CONTINUING MEDICAL EDUCATION
Clinical 3D ultrasound
Earn 1.0 hours of AMA PRA
Category 1 Credits™ through
January 2009
Upon completion of this
activity, participants should
be able to:
• Describe general potential
advantages of 3D (versus 2D)
sonographic image acquisition.
• Summarize the basic principles
of volumetric image acquisition.
• Describe specific applications of
3D sonographic technology for a
variety of clinical indications and
organ systems.
• Explain the limitations and
future challenges for 3D
sonographic technology.
Who will benefit:
Radiologists, sonographers,
physicians, physician assistants,
nurses, and referring physicians
interested in body imaging will
benefit from the information in
this educational activity and can
receive Continuing Medical
Education credit by completing
the post-test and evaluation
provided.
January 2007
imaging: beyond
obstetrical applications
By Roee S. Lazebnik, M.D., Ph.D., and Terry S. Desser, M.D.
ver the past 50 years, imagers have wit-
O nessed dramatic improvements in ultra-
sound image quality, resolution, avail-
ability, and range of indications. Most of
these advances occurred within the confines
of 2D planar imaging. Meanwhile, produc-
tivity gains and the explosion of applications
for volumetric CT and MRI have whetted
sonographers’ appetite for comparable volu-
metric technologies because several funda-
mental limitations persist in 2D ultrasound
imaging.
First, the radiologist is dependent on a
series of noncontinuous, presumably repre-
sentative sections of the imaged organ to
depict its entire complex anatomy. In-
adequate sampling of pathology, assuming
this is even apparent, requires repeat exami-
nation. Moreover, the imaging plane is fixed
Dr. Lazebnik is a resident physician and Dr.
Desser is an associate professor and residency
program director, both in the radiology
department at Stanford University School of
Medicine.
Dr. Desser is a shareholder of SonoSite. Dr.
Lazebnik has no significant financial
arrangement or affiliation with any manu-
facturer of any pharmaceutical or medical
device and is not affiliated in any manner
with any provider of any commercial medical
or healthcare professional service.
DIAGNOSTIC IMAGING: CONTINUING MEDICAL EDUCATION
during the examination, precluding recon-
struction of other cross sections.
Second, the images submitted for review
show no quantitatively documented spatial
relationship. The radiologist must rely on
image labels and trust that the acquisition
technique conformed to a given protocol of
orientations with minimal sonographer vari-
ability. Comparison of serial exams is thus
difficult, as exact corresponding planes are
rarely acquired.
Third, volume measurements typically
rely on the assumption that a simple geomet-
ric model, such as an ellipsoid defined by
length and width, is an accurate proxy of the
true 3D shape.
Finally, extrapolation from 2D to 3D
anatomy is entirely mental and does not
exploit modern 3D surface or volume ren-
dering techniques.
Volumetric (3D) ultrasound overcomes
these limitations. Numerous approaches
allow acquisition of a sonographic volume.
The simplest is offline workstation postpro-
cessing of 2D cine clips acquired by freehand
scanning into 3D volumes. While easy to
implement, these are less accurate than volu-
metric acquisition. To obtain a true 3D
sonographic volume, options include
2D transducer arrays, mechanical localizers
(continuous linear, tilt, and rotational
motion devices), and freehand scanning with
automated localization (articulated arms,
1
 CLINICAL 3D ULTRASOUND IMAGING:
BEYOND OBSTETRICAL APPLICATIONS
FIGURE 1. Tomographic sections of neonatal brain generated using a single sweep of the volumetric transducer.
(Provided by Siemens Medical Solutions)
magnetic field sensors, and others).
In general, these methods either
acquire volume information directly or
assign 3D spatial coordinates to a series
of continuous or noncontinuous 2D
images. An extension of these techniques
is 4D ultrasound, the continuous acquisi-
tion of 3D volume data so as to represent
the volume dynamically through the
imaged time interval (1).
