OVARIAN TUMORS AND DOPPLER DETERMINANTS

1. DOPPLER DETERMINANTS
IN OVARIAN TUMORS
DR.MANJULA DHINAKAR
RADIOLOGIST
SULTAN QABOOS HOSPITAL
SALALAH, OMAN.

2. INTRODUCTION
• Ovarian cancer is the second
most common gynecological
malignancy.
• Ovarian tumors can be
categorized as epithelial, germ
cell, sex cord–stromal, or
metastatic.
• Epithelial tumors are the most
common type of malignant
ovarian tumor (85% of cases).

3. • Subtypes include serous,
mucinous, endometrioid, clear
cell, and Brenner tumors.
• Epithelial tumors are rare
before puberty.Their
prevalence increases with age
and peaks in the 6th and 7th
decades of life .

4. • The advent of High-frequency
Ultrasound probes allow High-
resolution imaging of the pelvic
organs in general and of the ovaries
in particular.
• Endovaginal US/Doppler has
markedly improved resolution for
uterine and adnexal imaging.
• It is essential for imaging adnexal
masses whose nature is not
apparent at TAS.

5. THE STUDY
AIM
A Comparative study of USG (TAS/TVS)
and USG in combination with Doppler
(color/power/spectral determinants) in
Ovarian Tumors.
Correlation with HPE findings to ascertain
the Doppler Determinants for a definite
diagnosis in cases of early malignancy.

6. MATERIALS & METHODS
• Study conducted at the Sultan
Qaboos Hospital, Salalah,Oman.
• Period – Over two years from
2004.
• About 100 cases referred from the
Gynaecology Department, of
palpable and incidental adnexal
masses were studied.
• Age group -: 12-80yrs.

7. • All the patients were scanned
preferably during the proliferative
phase of menstrual cycle.
• TOSHIBA Nemio real-time
Ultrasound and Doppler Scanner was
used.
• Using a 3.75 MHZ sector
transducer through a trans-vesical
approach,B-mode Ultrasonography,
Color,power,Doppler and Spectral
Doppler was performed.
• Endo-vaginal sonography was also
performed with a 5.0 MHZ vaginal
transducer.

8. Cases excluded from study-:
• Uterine fibroids-4
• Unilocular cysts that resolved-20
• Nonadnexal mass-8
• Lost to followup-8
60 ovarian tumors-Benign/Malignant
were studied.

9. EVALUATION BY USG
1. Site/Size
2. Consistency- cystic/solid/mixed
Cystic
Internal echoes/border/papillary
projections/septations/septal
nodules/mural nodules.

10. Solid
• Areas of Necrosis
• Sound Transmission
3. Others
Ascites/Peritoneal/Liverdeposits/
Pleural deposits/Nodes/Relation to
adjacent structures.

11. EVALUATION BY DOPPLER
4. Color/ Power Doppler
Neovascularisation- single/complex
Vascularity Site
Cystic Mural/Septal
Solid Central/Peripheral
5.Spectral Doppler - R.I / P.I

12. JUDAH FOLKMAN

13. NEOVASCULARISATION
• He called that theory angiogenesis, and
in it he postulated that tumors could not
grow larger than the head of a pin
without a blood supply. He also believed
that the tumor secreted some mystery
factor that stimulated new blood vessels
to form, bringing nutrition to the tumor
and allowing it to grow.

40. RESULTS OF THE STUDY

41. HPE WITH DOPPLER
CORRELATION
TOTAL NO
OF CASES
60
NEOVASCULARISATION
CYSTIC
WITH
MURAL
CYSTIC
WITH
SEPTAL
SOLID
WITH
CENTRAL
SOLID WITH
PERIPHERAL
BENIGN
TUMORS
47 20 ( 42.5%) 10
( 21.2%)
7
(14.8%)
1
(2.1%)
2
(4.2%)
MALIGNANT
TUMORS
13 12 ( 92.3%) 11
(84.6%)
10
(76.9%)
11
(84.6%)
5
(38.4%)

42. HPE WITH SPECTRAL
DOPPLER CORRELATION
TOTAL NO
OF CASES
60
PI < 0.8 RI < 0.6 PI < 1 RI < 0.4
BENIGN
47 3(6.3%) 4(8.5%) 5(10.6%) 0
MALIGNANT
13 12(92.3%) 12(92.3%) 13(100%) 4(30.7%)

43. HPE WITH SPECTRAL
DOPPLER CORRELATION

44. DETECTION OF
MALIGNANCY
MODE OF USG SENSITIVITY% SPECIFICITY% PPV% NPV%
B-MODE 53 83 67 65
B –MODE WITH
COLOUR&SPECTRAL
DOPPLER
82 94.2 92.4 88.1

45. DETECTION OF
MALIGNANCY
B-MODE+DOPPLER
B-MODE

46. CONCLUSION
• B-mode USG in combination with
Colour power & Spectral Doppler is
more diagnostic in determining the
nature of the tumor( Benign or
malignant) than B-mode USG alone.
• Trans Vaginal scan more diagnostic
than Trans abdominal scan in B-
mode USG as well as in Doppler
scan especially for small tumors.

47. • The information from color Doppler
increases the confidence level,
raising the specificity, PPV.
• 92% malignant tumors & 42% Benign
tumors showed neovascularization.
• An RI of < 0.6 and PI < 0.8 was
found in 92% of malignant and
6.4% of benign ovarian tumors.

48. • An RI <0.4 was not seen in Benign
tumors
• Site of the vascularity did not affect
the diagnosis in cystic tumors.
• Absence of colour flow in solid tumors
was found mainly in benign tumors
• Central Vascularity in Solid tumors
more diagnostic of malignancy.

49. REFERENCES
• Timor-Tritsch et al demonstrated that
use of a morphologic scoring system in
conjunction with color Doppler US.
• Sharonstein etal demonstrated low R.I
and Central pattern-malignancy.
• Conventional and color Doppler
sonography in preoperative assessment of
ovarian tumors.
A. Tempea, S. Singha, L. Wadhwaa,
and A. Gargb.

50. • Preoperative differentiation of
malignant from benign ovarian
tumors: the efficacy of morphology
indexing and Doppler flow
sonography.
GynecologicOncology, Dec 2002.
• Fleischer AC – Color Doppler
sonography of benign & Malignant
adnexal masses.
Doppler USG in Gynaecology, 1998.

51. • Brown et al used a scoring system
based solely on findings of solid
nonhyperechoic components, pattern
of flow (central or peripheral),
ascites, and septations and
demonstrated high levels of
accuracy.

52. • Ultrasound Beats CA-125 for
Distinguishing Benign From Malignant
Adnexal Masses.
• "The International Ovarian Tumor
Analysis (IOTA) study not only
demonstrated that in experienced hands
ultrasound/Doppler is significantly better
than serum CA 125, but also that CA-
125 does not give additional benefit in
mathematical models developed to
distinguish between benign and malignant
masses," Dr. Dirk Timmerman -2007.

53. I THANK
DEPT. OF OBS&GYN
FOR THEIR CONTRIBUTION TO THIS STUDY.