Ovarian malignancies take the highest toll among all gynecological malignancies in developed countries. In 2018, 4.4% of entire cancer-related mortality among women was attributed to ovarian cancer. The reason probably is that its symptoms do not become evident till the tumor invades the surrounding structures or metastasis or ascites develop. A total of 65% of women with ovarian cancers have stage III or IV diseases at diagnosis, with a 5-year survival rate of only 20–30%. Instead, if the disease is diagnosed at stage IA, when the disease is confined only to the ovary, survival rates of as high as 90% can be achieved. Ultrasound (US) is a modality of choice for the primary diagnosis of the lesion as it clearly demonstrates the morphology. Solid tumors cannot grow larger than 2–3 mm in diameter without inducing their own blood supply. Doppler plays a major role in diagnosis because neoangiogenesis is the major feature of malignant lesions. A resistance index (RI) of <0.4 was found to strongly correlate with the malignant nature of the lesion. But an overlap in RI values between benign and malignant lesions is not uncommon. Three-dimensional (3D) is superior in evaluating papillary projections and characteristics of cystic walls, calcifications, and bone densities, identifying the extent of capsular infiltration of tumors, and calculating the volume.
Disorganized, randomly dispersed vessels with irregular branching and asymmetrical caliber with microaneurysms (MAs) and arteriovenous (AV) fistulae with dichotomous branching are typical features of malignant vasculature and are best studied on 3D power Doppler (3D-PD).
A study by Kurjak et al. showed a qualitative analysis of the tumor vascular architecture added to morphologic parameters and was clinically pertinent, reaching sensitivity, and specificity of 97 and 99%, respectively.
Gupta MK, Qin RY. Mechanism and its regulation of tumour induced angiogenesis. World J Gastroenterol 2003;9(6):1144–1155. DOI: 10.3748/wjg.v9.i6.1144
Folkman J. The Molecular Basis of Cancer. Philadelphia: WB Saunders; 1995. Tumour Angiogenesis. In: Mendelsohn J, Howley PM, Israel MA, Liotta LA, eds; pp. 206–32.
Weiner Z, Thaler I, Beck D, et al. Differentiating malignant from benign ovarian tumors with transvaginal color flow imaging. Obstet Gynecol 1992;79(2):159–162. PMID: 1731278.
Hata T, Hata K, Senoh D, et al. Doppler ultrasound assessment of tumor vascularity in gynecologic disorders. J Ultrasound Med 1989;8(6):309–314. DOI: 10.7863/jum.19188.8.131.529
Kurjak A, Zalud I, Alfirevic Z. Evaluation of adnexal masses with transvaginal color ultrasound. J Ultrasound Med 1991;10(6):295–297. DOI: 10.7863/jum.19184.108.40.2065
Chan L, Lin WM, Verpairojkit B, et al. Evaluation of adnexal masses using three-dimensional ultrasonographic technology: preliminary report. J Ultrasound Med 1997;16(5):349–354. PMID: 9315174.
Hata K, Hata T, Kitao M. Intratumoral peak systolic velocity as a new possible predictor for detection of adnexal malignancy. Am J Obstet Gynecol 1995;172(5):1496–1500. DOI: 10.1016/0002-9378(95)90485-9
Kurjak A, Kupesic S. Transvaginal colour Doppler and pelvic tumour angiogenesis lessons learned and future challenges. Ultrasound Obstet Gynecol 1995;6(2):145–159. DOI: 10.1046/j.1469-0705.1995.06020145.x
Kurjak A, Shalan H, Kupesic S, et al. Transvaginal colour Doppler sonography in assessment of pelvic tumour vascularity. Ultrasound Obstet Gynecol 1993;3(2):137–154. DOI: 10.1046/j.1469-0705.1993.03020137.x
Kurjak A, Predamic M, Kupesic S, et al. Transvaginal color and pulsed Doppler assessment of adnexal tumor vascularity. Gynaecol Oncol 1993;50(1):3–9. DOI: 10.1006/gyno.1993.1154
Bromley B, Goodman H, Benacerraf BR. Comparison between sonographic morphology and Doppler waveform for the diagnosis of ovarian malignancy. Obstet Gynecol 1994;83(3):434–437. PMID: 8127538.
Bonilla-Musoles F, Raga F, Osborne NG. Three dimensional ultrasound evaluation of ovarian masses. Gynecol Oncol 1995;50(1):129–135. DOI: 10.1006/gyno.1995.1279
Sassone AM, Timor-Tritsch IE, Artner A, et al. Transvaginal sonographic characterization of ovarian disease: evaluation of a new scoring system to predict ovarian malignancy. Obstet Gynecol 1991;78(1):70–76. PMID: 2047071.
