Screening for Chromosomal and Congenital Anomalies

Posted on September 19, 2023 by aium1952

Screening for chromosomal and congenital anomalies has evolved significantly with the use of ultrasound. Adding Serum analytes to the evaluation of congenital anomalies has increased the detection rate. This addition includes maternal serum alpha fetoprotein (MSAFP), b-HCG, Estriol, Inhibin A, Free bHCG, and Pregnancy Associated Plasma Protein A (PAPP-A).

Sequential screening consists of two steps:

Nuchal translucency (NT), with Free b-HCG and PAPP-A during the first trimester, and
Quadruple testing during the second trimester.
This modality takes the detection of trisomy 21 (T21) to 95%.

More recently, tests that measure the cell free fetal DNA (NIPT) in the maternal serum have become commercially available. The detection rate for T21 is 99%.

Many patients have opted for a first-trimester NT measurement, NIPT, and a 20-week ultrasound for anatomical survey. My concern and question to our group is where do we leave the MSAFP screening? Does your practice offer MSAFP to patients that opt for this approach?

Luis A. Izquierdo, MD, MBA, CPE, FAIUM, is a professor of OB GYN and Maternal Fetal Medicine at the University of New Mexico.

The Game-Changing Use of Ultrasound on the Sideline: Revolutionizing Sports Medicine

Posted on September 5, 2023 by aium1952

In the world of sports, injuries are an unfortunate reality that athletes must face. Rapid and accurate diagnosis is crucial to ensure timely treatment and minimize downtime. Traditionally, athletes would have to undergo imaging scans off-site, resulting in delays and limited access to immediate medical care. However, with recent advancements in medical technology, ultrasound has emerged as a game-changing tool. The terms, “venue ultrasound” and “sideline ultrasound” refer to the use of ultrasonography at a sports venue, in a stadium, on the sideline of a sporting event, or in the athletic training room. Its portability and real-time imaging capabilities make it an invaluable asset for sports medicine providers. In fact, the pilot investigation using venue ultrasound at the 2020 Tokyo Olympic Games was successful in diagnosing injuries among athletes.¹

Portable and Convenient
Ultrasound technology has undergone significant advancements, making it more compact, portable, and user-friendly. Modern handheld ultrasound devices are lightweight, battery-operated, and can be easily transported to sporting events or training facilities. This portability allows medical professionals to perform immediate on-site evaluations, enabling faster diagnosis and treatment decisions. The technology continues to evolve with many pocket-sized, handheld devices by leading manufacturers. Examples include the Philips Lumify, GE Vscan, Sonosite iViz, Butterfly iQ, Viatom, and Clarius. In addition, many of the units allow for easy wireless exchange of images and remote access by off-site professionals, if further assistance is needed.

Real-Time Imaging
One of the most significant advantages of sideline or venue ultrasound is its ability to provide real-time imaging. Unlike other imaging modalities, such as X-ray (XR) or magnetic resonance imaging (MRI), which require athletes to wait for results, ultrasound allows for immediate visualization of internal structures. This real-time feedback empowers medical staff to make quick and accurate diagnoses, as well as enables expedited triage of acute athlete conditions. This is particularly useful when XR is not readily available, which is commonplace at many events, particularly non-stadium venues.

Injury Assessment and Diagnosis
Portable handheld ultrasound devices can accurately assess soft tissue injuries, detect fractures, evaluate joint stability, and identify potential nerve or vascular involvement. During the last Olympics, ultrasound showed 100% accuracy in cases that underwent confirmatory imaging.¹ In the emergency department (ED), which can be a similar setting to the sports sideline, point-of-care ultrasound (POCUS) enables appropriate medical decision-making using real-time imaging. Applications of POCUS for musculoskeletal conditions in the ED include joint effusions, long bone fractures, and muscle and tendon injuries.² Long bone fractures can be excluded and tendon injuries can be diagnosed by physicians in the ED using POCUS with high sensitivity and specificity.^3,4 Further, POCUS in the ED positively impacts medical decision-making for musculoskeletal complaints.⁵

Monitor Healing
Once an injury has occurred, ultrasound can be used to monitor the healing progress during the rehabilitation phase. Regular ultrasound assessments allow medical staff to evaluate tissue repair, assess the formation of scar tissue, and track the restoration of normal function. This real-time monitoring provides valuable insights into an athlete’s recovery trajectory, enabling adjustments to treatment plans as needed. This can be particularly helpful in athletic training room situations in determining time to return to play.⁶

Additional Applications
Sideline ultrasound has numerous applications in the care of athletes, including trauma assessments and guided injections. One notable application is the Focused Assessment with Sonography for Trauma (FAST) exam, which is a POCUS examination used to evaluate potential internal injuries, particularly within the abdomen and chest, in the context of acute trauma. While the FAST exam has more traditionally been utilized in the ED, it is becoming increasingly popular on the sideline. The exam involves using ultrasound to evaluate specific regions of the body quickly, aiding in the identification of potential organ damage or bleeding. It allows for rapid assessment and triage regarding further medical interventions or necessary actions. Meanwhile, ultrasound-guided injections and interventions have long been an essential component of sports medicine. The addition of ultrasound guidance enables medical providers to be more targeted in their treatments.

Limitations and Future Directions
While venue ultrasound has enhanced sports medicine, it is essential to acknowledge its limitations. The depth of penetration, image quality, time from injury, and operator dependence can impact the accuracy of diagnoses. Continued advancements in technology and ongoing training for sports medicine professionals are crucial to maximize the potential of sideline ultrasound.

Conclusion
The use of ultrasound on the sideline has revolutionized sports medicine, enabling rapid and accurate diagnosis of injuries. Its portability, real-time imaging capabilities, and dynamic ability to assess musculoskeletal injuries make it an invaluable tool for healthcare professionals on the sideline and in the training room. With further advancements, ultrasound’s role in sports medicine is poised to continue expanding, benefiting athletes worldwide by providing more immediate and personalized care. For further information on this topic, consider reviewing the AIUM webinar, Sideline Ultrasound (https://www.youtube.com/watch?v=aX-AibSfctc).

