3D in 3D in GynGynUltrasound:Ultrasound: The Basics and ... · 3D in 3D in...
Transcript of 3D in 3D in GynGynUltrasound:Ultrasound: The Basics and ... · 3D in 3D in...
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3D in 3D in GynGyn Ultrasound:Ultrasound:The Basics and ApplicationsThe Basics and Applications
WILLIAM W. BROWN, III, MDWILLIAM W. BROWN, III, MDDirector, Ambulatory Ob/Director, Ambulatory Ob/GynGyn and Ultrasoundand Ultrasound
Denver Health Medical CenterDenver Health Medical Center
Associate ProfessorAssociate Professor, Dept. Ob/, Dept. Ob/GynGyn
University of Colorado School of MedicineUniversity of Colorado School of Medicine
Conflict of Interest DisclosureConflict of Interest Disclosure
Consultant—Philips Ultrasound
Learning ObjectivesLearning Objectives
BBehavioral objective: ehavioral objective: –– Incorporate 3Incorporate 3--dimensional pelvic ultrasound dimensional pelvic ultrasound
into practice where there are clear benefits to into practice where there are clear benefits to the technology the technology
Content:Content:–– The “ZThe “Z--technique” and the midtechnique” and the mid--coronal plane coronal plane
of the uterusof the uterus
–– Formatting Formatting –– MPR, rendered, inversion and MPR, rendered, inversion and tomographic views tomographic views
–– Technical tips to expand practiceTechnical tips to expand practice
33--D Ultrasound in GYND Ultrasound in GYN
Areas of clear benefit– Uterus and endometrium
• Müllerian uterine anomalies (CUA)
• IUD location/managementIUD location/management
• Sub-mucous myomas
• 3D sonohysterography (SIS)
• Essure micro-inserts
• Intrauterine adhesions (Asherman’s)
33--D Ultrasound in GYND Ultrasound in GYN
Areas of clear benefit– Fallopian tube
• Cornual/interstitial pregnancy
• HydrosalpinxHydrosalpinx
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22--Dimensional ImagingDimensional Imaging
Limitations – Scanning planes – two
• Sagittal
H i t l• Horizontal
– Bony structures of the pelvis reduce vaginal probe mobility
33--D Imaging D Imaging Orthogonal Planes
Th l f d t iPlane 3
The volume of data is displayed as three orthogonal planes at 90°to each other
Plane 1
33--D DisplayD DisplayWhat does it mean?
Acquisition view
90° toPlane 1
90° to bothPlanes 1&2
3-D Imaging Multi-planar (MPR) Views
Three MPR views displayed
Ability to
Plane 1 (A) Plane 2 (B)
Ability to – Slice through the
planes sequentially or rotate any plane
– Reconstruct the MPR views in different planes
Plane 3 (C)
3-D Imaging Rendered Volume
2-Dimensional Imaging3-Dimensional ImagingUterusUterus
Sagittal TransverseCoronalCoronal
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“Volume Data Set” Manipulation“Volume Data Set” ManipulationMultiMulti--Planar Reconstruction, RenderingPlanar Reconstruction, Rendering
33--D Ultrasound in GYND Ultrasound in GYNUterus and EndometriumUterus and Endometrium
Z-Technique1 for mid-coronal view – Board certified physicians already practicing
2-D TVS
1Abuhamad A. JUM 2006;25:607
– No prior exposure to post-processing 3-D volume data sets
– Mean time required to display the C-plane was 47.7 seconds
– Easy to learn!
Congenital Uterine Congenital Uterine AnomaliesAnomalies Congenital Uterine AnomaliesCongenital Uterine AnomaliesAccuracy Accuracy
3-D ultrasound as effective as MRI, but less costly and faster– Raga, F. Fertil Steril 1996;65:523
• 42 patients, infertility, LS and HS confirmation
• 11/12 correct anomaly diagnosis
• 41/42 correct external configuration of the uterus
– Kupesic S. J Ultrasound Med 1998;17:631• 420 patients, infertility or RPL, 278 septate uterus
• LS and HS confirmation
• Sensitivity 98.4%, specificity 100%
Congenital Uterine AnomaliesCongenital Uterine Anomalies
Septate
Congenital Uterine AnomaliesCongenital Uterine Anomalies
Septate
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Congenital Uterine AnomaliesCongenital Uterine Anomalies
Septate
Congenital Uterine AnomaliesCongenital Uterine Anomalies
Arcuate
Congenital Uterine AnomaliesCongenital Uterine Anomalies
< 1 cm
Arcuate
Congenital Uterine AnomaliesCongenital Uterine Anomalies
T-Shaped
Congenital Uterine AnomaliesCongenital Uterine AnomaliesTechnical Tips Technical Tips
With TVS, consider late luteal phase timing– Sonohysterography (SIS) helpful, not mandatory
Uterine size/architecture may require moreUterine size/architecture may require more than one automated sweep or a handheld sweep– Alternative: horizontal plane of acquisition
Separate 3D imaging of the cervix
IUDIUD
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IUDIUD
Improved accuracy for IUD identification and positioning– Bonilla-Musoles F. J Clin Ultrasound 1996;
24:263 26724:263-267• 2D vs. 3D assessment of IUD location
• 2D: 10/66 either misidentified location/position or not seen
• 3D: all IUDs accurately identified—confirmed by hysteroscopy (HS)
IUDIUD
Ideal means to image myometrial side arm penetration– Benacerraf B. Ultrasound Obstet Gynecol
2009;34:110-115• 16.8% of 167 pts showed side arm penetration into
the myometrium and this finding only detected on 3-D coronal view of the uterus
• Higher proportion (75%) of pts with abnormal IUD location had pain or bleeding than those with normal IUD location (34.5%)
• 20/21 symptomatic pts with abnormal IUD location improved after removal
IUDIUD
Benacerraf B. Obstet Gynecol 2010;116:305-10
IUDIUD
Shipp T. J Ultrasound Med 2010;29:1453-6
IUDIUD
32 mm
Mirena® Paraguard®
36 mm
Skyla®
IUDIUD
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IUDIUD IUDIUD
IUDIUDTechnical Tips Technical Tips
Consider 3D sweep on all patients with IUD in-situ presenting for ultrasound
Rendered/slab/thick slice view may improveRendered/slab/thick slice view may improve contrast and detection of myometrial penetration
Should ‘best practice’ mean a 3D ultrasound before/after IUD insertion?
