How to use power Doppler ultrasound in transvaginal assessment of uterine fibroids

A novel step-by-step teaching method improves training outcomes in transvaginal ultrasound for postgraduate reproductive medicine students: an exploratory randomized controlled study

BACKGROUND

Traditional methods of training in ultrasound technology make it difficult for postgraduate reproductive medicine students to rapidly develop into doctors who can perform clinical examinations independently. It is necessary to explore an efficient method for ultrasound training. The purpose of this study was to investigate whether the step-by-step (SBS) teaching improves the ultrasound diagnosis and clinical work level of reproductive medicine graduate students.

METHODS

A total of fifty postgraduate reproductive medicine students who participated in ultrasound room training were selected at random and divided into two groups: a traditional teaching control group and a stepwise teaching experimental group. A comparison was subsequently conducted between the two groups in terms of theoretical level, skill operation, comprehensive ability and teaching evaluation.

RESULTS

In terms of theory, skills, and comprehensive assessment, the experimental group exhibited superior performance compared to the control group (P < 0.05). The experimental group rated the instructors' teaching ability and methods significantly better than did the control group (P < 0.05). The experimental group's overall satisfaction with the training was better than that of the control group, but the difference was not statistically significant (P > 0.05).

CONCLUSIONS

The stepped teaching model has the potential to facilitate the acquisition of clinical ultrasound detection and diagnostic techniques by postgraduate reproductive medicine students, thereby enhancing their overall competence and satisfaction with the teaching process.

Microvascular flow imaging of fibroids: A prospective pilot study

INTRODUCTION

Imaging fibroid vascularity may predict fibroid growth and aid to determine most appropriate therapy. Microvascular (MV) flow imaging is relatively new and is able to detect slow flow in small vessels. Data on feasibility, reproducibility, and reliability of MV-flow imaging in fibroids is lacking. The purpose of our study was to determine the reproducibility of MV-flow imaging and to explore this technique for clinical practice for assessing blood flow in fibroids.

MATERIAL AND METHODS

Thirty patients with one or multiple fibroids (diameter 1.5-12.0 cm) were prospectively included. Transvaginal ultrasound scanning was performed in B-mode, 2D MV-Flow™, 2D and 3D power Doppler mode (HERA W10, Samsung) by two experienced gynecologists at a tertiary care clinic from February to December 2021. The primary outcome was intra- and interobserver agreement of the vascular index (VI) and color score (CS). The following parameters: '2D MV-flow VI', '3DPD VI', '2D MV-flow CS' and '2DPD CS' were measured offline in the center, pseudocapsule, and entire fibroid. Secondary offline outcomes for exploring 2D MV-flow for clinical practice, included (1) ability to discern vascular structures, (2) assessing the degree of vascularity via CS and calculating a VI, and (3) determining penetration depth of the ultrasound signal in both power Doppler and MV-flow imaging.

RESULTS

All scans of the 30 included patients were of sufficient quality to analyze. Inter- and intra-observer correlations of all studied parameters were good to excellent, both for 2D MV-flow and 2D power Doppler (intercorrelation coefficient 0.992-0.996). Using 2D MV-flow different vascular structures were visible in detail, in contrary to using 2D and 3D power Doppler. In significantly more fibroids central flow could be visualized using 2D MV-flow (63%) than with 2D power Doppler (13%, p = 0.001). Finally, penetration of the ultrasound signal was deeper using 2D MV-flow (3.92 cm) than with 2D power Doppler (2.95 cm, p = 0.001).

CONCLUSIONS

Using 2D MV-flow imaging for determining vascularity is highly reproducible. It has potential added value for clinical practice as it depicts detailed vascular structures and the degree of vascularity, especially in the center of the fibroid.

How to perform standardized sonographic examination of Cesarean scar pregnancy in the first trimester