Robert Monaco and Lauren Rudolph.
Robert Monaco, MD, MPH, RMSK, is a physician at Atlantic Sports Health and is a team physician for USA Figure Skating. Lauren Rudolph, MD, is a physician at Boulder Biologics, adjunct faculty for ultrasound education at Rocky Vista University, and a traveling physician with the US Ski team.

References:

Onishi K, Engebresten L, Budgett R, Soligard T, Forster BB. The International Olympic Committee venue ultrasound program: A pilot study from Tokyo 2020 Olympic Games. Am J Phys Med Rehabil 2023; 102:449–453.
Chen KC, Lin A, Chong CF. et al. An overview of point-of-care ultrasound for soft tissue and musculoskeletal applications in the emergency department. J Intensive Care 2016; 4:55.
Waterbrook AL, Adhikari S, Stolz U, Adrion C. The accuracy of point-of-care ultrasound to diagnose long bone fractures in the ED. Am J Emerg Med 2013; 31:1352–1356.
Wu TS, Roque PJ, Green J, et al. Bedside ultrasound evaluation of tendon injuries. Am J Emerg Med 2012; 30:1617–1621.
Situ-LaCasse E, Grieger RW, Crabbe S, Waterbrook AL, Friedman L, Adhikari L. Utility of point-of-care musculoskeletal ultrasound in the evaluation of emergency department musculoskeletal pathology. World J Emerg Med 2018; 9:262–266.
Bailowitz Z, Visco C, Christen K, Ahmad C. Diagnostic musculoskeletal ultrasound for the acute evaluation and management of soccer players. Curr Sports Med Rep 2021; 20: 525–530.

Ultrasound: The Therapy of the Future Coming to a Clinic Near You!

Posted on August 22, 2023 by aium1952

Ultrasound is most commonly known for diagnostic imaging and image-guided interventions, but there is also the potential to harness its power for therapeutic benefits. The use of ultrasound as a therapy is growing, with more than 1,900 active clinical investigations underway. There are also avenues to get insurance reimbursement for the treatment of certain ailments with ultrasound therapy, including bone metastases, essential tremor, and prostate.

In order to help guide physicians that may become involved in the use of ultrasound therapies, the Bioeffects Committee of the American Institute of Ultrasound in Medicine (AIUM) has issued new and updated statements on the AIUM website. These statements help to identify what to consider when using ultrasound therapies, including what happens to the targeted tissue and safety. Some highlights from these statements include:

Although safe when used properly for imaging, ultrasound can cause biological effects associated with therapeutic benefits when administered at sufficient exposure levels. Ultrasound therapeutic biological effects occur through two known mechanisms: thermal and mechanical. Thermal effects occur as the result of absorption of ultrasound waves within tissue, resulting in heating. Mechanical effects, such as fluid streaming and radiation force, are initiated by the transfer of energy/momentum from the incident pulse to tissue or nearby biofluids. Indirect mechanical effects can also occur through interaction of the ultrasound pulse with microbubbles such as ultrasound contrast agents. Importantly, thermal and mechanical mechanisms can trigger biological responses that result in desired therapeutic endpoints.
The type of bioeffects generated by ultrasound depend on many factors, including the ultrasound source, exposure conditions, presence of cavitation nuclei, and tissue type. Different bioeffects will require different amounts of ultrasound, and thermal and mechanical mechanisms can occur simultaneously for some exposure conditions.
There is the possibility of adverse effects in therapeutic ultrasound for targeted and untargeted tissue. Practitioners using these modalities must be well trained on the safe and effective use of therapeutic devices, knowledgeable about potential adverse events, aware of contraindications, and diligent in performing safe procedures. Image guidance should be used to ensure accurate targeting and dosing to maximize the outcomes for patients.

The statements issued by the AIUM’s Bioeffects Committee are intended as baseline considerations when a new therapy device is being put into practice. As ultrasound therapies continue to be adopted into clinical use, the Bioeffects Committee will continue to monitor outcomes in order to inform and educate the community.

Interested in learning more about the bioeffects of ultrasound? Check out the following Official Statements from the American Institute of Ultrasound in Medicine (AIUM):

Ultrasound to Differentiate Benign From Malignant Ovarian Tumors—Are We There Yet?

Posted on August 8, 2023 by aium1952

Adnexal (ovarian) tumors present a complex problem. Ovarian cancer (Ovca) is the second most common gynecologic cancer in the United States with the highest mortality rate of all gynecologic cancer, 7^th among all cancers, and with a general survival rate of 50%.¹ Thus, missing Ovca when performing any kind of test (false negative) will have grave consequences but suspecting it when not present (false positive) can have almost as critical results with morbidity and mortality secondary to (unnecessary) intervention.

The purpose of this post is not to review the differential diagnosis of ovarian tumors nor to discuss chemical markers such as CA125 or cancer-specific signal found on cell-free DNA (cfDNA) but to concentrate on ultrasound. Some tumors are relatively easy to recognize because of defined ultrasound characteristics: corpus luteum with the classic “ring of fire” or endometrioma with the ground-glass appearance content, for instance (image 1a and b). Conversely, a large, multilocular lesion with solid components and profuse internal Doppler blood flow leaves little doubt about its malignant nature (image 2).

Image 1a: Corpus luteum with the classic
“ring of fire”.

Image 2: A large, multilocular lesion with solid components.

What are the ultrasound characteristics we look at?

Size: Unilocular cystic ovarian tumor < 10 cm in diameter or simple septated cystic ovarian tumor < 10 cm in diameter rarely, if ever, are neoplastic.²
Volume: Normal volume for premenopausal and postmenopausal ovaries are < 20 cm³ and 10 cm³, respectively.
Appearance: Risk of malignancy in simple, unilocular anechoic cyst, less than 5 cm is < 1% in premenopause and about 2.8% in postmenopause.³
Blood flow criteria: The rationale is that arteries formed by neovascularization in malignant tumors lack tunica media, resulting in lowered impedance (= less resistance to blood flow). Thus, resistance indices will be lower in cancer than in benign tumors. Malignancy was suspected with Doppler indices: pulsatility index (PI)<1 and/or resistive index (RI)<0.4.⁴ However, too much overlap makes reliance on only Doppler unjustified.