ADVANTAGES OF
VOLUMETRIC ACQUISITION
Independent of the imaged organ system,
3D sonography features several universal-
ly applicable advantages. In a typical 3D
acquisition, the sonographer scans the
region of interest with a single sweep of a
volumetric transducer. He or she no
longer needs to acquire multiple image
series through the organ of interest, so
scan times can be greatly reduced. For
applications such as bedside neonatal 3D
neurosonography, scanning is performed
quickly, with a single sweep through the
brain and without the sedation required
for modalities such as MRI (2) (Figure 1).
Similar to volumetric CT data, 3D
ultrasound volumes may be processed
January 2007 DIAGNOSTIC IMAGING: CONTINUING MEDICAL EDUCATION
subsequent to acquisition to obtain dif-
ferent views or to troubleshoot interpre-
tation questions. Evaluation of multin-
odular thyroid glands or fibroid uteri, for
example, may become much easier when
the organ is viewed in multiple planes
simultaneously on tomographic display
workstations. Postprocessing allows
remote interpretation and teleradiology
for sonography, as the reader has all nec-
essary information in the scanned volume
(3). Comparison of serial imaging studies
over time is facilitated, as multiple corre-
sponding anatomic landmarks are pres-
ent in all data sets.
Measurement of organ or lesion vol-
umes with 3D ultrasound does not
require assumption of any specific geom-
etry but can be directly computed by
manual or automatic segmentation of
continuous slice data. Similarly, 3D sur-
face visualization is accomplished by seg-
mentation of the data set by manual or
automated methods.
ABDOMEN AND PELVIS
APPLICATIONS
Almost all organ systems that are feasibly
evaluated by 2D ultrasound benefit from
the general advantages of 3D ultrasound
outlined above. Abdominal imaging, for
example, may involve estimating volumes
of liver masses, gallbladder, or gallstones.
Other size measurements such as the kid-
ney long axis, which has traditionally
relied on the sonographer’s accurate
imaging of this plane, are made easier
and are more readily reproducible. As 3D
ultrasound technology continues to
mature, many more novel and specific
applications will be investigated. Several
already demonstrate clinical utility.
Given the unmatched benefits of 2D
ultrasound for obstetric imaging, it is not
surprising that much of the initial 3D
ultrasound literature focused on obstetric
applications (4,5). Many gynecological
applications have also been explored, and
these demonstrate great promise. They
include evaluation of congenital uterine
anomalies, where postprocessing into the
coronal plane permits visualization of the
uterine fundal contour (Figure 2).
Volumetric images of the fibroid
uterus can facilitate measurement and
comparison studies. Three-D imaging has
also proven useful for endometrial polyps
(Figure 3), cornual ectopic pregnancies,
intrauterine devices, and adnexal lesions.
Interventions, including abscess drainage
of the pelvis and abdomen as well as fer-
tility procedure guidance, are made easier
by viewing multiple planes at once (6).
Urologic sonography is well estab-
lished for both urodynamic imaging and
anatomic survey. In these contexts, 3D
imaging offers several benefits. For pedi-
atric applications, 3D ultrasound is
intrinsically superior to 2D in document-
ing congenital renal anomalies and ureter
configuration (in context of reflux), as
these 3D structures cannot be complete-
ly visualized in a single plane.
Transabdominal 4D ultrasound accu-
rately depicts voiding and dynamic blad-
der volume when validated by uroflow-
metry measurements (7). In comparison
with 2D sonography, 3D ultrasound is
superior for evaluation of hematuria with
regard to identifying bladder cancer,
bladder wall hypertrophy, bladder diver-
2
 CLINICAL 3D ULTRASOUND IMAGING:
BEYOND OBSTETRICAL APPLICATIONS
FIGURE 2. Coronal reconstructed images of uterus demonstrate fundal contour. Visualization of this contour per-
mits differentiation of this arcuate uterus from a bicornuate uterus. (Provided by GE Healthcare Technologies)
ticula, mucosal bladder folds, and re-
growth of the prostate, as validated by
cystoscopy and/or bladder biopsy (8).
