5 - TV3D in GYN and Breast 3D

T/V 3D in Gynecology and Breast 3D
3D4D Training
29th – 30th August 2017
Luca Mastrogirolamo
Luca Mastrogirolamo © Hitachi Medical Systems Europe 2017. All rights reserved.
Benefits of 3D in Gynaecology
3D Ultrasound in Gynecology represents a big improvement in investigation with infinite benefits

in many clinical applications:
•  Can Evaluate data at a later stage

•  Data Sets can be sent to Expert for independent evaluation
•  Display planes or rendered images in plane not obtainable by 2D sonography
Display used
•  MPR
•  Coronal View
•  Inverse view
•  Multi Follicle Volumes
Luca Mastrogirolamo © Hitachi Medical Systems Europe 2017. All rights reserved. 2
Benefits of 3D in Gynecology
The most important aspect of 3D ultrasound in Gynecology is the C Plane

as anatomical aspect can be easily studied
Benefits of 3D in Gynecology
•  The 3 Orthogonal planes are

necessary to evaluate the shape of
the uterine cavity. Short of an MRI,
the Coronal plane shows cervix
and 2 courna (Same plane)
•  i.e. Distinguish a Septate from a
Bicornuate uterus, IUD location,
etc.
Different IUD’s
3D in Gyn
Area of clear benefit

•  Uterus and endometrium
•  Mullerian uterine anomalies
•  IUD location/management
•  Adenomyosis
•  Sub-mucous myomas
•  3D sonohisterography (SIS)
•  Essure micro-inserts
•  Intrauterine adhesion (Asherman’s)
•  Pelvic Floor
•  IOTA assessment of malignant lesion Wrong
•  Fallopian Tube insertion
•  Comual/interstitial pregnancy of IUD
•  Hydrosalpinx
3D in Gyn
IUD Location and management

•  Location of the IUD
•  Size of the Uterus to fit the IUD
•  Check for Embedded IUD
•  Management of the patient
Uterus too small for IUD
Measure of the fundus of

the Uterus to check the
correct size
3D in Gyn
Adenomyosis
•  Characterized by invasion of endometrial glands into the neighboring myometrium
•  3D provides better outline of the endometrial/myometrial junction than 2D
Blurry myometrium, poorly defined Details of the myometrium, stripes

endometrium, asimmetry of the on the junctional zone typical for
walls adenomysis
3D in Gyn
Inversion mode to demonstrate the fuzzy border of the junctional zone typical for adenomyosis
Outline of the endometrium full of cavities in inversion mode demonstrating the adenomyosis is
spreading in perifery and myometrium
3D in Gyn
Shape of the uterine cavity

Prevalence of mullerian duct anomalies
3-10% in infertility and recurrent pregnancy loss

1-0,4% for other patients
Normal uterus Vs sub-septate uterus
Source: Troiano RN Mc Carthy

Mullerian duct anomalies: imaging and clinical issue 2014
3D Gyn
Measuring the Septum

To assess septate or Arcuate
uterus.
Follow international guidelines
that describe the difference in
shape and the level of distortion.
3D Gyn
Uterus shape
Tips & Tricks
Sometimes a single scan is not enough to
assess the entire uterus.
In some cases two separate volumes for
fundus and Cervix are needed in order to get
all the information.
Complete septum of the uterus. Two

volumes for the fundus and cervix
Thin septum seen in two volumes

3D Gyn
Uterus Shape
Sonohistero in 3D to check the shape of the cavity
3D Gyn
Why it is important 3D in Gynecology? Are the images the same?
The use of Coronal plane changed the

ultrasound in Gynecology
Normal Uterus?
Uterus Arcuate Uterus Septate

Unicornuate uterus
3D Gyn
Surgery
3D Images useful for surgeons for the pre-
operative planning
Uterus Septate in pre and post surgery
Uterus Septate in pre and post surgery
Uterus Didelphys
3D Gyn
Surgery
3D Images useful for surgeons for the pre-operative planning
Asherman’s syndrome with severe adhesion. Myometrium full of scars.
Adhesions in pre and post surgery
3D Gyn
Fibroids seen best in reconstructed views in 3D
Use Endomentrium as contrast

