Society of Radiologists in Ultrasound Consensus on Routine Pelvic US for Endometriosis.

Endometriosis is a prevalent and potentially debilitating condition that mostly affects individuals of reproductive age, and often has a substantial diagnostic delay. US is usually the first-line imaging modality used when patients report chronic pelvic pain or have issues of infertility, both common symptoms of endometriosis. Other than the visualization of an endometrioma, sonologists frequently do not appreciate endometriosis on routine transvaginal US images. Given a substantial body of literature describing techniques to depict endometriosis at US, the Society of Radiologists in Ultrasound convened a multidisciplinary panel of experts to make recommendations aimed at improving the screening process for endometriosis. The panel was composed of experts in the imaging and management of endometriosis, including radiologists, sonographers, gynecologists, reproductive endocrinologists, and minimally invasive gynecologic surgeons. A comprehensive literature review combined with a modified Delphi technique achieved a consensus. This statement defines the targeted screening population, describes techniques for augmenting pelvic US, establishes direct and indirect observations for endometriosis at US, creates an observational grading and reporting system, and makes recommendations for additional imaging and patient management. The panel recommends transvaginal US of the posterior compartment, observation of the relative positioning of the uterus and ovaries, and the uterine sliding sign maneuver to improve the detection of endometriosis. These additional techniques can be performed in 5 minutes or less and could ultimately decrease the delay of an endometriosis diagnosis in at-risk patients.

Ultrasound findings in endometriosis: avoid hidden surprises.

OBJECTIVE: To discuss the steps to performing and interpreting ultrasound imaging for pelvic pain in women with suspicions of endometriosis. DESIGN: Educational video. SETTING: Specialized gynecologic ultrasound clinic. PATIENTS: Reproductive-age women with pelvic pain with findings suggestive of endometriosis. INTERVENTION: Transvaginal ultrasound imaging. MAIN OUTCOME MEASURES: A detailed discussion of findings suggesting endometriosis. RESULTS: There are four basic sonographic steps for examining women with pelvic pain, especially when there is suspicion of endometriosis. Step 1: routine evaluation of the uterus and adnexa (this includes uterine orientation, sonographic signs of adenomyosis, and the presence or absence of endometrioma). Step 2: evaluation of transvaginal sonographic markers for endometriosis, for example, site-specific tenderness and ovarian mobility. Step 3: assessment of anterior and posterior compartments using a real-time ultrasound-based "sliding sign"; and Step 4: assessment for deep endometriotic nodules in anterior and posterior compartments. Note: the bladder should contain a small amount of urine for anterior compartment evaluation. CONCLUSIONS: Ultrasound is a powerful and dynamic tool for evaluating pelvic pain with high sensitivity, specificity, and accuracy in diagnosing deep endometriosis. Ultrasound imaging is important not only for diagnosing but also to counsel patients properly, consent appropriately, and plan for interdisciplinary consultations.

A Bibliometric Analysis of Citation Classics in the Journal of Ultrasound in Medicine.

OBJECTIVES: A bibliometric analysis of articles in the Journal of Ultrasound in Medicine (JUM) identified the journals' most impactful articles. METHODS: A bibliometric analysis of citation classics that were published in the JUM from its inception in 1982 to 2019 was performed. All citation classics, defined as articles cited 100 or more times, were evaluated for the number of citations, citations per year, publication year, subspecialty, design, and country of origin. Characteristics were compared before and after 1998 by the Mann-Whitney test for unpaired data and 2-sample z tests of sample proportions. The Kruskal-Wallis test for nonparametric continuous data was used to compare the median number of citations per year by decade of publication. RESULTS: A total of 7868 articles were published in the JUM between 1982 and 2019; 54 (0.7%) were citation classics. The median citation classics year of publication was 1998 (interquartile range [IQR], 1991-2003). Most citation classics originated from the United States (36 of 54 [66.7%]), were observational (47 of 54 [87%]), and were related to obstetric and gynecologic topics (16 of 54 [29.6%]). Citation classics after 1998 received significantly more citations per year (9.3 versus 4.7; P < .001), with no other differences noted. The median number of citations per year increased for each decade, with medians of 4 citations (IQR, 3.6-4.7) in 1982 to 1991 and 11.2 citations (IQR, 9-13.9) in 2002 to 2012 (P < .001). CONCLUSIONS: This list provides insight into the most influential articles that were published in the JUM. Most citation classics were observational, were from the United States, and covered obstetric and gynecologic topics. Citation classics received more citations per year after 1998.

