Ultrasound Features of Rudimentary Horn Ectopic Pregnancies

Rudimentary horn ectopic pregnancies are uncommonly encountered in women with müllerian duct anomalies. The clinical presentation of this entity is nonspecific, giving ultrasound a critical role in making the diagnosis. Timely diagnosis and management of rudimentary horn ectopic pregnancies are pivotal in reducing the high rates of uterine rupture and maternal mortality historically associated with this condition.

Probe Covers and Disinfectants for Transvaginal Transducers

There are a variety of probe covers and disinfectants available to minimize the risk of transferring infections to patients during transvaginal sonography (TVS). This article describes the methodology for preventing transmission of pathogenic microorganisms to patients and personnel.

Sonography of Responsive Versus Nonresponsive Ectopic Pregnancies

This case series describes changes in size, vascularity, and cul-de-sac fluid in 30 patients with ectopic pregnancies who were treated with systemic methotrexate. Pretreatment and posttreatment transvaginal sonography of the ectopic pregnancies was performed with color Doppler imaging, and the images were assessed for changes in size, vascularity, and cul-de-sac free fluid. There was a trend for nonresponders to show increased vascularity on serial examinations, although this finding was also seen in a single responder. There was also a trend for nonresponders with increased vascularity to be associated with a greater increase in β-human chorionic gonadotropin levels and responders with decreased vascularity to be associated with a greater decrease in β-human chorionic gonadotropin levels.

Practical applications of 3D sonography in gynecologic imaging

Volume imaging in the pelvis has been well demonstrated to be an extremely useful technique, largely based on its ability to reconstruct the coronal plane of the uterus that usually cannot be visualized using traditional 2-dimensional (2D) imaging. As a result, this technique is now a part of the standard pelvic ultrasound protocol in many institutions. A variety of valuable applications of 3D sonography in the pelvis are discussed in this article.

Color Doppler sonography in obstetrics and gynecology

This review aims to provide the reader with an overview of the present and future clinical applications in color Doppler sonography for the evaluation of vascularity and blood flow within the uterus (both gravid and nongravid), ovaries, fetus and placenta. The clinical use of color Doppler sonography has been demonstrated within many organ systems. Color Doppler sonography has become an integral part of cardiovascular imaging. Significant improvements have recently occurred, improving the visualization and evaluation of intra-organ vascularity, resulting from enhancements in delineation of tissue detail through electronic compounding and harmonics, as well as enhancements in signal processing of frequency- and/or amplitude-based color Doppler sonography. Spatial representation of vascularity can be improved by utilizing 3D and 4D (live 3D) processing. Greater sensitivity of color Doppler sonography to macro- and microvascular flow has provided improved anatomic and physiologic assessment throughout pregnancy and for pelvic organs. The potential use of contrast enhancement is also mentioned as a means to further differentiate benign from malignant ovarian lesions. The rapid development of these new sonographic techniques will continue to enlarge the scope of clinical applications in a variety of obstetric and gynecologic disorders.

Correlation of quantified contrast-enhanced sonography with in vivo tumor response

OBJECTIVE

The purpose of our study was to establish in vivo criteria for monitoring tumor treatment response using 3-dimensional (3D) volumetric gray scale, power Doppler, and contrast-enhanced sonography.

METHODS

Twelve mice were implanted with Lewis lung carcinoma cells on their hind limbs and categorized to 4 groups: control, chemotherapy, radiation therapy, and chemoradiation. A high-frequency ultrasound system with a 40-MHz probe was used to image the tumors. Follow-up contrast-enhanced sonography was performed on days 7 and 14 of treatment with two 50-microL boluses of a perflutren microbubble contrast agent injected into the tail vein. The following contrast-enhanced sonographic criteria were quantified: time to peak, peak intensity, alpha (microvessel cross-sectional area), and beta (microbubble velocity). Three-dimensional power Doppler images were also obtained after the acquisition of contrast data. On day 15, the tumors were excised for immunohistochemical analysis with CD31 fluorescent staining.

RESULTS

The tumor size and 3D power Doppler vascular index showed no statistically significant correlation with microvascular density in all examined groups. Among all of the analyzed contrast-enhanced sonographic parameters, relative alpha showed the strongest correlation with the histologic microvessel density (Pearson r = 0.93; P < .01) and an independent association with the histologic data in a multiple regression model (beta = .93; R(2) = 0.86; P < .01).

CONCLUSIONS

Of the various examined sonographic parameters, alpha has the strongest correlation with histologic microvessel density and may be the parameter of choice for the noninvasive monitoring of tumor angiogenic response in vivo.

Diagnostic parameters to differentiate benign from malignant ovarian masses with contrast-enhanced transvaginal sonography

OBJECTIVE

The aim of this study was to evaluate diagnostic parameters to differentiate between benign versus malignant ovarian masses using contrast-enhanced transvaginal sonography (TVS).

METHODS

Thirty-three consecutive patients with 36 morphologically abnormal ovarian masses (solid or cystic with papillary excrescences, focally thickened walls, or irregular solid areas) smaller than 10 cm received a microbubble contrast agent intravenously while undergoing pulse inversion harmonic TVS. The following parameters were assessed: presence of contrast enhancement, time to peak enhancement, peak contrast enhancement, half wash-out time, and area under the enhancement curve (AUC). Tumor histologic analysis was used to distinguish benign from malignant ovarian tumors.

RESULTS

Twenty-six benign masses and 10 malignancies were studied. Of all examined criteria, an AUC of greater than 787 seconds(-1) was the most accurate diagnostic criterion for ovarian cancer, with 100.0% sensitivity and 96.2% specificity. Additionally, peak contrast enhancement of greater than 17.2 dB (90.0% sensitivity and 98.3% specificity) and half wash-out time of greater than 41.0 seconds (100.0% sensitivity and 92.3% specificity) proved to be useful.

CONCLUSIONS

Our data suggest that the AUC, peak enhancement, and half wash-out time had the greatest diagnostic accuracy for contrast-enhanced TVS in differentiation between benign and malignant ovarian masses.

Contrast-enhanced transvaginal sonography of benign versus malignant ovarian masses: preliminary findings

OBJECTIVE

The aim of this prospective study was to evaluate differences in contrast enhancement and contrast enhancement kinetics in benign versus malignant ovarian masses with pulse inversion harmonic transvaginal sonography.

METHODS

Seventeen consecutive patients with 23 morphologically abnormal ovarian masses (solid or cystic with papillary excrescences, focally thickened walls, or irregular solid areas) smaller than 10 cm received a microbubble contrast agent intravenously while undergoing pulse inversion harmonic transvaginal sonography. The following parameters were assessed in all tumors: detectable contrast enhancement, time to peak enhancement (wash-in), peak contrast enhancement, half wash-out time, and area under the enhancement curve. Tumor histologic analysis was used to distinguish benign from malignant ovarian tumors.

