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Doppler Examination of the Normal Endometrium and Benign Endometrial Changes
Fig. 27.10 Color Doppler reveals diffuse blood flow in the thickened
myometrium (“Swiss cheese” appearance) in a dysmenorrheic
patient. A moderate to high RI (0.60) was recorded from the en-
dometrial tissue that had invaded the myometrium. Histology confirmed adenomyosis.
Endometritis
27
Endometritis is characterized by a thickened endometrium
that shows increased echogenicity and vascularization
RI is moderately increased to ⬎0.50 ⫾ 0.06 (Table 27.
Incomplete Abortion
While the value of Doppler sonography in predicting pregnancy outcomes is still uncertain, it is clear that the use of
Doppler sonography can significantly reduce uncertainties in
the diagnosis of early pregnancy loss.
The manifestations of incomplete abortion vary depending
on gestational age and the amount of tissue that has already
been expelled at the time of examination. Ultrasound generally
shows fluid and echogenic tissue fragments of varying size
within the uterine cavity. Color Doppler demonstrates good
34
. The
3,
Fig. 27.11 Transvaginal scan of the uterus shows increased thickness,
echogenicity, and vascularity of the endometrium and inner third of
the myometrium in a patient with endometritis. Moderate to high im-
pedance values (RI = 0.53) are measured in the corresponding vessels.
Fig. 27.
11). The clinical symptoms and vascularity tend to re-
gress over time, while the RI values remain elevated.
perfusion of gestational products that have not been expelled.
The good perfusion is based on the dilatation of the spiral arteries and venous vessels caused by the active trophoblast.
A low vascular resistance (RI = 0.41 ⫾ 0.01) can be detected
in the endometrium even if there is no identifiable conceptus
(Table 27.
and hypoechoic areas in the endometrium is still the most important criterion for diagnosing incomplete abortion.
3). However, the combined presence of hyperechoic
272
Decidua
The differentiation of endometrial structures, decidual tissue,
normal early pregnancy, and molar pregnancy is critically important in the differential diagnosis of amenorrhea
pregnancy should be considered in all patients who have a
positive pregnancy test and an empty uterus with a decidual
reaction or a small, central fluid collection. Color Doppler
sonography is helpful in patients with nonspecific adnexal
findings, as it can detect a decrease in vascular resistance on
the affected side. Unlike the two concentric decidual circles of
early intrauterine pregnancy, the decidual ring in an early ectopic pregnancy consists of only one layer.
9
. Ectopic
Doppler parameters in intrauterine and ectopic pregnancies.
When Jurkovic et al.
trauterine and ectopic pregnancies, they found no differences
in the blood flow impedance of the uterine arteries, spiral arteries, and luteal vessels. However, the peak systolic velocity in
the uterine arteries was identified as a parameter that very accurately reflects the increased blood flow in an ectopic pregnancy. Thus, the use of transvaginal color Doppler sonography
appears to be useful as an aid to therapeutic decision-making
(noninterventional conservative therapy, minimally invasive
surgery, or laparotomy).
21
compared the Doppler parameters of in-
References
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Gynecological Ultrasound
273
Transvaginal Color Doppler and Pulsed Doppler Diagnosis of
28
Benign Changes in the Uterine Myometrium
A. Kurjak and S. Kupesic
Examination Technique, Anatomy, and Physiology
Transvaginal color Doppler sonography can provide detailed
images of the entire uterus, myometrial and endometrial
changes, and the uterine vessels
Scan planes. The uterus can be imaged in three cardinal planes:
long axis, semichorionic or semiaxial, and short axis
long axis view is obtained by inserting the ultrasound probe
into the vagina and imaging the uterus in its greatest longitudinal dimension. A semiaxial scan is obtained by rotating the
probe 90⬚ to the long axis, delineating the full width of the
28
uterus. For the short axis view, the probe is withdrawn to the
middle third of the vagina and directed toward the anterior fornix wall.
