Evaluation of the fetal secondary palate by 3-dimensional ultrasonography.

OBJECTIVE: Diagnosis of cleft lip and palate remains a challenge with 2-dimensional ultrasonography, particularly when clefting involves only the secondary palate. The utility of 3-dimensional ultrasonography (3DUS) has enhanced our ability to detect clefts. We report our experience with a modification of the flipped face technique to aid in the diagnosis of clefting of the secondary palate. METHODS: Ninety-two volumes of 92 fetal faces were evaluated. Thirty-six volumes were acquired prospectively. Fifty-six volumes had previously been acquired and included 8 with clefting of the secondary palate. Volumes were obtained on 3DUS systems and reviewed by 4 blinded readers on personal computer workstations. Volumes were manipulated so that an upright profile was visualized. The palate was then rendered using a thin, curved render box. Statistical analysis was performed using the Fisher exact test for categorical data. Intraclass correlations were computed to assess inter-rater agreement. RESULTS: The mean gestational age at image acquisition +/- SD was 22 +/- 5 weeks. Image quality of the secondary palate was obtained and rated as adequate by at least 2 reviewers in 34% (31 of 92) of volumes. The sensitivity of cleft detection ranged from 33% to 63%, and the specificity ranged from 84% to 95%. The low sensitivity was mainly due to artifacts/shadowing. The inter-rater reliability was 0.62 (95% confidence interval, 0.47-0.76). CONCLUSIONS: Three-dimensional ultrasonography can be used to diagnose clefts of the secondary palate. This evaluation is limited by the fetal position and artifacts from shadowing of adjoining structures. Pseudoclefts can be created, and optimal imaging cannot be obtained in all fetuses.

Multislice display of the fetal face using 3-dimensional ultrasonography.

OBJECTIVE: Multislice 3-dimensional ultrasonography (3DUS) allows ultrasonographic volume data to be presented in parallel slices. Our aim was to develop a technique using a multislice display to specifically differentiate the maxilla (primary palate) from the mandible and to display the orbits in a single image in fetuses with normal anatomy and cleft lip/palate. METHODS: Three-dimensional ultrasonographic volumes of the fetal face were acquired in 142 patients (49 prospective and 93 retrospective). Fifteen patients had a confirmed diagnosis of cleft lip with or without cleft palate. Three readers manipulated volumes in a standardized fashion to show the orbits, maxilla, and mandible. The best interslice distance was determined. Image quality was assessed. RESULTS: The mean gestational age of the fetuses was 23 weeks (range, 11-38 weeks). The mean interval distance used varied from 3 to 3.7 mm (range, 1-5.8 mm). The interval distance correlated with gestational age (Spearman rho = 0.66; P < .0001). Image quality obtained through multislice evaluation of the orbits, maxilla, and mandible was high and did not vary with gestational age, interval distance, retrospective versus prospective acquisition, or 3DUS versus 4-dimensional volumes. A higher image quality rating was associated with axial and sagittal planes of acquisition as opposed to coronal and oblique planes (Wilcoxon P < .002). All cases of cleft lip with or without cleft palate were correctly identified retrospectively. CONCLUSIONS: Multislice 3DUS evaluation of the fetal face can be performed successfully with high image quality. This technique can be used to consistently and accurately differentiate the fetal primary palate and mandible. Fetuses with cleft lip with or without cleft palate can be identified with confidence.

Computer-aided detection of breast cancer: a cost-effectiveness study.

PURPOSE: To analyze the cost-effectiveness of adding computer-aided detection (CAD) to a screening mammography program. MATERIALS AND METHODS: A Markov model was developed to compare three hypothetical groups of women aged 40-79 years. The first group was composed of women undergoing mammographic screening without CAD; the second, of women undergoing mammographic screening with CAD; and the third, of women undergoing observation without screening. Cost-effectiveness was expressed as the marginal cost per year of life saved (MCYLS). MCYLS was calculated for screening mammography with CAD compared with screening mammography alone and for screening mammography alone compared with observation. Sensitivity analyses were performed by varying the cost of CAD, the rates of cancer detection with CAD, and the stage distribution of breast cancers diagnosed with CAD. RESULTS: Adding CAD to a mammographic screening program resulted in a MCYLS of $19,058. The MCYLS of screening mammography alone compared with observation was $16,023. CAD increases the marginal effectiveness of screening by 29%; however, the marginal cost of screening is also increased by 34%. Varying the cost of CAD yields a linear increase in MCYLS from $8937 with CAD at $9 per case to $24,924 with CAD at $25 per case. The cost-effectiveness of CAD is dependent on the magnitude of the increase in cancer detection rates with CAD but is also affected by the stage distribution of cancers diagnosed with CAD. CONCLUSION: The MCYLS is 19% greater for CAD added to screening versus screening mammography alone but is still within the accepted range for cost-effectiveness.