Think in 3D/4D!

3D/4D Pelvic Sonography: Instrumentation, Techniques and Clinical Applications Arthur C. Fleischer, M.D.* Vanderbilt Medical Center Beryl Benacerraf, M.D. Harvard Medical Center *no disclosures

3D Scanning Probes

Clinical Applications „ „ „ „ „ „ „

Uterine malformations Endometrial polyps Fibroids Ovarian/ Paraovarian masses Ectopic pregnancies Tubal disorders IUD localization

Mechanical Array 3D Probe

Key terms „ „ „ „ „ „

Acquistion scan plane Multiplanar Reconstruction (MPR) Volumetric rendering Surface rendering Inversion rendition Selection of scan plane from volume

Normal uterus (acquistion)

Normal 3D US of Uterus/Endometrium

Normal endometrium

Normal Uterus/Endometrium

Normal endometrium-coronal

Uterus with ascites (volume acquistion) acquistion)

Normal ovary with follicles

Uterine Malformations -important conceptsconcepts„

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Septate Uterus

Septate uterus more common than bicornuate, bicornuate, assoc with reduced implantion Bicornuate uterus has fundal cleft Depict fundal contour on coronal to distinguish these Many variants of fusion anomaliesanomaliesmake sure to evaluate kidneys

Septate Uterus

Septate Uterus/L horn

? Septate uterus-2D

Complete Septate Uterus

? Synechia (2D)

Uterine synechia (3D)

Arcuate uterus (3D)

Septated Uterus (loop of 3D)

? Arcuate Uterus

Arcuate/ T-shaped uterus

?Rudimentary R horn

Rudimentary R horn

Bicornuate uterus with rudimentary R horn

? Gestational sac within a bicornuate uterus (2D)

? Gestational sac within a bicornuate uterus (2D)

5 week IUP in a bicornuate uterus (coronal viewview-3D)

Twin Gestational Sacs within Subseptate Uterus

Subseptate, 2 Cx’s (3D)

Uterus didelphys (3D)

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Bicornuate/Bicollis Uterus

Bicollus (2 cervices)

? Normal on 2D

Unicornuate Uterus on 3D

Intraluminal Disorders

Polyp (3D)

PolypsPolyps-delineate pedicle/feeding vessel (s) Synechae Submucosal fibroidsfibroids-evaluate extent of myometrial involvement

3D of sessile polyp (loop of 3D)

Polyps

A. Lev-Toaff, MD

Polyps

Polyps /vessels

Polyp with vessels on 3D

Vascular Polyp

SHG using 3D

SHG-polyp

SHG-Polyp Rendering

SHG/polyp (3D)

SHG/polyp (3D) (surface rendering)

Polyp (3D)

Intracavitary submucosal fibroid (3D)

Submucosal fibroid-2D

Submucosal Fibroid

Submucosal Fibroid-2D

Stalk of Submucosal Fibroid-3D

Submucosal Fibroid

3D US of IUDs „ „ „ „ „

I.U.C.D. (3D)

Coronal viewview-show shaft and arms Shadow “under” under” the IUD Use 3D Tomosonography for “Lost IUD/string Merina IUD may be hard to see

IUCD-Tomographic 3DUS

Mirena I.U.C.D. (3D)

Mirena I.U.C.D. (3D)

Optimal position of IUCD

Low IUCD

Embedded low IUCD

Embedded IUCD

Embedded IUCD

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Embedded IUCD

Low embedded IUCD

3D US of Pelvic Masses

Cyst with fibrin strands (3D)

Use select planes of volume redition Look for papilllary excrescences both Inside and capsular Comment on thinness of septa/wall

Septated Cyst

Hemorrhagic cyst with formed clot (3D)

Colon Ca Mets to Ovary (3D)

Colon Ca Mets to Ovary (3D)

Colon Ca Mets to Ovary (3D)

Ovarian TumorTumorPapillary Excrescences

Papillary cystadenoma (3D)

Papillary excresence (3D)

Live 3D/4D Matrix Array Probe

Dermoid cyst

Hydrosalpinx (3D)

Hydrosalpinx (3D)

Hydrosalpinx

Hydrosalpinx-2D/3D

Hydrosalpinx-axial/coronal

Hydrosalpinx-inversion mode

R/O Ectopic (2D)

R/O Ectopic (3D)

R/O Ectopic (3D)

Mtx Rx’ed Ectopic (2D)

Mtx Rx’ed Ectopic (2D)

Mtx Rx’ed Ectopic (3D)

Composition of Solid Tumors

Tumor Neovascularity

Kuszyk, B., AJR, 177:747, 2001 McDonald, Choyke Nat Med 9:713, 2003

Ovarian Cancer (MPR/3D)

WARNING! It’ It’s academic! (Microbubble USUS- FDA approved for cardiac applications only!)

Microbubble US Contrast

Bolus injection of UCA

B-mode ultrasound

UCA signal

3D of murine ovary

Contrasted Ovarian Sonogram

3D Contrasted Ovarian Mass

3D Color Doppler Pelvic Sonography Applications „

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Complete evaluation of pelvic mass - location, organ of origin - relation to other pelvic structures - vascularity Serial assessment of fibroids Evaluation of uterine malformations Detection of tubal abnormalities

3D Color Doppler Pelvic Sonography Instrumentation/Technique „

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3D Color Doppler Pelvic Sonography „

Freehand vs automated scanning

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Volume rendered image can be manipulated to emphasize internal contents of surface

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3D “feel” feel” by manipulating images

3D Volumetric CDS „

Qualitative assessment of microvascularity • Vessel caliber • Vessel branching

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Affords complete delineation of pelvic mass its organ of origin and vascularity Affords depiction of areas not readily obtainable with 2D Allows accurate determination of volumentric changes of fibroids, pelvic masses Affords depiction or vascularity within uterus, ovaries, tubes Improves evaluation of uterine malformations

Quantitative assessment of microvascularity • Vascular Index • Flow Index • Vascular Flow Index

Quantitification of Vascularity „

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Vascularity Index=% pixels/voxels pixels/voxels with color/total Flow Index=power weighted pixel/voxel pixel/voxel density/total Vascularity/Flow Vascularity/Flow Index=product of VI x FI Fractal dimension Vessel branching/caliber

3D CDS of Ovarian Masses (Alcazar, J JUM 28:275, 2009) „ „ „ „

V.I.V.I.-sens 92%; spec 33% F.I.F.I.-sens 95%; spec 33% V.F.I.V.F.I.-sens 94%; spec 33% Helps reduce falsefalse-positives

Papillary serous Ca with feeding vessel

Tumor neovascularity

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Bladder Tumor

Pelvic Floor-3D/4D

Conclusions

Acknowledgements

3D pelvic sonography has many applications including uterine (myometrial and endometrial) and adnexal (ovarian and tubal) tubal) disorders Best used as problemproblem-solver Potential to obtain volumetric images

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B. Benacerraf, M.D.,R. Andreotti, Andreotti, M.D., A. Lyshchik, Lyshchik, M.D.,Ph.D. M.D.,Ph.D. L. Sheets, R.D.M.S., S. Rivers, R.D.M.S, L. Pertl, Pertl, R.D.M.S., P. Kalman (Philips Medical Systems) P. Williams, R.D.M.S, M. Davis, R.D.M.S. and all VUMC and CWI sonographers