Exploring the Potential of Ultrasound for Endometriosis

Endometriosis is a benign and chronic condition that can cause women to experience pain and fertility problems. For a long time, and to an extent still today, surgery is required to diagnose the disease. However, in the hands of an expert, a transvaginal ultrasound can accurately map deep endometriotic nodules and identify pouch of Douglas obliteration in a noninvasive fashion (Figure 1). Though this statement exhibits optimism in the effort to minimize the use of invasive surgery for diagnostic purposes, there are a few limitations with ultrasound in this scenario.

Leonardi Fig 1

Figure 1: Ultrasound depiction of bowel deep endometriosis and negative sliding sign (can only be noted with dynamic movements) (left) and laparoscopic depiction of bowel deep endometriosis and obliterated pouch of Douglas.

This blog post will attempt to highlight a few key issues with ultrasound’s potential in the realm of endometriosis. We also encourage your comments below on how you feel about ultrasound for endometriosis. Ultimately, we must all be critical of what can and cannot be achieved with ultrasound to ensure appropriate day-to-day clinical practice. This then also allows us to pursue ongoing cutting-edge research endeavors.Leonardi

Our first limitation is in the definition of the word, “expert.”  Thus far, one might attach the term “expert” to those responsible for the bulk of the literature on ultrasound for endometriosis. Certainly, in the view of these academics, ultrasound can see much more endometriosis than previously thought. The belief in the value of ultrasound and expertise in scanning/interpreting scans may trickle down the typical training ladder to fellows, residents, and sonographers. But is there any formal teaching—didactic or tactile? Is there any formal assessment of skill to suggest a minimum level of competency? Is there, at this time, even an understanding of how to evaluate a trainees’ learning curve of endometriosis ultrasound? What is to there to stop an individual from claiming competency when ultrasound for endometriosis is still in its infancy? One concern with pseudo-experts is that they may actually impede the advancement of endometriosis ultrasound integration because surgeons do not verify their findings intraoperatively, leading to skepticism.

Another big problem with the current potential for noninvasive ultrasound diagnosis of endometriosis is the inability to visualize superficial endometriosis, the mildest form of the disease. In surgery, deposits of superficial endometriosis are generally small, only a few millimeters in width and depth, and discolored (Figure 2). They sometimes cause adhesions to form between structures, such as the ovaries and the pelvic sidewall or uterosacral ligament. Thus far, no one has been able to directly identify superficial endometriosis deposits on ultrasound. However, soft markers on ultrasound, such as ovarian immobility and site-specific tenderness (ie, the ability to elicit pain with the pressure of the transvaginal probe during the scan) may hold some secrets to the diagnosis of this enigmatic form of the disease. Until further research supports the routine use of these components in ultrasound for endometriosis, the superficial disease remains a surgical, and therefore invasive, diagnosis.

Condous and Leonardi Fig 2

Figure 2: Laparoscopic depiction of small superficial endometriosis deposit.

Despite these limitations and others not highlighted here, the ability to directly visualize the more severe forms of the disease (ie, ovarian endometriomas, deep endometriosis of the bowel, and pouch of Douglas obliteration) has led to two very clear and significant benefits. One, the patient may be able to receive a diagnosis of disease in a noninvasive fashion, which may guide treatment. Second, if surgery is elected as the treatment of choice, surgeons can prepare. If severe disease is noted on a scan, surgeons can anticipate advanced level surgery, which may necessitate skill from a minimally invasive gynecologic surgeon and/or colorectal surgeon. If no disease is identified on a scan, there will be superficial endometriosis or no disease at all in surgery.

Overall, we are at a much better place right now than we have ever been when it comes to ultrasound for endometriosis. There are still limits that must be addressed, many of which are actively being investigated by dedicated teams around the world. This blog commentary does not attempt to offer solutions to the obstacles highlighted. However, please feel free to comment below if you have any thoughts on an approach to these, or other, limitations.

