Contrast-enhanced sonography in the examination of benign and malignant adnexal masses

Contrast-enhanced ultrasonography for differential diagnosis of adnexal masses

Background

Quantitative contrast-enhanced ultrasonography parameters are affected by various factors. We evaluated corrected quantitative contrast enhanced ultrasonography in differentiating benign adnexal tumors from malignant tumors.

Methods

Patients with adnexal masses who underwent conventional and contrast-enhanced ultrasonography were included. Contrast-enhanced ultrasonography parameters such as base intensity, arrival time, peak intensity, time to peak intensity, ascending slope, and descending slope were measured. Corrected (time to peak intensity − arrival time) _mass/(time to peak intensity − arrival time) _uterus and (peak intensity − base intensity) _mass/(peak intensity − base intensity) _uterus were calculated. Lesions were confirmed by pathologic examination of surgical specimens.

Results

This study included 31 patients with 35 adnexal lesions including 20 (57.10%) benign and 15 (42.90%) malignant lesions. The corrected contrast-enhanced ultrasonography quantitative parameters in lesions were statistically different between malignant and benign groups (P<0.05). The optimal cut-off value for (time to peak intensity − arrival time) _mass/(time to peak intensity − arrival time) _uterus, ascending slope, and (peak intensity − base intensity) _mass/(peak intensity − base intensity) _uterus, and descending slope for differentiating malignant adnexal masses from benign tumors were 1.05 (area under curve: 0.93, P<0.05), 1.11 (area under curve: 0.83, P<0.05), 0.82 (area under curve: 0.73, P<0.05), and −0.27 (area under curve: 0.66, P=0.16), with sensitivity and specificity of 93.33% and 85.00%, 86.67% and 75.00%, 86.67% and 60.00%, and 54.55% and 66.67%, respectively.

Conclusions

Corrected contrast-enhanced ultrasonography parameters provide practical differential diagnosis value of adnexal lesions with high reliability for sonologists.

The Multimodal Ultrasound Features of Ovarian Serous Surface Papillary Borderline Tumor

Aim:

Ovarian serous surface papillary borderline tumor (OSSPBT) is very rare. Combined with clinical and pathological features, we aim to investigate the multimodal ultrasound features of OSSPBT.

Patients and Methods:

There were only 18 patients diagnosed with OSSPBT among the 142 patients who were diagnosed with borderline serous ovarian tumor by pathology from June 2008 to December 2020 in our hospital. Their clinical data, conventional ultrasound, two-dimensional contrast-enhanced ultrasound (2D-CEUS), three-dimensional contrast-enhanced ultrasound (3D-CEUS) characteristics, pathology, and prognosis were retrospectively analyzed.

Results:

The 18 patients had no specific clinical symptoms. Multiple implantable nodules were found in 8 patients (44.4%), ascites in 13 patients (72.2%), and elevated carbohydrate antigen 125 (CA125) in 15 patients (83.3%). After excluding 2 misdiagnosed patients from 18 patients, 26 tumors in 16 patients (6 unilateral and 10 bilateral) were studied. Conventional ultrasound findings of OSSPBT showed that large solid masses around normal ovary without capsule, and numerous small dense anechoic areas were observed in the parenchyma of the lesion, with strong speckle echo (“blizzard” sign) of varying degrees. The 2D-CEUS and 3D-CEUS showed a normal ovary in the center surrounded by a radial blood supply of OSSPBT with thick and irregular branches. Histopathologically, the papillary fibrous stalk of OSSPBT had a large number of sand bodies and tortuous dilated microvessels. All patients had no recurrence after surgery, and two of them delivered successfully through assisted reproductive technology.

Conclusion:

OSSPBT has a good prognosis. Its conventional ultrasound is characterized by irregular solid masses surrounding normal ovaries and a large number of “blizzard” signs. It showed low enhancement of eccentricity with irregular radial branches centered on the ovary by CEUS.

