3D in Gynecology: Luxury or necessity?
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1 ISUOG 2011 Los Angeles September D in Gynecology: Luxury or necessity? Ilan E. Timor-Tritsch
2 Educational objectives To describe the 3D US tools available to complement 2D US To apply these tools to clinical situations To encourage those who perform Gyn US to use them to shorten their way to the Dx, in spite of problems in reimbursement To teach those who do not do Gyn US to understand in which cases does 3D really add to making the right diagnosis To point out when does 3D really help
3 3D Ultrasound in Gynecology- Literature Review: Where are we now? For every 6 articles in OB there is 1 in Gyn Search : 31 3D Gyn articles found Mostly from Europe Majority show-and-tell or case presentations Few real data on very few patients Lately 3D Doppler articles start to appear
4 3D Ultrasound in Gynecology- Literature Review: Where are we now? PubMed Search 2011: 496 3D in Gyn articles 3D US & uterus: 153 3D US & uterine malformations: 24 3D US& ovary: 86 3D UD & ovarian cancer Lately 3D & Gyn Doppler articles start to appear
5 3D Ultrasound in Gynecology Gaining increasing acceptance More 3D machines in use More are familiar with the technique Versatile & expanding display modes Versatile & expanding clinical use More literature Laptop software: off-line use easier
6 What indeed is 3D US? A series of 2 dimensional image slices saved into a volume with possibility to: re-slice, re-study save for future studies, mail, teach make measurements in the volume Use different rendering apps
7 Use specific displays generic to 3D: Multiplanar navigation, scrolling Thick slice (VCI) 3D Angiography Inversion Sculpting tools Tomography SonoAVC
8 ORTHOGONAL PLANES Multiplanar navigation (scrolling)
9 Multiplanar navigation Simultaneous & continuous display of the orthogonal planes (which are at right angles to each other) Achieve any desired plane The niche mode is a variation of the orthogonal planes
10
11 Multiplanar imaging navigating, scrolling in the volume
12 ORTHOGONAL PLANES Thick slice Volume Contrast Imaging These display methods enhance picture quality
13 Using the thick slice display
14
15 Power Doppler Angiography
16 What indeed is power Doppler angiography? A special 3D imaging mode, which selectively displays blood flow in a volume acquired using color or power Doppler
17 How is it done? Switch on the power (or color) Doppler feature to image the desired vessels Display in the orthogonal planes Turn on the render mode Strip the volume of the gray scale data The 3D Power or Color Doppler Angiogram of blood vessels is thus obtained
18 The process to assess vessel density is Coronal Figure Axial 1 (horizontal) Sagittal Obtain volume & display planes 3D volume-angiogram Get the volume shell Actual volume 3D transparency mode: the glass-body appearance of the ovary and its blood vessels 3D volume angiogram mode: the color appearance of the ovarian blood vessels only Get Histogram
19 What is 3D Power Doppler Angiography? The cut-out structure can be rendered to display the vessels via a transparent glass body and an angiographic display this is 3D angiography
20 A histogram displays: - MG (mean grayness: on a scale of 1-100) - VI (vascularization index: %) - FI (flow index: on a scale of 1-100) - VFI (vascularization flow index: on a scale of )
21 Vascular pattern of endometrial ca.)
22 In Short: 3D Doppler angiogram tells you about vessel density 1. Quantitatively (in %): within a a given volume Get Histogram 2. Qualitatively: impression of vessel shape, tortuosity, lakes etc.
