Transvaginal saline hysterosonography: characteristics distinguishing malignant and various benign conditions.

OBJECTIVE: The objective of this study is to establish criteria for distinguishing endometrial polyps, submucosal leiomyomas, endometrial hyperplasia, and endometrial carcinoma on saline hysterosonography. MATERIALS AND METHODS: Sixty-three saline hysterosonograms with histologic confirmation were retrospectively analyzed. We found 26 endometrial polyps, 16 submucosal leiomyomas, three endometrial hyperplasias, one abnormal endometrium associated with a sloughed polyp, one pseudopolyp, and three endometrial carcinomas; 15 sonograms revealed no abnormality. In two patients, sonography revealed both polyps and submucosal leiomyomas. The sonographic appearance of these abnormalities was analyzed to define criteria for their diagnosis. RESULTS: Twenty-five of 26 polyps were uniformly echogenic with smooth borders and either had a stalk or formed acute angles with underlying endometrium. Sixteen of 16 submucosal leiomyomas showed heterogeneous echogenicity; however, 13 were sessile and three were pedunculated. Endometrial hyperplasia was manifested by wall thickening in two patients and tiny polypoid excrescences in one patient. In all patients with endometrial carcinoma, the endometrial cavities were poorly distensible despite successful cervical os cannulation. All patients with abnormalities other than endometrial carcinoma had fully distensible uterine cavities. CONCLUSION: Malignant and various benign endometrial conditions may be accurately distinguished on saline hysterosonography. Uniformity of echogenicity distinguished all polyps from submucosal leiomyomas, but the angulation formed with the endometrial wall by the intracavitary mass did not distinguish all polyps from submucosal leiomyomas. Lack of distensibility of the endometrial canal is a potential sign of endometrial carcinoma.

Current Status of Partial Nephrectomy in the Management of Kidney Cancer.

BACKGROUND: The technique of partial nephrectomy for managing renal cancers is well recognized, but guidelines regarding indications for its use are not generally accepted. METHODS: The authors review the indications for partial nephrectomy in various clinical situations, and they include their own experience to clarify the utility of the technique. RESULTS: Intraoperative renal ultrasound and helical computed tomography can assist the surgeon in technical decisions. Partial nephrectomy is considered when nephrectomy would render the patient anephric and dependent on dialysis. CONCLUSIONS: The technical and operative advances in partial nephrectomy make the approach increasingly attractive for patients with kidney cancer in a variety of clinical circumstances.

Disclosure of results of sonographic examinations to patients by sonologists.

OBJECTIVE: The aim of this study was to assess if patients prefer to talk with a sonologist concerning the results of sonographic examinations. MATERIALS AND METHODS: The study involved outpatients who underwent diagnostic sonography. Technologists offered patients the chance to speak with a sonologist about the results of their sonograms. If requested, a sonologist reviewed the results, and if the study showed an abnormality, its significance was discussed. No treatment recommendations were offered. Patients then filled out a questionnaire. RESULTS: Of the 391 outpatients given the choice, 348 (89%) requested a consultation and 207 of those (60%) returned the completed questionnaire. Of the 207 patients completing the questionnaire, 94% preferred receiving the results from the sonologist rather than from their referring physician. CONCLUSION: We propose a revision of the traditional role of the office-based sonologist to one in which he or she will function as a consultant to both the patient and the patient's physician.

Significance of fetal intracardiac echogenic foci in relation to trisomy 21: a prospective sonographic study of high-risk pregnant women.

OBJECTIVE: The aim of the study was to determine if an association exists between intracardiac echogenic foci in the second-trimester fetus and trisomy 21. SUBJECTS AND METHODS: Over a 2-year period, targeted fetal sonography was performed for various indications in 1593 second-trimester high-risk pregnant women. Presence or absence of echogenic foci was recorded for each fetus. Amniocentesis for karyotype analysis was performed in 901 subjects immediately after sonography. The findings of these 901 subjects formed the basis of this report. RESULTS: Intracardiac echogenic foci were present in the left ventricle of 24 (3%) of the 901 fetuses. Three (13%) of these 24 fetuses had trisomy 21; no chromosomal abnormalities were found in the other 21 fetuses. Karyotype analysis revealed trisomy 21 in 14 (2%) of the remaining 877 fetuses who did not exhibit intracardiac echogenic foci. The sensitivity, specificity, positive predictive values, and negative predictive values for intracardiac echogenic foci in predicting trisomy 21 were 18%, 98%, 13%, and 98%, respectively. The association of intracardiac echogenic foci and trisomy 21 was significant (p < .009) by the two-tailed Fisher's exact test. CONCLUSION: In a high-risk obstetric population, the association between fetal intracardiac echogenic foci and trisomy 21 was statistically significant. Therefore, women carrying fetuses with intracardiac echogenic foci should be informed of the statistical association with trisomy 21.

Harmonic imaging of porcine intraovarian arteries using sonographic contrast medium: initial findings.

