Alfred B. Kurtz

Evaluation of the woman with postmenopausal bleeding: Society of radiologists in ultrasound-sponsored consensus conference statement

A panel of 14 physicians practicing medicine in the United States with expertise in radiology, obstetrics and gynecology, gynecologic oncology, hysteroscopy, epidemiology, and pathology was convened by the Society of Radiologists in Ultrasound to discuss the role of sonography in women with postmenopausal bleeding. Broad objectives of this conference were (1) to advance understanding of the utility of different diagnostic techniques for evaluating the endometrium in women with postmenopausal bleeding; (2) to formulate useful and practical guidelines for evaluation of women with postmenopausal bleeding, specifically as it relates to the use of sonography; and (3) to offer suggestions for future research projects.

CT-pathologic correlation of axillary lymph nodes in breast carcinoma

A prospective study was performed to determine whether thoracic CT yielded useful information regarding the status of axillary lymph nodes (LNs) in patients with breast cancer. Thirty-five consecutive patients with clinically suspected stage II or III breast carcinomas were scanned preoperatively from the supraclavicular regions to the lung bases. Axillary LNs measuring greater than or equal to 1 cm were considered abnormal. The lymph nodes were classified according to their relationship to the pectoralis muscle. Extracapsular lymph node extension was diagnosed when there was irregularity and spiculation of the lymph node margin with surrounding fatty infiltration. Correlation with axillary dissection was obtained in 20 patients, giving a positive predictive value for axillary metastases of 89% with 50% sensitivity, 75% specificity, and 20% negative predictive value. CT was also able to detect the level of axillary involvement accurately when the lymph nodes were enlarged and to evaluate extracapsular LN extension. Although superior to physical examination, CT was not an accurate predictor of axillary LN involvement, primarily because of its low negative predictive value.

Diagnostic capabilities of high-resolution scrotal ultrasonography: prospective evaluation.

The use of scrotal ultrasonography has been advanced with the development of high‐resolution real‐time equipment. A group of 284 consecutive patients referred for scrotal examination was studied ultrasonically and followed over a three‐year period. Abnormal scrotal contents were accurately detected in 98.5 per cent of cases. Separation of testicular from extratesticular pathology was 99 per cent accurate. While all malignant testicular lesions could be identified, there were examples which could not be differentiated from benign lesions prior to surgical exploration and biopsy. However, there are many examples where the ultrasound results can change clinical management of the patient.

Three-dimensional Ultrasonography in Gynecology Technical Aspects and Clinical Applications

Objective. The aim of this work was to review the technical aspects and clinical applications of three‐dimensional ultrasonography in gynecologic imaging. Methods. With the use of a computerized database (MEDLINE), articles on three‐dimensional ultrasonography were reviewed. Other pertinent references were obtained from the references cited in these articles. In addition, we reviewed our own clinical experience over the past 7 years. Results. Numerous applications of three‐dimensional ultrasonography have been reported, including imaging of the uterus, the endometrial cavity, adnexa, and the pelvic floor and color and power Doppler applications. The accuracy of volume calculations and the networking opportunities with three‐dimensional ultrasonography have also been reported. Technical problems and limitations of this technique are summarized. Conclusions. Three‐dimensional ultrasonography has proved to be a useful imaging tool for clinical problem solving in gynecology, especially in imaging the uterus and uterine cavity.

Three-dimensional ultrasonographic imaging in obstetrics: Present and future applications

Received September 28, 2000, from the Departments of Radiology, Division of Ultrasound (G.B., A.L.-T., A.K., B.G.), and Obstetrics and Gynecology, Division of Maternal-Fetal Medicine (K.K., R.W.), Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Revision requested November 7, 2000. Revised manuscript accepted for publication January 22, 2001. We thank Frederic Ross for expert assistance with preparation of the images. Address correspondence and reprint requests to Gjergji Bega, MD, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, 834 Chestnut St, Suite 400, Philadelphia, PA. Abbreviations GSV, gestational sac volume; RVOT, right ventricular outflow tract; 3D, three dimensional; 3DUS, three-dimensional ultrasonography; 2D, two-dimensional; 2DUS, two-dimensional ultrasonography onventional two-dimensional ultrasonography (2DUS), which is routinely used in obstetrics, has proved to be a powerful tool in clinical diagnosis and management. However, the ability to obtain certain views of the fetus may be limited with 2DUS because of fetal position. With three-dimensional ultrasonography (3DUS) any desired plane through the fetus can be obtained regardless of fetal position at the time of volume acquisition, although image quality will vary among planes. As with 2DUS, certain factors such as oligohydramnios and maternal body habitus influence image quality. Using 2DUS images, the operator mentally constructs a three-dimensional (3D) concept of fetal anatomy and pathologic features. However, the ability to “think three-dimensionally” is variable among practitioners and depends on experience and innate ability. Some clinicians and patients find it difficult to gain a 3D understanding from conventional “slices” of ultrasonographic information. In addition, even experts may have difficulty interpreting 2DUS images of some complex or subtle lesions. Three-dimensional ultrasonography has recently been introduced into clinical practice. In 3DUS, a volume of ultrasonographic data, rather than a 2D slice of ultrasonographic data, is acquired and stored. The stored data can be reformatted and analyzed in numerous ways. With 3DUS, numerous arbitrary planes can be shown. By correlating the 3 perpendicular planes, which are seen in the multiplanar display, it is possible to verify that a true coronal or true midsagittal plane has been obtained. After reformatting the planes, surface rendering can be accomplished to show a lifelike 3D image. Work to date suggests that these postprocessing capabilities make 3DUS a useful tool in the visualization of normal and abnormal fetal anatomy. Furthermore, multiplanar