Have you tried ultrasound for endometriosis? What is your experience with ultrasound and endometriosis? What are your thoughts on the limitations of ultrasound for endometriosis? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

Connect

Mathew Leonardi, MD, FRCSC, is an Honorary Lecturer in the Department of Obstetrics and Gynaecology and PhD student at the Nepean Clinical School, University of Sydney, under the supervision of Associate Professor George Condous. His Twitter handle is @mathewleonardi

From Sonographer to Ultrasound Practitioner: My Career Journey

I have been a sonographer for 18 years, and this year I was awarded Distinguished Sonographer at the 2018 AIUM Annual Convention. I can say without reservation that it is the biggest career honor that I have ever received and a moment that I will never forget. My path to becoming an Ultrasound Practitioner with a faculty appointment in the Department of Reproductive Medicine at UC San Diego has been rewarding, but it has not been easy. To be honest, I wasn’t always sure that I wanted to be a sonographer for more than a few years. I remember asking myself: Is this career as a sonographer enough or should I push myself further and go back to medical school? I have an incredible husband (who is also a sonographer) and he would have supported any choice I made, but ultimately – I decided not to pursue medical school. Even though I made that choice, I also told myself that there was nothing stopping me from learning as much as I could—my degree would not limit my potential and would not be what defines me.tantonheadshotblog

Since then, I have been studying the fetal heart A LOT. I enjoy all aspects of Maternal-Fetal Medicine (MFM) ultrasound, but the heart has always been an area of fascination for me. I love that it is both dynamic and complex, and, in my opinion, the most challenging aspect of fetal ultrasound. I have taken every opportunity to learn as much as I can from the incredible mentors that I have had the privilege of working with over the years. To this day, I am still learning, and I am amazed at all of the details we can see in these tiny little hearts! I eventually got the opportunity to cross train in pediatric echo and I jumped at that chance as well. I really enjoy being a part of a team of providers that can help the families affected by congenital heart disease.

I am, or I guess I should say I used to be, terrified of public speaking. I am proud of myself for overcoming this fear. Being in an academic center, I was used to teaching one on one, but it was about 8 years ago when I really pushed myself out of my comfort zone by lecturing to larger groups in the San Diego community. Putting together lectures can be time-consuming, difficult, and even stressful. I have spent many hours on weekends and evenings working on them, but I have also learned so much in the process. I started by speaking at local societies and hospitals, but over the years I have progressed and now I am proud to be invited to lecture at AIUM, SMFM, and other CME events around the country. Overcoming my fear of public speaking has been a huge stepping stone in my career and I love representing the sonographer voice on a larger platform.

So, how did I become a Practitioner with a faculty appointment?

I had a vision of how an Ultrasound Practitioner could function in our department. After all, by that point in my career, I was a seasoned MFM sonographer with 10 years of experience and I was still incredibly driven to learn and grow. I was keen to expand my skill set to function as a mid-level provider. Ultrasound Practitioner is not a new concept; SDMS had proposed a working model for an Ultrasound Practitioner in 2001. Dr. Beryl Benacerraf, among others, had already been successfully using an Ultrasound Practitioner for years. But working in a large academic center – my vision took years to bring to reality. I knew it would never happen if I didn’t continue to push for it. Along the way, I struggled, I questioned myself, I got overwhelmed, but I never gave up. I also had the support of some key physicians who believed in me. Their support was crucial to my eventual success.

I have now been an Ultrasound Practitioner for 6 years and as our department has grown to 8 ultrasound rooms, my role has expanded. Some of my responsibilities include: checking sonographers’ cases for quality and completeness, directing sonographers to get more images, obtaining images on difficult or complex cases, deeming the exam complete, writing preliminary reports, and discussing routine sonographic findings with patients. This working model frees up the physicians to spend more time with patients with abnormal findings and also allows the sonographers to keep moving with their schedules while ensuring quality patient care. Of course, this is only a snapshot of my day to day work, I still perform many of the fetal echocardiograms. I love to scan and I wouldn’t have it any other way.

My path to becoming a faculty member in the Department of Reproductive Medicine at UC San Diego was similar to my journey to becoming an Ultrasound Practitioner: it took time, lecturing nationally as well as teaching locally, coauthoring research papers and once again, having mentors who supported my appointment.

