Contrast - Enhanced Ultrasound in Gynecology - HD

Introduction

Hi.
I am Dr. Nathan Sobel. I'm from India.
I work at the JLo Hospital Mumbai as a consultant.
I'm also the director of tan Alsan Center,
which is in Tani, both places in Mumbai, India.
And I'm going to talk on contrast enhanced
alsan in gynecologic.

Contrast Enhanced Ultrasound in Gynecology

Contrast enhanced ultrasound in gynecology is a new
and a very exciting branch of or
or advancement in the field of ultrasound.
We used two microbus in our practice, sono view,
which is sulfur hexa fluoride microbus
and definitive, which is per flut trend.
Microbes, both these microbes are equal as far
as clinical efficacy is concerned
and they're also equal as far
as cost effectiveness is concerned.

Guidelines and Applications

The guidelines for the use
of contrast in liver are well established
and this was published in 2012
and I was very fortunate to be a part
of this very allied group.
But when it comes to gynecology, there is not much
of literature as far as contrast
and a**l sound is concerned,
but potentially one can use it
to evaluate endometrial cavity
and look at the tubal patency.
We can evaluate endometrial pathologies.
It can be useful to differentiate between fibroid
and adeno masses.
It can be useful to characterize ovarian masses useful in
that nex cell toin and some other conditions.
And today, we will highlight some
of the very important applications as far
as this is concerned, as compared to color doppler,
which shows us blood flow in larger vessels.
Contrast enhanced ultrasound has a capacity
or a capability to look at blood flow in very tiny vessels
or micro vessels.
This is because these bubbles are very tiny, about five
to 10 microns
and then in easy to go through the smallest capillaries
and therefore on ultrasound we can get in real time
the hemodynamic changes which happen within a mass lesion
or any other lesion in the body.

Saline Infusion Sonography

Contrast, NAL ultrasound is nothing new in gynecology.
We have been using saline as a negative contrast media
over years, and this has been very useful in looking at
endometrial pathologies.
This can be done with very sophisticated catheters such
as this, or they can be used done with Goldstein Cannula,
which is a very popular cannula,
but a very cost effective way
of doing a saline infusion sonography is to use a simple
infant fitting tube.
So this technique
of saline infusion sonography is very useful
in looking at endometrial pathologies like polyps,
looking at extension of a submucosal fibroid as well
as picking up uterine sine
the transfer channel cell align Contrast sonohysterography
is quick, simple, safe, inexpensive, and append technique,
and it is as reliable his ASRA hysteroscopy
to detect endometrial polyps and submucosal myomas.

Tubal Patency with Saline

Now we go one step further,
and as this align goes through the fallopian tube
through the corn, we can actually trace this align on either
side and see it fall in the atixa.
This test is used to confirm tubal patency
and is popularly known as a scientist.

Color Doppler for Tubal Patency

Now we go one step ahead and as we inject the cell line
and as it comes through the tubes into the atixa,
we can switch on the color doppler.
And if you see a flash of color in that annexa, it confirms
that the tube is patent on that side.
This is a very simple technique to look at tubal patency
and can be done very easily
as an office procedure within a matter of few minutes
and the effect and it's very effective
and accurate as far as the test for tub as a test
for tubal patency.

HyCoSy for Tubal Patency

Now we go one step ahead
and we inject contrast within the uterine cavity,
and then as we inject the contrast,
we trace the con contrast as it goes
through the fallopian tube up to the fia
and we can actually see the spill
of the contrast in that annexa.
This is turning out to be a much better
and more effective way to not only look at tubal patency,
but also to visualize the fallopian tubes
as the contrast media goes through the fallopian tubes.
Here, for example, if you trace the right side,
we can see the fallopian tube going
all the way into the aex.
However, we are not seeing any spill across the FIA
suggesting that there could be a FIA block on the left side.
The contrast media is not going beyond the con suggesting
that there is a corneal block on the left side.
So we have got a very good diagnosis
with the help of contrast.
This technique, which is known as popularly known as koi
or hissing.
ISO contrast sonography is a very popular technique in many
institutes, and in fact in the UK it has been recommended
by the National Institute for Health
and Clinical Excellence as the investigation of choice
for a symptomatic woman
who need fallin two patency assessment as a part
of the investigation for Subfertility
high Co C has several advantages.
It has no radiation, it's an easy office procedure,
very well tolerated by the patients and very cost effective
and very accurate as far as the results are concerned.

