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a Chapter 38 Three-Dimensional Doppler Ultrasound in Gynecology 563
It appears that 3D sonography is a novel diagnostic
method proposed to be an additional non-invasive
tool in the assessment of ovarian tumors. Czekierdowski
et al. also studied the diagnostic potential of
3D sonography and power Doppler in the preoperative
differentiation of adnexal masses [12]. One hundred
twenty-eight women with tumors thought to be
of adnexal origin were examined preoperatively. Following
morphologic (papillae, septa, tumor size, and
volume) and color Doppler (PI, RI, V max , and TAMX)
assessment, 3D Doppler ultrasound of adnexal tumors
was performed. Various scanners were used and included:
ATL 5000 HDI (Phillips, Bothell, Mass.) and
Combison 530 and Voluson 730 (Kretztechnik, Austria)
machines. The following variables were studied:
inner wall structure; presence of papillae; thickening
> 3 mm of septa as well as vascular branching pattern;
number and localization of small blood vessels;
and the presence of vascular anastomoses. Twentyone
tumors were malignant (3 FIGO stage I) and 101
masses were benign. Power Doppler combined with
3D sonography predicted malignancy with a sensitivity
of 92.6% (25 of 27 patients). Commonly used
morphologic and Doppler criteria produced lower
sensitivity, the values being in range of 45%±87.5%.
Negative predictive value of 97.2% was the highest
for 3D sonography. The authors concluded that the
selective use of 3D ultrasound and power Doppler
could be used to better characterize adnexal tumors.
Detailed 3D sonography can help in identifying women
who can have less invasive surgical procedure, if
needed, such as laparoscopy, or be referred to a gynecologic
oncologist.
Cohen and co-authors wanted to determine if 3D
power Doppler ultrasound improves the specificity
for ovarian cancer detection as compared with 2D ultrasound
[13]. Seventy-one women with a known
complex pelvic mass were referred for a preoperative
ultrasound evaluation with both 2D and 3D gray-scale
ultrasonography. The 3D studies were performed with
the Kretz Voluson 530D using a mechanized transvaginal
probe. Surface rendering and power Doppler
imaging were performed by the same gynecologic sonologist
and reassigned to one of four echo patterns:
cystic; multicystic; complex; or solid. Sonographic
criteria used for diagnosing ovarian cancer were
based on a system that included morphologic characteristics,
histologic prediction, and power Doppler
imaging. Seventy-one women underwent surgical exploration:
14 (19.7%) had ovarian cancer (2 FIGO
stage I, 2 stage II, 7 stage III, and 3 metastatic colon)
and 2 had uterine cancer. Two-dimensional gray-scale
ultrasound identified 40 masses as suspicious for cancer,
including all 14 malignancies, yielding a sensitivity,
specificity, and positive predictive value of 100%,
54%, and 35%, respectively; however, evaluation with
3D power Doppler identified only 28 cases as suspicious
(including all 14 cancers), resulting in a sensitivity,
specificity, and positive predictive value of
100%, 75%, and 50%, respectively. It was an obvious
conclusion from this study that 3D power Doppler
imaging better defines the morphologic and vascular
characteristics of ovarian lesions. Both 2D and 3D
imaging correctly identified all malignancies; however,
the specificity significantly improved with the
addition of 3D power Doppler. This improved diagnostic
accuracy may promote improved patient care
by separating complex benign masses from ovarian
cancer, thereby facilitating appropriate physician referral.
In another study, the Zagrebgroup tried to determine
whether 3D and 3D power Doppler can improve
the ability to differentiate benign from malignant
ovarian lesions [14]. Transvaginal ultrasound, transvaginal
color Doppler, 3D US, and 3D power Doppler
were performed on 90 patients with ovarian lesions
during the week prior to surgery. Four independent
sonographers were blinded to the results of other ultrasound
studies. Color Doppler studies added to
transvaginal gray-scale characterization of ovarian lesions
resulted in sensitivity of 88.89 and specificity of
97.53% in diagnosing ovarian malignancy. Qualitative
analysis of tumor vascularity by 3D power Doppler
added to morphologic features obtained by 3D ultrasound
was clinical pertinent and reached sensitivity
and specificity of 100% and 98.76%, respectively.
They concluded that 3D ultrasound and power Doppler
can enhance and facilitate the morphologic and
functional evaluation of both benign and malignant
ovarian lesions. Introduction of the 3D quantitative
technique for measurements of blood flow and vascularization
may increase clinical relevance of these
studies.
The same authors investigated the potential usefulness
of contrast-enhanced 3D power Doppler sonography
in the differentiation of benign and malignant
adnexal lesions [16]. Thirty-one patients with complex
adnexal lesions of uncertain malignancy at
transvaginal B-mode and/or color Doppler sonography
were prospectively evaluated with 3D power Doppler
sonography before and after injection of a contrast
agent. Presence of a penetrating pattern and a
mixed penetrating and/or peripheral pattern suggested
adnexal malignancy. The results were compared
with histopathologic findings. There were 10
cases of ovarian malignancy and 21 benign adnexal
lesions. Of 10 ovarian cancers, 6 showed vascular distribution
suggestive of malignancy at non-enhanced
3D power Doppler sonography. After injection of contrast
agent, a penetrating vascular pattern and/or
mixed penetrating and peripheral pattern were detected
in all cases of ovarian malignancy as well as in