Three-dimensional power Doppler angiography in endometrial cancer: correlation with tumor characteristics.

OBJECTIVE: To assess the correlation between intratumoral vascularization using three-dimensional power Doppler angiography (3D-PDA) and several histological tumor characteristics in a series of patients with endometrial carcinoma. METHODS: Ninety-nine women (mean age, 61.7 (range, 31-84) years) diagnosed as having endometrial cancer were assessed by transvaginal 3D-PDA before surgical staging. Endometrial volume (EV) and 3D-PDA vascular indices (vascularization index (VI), flow index (FI) and vascularization flow index (VFI)) were calculated using the Virtual Organ Computer-aided AnaLysis (VOCAL) method. All patients were surgically staged. Individual tumor features such as histological type, tumor grade, myometrial infiltration depth, lymph-vascular space involvement, cervical involvement, lymph node metastases and tumor stage were considered for analysis. Multivariate logistic regression (MLR) analysis was used to determine which 3D-PDA parameters were independently associated with each histological characteristic. RESULTS: MLR analysis showed that only EV and VI were independently associated with myometrial infiltration (EV: odds ratio (OR), 1.119 (95% CI, 1.025-1.221), P = 0.012; VI: OR, 1.127 (95% CI, 1.063-1.195), P = 0.001) and tumor stage (EV: OR, 1.103 (95% CI, 1.012-1.202), P = 0.025; VI: OR, 1.120 (95% CI, 1.057-1.187), P = 0.001), only VI was independently associated with tumor grade (OR, 1.056 (95% CI, 1.023-1.091), P = 0.001) and only EV was independently associated with lymph node metastases (OR, 1.086 (95% CI, 1.017-1.161), P = 0.001). CONCLUSION: 3D-PDA analysis of tumor vascularization in endometrial cancer correlates with some prognostic histological characteristics.

B-mode, utero-ovarian and intratumoural transvaginal colour Doppler ultrasonography for differential diagnosis of ovarian tumours.

OBJECTIVES: The aim of this study was to evaluate and compare the use of B-mode transvaginal, utero-ovarian Doppler and intratumoural colour Doppler imaging in the diagnosis of ovarian tumours in order to establish whether they are organic or functional, and malignant or benign in nature prior to surgery. STUDY DESIGN: A series of 213 women between the ages of 15 and 87 presenting ovarian tumours were examined with pulsed and colour Doppler and the functional state of the ovary at the time of the exploration was also established. Size and morphology were evaluated through a new scoring system called sonographic index. This score is calculated as the sum of the points corresponding to tumoural volume (< or = 8 ml = 1 point; > 8 ml and < or = 100 ml = 2 points; > 100 ml = 3 points) and the points corresponding to morphological characteristics (negative echogenicity = 1 point; mixed echogenicity = 2 points; multilocular morphology = 3 points; complex morphology = 4 points; positive echogenicity = 5 points) varying between 2 and 8 points. The flow velocity waveform (FVW) of the utero-ovarian and intratumoural arteries were obtained and analyzed after assessing their resistance indices. Other parameters studied were the presence and location of the colour signal in the intratumoural arteries. RESULTS: Of the total, 84 of the tumours were found to be functional and had disappeared by the time later examinations took place. Surgery was performed in 129 of the patients, and posterior histopathological studies permitted classifying the tumours as benign in 107 cases and malignant in 22. The sonographic index was significantly higher in the organic (4.9 +/- 1.5) and malignant (6.9 +/- 1.0) tumours than in the functional (3.6 +/- 1.5) and the benign (4.1 +/- 1.2) tumours. The utero-ovarian and intratumoural blood flow RIs in the malignant tumours (0.48 +/- 0.12 and 0.43 +/- 0.08, respectively) was significantly lower than in the benign tumours (0.83 +/- 0.12 and 0.58 +/- 0.15, respectively). There were no significant differences in the utero-ovarian and intratumoural blood flow RIs when organic and functional tumours were compared. In all of the malignant tumours a colour signal was identified; it was centrally located in 90% of the cases. A colour signal was observed in 83% of the functional tumours, and in 52% of the organic benign tumours. In the benign tumours the colour signal was peripherally located in 98% of the cases. The variables for sensitivity, specificity, positive predictive value, negative predictive value and precision when organic tumours were diagnosed were 82.9, 65.5, 78.7, 71.4 and 76.1 for a sonographic index where the score was > or = 4; the values for the utero-ovarian RI were 48.4, 90.4, 88.4, 53.6 and 65.1 (cut-off 0.55 > or = RI > or = 0.90); the values for the intratumoural RI were 56.5, 68.6, 54.2, 70.6 and 63.8 (cut-off < or = 0.55). When malignancy was diagnosed these variables were 95.5, 82.2, 38.2, 99.4 and 83.6 for the sonographic index (score > or = 6); 90.9, 98.9, 90.0, 98.9 and 98.1 for the utero-ovarian RI (cut-off < or = 0.55) and 80.0, 66.7, 33.3, 94.1 and 69.0 for the intratumoural RI (cut-off < or = 0.50). The number of false positives diagnosed on the basis of the intratumoural RI decreased when cases that had been evaluated during the luteal phase were excluded from the study. Notwithstanding, the phase of the cycle does not seem to interfere with the diagnosis when utero-ovarian Doppler imaging is used. CONCLUSIONS: B-mode transvaginal ultrasonography and utero-ovarian Doppler velocimetry seem to complement each other to aid in differentiating between organic and functional ovarian tumours. Transvaginal ultrasonography and Doppler imaging provide good results for the diagnosis of malignancy, although the utero-ovarian RI reduces the number of false positives that occur with ultrasonography. Our group, therefore, believes that the combined use of these techniques is beneficial in the clinical d

