ElastoScan™ in breast ultrasound: a novel technique is improving diagnostic accuracy

ElastoScan™ is a novel ultrasound technique,

which visualizes the elasticity of tissue and is thus

improving diagnostic accuracy when used in

combination with standard ultrasonographic

procedures . In this paper examples of

ElastoScan™ in breast ultrasound are shown and

described in order to elucidate the benefit of this

method. Breast ultrasound elastography is easily

applied during a standard examination and rapid

results can be interpreted instantaneously. It is

therefore being adopted by an increasing number

of clinicians as a daily diagnostic routine.

W H I T E P A P E R

Article # WP201108-ELS

Issue Date 31 Aug, 2011

Dr. Katja Gabriel Hirschhauser & Gabriel - Praxis fur Frauenheilkunde und Geburtshilfe, Karschhauser Str. 23, 40699 Erkrath, Germany

1

Abstract

In recent years, the technique of breast ultra-

sonography has become an essential procedure

in the diagnostic evaluation of breast tissue.

The improvement of ultrasound technology,

especially with regards to the high resolution of

modern devices and the use of colour Doppler

sonography, has made th i s techn ique

indispensable in our daily routine. Although the

value of conventional breast ultrasound has been

proven in several studies (1-2), there are still a

growing number of patients who have to undergo

unnecessary breast biopsy even when techniques

such as ultrasound, mammography and MRI are

combined. The use of ultrasound elastography

seems to enhance diagnostic accuracy by

Introduction

visualizing the elasticity of tissue. In breast

examination, the assessment of the rigidity of a

lump has always been done with normal palpation.

It is well known, that malignant lesions are

generally harder than benign lesions. Therefore,

elastography appears to increase the sensitivity

and specificity of breast ultrasound (4-6).

In the examples shown below, ultrasound

was carried out using the Samsung Medison

Accuv ix V20 Prest ige system. Rea l- t ime

elastography using ElastoScan™ was performed

with a 5-13 MHz linear transducer. Most women

underwent the examination for screening

purposes, however some patients were examined

because of a palpable breast lump or on routine

follow-up after breast cancer therapy. Each breast

was examined systematically in B-mode. Detected

lesions were carefully assessed using the

following standard criteria: Shape, margin,

orientation, lesion boundary, echogenic pattern,

posterior acoustic features, effect on surrounding

tissue, calcifications and vascularisation using

colour Doppler. They were then classif ied

according to the BI-RADS score. This standard

approach was immediately followed by the

elastographic examination. For this purpose, the

transducer was not moved from the previous

Methods

Table 1. BI-RADS classification system

BI-RADS category Radiological finding

Figure 1 shows the scan of a breast screening ultrasound of a

47-year-old female. The lesion was non-palpable, 14 x 13 x 11

mm in size, irregularly shaped, hypoechoic with indistinct

margins. There was posterior shadowing, disruption of the

surrounding tissue architecture and suspicious adjacent

vascularisation. The lesion was therefore classified BI-RADS V.

The ElastoScan™ revealed the stiffness of the tumour, indicated

by blue to purple colour in contrast to the soft surrounding

fibroglandular and fat tissue indicated by red and yellow

colour. This information did not only support the suspicion of

malignancy, but also contributed to the identification of

the tumour boundaries, indicating a wider tumour

expansion laterally but not posteriorly. Core needle biopsy

revealed invasive-ductal carcinoma.

Figure 2 is a scan of a 60-year-old woman with macromastia

and status post breast surgery with extirpation of a

fibroadenoma. There was a diffuse hypoechoic area. The

ElastoScan™ revealed the softness of the tissue indicated by

yellow and red colour. Therefore, with knowledge of the

Examples

position and only slight pressure was applied. The colour map 4

was used with red indicating soft tissue or fluid and purple

indicating hard tissue.