RESULTS

Fourteen benign masses and 9 malignancies were studied. There was a statistically significant difference in the peak enhancement (mean +/- SD, 23.3 +/- 2.8 versus 12.3 +/- 3.9 dB; P < .01), half wash-out time (139.9 +/- 43.6 versus 46.3 +/- 19.7 seconds; P < .01), and area under the enhancement curve (2012.9 +/- 532.9 versus 523.9 +/- 318 seconds(-1); P < .01) in malignant masses compared with benign disease. There was no statistically significant difference in the time to peak enhancement (26.1 +/- 6.3 versus 24.9 +/- 7.6 seconds; P = .07).

CONCLUSIONS

Overall, our data showed a significant difference in the contrast enhancement kinetic parameters between benign and malignant ovarian masses.

Relationship between retention of a vascular endothelial growth factor receptor 2 (VEGFR2)-targeted ultrasonographic contrast agent and the level of VEGFR2 expression in an in vivo breast cancer model

OBJECTIVE

The aim of this study was to characterize the relationship between retention of a vascular endothelial growth factor receptor 2 (VEGFR2)-targeted ultrasonographic contrast agent (UCA) and VEGFR2 expression in tumor vasculature of breast cancer.

METHODS

67NR breast cancer tumors implanted in mice were evaluated in vivo with both VEGFR2-targeted and nontargeted UCAs, and a high-frequency ultrasound system. A bolus of the UCA was injected and allowed to circulate for 4 minutes to allow binding of targeted microbubbles. After that, 2 sets of images before and after a high-power ultrasonic destruction sequence were acquired. The average video intensity of predestruction and postdestruction images was measured and used as a relative measure of retention of the UCA in the tumor. Levels of VEGFR2 expression and tumor vascular density were quantified by immunohistochemical staining and compared with retention of the VEGFR2-targeted UCA.

RESULTS

Retention of VEGFR2-targeted microbubbles in tumors was significantly higher than retention of nontargeted microbubbles (mean +/- SD, 47.75+/-9.85 versus 18.5+/-5.46 dB; P< .001). Retention of the VEGFR2-targeted UCA was found to correlate with the level of VEGFR2 expression in the studied tumors (r(2)=0.41). In contrast, retention of the nontargeted UCA was not correlated with the level of VEGFR2 expression (r(2)=0.08). Furthermore, retention of the VEGFR2-targeted UCA was not correlated with the level of tumor vascularity.

CONCLUSIONS

The magnitude of the molecular ultrasonographic signal from a VEGFR2-targeted UCA retained by tissue correlates with VEGFR2 expression. These results validate the use of molecular ultrasonography for in vivo detection and quantification of VEGFR2 expression in this breast cancer model.

Molecular imaging of vascular endothelial growth factor receptor 2 expression using targeted contrast-enhanced high-frequency ultrasonography

OBJECTIVE

The aim of our study was to investigate the use of targeted contrast-enhanced high-frequency ultrasonography for molecular imaging of vascular endothelial growth factor receptor 2 (VEGFR2) expression on tumor vascular endothelium in murine models of breast cancer.

METHODS

Highly invasive metastatic (4T1) and nonmetatstatic (67NR) breast cancer cells were implanted in athymic nude mice. Tumors were examined in vivo with targeted contrast-enhanced high-frequency ultrasonography using a scanner with a 40-MHz probe. Randomized boluses of ultrasound contrast agents (UCAs) conjugated with an anti-VEGFR2 monoclonal antibody or an isotype control antibody (immunoglobulin G) were injected into the animals. Sonograms were analyzed by calculation of the normalized video intensity amplitudes caused by backscatter of the bound UCA. After ultrasonography, the tumor samples were harvested for analysis of VEGFR2 expression by immunoblotting and immunocytochemistry.

RESULTS

The mean video intensity amplitude caused by backscatter of the retained VEGFR2-targeted UCA was significantly higher than that of the control UCA (mean +/- SD: 4T1 tumors, 15 +/- 3.5 versus 7 +/- 1.6 dB; P < .01; 67NR tumors, 50 +/- 12.3 versus 12 +/- 2.6 dB; P < .01). There was a significant difference in VEGFR2-targeted UCA retention between 4T1 and 67NR tumors (normalized video intensity amplitudes, 15 +/- 3.5 and 50 +/- 12.3 dB, respectively; P < .001), and this correlated well with relative VEGFR2 expression in the two tumor types.

CONCLUSIONS

Targeted contrast-enhanced high-frequency ultrasonography may enable in vivo molecular imaging of VEGFR2 expression on the tumor vascular endothelium and may be used for noninvasive longitudinal evaluation of tumor angiogenesis in preclinical studies.

Ovarian volume measurements in mice with high-resolution ultrasonography

OBJECTIVE

The aim of our study was to evaluate the intraobserver and interobserver variability of ovarian volume measurements in mice with high-resolution 2-dimensional ultrasonography (2DUS) and 3-dimensional ultrasonography (3DUS).

METHODS

Ovaries of 10 nude mice were visualized with a small-animal ultrasound scanner and a 40-MHz probe. For each ovary, volume was measured 3 times by 2 independent readers using both 2DUS and 3DUS methods. The 2DUS method used a biplane ellipsoid model. The 3DUS method estimated the volume by integrating 10 to 12 parallel image planes of the ovary after semiautomated outlining of the boundaries. For each type of measurement, intraobserver and interobserver standard error of measurement (SEM) values and minimal detectable volume changes were calculated by analysis of variance.

RESULTS

Two-dimensional ultrasonography showed much poorer reproducibility, with higher absolute intraobserver and interobserver SEM values (0.50 and 0.61 mm3, respectively) than 3DUS (0.20 and 0.35 mm3; P < .01). Relative intraobserver and interobserver SEM values were also much higher for 2DUS (12.20% and 14.88%) than for 3DUS (5.12% and 8.97%; P < .01). The minimal volume changes that could be detected with a 95% confidence level in successive measurements by the same (or different) observers were 33.90% (41.22%) for 2DUS and 14.10% (24.87%) for 3DUS.

CONCLUSIONS

High-resolution 3DUS can provide a reliable tool for noninvasive, longitudinal ovarian volume measurements in mice.

Measuring tumor perfusion in control and treated murine tumors: correlation of microbubble contrast-enhanced sonography to dynamic contrast-enhanced magnetic resonance imaging and fluorodeoxyglucose positron emission tomography

OBJECTIVE

The purpose of this study was to evaluate the ability of dynamic microbubble contrast-enhanced sonography (MCES), in comparison with dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and fluorodeoxyglucose positron emission tomography (FDG-PET), to quantitatively characterize tumor perfusion in implanted murine tumors before and after treatment with a variety of regimens.