Application of Combined Two-Dimensional and Three-Dimensional Transvaginal Contrast Enhanced Ultrasound in the Diagnosis of Endometrial Carcinoma

Objective. The goal of this study was to explore the clinical value of combining two-dimensional (2D) and three-dimensional (3D) transvaginal contrast-enhanced ultrasounds (CEUS) in diagnosis of endometrial carcinoma (EC). Methods. In this prospective diagnostic study, transvaginal 2D and 3D CEUS were performed on 68 patients with suspected EC, and the results of the obtained 2D-CEUS and 3D-CEUS images were compared with the gold standard for statistical analysis. Results. 2D-CEUS benign endometrial lesions showed the normal uterine perfusion phase while EC cases showed early arrival and early washout of the contrast agent and nonuniform enhancement. The 3D-CEUS images differed in central blood vessel manifestation, blood vessel shape, and vascular pattern between benign and malignant endometrial lesions (P < 0.05). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of transvaginal 2D-CEUS and 2D-CEUS combined with 3D-CEUS for diagnosis of benign and malignant endometrial lesions were 76.9%, 73.8%, 64.5%, 83.8%, and 75.0% and 84.6%, 83.3%, 75.9%, 89.7%, and 83.8%, respectively. Conclusion. 3D-CEUS is a useful supplement to 2D-CEUS and can clearly reveal the angioarchitecture spatial relationships between vessels and depth of myometrial invasion in EC. The combined use of 2D and 3D-CEUS can offer direct, accurate, and comprehensive diagnosis of early EC.

Combination of 2- and 3-dimensional contrast-enhanced transvaginal sonography for diagnosis of small adnexal masses

OBJECTIVES

The purpose of this study was to evaluate the efficacy of the combination of 2-dimensional (2D) and 3-dimensional (3D) contrast-enhanced sonography in discriminating between benign and malignant small adnexal masses.

METHODS

Selected patients were evaluated with both 2D and 3D contrast-enhanced sonography after conventional sonography before undergoing any surgery. Time-intensity curves for 2D contrast-enhanced sonography were constructed by using contrast-enhanced sonographic software. A vascular perfusion characteristic analysis was achieved by 2D and 3D contrast-enhanced sonography. Results were finally verified by surgery.

RESULTS

Forty-seven cases of benign and 10 cases of malignant small adnexal masses were discovered. Significant differences in perfusion patterns, time-intensity curve shapes for 2D contrast-enhanced sonography, grayscale contrast-enhanced sonography, and blood flow imaging on 3D contrast-enhanced sonography were observed between benign and malignant masses (P< .05). Two-dimensional contrast-enhanced sonography, 3D contrast-enhanced sonography, parallel combination of 2D and 3D contrast-enhanced sonography, and serial combination of 2D and 3D contrast-enhanced sonography all reached diagnostic sensitivity of 100% for discriminating benign from malignant masses, whereas specificity values were 61.7%, 63.8%, 68.1%, and 57.4%, respectively. Areas under the receiver operating characteristic curves were 0.809, 0.819, 0.840, and 0.787.

CONCLUSIONS

Two-dimensional contrast-enhanced sonography is of high value in distinguishing malignant from benign small adnexal masses; 3D contrast-enhanced sonography provides richer and more useful information for evaluation of these masses. Diagnostic sensitivity of 100% can be achieved when using a serial combination of 2D and 3D contrast-enhanced sonography, although specificity needs further improvement.

[Sonographic diagnosis of presumed benign ovarian tumors]

To discriminate ovarian lesions is of particular importance in gynecological practice. Two main problems need answers: discrimination of benign and malignant adnexal masses and choice of the appropriate surgical treatment if necessary. Nearly 2% of the adnexal masses are ovarian carcinomas or borderline tumors. It is now, well established that ultrasonography is the gold standard for ovarian cyst diagnosis. The purpose of this data was to review the literature and to establish, with the evidence base medicine model, which parameters and existing diagnostic models using ultrasound and Doppler perform best in the evaluation of adnexal masses. Transvaginal sonography has demonstrated considerable advantage over conventional transabdominal sonography. However, transparietal sonography is still useful in large tumors. Definition of the nomenclature and classification was done and should be used. Unilocular ovarian cyst characterization seems easy using sonography and Doppler. In front of complication, discrimination of such functional cyst may be difficult but spontaneous regression confirms usually the expectative management. Dermoid cysts and endometriomas seem to be easier to discriminate from other adnexal masses. Ultrasound and morphologic parameters have a sensitivity of about 90% and a specificity of 80%; that makes this exam the gold standard for ovarian masses diagnosis. Only 50% of ovarian masses are characterized by sonography. Scoring systems help to differentiate benign from malignant masses (sensitivity of about 90%). Logistic regression and models are good methods especially for LR1 and 2 and RMI and may be useful for malignancy prediction but are difficult to use in current practice. Expert diagnosis is a subjective but most important performing parameter. Any suspicious ovarian mass or not easily diagnosed mass requires sonography by an expert, which can first use all the techniques and the different parameters to discriminate benign and malignant tumors. An explicit report will help the physician to define the right attitude for an appropriate management. Six to 16% of adnexial masses are complex or not classified and will result in MRI prescription or surgery.