Granberg S, Wikland M, Jansson I. Macroscopic characterization of ovarian tumors and the relation to histological diagnosis criteria to be used for the evaluation. Gynecol Oncol 1989;35(2):139–144. DOI: 10.1016/0090-8258(89)90031-0
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
Levine D, Feldstein VA, Babcook CJ, et al. Sonography of ovarian masses: poor sensitivity of resistive index for identifying malignant lesions. AJR Am J Roentgenol 1994;162(6):1355–1359. DOI: 10.2214/ajr.162.6.8191998
Tekay A, Jouppila P. Validity of pulsatility and resistance indices in classification of adnexal tumors with transvaginal color Doppler ultrasound. Ultrasound Obstet Gynecol 1992;2(5):338–344. DOI: 10.1046/j.1469-0705.1992.02050338.x
Kurjak A, Kupesic S, Sparac V, et al. The detection of stage I ovarian cancer by three-dimensional sonography and power Doppler. Gynecol Oncol 2003;90(2):258–264. DOI: 10.1016/s0090-8258(03)00205-1
Jain RK, Ward-Harley K. Tumor blood flow characterization, modifications and role in hyperthermia. Trans Sonics Ultrasonics 1984;31(5):504–525. DOI: 10.1109/T-SU.1984.31536
Rubin JM, Bude RO, Carsson PL, et al. Power Doppler US: a potentially useful alternative to mean frequency-based color Doppler US. Radiology 1994;190(3):853–856. DOI: 10.1148/radiology.190.3.8115639
Kurjak A, Kupesic S, Breyer B, et al. The assessment of ovarian tumor angiogenesis: what does three-dimensional power Doppler add?. Ultrasound Obstet Gynecol 1998;12(2):136–146. DOI: 10.1046/j.1469-0705.1998.12020136.x
Vaupel P, Kallinowski F, Okunieff P. Blood flow oxygen and nutrient supply, and metabolic microenvironment of human tumors: a review. Cancer Res 1989;49(23):6449–6465. PMID: 2684393.
Shi H, Wang H, Wang Y, et al. Three-dimensional color power Doppler as an imaging technique in cancer. Int J Clin Exp Med 2016;9(6):9781–9790.
Cohen LS, Escobar PF, Scherm C, et al. Three dimensional power Doppler ultrasound improves the diagnostic accuracy for ovarian cancer prediction. Gynecol Oncol 2001;82(1):40–48. DOI: 10.1006/gyno.2001.6253
Bourne T, Campbell S, Steer C, et al. Transvaginal colour flow imaging: a possible new screening technique for ovarian cancer. BMJ 1989;299(6712):1367–1370. DOI: 10.1136/bmj.299.6712.1367
Kurjak A, Shalan H, Matijevic R, et al. Stage I ovarian cancer by transvaginal color Doppler sonography: a report of 18 cases. Ultrasound Obstet Gynecol 1993;3(3):195–198. DOI: 10.1046/j.1469-0705.1993.03030195.x
Fleischer AC, Cullinan JA, Peery CV, et al. Early detection of ovarian carcinoma with transvaginal color Doppler ultrasound. Am J Obstet Gynecol 1996;174(1 Pt 1):101–106. DOI: 10.1016/s0002-9378(96)70380-0
Medeiros LR, Rosa DD, da Rosa MI, et al. Accuracy of ultrasonography with color Doppler in ovarian tumor: a systematic quantitative review. Int J Gynecol Cancer 2009;19(2):230–236. DOI: 10.1111/IGC.0b013e31819c1369
Folkman J, Merler E, Abernathy C, et al. Isolation of a tumor factor responsible for angiogenesis. J Exp Med 1971,133(2):275–288. DOI: 10.1084/jem.133.2.275
Auerbach R. Angiogenesis-inducing factors: A review. In: Pick E (Ed). Limphokines, London: Academic Press 1981;4:69–88.
Hanahan D, Folkman J. Patterns and emerging mechanisms of the angiogenetic switch during tumorogenesis. Cell 1996;86(3):353–364. DOI: 10.1016/s0092-8674(00)80108-7
Valentin L. Ultrasound and endoscopic surgery in Obstetrics and gynaecology, Timmerman D, et al. (eds), Springer-Verlag: London 2002; 153–164.
Kupesic S, Kurjak A. Contrast-enhanced, three-dimensional power Doppler sonography for differentiation of adnexal masses. Obstet Gynecol 2000;96(3):452–458. DOI: 10.1016/s0029-7844(00)00923-6
Kupesic S, Plasvic BM. Early ovarian cancer: 3-D power Doppler. Abdom Imaging 2006;31(5):613–619. DOI: 10.1007/s00261-005-0398-1
Kurjak A, Kupešic S. Three dimensional ultrasound and power Doppler in assessment of uterine and ovarian angiogenesis: a prospective study. Croat Med J 1999;40(3):413–420. PMID: 10411971.