Three-dimensional ultrasonography and power Doppler for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding

Additional value of Doppler ultrasound to B-mode ultrasound in assessing for uterine intracavitary pathologies among perimenopausal and postmenopausal bleeding women: a multicentre prospective observational study in Vietnam

PURPOSE

To determine the role of Doppler ultrasonography when combined with B-mode ultrasonography in diagnosing uterine intracavitary pathologies (UIPs) in perimenopausal and postmenopausal bleeding women.

METHODS

This multicentre prospective observational study included 150 women aged > 40 years with abnormal uterine bleeding (AUB), who were hospitalised at Hospital X and Hospital Y between June 2016 and June 2019. All participants underwent transvaginal B-mode ultrasound and transvaginal Doppler ultrasound, and the results of sonography were compared to histopathological endpoint.

RESULTS

The morphological features, structure, margin, border line of the endometrial-mass lesion, intracavitary uterine fluid, and Doppler signal clearly differed between benign and malignant intracavitary pathologies (p < 0.0001). However, echogenicity had a limited value in differentiating among UIPs (p = 0.1). The sensitivity and specificity of the pedicle sign in diagnosing endometrial polyps were 50.0% and 97.6%; for the circular pattern in endometrial fibroids were 46.2% and 100.0%; for the multiple vessel pattern in endometrial cancer were 64.0% and 96.0%; and for the scattered vessel pattern in endometrial hyperplasia were 43.96% and 56.43%, respectively. The additional value of Doppler ultrasound was greater than that of separate B-mode ultrasound in assessing UIPs in our study.

CONCLUSIONS

B-mode ultrasound used in combination with Doppler as a noninvasive tool was significantly valuable in the diagnostic procedures for UIPs in perimenopausal and postmenopausal bleeding women. Doppler ultrasound and B-mode transvaginal ultrasound should be used together routinely for discrimination between malignant diseases and benign endometrial changes. Further studies are needed to better understand the benefits of combining Doppler ultrasound and B-mode ultrasound in routine sonographic practice.

Endometrial Cut Off Thickness as Predictor of Endometrial Pathology in Perimenopausal Women with Abnormal Uterine Bleeding: A Cross-Sectional Study

Purpose

We aim to determine the predictive value of endometrial thickness by transvaginal ultrasonography (TVS) in diagnosing endometrial pathology and to evaluate whether Doppler complements its diagnostic efficacy in perimenopausal women with abnormal uterine bleeding.

Methods

This cross-sectional observational study was conducted among 70 perimenopausal women with AUB who underwent TVS measurement of endometrial thickness (ET) and Doppler flow indices followed by endometrial sampling and histopathological examination (HPE).

Results

In HPE, 51 (73%) women had normal diagnosis while 19 (27%) women had neoplastic histology either benign or malignant. They were categorised into group I and group II, respectively. There was a significant difference in age (P=0.001) and incidence of obesity (P=0.01) between the two groups. The ETs measured in group I and group II were 7.89 ± 2.62 mm and 14.07 ± 3.96 mm, respectively, with significant difference (P < 0.001). A TVS-ET of 10.5 mm had the highest sensitivity and specificity of 89.5% and 86.3%, respectively, PPV of 70.68%, NPV of 95.68%, LR+ of 6.52, and LR- of 0.12. Doppler flow velocimetric study of endometrial and uterine vessels did not demonstrate a significant difference.

Conclusions

Women in perimenopause with AUB should be offered to undergo endometrial sampling for histopathological examination if TVS ET ≥10.5 mm. The coexisting risk factors especially higher age (>45 years) and obesity (BMI>30) significantly escalate the chances of developing endometrial pathology.

ACR Appropriateness Criteria® Abnormal Uterine Bleeding

This publication summarizes the relevant literature for the imaging of patients with symptoms of abnormal uterine bleeding, including initial imaging, follow-up imaging when the original ultrasound is inconclusive, and follow-up imaging when surveillance is appropriate. For patients with abnormal uterine bleeding, combined transabdominal and transvaginal ultrasound of the pelvis with Doppler is the most appropriate initial imaging study. If the uterus is incompletely visualized with the initial ultrasou2nd, MRI of the pelvis without and with contrast is the next appropriate imaging study, unless a polyp is suspected on the original ultrasound, then sonohysterography can be performed. If the patient continues to experience abnormal uterine bleeding, assessment with ultrasound of the pelvis, sonohysterography, and MRI of the pelvis without and with contrast would be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Antidiastole Value of Three-dimensional Ultrasonography and Power Doppler between Uterine Parenchyma Lumps and Endometrial Cancer: A Retrospective Study

Sometimes endometrial polyps, submucosal myomas, and endometrial cancer show similar findings under ultrasonography. The aim of this study was to assess the antidiastole value of blood flow parameters using three-dimensional (3D) power Doppler ultrasonography angiography (PDA) between endometrial cancer and uterine parenchyma lumps. The data of the blood flow indices in 3D-PDA including the vascularization index (VI), flow index (FI), and vascularization flow index (VFI) in 40 patients with endometrial cancer and 41 patients with uterine parenchyma lumps (endometrial polyps and submucosal myomas) were retrospectively analysed and compared utilizing Virtual Organ Computer-aided AnaLysis (VOCAL) software. The results showed that all the blood flow parameters (VI, FI, VFI) were significantly higher in women with endometrial cancer than in those with uterine parenchyma lumps (P<0.001). The area under the curve of ROC of VI, FI, and VFI was 0.98, 0.84, and 0.97, respectively. Thus, the best predictor of endometrial carcinoma was VI with a sensitivity of 97.0% and a specificity of 91.0%. The optimal cutoff value of VI was 4.06%. Our data demonstrated that all of the blood flow signal parameters (including VI, FI, and VFI) in 3D power Doppler ultrasonography had significant antidiastole values between endometrial cancer and uterine parenchyma lumps to assist clinicians in properly diagnosing patients.