Ultrasound and ovarian cancer screening: is there a future?

Ovarian cancer is a leading cause of death due to gynecologic malignant disease. Advances in ultrasound have improved the ability to identify the more subtle characteristics of adnexal masses, resulting in an increasing volume of research addressing its use to accurately predict whether masses are benign or malignant, and the inclusion of ultrasound in large-scale studies addressing screening for ovarian cancer. Herein, we explore some of the factors that make screening for ovarian cancer challenging, review the major trials addressing the effect of ovarian cancer screening, and examine data relating to more recent advances in ultrasound technology.

Contrast-enhanced sonography depicts spontaneous ovarian cancer at early stages in a preclinical animal model

OBJECTIVE

Our goal was to examine the feasibility of using laying hens, a preclinical model of human spontaneous ovarian cancer, in determining the kinetics of an ultrasound contrast agent indicative of ovarian tumor-associated neoangiogenesis in early-stage ovarian cancer.

METHODS

Three-year-old White Leghorn laying hens with decreased ovarian function were scanned before and after intravenous injection of a human serum albumin-perflutren contrast agent at a dose of 5 μL/kg body weight. Gray scale morphologic characteristics, Doppler indices, the arrival time, peak intensity, and wash-out of the contrast agent were recorded and archived on still images and video clips. Hens were euthanized thereafter; sonographic predictions were compared at gross examination; and ovarian tissues were collected. Archived clips were analyzed to determine contrast parameters and Doppler intensities of vessels. A time-intensity curve per hen was drawn, and the area under the curve was derived. Tumor types and the density of ovarian microvessels were determined by histologic examination and immunohistochemistry and compared to sonographic predictions.

RESULTS

The contrast agent significantly (P < .05) enhanced the visualization of microvessels, which was confirmed by immunohistochemistry. Contrast parameters, including the time of wash-out and area under the curve, were significantly different (P < .05) between ovaries of normal hens and hens with ovarian cancer and correctly detected cancer at earlier stages than the time of peak intensity.

CONCLUSIONS

The laying hen may be a useful animal model for determining ovarian tumor-associated vascular kinetics diagnostic of early-stage ovarian cancer using a contrast agent. This model may also be useful for testing the efficacy of different contrast agents in a preclinical setting.

Diagnostic value of contrast-enhanced ultrasonography in the characterization of ovarian tumors()

INTRODUCTION

Vascularity influences the characteristics of gynecologic tumors observed with direct imaging techniques that reveal the macrovascular component of these lesions (color and power Doppler) and with indirect imaging involving the administration of contrast agents to examine the microcirculation and interstitial perfusion (contrast-enhanced computed tomography [CT] and magnetic resonance [MR] imaging). The purpose of this study was to determine whether contrast-enhanced ultrasonography (CEUS) of ovarian lesions provides useful information that cannot be obtained with conventional US.

MATERIALS AND METHODS

We used CEUS to assess 72 nonspecific adnexal lesions in 61 patients. CEUS was performed with a 4.8-ml bolus of a second-generation ultrasonographic contrast agent and dedicated imaging algorithms. For each lesion, B-mode morphology, CEUS morphology, and time/intensity curves were evaluated.

RESULTS

In 8/61 cases (13.1%) CEUS offered no additional morphovascular information. In 38/61 cases (62.3%), it provided additional information that did not modify the management of the lesion, and in 15/61 cases (24.6%) it gave additional information that modified the management of the lesion. Malignant lesions were characterized by significantly shorter times to peak enhancement (11.9 ± 3.1 s vs 19.8 ± 4.0 s p < 0.01) and significantly higher peak intensity (24.7 ± 4.2 dB vs 17.8 ± 3.3 dB p < 0.01) compared with benign lesions.

