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Elastography
Regina J. Hooley, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Pathology

        • Clinical Issues

          • Diagnostic Checklist

            TERMINOLOGY

            • Definitions

              • 2 distinct elastography techniques
                • Strain elastography: Evaluates shape of lesion before and after applied stress; deformability; static or compression elastography
                • Shearwave elastography (SWE): Applied stress generates tissue displacement and transverse oriented shearwaves; transient elastography
              • US measurement of tissue stiffness
                • Based on principle of physical exam: Benign lesions feel soft and mobile; malignant lesions feel hard
                  • Malignancies: Surrounding rim of tissue often hard
                    • Evaluate elasticity of lesion and surrounding tissue
                  • Size ratio: Diameter of elastography zone of stiffness (including lesion and surrounding tissue) compared to diameter of lesion on grayscale US; ratio > 1 suspicious
                • Noninvasive option on US equipment
              • Elasticity (E) = stress/strain
                • Strain elastography: Initial stress originates in operator transducer pressure, automated push pulse, or respiratory or cardiac motion; varies with angle at which force is applied
                • Optimal initial stress is vendor dependent
                  • Automated transducer push pulse may provide more reliable results compared to operator transducer pressure
                  • Quantitation of stiffness is typically only relative to surrounding tissue since applied stress is variable
              • SWE: Stiffness quantified by Young modulus
                • E (in kPa) = 3ρc², where ρ = tissue density, assumed to be 1,000 kg/m³, and c = shearwave velocity in m/s
                • With SWE, low frequency ~ 1 MHz pulse is applied to tissue electronically (no pressure from operator) → horizontal propagation of shear waves in tissue, faster with stiffer lesions

            IMAGING

            • Ultrasonographic Findings

              • Technique

                PATHOLOGY

                • General Features

                  • Pathologic Features

                    CLINICAL ISSUES

                    • Limitations and Pitfalls

                      DIAGNOSTIC CHECKLIST

                      • Consider

                        • Image Interpretation Pearls

                          • Reporting Tips

                            Selected References

                            1. Barr RG et al: Diagnostic performance and accuracy of the 3 interpreting methods of breast strain elastography: A systematic review and meta-analysis. J Ultrasound Med. ePub, 2018
                            2. Evans A et al: Pre-operative stromal stiffness measured by shear wave elastography is independently associated with breast cancer-specific survival. Breast Cancer Res Treat. 171(2):383-9, 2018
                            3. Farrokh A et al: Accuracy of tumor size measurement: comparison of B-mode ultrasound, strain elastography, and 2D and 3D shear wave elastography with histopathological lesion size. Acta Radiol. 284185118787354, 2018
                            4. Lowes S et al: Evolving imaging techniques for staging axillary lymph nodes in breast cancer. Clin Radiol. 73(4):396-409, 2018
                            5. Sigrist RMS et al: Ultrasound Elastography: Review of Techniques and Clinical Applications. Theranostics. 7(5):1303-1329, 2017
                            6. Barr RG et al: Shear-wave elastography of the breast: value of a quality measure and comparison with strain elastography. Radiology. 275(1):45-53, 2015
                            7. Berg WA et al: Quantitative maximum shear-wave stiffness of breast masses as a predictor of histopathologic severity. AJR Am J Roentgenol. 205(2):448-55, 2015
                            8. Evans A et al: Does shear wave ultrasound independently predict axillary lymph node metastasis in women with invasive breast cancer? Breast Cancer Res Treat. 143(1):153-7, 2014
                            9. Balleyguier C et al: Breast elasticity: principles, technique, results: an update and overview of commercially available software. Eur J Radiol. 82(3):427-34, 2013
                            10. Chang JM et al: Comparison of shear-wave and strain ultrasound elastography in the differentiation of benign and malignant breast lesions. AJR Am J Roentgenol. 201(2):W347-56, 2013
                            11. Chang JM et al: Stiffness of tumours measured by shear-wave elastography correlated with subtypes of breast cancer. Eur Radiol. 23(9):2450-8, 2013
                            12. Mendelson EB et al: Breast Imaging Reporting and Data System, BI-RADS: Ultrasound. 2nd ed. Reston: American College of Radiology, 2013
                            13. Barr RG et al: Evaluation of breast lesions using sonographic elasticity imaging: a multicenter trial. J Ultrasound Med. 31(2):281-7, 2012
                            14. Barr RG: Sonographic breast elastography: a primer. J Ultrasound Med. 31(5):773-83, 2012
                            15. Berg WA et al: Shear-wave elastography improves the specificity of breast US: the BE1 multinational study of 939 masses. Radiology. 262(2):435-49, 2012
                            16. Cosgrove DO et al: Shear wave elastography for breast masses is highly reproducible. Eur Radiol. 22(5):1023-32, 2012
                            17. Evans A et al: Invasive breast cancer: relationship between shear-wave elastographic findings and histologic prognostic factors. Radiology. 263(3):673-7, 2012
                            18. Wojcinski S et al: Real-time ultrasound elastography in 180 axillary lymph nodes: elasticity distribution in healthy lymph nodes and prediction of breast cancer metastases. BMC Med Imaging. 12:35, 2012
                            19. Zhao QL et al: Diagnosis of solid breast lesions by elastography 5-point score and strain ratio method. Eur J Radiol. 81(11):3245-9, 2012
                            20. Barr RG et al: The utility of the "bull's-eye" artifact on breast elasticity imaging in reducing breast lesion biopsy rate. Ultrasound Q. 27(3):151-5, 2011
                            21. Schaefer FK et al: Breast ultrasound elastography--results of 193 breast lesions in a prospective study with histopathologic correlation. Eur J Radiol. 77(3):450-6, 2011
                            22. Itoh A et al: Breast disease: clinical application of US elastography for diagnosis. Radiology. 239(2):341-50, 2006
                            Related Anatomy
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                            Related Differential Diagnoses
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                            References
                            Tables

