Douglas L. Brown

Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement.

The Society of Radiologists in Ultrasound convened a panel of specialists from gynecology, radiology, and pathology to arrive at a consensus regarding the management of ovarian and other adnexal cysts imaged sonographically in asymptomatic women. The panel met in Chicago, Ill, on October 27-28, 2009, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies, and are thought to represent a reasonable approach to asymptomatic ovarian and other adnexal cysts imaged at ultrasonography.

Diagnostic criteria for nonviable pregnancy early in the first trimester.

Determining the viability of a pregnancy is a major challenge, especially with a pregnancy of unknown location. This review provides specific guidance, including stringent criteria for nonviability, that can reduce the risk of inadvertent harm to a potentially normal pregnancy.

Contained power morcellation within an insufflated isolation bag.

OBJECTIVE: To describe a technique for contained power morcellation within an insufflated isolation bag at the time of uterine specimen removal during minimally invasive gynecologic procedures. METHODS: Over the study period of January 2013 to April 2014, 73 patients underwent morcellation of the uterus or myomas within an insufflated isolation bag at the time of minimally invasive hysterectomy or myomectomy. This technique involves placing the specimen into a large plastic bag within the abdomen, exteriorizing the opening of the bag, insufflating the bag within the peritoneal cavity, and then using a power morcellator within the bag to remove the specimen in a contained fashion. Procedures were performed at four institutions and included multiport laparoscopy, single-site laparoscopy, multiport robot-assisted laparoscopy, or single-site robot-assisted laparoscopy. Demographic and perioperative characteristics were collected for the cases. RESULTS: Surgical specimen morcellation within an insufflated isolation bag was successfully used in all cases. The median operative time was 114 minutes (range 32–380 minutes), median estimated blood loss was 50 mL (range 10–500 mL), and the median specimen weight was 257 g (range 53–1,481 g). There were no complications related to the contained morcellation technique nor was there visual evidence of tissue dissemination outside of the isolation bag. CONCLUSION: Morcellation within an insufflated isolation bag is a feasible technique. Methods for morcellating uterine tissue in a contained manner may provide an option to minimize the risks of open power morcellation while preserving the benefits of minimally invasive surgery. LEVEL OF EVIDENCE: II

Magnetic resonance-guided focused ultrasound of uterine leiomyomas: review of a 12-month outcome of 130 clinical patients.

PURPOSE To assess 12-month outcomes and safety of clinical magnetic resonance (MR)-guided focused ultrasound (US) treatments of uterine leiomyomas. MATERIALS AND METHODS Between March 2005 and December 2009, 150 women with symptomatic uterine leiomyomas were clinically treated with MR-guided focused US at a single institution; 130 patients completed treatment and agreed to have their data used for research purposes. Patients were followed through retrospective review of medical records and phone interviews conducted at 3-, 6-, and 12-month intervals after treatment to assess additional procedures and symptom relief. Outcome measures and treatment complications were analyzed for possible correlations with the appearance of the tumors on T2-weighted imaging. RESULTS The cumulative incidence of additional tumor-related treatments 12 months after MR-guided focused US was 7.4% by the Kaplan-Meier method. At 3-, 6-, and 12-month follow-up, 86% (90 of 105), 93% (92 of 99), and 88% (78 of 89) of patients reported relief of symptoms, respectively. No statistically significant correlation between tumor appearance on T2-weighted imaging and 12-month outcome was found. Treatment-related complications were observed in 17 patients (13.1%): 16 patients had minor complications and one had a major complication (deep vein thrombosis). All complications were resolved within the 12-month follow-up period. CONCLUSIONS MR-guided focused US is a noninvasive treatment option that can be used to effectively and safely treat uterine leiomyomas and delivers significant and lasting symptom relief for at least 12 months. The incidence of additional treatment during this time period is comparable with those in previous reports of uterine artery embolization.

A Clinical Review of Focused Ultrasound Ablation With Magnetic Resonance Guidance: An Option for Treating Uterine Fibroids

Uterine fibroids are common smooth muscle tumors, which can result in substantial symptoms affecting the quality of life of women. Whereas patients have several options available for treatment, focused ultrasound ablation is one of the least invasive treatment options outside medical therapy. Magnetic resonance-guided focused ultrasound (MRgFUS) ablation combines therapy delivered by an ultrasound transducer with imaging, guidance for therapy, and thermal feedback provided by magnetic resonance imaging. In 2004, the MRgFUS system ExAblate 2000 (InSightec, Haifa, Israel) was approved by the United States Food and Drug Administration for clinical treatments of uterine fibroids. Since its approval, our institution has performed more than 140 treatments. This paper provides an overview of our sites clinical experience with MRgFUS, including a brief description of the treatment system, pertinent features to review on screening magnetic resonance imaging, how the procedure is performed, and risks and benefits of the treatment. Some potential clinical applications of the technology are also briefly reviewed.