CONCLUSIONS

CEUS improves diagnostic confidence in the characterization of liquid-corpuscular lesions where conventional US is inconclusive. CEUS can be proposed as a valid alternative to CT and MR. However, information obtained by CEUS influences the therapy in a limited percentage of cases (24.6%).

Doppler Evaluation of the Ovary: Clinical Applications and Challenges

Transvaginal sonography has been shown to be an accurate technique for discriminating between benign and malignant adnexal masses. Accurate preoperative differential diagnosis of adnexal masses is essential for optimizing patients’ treatment. The advancement and wider availability of therapies of assisted conception have occurred to a large extent as a result of developments in ultrasonography. Transvaginal color Doppler has opened up exciting new possibilities for the better understanding of the physiology and pathophysiology of ovarian blood flow, resulting in a number of completely new diagnostic parameters.

The role of CnTI-SonoVue in the diagnosis of ovarian masses with papillary projections: a preliminary study

OBJECTIVES

To describe sonographically the distribution patterns of a second-generation contrast agent in the microcirculation of unilocular and multilocular ovarian masses with papillary projections, and to investigate whether qualitative evaluation of the passage of the contrast agent can improve the performance of sonography in distinguishing between benign and malignant masses with papillary projections.

METHODS

Thirty-three patients with unilocular or multilocular ovarian masses with papillary projections were enrolled into the study in three clinical centers. The contrast-enhanced transvaginal examination was performed using 'Contrast Tuned Imaging' (CnTI) technology and SonoVue ultrasound contrast agent.

RESULTS

Twenty-four (73%) lesions were benign, eight (24%) were borderline ovarian tumors, and one patient presented with an endometrioid ovarian adenocarcinoma. On color and power Doppler examinations the presence of vessels was demonstrated in 17 papillary projections, while on CnTI-SonoVue examination, the presence of vessels was shown in these 17 and in six additional cases. In all cases with absent papillary perfusion after SonoVue intravenous injection, the cyst wall appeared unequivocally regular. The sensitivity and specificity of conventional color Doppler examination with regard to malignancy were 100% and 67% and the positive and negative likelihood ratios were 3.03 and 0.16, respectively. For the contrast-enhanced examination the corresponding values were 100%, 42%, 1.7 and 0.26. The difference in specificity was statistically significant (P<0.05) because 14 cases, in which papillary perfusion was detected after SonoVue injection, proved to be benign on pathological examination.

CONCLUSION

Qualitative evaluation of blood circulation in papillary projections using CnTI-SonoVue examination does not improve the discrimination of benign from borderline/malignant ovarian masses with papillary projections.

Contrast-enhanced power Doppler sonography of malignant ovarian tumors using harmonic flash-echo imaging: preliminary experience

To investigate the potential usefulness of contrast-enhanced intermittent harmonic sonography in the diagnosis of ovarian cancer, we evaluated 4 patients with complex adnexal masses suspected of malignancy using intermittent harmonic sonography after injection of a contrast agent. Tumor and/or mural nodule tissue enhancement was detected in all cases of ovarian malignancy. Contrast-enhanced, intermittent harmonic sonography provides a satisfactory visualization of blood flow in the solid portion of the tumor tissue and may support a diagnosis of ovarian malignancy. Depiction of blood vessels using low MI techniques may be possible with other vascular ultrasonographic contrast agents.

Ultrasonographic contrast media: has the time come in obstetrics and gynecology?

OBJECTIVE

The aim of this work was to review the technical aspects and clinical applications of contrast media (microbubbles and nanomolecular agents) in obstetric and gynecologic ultrasonographic imaging.

METHODS

With the use of a computerized database (MEDLINE) and several Web-based search engines (Google Scholar and Copernic), relevant articles on ultrasonographic contrast media were reviewed. References cited in these articles and not obtained via the search engines were also reviewed.