Early diagnosis and appropriate management of Cesarean scar pregnancy (CSP) are crucial to prevent severe complications, such as uterine rupture, severe hemorrhage and placenta accreta spectrum disorders. In this article, we provide a step-by-step tutorial for the standardized sonographic evaluation of CSP in the first trimester. Practical steps for performing a standardized transvaginal ultrasound examination to diagnose CSP are outlined, focusing on criteria and techniques essential for accurate identification and classification. Key sonographic markers, including gestational sac location, cardiac activity, placental implantation and myometrial thickness, are detailed. The evaluation process is presented according to assessment of the uterine scar, differential diagnosis, detailed CSP evaluation and CSP classification. This step-by-step tutorial emphasizes the importance of scanning in two planes (sagittal and transverse), utilizing color or power Doppler and differentiating CSP from other low-lying pregnancies. The CSP classification is described in detail and is based on the location of the largest part of the gestational sac relative to the uterine cavity and serosal lines. This descriptive classification is recommended for clinical use to stimulate uniform description and evaluation. Such a standardized sonographic evaluation of CSP in the first trimester is essential for early diagnosis and management, helping to prevent life-threatening complications and to preserve fertility. Training sonographers in detailed evaluation techniques and promoting awareness of CSP are critical. The structured approach to CSP diagnosis presented herein is supported by a free e-learning course available online. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Is three-dimensional ultrasonography a valuable diagnostic tool for patients with ovarian cancer? Systematic review and meta-analysis

Introduction

This paper was to assess the diagnostic performance and clinical value of three-dimensional ultrasonography (3DUS), three-dimensional ultrasonography power Doppler (3DPD), and 3DUS combined with 3DPD in ovarian cancer (OC).

Methods

The study was registered with PROSPERO (CRD 42023405765). PubMed and Web of Science were searched from inception to 25 January 2022, and reference lists of potentially eligible studies were also manually searched. Patient and study characteristics were extracted by two independent reviewers. Any discrepancies were addressed through discussion. The sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR, respectively), and the area under the receiver operating characteristic curve (AUC) were pooled separately.

Results

We retrieved 2,566 studies, of which 18 were finally enrolled, with 2,548 cases. The pooled sensitivity, specificity, PLR, NLR, and AUC for 3DUS were 0.89 (95% CI: 0.85-0.93), 0.93 (95% CI: 0.88-0.96), 13.1 (95% CI: 7.3-23.4), 0.11 (95% CI: 0.08-0.16), and 0.90 (95% CI: 0.87-0.93), respectively. The pooled sensitivity, specificity, PLR, NLR, and AUC for 3DPD were 0.90 (95% CI: 0.80-0.95), 0.85 (95% CI: 0.71-0.92), 5.8 (95% CI: 3.0-11.2), 0.12 (95% CI: 0.06-0.24), and 0.94 (95% CI: 0.91-0.96), respectively. The pooled sensitivity, specificity, PLR, NLR, and AUC for 3DUS combined with 3DPD were 0.99 (95% CI: 0.73-1.00), 0.95 (95% CI: 0.85-0.99), 21.9 (95% CI: 6.1-78.9), 0.01 (95% CI: 0.00-0.37), and 0.99 (95% CI: 0.98-1.00), respectively.

Conclusions

3DUS, 3DPD, and 3DUS combined with 3DPD are promising diagnostic tools for OC, alongside elevated sensitivity and specificity. However, the combination of 3DUS and 3DPD techniques has higher diagnostic efficiency.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD 42023405765.

Long-term Efficacy of Fibroid Devascularization with Ultrasound-Guided High-Intensity Focused Ultrasound

RATIONALE AND OBJECTIVES

High-intensity focused ultrasound (HIFU) has been increasingly used for treatment of uterine leiomyoma. The superiority of HIFU therapy targeting uterine leiomyoma blood vessels, however, still needs to be further explored. This study aims to evaluate the long-term efficacy of fibroid devascularization with ultrasound-guided HIFU (USgHIFU) and the effects of treatment on the ovarian reserve and endometrial injury.

MATERIALS AND METHODS

Fibroid devascularization was assessed with the Adler grade obtained by color Doppler flow imaging and power Doppler imaging (PDI). The targeted vessels were covered and then sonicated by HIFU focal spots. The patients were followed up at 1 month, 3 months, 6 months, 1 year, 2 years and 3 years after treatment. Adverse effects and complications were recorded. The non-perfusion volume rate (NPVR), fibroid volume shrinkage rate (FVSR), Adler Grade, symptom severity score (SSS) and uterine fibroid symptom and quality of life (UFS-QOL) were evaluated. Adverse events (AEs) were recorded. In Center 1, the enrolled patients completed the anti-Müllerian hormone (AMH) test before and at 6 months after treatment.