With an anteflexed uterus, the probe handle is angled posteriorly to direct the beam forward. This technique is reversed
for a retroflexed uterus. In a semiaxial scan of the anteflexed
uterus, the cervix is the first structure to appear on the monitor. In a retroflexed uterus, the first structure to be visualized is
the uterine fundus.
Uterine size. The normal size of the uterus varies as a function
of parity and menopausal status. In nulliparae, the uterus
measures approximately 6 cm in length and 3–4 cm in its an-
9
.
8, 9
. The
teroposterior and transverse diameters
may measure up to 8 cm in parous women, decreasing to approximately 4–6 cm after menopause.
Blood supply. The uterus derives its blood supply from a com-
plex vascular network arising from the uterine arteries. The
main branches penetrate to about the outer third of the myometrium and form the network of arcuate arteries that encircle
the uterus
toward the uterine lumen
myometrium and crossing the myometrial–endometrial junction, they become the spiral arteries.
Contractions. The myometrial muscle fibers undergo contractions during a normal menstrual cycle. Focal contractions
occur in the middle or outer muscle layer during pregnancy
while subendometrial contractions are common during menstruation and ovulation
toward the cervix during menstrual bleeding and away from
the cervix during ovulation. Presumably, contractions during
the periovulatory period play an important role in sperm
transport, and a deficiency of these contractions can lead to
fertility problems.
4
. Smaller branches called the radial arteries run
18
. On reaching the inner third of the
1, 30
. These contractions are directed
8
. The uterine long axis
8
,
274
Leiomyomas (Fibroids)
Forms and symptoms. Uterine leiomyomas, also known as fi-
broids or myomas, are by far the most common pelvic tumors
in women of childbearing age
smooth muscle and sof t tissues of the uterine corpus and fundus. Only 3% are of cervical origin
often multiple than solitary and vary greatly in size. They may
be confined to the uterine musculature (intramural) or may extend toward the uterine cavity, becoming submucosal. Centripetal growth leads to subserous or pedunculated forms
intramural type is the most common, the subserous type the
least common
vic pain, and infertility usually occur in patients with submucous leiomyomas, while subserous leiomyomas tend to be
asymptomatic. The presence and severity of symptoms correlate closely with the number, size, and location of the tumors.
Sonographic features. The ultrasound diagnosis of leiomyomas
is based on uterine contour changes, uterine enlargement, and
changes in echo texture. The sonographic structure ranges
20
. Clinical symptoms such as metrorrhagia, pel-
7,20, 39
. They arise from the
26
. Leiomyomas are more
7
. The
from hypoechoic to hyperechoic, depending on the proportions of muscle and connective tissue. If secondary changes
have developed (necrosis, intratumoral hemorrhage,
degeneration, calcification), they present a broad spectrum of
sonographic appearances (Fig. 28.
Leiomyomas that enlarge and outstrip their blood supply
develop central ischemia, usually followed by varying degrees
of degenerative change. There are reports
fibroids are associated with calcifications ranging from small
calcific foci to large deposits or complete calcification. Because
of their variable appearance, leiomyomas may be misinterpreted as solid ovarian tumors, endometrial polyps, blood, or
8
mucus
ultrasound in the detection of small submucous myomas in
women who had undergone both transvaginalsonography and
hysteroscopy before a scheduled hysterectomy. The sensitivity
and specificity of transvaginal sonography and hysteroscopy
were comparable in this study.
. Fedele et al.5investigated the accuracy of transvaginal
1).
14
that almost 25% of
Leiomyomas (Fibroids)
Fig. 28.1 Transvaginal ultrasound scan of a leiomyoma with central
ischemia and necrosis.
Leiomyomas and infertility. The clinical and/or surgical management of leiomyomas are directed by the symptoms and size
of the palpable mass and the desire of the patient to preserve
her fertility
39
. Because leiomyomas tend to occur later in a
woman’s reproductive life, the trend toward delaying parenthood could increase the association of fibroids with infertility.
