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12 CEUS inGynecology
213
c
Fig. 12.8 (continued)
Another promising application of CEUS in
gynecology is the evaluation of uterine artery
embolization and ablation with high-intensity
focused ultrasound (HIFU). With CEUS, it is
considered that the areas without contrast
enhancement are represented by necrotic tissue,
whereas the enhancing areas—viable tissue.
Therefore, CEUS immediately after the HIFU
session detects the areas for additional ablation,
which improves the treatment result. When comparing the ablation coefcient, measured as the
ratio of non-enhanced broid volume to the total
broid volume after HIFU treatment, a strong
correlation between CEUS values with dynamic
MRI was noted. It suggests CEUS as an alternative method for evaluation of the treatment effect
[17]. Similar results were obtained for superselective embolization of the uterine arteries in
patients with uterine broids [9].
12.2 Ovary
The ovaries are supplied with blood from the
ovarian artery, which arises from the abdominal
aorta. It sometimes may branch from the renal
artery. It travels down with the ureter, passes in
the suspensory ligament of the ovary to the upper
part of the broad ligament of the uterus, and gives
branches to the ovary and tube. The end section
of the ovarian artery anastomoses with the uterine artery.
The ovary usually exhibits intense enhancement with CEUS, which is quite symmetrical
with even and clear boundaries. The follicles
demonstrate a persistent perfusion defect of a
rounded shape (Fig.12.9, Video 12.5).
Functional and paraovarian cysts are common
ndings with traditional echography in fertile
women and typically cause no diagnostic difculties. Some questions may arise if the cyst contains echogenic structures. In simple cysts, CEUS
reveals no contrast enhancement within the cystic
lumen, which excludes malignancy. Mild
enhancement of the thin walls can be identied
[18, 19] (Fig.12.10, Video 12.6).
An endometriotic cyst is a manifestation of
ovarian endometriosis. Irregular wall thickening
and parietal echogenic component complicate its
differentiation with cystadenoma and cystadenocarcinoma. Additionally, there is a risk of malignant transformation of endometrioma in
postmenopausal women [4]. With CEUS, endometriotic cyst exhibits annular hyperenhancement of the walls in the arterial phase with slow
washout in the venous phase and non-enhancing
contents (Fig.12.11, Video 12.7).
Borderline ovarian tumors comprise a number of lesions, which exhibit atypical epithelial
proliferation without stromal invasion. They
are usually represented by serous or mucinous
variants. Endometrioid, Brenner, and clear cell
variants are rare. With CEUS, they are characterized by hyperenhancement of the solid component with prolonged washout, which does
not exclude their malignancy. Therefore, the
diagnosis usually implicates histopathology
[10, 18] (Fig.12.12).
Ovarian cancer is an important problem in
oncogynecology. Evaluation of neoangiogenesis
and the density of microvessels in the tumor is
important for assessing the prognosis. The sensitivity and specicity of CEUS in the differential
diagnosis of benign and malignant ovarian
tumors were 89–96% and 91–97%, respectively
[18, 19]. Malignant tumors exhibit earlier heterogeneous hyperenhancement (Fig. 12.13 and
Video 12.8).
214
E. P. Fedotkina et al.
Fig. 12.9 Normal ovary. The arterial phase CEUS image. Enhancement of the ovarian stroma with non-enhancing follicles. Note a larger dominant follicle
Benign tumors demonstrate synchronous or
late homogeneous arterial isoenhancement. Both
benign and malignant lesions are hypoenhanced
in the venous phase. In the study [20], which
quantitatively analyzed CEUS with UCA
Denity, malignant lesions had a longer half
washout time (139.9 ± 43.6 vs. 46.3 ± 19.7 s)
when compared with enhancing benign lesions.
Greater peak enhancement (23.3 ± 2.8 vs. 12.3 ±
3.9 dB) and AUC (2012.9 ± 532.9 vs. 523.8 ± 318
s−1) quantitatively conrmed intense perfusion of
ovarian malignancies. Ovarian germ cell tumors
also demonstrate heterogeneous hyperenhancement with penetrating vessels [10].
CEUS with the study of ovaries can conrm
the ovarian torsion and assess its severity.