In the scrotum, 3D ultrasound may
provide better depiction of the complex
geometry of the epididymis and other
extratesticular structures, potentially
improving diagnostic confidence and
speed workflow.
For patients with suspected prostate
cancer, 3D power Doppler sonography
improves the diagnostic and staging
accuracy of anatomic imaging through
improved depiction of prostate vascular
structures. Optimization of biopsy site
selection is also aided by identification of
areas of abnormal blood flow. Finally,
extracapsular involvement is evaluated by
detecting the presence of vessels perforat-
January 2007 DIAGNOSTIC IMAGING: CONTINUING MEDICAL EDUCATION
ing the capsule (9). Use of microbubble-
based contrast agents further increases
the sensitivity of 3D ultrasound for
prostate malignancy (10).
BREAST IMAGING
The role of volumetric scanning contin-
ues to evolve in sonography of breast
masses. The multiplanar capability of 3D
has introduced to the imaging palette
the coronal plane, which some investiga-
tors suggest improves depiction of
tumor margins and of the orientation of
tumors relative to ductal structures
(Figure 4). One study, however, found
no significant benefit for 3D ultrasound
compared with 2D techniques for distin-
guishing benign from malignant breast
masses (11).
CARDIOVASCULAR APPLICATIONS
Ultrasound is a proven modality for vas-
cular imaging. In addition to anatomic
detail, color and spectral Doppler imag-
ing allow visualization and quantification
of blood flow. But 2D ultrasound estima-
tion of flow volume is inherently inaccu-
rate because vessel cross-sectional area is
unknown. Recent work suggests that 3D
techniques provide true volumetric flow
estimates that are angle-independent
(12). While 2D ultrasound allows for
detection of arterial atherosclerosis pri-
marily through flow velocity measure-
ments, 3D ultrasound allows for direct
visualization and quantification of plaque
volume.
The addition of microbubble contrast
agents allows for up to 30 dB of signal
enhancement and depiction of minute
detail (13). Several studies have demon-
strated the utility of 3D ultrasound for
accurate carotid and aortic plaque charac-
terization (14-16). Correlation of 3D
ultrasound with gold standard digital
subtraction angiography (DSA) demon-
strates excellent agreement in describing
plaque morphology (17,18).
The addition of 3D color Doppler
information may provide benefits in the
grading of stenotic lesions with respect to
flow dynamics (19). Given the ability to
reformat volumetric data to visualize flow
in a plane parallel to the interrogated ves-
sel, very low interobserver variability is
achievable (20,21). Rather than search-
ing for a single plane that contains relat-
ed vasculature, such as the hepatic arteri-
al system, the viewer can observe the
entire vascular tree in 3D.
Evaluation of cardiac anatomy and
functional is commonly performed using
echocardiography techniques. Given that
the heart’s contraction motion is intrinsi-
cally three-dimensional, 3D imaging
presents several advantages. The most
intuitive is more accurate measurement
of chamber volume and ejection fraction.
While 2D echocardiography requires
assumption of a simplified geometric
model of ventricular shape, a 3D ap-
proach allows for direct ventricle
3
 CLINICAL 3D ULTRASOUND IMAGING:
BEYOND OBSTETRICAL APPLICATIONS
FIGURE 3.Axial, sagittal, reconstructed coronal, and volumetric images of sonohysterogram demonstrate endome-
trial polyps.Volumetric image displays both polyps in one image and shows their orientation relative to each other
and uterine cavity. (Provided by Siemens Medical Solutions)
segmentation (22).
Another dramatic advantage is visuali-
zation of an entire valve at a given time
point or cinematically throughout the
cardiac cycle (23). Other advantages
include improved visualization of septal
defects and assessment of anatomic rela-
tionships in congenital heart disease (24).
ULTRASOUND-GUIDED
INTERVENTIONS
Ultrasound’s real-time visualization capa-
bility has well-established benefits in
guidance of both minimally invasive and
operative interventional procedures.
