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Original Research |
1 Diagnostic Ultrasound Associates, 333 Longwood Ave., Boston, MA 02115.
2 Departments of Radiology, Brigham and Women's Hospital, Massachusetts General
Hospital, and Harvard Medical School, Boston, MA.
3 Departments of Obstetrics and Gynecology, Brigham and Women's Hospital,
Massachusetts General Hospital, and Harvard Medical School, Boston, MA.
Received May 25, 2007;
accepted after revision September 27, 2007.
Address correspondence to B. R. Benacerraf.
Abstract
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MATERIALS AND METHODS. Sixty-six consecutive patients underwent standard 2D pelvic sonography followed by 3D sonography. The physician determined whether the reconstructed coronal view of the uterus was helpful to make a diagnosis not possible with the 2D scan, helpful to be more confident of a diagnosis suspected on the basis of the 2D scan, or not helpful. Comparison of the demographic information, sonographic findings, and endometrial thickness was made between the patient groups.
RESULTS. The 3D coronal views of the uterus added value to the 2D
scan in 16 (24%) of the 66 patients. In five of these 16 patients, the coronal
view added information about findings not seen using 2D imaging. In the other
11 patients, the diagnostic findings were more confidently seen using the
coronal view. The coronal view added no information in 50 patients. The
coronal view was helpful in four (12.5%) of 32 patients with an endometrium
< 5 mm, one of six patients whose endometrium was incompletely seen with 2D
sonography, and 11 (39%) of 28 patients whose endometrium measured 
5 mm.
The coronal view did not provide benefit in patients who had normal findings
on 2D scanning. In three patients referred because of infertility, uterine
shape anomalies were diagnosed using the coronal view.
CONCLUSION. The 3D coronal view of the uterus is a valuable adjunct
to a 2D pelvic scan, particularly in patients presenting with infertility or
suspected endometrial lesions. In addition, the coronal view is helpful in
patients with an endometrium 5 mm.
Keywords: 3D sonography • infertility • obstetrics and gynecology • pelvic sonography • women's imaging
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The coronal volume was centered around the region of the endometrium and taken longitudinally. The study was initially read using the information available with standard 2D imaging. Thereafter, one of three sonologists manipulated the additional volume sweep to display the three perpendicular planes (multiplanar reconstruction). A 3D coronal view of the uterus was generated using the technique of Abuhamad et al. [7], and any additional sonographic information obtained from that view was tabulated. The sonologist reviewing the volume had access to the entire volume so that the best coronal view of the uterine cavity could be generated. The sonologist then determined if the reconstructed 3D coronal view was, first, critical in making a diagnosis that was not possible based on 2D imaging alone; second, helpful in increasing the confidence of a diagnosis suspected based on the 2D scan; or, third, did not provide any additional useful diagnostic information.
A comparison was made between patients who benefited from the reconstructed coronal view of the uterus versus those who did not based on the patient's age, indication for scanning, and sonographic findings on 2D sonography. Statistical comparisons of the subgroups were performed using the Student's t test or chi-square test as appropriate. A p value of < 0.05 was considered statistically significant.
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The width of the endometrium was an important predictor of whether the
reconstructed coronal view would be helpful. Among patients with an
endometrium 5 mm, the 3D coronal view provided additional information or
information that allowed a more confident diagnosis in 11 (39%) of 28
patients. On the other hand, the 3D coronal view was helpful in only four
(12.5%) of 32 patients whose endometrium was < 5 mm (p = 0.02):
one subseptate uterus, one polyp in the cervix, one arcuate uterus, and one
submucosal fibroid. There were six patients in whom the endometrium was
incompletely seen with 2D sonography; in one of these patients, a submucosal
fibroid was better shown by the 3D reconstruction. However, obtaining a good
3D coronal view of the uterus in patients whose standard 2D sonograms showed
an endometrium measuring < 5 mm or an ill-defined endometrium was
technically more difficult than in patients with a thicker or a well-defined
endometrium.
Thirty-four patients had fibroids identified on 2D sonography; in eight (24%) of these 34 patients, the presence of a fibroid and its location were better seen using the 3D coronal view (seven submucosal and one intramural) (Figs. 1A, 1B and 2A, 2B).
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Five patients in our series had uterine anomalies: four had an arcuate uterus and one, a subseptate uterus. The 3D coronal view was required to make the correct diagnosis of an arcuate uterus in three of the four patients. In the fourth patient, arcuate uterus was correctly diagnosed using standard 2D sonography and 3D imaging did not provide additional information. Two of the four patients with arcuate uteri were referred for sonography because of infertility, and the other two underwent scanning because of suspected ovarian cysts and pelvic pain; for the latter patients, arcuate uterus was an incidental finding. The fifth patient with a uterine anomaly was referred because of infertility and had a subseptate uterus. Although the 2D sonography findings were suspicious for a uterine anomaly, the exact diagnosis of the septum could not be made without the benefit of the 3D-generated coronal view.
