elastography in breast ultrasound imaging 1

Hamid Hamid TahmasebpourTahmasebpour, BSC CRGS, BSC CRGS

Clinical Instructor, University of British ColumbiaClinical Instructor, University of British Columbia

Program Director, Ultrasound Seminars & Workshops, Program Director, Ultrasound Seminars & Workshops, www.sonographers.cawww.sonographers.ca

Contact: Contact: hamid@sonographers.cahamid@sonographers.ca

ElastographyElastographyinin

Breast Ultrasound ExaminationsBreast Ultrasound Examinations

●● Elastography = EchopalpationElastography = Echopalpation

●● MethodsMethods

1.1. Strain Elastography (EI)Strain Elastography (EI)

�� Manual compressionManual compression

2.2. Shear Wave Elastography (SWE)Shear Wave Elastography (SWE)

�� ARFI (Acoustic Radiation Force Impulse)ARFI (Acoustic Radiation Force Impulse)

IntroductionIntroduction

Strain ElastographyStrain Elastography

TransducerTransducer

Correlation of pre/post compression images Correlation of pre/post compression images �������� EIEI

●● Stiffer: BlackStiffer: Black

●● Softer: WhiteSofter: White

Strain ElastographyStrain Elastography

●● Stiffer: RedStiffer: Red

●● Softer: PurpleSofter: Purple

Strain ElastographyStrain Elastography

●● Benign lesion are more easily deformedBenign lesion are more easily deformed

●● TumorsTumors are typically stiffer than surrounding tissue (5 to 28 times)are typically stiffer than surrounding tissue (5 to 28 times)

●● IsoIso--echoic lesions are detectableechoic lesions are detectable

●● More accurate triage for breast biopsiesMore accurate triage for breast biopsies

–– 1.4 M biopsies in USA per year 1.4 M biopsies in USA per year

•• 80% benign80% benign

•• cost $2 billion/yearcost $2 billion/year

•• Stressful invasive unnecessary biopsies can be avoidedStressful invasive unnecessary biopsies can be avoided

Application of EIApplication of EI

Simple CystSimple Cyst

Strain ElastographyStrain Elastography

Strain ElastographyStrain Elastography

Invasive Ductal CarcinomaInvasive Ductal Carcinoma

Strain ElastographyStrain Elastography

Invasive Ductal CarcinomaInvasive Ductal Carcinoma

Isoechoic Breast CarcinomaIsoechoic Breast CarcinomaDisclaimer from Philips:Disclaimer from Philips: Philips Healthcare Elastography has received FDA cl earance and Philips Healthcare Elastography has received FDA cl earance and is pending Health Canada approvalis pending Health Canada approval

Strain ElastographyStrain Elastography

Invasive Ductal CarcinomaInvasive Ductal Carcinoma

Strain ElastographyStrain Elastography

Strain ElastographyStrain Elastography

What is this lesion?What is this lesion?

Strain ElastographyStrain Elastography

EI confirmed a simple cystEI confirmed a simple cyst

Shear Wave Elastography (SWE)Shear Wave Elastography (SWE)

●● Operator independentOperator independent

●● QuantitativeQuantitative

●● ReproducibleReproducible

●● High spatial resolutionHigh spatial resolution

1. Pre1. Pre--Shear Wave data acquisition of relaxed tissueShear Wave data acquisition of relaxed tissue

Shear Wave Elastography (SWE)Shear Wave Elastography (SWE)

TransducerTransducer

Shear Wave Elastography (SWE)Shear Wave Elastography (SWE)

TransducerTransducer

2. ARFI (Push Pulse) creates Shear Waves2. ARFI (Push Pulse) creates Shear Waves

Shear Wave Elastography (SWE)Shear Wave Elastography (SWE)

TransducerTransducer

3. Shear Wave velocity (Vs) is calculated by tracking pulses3. Shear Wave velocity (Vs) is calculated by tracking pulses

From: Supersonic Imagine S.A., France

Shear Wave Elastography (SWE)Shear Wave Elastography (SWE)

Shear Wave Elastography (SWE)Shear Wave Elastography (SWE)

Courtesy of Drs Nestle-Krämling, Junkermann, Henrot , Tourasse, Piccoli, Supersonic Imagine S.A., France

1.1. Simple CystsSimple Cysts

2.2. FibroadenomaFibroadenoma

3.3. Benign Lymph NodeBenign Lymph Node

4.4. Reabsorbing AbscessReabsorbing Abscess

5.5. Invasive Ductal CarcinomaInvasive Ductal Carcinoma

11 22 33

4455

Shear Wave Elastography (SWE)Shear Wave Elastography (SWE)

Courtesy of Drs Nestle-Krämling, Junkermann, Henrot , Tourasse, Piccoli, Supersonic Imagine S.A., France

E: Elasticity (E: Elasticity (kPakPa), P: Density of tissue (kg/m), P: Density of tissue (kg/m3), 3), C: Shear wave propagation speed (C: Shear wave propagation speed (m/sm/s))

DCISDCIS IDCIDC

Shear Wave Elastography (SWE)Shear Wave Elastography (SWE)

Tanter M et al: Quantitative Assessement Of Breast Le sion Viscoelasticity: Initial Clinical Results Usin g Supersonic Shear Imaging. Ultrasound in Med. & Biol., Vol. 34, No. 9 , pp. 1373–1386, 2008.

E: Elasticity (E: Elasticity (kPakPa), P: Density of tissue (kg/m), P: Density of tissue (kg/m3), 3), C: Shear wave propagation speed (C: Shear wave propagation speed (m/sm/s))

Shear Wave Elastography (SWE)Shear Wave Elastography (SWE)

Tanter M et al: Quantitative Assessement Of Breast Le sion Viscoelasticity: Initial Clinical Results Usin g Supersonic Shear Imaging. Ultrasound in Med. & Biol., Vol. 34, No. 9 , pp. 1373–1386, 2008.

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Elasticity distribution of 138 breast lesionsElasticity distribution of 138 breast lesions

●● Strain EI:Strain EI:

�� Demonstrates relative tissue stiffness Demonstrates relative tissue stiffness

�� Benign lesions: softer, smaller or the same size and brighter Benign lesions: softer, smaller or the same size and brighter

�� Malignant lesions: harder, larger size and darkerMalignant lesions: harder, larger size and darker

�� Detects isoechoic lesions with more confidenceDetects isoechoic lesions with more confidence

�� Provides additional information to describe a massProvides additional information to describe a mass

�� Helps to triage breast biopsiesHelps to triage breast biopsies

�� Downside: operator dependent, qualitative, motion artifacts, lesDownside: operator dependent, qualitative, motion artifacts, less reproducibles reproducible

●● SWE: a new exciting technology in diagnostic ultrasoundSWE: a new exciting technology in diagnostic ultrasound

�� Operator independent, higher spatial resolution, small masses arOperator independent, higher spatial resolution, small masses are detectable, e detectable,

quantitative, no motion artifacts, reproduciblequantitative, no motion artifacts, reproducible

●● Overall, EI improves the diagnostic confidence of US examsOverall, EI improves the diagnostic confidence of US exams

SummarySummary