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.     

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.     

Reproducibility of Placental Volume and Vasculature Indices Obtained by 3‐Dimensional Power Doppler Sonography

Objective. The purpose of this study was to evaluate the reproducibility of 3‐dimensional (3D) power Doppler assessment of placental volumes and vascularization before adopting these in routine evaluation of normal and complicated pregnancies. Methods. A prospective study was performed on 30 normal singleton pregnancies from 11 to 14 weeks. To evaluate placental vascularization, 3D power Doppler sonography was applied to obtain a placental volume, and the volume acquired was analyzed using virtual organ computer‐aided analysis. Two consecutive measurements were taken from each patient by two observers blinded to each other's and the individual's previous measurement. This yielded a total of 60 data set pairs. The placental volume, vascularization index, flow index, and vascularization‐flow index (VFI) were calculated. Normal distribution of the data was confirmed with the Kolmogorov‐Smirnov test. Intraobserver and interobserver correlations were evaluated. Bland‐Altman plots and statistics were used to compare the 95% limits of agreement between measurements. Results. All 3D power Doppler placental volumes and vascular indices showed intraobserver correlations of 0.80 or higher. Similar excellent interobserver correlations were seen for all indices with the exception of the VFI, which showed a lower but acceptable correlation. The Bland‐Altman analyses indicated good reproducibility of the evaluated placental indices. Conclusions. Our findings provide validation of the technique, showing good reproducibility of the 3D power Doppler parameters when applied to studies of the placental volume and vascular tree.     

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.     

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 quantification of tumor vascularity as a tertiary test after B-mode and power Doppler evaluation for detection of ovarian cancer.

OBJECTIVE: The purpose of this study was to investigate the role of 3-dimensional (3D) quantification of tumor vascularity in the differential diagnosis of pelvic indeterminate masses with a solid appearance or unilocular or multilocular cysts with a solid component showing central vascularization on 2-dimensional power Doppler sonography. METHODS: One hundred fifty-seven consecutive pelvic masses in 153 patients were included in this study and underwent sonography before surgery. Masses that showed a typical benign pattern on B-mode sonography (n = 112) and indeterminate masses with peripheral or absent flow on power Doppler sonography (n = 10) were not evaluated by 3D sonography. Only masses with central vascularization were submitted to 3D power Doppler imaging (n = 35). The following 3D vascular parameters were calculated: relative color and flow measure (similar to the vascularization flow index obtained with other systems). RESULTS: With receiver operating characteristic curve analysis, the best cutoff values for relative color and flow measure were 4.4 and 2.7, respectively. Flow measure had sensitivity of 68% and specificity of 40% in the overall population submitted to 3D power Doppler sonography. Accuracy slightly increased when masses with small papillary projections (<10 mL) were excluded. In this group (n = 22), sensitivity was 83%, and specificity was 50%. CONCLUSIONS: In masses with central vascularization on 2-dimensional power Doppler sonography, the use of 3D quantification of tumor vascularity had low diagnostic accuracy in the detection of adnexal malignancies, although an increase in accuracy in masses with a solid portion of greater than 10 mL was reported.     

Intraobserver and interobserver reproducibility of three-dimensional gray-scale and power Doppler ultrasound examinations of the cervix in pregnant women.

OBJECTIVES: To determine intraobserver and interobserver reproducibility of three-dimensional (3D) gray-scale and power Doppler ultrasound examinations of the cervix in pregnant women. METHODS: Thirty-two pregnant women underwent transvaginal 3D gray-scale and power Doppler ultrasound examination of the cervix by two examiners. Each observer acquired two volumes, and they each analyzed their volumes twice using the commercially available software Virtual Organ Computer-aided AnaLysis (VOCAL). The variables analyzed were cervical volume (cm3), vascularization index (VI), flow index (FI) and vascularization flow index (VFI). Intraobserver repeatability was expressed as the difference between two measurement results (mean difference +/- 2 SD, i.e. limits of agreement) and as intraclass correlation coefficient (intra-CC). Interobserver agreement was expressed as the difference between the results of the two observers (limits of agreement) and as interclass correlation coefficient (inter-CC). The contribution of various factors (examiner, acquisition, analysis of acquired volume) to intrasubject variance was estimated using different analysis of variance models. All statistical analyses were performed using log-transformed data. The results presented are those obtained after antilogarithmic transformation, i.e. the results are presented as ratios between two results of the same observer, or as ratios between the results of Observer 1 and Observer 2. RESULTS: All intraobserver and interobserver log-transformed differences were normally distributed. There was no systematic bias between the two observers. Both intra- and inter-CC values were high (0.93-0.98) for all variables except FI (0.63-0.88), despite the limits of agreement being wide, especially for VI (widest range 0.4-2.4) and VFI (widest range 0.3-2.6). Acquisition explained most of the intrasubject variance of the flow indices, the contribution of examiner and analysis being unimportant. CONCLUSIONS: Given the wide range between the lower and upper limits of agreement, it would probably not be possible to detect anything but large differences or changes in cervical volume or cervical flow indices using current 3D ultrasound techniques. Because acquisition explained most of the intrasubject variance, the average of several repeated acquisitions should be used to enhance reproducibility. However, it is not worth doing more than one analysis of an acquired volume, because the effect of analysis on measurement results is small.     