While many surgical specialties may ben-
efit from 3D ultrasound technology, its
application to neurosurgical procedures
has prompted particularly rapid adoption
and intensive research. Continuous intra-
operative monitoring of 3D brain shift is
very useful during resection of intracra-
nial tumors. This information allows a
surgeon to modify preoperative planning
maps to account for warping and tissue
removal (25).
January 2007 DIAGNOSTIC IMAGING: CONTINUING MEDICAL EDUCATION
Doppler imaging allows for improved
visualization of vasculature of interest
(26). This is beneficial in a variety of pro-
cedures, including biopsy guidance,
resection guidance, arteriovenous mal-
formation localization (and involved ves-
sel identification), localization of periph-
eral aneurysms, and delineation of cav-
ernous hemangiomas in both brain
parenchyma and the brain stem (27,28).
For glioma resection, 3D ultrasound
FIGURE 4. A. Axial breast ultrasound image demonstrates lobulated mass with refractive edge shadowing.
B. Coronal reconstructed image demonstrates intraductal location of mass. (Provided by GE Healthcare
Technologies)
volumes provide delineation of metas-
tases and solid component at least as reli-
ably as navigated 3D MRI (29). Unlike
MRI-based navigation, no preoperative
data set is required, and thus craniotomy
does not affect navigational accuracy.
LIMITATIONS OF 3D ULTRASOUND
While 3D ultrasound demonstrates
much promise, several limitations and
pitfalls remain that must be considered to
successfully integrate the technology in
clinical practice.
First, 3D image acquisition is logisti-
cally but not fundamentally different
from 2D ultrasound. The source of con-
trast — acoustic impedance differences
— is identical, so current contrast limita-
tions still apply. In obstetrics, where
amniotic fluid provides high contrast
between the background and the fetal
surface, 3D renderings provide impres-
sive verisimilitude, but in other organ sys-
tems, the effects have been less dramatic.
Second, user interfaces are complex
and challenging to master. No standard-
ized display convention has emerged to
date for the reconstructed images, so
image orientation can be difficult to
determine. Common artifacts used for
characterization, such as posterior
enhancement, are more difficult to inter-
pret in the context of multiple simultane-
ous transducer orientations.
Third, while most 2D studies are stan-
dardized on a per-organ or per-indication
basis, currently no standard methodolo-
4
 CLINICAL 3D ULTRASOUND IMAGING:
BEYOND OBSTETRICAL APPLICATIONS
gy for 3D data set acquisition or interpre-
tation exists.
Fourth, rendering of data in 3D using
volume or surface rendering techniques
introduces an additional layer of potential
artifacts and lack of standardized review.
Finally, while 3D images are qualita-
tively more intuitive than traditional 2D
sections, data as to the quantitative clini-
cal benefits of 3D ultrasound imaging are
limited, particularly compared with the
vast volume of literature and expertise
available for 2D imaging. Thus, more
research is required to identify the bene-
fits and indications for 3D imaging.
CONCLUSION
Three-D ultrasound is an emerging
modality that extends the scope and
potentially improves the clinical utility of
2D ultrasound for a variety of organ sys-
tems and indications. Unlike 2D ultra-
sound, 3D technology is only in its infan-
cy. Undoubtedly, the next decade will see
both technological refinement and
increased standardization of 3D ultra-
sound evaluation. Thus, 3D ultrasound is
a frontier that has been discovered but is
yet to be settled. ■
POST-TEST INSTRUCTIONS
To take your post-test and receive CME credit, go to http://education.cmellc.com
1. Login using your email address and password or “register now” if you are a first-time user
2. Click on CME Programs
3. Click on “Clinical Three Dimensional Ultrasound Imaging: Beyond Obstetrical Applications” in the list of programs
4. Click on “Take Exam” at the bottom, left side of the page to complete your post-test
5. After receiving a passing grade on the post-test, follow the online instructions to complete your evaluation and print your
statement of credit.