METHODS

Seventeen mice with Lewis lung carcinoma implants were categorized to control, radiation therapy alone, antiangiogenic chemotherapy alone, and combined chemoradiation. On day 0 of each treatment regimen, MCES and DCE-MRI of each tumor were performed. On day 5 of treatment, dynamic FDG-PET, MCES, and DCE-MRI were performed.

RESULTS

Microbubble contrast-enhanced sonography showed that intratumoral perfusion, blood volume, and blood velocity were highest in the untreated control group and successively lower in each of the treatment groups: radiation therapy alone resulted in a two-thirds reduction of perfusion; antiangiogenic chemotherapy resulted in a relatively larger reduction; and combined chemoradiotherapy resulted in the largest reduction. Microbubble contrast-enhanced sonography revealed longitudinal decreases in tumor perfusion, blood volume, and microvascular velocity over the 5-day course of chemoradiotherapy (all P < .01); conversely, these values rose significantly for the untreated control tumors (P < .01). Dynamic contrast-enhanced MRI showed a smaller and statistically insignificant average decrease in relative tumor perfusion for treated tumors. Dynamic PET revealed delayed uptake of FDG in the tumors that underwent chemoradiotherapy.

CONCLUSIONS

Microbubble contrast-enhanced sonography is an effective tool in the noninvasive, quantitative, longitudinal characterization of neovascularization in murine tumor models and is correlative with DCE-MRI and FDG-PET. Microbubble contrast-enhanced sonography has considerable potential in the clinical assessment of tumor neovascularization and in the assessment of the response to treatment.

Quantitative analysis of tumor vascularity in benign and malignant solid thyroid nodules

OBJECTIVE

The purpose of our study was to analyze the accuracy of quantitative analysis of tumor vascularity on power Doppler sonograms in differentiating malignant and benign solid thyroid nodules using tumor histologic evaluation as the reference standard. Methods. Eighty-six solid thyroid tumors (46 malignant and 40 benign) in 56 consecutive patients (mean age +/- SD, 53.1 +/- 11.6 years; 12 male and 44 female) referred for the surgical treatment were included in our study. Visual and qualitative analysis of patterns of nodule vascularity was performed for all tumors. Quantification of the power Doppler sonograms was performed with normalized and weighted vascular indices (VIs). The accuracy of sonographic criteria for thyroid cancer was evaluated with univariate analysis. Results. Among benign thyroid tumors, there was a statistically significant increase in the levels of intranodular vascularization with an increase in tumor size (P < .001). In all tumors, increased intranodular vascularization showed 65.2% sensitivity, 52.5% specificity, and 58.9% overall accuracy in differentiation between benign and malignant thyroid lesions. In tumors smaller than 2 cm, it had 65.5% sensitivity, 85.7% specificity, and 72.1% overall accuracy. Quantitative analysis of tumor vascularity significantly overperformed visual analysis of power Doppler patterns (P < .05). Among thyroid lesions with diameters of less than 2 cm, a normalized VI of greater than 0.14 had 72.4% sensitivity, 100% specificity, and 86.2% overall accuracy. A weighted VI of greater than 0.24 showed compatible results, with 69.0% sensitivity, 100% specificity, and 84.5% overall accuracy.

CONCLUSIONS

Our study indicates that in small thyroid nodules, quantitative analysis of tumor vascularity has benefits over visual inspection and can be useful in differentiation between benign and malignant thyroid tumors.

Noninvasive assessment of tumor vasculature response to radiation-mediated, vasculature-targeted therapy using quantified power Doppler sonography: implications for improvement of therapy schedules

OBJECTIVE

Stereotactic radiotherapy (ablative radiation) is a modality that holds considerable promise for effective treatment of intracranial and extracranial malignancies. Although tumor vasculature is relatively resistant to small fractionated doses of ionizing radiation, large ablative doses of ionizing radiation lead to effective demise of the tumor vasculature. The purpose of this study was (1) to noninvasively monitor and compare tumor physiologic parameters in response to ablative radiation treatments and (2) to use these noninvasive parameters to optimize the schedule of administration of radiation therapy.

METHODS

Lewis lung carcinoma tumors were implanted into C57BL/6 mice and treated with ablative radiation. The kinetics of change in physiologic parameters of a response to single-dose 20-Gy treatments was measured. Parameters studied included tumor blood flow, apoptosis, and proliferation rates. Serial tumor sections were stained to correlate noninvasive Doppler assessment of tumor blood flow with microvasculature histologic findings.

RESULTS

A single administration of 20 Gy led to an incomplete tumor vascular response, with subsequent recovery of tumor blood flow within 4 days after treatment. Sustained reduction of tumor blood flow by administering the successive ablative radiation treatment before tumor blood flow recovery led to a 3-fold tumor growth delay. The difference in tumor volumes at each measurement time point (every 2 days) was statistically significant (P=.016).

CONCLUSIONS

This study suggests a rational design of schedule optimization for radiation-mediated, vasculature-directed treatments guided by noninvasive assessment of tumor blood flow levels to ultimately improve the tumor response.

Sonographic quantification of ovarian tumor vascularity

OBJECTIVE

The purpose of this study was to assess the diagnostic accuracy of quantitated color Doppler sonography in differentiating benign from malignant ovarian tumors, with the use of tumor histologic examination as a reference standard.

METHODS

The vascularity of 38 ovarian masses (30 benign and 8 malignant) as quantitatively depicted with color Doppler sonography was analyzed with a readily available software program (ImageJ; National Institutes of Health, Bethesda, MD). The following quantitative sonographic criteria for tumor vascularity were analyzed: the vascularity index (VI) quantified the difference between the total number of pixels and the number of pixels containing no color/totalx100, whereas the power-weighted pixel density (PWPD) weighted the strength of the signal/total. The accuracy of sonographic criteria for malignant ovarian tumors was evaluated with univariate analysis. Results of tumor histologic examination were used as proof of the final diagnosis.

RESULTS

The mean values of VI and PWPD were significantly different in benign versus malignant ovarian lesions (VI, 1.3+/-1.6 versus 4.7+/-3.9; P<.01; PWPD, 2338+/-3305 versus 9403+/-9946; P<.05). With a VI of greater than 2.3, sensitivity of 75% and specificity of 90% were obtained. When combined with a PWPD of greater than 4555, sensitivity improved to 88%, and specificity improved to 93%. Morphologic analysis had sensitivity of 72% and specificity of 76% for malignancies.