RESULTS

A total of 117 eligible patients were consecutively enrolled to receive interventions and follow-up evaluations of the three centers from January 2019 to May 2023. The 1-month and 6-month NPVRs were 66.60% ± 33.14% and 51.12% ± 39.84%, respectively. The mean FVSRs at 1 month and 6 months after treatment were 38.20% and 43.89%, respectively. No significant difference was observed in AMH levels before and after treatment (p > 0.05). No irreversible endometrial injury was observed in MR images after HIFU treatment. No significant difference was observed in both 1-month and 6-month FVSRs among Center 1, 2 and 3 (p > 0.05). No severe AEs occurred. For long-term outcomes, significant differences were observed in Adler grade, FV, FVSR, SSS, reduction in SSS and UFS-QOL before and after treatment (p < 0.001) whereas no significant difference was observed in Adler grade among 3 months, 1 year, 2 years and 3 years after treatment (p > 0.05). The SSSs were reduced by 33.42% at 1 year, 42.32% at 2 years and 52.46% at 3 years after treatment.

CONCLUSION

For patients with uterine fibroids, USgHIFU-induced devascularization is a safe and effective treatment option. It has little effect on ovarian function and the endometrial injury is reversible, which could be attractive for patients who plan to become pregnant.

Management of Uterine Fibroids and Sarcomas: The Palermo Position Paper

BACKGROUND

Uterine fibroids are benign monoclonal tumors originating from the smooth muscle cells of the myometrium, constituting the most prevalent pathology within the female genital tract. Uterine sarcomas, although rare, still represent a diagnostic challenge and should be managed in centers with adequate expertise in gynecological oncology.

OBJECTIVES

This article is aimed to summarize and discuss cutting-edge elements about the diagnosis and management of uterine fibroids and sarcomas.

METHODS

This paper is a report of the lectures presented in an expert meeting about uterine fibroids and sarcomas held in Palermo in February 2023.

OUTCOME

Overall, the combination of novel molecular pathways may help combine biomarkers and expert ultrasound for the differential diagnosis of uterine fibroids and sarcomas. On the one hand, molecular and cellular maps of uterine fibroids and matched myometrium may enhance our understanding of tumor development compared to histologic analysis and whole tissue transcriptomics, and support the development of minimally invasive treatment strategies; on the other hand, ultrasound imaging allows in most of the cases a proper mapping the fibroids and to differentiate between benign and malignant lesions, which need appropriate management.

CONCLUSIONS AND OUTLOOK

The choice of uterine fibroid management, including pharmacological approaches, surgical treatment, or other strategies, such as high-intensity focused ultrasound (HIFU), should be carefully considered, taking into account the characteristics of the patient and reproductive prognosis.

An Evaluation of Ultrasound-Guided Percutaneous Microwave Ablation for the Treatment of Symptomatic Uterine Fibroids

PURPOSE

To evaluate the feasibility and effectiveness of ultrasound-guided percutaneous microwave ablation (MWA) for the treatment of symptomatic uterine fibroids.

MATERIALS AND METHODS

A single-center retrospective study was conducted on 17 patients, mean age 37.5 years (SD ± 7.3; range 19-47 years) with symptomatic uterine fibroid who underwent MWA between September 2018 and December 2022. Outcomes included volume reduction of uterine fibroids, hemoglobin levels, uterine fibroid symptoms, and health-related quality-of-life questionnaire scores before and 12 months after ablation.

RESULTS

Preoperative fibroid diameter was a mean of 6.7 cm (SD ± 1.1; range 5-9 cm), and volume was a mean of 101.9 cm3 (SD ± 63.3; range 16.9-264.1 cm3). The mean ablation time was 12.2 minutes (SD ± 3.1; range, 8-20 minutes). The mean reduction of volume at 12 months after treatment was 70.9% (SD ± 23.8). The hemoglobin level increased significantly from 9.96 g/dL ± 2.33 before treatment to 12.14 g/dL ± 1.34 at 12 months after treatment (P = .002). The symptom severity score and health-related quality-of-life scores were significantly improved at follow-up (P < .001).

CONCLUSIONS

The application of MWA as a standalone treatment method might provide an effective, minimally invasive option for Federation of Gynecology and Obstetrics Types 1-6 symptomatic uterine fibroids with the potential to enhance patients' quality of life.

Visualisation of microvascular flow in benign uterine disorders: a pilot study of a new diagnostic technique

BACKGROUND

Uterine disorders have clear overlapping symptoms and ultrasound discrimination is not always easy. Accurately measuring vascularity is of diagnostic and prognostic value. Power Doppler is limited to imaging only the larger vessels. Assessment of the microvasculature requires advanced machine settings.

OBJECTIVES

In this pilot study, we aimed to test the feasibility of microvascular flow imaging of benign uterine disorders.