Reference #: A07019012
Release Date: JAN 2007
Expiration Date: JAN 2009
Number of AMA PRA Credits Designated
for this Activity: 1.0
January 2007 DIAGNOSTIC IMAGING: CONTINUING MEDICAL EDUCATION
REFERENCES
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3. Nelson TR, Pretorius DH, Lev-Toaff A, et al. Feasibility of per-
forming a virtual patient examination using three-dimensional
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4. Benacerraf BR, Benson CB, Abuhamad AZ, et al. Three- and
4-dimensional ultrasound in obstetrics and gynecology: proceed-
ings of the american institute of ultrasound in medicine consensus
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5. Benacerraf BR, Shipp TD, Bromley B. Three-dimensional US
of the fetus: volume imaging. Radiology 2006;238(3):988-996.
6. Bega G, Lev-Toaff AS, O’Kane P, et al. Three-dimensional
ultrasonography in gynecology: technical aspects and clinical
applications. J Ultrasound Med 2003;22(11):1249-1269.
7. Hirahara N, Ukimura O, Ushijima S, et al. Four-dimensional
ultrasonography for dynamic bladder shape visualization and
analysis during voiding. J Ultrasound Med 2006;25(3):307-313.
8. Mitterberger M, Pinggera GM, Neuwirt H, et al. Three-dimen-
sional ultrasonography of the urinary bladder: preliminary experi-
ence of assessment in patients with haematuria. BJU Int 2006;Oct
11 [Epub ahead of print].
9. Sauvain JL, Palascak P, Bourscheid D, et al. Value of power
doppler and 3D vascular sonography as a method for diagnosis
and staging of prostate cancer. Eur Urol 2003;44(1):21-30; dis-
cussion 30-31.
10. Bogers HA, Sedelaar JP, Beerlage HP, et al. Contrast-
enhanced three-dimensional power Doppler angiography of the
human prostate: correlation with biopsy outcome. Urology
1999;54(1):97-104.
11. Cho N, Moon WK, Cha JH, et al. Differentiating benign from
malignant solid breast masses: comparison of two-dimensional and
three-dimensional US. Radiology 2006;240(1):26-32.
12. Kripfgans OD, Rubin JM, Hall AL, et al. Measurement of vol-
umetric flow. J Ultrasound Med 2006;25(10):1305-1311.
13. Forsberg F, Rawool NM, Merton DA, et al. Contrast
enhanced vascular three-dimensional ultrasound imaging.
Ultrasonics 2002;40(1-8):117-122.
14. Fenster A, Blake C, Gyacskov I, et al. 3D ultrasound analysis
of carotid plaque volume and surface morphology. Ultrasonics
2006;Jun 30 [Epub ahead of print].
15. Landry A, Spence JD, Fenster A. Quantification of carotid
To earn AMA PRA Category 1 Credits™ read the article and complete the post
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©2007 CMPMEDICA • CME ULTRASOUND • CLINICAL 3D ULTRASOUND IMAGING: BEYOND OBSTETRICAL APPLICATIONS
plaque volume measurements using 3D ultrasound imaging.
Ultrasound Med Biol 2005;31(6):751-762.
16. Bainbridge D. 3-D imaging for aortic plaque assessment.
Semin Cardiothorac Vasc Anesth 2005;9(2):163-165.
17. Landry A, Spence JD, Fenster A. Measurement of carotid
plaque volume by 3-dimensional ultrasound. Stroke
2004;35(4):864-869.
18. Harrer JU, Wessels T, Poerwowidjojo S, et al. Three-dimen-
sional color-coded duplex sonography for assessment of the verte-
bral artery origin and vertebral artery stenoses. J Ultrasound Med
2004;23(8):1049-1056.
19. AbuRahma AF, Jarrett K, Hayes DJ. Clinical implications of
power Doppler three-dimensional ultrasonography. Vascular
2004;12(5):293-300.