Incomplete ovarian torsion is characterized by
low enhancement of the ovarian tissue. The
absence of enhancement indicates a complete
ovarian torsion. The volume of enhanced areas
within the ovary is related to its viability [10].
Currently, single reseachers attempt to integrate CEUS in GI-RADS (gynecological imaging reporting and data system) for evaluation of
the ovarian lesions [21].
Despite a certain potential, the place of CEUS
in the diagnostic owchart in gynecological
patients is currently not specied. The EFSUMB
Guidelines and Recommendations for the
Clinical Practice of Contrast-Enhanced
Ultrasound (CEUS) in Non-Hepatic Applications
[22] indicate that there are no recommended
gynecological clinical indications for the use of
CEUS, despite the nding that the absence of any
enhancement in adnexal masses corresponds to
benign lesions. However, according to the guidelines, intra-cavity administration of UCA can be
used to determine tubal patency.
12 CEUS inGynecology
a
b
215
Fig. 12.10 Ovarian serous cystadenoma. CEUS images demonstrate a perfusion defect. (a) The arterial phase. (b) The
venous phase
216
E. P. Fedotkina et al.
a
b
Fig. 12.11 Endometriotic cysts of the ovary. (a)
Grayscale and PDI. (b) The arterial phase CEUS image
demonstrates the enhancement of the cystic walls, even
boundaries, and the avascularity of the inner contents. (c)
Example 2 of an endometriotic cyst. (d) Example 3 of an
endometriotic cyst
12 CEUS inGynecology
c
d
217
Fig. 12.11 (continued)
218
E. P. Fedotkina et al.
a
b
Fig. 12.12 Borderline ovarian tumor. (a) Grayscale and CDI. (b) The arterial phase CEUS image demonstrates the
hyperenhancement of the solid component and regular boundaries of the lesion
12 CEUS inGynecology
a
b
219
Fig. 12.13 Ovarian cancer. Irregular shape and enhancement of the solid component. (a) The arterial phase CEUS
image. (b) The venous phase CEUS image
220
E. P. Fedotkina et al.
12.3 Hystero-Salpingo-Contrast Sonography
Female infertility is often a consequence of tubal
and peritoneal factors, which account for 30–50%
of cases [23–25]. Fallopian tube patency and the
uterine cavity may be accurately assessed with
imaging methods. One technology is multiparametric echography, which has an optional UCA
application [26–28].
Hystero-salpingo-contrast sonography
(HyCoSy) is a method of ultrasound imaging
based on the introduction of a liquid contrast
medium into the uterine cavity under the control
of transvaginal echography, which permits the
real-time diagnosis of structural abnormalities in
the uterine cavity, evaluation of the anatomical
and functional state of the fallopian tubes and
paraovarian space.
For HyCoSy, both anechoic (saline) and echopositive (e.g. SonoVue®) contrast agents can be
used.
There are the following indications for
HyCoSy:
• assessment of the tubal patency in the diagno-
sis of infertility,
• habitual miscarriage,
• abnormal uterine bleeding,
• the suspicion of endometrial polyps, submu-
cous broid, or intrauterine adhesions,
• assessment of the scar on the uterus after
cesarean section,
• poor imaging of the uterine cavity with trans-
vaginal US or detection of local or diffuse
thickening of the endometrium,
• congenital abnormalities of the uterus.
There are the following contraindications to
HyCoSy:
performed. Voluntary informed consent from the
patient is necessary.
HyCoSy in fertile women is performed in the
proliferative phase of the menstrual cycle (7–11
days). In patients with irregular menstrual cycles,
the procedure should be performed only after a
negative beta hCG blood pregnancy test. The
patient is recommended to take an oral antispasmodic drug 15–30min before the study to eliminate possible tubal spasms.
The HyCoSy procedure, like the standard
CEUS, consists of several stages, as follows:
1. Preparatory stage
• interview the patient, revise case history,
and obtain informed consent for the
procedure,
• position the patient such a way to ensure
convenient manipulations,
• perform preliminary conventional US and
determine the target area,
• introduce and x a HSG catheter,
• pre-setup US equipment to contrast mode
and make necessary adjustments,
• prepare the UCA and make it ready for
intravenous administration.
