Background: Adnexal masses are a common clinical problem in gynecology. Most adnexal masses are benign, but few of them are malignant. An accurate diagnosis is essential for adequate management. There is a possibility to make a distinction between benign and malignant adnexal masses using two-dimensional grayscale ultrasound (2D-US) and color Doppler ultrasound, which are the best imaging techniques for that purpose.
Objective: To review current state-of-art of 3D/4D ultrasound in assessing ovarian masses.
Materials and methods: Narrative review of literature published from 1995 to 2017 using 3D/4D ultrasound for assessing adnexal masses masses.
Results: Three-dimensional ultrasound (3D-US) has become a routine practice in many gynecologic ultrasound laboratories because it overcomes the limitations of two-dimensional ultrasound (2D-US). This technique allows a surface rendering of the internal aspect of the cyst\'s wall. It can also present the masses in new different ways, such as “inversion mode” or “silhouette mode” or it can represent the vascular tree of the tumor using a 3D reconstruction, or even allowing a unique way for estimating the amount of vessels within the tumor or a part of the tumor. The reproducibility of 3D-US performed by different sonographers has been assessed in several studies. All of them have found that this technique is reproducible among different observers. The main limitations of all the studies are a few cases compared to the high prevalence of malignancies.
Conclusion: 3D-US probably have better diagnostic performance than 2D-US assessing malignancies in adnexal masses. However, better-designed studies are needed to draw definitive conclusions.
American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. Practice bulletin no. 174: evaluation and management of adnexal masses. Obstet Gynecol 2016;128(5):e210–e226. DOI: 10.1097/AOG.0000000000001768.
Valentin L, Ameye L, Jurkovic D, et al. Which extrauterine pelvic masses are difficult to correctly classify as benign or malignant on the basis of ultrasound findings and is there a way of making a correct diagnosis? Ultrasound Obstet Gynecol 2006;27(4):438–444. DOI: 10.1002/uog.2707.
Alcázar JL. Three-dimensional ultrasound in gynecology: current status and future perspectives. Curr Women's Health Rev 2005;1(1): 1–14. DOI: 10.2174/1573404052950221.
Alcázar JL. Three-dimensional ultrasound in gynecological practice. Report Med Imag 2012;5:1–13. DOI: 10.2147/RMI.S21963.
Hata T, Yanagihara T, Hayashi K, et al. Three-dimensional ultrasonographic evaluation of ovarian tumours: a preliminary study. Hum Reprod 1999;14(3):858–861. DOI: 10.1093/humrep/14.3. 858.
Alcázar JL, Galán MJ, García-Manero M, et al. Three-dimensional ultrasound morphologic assessment in complex adnexal masses a preliminary experience. J Ultrasound Med 2003;22(3):249–254. DOI: 10.7863/jum.2003.22.3.249.
Laban M, Metawee H, Elyan A, et al. Three-dimensional ultrasound and three-dimensional power Doppler in the assessment of ovarian tumors. Int J Gynaecol Obstet 2007;99(3):201–205. DOI: 10.1016/j.ijgo.2007.03.027.
Alcázar JL, García-Manero M, Galván R. Three-dimensional sonographic morphologic assessment of adnexal masses: a reproducibility study. J Ultrasound Med 2007;26(8):1007–1011. DOI: 10.7863/jum.2007.26.8.1007.
Pascual MA, Graupera B, Hereter L, et al. Intra- and interobserver variability of 2D and 3D transvaginal sonography in the diagnosis of benign versus malignant adnexal masses. J Clin Ultrasound 2011;39(6):316–321. DOI: 10.1002/jcu.20808.
Sladkevicius P, Valentin L. Re: Intra- and inter-observer agreement when describing adnexal masses using the International Ovarian Tumour Analysis terms and definitions: a study on three-dimensional ultrasound volumes. P. Sladkevicius and L. Valentin. Ultrasound Obstet Gynecol 2013;41:318–327. Ultrasound Obstet Gynecol 2013;41(3):318–327. DOI: 10.1002/uog.12289.
Timor-Tritsch IE, Monteagudo A, Tsymbal T. Three dimensional ultrasound inversion rendering technique facilitates the diagnosis of hydrosalpinx. J Clin Ultrasound 2010;38(7):372–376. DOI: 10.1002/jcu.20707.
Alcázar JL, León M, Galván R, et al. Assessment of cyst content using mean gray value for discriminating endometrioma from other unilocular cysts in premenopausal women. Ultrasound Obstet Gynecol 2010;35(2):228–232. DOI: 10.1002/uog.7535.
Kurjak A, Kupesic S, Anic T, et al. Three-dimensional ultrasound and power Doppler improve the diagnosis of ovarian lesions. Gynecol Oncol 2000;76(1):28–32. DOI: 10.1006/gyno.1999.5647.
Cohen LS, Escobar PF, Scharm C, et al. Three dimensional ultrasound power Doppler improves the diagnostic accuracy for ovarian cancer prediction. Gynecol Oncol 2001;82(1):40–48. DOI: 10.1006/gyno.2001.6253.