CONCLUSIONS

Quantitated color Doppler sonography was found to be helpful for distinguishing benign from malignant ovarian masses. However, the wide range in values makes it most useful as an adjunct to morphologic assessment. It is anticipated that quantitated color Doppler sonography could result in a slight improvement in detection of ovarian malignancies.

Three-dimensional sonography of the endometrium and adjacent myometrium: preliminary observations

OBJECTIVE

By evaluating a series of patients undergoing pelvic sonography with routine 2-dimensional (2D) as well as 3-dimensional (3D) reconstructed images in the coronal plane, we attempted to characterize the types of additional information that can be obtained.

METHODS

Ninety randomly selected patients undergoing transvaginal pelvic sonography were imaged according to a standard 2D protocol. A 3D uterine volume was then acquired in the sagittal plane and reconstructed in the coronal plane. The endometrium and surrounding myometrium were evaluated for architecture, masses, the relationship of masses to the endometrial cavity, and the anatomic configuration of the cavity.

RESULTS

Ninety-one studies were obtained. Additional findings were obtained on the coronal view in 28 studies (30.8%). No additional findings were obtained in 63 studies (69.2%). Normal endometrial and myometrial findings were obtained by conventional 2D imaging in 42 of 91 patients. Of this group, additional findings were shown in 2 (5%) patients. Forty-nine of the 91 patients had abnormal findings by 2D imaging. Additional information was obtained in 26 (53%) of these patients. Added information included uterine anomalies, better definition of the endometrium, more accurate delineation and location of endometrial polyps, location of leiomyomas, visualization of cystic areas within the myometrium, and confirmation of the location of intrauterine devices.

CONCLUSIONS

The 3D reconstructed view of the endometrium and adjacent myometrium appears to be most helpful after a conventional transvaginal study, showing abnormalities within the endometrium and myometrium but being of little added benefit if the conventional findings are normal.

Phase I/pilot study of SU5416 (semaxinib) in combination with irinotecan/bolus 5-FU/LV (IFL) in patients with metastatic colorectal cancer

OBJECTIVES

Determine the toxicity, tolerability, and pharmacokinetics of SU5416, a vascular endothelial growth factor receptor-2 (VEGFR-2) tyrosine kinase inhibitor, coadministered with bolus 5-fluorouracil (5-FU), leucovorin, and irinotecan (IFL) in untreated patients with metastatic colorectal cancer.

METHODS

SU5416 (85 or 145 mg/m2) was administered twice weekly throughout a 6-week period along with standard IFL (4 weeks on/2 weeks off). Plasma samples were assayed for SU5416, irinotecan, and SN-38 by reverse-phase HPLC. Contrast enhanced, color Doppler sonography was performed on patients at the MTD to identify changes in tumor perfusion.

RESULTS

Eleven patients received treatment with SU5416 85 mg/m2 (n = 5) or 145 mg/m2 (n = 6). At 85 mg/m2, no DLTs were observed. At 145 mg/m2, grade 3 diarrhea and vomiting were observed during cycle 1; other grade 3 toxicities included fatigue, nausea, anorexia, anemia, pain, urinary retention, and hypertension. The pharmacokinetics of irinotecan and SN-38 were not altered by coadministration of SU5416. SU5416 pharmacokinetics were not altered by IFL. Contrast-enhanced, color Doppler sonography was performed on 2 patients and demonstrated reduced tumor perfusion after treatment in a patient who responded to treatment and increased perfusion in a patient who developed progressive disease. Three patients (27%) had confirmed partial responses, 2 patients (18%) had unconfirmed partial responses, and 4 patients (36%) had stable disease.

CONCLUSIONS

Twice weekly SU5416 can be administered with bolus IFL without unexpected toxicities or altering the pharmacokinetic behavior of the administered drugs. Changes in tumor blood perfusion can be detected by contrast-enhanced, color Doppler sonography. The further development of SU5416 was halted before this study was completed.

Correlation between estimates of tumor perfusion from microbubble contrast-enhanced sonography and dynamic contrast-enhanced magnetic resonance imaging

OBJECTIVE

We compared measurements of tumor perfusion from microbubble contrast-enhanced sonography (MCES) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in an animal tumor model.

METHODS

Seven mice were implanted with Lewis lung carcinoma cells on their hind limbs and imaged 14 days later with a Philips 5- to 7-MHz sonography system (Philips Medical Systems, Andover, MA) and a Varian 7.0-T MRI system (Varian, Inc, Palo Alto, CA). For sonographic imaging 100 microL of a perfluoropropane microbubble contrast agent (Definity; Bristol-Myers Squibb Medical Imaging, Billerica, MA) was injected and allowed to reach a pseudo steady state, after which a high-mechanical index pulse was delivered to destroy the microbubbles within the field of view, and the replenishment of the microbubbles was imaged for 30 to 60 seconds. The MRI included acquisition of a T(10) map and 35 serial T(1)-weighted images (repetition time, 100 milliseconds; echo time, 3.1 milliseconds; alpha, 30 degrees ) after the injection of 100 microL of 0.2-mmol/kg gadopentetate dimeglumine (Magnevist; Berlex, Wayne, NJ). Region-of-interest and voxel-by-voxel analyses of both data sets were performed; microbubble contrast-enhanced sonography returned estimates of microvessel cross-sectional area, microbubble velocity, and mean blood flow, whereas DCE-MRI returned estimates of a perfusion-permeability index and the extravascular extracellular volume fraction.

RESULTS

Comparing similar regions of tumor tissue seen on sonography and MRI, region-of-interest analyses revealed a strong (r(2) = 0.57) and significant relationship (P < .002) between the estimates of perfusion obtained by the two modalities.

CONCLUSIONS

Microbubble contrast-enhanced sonography can effectively depict intratumoral heterogeneity in preclinical xenograft models when voxel-by-voxel analysis is performed, and this analysis correlates with similar DCE-MRI measurements.

Sonography for Deep Venous Thrombosis

Deep venous thrombosis (DVT) is a one of the most common problems facing the clinician in medicine today. It is often asymptomatic and goes undiagnosed with potentially fatal consequences. Ultrasound has become the "gold standard" in the diagnosis of deep venous thrombosis and with proper attention to technique sensitivity of this test is approximately 97%. An understanding of anatomy, pathophysiology, and risk factors is important. Thrombus formation usually begins beneath a valve leaflet below the knee. Approximately 40% will resolve spontaneously, 40% will become organized, and 20% will propagate. Whether or not a calf vein thrombus is identified, a repeat examination in 7 to 10 days is recommended in patients with risk factors or when deep venous thrombosis is suspected. The three main risk factors for thrombus formation are age greater than 75 years, previous history of deep venous thrombosis, and underlying malignancy. Other diagnostic studies include the contrast venogram, CT or MRI venogram, Tc99m Apcitide study, and the laboratory test D-Dimer. The D-Dimer study is being used more frequently as a screening test with 99% sensitivity in detecting thrombus, whether deep venous thrombosis or pulmonary embolism. However, specificity is only approximately 50% with many conditions leading to false-positive exams. Therefore, a negative examination is useful in avoiding other diagnostic studies, but a positive one may be misleading. Conditions that can lead to a false-positive examination include, but are not limited to diabetes, pregnancy, liver disease, heart conditions, recent surgery, and some gastrointestinal diseases. Like the sonogram, two negative D-Dimer studies a week apart exclude the diagnosis of deep venous thrombosis. Compression sonography with color Doppler remains the best overall test for deep venous thrombosis. It is easy to perform, less expensive than most "high tech" studies, can be performed as a portable examination, and is highly reliable when done properly.

