The clinical value of 3-dimensional saline infusion sonography in addition to 2-dimensional saline infusion sonography in women with abnormal uterine bleeding: work in progress

Comparison of Two-Dimensional Transvaginal Ultrasound, Three-Dimensional Transvaginal Ultrasound and Hysteroscopy to Diagnose in Patients With Abnormal Uterine Bleeding: A Retrospective Observational Study

Objective:

The principal objective was to compare the diagnostic accuracy of two-dimensional transvaginal ultrasonography (2D TVUS), three-dimensional transvaginal ultrasonography (3D TVUS), and hysteroscopy with histopathology in patients with abnormal uterine bleeding.

Materials and Methods:

Fifty patients were included and underwent the three imaging methods. The negative predictive value, positive predictive value, sensitivity, and specificity of the methods were calculated. Determination of endometrial pathology and endometrial polyps by measuring the endometrial thickness, volume, and uterine area was examined.

Results:

The complaint of menorrhagia was reported by 72.0% of participants. Histopathologically, 70.0% of the patients had endometrial polyps and leiomyoma being monitored. An endometrial polyp was detected in 58.0% of the patients by 2D TVUS, 80.0% by 3D TVUS, and 68.0% by hysteroscopy. While 2D TVUS demonstrated 65.71% accuracy in the detection of an endometrial polyp, 3D TVUS had an 80.0% accuracy, and hysteroscopy had a 77.77% accuracy. An endometrial polyp was detected when the uterine area was ≥237 mm2. If the endometrial thickness was over 10.5 mm, it was found to be related to an endometrial polyp. According to the volume measurements by 3D TVUS, the detection of an endometrial polyp was made with 96.4% sensitivity, provided that the pathology volume was ≥0.082 cm3.

Conclusion:

In this cohort of patients, 3D TVUS achieved a high sensitivity to detect abnormalities and could be considered as an initial diagnostic modality, prior to the surgery, and may rival invasive procedures, such as hysteroscopy.

Diagnostic efficacy of gel infusion sonography in post-menopausal bleeding

Background

Our purpose was to evaluate the diagnostic performance of two-dimensional transvaginal ultrasound (2D-TVUS) and gel infusion sonography (GIS) at offline analysis for endometrial characterization compared with real-time evaluation during scanning.

One hundred fifty women presented with PMB. At TVUS, endometrial thickness was ≥ 4 mm in 122 (81.3%) women and < 4 mm in 28 (18.72%). Among 122 women with endometrial thickness > 4 mm, GIS was successfully performed in 117 (95.9%). Examinations were stored as video clips for later evaluation (offline analysis) by two less experienced radiologists. Endometrial lesions were classified into four categories: no endometrial abnormality, hyperplasia, polyps, and cancer. Diagnostic efficiency of real-time and offline analysis for diagnosis of each category was calculated and compared, and inter-observer agreement for offline analysis was calculated.

Results

All patients underwent hysteroscopy and/or hysterectomy. Histopathological results confirmed no endometrial abnormality in (27.3%, 41/150), endometrial hyperplasia in (12.7%, 19/150), endometrial polyps in (17.3%, 26/150), and endometrial cancer in (42.7%, 64/150).

Overall diagnostic accuracy of real-time imaging was 89.7% (CI 84–91%)). The highest accuracy 92.7% (CI 88–98%) was seen in the diagnosis of cancer, and polyps 91.5% (CI 86–97%). The lowest accuracy 75% (CI 69–82%) was seen in hyperplasia.

Overall diagnostic accuracy of offline analysis was 81%, and it increased to 88% (CI 83–92%) after a restricted analysis of good quality clips. The highest accuracy 90.7% (CI 83–95%) was seen in the diagnosis of polyps, and cancer 90.4% (CI 83–96%). The lowest accuracy 71% (CI 69–75%) was seen in hyperplasia.

At offline analysis, the inter-observer agreement was substantial k = 0.77 (CI 71–84) in the evaluation of four endometrial categories after the exclusion of bad quality videos. It was excellent in exclusion of endometrial abnormalities k = 0.85 (0.78–0.90), substantial in the diagnosis of polyps k = 0.71 (0.69–0.88), cancer k = 0.61 (0.61–0.77), and moderate in the diagnosis of hyperplasia k = 0.41 (0.30–0.41).