A very important point is that the expert performs very well when analyzing the ultrasound images of an ovarian mass, with a sensitivity of 92–98% and a specificity of 89%. The issue is how to help the non-expert decide whether he/she can continue the care of the patient or needs to refer her to a specialist. Based on several ultrasound criteria, scoring systems were implemented. The first one, in 1990, included appearance (unilocular, unilocular solid, multilocular, multilocular solid, or solid cyst) and presence of papillae (graded according to their number: 0 [none], 1 [one to five], or 2 [more than five]). This method had a sensitivity (true positive rate, or chance that person testing positive actually has Ovca) for malignancy of 82% with a specificity (true negative rate or chance that person with a negative test does not have Ovca) of 92%.5 Two important additional scoring systems were described later: the Morphology Index (MI) combining tumor volume, wall structure, and septal structure and the Risk of Malignancy Index (RMI), the product of ultrasound morphology score, CA 125 level, and menopausal status.⁶ Additional systems included the Logistic Regression 1 (LR1) and 2 (LR2). None of the published scoring systems were superior to image assessment by an expert, including in a meta-analysis of 47 articles, including over 19000 adnexal masses⁷ and, in reality, were not used widely in clinical practice.

The International Ovarian Tumor Analysis (IOTA) models

In 2000, a large group of European experts (gynecologists, radiologists, statisticians, biology, and computer experts) published a standardized terminology for the characterization of adnexal masses.⁸

The two important systems are the Simple Rules (SR) and the Assessment of Different NEoplasias in the adneXa (ADNEX) model. These were externally validated in numerous centers across the world but not in the USA.⁹ Recently, however, validation on the largest hitherto US population was published.¹⁰ This study showed for the first time that the models were effective in this population, regardless of menopausal status or race. These models are easy to learn and are geared towards non-experts.¹¹ It is important to note that the IOTA group was one of the first to incorporate acoustic shadow as a key feature, and the acoustic shadow has been shown to be an important sonographic feature to consider.¹²

Simple Rules: The IOTA Simple-Rules consist of 2 sets of 5 elements each: benign and malignant.¹³ Three simple rules are applied: if only benign characteristics are present, the mass is classified as benign. If only malignant features are present, the mass is considered malignant. If no features or both are, the findings are inconclusive. This model works well in about 80% of cases. The other 20% should be referred to an expert.
ADNEX model¹⁴: This is a multiclass prediction model to differentiate between benign and malignant tumors and allows automatic calculation of sub-classification of malignant tumors into borderline tumors, Stage I, and Stage II–IV primary cancers, and secondary metastatic tumors. “The advantage of this model is that it gives a personalized risk score for each patient, based on age, whether the patient is seen at an oncology center or not, maximal diameters of the lesion and the solid parts, number of cysts and papillary projections, whether acoustic shadows are present, whether ascites is present and CA125 value (if available, not mandatory for calculation). With a cut-off value for malignancy risk set at 10%, the ADNEX model (with CA125) had a sensitivity of 94.3%, with a specificity of 74%, positive predictive value of 76%, and negative predictive value of 93.6%.”¹⁴

The O-RADS model

In 2020, the American College of Radiology convened an international multidisciplinary committee that developed an ultrasound model based on an MRI model used in mammography (the BI-RADS atlas), the O-RADS model (the Ovarian-Adnexal Reporting and Data System) to facilitate differentiation between benign and malignant ovarian tumors.¹⁵ It relies on the sonographic nomenclature developed by the IOTA group, but it classifies tumors into 1 of 6 categories (O-RADS 0–5), from normal to high risk of malignancy. O-RADS also includes guidelines for the management of the findings. It should be noted that the O-RADS first model did not take into account the presence or absence of an acoustic shadow, although this has now been amended.

A description of the most recent common ultrasound scoring systems (SR, ADNEX, and O-RADS) is available in the Journal of Ultrasound in Medicine (JUM): Yoeli-Bik R, Lengyel E, Mills KA, Abramowicz JS. Ovarian masses: The value of acoustic shadowing on ultrasound examination. J Ultrasound Med 2023; 42:935–945.

References

https://www.cancer.org/cancer/types/ovarian-cancer/about/key-statistics.html
Saunders et al. Risk of malignancy in sonographically confirmed septated cystic ovarian tumors. Gynecol Oncol 2010; 118:278–282.
Valentin et al. Risk of malignancy in unilocular cysts: a study of 1148 adnexal masses classified as unilocular cysts at transvaginal ultrasound and review of the literature. Ultrasound Obstet Gynecol 2013; 41:80–89.
Bourne et al. Transvaginal colour flow imaging: a possible new screening technique for ovarian cancer. BMJ 1989; 299:1367–370.
Granberg S et al. Tumors in the lower pelvis as imaged by vaginal sonography. Gynecol Oncol 1990; 37: 224–229.
Yamamoto Y, Yamada R, Oguri H, Maeda N, Fukaya T. Comparison of four malignancy risk indices in the preoperative evaluation of patients with pelvic masses. Eur J Obstet Gynecol Reprod Biol 2009; 144:163–167.
Meys EM et al. Subjective assessment versus ultrasound models to diagnose ovarian cancer: A systematic review and meta-analysis. Eur J Cancer 2016; 58:17–29.
Timmerman D, Van Calster B, Testa A, et al. Predicting the risk of malignancy in adnexal masses based on the simple rules from the international ovarian tumor analysis group. Am J Obstet Gynecol 2016; 214:424–437.
Abramowicz JS, Timmerman D. Ovarian mass-differentiating benign from malignant: the value of the International Ovarian Tumor Analysis ultrasound rules. Am J Obstet Gynecol 2017; 217:652–660.
Yoeli-Bik R, Longman RE, Wroblewski K, Weigert M, Abramowicz JS, Lengyel E. Diagnostic performance of ultrasonography-based risk models in differentiating between benign and malignant ovarian tumors in a US cohort. JAMA Netw Open 2023; 6:e2323289.
Valentin L, Ameye L, Jurkovic D, et al. Which extrauterine pelvic masses are difficult to correctly classify as benign or malignant on the basis of ultrasound findings and is there a way of making a correct diagnosis? Ultrasound Obstet Gynecol 2006; 27:438–444.
Yoeli-Bik R, Lengyel E, Mills KA, Abramowicz JS. Ovarian masses: The value of acoustic shadowing on ultrasound examination. J Ultrasound Med 2023; 42:935–945.
Timmerman D, Testa AC, Bourne T, et al. Simple ultrasound-based rules for the diagnosis of ovarian cancer. Ultrasound Obstet Gynecol 2008; 31:681–90.
Van Calster B, et al. Evaluating the risk of ovarian cancer before surgery using the ADNEX model to differentiate between benign, borderline, early and advanced stage invasive, and secondary metastatic tumours: prospective multicentre diagnostic study. BMJ 2014; 349:g5920.
Andreotti RF, Timmerman D, Strachowski LM, et al. O-RADS US risk stratification and management system: a consensus guide-line from the ACR ovarian-adnexal reporting and data system committee. Radiology 2020; 294:168–185.