The Sonographic Diagnosis of Adenomyosis

Adenomyosis is a common but under-diagnosed gynecologic condition due to hypertrophied myometrial smooth muscle containing ectopic endometrial glands that is associated with pelvic pain, menorrhagia, and an enlarged uterus. This is an overview of the sonographic and magnetic resonance imaging features that have been developed in the diagnosis of adenomyosis emphasizing sonography as the initial study performed in the symptomatic patient. These features include myometrial heterogeneity, asymmetric thickening of myometrium, cysts, linear striations, and an ill-defined endometrium. Both magnetic resonance imaging and sonography can now diagnose adenomyosis with a high degree of accuracy so that treatment may be instituted specific to the disease process.

Clarifying the role of three-dimensional transvaginal sonography in reproductive medicine: an evidenced-based appraisal

This overview describes and illustrates the clinical applications of three-dimensional transvaginal sonography in reproductive medicine. Its main applications include assessment of uterine anomalies, intrauterine pathology, tubal patency, polycystic ovaries, ovarian follicular monitoring and endometrial receptivity. It is also useful for detailed evaluation of failed and/or ectopic pregnancy. Three-dimensional color Doppler sonography provides enhanced depiction of uterine, endometrial, and ovarian vascularity.

Recent advances in the sonographic assessment of vascularity and blood flow in gynecologic conditions

OBJECTIVE

This overview presents recent advances in sonographic depiction of vascularity and blood flow in the uterus, ovaries, and breasts. Enhanced sonographic visualization and evaluation of intraorgan vascularity has resulted from improved image processing and display. Future advances, such as the use of contrast enhancement, are also mentioned in this overview as one of many topics for future investigation.

STUDY DESIGN

This is an overview of the topic based on review of the literature and the authors' experience.

RESULTS

Specifically, the sensitivity of color Doppler sonography has been enhanced with the use of amplitude or power Doppler techniques. Spatial depiction of vascularity has improved because of 3-dimensional and "live 3-dimensional" processing.

CONCLUSION

The combination of more sensitive color Doppler sonography and 3-dimensional imaging provides both anatomic and physiologic assessment of the vascularity and blood flow of the ovary, uterus, and breast.

Sonographic depiction of changes of tumor vascularity in response to various therapies

PURPOSE

To evaluate the diagnostic accuracy of power Doppler sonography for the depiction of changes in tumor vascularity with various therapeutic regimens.

MATERIALS AND METHODS

Tumor cells were implanted subcutaneously in thirty-two mice and assigned to four treatment groups: control, radiation therapy, antiangiogenesis therapy (VEGF [vascular endothelial growth factor] receptor antagonist, SU11248), or combined antiangiogenesis and radiation therapy. Twenty of these mice were scanned with power Doppler sonography at two time points over the course of treatment, and power-weighted pixel densities were assessed. The other twelve mice each underwent subcutaneous placement of a dorsal skin-fold window over the tumor site, allowing for daily angiogenesis assessment of vascular length density. All tumor specimens had correlative histologic analyses performed, including immunohistochemical stains for microvasculature.

RESULTS

Sonographic measurements revealed significant longitudinal differences in tumor vascularity among the four treatment groups: control mice receiving no treatment demonstrated a doubling in intra-tumor color pixel density (P < 0.02); those receiving radiation alone increased by 68% (P < 0.04); those receiving oral therapy alone increased by 44% (P = 0.016); and those receiving combination therapy decreased by 38% (P < 0.02). Tumor vascularity independently measured in the twelve mice with the skin-fold windows revealed a similar response to each type of treatment. Post-mortem tumor histology was consistent with both sonographic and skin-fold window measurements.

CONCLUSION

Power Doppler sonography was accurate and reliable in measuring tumor vascularity changes in this model. These results were independently confirmed by a quantitative method relying on direct visualization of the microvasculature. Because it is rapid and non-invasive, sonographic quantification is beneficial in assessing the anti-angiogenic effects of various treatment strategies for cancer.

Sonographic depiction of intratumoral vascularity with 2- and 3-dimensional color Doppler techniques

OBJECTIVE

The purpose of this study was to describe patterns seen on 2- and 3-dimensional color Doppler sonographic depiction of intratumoral vessels and to correlate these patterns to histopathologic findings in an attempt to assess their clinical importance.

METHODS

We conducted a retrospective analysis of 26 patients with ovarian masses and intratumoral abnormalities in whom standard 2- and 3-dimensional color Doppler sonography was performed.

RESULTS

Two- and 3-dimensional color Doppler sonography depicted several patterns of vascularity within ovarian masses. These included masses with vascularity confined to the wall or loculus and those with central versus peripheral vascularity. The presence of central intratumoral vascularity had a high positive predictive value (90%) for malignancy. Conversely, the absence of intratumoral vascularity had a high negative predictive value (96%).

CONCLUSIONS

Three-dimensional color Doppler sonography is helpful in depicting overall vessel density and branching patterns within an intratumoral abnormality. This technique seems to be useful in distinguishing benign from malignant ovarian masses.

Sonographic depiction of microvessel perfusion: principles and potential

OBJECTIVE

To provide an overview of the technical aspects and potential clinical applications of microvessel perfusion as depicted by microbubble-enhanced sonography.

METHODS

Sonographic depiction of microvessel perfusion was obtained by microbubble-enhanced sonography. This technique was used for imaging in vivo murine tumors and was correlated with magnetic resonance and fluorodeoxyglucose autoradiography. Sonographic estimation of microvessel perfusion used parameters derived from time-activity curves.

RESULTS

Preliminary data indicate that accurate and reproducible quantification of microvessel perfusion is possible with the use of microbubble-enhanced sonography.

CONCLUSIONS

Microbubble-enhanced sonography can depict microvessel perfusion. This technique has several potential clinical applications, including assessment of tumor blood flow and changes that occur with treatment.

