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Objective. The aim of this work was to review the technical aspects and clinical applications of three-dimensional ultrasonography in gynecologic imaging. Methods. With the use of a computerized database (MEDLINE), articles on three-dimensional ultrasonography were reviewed. Other pertinent references were obtained from the references cited in these articles. In addition, we reviewed our own clinical experience over the past 7 years. Results. Numerous applications of three-dimensional ultrasonography have been reported, including imaging of the uterus, the endometrial cavity, adnexa, and the pelvic floor and color and power Doppler applications. The accuracy of volume calculations and the networking opportunities with three-dimensional ultrasonography have also been reported. Technical problems and limitations of this technique are summarized. Conclusions. Three-dimensional ultrasonography has proved to be a useful imaging tool for clinical problem solving in gynecology, especially in imaging the uterus and uterine cavity.

The objective of this study was to assess the value of combining transvaginal sonohysterography with three-dimensional multiplanar ultrasonography to optimize assessment of the uterus. To make this assessment, we compared findings on three-dimensional sonohysterography with those on two-dimensional sonohysterography and X-ray hysterosalpingography. Of 20 women who underwent three-dimensional sonohysterography for various indications, 13 also underwent two-dimensional sonohysterography, and 12 had X-ray hysterosalpingography. We reviewed the 3 types of examinations separately and compared the standard techniques with three-dimensional sonohysterography to determine whether three-dimensional sonohysterography provided additional information. In 9 (69%) of 13 comparisons between three-dimensional sonohysterography and two-dimensional sonohysterography and in 11 (92%) of 12 comparisons between three-dimensional sonohysterography and X-ray hysterosalpingography, three-dimensional sonohysterography was advantageous. The coronal plane was most useful for displaying the relationship between lesions and the uterine cavity. Three-dimensional sonohysterography provided additional information compared with standard accepted techniques in the vast majority of women.

To analyze ultrasonographic (US), computed tomographic (CT), and magnetic resonance (MR) imaging features of primary and secondary ovarian malignant neoplasms to determine if there is any significant difference in their appearance.Analysis of the multi-institutional Radiology Diagnostic Oncology Group data revealed 86 patients with primary ovarian carcinoma and 24 patients with a secondary ovarian neoplasm. Numerous imaging features that had been recorded for the adnexal masses with each imaging modality were reviewed and compared between primary and secondary malignant ovarian neoplasms.Of the imaging features assessed with all three modalities, multilocularity as determined at US (P =.02) or MR imaging (P: =.01) was the only significant feature. At US, 30 (37%) of 81 primary ovarian cancers were multilocular, whereas only three (12%) of 24 metastatic neoplasms were multilocular. At MR imaging, 40 (74%) of 54 primary ovarian cancers were multilocular, whereas only five (36%) of 14 metastatic neoplasms were multilocular. Neither a predominately solid appearance nor bilaterality was significantly different between primary and secondary neoplasms.For malignant ovarian masses, multilocularity at MR imaging or US favors the diagnosis of primary ovarian malignancy rather than secondary neoplasm, but it is difficult to accurately distinguish between primary and secondary ovarian malignancies.

To compare ultrasonography (US), magnetic resonance (MR) imaging, and computed tomography (CT) for diagnosing and staging advanced ovarian cancer.US, CT, and MR imaging were performed in 280 patients. Images were read by three radiologists from each of the five hospitals. Image analysis included determination of malignancy within the peritoneum (11 sites), lymph nodes (10 sites), and hepatic parenchyma. The standard of reference was based on surgical and histopathologic findings. Statistical methods used were receiver operating characteristic (ROC) curve analysis, pairwise comparison of areas under the ROC curves (A(z)), analysis of sensitivity and specificity pairs, and assessment of agreement between the degree of suspicion and standard of reference.There were 118 patients with malignant tumors; 73 (62%) had stage III or IV disease. Metastases were found in the peritoneum in 70 (59%), nodes in 20 (17%), and liver in seven (6%) cases. In the peritoneum, MR imaging and CT (A(z) = 0.96 for both) were more accurate than US (A(z) = 0.86), especially in the subdiaphragmatic spaces and hepatic surfaces. MR imaging and CT were more sensitive than US (95%, 92%, and 69%, respectively) for peritoneal metastases. MR imaging was more accurate than CT for detection of lymph node metastases (A(z) = 0.76 vs 0.57, P =.04). In the liver, the A(z) values for the three modalities were 0.77-0.94.CT and MR imaging are equally accurate, and either modality can be used to stage advanced ovarian cancer.