Nevertheless, the relationship between these benign pelvic
tumors and infertility/pregnancy failure is not yet fully understood. A change in the shape of the uterine cavity or an obstruction of the cervix and fallopian tubes could interfere with
sperm transport. Leiomyomas can also lead to venous dilatation, with consequent swelling of the myometrium and endometrium. This would impede the implantation of a fertilized
ovum and might also restrict the blood supply to the developing embryo. Myoma-related mehorrhagia could result from
congestion and dilatation of the adjacent endometrial venous
plexus, with an associated adverse effect on the myometrial,
radial, and arcuate veins.
Vascularization of Leiomyomas
The blood flow impedance in small vascular branches can b e
reproducibly measured with transvaginal color Doppler ultra-
16, 27
sound
with this method. Transvaginal color Doppler has been used to
investigate the blood supply to leiomyomas
ological and pathophysiological characteristics of blood flow in
the uterine artery
proved particularly helpful for the in-vivo differentiation of
benign and malignant uterine tumors
that benign uterine masses derive their blood supply from
preexisting normal vessels (Figs. 28.
color Doppler waveforms showed a slight decrease in blood
flow impedance or similar perfusion patterns as in the terminal branches of the uterine arteries in the normal myometrium.
Premenopausal patients. Examinations in premenopausal
women consistently demonstrated diastolic blood flow, which
was usually increased relative to the blood flow in the uterine
artery. Color Doppler also demonstrated flow at the peripher y
and/or center of the leiomyoma. The mean RI of blood flow in
. Small tumor-feeding vessels are very easy to detect
23, 37
and the physi-
13,21,24,28,33,38
. Transvaginal color Doppler has
23, 27
. It has been shown
2, 28.3). Analysis of the
Fig. 28.2 Transvaginal scan of a patient with a posterior, isoechoic
leiomyoma. Color Doppler shows a large-caliber vessel at the tumor
periphery.
Fig. 28.3 Same patient as in Fig. 28.2. The vessel at the border of the
leiomyoma is defined more clearly by power Doppler.
leiomyomaswas 0.54, and the mean PI was0.89 (Fig. 28.
4). Low
resistance indices were found in cases with necrosis and secondary degenerative or inflammatory changes within the
myoma (Fig. 28.
5).
In our own studies of patients with leiomyomas and
healthy volunteers, the same technique was used to investigate
blood flow in the uterine arteries. In patients with leiomyomas,
we found increased blood flow velocities and decreased RI and
PI values in both uterine arteries (Fig. 28.
6). The different
vascularization patterns observed in this study could be useful
in predicting the growth rates of these benign uterine tumors.
Postmenopausal patients. Several interesting observations
were made in women with shrunken fibroids after
menopause
33
. The blood flow at the periphery of the tumors
showed a higher RI than in premenopausal women, and some
cases showed a complete absence of end-diastolic blood flow.
Transvaginal color Doppler can also be used to evaluate the effect of hormone replacement therapy on the thickness of the
endometrium and myometrium. Moreover, Doppler examinations can supply additional information on the quality of blood
flow in the uterine, myometrial, and endometrial vessels. It can
be used to assess the effect of treatment measures on uterine
morphology and perfusion and even answer the question of
whether hormone replacement therapy increases the risk of a
myometrial neoplasm.
Gynecological Ultrasound
275
Transvaginal Color Doppler and Pulsed Doppler Diagnosis of Benign Changes in the Uterine Myometrium
Fig. 28.4 Same patient as in Figs. 28.2 and 28.3. The Doppler spec-
trum indicates a moderate RI (0.59). Histopathology confirmed the
benign nature of the tumor.
28
Fig. 28.6 A giant intramural leiomyoma has caused a significant fall
of vascular resistance in the uterine arteries (RI = 0.61).