Conclusion

Offline 2D analysis with a good image quality has comparable accuracy to a real-time evaluation during scanning in the diagnosis of endometrial lesions. It can increase the accuracy of sonography in ruling out endometrial abnormalities and diagnose non-hyperplastic endometrial pathologies. High NPV and substantial reproducibility can make it an efficient initial screening method in a post-menopausal bleeding.

Diagnostic value of three-dimensional saline infusion sonohysterography in the evaluation of the uterus and uterine cavity lesions

Purpose

The purpose of this review is to illustrate and discuss the seldom used technique of three-dimensional (3D) saline infusion sonohysterography (SIS) based on instillation of sterile saline through a catheter into the uterus under real-time vaginal transducer observation for assessment of the endometrial cavity.

Material and methods

The cases for this pictorial review were selected from the imaging material collected at the Ultrasound Unit, Clinical Imaging Department, Women’s Hospital of Hamad Medical Corporation during a seven-year period from 2011 to 2017. This was a retrospective collection of 216 consecutive cases that underwent two-dimensional (2D) and 3D SIS for evaluation of the uterine cavity, followed by verification of results with histopathology. An open-sided speculum is inserted into the vagina. An intrauterine catheter is then threaded into the endometrial cavity. After that, the speculum is removed carefully, and a vaginal transducer is inserted. Using a 60-ml syringe attached to the catheter, saline solution is instilled under direct real-time observation (2D SIS). Subsequently, reconstruction of the three-dimensional anatomy of the intrauterine cavity is performed.

Pictorial review

The review presents the most common indication for SIS, like abnormal bleeding in pre- and postmenopausal patients. SIS allows us to distinguish between focal lesions and global endometrial thickening. SIS should be supported as a second-line diagnostic procedure for abnormal uterine bleeding, when findings from transvaginal ultrasound are inconclusive.

Conclusions

The addition of 3D techniques to SIS procedure helps in the distinction between endometrial and myometrial lesions, also it facilitates delineation of uterine anatomy, resulting in more precise and accurate diagnosis.

Role of 3-Dimensional Sonography in the Assessment of Submucous Fibroids: A Pilot Study

OBJECTIVES

To investigate the accuracy and reliability of 3-dimensional (3D) transvaginal sonography in classifying submucous fibroids using the International Federation of Gynecology and Obstetrics PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) classification and protrusion (percent) compared to 2-dimensional (2D) transvaginal sonography, 2D saline infusion sonography, and 3D saline infusion sonography, using hysteroscopy as a reference test.

METHODS

A prospective cohort pilot study was performed among 14 consecutive patients undergoing hysteroscopic surgery, preceded by routine sonography (2D transvaginal sonography, 2D saline infusion sonography, 3D transvaginal sonography, and 3D saline infusion sonography).

RESULTS

The intraclass correlation coefficient (ICC) for 2D transvaginal sonography versus hysteroscopy was 0.69 (95% confidence interval [CI], 0.06, 0.90) compared to 0.94 (95% CI, 0.83, 0.98) for 2D saline infusion sonography. The ICCs for 3D transvaginal sonography versus hysteroscopy were 0.69 (95% CI, 0.03, 0.90 [investigator A]) and 0.55 (95% CI, -0.48, 0.86 [investigator B]). The ICCs for 3D saline infusion sonography versus hysteroscopy were 0.94 (95% CI, 0.81, 0.98 [investigator A]) and 0.87 (95% CI, 0.60, 0.96 [investigator B]). Interobserver agreement of 3D transvaginal sonography was 0.81 (95% CI, 0.43, 0.94) compared to 0.86 (95% CI, 0.56, 0.96) for 3D saline infusion sonography.

CONCLUSIONS

In these preliminary data, 3D transvaginal sonography was not as accurate as 2D or 3D saline infusion sonography and was not more accurate than 2D transvaginal sonography. There was moderate interobserver agreement for 3D transvaginal sonography. There might be room for improvement, as 3D transvaginal sonography is more accurate when endometrial thickness increases. Further study is warranted to evaluate in which patients saline infusion sonography eventually can be obviated.