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.     

Reproducibility of endometrial vascular patterns in endometrial disease as assessed by transvaginal power Doppler sonography in women with postmenopausal bleeding.

OBJECTIVE: The purpose of this study was to assess the intraobserver and interobserver agreement for identifying different endometrial vascular patterns using power Doppler sonography in women with postmenopausal bleeding and a thickened endometrium. METHODS: Digitally stored sonographic images from a random sample of 65 patients with postmenopausal bleeding and a thick endometrium (>5 mm) on B-mode sonography and evaluated by transvaginal power Doppler sonography for assessment of endometrial blood flow mapping were evaluated by 5 different examiners with different levels of expertise in Doppler sonography. Intraobserver and interobserver agreement according to the level of experience were assessed by calculating the kappa index. RESULTS: Intraobserver agreement was good or very good for all experienced examiners (kappa = 0.78-0.96) and moderate (kappa = 0.52) for the inexperienced examiner. Interobserver agreement was moderate among all experienced examiners (kappa = 0.45-0.80). The inexperienced examiner showed fair or moderate interobserver agreement (kappa = 0.32-0.45). CONCLUSIONS: Our results indicate that endometrial blood flow mapping using transvaginal power Doppler sonography is acceptably reproducible. More experience was associated with better intraobserver and interobserver agreement.     

Intraobserver and interobserver variability of ovarian volume, gray-scale and color flow indices obtained using transvaginal three-dimensional power Doppler ultrasonography.

OBJECTIVE: To assess intraobserver and interobserver variability in ovarian volume and gray-scale and color flow index measurements using transvaginal, three-dimensional, power Doppler ultrasonography. METHODS: Eleven women (22 ovaries) were examined on day 8 of controlled ovarian hyperstimulation therapy, which was part of their in vitro fertilization treatment protocol. The patients were examined twice by the first observer and once by the second observer. The acquired volume datasets were analyzed using the VOCAL imaging program, enabling the assessment of ovarian volume, vascularization index (VI), flow index (FI), vascularization flow index (VFI) and mean grayness (MG). For these parameters the intraclass (intra-CC) and interclass (inter-CC) correlation coefficients, within-observer and between-observers repeatability coefficient (r) and limits of agreement were calculated. RESULTS: Both intraobserver and interobserver repeatability of ovarian volume measurements were considered very good with an intra-CC value of 1.00 and inter-CC value of 0.99, respectively. Also VI, FI, VFI and MG measurements were repeatable by a single observer, the intra-CC ranging from 0.82 to 0.91. The interobserver reproducibility was also good for VI, VFI and MG measurements (inter-CC values 0.73, 0.70 and 0.81, respectively), but for FI measurements the reproducibility was poor (inter-CC = 0.29, r = 7.87). CONCLUSIONS: In general, the intraobserver reproducibility was better than interobserver reproducibility for all parameters. The volume assessments were reproducible both by one observer and by two separate observers. The intraobserver and interobserver variabilities were acceptable for VI, VFI and MG, whereas for FI the interobserver reproducibility was poor. Our results suggest that measurement of gray-scale and color Doppler flow indices is reproducible thus allowing them to be used in clinical practice and research.     

Intraobserver and interobserver reproducibility of ovarian volume, antral follicle count, and vascularity indices obtained with transvaginal 3-dimensional ultrasonography, power Doppler angiography, and the virtual organ computer-aided analysis imaging program.