To determine the optimal imaging modality for diagnosis and staging of ovarian cancer.Two hundred eighty women suspected to have ovarian cancer were enrolled in a prospective study before surgery. Doppler ultrasonography (US), computed tomography (CT), and magnetic resonance (MR) imaging were used to evaluate the mass; conventional US, CT, and MR imaging were used to stage spread.All three modalities had high accuracy (0.91) for the overall diagnosis of malignancy. In the ovaries, the accuracy of MR imaging (0.91) was higher than that of CT and significantly higher than that of Doppler US (0.78). In the extraovarian pelvis and in the abdomen, conventional US, CT, and MR imaging had similar accuracies (0.87-0.95). In differentiation of disease confined to the pelvis from abdominal spread, the specificity of conventional US (96%) was higher than that of CT and significantly higher than that of MR imaging (88%), whereas the sensitivities of MR imaging (98%) and CT (92%) were significantly higher than that of conventional US (75%).MR imaging is superior to Doppler US and CT in diagnosis of malignant ovarian masses. There is little variation among conventional US, CT, and MR imaging as regards staging.

To determine the effects of level of training and other factors on the rate of discrepant interpretation of emergency body computed tomographic (CT) scans by trainees and staff radiologists.Five hundred ninety-eight consecutive emergency CT studies were prospectively interpreted by radiology residents or board-certified body imaging fellows over a 12-month period. Each interpretation was reviewed within 12 hours by an attending body CT radiologist. Major discrepancies between staff radiologists' and trainees' interpretations were defined and those with the potential to affect immediate patient therapy; minor discrepancies were defined ad those without such potential. The effects on discrepancy rates were examined for abnormal versus normal CT findings and trauma versus nontrauma cases.Major and minor discrepancy rates were 1.2% and 6.5%, respectively, between interpretations made by the trainee and the staff radiologist. Overall, fellows demonstrated statistically significantly lower discrepancy rates than did senior of junior residents (5.9%, 13.7%, and 13.3%, respectively). The discrepancy rate was higher when CT findings were abnormal than when they were normal (13.5% vs 2.6%). There were no differences between discrepancy rates for trauma and nontrauma cases.Experience appeared to decrease discrepancy rates. Trainees were more likely to miss findings than to read normal scans as abnormal.

Background: To determine whether intravenous contrast improves the ability of radiologists to establish the cause of acute abdominal pain after nondiagnostic or normal unenhanced CT. Methods: Out of 164 consecutive emergency department patients presenting with less than 48 h of nontraumatic, acute abdominal pain, a confident diagnosis for cause of pain was made prospectively in 71/164 (43%) patients on these unenhanced scans by the monitoring radiologist. In the other 93 patients, our study sample, intravenous contrast-enhanced CT was obtained. At a later date, retrospectively, two experienced abdominal CT radiologists independently evaluated unenhanced CT scans alone for potential causes of pain and diagnostic confidence level on a 1–3 scale. At least 2 weeks later, intravenous enhanced and unenhanced scans were read side-by-side for the same assessment. Results: There was no significant difference in diagnostic confidence levels comparing unenhanced CT alone (2.59) vs. intravenous enhanced and unenhanced CT together (2.64). Chi-square analysis found no significant difference in finding a cause for pain when intravenous contrast was added compared to the initial unenhanced scan alone. Conclusions: Intravenous contrast did not significantly improve the ability of CT to establish a cause of abdominal pain after a negative or nondiagnostic unenhanced CT.

The routine ultrasound examination of the pregnant uterus is presented in this article. The approach is based on published guidelines, dividing the examination into studies of the first trimester and studies of the second and third trimesters. The discussion emphasizes the standard anatomical views and describes the normal sonographic appearances. The methods of obtaining important measurements are described, and tables are provided to analyze these measurements. A systematic approach to obstetric ultrasound is important in ensuring completeness and in maximizing the detection of fetal abnormality.

Specially developed high-resolution real-time ultrasound transducers (12.5 and 20 MHz) on the tip of endoluminal catheters were inserted into the endometrial canal to evaluate the usefulness of this approach. Uterine abnormalities, most confirmed by biopsy, surgery, or both, were detected in 12 patients, including submucosal myomas, nabothian cysts, endometrial polyps, synechiae, and endometrial and cervical carcinoma. In one case the catheter was directed under hysteroscopic guidance into a fallopian tube, demonstrating its potential usefulness in this region. In 4 of the 12 cases in which a hysterectomy was performed, an in vitro ultrasound examination of the organ was performed, which confirmed the initial in vivo ultrasound impressions. Anatomic cross-sectional slices of the uterus resulted in excellent correlation with the ultrasound findings. These preliminary results suggest that this new sonographic procedure will become an important diagnostic tool, supplementing abdominal and endovaginal ultrasound approaches.

