2D / 3D COLOR DOPPLER and Newer Advances in Detection of OVARIAN MASS LESIONS

DR CHANDER LULLA RIA CLINIC JASLOK HOSPITAL MUMBAI INDIA Email: riaclinic@gmail.com The early detection of ovarian carcinoma continues to be a formidable challenge and an elusive task. The poor prognosis of ovarian cancer is associated with the advanced stages of the disease at the time of diagnosis . The Ultrasound evaluation appearences of the normal and abnormal ovary have been extensively studied. The most common evaluation is in the setting of a clinically suspected pelvic mass, but studies have also investigated the role of ultrasound as part of screening protocols for detection of ovarian cancer Transvaginal ultrasound has improved visualization of normal ovarian function and ovarian tumors, and much work has been done to define and standardize ovarian tumor characteristics An important role of ovarian/adnexial mass evaluation by ultrasound is to determine the differences between normal physiologic findings, inflammatory changes, benign neoplastic processes, and ovarian cancer.. The use of Doppler analysis for the purposes of color-flow mapping and characterization of waveforms has been used to evaluate neovascularity of ovarian neoplasms, often combined with other ultrasound markers Tumor markers, such as CA-125, have been used to assign a relative risk of malignancy in certain clinical scenarios associated with an increased likelihood of ovarian cancer. New modalities like 3D, 3D power Doppler and Microbubble contrast imaging are providing new insights for tumour characterization and will hopefully enable earlier and more accurate diagnosis of Early stage Ovarain Carcinoma 2D Morphologic Characteristics

Sonographic features to predict tumor morphology include the cystic and solid tumor compositions presence and type of septations and papillations. An important role of ultrasound analysis of ovarian and adnexal masses is an attempt to identify nonneoplastic entities, such as functional cysts, tubal and inflammatory diseases, or endometriosis. There can e a considerable overlap in appearences and nonneoplastic lesions can t mimic neoplastic processes as well. If the mass is thought to be neoplastic,the classic appearance of the most common benign neoplasm of the ovary, the dermoid tumor needs to be evaluated for If the ovarian or adnexal mass does not fit any of classic descriptions, further evaluation of the tumor is performed. Many authors have designed quantitative scales or qualitative pattern recognition algorithms that facilitate categorization of a mass on a spectrum of worsening appearance, from simple cyst to a cyst with septations, loculations, then papillations, and ultimately varying degrees of predominantly solid (nondermoid lesions) . Granberg et al. reported that the gross morphology of adnexal masses could be used to predict the likelihood of malignancy. Subsequently, Sassone et al. devised a scale for such morphologic ovarian characteristics, including inner wall structure, wall thickness, the presence of septa, and echogenicity of the mass, and were able to distinguish benign from malignant masses with specificity of 83%, sensitivity of 100%, and positive and negative predictive values of 37% and 100%, respectively. Most recently the IOTA Group have used this qualitative pattern recognition scale to differentiate between benign and malignant tumors

2D COLOR DOPPLER Evaluation Doppler examination once promised to be the key in distinguishing between benign and malignant masses Malignant lesions usually produce increase in color Doppler flow signals secondary to angiogenesis. The color content of the tumor probably reflects tumor vascularity better than any other Doppler parameter The IOTA Group has suggested the use of such a subjective semiquantitative assessment of flow to describe the vascular features of ovarian masses . A color score is used to describe the amount of blood flow for the tumor as a whole: color score 1, no detectable blood flow; score 2, minimal flow; score 3, moderate flow; and score 4, highly vascular. Malignancies often exhibit their increased flow signals in the periphery and in the central regions of the mass, including within septations and solid tumor areas. The neovascularity within malignancies is made up of abnormal vessels, lacking smooth muscle within their walls and containing multiple arteriovenous

shunts, resulting in low-impedance flow (pulsatility index < 1.0) and (resistance index < 0.4), high timeaveraged maximum velocity (> 15 cm/s), and absence of a diastolic notch in such masses . However, because of the overlap of vascular parameters between malignant and benign neoplasms, a accurate differential diagnosis based on spectral Doppler evaluation alone is not always possible . In 1999, Twickler et al. incorporated the patient s age, ovarian volume, Doppler velocimetry and vessel location, and echogenic predominance of the mass (suggestive of a dermoid) with the morphology scale of Sassone et al. to compute the ovarian tumor index, a calculated probability of malignancy In 1999, a prospective, multicenter study including nine centers from five European countries, the IOTA study was initiated to describe the ultrasound features of adnexal tumors. From this data, a mathematic model was developed to calculate the risk of malignancy in an adnexal mass, with an area under the ROC of 0.96. In 2007, the IOTA group tested the accuracy of previously published various mathematic models and ROC curves were constructed to compare the performance of the models . They found that simple morphologic scoring systems performed the least well overall, whereas multitechnique risk of malignancy index models performed better and similar to that of most logistic regression and artificial neural network models. Three-dimensional ultrasonographic evaluation of ovarian tumours In a study by Toshiyuki Hata et al diagnostic criteria for ovarian malignancy by 3D ultrasonograph were: irregular thick septa, irregular papillary projection, mostly solid tumour, high echogenicity, and irregular inner wall. Compared with 2D ultrasound, 3D ultrasound had a significantly higher specificity (P < 0.005) and accuracy (P < 0.01), and a significantly lower false positive rate (P < 0.005). Their results suggest that 3D ultrasonography might be a better means of differentiating between malignant and benign ovarian tumours. The 3D ultrasound specificity (92.3%) and accuracy (95%) were significantly higher than those with 2D ultrasound (specificity 38.4% and accuracy 60%) (P , 0.005 and P , 0.01 respectively). The 3D ultrasound false positive rate (7.7%) was significantly lower than that with 2D ultrasound (61.5%) (P , 0.005). No significant differences were noted between sensitivity, positive predictive value, negative predictive value, and false negative rate characterized by 2D and 3Dultrasound diagnosis in detecting malignant ovarian tumours.