Appendix

Classification of primary ovarian tumors

Ovulatory: functional or corpus luteum cyst; theca lutein cyst; polycystic ovary
Infectious or inflammatory: tubo-ovarian abscess; hydrosalpinx
Benign: serous or mucinous cystadenoma; endometrioma; mature cystic teratoma (most common primary benign tumor of the ovary); paraovarian/paratubal cysts
Borderline: serous, mucinous
Malignant
Epithelial: high-grade serous carcinoma (HGSC; 70 to 80%); endometrioid carcinoma (10%); clear cell carcinomas (10%); mucinous carcinoma (3%); Low-grade serous carcinoma (LGSC; <5%); Brenner tumor; carcinosarcoma or malignant mixed müllerian tumor (MMMT); undifferentiated,
Germ cell (20%): teratoma: immature, specialized teratomas of the ovary (struma ovarii, carcinoid tumor); dysgerminoma; yolk sac tumor: endodermal sinus tumor; embryonal carcinoma; choriocarcinoma: <1% of ovarian tumors; malignant mixed germ cell tumor
Sex cord / stromal ovarian tumors (8–10%): fibrothecoma (fibroma, thecoma); Sertoli-Leydig cell tumor; granulosa cell tumor (juvenile or adult); small cell carcinoma

Jacques S. Abramowicz, MD, is a professor in the Department of Obstetrics and Gynecology at the University of Chicago.

Interested in learning more about gynecologic ultrasound? Check out the following posts from the Scan:

Lymphosonography: The use of contrast-enhanced ultrasound as a lymphatic mapping technique

Posted on July 25, 2023 by aium1952

Ipsilateral axillary diagnostic ultrasound is part of the initial staging for breast cancer to evaluate lymph nodes using a b-mode classification where certain aspects, when present, increase the level of suspicion for metastatic disease, such as cortical thickening and poor hilar visibility.¹^–3 Diagnostic ultrasound is also used as a method to guide biopsies of the suspicious lymph nodes.¹

The majority of patients will have no suspicious lymph nodes findings at the time of diagnosis, the lymphatic system mapping after the injection of blue dye and/or a radioactive tracer followed by a surgical excision becomes the only way to determine the final stage of disease. However, these methods have limitations such as the use of radiation and lack of an imaging component.

In the past, ultrasound could not be used for lymphatic mapping, since mapping requires administration of a tracer. This changed with the use of contrast-enhanced ultrasound (CEUS) to detect lymph nodes after subcutaneous injections of microbubble-based ultrasound contrast agents (UCA), termed “lymphosonography”.^4–6 The development of the lymphosonography technique addressed the limitations of the currently used lymphatic mapping techniques.

Our group conducted a clinical trial to evaluate the efficacy of CEUS lymphosonography in the identification of sentinel lymph nodes (SLN) in patients with breast cancer undergoing surgical excision following the injection of blue dye and radioactive tracer as part of their standard of care using pathology results for malignancy as a reference standard.^6,7

In the clinical trial, 86 subjects were enrolled and 79 completed the study. The subjects received 4 subcutaneous injections of ultrasound contrast agent around the tumor, for a total of 1.0 ml. A clinical ultrasound scanner with CEUS capabilities was used to identify SLNs. After the ultrasound study examination, the subjects received blue dye and radioactive tracer for guiding SLN excision as part of their standard of care. The SLNs excised during the standard-of-care surgical excision were classified as positive or negative for presence of blue dye, radioactive tracer and UCA, and sent for pathology to determine presence or absence of metastatic involvement.

Example of a sentinel lymph node (SLN) seen with lymphosonography. The arrow indicates the SLN. The arrowhead indicates the lymphatic channel.

A total of 252 SLNs were excised from the 79 subjects. Of the 252 SLNs excised, 158 were positive for blue dye, 222 were positive for radioactive tracer and 223 were positive for UCA. Statistical comparison showed that compared with the reference standards, lymphosonography showed similar accuracy with radioactive tracer (p > 0.15) and higher accuracy (p < 0.0001). The pathology results showed that, of the 252 SLNs excised, 34 had metastatic involvement and were determined malignant by pathology. Of these 34 SLNs, 18 were positive for blue dye (detection rate of 53%), 23 were positive for radioactive tracer (detection rate of 68%) and 34 were positive for UCA (detection rate of 100%; p < 0.0001).

The conclusion of this study indicates that lymphosonography had similar accuracy as the standard-of-care methods for identifying SLNs in breast cancer patients, with the added advantage of an imaging component that allows for a preoperative evaluation of SLNs and that lymphosonography may be a more specific and precise approach to SLN identification in patients with breast cancer.⁶

Larger multicenter clinical trials are necessary to be able to translate this technique to the clinical setting and to be able to incorporate it as part of the breast cancer patients’ standard of care.

