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Future of Breast Elastography

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Future of Breast Elastography Future of breast elastography Richard Gary Barr1,2 1Department of Radiology, Northeastern Ohio Medical University, Rootstown, OH; 2Southwoods Imaging, Youngstown, OH, USA REVIEW ARTICLE Both strain elastography and shear wave elastography have been shown to have high sensitivity https://doi.org/10.14366/usg.18053 pISSN: 2288-5919 • eISSN: 2288-5943 and specificity for characterizing breast lesions as benign or malignant. Training is important for Ultrasonography 2019;38:93-105 both strain and shear wave elastography. The unique feature of benign lesions measuring smaller on elastography than B-mode imaging and malignant lesions appearing larger on elastography is an important feature for characterization of breast masses. There are several artifacts which can contain diagnostic information or alert to technique problems. Both strain and shear wave elastography continue to have improvements and new techniques will soon be available for Received: September 21, 2018 clinical use that may provide additional diagnostic information. This paper reviews the present Revised: January 4, 2019 Accepted: January 4, 2019 state of breast elastography and discusses future techniques that are not yet in clinical practice. Correspondence to: Richard Gary Barr, MD, PhD, Keywords: Breast; Elasticity imaging techniques; Strain; Shear wave; Strain ratio; Southwoods Imaging, 7623 Market Street, Youngstown, OH 44512, USA Breast neoplasms Tel. +1-330-965-5100 Fax. +1-330-965-5109 E-mail: [email protected] Introduction The use of palpation to determine the stiffness of a lesion has been used since the time of the ancient Greeks and Egyptians [1]. Stiff, non-mobile lesions of the breast have a high probability of being malignant. In vitro experiments it has been shown that the difference in stiffness of malignant breast lesions and benign breast lesions is substantial with little overlap [2]. These characteristics of This is an Open Access article distributed under the terms of the Creative Commons Attribution Non- malignant breast masses suggest that elastography should have a high accuracy for characterization Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/) which permits unrestricted non- of breast lesions. commercial use, distribution, and reproduction in Both strain elastography (SE) and shear wave elastography (SWE) [3] have been used to evaluate any medium, provided the original work is properly cited. breast pathology with high sensitivity and specificity. For reasons not fully understood malignant breast lesions appear larger on elastography compared to B-mode while benign lesions appear Copyright © 2019 Korean Society of Ultrasound in Medicine (KSUM) smaller. This has allowed for a semi-quantitative method in SE to characterize breast lesions. SWE can determine the lesion stiffness and determine with high probability of a lesion is benign or malignant. On SWE, some cancers have properties that do not allow for good shear wave propagation and may be interpreted as false negative lesions. This has been overcome by the addition of a quality measure (QM) which can detect the quality of the shear waves and alert the interpreter of an erroneous measurement. Breast elastography has now been clinically available for over 10 years and has continued to improve. We now understand its advantages and limitations. The techniques have not been widely accepted due to a substantial learning curve for performing and interpreting examinations. How to cite this article: Barr RG. Future of breast elastography. Improvements in the technology are being developed to overcome these limitations and may make Ultrasonography. 2019 Apr;38(2):93-105. e-ultrasonography.org Ultrasonography 38(2), April 2019 93 Richard Gary Barr elastography a primary method of characterization of breast lesions. radiation force impulse (ARFI) push pulse. Most vendors offer manual compression strain on their system. The systems vary significantly Types of Elastography in the degree of stress that is needed for optimal images. Some systems require minimal compression and release while others There are two types of ultrasound elastography strain (SE) and SWE require a moderate amount of compression and release. There is [3]. a learning curve for each system. There is a sweet spot where the SE is a qualitative technique. This technique evaluates the algorithm is most accurate. Too little or too much compression changes in tissues when an external force is applied. Softer tissues will lead to suboptimal elastograms (Fig. 1). Most systems have deform more than stiffer tissues. There are two methods of applying a visual display of the amount of compression release applied so the stress, manual compression and release or using an acoustic the operator can find the optimal technique. When using the ARFI A Fig. 1. The effect of optimal and sub- optimal displacement/release compression B in