Elastography: An Additional Tool for Characterisation of Breast Lesions

Elastography:AnAdditionalToolfor
CharacterisationofBreastLesions

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Elastography: An additional tool for characterisation of
breast lesions
Poster No.: C-0427
Congress: ECR 2010
Type: Educational Exhibit
Topic: Breast
Authors: A. M. Makudamudi, A. Kanakarajan, B. Raghavan, J. Govindaraj;
Chennai/IN
Keywords: elastography, BI-RADS, spatial resolution
DOI: 10.1594/ecr2010/C-0427
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Learning objectives
Elastography New imaging method which provides very high contrast between masses
and host tissue, by estimating the measure of visco-elastic properties of tissues.
Types: Ultrasound Elastography MR Elastography
Slide 3
•Elasticity Imaging looks at mechanical properties -Show relative tissue stiffness or
hardness -Different information than B-mode which shows backscatter information
-Provides further insight into potential pathology •Helps to differentiate hard from
soft lesions. •Differentiates cystic from solid lesions. Advantages of ultrasound in
Elastography: real-time imaging capabilities, very high resolution in motion estimation
(~1mm), simplicity, non-invasiveness, and relative low cost.
Background
PRINCIPLE Slide 5 Palpation creates & senses strain. Elasticity is the physical
property of a material when it deforms under stress (e.g. external forces), but returns
to its original shape when the stress is removed. Stress is the force causing the
deformation. Strain is the amount of deformation produced by the stress. Young's
modulus (E) describes tensile elasticity as the tendency of an object to deform along
the axis of compression It is a measure of the stiffness of an elastic material. Therefore
easily deformable substances will have low value of E and substances which are
difficult to deform will have high values Ultrasound Elastography Slide 6 •The
strain is estimated from minute differences between two B-mode images, during
compression either by the transmitted pulsation in cardiac cycle or by minimal active
probe compression. •The differences are in the order of 0.1 to 0.2 mm •Strain values
are then displayed as an image. •Image is displayed using either different shades of
gray or using different colours to represent the varying magnitude of strain values.
•Elastogram is superimposed on B-mode image. •Stiffer lesions appear darker & larger.
Technique of Image Acquisition •Probe and lesion perpendicular to gravity •Motion
is provided by the patient's breathing and heart beat •If insufficient, slow minimal
compression with the probe is applied Fig 5 Methods of computation of
tissue elasticity [1] 1.Spatial correlation method 2.Phase-shift tracking method
3.Combined autocorrelation method Spatial correlation method [1] •Uses an
ordinary two-dimensional pattern matching algorithm •Searches for the position that
maximizes the cross correlation between ROI's selected from two images obtained
before and after deformation. •This method can be used to demonstrate displacement
in two dimensions - longitudinal and lateral. Disadvantage : Processing time is

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lengthy for real-time assessment. COLOR MAPPING -ELASTICITY SCORE (Spatial
correlation method) Fig 1
Elasticity Score Fig 2
Slide 12 Fig 3 CYST - variable appearances
(Spatial correlation method) [2]
• 3-layered pattern with both bright and dark regions
• darker (stiffer) area with a brighter (softer) center, "bull's eye"
• a uniformly dark area
• Ill-defined margins
• Smaller or same size
Fig 4 Phase-shift tracking method [1] Based on autocorrelation method- principle
of color Doppler US. This method can be used to rapidly and precisely determine
longitudinal tissue motion because of phase-domain processing. Disadvantage:
•Errors related to aliasing - fails when used to measure large displacements. •Poorly
compensates for movement in the lateral direction - disadvantage for freehand
compression. Slide 15 •Slightly different technique is used in acquisition & computation
•B-mode image is obtained & ROI is placed within it •Lesion is actively compressed &
released for 3-5 times and frozen. •Elastography is computed by pressing Elastography
Q button. •Elasticity value obtained from the strain graph Fig 6 Slide 16 Fig 7 Slide 17
Fig 8
Images for this section:
Fig. 1: Color mapping- Elasticity score (Spatial correlation method)

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Fig. 2: Elasticity score

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Fig. 3: Elasticity score

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Fig. 4: Cyst-variable appearances (Spatial correlation method)
Fig. 5: Technique of Image acquisition

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Fig. 6: Phase shift tracking method
Fig. 7: Elastographic computation in Phase tracking method

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Fig. 8: Phase tracking method- graphical display

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Imaging findings OR Procedure details
Cystic lesions Fig 1 Cystic & complex cystic lesions Fig 2 Cystic & complex
cystic lesions Fig 3 Discordant Elastogram in benign lesions Fig 4 Solid rounded
lesions Fig 5 Solid rounded lesions Fig 6 Irregular small lesions Fig 7 Slide 25 Fig
8 Slide 26 Fig 9
Fig. 1: Cystic lesions

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Fig. 2: Cystic & complex cystic lesions

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Fig. 3: Cystic & complex cystic lesions
Fig. 4: Discordant Elastogram in benign lesions

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Fig. 5: Solid rounded lesions
Fig. 6: Solid rounded lesions

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Fig. 7: Irregular small lesions
Fig. 8: Bilateral & Multifocal malignancy

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Fig. 9: Elastography in microcalcifications

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Conclusion
<</p>
Statistics Slide 27
Total no. of lesions studied- 100 (Spatial correlation method) Kappa agreement shows
elastography correlates better with pathology when compared to USG. Specificity
of elastography is better than ultrasound and correlates with literature. [3] Fig 1,
Fig 2, Fig 3 •Elastography provides additional information not otherwise available.
•Complementary to B-mode USG/ mammography. •Can reduce the indications for
unnecessary biopsies & interventions in benign lesions like complex cysts & in some
instances MRI. •Can help in guiding the appropriate area for biopsy (hard area)
•Quantitative analysis can be performed. •Increases confidence level. •Cost effective.
Fig. 1: Statistics

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Fig. 2: Statistics- Kappa agreement

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Fig. 3: Statistics- Sensitivity & Specificity

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Personal Information
Presenters:
Dr.Anugayathri Makudamudi
Resident in Radiology
Dr.Bagyam Raghavan
Senior Consultant
docbagyam@gmail.com
Department of Radiology & Imaging Sciences,
Apollo Speciality Hospital,
Chennai, India.
Acknowledgements:
Dr.S.Suresh,
Mediscan Systems,
Chennai, India.
References
References < 1.Ako Itoh, Ei Ueno, Eriko Tohno, Hiroshi Kamma, et al. Breast Disease:
Clinical Application of US Elastography for Diagnosis. Radiology: May 2006; 239:
341-350. 2.Tardivon A, et al. Elastosonography ofthe breast: prospective study of
122 lesions. J Radiol 2007;88:657-662. 3.Thomas A, Fischer T, Frey H, Ohlinger,
et al. Real-time elastography- an advanced method of ultrasound: first results in
108 patients with breast lesions. Ultrasound Obstet Gynecol 2006; 28: 335-340.
4.Garra BS, Cespedes EI, Ophir J, et al. Elastography of breast lesions: initial clinical
results. Radiology 1997;202:79-86. 5.Shiina T, Nitta N, Ueno E, Bamber JC. Real
time tissue elasticity imaging using the combined autocorrelation method. J Med

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Ultrason 2002;29:119-128. 6.ZhiH, et al. Comparison of ultrasound Elastography,
mammography, and sonography in the diagnosis of solid breast lesions. J Uìtrasound
Med 2007; 26:807-815.

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