Voit CA, van Akkooi ACJ, Schäfer-Hesterberg G, et al. Rotterdam Criteria for sentinel node (SN) tumor burden and the accuracy of ultrasound (US)-guided fine-needle aspiration cytology (FNAC): can US-guided FNAC replace SN staging in patients with melanoma? J Clinical Oncol 2009; 27(30):4994–5000.
Dialani V, Dogan B, Dodelzon K, Dontchos BN, Modi N, Grimm L. Axillary imaging following a new invasive breast cancer diagnosis—A radiologist’s dilemma. J Breast Imaging 2021; 3:645–658.
Chang JM, Leung JWT, Moy L, Ha SM, Moon WK. Axillary nodal evaluation in breast cancer: state of the art. Radiology 2020; 295:500–515.
Goldberg BB, Merton DA, Liu J-B, Thakur M, et al. Sentinel lymph nodes in a swine model with melanoma: contrast-enhanced lymphatic US. Radiology 2004; 230:727–734.
Goldberg BB, Merton DA, Liu J-B, Murphy G, Forsberg F. Contrast‐enhanced sonographic imaging of lymphatic channels and sentinel lymph nodes. J Ultrasound Med 2005; 24:953–965. doi: 10.7863/jum.2005.24.7.953.
Machado P, Liu J-B, Needleman L, et al. Sentinel lymph node identification in patients with breast cancer using lymphosonography. Ultrasound Med Biol 2023; 49:616–625. Epub 2022 Nov 26.
Machado P, Liu JB, Needleman L, et al. Sentinel lymph node identification in post neoadjuvant chemotherapy breast cancer patients undergoing surgical excision using lymphosonography. J Ultrasound Med 2023; 42:1509–1517. doi: 10.1002/jum.16164. Epub 2023 Jan 2.

Priscilla Machado, MD, FAIUM, is a Research Assistant Professor in the Department of Radiology at Thomas Jefferson University in Philadelphia, PA.

Interested in learning more about ultrasound? Check out these posts from the Scan:

Is the Radiologist In-house Today? Optimizing Ultrasound in the Age of Teleradiology

Posted on July 11, 2023 by aium1952

My dilemma: I am a radiologist at a pediatric hospital with multiple satellite ultrasound sites. Though most ultrasounds can be performed at the satellites, a small subset of advanced ultrasounds are only scheduled at our main hospital where a radiologist is available to scan. Recently, a family expected to schedule a complex scan at our satellite location near their home, so they understandably had questions when they were told to drive 2 hours to the main hospital instead. Is the quality of ultrasound services different? Would the radiologist scan if they traveled to our main hospital? Could they get the same study at a local non-pediatric, small community imaging center? They wanted answers! It was challenging to explain why it was worth their time to make such a long drive to get a “better” study. This led me to ask, what is the right answer at a time when teleradiology is commonplace?

Challenges and Potential Solutions of Teleradiology in Ultrasound

1. Retaining Clinical Context

Problem: Typically, radiologists interpret exams solely based on the images. However, additional patient history that was not in the original order and physical exam findings can be of tremendous value. For example, a sonographer might image a cutaneous vascular lesion compatible with a hemangioma. If a pediatric radiologist were present to ask additional questions, they would learn that the hemangioma only just appeared in the 2-month-old patient a couple of weeks ago, is rapidly growing, and is one of multiple cutaneous lesions concerning for infantile hemangiomas. Additionally, they could look at the color of the lesion and see if it blanches upon compression. Such additional historical and physical information warrants a recommendation in the ultrasound report for an abdominal ultrasound to assess for hepatic hemangioma involvement. If this clinical context is lost, then the full value and specificity of the superficial ultrasound could be lost as well.

Solution: If a radiologist is not present in-person for scanning or image review, the sonographer must know what questions to ask and what additional information might be helpful to the radiologist. Sonographers can add extra history and physical exam findings directly into the PACS technician notes, via institutional communication tools like Microsoft Teams, or on scanned worksheets. A radiologist might even talk directly with the family over the phone or ask the sonographer to include a picture of the patient in the medical record of the patient.

2. Optimizing Image Quality

Problem: The ability of the radiologist to provide image quality control is diminished when working remotely. There is more responsibility on the sonographer to optimize imaging and to recognize pitfalls independently. To this point, for example, consider a sonographer imaging a joint with concern for effusion and septic arthritis. However, she may not realize that the gain was set too low. Cartilage would look anechoic like joint fluid instead of the normal speckled hypoechoic appearance in cases such as this. Therefore, the images would look like there was a joint effusion when in fact there was no joint effusion at all.

Solution: Radiologists must provide feedback, ideally in real time, to sonographers. Standardized protocols, as well as in-person on-the-job training with experienced sonographers and radiologists, are also needed for sonographers to function independently at remote sites. In this case, the sonographer should ask a radiologist to review the images in real time so they can identify such mistakes, affording the sonographer opportunity to rescan the patient before they left.

3. Understanding Variability in Practices Between Institutions

Problem: Teleradiologists read for multiple sites, all with unique workflows and varying levels of sonography expertise. As a pediatric radiologist, I read pediatric studies from both pediatric and adult hospitals. There is a wide variety in the experience of the sonographers, as I learned recently when I opened a pyloric ultrasound exam only to realize that the sonographer had incorrectly imaged the gastroesophageal junction instead of the pylorus. I subsequently learned that this site did not have pediatric sonographers or pediatric sonography training.

An image of the gastroesophageal (GE) junction instead of the pylorus. The arrow points to the GE junction with gastroesophageal reflux during the exam, which can be mistaken for transit through a normal pylorus. Proximity to the spine (S) and the aorta (A) confirms the gastroesophageal junction is being imaged.

Solution: As a radiology team, we must provide additional resources to support sonographers if they are to assume more responsibility. At my institution, radiologists are available for questions 24 hours a day, 7 days a week to sonographers before, during, and after image acquisition. Additionally, we provide a free, CME-accredited, internet-based didactic series for optimizing pediatric imaging technique. We also solicit topic ideas from our affiliate institutions so that we can elevate the quality of imaging at all sites. When one person or one site has a particular ultrasound question, there are often many others with the same struggle.

After feedback and instruction between the radiologist and the sonographer, a sonographer can correctly identify a normal pylorus (arrow), which is confirmed by the adjacent duodenal bulb (D) and gallbladder (G).

In conclusion, teleradiology in ultrasound is here to stay. Our responsibility going forward is to optimize it, support our sonographers as they become more independent, and understand that while we as radiologists may not physically be there, there are many technological advances that we can leverage to optimize imaging.

Dr Lauren May, MD, is a pediatric radiologist at Nemours Children’s Health in Wilmington, DE. Her primary interests are in ultrasound and medical education. She can be contacted by email, Lauren.May@nemours.org.