A prospective study was performed to determine whether thoracic CT yielded useful information regarding the status of axillary lymph nodes (LNs) in patients with breast cancer. Thirty-five consecutive patients with clinically suspected stage II or III breast carcinomas were scanned preoperatively from the supraclavicular regions to the lung bases. Axillary LNs measuring greater than or equal to 1 cm were considered abnormal. The lymph nodes were classified according to their relationship to the pectoralis muscle. Extracapsular lymph node extension was diagnosed when there was irregularity and spiculation of the lymph node margin with surrounding fatty infiltration. Correlation with axillary dissection was obtained in 20 patients, giving a positive predictive value for axillary metastases of 89% with 50% sensitivity, 75% specificity, and 20% negative predictive value. CT was also able to detect the level of axillary involvement accurately when the lymph nodes were enlarged and to evaluate extracapsular LN extension. Although superior to physical examination, CT was not an accurate predictor of axillary LN involvement, primarily because of its low negative predictive value.

After Wilhelm Conrad Roentgen's discovery of the X-ray in 1895, it was initially thought that gallstones could not be visualized. Surgeons relied solely on the clinical examination to detect biliary disease. Today, no evaluation of the gallbladder would be complete without the performance of an imaging study. Radiology has gone through several eras in the imaging of gallstones. The plain film era, 1895-1924, was characterized by techniques that improved soft-tissue detail, allowing better detection of radiopaque stones. The contrast media era, 1924-1960, was initiated by the invention of IV cholecystography. In 1925, oral cholecystography was developed. During the era of expanding technology, 1960-1979, percutaneous transhepatic cholangiography, scintigraphy, and sonography came into use. The therapeutic era began in the 1980s.

In 28 fetuses studied during a 4 1/2-year period, the initial femur was below 2 standard deviations (SDs) of the mean when compared with the biparietal diameter. These fetuses were considered at risk for skeletal dysplasias and were followed up. Studies were performed at a mean gestational age of 26.7 weeks (range, 15.3-41.0 weeks). Group 1 had a femur length 1-4 mm below the 2-SDs line (range, -2.0 to -4.0 SDs); no other abnormalities were detected. Interval examination of 12 femurs showed that 10 either remained shortened to the same degree or had a growth spurt. At birth, all subjects were healthy except one with mild growth retardation and one with a chromosomal abnormality. Of the two subjects that failed to continue normal growth, one was healthy and the other was a heterozygous achondroplastic dwarf. Group 2 had greater femoral shortness; all measurements were more than 5 mm below the 2-SD line (range, -4.3 to -31.0 SDs). All had fetal abnormalities and significant skeletal dysplasias. The authors conclude that the number of millimeters below the 2-SDs line is an accurate, easy criterion for evaluation of femoral length.

A prospective comparison of contrast-enhanced computed tomography (CT) and duplex sonography (DS) was performed to examine the Kimray-Greenfield filter in the inferior vena cava (IVC) in the immediate postoperative period. Fourteen patients were studied for five complications: IVC thrombosis, malpositioning, pericaval hematoma, filter angulation, and prong perforation. Our results found CT to be more efficacious because it was a) able to evaluate more patients with fewer technically inadequate scans and b) more definitive in all categories. However, when visualized, DS was as accurate as CT in the evaluation of thrombosis.

Color Doppler imaging has been used to evaluate a variety of abnormalities in the iliofemoral region. This pictorial essay demonstrates how use of color Doppler techniques aids in the diagnoses of iliofemoral pseudoaneurysms, fluid collections, aneurysms, arteriovenous fistulas and malformations, venous thrombosis, vascular grafts, and soft-tissue masses including tumors and benign lymphadenopathy.

We studied 54 asymptomatic postmenopausal women to characterize normal contrast-enhanced computed tomography (CT) appearance of endometrium. Endometrium was visualized in 26 out of 54 (48.1%) women, and when seen its mean short-axis thickness was 7.5 mm. The anteroposterior thickness varied directly with uterine angulation (P.05). Endometrial attenuation was significantly less than that of the myometrium (P.05). Endometrial thickness (short axis) and attenuation were inversely correlated to patient age and to years after menopause (P.05). We believe that our findings will help prevent overdiagnosis of endometrial fluid or thickening in asymptomatic women.

