Three-dimensional power Doppler ultrasound scanning for the prediction of endometrial cancer in women with postmenopausal bleeding and thickened endometrium

Published:November 03, 2008DOI:


      The purpose of this study was to evaluate the role of 3-dimensional power Doppler angiography (3D-PDA) to discriminate between benign and malignant endometrial disease in women with postmenopausal bleeding and thickened endometrium.

      Study Design

      Ninety-nine postmenopausal women (median age, 63.1 years; range, 48-84 years) with uterine bleeding and a thickened endometrium (≥ 5 mm) at baseline transvaginal sonography were assessed by 3D-PDA before endometrial biopsy. Endometrial volume, vascularity index (VI), flow index, and vascularity-flow index were calculated with the virtual organ computer-aided analysis method.


      Histologic diagnoses were endometrial cancer (44 cases), hyperplasia (13 cases), polyp (23 cases), cystic atrophy (14 cases), and submucous myoma (5 cases). Endometrial volume, VI, and vascularity-flow index were significantly higher in malignant vs benign conditions. Receiver operating characteristic analysis revealed that VI was the best parameter for the prediction of endometrial cancer.


      The findings show that 3D-PDA may be useful for the prediction of endometrial cancer in women with postmenopausal bleeding and thickened endometrium at baseline sonography.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Smith-Bindman R.
        • Kerlikowske K.
        • Feldstein V.A.
        • et al.
        Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities.
        JAMA. 1998; 280: 1510-1517
        • Gupta J.K.
        • Chien P.F.
        • Voit D.
        • Clark T.J.
        • Khan K.S.
        Ultrasonographic endometrial thickness for diagnosing endometrial pathology in women with postmenopausal bleeding: a meta-analysis.
        Acta Obstet Gynecol Scand. 2002; 81: 799-816
        • Clark T.J.
        • Barton P.M.
        • Coomarasamy A.
        • Gupta J.K.
        • Khan K.S.
        Investigating postmenopausal bleeding for endometrial cancer: cost-effectiveness of initial diagnostic strategies.
        BJOG. 2006; 113: 502-510
        • Dijkhuizen F.P.
        • Mol B.W.
        • Brölmann H.A.
        • Heintz A.P.
        Cost-effectiveness of the use of transvaginal sonography in the evaluation of postmenopausal bleeding.
        Maturitas. 2003; 45: 275-282
        • Chan F.Y.
        • Chau M.T.
        • Pun T.C.
        • et al.
        Limitations of transvaginal sonography and color Doppler imaging in the differentiation of endometrial carcinoma from benign lesions.
        J Ultrasound Med. 1994; 13: 623-628
        • Kurjak A.
        • Shalan H.
        • Sosic A.
        • et al.
        Endometrial carcinoma in postmenopausal women: evaluation by transvaginal color Doppler ultrasonography.
        Am J Obstet Gynecol. 1993; 169: 1597-1603
        • Campbell S.
        • Bourne T.
        • Crayford T.
        • Pittrof R.
        The early detection and assessment of endometrial cancer by transvaginal colour Doppler ultrasonography.
        Eur J Obstet Gynecol Reprod Biol. 1993; 49: 44-45
        • Sladkevicius P.
        • Valentin L.
        • Marsal K.
        Endometrial thickness and Doppler velocimetry of the uterine arteries as discriminators of endometrial status in women with postmenopausal bleeding: a comparative study.
        Am J Obstet Gynecol. 1994; 171: 722-728
        • Aleem F.
        • Predanic M.
        • Calame R.
        • Moukhtar M.
        • Pennisi J.
        Transvaginal color and pulsed Doppler sonography of the endometrium: a possible role in reducing the number of dilatation and curettage procedures.
        J Ultrasound Med. 1995; 14: 139-145
        • Sheth S.
        • Hamper U.M.
        • McCollum M.E.
        • Caskey C.I.
        • Rosenshein N.B.
        • Kurman R.J.
        Endometrial blood flow analysis in postmenopausal women: can it help differentiate benign from malignant causes of endometrial thickening?.
        Radiology. 1995; 195: 661-665
        • Epstein E.
        • Skoog L.
        • Isberg P.E.
        • et al.
        An algorithm including results of gray-scale and power Doppler ultrasound examination to predict endometrial malignancy in women with postmenopausal bleeding.
        Ultrasound Obstet Gynecol. 2002; 20: 370-376
        • Alcázar J.L.
        • Castillo G.
        • Mínguez J.A.
        • Galán M.J.
        Endometrial blood flow mapping using transvaginal power Doppler sonography in women with postmenopausal bleeding and thickened endometrium.
        Ultrasound Obstet Gynecol. 2003; 21: 583-588
        • Alcázar J.L.
        • Ajossa S.
        • Floris S.
        • Bargellini R.
        • Gerada M.
        • Guerriero S.
        Reproducibility of endometrial vascular patterns in endometrial disease as assessed by transvaginal power Doppler sonography in women with postmenopausal bleeding.
        J Ultrasound Med. 2006; 25: 159-163
