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.     

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.     

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.     

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.     

Early ovarian cancer: 3-D power Doppler

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

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.     

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.     

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.     

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.     

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.     

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.     

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.     

Three-dimensional sonographic morphologic assessment in complex adnexal masses: preliminary experience.

OBJECTIVE: To evaluate the role of three-dimensional transvaginal sonography in assessing complex adnexal masses. METHODS: Forty-one women (mean age, 49.5 years; range, 23-75 years) with the diagnosis of complex adnexal masses on the basis of two-dimensional transvaginal sonography were reevaluated by three-dimensional transvaginal sonography. Two different sonologists evaluated the two- and three-dimensional transvaginal sonograms. Criteria indicative of malignancy included the presence of gross papillary projections, solid areas, and solid echogenicity for both techniques. Three women (7%) had bilateral masses, giving a total of 44 masses that were ultimately assessed. A definitive histologic diagnosis was obtained in every case after surgical tumor removal. RESULTS: Twenty-one tumors (47.7%) were proved malignant, and 23 (52.3%) were benign. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for two- and three-dimensional transvaginal sonography were 90%, 61%, 68%, 87%, and 75% and 100%, 78%, 81%, 100%, and 89%, respectively. There were no statistical differences between two- and three-dimensional transvaginal sonography (McNemar test, P = .687). The agreement between both examiners was high (kappa index = 0.71). CONCLUSIONS: The use of three-dimensional transvaginal sonography does not significantly improve the two-dimensional transvaginal sonographic morphologic assessment of complex adnexal masses; however, we found it useful for reinforcing initial diagnostic impressions.     

Three-dimensional power Doppler imaging in depicting vascularity in hepatocellular carcinoma.

OBJECTIVE: To assess the ability of three-dimensional power Doppler imaging to depict vascularity in hepatocellular carcinoma. METHODS: Forty-three patients with hepatocellular carcinomas were subjected to two- and three-dimensional power Doppler imaging, and 14 of them also underwent angiography. The delineated amounts of intratumoral Doppler signals were compared between 2 methods of power Doppler imaging in 43 patients. In the 14 patients who also underwent angiography, the patterns of blood supply depicted by 2 methods of power Doppler imaging were compared with that depicted by angiography, and the intratumoral vascularity on three-dimensional projection images and angiograms was also quantitatively assessed by calculating the vascularity-area ratio with graphics software. RESULTS: In comparison with two-dimensional power Doppler imaging, three-dimensional power Doppler imaging was subjectively determined as showing more intratumoral Doppler signals in 32 (74.4%) of the 43 lesions. The accuracies in depicting vascular patterns were 64.3% (9 of 14) for three-dimensional projection images and 14.3% (2 of 14) for two-dimensional slices compared with the results of angiography. The vascularity-area ratios on three-dimensional power Doppler imaging projections and angiograms were 46.0% +/- 25.6% and 48.5% +/- 22.5% (mean +/- SD), respectively (P > .05). Three-dimensional projection images correlated significantly with angiograms in quantifying the vascularity (gamma = 0.87; P < .001). CONCLUSIONS: A three-dimensional power Doppler projection image gives a better overall picture of vascular distribution than a two-dimensional slice and correlates with angiography significantly for delineating vascularity in hepatocellular carcinoma.     

Three-dimensional inversion rendering: a new sonographic technique and its use in gynecology.

OBJECTIVE: The purpose of this presentation is to describe the use of the 3-dimensional (3D) sonographic inversion rendering mode in displaying fluid-filled structures using dedicated hardware and software in gynecology. METHODS: The 3D software used inverts anechoic into echogenic voxels, which, against the black background of the monitor screen, display the fluid-filled structure as a "cast" of it. The technique of the rendering process is described. Three-dimensional sonographic volumes of the adnexal area in 3 patients thought to have adnexal or ovarian masses were stored and rendered with the use of the laptop version of the inversion software. The same process was used in an additional 12 women for various indications: 7 with suspected uterine malformations and 5 with uterine bleeding. Of these 12 women, 11 underwent saline infusion sonohysterography. RESULTS: Rendering the inverted fluid-filled adnexal structures revealed that, in all 3 cases, they were tubal, not ovarian, in origin (chronic hydrosalpinges). Of the 7 uterine cavities suspected of malformation, 3 were normal and 4 had uterine malformations: 2 arcuate uteri and 2 incomplete septate uteri. Of the 4 woman with dysfunctional uterine bleeding, 3 had endometrial cavities with polyps and 1 had an irregular surface of the cast. One woman with postmenopausal spotting had an enlarged but otherwise normal cavity. CONCLUSIONS: After a relatively short learning curve to master the inversion rendering technique, it is possible to use it in a selected number of gynecologic cases with fluid-filled structures. In resolving the correct diagnosis of the adnexal masses, the inversion images performed better than the 2-dimensional (2D) and 3D orthogonal planes. For diagnosis of uterine disease, the inversion pictures presented marginal value over the 2D and 3D images. The 3D inversion rendering technique may have added value in selected gynecologic cases, establishing a more accurate diagnosis somewhat faster than only 2D sonography or even the 3D orthogonal planes.