MATERIAL AND METHODS

Two experienced gynaecologists (JH, RL) randomly applied power Doppler and MV-flowTM mode during a single day, in ten patients each visiting the outpatient clinic. Images of eight patients were labelled with a diagnosis by the attending physicians and collected as coded data.

MAIN OUTCOME MEASURES

Microvascular flow images of normal uterine architecture including the fallopian tube, and of benign disorders such as fibroids, adenomyosis, endometriosis and uterine niches were collected. For both Doppler techniques, qualitative descriptive evaluation of the vascular architecture and a quantitative vascular index of fibroids were provided. Finally, we evaluated the effect of the cardiac cycle.

RESULTS

All microvascular flow images showed more distinctive vascular structures than visible on power Doppler. Calculating a vascular index for fibroids on 2D MV-flowTM images was easily performed on-site. During the cardiac cycle a higher vascular index (VI 75.2) is obtained in systole as compared with diastole (VI 44.0).

CONCLUSION

Microvascular flow imaging allowed detailed visualisation of the uterine vascular architecture and is easy to use.

WHAT IS NEW?

Microvascular flow imaging may be of added value for diagnosing uterine disorders, as well as for pre- and post-operative assessment of suited surgical techniques. Yet, validation with histology and clinical outcomes is required.

Automated Uterine Fibroids Detection in Ultrasound Images Using Deep Convolutional Neural Networks

Fibroids of the uterus are a common benign tumor affecting women of childbearing age. Uterine fibroids (UF) can be effectively treated with earlier identification and diagnosis. Its automated diagnosis from medical images is an area where deep learning (DL)-based algorithms have demonstrated promising results. In this research, we evaluated state-of-the-art DL architectures VGG16, ResNet50, InceptionV3, and our proposed innovative dual-path deep convolutional neural network (DPCNN) architecture for UF detection tasks. Using preprocessing methods including scaling, normalization, and data augmentation, an ultrasound image dataset from Kaggle is prepared for use. After the images are used to train and validate the DL models, the model performance is evaluated using different measures. When compared to existing DL models, our suggested DPCNN architecture achieved the highest accuracy of 99.8 percent. Findings show that pre-trained deep-learning model performance for UF diagnosis from medical images may significantly improve with the application of fine-tuning strategies. In particular, the InceptionV3 model achieved 90% accuracy, with the ResNet50 model achieving 89% accuracy. It should be noted that the VGG16 model was found to have a lower accuracy level of 85%. Our findings show that DL-based methods can be effectively utilized to facilitate automated UF detection from medical images. Further research in this area holds great potential and could lead to the creation of cutting-edge computer-aided diagnosis systems. To further advance the state-of-the-art in medical imaging analysis, the DL community is invited to investigate these lines of research. Although our proposed innovative DPCNN architecture performed best, fine-tuned versions of pre-trained models like InceptionV3 and ResNet50 also delivered strong results. This work lays the foundation for future studies and has the potential to enhance the precision and suitability with which UF is detected.

Combined transabdominal and transvaginal ultrasound-guided percutaneous microwave ablation of uterine myomas: an effective monitoring technique

OBJECTIVE

This study compared the feasibility and efficacy of transabdominal ultrasound (TAU) and combined transabdominal and transvaginal ultrasound (TA/TV US)-guided percutaneous microwave ablation (PMWA) for uterine myoma (UM).

METHOD

This study enrolled 73 patients with UM who underwent PMWA via the transabdominal ultrasound-guided (TA group) or the combined transabdominal and transvaginal ultrasound-guided (TA/TV group) approaches. The intraoperative supplementary ablation rates, postoperative immediate ablation rates, lesion reduction rates and other indicators three months postoperatively were compared between the groups. The display of the needle tip, endometrium, uterine serosa, rectum and myoma feeding vessels under the guidance of TAU, transvaginal ultrasound (TVU) and TA/TV US were evaluated in the TA/TV group.

RESULTS

In the TA/TV group, the real-time position of the needle tip and the endometrium complete display rate of the same lesions with TVU guidance were significantly higher than those using TAU. TA/TV US guidance significantly improved the complete display rate of each indicator. The intraoperative supplementary ablation rate in the TA/TV group was lower than that in the TA group. Similarly, the postoperative immediate ablation and volume reduction rates of the lesions three months postoperatively were higher than those in the TA group, especially for lesions with a maximum diameter ≥6 cm.

CONCLUSION

TA/TV US is an effective monitoring method that can be used to improve imaging display. Its use is recommended in patients with obesity, poor transabdominal ultrasound image quality and large myoma volumes.