3D HyCoSy

Now what we can do is
as we inject the contrast in the uterine cavity
and as the contrast goes through the fallopian tube,
we can do volumetric reconstruction
of the contrast within the uterine cavity as well
as the Philippine tube, and this is known as 3D high coi.
And this will catch up as more
and more machines are able to do more and more
and better volumetric work.
In fact, if you use a oil soluble contrast medium
to look at the tubal patency, there are very good chances
that actually this will work not only as a diagnostic test,
but in fact it has been reported
that the pregnancy rates have been higher after the test.
So in a way, it also acts as a therapeutic procedure.

Endometrial Evaluation

Let's go on to endometrium.
We all know that
whenever we have a patient with postmenopausal bleeding or
whenever we see a thick endometrium,
we are worried about endometrium.
Malignancy. We also know
that routine gray scale findings such as three endometrium
colored oler findings, as well
as pulse doppler findings have serious limitations in
differentiating endometrial hypoplasia from
endometrial malignancy.
Therefore, we look at contrast
and when we look at a normal enhancement pattern in the
endometrium and the myometrium, we realize
that the endometrium announces late as compared
to the myometrium,
and the peak enhancement of the
contrast within the endometrium is less as compared
to the myometrium.
And this is what happens in a normal patient.
If you look at patients with endometrial hypoplasia,
which is a benign condition, we always, we also realize
that the same thing happens.
The endometrium picks up the contrast late as compared
to the surrounding myometrium,
and the peak intensity
of the contrast within the endometrium is less as compared
to the myometrium.

Time-Intensity Curves for Endometrium

Now, if we were to plot this on a time intensity graph,
if we were to assign the yellow dot for myometrium
and the red dot for the endometrium, we realized
that myometrium as enhanced early
and the peak intensity within the myometrium is much more
as compared to the endometrium, as opposed to that,
whenever we have an endometrial malignancy,
the endometrium shows a quick enhancement
enhancement coming up faster than the myometrium.
And the peak intensity
of enhancement within the endometrium is much more
as compared to the surrounding myometrium.
And now if we were to plot a graph again,
and in this graph if red were to represent the myometrium
and the yellow, the endometrium, we see
that the endometrium has picked up the contrast very fast
and the intensity of contrast is also much more as compared
to the myometrium.
So this fact where the peak announcement time is less
in a tumor as compared to natrium
and the peak intensity is much more as compared
to the normal myometrium has been confirmed
by several studies and several articles,
and it seems that this is a very effective way
of differentiating endometrial hypoplasia from
endometrial malignancy.

Guiding Biopsy in Endometrium

What is more important is that very often we know
that within a thickened endometrium
that can be a focus of malignancy.
And if we were to do a blind sampling of this endometrium,
one could miss this focus of malignancy.
Here, for example, in the fundal anterior wall,
we see a localized area
of endometrial thickening with increased flow.
On contrast, we can see
that this area is enhancing much more as compared
to the rest of the endometrium, and
therefore if we were to do a sampling in this case,
one would sample exactly this area
and our eel would be much better than
doing a blind sampling.
So contrast enhanced ultrasound can help us in guiding the
biopsy procedure.

Differentiating Retained Products from AVM

Very often in clinical practice we have this dilemma.
We have ill-defined masses in the endometrium
and the myometrium, which are extremely vascular on color
doppler or power doppler.
We are worried whether these are just retained products
of conception or whether it's a vascular malformation.
Contrast can help us in differentiate the two.
For example, when we inject contrast,
and if you're dealing with a detained product of conception,
only that area lights up
and we do not see any abnormal vessels
within the myometrium.
Whereas if we are dealing
with the true arterio venous malformation,
what we see is enhancement of not only of that area,
but we see vessels in the surrounding area
which fill up fast.
These are the draining veins,
and that is very typical
of an artery vein, a small formation.
So in day-to-day practice,
whenever we have a dilemma between in differentiating
between need in products
and ous malformation contrasts can potentially help us.

