumoral abnormality. This technique seems to be useful in distinguishing benign from malignant ovarian masses.     

Intraobserver and interobserver reproducibility of 3-dimensional power Doppler vascular indices in assessment of solid and cystic-solid adnexal masses.

OBJECTIVE: The purpose of this study was to assess the intraobserver and interobserver reproducibility of 3-dimensional (3D) power Doppler angiography-derived vascular indices in evaluation of vascularized solid and cystic-solid adnexal masses. METHODS: Stored 3D power Doppler angiographic volume data from 12 consecutive women with a diagnosis of a complex adnexal mass (6 cystic-solid and 6 solid) evaluated and treated at our institution were retrieved from our database for analysis. Two examiners performed the calculations blinded to each other. Calculations were performed offline in a computer using Virtual Organ Computer-Aided Analysis software (plane A, 9 degrees rotation step) to assess volume and vascularization (vascularization index, flow index, and vascularization-flow index) from solid areas within the tumor. In all cases, a definitive histologic diagnosis was obtained. Intraobserver and interobserver reproducibility was assessed by calculating the intraclass and interclass correlation coefficients for each index. RESULTS: All tumors proved to be malignant after surgical removal. Intraobserver reproducibility for both examiners and interobserver reproducibility were high for all indices (interclass correlation coefficient > 0.95). CONCLUSIONS: Three-dimensional power Doppler angiography is a reproducible technique for offline assessment of stored 3D volume data of vascularized adnexal masses.     

Three‐Dimensional Power Doppler Vascular Sonographic Sampling for Predicting Ovarian Cancer in Cystic‐Solid and Solid Vascularized Masses

Objective. The purpose of this study was to explore the role of 3‐dimensional (3D) power Doppler (PD) sonography to discriminate between benign and malignant cystic‐solid and solid vascularized adnexal masses and to define cutoff values for 3D PD indices to be used in a clinical setting. Methods. A total of 143 consecutive women (mean age, 50.4 years; range, 17–82 years) with diagnoses of cystic‐solid or solid vascularized adnexal masses on B‐mode and 2‐dimensional PD sonography were evaluated by 3D PD sonography before surgery. Three‐dimensional PD sonography was used to assess vascularization within papillary projections and solid areas with a virtual organ computer‐aided analysis program. Three‐dimensional PD vascular indices (vascularization index [VI], flow index [FI], and vascularization‐flow index [VFI]) were automatically calculated. A definitive histologic diagnosis was obtained in each case. Results. A total of 113 masses (74%) were malignant, and 39 (26%) were benign. Morphologic evaluation revealed 30 unilocular solid masses (19.7%), 43 multilocular solid masses (28.3%), and 79 mostly solid masses (52%). The mean VI (9.365% versus 3.3%; P < .001), FI (34.318 versus 28.794; P < .001), and VFI (3.233 versus 1.15; P < 0.01) were significantly higher in malignant tumors. No differences were found in the resistive index, pulsatility index, and peak systolic velocity. Receiver operating characteristic analysis revealed an area under the curve of 0.77 (95% confidence interval, 0.69–0.85), 0.71 (0.60–0.81), and 0.75 (0.66–0.83) for the VI, FI and VFI, respectively. For reducing the false‐positive rate by almost one‐third, sensitivity values for the VI (cutoff, 1.556%), FI (25.212), and VFI (0.323) were 92%, 95%, and 93%, respectively. Conclusions. Three‐dimensional PD vascular indices could be helpful for reducing the false‐positive rate in cystic‐solid and solid vascularized adnexal masses.     

Three-dimensional sonographic morphologic assessment of adnexal masses: a reproducibility study.