Not needed fluid in cavity
Submocous fibroid in 2D Submocous fibroid in 3D C plane

3D Gyn
Fibroids seen best in reconstructed views in 3D
Use Endomentrium as contrast

Not needed fluid in cavity
Where is thefibroid? Submocous fibroid in cavity Cavity not well seen in 2D Fibroid best Seen
fundus in 3D
3D Gyn
3D Sonohysterography
•  3D sonohysterography shows
intrauterine cavity. A quick
acquisition is sufficient to then
reconstruct the three orthogonal
planes and show the cavity in every
orientation desired (rescanning the
volume)
3D Gyn
3D Sonohysterography
Sonohystero in VSI and realistic rendering
Sonohystero in MPR
Sonohystero in 4D
3D Gyn
3D Gyn
Adnexal masses
3D T/V is very useful in Adnexal region
Ovaric Cyst?
Adnexal Cystic masses

Hydrosalpinx
Hydrosalpinx in Inversion mode
3D Gyn - IOTA
IOTA
the International Ovarian Tumor Analysis (IOTA) consortium published the Assessment of Different Neoplasias
in the adneXa (ADNEX) model, the first risk model that differentiates between benign and four types of
malignant ovarian tumors: borderline, stage I cancer, stage II-IV cancer, and secondary metastatic cancer. This
approach is novel compared to existing tools that only differentiate between benign and malignant tumors. The
model was developed by clinicians and statisticians from the IOTA group, and is based on clinical and
ultrasound data from almost 6000 women recruited at 24 centers in 10 countries (Italy, Belgium, Sweden,
Czech Republic, Poland, France, UK, China, Spain, and Canada).
Correct discrimination between benign and
malignant ovarian masses
Previous studies limited by:
–  small sample size
–  single-center population
–  different tumor types
–  not standardized ultrasound terms and
definitions
–  lack of consistency in histological reports
3D Gyn - IOTA
Aims of the IOTA Studies

The ADNEX model uses nine predictors. There are three clinical variables, age, serum CA-125 level, and type of center
(oncology referral center vs other), and six ultrasound variables, maximal diameter of lesion, proportion of solid tissue, more than
10 cyst locules, number of papillary projections, acoustic shadows, and ascites. All patients included required surgery as judged
by a local clinician. As with all current diagnostic models for adnexal tumors (e.g. IOTA models, RMI, ROMA) it implies that
patients selected for expectant management were excluded when creating the model. As a consequence ADNEX cannot be
applied to conservatively treated adnexal tumors.
•  To develope rules and models to characterize ovarian pathology
•  To test the diagnostic performance of rules and models by external validation with
examiners of different levels of ultrasound experience
•  To establish the role of CA 125 and other serum tumor markers for the diagnosis
of ovarian cancer
•  To identify the characteristics of ovarian tumors that are difficult to classify as

benign or malignant
•  To validate these models or rules in non-operated patients by studying the

outcome of adnexal masses classified as benign
3D Gyn - IOTA
The ADNEX model has been externally validated in the original paper, and in six subsequent studies. These
studies confirm the discrimination between benign and malignant masses. Further calibration results when
presented are good. Discrimination between the five tumor types is more difficult to investigate due to the low
prevalence of several categories, and the fact that this is a non-standard analysis that needs to be done with
care. Nevertheless, available results are good. The ADNEX model is implemented electronically in various
formats
•  App for Android