OBJECTIVES: The purpose of this study was to assess intraobserver and interobserver reproducibility of the parameters of ovarian response and oocyte ability, studied by 3-dimensional ultrasonography and power Doppler angiography (PDA), and the possible influence of the ovarian functional stage. METHODS: Twenty-nine women were included in an in vitro fertilization program. Fourteen women were evaluated after pituitary suppression (basal group), and 15 were scanned on the human chorionic gonadotropin administration day, after gonadotropin ovarian stimulation (stimulated group). A first observer acquired 2 volumes for each ovary. Another observer performed a second analysis of the volumes acquired by the first observer. We analyzed ovarian volume, follicle number in the basal group, vascularization index, flow index, and vascularization-flow index. The volumes were processed by the Virtual Organ Computer-Aided Analysis imaging program using plane A and 15 degrees rotational steps. RESULTS: Ovarian volume showed excellent intraobserver and interobserver agreement, with an intraclass correlation coefficient (Intra-CC) and an interclass correlation coefficient (Inter-CC) close to the unit. The Intra-CC and Inter-CC about the number of follicles were 0.964 and 0.978, respectively. Vascularity indices showed an Intra-CC greater than 0.90. The vascularization index and the vascularization-flow index showed higher interobserver than intraobserver reproducibility (Inter-CC > 0.96 for both). The flow index Inter-CC was 0.898. The reproducibility differences between the basal and stimulated ovary measurements were not significant. CONCLUSIONS: There is an excellent intraobserver and interobserver reproducibility of the ovarian volume, follicle counts, and 3-dimensional PDA indices. The ovarian functional stage has no influence on the reliability. Three-dimensional ultrasonography and PDA improve the study of ovarian parameters, and their reliability impels a change in the current clinical routine of performing and interpreting ultrasonography.     

Transvaginal 3-d power Doppler ultrasound evaluation of the fetal brain at 10-13 weeks' gestation

The objective of this study was to measure the fetal brain volume (FBV) and vascularization and blood flow using transvaginal 3-D power Doppler (3DPD) ultrasound late in the first trimester of pregnancy. 3DPD ultrasound examinations with the VOCAL imaging analysis program were performed on 36 normal fetuses from 10-13 weeks' gestation. FBV and 3DPD indices related to the fetal brain vascularization (vascularization index [VI], flow index [FI] and vascularization flow index [VFI]) were calculated in each fetus. Intra- and interclass correlation coefficients and intra- and interobserver agreements of measurements were assessed. FBV was curvilinearly correlated well with the gestational age (R2 = 0.861, p < 0.0001). All 3-D power Doppler indices (VI, FI and VFI) showed no change at 10-13 weeks' gestation. FBV and all 3-D power Doppler indices (VI, FI and VFI) showed a correlation > 0.82, with good intra- and interobserver agreement. Our findings suggest that 3-D ultrasound is a superior means of evaluating the FBV in utero, and that 3-D power Doppler ultrasound histogram analysis may provide new information on the assessment of fetal brain perfusion.     

Three-dimensional power Doppler sonography: imaging and quantifying blood flow and vascularization.

OBJECTIVES: To assess the feasibility of imaging low-velocity blood flow in adnexal masses by transvaginal three-dimensional power Doppler sonography, to analyze three-dimensional power Doppler sonography data sets with a new computer-assisted method and to test the reproducibility of the technique. METHODS: A commercially available 5-MHz Combison 530 ultrasound system was used to perform three-dimensional power Doppler sonography transvaginally. A cube (= volume of interest) was defined enclosing the vessels of the cyst and the Cartesian characteristics were stored on a hard disk. This cube was analyzed using specially designed software. Five indices representing vascularization (the vascularization index (VI) or blood flow (the flow index (FI)) or both (the vascularization-flow index (VFI)) were calculated. The intraobserver repeatability of cube definition and scan repetition was assessed using Hartley's test for homogeneous variances. Interobserver agreement was assessed by the Pearson correlation coefficient. RESULTS: Imaging of vessels with low-velocity blood flow by three-dimensional power Doppler sonography and cube definition was possible in all adnexal massed studied. In some cases even induced non-vascular flow related to endometriosis was detected. The calculated F value with intraobserver repeated Cartesian file-saving ranged from 0 to 18.8, with intraobserver scan repetition from 4.74 to 24.8 for VI, FI 1, FI 2 and VFI 1; for VFI 2 the calculated F value was 64. The interobserver correlation coefficient ranged between 0.83 and 0.92 for VI, FI 1, FI 2 and VFI 1; for VFI 2 the correlation coefficient was less than 0.75. CONCLUSION: Vessels with low-velocity blood flow can be imaged using three-dimensional power Doppler sonography. Induced non-vascular flow was detected in endometriotic cyst fluid. Three-dimensional power Doppler sonography combined with the cube method gave reproducible information for all indices except VFI 2. These indices might prove to be a new predictor in all fields of neoangiogenesis. The clinical relevance remains to be determined.     