OBJECTIVE: The purpose of this study was to assess the reproducibility of 3-dimensional (3D) sonography for classifying adnexal masses. METHODS: Eighty-two consecutive women with the diagnosis of an adnexal mass on 2-dimensional transvaginal sonography were reevaluated by 3D sonography, and 3D volume data from each mass were stored. Two different examiners (6 years and 1 year of experience in 3D sonography, respectively) reviewed 3D sonograms 1 month after the last patient was recruited and then 1 week later again. Masses had to be classified as benign or malignant. Criteria suggestive of malignancy were the presence of a thick wall, gross papillary projections, solid areas, and solid echogenicity. A definitive histologic diagnosis was obtained in every case. Intraobserver and interobserver agreement was estimated by calculating the Cohen kappa index. RESULTS: Twenty-seven (33%) tumors were malignant, and 55 (67%) were benign. Intraobserver agreement for both examiners was good (kappa = 0.78 and 0.72, respectively). Interobserver agreement was also good (kappa = 0.70). CONCLUSIONS: Three-dimensional sonography is a reproducible technique for morphologic assessment of adnexal masses.     

Complex pelvic mass as a target of evaluation of vessel distribution by color Doppler sonography for the diagnosis of adnexal malignancies: results of a multicenter European study.

OBJECTIVE: To compare the diagnostic accuracy of gray scale sonography and color Doppler imaging in the differential diagnosis of adnexal malignancies from benign complex pelvic masses in a multicenter prospective study. METHODS: The study was performed as a collaborative work at 3 European university departments of obstetrics and gynecology. A total of 826 complex pelvic masses on which transvaginal sonography and evaluation of cancer antigen 125 plasma concentrations were performed before surgical exploration were included in the study. The scanning procedure was the same in the 3 institutions. An adnexal mass was first studied in gray scale sonography, and a probable histologic type was predicted. Second, solid excrescences or solid portions of the tumor were evaluated for vascular flow with color Doppler sonography (conventional or power). A mass was graded malignant if flow was shown within the excrescences or solid areas and benign if there was no flow. The overall agreement between the test result and the actual outcome was calculated by kappa statistics. RESULTS: Color Doppler evaluation was more accurate in the diagnosis of adnexal malignancies in comparison with gray scale sonography (kappa = 0.82 and 0.65, respectively) because of significantly higher specificity (0.94 versus 0.84; P < .001). The evaluation of the cancer antigen 125 plasma concentration did not seem to increase the accuracy of either method. CONCLUSIONS: The evaluation of vessel distribution by color Doppler sonography in complex adnexal cysts seems to increase the diagnostic accuracy of gray scale sonography in the detection of adnexal malignancies in a large study population.     

Does quantitative analysis of three-dimensional power Doppler angiography have a role in the diagnosis of malignant pelvic solid tumors? A preliminary study.

OBJECTIVE: To investigate the role of a simplified method for the three-dimensional (3D) quantification of tumor vascularity in the differential diagnosis of solid pelvic masses. METHODS: Twenty-four patients with a solid pelvic mass on B-mode ultrasound evaluation underwent 3D power Doppler evaluation before surgery. The volume of interest was obtained by drawing the largest section of the mass in three orthogonal planes. The following 3D vascular parameters were calculated for all patients: relative color, average color and flow measure. Receiver-operating characteristics curve analysis was used to choose the best cut-off value. The overall agreement between the test result and the actual outcome was calculated using kappa statistics. RESULTS: Fifteen of 24 subjects were found to have pelvic malignancy. The relative color and the flow measure were significantly higher in malignant (9.7 (8.98) and 8.95 (8.78) (median (interquartile range (IQR)), respectively) than in benign masses (2 (4.42) and 1.79 (4.71), respectively; P < 0.05) but there was no difference in the average color. The best cut-off values of relative color and flow measure were 3.2 and 2.8, respectively. The use of relative color showed a sensitivity of 80% with a specificity of 67% with an overall agreement that was higher, though only marginally so, than that of qualitative 3D power Doppler (kappa = 0.47 and 0.44, respectively). CONCLUSIONS: In a small group of pelvic masses that appear malignant on B-mode ultrasonography, the use of 3D quantification of tumor vascularity yields a diagnostic accuracy that is similar to that of subjective evaluation of vascularity. We suspect, however, that the quantitative method will produce more consistent results between operators.     

Correlation between color power Doppler sonographic measurement of breast tumor vasculature and immunohistochemical analysis of microvessel density for the quantitation of angiogenesis.