Three-dimensional saline infusion sonography compared to two-dimensional saline infusion sonography for the diagnosis of focal intracavitary lesions

BACKGROUND

Focal abnormalities most commonly acquired within the uterine cavity include endometrial polyps (arising from the endometrium) and submucous fibroids (arising from the myometrium). These benign abnormalities can cause several problems, including abnormal uterine bleeding (AUB) and subfertility. Two-dimensional saline infusion sonography (2D SIS) is a minimally invasive test that can be used to diagnose these pathologies, but it is less accurate than hysteroscopy, which is a more invasive procedure by which an endoscope allows direct visualisation of the uterine cavity. Three-dimensional (3D) SIS appears to enhance sonographic visualisation within the uterine cavity, thereby offering a potentially more accurate minimally invasive diagnostic test.

OBJECTIVES

Primary objectives • To evaluate the diagnostic accuracy of 3D SIS (index test 1) compared with 2D SIS for the diagnosis of focally growing lesions (presence or not) in women with AUB or subfertility, with hysteroscopy performed as the reference test. • To evaluate the diagnostic accuracy of 2D+3D SIS (index test 2) compared with 2D SIS for the diagnosis of focally growing lesions (presence or not) in women with AUB or subfertility, with hysteroscopy performed as the reference test. In this case, any abnormality on either modality was regarded as a positive result ('OR' approach). Secondary objectives • To evaluate the diagnostic accuracy of 3D SIS (index test 1) compared with 2D SIS according to type of abnormality and discrimination between uterine polyps and submucous fibroids in women with AUB or subfertility, with hysteroscopy and histology used as the reference.• To evaluate the diagnostic accuracy of 2D+3D SIS (index test 2) compared with 2D SIS according to type of abnormality and discrimination between uterine polyps and submucous fibroids in women with AUB or subfertility, with hysteroscopy and histology used as the reference.

SEARCH METHODS

We searched the following databases: Cochrane Central Register of Studies Online (CENTRAL CRSO), MEDLINE, Embase, PubMed, Cochrane Gynaecology and Fertility Group (CGF) Specialised Register and CGFG Diagnostic Test Accuracy (DTA) Specialised Register, clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). Screening reference lists of appropriate studies was also performed. We screened for eligibility all studies identified from inception until March 2016. We performed searches with no date or language restrictions.

SELECTION CRITERIA

The population of interest consisted of premenopausal women with AUB or subfertility and postmenopausal women with AUB. Diagnostic test accuracy studies, randomised controlled trials (RCTs) and prospective cohort studies were eligible for inclusion if they evaluated the accuracy of both 2D SIS and 3D SIS for the diagnosis of acquired intracavitary abnormalities with hysteroscopy used as the reference standard. In light of the lack of data for 3D SIS, we also included studies that evaluated the accuracy of 3D SIS alone.

DATA COLLECTION AND ANALYSIS

Two review authors read all potentially eligible references after performing a first screening by title and abstract (LLN and FJRH). They independently extracted data to construct 2×2 tables from eligible studies and assessed studies for methodological quality using the QUADAS-2 tool (revised tool for quality assessment of diagnostic accuracy studies). To describe and visually present results, we produced in RevMan forest plots showing pairs of sensitivity and specificity together with 95% confidence intervals from each study, as well as raw receiver operating characteristic (ROC) plots. We displayed paired analyses in an ROC plot by linking sensitivity-specificity pairs from each study by using a dashed line. To compare 3D SIS versus 2D SIS, we restricted analyses to studies that provided 2×2 tables for both tests and used the bivariate meta-analysis of sensitivity and specificity.

MAIN RESULTS

Thirteen studies (1053 women) reported the accuracy of 3D SIS for focal uterine abnormalities; 11 of these (846 women) were suitable for meta-analysis, and eight reported accuracy according to the type of focal abnormality. The design of the included studies seems applicable. The main problem involving the quality of included studies is insufficient reporting of study methods, resulting in unclear risk of bias for several of the quality domains assessed. Therefore, we considered the overall quality of the evidence as low. The summary estimate (11 studies reporting absence or presence of abnormality at 3D SIS) for sensitivity was 94.5% (95% confidence interval (CI) 90.6% to 96.9%) and for specificity 99.4% (95% CI 96.2% to 99.9%). Meta-analysis of the eight studies (N = 716) directly comparing 2D SIS versus 3D SIS showed summary sensitivity of 96.9% (95% CI 91.9% to 98.8%) and summary specificity of 99.5% (95% CI 96.1% to 100%) for 3D SIS. For 2D SIS, summary sensitivity was 90.9% (95% CI 81.2% to 95.8%) and summary specificity was 96.3% (95% CI 86.1% to 99.1%). The difference in accuracy between 2D SIS and 3D SIS was non-significant (P values of 0.07 for sensitivity and 0.10 for specificity).

