3D in Gynecology: Luxury or necessity?

ISUOG 2011 Los Angeles September 16-22 3D in Gynecology: Luxury or necessity? Ilan E. Timor-Tritsch

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

3D Ultrasound in Gynecology- Literature Review: Where are we now? For every 6 articles in OB there is 1 in Gyn Search 97-2008: 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

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

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

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

Use specific displays generic to 3D: Multiplanar navigation, scrolling Thick slice (VCI) 3D Angiography Inversion Sculpting tools Tomography SonoAVC

ORTHOGONAL PLANES Multiplanar navigation (scrolling)

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

Multiplanar imaging navigating, scrolling in the volume

ORTHOGONAL PLANES Thick slice Volume Contrast Imaging These display methods enhance picture quality

Using the thick slice display

Power Doppler Angiography

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

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

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

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

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 1-100 )

Vascular pattern of endometrial ca.)

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.

3D US Accurate volumes for following sizes of pelvic lesions

Inversion Special computer program switching anechoic spaces into echo-filled spaces sort of a cast appearance..

3D SIS of a septate uterus

Rt ovary Lt ovary Inversion rendering

Sono AVC Special computer program calculating volumes of cystic structures

SonoVAC Volume calculation of cystic structures Color coding them for 3D display Displays follicular measurements in a table form according to size and volume

(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

Endometrial pathology:

Septate uterus SIS

Endometrial ca.

Special tools The electronic scalpel and eraser

Electronic scalpel ( sculpting tools)

The rendered cyst Electronic scalpel removes part of cyst!! What about the other compartment? Both compartments have papillae Rotate

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?

Clinical examples

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

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

Uterine malformations

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

Classification of Uterine Anomalies (AFS*) *Modification after Buttram & Gibbons, AFS 1979;32:40

Tx AP 2D Ultrasound Sono-clue to uterine malformations Split endometrial echoes AP/Tx Ratio= <0.6 Width larger than height on axial section

What determines the type of uterine malformation? The fundal contours The shape the uterine cavity The cervix

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!

Uterine HSG: No information anomalies: about the HSG vs. 3D US contours of the fundus??!!! Hysterosalpingogram 3 D ultrasound

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

Arcuate Uterus

Arcuate uterus Thick slice

Arcuate uterus: Sonographic cast of the endometrial cavity

Bicornuate Uterus

Bicornuate uterus SIS

Septate Uterus

Incomplete septate uterus SIS 3D SIS of a septate uterus

Incomplete sepate uterus: Sonographic cast of the endometrial cavity

Didelphic Uterus

SIS Uterus didelphis

Complex anomalies

Hypoplasic rt. horn

Rudimentary horn

Unicornuate uterus

Rendering curved surfaces

Localizing and defining IUDs

Burried arms of IUD

IUD Rt ovary Uterus

3D Ultrasound technique to visualize a Mirena

Localizing ectopic pregnancies

Right interstitial ectopic pregnancy??!!

Cervical ectopic pregnancy

Vascularization in a choriocarcinoma in a cornual pregnancy. 3D angiograms

3D ultrasound of the endometrial cavity

Endometrial polyp

Endometrial polyps

Endometrial ca.

Pyometra/hematometra

3D ultrasound and the tube

3D ultrasound and the ovary

32 y.o. asymptomatic, lt. ov. suspect for ca.

32 y.o. asymptomatic, lt. ov. suspect for ca. The 3D volume

32 y.o. asymptomatic, lt. ov. suspect for ca.

The color of slide 7 belongs to this one. As a matter of fact, the most important pair is this one and #7

Graphics: Dr. Philippe Jeanty, Nashville TN Composite rendering of the follicles & the vessel angiogram of a PCO

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

Effect of solid & cystic areas on the Mean Grayness Solid area of teratoma Cystic area of teratoma

Effect of vascularity on the color flow values Benign serous cystadenoma Corpus luteum

3D P D A of the same whole ovary with its histogram 3D P D A of 1cc spherical sample with related histogram.

Scanning the pelvic floor Anal sphincter and pelvic floor anatomy New kid on the block!!

Scanning the sphincter in the transverse plane The probe Anus Scanning plane

Cross section through the external and internal sphincters External sphincter Internal sphincter Rectal mucosa Rectal lumen 2D image

Normal anal sphincter

History of 3 rd degree tear

Hx of 4 th degree tear

3D static approach: orthogonal display & 3D rendering Sagittal Rectum A Axial Urethra Vagina B Rendering box Urethra Vagina Rectum C LEVATOR

1 st plane: measure hiatal area 2 nd plane: measure levator thickness After Dietz 2004

Potential measurements of pelvic support structures

Measurement of the levator ani hiatus Dietz HP UOG 2004;23:611

Measurement of the levator thickness Dietz HP UOG 2004;23:611

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: 580-585 Yang JM, Yang SH, Huang WC. Ultrasound Obstet Gynecol 2006; 8:710-716. Parameter ICC 95% CI ICC 95% Pubovisceral muscle diameter (axial) 0.52 0.12 0.74 0.68 0.36-0.86 Pubovisceral muscle area (axial) 0.44 0.02 0.70 0.78 0.61-0.84 Levator hiatus at rest (AP diameter) 0.82 0.63 0.92 0.83 0.63-0.93 Levator hiatus at rest (LR diameter) 0.70 0.38 0.86 0.79 0.41-0.92 Hiatal area at rest 0.74 0.49 0.87 0.63 0.27-0.83 Hiatal area on Valsalva 0.50 0.23 0.70 Pubovisceral muscle diameter (coronal) 0.54 0.16 0.75 Pubovisceral muscle area (coronal) 0.45 0.00 0.70

VALSALVA

Tension-free vaginal tape

The Monarc sling and the TVT Dietz HP UOG 2004;23:611

Injectable periurethral bulking agent Dietz HP UOG 2004;23:611

Sagittal Rectum Urethra Vagina Axial Urethra Vagina Rectum LEVATOR

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

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!!!

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