Fig. 28.5 Pulsed Doppler signals from a small vessel at the border of
the leiomyoma indicate a small variation between systolic and end-diastolic blood flow (RI = 0.52).
Fig. 28.7 Transvaginal scan of a subserous leiomyoma. The color
Doppler image shows normal branching of the vessels arising at the
periphery of the uterus. The spectral trace indicates moderate to high
impedance in the tumor vessels (RI = 0.61).
276
Differentiation from ovarian tumors. Color Doppler sonography is useful in differentiating intraligamentous fibroids from
solid ovarian tumors (Fig. 28.
7). Even if the uterine tumor is lo-
cated outside the uterine corpus, Doppler can still reveal
waveforms that are typical of the uterine vascular network.
The flow pattern in these cases generally resembles the pattern
of normal myometrial blood flow arising from the terminal
branches of the uterine arteries. By contrast, the vessels that
supply adnexal tumors are derived from the ovarian vessels.
Leiomyomas during pregnancy. Since leiomyomas are responsive to female sex hormones, they frequently enlarge during
early pregnancy
29, 36
. Transvaginal color Doppler sonography is
the method of choice for observing hemodynamic changes in
the maternal and fetal vascular system of the placenta, both in
normal early pregnancies and in pregnancies with uterine fi-
19,22, 25
broids
. No significant difference in blood flow impedance (p ⬎ 0.05) was observed between the two groups.
Leiomyomas affect neither the hemodynamics of the uteroplacental circulation nor the maternal or fetal components of
the placental circulation. The marked rise of blood flow velocity measured in the radial arteries from the 10th to 13th weeks
of gestation (p ⬍ 0.001) is probably due to the increased metabolism of the growing fibroid cells.
Management of Uterine Leiomyomas and the Importance of Color Doppler Sonography
Management of Uterine Leiomyomas and the Importance of Color Doppler Sonography
Current treatment options for uterine fibroids include nonsurgical therapies (especially the use of gonadotropin-releasing
hormones, GnRH agonists) as well as various surgical options
such as abdominal, laparoscopic, or hysteroscopic myomectomy and abdominal or vaginal hysterectomy (which may be
laparoscopy-assisted).
Medical Treatment with GnRH Agonists
Mechanism of action. Hormonal therapy is best for reducing
the size of submucous leiomyomas to relieve postoperative
symptoms, facilitate hysteroscopic resection, or temporize
until menopause in perimenopausal women. Synthetic GnRH
agonists inhibit estrogen production, leading to a decrease in
uterine size. Filicori et al.
with uterine fibroids and anemia who was treated with GnRH
agonists. Since then, many studies have been publishe d confirming the efficacy of GnRH agonistsin reducing the size of the
uterus and leiomyomas and suppressing menstrual bleeding.
Reduction in uterine volume. Friedman10documented an average
40–50% reduction of uterine volume relative to pretreatment size
in women who were treated with GnRH agonists for 3–6 months.
Generally the decrease in uterine volume was greatest during the
first 12 weeks of therapy. More than a 50 % reduction in uterine
volume was achieved in 20% of the women, and a moderate reduc-
tion of 26–50 % was achieved in half of the women. A slight reduc-
tion of up to one-fourth the pretreatment size was obtained in 25 %
of the women, and in 5% the uterus enlarged by up to 25% of the
pretreatment size. GnRH agonists did not continue to afford pro-
tection after they were discontinued. The myomas generally re-
turned to their original size within four months after the end of
treatment.
Measurement of RI. The first Doppler examination of the uterine
arteries in fibroid patients treated with GnRH agonists was per-
formed by Matta et al. in 1988
eight patients, showed a significant rise of resist ance in the uterine
vessels after four months’ treatment with GnRH agonists. During
that time the RIs were measured in the uterine arteries and in the
larger fibroid vessels. After treatment, the RI rose significantly from
an average of 0.52 in the uterine arteries and 0.48 in the fibroid ar-
teries to respective values of 0.92 and 0.91. The authors concluded
that a decrease in uterine vasculature was responsible for the reduction in uterine volume after treatment with GnRH agonists.