Sonographer-acquired ultrasound protocol for deep endometriosis.

Endovaginal sonographic imaging has been shown to reliably identify pelvic endometriosis, but most United States imaging practices do not adequately assess locations and features of endometriosis beyond ovarian endometrioma. In this article, we propose a protocol for sonographer-acquired images and maneuvers to be interpreted subsequently by sonologists (radiologists or gynecologists). The purpose is to improve the sensitivity of endovaginal sonography for the detection of endometriosis in imaging practices that involve the non-physician sonographer as part of their workflow.

Complete evaluation of anatomy and morphology of the infertile patient in a single visit; the modern infertility pelvic ultrasound examination.

The comprehensive "one-stop shop" ultrasound evaluation of an infertile woman, performed around cycle days 5 to 9, will reveal abundant information about the anatomy and morphology of the pelvic organs and thereby avoid costly radiation and iodinated contrast exposure. We propose a two-dimensional and three-dimensional ultrasound to examine the appearance and shape of the endometrium, endometrial cavity, myometrium, and junctional zone, to assess for müllerian duct anomalies fibroids, adenomyosis, and polyps. We then evaluate the adnexa with grayscale ultrasound and Doppler, looking for ovarian masses or cysts, and signs of tubal disease. The cul-de-sac is imaged to look for masses, endometriosis, and free fluid. We then push gently on the uterus and ovaries to assess mobility. Lack of free movement of the organs would suggest adhesions or endometriosis. The sonohysterogram then allows for more detailed evaluation of the endometrial cavity, endometrial lining, and any intracavitary lesions. Tubal patency is then assessed during the sonohysterogram in real time by introducing air and saline or contrast and imaging the tubes (HyCoSy). With this single comprehensive ultrasound examination, patients can obtain a reliable, time-efficient, minimally invasive infertility evaluation in their own clinician's office at significantly less cost and without radiation.

Consider ultrasound first for imaging the female pelvis.

Ultrasound technology has evolved dramatically in recent years and now includes applications such as 3-dimensional volume imaging, real-time evaluation of pelvic organs (simultaneous with the physical examination), and Doppler blood flow mapping without the need for contrast, which makes ultrasound imaging unique for imaging the female pelvis. Among the many cross-sectional imaging techniques, we should use the most informative, less invasive, and less expensive modality to avoid radiation when possible. Hence, ultrasound imaging should be the first imaging modality used in women with pelvic symptoms.

Deep infiltrating endometriosis of the bowel wall: the comet sign.

The purpose of this study was to evaluate the appearance of deep infiltrating endometriosis of the bowel wall in the cul-de-sac and determine the characteristic appearance of these lesions. We searched our database between January 1, 2011, and December 31, 2013, for all patients who had sonographic findings of suspected deep infiltrating endometriosis of the bowel with obliteration of the cul-de-sac. The medical record of each patient was examined retrospectively for evidence of surgical confirmation of disease. The sonographic appearance, shape, and size of the bowel wall lesions were evaluated to develop criteria for deep infiltrating endometriosis of the rectosigmoid and cul-de-sac. The search of our database revealed 35 patients with sonographic findings of pelvic bowel wall endometriosis associated with obliteration of the cul-de-sac. Ten of these patients had surgical confirmation of bowel wall endometriosis after the scan, and another 4 patients had surgical evidence of endometriosis from prior surgery. All of the patients who underwent surgery subsequent to sonography had confirmation of their bowel wall infiltrative endometriosis. Sonographically, the bowel lesions were solid, focal, and tubular with slightly irregular margins and in most cases a thinner section or a "tail" at one end, resembling a comet. This study confirms that bowel wall implants have a very characteristic appearance, and extending the transvaginal examination to include an evaluation of the rectosigmoid seeking these bowel lesions is valuable, especially in any patient presenting with a history of pelvic pain.

Decidualized endometrioma masquerading as ovarian cancer in pregnancy.

