Breast 2D Shear Wave Imaging Clinical Case Study

Ultrasound Breast 2D Shear Wave Imaging Clinical Case Study SIEMENS Healthineers New Clinical Trends in Ultrasound Breast Imaging Courtesy of Dr. Alexandria Economacos, Mediclinic Hospital, Dubai, United Arab Emirates Abstract B-mode ultrasound is used as an adjunct to mammography to differentiate between benign and malignant breast lesions. An additional ultrasound technique, elastography, can evaluate the stiffness of tissue. It is believed that malignant lesions are generally stiffer than benign lesions. 2D Shear Wave Elastography (2D SWE) is a new elastography method for measuring the stiffness of tissue. Because this method does not depend on the degree of compression, measurements are reliable and reproducible. 2D Shear Wave Elastography (2D SWE) in combination with ultrasonography - has the potential to characterise abnormalities in more detail. Adding elastography to traditional B-mode ultrasound improves the diagnostic specificity without loss of sensitivity. This suggests that Virtual TouchTM 2D Shear Wave Elastography (2D-SWE) might change patient management and avoid unnecessary biopsies. However, further research involving a greater variety of abnormalities and larger study populations is indicated. Below cases are done in combination of Ultrasound imaging, 2D Shear Wave Elastography (2D SWE), Mammography and MRI Imaging. MEDICLING Mediclinic Comprehensive Cancer Center, City Hospital Dubai Case 1 Patient History: 25-year-old patient with no family Virtual TouchTM 2D Shear Wave Elastography (2DSWE) history of breast cancer, presents with newly felt lump Outcome: Elastography images confirm a hardened lesion in right breast (lower outer quadrant) and is not sure of (red lateral aspect) with central necrosis (signal void) duration. External ultrasound study suspects a 22 x 13mm suggestive of liquefaction/necrosis. Further assessment hypoechoic mass with posterior enhancement and mild post-biopsy with 2D-SWE imaging confirms the lesion vascularity. Core biopsy is advised, and she presents for a to reveal exaggerated hypoechoic margin beyond visible 2nd opinion. boundary, confirming adjacent hardened/ infiltrated Technology used: 2D Shear Wave Elastography (2D SWE) parenchyma. 2 | HOOD05162003084156 1A 1B 3 A 10176427 10176427 HEMENS RT BREAST 40EL RIGHT 1C 8:56:40 AM 2/26/2017 26y SIEMENS Breast 3 B 3 Fig. 3A - Axial Subtraction image Fig. 3B - T1 non fat suppressed with signal voboundaries, - D=1.55 cm RIGHT WITH A MARKER POST BIOPSY_ D=1.71 cm presentation is with black and white scale map. 1 Fig. 1A - B-mode ultasound image, Fig. 1B 2D Shear Wave Elastography (2D SWE) image with color map and shear velocities, shows hardened tissue with red color presentation with high velocities, Fig. 1C Image with 2D Shear Wave Elastography (2D SWE) shows infiltration beyond identified boundaries, presentation is with black and white scale map. The patient was found to have a unifocal high grade ductal Post core biopsy images were conducted cancer with no metastases and she proceeded for further to identify the presence of the marker and management. further characterize the mass. Case 2 2 A 2 B Patient History: 53-year-old patient complained of a tender solid mass newly identified in her left breast at 15:00 hrs. Clinical Finding: Ultrasound reveals rounded ovoid mass with internal echoes and posterior transmission - features suggestive of complicated cyst but differential included a fibroadenoma. 4 A SIEMENS 914 "Breast-1 General MI: 1.2 47fps 2D- 100% THI H8.00 MHZ 308/DR65 CTI1 ASC 5 DICEM MapE/ST3 Mediclinic Comprehensive Cancer Center, City Hospital Dubai 2 Fig. 2A - Post core biopsy RCC- irregular hyperdense mass identified posterolateral with marker within. Fig. 2B - Post core biopsy RMLO- irregular hyperdense mass D=1.49 cm identified posterolateral with marker within. D=1.26 cm MRI confirms the unifocal irregular heterogeneously enhancing mass in the RUOQ with signal void within. Irregular and poorly defined margins are clearly apparent 4cm on the T1 nonfat suppressed study and are confirmed as 4 Fig. 4A - B-mode ultrasound, shows well circumscribed darkly enhancing tendrils with post contrast images revealing hypoechoic mass with internal echogenic foci. extension specifically posteromedial to the lesion. HOOD05162003084156 | 3 Technology used: 2D Shear Wave Elastography Case 4 (2D SWE) Patient History: 45-year-old patient with history of a RUOQ mass in 2015 thought to represent a fibroadenoma. 