Effect of RU 486 and leuprolide acetate. Reinsch et al.
studied the effect of RU 486 (mifepristone, a synthetic steroid with
both antiprogesterone and antiglucocorticoid properties) compared with leuprolide acetate on uterine blood flow in 14 women.
Both groups showed a rise of RI values in the uterine arteries and a
reduction in uterine volume following three months’ treatment.
The RI rose in 2–51% of the patients who had received RU 486 and in
8–39% of the patients treated with leuprolide acetate. The authors
interpreted the rise of RI in response to GnRH agonist therapy as a
hypoestrogenic effect, while the decreased blood flow in response
to RU 486 was apparently caused by other, previously unknown
mechanisms.
Our studies. In one study we observed 25 women with symptomatic uterine leiomyomas, 88% of whom complained of metrorrha-
6
were the first to report on a patient
33
. Their study, which involved only
35
recently
gia, 52 % of lower abdominal pain or pressure, and 40 % of dysmenorrhea. We performed transabdominal and/or transvaginal
sonography in these patients to examine the uterus and adnexa.
The volume of the myomas was calculated using the formula for an
ellipsoid (0.521⫻ length ⫻ width ⫻ depth). Pulsed and color Doppler ultrasound were used to identify and quantitate blood flow in
the main arteries supplying the myomas. The initial tumor volumes
were between 25 and 390 mm
amination, 1200
ministered intranasally. Transvaginal color Doppler examinations
were performed for follow-up during and at the end of GnRH analogue therapy. The mean RI in the principal myoma-feeding vessels
was 0.54 ⫾ 0.08. The resistance in these vessels rose markedly
during the first three months of treatment to a mean RI of 0.78,
while the myoma volume decreased to 76% of the initial value.
After six months’ treatment, the mean myoma volume had been reduced to 56% of the pretreatment volume, with color Doppler
showing a rise of impedance to RI = 0.88 in the uterine arteries and
RI = 0.82 in the myoma vessels in 80% of the patients treated.
We also observed that three myomas disappeared completely
and had not recurred by six months after the end of treatment. The
remaining myomas increased their volume by 24% of the initial
posttreatment size. Nine of the 25 patients were referred for surgical treatment with improved hemoglobin levels. The reduced
uterine and myoma volumes, which now enabled operative treatment, resulted in less intraoperative blood loss, facilitated enuclea-
tion of the myomas, and reduced the number of postoperative
complications
metrorrhagia experienced menopause during the therapy.
µg/day of buserelin (Suprefact, Höchst) was ad-
31, 32
. Four perimenopausal patients with severe
3
(mean value 85 mm3). After this ex-
Surgical Treatment
Methods. The surgical treatment options for uterine leiomyo-
mas include abdominal, laparoscopic, and hysteroscopic myomectomy as well as abdominal and vaginal hysterectomy. The
main advantage of myoma enucleation is that it preserves the
uterus and thus the patient’s fertility.No benefit has been demonstrated for laparoscopic removal, however. Several published cases document possible complications including
uterine suture dehiscence
treatment for symptomatic uterine fibroids in women who
have concluded their childbearing. The mortality risk of hysterectomy for a benign indication is approximately 1 : 1000
Laser therapy. A small study34described a very promising alterna-
tive to the above surgical treatments for uterine fibroids: laparoscopic myolysis with the Nd:YAG laser. The laser applicator was in-
troduced laparoscopically into the myoma. During treatment, the
applicator was repeatedly inserted into the leiomyoma to reduce
the stroma, denature tumor proteins, destroy tumor vessels, and
reduce the tumor volume. The insertion sites were spaced 5–7 mm
apart, and the blood vessels at a 3–5 mm radius around each inser-
tion site were coagulated. Multiple punctures were effective in obliterating the myomas. Since the uterus remains fully intact, there is
no impairment of hormonal or sexual function. At six-month followup, the echo structure of the coagulated myomas so closely resembled normal myometrium that only an experienced examiner
could tell the difference. A long-term study of seven patients
showed no evidence of tumor regrowth. Histological examination
showed complete devascularization of the myoma tissue with subsequent necrosis
34
.