OBJECTIVE: To record the correlation between color power Doppler sonographic measurement of breast tumor vasculature and immunohistochemical analysis of microvessel density for the quantitation of angiogenesis. METHODS: Women with palpable breast masses scheduled for excision biopsy were scanned with two- and three-dimensional color power Doppler sonography before and after the administration of a sonographic contrast agent. Vessel counts were performed on two- and three-dimensional sonographic images before and after contrast agent administration. All tumors were surgically removed and underwent immunohistochemical analysis for microvessel density assessment. The sonographic measure of tumor vascularity was correlated with microvessel density. RESULTS: Pathologic examination showed 43 breast cancers and 14 benign breast masses. Higher microvessel density was noted in malignant than benign breast masses (P < .0005). Color power Doppler sonographic measurement of tumor vessel number showed a significant positive correlation with tumor size (P < .05) and progesterone receptor negativity (P < .05). A significant positive correlation was observed between microvessel density and the number of intratumoral blood vessels assessed by both two- and three-dimensional color power Doppler sonography (P < .05). Regression models showed three-dimensional color power Doppler sonography to have a significantly higher correlation with microvessel density when compared with two-dimensional color power Doppler sonography at baseline (P < .005). The administration of a sonographic contrast agent did not improve correlation with microvessel density. CONCLUSIONS: A significant correlation was shown between color power Doppler sonographic measurement of tumor vascularity and microvessel density by immunohistochemical analysis. Further improvement in Doppler sonographic techniques to map capillary vessel flow should be explored to improve the current association with pathologic findings.     

Three-dimensional power Doppler vascular network assessment of adnexal masses: intraobserver and interobserver agreement analysis.

OBJECTIVE: The purpose of this study was to assess intraobserver and interobserver agreement for tumor vascular network evaluation as assessed by 3-dimensional (3D) power Doppler sonography for discriminating benign from malignant adnexal masses. METHODS: Stored 3D power Doppler angiographic volume data from 39 women with a diagnosis of a vascularized adnexal mass who were evaluated and treated at our institution were retrieved from our database for analysis. Two different examiners (observer A, with 6 years of experience in 3D sonography; and observer B, with 1 year of experience) reviewed 3D sonograms blinded to each other. Three-dimensional vascular network reconstruction was done with surface rendering in the color mode. Malignancy was considered in the presence of at least 2 of the following: irregular branching, vessel caliber changes, microaneurysms, and vascular lakes. A definitive histologic diagnosis was obtained in all cases. Intraobserver and interobserver agreement rates were estimated by calculating the kappa index. RESULTS: Twenty (51%) tumors were malignant, and 19 (49%) were benign. Intraobserver agreement was good for observer A (kappa = 0.69) and moderate for observer B (kappa = 0.54). Interobserver agreement was moderate (kappa = 0.49). CONCLUSIONS: We found intraobserver and interobserver agreement to be moderate for 3D power Doppler assessment of the vascular network in adnexal masses.     

Contrast-enhanced power Doppler sonography in breast lesions: effect on differential diagnosis after mammography and gray scale sonography.

OBJECTIVE: To evaluate the efficacy of contrast-enhanced power Doppler sonography in the differential diagnosis of breast lesions after a mammography-gray scale sonography combination. METHODS: Sixty-eight patients with 69 breast masses underwent power Doppler sonography before and after intravenous injection of a contrast agent. The lesions were diagnosed as "highly suggestive of malignancy" (category 5; n = 32), "suspicious" (category 4; n = 21), and "probably benign" (category 3; n = 16) by mammography and gray scale sonography, modeled on the American College of Radiology Breast Imaging Reporting and Data System classification. Power Doppler findings did not affect patient treatment. The authors subjectively evaluated the estimated area of vascularity, degree of enhancement following contrast agent administration, morphologic features, and distribution of vessels within the lesions. RESULTS: The final diagnoses were malignant in 28 lesions and benign in 41. Significant enhancement after contrast agent injection was detected in both the malignant and benign groups. Only 2 criteria, estimated area of vascularity and degree of enhancement following contrast agent administration, proved to be significant diagnostic determinants for contrast-enhanced power Doppler sonography (P < .001; interobserver agreements, 74.4 and 77.8, respectively). Contrast-enhanced power Doppler sonography provided a higher specificity, positive predictive value, and negative predictive value than power Doppler sonography but a lower sensitivity and negative predictive value than mammography-gray scale sonography. Only in the category 4 lesions could the combination of mammography-gray scale sonography and contrast-enhanced power Doppler sonography accomplish a higher specificity (71%) and positive predictive value (70%) than mammography-gray scale sonography (39% and 53%, respectively). CONCLUSIONS: Power Doppler and contrast-enhanced power Doppler sonography cannot be recommended as confirmatory tests in Breast Imaging Reporting and Data System category 3 and category 5 lesions. Although contrast-enhanced power Doppler sonography may help reduce unnecessary biopsies in Breast Imaging Reporting and Data System category 4 lesions, recommendation of its use has many drawbacks, such as imperfectly established criteria, lack of absolute certainty, and high cost.     

