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GENITOURINARY TRACT IMAGING Table of Contents   
Year : 2002  |  Volume : 12  |  Issue : 2  |  Page : 245-249
"Doppler determinants of Ovarian malignancy : Experience with 60 patients


Govt. Medical College Nagpur, India

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   Abstract 

Present study was based on 'Folkman's theory of neovascularisation' , according to which malignant neoplasms elaborate a factor named Tumor Angiogenesis factor (TAF), which stimulates rapid formation of new capillaries. The study aimed at evaluating the efficacy of Color and Spectral Doppler in diagnosing the ovarian malignancy. In all, 121 patients with adnexal masses were examined over a period of 2 years, out of which 60 patients with neoplastic ovarian tumors were retained as the study subject. Color Doppler showed blood flow in 92.59 percent of malignant tumors in contrast to only 42.24 per cent of benign tumors. Absent blood flow in a solid tumor almost always ruled out the possibility of malignancy. Spectral Doppler helped to assess the nature of the blood vessels picked up on Color Doppler. In the present study. 96.29 per cent of malignant tumors had PI less thsn 0.8 in contrast to only 6.06 per cent of benign tumors. Similarly, 92.59 percent of malignant tumors showed RI less than 0.6 in contrast to only 9.09 per cent of benign tumors. Thus, Color Doppler and Spectral Doppler tremendously increased the reliability in diagnosing a malignant ovarian tumor. Color Doppler served as an important tool to rule out malignancy in solid tumors if they failed to show any intratumoral vascularity. B-Mode USG in combination with Color Doppler and Spectral Doppler is proposed as the first and foremost diagnostic modality in patients with ovarian tumor, so as to establish the definite diagnosis of malignancy early in the course of the disease.

Keywords: Ovarian Malignancy; Tumor neovascularisation; pelvic Doppler

How to cite this article:
Taori K B, Mitra K R, Ghonge N P, Ghonge S N. "Doppler determinants of Ovarian malignancy : Experience with 60 patients. Indian J Radiol Imaging 2002;12:245-9

How to cite this URL:
Taori K B, Mitra K R, Ghonge N P, Ghonge S N. "Doppler determinants of Ovarian malignancy : Experience with 60 patients. Indian J Radiol Imaging [serial online] 2002 [cited 2019 May 25];12:245-9. Available from: http://www.ijri.org/text.asp?2002/12/2/245/28456
Mattingly RF (1977): [1]

The management of ovarian tumors remains a common clinical gynecologic problem. The early and definite diagnosis of ovarian malignancy is of grave clinical importance. Recently the role of color and spectral Doppler in the diagnosis of ovarian malignancy has been a subject of enormous debate [2] with varying opinions on the efficacy of color and spectral Doppler. The aim of this study was to assess the relative value of B-mode ultrasonography alone and in combination with Color Doppler and Spectral Doppler in differentiating benign and malignant ovarian neoplasms and to correlate the imaging findings with intra-operative details and histo-pathological findings. Out study was based on Folkman's theory of tumor neovascularisation; according to which tumor cells elaborate a factor named as Tumor Angiogenesis Factor [TAF] that is mitogenic to endothelial cells and stimulates rapid formation of new capillaries (neovascularisation). Thus the study tests the ability of the Color and Spectral Doppler to detect the tumor neovascularity as far as ovarian tumors are concerned. We are presenting this study to enumerate and express our experiences regarding this issue.


   Material and Methods Top


This study was carried out in the Department of Radio-Diagnosis; Government Medical College and Hospital, Nagpur. The patients included in the study were those referred with a palpable adnexal mass and with incidentally detected adnexal masses, (Irrespective of their age or menstrual status). Criterion for patient exclusion from study (after scan) includes: Patients with anechoic Unilocular cysts in ovary that resolves or reduce substantially on follow-up USG; patients with pelvic mass that were determined to arise from uterus intra-operatively or on histo-pathology report and patients who did not undergo FNAC or HPE or were lost to follow-up. Patients were subjected to study, preferably during the proliferative phase of menstrual cycle, with a TOSHIBA ECCOOCEE real-time Ultrasound and Doppler Scanner. Using a 3.75 MHZ sector transducer through a trans-vesical approach, we performed B-mode ultrasonography, Color Doppler and Spectral Doppler. If required, endo-vaginal sonography was also performed with a 5.0 MHZ vaginal transducer. Indications for endo-vaginal study during the study were: small adnexal mass on transvesical study; uncertain finding on trans-vesical study and patients with strong family history and normal trans-vesical ultrasound study. Contra-indications for endo-vaginal study during the study were: Virgin patients; patients with imperforate hymen; patient's refusal and pregnant patient with pre-mature rupture of membranes.

