Advanced Applications for Ultrasound in Gynutcomchatt.org/...Advanced_Applications_for_Ultrasound_in_Gyn_2294.pdf · Advanced Applications for Ultrasound in Gyn Theodore Tsaltas,

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Advanced Applications for Ultrasound in Gyn

Theodore Tsaltas, MD Assistant Professor Ob/Gyn Head of Ultrasound Services

University Ob/Gyn

Learning Objectives

-advantages of USG over CT

-USG for localization of IUDs and cavitary masses

-evaluation of the endometrium

-evaluation of masses

-pain mapping

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Why USG?

-differentiation of pelvic tissues

-details of endometrium

-details of ovarian masses

-evaluation for sources of pelvic pain

What Type of USG

Vaginal probe scanning is best

-most detailed view of pelvis

-direct contact evaluation for pain

-less painful than digital exam

-empty bladder

no filling time

no catheter

no discomfort

Who should do it?

Get an Ob/Gyn with specialized training and experience

-direct hx/exam/USG correlation

-knowledgeable of details needed

-no abdominal scout film

no full bladder

exam takes its place

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Equipment

Not all machines and probes are alike! Best results obtained with -multi and high frequency probe best is 7+ mHz 7-2 or 9-3 -3D capability -doppler capability -adjustable frequency distribution penetration vs resolution

Why Not CT?

CT is terrific for retroperitoneum

Cannot discriminate between adjacent

tissue density organs/masses

USG readily differentiates organs

relies on water content

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IUDs

Positioning

Orientation

Localization if mis-positioned

3D images greatly superior to 2D

IUDs

2D image of IUD

Cannot determine orientation or position of arms

Only position relative to fundus

IUDs

3D images define position exactly

IUDs

Another 3D picture

Coronal plane only visualized by 3D reconstruction

IUDs

-Perforation is sometimes readily visualized by 2D USG

-Easier and much more precise in 3D

-Exact part of IUD and location of perforation can be shown

-Easier and safer for removal, surgery

IUD localization

-3D technique is a reconstruction

-Good 3D requires good 2D

-Details of IUD type, location and position can be precisely described

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IUD misplacement

Sometimes perforation is obvious

sagittal transverse

IUD Misplacement

3D is typically much clearer

IUD Misplacement

Even complex malposition can be precisely located

IUD placement

shape and

position

exquisitely

definable

Endometrium

Menstrual phase readily diagnosed

-follicular- ‘triple track’ sign

-luteal- one hazy, uniform mass

more water makes for finding

Maximum NL thickness- 15 mm

Endometrium

Follicular Late Follicular

Luteal

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Endometrium

Not simply thickness and cycle phase Character must be defined Elements- Interface Regularity vacuoles calcifications Masses Compression/distortion

Endometrium

Character details major aid in dx- -polyps -hyperplasia -cancer -retained placental tissue -IUD infection -myomas -adenomyosis

Endo-myometrial interface

Smooth is normal, w/ sharp demarcation line

Irregularity is 1 of 4 major criteria for adenomyosis

Loss of boundary suggestive of endometrial CA

Endo-myometrial interface

Normal

Endo-myometrial interface

Normal luteal interface

Endo-myometrial interface

adenomyosis

Loss of border

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Endo-myometrial interface

Endometrial CA Highly irregular

interface although

with smooth echo

appearance

Vacuoles and Calcifications

Endometrial echo should be smooth

Irregularity suggests pathology

Most commonly associated with-

polyps

hyperplasia

retained tissue

Echoirregularity

Vacuolization

Echoirregularity

Calcifications

Endometrial Masses Polyps and Myomas

50-80% of polyps can be found with sensitive vaginal USG

Sonohysterography major tool in Dx

100% of intracavitary masses

3D cavitary recontruction helpful in determining surgical management

Polyps

2D findings-

disruption in endometrial stipe

best seen in follicular phase

SHG-

mass within cavity

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Disruption of midline stripe by mass effect

Simple disruption without mass is enough to prompt SHG

note NL thickness

but abnormal

regularity

Polyp in 2D-

Polyp on SHG-

SHG Hysteroscopy

Polyp Vasculature

Doppler allows visualization of the blood supply to a polyp

Vessels not normally seen in endometrium

Vascular pattern can also suggest CA

Myomas have different echo texture

USG critical tool for hysteroscopic resectabiltiy

<50% of myoma in cavity

unresectable

>50% of myoma in cavity

resectable

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Resectable Nonresectable

USG, 3D USG and SHG make the

difference between-

-invasive vs non-invasive eval

-open vs endoscopic surgery

USG techniques allow complete evaluation and management as outpt

and with minimal invasion

Uterine Anomalies

USG replaces HSG in diagnosis

Non-invasive

No radiation exposure

USG allows exquisite evaluation of

-uterine horns

-cavitary size and symmetry

-associated tubal/ovarian path

Uterine Anomalies

Traditional methods of dx require

HSG (radiation exposure)

laparoscopy

Cannot differentiate

septate vs bicornuate on HSG

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Uterine Anomalies

USG can readily distinguish

septate from bicornuate

SHG + 3D produces an exquisite rendering of cavity shape

Size, thickness and depth of septum can be precisely known preop

More Fun with USG- Ovarian Masses

USG is powerful tool for differential diagnosis of adnexal masses plain 2D 3D views of cyst walls 3D reconstruction of shape RI on doppler Combined with tumor markers can correctly predict nature of mass more than 90% of time

Differentiation of-

corpus luteum vs complex mass

dermoid vs endometrioma

benign and malignant masses

tube vs ovary

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Always look at films or get GYN to scan pt

details of masses make all the difference

EG-

Do not accept report of corpus luteum as ‘complex mass’

Tracking Ovulation

Corpus Luteum

The doppler ‘ring of fire’

Corpus Luteum Development

It is wall thickness, not size, that determines adequacy of CL

Hemorrhagic Corpus Luteum

Common finding- rarely requires OR

Don’t let this be called ‘complex mass’

Corpus Luteum or Endometrioma

Corpus Luteum Endometrioma

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Hydro- and Pyosalpinx

Fluid and pus filled tubes

Result of salpingitis (PID)

3D reconstruction very helpful in dx between bowel, tumor and tube

Here is gross appearance-

Plain vs 3D-

Dermoids

Highly variable appearance

May contain teeth, hair and sebum

Differentiate from endometrioma

Dermoids

All the following images are dermoids

All are benign!

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Malignancies

Diagnosis can be subtle, BUT---

Usually the findings are striking

Associated RI, serology make dx

All the following images are of benign ovarian tumors…..

These masses may be managed by-

-needle drainage reduction

-laparoscopic removal

Outpatient procedures

Minimal scars or recovery

The next images are all of malignant tumors…..

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These masses require oncologic surgery-

-debulking

-large incisions

-chemo

Large masses require careful evaluation

They do not need an oncologist ab initio

High quality USG and tumor markers first

Many cases managed by generalists and minimally invasive procedures

Summary

USG powerful tool for Gyn diagnosis

-endometrial character and pathology

-polyps and myomas

-uterine anomalies

-benign ovarian masses

-ovarian malignancies

Summary

USG allows guidance of management

-minimally invasive management

-correct referrals

-prevention of alarm

-best counseling

Summary

Think of ultrasound for evaluation of Gyn pathology

Get scan done by someone with significant expertise and interest-

Details matter!

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THANK YOU

Theodore Tsaltas, MD

Assistant Professor, Ob/Gyn

Head of Ultrasound Services

University Ob/Gyn