AUTHORS' CONCLUSIONS

Low-quality evidence suggests that 3D SIS may be very accurate in detecting intracavitary abnormalities. Meta-analysis revealed no statistically significant differences between 2D SIS and 3D SIS. Summary sensitivity and summary specificity are higher for 3D SIS, but margins of improvement are limited because 2D SIS is already very accurate. When the technology and appropriate expertise are available, 3D SIS offers an alternative to 2D SIS. Both 2D SIS and 3D SIS should be considered alternatives to diagnostic hysteroscopy when intracavitary pathology is suspected in subfertile women and in those with abnormal uterine bleeding.

Premenopausal abnormal uterine bleeding and risk of endometrial cancer

BACKGROUND

Endometrial biopsies are undertaken in premenopausal women with abnormal uterine bleeding but the risk of endometrial cancer or atypical hyperplasia is unclear.

OBJECTIVES

To conduct a systematic literature review to establish the risk of endometrial cancer and atypical hyperplasia in premenopausal women with abnormal uterine bleeding.

SEARCH STRATEGY

Search of PubMed, Embase and the Cochrane Library from database inception to August 2015.

SELECTION CRITERIA

Studies reporting rates of endometrial cancer and/or atypical hyperplasia in women with premenopausal abnormal uterine bleeding.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two reviewers and cross-checked. For each outcome, the risk and a 95% CI were estimated using logistic regression with robust standard errors to account for clustering by study.

MAIN RESULTS

Sixty-five articles contributed to the analysis. Risk of endometrial cancer was 0.33% (95% CI 0.23-0.48%, n = 29 059; 97 cases) and risk of endometrial cancer or atypical hyperplasia was 1.31% (95% CI 0.96-1.80, n = 15 772; 207 cases). Risk of endometrial cancer was lower in women with heavy menstrual bleeding (HMB) (0.11%, 95% CI 0.04-0.32%, n = 8352; 9 cases) compared with inter-menstrual bleeding (IMB) (0.52%, 95% CI 0.23-1.16%, n = 3109; 14 cases). Of five studies reporting the rate of atypical hyperplasia in women with HMB, none identified any cases.

CONCLUSIONS

The risk of endometrial cancer or atypical hyperplasia in premenopausal women with abnormal uterine bleeding is low. Premenopausal women with abnormal uterine bleeding should first undergo conventional medical management. Where this fails, the presence of IMB and older age may be indicators for further investigation. Further research into the risks associated with age and the cumulative risk of co-morbidities is needed.

TWEETABLE ABSTRACT

Contrary to practice, premenopausal women with heavy periods or inter-menstrual bleeding rarely require biopsy.

The evolving role of saline infusion sonography (SIS) in infertility

Saline infusion sonography (SIS) has become a valuable diagnostic modality in gynaecology over the last three decades. SIS is now commonly employed for detailed evaluation of the uterine cavity as part of pre-treatment assessment in infertile women. The objective of this paper is review the scientific literature on SIS in infertility. Medline, Ovid and Cochrane databases were searched for relevant articles. The indications, technical aspects and the potential advantages of SIS are discussed. The efficacy and sensitivity of SIS are compared to hysteroscopy in the evaluation of uterine polyps, fibroids, intrauterine adhesions and uterine anomalies. Increasing evidence suggests the use of SIS prior to an in-vitro fertilization (IVF) cycle as it has increased sensitivity in the detection of intrauterine pathology. SIS is cost-effective and results in better patient satisfaction scores than hysteroscopy.

Diagnostic and clinical value of 3D gel installation sonohysterography in addition to 2D gel installation sonohysterography in the assessment of intrauterine abnormalities

OBJECTIVE

To study the diagnostic value of three-dimensional gel instillation sonography (3D GIS) in addition to two-dimensional (2D) GIS in the assessment of intrauterine abnormalities. Secondly, the clinical value of 3D GIS in the planning for hysteroscopic procedures was evaluated.