To assess whether sonohysterography provides added diagnostic value over transvaginal sonography in patients with suspected or known myomas by comparing diagnostic confidence, interobserver agreement, accuracy, and change in diagnoses when 2 independent observers interpreted transvaginal sonography alone and later interpreted transvaginal sonography and sonohysterography together.Hard copy images from 72 women were interpreted independently by 2 sonologists on separate occasions, rating parameters (abnormal uterus, myoma in any location, submucous myoma, classification of location of a submucous myoma with respect to the uterine cavity, myoma remote from the cavity, adenomyosis, and focal and diffuse endometrial lesions) on a scale of 1 to 5 (1 indicated definitely no; 2, probably no; 3, uncertain; 4, probably yes; and 5, definitely yes). Correlation was made with clinical and imaging follow-up, surgery, and pathologic examination.The added information provided by sonohysterography resulted in improved diagnostic confidence for most parameters. Interobserver agreement was markedly improved for the diagnosis and location of submucous myomas and focal endometrial lesions. Sensitivity values for submucous myomas and focal endometrial lesions were 100% and 90% for transvaginal sonography and sonohysterography together and 100% and 70% for transvaginal sonography alone.We found that sonohysterography does provide additional information over transvaginal sonography alone and is an important adjunct to transvaginal sonography in symptomatic women with known or suspected myomas, particularly before surgical or medical therapy.

Objectives A panel of 14 physicians practicing medicine in the United States with expertise in radiology, obstetrics and gynecology, gynecologic oncology, hysteroscopy, epidemiology, and pathology was convened by the Society of Radiologists in Ultrasound to discuss the role of sonography in women with postmenopausal bleeding. Broad objectives of this conference were (1) to advance understanding of the utility of different diagnostic techniques for evaluating the endometrium in women with postmenopausal bleeding; (2) to formulate useful and practical guidelines for evaluation of women with postmenopausal bleeding, specifically as it relates to the use of sonography; and (3) to offer suggestions for future research projects. Setting October 24 and 25, 2000, Washington, DC, preceding the annual Society of Radiologists in Ultrasound Advances in Sonography conference. Procedure Specific questions to the panel included the following: (1) What are the relative effectiveness and cost-effectiveness of using transvaginal sonography versus office (nondirected) endometrial biopsy as the initial examination for a woman with postmenopausal bleeding? (2) What are the sonographic standards for evaluating a woman with postmenopausal bleeding? (3) What are the abnormal sonographic findings in a woman with postmenopausal bleeding? (4) When should saline infusion sonohysterography or hysteroscopy be used in the evaluation of postmenopausal bleeding? (5) Should the diagnostic approach be modified for patients taking hormone replacement medications, tamoxifen, or other selective estrogen receptor modulators? Conclusions Consensus recommendations were used to create an algorithm for evaluating women with postmenopausal bleeding. All panelists agreed that because postmenopausal bleeding is the most common presenting symptom of endometrial cancer, when postmenopausal bleeding occurs, clinical evaluation is indicated. The panelists also agreed that either transvaginal sonography or endometrial biopsy could be used safely and effectively as the first diagnostic step. Whether sonography or endometrial biopsy is used initially depends on the physician's assessment of patient risk, the nature of the physician's practice, the availability of high-quality sonography, and patient preference. Similar sensitivities for detecting endometrial carcinoma are reported for transvaginal sonography when an endometrial thickness of greater than 5 mm is considered abnormal and for endometrial biopsy when "sufficient" tissue is obtained. Currently, with respect to mortality, morbidity, and quality-of-life end points, there are insufficient data to comment as to which approach is more effective. The conference concluded by identifying several important unanswered questions and suggestions that could be addressed by future research projects.

Color Doppler sonographic detection of tumor flow within superficial melanoma metastases was investigated to determine if tumor size, vessel size, or vessel number influences signal detection. Color Doppler imaging of 32 pathologically proved melanoma metastases was performed at 6 MHz with color Doppler imaging parameters optimized for each lesion scanned. All lesions were measured in three dimensions and the presence or absence of internal flow was documented. Seven surgically excised metastases underwent immunohistochemical staining for endothelial markers. Internal flow was detected in 21 of 32 masses and was completely absent in 11. In comparison to all masses without flow, the masses with flow had significantly greater anteroposterior dimensions (P < 0.00036) and volumes (P < 0.01). Histologically, mean vessel diameter in masses with flow was significantly greater (P < 0.05) than in those without flow, but mean vessel number was not significantly different. In conclusion, detectability of tumor blood flow in superficial melanoma metastasis may be related more to tumor size and vessel size than vessel number. Failure to detect color signal within a superficial melanoma mass does not indicate a lack of internal vascularity.

