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11 Prostate
193
a
b
c
Fig. 11.4 Prostate adenocarcinoma. (a) Grayscale US
image demonstrates a lesion (markers) of decreased echogenicity with indistinct margins in the peripheral zone of
the left lobe of the prostate. (b) PDI detects increased vas-
cularity of the lesion. (c) CEUS image quantitative analysis. The TICs demonstrate the differences in the contrast
enhancement of the lesion (pink ROI) and the intact
parenchyma of the right lobe (yellow ROI)
194
M. G. Tukhbatullin et al.
Fig. 11.5 BPH.CE-TRUS image, the arterial phase. Hyperenhanced inner aspects and isoenhanced peripheral zone of
the prostate with a clear boundary between them (marked with arrows)
11 Prostate
195
a
b
c
Fig. 11.6 BPH. (a) Grayscale TRUS detects a hypoecho-
genic lesion with clear margins in the left lobe (distance
markers). (b) PDI demonstrates hypovascularity of the
lesion (arrow). (c) CE-TRUS image, quantitative analysis.
The lesion (pink ROI) exhibits slight hyperenhancement
as compared with the contralateral peripheral zone (yellow ROI) and its enhancement does not exceed the same
of the central part (blue ROI). (d) Numeric data of the
enhancement for part (c)
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M. G. Tukhbatullin et al.
d
Fig. 11.6 (continued)
11 Prostate
a
b
197
Fig. 11.7 BPH. (a) CDI demonstrates a hypoechogenic
hypovascular lesion with blurred margins in the peripheral
zone of the right lobe of the prostate. (b) CE-TRUS image.
Quantitative analysis. The lesion in the right lobe is isoen-
hanced (pink ROI) with a moderately increased washin
rate and a comparable washout rate as compared with the
relatively intact peripheral zone of the left lobe (yellow
ROI)
198
M. G. Tukhbatullin et al.
a
b
Fig. 11.8 BPH. (a) CE-TRUS image demonstrates regular symmetric enhancement in the transitional zone of the
prostate. (b) CE-TRUS cine loop at ×1.5 speed exhibits regular distribution of microbubbles
11 Prostate
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CEUS inGynecology
ElenaP.Fedotkina , AlexanderN.Sencha ,
AlexeyV.Pomortsev , MunirG.Tukhbatullin ,
AnatolyG.Bykov , YuliaY.Dyachenko ,
ElenaE.Fomina , NatalyaI.Bayazova ,
andPolinaL.Sheshko
12
Ultrasound is a rapid and feasible method for primary imaging in women’s health. Doppler assessment of tumor vascularity signicantly
contributed to modern oncogynecology with the
possibility to identify tumor neovascularization
[1]. CEUS is superior to Doppler imaging in the
assessment of perfusion and microvascularity. It
is successfully applied in some parenchymal
organs. However, its role in the diagnosis of the
diseases of the female reproductive system
remains underestimated.
Supplementary Information The online version contains supplementary material available at [https://doi.
org/10.1007/978- 3- 030- 91764- 7_12].
E. P. Fedotkina · A. N. Sencha (*)
Department of Visual and Functional Diagnostics,
Federal State Budget Institution “National Medical
Research Center for Obstetrics, Gynecology and
Perinatology n.a. V.I.Kulakov”,
Moscow, Russian Federation
A. V. Pomortsev · Y. Y. Dyachenko
Department of Radiation Diagnostics, Federal State
Budgetary Educational Institution of Higher
Education “Kuban State Medical University”,
Krasnodar, Russian Federation
M. G. Tukhbatullin · E. E. Fomina · N. I. Bayazova
Department of Ultrasound Diagnosis, Kazan State
Medical Academy, Kazan, Russian Federation
12.1 Uterus
The main blood supply to the uterus, broad and
round ligaments, Fallopian tubes, ovaries, and
vagina is provided by the uterine artery, which
originates from the internal iliac artery. It runs
down and medially at the base of the broad ligament, crosses the ureter, and supplies a vaginal
branch to the uterine cervix and vagina. Then it
turns up to the upper corner of the uterus and
travels along the attachment line of the broad
ligament. It anastomoses with the uterine branch
of the ovarian artery and forms an arterial arch
between the leaves of the broad ligament. The
branches of the uterine artery after entering myometrium are arranged parallel to the uterine outer
surface and form the arcuate arteries.
A. G. Bykov
Department of Gynecology, Federal State Budget
Institution “National Medical Research Center for
Obstetrics, Gynecology and Perinatology n.a.