                            Tables

                            KEY FACTS

                            • Terminology

                              • Imaging

                                • Pathology

                                  • Clinical Issues

                                    • Diagnostic Checklist

                                      TERMINOLOGY

                                      • Definitions

                                        • 2 distinct elastography techniques
                                          • Strain elastography: Evaluates shape of lesion before and after applied stress; deformability; static or compression elastography
                                          • Shearwave elastography (SWE): Applied stress generates tissue displacement and transverse oriented shearwaves; transient elastography
                                        • US measurement of tissue stiffness
                                          • Based on principle of physical exam: Benign lesions feel soft and mobile; malignant lesions feel hard
                                            • Malignancies: Surrounding rim of tissue often hard
                                              • Evaluate elasticity of lesion and surrounding tissue
                                            • Size ratio: Diameter of elastography zone of stiffness (including lesion and surrounding tissue) compared to diameter of lesion on grayscale US; ratio > 1 suspicious
                                          • Noninvasive option on US equipment
                                        • Elasticity (E) = stress/strain
                                          • Strain elastography: Initial stress originates in operator transducer pressure, automated push pulse, or respiratory or cardiac motion; varies with angle at which force is applied
                                          • Optimal initial stress is vendor dependent
                                            • Automated transducer push pulse may provide more reliable results compared to operator transducer pressure
                                            • Quantitation of stiffness is typically only relative to surrounding tissue since applied stress is variable
                                        • SWE: Stiffness quantified by Young modulus
                                          • E (in kPa) = 3ρc², where ρ = tissue density, assumed to be 1,000 kg/m³, and c = shearwave velocity in m/s
                                          • With SWE, low frequency ~ 1 MHz pulse is applied to tissue electronically (no pressure from operator) → horizontal propagation of shear waves in tissue, faster with stiffer lesions