Quantification of tumor vascularity with contrast-enhanced sonography: correlation with magnetic resonance imaging and fluorodeoxyglucose autoradiography in an implanted tumor

OBJECTIVE

To correlate the quantitated tumor vascularity of implanted murine tumors as depicted by contrast-enhanced sonography with estimates made with magnetic resonance imaging and with estimates of the percentage of viable (metabolically active) tumor as depicted by fluorodeoxyglucose autoradiography.

METHODS

Implanted tumors in 10 mice were imaged with contrast-enhanced sonography, magnetic resonance imaging, and fluorodeoxyglucose autoradiography. Tumor vascularity was estimated with each modality and compared with the percentage of viable tumor.

RESULTS

Quantitated estimates of tumor vascularity with contrast-enhanced sonography closely correlated (r = 0.95) with estimates made by magnetic resonance imaging and with the percentage of viable tumor (r = 0.93) as depicted by fluorodeoxyglucose autoradiography.

CONCLUSIONS

Contrast-enhanced sonography accurately depicts tumor vascularity in these implanted tumors. Tumor vascularity correlated with the amount of metabolically active tumor.

Color Doppler Sonography of Uterine Disorders

Color Doppler sonography (CDS) of uterine disorders has clinical applications for the evaluation of uterine fibroids, polyps, and vascular malformations. This review describes and illustrates these applications as well as the use of 3D CDS.

Color Doppler sonohysterography of endometrial polyps and submucosal fibroids

OBJECTIVE

To describe the typical sonographic findings and clinical applications of color Doppler sono-hysterography and to correlate the vascularity of lesions seen on color Doppler sonohysterography to microvessel density and the presence of vessels greater than 0.5 mm.

METHODS

Color Doppler sonohysterography was performed on 25 women with abnormal uterine bleeding. The vascularity (number of vessels > 0.5 mm) and their configuration seen on color Doppler sonohysterography were compared with those obtained on the excised specimen. Microvessel density and histologic features were correlated to the visualization of vessels greater than 0.5 mm and their arrangement on color Doppler sonography.

RESULTS

The color Doppler sonographic findings in 18 polyps, 3 submucosal fibroids, and 1 clot showed distinct vascularity patterns. Polyps typically contained a single feeding vessel, whereas fibroids had several vessels, which arose from the inner myometrium. Lesions with higher microvessel density tended to have more vessels greater than 0.5 mm as depicted on color Doppler sonography.

CONCLUSIONS

Color Doppler sonohysterography may be useful in distinguishing polyps from submucosal fibroids based on the vascularity of the lesions. The number of vessels seen on color Doppler sonography approximates microvessel density within the lesions.

Color Doppler sonography of endometrial masses

OBJECTIVE

To correlate the color Doppler sonographic features of endometrial masses with histologic characteristics and microvessel density.

METHODS

We performed a retrospective analysis of 10 postmenopausal and 5 premenopausal women with abnormal bleeding who had color Doppler sonography and histologic studies of endometrial masses.

RESULTS

Endometrial masses that contained multiple branches on color Doppler sonography were more likely carcinomas, even though both polyps and carcinomas were vascular on color Doppler sonography and their microvessel densities were similar. On color Doppler sonography, polyps averaged 1.2 detectable vessels versus 3.4 for carcinomas.

CONCLUSIONS

Color Doppler sonography may be useful in distinguishing carcinomas from polyps in women with thickened endometria.

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.

Three-dimensional color Doppler sonography and uterine artery arteriography of fibroids: assessment of changes in vascularity before and after embolization

OBJECTIVE

To assess the accuracy of three-dimensional color Doppler sonography and uterine artery arteriography in depicting changes in fibroid vascularity before and after embolization.

METHODS

Preembolization and postembolization three-dimensional color Doppler sonography and selective uterine artery arteriography were retrospectively compared in 15 patients who underwent uterine artery embolization for treatment of symptomatic fibroids. Three-dimensional color Doppler sonography was performed by using a scanner with color power angiographic imaging capability. Vascularity was quantified by using an estimation of power-weighted pixel density as described by our group in previously published studies. Uterine artery arteriography was performed by using a standard selective microcatheter embolization technique. For purposes of comparison, fibroids were classified as either hypervascular or hypovascular relative to myometrial vascularity before and minutes to several hours after uterine artery embolization. Changes in fibroid vascularity (i.e., from hypervascular to hypovascular) as depicted by three-dimensional color Doppler sonography were compared with those shown on uterine artery arteriography and classified as being in agreement or disagreement.

RESULTS

In 13 (87%) of 15 patients there was agreement; in 2 (13%) of 15 there was disagreement. In both cases of disagreement, three-dimensional color Doppler sonography showed collateral flow not depicted by uterine artery arteriography The mean reduction in quantitated vascularity after uterine artery embolization was 44% (range, 19%-78%).

CONCLUSIONS

Three-dimensional color Doppler sonography accurately depicts fibroid vascularity and in some cases can reveal collateral flow not depicted by uterine artery arteriography.

Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement

OBJECTIVES

A panel of 14 physicians practicing medicine in the United States with expertise in radiology, obstetrics and gynecology, gynecologic oncology, hysteroscopy, epidemiology, and pathology was convened by the Society of Radiologists in Ultrasound to discuss the role of sonography in women with postmenopausal bleeding. Broad objectives of this conference were (1) to advance understanding of the utility of different diagnostic techniques for evaluating the endometrium in women with postmenopausal bleeding; (2) to formulate useful and practical guidelines for evaluation of women with postmenopausal bleeding, specifically as it relates to the use of sonography; and (3) to offer suggestions for future research projects.

SETTING

October 24 and 25, 2000, Washington, DC, preceding the annual Society of Radiologists in Ultrasound Advances in Sonography conference.

PROCEDURE

Specific questions to the panel included the following: (1) What are the relative effectiveness and cost-effectiveness of using transvaginal sonography versus office (nondirected) endometrial biopsy as the initial examination for a woman with postmenopausal bleeding? (2) What are the sonographic standards for evaluating a woman with postmenopausal bleeding? (3) What are the abnormal sonographic findings in a woman with postmenopausal bleeding? (4) When should saline infusion sonohysterography or hysteroscopy be used in the evaluation of postmenopausal bleeding? (5) Should the diagnostic approach be modified for patients taking hormone replacement medications, tamoxifen, or other selective estrogen receptor modulators?