The sagittal sign: an early second trimester sonographic indicator of fetal gender

The sagittal sign for sonographic prediction of fetal gender in the early second trimester is described and its sensitivity and accuracy evaluated. One hundred eighty‐four ultrasound examinations with gestational ages between 10 weeks and 20.5 weeks were performed in 165 patients over a three month period. Of the 165 patients included in this prospective study, the gender of the fetus in 105 patients was known as a result of amniocentesis or chorionic villus sampling. These 105 patients with known results were used to compare gender prediction based on conventional views with prediction based on the sagittal sign. The results of this study reveal the superiority of the sagittal view for predicting gender in the gestational age group of 14 weeks to 20.5 weeks.

Adnexal Masses: US Characterization and Reporting

Pelvic ultrasonography (US) remains the imaging modality most frequently used to detect and characterize adnexal masses. Although evaluation is often aimed at distinguishing benign from malignant masses, the majority of adnexal masses are benign. About 90% of adnexal masses can be adequately characterized with US alone. In this article, the important US features that should allow one to make a reasonably confident diagnosis in most cases will be discussed. The role of follow-up US and alternative imaging modalities, along with the importance of careful reporting of adnexal masses, will also be reviewed.

Ultrasound of the fetal thymus.

A prospective study was performed in 340 obstetric sonograms to evaluate the sonographic characteristics of the fetal thymus. The thymus was identified as a homogeneous structure in the anterior fetal mediastinum in 251 cases (74%). The thymus was categorized as either hyperechoic, isoechoic, or hypoechoic relative to fetal lung. Seventy one of 115 cases (62%) prior to 27 weeks gestation were hyperechoic relative to fetal lung whereas 100 of 136 cases (73%) after 27 weeks were hypoechoic relative to lung (p less than .0001). Thymic measurements and shape were also recorded. The anterior‐posterior AP thickness, measured in the midline at the sternum, ranged from 2 mm at 14 weeks to 20.8 mm at term. This study demonstrates that the thymus can be imaged in most fetuses.

National Ultrasound Curriculum for Medical Students

Abstract Ultrasound (US) is an extremely useful diagnostic imaging modality because of its real-time capability, noninvasiveness, portability, and relatively low cost. It carries none of the potential risks of ionizing radiation exposure or intravenous contrast administration. For these reasons, numerous medical specialties now rely on US not only for diagnosis and guidance for procedures, but also as an extension of the physical examination. In addition, many medical school educators recognize the usefulness of this technique as an aid to teaching anatomy, physiology, pathology, and physical diagnosis. Radiologists are especially interested in teaching medical students the appropriate use of US in clinical practice. Educators who recognize the power of this tool have sought to incorporate it into the medical school curriculum. The basic question that educators should ask themselves is: “What should a student graduating from medical school know about US?” To aid them in answering this question, US specialists from the Society of Radiologists in Ultrasound and the Alliance of Medical School Educators in Radiology have collaborated in the design of a US curriculum for medical students. The implementation of such a curriculum will vary from institution to institution, depending on the resources of the medical school and space in the overall curriculum. Two different examples of how US can be incorporated vertically or horizontally into a curriculum are described, along with an explanation as to how this curriculum satisfies the Accreditation Council for Graduate Medical Education competencies, modified for the education of our future physicians.

A practical approach to the ultrasound characterization of adnexal masses.

Because pelvic ultrasound is commonly used to evaluate adnexal masses, it is important to understand the most useful sonographic features for predicting benign and malignant masses. Determining whether an adnexal mass is of ovarian or extraovarian origin is key in arriving at the most likely diagnosis. Most adnexal masses are benign, and each of the most common benign ovarian lesions has a typical sonographic appearance. Additionally, most malignant ovarian neoplasms have a solid component with detectable flow by Doppler ultrasound, allowing one to strongly suggest the diagnosis. We will review an approach to the ultrasound diagnosis of adnexal masses that progresses through a series of 4 questions to help lead one to the most likely diagnosis.