STUDY DESIGN

A prospective cohort study was performed from 2008 till 2010. All women with a suspected intrauterine abnormality on 2D GIS suitable for hysteroscopic resection or with recurrent postmenstrual bleeding were planned for a hysteroscopic procedure. Diagnostic accuracy tests were calculated for the detection of fibroids and polyps with both histology and hysteroscopy as the reference standard. For the assessment of type and size of fibroids hysteroscopy was used as the reference standard. We compared the planning for type of hysteroscopy based on 2D GIS findings with the combined 2D-3D GIS findings.

RESULTS

In total 110 patients were analysed. In comparison to histology, addition of 3D GIS did not change sensitivity or specificity substantially in the discrimination between fibroids and polyps. In comparison to hysteroscopy, sensitivity increased for detecting fibroids and polyps, without major interference with the specificity. Despite an improved accuracy after the addition of 3D GIS, the planning for hysteroscopic procedures did not improve substantially.

CONCLUSION

In daily practice, the addition of 3D GIS to 2D GIS improved the accuracy for the detection of polyps and fibroids compared to hysteroscopy, but only marginally improved the planning of hysteroscopic procedures, and therefore the clinical relevance seems to be limited.

Value of 3-dimensional sonohysterography for detection of intrauterine lesions in women with abnormal uterine bleeding

STUDY OBJECTIVE

To compare 2-dimensional (2D) sonohysterography (SHG) and 3D-SHG with saline solution infusion vs diagnostic hysteroscopy for investigation of intrauterine lesions in perimenopausal and postmenopausal women with abnormal uterine bleeding.

DESIGN

Comparative observational cross-sectional study (Canadian Task Force classification II-1).

SETTING

University hospital.

PATIENTS

Fifty perimenopausal and 20 postmenopausal women with abnormal intrauterine bleeding with clinically or ultrasonically suspected intrauterine lesions.

INTERVENTIONS

Conventional 2D- and 3D ultrasonography and 2D- and 3D-SHG with saline solution infusion followed by diagnostic hysteroscopy, and endometrial curettage or subsequent operative treatment (e.g., hysterectomy, myomectomy, or polypectomy). Ultrasonographic and hysteroscopic findings were compared with histopathologic findings.

MEASUREMENTS AND MAIN RESULTS

For 2D-SHG, sensitivity, specificity, positive predictive value, negative predictive value, overall accuracy, likelihood ratio for a positive result, and likelihood ratio for a negative result were 79%, 72%, 89%, 54%, 76%, 2.82, and 0.29, respectively, and for 3D-SHG, were 92%, 89%, 96%, 80%, 91%, 8.36, and 0.09, respectively; and for diagnostic hysteroscopy, were 94%, 89%, 96%, 84%, 93%, 8.55, and 0.07, respectively. Thus, 3D-SHG was superior to 2D SHG (p = .02) and comparable to diagnostic hysteroscopy (p = .75) for diagnosis of intrauterine lesions.

CONCLUSION

3D-SHG can be used in the initial investigation of intrauterine lesions in perimenopausal and postmenopausal women with abnormal uterine bleeding before resorting to invasive procedures such as diagnostic hysteroscopy. Further studies of computer-reconstructed 3D-SHG virtual hysteroscopy are recommended.

Gel instillation sonohysterography (GIS) and saline contrast sonohysterography (SCSH): comparison of two diagnostic techniques

OBJECTIVE

To compare gel instillation sonohysterography (GIS) with saline contrast sonohysterography (SCSH) as diagnostic methods for the evaluation of the uterine cavity.

METHODS

A prospective cohort study was performed at the Department of Obstetrics and Gynecology of the VU University Medical Center, Amsterdam, between September 2007 and April 2008. We included 65 women suspected of having an intrauterine abnormality with an indication for SCSH/GIS. First SCSH and subsequently GIS were performed in all women. Distension of the uterine cavity, image quality, visualization of intrauterine abnormalities and pain experienced on a visual analog scale (VAS score) were recorded for both procedures.

RESULTS

The mean distension with GIS was 9.0 mm and with SCSH it was 8.5 mm (P = 0.15). The mean image quality, on a scale from 0 to 5, for SCSH was 4.0 and for GIS it was 3.6 (P = 0.01). No difference was found for the visualization of intrauterine abnormalities, and the VAS scores for pain experienced on SCSH and GIS were 1.5 and 1.6, respectively (P = 0.62).