RESULTS

Ultrasonographic contrast media constitute a new and expanding technology. They are frequently used, for example, in adult cardiology. Extensive research in laboratory setups, animals, and human subjects has shown their safety and huge potential as an adjunctive tool in clinical practice. They increase signals returning from insonated tissues and are particularly effective as intravascular agents, enhancing color and Doppler signals, for instance. Preliminary results in tumor imaging are encouraging. The ultrasonographic contrast media permit pharmacokinetic perfusion studies, which may be of enormous clinical importance in the study of early cancer development. Targeted imaging and therapies are becoming a reality. Microbubbles have already brought a new dimension to diagnostic ultrasonographic imaging. Many authors have described the clinical value of these agents in liver, prostate, and breast imaging, among others. Newer types of media, the nanomolecules, are now emerging as the latest in imaging enhancers as well as therapeutic agent carriers.

CONCLUSIONS

Although showing potential in imaging of the uterus and fallopian tubes as well as some obstetric applications, the contrast media, in particular the nanomolecules, seem to be most promising in ovarian cancer.

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.

Imaging of renal tumours in infancy and childhood

There is a large range of benign and malignant renal neoplasms. This article lists the most benign, indeterminate and malignant renal tumours that occur during infancy and childhood. It briefly describes the most important entities, including their imaging features, and important complications. Differential diagnosis and pitfalls are discussed, and a brief suggestion for a standardised imaging algorithm is proposed. Although modern imaging techniques, including colour Doppler sonography, helical or multidetector CT, and MR have significantly improved imaging potential, the definite diagnosis on tumour entity still is established only by histology.

A review of nonconventional ultrasound techniques and contrast-enhanced ultrasonography of noncardiac canine disorders

Modern ultrasound contrast media are gas-containing stabilized microbubbles that remain intact in the circulating blood for several minutes after intravenous injection and increase the intensity of the backscattered ultrasound. When the microbubbles disappear from the blood, they can be detected in the parenchyma of the liver and the spleen for about 30 more minutes (late liver- and spleen-specific phase). The insonated microbubbles produce second harmonic ultrasound frequencies, whose detection requires nonconventional ultrasound modalities such as pulsed inversion imaging. Nonconventional ultrasound techniques can also be used without microbubbles because second harmonics can be generated by ultrasound in tissues as well. The physical principles and advantages of nonconventional ultrasound techniques are described. The circulating microbubbles can be used not only to enhance weak Doppler signals, but also to perform dynamic contrast studies. Contrast-enhanced dynamic ultrasound studies--similar to contrast-enhanced CT and MRI examinations--have been used in humans to characterize lesions noninvasively (i.e., without biopsies) found during conventional ultrasound examinations. To map the distribution of contrast medium in a nodule or in an organ, specific scanning techniques such as stimulated acoustic emission have been developed. Stimulated acoustic emission occurs when high acoustic pressure ultrasonic waves disrupt the stationary or slowly moving microbubbles. This results in the release of a large amount of harmonic ultrasound frequencies. When the stimulated acoustic emission technique is used for dynamic studies, scanning must be interrupted several times to allow the microvasculature of the lesion to refill with microbubbles (interval delay imaging). The contrast patterns of malignant and benign hepatic nodules in humans have been the most intensively studied. Another type of dynamic study in humans measures the transit time of the contrast medium; that is, how fast the peripherally injected microbubbles reach the hepatic veins. Hepatic cirrhosis can be differentiated from other diffuse parenchymal liver diseases by a shorter transit time. Introducing nonconventional ultrasound techniques and ultrasound contrast media in veterinary diagnostic imaging may have potential value; however, intensive research should be carried out before ultrasound contrast agents can routinely be used in clinical practice.

The use of contrast-enhanced power Doppler ultrasound in the diagnosis and follow-up of inflammatory abdominal masses associated with Crohn's disease

1. Contrast-enhanced power Doppler ultrasound has a high sensitivity and specificity in the detection and evaluation of inflammatory abdominal masses associated with Crohn's disease. 2. The spatial resolution and sensitivity of this technique allows the detection of small inflammatory abdominal masses of 1 cm or above. 3. The absence of any associated X-ray radiation allows repeated examinations to be undertaken. This facilitates assessment of disease progression and response to treatment 4. The early detection of the complications of Crohn's disease may facilitate treatment by medical means rather than necessitating surgical intervention. Clinical and biochemical assessment of the complications of Crohn's disease such as abscess, stricture and fistula formation is extremely difficult. Radiological imaging is therefore widely utilized. This includes barium studies, ultrasound, computed tomography and nuclear medicine techniques. Contrast-enhanced power Doppler ultrasound has high sensitivity and specificity in the detection and evaluation of inflammatory abdominal masses associated with Crohn's disease, and compares favourably with computed tomography. The spatial resolution and sensitivity of contrast-enhanced power Doppler ultrasound enables the detection of small inflammatory abdominal masses. The absence of radiation dose to the patient allows multiple and serial examinations to be undertaken. This facilitates assessment of disease progression and response to treatment. The early detection of the extra-mural complications of Crohn's disease and the close monitoring of response to medical treatment may obviate the need for surgical intervention.

