ACUSON Maple 1.0 VT Elastography Presentation

SIEMENS Healthineers ... ACUSON Maple Ultrasound System Virtual Touch Elastography 1.0 Software Release 1 Unrestricted © Siemens Healthineers 2023 Speaker Notes: In this presentation we will discuss elastorgraphy using Virtual Touch™ technologies on the ACUSON Maple™ ultrasound system. Notes No. 1 Objectives SIEMENS . Healthineers ... • Explain Virtual TouchTM technologies • Demonstrate strain imaging (eSie TouchTM elasticity imaging)* controls and techniques *Note: This presentation uses the term “Strain imaging” to refer to “eSie Touch elasticity imaging” displayed as “eSie Touch” under the “Elasticity” tab on the ultrasound 2 system. It also uses the term “Virtual Touch pSWE” to refer to “Virtual Touch™ quantification” displayed under the “Elasticity” tab on the ultrasound system. Unrestricted © Siemens Healthineers 2023 Speaker Notes: Here are the objectives for this presentation. We will begin with explaining the Virtual Touch technologies. *Note: This presentation uses the term “Strain imaging” to refer to eSie Touch™ elasticity imaging displayed as eSie Touch under the “Elasticity” tab on the ultrasound system. It also uses the term “Virtual Touch pSWE” to refer to “Virtual Touch™ quantification” displayed under the “Elasticity” tab on the ultrasound system. Notes No. 2 The next dimension of diagnostic information SIEMENS . Healthineers ... Additional information towards Anatomy clinical diagnosis and patient care B-mode Elastography Mechanical stiffness Doppler Vascular flow 3 Unrestricted © Siemens Healthineers 2023 Speaker Notes: Elastography provides a new dimension of diagnostic information to the ultrasound exam. With B-mode imaging, a diagnosis is based on the appearance of tissue in levels of gray and the presence of clinical markers, such as shadowing or enhancement. Doppler provides information on the presence or absence as well as speed and direction of vascular flow. Elastography allows us to assess the mechanical stiffness of tissue, providing additional information towards the clinical diagnosis and care of the patient. Notes No. 3 Elastography provides information on tissue stiffness SIEMENS . Healthineers' ... Hooke’s Law Stress = Force/Area Strain = ∆ Length/Original Length 𝐿1 − 𝐿0 L₀ L₁ ℇ = 𝐿0 Deformation = Relative change in shape or size of tissue after it is stressed 4 Unrestricted © Siemens Healthineers 2023 Speaker Notes: Elastography provides information on tissue stiffness. To obtain this information, the tissue needs to be deformed. Since elastography is based on Hooke’s Law, let’s go over the basic concept of Hooke’s Law. Here we have a structure; let’s say, for example, it’s tissue, with a length of L0. We deform the tissue with an applied force to stress the tissue. Now the tissue has a length of L1. Next, we compare the before and after lengths of the tissue by dividing the change in length from the original length to calculate the strain, or the variation in tissue deformation, which is the relative change in shape or size of the tissue after it is stressed. Notes No. 4 Relative stiffness information on elastogram SIEMENS . Healthineers ... Hard tissue = Less deformation Soft tissue = More deformation Grayscale or color-coded stiffness 5 Unrestricted © Siemens Healthineers 2023 Speaker Notes: Now let’s go over how we display the result as an elastogram on ultrasound. Here we have a column of tissue elements that might appear identical on the B-mode image. When stress is applied, the tissue elements can behave differently. The middle tissue element experiences almost no deformation because it is hard, but the elements at the periphery of the column experience more deformation because they are soft. By using the difference between the original and stressed image, the original image can now be labeled and displayed with stiffness information. We look to the grayscale or color bar that is displayed next to the image, and, by convention, a dark shade is used to indicate stiff or hard tissue and lighter shades are used to indicate softer tissue. If a color map is selected, the color bar indicates which color represents soft or hard tissues. These gray or color shades are then