Spherical tissue sampling in 3-dimensional power Doppler angiography: a new approach for evaluation of ovarian tumors.

OBJECTIVE: The purpose of this study was to evaluate the usefulness of virtual spherical tissue sampling using 3-dimensional (3D) ultrasound power Doppler angiography to enhance differentiation between normal and pathologic ovaries. METHODS: Twenty-seven cases with ovarian tumors were analyzed: 14 with invasive cancers and 13 with borderline tumors confirmed by surgery. The control subjects consisted of 53 healthy ovulating women. Ultrasound scans were done, and 3D volumes were analyzed with 3-/4-dimensional software for personal computers based on 3D vascularity indices: the vascularization index, flow index, and vascularization-flow index. A virtual spherical tissue sample of 1 cm3 was taken from the place of the highest vessel density contained completely within the contours of the ovary. Calculations for the whole solid volume were done for comparison. RESULTS: Vascularity indices for both 1-cm3 spherical samples and whole dense parts of the ovaries were compared in the following groups: (1) ovarian tumors versus controls, (2) normal ovaries in the proliferative versus secretory phase, (3) invasive cancers versus borderline tumors, (4) invasive cancers versus normal ovaries, and (5) borderline tumors versus normal ovaries. Spherical 1-cm3 sampling achieved a higher degree of discrimination between the groups compared with the whole solid-part approach. CONCLUSIONS: Spherical 1-cm3 sampling of ovarian tissue with 3D ultrasound power Doppler angiography is a sensitive and promising approach to differentiate between ovarian tumors and normal ovaries. It opens the possibility to implement objective computerized positioning, standardized comparison, and analysis of ovarian tumors.     

三维能量多普勒超声与血管造影对比观察肿瘤血管

目的：与血管造影对比。评价三维能量多普勒超声在观察肿瘤血上的可靠性和对肿瘤定性诊断的准确性。方法：58例经病理证实的腹部肿瘤患者接受三维能量多普勒超声检查,其中肝细胞性肝癌25例。肾癌5例。肝转移癌16例,肝血管瘤8例,肾血管瘤4例。58例中28例在一周内进行血管造影。结果：三维多普勒超声显示出肿瘤周连粗大、弯曲的供血动脉向肿瘤内部延伸,在肝转移瘤病例,可见肿瘤周边正常粗细的敌国管受压变形、移位并环绕肿瘤,在肝血管瘤,表现为肿瘤内部无明显血管,肿瘤周围可见部分血管环绕。结论：肿瘤三维能量多普勒超声图像与篾这造影动脉期图像非常相似,能准确显示肿瘤内部及周连的血流情况。三维能量多普勒超声显示肿瘤积压流的明显差异有助于鉴别肿瘤的性质。     

Transvaginal gray scale and color Doppler sonography in primary ovarian cancer and metastatic tumors to the ovary.