Initially, the lesion was evaluated in terms of morphology Color Doppler study was done at high sensitivity settings and lowest pulse repetition frequency possible without aliasing. The spectral Doppler analysis was done and PSV, PI and RI values were calculated. Three readings were obtained and the lowest of PI and RI and highest value for PSV were recorded. Follow - up details were obtained in the form of intra operative details and FNAC or histo-pathology and were correlated with the Ultrasound and Doppler findings; prospectively as well as retrospectively. Results were recorded under the following headings:


   Results Top


A total of 121 patients were examined over a period of two years, out of which in three patients mass was found to have uterine origin on B-mode USG. 13 patients had anechoic unilocular ovarian cysts, which resolved on follow up USG. Three patients with anechoic unilocular ovarian cysts were lost to follow up. 12 patients with adnexal masses did not undergo either FNAC or histopathology examination or were lost to follow up and in four patients, mass was found to have uterine origin on HPE. These 35 patients were excluded from the study. Then, 26 patients were further excluded from the study, as they were the patients with non-neoplastic ovarian masses and non-ovarian adnexal masses. Thus, the study group comprised of 60 patients with neoplastic ovarian masses. Color Doppler showed blood flow in 92.59% of malignant tumors in contrast to only 42.24% of benign tumors. [Table - 1] Absent blood flow in a solid tumor almost always ruled out the possibility of malignancy. In the present study, 96.29% of malignant tumors had PI < 0.8 in contrast to only 6.06% of benign tumors. Similarly, 92.59% of malignant tumors showed RI< 0.6 in contrast to only 9.09% of benign tumor. [Table - 2] Out of a total of 33 patients with benign tumors, 25 patients were correctly diagnosed on B mode USG alone, while 31 patients were correctly diagnosed when color and spectral Doppler were used along with the B-mode USG. Out of a total of 27 patients with malignant tumors, 14 patients were correctly diagnosed on B mode USG alone, while 22 patients were correctly diagnosed when color and spectral Doppler were used along with the B-mode USG [Table - 3]


   Discussion Top


B-mode features suggestive of malignancy were studied using a scoring system on the lines of scoring system described earlier [3],[4] and the tumor evaluated with Color Doppler which showed presence of tumor neovascularisation in 92.59% of malignant tumors in contrast to 42.24% benign tumors. The site of tumor vascularity did not affect the diagnosis in cystic neoplasm, as the tumor vascularity was encountered almost equally in the wall and septae. But, in solid malignant neoplasms; the central vascularity was encountered in 81.25% cases while peripheral vascularity was present in 18.75% cases. These results correlate quite well with the study by Lil Valentin et al [5] and Sim Kurjak et al [3] while Sharon Stein et al [6] found that internal color flow can not be used as a predictor of malignancy (PPV 49%) but absence of color flow suggested benignity(NPV 94%). Their study also yielded statistically significant difference in the site of tumor vascularity between benign and malignant lesion.

