Elastosonography. Prof. Massimo Midiri Direttore Istituto di Radiologia Policlinico Universitario Paolo Giaccone Diagnostica per Immagini, - Palermo

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1 Elastosonography Prof. Massimo Midiri Direttore Istituto di Radiologia Policlinico Universitario Paolo Giaccone Diagnostica per Immagini, - Palermo

2 everybody has certainly had, at least once in a lifetime, the experience of a medical examination and therefore knows, for personal experience, the meaning of the term "clinical palpation".

3 everybody has certainly had, at least once in a lifetime, the experience of a medical examination and therefore knows, for personal experience, the meaning of the term "clinical palpation". The reason why each good medical doctor does not omit palpating the Patient is that it has been known since the ancient times that the different tissues and organs have different elasticity or stiffness and that the pathological processes generally determine a variation of suchphysical properties.

4 everybody has certainly had, at least once in a lifetime, the experience of a medical examination and therefore knows, for personal experience, the meaning of the term "clinical palpation". The reason why each good medical doctor does not omit palpating the Patient is that it has been known since the ancient times that the different tissues and organs have different elasticity or stiffness and that the pathological processes generally determine a variation of suchphysical properties. For this reason the "palpation" performed during a medical examination is of fundamental utility for the identification of a process. The different nature of the pathological processes determines variations in the elastic properties and consequently the terms "elastic" or "stiff" can be generally associated with "benign" or "malignant" (as a general rule)

5 The limitations of Clinical Palpation" made by the Doctor with his hands and so that manual are:? -the subjectivity of the feeling that by definition can not be quantified and therefore can not be reproduced -the inability to identify the different tissue components (or organs ) and that together generate the feeling of "elastic" or "hard". LIMITS CLINICAL PALPATION - SUBJECTIVE - NON RECOGNIZE THE STRUCTURES

6 The ELASTOSONOGRAPHY must be considered as an Electronic Palpation, that can overcome some limits of the clinical palpation. ELECTRONIC PALPATION -NON SUBJECTIVE - RECOGNIZE THE STRUCTURES

7 The ELASTOSONOGRAPHY is a diagnostic method: -Non Invasive (Patients does not discomfort) Real-time Tissue Elastography -Simple and Rapid (few buttons, no adjustments, few minutes) -Not "Easy" (in its execution... as Ultrasound Exams in general; better skilled Operator) -Interpretation of imaging (is useful integration with the ultrasound data; NO alone!)

8 ELASTOSONOGRAPHY is a diagnostic method of recent introduction, which uses ultrasound and intends to obtain accurate information on the"elasticity and "stiffness" of the anatomical and pathological structures identified with US imaging.

9 GUIDELINES Elastosonography is an ultrasound technology currently used in the characterization of the focal and nodular areas of breast; nodules on scars and big lesions (more than 2 cm and anyway wider than the sampled area) must be preferentially excluded. The interpretation of the elastosonograms requires to the operator a global experience in the diagnostic imaging in senology. Unlike Color-Doppler, the Elastosonographic module does not require particular adjustments for use.

10 METHODOLOGY The nodular lesion must be centrally localized in relation to the sampled area. The dimensions of the Elastosonographic box must preferably take up almost the whole field of vision of the transducer for a correct analysis of the elasticity of the nodule and of the surrounding parenchyma. It is better to use a view in Dual Mode to obtain at the same time on the screen of the scanner both the elastosonographic image and the related C-Mode one; this trick is very useful to check in real time the position of the lesion in relation to the scanning plane.

11 The right elastosonographic scanning is based on a rhythmical compression and a release movement perpendicular to the skin surface, performed with constancy -Today it is easier (more sensitive US systems!!!!) rhythmic compression and release movement perpendicular to skin surface

12 Non Correct movement (oblique)

13 MALIGNANT BENIGN The Italian Team of Study, on the basis of its clinical experience of above 1000 cases studied, proposes a revision of the classification of Prof. Ueno. The aim is to give a graduation of scores more in accordance with the distribution of the pathologies in the normal routine of work, including therefore also scores which can favour, above all in the small lesions, the not always easy differentiation between liquid and solid.

14 Breast Carcinoma

15 RESULTS Elastosonography proved to be specific in the benign lesions, including the BI-RADS 3 ones of more critical interpretation (329 lesions, equal to 37,6%). Setting the cut-off point between the elastosonographic scores 3 and 4, the negative predictive value was 98%. BI-RADS 3 VPN = 98% BI-RADS 3 per US (American College of Radiology), a solid mass with circumscribed magins, oval shape and horizontal orientation, most likely a fibroadenoma, should have a less than 2 percent risk of malignancy. Altough additional multicentric data may confirm safety of follow-up rather than biopsy based on us findings,short-interval follow-up is currently increasing as a manegement strategy. Nonpalpable complicated cysts and clustered microcysts might also be placed in this category for short-interval follow-up.

16 What can be studied with Elastosonography? Among the other fields of employment in the study of the superficial organs, we must quote, always with the target of characterization "benign versus malignant", lymph nodes, thyroid and the muscle-articular structures. In this application, however, the results of Elastosonography are not proven as in the case of the breast

17 Thyroid benign nodules with shell "calcified.... is HARD At Thyroid Scintigraphy the nodule.. is COLD (Tumor or Cyst?)

18 What can be studied with Elastosonography? A particular case, also from a historic point of view, is represented by the study of the hepatic parenchyma. This peculiarity derives from the anatomical position of liver (which is not a superficial organ), from the specific object of study (the hepatic fibrosis, associated with cirrhosis, not the study of the nature of focal lesions) and from the kind of methodological approach, which, in the case of liver, were various. At present, thanks to probes with higher capability of penetrationand particular anatomical approaches, it is possible to obtain, with the systems commercially available, elastometric information at least for thesuperficial portions of the hepatic parenchyma.

19 FNH Object of study: the nature of focal lesions

20 Conclusions Elastosonography is, among the different methods that use Ultrasound to get diagnostic information, the technique with the most recent clinical introduction. Therefore we must not be surprised by the related lack of scientific contributions available in literature which evaluate the diagnostic performances The diagnostic potentiality of Elastosonography is linked to the operator's individual capability (it is performed by an expert Ultrasound user) and if combined with the traditional ultrasound analysis, it can give diagnostic data of considerable importance. All this in a non-invasive way and without increasing discomfort for the Patient.

21 Conclusions B-mode Color Doppler e Power Doppler FNH? Adenoma? Ultrasound Characterization Elastosonography CEUS

22 Conclusions Elastosonography Other Modality FUSION IMAGING