3D Ultrasound in the Evaluation of Small Parts - SD

Introduction

I am Dr. Leandro Fernandez, director of the Laboratory of Advanced Sonography at Institute Medical Florisa in Caracas, Venezuela.

I will present the topic three dimensional ultrasound in small parts.

Overview of 3D Ultrasound

3D ultrasound in the evaluation of a small parts three dimensional ultrasound is a relatively recent technique in clinical practice, which is more frequently used in obstetrics and gynecology, but there is a wide range of current and potential applications in other medical specialties.

There are different types of three-dimensional ultrasound vascular, 3D ultrasound, volumetric surface mode, multiplanar ultrasound, niche mode, and vocal. Vocal stands for vertical organ computed aided analysis.

The volume acquisition can be done by using two different techniques, free hands or automatic acquisition.

And the three dimensional reconstruction can be done built in, working in our equipment or by using a work station.

Acquisition Techniques

This is a diagram representing the freehand three-dimensional acquisition. In this case, we sweep the transducer over the area that we want to study or assess, and then the computer constructs a different planes, a different, group of images. And then, three dimensional rendering is produced by using, automatic transducers.

It's not necessary to move the transducer over the surface. You can set the transducer or place the transducer over the organ or this area that you want to assess for. And then the transducer automatically by using electro electro mechanic component components, will make the three dimensional acquisition.

Sonographic Planes and Advantages

These are the sonographic planes you all know, the longitudinal, the transversal, and the Corona plane.

And the advantage of three dimensional ultrasound is that we can have at the same time on the same screen, these three sonographic planes obtaining, obtaining this kind of image.

Clinical Examples

This is an example of a three dimensional ultrasound of a of, of a testis. And here we have the longitudinal, the transversal, and the cornal plane. And here we have the three dimensional volumetric image. We will, go back to this image later on in this presentation.

I will show you clinical examples of 3D ultrasound in thyroid, parathyroid a**l.

Thyroid

Let's begin with thyroid. This is the normal 2D image of the thyroid with, right lobe left, left lobe, and the isus itus. And here we have a cornal view. This view is only obtained by using three dimensional ultrasound. This is a cornal view, constructed by the computer where we can see here the right, the left lobe. Again, the isus is the same patient, and also we can observe here the cartilage of the trachea. Again, this is the same image, and we can change the perspective by modifying our controls.

This is a case of a subacute thyroiditis By using extended field of view ultrasound, we can observe an enlarged gland here, the right, the left, and the isus here, a closeup by using the zoom function of the zoom tool. And here the cornal view of the right isus and left lobe.

This is the three dimensional representation of the vascularization, an increased vascularization in this case.

Another case of sub subacute thyroiditis. Here we can observe in this volumetric representation or presentation, the, the altered echogenicity in longitude in transversal, but also in longitudinal plane, multi multina art goiter, again with, extended field of view ultrasound, the hyper vascularization by using power doubler. And here the three dimensional reconstruction. The, we call the, this technique, three dimensional biography, a complex cyst in thyroid. Also with this solid nodular image inside a cyst vascularized when, power doppler is used. The three dimensional or multiplanar, in this case, the multiplanar rendering. And then this com, the combination of surface and volumetric mode of the lesion.

A follicular cyst observed with 2D power doppler, and then the multiplanar, 3D ultrasound again with the three planes. And then a combination of volumetric and surface mode Thyroid adenoma with 2D and color doppler power doppler. And here we can see how apparent is the vascularization is by using the three dimensional reconstruction. This is the image obtained by only power doppler, and this is the image obtained by using the 3D power doppler, conventional ultrasound of thyroid carcinoma. Here, these hyper echogenic with hyper echogenic areas in the junction of the, isus with the right lobe. And here volumetric representation or cons, reconstruction where we can observe the longitudinal and the transversal plane.

The advantage to 3D ultrasound is that we can rotate it, we can rotate the image in any direction. We can change the perspectives, and we can, perform cuts in the image just looking for the extension of the lesion or trying to define or trying to obtain a better definition of the limits of, of eventual tumor. In this case. The same case now showing the, vascularization, the increased vascularization with power, with with color doppler. And here we have a 3D color doppler, and we can do also digital abstractions of the B mode image. And we can have only the vascularization three dimensional representation.

Parathyroid

Parathyroid. Well, we start this study knowing, of course, the parathyroid localization. Sometimes it's difficult with 2D ultrasound to localize a normal para parathyroid gland. In this case, this is the normal gland observed by using a 12 to five megahertz transducer with extended field of view technique. Those are the correct the sonographic characteristics of the para hyperplasia. Normally there are hypo echogenic or isogenic with a measurement of five to 10 millimeters in longitudinal view, only few vessels are observed in these cases and generally are multiple lesions.

