BREAST ELASTOGRAPHY AND POWER DOPPLER VOCAL FREMITUS SONOGRAPHY (PDVF) A Technologist’s Point of View Lisa Smith, Nancy Infusini, Nicoleta Miclea Miron, Martine Paré Cedars Breast Clinic

Disclosure Statement: No Conflict of Interest 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. May 28 – 30, 2015, Montréal, Québec

THE CEDARS BREAST CLINIC TEAM

OBJECTIVES BREAST ANATOMY WHAT IS ELASTOGRAPHY TYPES OF ELASTOGRAPHY ELASTOGRAPHY MAPS WHAT IS POWER DOPPLER VOCAL FREMITUS (PDVF) THE EFFECTS OF THE APPLICATIONS EXAMPLES OF DIFFERENT LESIONS

ANATOMY OF THE BREAST

BREAST TYPES DENSE 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 Contours Transmission

LACK OF WORRISOME SIGNS BENIGN SIGNS ? Shape Orientation Contours 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 tissue Implement young’s modulus theory

ELASTICITY Young’s modulus = elasticity modulus Constant E E =

TYPES OF ELASTOGRAHPY CONVENTIONAL STRAIN Gray scale Computer algorithm Operator induces force/compress Probe 12mhz, 8mhz Map colour scale

STRAIN IMAGING COMPRESSION ELASTOGRAPHY Compare the image before and after compression Compare with adjacent structure Algorithm 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 2D QUANTITATIVE 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

SHEAR WAVE IMAGING Total duration = 20msec Step 1 Step 2 Step 3 Shear waves generated by sending a long focused pulse into the tissue: Step 2 Ultrafast Imaging Step 3 Processing Total duration = 20msec 25

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 Conventional quantitative measurement No compression Conventional linear array probe Time frame is faster (20ms) Conventional Gray scale and strain Computer assisted operator 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 artifacts Differentiates 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

? COLOR MAP FOR STRAIN & SHEAR ELASTO Benign : 1-2 ? Category : 3 É N I M A L 1 2 3 4 5 Shear wave [Itoh A, 2006] Strain Elasto [1-5] Benign : 1-2 ? Category : 3 Malignant : 4 ?

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

6 Autres Indications SCFR

OTHER INDICATIONS Lundi 29 octobre 2012 60

OTHER INDICATIONS Lundi 29 octobre 2012 SCFR

LIMITS

LIMITS

LIMITS B É N I M A L 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).

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