        • Alcazar J.L.
        Three-dimensional ultrasound in gynecology: current status and future perspectives.
        Curr Women's Health Rev. 2005; 1: 1-14
        • Raine-Fenning N.J.
        • Campbell B.K.
        • Clewes J.S.
        • Kendall N.R.
        • Johnson I.R.
        The reliability of virtual organ computer-aided analysis (VOCAL) for the semiquantification of ovarian, endometrial and subendometrial perfusion.
        Ultrasound Obstet Gynecol. 2003; 22: 633-639
        • Alcázar J.L.
        • Mercé L.T.
        • Manero M.G.
        • Bau S.
        • López-García G.
        Endometrial volume and vascularity measurements by transvaginal 3-dimensional ultrasonography and power Doppler angiography in stimulated and tumoral endometria: an interobserver reproducibility study.
        J Ultrasound Med. 2005; 24: 1091-1098
        • Mercé L.T.
        • Alcázar J.L.
        • Engels V.
        • Troyano J.
        • Bau S.
        • Bajo J.M.
        Endometrial volume and vascularity measurements by transvaginal three-dimensional ultrasonography and power Doppler angiography in stimulated and tumoral endometria: intraobserver reproducibility.
        Gynecol Oncol. 2006; 100: 544-550
        • Hanley J.A.
        • McNeil B.J.
        A method of comparing the areas under receiver operating characteristic curves derived from the same cases.
        Radiology. 1983; 148: 839-843
        • Mercé L.T.
        • Alcázar J.L.
        • López C.
        • et al.
        Clinical usefulness of 3-dimensional sonography and power Doppler angiography for diagnosis of endometrial carcinoma.
        J Ultrasound Med. 2007; 26: 1279-1287
        • Goldstein R.B.
        • Bree R.L.
        • Benson C.B.
        • et al.
        Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement.
        J Ultrasound Med. 2001; 20: 1025-1036
        • Epstein E.
        • Valentin L.
        Managing women with post-menopausal bleeding.
        Best Pract Res Clin Obstet Gynaecol. 2004; 18: 125-143
        • Timor-Tritsch I.E.
        • Monteagudo A.
        Three and four-dimensional ultrasound in obstetrics and gynecology.
        Curr Opin Obstet Gynecol. 2007; 19: 157-175
        • Martins W.P.
        • Ferriani R.A.
        • Barra D.A.
        • et al.
        Reliability and validity of tissue volume measurement by three-dimensional ultrasound: an experimental model.
        Ultrasound Obstet Gynecol. 2007; 29: 210-214
        • Foster F.S.
        • Burns P.N.
        • Simpson D.H.
        • Wilson S.R.
        • Christopher D.A.
        • Goertz D.E.
        Ultrasound for the visualization and quantification of tumor microcirculation.
        Cancer Metastasis Rev. 2000; 19: 131-138
        • Moskalik A.P.
        • Rubin M.A.
        • Wojno K.J.
        • et al.
        Analysis of three-dimensional Doppler ultrasonographic quantitative measures for the discrimination of prostate cancer.
        J Ultrasound Med. 2001; 20: 713-722
        • Goertz D.E.
        • Yu J.L.
        • Kerbel R.S.
        • Burns P.N.
        • Foster F.S.
        High-frequency 3-D color-flow imaging of the microcirculation.
        Ultrasound Med Biol. 2003; 29: 39-51
        • Exacoustos C.
        • Zupi E.
        • Cangi B.
        • Chiaretti M.
        • Arduini D.
        • Romanini C.
        Endometrial evaluation in postmenopausal breast cancer patients receiving tamoxifen: an ultrasound, color flow Doppler, hysteroscopic and histological study.
        Ultrasound Obstet Gynecol. 1995; 6: 435-442
        • Bonilla-Musoles F.
        • Marti M.C.
        • Ballester M.J.
        • Raga F.
        • Osborne N.G.
        Normal uterine arterial blood flow in postmenopausal women assessed by transvaginal color Doppler sonography: the effect of hormone replacement therapy.
        J Ultrasound Med. 1995; 14: 497-501
        • Gruboeck K.
        • Jurkovic D.
        • Lawton F.
        • Savvas M.
        • Tailor A.
        • Campbell S.
        The diagnostic value of endometrial thickness and volume measurements by three-dimensional ultrasound in patients with postmenopausal bleeding.
        Ultrasound Obstet Gynecol. 1996; 8: 272-276
        • Raine-Fenning N.
        • Campbell B.
        • Collier J.
        • Brincat M.
        • Johnson I.
        The reproducibility of endometrial volume acquisition and measurement with the VOCAL-imaging program.
        Ultrasound Obstet Gynecol. 2002; 19: 69-75
        • Mansour G.M.
        • El-Lamie I.K.
        • El-Kady M.A.
        • El-Mekkawi S.F.
        • Laban M.
        • Abou-Gabal A.I.
        Endometrial volume as predictor of malignancy in women with postmenopausal bleeding.
        Int J Gynaecol Obstet. 2007; 99: 206-210
        • Odeh M.
        • Vainerovsky I.
        • Grinin V.
        • Kais M.
        • Ophir E.
        • Bornstein J.
        Three-dimensional endometrial volume and 3-dimensional power Doppler analysis in predicting endometrial carcinoma and hyperplasia.
        Gynecol Oncol. 2007; 106: 348-353