23 3D US Accurate volumes for following sizes of pelvic lesions
24 Inversion Special computer program switching anechoic spaces into echo-filled spaces sort of a cast appearance..
25 3D SIS of a septate uterus
26
27 Rt ovary Lt ovary Inversion rendering
28 Sono AVC Special computer program calculating volumes of cystic structures
29 SonoVAC Volume calculation of cystic structures Color coding them for 3D display Displays follicular measurements in a table form according to size and volume
30
31 (Finally we joined the league of displays in MRI & CT!!) The tomographic (Multi-slice) display technique Serially displays several consecutive scanned sections on one image similarly to CT and MRI
32 Endometrial pathology:
33 Septate uterus SIS
34 Endometrial ca.
35 Special tools The electronic scalpel and eraser
36 Electronic scalpel ( sculpting tools)
37 The rendered cyst Electronic scalpel removes part of cyst!! What about the other compartment? Both compartments have papillae Rotate
38
39 Proprietary laptop version of 3D software QLab (Phillips) 4DView (GE) Sonoviewpro (Medison) 3D Volume Viewer (Siemens) Best way to gain experience in 3D techniques How easy is it to handle volumes off-line on a laptop?
40 Clinical examples
41 The Uterus Where does 3D UD help? To define a normal uterus Find & define uterine malformations Look at the uterine cavity (polyps, fibroids etc.) Image the cervix
42 Three dimensional ultrasound: Normal uterus In scanning the uterus, the most important feature of 3D is, that we can now see the REAL coronal section of it
43 Uterine malformations
44 Three dimensional ultrasound Uterine malformations are a significant problem in reproductive performance The Dx depended upon HSG, MRI & laparoscopy Lately 2D & 3D US became relatively simple, effective and inexpensive diagnostic modalities to allow appropriate clinical management
45 Classification of Uterine Anomalies (AFS*) *Modification after Buttram & Gibbons, AFS 1979;32:40
46 Tx AP 2D Ultrasound Sono-clue to uterine malformations Split endometrial echoes AP/Tx Ratio= <0.6 Width larger than height on axial section
47 What determines the type of uterine malformation? The fundal contours The shape the uterine cavity The cervix
48 Uterine anomalies: 3D Ultrasound The correct diagnosis depends upon imaging the contours of the cavity as well as the fundal contours! 3D US can do the job better, cheaper and faster than any imaging method!
49 Uterine HSG: No information anomalies: about the HSG vs. 3D US contours of the fundus??!!! Hysterosalpingogram 3 D ultrasound
50 Tomographic display Uterine anomalies: 3D Ultrasound The different ways imaging the uterus Un-enhanced exam in the follicular phase Un-enhanced exam in the secretory phase (best is the thick slice technique) Saline infusion sonohysterography with, or w/o inversion
51 Arcuate Uterus
52 Arcuate uterus Thick slice
53 Arcuate uterus: Sonographic cast of the endometrial cavity
54 Bicornuate Uterus
55 Bicornuate uterus SIS
56
57 Septate Uterus
58 Incomplete septate uterus SIS 3D SIS of a septate uterus
59 Incomplete sepate uterus: Sonographic cast of the endometrial cavity
60 Didelphic Uterus
61 SIS Uterus didelphis
62 SIS Uterus didelphis
63 Complex anomalies
64 Hypoplasic rt. horn
65 Rudimentary horn
66 Unicornuate uterus
67 Unicornuate uterus
68 Rendering curved surfaces
69 Localizing and defining IUDs
70
71 Burried arms of IUD
72 IUD Rt ovary Uterus
73
74 3D Ultrasound technique to visualize a Mirena
75 Localizing ectopic pregnancies
76 Right interstitial ectopic pregnancy??!!
77 Cervical ectopic pregnancy
78
79
80 3 cm
81 Vascularization in a choriocarcinoma in a cornual pregnancy. 3D angiograms
82 3D ultrasound of the endometrial cavity
83 Endometrial polyp
84 Endometrial polyps
85 Endometrial ca.
86 Endometrial ca.
87 Pyometra/hematometra
88 Pyometra/hematometra
89 3D ultrasound and the tube
90
91
92
93
94
95
96 3D ultrasound and the ovary
97 32 y.o. asymptomatic, lt. ov. suspect for ca.
98 32 y.o. asymptomatic, lt. ov. suspect for ca.
99 32 y.o. asymptomatic, lt. ov. suspect for ca. The 3D volume
100 32 y.o. asymptomatic, lt. ov. suspect for ca.