This is another case of parathyroid hyperplasia, and again, another one with 9.7 millimeters. In this case, it's not hyper genic, but it is hyper headache. This is a oid adenoma, so the measurement is higher than 10 millimeters, in this case, 20 millimeters by using conventional 2D ultrasound here, the transversal view of the same case and the power doppler showing us the vascularization. And this is very important because we have here a nutritious vessels. It's quite ior important to determine the presence of these vessels. And this is an important information for the referral physician.

And now this same case with a 3D reconstruction. First the MultiPlan, and then we have the combination. This is a volumetric rendering where we can observe an enlarged thyroid lobe with lesions inside the thyroid lobe. And we have at the same time, the parathyroid adenoma. This volumetric image is always reconstructed or rendered by processing the multiplanar image first.

This is another example of parathyroid adenoma is an important, is a huge lesion with the main, nutritious vessels. And the same case. This is the three dimensional reconstruction of the vascularization. We, with this technique, we can, we can better determine the insertion of the vascular of the vessels, which could be an important information for the surgeon.

These patients was referred to our lab for a renal sonogram. We found this, these lesions here. This is a nephrocalcinosis. It was a bilateral, bi bilateral nephrocalcinosis. So we decide, we decide to explore the neck of this patient, and we found this important and huge, parathyroid adenoma correspondent to the same disease. In this case, this is the adenoma showing the hyper vascularized, condition with power doppler and again, compare. And we can see how apparent the vascularization is by using 3D ultrasound.

The Aden autonomous, the parathyroid Aden autonomous al also can be found, in, an, an, ectopic position. In this case, we have a three dimensional reconstruction. Here. We have the subclavian artery. Here we have the carotid artery, and we have two structures here, two hyper cogenic, structures here. This is one here. This is the second one beside the main vessels of the neck, the subclavian. And here the carotid artery. We can rotate the image. And in this case, we can use this transducer of this image of the transducer in order to get oriented. And we can perform the cuts and these different slices in order to determine, the extension of the lesions. Those are ectopic adenomas.

Another example of 3D. Ultrasound disease is an image corresponding to a vocal, to the vocal technique. Virtual organ computed aided analysis. This is a parathyroid adenoma of only nine millimeters, longitudinal measurement. And here we have the reconstruction, the volumetric reconstruction, and the computers offers an automatic, calculation of the volume.

This is a case of pleomorphic adenoma of the paraic land. This is the, the, usual image that we can obtain by using two dimensional ultrasound. And this is the multiplanar image. And then we have here the volumetric, image combined with the surface mode image. And then we can make the different slices or digital sub abstraction, and we can obtain this kind, this kind of image. And we can even navigate inside the lesion and, and calculate, the, the volume of the lesion and the diverse or the diverse components inside this tiny, tiny polymorphic adenoma

Scrotal 3D Ultrasound

scrotal three dimensional ultrasound. Well, Well, those are the applications of clinical condition that we can observe by using two dimensional ultrasound, testicular masses, hematomas or, and epi mitis forico cell hydrocele with three dimensional ultrasound. We, we can obtain, we can study these conditions too, and we can obtain specials view of this organ.

This is a normal testicle, presented by using 3D ultrasound longitudinal. This is the transversal, and the computer offers an immediate al, virtual view. And this al view, we can rotate it. And this al corresponds, this al view corresponds with the anatomical image that we all have studied in our anato textbooks. This is the epi mosquito. This is the upper pole, the lower pole. This is the body of the, of the testes. And this is the only way to have a coronal view is by using three dimensional ultrasound, another image, but now combining volumetric and surface mode. This is the scrotal surface, and this is, again, the testicle, normal testicle. This is upper pole, lower pole. This is anterior, and this is posterior.

An example of an epidermal cyst and an koic koic image. And this is the multiplanar reconstruction. And then we have the combination of volumetric with surface mode inside Or kites and epi mitis. We can observe an altered echogenicity of the head of the epi with an hyper vascularized condition, better depicted when the three dimensional power doppler is used.

Examples of a mitis by using color doppler. And this is a combination of B mode and power doppler. Power doppler. Another example of oris with color doppler. And then with 3D power doppler. An example of oris is hyper vascularized. And then the three-dimensional reconstruction, intra testicular trauma. It is, an image corresponding to a intra testicular hematoma after severe trauma. Very interesting, because we didn't have lesion here inside the, the EPIs, only intra testicular.

