BREAST ELASTOGRAPHY AND POWER DOPPLER VOCAL FREMITUS SONOGRAPHY (PDVF)

Lisa Smith, Nancy Infusini, Nicoleta Miclea Miron, Martine Paré

Cedars Breast Clinic

A Technologist’s Point of View

Disclosure Statement: No Conflict of Interest

May 28 – 30, 2015, Montréal, Québec

I do not have an affiliation, financial or otherwise, with a pharmaceutical company, medical device or communications organization.

I have no conflicts of interest to disclose ( i.e. no industry funding received or other commercial relationships).

I have no financial relationship or advisory role with pharmaceutical or device-making companies, or CME provider.

I will be discussing the results of ____ (“off-label” use), which is currently classified by Health Canada as investigational for the intended use.

I will not discuss or describe in my presentation at the meeting the investigational or unlabeled ("off-label") use of a medical device, product, or pharmaceutical that is classified by Health Canada as investigational for the intended use.

THE CEDARS BREAST CLINIC TEAM

OBJECTIVES

BREAST ANATOMYWHAT IS ELASTOGRAPHY TYPES OF ELASTOGRAPHYELASTOGRAPHY MAPSWHAT IS POWER DOPPLER VOCAL

FREMITUS (PDVF)THE EFFECTS OF THE APPLICATIONS EXAMPLES OF DIFFERENT LESIONS

ANATOMY OF THE BREAST

BREAST TYPESDENSE BREAST

GLANDULAR BREAST TISSUE

FATTY BREAST TISSUE

BREAST FEEDING

CHARACTERISTICS OF MASSES Benign

SHAPE(round, oval)

MARGIN (well circumscribed ,)

ECHO PATTERN (anechoic isoechogenic , hyperechogenic)

Posterior enhancement

Malignant

SHAPE (irregular)MARGIN

(spiculated, indistinct, angular)

ECHO PATTERN (hypo echogenic )

Posterior shadowing

WORRISOME SIGNS

Shape Orientation ContoursTransmissi

on

LACK OF WORRISOME SIGNSBENIGN SIGNS ?

Shape

OrientationContours Transmission

ELASTOGRAPHY ?

Application introduced to differentiate different types of breast tissues, i.e. benign lesions, (soft tissues) and malignant lesions (hard tissues).

WHAT IS ELASTOGRAPHY ?

It’s the difference in elasticity of different tissues.

It’s the deformation of the tissueImplement young’s modulus theory

ELASTICITY

Young’s modulus = elasticity modulus

Constant E

15

E =

TYPES OF ELASTOGRAHPY

CONVENTIONAL STRAIN

Gray scaleComputer algorithmOperator induces

force/compressProbe 12mhz, 8mhzMap colour scale

STRAIN IMAGINGCOMPRESSION ELASTOGRAPHY

Compare the image before and after compression

Compare with adjacent structureAlgorithm code in colour or Grey

FIBROADENOMA

COLOUR MAP OF A FIBROADENOMA

THE RATIO IS 2.0

ELASTOGRAPHY OF A CYST

ELASTOGRAPHY OF A

FIBROADENOMA

SHEAR WAVE

COLOUR MAP 2DQUANTITATIVE MEASUREMENT

(max, mean and SD) kPa(180)PROBE : Conventional Linear Array. Radiated force induced by probe.Optional : play with resolution for small and

cystic lesions play with penetration for deep and large lesions.

Step One Step Two Step Three

Step 1Shear waves generated by sending a long focused pulse into the tissue:

Step 2Ultrafast Imaging

Step 3Processing

Total duration = 20msec

SHEAR WAVE IMAGING

ELASTOGRAPHY OF A FIBROCYSTIC LESION

ELASTOGRAPHY OF A MASS

COMPARISON OF SOFT AND HARD LESION. FALSE NEGATIVE

It is stated that benign lesions are soft and malignant lesions are hard. But there are exceptions.

A palpable area biopsied , the result was fibrous breast tissue. Some cancers are soft hyper echogenic, like (mucinous carcinomas) and like scars are hard.

PALPABLE NODULE

DIFFERENCES Shear wave

quantitative measurementNo compressionConventional linear array probeTime frame is faster (20ms)

ConventionalGray scale and strain Computer assistedoperator induces pressure

LIMITATIONS

Shear wave; Fatty breast with deep lesions. Mobile lesions, Breast implants

Conventional: Breast implants, Deep lesions, superficial lesions, Mobile lesions, small lesions, Excessive pressure

ELASTOGRAGHY OF A BREAST IMPLANT

POWER DOPPLER VOCAL FREMITUS (PDVF)

Technique using artifactsDifferentiates normal tissue from a lesion,Outlines the contour of nodules,

Technique using phonation via the thoracic wall Humming

PDVF OF A FIBROADENOMA

PDVF OF A PAPILOMA

PDVF OF A CALCIFIED FIBROADENOMA

PDVF OF A CYSTIC AREA

ELASTOGRAPHY OF A MASS AND PDVF

PDVF

STRAIN ELASTO OR TISSUE STRAIN

COLOUR MAP OF THE MASS

THE ELASTO RATIO IS 6.34

VIDEO OF THE LESION

VIDEO OF THE CLIP PLACEMENT

TOMOSYNTHESIS

BÉNIN

MALIN

1

2

3

4

5

COLOR MAP FOR STRAIN & SHEAR ELASTO

[Itoh A, 2006]

?

Benign : 1-2

? Category : 3

Malignant : 4

Shear waveStrain Elasto [1-5]

FIBROADENOMA

THE RELATION TO THE COLOUR MAP OF STRAIN ELASTOGRAGHY

THE RATIO IS 1.1 (BENIGN)

THE CORRELATION OF ULTRASOUND AND MRI

CONTRAST ENHANCING LESION RIGHT BREAST ON MRI, PRONE

SAGITTAL MRI DELAYED CONTRAST, RIGHT BREAST

ULTRSOUND OF THE LESION

PDVF

STRAIN ELASTOGRAGHY OF THE LESION

GREY SCALE

THE ELASTOGRAPHY RATIO IS 35.

IMPORTANCE OF ELASTOGRAPHY WITH SECOND LOOK ULTRASOUND

SCFR 59

6 Autres Indications

Lundi 29 octobre 2012

OTHER INDICATIONS

60

Lundi 29 octobre 2012

SCFR 61

OTHER INDICATIONS

LIMITS

LIMITS

LIMITSBÉNIN

MALIN

1

2

3

4

5

CONCLUSION

Elastography, Power Doppler Vocal Fremitus ( PDVF) ultrasound along with Mammography, Magnectic resonance and Tomosynthesis can assist in the detection of lesions.

The radiologist will use the findings to assign a BI-RADS classification ( Breast imaging report and data system) (ACR).

THANK YOU