2. HyCoSy performance
• introduce UCA into the uterine cavity
through the catheter,
• ensure simultaneous CEUS study with
constant cine loop recording,
• nish the procedure and cine loop recording once the required clinical information
has been obtained.
3. Post-processing stage
• revise the cine loop for further clarication
if necessary, conduct quantitative analysis,
• discuss the study results and make a report,
• dene further recommendations and consult the patient on the study result.
• progressive pregnancy,
• malignant lesions of the reproductive system,
• inammatory diseases of the pelvic organs,
inclusive of salpingitis and hydrosalpinx.
Before HyCoSy, the case history is claried
and the transvaginal US of the pelvic organs is
HyCoSy is performed in the conditions of
the manipulation room and demands an US
scanner with a transvaginal probe and a contrast option.
The patient is in a supine position with her
legs bent at the knee and hip joints. The procedure may follow several stages. A two-stage
ab
12 CEUS inGynecology
Fig. 12.14 HyCoSy with saline. Normal uterine cavity. (a) Grayscale US image. (b) 3D volume reconstruction image
of the uterine cavity
221
HyCoSy procedure has been suggested [29,
30], which utilizes sequential use of two types
of US media. Anechoic saline is used rst to
assess the condition of the uterine cavity and
tubes followed by echopositive SonoVue® in
ambiguous cases.
HyCoSy passes the following steps:
After the rst stage is completed, prepare
SonoVue® the standard way by adding 5 ml of
saline to the vial with a dry substance. The technology of dilution of the SonoVue® lyophilisate
is the same as for its intravenous use. Take 0.5ml
of the ready suspension into a syringe and additionally ll it with 0.9% normal saline up to
5.0ml. The obtained uid is introduced into the
1. overview the pelvic organs with the transvaginal US,
2. install a disposable Cusco’s speculum, expose
the cervix, prepare the vagina and cervix with
an antiseptic solution,
3. install a soft 5–7 Fr balloon HSG catheter
through the cervix into the uterine cavity
and inflate the balloon of the catheter with
1.5–2 mL sterile saline to secure the
catheter,
4. introduce echonegative contrast agent (sterile
saline) into the uterine cavity in a volume that
allows for a 1.0cm divergence of the anterior
and posterior uterine walls to reliably outline
the uterine cavity (Fig.12.14).
5. The tubal patency with anechoic contrast is
evaluated according to the following criteria:
• accumulation of the contrast medium and
air bubbles in the periovarian space,
• turbulent uid movement in the projection
of the mbrial part of the fallopian tube,
• appearance of free uid in the recto-uterine
pouch indicates the free patency of the fallopian tube.
uterine cavity at the second stage of the study.
Normally, the uterine cavity is triangular with
the apex pointing to the cervix. The base of the
triangle corresponds to the uterine fundus. It may
have a slightly concave or convex contour. With a
tight lling, the uterine cavity boundaries are
smooth and clear. UCA is uniformly distributed
within the cavity without lling defects. In general, the shape of the uterine cavity does not
depend on the position of the uterus and its contractions. The size depends on many aspects,
such as the age, history of childbirth, etc. The
cervical canal often has a fusiform shape and a
width of about 3–4mm.
The fallopian tubes originate at the lateral
parts of the fundus of the uterus. They normally
look like winding structures 2–6 mm in width
and 10–12cm long, located along with the upper
parts of the broad ligaments of the uterus. Routine
echography hardly identies normal fallopian
tubes. They are better imaged on the background
of free uid in the pelvis.
However, HyCoSy image of the fallopian
tubes differs from the same in routine echogra-
222
E. P. Fedotkina et al.
a
b
Fig. 12.15 HyCoSy images. Normal fallopian tubes. (a) Patient A CEUS image. (b) Patient B CEUS image
phy. SonoVue® depicts the lumen and is visualized as a hyperintense substance, which moves
from the uterine cavity within the fallopian tube
(Fig.12.15, Videos 12.9 and 12.10).
The length of the rst (interstitial) tubal seg-
ment is below 12mm. The isthmic part is the lon-
gest and thinnest. With the enhancement, its
width is about 1mm. It starts from the interstitial
segment and passes into the ampullary. The
ampullary segment is the widest one, up to
10–12mm. It approaches the ovary and ends with
the infundibulum and mbriae.