Endometrial volume and vascularity measurements by transvaginal 3-dimensional ultrasonography and power Doppler angiography in stimulated and tumoral endometria: an interobserver reproducibility study.

OBJECTIVE: The purpose of this study was to evaluate interobserver reproducibility of endometrial volume and vascular indices of the endometrium and subendometrial area estimated by 3-dimensional power Doppler angiography (3D-PDA) using the Virtual Organ Computer-Aided Analysis program, determining the influence of the endometrial growth etiology on measurements. METHODS: Forty women underwent 3D-PDA ultrasonography. Group A comprised 25 women scanned on the day after controlled ovarian stimulation with human chorionic gonadotropin. Group B comprised 15 patients who had uterine bleeding and questionable endometrial thickening. (Histologic evaluation revealed 10 endometrial cancers and 5 endometrial hyperplasias.) A single observer examined all patients and acquired all volume data sets. Forty volume data sets were then analyzed with the Virtual Organ Computer-Aided Analysis program by 2 different observers. Endometrial volume and vascularity indices (vascularization index [VI], flow index [FI], and vascularization flow index [VFI]) of the endometrium and subendometrium were manually calculated in the coronal plane with a 9 degrees rotation step. An intraclass correlation coefficient (ICC) was used to assess interobserver reliability. RESULTS: Endometrial volume was more reproducible in group A (ICC = 0.98) than in group B (ICC = 0.58) (P < .05). Endometrial and subendometrial VI, FI, and VFI also presented good reproducibility with ICC greater than 0.84. The ICC was not statistically different for endometrial and subendometrial VI, FI, and VFI according to patient group, although subendometrial VFI was less reproducible in group B (ICC = 0.53) than in group A (ICC = 0.88). CONCLUSIONS: Endometrial volume and endometrial and subendometrial 3D power Doppler indices have acceptable reproducibility. The interobserver reproducibility in tumoral endometrium was more similar than in stimulated endometrium. Our results indicate that 3D-PDA is a reliable method to evaluate physiologic and pathologic endometrial changes.     

Contrast-enhanced sonography helps in discrimination of benign from malignant adnexal masses.

OBJECTIVE: To investigate the potential efficacy of real-time contrast-enhanced power Doppler sonography in the differentiation of benign and malignant adnexal masses in a pilot study. METHODS: Before surgical treatment, adnexal masses were prospectively evaluated with power Doppler sonography before and after injection of a contrast agent. Real-time postinjection sequences were computerized with time-intensity analysis software to determine an enhancement curve and contrast parameters. The intraobserver and interobserver reproducibilities of these criteria were assessed on a subsample. These contrast parameters were compared between benign and malignant tumors using logistic regression. Sensitivity and specificity were used to compare contrast parameters with sonographic and Doppler variables. RESULTS: Ninety-nine women were included, for a total of 101 adnexal masses. There were 23 cases of ovarian malignancies and 78 benign adnexal lesions. Our procedure had excellent intraobserver and interobserver reproducibility, with an average intraclass correlation coefficient of 0.92. The time before enhancement and intensity ratio did not reliably differentiate between the benign and malignant masses. Washout times and areas under the curves were significantly greater in ovarian malignancies than in other benign tumors (P < .001), leading to sensitivity estimates between 96% and 100% and specificity estimates between 83 and 98%. Contrast parameters had slightly higher sensitivity and slightly lower specificity when compared with transvaginal sonographic variables of the resistive index and serum cancer antigen 125 levels. CONCLUSIONS: Contrast-enhanced power Doppler imaging may easily and precisely discriminate benign from malignant adnexal lesions. Larger studies are needed to determine the appropriate use and benefits of this new procedure.     

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.     

The reliability of virtual organ computer-aided analysis (VOCAL) for the semiquantification of ovarian, endometrial and subendometrial perfusion.

