Three-dimensional power Doppler with silhouette mode for diagnosis of malignant ovarian tumors.

Abstract

Preoperative differentiation between primary and metastatic ovarian cancer is useful for optimizing management. We present our experience using a new three-dimensional (3D) power Doppler imaging technique (HDliveFlow) with HDlive silhouette mode to differentiate between primary and metastatic malignant ovarian tumors. A 78-year-old Japanese woman had been diagnosed with lung cancer 10 years previously. Resection of the right middle lobe had been performed with subsequent chemotherapy. Lobectomy of the right lower lobe and resection of the diaphragm to assess for recurrence of the cancer were conducted, followed by chemotherapy, approximately 5 years later. She subsequently presented with abdominal bloating and was referred to our hospital because of suspected bilateral ovarian masses. Ultrasound imaging with HDlive silhouette mode demonstrated cystic components of varying size within the ovarian tumors, producing a lettuce-like appearance (Figure 1). HDliveFlow with HDlive silhouette mode (Voluson E10 GE Healthcare Japan, Tokyo, Japan) showed in both tumors the main penetrating blood vessel, its branches forming a dense vascular network (vascular tree-like pattern) (Figure 2). A preoperative diagnosis of Krukenberg tumors was suggested. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histopathological examination of both adnexal masses confirmed Krukenberg tumor. A 55-year-old Japanese woman with breast cancer was referred to our hospital because of bilateral ovarian tumors detected during a preoperative check-up prior to resection of the left breast tumor. HDliveFlow with HDlive silhouette mode showed in both tumors abundant branching vessels of varying caliber forming a vascular network (vascular-net pattern) (Figure 3). Bilateral salpingo-oophorectomies were conducted and histopathological examination of the masses showed serous adenocarcinoma of both ovaries. Histological assessment of the left breast tumor revealed an invasive ductal carcinoma and solid tubular carcinoma with cystic degeneration, indicating that the masses in the ovaries were primary ovarian cancer. HDliveFlow is a new 3D power Doppler technique that uses an adjustable light source providing the ability to create light and shadow effects, thereby increasing the depth perception for 3D imaging of blood flow1, 2. HDlive silhouette mode is also a new technology that images the fetus and placenta with vitreous-like clarity, and the internal structures can be seen clearly, resembling holographic technology3, 4. HDliveFlow with HDlive silhouette mode therefore facilitates the spatial visualization of blood vessels, demonstrating their dimensions and the relationships between them2. Conventional two-dimensional color Doppler reveals abundant vascularization, and in the case of Krukenberg tumor it will show the main vessel with a tree-shaped structure penetrating from the periphery into the central part5. However, elucidation of the precise pattern of intratumoral vasculature is easier to achieve using HDlive. In the present report, HDliveFlow with HDlive silhouette mode demonstrated clearly a typical vascular tree-like pattern in the Krukenberg tumors, whereas this technique revealed complicated abundant branching vessels of varying caliber forming a vascular network (vascular-net pattern) in the primary ovarian cancer. However, the extent to which HDliveFlow with HDlive silhouette mode may help in differentiating primary from metastatic ovarian cancer would need to be investigated in further studies involving groups of patients rather than individual cases. This work was supported by a Grant-in-Aid for Scientific Research on Innovative Areas ‘Constructive Departmental Science’ (No.24119004), and a Research Grant (No.25462561) from The Ministry of Education, Culture, Sports, Science and Technology, Japan.