Malignant neoplasm offered lower resistance to blood flow due to presence of aberrant tumor vessels. [Figure - 1],[Figure - 2] and [Figure - 3] Present study used a pre-established cut-off criterion of PI < 0.8 and RI < 0.6 so as to optimize the study in terms of sensitivity and specificity as used by Jonathan Carter et al [7]. Though, Kurjak et al [3] used the cut-off criterion of PI < 1.0 and RI < 0.4; they achieved high sensitivity and specificity owing to the study group comprising of postmenopausal woman only. In the present study, 96.29% of malignant tumors had PI < 0.8 in contrast to only 6.06% of benign tumors. Similarly, 92.59% of malignant tumors showed RI < 0.6 in contrast to only 9.09% of benign tumor. When the data of present study was extrapolated using the criterion PI < 1.0 and < 0.4 proposed by Kurjak et al [3] and Jean Noel Buy et al [8]: 100% of malignant tumors and 15.15% of benign tumors showed PI < 1.0 while only 29.62% malignant tumors and none of the benign tumors showed RI < 0.4. Thus present study data was rendered slightly more specific and less sensitive with RI < 0.4 and slightly more sensitive and less specific with PI < 1, thus establishing the PI < 0.8 and RI < 0.4 as the better choice for the threshold values, in terms of optimizing the sensitivity and specificity. Our study also illustrated the special role of Color Doppler in labeling the solid tumor of ovary as benign; if it did not showed any significant vascularity. [Figure - 4]. In the present study, the prediction of benignity of tumor was more reliable with B-mode USG comined with Color Doppler and Spectral Doppler as only 6.06% benign tumors were incorrectly diagnosed in contrast to 18.51% of malignant tumors. This feature correlates well with the study by Sharon Stein et al [6]. The definite diagnosis of malignancy in solid tumors was made only after the Color Doppler showed intratumoral vascularity (mainly central) and Spectral Doppler showed low resistance velocity waveforms in intratumoral vessels [Figure - 5]aandb. The present study yielded fairly good specificity and sensitivity with PI and RI values of < 0.8 and < 0.6 respectively, despite some overlap in the values between benign and malignant lesions [9]; [10].

The present study established the multi fold increase in the Sensitivity, Specificity, Positive Predictive Value and Negative Predictive Value in establishing the pre-operative diagnosis of adnexal masses (especially in terms of benign and malignant); when using the B-Mode USG in combination with color and spectral Doppler as compared to the B-Mode USG alone.

Thus B-Mode USG in combination with Color Doppler and Spectral Doppler is proposed as the first and foremost diagnostic modality for the patients with adnexal mass. This will go a long way in establishing an early and definite diagnosis of ovarian malignancy.

 
   References Top

1.Te Linde's Operative Gynecology; Mattingly RF (ed). Philadelphia: JB Lippincott, 1977:809-53.  Back to cited text no. 1    
2.Kirk Shy and Ted Dubinsky: Is Color Doppler ultrasound useful in diagnosing ovarian cancer. Clin Obstetrics and Gynecology 1999; 42(4):902-15.  Back to cited text no. 2    
3.Siim Kurjak and Harold Schulman et al : Transvaginal ultrasound color flow and Doppler waveform of the postmenopausal adnexal masses. Obstet Gynecol 1992;80;917-21.  Back to cited text no. 3    
4.Bryan Bromley; Howard Goodman and Breyll Benacerraf: Comparison between sonographic morphology and Doppler velocity waveform in the diagnosis of ovarian malignancy. Obstet Gynecol 1994;83:434-37.  Back to cited text no. 4    
5.Lil Valentin; Povilar Sladkaricuss et al : Limited contribution of Doppler velocitimetry in the differential diagnosis of extra uterine pelvic tumors. Obstet Gynecol 1994;83:425-33.  Back to cited text no. 5    
6.Shareb Stein and Sherette Narin et al : Differentiation of bening and malignant adnexal masses; relative value of grey scale ultrasound, Color Doppler and Spectral Doppler. AJR 1995; 164:381-86.  Back to cited text no. 6    
7.Jonathan Carter and An brews Stalzman et al : Flow characteristics of benign and malignant Gynecological tumors using transvaginal color flow Doppler. Obstet Gynecol 1994;83:125-30.  Back to cited text no. 7    
8.Jean-Noel-Buoy; Michel Ghossain etal: Characterisation of Adnexal Masses: Combination of Color Doppler and conventional sonography compared with Spectral Doppler analysis and conventional sonography alone. AJR 1996;166:385-93.  Back to cited text no. 8    
9.Zeev Wiener, Israel Thaler et al : Differentiating bening from malignant ovarian tumors with transvaginal color flow imaging. Obstet Gynecol 1992; 79:159-62.  Back to cited text no. 9    
10.Ulrike Hamper; Sheila Sheth et al : Transvaginal Color Doppler sonography of adnexal masses: differences in a blood flow impedance in benign and malignant lesions. AJR 1993; 160:1225-28  Back to cited text no. 10    

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Correspondence Address:
N P Ghonge
Hig 8; Mhada Colony, Near Friend's Colony, Katol Road, Nagpur (Maharashtra)
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]

    Tables

[Table - 1], [Table - 2], [Table - 3]



 

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