3D COLOR DOPPLER IMAGING Until recently, 2-dimensional (2D) color Doppler sonography (CDS) has been used to assess the presence or absence and flow characteristics of tumor vessels within ovarian masses. This technique is limited by its inability to assess the location and spatial characteristics of vessels surrounding or within these masses in more than a single scan plane. Conversely, 3-dimensional (3D) CDS can depict the vascularity within mural nodules, papillary excrescences,and septations in an ovarian mass in multiple selectable scan planes. These included masses with vascularity confined to the wall or loculus and those with central versus peripheral vascularity.

The presence of central intratumoral vascularity had a high positive predictive value (90%) for malignancy. Conversely, the absence of intratumoral vascularity had a high negative predictive value (96%). Depiction of Tumor Neovascularity With Microbubble Sonovue contrast material Sonographic techniques using morphologic criteria (presence of papillary excrescences, irregular septae, and mural nodules) have shown 80 85% accuracy in distinguishing benign from malignant ovarian tumors . The combined use of morphologic parameters and vascularity depicted by color Doppler sonography improves the ability to diagnose ovarian cancer, although some overlap exists between benign and malignant masses . Therefore, the need for even more accurate detection of early-stage disease remains.Recent technical improvements in image processing have afforded 3D and live 3D depiction of tumor morphology and vascularity with transvaginal sonography. Even with the best technology, only the macrovessel network (between 100 and 200 m) can be shown, and the need for depiction of tumor neovascularity at the capillary level remains.This can be accomplished with the use of contrast-enhanced transvaginal sonography using microbubbles. The macroscopic features of the vascularity within ovarian masses can be depicted using 3D color Doppler sonography. With this technique,the relative vascularity can be assessed both qualitatively and quantitatively. Differences in vessel morphology, branching, and relative vessel density can be assessed qualitatively.. Using these parameters, 3D power Doppler sonography has been reported to reduce the false-positive rate in cystic solid and solid ovarian masses The recent use of microbubble contrast agents has afforded sonographic depiction of tumor neovascularity in ovarian masses. Data from several studies have shown that even early-stage ovarian cancers can be distinguished from benign lesions by their enhancement parameters . In general, malignant ovarian masses have greater peak enhancement, longer wash-out time, and increased vascular volume than benign masses. Although no significant differences are seen in sensitivity, contrast-enhanced transvaginal sonography had the highest specificity, ranging from 90% to 96%.

Conclusion

Ultrasound characteristics can be used to categorize ovarian and adnexal masses, and pattern recognition can accurately diagnose some of the classic-appearing nonneoplastic entities, benign neoplasms, and malignancies. Often, however, the sonographic appearance of an ovarian mass is not pathognomonic. It is in these indeterminate cases that an assignment of a relative risk of malignancy is beneficial for patient care. Features that have been found to contribute to malignancy risk include clinical issues such as age and cancer history, morphology and size of the mass, and Doppler parameters.

The IOTA ultrasound and clinical multiparametric analyses and the subgroup analysis are at the moment the best predictiontors of malignancy in the largest series to date, and combine the best predictors of previous studies 3D ultrasonography provides novel information on the visualization of intratumoral structures of the ovarian masses. 3D ultrasonography has the potential to be a supplement to 2D ultrasonography and might be useful in identifying malignant ovarian tumours. However, in view of small number of ovarian tumours studied so far further validation is necessary. Three-dimensional color Doppler sonography is helpful in depicting overall vessel density and branching patterns within an intratumoral abnormality. This technique seems to be useful in distinguishing benign from malignant ovarian masses. Microbubble-enhanced transvaginal sonography can enhance the evaluation of ovarian masses by early detection of tumor microvascularity. This provides an excellent secondary test to distinguish benign from malignant ovarian masses

ACKNOWLEDGEMENTS AND SUGGESTED READING AJR 2010; 194:322 329 Ultrasound and Assessment of Ovarian Cancer Risk Diane M. Twickler,Elysia Moschos Human Reproduction vol.14 no.3 pp.858 861, 1999 Three-dimensional ultrasonographic evaluation of ovarian tumours: a preliminary study Toshiyuki Hata1,3, Toshihiro Yanagihara1, Keiji Hayashi1, Chizu Yamashiro1, Yohichi Ohnishi1, Masashi Akiyama1, Atsushi Manabe2 and Kohji Miyazaki2

J Ultrasound Med 2005; 24:533 537 Sonographic Depiction of Intratumoral Vascularity With 2- and 3-Dimensional Color Doppler Techniques Arthur C. Fleischer, MD, Michael R. Milam, MD, Marta A. Crispens, MD, Heidi W. Shappell, MD

AJR 2010; 194:343 348 Advances in Sonographic Detectionof Ovarian Cancer: Depiction of Tumor Neovascularity With Microbubbles Arthur C. Fleischer Andrej Lyshchik Rochelle F. Andreotti

Misun Hwang Howard W. Jones, II David A. Fishman