Differentiating Fibroids from Adenomyosis

The other common dilemma in a day-to-day practice is
differentiating fibroid from focal adenos.
We all know that fibroids tend to be hypo coic
as compared to the myometrium.
They're well-defined margins.
And if you look at color doppler
or power doppler, we see peripheral draping vessels.
Admiss on the other hand, as ill-defined margins,
very often we have this myometrial cyst sundry appearance.
They tend to be more hyporeflective
as compared to the myometrium.
And if you look at the color dola
or power dola, very often we see ill-defined scattered
penetrating vessels in that area.
If we inject contrast in a patient who has got a fibroid,
what we typically see is a peripheral announcement
of the capsule of the fibroid with a gradual filling
of the fibroid from the periphery into the center.
This is known as a sedentary petal enhancement.
This pattern is very often referred to as a basket pattern
and is now very characteristic of a fibroid.
So that's another example of a fibroid.
We see a capsular vessel there in the periphery,
and with time we see a gradual filling from the periphery
into the center, which is, as I said, very typical
and diagnostic of a fibroid.
On the other hand, adenos shows heterogeneous enhancement,
which is quite diffused
and quite irregular without any discipline.
So as an example of adenos,
very often the contrast comes up early.
However, it is quite a diffuse
and a heterogeneous enhancement.
We are vessels which are penetrating
quite irregular coming from within the tumor.
And this appearance of contrast in a focal lesion
in focales is very often referred to
as a moth eaten filling defect.
So here's a side to side comparison of a fibroid and ados.
We have well-defined flow pattern
with the feeding vessel there,
and here we have a diffuse heterogeneous enhancement.
So contrast definitely helps us in differentiating fibroids
from focal ados.

Devascularization Procedures

Furthermore, whenever we do a devascularization procedure
like for example, embolization
or a HIFU contrast, enhanced ultrasound is helpful
in guiding these procedures
and ensuring that the embolization
or the HIFU has been adequate as far
as devascularization procedure is.
So rather than rather do an expensive MR again
or do an invasive test like an angiography contrast,
enhanced ultrasound is unsafe
and a non-invasive way of finding out defectiveness
of such procedures.

Ovarian Masses

Let us switch gears and come to ovarian masses.
In practice, whenever we see such ovarian mass,
which are quite obviously malignant with solid areas
vascularity, we do not require any other imaging modality
to characterize this masses.
But in practice, very often we have borderline cases
and contrast in an ultrasound is promising tool
to pick up an early ovarian malignancy.
Typically, if we were to inject contrast in a patient
with ovarian malignancy,
what we would get it marked enhancement of the entire tumor,
enhancement of the septe and enhancement of the solid areas.
At this point of time, we do not know whether contrast
enhanced ultrasound is going
to help us in actually diagnosis of
or diagnosis of picking up more ovarian malignancies,
but we do know that it can definitely rule out ovarian
malignancies in a good number of patients.
Here, for example, we have an ovarian cyst which looks
complex and looks like a mass,
which has got a lot of solid area, solid areas,
is definitely suspicious of a malignancy.
However, when we inject contrast, we realize
that there is only peripheral enhancement
and there is no intrinsic enhancement
of the solid areas at all confirming that this is not,
this is nothing but areas
of hemorrhage within a cystic mass which are not enhancing
and therefore this is definitely a benign tumor
and not a malignancy.
Here we have three examples of cystic ovarian masses
with suspicious solid areas
which look quite suspicious on suspicious on the gray scale.
But when we inject contrast, we realize that none
of this solid looking area
is actually enhancing on contrast.
And in fact, this makes us believe
that this could be benign masses
and all three of them were in fact benign ovarian masses.
On the other hand, if you have a complex ovarian mass
or a predominantly cystic mass with such a area within it,
which has septe and solid A elements,
and if this area is enhancing on contrast,
this is very suspicious of malignancy.
And in fact, this ovarian mass turned out
to be a malignant one.
Similarly, when we see thick septe within a ovarian mass
and these septe are enhancing on contrast,
this is very suspicious of ovarian malignancy.
Very often in practice within an ovarian cystic mass,
we see papillary projections.
If these papillary projections are
more than nine millimeters
or enhancing on contrast,
then we should worry about malignancy.
On the other hand, smaller papillary projections which are
not enhancing on contrast would represent benign masses.
In a day-to-day practice.
Here, for example, we see multiple papillary projections
within an ovarian cystic lesion.
All these papillary areas are large,
and if you look at the enhancement pattern, all
of them are markedly enhancing on contrast.
And in fact, this was a borderline tumor
on histopathology.
So contrast in an ultrasound actually helped us
in differentiating this tumor.