Interested in reading more about ultrasound in pediatrics? Check out these posts from the Scan:

The Power of Ultrasound in Physiotherapy

Posted on June 27, 2023 by aium1952

In incredible ways, ultrasound has revolutionized the path to recovery for patients with soft tissue damage and enhanced the patients’ overall well-being. It is a cutting-edge therapeutic technique that harnesses the power of sound waves to stimulate deep tissues, accelerate healing, and alleviate pain. Through its mechanical vibrations, ultrasound effectively increases blood flow, reduces inflammation, and enhances the flexibility of muscles and tendons. This noninvasive modality has significantly impacted the field of physiotherapy.

The Benefits of Ultrasound in Physiotherapy

Accelerated Healing: The primary benefit of ultrasound therapy is its ability to expedite the healing process. By encouraging collagen production, ultrasound facilitates the repair of tissues, enabling faster recovery from various injuries and conditions. Witnessing the speed at which a body can regenerate and mend itself is truly remarkable.
Pain Relief: Dealing with pain can be physically and mentally debilitating. Thankfully, ultrasound therapy can provide immense relief. By stimulating sensory nerves, this modality effectively alleviates pain, allowing a runner to focus on their recovery and regain their quality of life.
Improved Circulation: Optimal blood circulation is vital for the healing process. Ultrasound therapy can be instrumental in enhancing circulation, ensuring that oxygen and essential nutrients reach the damaged tissues more efficiently. As a result, inflammation reduces, and overall healing is optimized.
Enhanced Mobility and Flexibility: A lack of mobility and flexibility can hinder daily activities and impact overall well-being. Ultrasound therapy can cause significant improvements in these areas. The targeted sound waves promote soft tissue mobilization, increasing flexibility and range of motion. This newfound freedom of movement has been a game-changer for many patients.
Noninvasive and Safe: One of the most appealing aspects of ultrasound therapy is its noninvasive nature. Patients can receive effective treatment without the need for surgical interventions or invasive procedures. This not only minimizes downtime but also provides peace of mind for the patient, who knows that they are undergoing a safe and risk-free therapy.

Incorporating Ultrasound Into Physiotherapy Sessions

During physiotherapy sessions, the utilization of ultrasound therapy can be a straightforward and comfortable experience. The physiotherapist applies a gel to the targeted area and gently moves a handheld transducer over the skin. The transducer emits therapeutic sound waves, which penetrate deep into the tissues, providing the desired benefits. The duration and frequency of ultrasound treatment are tailored to the patient’s specific needs, ensuring optimal results.

It is crucial to emphasize that ultrasound therapy should always be administered by trained professionals who can customize the treatment according to individual requirements, and can take into account any contraindications. Physiotherapists conduct thorough assessments and develop personalized treatment plans that may include a combination of ultrasound therapy, stretching exercises, strengthening routines, and other complementary techniques.

Ultrasound is a transformative, revolutionary therapy in the realm of physiotherapy. Through its ability to accelerate healing, alleviate pain, improve circulation, and enhance mobility, ultrasound has become an indispensable tool in the journey toward improved well-being. If you are considering physiotherapy or seeking effective treatment options, I highly encourage you to explore the incredible benefits of ultrasound therapy. Consult with a qualified physiotherapist who can review your case and determine whether it is in your best interest to experience the remarkable healing potential of ultrasound firsthand.

Interested in learning more about ultrasound in physiotherapy? Check out the following articles from the American Institute of Ultrasound in Medicine’s (AIUM’s) Journal of Ultrasound in Medicine (JUM). Members of AIUM can access them for free after logging in to the AIUM. Join the AIUM today!

And, check out this post from the Scan:

Real-time Ultrasound in Physical Therapy

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Predicting Risk of 30-Day Readmission in Heart Failure Patients

Posted on June 13, 2023 by aium1952

Pulmonary congestion is the most frequent cause of heart failure hospitalizations and readmissions. In addition, approximately 20%–25% of heart failure patients aged 65 years and older in the United States are readmitted within 30-days after hospital discharge,^1–5 despite efforts to identify predictors of readmission for acute decompensated heart failure (ADHF), such as laboratory markers, the readmission rates remain high. Lung ultrasound (LUS), however, has been shown to be a valuable tool for assessing pulmonary congestion, providing a reliable assessment based on the presence of B-lines.

A recent study by Cohen et al⁷ evaluated the association between lung ultrasound findings and the risk of 30-day readmission among HF patients, hypothesizing that a higher number of positive B-line lung fields on LUS will indicate an increased risk of readmission. Using a log-binomial regression model in an 8-zone LUS exam from the day of discharge, the researchers assessed the risk of 30-day readmission associated with the number of lung zones positive for B-lines, considering a zone positive when ≥3 B-lines were present. According to the results from 200 patients, the risk of 30-day readmission in patients with 2–3 positive lung zones was 1.25 times higher (95% CI: 1.08–1.45), and in patients with 4–8 positive lung zones was 1.50 times higher (95% CI: 1.23–1.82), compared with patients with 0–1 positive zones, after adjusting for discharge blood urea nitrogen, creatinine, and hemoglobin.

Ultrasound image of a lung with B-lines. The pleural line is indicated by the arrow. Emanating from the pleural line are hyperechoic reverberation artifacts, which are B-lines (indicated by the star), indicating the presence of fluid within the interstitium of the lung.

This study adds to the research on LUS in patients with HF in inpatient or intensive care units and emergency departments, including studies on identifying pulmonary congestion to reduce decompensation in heart failure patients,⁷ the risk of hospitalization or all-cause death was greater in patients with more B-lines at discharge,⁸ and the prognostic value of LUS as an independent predictor of 90-day readmission.^9,10

The study by Cohen et al⁷ expands on the prior research and demonstrates the prognostic importance of more B-lines at discharge for HF patients. Failure to relieve congestion before discharge is associated with increased morbidity and mortality and is a strong predictor of poor outcomes in patients with acute decompensated HF.

By evaluating HF patients with LUS, we may be better able to risk-stratify the severity of asymptomatic pulmonary congestion on discharge and identify patients at higher risk of readmission.