So, when people ask me about my success, I tell them it is because of hard work, persistence, believing in myself, and having mentors who believe in me too. My advice to sonographers is to know how important your role is; you are not “just a sonographer.” You should always keep learning, take pride in your work, and don’t be intimidated by the hierarchy of medicine. Our voice is crucial to the care of our patients, and that is really what matters.

Benacerraf BR, Bromley BS, Shipp TD, et al. The making of an advanced practice sonographer. J. Ultrasound Med 2003; 22:865–867.

Lockhart ME, Robbin ML, Berland LL, Smith JK, Canon CL, Stanley RJ. The sonographic practitioner: piece to the radiologist shortage puzzle. J Ultrasound in Med 2003; 22:861–864.

Bude RO, Fatchett AS, Lechtanski RT. The Use of Additionally Trained Sonographers as Ultrasound Practitioners. J Ultrasound Med 2006; 25:321–327

Society of Diagnostic Medical Sonography. Ultrasound Practitioner master’s degree curriculum and questionnaire: response by the SDMS membership. J Diagn Med Sonography 2001; 17:154–161.

How has ultrasound shaped your career? If you are an Ultrasound Practitioner, how did you get there? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

Connect

Tracy Anton, BS, RDMS, RDCS, FAIUM, is an Ultrasound Practitioner with a faculty appointment in the Department of Reproductive Medicine at University of California, San Diego.

Our Accreditation Experience

Ultrasound accreditation.

I’m sure you’ve heard about it, but you may be wondering: what does it really mean? Does it really matter if my practice site is accredited?

At one point I know that I wondered this myself! However, as a 17-year chief sonographer, and as the Ultrasound Technical Consultant for Allina Health Clinics, I can now tell you that for our sites, it absolutely does.

As a quality measure to ensure all ultrasound examinations are being performed and reported with the same standards of excellence, we decided to seek accreditation with the AIUM. Included under one AIUM accreditation, we have multiple clinic sites where the OB/GYN physicians read the ultrasound studies. It is a strict policy in our organization that any OB/GYN physician who wishes to read and bill for ultrasound exams must be added to our current AIUM accreditation.

With so many employees included in our accreditation, we knew that we needed to come up with a way to be able to facilitate new additions in a proficient manner, so that all sites received the same information and training. Thus (cue the climactic music), the “AIUM Physician Orientation and Mentoring” program was born!

We created this program for our organization as a virtual checklist of education and documentation needs, report over-reads, and competencies for the new physicians wishing to be added to our accreditation. We have a similar program for the sonographers that incorporates information and requirements for protocols, procedures, processes, and safety.

The Process

When I first started working with site accreditations everything was done on paper and case studies were submitted either on film or CDs. Now this process has been streamlined and all information that is required is easily uploaded to the AIUM site for their review.

For an accreditation such as ours that includes multiple sites, it was essential that we create a timeline to help us stay on track of what needed to be done and by when. The truth is, this is a very good way for any size site to make sure it stays on task and on time.
AIUM Accred Timeline

For us, this time around was a reaccreditation. So it is good to note that our information and supporting documents were due to the AIUM 6 months before the end of our current accreditation cycle. As you can see by the timeline, I set a goal of submitting 1 month before the due date. And that ended up being a good call because our actual submission date was only one week before the AIUM deadline.

Once all of our information was submitted, the Accreditation Team at the AIUM responded to us with any items that needed tweaking or were not quite hitting the mark. We replied to the AIUM on the changes that we would make and the education that we would provide our staff, and have been able to improve our services even more based on what we learned from those responses.

As one item of note, for us, the case submission selection and preparation was the longest and most time-consuming aspect of the process. Next time, we will start this task even earlier than outlined. Live and learn!

The Questions, Oh the Questions!
I had gone through an accreditation process before, but not with the AIUM. Since this was the first time for me, I had a ton of questions. I can’t even count how many times I emailed or called the AIUM staff, but I am sure they were groaning every time they heard from me.