15
. Hysterectomy is the definitive
2, 40
Gynecological Ultrasound
.
277
Transvaginal Color Doppler and Pulsed Doppler Diagnosis of Benign Changes in the Uterine Myometrium
Electrocautery. Currently we are completing a study to evaluate
the size, vascularity, and degenerative changes in myomas whose
feeding vessels were electrocoagulated by the laparoscopic route.
Color Doppler ultrasound was used to demonstrate the myoma vessels during the electrocautery. Accurate spatial placement of the
bipolar needles in the vascularized plane of the myoma was compared with “blind” electrocautery. We believe that the treatment
can be made more successful and the procedure shortened with
the aid of color Doppler.
We therefore investigated key variables such as the amount of
bleeding and the reduction in myoma size following laparoscopic
electrocautery in one group of patients in which color Doppler had
been used and another group in which the entire myoma had been
“blindly” coagulated. We found that the size and vascular supply of
the myomas showed a much greater regression in the color Doppler group than in the group without color Doppler guidance. These
initial results underscore the value of color Doppler sonography in
the management of leiomyomas, not only to better document lesion size and structure but also as an aid to preoperative planning
and intraoperative guidance for resection or electrocautery.
Vascular Diseases in the Lesser Pelvis (Varicose Veins or Arteriovenous Malformations)
These lesions are easily demonstrated by duplex sonography
or color Doppler imaging
17
(Figs. 28.8, 28.9). Doppler sonography is the modality of choice for distinguishing these vascular
lesions from cystic structures without internal echoes such as
hydrosalpinx and from cysts diagnosed by B-mode imaging
(Figs. 28.
10– 28.12).
Uterine adenomyosis is discussed in Chapter 27 (Doppler
Examination of the Normal Endometrium and Benign Endometrial Changes).
28
278
Fig. 28.8 Color Doppler image (right) reveals a dilated uterine vein in
the outer third of the myometrium.
Fig. 28.10 Transvaginal sonogram shows irregular structures near the uterus of a
woman with chronic lower abdominal pain. A
definitive diagnosis could not be made from
the B-mode image.
Fig. 28.11 Same patient as in Fig. 28.10.
The color Doppler image shows dilated pelvic
veins consistent with pelvic congestion syndrome.
Fig. 28.9 Color Doppler is the method of choice for diagnosing pelvic
congestion syndrome.
Fig. 28.12 Same patient as in Figs. 28.10
and 28.11. Appearance of the dilated pelvic
veins in the power Doppler mode.
References
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Gynecological Ultrasound
279
Use of Color Doppler in the Evaluation of
280
29
Suspicious Endometrial Findings
M. Holländer, C. Villena-Heinsen, A. K. Ertan, and W. Schmidt
Incidence of Endometrial Carcinoma
Endometrial carcinoma has become the most common tumor
of the female genital tract. While the incidence of cervical
cancer is definitely on the decline, owing largely to effective
Pap screening programs, the incidence of endometrial cancer is
slightly on the rise. The rate of new cases in Saarland, Germany,
during the 1970 s and 1980 s was between 20 and 30 per
100,000 population, or approximately 15 cases per 100,000
Diagnostic Investigation of Suspicious Endometrial Findings
29
Transvaginal sonography. Malignancy should be suspected in
women with postmenopausal bleeding or other bleeding irregularities and when thickened or irregular endometrium is
noted at ultrasound. There is no question that transvaginal
sonography has added much new information to endometrial
examinations compared with transabdominal scanning. On
closer scrutiny, however, we find that vaginal sonography is inaccurate in a considerable number of the cases examined and
that different authors have cited very different cutoff levels for
endometrial thickness at which curettage is urgently indicated, ranging from
sensitivity and specificity data are not sufficient to eliminate
the need for histological evaluation
fractional curettage is still the “gold standard” for excluding
cancer in women with postmenopausal bleeding or sonographic abnormalities, even though endometrial cancer is actually found in only a small percentage of cases
necessary biopsies in this predominantly older population
with an increased surgical risk, noninvasive methods are being
sought that can differentiate benign endometrial changes from
carcinoma.