Recommended approach

0

Ⅰ

Ⅱ

Ⅲ

Ⅳ

Ⅴ

Ⅵ

Presence of a radiological finding requiring evaluation with a complementary imaging method

No radiological finding is observed. The study is normal

Benign radiological findings

Probably benign radiological findings (with < 2% chance of malignancy). This specific case includes clustered, punctate, isodense micro calcifications, regular, well-defined mass and non-palpable focal asymmetry suggestive of confluent fibro glandular tissue

Presence of radiological findings suspicious for malignancy with a risk for malignancy ranging from 2% to 95%

Highly suspicious radiological findings, with a malignancy risk greater than 95%

Proven malignant lesion

Further evaluation with other imaging method is required

12 month radiological follow-up is suggested

12 month radiological follow-up is suggested

6 month radiological follow-up is suggested

Further diagnostic investigation is required. Biopsy is recommended

Further diagnostic investigation is required. Biopsy is recommended

-

2

Figure 1 BI-RADS V: The ElastoScan™ revealed the stiffness of the tumour, indicated by blue to purple

Figure 2 Post breast surgery status: the ElastoScan™ revealed the softness of the tissue indicated by yellow and red colour

patient's history of surgery, the changes were attributed to

post-operative scarring. This was supported by mammography.

No core-needle biopsy was performed.

Figure 3 depicts the scan of a 57 year-old female with

mastodynia. There was a non-palpable hypoechoic lesion of

ovaloid shape with only discretely irregular margins, horiz-

ontal orientation, distinct boundaries, posterior

enhancement and no calcifications or suspicious vascularisation.

The lesion was classified BI-RADS II. The ElastoScan™ showed

yellow and red colour of the lesion and yellow and blue colour

of the surrounding fibroglandular tissue supporting the benign

aspect. The lesion was classified BI-RADS II and therefore

biopsy was not required.

Figure 4 and figure 5 pictures the scans of a 32-year-old

woman with palpable lymphadenopathy on routine annual

check-up. Breast ultrasound showed no lesions. The palpable

lymph node showed loss of the typical target structure and a

suspicious vascularisation on colour Doppler imaging. The

ElastoScan™ indicated the node as soft indicated by red and

yellow colour. Because of the irregular vascularisation the lymph

node was removed and histology revealed a benign castleman-

lymphoma.

Figure 6 depicts the scan of a 71-year-old female who

had a round hypoechoic lesion on a screening breast

ultrasound. Conventional ultrasound criteria led to the BI-RADS

classification II, but the ElastoScan™ showed that the lesion

was hard. Mammography showed a calcified intramammary

lymph node in the same region. Because this finding had been

seen before, no biopsy was performed. After 5 months, the

sonographic aspect was unchanged.

There are a growing number of studies, which indicate the

diagnostic value of elastography when added to conventional

breast ultrasound (4-6). Especially in BI-RADS III lesions, an

elastogram that shows relative softness can be reassuring and

thus prevent unnecessary breast biopsy. Our clinical experience

shows, that ElastoScan™ is easily conducted and gives

Conclusion

3

Figure 3 BI-RADS II: The ElastoScan™ showed yellow and red colour of the lesion and yellow and blue colour of the surrounding fibroglandular tissue

Figure 6 BI-RADS II: the ElastoScan™ showed that the lesion was hard with blue and purple colour

Figure 4 A suspicious vascularisation on colour Doppler imaging

Figure 5 Breast ultrasound showed no lesions: The ElastoScan™ indicated the node as soft indicated by red and yellow colour

results instantaneously. Elastography should always

be used in combination with conventional ultra-

sonography and further studies need to be done

to show the sensitivity and specificity of the

technique. In the future, elastographic findings

should be included as an independent

criterion in the BI-RADS score. Although we

cannot yet abstain from breast biopsy in BI-RADS

IV conventional ultrasounds, even if the

ElastoScan™ shows softness, we will continue to

use it in order to support our breast ultrasound

diagnosis and in many cases to reassure our

anxious patients.

1.

2.

3.

4.

5.

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