                                      IMAGING

                                      • Ultrasonographic Findings

                                        • Technique

                                          PATHOLOGY

                                          • General Features

                                            • Pathologic Features

                                              CLINICAL ISSUES

                                              • Limitations and Pitfalls

                                                DIAGNOSTIC CHECKLIST

                                                • Consider

                                                  • Image Interpretation Pearls

                                                    • Reporting Tips

                                                      Selected References

                                                      1. Barr RG et al: Diagnostic performance and accuracy of the 3 interpreting methods of breast strain elastography: A systematic review and meta-analysis. J Ultrasound Med. ePub, 2018
                                                      2. Evans A et al: Pre-operative stromal stiffness measured by shear wave elastography is independently associated with breast cancer-specific survival. Breast Cancer Res Treat. 171(2):383-9, 2018
                                                      3. Farrokh A et al: Accuracy of tumor size measurement: comparison of B-mode ultrasound, strain elastography, and 2D and 3D shear wave elastography with histopathological lesion size. Acta Radiol. 284185118787354, 2018
                                                      4. Lowes S et al: Evolving imaging techniques for staging axillary lymph nodes in breast cancer. Clin Radiol. 73(4):396-409, 2018
                                                      5. Sigrist RMS et al: Ultrasound Elastography: Review of Techniques and Clinical Applications. Theranostics. 7(5):1303-1329, 2017
                                                      6. Barr RG et al: Shear-wave elastography of the breast: value of a quality measure and comparison with strain elastography. Radiology. 275(1):45-53, 2015
                                                      7. Berg WA et al: Quantitative maximum shear-wave stiffness of breast masses as a predictor of histopathologic severity. AJR Am J Roentgenol. 205(2):448-55, 2015
                                                      8. Evans A et al: Does shear wave ultrasound independently predict axillary lymph node metastasis in women with invasive breast cancer? Breast Cancer Res Treat. 143(1):153-7, 2014
                                                      9. Balleyguier C et al: Breast elasticity: principles, technique, results: an update and overview of commercially available software. Eur J Radiol. 82(3):427-34, 2013
                                                      10. Chang JM et al: Comparison of shear-wave and strain ultrasound elastography in the differentiation of benign and malignant breast lesions. AJR Am J Roentgenol. 201(2):W347-56, 2013
                                                      11. Chang JM et al: Stiffness of tumours measured by shear-wave elastography correlated with subtypes of breast cancer. Eur Radiol. 23(9):2450-8, 2013
                                                      12. Mendelson EB et al: Breast Imaging Reporting and Data System, BI-RADS: Ultrasound. 2nd ed. Reston: American College of Radiology, 2013
                                                      13. Barr RG et al: Evaluation of breast lesions using sonographic elasticity imaging: a multicenter trial. J Ultrasound Med. 31(2):281-7, 2012
                                                      14. Barr RG: Sonographic breast elastography: a primer. J Ultrasound Med. 31(5):773-83, 2012
                                                      15. Berg WA et al: Shear-wave elastography improves the specificity of breast US: the BE1 multinational study of 939 masses. Radiology. 262(2):435-49, 2012
                                                      16. Cosgrove DO et al: Shear wave elastography for breast masses is highly reproducible. Eur Radiol. 22(5):1023-32, 2012
                                                      17. Evans A et al: Invasive breast cancer: relationship between shear-wave elastographic findings and histologic prognostic factors. Radiology. 263(3):673-7, 2012
                                                      18. Wojcinski S et al: Real-time ultrasound elastography in 180 axillary lymph nodes: elasticity distribution in healthy lymph nodes and prediction of breast cancer metastases. BMC Med Imaging. 12:35, 2012
                                                      19. Zhao QL et al: Diagnosis of solid breast lesions by elastography 5-point score and strain ratio method. Eur J Radiol. 81(11):3245-9, 2012
                                                      20. Barr RG et al: The utility of the "bull's-eye" artifact on breast elasticity imaging in reducing breast lesion biopsy rate. Ultrasound Q. 27(3):151-5, 2011
                                                      21. Schaefer FK et al: Breast ultrasound elastography--results of 193 breast lesions in a prospective study with histopathologic correlation. Eur J Radiol. 77(3):450-6, 2011
                                                      22. Itoh A et al: Breast disease: clinical application of US elastography for diagnosis. Radiology. 239(2):341-50, 2006