Kinetics of a US contrast agent in benign and malignant adnexal tumors

PURPOSE

To evaluate the effects of a microbubble contrast agent on the power Doppler ultrasonographic (US) examination of adnexal tumors, with a special focus on the timing of the transit of the microbubble bolus.

MATERIALS AND METHODS

Seventy patients who were suspected of having ovarian tumors were examined preoperatively with contrast material-enhanced US. Images obtained during a 5-minute examination were stored digitally, and the behavior of the contrast agent was evaluated objectively with measurement of the time-dependent image intensity at the region of interest with a computer program. A time-intensity curve in each case was derived and analyzed. The Mann-Whitney U test was used to compare intensity changes and tumor parameters in benign and malignant adnexal tumors.

RESULTS

Both the baseline and maximum power Doppler intensities, as well as the absolute and relative (percent) rise in intensity, were significantly higher (P <.001) in malignant as compared with benign tumors. The arrival time was shorter (17.5 vs 22.5 seconds; P =.005) and the duration of contrast agent effect was longer (190.4 vs 103.6 seconds; P <.001) in malignant tumors than they were in benign tumors. The area under the time-intensity curve was significantly greater in malignant tumors compared with that in benign tumors (P <.001).

CONCLUSION

After microbubble contrast agent injection, malignant and benign adnexal lesions behave differently in degree, onset, and duration of Doppler US enhancement.

Ovarian mass--benign or malignant?

Ovarian cancer strikes 23,000 American women every year, accounting for 52% of all gynecological cancer deaths. The death of comedienne Gilda Radner from ovarian cancer in 1991 brought the disease to the forefront for the American public. Unfortunately, since that time, there has been an absence of publicity about this dreadful disease. Seventy-five percent of ovarian cancers are not diagnosed until the cancer has advanced to stage III or IV for several reasons. Clinical guidelines for the diagnostic screening of ovarian cancer have not been developed, which markedly hinders the diagnosis of ovarian cancer until it is in later stages. The tumor marker CA-125 is not specific and, therefore, is an inadequate screening tool. This article discusses the epidemiology of ovarian cancer, the components of diagnostic screening, and treatment options. Nursing care of the patient undergoing surgical treatment for ovarian cancer also is discussed.

The sonographic evaluation of tubal patency with stimulated acoustic emission imaging

OBJECTIVES

Experimental and clinical data suggest that insonation of echo-enhancing contrast agents with high acoustic power produces disintegration of microbubbles, resulting in a phenomenon called stimulated acoustic emission (SAE). The purpose of this study was to investigate whether SAE might be detected by transvaginal sonography and whether this technique may be useful in the assessment of tubal patency by hysterosalpingo-contrast sonography (SAE-HyCoSy).

METHODS

Patients booked for X-ray hysterosalpingography (HSG) for infertility evaluation also received SAE-HyCoSy. The order of the two procedures was established in each patient by randomization after placement of a transcervical balloon catheter. For SAE-HyCoSy, the ultrasound contrast medium Levovist was injected, with the acoustic power set at the maximum level permitted on ultrasound machines employing dedicated algorithms. Conventional HSG was performed for comparison.

RESULTS

Seventy-seven Fallopian tubes were examined in 41 patients. In all cases it was possible to obtain the SAE phenomenon. In 10 tubes (13%) proximal filling was not observed by both SAE-HyCoSy and HSG. In the remaining 67 tubes, free spill from the distal end of the lumen was demonstrated in 96% of cases (64/67) with SAE-HyCoSy and in 97% of cases (65/67) with HSG. Disagreement between the two techniques was observed in five tubes only, with a Cohen's kappa coefficient of 0.76 (95% confidence interval, 0.56-0.96).