This is a typical case of seminoma by using 2D ultrasound. And here three dimensional ultrasound. We have some kind of box or some kind of purine block, has used by the, physician specialized in, pathological an anatomy. And here we have, we can observe microcalcifications. We can perform different cuts of slices in the organ that we're studying this case testicle. We can do digital abstractions and we can, observe different planes by using this technology. In this case of Seminoma MultiPlan here, this is the al view. This is the right testis. This is the left testis. Here we have the, we have the, volumetric representation. And we can see here, the complex image corresponding to a benign testicular teratoma in a patient of two years old.

Hydrocele we're using here. The liquid of the hydrocele has as an acoustic window. This is the power dopper, and here we have the MultiPlan, image. This is the same image I showed you before at the beginning of the lecture, but with the, the, acoustic window, we can even observe the surface of the testis, the surface of the organ. And this can of image is only obtained by using three dimensional ultrasound with the use of 3D on four D ultrasound. We can also perform, perform needle guidance. We can do fine needle aspiration, ultra guided ultrasound functions. This is the tip of the needle. This is the tip of the needle. This is the lumen of the needle. And here, this is an example, by using 3D technology. And, we are absolutely sure that our needle is placed on the proper side.

Study Results

Our group published, this paper, some years ago in 2004. And, we try to determine if, it's just a nice picture or can we use, its affordable. It, it's can be done. And, we work with more than 800 patients with, an age of, of, between two and 81 years old. And we use different technologies, automatic transducers, automatic technology, freehand technology even, workstations by using portable ultrasound, as you can see here. And always, we use, linear array broadband trans users from two 12 to five megahertz and 13 to five megahertz.

And our results were that we found a copi liquidity of excellent and moderate, of all more than 95%, in fact, 97%, 96%, and we obtain a poor image only in 3.8% of the patients. And if he has the ability to perform 3D ultrasound in the small parts, it was a very easy study in 65% of the cases easy in 32, 8 0.8% of the cases, and only was difficult only in 2% of the cases.

The reason is because the small parts are very stable, are not moving like a fetus. And fetus is more difficult because the, the or, or, or, or different organs, the organs are moving with respiration, the fetus are moving, him or herself. so in this case, it is quite easy because the, the organ are a statics and the reproducibly of the method was 94.9%.

Advantages and Disadvantages

3D ultrasound in a small parts has disa disadvantages the cost of the equipment. No measurements can be done when you use the freehand mo. The freehand mode can be done if we are using automatic transducers, but not in the freehand mode unless you are using magnetic, positioners. All the images I presented in these lectures, or most of the images were done with a free hand technique. Of course, it's necessary a learning curve that at the beginning is time consuming.

The three dimensional approach, rapidly, digitalized conventional 2D ultrasound, images and, not only blood flow, but also also the anatomy images. And, 3D ultrasound rapidly. Decon con reconstruct these 3D images and, offers an interactive viewing of 3D imaging. And we can, do needle guidance in 3D and four D permitting to do therapy planning. And, 3D ultrasound offers a virtual Corona plane view and a comprehensive image, it's obtained for the referral physician.

It has, advantages because we can obtain realistic images with high conspicuity, and we have the capability to work offline. So we can make volume storage, storage. We can compare results and make follow up. We can compare the previous ultrasound 3D ultrasound. We can, we can store storage, the image, we can do post-processing, and we can also transfer the data and working offline.

We have another advantage when we are working with conventional ultrasound. It takes, takes time, to prepare the patient. Five minutes, maybe 30 minutes to perform the ultrasound. if, it's a sonographer is doing the test, he has, he or she has to organize the data or the, or the images in more or less 10 minutes. And then the ologist, that will, that will review. the images take more 10 minutes, so we can, we can calculate 55 minutes, to make a conventional ultrasound working offline. you can save time to the patient and save time to the lab, because okay, the same, the same five minutes to prepare the patient. But you can obtain all the volumetric data in only 10 minutes or less. And, the radiologist can go there and go through the multiplanetary image and go through the volumetric images, and you can save even, you can save up 20 minutes per patient.

It was demonstrated, in different, studies and trials. And, Dr. Be Raf published a very interesting, paper, making the measurements of the time, by, with the observation of the fetus, the volumetric images of fetuses.

Conclusion

So, in conclusion, three dimensional, ultrasound and three dimensional reconstruction provides a very effective view of vessels, smallest structures, and internal art surfaces. the assessment of the testicle, parid, thyroid and parathyroid gland is properly achieved, achieved by using 3D ultrasound, known OB GYN 3D. Ultrasound is a new and promising technique that opens a new vision in diagnostic ultrasonography, but absolutely further studies to determine efficacy, sensitivity, specificity and accuracy of three dimensional ultrasound in this field are still required.

3D ultrasound in the evaluation of a small parts.