CONCLUSIONS

The image quality of SCSH is slightly better than that of GIS. This difference is likely to be attributable to the presence of air bubbles in the gel. The small difference in uterine cavity distension in favor of GIS and comparable stable distension during at least 4 min make GIS a suitable alternative for SCSH if air bubbles can be prevented.

Management of uterine fibroids in the patient pursuing assisted reproductive technologies

Uterine leiomyomas are present in 30-70% of women of reproductive age. In addition to causing menstrual disorders and pain, uterine fibroids negatively affect fertility and pregnancy outcome for patients pursuing assisted reproduction. The two questions that have to be addressed are: which fibroids should be treated and how should they be treated? Submucosal fibroids are associated with a 70% reduction in delivery rate. Intramural fibroids had a lesser effect and reduced the delivery rate by approximately 30%. By contrast, studies have demonstrated that subserosal fibroids did not negatively impact fertility. Furthermore, both submucosal and intramural fibroids were associated with an increased risk of spontaneous miscarriage. Myomectomy is considered the treatment of choice to alleviate these detrimental effects. Further research is needed before alternative treatments can be recommended.

Comparison of 3-dimensional with 2-dimensional saline infusion sonohysterograms for the evaluation of intrauterine abnormalities

OBJECTIVE

To compare 3-dimensional saline infusion sonohysterography (3DSIS) with 2-dimensional sonohysterography (2DSIS) using hysteroscopy and histologic diagnosis as the gold standard.

METHOD

A retrospective analysis of all SIS examination performed between July 1, 2005 and April 30, 2007 in our gynecological sonographic unit. 2DSIS or 3DSIS sonographic techniques were used randomly. Management decisions and operative procedures were done by the referring provider. Patients that had diagnostic hysteroscopy and complete histologic evaluation were included. Concordance between the various assessment methods as well as sensitivity and specificity were compared between 2DSIS and 3DSIS. Student's t test and chi-square test were used for statistical analysis. p < 0.05 was considered statistically significant.

RESULT

Of 804 patients that had SIS, 125 patients met the inclusion criteria. Patient median age was 48 (range 19-82). Also, 77 patients were premenopausal, and 48 patients were postmenopausal. Furthermore, 43 patients had 2DSIS and 82 patients had 3DSIS. 3DSIS was found to correlate with hysteroscopic findings more often than 2DSIS (p < 0.05). A trend for higher specificity of 3DSIS with the different uterine pathologies was seen, but it did not reach statistical significance. No difference in sensitivity of 3DSIS compared with 2DSIS was found for all pathologic diagnoses.

CONCLUSION

3DSIS correlated better with hysteroscopy than 2DSIS. Specificity for histologic diagnosis appears to be higher with 3DSIS compared with 2DSIS but larger-scale studies are needed to confirm this finding.

Two- and three-dimensional saline contrast sonohysterography: interobserver agreement, agreement with hysteroscopy and diagnosis of endometrial malignancy

OBJECTIVES

The aims of our study were to compare the interobserver reproducibility of two-dimensional (2D) and three-dimensional (3D) saline contrast sonohysterography (SCSH) and agreement of these techniques with hysteroscopy, and to determine which SCSH findings best discriminate between benign and malignant endometrium.

METHODS

Consecutive women with postmenopausal bleeding and endometrial thickness > or = 4.5 mm underwent 2D and 3D SCSH; the results were videotaped and stored electronically, respectively, for analysis by two independent experienced examiners who were blinded to each other's results. A histological diagnosis was obtained by dilatation and curettage, hysteroscopic resection or hysterectomy. The hysteroscopist was blinded to the ultrasound results and used the same standardized research protocol to describe the uterine cavity as the ultrasound examiners.

RESULTS

Of 170 consecutive women with postmenopausal bleeding and endometrial thickness > or = 4.5 mm, 84 (14 with endometrial malignancy) fulfilled our inclusion criteria. Hysteroscopy findings in 54 women (one with endometrial malignancy) were used to determine agreement with SCSH. Interobserver agreement of 2D and 3D SCSH was 95% (80/84) vs. 89% (75/84) with regard to presence of focal lesions, 89% (75/84) vs. 88% (74/84) for presence of focal lesions with irregular surface, 67% (54/81) vs. 63% (51/81) for number of focal lesions, and 77% (46/60) vs. 70% (42/60) for location of focal lesions. The agreement between 2D and 3D SCSH and hysteroscopy was 94% (51/54) vs. 93% (50/54) with regard to presence of focal lesions, 74% (40/54) vs. 76% (41/54) for presence of focal lesions with irregular surface, 63% (34/54) vs. 54% (29/54) for number of focal lesions, and 66% (29/44) vs. 64% (28/44) for location of focal lesions. The SCSH finding that best discriminated between benign and malignant endometrium was the presence of focal lesion(s) with irregular surface (for 2D SCSH: sensitivity 71%, specificity 97%, positive likelihood ratio 25, negative likelihood ratio 0.3; for 3D SCSH: sensitivity 43%, specificity 97%, positive likelihood ratio 15, negative likelihood ratio 0.6).