[Study of placenta blood flow throughout pregnancy]. / Estudio del flujo sanguíneo placentario a lo largo de la gestación.

The human placenta has a double vascularization which provides with two different blood flows: the uteroplacental and fetoplacental or umbilical ones. Gestational success depends on its adequate interrelationship. Uteroplacental blood flow experiences a progressive increase during gestation, being at term 17 to 20-fold that of non-pregnant uterus (600 ml/min). There are two periods of greater increase: placentation and the last part of gestation. Umbilical blood flow increases in parallel with fetal weight. Uteroplacental and umbilical blood flows are influenced by nervous, chemical and mechanical factors, but the main determinant are the vascular changes which include histological and growing and development phenomena.

Doppler study of arterial and venous intraovarian blood flow in stimulated cycles.

OBJECTIVE: To evaluate arterial and venous intraovarian blood flow in follicle stimulating hormone-stimulated cycles. SUBJECTS AND METHODS: This was a prospective study of 76 follicle stimulating hormone-stimulated cycles carried out in 39 infertile patients who were included in a timed intercourse or intrauterine insemination program in a referral center for assisted reproduction. Transvaginal color and pulsed Doppler measurements of the follicular and luteal phase resistance index, pulsatility index, peak systolic velocity and maximum venous velocity were made and serum progesterone levels during the mid-luteal phase were recorded. Velocimetric parameters were established and then used to classify ovarian function as having a normal ovulatory cycle, or a cycle in which there was either luteal phase deficiency or a luteinized unruptured follicle. RESULTS: In 52 normal ovulatory cycles, the luteal phase peak systolic and maximum venous velocities were significantly higher and resistance and pulsatility indices were significantly lower than those found in the follicular phase. In 15 women with luteal phase deficiency we did not find any differences in arterial velocimetric parameters when compared with normal ovulatory cycles. However, luteal phase maximum venous velocities were lower in the luteal phase deficiency cycles and there was a significant correlation between luteal phase maximum venous velocity and serum progesterone levels (r = 0.36). Luteinized unruptured follicle cycles (n = 9) did not show significant changes during the ovarian cycle and no 'luteal conversion' of the Doppler signal was identified. CONCLUSIONS: Follicle stimulating hormone-stimulated cycles in infertile patients can have a high percentage of abnormal functional responses that can be diagnosed only by sonographic assessment, Doppler and the appropriate hormonal follow-up. Arterial and venous intraovarian blood flow remain unaltered during luteinized unruptured follicle cycles and serum progesterone levels correlated with luteal phase maximum venous velocity, which makes Doppler a potentially useful non-invasive test to assess ovulation and luteal function.