4 mm
10
to as much as 10mm23. At present,
6, 22, 31, 33, 34, 43
. As a result,
9, 32
. Toavoid un-
Color Doppler Sonography
Neovascularization of tumors. The hope that color Doppler
sonography will yield additional diagnostic information is
based on the following theoretical considerations. Solid
tumors have the capacity to induce angiogenesis, and they require these newly formed vessels in order to grow
new vessels have a distinctive histological morphology: they
are dilated, saccular, and tortuous with arteriovenous shunts
and intervenous connections. The vessel walls contain very
little smooth muscle, giving the vessels a lower impedance to
flow than “normal” arterioles. This results in a markedly lower
flow velocity
15, 20, 28, 37
.
13, 14
. These
based on the World Standard Population
in obese postmenopausal women, with a peak age incidence of
60–65 years (normally distributed)
are diabetes mellitus, arterial hypertension, infertility, unopposed estrogen use, tamoxifen therapy, and genetic predisposition
Doppler parameters. Color Doppler is being used in an attempt
to detect this altered flow pattern. Waveforms are recorded to
derive objective parameters that may be useful for noninvasive
benign–malignant discrimination. Because absolute flow
velocity depends on the incidence angle of the color Doppler
beam and an accurate angle correction often cannot be made, it
is better to use standard angle-independent parameters that
indicate flow resistance: the S/D ratio, the resistance index
(RI) = (S–D)/S, or the pulsatility index (PI) = (S –D)/mean, where
S = maximum frequency shift in systole, D = minimum
frequency shift in diastole, and mean = mean value.
Breast and ovarian cancers. The Doppler examination of blood
vessels has already been applied to the differential diagnosis of
other gynecological tumors, particularly breast and ovarian
cancers. With regard to ovarian cancer, initial studies reporting
extremely positive results
studies giving reports of poor accuracy and specificity
Contradictory studies have also been published on breast
cancer diagnosis. While Sohn in 1992 found a statistically significant decline of maximum resistance indices in breast
cancers compared with benign tumors and Madjar in 1994
noted higher velocity sums in breast malignancies, the workers at our center were unable to confirm these positive results
either as discriminatory parameters or as a means of assessing
breast cancer prognosis
Endometrial findings. In the early 1990s, the first studies ap-
peared on the use of color Doppler sonography in the differential diagnosis of endometrial pathology. The authors initially
limited their work to large-vessel examinations such as that of
the uterine artery
sels in the endometrium and also in tumors. Most of the studies analyzed the angle-independent parameters RI and/or PI,
since the sampled vascular segments are often very short and
precise angle correction is difficult to achieve.
11,16,19,40
24
. The risk is highest
24
. Additional risk factors
.
17, 26
gave way to increasingly critical
41
.
4, 5, 21
, but soon they also studied smaller ves-
38, 39
.
Experience at the Department of Obstetrics and Gynecology, Homburg University Hospital, Saar
Examination of the Uterine Artery
Several authors found significant differences in flow resistance
between benign and malignant endometrial lesions. Bourne et
4
al.
stated a cutoff value of PI = 2.0 for the uterine artery. Chan
8
et al.
also found significant PI differences, but only between
normal and abnormal endometrium; benign lesions could not
be distinguished from their malignant counterparts. The
authors used a higher cutoff value than Bourne et al., with
PI
= 2.17 for endometrial carcinoma. Similarly, Merce
mean
could distinguish only between normal endometrium and endometrial disease (i.e., benign and malignant changes).