References

Desai AS, Stevenson LW. Rehospitalization for heart failure: predict or prevent? Circulation 2012; 126:501–506.
Suter LG, Li SX, Grady JN, et al. National patterns of risk-standardized mortality and readmission after hospitalization for acute myocardial infarction, heart failure, and pneumonia: update on publicly reported outcomes measures based on the 2013 release. J Gen Intern Med 2014; 29:1333–1340.
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:e240–e327.
Tavares LR, Victer H, Linhares JM, et al. Epidemiology of decompensated heart failure in the city of Niter_oi: EPICA -Niter_oi Project. Arq Bras Cardiol 2004; 82:125–128.
Cleland JG, Swedberg K, Cohen-Solal A, et al. The Euro Heart Failure Survey of the EUROHEART survey programme. A survey on the quality of care among patients with heart failure in Europe. The study group on diagnosis of the working group on heart failure of the European Society of Cardiology. The medicines evaluation Group Centre for Health Economics University of York. Eur J Heart Fail 2000; 2:123–132.
Cohen A, Li T, Maybaum S, et al. Pulmonary congestion on lung ultrasound predicts increased risk of 30-day readmission in heart failure patients [published online ahead of print February 25, 2023]. J Ultrasound Med. doi: 10.1002/jum.16202.
Araiza-Garaygordobil D, Gopar-Nieto R, Martinez-Amezcua P, et al. A randomized controlled trial of lung ultrasound-guided therapy in heart failure (CLUSTER-HF study). Am Heart J 2020; 227:31–39.
Platz E, Lewis EF, Uno H, et al. Detection and prognostic value of pulmonary congestion by lung ultrasound in ambulatory heart failure patients. Eur Heart J 2016; 37:1244–1251.
Gargani L, Pang PS, Frassi F, et al. Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure: a lung ultrasound study. Cardiovasc Ultrasound 2015; 13:40.
Coiro S, Rossignol P, Ambrosio G, et al. Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure. Eur J Heart Fail 2015; 17:1172–1181.

To read more about this study, download the Journal of Ultrasound in Medicine article, “Pulmonary Congestion on Lung Ultrasound Predicts Increased Risk of 30-Day Readmission in Heart Failure Patients” by Allison Cohen, MD, et al. Members of the American Institute of Ultrasound in Medicine (AIUM) can access it for free after logging in to the AIUM. Join the AIUM today!

Interested in reading more about ultrasound? Check out these posts from the Scan:

The Value of a Repeat Nasal Bone Evaluation in First-Trimester Screening for Down Syndrome

Posted on May 2, 2023 by aium1952

First-trimester screening for Down syndrome, a genetic disorder caused by the presence of an extra chromosome, usually involves a combination of maternal blood tests and an ultrasound exam (ie, a combined first-trimester screening [FTS]), which is performed between 11 and 14 weeks of pregnancy.

During the ultrasound exam, the healthcare provider evaluates various markers that can indicate an increased risk of Down syndrome, such as the thickness of the nuchal translucency (a fluid-filled space at the back of the fetus’s neck) and the presence of certain physical features, including the nasal bone. Because research has shown that fetuses with Down syndrome are less likely to have a visible nasal bone on ultrasound than fetuses without the condition, evaluating the nasal bone can help healthcare providers assess the risk of Down syndrome more accurately.

Although visualizing the nasal bone is not a mandatory component of the screening, the inclusion of fetal nasal bone evaluation in the screening improves the clinical performance of the screen for the detection of fetal Down syndrome. Unfortunately, factors such as maternal body habitus (such as increased body mass index [BMI]), poor acoustic windows, unfavorable fetal position, delayed nasal bone ossification, and early gestational age can hinder nasal bone visualization then. In addition, ethnicity may also affect the visualization of the fetal nasal bone as the development of the fetal nasal bone differs between populations. Acknowledging and integrating the differences in facial structure between different racial and ethnic groups can help to promote equity in prenatal imaging and ensure the provision of accurate, personalized risk counseling across patient populations.

Therefore, a recent study aimed to determine if repeat nasal bone evaluation provided a significant improvement in refining the specificity of Down syndrome risk assessment by combined FTS, as well as determine the efficacy of a repeat nasal bone evaluation across various maternal ethnicities.

The study reviewed the medical records of patients who underwent a first-trimester ultrasound evaluation in an American Institute of Ultrasound in Medicine (AIUM)-accredited center between January 2015 and January 2018. The study focused on patients with fetal nasal bone labeled as “absent or hypoplastic” or “unable to be adequately visualized” during the ultrasound. The researchers reviewed the records to assess factors such as patient age, ethnicity, follow-up evaluations, and fetal anomalies. They analyzed the combined FTS results and followed up with patients with abnormal results. They then conducted statistical analyses to compare patient ethnicity and nasal bone visualization on the second exam, as well as to compare patient ethnicity and fetal Down syndrome risk by combined FTS.

The study identified 589 cases (8.7%) of absent or uncertain fetal nasal bone on initial nuchal translucency (NT) ultrasound evaluation among the 6780 total NT ultrasounds performed, with the most frequently represented ethnicities being African American/Caribbean (46.2%) and White (36.8%). Of the total, 125 patients (21.2%) did not complete a repeat nasal bone evaluation, and 105 patients with additional risk factors pursued genetic counseling. Of these patients, 20 pursued chorionic villus sampling (CVS), and 11 of these cases (55.0%) reported abnormal karyotypes. Of the 376 eligible patients who completed a second nasal bone evaluation (exam 2), 82 patients (21.8%) had an absent fetal nasal bone, 26 (6.9%) had an uncertain fetal nasal bone, and 268 (71.2%) had a present fetal nasal bone. White patients were statistically significantly more likely than African American/Caribbean patients to have a present nasal bone on exam 2 (82.9% and 59.2% respectively, P < .0001), as were Asian Indian patients (100% and 59.2%, respectively, P < .0001).

Combined FTS can identify fetuses at high risk for aneuploidy, but it has a relatively high false positive rate. Therefore, proper identification of the absence or presence of the fetal nasal bone during FTS plays a critical role in identifying and counseling patients at increased risk for fetal aneuploidy. The study found that repeat nasal bone evaluation could reduce false positive FTS results, particularly in African American/Caribbean populations.

Even with the widespread use of cell-free DNA screening, combined FTS, including nasal bone assessment, remains an important tool for first-trimester aneuploidy risk assessment.

To read more about this study, download the Journal of Ultrasound in Medicine article, “Follow Your Nose: Repeat Nasal Bone Evaluation in First-Trimester Screening for Down Syndrome” by Kristen A. Miller, MGC, et al. Members of the American Institute of Ultrasound in Medicine (AIUM) can access it for free. Join the AIUM today!