Time-Intensity Curves for Ovarian Masses

We can also do the time intensity curves for ovarian masses.
What we can do is look at the contrast uptake
within the ovarian mass
and compare it with the surrounding ovary.
And we realize that the time in if
and when you plot the time in intensity graph,
we typically realize
that the area under the curve is much greater
for ovarian malignancies as compared to benign tumors.
We can use multiple modalities to help us in coming
to a diagnosis yet, for example,
we see a solid looking ovarian mass.
This mass is extremely hard on elastography.
Around contrast, we see marked enhancement
with a large area under the curve.
All these features are very s suggestive of malignancy,
and this was a very early ovarian malignancy,
which was picked up at a very early stage.
So in fact, contrast enhance ultrasound promises
to be a very good tool to
pick up ovarian malignancies, and the reported specificity
and sensitivity is very high.

Differentiating Complex Ovarian Masses

So in a day-to-day practice,
this is a common problem which we have
here we have two examples of complex ovarian masses.
We would like to know which mass to pursue further
and which mass to just follow up.
With ordinary gray scale
or color doppler, we would not get the answer.
But when we inject contrast, we realize that the mass
on the top is markedly enhancing the solid areas the septe
are markedly enhancing.
And here would be we would be worried about malignancy.
Whereas in this mass, which almost looks similar to the say
above mass, there is no intrinsic enhancement at all.
And in fact, this was just an imaging cyst,
whereas this was an ovarian malignancy.
So we can basically separate out lesions which require
intense follow-ups
or further evaluation versus lesions,
which could be just followed up considering
that they're more likely to be benign.

Peritoneal Deposits and Recurrence

Very often in patients with COA,
we see this hypo coic areas along the peritoneal cavity all
along the mesentry,
and we are worried about peritoneal metastatic deposits.
If these lesions are enhancing on contrast, the diagnosis
of peritoneal deposits can be confirmed.
Similarly, in the patient of c ovary
after surgery, very often we see this masses coming up
and we are worried about recurrent tumors.
If this lesion show marked enhancement again on contrast,
then we are dealing with a recurrence of the tumor,
Any malignancy or for that matter, ovarian malignancy.
We are always worried about metastatic deposits
and contrast enhance ultrasound is a excellent tool
to pick up liver metastasis.
So very often on gray scale, we do not see any lesions,
but while after we inject contrast, these lesions stand out
because they wash out the contrast in a very early phase.

3D Reconstruction for Ovarian Masses

Nowadays what we can further do is
as the contrast bubbles come within a tumor,
we can do a 3D reconstruction during the arterial phase.
And this technique can be useful to us potentially
to characterize ovarian masses further,
but we need to do more studies on this.

Ovarian Torsion

The other common clinical problem,
which we have in a day-to-day practice, is patients coming
with pain and we suspect ovarian toin.
We again know that a conventional gray scale as well
as color doppler has several limitations.
When we want to diagnose ovarian tohin here, for example,
we have a complex ovarian mass in a young girl
who had pain on gray scale.
We can see the snail sign, which is very diagnostic
of toin on color doppler.
We can see the snail sign again,
but contrast shows us the snail sign in a much better way.
And moreover, if you look at a tumor, there is hardly any
contrast uptake or blood flow confirming a
diagnosis of toin.
So contrast in a patient with suspected toin
confirms the diagnosis of toin in two ways.
One, it shows
that the contrast uptake within the ovarian lesion is very
scanty or almost absent.
And number two, it shows us the pedicle
or the snail side in a much better way confirming the
diagnosis of ovarian toin.

Conclusion

So in nutshell, contrast ance, ultrasound
and gynecology has a very vast potential,
which is here to be explored.
There are a lot of more avenues to be explored.
For example, looking at cervical malignancy,
looking at versa, cogen, fistula, et cetera,
where contrast can be very useful.
But once everyone starts using it,
maybe the full potential would be realized.
Thank you so much.