1

Applications of 3D Ultrasound in Gynecology- What Really Works

Ulrike M. Hamper, MD; MBA; FACRRussell H. Morgan Department of Radiology and

Radiological SciencesJohns Hopkins University School of Medicine

Baltimore, Maryland, USA

Disclosures

No conflict of Interest

Nothing to Disclose

3D US in Gynecology: Objectives

• Technique and limitations of 2D/3D US• Role of 3D GYN imaging for: • Uterine anomalies• Myometrial and endometrial lesion•  IUD localization• Adnexal masses• Essure device

2

Conventional 2 D Imaging

•  Limited by small FOV of the EV probe and anatomical conditions

• Mainly obtain sagittal and transverse images- rarely obtain coronal views of the uterus - depends on uterine orientation

•  Limited imaging of the cervix•  Can obtain video clips for consultation or

later review

3 D US- Background

•  Increased interest in 3D US as equipment performance and user experience have changed rapidly

• Primarily applied in OB and GYN• Limited abdominal and vascular

application• Limited endocavitary experience for

prostate and peri-prostatic structures

3 D US in Gynecology-Advantages

• Acquire Volume data set• Any desired plane- regardless of uterine

orientation•  Interactive correlation of 3 orthogonal planes• Accurate volume calculations• Different rendering techniques- less important•  Stored volume data sets

– Review at later time (patient, referring MD) •  Consulting across networks

3

3D Gyn Imaging: Problems/Issues• Need for special equipment/transducer•  Size limitations of the volume box•  Problems with orientation and labeling of

volumes – steep learning curve• Most US PACS currently cannot easily

handle large volume data sets•  ??- Who performs the reconstructions?• US community at large not yet prepared for

generalized volume imaging

Why 3-D US in Gyn?- Some Facts•  Anecdotal experience reported over the past

15-20 years•  Increasing reports in the literature recently•  Fiscal/time pressure on clinical practices•  ? Can 3D US increase/improve workflow ?•  3-D US is now competing with CT and MRI•  ñ marketing to clinicians and patients•  Separate workstation for off-site review is a

must to be successful in daily practice and for billing and reimbursement

3-D US - GYN

•  Most useful plane: coronal or “face on” plane

•  Best for assessment of uterine anatomy/anomalies

•  Assessment of adnexae•  Assessment of endometrium - depiction of

polyps, location of IUD’s, location of fibroids•  ? Better assessment of EM thickening / EM

volume measurements more relevant?•  ? Myometrial invasion of EM cancer

4

3D US or Volume US - Technique•  Volume data acquired, stored and reviewed

immediately or when patient has left or from remote site

•  Data reformatted and post processed with different rendering techniques

•  Display in multiplanar, multislice and/or 3D rendered views–  surface rendering or inversion mode (cystic areas

displayed as echogenic-bright, gray scale portion as transparent)

Multi-Planar Reconstruction

3D Gyn- Multislice US

• 50-100 slices can be displayed• Similar to number of slices in

uterine MRI• Slice thickness 0.5 to 5mm• Goal: precise sequential display of

anatomy

5

3 D- Multislice US - Septate Uterus

Multi- slicing Technique - Corpus Luteum

Surface Rendering Technique

6

Endometrial Polyp

3 D - Sonography of Endometrium and Myometrium

•  Additional findings observed in 30.8 % of patients

•  Added information: uterine anomalies, better definition of the endometrium, more accurate delineation of endometrial polyps, location of leiomyomas, visualization of cystic areas within myometrium and confirmation and location of intrauterine contraceptive devices

Andreotti et al: JUM 2006;25: 1313-1319

3 D US an Adjunct to 2D-Imaging

•  3 D coronal views added value to the 2D scan in 16/66 (24 %) of patients •  3 D added information not seen at all on 2 D imaging

in 5/16 pts, added diagnostic confidence in 11/16 pts •  3 D added information when EMS incompletely seen

on 2 D imaging or when EMS > 5 mm in 39 % of pts •  Uterine shape anomalies identified in 3 pts with

infertility •  Location of fibroids (submucous vs. intramural) more

accurately identified on coronal views in 24% of pts

•  3 D not helpful in pts with normal findings on 2 D scanning !!

