2. Breast sonoelastography
Clinical cases discussion
Dr. Antonio Pio Masciotra
Campobasso

3. Correct tissue elasticity quantification
Aims of elastography
Correct tissue elasticity quantification
Identification of ‘cut off’ elasticity values for the right diagnostic workup of diffuse and focal diseases

5. Tessuto fibroso normale 96-244
Breast
Tissue
Young’s modulus (kPa)
Normal fat
18-23
Normal gland
28-66
Normal fibrous tissue
96-244
Carcinoma
22-560
Mammella
Tessuto
Modulo di Young (kPa)
Grasso normale
18-23
Ghiandola normale
28-66
Tessuto fibroso normale
96-244
Carcinoma
22-560
Breast
Tissue
Speed of sound (m/s)
Whole breast post-menopausal
1.468 (5.2%)
Whole breast pre-menopausal
(2.5%)
Normal fat
1.478 (4.7%)
Normal gland
Benign tumors
1.513 (2.3%)
Carcinoma
1.548
Breast
Tissue
Speed of sound (m/s)
Mammella intera post-menopausa
1.468 (5.2%)
Mammella intera pre-menopausa
(2.5%)
Grasso normale
1.478 (4.7%)
Ghiandola normale
Tessuto fibroso normale
1.513 (2.3%)
Carcinoma
1.548

6. Feature
Longitudinal plane
Fibrous tissue
Fat
Ratio
Echogenicity
116.9
45.4
2.57
Stiffness
26.6 kPa
21.3 kPa
1.30
Feature
Transverse plane
Fibrous tissue
Fat
Ratio
Echogenicity
121.8
37.4
3.26
Stiffness
20.0 kPa
14.2 kPa
1.40

7. Breast papillary carcinoma
2008
2011
2010
2009
2008
2009
2010
2011

8. Woman 41 years old

9. Woman 41 years old

10. Woman 41 years old

11. ATOMIC FORCE MICROSCOPE

12. Normal cell toward cancer cell
Single cell’s progressive stiffness reduction
Normal cell
Less invasive cell
The distribution of the actin network plays an important role in determining the mechanical properties of single cells.
As cells transform from non-malignant to cancerous states, their cytoskeletal structure changes from an organized to an irregular network and this change subsequently reduces the stiffness of single cells.
Further progressive reduction of stiffness corresponds to an increase in invasive and migratory capacity of malignant cells.
Single cell’s progressive stiffness reduction
More invasive cell

13. Dalla cellula normale alla cellula cancerosa
Riduzione progressiva della rigidità della cellula
Cellula normale
Cellula meno invasiva
La distribuzione della trama di actina è fondamentale nella determinazione delle proprietà meccaniche delle singole cellule.
Nella trasformazione da cellula normale a cellula cancerosa la struttura del citoscheletro da ben organizzata diventa irregolare con conseguente perdita della rigidità.
L’ulteriore riduzione progressiva della rigidità della cellula maligna le conferisce un progressive aumento delle sue capacità invasive e migratorie con conseguente metastatizzazione.
Riduzione progressiva della rigidità della cellula
Cellula più invasiva

14. Tumor cells’ stiffness decreases

15. La rigidità delle cellule neoplastiche diminuisce
La rigidità della matrice extracellulare aumenta

16. On the SWE image for each ROI selected (described both in its dimension and in its depth from the surface) in the colored box are displayed different information on stiffness quantification expressed in kPa (Young’s modulus) or in m/s (SW speed) :
Mean value
Minimum value (softest)
Maximum value (stiffest)
Standard deviation
Mean Stiffness ratio if 2 ROIs are selected - < or > 1 with numeric value depending on the unit of measurement applied (kPa or m/s)

17. Feature (kPa) Ratio (circ.ROI) Ratio (free ROI) Mean stiff. 7.0 5.6
Nodule (circ. ROI)
Fat
Ratio
Mean stiff.
58.9
5.8
10.1
Minimun stiff.
47.1
4.8
9.8
Maximum stiff.
65.5
8.2
8.0
Standard Deviation
5.2
0.9
Feature (kPa)
Ratio (circ.ROI)
Ratio (free ROI)
Mean stiff.
7.0
5.6
Minimun stiff.
14.4
0.02
Maximum stiff.
5.1
9.0
Standard Deviation
1.3
18.0
Feature (kPa)
Nodule (free ROI)
Fat
Ratio
Mean stiff.
32.6
5.8
5.6
Minimun stiff.
0.1
4.8
0.02
Maximum stiff.
72.1
8.2
9.0
Standard Deviation
16.2
0.9
18.0

18. SW Elastography precision and repeatibility
Breast lipoma
Time of sampling
Mean stiffness
Lipoma
Fat
Lipoma/Fat Ratio
10:07:09
20.5 kPa
19.9 kPa
1.03
10:07:34
8.0 kPa
7.8 kPa