101 32 y.o. asymptomatic, lt. ov. suspect for ca.
102
103
104
105
106 The color of slide 7 belongs to this one. As a matter of fact, the most important pair is this one and #7
107
108
109 Graphics: Dr. Philippe Jeanty, Nashville TN Composite rendering of the follicles & the vessel angiogram of a PCO
110 The issue of the blood vessels detected in an ovarian papilla Papillae are the most sensitive predictors of malignancy in the ovary Most believe that a vessel in the papilla is even more indicative of malignancy Color Doppler, using a low PRF, is effective imaging small vessels in a papilla 3D color Doppler helps in such detections
111 Effect of solid & cystic areas on the Mean Grayness Solid area of teratoma Cystic area of teratoma
112 Effect of vascularity on the color flow values Benign serous cystadenoma Corpus luteum
113 3D P D A of the same whole ovary with its histogram 3D P D A of 1cc spherical sample with related histogram.
114 Scanning the pelvic floor Anal sphincter and pelvic floor anatomy New kid on the block!!
115 Scanning the sphincter in the transverse plane The probe Anus Scanning plane
116 Cross section through the external and internal sphincters External sphincter Internal sphincter Rectal mucosa Rectal lumen 2D image
117 Normal anal sphincter
118 History of 3 rd degree tear
119 Hx of 4 th degree tear
120 3D static approach: orthogonal display & 3D rendering Sagittal Rectum A Axial Urethra Vagina B Rendering box Urethra Vagina Rectum C LEVATOR
121 1 st plane: measure hiatal area 2 nd plane: measure levator thickness After Dietz 2004
122 Potential measurements of pelvic support structures
123 Measurement of the levator ani hiatus Dietz HP UOG 2004;23:611
124 Measurement of the levator thickness Dietz HP UOG 2004;23:611
125 Levator Ani Area Levator Hiatus Area A/P & LR diameter Levator Ani thickness / diameter U V R Intraclass correlation coefficients for parameters of pubovisceral muscle and levator hiatal anatomy on 3D pelvic floor ultrasound (test-retest series, n = 20) Dietz HP, Shek C, Clarke B. Ultrasound Obstet Gynecol 2005; 25: Yang JM, Yang SH, Huang WC. Ultrasound Obstet Gynecol 2006; 8: Parameter ICC 95% CI ICC 95% Pubovisceral muscle diameter (axial) Pubovisceral muscle area (axial) Levator hiatus at rest (AP diameter) Levator hiatus at rest (LR diameter) Hiatal area at rest Hiatal area on Valsalva Pubovisceral muscle diameter (coronal) Pubovisceral muscle area (coronal)
126 VALSALVA
127
128 Tension-free vaginal tape
129 The Monarc sling and the TVT Dietz HP UOG 2004;23:611
130 Injectable periurethral bulking agent Dietz HP UOG 2004;23:611
131 Sagittal Rectum Urethra Vagina Axial Urethra Vagina Rectum LEVATOR
132 Summary & Conclusion 2D & 3D of the Ovary, Uterus & Tube In an increasing number of cases 3D US is the simplest and most effective additional tool to complement 2D evaluation of Gyn pathology 3D angio, inversion, tomography, volume calculation, dynamic 3D are promising tools Near future: we will see several new computer aided software methods to analyze US volumes
133 Luxury or Necessity? Luxury? NO! Necessity? PROBABLY SO! Learning curve steeper than 2D Needs time & investment in equipment Needs constant maintenance of knowledge and training Important adjuvant to 2D & Doppler 3D volume manipulation on laptop makes training easier and faster!!!
134 What is the value on 3D US in Gyn? Airfare to a 3D US course. $375.- (?) 2 nights at a Hotel... $600.- (?) 2 good dinners for two.. $200.- (?) Transvaginal 3D US (Doppler angiography, inversion mode. Etc.) in Gyn.. Priceless
135
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