Alcázar JL, Castillo G. Comparison of 2-dimensional and 3-dimensional power-Doppler imaging in complex adnexal masses for the prediction of ovarian cancer. Am J Obstet Gynecol 2005;192(3): 807–812. DOI: 10.1016/j.ajog.2004.10.630.
Kurjak A, Kupesic S, Sparac V, et al. Preoperative evaluation of pelvic tumors by Doppler and three-dimensional sonography. J Ultrasound Med 2001;20(8):829–840. DOI: 10.7863/jum.2001.20.8.829.
Chase DM, Crade M, Basu T, et al. Preoperative diagnosis of ovarian malignancy: preliminary results of the use of 3-dimensional vascular ultrasound. Int J Gynecol Cancer 2009;19(3):354–360. DOI: 10.1111/IGC.0b013e3181a1d73e.
Mansour GM, El-Lamie IK, El-Sayed HM, et al. Adnexal mass vascularity assessed by 3-dimensional power Doppler: does it add to the risk of malignancy index in prediction of ovarian malignancy?: four hundred-case study. Int J Gynecol Cancer 2009;19(5):867–872. DOI: 10.1111/IGC.0b013e3181a8335e.
Kalmantis K, Rodolakis A, Daskalakis G, et al. Characterization of ovarian tumors and staging ovarian cancer with 3-dimensional power Doppler angiography: correlation with pathologic findings. Int J Gynecol Cancer 2013;23(3):469–474. DOI: 10.1097/IGC.0b013e3182866679.
Sladkevicius P, Jokubkiene L, Valentin L. Contribution of morphological assessment of the vessel tree by three-dimensional ultrasound to a correct diagnosis of malignancy in ovarian masses. Ultrasound Obstet Gynecol 2007;30(6):874–882. DOI: 10.1002/uog.5150.
Alcázar JL, Cabrera C, Galván R, et al. Three-dimensional power Doppler vascular network assessment of adnexal masses: intraobserver and interobserver agreement analysis. J Ultrasound Med 2008;27(7):997–1001. DOI: 10.7863/jum.2008.27.7.997.
Dai SY, Hata K, Inubashiri E, et al. Does three-dimensional power Doppler ultrasound improve the diagnostic accuracy for the prediction of adnexal malignancy? J Obstet Gynaecol Res 2008;34(3):364–370. DOI: 10.1111/j.1447-0756.2007.00702.x.
Sajapala S, AboEllail MA, Tanaka T, et al. Three-dimensional power Doppler with silhouette mode for diagnosis of malignant ovarian tumors. Ultrasound Obstet Gynecol 2016;48(6):806–808. DOI: 10.1002/uog.15730.
Alcázar JL, Merce LT, Garcia Manero M. Three-dimensional power Doppler vascular sampling: a new method for predicting ovarian cancer in vascularized complex adnexal masses. J Ultrasound Med 2005;24(5):689–696. DOI: 10.7863/jum.2005.24.5.689.
Geomini PM, Kluivers KB, Moret E, et al. Evaluation of adnexal masses with three-dimensional ultrasonography. Obstet Gynecol 2006;108(5):1167–1175. DOI: 10.1097/01.AOG.0000240138.24546.37.
Jokubkiene L, Sladkevicius P, Valentin L. Does three-dimensional power Doppler ultrasound help in discrimination between benign and malignant ovarian masses? Ultrasound Obstet Gynecol 2007;29(2):215–225. DOI: 10.1002/uog.3922.
Kudla MJ, Timor-Tritsch IE, Hope JM, et al. Spherical tissue sampling in 3-dimensional power Doppler angiography: a new approach for evaluation of ovarian tumors. J Ultrasound Med 2008;27(3):425–433. DOI: 10.7863/jum.2008.27.3.425.
Abbas AM, Zahran KM, Nasr A, et al. Three-dimensional power Doppler evaluation of adnexal masses. Which parameter performs best? Thai J Obstet Gynecol 2014;22:102–107.
Ohel I, Sheiner E, Aricha-Tamir B, et al. Three-dimensional power Doppler ultrasound in ovarian cancer and its correlation with histology. Arch Gynecol Obstet 2010;281(5):919–925. DOI: 10.1007/s00404-009-1269-8.
Perez-Medina T, Orensanz I, Pereira A, et al. Three-dimensional angioultrasonography for the prediction of malignancy in ovarian masses. Gynecol Obstet Invest 2013;75(2):120–125. DOI: 10.1159/000345576.
Niemi RJ, Saarelainen SK, Luukkaala TH, et al. Reliability of preoperative evaluation of postmenopausal ovarian tumors. J Ovarian Res 2017;10(1):15. DOI: 10.1186/s13048-017-0309-4.
Alcázar JL, Rodriguez D, Royo P, et al. Intraobserver and interobserver reproducibility of 3-dimensional power Doppler vascular indices in assessment of solid and cystic-solid adnexal masses. J Ultrasound Med 2008;27(1):1–6. DOI: 10.7863/jum.2008.27.1.1.
Alcázar JL, Prka M. Evaluation of two different methods for vascular sampling by three-dimensional power Doppler angiography in solid and cystic-solid adnexal masses. Ultrasound Obstet Gynecol 2009;33(3):349–354. DOI: 10.1002/uog.6312.