CONCLUSIONS

3D SCSH does not seem to be superior to 2D SCSH when performed by experienced ultrasound examiners either with regard to reproducibility, agreement with hysteroscopy findings or diagnosis of endometrial malignancy. The presence of focal lesion(s) with irregular surface is the best SCSH variable for discrimination between benign and malignant endometrium.

Which patients benefit from a 3D reconstructed coronal view of the uterus added to standard routine 2D pelvic sonography?

OBJECTIVE

The objective of our study was to evaluate whether a 3D reconstructed coronal view of the uterus provides added benefit to standard gynecologic sonography.

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 > or = 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 > or = 5 mm.

Reproducibility of saline contrast sonohysterography for the detection of intracavitary abnormalities in women with abnormal uterine bleeding

OBJECTIVES

Saline contrast sonohysterography (SCSH) is a diagnostic test for the examination of intracavitary abnormalities. The objective of this study was to calculate interobserver and intraobserver agreement for the interpretation of video recordings of SCSH procedures according to different levels of experience.

METHODS

SCSH examinations were carried out by an operator experienced at performing SCSH and were recorded on video. To assess interobserver and intraobserver agreement, video material was scored by observers allocated to different groups according to their level of experience. Observers who had performed 25 or more SCSH procedures were defined as experienced (Group A), those who had carried out 1-24 as less experienced (Group B), and those with no experience of performing SCSH as inexperienced (Group C). All observers were blinded to the case histories of the patients.

RESULTS

There was a significant difference in kappa values for interobserver agreement between the most experienced group and the less experienced observers. Group A, with the highest level of experience, had a mean kappa value of 0.62 (95% CI, 0.56-0.67), compared with 0.38 (95% CI, 0.33-0.43) in Group B and 0.47 (95% CI, 0.43-0.52) in Group C. The interobserver agreement in Group A was significantly higher than that in Groups B and C (P < 0.001 and P = 0.023, respectively), and Group C performed better than Group B (P = 0.024). Intraobserver agreement (n = 7) was good, with a mean kappa value of 0.66 (Group A, 0.63; Group C, 0.71).

CONCLUSIONS

Interobserver agreement in interpretation of video recordings of SCSH by inexperienced sonographers is poor, whereas the intraobserver agreement is good. We consider the poor interobserver agreement to be due to non-uniform diagnostic criteria. Uniform diagnostic criteria for SCSH should be incorporated into the training of residents and other physicians performing these examinations.

Transvaginal ultrasonography with and without saline infusion in assessment of myometrial invasion of endometrial cancer

OBJECTIVE

The purpose of this study was to determine the diagnostic accuracy of saline infusion ultrasonography (SIUS) compared with transvaginal ultrasonography (TVUS) in the assessment of myometrial invasion of endometrial cancer.

METHODS

A total of 53 patients with endometrial cancer were examined preoperatively with TVUS and SIUS with respect to myometrial invasion. All patients were postmenopausal. Ultrasonographic findings were compared with histopathologic findings of the surgical specimens.

RESULTS

The median age of the patients +/- SD was 64 +/- 7 years (range, 51-77 years). In all patients, the procedure was well tolerated. The median thickness of malignant endometria was 17 +/- 9 mm (range, 2-51 mm). The specimens consisted of 40 endometrioid adenocarcinomas, 2 serous papillary carcinomas, 5 clear cell adenocarcinomas, 2 adenosquamous carcinomas, 3 mixed types, and 1 undifferentiated carcinoma. There were 18 grade G1, 24 G2, and 11 G3 cases. On histopathologic examination, superficial myometrial invasion (<or=50% of the myometrium) was present in 25 specimens (47.2%), and deep myometrial invasion (>50% of the myometrium) was present in 28 (52.8%). For superficial myometrial invasion, evaluation by TVUS was accurate in 19 (76.0%) of 25 cases, and evaluation by SIUS was accurate in 18 (72.0%) of 25. For deep myometrial invasion, evaluation by TVUS was accurate in 24 (85.7%) of 28 cases, and evaluation by SIUS was accurate in 27 (96.4%) of 28.

