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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5767_Библиотеки_им_академика_М_И_Перельмана.pdf
12 CEUS inGynecology
a
203
b
Fig. 12.1 Normal uterus. CEUS images. Intensive, symmetrical contrast enhancement of the myometrium and
endometrium. (a) The arterial phase. (b) The venous
phase. (c) Quantitative analysis of CEUS with TIC in different areas of the myometrium
204
E. P. Fedotkina et al.
c
Fig. 12.1 (continued)
from the presence of avascular areas of degeneration or necrosis. In subserous and submucosal
leiomyomas, the typical character of enhancement is preserved, and feeding arteries in the
pedicle can be detected [10–12]. Leiomyoma
sometimes demands differential diagnosis with
leiomyosarcoma, which is a rare aggressive
malignant tumor that develops from smooth muscle. Leiomyosarcoma is characterized by earlier
and more intense contrast enhancement and lacks
the typical basket vascular pattern.
Cervical cancer is a widespread malignancy
and the fourth most common cause of cancer
death among women worldwide. Active neoan-
giogenesis in the tumor serves as a poor prognostic factor for the recurrence and overall patients
survival [13, 14]. In the initial stages, the arterial
phase CEUS reveals a hyperenhancing lesion
with further venous phase washout. As a result, in
the venous phase, the tumor typically becomes
hypoenhanced as compared to the myometrium
(Fig.12.7, Video 12.3).
The larger is the tumor, the more heterogeneous is the enhancement due to non-enhancing
areas of necrosis [10]. With quantitative analysis,
TIC in cervical cancer is characterized by higher
peak intensity with shorter rise time and time to
peak intensity than intact myometrium
12 CEUS inGynecology
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b
205
Fig. 12.2 Endometrial cancer. (a) CDI. (b) The venous
phase CEUS image. Hypervascularization and indistinct
contours of the thickened endometrium. (c) Quantitative
analysis of CEUS with TIC in the endometrium (yellow
and blue ROIs). (d) Coronal MRI. (e) Axial MRI
206
de
E. P. Fedotkina et al.
c
Fig. 12.2 (continued)
Table 12.1 The values of TIC in endometrial cancer and endometrial hyperplasia [5]
Parameter Endometrial cancer Endometrial hyperplasia Sensitivity, specicity, AUC
PI (dB) 33.82 ± 3.17 26.80 ± 2.39 91.8%, 88.1%, 0.963
EI (dB) 25.05 ± 3.19 18.25 ± 2.57 85.7%, 92.9%, 0.951
AT (s) 11.79 ± 1.47 13.08 ± 1.24 64.3%, 75.5%, 0.741
TTP (s) 23.76 ± 2.39 28.56 ± 3.59 71.4%, 87.8%, 0.855
RT (s) 11.96 ± 2.76 15.48 ± 3.39 81.0%, 73.5%, 0.787
Was-out half-time (s) 71.26 ± 4.41 79.38 ± 6.27 71.4%, 81.6%, 0.848
12 CEUS inGynecology
Fig. 12.3 Endometrial polyp. CEUS image
207
(Table12.2). Besides, the intensity of tumor contrast enhancement correlates with the density of
intratumoral vessels with the immunohistochemical study [15].
Focal and diffuse adenomyosis may cause pelvic pain, uterine bleeding, and implantation failures [16]. With CEUS, adenomyosis is
characterized by a relatively rapid diffuse heterogeneous enhancement with hypoenhanced areas.
This enhancement pattern is often referred to as
“moth-eaten” [10] (Fig. 12.8, Video 12.4). It
exhibits the sensitivity in the diagnosis of adenomyosis of 100% with the specicity of 83.3%. In
the venous phase, adenomyosis exhibits diffuse
contrast enhancement.
When analyzing the time-intensity curves,
peak intensity and time to peak values showed
the best accuracy. The peak intensity of contrast
enhancement in adenomyosis is lower than in the
intact myometrium (33.86 ± 1.89 dB vs. 37.39 ±
1.65 dB, respectively), which is probably due to
the presence of hypoenhanced areas. The time to
peak intensity in adenomyosis is longer than in
the intact myometrium (22.30 ± 2.18 s vs.18.16 ±
2.67 s, respectively).
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E. P. Fedotkina et al.
a
b
Fig. 12.4 Uterinebroid. (a) Grayscale US and strain elastography. The hard pattern of the broid. (b) CEUS image in
the arterial phase demonstrates vascularization of the lesion and its clear boundaries
12 CEUS inGynecology
a
b
209
Fig. 12.5 Uterine broid. (a) Grayscale US and PDI.Intense vascularity of the broid. (b) CEUS image in the arterial
phase demonstrates hyperenhancement of the lesion
210
E. P. Fedotkina et al.
a
b
Fig. 12.6 Uterine broid. (a) Grayscale US and CDI.Moderate vascularity of the broid. (b) Quantitative analysis
CEUS with TIC demonstrates hyperenhancement of the lesion (pink ROI)
12 CEUS inGynecology
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b
211
Fig. 12.7 Cervical cancer. (a) Arterial phase CEUS image. (b) Venous phase CEUS image
Table 12.2 Quantitative values of TIC in cervical cancer as compared with the reference zone [15]
Time to peak
Parameter Peak intensity (%) Rise time (s)
Cervical cancer 143.24 ± 54.54 9.36 ± 2.84 9.86 ± 3.00 100.95 ± 79.48
Reference area 100 17.49 ± 6.90 19.21 ± 7.97 121.12 ± 91.13
intensity (s) Mean transit time (s)
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E. P. Fedotkina et al.
a
b
Fig. 12.8 Diffuse adenomyosis. (a) Arterial phase CEUS image. Irregular mild asymmetric enhancement of the myo-
metrium. (b) Venous phase CEUS image. Diffuse contrast enhancement. (c) MRI, T1WI