The purpose of this study was to describe the sonographic appearances of melanoma metastases of the skin, subcutaneous tissues, and superficial lymph nodes.Gray-scale sonography was performed on 31 superficial melanoma metastases in 18 patients. Discreteness of borders, contours, echogenicity, echotexture, and degree of acoustic through-transmission were evaluated for each lesion. Color Doppler sonography was also performed on 25 of the 31 lesions, by which the amount of internal color flow was qualitatively assessed.Twenty-eight (90%) of the 31 metastases had well-defined borders. Contours were smooth in 17 (55%), lobulated in 12 (39%), and spiculated in two (6%). Nineteen metastases (61%) were hypoechoic to muscle, 10 (32%) were isoechoic, and two (6%) were hyperechoic. Echotexture was homogeneous in six lesions (19%), mildly heterogeneous in 13 (42%), moderately heterogeneous in 11 (35%), and markedly heterogeneous in one (3%). Twenty-two lesions (71%) showed enhanced acoustic through-transmission. Of the 25 melanoma metastases for which we performed color Doppler sonography, 18 (72%) had internal arterial color flow and seven (28%) did not. The flow was characterized as mild in 13 (72%) of 18, moderate in four (22%), and marked in one (6%).On sonography, superficial melanoma metastases typically are well-defined hypoechoic lesions with smooth or lobulated contours, mild to moderate heterogeneity, and enhanced acoustic through-transmission. Internal flow revealed by color Doppler sonography is present in many, but not all, superficial melanoma metastases.

To evaluate the impact of superficial ultrasonography (US) on clinical management of melanoma.Superficial US in areas at high risk for local recurrence or nodal metastases was performed in 33 patients with cutaneous melanoma. Impact categories were assigned to each US study (n = 55): category 3, US added information that altered clinical management; category 2, US added information that did not change management; category 1, no added information and management unchanged; category 0, not helpful or was misleading.Twenty-two US studies (40%) were category 3: detection of nonpalpable metastases altered surgical therapy (n = 2), demonstration of pharmacodynamic response to chemotherapy (n = 5), and determination of benignancy or malignancy (n = 15). Nine (16%) were category 2: identification of nonpalpable metastases did not alter management. Twenty-two (40%) were category 1: supported clinical impression of no metastases (n = 18) or helped confirm cutaneous, subcutaneous, or nodal metastases (n = 4). Two (4%) were category 0: missed proved metastases.Superficial US affected management of melanoma by allowing detection and characterization of masses, guidance of biopsy, and assessment of pharmacodynamic response.

We evaluated normal uterine involution prospectively with real-time ultrasonography in 100 women after uncomplicated term vaginal delivery. Transducers easily distorted the spongy uterus during early postpartum scanning, an effect minimized with sector transducers that are superior to linear or convex probes for accurate early postpartum uterine measurement. Long-axis measurements correcting for uterine angulation were the most reproducible and accurate, irrespective of bladder distention. Uterine contractions caused instability of particularly the transverse dimension. Increasing maternal parity was associated with slightly but significantly larger uterine dimensions up to 4 weeks post partum. The uterus reassumed nongravid dimensions by 6 to 8 postpartum weeks. Uterine involution was unrelated to infant birth weight or breast feeding.

Recent reports have indicated that identification of the yolk sac should precede the detection of the embryo in a normal first-trimester sonographic examination and that failure to visualize a yolk sac strongly suggests an abnormal intrauterine pregnancy. A first-trimester prospective study was performed in 163 normal and 49 abnormal consecutive singleton gestations. All women were examined both abdominally and transvaginally, with pregnancy outcome determined by delivery of a normal infant or a spontaneous abortion. The yolk sac was analyzed in all patients in whom an embryo was not identified (n = 76). When the yolk sac was identified, the following was found: by the abdominal approach with the mean sac diameter (MSD) less than 27 mm (n = 15), nine gestations were normal and six were abnormal, and by the transvaginal approach with the MSD less than 18 mm (n = 13), seven gestations were normal and six were abnormal. The presence of a yolk sac was not consistently predictive of a normal early pregnancy. When the yolk sac was also not identified, the following was found: abdominally with the MSD less than 27 mm (n = 41), 19 gestations were normal and 22 were abnormal, and transvaginally with the MSD less than 18 mm (n = 11), six gestations were normal and five were abnormal. Absence of the yolk sac was not consistently predictive of a spontaneous abortion. When using the MSD range (20-27 mm abdominally and 7-16 mm transvaginally), over which the yolk sac but not the embryo should be identified sonographically, the yolk sac was again not consistently visualized. On abdominal sonograms, the yolk sac was present and absent in three and 10 patients, respectively, for both normal and abnormal pregnancies. On transvaginal sonograms, the yolk sac was present and absent in seven and five normal gestations and in six and four abnormal gestations, respectively. The results of this study suggest that detection of the yolk sac in the first trimester is not an early predictor of pregnancy outcome.