CONCLUSION

SAE techniques were successfully applied to HyCoSy and allowed the visualization of the free spill of contrast agent into the peritoneal cavity in the majority of cases. SAE-HyCoSy showed good agreement with HSG in this preliminary study.

An algorithm including results of gray-scale and power Doppler ultrasound examination to predict endometrial malignancy in women with postmenopausal bleeding

OBJECTIVE

To determine if power Doppler ultrasound examination of the endometrium can contribute to a correct diagnosis of endometrial malignancy in women with postmenopausal bleeding and endometrium > or = 5 mm.

METHODS

Eighty-three women with postmenopausal bleeding and endometrium > or = 5 mm underwent gray-scale and power Doppler ultrasound examination using predetermined, standardized settings. Suspicion of endometrial malignancy at gray-scale ultrasound examination (endometrial morphology) was noted, and the color content of the endometrium at power Doppler examination was estimated subjectively (endometrial color score). Computer analysis of the most vascularized area of the endometrium was done off-line in a standardized manner. Stepwise multivariate logistic regression analysis was carried out to determine which subjective and objective ultrasound and power Doppler variables satisfied the criteria to be included in a model to calculate the probability of endometrial malignancy.

RESULTS

Endometrial thickness, vascularity index (vascularized area/endometrial area), and use of hormone replacement therapy (HRT) satisfied the criteria to be included in the model used to calculate the 'objective probability of endometrial malignancy'. Endometrial morphology, endometrial color score and HRT use satisfied the criteria to be included in the model to calculate the 'subjective probability of malignancy'. Endometrial thickness > or = 10.5 mm had a sensitivity with regard to endometrial cancer of 0.88 and a specificity of 0.61. At a fixed sensitivity of 0.88, the specificity of the 'objective probability of malignancy' (0.81) was superior to all other ultrasound and power Doppler variables (P = 0.001-0.02). The 'objective probability of malignancy' detected more malignancies at endometrium 5-15 mm than endometrial morphology (5/7 vs. 1/7, i.e. 0.71 vs. 0.14; P = 0.125) with a similar specificity (49/57 vs. 51/57, i.e. 0.86 vs. 0.89).

CONCLUSION

Power Doppler ultrasound can contribute to a correct diagnosis of endometrial malignancy, especially if the endometrium measures 5-15 mm. The use of regression models including power Doppler results to estimate the risk of endometrial cancer deserves further development.

Contrast Agents and Contrast Imaging in Ultrasound

This article reviews studies using ultrasound contrast agents and discusses several of the contrast agents currently available. The anatomical areas that are enhanced by contrast, examination, and techniques, are used in imaging with contrast agents.

Sonographic assessment of the morphology and vascularity of ovarian masses

This review describes sonographic assessment of the morphology and vascularity of ovarian masses. It emphasizes the evaluation of wall regularity and the detection of papillary excrescences as well as the vascularity of lesions as depicted with color Doppler sonography.

Contrast-enhanced power Doppler sonography of the intestinal wall in the differentiation of hypervascularized and hypovascularized intestinal obstructions in patients with Crohn's disease

OBJECTIVE

To use power Doppler sonography to quantify the vascularization in the area of stenosed bowel segments in patients with Crohn's disease and to draw conclusions from these findings with regard to the development of these stenoses.

METHODS

The study collective included 11 patients with confirmed Crohn's disease and sonographically visualized stenoses of the small bowel together with intermittent abdominal cramping as a clinical correlate. Power mode examination was repeated after application of a sonographic signal-enhancing agent. Semiquantitative evaluation based on the sonographically indicated degree of vascularization led to the presumptive diagnosis of either inflammatory or cicatricial intestinal obstruction. Sonographic diagnoses were compared with the findings of surgery and subsequent histologic examination or with patients' clinical responses to conservative therapy.

RESULTS

Nine of 11 patients underwent surgery within 1 year of examination. All 3 cases in which sonography had facilitated the diagnosis of cicatricial stenosis were confirmed at postoperative histologic examination; similarly, the surgical and histologic findings in the other 6 patients confirmed the sonographic diagnosis of inflammatory stenosis.

CONCLUSIONS

Power Doppler sonography in combination with the use of a signal-enhancing agent appears to be effective in the recognition of predominantly cicatricial stenoses in patients with Crohn's disease.