19. Similar elasticity ratio
Different kPa
Similar elasticity ratio
FA Echogeniciity
Mean stiffness FA
Gland
FA/Gland Ratio
Low
26.0 kPa
12.2 kPa
2.13
Medium
53.0 kPa
33.4 kPa
2.48

20. SW Elastography elasicity features
Breast fibroadenoma FA
Echogeniciity
Mean stiffness
Gland
Ratio
Low
26.0 kPa
12.2 kPa
2.13
Medium
53.0 kPa
33.4 kPa
2.48 FA
Echogeniciity
Standard deviation
Gland
Ratio
Low
3.0 kPa
1.6 kPa
1.87
Medium
5.7 kPa
17.2 kPa
0.33

21. Breast multiple fibroadenomata – Directional PD
Mother (58 years old)
Daughter (29 years old)

22. Breast multiple fibroadenomata – SW Elastography
Mother (58 years old)
41-66 kPa
Daughter (29 years old)
70-83 kPa

25. Representative case of a tumor with significant changes in mitotic index according to the tumor cells’ location with regard to surrounding adipose tissues.
The gland-side tumor cells show significantly higher mitotic index especially in ER-negative tumors.

27. Echogenicity
Comparation
Cancer
Other tissue
B Ratio
Ca Vs Fat
14.6
42.5
0.35
Ca Vs. Fibrous tissue
38.8
111.4

28. Echogenicity based data
Woman 48 years old
Feature
Echogenicity based data
Stiffness based data
Perimeter
5,42 cm
6,63 cm
Area
1,52 cm²
2,45 cm²
Diameter 1
1,48 cm
2,19
Diameter 2
1,45 cm
1,88
The tumor area traced according echogenicity is large smaller than the area traced according the stiffness.

29. Echogenicity based data
Plane
Feature
Echogenicity based data
Stiffness
based data
Difference
(%)
Coronal
Perimeter
5,89 cm
5,78 cm
-1,87%
Area
1,47 cm²
2,06 cm²
40,1%
Axial
3,03 cm
6,48 cm
80,9%
0,47 cm²
1,35 cm²
187,2%
Sagittal
4,06 cm
5,39 cm
32,8%
0,69 cm²
1,71 cm²
147,8%
Woman 48 years old
The tumor’s dimensions traced according echogenicity are always smaller than the ones traced according the stiffness in all planes.
Breast cancer is staged by the TNM System : Tumor Size, node status, and metastasis.
Tumor Size is divided into four classes based on the maximum diameter:
T-1 is from 0 to 2 centimeters.
T-2 is from 2 to 5 cm.
T-3 is greater than 5 cm .
T-4 is a tumor of any size that has broken through (ulcerated) the skin, or is attached to the chest wall.
So it would be wise to check which is the most reliable imaging technique of measurement of the ‘T’ parameter relating it to the more accurate prognostic significance and to the right choice in the therapeutic approach.
T1mi
Tumor ≤1 mm in greatest dimension.
T1a
Tumor >1 mm but ≤5 mm in greatest dimension.
T1b
Tumor >5 mm but ≤10 mm in greatest dimension.
T1c
Tumor >10 mm but ≤20 mm in greatest dimension.

30. Aims of elastography Precise tissue elasticity quantification
stiffness quantification
Identification of ‘cut off’ elasticity
values for the right diagnostic
workup of diffuse and focal diseases
Identification of elasticity
features for the right diagnostic
workup of diffuse and focal diseases

31. Ultrasonography of breast focal diseases : a true Multiparametric Diagnostic Modality
Mode
Features
Informations
B Mode
Shape
‘Taller-than-wide’ and “wider-than-tall”
Morphology
and
Structure
Internal component 
solid, mixed or cystic
Margins 
Well circumscribed, lobulated or irregular
Echogenicity (B Ratio Nodule/Parenchyma)
“hyperechogenicity”,“isoechogenicity”, 
“hypoechogenicity”and “marked hypoechogenicity”
Evidence of calcifications 
Micro-calcifications (< 3 mm)
Macrocalcifications (> 3 mm with acoustic shadowing)
Doppler Mode
CDI, PDI , dPDI
Number, density and distribution of the vessels
Vascular
Pulsed Wave
Blood flow characterisation and quantification
Blood Flow – Functional (?)
Sonoelastography
Strain
Relative Stiffness
Mechanical properties
Shear Wave
Relative stiffness and Stiffnes quantification

32. Thanks for your attention
Conclusion
The contribute offered by the new emerging tools in Ultrasound technology are really innovative in :
Ultrafast doppler acquisition (with detection of low resistivity flow in more vessels)
2D Shear Wave Elastography (with qualitative and quantitative information on elasticity features)
3D Shear Wave Elastography (with information on the topographical distribution of the stiffest sites)
Thanks for your attention
Antonio Pio Masciotra
Campobasso – Molise – Italy
Website
YouTube Channel