CONCLUSIONS

Consensus recommendations were used to create an algorithm for evaluating women with postmenopausal bleeding. All panelists agreed that because postmenopausal bleeding is the most common presenting symptom of endometrial cancer, when postmenopausal bleeding occurs, clinical evaluation is indicated. The panelists also agreed that either transvaginal sonography or endometrial biopsy could be used safely and effectively as the first diagnostic step. Whether sonography or endometrial biopsy is used initially depends on the physician's assessment of patient risk, the nature of the physician's practice, the availability of high-quality sonography, and patient preference. Similar sensitivities for detecting endometrial carcinoma are reported for transvaginal sonography when an endometrial thickness of greater than 5 mm is considered abnormal and for endometrial biopsy when "sufficient" tissue is obtained. Currently, with respect to mortality, morbidity, and quality-of-life end points, there are insufficient data to comment as to which approach is more effective. The conference concluded by identifying several important unanswered questions and suggestions that could be addressed by future research projects.

Quantified power Doppler US of tumor blood flow correlates with microscopic quantification of tumor blood vessels

PURPOSE

To evaluate the ability of a quantified power Doppler ultrasonography (US) system to help quantitate differences in tumor vascularity after radiation therapy and administration of tumor necrosis factor (TNF).

MATERIALS AND METHODS

Murine glioblastoma tumors were grown in the thighs of two sets of 25 mice each. Each mouse was assigned to one of four treatment groups: control (no treatment), radiation therapy, TNF therapy, or combination therapy (both radiation and TNF therapies). Mice were then evaluated with quantified power Doppler US, and a vascularity index (color area) was calculated for different tumor regions in each group. The tumors were then excised, and histologic evaluation was performed by using an immunofluorescence-tagged monoclonal antibody against blood vessel endothelium. The number of stained blood vessels per high-power field was correlated with the sonographically determined vascularity index.

RESULTS

The color area of the total tumor decreased to 37% of that in the control group in mice treated with radiation therapy alone (P: =.02), 26% of that in the control group in mice treated with TNF alone (P: =.05), and 8% of that in the control group in those treated with both TNF and radiation (P: =.006). These results correlated well with the quantified results from immunofluorescent staining (r = 0.98).

CONCLUSION

Quantified power Doppler US is a noninvasive method for the evaluation of tumor vascularity and blood flow.

The concepts of wrongful birth and wrongful life and their relation to medical imaging

Although often used interchangeably, "wrongful birth" and "wrongful life" are distinct legal concepts. Wrongful birth involves the physician's duty to impart to expectant parents information about potential fetal defects. Wrongful life suits reflect the child's right to recovery for life-long suffering as a result of the physician's inadequate pre- or peri-natal care. Modern medical imaging techniques can play a major role in the diagnosis of interuterine malformations; this article explores the legal duties which may be imposed upon physicians who interpret such tests.

New insights into transvaginal sonography of endometrial disorders

This overview provides information regarding the clinical application of transvaginal sonography of the endometrium. The latest information is described and illustrated.

Sonographic depiction of ovarian vascularity and flow: current improvements and future applications

The objective of this image presentation is to update the reader with the current clinical applications and future developments concerning the sonographic depiction of ovarian vascularity and flow. This topic is discussed and illustrated using numerous figures that show actual images and their histologic correlation as well as illustrative drawings of central concepts. Color Doppler sonography is an accurate means to depict ovarian vascularity and flow. This information can be used to detect ovarian cancer and adnexal torsion. Future developments include the use of sonographic contrast agents and three-dimensional imaging. This report describes the current state of the art regarding Color Doppler sonography of ovarian vascularity and flow. It also describes areas for future research and development.

New developments in the sonographic assessment of ovarian, uterine, and breast vascularity

Recent developments in ultrasound have presented new opportunities for assessing tissue vascularity and blood flow with ultrasound. These new methods include 3D imaging, power Doppler sonography, a variety of harmonic imaging techniques, ultrasound contrast agents, electronic compounding, and pulse sequencing methods that improve the signal-to-noise relationship as well as structural conspicuity. By using these technological advances, it is now possible to assess macroscopic blood flow in organs and tumors, and to assess changes in flow and vascularity that occur in response to therapeutic efforts. This review article describes and illustrates the concepts and methods used to evaluate vascularity and blood flow in tissues with ultrasound. It describes some of the potential clinical applications of these new techniques in the ovary, uterus, endometrium, adnexal vessels, and breast.

An assessment of the value of ultrasonographic screening for endometrial disease in postmenopausal women without symptoms

OBJECTIVE

Our purpose was to evaluate the use of transvaginal ultrasonography for the detection of endometrial disease in a population of postmenopausal women who were without symptoms.

STUDY DESIGN

Postmenopausal women were screened for potential inclusion in 2 multicenter, double-blind, placebo-controlled studies of 2 years' duration to evaluate the safety and efficacy of idoxifene in the prevention of osteoporosis. Baseline endometrial evaluation was performed by transvaginal ultrasonography and aspiration biopsy of the endometrium.

RESULTS

A total of 1926 women were screened by transvaginal ultrasonography, and 1833 of them had endometrial thickness < or =6 mm. Five cases of endometrial abnormality (adenocarcinoma [n = 1] and atypical hyperplasia [n = 4]) were detected in the 1750 women from this cohort who underwent biopsy. The negative predictive value was >99%. One case of adenocarcinoma was detected in the 42 women who had endometrial thickness >6 mm and underwent biopsy. However, the sampling rate (45%) of women with endometrial thickness >6 mm was too low for confidence in the positive predictive value of 2%.

CONCLUSIONS

Despite a high negative predictive value, transvaginal ultrasonography may not be an effective screening procedure for detection of endometrial abnormality in untreated postmenopausal women who are without symptoms.

Three-dimensional color Doppler sonography before and after fibroid embolization

Three-dimensional color Doppler sonography was performed within 1 hour, 1 day, 3 months, and 6 months of fibroid embolization in 20 patients who had a total of 31 fibroids greater than 2 cm in average dimension. The greatest decrease in vascularity occurred 1 day after the procedure, whereas the greatest volume change was found at the 3 month follow-up examination. In about one half of the patients scanned, depiction of fibroid vascularity by color Doppler sonography was found to improve the delineation of the size, location, and extent of myometrial involvement. Hypervascular fibroids (12 of 31) tended to decrease in size after treatment more than isovascular (10 of 31) or hypovascular ones (9 of 31). Additional investigations that are similar to this one will be needed to determine if three-dimensional color Doppler sonography can be used to predict those who will be responders, partial responders, or nonresponders to embolotherapy.

Sonographic depiction of tumor vascularity and flow: from in vivo models to clinical applications

This review discusses and illustrates the sonographic depiction and quantification of tumor vascularity and flow using three-dimensional color Doppler sonography. The potential clinical applications mentioned here are based on work done with in vivo tumor models and as well as extensive clinical experience with this technique. Three-dimensional color Doppler sonography, as used with contrast agents and novel imaging techniques, has significant current and potential clinical application for detailed depiction of tumor vascularity and flow. This technique can provide important information concerning changes in tumor vascularity and flow related to various biologic, chemical, and radiation therapies as demonstrated in animals and a few human studies. Additional animal and human studies are needed for further refinement and eventual clinical application of this technique.