Three-dimensional multiplanar sonohysterography: Comparison with conventional two-dimensional sonohysterography and X-ray hysterosalpingography

The objective of this study was to assess the value of combining transvaginal sonohysterography with three‐dimensional multiplanar ultrasonography to optimize assessment of the uterus. To make this assessment, we compared findings on three‐dimensional sonohysterography with those on two‐dimensional sonohysterography and X‐ray hysterosalpingography. Of 20 women who underwent three‐dimensional sonohysterography for various indications, 13 also underwent two‐dimensional sonohysterography, and 12 had X‐ray hysterosalpingography. We reviewed the 3 types of examinations separately and compared the standard techniques with three‐dimensional sonohysterography to determine whether three‐dimensional sonohysterography provided additional information. In 9 (69%) of 13 comparisons between three‐dimensional sonohysterography and two‐dimensional sonohysterography and in 11 (92%) of 12 comparisons between three‐dimensional sonohysterography and X‐ray hysterosalpingography, three‐dimensional sonohysterography was advantageous. The coronal plane was most useful for displaying the relationship between lesions and the uterine cavity. Three‐dimensional sonohysterography provided additional information compared with standard accepted techniques in the vast majority of women.

Detection of retained products of conception following spontaneous abortion in the first trimester.

A retrospective analysis was performed to determine whether ultrasound could reliably rule in or out retained products of conception (POC) in women after first‐trimester spontaneous abortions (miscarriages). Ninety‐seven first‐trimester pregnancies with pathologically proven results from dilatation and curettage (D&C) were studied within 7 days of ultrasound examination (60% within 2 days), either by the abdominal or a combination of abdominal and vaginal approaches. Cases were eliminated if there was clinical evidence of a spontaneous evacuation of POC during the interval between the ultrasound and the D&C. POC were diagnosed only if chorionic villi were evident pathologically. The pertinent ultrasound findings were related to the endometrium (thickness, echogenicity, a gestational saclike structure or a space‐occupying collection). The results indicated that ultrasound could correctly diagnose POC in all of the cases by detecting a gestational sac or collection (77 cases), or a thickened endometrium of greater than 5 mm (6 cases). Ultrasound was less reliable in ruling out retained POC. When only a thin endometrial stripe of less than 2 mm was present, there was little likelihood of having POC (1 of 7 cases) with a moderately thick endometrium of 2 to 5 mm not diagnostic. Vaginal ultrasound added little new information and failed to change the ultrasound interpretation.

The role of diagnostic ultrasonography in varicocele evaluation.

Twenty‐one patients with the clinical diagnosis of varicocele were evaluated with static and superficial organ scanners. The sonogram was able to image the dilated scrotal veins in all of these cases. The small, clinically subtle varicocele could be demonstrated only with high‐resolution, dedicated real‐time small‐parts scanners, whereas larger lesions could also be imaged with B‐mode contact equipment. Varicoceles are a well‐documented cause of male infertility amenable to surgical treatment. From this study it is felt that ultrasonography can accurately detect varicoceles. It can be used as a screening procedure so that only those men requiring therapy need undergo more extensive and complicated diagnostic procedures.

Prospective comparison of vaginal and abdominal sonography in normal early pregnancy.

Vaginal and abdominal sonography were prospectively compared in 309 consecutive pregnancies of which 175 were normal. Two sonographic criteria of normal were analyzed: (1) the presence of an embryo compared with average gestational sac size and (2) the presence of embryonic cardiac activity compared with crown‐rump length. Vaginally, 100% (160/160) of embryos were visualized when the average sac diameter was greater than or equal to 12 mm. Abdominally, an embryo was noted in 99.2% (123/124) of gestational sacs greater than or equal to 27 mm. Vaginal sonography revealed cardiac motion in all embryos of greater than or equal to 5 mm (149/149 cases); abdominal sonography revealed cardiac activity in 100% (132/132) of embryos with a crown‐rump length of greater than or equal to 9 mm. One‐third of normal embryos less than 5 mm crown‐rump length did not demonstrate cardiac activity. The study demonstrates through objective comparison that vaginal sonography is superior to abdominal sonography for detection of an intrauterine embryo and its cardiac activity before 8 menstrual weeks. The diagnosis of embryonic demise should not be made by vaginal sonography in embryos measuring less than 5 mm crown‐rump length without a heartbeat, and an empty gestational sac of less than 12 mm average diameter should not be diagnosed as blighted ovum by vaginal scans. In these cases follow‐up vaginal sonography is suggested.

Ultrasound appearance of myositis ossificans

Ultrasonic evaluation of a soft tissue mass of the thigh was performed and suggested the diagnosis of myositis ossificans. Correlation with routine radiographic studies is made, as well as with the follow-up radiographic examination.