Interested in reading more about obstetric ultrasound? Check out these posts from the Scan:

Preventing Work-Related Musculoskeletal Disorders Among Ultrasound Operators

Posted on April 4, 2023 by aium1952

Up to 90% of sonographers and other operators of diagnostic medical sonography report having painful work-related injuries affecting the muscles, nerves, ligaments, or tendons.¹ These work-related musculoskeletal disorders (WRMSDs) result from the multiple times a day the operators repeatedly make the same movements and maneuvers while performing ultrasound examinations.² For the ultrasound operator, the most common locations of WRMSDs include the shoulder, neck, wrist, and hands, and the results of WRMSDs can lead to serious health issues, absenteeism, presenteeism, and even leaving the field of ultrasound altogether.³

The following are some of the critical factors that can lead to the development of WRMSDs:

Poor ergonomics, including poor posture and machines with poor ergonomic design.³
Poor workflow, including the positions of the machine, bed, and workstation, leads to unnecessary arm abduction and overreaching.³
Lengthy exams with an increasing workload and number of exams to be performed during the workday.⁴
Inadequate breaks between examinations in addition to an increasing workload.⁵
Psychological stress and psychosocial factors in the workplace.⁶
Unsupportive or inflexible environments that fail to account for the diverse abilities and experiences of individual operators.⁷

The Occupational Safety and Health Administration has placed the primary responsibility for protecting workers on the employer.^8,9 So, when developing WRMSD prevention protocols, administrators should collaborate with ultrasound operators to create policies that support their safety.¹⁰ Such policies should take into account scheduling to limit overtime work and provide breaks, staffing levels to optimize patient care, proper ergonomic equipment and adjustable equipment, and room designs that facilitate proper ergonomics, such as adequate space for patients and equipment. The workplace culture should support wellness and also have transparent policies regarding reporting and tracking of WRMSDs.

The operator also needs to ensure their working space is set up in the best manner possible for preventing WRMSDs during their workday. They can do so by customizing their ultrasound environment to promote proper ergonomic technique.

At the beginning of each examination, the operator should properly position and make adjustments depending upon the body habitus of each patient.¹¹ Reaching movements should be avoided by keeping the operator, machine, bed, and patient as close together as possible and at appropriate heights.
The operator’s head and the screen/monitor should be on the same axis, and the eye-screen distance should be at least 60 cm. The top of the screen should be aligned with the level of the operator’s eyes; then, the top of the screen should be tilted back slightly to encourage proper neck posture.^11,12
The operator’s neck should be straight, and neck extension should be avoided.⁶
The operator should be positioned in order to allow the arm to be in a relaxed position with the upper arm close to the body (minimal flexion, ideally abduction <30 degrees) and the elbow at a 90-degree angle, ie, the forearm should be horizontal to the floor allowing the shoulder to remain in a neutral positionwhenever possible.
A “wearable transducer cable support device,”¹³ such as a cable brace, can be utilized to reduce arm strain during scanning. Also, the ultrasound transducer cable should not be passed around the operator’s neck as any traction force could result in a poor neck position.^11,12
A scanning chair should be equipped with a backrest for lumbar support and adjustable height to mold the lumbar lordosis. Moreover, a seatback inclined between 10° and 20° is recommended. The back should be well supported on the seat. A slight gap should remain between the edge of the seat and the back of the knee, and the body should be on the axis of the screen. The chair should be height adjustable so the operator can be properly positioned relative to the patient and ultrasound system. Exam chairs should not have armrests as they may restrict access to the patient.
Exam tables should be height adjustable to encourage proper positioning by minimizing extended reaching, elevated arms, and wrist deviation, and allowing operators to stand and/or sit while performing procedures.
The ultrasound machine keyboard should be easy to move and adjust.
Removing the transducer from the patient and relaxing the hand to allow for brief micro-breaks during the examination can help reduce muscle strain.
With the exception of point-of-care imaging, portable diagnostic exams should be limited to critically ill patients and those patients who are unable to come to the ultrasound department.

Specific types of ultrasound examinations also bring unique challenges. Some of these challenges are addressed, by specialty, in the AIUM Practice Principles for Work-Related Musculoskeletal Disorder.¹⁴

Increased awareness of the magnitude of the problem and local quality improvement (QI) efforts are necessary to ensure that these standards are translated into the successful reduction of WRMSDs among ultrasound operators.

A QI program should include ongoing tracking or logging of the following:

Ergonomic education for employees
Safety and resource utilization
Equipment updates
The numbers and types of reported symptoms and/or injuries, and
Organizational (ie, policies and practices) changes or updates made to improve employee safety and well-being.

A review of these data, along with a status check on overall workplace culture and worker well-being, should be conducted annually. To do so, a QI team composed of individuals from all levels of the organization (eg, administration, management, staff) should review aggregated data from tracking logs and any annual workplace environment reports to identify and prioritize areas for improvement.

The protection of our frontline workforce is paramount in retaining individuals with valuable skills. This protection requires a change in industry mindset that acknowledges the shared responsibility among both employers and ultrasound operators.

This post was created from the AIUM Practice Principles for Work-Related Musculoskeletal Disorder, which was developed by the American Institute of Ultrasound in Medicine in collaboration and with the expressed support of the American College of Emergency Physicians (ACEP), American College of Obstetricians and Gynecologists (ACOG), American College of Radiology (ACR), American Registry for Diagnostic Medical Sonography (ARDMS), American Society of Echocardiography (ASE), Australasian Society for Ultrasound in Medicine (ASUM), Fetal Heart Society (FHS), Intersocietal Accreditation Commission (IAC), International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), Joint Review Committee on Education in Cardiovascular Technology (JRC-CVT), Joint Review Committee on Education in Diagnostic Medical Sonography (JRC-DMS), Perinatal Quality Foundation (PQF), Society of Diagnostic Medical Sonography (SDMS), and Society for Maternal-Fetal Medicine (SMFM). The Practice Principle was developed to expand on the “Industry Standards for the Prevention of Work-Related Musculoskeletal Disorders in Sonography”¹³ to include safety practices for all health care professionals who utilize ultrasound.