MyomasMyomas
MyomasMyomas MyomasMyomas
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3D SIS vs. 2D SIS 3D SIS vs. 2D SIS(Compared to Hysteroscopy)
HS Abnormal NormalSIS
Abnormal 19 3Abnormal 19 3Normal 1 22
3D-SISAbnormal 19 0Normal 1 25
de Kroon et al. J Ultrasound Med 2004; 23: 1433-1440
3D SIS vs. 2D SIS
Procedure time and patient comfort– Shortens procedure time and improves
patient satisfaction/comfort1
Weinraub Z. Ultrasound Obstet Gynecol 1996;8:277-282
Essure
Adhesions Fallopian TubeFallopian Tube
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Fallopian TubeFallopian TubeInterstitial Ectopic
Izquierdo, L. J Clin Ultrasound 2003;31:484-7
Malinowski A. Fertil Steril 2006;86:e1711-4
Tulandi T. Obstet Gynecol 2004;103:47-50
Fallopian Fallopian TubeTubeHydrosalpinxHydrosalpinx
Fallopian Fallopian TubeTubeInversion Rendering
Timor-Tritsch I. JUM 2005;24:681-88
ResearchResearchInfertility/ARTInfertility/ART
Infertility/ART
Cancer– Uterine
– Cervix
– Ovarian
Incontinence/pelvic floor– Vaginal, transperineal, endoanal
3D Ultrasound Limitations3D Ultrasound Limitations
“What you see is what you get”
Technology cost
Sonographer and physician learning curve
Decreased spatial resolution, especially outside of the plane of acquisition
Entire organ may not be in view with a single sweep and may require 2-3 volumes
Work flow changes in the ultrasound unit
SummarySummary
Short acquisition time for the test
Images may be manipulated in any plane
Multiple formats can be customized di t f d t taccording to preference and structure
under evaluation (e.g., MPR, rendered, thick slice/slab, tomographic display, etc)
Increase efficiency and patient satisfaction (3-D SIS)
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SummarySummary
“Doable” learning curve for data manipulation
Several areas within Gynecology where this technology has moved from thethis technology has moved from the research bench into clinical practice
The ongoing areas of research predict further expanded clinical uses for this imaging modality in the future
Case ExamplesCase ExamplesCase a p esCase a p es
Case #1Case #1
24 y/o, G0– LMP ~ 6 weeks prior; no contraception
– 2 day hx of moderately severe pelvic cramping and light vaginal bleedingcramping and light vaginal bleeding
– PMH, PSH – unremarkable– Physical exam
• 36° F, HR 84, RR 16, 134/83• Abdomen: non-tender, soft
– Laboratory• WBC 8.4, Hct 45%, A positive• UPT +, hCG 3183
Case #1Case #1 Case #1Case #1
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Case #1Case #1 Case #1Case #1
Ultrasound dx: – Left cornual pregnancy
Case #1Case #1 Case #1Case #1
Case #1Case #1 Case #1Case #1
Ultrasound dx: eccentrically located “angular” IUP
Interstitial pregnancy
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Case Case #2#2
17 y/o, G0– LMP ~ 2 weeks prior– Sudden, progressive, severe pain mostly L-
sided; seen 1 day prior at another hospital– Nausea, emesis, intolerant of oral analgesics– Menarche age 13 x 28 days x 4 days– PMH, PSH, ROS negative– Physical exam
• VSS; Abd – non-surgical; Pelvic – tender, no mass
– Laboratory• WBC 8.7, Hct 34%, UPT negative
Case Case #2#2
Hospital course– Report of outside ultrasound: possible
bicornuate uterus with normal right horn and a left horn “full of blood and debris”. Plan was for uterine evacuation if necessary.
– Treatment: IV anti-emetics and narcotic analgesics, non-steroidal analgesics, IV fluid hydration
– Imaging performed
Case Case #2#2 Case Case #2#2
Case Case #2#2 Case Case #2#2
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Case Case #2#2
Hospital course– Relapsing 10/10 pain, nausea, vomiting
– Surgery: laparoscopy with resection of left non-communicating functional uterine horn and leftcommunicating functional uterine horn and left salpingectomy
Case Case #2#2
Case Case #2#2 Case #3Case #3
31 y/o presented to PCP for annual exam. Only complaint = daily, mild, non-lateralizing pelvic discomfortpelvic discomfort.
IUD of unknown type placed elsewhere 3 years prior. Strings not visible on pelvic examination.
Patient desired IUD removal and fertility.
Case #3Case #3 Case #3Case #3
Brown W. The Female Patient 2011;36:37-39
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Case #3Case #3
Brown W. The Female Patient 2011;36:37-39
Case #3Case #3
Case #4Case #4
29 y/o, G5 P4, desiring sterilization– Essure tubal micro-inserts placed bilaterally
• “scar tissue at left ostea”scar tissue at left ostea
– HSG performed 3.5 mos later• Patient c/o chronic LLQ pain since procedure and
admitted significant discomfort during the procedure with placement of the left device only
Case #4Case #4
Case #4Case #4 Case #4Case #4