However, each person that I spoke with was very understanding, helpful, and friendly. In fact, we communicated on such a regular basis that by the time I had submitted all of our information, they felt like good friends to me and I was tempted to invite them over for Thanksgiving dinner!

So Was It Worth It?
We expect our multiple sites to operate as one to ensure that patients are getting the same level of high-quality care when they go to site “A” for an OB/GYN  ultrasound, as when they go to site “B” for an OB/GYN ultrasound. For us accreditation has helped us accomplish that. The result has been higher patient satisfaction levels and improved quality and proficiency of our work.

Continuity of care. Improved quality. Higher patient satisfaction levels. Is accreditation worth it?

You bet it is!

Thinking about going through the AIUM practice accreditation process? Have any insights, tips, or ideas to share? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Laura M. Johnson, RDMS, RVT, is an Ultrasound Technical Consultant with Allina Health.

16 Years and Counting

Every year I look forward to February for a number of reasons. One is that I know spring in North Carolina is just around the corner. Another is that I know I will be escaping to Florida for a long weekend to attend my favorite ultrasound course, the AIUM Advanced Ultrasound Seminar: OB/GYN.

NC spring

Spring in North Carolina from http://www.visitnc.com.

I am a general OB/GYN and have been in practice in Durham, North Carolina, since 1998. I chose my current position because of its location, my family, and the chance to continue teaching OB/GYN residents.

In my early years as a resident educator, it was easy to teach the residents. But as time has passed and I have gotten busier, it seems that the residents have gotten smarter. They know about changes in protocols, new medications, new technology, and more. Therefore it is important for me to continue to educate myself through reading, listening, and attending courses.

I have always had an interest in ultrasound and received a great introduction to scanning as a resident at the Medial University of South Carolina in Charleston. My program directors put a strong emphasis on using ultrasound as a tool for caring for OB and GYN patients. So I probably have an interest in ultrasound beyond most generalists and I have enjoyed coming to the AIUM course since 1999.

One of the great things about the course is that it has adapted so well with the times. I remember the first 3D and 4D imaging that this course covered and how many questions people had about how they would be used. I remember discussions about whether an anatomy scan would be worthwhile and if insurance carriers would pay for it.

In the early years of the course there would be many long lectures about the frequency of X, the p values of certain markers, the RR of this thing or that thing, unreadable tables and presentations, and more. Recently, however, the course has become more evidence-based and clinically relevant for all participants. This has made the course even more worthwhile and shows that the enthusiastic and collegial faculty have dedicated their lives to medical ultrasound.

As we begin to move into fall and then winter, I start to long for February—for obvious reasons. I hope to see you in Florida.

Is there anything you have attended for more than a decade? What made it special? Have questions about the AIUM OB Course? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Frank Frenduto, M.D., is a managing partner and a board member for the Women’s Health Alliance in Durham, NC. His special interests are high-risk pregnancies, laparoscopic surgery, and gynecologic ultrasound.

Medicine, Music, and Moonlighting

I love my day job as a gynecologic oncologist at Princess Margaret Cancer Centre in Toronto as well as my role as the clinical lead for Royal Victoria Regional Health Centre regional gynecologic cancer program in Barrie, Ontario. My work keeps me very busy as do my three beautiful daughters. With great friends and family, and some of the best support staff any doctor could ask for, I’ve achieved my goal of becoming a successful doctor and surgeon for women with cancer. But I’ve always had another dream tucked away.

Dodge 2I’ve always been musical – in fact at age 3 I started playing the accordion, which I’m pretty sure was bigger than I was! But I put my musical dreams on hold while I pursued a medical career. I learned to play piano, percussion, and brass, and dabbled with songwriting over the years but most of my time was devoted to my medical training at Western University and University of Toronto.

A few years ago a patient in the palliative care ward asked me to play for her. I brought in my piano and surprised her with an original song I’d prepared for her titled, “It’s So Hard to Say Goodbye.” It was an emotional afternoon and afterward she made me promise that I would pursue my love of music professionally. Well, two albums later, here I am working on my third with two very accomplished and talented songwriters, Steve Dorff (whose songs have been sung by legends Barbra Streisand, Celine Dion, and Whitney Houston, to name a few) and Paul Overstreet (who wrote the number-one hit “Forever and Ever, Amen” for Randy Travis).