There was no significant difference between the ages of the patients for whom the 3D coronal view was or was not beneficial (p = 0.3) (Table 1). In most of the patients referred for an indication of fibroids or infertility, the coronal view yielded additional information, although the numbers are too small to make firm conclusions (Table 2).
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5 mm. In 39% of these
patients, additional information was derived from the 3D reconstructed view
compared with 12.5% of those with an endometrium of < 5 mm. The third type
was patients with uterine fibroids. The specific location of the fibroids
(i.e., submucous vs intramural) was more accurately identified in 24% of
patients with fibroids using the coronal view. Review of a 3D coronal view allowed abnormalities not fully detected on 2D sonography to be identified in five patients, including four patients with uterine abnormalities (three arcuate and one subseptate) and one patient with a submucosal fibroid or polyp.
Our findings confirm those of Andreotti et al.
[2], who also found that a 3D
coronal view was helpful in patients in whom 2D sonography findings of the
uterus were abnormal. Both studies agree that patients with fibroids and
polyps benefit from the 3D coronal view. In addition, our study shows that in
patients with an endometrium 5 mm, the 3D coronal view is more likely to
yield information than in those with a thin (< 5 mm) or an ill-defined
endometrium. This result suggests that in patients with fibroids or suspected
uterine anomalies, the gynecologic scan should be obtained in the luteal phase
of the menstrual cycle to use the echogenic endometrium to highlight the
location of any submucous fibroid or uterine cavity anomalies.
The age of the patients did not affect the utility of the coronal view of the uterus. Other than infertility or a question about the presence of a uterine anomaly, our study did not show any specific indications to be predictive of additional benefit from the 3D coronal view. The result of the initial 2D scan was the best criterion to determine in which patients the additional 3D coronal view should be obtained. The coronal view of the uterus was not helpful in patients with normal findings on 2D scans (except three patients with an arcuate uterus, two of whom had infertility) or in most patients with an endometrium measuring < 5 mm.
The results of many other studies suggest that reconstructed views from 3D volume acquisition can add to the information available with standard 2D sonography alone [1–6].
The addition of a 3D coronal view is not a time-consuming addition to a pelvic sonography examination, and this view can easily be added to the protocol when needed. Abuhamad et al. [7] have shown that reconstruction of the 3D coronal plane of the uterus (Z technique) during a gynecologic study takes less than 1 minute when performed by an operator without special training and less than 30 seconds when performed by an operator who has completed a short training session [7]. Adding this 3D coronal view to the standard 2D sonography protocols is therefore unlikely to add considerable time to the pelvic sonography examination.
The main limitation of our study was a lack of surgical confirmation for most of our cases because many of the patients did not undergo surgery. As with other studies similar to ours, the accuracy of 3D sonography reconstructions has been well substantiated in the literature [1, 2]; therefore, we do not think that the lack of surgical follow-up is problematic in our current investigation. Second, the acquisition of the 3D volumes was performed by the same sonographer who obtained the initial 2D scan. We do not believe that knowledge of the findings on the 2D scan was a drawback because we were investigating the benefit of adding the 3D coronal view to the standard 2D protocol, not of replacing the initial scan. The sonography practitioner is expected to know the results of prior 2D scanning when performing the 3D volume evaluation.
Another limitation is the small size of our study; however, this study was a pilot study of consecutive patients, and we hope that our results will stimulate others to perform a larger study, perhaps involving multiple centers, to confirm our results and further study about the benefit of adding 3D volume scanning to pelvic scanning protocols. Finally, the exact time in the menstrual cycle that each patient underwent imaging was not accurately recorded and therefore cannot be commented on.
A few points of clarification should be mentioned: The availability of the entire coronal volume for the sonologist to manipulate and generate the best view was an advantage. A single image of the coronal view of the uterus obtained randomly would be less valuable and is not the focus of this study. We aimed to optimize the additional information provided by seeing the endometrium from a coronal viewpoint. Also, our study does not address whether the sonologist goes into the room to scan the patient personally. Our protocol includes having the sonologist personally involved in every gynecologic scan working together with the sonographer. The use of the additional volume showing the coronal plane of the uterus (as shown in this study) is unrelated to whether the sonologist enters the room during the vaginal scan. Last, the volumes obtained during scanning can be quickly and efficiently manipulated at the sonography machine during scanning and do not require the additional cost of transferring them to a PACS system, as we did here.
In conclusion, the results of this study indicate that a 3D volume
acquisition of the uterus, used to reconstruct a 3D coronal view, is a
valuable adjunct in evaluating patients with abnormal findings on 2D pelvic
scans—particularly patients presenting with infertility, patients with a
2D finding of endometrial lesions or fibroids, and patients with an
endometrium 5 mm. The results of this study suggest that patients in any
one of these categories will benefit substantially from the addition of a 3D
coronal view of the uterus to the standard pelvic sonography protocol.
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