•  App for iOS
•  Web application
(http://www.iotagroup.org/adnexmodel/site%20iota.html)
3D Gyn – IOTA Simple Rules
3D Gyn - IOTA
New trend:
The use of 3D ultrasound
to improve reproducibility
of the IOTA simple US
rules for classifyng
adnexal masses as
benign or malignant
using 3D Volumes
Pelvic Floor
Pelvic Floor
So far pelvic floor imaging has been limited to the midsagittal plane. With the introduction of 3D
and 4D real time imaging, we are now able to access the axial plane for describing the normal
and abnormal morphology of the levator ani complex and levator hiatus. Up until recently imaging
of the levator ani complex was limited to magnetic resonance imaging
Pelvic Organs Prolapse
3D4D scanning
On 3D ultrasound static imaging planes can be varied in order to enhance the visibility of a give
anatomical structure either at the time of acquisition or at a later time during offline analysis. 4D real-
time imaging allows the investigator to obtain a dynamic assessment of the pelvic floor. Observations of
manoeuvres such as levator contraction and valsalva allow assessment of levator function and
delineate levator or fascial trauma more clearly. Detachment of the puborectalis muscle component of
the levator ani from the pubic bone, described as an “avulsion injury or defects” may be most clearly
visible at levator contraction, and defects of the rectovaginal septum are often visible only on valsalva.
3D Gyn
Multi Follicle Volume

The function to measure multiple follicles
automatically.
Volume of each follicle can be
calculated, and differentiated by color.
§  It is reported that follicle size is
reflected ovarian function and is
estimated the period to collect ovum
for fertility treatment.
§  Doctors measure long and short axes
of all follicles manually in each. It
takes long time and is examiner’s
dependency.
3D Gyn
MFV
Number of follicles Max. 20
to extract
Extraction size Min : 3mm　・　Max:100mm
Differentiation by Possible (Follicle of the biggest volume

color is displayed in red)
Measurement value ･Total number of extracted follicles

･Volume
･X,Y,Z axis length and its average
･Diameter of the sphere of the measured
volume
(The follicle is regarded as the sphere
whose volume is same as the original
shape )
Transfer to report Possible
Display a) Parallel Shift

b) Long axis view
3D Gyn
3D imaging modality is not new, as CT ad MR have used it for decades with reconstruction of
volumes in many planes.
Now that ultrasound has acquired similar capabilities, the benefits of using ultrasound as the first
imaging test are infinite. 3d ultrasound will challenge MR’s imaging capabilities
The ability to view reconstructed planes in the pelvis is the key to further developing helpful
imaging techniques.
3D Gyn
Example how to use 3D4D ARIETTA V60/V70

•  IUD
Gamma 7
•  Rendering X Ray
Brightness 3
•  3D Brightness 3
3D Gyn
•  MSI + VSI
•  Rendering X Ray
•  Slice thickness 5 mm
•  Slice distance 1mm
Breast 3D
•  Developed for breast 3D

•  Observe the relation with tumor and surrounding tissue with thickened 3D
image
–  Check a border of tumor or drawn texture by tumor
–  Check of degree of inversion, state of texture
Linear volumetric transducer, when combined with the advanced 3D visualization features of the HITACHI
product line, is ideal for breast scanning or any other small parts imaging.
VL54 / EUP-LV74
4D Linear
§  Volume
§  13 – 5 MHz
§  38 mm Radius
§  25° FOV
§  Smart / HI VISION connector
Clinical Usefulness of 3D Linear Probe in Breast
–  Breast
•  3D US (especially Coronal views) provides more comprehensive
information which can be of great help to the oncologists in
planning their treatment.
•  Tumor wall characterization & the surrounding tissue infiltration
appear more precise. 3D can play a major role when there is
multiplicity of lesions.
•  Tumor volume can be measure precisely and it is important to
evaluate the effect of chemo therapy.
Breast 3D
•  Note for after 3D Scan acquisition

–  Adjust Clipping Box size by manual
•  Thickened 3D image is obtained by thin clicking box
•  Or better VSI imaging
Breast 4D Elasto
•  Elasto 3D is available
–  For breast examination
Breast 4D Elasto
It is possible to display
both soft areas and hard
areas
Soft area
エラストエラスト３
2D D像
Luca Mastrogirolamo Hard area © Hitachi Medical Systems Europe 2017. All rights reserved. 38
Breast 4D Elasto
2D-3D MPR
Dual Elasto MPR MSI
3D Breast Case : Malignant tumor
Rendering Mode: X-ray