A retrospective analysis was performed to determine whether ultrasound could reliably rule in or out retained products of conception (POC) in women after first-trimester spontaneous abortions (miscarriages). Ninety-seven first-trimester pregnancies with pathologically proven results from dilatation and curettage (D&C) were studied within 7 days of ultrasound examination (60% within 2 days), either by the abdominal or a combination of abdominal and vaginal approaches. Cases were eliminated if there was clinical evidence of a spontaneous evacuation of POC during the interval between the ultrasound and the D&C. POC were diagnosed only if chorionic villi were evident pathologically. The pertinent ultrasound findings were related to the endometrium (thickness, echogenicity, a gestational saclike structure or a space-occupying collection). The results indicated that ultrasound could correctly diagnose POC in all of the cases by detecting a gestational sac or collection (77 cases), or a thickened endometrium of greater than 5 mm (6 cases). Ultrasound was less reliable in ruling out retained POC. When only a thin endometrial stripe of less than 2 mm was present, there was little likelihood of having POC (1 of 7 cases) with a moderately thick endometrium of 2 to 5 mm not diagnostic. Vaginal ultrasound added little new information and failed to change the ultrasound interpretation.

Vaginal and abdominal sonography were prospectively compared in 309 consecutive pregnancies of which 175 were normal. Two sonographic criteria of normal were analyzed: (1) the presence of an embryo compared with average gestational sac size and (2) the presence of embryonic cardiac activity compared with crown-rump length. Vaginally, 100% (160/160) of embryos were visualized when the average sac diameter was greater than or equal to 12 mm. Abdominally, an embryo was noted in 99.2% (123/124) of gestational sacs greater than or equal to 27 mm. Vaginal sonography revealed cardiac motion in all embryos of greater than or equal to 5 mm (149/149 cases); abdominal sonography revealed cardiac activity in 100% (132/132) of embryos with a crown-rump length of greater than or equal to 9 mm. One-third of normal embryos less than 5 mm crown-rump length did not demonstrate cardiac activity. The study demonstrates through objective comparison that vaginal sonography is superior to abdominal sonography for detection of an intrauterine embryo and its cardiac activity before 8 menstrual weeks. The diagnosis of embryonic demise should not be made by vaginal sonography in embryos measuring less than 5 mm crown-rump length without a heartbeat, and an empty gestational sac of less than 12 mm average diameter should not be diagnosed as blighted ovum by vaginal scans. In these cases follow-up vaginal sonography is suggested.

Endoluminal sonography of the urinary tract was performed by using endoluminal ultrasound transducers contained within 2-mm-diameter catheters. The catheters were inserted into the urinary bladder via the urethra and advanced into the ureters and renal pelvis under cystoscopic control; then, cross-sectional images of the bladder, ureters, and renal pelvis were obtained. Two dogs and seven human patients were studied. In one dog, a 4.5-mm pseudopolyp, which was surgically created in the bladder wall, was successfully imaged; in the other, stones 2 mm or larger inserted into the bladder were identified. Of the seven patients, sonography showed stones embedded in the renal parenchyma (one patient) and the mucosa of the distal ureter (one patient). These were ultimately confirmed by their eventual removal. In a third, sonography showed a tumor of the distal ureter and identified the depth of the tumor. This was confirmed by biopsy. In a fourth, sonography clearly showed a crossing vessel as the cause for narrowing of the proximal ureter. In a fifth, sonography showed that the cause of a ureteral stricture was idiopathic. In the last two cases, sonography did not reveal a cause for hematuria. In these last three cases, negative sonographic results were confirmed by direct ureteroscopic examinations and follow-up studies. Our observations based on this limited study suggest that endoluminal sonography is a useful procedure for diagnosing diseases of the urinary tract. Further study is warranted.

Antenatal monitoring studies to assess fetal well-being and to identify the compromised fetus are in widespread use. This literature review analyzes the theoretical basis for fetal monitoring and the clinical research that has defined its utility, and it discusses the variations in protocols and scoring systems for the biophysical profile. While recognizing that there, is as yet, no consensus on the optimal monitoring protocol, the authors espouse one approach in which the cardiac nonstress test and the amniotic fluid volume are the initial tests, with full biophysical profile reserved for abnormal test outcomes. This approach to monitoring should be expeditious without diminishing its predictive value.