Color Doppler sonographic assessment of placental circulation in the first trimester of normal pregnancy.

Our aim was to study placental circulation during the first trimester of normal pregnancy. For this purpose, 108 single pregnancies from 4 to 15 gestational weeks were evaluated through conventional Doppler ultrasonography. The flow velocity waveforms from the retrochorionic arteries (spiral-radial arteries) and the umbilical artery were assessed using the peak systolic velocity, resistive index, and pulsatility index). Intervillous flow velocity waveform was evaluated from the maximum velocity. The earliest color signal from the retrochorionic circulation was registered at 4.5 weeks along with gestational sac visualization. The venous Doppler signal from the intervillous space and the Doppler signal from the umbilical artery were recorded with an embryo visible from the end of week 5 onward. The retrochorionic, intervillous, and umbilical peak systolic velocities increase, whereas the resistive and pulsatility indices decrease progressively during early pregnancy with a significant correlation with gestational age. Similarly, intervillous maximum velocity gradually increases throughout the first trimester of pregnancy. Despite some methodologic problems related to Doppler technology and the vessels studied color Doppler sonography appears to be an adequate tool to assess the physiologic changes in the placental circulation during early pregnancy.

[Changes in the ovarian flow during the menstrual cycle: an echo-Doppler study]. / Variaciones del flujo ovárico durante el ciclo menstrual: estudio eco-Doppler.

The results of the velocimetric evolution of the ovarian flow with pulsed Doppler in 15 normal ovulatory cycles are presented. During the follicular phase the blood flow velocity waveforms (FVW) of the dominant ovary presented a progressive albeit non significant increment of its conductance. This rise was not confirmed in the contralateral ovary. After the echographic ovulation the ovarian FVW showed qualitative and quantitative modifications that determine its "luteal conversion". The conductance index (D/S x 100) was significantly higher (p less than 0.001) during the luteal phase than during the follicular and in the contralateral ovary. The luteal conversion of the ovarian FVW is proposed as a new criteria of ovulation and luteal function.

[Echography of the ovarian cycle]. / Ecografía del ciclo ovárico.

Using bidimensional echography 30 normal ovulatory cycles were evaluated. The following parameters were assessed: Ovarian volume; Volume of the dominant follicle; Corpus luteum volume; Residual follicular volume and Stromal volume. The maximum ovarian volume was reached in the dominant ovary the last day before ovulation: 11.68 +/- 0.52 cc, similarly the maximum volume of the dominant follicle: 3.60 +/- 0.36 cc, and the maximum stromal volume in the follicular phase: 7.98 +/- 0.41 cc. The maximum corpus luteum volume was seen on day +2 of the echographic ovulation, the maximum stromal volume was seen on day +7: 8.64 +/- 0.51 cc, in the dominant ovary. In the contralateral ovary the stromal volume did not show significant changes. The residual follicular volume in the dominant ovary, as in the contralateral, diminished gradually from the beginning of the follicular phase except by a slight postovulatory rise. The normal values are established and also the importance of its use in the diagnosis of the functional disorders of the ovary.

[Development of utero-chorionic vascular resistance in early pregnancy]. / Evolución de las resistencias vasculares uterocoriales en la gestación precoz.

The physiologic evolution of the utero-chorionic vascular resistances during the first trimester of pregnancy is described. With the use of pulsed Doppler, 25 normal pregnancies were followed weekly, performing 288 scans between the 6th and the 12th weeks of pregnancy. The detection of the FVW was done at the level of the uterine and retro-chorionic vessels. There is a progressive decrease of the vascular resistances to flow, with significant differences (p less than 0.001) between the values before and after the 9th week. The physiologic implications and its possible application to the study of the gestational pathology are commented.

Doppler velocimetry measured in retrochorionic space and uterine arteries during early human pregnancy.