Utility of three dimensional (3-D) ultrasound and power Doppler in identification of high risk endometrial cancer at a tertiary care hospital in southern India: A preliminary study

OBJECTIVE

The study was conducted to find the utility of three dimensional (3-D) ultrasound and Doppler sonography in differentiating benign and malignant endometrial lesions and to ascertain the association of sonology parameters with type, grade and stage of endometrial cancer.

MATERIALS AND METHODS

Women attending the gynaecology department of a tertiary care hospital, with a provisional diagnosis of carcinoma endometrium were subjected to three dimensional power Doppler ultrasound evaluation and assessment of vascular patterns. VOCAL (Virtual Organ Computer-aided Analysis) software was used to assess volume, Vascularisation Index (VI), Flow Index (FI) and Vascularisation Flow Index (VFI). Ultrasound parameters were compared with histologic diagnosis to evaluate the diagnostic performance using Receiver Operating Characteristic (ROC) Curve.

RESULTS

Sixty-four women were included in the study, 33 with benign and 31 with malignant endometrial lesions. Larger endometrial volume and higher Doppler indices correlated with malignant lesions. The variables with good discriminatory potential between benign and malignant status were VI and VFI, having a sensitivity of 90.3% and specificity of around 80%. VFI (adjusted odds ratio of 40.4; (95% CI - 8.46-192.88), p value < 0.001) was the only significant variable identified by multivariate logistic regression, when adjusted for age and post-menopausal status. Multiple global and focal vessel pattern was seen predominantly in malignant cases (specificity 93.9%), although the sensitivity was low (61.2%). Higher stages and grades of tumour and non-endometrioid types had higher Doppler indices, and requires further evaluation.

CONCLUSIONS

3-D ultrasound has good discrimination potential between benign and malignant endometrial lesions and could be useful as a screening tool. However, utility of 3-D tool for differentiation between tumour characteristics needs further validation.

The value of 3-dimensional color Doppler in predicting intraoperative hemorrhage for cesarean scar pregnancy

The aim of this study is to evaluate the efficacy of 3-dimensional (3D) ultrasonography and 3D color power Doppler ultrasound in the management of cesarean scar pregnancy (CSP).A case-control study enrolled 190 CSP patients who underwent uterine artery embolization (UAE) in combination with dilatation and curettage (D&C). The maximum diameter of gestational sac or CSP mass, uterine scar thickness, and resistance index (RI) were measured by 2D ultrasound. The lesion volume, vascular index (VI), flow index (FI), blood vessels, and blood flow index (VFI) were assessed by 3D ultrasound. The changes of these parameters before and after UAE were analyzed. Then, the patients were divided into bleeding group and control group according to the intraoperative hemorrhage during D&C to access and compare the significance of 2D and 3D parameters in intraoperative hemorrhage.The mean VI and the mean VFI were significantly reduced after embolization (P < .01). In the bleeding group, the lesion volume and diameter of gestational sac or CSP mass were significantly larger, VI and VFI were significantly higher, the uterine scar thickness was thinner, and RI was lower (P < .05). The best indicator for prediction of massive intraoperative bleeding was the VI with an area under the curve of 0.870, the best cut-off value of VI was 7.500, and the sensitivity and specificity were 88.2% and 82.4%, respectively. In comparing the receiver operating characteristic curves among 2D and 3D ultrasound parameters, the diagnostic efficacy of lesion volume was significantly higher than maximum diameter (P < .001). The diagnostic efficacy of VI was significantly higher than maximum diameter (P = .020) and RI (P = .011).UAE reduces the number of vessels and the blood flow perfusion obviously; however, it does not reduce lesion size or increases myometrial thickness. Three-dimensional ultrasonography and power Doppler, especially VI, lesion volume may be helpful in predicting excessive bleeding during D&C after UAE.

Sonographic Presentation of Endometrial Carcinoma Stage I: A Case Study

Endometrial carcinoma is the most commonly diagnosed malignancy in the female reproductive tract, mainly affecting women in their postmenopausal years. Although rare, it can also present in premenopausal women. The most common clinical presentation is episodes of abnormal uterine bleeding. Magnetic resonance imaging (MRI), computed tomography (CT), and sonography are imaging modalities used to detect endometrial carcinoma. However, a conclusive diagnosis is made through endometrial biopsy. A case is reported of endometrial distension with endometrial carcinoma and cervical stenosis listed as differentials and originally detected through CT. Sonographic assessment showed an irregular thickened endometrium and an endometrial cavity containing fluid with low-level echoes and areas of polypoid mass-like tissue. Based on these findings, the patient underwent an endometrial biopsy that provided confirmation of endometrioid adenocarcinoma (International Federation of Gynecology and Obstetrics [FIGO] Stage 1).