Quantified color Doppler sonography of tumor vascularity in an animal model

This study was designed to evaluate the accuracy of a system to quantitate tumor vascularity with amplitude (power) color Doppler sonography two- and three-dimensionally. The vascularity of 20 transplanted murine tumors was determined with quantitated amplitude color Doppler sonography both two- and three-dimensionally and compared to tumor vascularity estimated by histologic examination. Serial examinations were performed 15, 30, 45, and 60 min after the injection of the exotoxin CM-101 and saline solution to assess changes in tumor vascularity. Three-dimensional amplitude color Doppler sonography best depicted the overall vascularity of tumor when compared to histologic estimation of vessel density. However, neither two- nor three-dimensional amplitude color power angiography correlated well to the microvessel count, probably a reflection of the difference in the method for vessel quantification using sonographic versus histologic techniques. Three-dimensional amplitude Doppler sonography correlated better with counts of large vessels (> 100 microm) as opposed to small vessels (> 15 microm). Time-activity curves showed no difference in tumor flow at the times measured in the experimental group injected with CM-101 or when compared to saline solutions in either the peripheral or central portions of the tumor. This three-dimensional amplitude color Doppler sonographic system affords global quantification of tumor vascularity and flow that may, in turn, be useful in determining the probability of malignancy (by determination of branching patterns and vessel regularity) or tumor response or both to treatment.

Sonographic assessment of endometrial disorders

This overview describes the clinical applications of transvaginal sonography in the evaluation of women with suspected endometrial disorders. The role of sonohysterography is also presented as an additional test when evaluating women for possible endometrial disorders.

Sonographic assessment of the endometrium in osteopenic postmenopausal women treated with idoxifene

Idoxifene is a novel selective estrogen receptor modulator that has shown beneficial effects on bone turnover and lipid metabolism in clinical studies. Preclinical studies have demonstrated that idoxifene has estrogen antagonist activities on the endometrium. This paper describes the results of a double-blind, placebo-controlled, and dose ranging study involving 331 osteopenic postmenopausal women who were treated with either placebo or idoxifene (2.5, 5, or 10 mg/day) for 12 weeks. In these women, endometrial assessment was carried out by transvaginal sonography and endometrial biopsy on selected patients at baseline and on all women at the end of treatment. Women with an endometrial thickness greater than 10 mm were excluded from the study. Aspiration endometrial biopsy was performed on women with an endometrial thickness between 6 and 10 mm at baseline and on all women after treatment. Of the 298 biopsies performed in the subjects at the end of treatment, 99% of the women were reported to have either a benign or atrophic endometrium (85%) or insufficient tissue for diagnosis (14%). Proliferative histologic features were reported in two cases (1%) (2.5 mg idoxifene) and atypical hyperplasia in one placebo patient. Even though idoxifene use was associated with a dose related increase in endometrial thickness as evaluated by transvaginal sonography, no relationship was established between endometrial histologic features and change in endometrial thickness. On histologic analysis, the increase in endometrial thickness seen on transvaginal sonography was not associated with proliferative or hyperplastic change in the epithelial (glandular) endometrial tissue. In 48 patients (16% of total) transvaginal sonography showed endometrial thickening of 5 mm or more over the study period. The endometrial histologic features were benign in all these patients. Nineteen percent of women developed intraluminal fluid, even though endometrial thickness was normal and unchanged and histologic features were normal. Our data show that after 3 months of treatment, no significant pathologic changes of the endometrium were observed. Our data indicate that measurements of endometrial thickness by transvaginal sonography may falsely suggest the presence of endometrial pathologic changes in some postmenopausal women treated with idoxifene. Additional testing using saline infusion sonohysterography is an important part of the transvaginal sonography protocol in equivocal or abnormal cases to exclude focal lesions such as polyps. In addition, our data indicate that pathologic changes of the endometrium are extremely rare in the treated group, indicative of its short term safety. Continued investigation such as this will be needed to establish long term safety.

Sonographic features of ovarian remnants

Ovarian remnants occur after a portion of ovarian tissue is left behind unintentionally after oophorectomy. The ovarian remnant may be functional and cystic, producing pelvic pain and, in some patients, extrinsic compression of the distal ureter. Ovarian remnants frequently are associated with adhesions from previous pelvic surgery for endometriosis or pelvic inflammatory disease. Ovarian remnants also may be included within pelvic peritoneal inclusion cysts. In this retrospective study, the sonographic features of ovarian remnants in 10 patients with surgical proof or clinical follow-up data are described. Most ovarian remnants were simple cysts (seven of 10), three had multiple septations, and six had a rim of presumably ovarian tissue with arterial and venous flow. Three patients with ovarian remnant masses that were aspirated had symptomatic relief without recurrence. In one patient, guided aspiration was unsuccessful, probably owing to the presence of organized hemorrhage within the mass. Extrinsic compression of the distal ureter was observed in one patient, who was treated with gonadotropin releasing hormone agonist (Lupron). The sonographic findings of a completely cystic or multiseptated pelvic mass with a rim of vascularized solid tissue in a postoophorectomy patient, although such cases are rare, suggest the diagnosis of an ovarian remnant. If the diagnosis can be established with a high degree of certainty, sonographically guided aspiration may be attempted in an effort to provide symptomatic relief. Otherwise, sonography is useful in serial assessment of these masses in patients receiving medical treatment.

Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle

The purpose of this study was to assess the diagnostic value of ultrasonography for the detection of twisted vascular pedicle in ovarian torsion and to verify whether the blood flow alterations in the twisted vascular pedicle on color Doppler sonography can predict the viability of adnexal structures. In 28 of 32 patients with surgically proved torsion, the twisted vascular pedicle was detected preoperatively by ultrasonography, which shows a diagnostic accuracy of 87%. Arterial and venous flows were present in the twisted vessels on color Doppler sonography in 16 of 28 patients with a visible twisted vascular pedicle. In 11 patients who underwent adnexectomy, the pathologic findings revealed nonnecrotic ovaries in 10 patients. Untwisting of the twisted vascular pedicle was performed in five patients, and follow-up ultrasonography showed normal follicular development and ovulation. All 12 patients who showed no blood flow within the twisted vascular pedicle had necrotic ovaries. In conclusion, identification of the twisted vascular pedicle through ultrasonography is suggestive of ovarian torsion, and color Doppler sonography could be helpful in predicting the viability of adnexal structures by depicting blood flow within the twisted vascular pedicle.