The low echo mass with halo.
The boundary is irregular, it seems to be invasive to surrounding tissue.
Courtesy of Prof. WANG Yi
Luca Mastrogirolamo Huashan Hospital, Fudan University,
© Hitachi Shanghai,
Medical Systems China
Europe 2017. All rights
reserved. 40
Malignant tumor – MSI imaging
Multi Slice Imaging

Slice Direction: Ref C
Coronal plane (C-plane) We can confirm the extent of the

tumor in each depth by MSI mode.
Courtesy of Prof. WANG Yi It is important to decide the

Huashan Hospital, Fudan University, Shanghai, China
Luca Mastrogirolamo resection area of breast.
© Hitachi Medical Systems Europe 2017. All rights reserved. 41
Malignant tumor – Inversion mode
Rendering Mode: X-ray

The black part of tumor is
represented with white. The image
looks like a mammography image.
Inversion Mode
Courtesy of Prof. WANG Yi
Luca Mastrogirolamo Huashan Hospital, Fudan
© HitachiUniversity, Shanghai,
Medical Systems Europe 2017. All rightsChina
reserved. 42

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T/V 3D in Gynecology and Breast 3D

29th – 30th August 2017

3D Ultrasound in Gynecology represents a big improvement in investigation with infinite benefits

• Can Evaluate data at a later stage

The most important aspect of 3D ultrasound in Gynecology is the C Plane

• The 3 Orthogonal planes are

Area of clear benefit

IUD Location and management

Uterus too small for IUD

Measure of the fundus of

Blurry myometrium, poorly defined Details of the myometrium, stripes

Shape of the uterine cavity

3-10% in infertility and recurrent pregnancy loss

Normal uterus Vs sub-septate uterus

Source: Troiano RN Mc Carthy

Measuring the Septum

Complete septum of the uterus. Two

Thin septum seen in two volumes

Why it is important 3D in Gynecology? Are the images the same?

The use of Coronal plane changed the

Uterus Arcuate Uterus Septate

Uterus Septate in pre and post surgery

Uterus Septate in pre and post surgery

Asherman’s syndrome with severe adhesion. Myometrium full of scars.

Adhesions in pre and post surgery

Fibroids seen best in reconstructed views in 3D

Use Endomentrium as contrast

Submocous fibroid in 2D Submocous fibroid in 3D C plane

Fibroids seen best in reconstructed views in 3D

Use Endomentrium as contrast

Sonohystero in VSI and realistic rendering

Adnexal Cystic masses

Hydrosalpinx in Inversion mode

Aims of the IOTA Studies

• To develope rules and models to characterize ovarian pathology

• To identify the characteristics of ovarian tumors that are difficult to classify as

• To validate these models or rules in non-operated patients by studying the

• App for Android

Multi Follicle Volume

Extraction size Min : 3mm ・ Max:100mm

Differentiation by Possible (Follicle of the biggest volume

Measurement value ･Total number of extracted follicles

Transfer to report Possible

Display a) Parallel Shift

Example how to use 3D4D ARIETTA V60/V70

• Developed for breast 3D

• Note for after 3D Scan acquisition

Dual Elasto MPR MSI

Rendering Mode: X-ray

Multi Slice Imaging

Coronal plane (C-plane) We can confirm the extent of the

Courtesy of Prof. WANG Yi It is important to decide the

Rendering Mode: X-ray

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•  Can Evaluate data at a later stage

•  The 3 Orthogonal planes are

•  To develope rules and models to characterize ovarian pathology

•  To identify the characteristics of ovarian tumors that are difficult to classify as

•  To validate these models or rules in non-operated patients by studying the

•  App for Android

Extraction size Min : 3mm　・　Max:100mm

•  Developed for breast 3D

•  Note for after 3D Scan acquisition