Benacerraf et al: AJR 2008;190: 626-629

7

3D- Submucous Myoma

3D- Myoma Volume Calculations

Research topic to be explored and validated

Endocervical Polyp – 3D

8

Endocervical Polyp – 3D

Thickened Endometrium - ? Value of 3D

? EM Volumecalculations

? Myometrial invasion in endometrial ca

We do not know yet

Uterine Malformations

• Heterogeneous group of congenital anomalies due to:

• Underdevelopment of Müllerian ducts

• Fusion anomaly of Müllerian ducts• Alteration in septum resorption

between paired Müllerian ducts

9

Uterine Abnormalities - 3-D US

• Advantages– Obviates MRI in most cases– Facilitates rapid saline infusion

sonohysterogram – SIS– Optimizes communication with

patient and referring physician– Aids in treatment planning

Classification Uterine Malformation-�American Fertility Society

3D Surface Rendering of Uterine Malformations

Normal Unicornuate Didelphys Bicornuate Partial bicornuate

Septate w 2 cervices Septate/subseptate Arcuate DES-T shaped

10

Uterine Malformations - Conclusion

• High degree of concordance between 3D US and MRI in diagnosis of uterine malformations

• Relationship between uterine cavity and fundus equally well seen with both techniques

Uterine Malformations – 3D US

•  Some of minor malformations (arcuate , septate, bicornuate) seen on 2D US

•  3D-US allows visualization of relationship of uterine cavity with fundus on C-plane

• Allows measurement of thickness/ length of septum, calculate volume of uterine cavity

• Aids in choice of treatment

Unicornuate Uterus

11

Arcuate Uterus

Preserved uterine contour

Arcuateuterus

8mm

Septate UterusMultiplanar display- preserved uterine contour

Multislicing display- confirm if uncertain

12

Septate Uterus

Preserved uterine contour, midline septum to cx- US

Dark fibrous septum to cx, preserved uterus contour-MRI

Bicornuate UterusFundal Indentation

T-Shaped Uterus

•  In utero DES exposure

13

3D US and Intrauterine Contraceptive Device (IUD)�

• Often incidentally detected on pelvic US• Accurate position in uterine important•  2D mainly shows the shaft of the IUD•  3D coronal view demonstrates entire IUD -

shaft, side arms and relationship to endometrial cavity and exact position as well as location of the string

• Malposition of IUD: associated with pain/bleeding and ineffectiveness

3D IUD - Mirena & Copper T

CopperTIUD-normal

14

3D IUD – Lippes Loop & Skyla

IUD malpositioned low in Cervix

Sidearm embedded in cervical musculature

IUD Malpositioned

Normal looking on 2 DAbnormal right arm on 3 D embedded in the myometrium

15

MirenaIUD-SidearmsembeddedintheFundalMyometrium

IUD in Septate Uterus

Shaft extruding into myometrium

S/P IUD- String not Seen

IUD in normal location String recoiled in EM Canal

16

S/P IUD- String not Seen

IUD in normal location String recoiled in EM Canal

Saline Infusion Sonohysterography�(SIS)

•  Installation of sterile saline into endometrial cavity

•  Evaluation of endometrial or submucosal abnormalities

•  Perform during 1st week of menstrual cycle - EMS thinnest

•  SIS with 3D with multislicing display preferred over 2 D imaging

3D SIS- Multislice Display

17

Endometrial Polyp - 3D SIS

Submucous Myoma- 3D SISBroad based mass in the left myometrium protrudinginto endometrial canal

3-D Gyn- Adnexa

• Oblique coronal planes best for ovaries and tubes

• Tubal versus ovarian lesion• Hydrosalpinx• Paraovarian versus ovarian cyst• Assess cyst morphology• Bowel versus adnexal structures

18

3D Simple Ovarian Cyst

3D- Corpus Luteum- Ring of Fire

3D – Polycystic Ovary

19

3D

2D 2D

Hydrosalpinx- Multiplanar Views

3D shows tubularstructure

Essure - Tubal Sterilization

•  Permanent birth control device• Alternative to traditional

tubal ligation•  Inserted into tubal opening

via hysteroscopy•  Can be done as office procedure•  Tubal location of the device

will become scarred-blocking tube

Essure Device - Proper Location Confirmed on 3D US

20

Conclusion: 3D/4D US: �As a Problem -Solving Tool

Generally agreed upon:•  Uterine Malformations•  IUD placement assessment•  Some Adnexal Masses, e.g. hydrosalpinges•  Sonohysterography

Requires further study:•  Tubal Patency•  Endometrial Volume – vs. endometrial

thickness (benign/malignant, infertility/IVF)•  Ovarian or follicular volume

Conclusion - 3D/4D US

•  Valuable problem solving tool in Gyn imaging•  Allows more detailed and comprehensive exam

of the uterus and adnexa than 2-D US•  More applications are evolving as the technology

improves•  Need to educate more imagers and clinicians

about benefits of 3-D US•  Need to improve and standardize image displays •  Need to be able to store large data sets on PACS

Thank You!!umhamper@jhu.edudkanmani@montefiore.org