doppler application in pelvic ultrasound - home - kk … fibroid bridging vessel bridging vessel? 34...
TRANSCRIPT
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Chan Pei Pei Carman
Principal Sonographer, Department of Diagnostic & Interventional Imaging
6 Dec 2014
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Doppler application in
pelvic ultrasound
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Anatomy
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http://en.wikipedia.org/wiki/Arcuate_vessels_of_uterus#mediaviewer/File:Uterine_arterial_vasculature.svg
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http://www.dartmouth.edu/~humananatomy/figures/chapter_35/35-9.HTM
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Ovarian Vessels
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https://www.google.com.sg/search?q=ovarian+artery&biw=1229&bih=688&source=lnms&tbm=isch&sa=X&ei=0EhwVJ3iA46CuwSgu4KQCw&sqi=2&ved=0CAYQ_AUoAQ#facrc=_&imgdii=_&imgrc=14VzcIdJJNIGbM%253A%3BrG6UQygjgFWRWM%3Bhttp%253A%252F%252Fnaffaausa.org%252Fwp-content%252Fthemes%252Fmobile_pack_base%252Fgroups%252Fnokia_high%252Ftemplates%252Fgonadal-vein-i8.JPG%3Bhttp%253A%252F%252Fimages.frompo.com%252F7def3442e1707482c4a9d61a6dc2b827%3B672%3B712
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• Pelvic arteries <10 – 50cm/s
• Pelvic veins <10cm/s
• Preg RI decreases with gestation
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Resistive
index (RI)
Reproductive Menopause
Uterine artery
branches
0.80 0.84 - 1
Ovary 0.37- 0.67
lowest at late
follicular/early
secretory
0.60 -1
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Technical Aspect
Optimized for low flow:
• Power Doppler – more sensitive
• Low pulse repetition frequency: 300 - 600Hz
• Low wall filter
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Technical Aspect
Basic Doppler techniques:
• Appropriate color box size
• Correct Doppler gain
• Not excessive 2D gain – color write priority
• Adequate penetration for Doppler
• Appropriate Spectral Doppler gate size
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LO
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Applications
• Cervix
• Endometrium
• Myometrium
• Adnexa
• Pregnancy
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Cervix
Dilatation of endocervical canal with prominent endocervical glands
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Cervical Polyp
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Prolapsed Fibropolyp
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Cervix CA
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Cervix
• Nabothian cyst – usually do not need Doppler
• Cervical polyp – feeding artery
• Prolapsed fibropolyp – long pedicle
• Carcinoma - hypervascular
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Endometrium
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Polyp vs Submucosal Fibroid
Single primary feeding artery
Periphery vascularity
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CA
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CA with 40% invasion into myometrium
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Endometrium CA
• More advanced tumour, greater vascularities,
lower resistance
• Wide RI range: < 0.4 - < 0.7
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Myometrium
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Fibroid vs Adenomyoma / Adenomyosis
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Diffuse vascularities
straight through myometrium
Periphery
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Leiomyoma vs Leiomyosarcoma
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Leiomyoma
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Leiomyoma
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Leiomyosarcoma
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Literature on Leiomyosarcoma
• Literature in 90’s, PSV > 41cm/s, RI < 0.40
• Hypervascular
• Literature since 2007: no reliable Doppler criteria
• >8cm; 50% of cases has cystic degeneration8
• Single uterine tumour, rapid growth
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Adnexa
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Pedunculated Fibroid
Bridging vessel
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Bridging Vessel?