Kupesic-Urek examined both the uterine artery and endometrial vessels
uterine artery resistance indices were considerably less than
those reported by Merce (Table 29.
Table 29.1 Review of the literature on uterine artery examinations, with significant results
Author Number Vessel Indices for
malignant
Indices for
benign lesions
lesions
Bourne 1990
4
54 Uterine artery/
PI
= 0.89 PI
mean
= 3.82 Cutoff value: PI = 2.0
mean
(endometrium)
Bourne 1991
Mercé 1991
5
30
Kupesic-Urek 1993
Chan 1994
a
Includes different groups with benign pathology.
b
No distinction made between malignant and benign pathology, only between normal and abnormal.
8
138 Uterine artery PI
64 Uterine artery/
myometrial
25
276 Uterine artery
endometrial
67 Uterine artery PI
= 0.91 PI
mean
RI
= 0.79
mean
RI = 0.66
RI = 0.53
RI = 0.37
=2.17 A:PI
mean
ⱖ 2.53
mean
RI
⬎ 0.87
mean
RI ⬎ 0.78
RI = 0.76
RI = 0.54
mean
B: PI
mean
25
= 3.41
= 2.28
and found significant differences. The
1).
Analysis
a
(b)
Statistically significant
Statistically significant
A: normal, B: benign pathology; significant differences between A and B and
between A and cancer
30
Gynecological Ultrasound
Experience at the Department of Obstetrics and Gynecology,
Homburg University Hospital, Saar
tors for endometrial cancer (obesity, diabetes mellitus, arterial
Patients and Methods
We studied 95 women from 17 to 88 years of age (average 57.8
years) with clinically suspicious (menorrhagia, metrorrhagia,
postmenopausal bleeding) or sonographically suspicious
(structure, diameter) endometrial findings who had been referred to our department for further evaluation.
Sonographic and color Doppler sonographic examinations. All
patients underwent hysteroscopic biopsy or fractional curettage to establish a histological diagnosis. The surgery was
preceded by a transvaginal B-mode ultrasound examination of
the internal genitalia with assessment of endometrial diameter and structure. This was immediately followed by a color
Doppler examination to determine whether endometrial and
subendometrial blood vessels could be visualized and, if so,
how many. We also attempted to record a frequency-shift
waveform from each endometrial vessel that could be visualized. These waveforms were then used to determine the angleindependent parameters of S/D ratio, RI, and PI along with the
smallest value (min), greatest value (max), and mean value
(mean) for each patient. We also documented menopausal status, the use of hormonal products, and the presence of risk fac-
hypertension, positive family history). All examinations were
performed with an Acuson 128 XP/10 scanner with integrated
color Doppler using a 5 MHz endovaginaltransducer that could
be switched to 5 MHz pulsed color Doppler mode. The scanner
was operated over a power range of 50–500 mW/m
sensitivity was set to the lowest velocity range. For maximum
sensitivity in locating vessels, the color Doppler gain was set
just below the noise threshold.
Fractional curettage. Nineteen of the women (20%) were premenopausal, 62 (65.3 %) were postmenopausal, and 14 (14.7%)
were perimenopausal. The indication for curettage was a
bleeding disorder (postmenopausal bleeding, menorrhagia,
metrorrhagia) in 74.8% of the patients and suspicious endometrial findings in 16.8%. Other causes (lower abdominal
pain, search for a primary tumor, etc.) were present in 8.4%. Examination of the curettage material revealed a malignant condition in 23 cases (24.2 %) and a benign condition in 72 cases
(75.8%). As expected, the great majority of cancer patients
(87%) were in menopause. A histological breakdown of the
malignant lesions revealed 21 adenocarcinomas, one
müllerian mixed tumor, and one high-sited cervical carcinoma
(Tables 29.
2 and 29.3).
2
, and color
281