20. Bucek RA, Reiter M, Dirisamer A, et al. Three-dimensional
color Doppler sonography in carotid artery stenosis. AJNR
2003;24(7):1294-1299.
21. Klotzsch C, Bozzato A, Lammers G, et al. Contrast-enhanced
three-dimensional transcranial color-coded sonography of
intracranial stenoses. AJNR 2002;23(2):208-212.
22. Ota T, Kisslo J, von Ramm OT, Yoshikawa J. Real-time, vol-
umetric echocardiography: usefulness of volumetric scanning for
the assessment of cardiac volume and function. J Cardiol 2001;37
Suppl 1:93-101.
23. Chan KL, Liu X, Ascah KJ, et al. Comparison of real-time 3-
dimensional echocardiography with conventional 2-dimensional
echocardiography in the assessment of structural heart disease. J
Am Soc Echocardiogr 2004;17(9):976-980.
24. Houck RC, Cooke JE, Gill EA. Live 3D echocardiography: a
replacement for traditional 2D echocardiography? AJR
2006;187(4):1092-1106.
25. Lindner D, Trantakis C, Renner C, et al. Application of intra-
operative 3D ultrasound during navigated tumor resection.
Minim Invasive Neurosurg 2006;49(4):197-202.
26. Rygh OM, Cappelen J, Selbekk T, et al. Endoscopy guided by
an intraoperative 3D ultrasound-based neuronavigation system.
Minim Invasive Neurosurg 2006;49(1):1-9.
27. Unsgaard G, Rygh OM, Selbekk T, et al. Intra-operative 3D
ultrasound in neurosurgery. Acta Neurochir (Wien)
2006;148(3):235-253; discussion 253.
28. Woydt M, Horowski A, Krauss J, et al. Three-dimensional
intraoperative ultrasound of vascular malformations and supraten-
torial tumors. J Neuroimaging 2002;12(1):28-34.
29. Unsgaard G, Selbekk T, Brostrup Muller T, et al. Ability of
navigated 3D ultrasound to delineate gliomas and metastases —
comparison of image interpretations with histopathology. Acta
Neurochir (Wien) 2005;147(12):1259-1269; discussion 1269.
1 Credits™. Physicians should only claim credit commensurate with the
extent of their participation in the activity.
The American College of Radiology (ACR) accepts activities designated for
AMA PRA Category 1 Credits™.
Physician Assistants: The American Academy of Physician Assistants (AAPA)
accepts AMA PRA Category 1 Credits™ from organizations accredited by the
ACCME.
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Category 1 Credits™ toward recertification requirements.
CME LLC is approved by the California Board of Registered Nursing, Provider
No. CEP12748, and designates this educational activity for 1.0 contact
hours for nurses.
5
 CLINICAL 3D ULTRASOUND IMAGING:
BEYOND OBSTETRICAL APPLICATIONS

For further reading

Guerriero S, Ajossa S, Piras S, et al. Three-dimen-

sional quantification of tumor vascularity as a ter-
tiary test after B-mode and power Doppler evalu-
ation for detection of ovarian cancer. J Ultrasound
Med 2007;26(10):1271-1278.

Jokubkiene L, Sladkevicius P, Valentin L. Does

three-dimensional power Doppler ultrasound help
in discrimination between benign and malignant
ovarian masses? Ultrasound Obstet Gynecol
2007;29(2):215-225.

Alcázar JL, Mercé LT, García Manero M. Three-

dimensional power Doppler vascular sampling: a
new method for predicting ovarian cancer in vas-
cularized complex adnexal masses. J Ultrasound
Med 2005;24(5):689-696.

Geomini PM, Kluivers KB, Moret E, et al.

Evaluation of adnexal masses with three-dimen-
sional ultrasonography. Obstet Gynecol
2006;108(5):1167-1175.

January 2007 DIAGNOSTIC IMAGING: CONTINUING MEDICAL EDUCATION 6