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Ovarian CA
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Bridging Vessel
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Uterus X
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Paraovarian Cyst vs Blood Vessel
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Dilated Fallopian Tube vs Blood Vessel
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Tubo-ovarian Abscess
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Torsion
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Big teratoma
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Whirlpool Sign
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• Enlarged ovary (+/- ovarian lesion) /
Normal ovary + adnexal lesion
• Raised echogenicity of ovary
• Follicles displaced to periphery
• Whirlpool sign adds specificity: – target with concentric hypoechoic/ hyperechoic strips
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Torsion – 2D features
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• Absent venous + enlarged ovary, very suggestive
• Arterial can still be present, ovary has dual supply
• Present of arterial & venous – does not exclude torsion
– viability of ovarian tissue
• Whirlpool sign adds specificity: – Coiling of vessels showing red and blue
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Torsion – Doppler features
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Corpus
Luteum
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Mature Follicle
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Clot vs Solid Component
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High grade serous
cystadenocarcinoma
Clot resolve on follow-up
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Endometriotic
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vs Tumour
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2nd scan
Venous Flow
Doppler artifact
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Pregnancy
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Ectopic Pregnancy
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Molar
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Retained Product of Conception (RPOC)
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Arteriovenous Malformation
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Follow-up post embolization
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Lack of Typical Doppler Features
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Pedunculated fibroid
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Take Home Message
• Apply Power Doppler
• Absent Doppler feature, cannot exclude pathology
• Optimized for low flow
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References
1. Hagen-Ansert SL 2012, ‘The sonography and Doppler evaluation of the female pelvis’, in Textbook of diagnostic Sonography, Mosby.
2. Hagen-Ansert SL 2012, ‘Pathology of the uterus’, in Textbook of diagnostic Sonography, Mosby.
3. Plavsic SK & Larrazaleta M 2013, ‘Use of ultrasound in the field of infertility’, in Kurjak A & Arenas JB, Donald school textbook of transvaginal sonography, 2nd edn, Jaypee Brothers Medical Publishers (P) Ltd.
4. Pozniak MA & Allan PL 2014, ‘Doppler ultrasound of the female pelvis’, in Clinical Doppler ultrasound, 3rd edn, Churchill Livingstone Elsevier.
5. Secil M & Dogra VS 2008, ‘Color flow Doppler evaluation of the uterus and ovaries and its optimization technique’, Ultrasound Clin, 3, pp. 461-482, <10.1016/j.cult.2008.07.004>.
6. Younis JS, Jadaon JE, Haddad S, Izhaki I & Ben-Ami M Apr 2011, ‘Prospective evaluation of basal stromal Doppler studies in women with good ovarian reserve and infertility undergoing in vitro fertilization-embryo transfer treatment: patient with polycystic ovary syndrome versus ovalutory patients’, Fertility and Sterility, vol.95, no.5, <10.1016/j.fertnstert.2011.01.007>.
7. Ahuja AT, Griffith JF, Wong KT, Antonio GE, Chu WCW, Ho SSY, Lolge SJ, Paunipagar BK, Kennedy A, Sohey R, Ho SMS, Woodward PJ & Zwibel WJ 2007, Diagnostic Imaging Ultrasound.
8. Exacoustos C, Romanini ME, Amadio A, Amoroso C, Szabolcs B, Zupi E & Arduini D 2007, Journal of Clinical Ultrasound, vol.35, no.8, <10.1002/jcu>.
9. Hata K, Hata T, Maruyama R, et al. 1997, ‘Uterine sarcoma: can it be differentiated from uterine leiomyoma with Doppler ultrasonography? A preliminary report’, Ultrasound Obstet Gynecol, 9, 101. Exacoustos C, Romanini ME, Amadio A, Amoroso C, Szabolcs B, Zupi E & Arduini D 2007, Journal of Clinical Ultrasound, vol.35, no.8, <10.1002/jcu>.
10. Kurjak A, Kupesic S, Shalan H, et al. 1995, ‘Uterine sarcoma: a report of 10 cases studied by transvaginal color and pulsed Doppler sonography’, Gynecol Oncol, 59(3), 342 – 346. Plavsic SK, Kurjak A & Arenas JB 2013, ‘Uterine lesions’ in Kurjak A & Arenas JB, Donald school textbook of transvaginal sonography, 2nd edn, Jaypee Brothers Medical Publishers (P) Ltd.
11. Auslender R, Shen O, Kaufman Y, Goldberg Y, Bardicef M, Lissak A & Lavie O 2009, ‘Doppler and gray-scale sonographic classification of adnexal torsion’, Ultrasound Obstet Gynaecol, 34, 208-211.
12. Valsky DV, Cohen SM, Hamani Y, Lipschuetz M, Yagel S & Esh-Broder E 2009, ‘Whirlpool sign in the diagnosis of adnexal torsion with typical clinical presentation’, Ultrasound Obstet Gynecol, 34, 239-242, <10.1002/uog.7310>.
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Acknowledgement
Adj A/Prof. Ong Chiou Li
Ms Yang Yin
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