OBJECTIVE: To compare gray scale and color Doppler features of primary and metastatic ovarian carcinomas. METHODS: Clinical, sonographic (gray scale and color Doppler), and histopathologic data of 143 patients with primary (n = 127 adnexal masses) and metastatic (n = 34 adnexal masses) ovarian cancer were reviewed. Morphologic gray scale parameters assessed were bilaterality, tumor volume, echogenicity, and presence of septa, papillary projections, or solid areas. Color Doppler parameters were presence of blood flow, tumor blood flow location (central versus peripheral), subjective impression of blood flow amount (scanty, moderate, or abundant), lowest resistive index, lowest pulsatility index, and maximal peak systolic velocity (centimeters per second). RESULTS: No statistical differences were found in bilaterality, tumor volume, presence of septa, papillary projections or solid areas, presence of blood flow, tumor blood flow location, subjective impression of blood flow amount, lowest resistive index, lowest pulsatility index, and maximal peak systolic velocity. Metastatic carcinomas were more frequently purely solid tumors (47% versus 26%; P = .001; likelihood ratio, 2.4; 95% confidence interval, 1.2-4.7). CONCLUSIONS: The presence of a purely solid tumor indicates a higher probability of metastatic carcinoma than primary ovarian cancer. However, with the use of gray scale and color Doppler sonography, it is difficult to differentiate primary ovarian carcinomas from metastatic tumors to the ovary.     

Three‐Dimensional Vascular Indices Calculated Using Conventional Power Doppler and High‐Definition Flow Imaging

Objective. The purpose of this study was to determine whether there are differences in 3‐dimensional (3D) vascular indices when calculated using high‐definition flow imaging (HDF) and power Doppler imaging (PD). Methods. Twenty‐five consecutive asymptomatic premenopausal women (mean age, 31 years; range, 28–33 years) without a history of gynecologic disease who attended routine gynecologic checkups were included in the study. All women had regular menstrual cycles, and none had uterine or myometrial disease detected on basal transvaginal sonography. All women underwent 3D transvaginal sonography. In each patient, a first volume using conventional PD was obtained, immediately followed by a second volume using HDF. Volumes were stored and subsequently analyzed for calculating 3D vascular indices (vascularization index [VI], flow index [FI], and vascularization‐flow index [VFI]) from the endometrium. Results. The median VI, FI, and VFI were significantly higher when calculated using HDF compared with conventional PD (P < .05). Conclusions. Three‐dimensional vascular indices calculated using HDF are higher than those calculated using conventional PD.     

Three-dimensional power Doppler sonography in the prenatal diagnosis of a true knot of the umbilical cord: value and limitations.

OBJECTIVE: The purpose of this study was to examine the value of 3-dimensional power Doppler sonography in the prenatal diagnosis of a true knot of the umbilical cord. METHODS: Cases in which the diagnosis of a true knot of the umbilical cord was suspected by prenatal 2-dimensional sonography were reviewed. The presumably affected segment of the cord was examined with 3-dimensional power Doppler sonography for further characterization. Confirmation of the prenatal diagnosis was sought by reviewing the delivery records and contacting the referring obstetrician and the patients themselves. RESULTS: Eight consecutive cases were studied. Three-dimensional power Doppler sonography displayed a vascular spatial configuration pattern consistent with a true knot of the umbilical cord in all of them. However, the prenatal diagnosis was confirmed at delivery in only 5 cases (62.5%). Although there were no cases of a false knot mimicking a true knot of the umbilical cord, all incorrect diagnoses in this series were associated with multiple loops of the umbilical cord in the third trimester. CONCLUSIONS: Three-dimensional power Doppler sonography seems to be helpful in determining the presence of a true knot of the umbilical cord in utero, especially in the second trimester. However, this should not be considered a definitive method for the diagnosis because multiple loops of the umbilical cord lying close to each other can generate a sonographic image that can be undistinguishable from a true knot of the umbilical cord prenatally, especially when located in a small pocket of amniotic fluid. Therefore, the presumable diagnosis of a true knot of the umbilical cord in utero should be taken with caution.     

Role of color and power doppler imaging in differentiating between malignant and benign solid breast masses

PURPOSE: This study analyzed the color and power Doppler signals in solid breast masses and assessed their value in differentiating malignant from benign lesions. METHODS: One hundred twenty-nine biopsy-proven solid breast masses (54 malignant and 75 benign) were evaluated with color and/or power Doppler sonography using a 7-MHz linear-array transducer. We retrospectively analyzed the location, shape, and penetration of the Doppler vascular signals in the breast masses. The location of the vascular signals was categorized as central, peripheral, or both. The shape of the signals was categorized as linear, irregular, branching, or a single dot. A penetrating vessel was defined as a continuous vascular signal extending from outside the lesion to inside it. In 43 cases, power and color Doppler sonograms were compared. RESULTS: Doppler features suggestive of malignant lesions were the presence of both peripheral and central vascularity (odds ratio, 6.0), presence of penetrating vessels (odds ratio, 5.4), and presence of branching vessels (odds ratio, 13.7). Power Doppler sonography was more sensitive than color Doppler sonography in detecting vascular signals in 49% of cases. CONCLUSIONS: Color (power) Doppler imaging is a valuable adjunct to conventional sonography in differentiating between malignant and benign breast lesions.     