4 B 4 C No change annually in size or appearance but now the patient feels the lesion is getting larger. 6 A 6 B 6 Fig. 6A and Fig. 6B Right MLO and RCC reveal a well- defined, partially Fig. 4B 2D-SWE image with color map shows soft tissue with lobulated 2.2cm 4 green and blue color presentation, and thick wall presentation hypoechoic mass in with red color, Fig. 4C Image shows high quality map, reveals the RUOQ with no good quality elastography sonogram. microcalcifications. Biopsy Result: FNA conducted confirmed abscess. Case 3 Patient History: Missed cancer - externally presumed fibroadenoma. 6 C 6 D Patient Age: 42-year-old patient with no family history. Clinical Finding: Unifocal well - marginated triangular mass, very posterior on upper RMLO was presumed to represent a benign mass. Patient sought 2nd opinion. Ultrasound reveals an irregular lobulated hypoechoic mass in RUIQ adjacent to the pectoral muscle with echogenic margin. 6 Fig. 6C and Fig. 6D 2D ultrasound and color Doppler from 2015, 5 A 5 B ovoid hypoechoic mass with peripheral vascularity spanning 2cm – presumed then to be a fibroadenoma and was annually monitored. 6 E D=2.59 cm D-1.29 cm 5 Fig. 5A RMLO mammo with triangular density overlying the pectoral muscle in the upper aspect. Fig. 5B B-mode ultrasound shows irregular circumscribed hypoechoic mass with echogenic margin adjacent to pectoral 6 F muscle. 5 C 5 D 5 Fig. 5C shows 2D Shear Wave Elastography (2D SWE)imaging 6 Fig. 6E and Fig. 6F : 2D ultrasound and color Doppler - Follow-up elastogram with red color map suggestive of hard tissue, with scan shows 0.5cm increase in size as compared to previous scan, infiltration around, Fig. 5D high quality map reveals good quality and increased vascularity with color Doppler. elastogram. Biopsy Result: Invasive ductal carcinoma with DCIS grade 1 4 | HOOD05162003084156 Ultrasound Technology used: 2D Shear Wave Elastography (2D SWE) 2D-Shear Wave Elastography (2D SWE) Outcome: 2D-SWE imaging reveal soft lesion on elastography. 6 H 6 I 6 Fig. 6H and Fig. 6I with features confirming a soft lesion and no marked adjacent hardening on 2D SWE with correlate map confirming good quality. Biopsy Result: Core biopsy confirmed complex fibroadenoma which was excised and proven benign. References [1] Kapetas, P., Clauser, P., Woitek, R., Pinker, K., Bernathova, M., Helbich, T. H., & Baltzer, P. A. 2018. [2] “Virtual TouchTM IQ elastography reduces unnecessary breast biopsies by applying quantitative “rule-in” and “rule-out” threshold values.” [3] Scientific reports, 8(1), 3583. https://doi.org/10.1038/s41598-018-22065-7 [4] American College of Radiology. Breast imaging reporting and data system: BI- RADS atlas. 4th ed. Reston, VA: American College of Radiology; 2003. [4] Krouskop TA, Wheeler TM, Kallel F, Garra BS, Hall T. Elastic moduli of breast andprostate tissues under compression. Ultrason Imaging 1998;20(4):260–74. [5] Doherty JR, Trahey GE, Nightingale KR, Palmeri ML. Acoustic radiation forceelasticity imaging in diagnostic ultrasound. IEEE Trans Ultrason Ferroelectr FreqControl 2013;60(4):685–701 [6] Palmeri ML, Nightingale KR. Acoustic radiation force-based elasticity imagingmethods. Interface Focus 2011;1(4):553–64. [7] [14] Tozaki M, Isobe S, Sakamoto M. Combination of elastography and tissue quantification using the acoustic radiation force impulse (ARFI) technology fordifferential diagnosis of breast masses. Jpn J Radiol 2012;30(8):659–70. [8] Tamaki K, Tamaki N, Kamada Y, et al. A non-invasive modality: the US virtualtouch tissue quantification (VTTQ) for evaluation of breast cancer. Jpn J ClinOncol 2013;43(9):889–95 [9] Bai M, Du L, Gu J, Li F, Jia X. Virtual TouchTM tissue quantification using acousticradiation force impulse technology: initial clinical experience with solid breastmasses. J Ultrasound Med 2012;31(2):289–94. Courtesy of Dr. Alexandria Economacos, Mediclinic Hospital, Dubai, United Arab Emirates HOOD05162003084156 | 5 Disclaimer: For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively “Operator Manual”) issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training. The Operator’s Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions. 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