OBJECTIVES: Three-dimensional power Doppler angiography (3D-PDA) has been largely used for the subjective assessment of vascular patterns but semiquantification of the power Doppler signal is now possible. We examined the intraobserver and interobserver reliability of the semiquantification of ovarian, endometrial and subendometrial blood flow using 3D-PDA, virtual organ computer-aided analysis (VOCAL) and shell-imaging. METHODS: 3D-PDA was used to acquire 20 ovarian and 20 endometrial volumes from 40 different patients at various stages of in vitro fertilization treatment. VOCAL was then used to delineate the 3D areas of interest and the 'histogram facility' employed to generate three indices of vascularity: the vascular index, the flow index and the vascularization flow index. Intraobserver and interobserver reliability was assessed by two-way, mixed, intraclass correlation coefficients (ICCs) and general linear modeling was used to examine for differences in the mean values between each observer. RESULTS: The intraobserver reliability for both observers was extremely high and there were no differences in reliability between the observers for measurements of both volume and vascularity within the ovary or endometrium and its shells. With the exception of the outside subendometrial shell volumes, there were no significant differences between the two observers in the mean values obtained for either endometrial or ovarian volume and vascularity measurements. The interobserver reliability of measurements was equally high throughout with all measurements obtaining a mean ICC of above 0.985. CONCLUSIONS: 3D-PDA and shell-imaging offer a reliable, practical and non-invasive method for the assessment of ovarian, endometrial and subendometrial blood flow. Future work should concentrate upon confirming the reliability of data acquisition and the validity of the technique before its predictive value can be truly tested in prospective clinical studies.     

Intraobserver and interobserver agreement of grayscale typical ultrasonographic patterns for the diagnosis of ovarian cancer

The purpose of this study was to evaluate the intraobserver and interobserver agreement for identifying ovarian malignancy using typical grayscale ultrasonographic patterns. Digitally stored grayscale sonographic images from a random sample of 98 women with an adnexal mass submitted to surgery after a grayscale transvaginal sonography were evaluated by five different examiners with different degrees of experience in three European university departments of obstetrics and gynecology. Masses in which the echo features were highly characteristic of a benign pathology were categorized as benign. Any cystic mass containing excrescences, thick septations, multiple irregular septations or solid component in which the echo architecture was not highly suggestive of benign histology was categorized as malignant. Intraobserver and interobserver agreement according to the level of experience were assessed by calculating the kappa index. Of the 98 cases randomly selected, 28 (29%) were malignant masses and 70 (71%) were benign. Intraobserver agreement was good or very good for all examiners with different degrees of experience (kappa = 0.72 to 1). Interobserver agreement was good for all expert operators (kappa = 0.69 to 0.75). Interobserver agreement between experts and highly experienced operators was moderate or good (kappa = 0.51 to 0.63). Interobserver agreement between the moderately experienced operator and experts was fair to moderate (kappa = 0.29 to 0.46). Interobserver agreement between moderately and highly experienced operators was fair (kappa = 0.33). Our results indicate that ultrasonographic malignant patterns are reproducible, even in moderately experienced examiners, although more experience is associated with better interobserver agreement.     

Comparison of Reproducibility of Manual and Sphere Contour Methods for the Measurement of Vascularization in Cervical Carcinoma Using the Virtual Organ Computer‐Aided Analysis II System

Objective. The purpose of this study was to investigate the reproducibility of virtual organ computer‐aided analysis II software (GE Healthcare, Milwaukee, WI), an integrated tool for 3‐dimensional power Doppler angiography (3D‐PDA), in measuring vascularization of cervical carcinoma under manual and automatic sphere contour modes. Methods. Eighty patients with cervical carcinoma were prospectively examined by observer 1 using transvaginal 3D‐PDA. For each patient, measurements of the vascularization index, flow index, and vascularization‐flow index were repeated twice under both manual and automatic sphere contour modes. Forty patients were randomly selected for another round of examination by observer 2 under the same setting. The reproducibility of vascularization measurements was assessed by the intraclass correlation coefficient (intra‐CC), interclass correlation coefficient (inter‐CC), and 95% limits of agreement (LOAs). Various analysis of variance models were used to estimate the contribution of each factor (observer, contour mode, and patient) to measurement variance. Results. For each observer, the manual contour mode outperformed the automatic sphere contour mode in reproducibility (intra‐CC, 0.96 to 0.99 versus 0.77 to 0.94). In addition, repeated measurements of the manual mode had a smaller SD and a narrower LOA. For the manual contour mode, interobserver agreement was comparable with intraobserver agreement (inter‐CC, 0.91 to 0.98, versus intra‐CC, 0.96 to 0.99). However, the interobserver agreement was significantly smaller than the intraobserver agreement for the automatic sphere contour mode (inter‐CC, 0.51 to 0.85, versus intra‐CC, 0.77 to 0.94; P = .001). Conclusions. The manual contour mode for 3D‐PDA vascular measurements has better interobserver and intraobserver reproducibility than the automatic sphere contour mode. It is especially useful for measuring tumor tissues with irregular shapes and vascularity.     

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.