Many people ask me how I find the time to be a doctor at two hospitals and a professional musician.

Sometimes after a challenging day at the hospital, it can be hard to do anything at all, let alone write and play music. But music never feels like a chore. It calms my spirit and brings me a sense of peace. I find that music has a unique healing power both for me and for people going through tough times, whether struggling with illness or other personal issues. I always say that my goal is to share my music with as many people as possible with the hope that it will bring to them the same sense of passion, peace, and fulfillment it has brought to my own life. Here are a few ways in which music helps to heal both patients and myself.

How Music Helps Patients

  1. Pain relief
    Overall, music does have positive effects on pain management. It can help reduce both the sensation and distress of chronic pain, postoperative pain, and a range of conditions, according to a paper in the Journal of Advanced Nursing.
  2. Immunity boost
    Music can boost the immune function. A comprehensive study on the neurochemistry of music explains that a particular type of music can create a positive and profound emotional experience, which leads to secretion of immune-boosting hormones as well as endorphins. Listening to music, dancing, or singing can also decrease levels of the stress-related hormone cortisol.
  3. Increase energy and fight fatigue
    Many of my patients sometimes suffer from fatigue due to treatment or the postoperative healing process. Losing themselves in music helps reduce physical and emotional stress and can chase negative emotions away. Musical distraction can also help with sleepless nights.

How Music Helps Me

  1. Staying positive
    Music improves my moods and creates a more positive state of mind that helps me through busy days and emotional times.
  2. Mental and physical workout
    Music helps with concentration and staying focused. In addition, playing the piano improves motor coordination and dexterity – very beneficial when I’m at the operating table.
  3. Calm and cool
    The medical field can be very high-stress and emotionally taxing. Going home and playing the piano or writing lyrics really helps me channel this energy in a positive way. And music has been shown to help lower heart rate and blood pressure, which is great for my long-term health.

How does music affect you? What activities help you escape? How do you balance the demands of the job with your personal interests? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Jason Dodge, MD, Med, is a surgical oncologist at Princess Margaret Cancer Centre in Toronto. He participated in the AIUM International Consensus Conference on Adnexal Masses in 2014. You can check out his music on his website or on iTunes.

Ultrasound Can Catch What NIPT Misses

A few months ago a young couple, Michele and Dan, came to my office for a mid-trimester fetal anatomic survey at 21 weeks’ gestation. They were excited to see their fetus in 3D-4D ultrasound, and were wowed by the 3D image of their baby’s face. During the scan the couple related that they were sure their baby was OK “because the blood test came back negative,” and had decided to forego first trimester screening, despite their OB strongly recommending it.

unnamedThe blood tests, nuchal translucency measurement, and other sonographic parameters evaluated in first trimester screening are considered together to provide a risk profile for fetal chromosomal anomaly, particularly the risk of Down syndrome. If there is an increased risk, the parents may be advised to undergo invasive testing, such as chorionic villus sampling (CVS) or amniocentesis. In addition, first trimester screening can raise warning flags for structural anatomic malformations in the fetus, as well as other problems for the pregnancy. If first trimester screening includes a full fetal anatomic survey, it can spot about 40% of fetal malformations at a very early stage.

While I was reassured that Michele and Dan’s results on noninvasive prenatal testing (NIPT) meant the risk of their baby having Down syndrome and certain other aneuploidies was extremely low, I explained that structural malformations were still a much more common concern than chromosomal anomalies, and that a negative NIPT result did not rule out other conditions. Michele protested, “On the Internet it said that the blood test rules out Down syndrome 100%, that we didn’t have to worry.”

“The screening tests only give you a risk profile,” Dan insisted, “they don’t tell you if the baby is really affected. So we thought the blood test was the way to go.”

“I don’t want to have an amnio,” Michele continued, “I had a miscarriage in my last pregnancy,” she continued, as I proceeded to the echocardiography portion of the examination.

“Your baby appears to have a heart defect,” I said, as gently as I could, and began to explain the nature of transposition of the great arteries (TGA).

