Three-dimensional Ultrasonography and Power Doppler for Discrimination Between Benign and Malignant Endometrium in Premenopausal Women With Abnormal Uterine Bleeding

Mohamed El-Sharkawy; Akmal El-Mazny; Wafaa Ramadan; Dina Hatem; Aly Abdel-Hafiz; Mohamed Hammam; Adel Nada


BMC Womens Health. 2016;16(18) 

In This Article


To the best of our knowledge and review of literature, this is the first study to evaluate the efficacy of 3D ultrasonography and power Doppler for discrimination between benign and malignant endometrium in women with premenopausal bleeding. Several previous studies have evaluated the role of 3D ultrasonography/power Doppler for the investigation of patients with postmenopausal bleeding.

Our results showed that the ET, EV, and endometrial VI and VFI were significantly increased in patients with malignant endometrium than those with benign endometrium; whereas, the uterine artery PI and RI and endometrial FI were not significantly different between the two groups. The best parameter for discrimination between benign and malignant endometrium was the VI with an AUC of 0.88 at a cutoff value of 0.81 %.

In agreement with our results, Mercé et al.[9] and Alcazar and Galvan[10] found that the flow indices were superior to EV for discrimination between endometrial carcinoma and endometrial hyperplasia, and between benign and malignant endometrium, respectively. The best predictor for endometrial cancer was VI. Odeh et al.,[11] however, found that EV was superior to the flow indices for discrimination between hyperplasia/malignant endometrium and benign endometrium other than hyperplasia.

Epstein et al.[12] estimated the color content of the endometrium subjectively by choosing the most vascularized area and applying computer analysis to that area. They concluded that power Doppler analysis can contribute to a correct diagnosis of endometrial cancer in women with postmenopausal bleeding. Makled et al.[13] also concluded that 3D power Doppler measurements may be useful for distinguishing between benign endometrial lesions and endometrial carcinoma in women with postmenopausal bleeding.

Kurjak et al.[14] and Kupesic et al.[15] reported the use of volume measurements and power Doppler in diagnosing endometrial and adnexal malignancies; they found significant differences in the volume of malignant and benign lesions. They suggested that a combination of morphologic criteria and 3D power Doppler findings could identify endometrial lesions with sensitivity and specificity of 89 and 97 %, respectively.

Galván et al.[16] found that EV and VI were independently related to myometrial infiltration and tumor stage in endometrial carcinoma; VI was independently associated with tumor grade and EV correlated with lymph node metastases. Saarelainen et al.[17] also suggested that endometrial and, to a lesser degree, myometrial vascular indices and EV correlate with the depth of myometrial invasion in endometrial carcinoma.

Contrary to our results, Lieng et al.[18] did not find differences in 3D power Doppler indices between women with endometrial polyps and endometrial cancer before and after contrast enhanced examination. Opolskiene et al.[19] also concluded that, although 3D power Doppler indices were significantly higher in women with endometrial cancer as compared with those with benign pathology, the diagnostic performance of 3D ultrasound imaging was not superior to that of ET as measured by 2D ultrasound examination.

De Smet et al.[20] analyzed the correlation between EV and myometrial infiltration in a series of 97 women with endometrial cancer. They found that the predicted probability of deep myometrial infiltration increased when the ET increased, while this probability decreased when EV increased. This could be explained by non-linear effects.

The differences in results between our study and previous studies can almost certainly be explained by substantial differences in study populations and study design. There are differences in menopausal status, use of hormone replacement therapy, rate of endometrial cancer, and mix of benign histologies. There are also differences in the methods used to determine diagnostic performance of ultrasound markers. The relatively high rate of endometrial carcinoma and atypical hyperplasia in our study can be explained by exclusion of other causes of premenopausal bleeding in the study population.