strain elastography. For displacement/release, strain elasto- graphy each vendor has a sweet spot where the optimal elastogram is obtained. A. When there is too much displacement only noise is obtained, the lesion is not identified on the elastogram. B. When not enough displacement is obtained, an elastogram is not obtained. C. When the appropriate displacement/release is applied an accurate elastogram is obtained. The lesion measures 1.03 cm on B-mode (left) and 1.34 cm on strain elastography (right) suggestive of a benign lesion. The lesion was an invasive D=1.03 cm ductal carcinoma. D=1.34 cm C 94 Ultrasonography 38(2), April 2019 e-ultrasonography.org Future of breast ultrasound technique for SE, which is presently only offered by one vendor, the compression and release. The operator just needs to hold the transducer is held still with minimal pressure on the breast and the transducer with minimal compression on the breast. Those that ARFI pulse initiated. The learning curve for the ARFI technique is require more compression and release have a more significant less than that of the compression-release techniques. The systems learning curve and have more artifacts particularly in the near field. that require minimal compression and release are easier to learn as SWE techniques use the ARFI technology to generate shear waves most require just the patient breathing or heart beat to generate the that propagate perpendicular to the ARFI pulse. Therefore, ARFI Vs=2.40 m/s E=17.2 kPa Depth=1.7 cm Vs=1.81 m/s E=9.8 kPa A B Vs=3.06 m/s Vs=3.79 m/s E=28.2 kPa E=43.0 kPa Depth=1.5 cm Depth=1.5 cm Vs=2.62 m/s Vs=2.92 m/s E=20.5 kPa E=25.5 kPa Depth=1.5 cm Depth=1.5 cm C D Fig. 2. The effect of pre-compression on stiffness values. When pre-compression (added pressure on the breast with the transducer) is added, the stiffness value of the lesion will increase. It is important to only apply minimal pressure with the transducer. A-E. In this series of images, the lesion a benign fibroadenoma (A), its stiffness when done properly is 2.4 m/sec (B) as increased compression is Vs=5.14 m/s E=79.3 kPa added, the lesion stiffness increases to 3.0 m/sec (C), 3.79 Depth=1.4 cm Vs=3.51 m/s m/sec (D), and 5.1 m/sec (E). Note also that the stiffness E=37.1 kPa Depth=1.4 cm value of fat also increases with increased compression. E e-ultrasonography.org Ultrasonography 38(2), April 2019 95 Richard Gary Barr technology can be used to generate both SE, measuring the axial Table 1. Technical factors for performing breast elastography displacement, and SWE measuring the speed of the perpendicular Strain elastography Shear wave elastography shear waves generated. It is important to remember that the shear Avoid pre-compression Avoid pre-compression waves are tracked using B-mode ultrasound so optimal B-mode Use optimal compression/release Hold transducer still images are required to obtain accurate stiffness values. The SWE for system technique is quantitative providing a stiffness value either by the No out of plane motion No out of plane motion shear wave speed in meters per second (m/sec) or converting to the Position patient so respiratory Position patient so lesion is at least motion is in plane with imaging 5 mm deep and less than 4 cm deep Young’s modulus in kiloPascals [4]. The learning curve for SWE is Have a large FOV containing fat, Monitor the stiffness of fat to confirm less than that of SE although one important factor that affects both glandular tissue, pectoralis muscle no pre-compression SE and SWE is pre-compression which is discussed in detail below and the lesion [5,6]. FOV, field of view. Technique the measurement. Both point shear wave elastography and two- One of the most critical factors in performing breast elastography dimensional (2D)-SWE have been used to evaluate breast lesions is pre-compression [7]. When a material is compressed its stiffness [9]. Breast masses, especially malignancies, tend to be very increases (Fig. 2). To perform accurate breast elastography, both heterogeneous in stiffness. Therefore, the 2D-SWE technique is strain and shear wave, minimal compression of the breast must preferred as the larger FOV can depict the differences in stiffness be applied. Usually some pre-compression is used in B-mode and the area of highest stiffness can be identified. Table 1 lists the imaging as this straightens Cooper’s ligaments decreasing artifacts. important technical factors when obtaining SE and SWE breast In SE when significant pre-compression is applied the result is images. noise. While with mild to moderate pre-compression there may be alternating good images and noise. The good images are obtained Interpretation of SE in the upstroke of the compression cycle. If serial images are not For reasons not fully understood, breast cancers appear larger on similar when performing SE, the reason is either too much pre- the elastogram than on the B-mode image while benign lesions compression or movement of the lesion in the scanning plane.
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