The space between the left lobe of the liver and the lesser curvature of the stomach normally contains intraperitoneal structures. These include the gastrohepatic recess of the greater peritoneal cavity, the medial recess of the lesser sac and the interposed gastrohepatic ligament. An anterior protrusion of retroperitoneum can project into this space, dorsal to the posterior reflection of the medial compartment of the lesser sac. Tumors that extend into this fossa are anterior and medial to the fundic and upper body region of the stomach. These tumors may cause confusion regarding their origin if the radiologist is not aware of the existence of this retroperitoneal protrusion. Between 1982, and 1986, 183 patients with pancreatic cancer were hospitalized at our institution, 63 of whom had computed tomography (CT) scans of the abdomen. Four of these patients (6.3%) demonstrated direct tumor extension anterior to the stomach. During this same period, four large benign retroperitoneal tumors also exhibited this finding. Masses in the gastrohepatic interval between the liver and stomach can be extensions of retroperitoneal processes and should not be assumed to represent intraperitoneal involvement.

Sonograms of 110 patients were compared to recently performed liver biopsies for evaluation of the accuracy of sonography in predicting the type (pattern) of pathology and its grade of severity (mild, moderate, or severe) in a wide variety of diffuse liver processes. There are two distinct, abnormal sonographic patterns: the fatty-fibrotic pattern seen primarily with cirrhosis, chronic hepatitis, and/or fatty infiltration, and the centrilobular pattern seen primarily with acute hepatitis. Sonography was 88% accurate in assigning the correct pattern to the corresponding pathology (sensitivity 89%, specificity 86%, p less than 0.001). The degree of accuracy was dependent on the grade of pathologic severity, with mild disease offering the greatest difficulty; moderate and severe diseases were accurately detected and placed in the correct pattern in all cases. Sonographic grading of the severity of disease was far less precise (63% overall). This study showed that sonography can distinguish between two abnormal sonographic patterns of diffuse benign liver disease as well as between normal and abnormal patterns.

Ultrasound examinations were performed on 25 women with augmented breasts using whole-breast water-path scanning. In these patients, ultrasound imaged carcinoma, benign lesions, and fibrous capsule formation; these were confirmed by surgery. In addition, it was noted that certain prostheses appeared to be displaced posteriorly onto the chest wall and some prostheses had internal echoes. To evaluate these findings, in vitro B-scanning was performed on three different commonly used mammary prostheses: the silicone gel, the saline inflatable, and the double-membrane gel-inflatable type. Ultrasound study of the augmented breast allowed evaluation of breast abnormalities in the parenchyma overlying the prostheses and also permitted evaluation of the complications unique to the implantation procedure: abscess formation, displacement of the implants, fibrous capsule formation, and wrinkles or cracks within the implant.

To date, there have been 25 studies attempting to correlate biparietal diameter and gestational age; of these, 17 meet specific criteria and thus are included in this evaluation. Although all studies have shown an increase in biparietal diameter with advancing gestational age, between 17 wk and term there is a discrepancy of approximately 3 wk. In this evaluation the charts are compared and the variations analyzed. An ideal table is constructed by combining the mean gestational age, calculated from a statistical analysis, and the variation at each millimeter point, determined by comparison of all the studies. It is hoped that this new 90% composite table, which consists of a range of gestational ages in weeks for each biparietal diameter, will not only provide more realistic indications of fetal age but also will serve as a reminder to sonographers, obstetricians, and patients of the relative accuracy and variations of biparietal diameter measurements.

Various formulas have been employed to compute the circumference of an ellipse. These formulas can be separated into three groups: formulas for a circle, formulas for an incorrect ellipse, and a very complicated formula for a correct ellipse. The errors caused by the first two groups are termed systematic because they occur every time that one of these formulas is used. When measuring fetal head circumference, the errors increase as the fetal head is more ellipsoid, becoming more than 1% when the ratio of the biparietal to fronto-occipital diameter decreases to less than .70. Near term, when the fetal head is large, this could create an error in predicting gestational age of almost .8 weeks. The third group is associated with mathematical random errors because of the difficulty in using a cumbersome equation. All of these formulas and their shortcomings are analyzed. A calculation for the correct circumference of an ellipse is proposed using the simple formula for a circle times a correction factor. The correction factor depends solely on the ratio of the biparietal to fronto-occipital diameter. This formula should minimize random errors and eliminate systematic errors in the calculation of fetal head circumference and will permit a more accurate analysis of fetal age.