Kudla M, Alcázar JL. Does the size of three-dimensional power Doppler spherical sampling affect the interobserver reproducibility of measurements of vascular indices in adnexal masses? Ultrasound Obstet Gynecol 2009;34(6):732–734. DOI: 10.1002/uog.7462.
Alcázar JL, Rodriguez D. Three-dimensional power Doppler vascular sonographic sampling for predicting ovarian cancer in cystic-solid and solid vascularized masses. J Ultrasound Med 2009;28(3):275–281. DOI: 10.7863/jum.2009.28.3.275.
Kudla MJ, Alcázar JL. Does sphere volume affect the performance of three-dimensional power Doppler virtual vascular sampling for predicting malignancy in vascularized solid or cystic-solid adnexal masses? Ultrasound Obstet Gynecol 2010;35(5):602–608. DOI: 10.1002/uog.7601.
Vrachnis N, Sifakis S, Samoli E, et al. Three-dimensional ultrasound and three-dimensional power Doppler improve the preoperative evaluation of complex benign ovarian lesions. Clin Exp Obstet Gynecol 2012;39(4):474–478.
Utrilla-Layna J, Alcázar JL, Aubá M, et al. Performance of three-dimensional power Doppler angiography as third-step assessment in differential diagnosis of adnexal masses. Ultrasound Obstet Gynecol 2015;45(5):613–617. DOI: 10.1002/uog.14674.
Silvestre L, Martins WP, Candido-Dos-Reis FJ. Limitations of three-dimensional power Doppler angiography in preoperative evaluation of ovarian tumors. J Ovarian Res 2015;8:47. DOI: 10.1186/s13048-015-0174-y.
Huchon C, Metzger U, Bats AS, et al. Value of three-dimensional contrast-enhanced power Doppler ultrasound for characterizing adnexal masses. J Obstet Gynaecol Res 2012;38(5):832–840. DOI: 10.1111/j.1447-0756.2011.01785.x.
Zhang X, Mao Y, Zheng R, et al. The contribution of qualitative CEUS to the determination of malignancy in adnexal masses, indeterminate on conventional US - a multicenter study. PLoS One 2014;9(4):e93843. DOI: 10.1371/journal.pone.0093843.
Hu R, Xiang H, Mu Y, et al. Combination of 2- and 3-dimensional contrast-enhanced transvaginal sonography for diagnosis of small adnexal masses. J Ultrasound Med 2014;33(11):1889–1899. DOI: 10.7863/ultra.33.11.1889.
Alcázar JL. Three-dimensional power Doppler derived vascular indices: what are we measuring and how are we doing it? Ultrasound Obstet Gynecol 2008;32(4):485–487. DOI: 10.1002/uog.6144.
Raine-Fenning NJ, Nordin NM, Ramnarine KV, et al. Evaluation of the effect of machine settings on quantitative three-dimensional power Doppler angiography: an in-vitro flow phantom experiment. Ultrasound Obstet Gynecol 2008;32(4):551–559. DOI: 10.1002/uog.6138.
Raine-Fenning NJ, Nordin NM, Ramnarine KV, et al. Determining the relationship between three-dimensional power Doppler data and true blood flow characteristics: an in-vitro flow phantom experiment. Ultrasound Obstet Gynecol 2008;32(4):540–550. DOI: 10.1002/uog.6110.
Martins WP. Three-dimensional power Doppler: validity and reliability. Ultrasound Obstet Gynecol 2010;36(5):530–533. DOI: 10.1002/uog.8836.
Kudla MJ, Alcázar JL. Spatiotemporal image correlation using high-definition flow: a new method for assessing ovarian vascularization. J Ultrasound Med 2010;29(10):1469–1474. DOI: 10.7863/jum.2010.29.10.1469.
Martins WP, Welsh AW, Lima JC, et al. The “volumetric” pulsatility index as evaluated by spatiotemporal imaging correlation (STIC): a preliminary description of a novel technique, its application to the endometrium and an evaluation of its reproducibility. Ultrasound Med Biol 2011;37(12):2160–2168. DOI: 10.1016/j.ultrasmedbio.2011. 08.014.
Kudla MJ, Alcázar JL. Spatiotemporal image correlation with spherical sampling and high-definition flow: new 4-dimensional method for assessment of tissue vascularization changes during the cardiac cycle: reproducibility analysis. J Ultrasound Med 2012;31(1):73–80. DOI: 10.7863/jum.2012.31.1.73.
Alcázar JL, Kudla MJ. Ovarian stromal vessels assessed by spatiotemporal image correlation-high definition flow in women with polycystic ovary syndrome: a case-control study. Ultrasound Obstet Gynecol 2012;40(4):470–475. DOI: 10.1002/uog.11187.
Alcázar JL, Auba M, Ruiz-Zambrana A, et al. Evaluation of the 4D “Spatiotemporal Image Correlation” technology with high-definition color Doppler as third step for preoperative differential diagnosis of ovarian tumors. A prospective study. Donald School J Ultrasound Obstet Gynecol 2018;12:1–8. DOI: 10.5005/jp-journals-10009-1545.