The natural course of uterochorionic vascular resistance during the first trimester of pregnancy is described. We performed a weekly study using a pulsed Doppler in 25 normal pregnancies, with a total of 191 examinations made. The flow velocity waveform was studied simultaneously in the retrochorionic area as well as in the uterine arteries. Different velocimetry indices were analysed, which demonstrated the feasibility of the (D/S) x 100 index for study of the retrochorionic vessels and of the Pourcelot index (S-D/S) for the uterine arteries. A gradual weekly decrease in flow resistance was found, with significant differences before [(D/S) x 100 = 52.01 +/- 8.33; S-D/S = 0.83 +/- 0.09] vs after the 9th week [(D/S) x 100 = 58.9 +/- 8.78; S-D/S = 0.72 +/- 0.10]. Further evaluation of its predictive and diagnostic value in gestational pathology is necessary.

Intraovarian Doppler velocimetry in ovulatory, dysovulatory and anovulatory cycles.

We have evaluated 48 spontaneous ovarian cycles in 23 women by transabdominal Doppler ultrasound. A total of 1064 intraovarian flow velocity waveform recordings were obtained. The ultrasound assessment of follicular growth, and changes in the concentrations of urinary luteinizing hormone and serum progesterone were used to classify the cycles. After follicular rupture (and presumed ovulation) in 30 cycles, the intraovarian flow velocity waveform (dominant ovary) showed a turbulent flow during the luteal phase ('luteal conversion'). The maximal resistance index was lower compared to values obtained during the follicular phase, and from the contralateral ovary. The intraovarian flow velocity waveform from 12 abnormal cycles showed similar quantitative and qualitative changes. When ovulation did not occur (three cases of the luteinized unruptured follicle syndrome, three anovulatory cycles), there was no evidence of 'luteal conversion' and the velocimetry values were similar throughout the study. Intraovarian Doppler velocimetry makes it possible to distinguish between ovulatory and anovulatory cycles, and provides a non-invasive diagnosis of the luteinized unruptured follicle syndrome.

Doppler ultrasound assessment of endometrial pathology.

In forty-five metrorrhagic patients, transvaginal Doppler ultrasound examinations were performed in order to test the correlation between the modified resistance index (RI) of the uterine and intramyometrial arteries and the histopathologic findings. Uterine volume (UV) and endometrial thickness (ET) were studied. The results were compared with 19 otherwise normal patients. UV and ET were found increased in metrorrhagic patients with abnormal histopathology. These showed a significant decrease in intramyometrial RI (66.7 +/- 15.9) and uterine RI (79.6 +/- 9.4) compared with a control group (intramyometrial RI: 78.8 +/- 16; uterine RI: 87.8 +/- 9.4). Uterine resistance was significantly greater in patients with normal histopathology (intramyometrial RI: 94.2 +/- 13.2; uterine RI: 89.1 +/- 9.3). Only three false-positive and three false-negative results were found upon analysing the predictive accuracy of intramyometrial Doppler examinations. However, the uterine resistance index was less specific. Although transvaginal Doppler velocimetry cannot replace histopathologic diagnosis, it does provide a high prognostic precision in cases of metrorrhagia.

Cyclic changes of the functional ovarian compartments: echographic assessment.

Using bidimensional echography, 25 normal ovulatory cycles were evaluated. The following parameters were assessed: 1) ovarian volume, 2) volume of the dominant follicle, 3) corpus luteum volume, 4) residual follicular volume, and 5) stromal volume. Ovarian volume and dominant follicle volumes reached their maximum on day -1: 11.68 +/- 2.87 ml and 3.60 +/- 1.20 ml respectively. The maximum stromal volume was seen during the follicular phase: 7.98 +/- 2.29 ml. In the dominant ovary the maximum corpus luteum volume was observed on day +1 and the maximum stromal volume on day +7 (8.64 +/- 2.53 ml). In the contralateral ovary, the stromal volume did not show significant changes. The residual follicular volume in both ovaries diminished gradually from the early follicular phase except for a slight postovulatory rise. In this study, normal values during the ovulatory cycle were obtained as indicated above. The use of bidimensional echography in the diagnosis of functional disorders of the ovary is stressed.