CONCLUSIONS

Transvaginal ultrasonography is a reliable method for assessing myometrial invasion of endometrial cancer. Saline infusion ultrasonography showed slightly better accuracy in the assessment of myometrial invasion than TVUS, but the differences were not statistically significant.

Saline infusion sonography in women with abnormal uterine bleeding: an update of recent findings

PURPOSE OF REVIEW

To inform about new developments concerning saline infusion sonography, especially in women suffering from abnormal uterine bleeding.

RECENT FINDINGS

The diagnostic accuracy of saline infusion sonography has been established before the period of this review; however, recent papers support the high diagnostic accuracy and conclude saline infusion sonography is able to replace diagnostic hysteroscopy in the evaluation of the uterine cavity. The use of gel instead of saline as distension medium and the introduction of new three-dimensional inversion rendering techniques enhances the visualization of the endometrium which may improve the diagnostic accuracy of saline infusion sonography. A simple, feasible and seemingly cost-effective method of saline infusion sonography-based guided endometrial biopsy has been developed. The technique may allow saline infusion sonography based polypectomy. A classification of submucous fibroids has been proposed in order to allow more accurate, saline infusion sonography-based, preoperative selection of fibroids suitable for hysteroscopic resection.

SUMMARY

The development of saline infusion sonography-based guided biopsies allows saline infusion sonography to compete with vaginoscopic operative hysteroscopy. Additional comparative trials are needed in order to finalize the decision about the proper method of the assessment of the uterine cavity.

Improving the efficiency of gynecologic sonography with 3-dimensional volumes: a pilot study

OBJECTIVE

The purpose of this study was to determine whether 3-dimensional (3D) sonography can provide a rapid, efficient, and accurate way to do a transvaginal gynecologic scan compared with traditional 2-dimensional (2D) sonography.

METHODS

Thirty-five consecutive patients who underwent gynecologic sonography formed the study cohort. After a standard 2D transvaginal scan was done, including measurements of the endometrium and abnormalities, 4 volume acquisitions were obtained, encompassing the uterus (2 volumes) and the ovaries. These volumes were reviewed offline without any patient information. Endometrium and other measurements were performed on the volumes. The 2D and 3D results were compared by paired t tests.

RESULTS

The mean time needed for the standard 2D scan was 2.6 minutes compared with 1.07 minutes for the 3D volume acquisitions. The mean time for the reconstruction, measurement, and interpretation of the volumes offline was 1.19 minutes. The mean time for the entire 3D examination (both parts) was 2.26 minutes (P = .047, comparing 2D with total 3D). There was no significant difference between the measurements of the endometrium, fibroids, and ovarian cysts when comparing 2D and reconstructed 3D images. Two-dimensional and 3D sonography differed little in their ability to identify the organs and the abnormalities on the scans.

CONCLUSIONS

This study shows that a complete transvaginal gynecologic examination can be done in 1.07 minutes of scan time and interpreted offline in an additional 1.19 minutes. The 35 cases were scanned and interpreted with the use of 3D sonography in 79.17 minutes total compared with 91.46 minutes of 2D scan time (P = .047). The accuracy of the scan was similar for both techniques.

Three- and 4-dimensional ultrasound in obstetrics and gynecology: proceedings of the American Institute of Ultrasound in Medicine Consensus Conference

The American Institute of Ultrasound in Medicine convened a panel of physicians and scientists with interest and expertise in 3-dimensional (3D) ultrasound in obstetrics and gynecology to discuss the current diagnostic benefits and technical limitations in obstetrics and gynecology and consider the utility and role of this type of imaging in clinical practice now and in the future. This conference was held in Orlando, Florida, June 16 and 17, 2005. Discussions considered state-of-the-art applications of 3D ultrasound, specific clinical situations in which it has been found to be helpful, the role of 3D volume acquisition for improving diagnostic efficiency and patient throughput, and recommendations for future investigations related to the utility of volume sonography in obstetrics and gynecology.