V.I.Kulakov”, Moscow, Russian Federation
P. L. Sheshko
Department of Innovative Oncology and Gynecology,
Federal State Budget Institution “National Medical
Research Center for Obstetrics, Gynecology and
Perinatology n.a. V.I.Kulakov”,
Moscow, Russian Federation
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
A. N. Sencha, Y. N. Patrunov (eds.), Contrast-Enhanced Ultrasound,
https://doi.org/10.1007/978-3-030-91764-7_12
201
202
E. P. Fedotkina et al.
The largest arteries are located between the
outer and middle muscle layers, forming the stratum vasculosum. They give rise to numerous
smaller radial arteries that continue into the spiral
arteries (anastomosing capillaries) of the inner
muscle layer, which provide blood supply to the
endometrium. There are two types of endometrial
arterioles. The basal layer of the endometrium is
supplied with blood by basal arterioles, and spiral
arterioles feed the functional layer, which
changes in different phases of the menstrual
cycle. The outow from the endometrium is provided by spiral veins, which continue to the radial
and arcuate veins of the myometrium with further
drainage to the uterine branch of the uterine vein.
The latter vein is located along the lateral surface
of the uterus and merges with the vaginal
branches composing the uterovaginal venous
plexus. The venous blood further drains through
the uterine veins to the internal iliac veins [1–4].
CEUS of the uterus can be performed with
either transabdominal or transvaginal access,
depending on the size of the lesion. Transvaginal
CEUS is preferable in most cases. SonoVue® in
the dose of 1.5–2.4ml is used. The arterial phase
lasts up to 40 s from the moment of UCA administration. The uterus is enhanced from the periphery to the central aspects. The uterine arteries
enhance rst, followed by the enhancement of
the outer layers of the myometrium, the inner
layers of the myometrium, ending with the endometrium (Fig. 12.1). The venous phase follows
the arterial phase and is characterized by a gradual decrease in the intensity of contrast
enhancement.
Endometrial hyperplasia occurs under the
inuence of estrogen. It is a borderline condition
between normal endometrium and invasive carcinoma [5] and an often cause of postmenopausal
bleeding. The diagnosis requires histopathological study, which divides hyperplasia into simple
and complex, with or without atypia. With traditional echography, the differential diagnosis of
benign endometrial changes and endometrial
cancer is difcult. CEUS permits detailed assessment of the perfusion of the thickened endometrium and identication of the invasion.
Endometrial hyperplasia with CEUS demon-
strates delayed hypoenhancement as compared
with normal myometrium (Fig.12.2, Video 12.1).
As opposed to hyperplasia, endometrial cancer typically exhibits early heterogeneous hyperenhancement and faster washout (67 s) as
compared with normal myometrium (76 s). In
combination with the assessment of the course of
arcuate arteries, it enables assessment of the invasion of carcinoma into the myometrium [6–9].
Quantitative analysis conrms this data [5].
Endometrial cancer is characterized by a shorter
arrival and rise time, shorter time to peak, higher
average peak intensity and enhancement intensity, shorter half clearing time, and shorter washout half-time (Table12.1). Average peak intensity
and enhancement intensity demonstrate higher
diagnostic accuracy with an AUC of 0.963 and
0.951, respectively.
One common nding with traditional echography is an endometrial polyp, which is associated with a low risk of malignancy. An important
aspect in its diagnosis is the assessment of the
stalk. CEUS depicts not only the vascular pedicle
but also the perfusion of the entire polyp. Polyp
exhibits rapid enhancement in the arterial phase
with prolonged washout. However, histopathology is necessary for the nal diagnosis [6]
(Fig.12.3).
Uterine broid is a common benign tumor of
the myometrium. CDI usually identies peripheral vessels with a basket-like pattern. Small
broids and the periphery of large broids are
more biologically active than the myometrium
[7, 8]. The perfusion within the tumor cannot be
assessed with CDI and PDI. It is traditionally
studied with CE-MRI. Some researchers [9]
report that CEUS is not inferior to MRI in detecting tumor microvascularization. After UCA
injection, microbubbles rst appear in the broid
periphery with a characteristic basket vascular
pattern, followed by centripetal lling of the
whole mass. After that, the myometrium and
endometrium enhance (Figs.12.4, 12.5, and 12.6,
Video 12.2).
The boundaries of the tumor with CEUS are
clear and distinct. In the venous phase, homogeneous enhancement usually persists with gradual
washout. Heterogeneous enhancement may result