NIPT is the name applied to new techniques that use a sample of a pregnant woman’s blood to examine her fetus’s chromosomes. As early as 10 weeks of pregnancy there is sufficient fetal genetic material, called cell-free DNA, found in the maternal serum to allow analysis. A negative result from NIPT is a very good test to rule out Down syndrome in the fetus: it is highly specific, meaning that in almost all cases, a negative result is truly negative. NIPT is also highly sensitive, which means that in almost all cases, a positive result is truly positive. However, because there is a chance (however small) of a false positive (a healthy fetus may have a result showing him/her to have Down syndrome), a positive test result always needs to be confirmed with invasive testing, such as CVS or amniocentesis, before any decisions are made regarding the further management of the pregnancy. NIPT has also been found useful in identifying fetuses with other chromosomal anomalies and certain other genetic conditions. NIPT can also be used to determine the fetal sex.

However, while NIPT does a very good job at what it is designed for: looking at fetal chromosomal complement in specific conditions, it does not examine all the fetal chromosomes, nor does it look at the anatomy of the fetus. Fetal anatomy is examined in detail by ultrasound scanning. There is some debate among practitioners regarding the optimal week of pregnancy when full early fetal anatomy scanning should be performed. Some practitioners prefer performing the scan at the time of nuchal translucency screening, 11-13 weeks, while others prefer 14-16 weeks, when the fetal organs are more developed. The important point to remember: a fetus with a normal (negative) NIPT result can have an anatomic structural malformation. It has been shown that while fetuses with malformations may be at increased risk of chromosomal anomaly, the majority have healthy chromosomes. The diagnosis of a malformation by ultrasound should prompt invasive testing such as CVS or amniocentesis. In some centers, more detailed investigation by chromosomal microarray analysis (CMA), which may discover subtle anomalies, will also be ordered. CMA detects duplicated or deleted chromosomal segments and translocations—rearrangements of chromosomal structure, which may not be evident on traditional karyotyping.

NIPT is a very reliable test. But patients may have a false sense of security regarding their baby’s well-being. A negative NIPT result cannot rule out anatomic structural malformations in the fetus, nor does it rule out all chromosomal anomalies. There is ongoing debate surrounding the integration of NIPT into existing screening programs.

I continued to follow Michele and Dan in the weeks and months that followed. They were, of course, shocked and dismayed by their diagnosis. With Michele at 21 weeks, we immediately arranged multidisciplinary consultation with the cardiologists, who explained the procedures the baby would have to undergo, and how Michele’s plans for the birth would have to change. Prenatal diagnosis of TGA can improve the baby’s surgical outcome, and with prompt intervention, prognosis is excellent. They met with a genetic counselor, and despite Michele’s fears, underwent amniocentesis. CMA is performed in all such cases in our center. Testing ruled out genetic syndromes that we suspected based on the anatomic malformation, none of which could have been diagnosed by NIPT.

With comprehensive information in hand about their baby’s prognosis and the options open to them, Michele and Dan decided to continue the pregnancy, despite the difficult road they knew was ahead. They made arrangements for delivery in the tertiary care center where the baby would undergo surgery, so she would not have to be transferred from their community hospital and would be under constant surveillance. “I fell in love when I first saw the baby’s face in 3D,” she told me. “Whatever comes, we’ll handle it together.”

How do you think NIPT should be integrated into prenatal care? How do you advise your patients who ask about NIPT? Have you encountered patients with negative NIPT results whose fetus has a structural anomaly? Have you encountered patients with false negative or false positive NIPT? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Simcha Yagel, MD, is Head of the Division of Obstetrics and Gynecology Hadassah-Hebrew University Medical Centers, Jerusalem, Israel, and Head of the Center for Obstetric and Gynecological Ultrasound at the Hadassah-Hebrew University Medical Centers, Mt. Scopus, Jerusalem. He served as moderator for a panel discussion, “Noninvasive Prenatal Testing and Fetal Sonographic Screening,” that appeared in the March 2015 issue of the Journal of Ultrasound in Medicine.