Seven cases of heterozygous achondroplasia were examined in utero. Although the head shape and growth were normal, the initially normal femur length showed a decrease in growth and fell below the lower 99 per cent confidence limit in all cases. The time of presentation of achondroplasia varied between 21 and 27 gestational weeks. This study suggests that the diagnosis of achondroplasia can be reasonably made when the femur is abnormally short. When the femoral length is appropriate prior to 30 weeks, more caution should be taken in interpretation. Because of the variability in presentation, the fetus could be normal or still could be affected.

Endovaginal ultrasound (US) was performed in 38 pregnant women at 5-12 menstrual weeks, when the initial transabdominal sonograms had been considered inconclusive or equivocal. Clinical follow-up disclosed 32 intrauterine pregnancies (12 living, 18 spontaneous incomplete abortions, and two embryonic demises) and six ectopic pregnancies. In the 32 intrauterine pregnancies (normal and abnormal), the correct diagnosis was made in all cases with endovaginal US. The endovaginal images demonstrated the intrauterine embryo, its heart motion, and the yolk sac more clearly and more often when these structures were not apparent on the transabdominal scans. Abnormal gestational sacs were better resolved. In the six cases of ectopic pregnancy, while an extrauterine ectopic sac was visualized in only three, absence of an intrauterine gestational sac was confirmed in all cases with endovaginal scanning. No endovaginal study yielded less information than its transabdominal counterpart. Endovaginal sonography is likely to be diagnostic when transabdominal images fail to yield a definitive diagnosis in early pregnancies.

Thirty-eight patients with suspected rotator cuff tears were examined at 1.5 T by using a loop-gap resonator surface coil. The MR findings were compared prospectively in a blinded fashion with the results from double-contrast arthrography in all 38 patients, high-resolution sonography in 23 patients, and surgery in 16 patients. In the total group of 38 patients, MR imaging detected 22 of 22 tears and 14 of 16 intact cuffs as determined by arthrography. In the 16 surgically proved cases, MR and arthrography showed identical results, with 92% sensitivity in the diagnosis of 12 tears and 100% specificity in the diagnosis of four intact cuffs. In a subgroup of 23 patients, sonography detected nine of 15 tears and seven of eight intact cuffs as determined by comparison with arthrography. In 10 surgically proved cases, sonography was 63% sensitive in the diagnosis of eight rotator cuff tears and 50% specific in the diagnosis of two intact cuffs. For the diagnosis of rotator cuff tears, MR imaging is comparable to arthrography in both sensitivity and specificity. In this study, sonography was not as accurate in the diagnosis of rotator cuff tears as were the other two techniques. These results suggest that MR imaging should be considered the noninvasive test of choice for patients with suspected rotator cuff disease.

The prolate ellipse formula has been shown to be inaccurate and inconsistent in the calculation of total uterine volume. The stepped area-to-volume technique has proven to be both accurate and consistent and provides a value equal to the true uterine volume. When these true volumes were plotted on previously published graphs of total uterine volume derived from the prolate ellipse formula, the graphs were found to be inaccurate. New graphs based on normal values have been constructed, comparing total uterine volume with both biparietal diameter and average gestational age. When 26 abnormal values were plotted on the total uterine volume versus biparietal diameter graph, almost all fell outside the 90 per cent confidence limits. Seven of the abnormal value were from fetuses found to have growth retardation. Six of these cases, including two not appreciated either clinically or ultrasonographically, were detected by this method. The stepped area-to-volume technique should allow reconsideration of the total uterine volume concept and aid in the detection of the subtle changes in uterine size.

Cranial ultrasound examinations were performed during the first 3 days of life and at age 1 month on 22 infants with the neonatal abstinence syndrome. The results were compared to those obtained in 15 control infants who were not exposed to narcotic drugs in utero. The ultrasound images were examined for ventricular configuration, intracranial hemidiameters, area of thalami, and width of temporal lobes. At 24 to 72 h and at 1 month of age, significantly more drug-exposed than control infants had a slit-like ventricular configuration. The intracranial hemidiameter was significantly smaller in the drug-exposed than in the control infants. All cerebral measurements except the right temporal lobe demonstrated significant growth over the first month of life in both groups of infants. By means of ancillary examinations (computerized tomography and transfontanel pressure measurements) the pathogenesis of the slit-like ventricles was found not to be related to edema or to increased intracranial pressure. Whether or not the ventricles remain small and brain growth remains parallel after the period of abstinence awaits further investigation.