The purpose of this study was to visualize, using harmonic gray-scale imaging, blood flow in porcine intraovarian arteries after intravenous injections of a bubble-based sonographic contrast medium. Five female pigs underwent laparotomy. Surgically isolated ovaries were scanned intraperitoneally by an ultrasound system reconfigured with software changes to accomplish harmonic imaging. The transmission and receiving frequencies were set at 3.75 and 7.5 MHz, respectively. After injection of the sonographic contrast medium (Aerosomes) into a peripheral vein, the ovaries were imaged in the harmonic mode. Ten minutes later, another contrast injection was administered and conventional gray-scale imaging of the ovary performed. In all five pigs, intraovarian arteries were clearly identified upon harmonic imaging as brightly echogenic moving columns. The arterial blood pool appeared brighter during systole than diastole. Upon ultrasound contrast-assisted conventional gray-scale imaging, intraovarian arteries were not visualized in four pigs and poorly visualized in one. We conclude that contrast-assisted harmonic imaging can adequately visualize blood flow in intraovarian arteries of surgically exposed porcine ovaries. Clinically, harmonic imaging may facilitate early detection of tumor-induced angiogenesis in the human ovary.

Pelvic examination, tumor marker level, and gray-scale and Doppler sonography in the prediction of pelvic cancer.

OBJECTIVE: To determine the ability of pelvic examination, tumor marker assessment, and transvaginal ultrasonography, with selected use of Doppler ultrasonography, to predict pelvic malignancy. METHODS: Two hundred twenty-six women scheduled for operative removal of a pelvic mass were entered in the study prospectively. Each woman underwent pelvic examination, tumor marker assessment, and transvaginal ultrasonography preoperatively. Women whose gray-scale findings were suspicious for malignancy underwent Doppler ultrasonography. Suspicious findings included masses that were fixed or irregular on pelvic examination; CA 125 level greater than 35 U/mL; elevations in serum lactic dehydrogenase, alpha-fetoprotein, or hCG; and the presence of a substantial solid component on gray-scale ultrasonography. Suspicious Doppler findings included intratumoral color flow, pulsatility index less than 1.0, or resistance index 0.4 or lower. The findings were correlated with the presence of malignancy. RESULTS: If all three indicators (examination, tumor marker assessment, and gray-scale ultrasound findings) were nonsuspicious, 99% of premenopausal women and 100% of postmenopausal women had benign masses. If all three indicators were suspicious, 77% of premenopausal women and 83% of postmenopausal women had malignant tumors. Logistic regression identified ultrasound impression and tumor size to be significant predictors of malignancy in premenopausal women, whereas CA 125 level and ultrasound impression were significant in postmenopausal women. In patients with suspicious gray-scale findings, recategorization based on Doppler findings resulted in inferior diagnostic indices. CONCLUSIONS: Ultrasonographic tumor size and appearance are the best predictors of pelvic malignancy in premenopausal women, whereas CA 125 level and ultrasonographic appearance are the best predictors in postmenopausal women. Neither color nor spectral Doppler is useful in this setting.

Differentiation of benign and malignant adnexal masses: relative value of gray-scale, color Doppler, and spectral Doppler sonography.

OBJECTIVE: The purpose of this study was to evaluate prospectively the relative usefulness of color Doppler, spectral Doppler, and gray-scale sonography in differentiating benign from malignant adnexal masses. SUBJECTS AND METHODS: A total of 170 adnexal masses in 161 patients were classified prospectively as suggestive of or not suggestive of malignant tumor on the basis of gray-scale morphology, internal flow versus peripheral or no flow, and spectral Doppler pulsatility, as measured by a pulsatility index (PI) threshold of 1.0 and a resistive index (RI) threshold of 0.4. RESULTS: Surgical pathology revealed 123 benign masses and 46 malignant masses. One malignant mass was confirmed by cytologic evaluation of ascitic fluid. On gray-scale analysis, 46 of the 47 malignant masses were classified as suggestive of tumor, and 76 of the 123 benign masses were classified as not suggestive of tumor (sensitivity, 98%; specificity, 62%; negative predictive value [NPV], 99%; and positive predictive value [PPV], 50%). The use of internal color flow as a predictor of malignant tumor yielded a sensitivity of 77%, a specificity of 69%, an NPV of 89%, and a PPV of 49%. The PI and RI values were significantly lower (p < .0001) in malignant masses than in benign masses, although the values overlapped considerably. For a PI of less than 1.0, sensitivity was 67%, specificity was 66%, NPV was 83%, and PPV was 46%. For an RI of less than 0.4, sensitivity was 24%, specificity was 90%, NPV was 73%, and PPV was 50%. CONCLUSION: In our series, a gray-scale prediction of benignity was reliable (NPV = 99%), and a prediction of malignancy was unreliable (PPV = 50%). Internal color flow was not useful as a predictor of malignancy (PPV = 49%). Although the absence of internal or peripheral color flow suggested benignity (NPV = 94%), only 17 (16 benign) of the masses (about 10%) had no flow. Spectral Doppler analysis with RI and PI was not useful, as no reliable discriminatory value with both high sensitivity and high specificity could be found for either parameter because of the overlap in values obtained for benign and malignant masses.