Contrast-enhanced power Doppler sonography of ductal pancreatic adenocarcinomas: correlation with digital subtraction angiography findings

PURPOSE: The purpose of this prospective study was to utilize contrast-enhanced power Doppler sonography to evaluate the enhancement characteristics of ductal pancreatic adenocarcinomas and correlate them with the tumor vascularity observed on digital subtraction angiography (DSA). METHODS: Twenty consecutive patients with ductal pancreatic adenocarcinoma underwent power Doppler sonography and DSA. Tumor vascularity was assessed using unenhanced and contrast-enhanced power Doppler sonography. The contrast agent Levovist was administered intravenously by bolus injection of a dose of 2.5 g at a concentration of 350 mg/mL; saline was administered immediately thereafter. The patients were asked to hold their breath for 30 seconds (for the period 15-45 seconds after saline injection) while the early phase of enhancement was studied; the delayed phase of enhancement was observed between 60 and 120 seconds after saline administration, while patients breathed gently. RESULTS: None of the 20 pancreatic carcinomas showed any color signals on power Doppler sonography before administration of the contrast medium. Seventeen (85%) of the 20 pancreatic carcinomas also showed no enhancement in the early and delayed phases of contrast-enhanced power Doppler sonography. However, in the early phase of contrast-enhanced power Doppler sonography; 1 lesion showed pronounced enhancement and 2 showed mild enhancement. On DSA, the 17 carcinomas showing no enhancement on power Doppler sonography were found to be hypovascular, whereas the remaining 3 carcinomas with contrast enhancement on power Doppler sonography were found to be hypervascular. CONCLUSIONS: The enhancement characteristics of the ductal pancreatic adenocarcinomas correlated well with the tumor vascularity observed on DSA. However, further study is needed to determine the accuracy of contrast-enhanced sonography in the diagnosis of pancreatic masses.     

Accuracy of 3-dimensional color Doppler-derived flow volumes with increasing image depth.

OBJECTIVES: We and others have reported on the use of digital color Doppler sonography from real-time 3-dimensional (3D) echocardiography and its use in accurately calculating cardiac flow volumes, namely stroke volume (SV) and, hence, cardiac output. However, in some patients, image depth is higher than average, and this may affect the accuracy of volume calculation. We sought to investigate the impact of image depth and the accompanying change in signal strength, spatial resolution, and pulse repetition frequency on the accuracy of SV calculation from 3D color Doppler data in an in vitro model. METHODS: A tube model of the left ventricular outflow tract was constructed from plastic tubing and connected to a pulsatile pump. The volume flowing through the tube was imaged using a 3D echocardiography system. Stroke volumes from the pump were computed from the DICOM data using commercially available software and compared with a reference standard of timed volumes with the use of a graduated measuring cylinder over a range of depth settings and SVs. RESULTS: There was good correlation between the 3D-derived SVs and the reference cylinder measures over all depths from 4 to 16 cm at 1-cm increments with a tube diameter of 17 mm, a pump rate of 60 beats/min, and SVs ranging from 20 to 70 mL. The average r(2) value for the 13 different depths was 0.976. However, the accuracy of the 3D method of volume calculation appeared to fall at depths greater than 13 cm, especially at higher SVs. CONCLUSIONS: Stroke volume calculation from real-time 3D color Doppler data in this in vitro study shows that at depths greater than approximately 13 cm, accuracy decreases, especially at higher SVs. This may be due to decreased resolution and the reduced frame rate at these depths. At shallower depths, volume calculation form the 3D Doppler data appears very accurate.