OBJECTIVES: To identify the sonographic features of decidualized endometriomas in patients treated at a single institution and to determine whether sonographic findings can distinguish these lesions from malignant ovarian tumors during pregnancy. METHODS: We conducted a retrospective cohort study that included pregnant women with a histologic diagnosis of decidualized endometrioma between January 1, 2005, and December 1, 2012, and had an ovarian cyst or mass seen preoperatively on obstetrical sonography. Sonographic characteristics of these masses were retrospectively evaluated using the International Ovarian Tumor Analysis Group definitions for adnexal masses. RESULTS: Seventeen patients with 22 adnexal masses were included in our study. Nine of 22 lesions (41%) were classified as unilocular solid, and 14 of 22 (64%) had solid components, of which 12 of 14 (86%) had substantial blood flow. Septations were present in 8 of 22 masses (36%). Cyst sizes varied from 30 to 120 and 32 to 270 mm at the initial and follow-up scans, respectively. Eight patients had no follow-up scans and underwent surgery within 3 weeks of diagnosis. The other 9 patients (14 masses), had follow-up scans and underwent surgery from 3 to 34 weeks after their initial scans. Eight of these masses showed no notable change in size or appearance, and 1 became smaller. CONCLUSIONS: There were no characteristic sonographic features identified to distinguish decidualized endometrioma from ovarian malignancy. However, lesions showing no change in size over 4 weeks or lacking solid components and vascularity are more likely to be benign rather than malignant and may justify delaying surgery until delivery or postpartum.

Detection of fetal structural anomalies in a basic first-trimester screening program for aneuploidy.

OBJECTIVES: The purpose of this study was to determine whether first-trimester aneuploidy screening sonography initially performed by credentialed sonographers was useful for detecting fetal anomalies between 11 and 14 weeks' gestation. METHODS: We conducted a retrospective cohort study of consecutive patients referred to a private ultrasound facility between January 1, 2008, and June 30, 2012, for measurement of the nuchal translucency (NT) and crown-rump length as part of a screening protocol for aneuploidy. Patients were included if there was at least 1 live fetus with a crown-rump length between 34 and 84 mm. No specific anatomic imaging protocol was followed. The presence of anomalies was based on the sonographic report and review of the medical record. The absence of anomalies was based on the report from the anatomic survey. Anomalies were categorized as lethal, major, and minor. The anomaly category and gestational age at diagnosis (≤14 versus >14 weeks) were compared. RESULTS: An NT scan was performed on 9692 fetuses. Anatomic surveys were done on 9077 (93.7%) of these fetuses at a mean of 18 weeks' gestation. Anomalies were detected in 180 fetuses (1.8%): 50 (0.5%) at the NT scan and 130 (1.3%) at the anatomic scan. Overall, 46 of 111 fetuses (41.4%) with major or lethal anomalies were detected at the NT scan. Two suspected abnormalities at the NT scan were not present at the anatomic scan. CONCLUSIONS: First-trimester aneuploidy screening sonography initially performed by credentialed sonographers can identify a substantial proportion of major and lethal anomalies.

What is the importance of second-trimester "soft markers" for trisomy 21 after an 11- to 14-week aneuploidy screening scan?

OBJECTIVES: The purpose of this study was to evaluate the importance of second-trimester "soft markers" for trisomy 21 after an 11- to 14-week aneuploidy screening scan. METHODS: We conducted a retrospective cohort study of consecutive patients referred for measurement of the nuchal translucency (NT) as part of a screening protocol for aneuploidy. Patients who returned for an anatomic survey between 16 and 20 weeks' gestation were evaluated. The sonographic markers and anomalies associated with the detection of trisomy 21 in the second trimester were analyzed. RESULTS: There were 42 fetuses (0.4%) with trisomy 21 identified in the study cohort of 9692 patients. Trisomy 21 was suspected at the NT scan in 28 fetuses (67%) and at the second-trimester anatomic survey in 14 (33%). In fetuses first suspected of having trisomy 21 in the second trimester, 9 of 14 had normal anatomic survey results, and 5 of 14 had congenital malformations. All 14 fetuses had soft markers for aneuploidy. A thickened nuchal fold was identified in 5 of 9 fetuses with trisomy 21 and normal anatomic survey results, all of whom had an NT of less than 3.0 mm at the initial screening scan. CONCLUSIONS: Second-trimester soft markers, especially a thickened nuchal fold, remain important observations in the detection of trisomy 21 by sonography among fetuses who have had first-trimester sonographic screening for aneuploidy.