used to assign and display the relative stiffness of tissue on the elastogram. Notes No. 5 Methods to deform tissue SIEMENS . Healthineers ... Transducer Soft Tissue ----- Region of Stiff Lesion Interest Manual compression 6 Unrestricted © Siemens Healthineers 2023 Speaker Notes: Now let’s discuss the method used to deform the tissue. The manual compression technique is described as Strain imaging. Using manual compression, stress is created by the user applying minimal compression with the transducer. Notes No. 6 Virtual Touch applications display SIEMENS . Healthineers ... Strain imaging 1213 Breast Tx Power 100% MI 0.94 TIS 0.2 TIB 0.2 SC 2 DICE High Dyn R 68 dB THI 10.0 MHZ 1 dB 12 fps OF 90 3.5 om Z Displacement correlation image Qualitative (soft to hard scale) 7 Unrestricted © Siemens Healthineers 2023 Speaker Notes: Strain imaging creates a displacement correlation image, mapping relative stiffness, which can be qualitatively assessed. Notice that the gray or color bar next to the strain image indicates hard or soft and has no numerical values. Notes No. 7 Strain imaging SIEMENS . Healthineers ... Region of interest Transducer 1213 Thyroid MI 1.19 TIS 0.3 TIB 0.3 SC 2 Soft Tissue DTCE Med Dyn R 68 dB THI 8.4 MHZ 3 dB 11 fps QF 80 Region of Stiff Lesion Interest 8 Unrestricted © Siemens Healthineers 2023 Speaker Notes: Strain imaging provides a visual assessment of tissue stiffness and can, for example, allow a subtle lesion in soft tissue to be more clearly visualized and assessed. When uniform stress is applied, each tissue type will deform differently. The resultant mapping of these different degrees of deformation clearly illustrates relative tissue stiffness. When Strain imaging is activated, the B-mode image will display side-by-side with the elastogram and the region of interest (ROI) box can be resized and repositioned over the desired area. Using real-time correlation methods, the system continuously estimates the degree of tissue deformation and displays the relative stiffness in either a gray scale or colorized elastogram. Notes No. 8 Strain imaging SIEMENS . Healthineers' ... Relative stiffness Qualitative gray map 13L4 Thyroid MI 1.03 TIS 0.5 • Stiff lesion TI8 0.5 SC 2 DICE Med Darker gray = Harder than surrounding Dyn R 66 dB • THI 13.3 MHZ 0 dB tissue 13 fps OF 90 Qualitative color map • Stiff lesion • Red = Harder than surrounding tissue 13L4 Thyroid MI 1.03 TIS 0.5 TIB 0.5 SC 2 DICE Med Dyn R 66 dB THI 13.3 MHZ O de 13 fps OF 90 9 Unrestricted © Siemens Healthineers 2023 Speaker Notes: When using Strain imaging, it is important to understand what the gray shades and color shades indicate on the elastogram in terms of “relative stiffness”. The qualitative gray map and color map in these two images indicates that the lesion is stiffer, or harder, relative to the surrounding tissue. As shown in the image on the top, the gray bar located next to the image indicates that tissue displayed in darker gray shades are “harder”, while lighter gray shades are “softer”. In the image on the bottom, the color bar located next to the image indicates that tissue displayed in redder colors are “harder”, while pinker colors are “softer”. Notes No. 9 ACUSON Maple ultrasound system SIEMENS. Healthineers ... 13L4 Breast 5C1 12L3 16L4 9MC3 CW8 Add Exam Elasticity ? 2D lasticity estesca Clear Screen THI Split Biopsy Settings Biopsy Hide Physio Settings > Trapezoid 4B CTI Patient Clarify VE Daran Param Clip Settings Needle Visual. DTI Clarify VE Levels nd Exam > High Density DTCE Med R/S Tint 10 Image Size Tx Power 100% MultiHertz 10.0 MHz Adv. SieClear 2 Dyn R 65 dB Map D Focus Width TEQ Gain 10 Unrestricted © Siemens Healthineers 2023 Speaker Notes: To access the Virtual Touch elastography mode on the ACUSON Maple ultrasound system, select a compatible transducer and exam preset and then select the Elasticity tab on the Touch Screen. Notes No. 10 Virtual Touch application compatibility matrix SIEMENS . Healthineers ... Application 16L4 14L4a L10-5v Strain imaging Thyroid & Breast Thyroid & Breast Thyroid 11 Unrestricted © Siemens Healthineers 2023 Speaker Notes: Elastography is a technique that non-invasively visualizes and measures the change in tissue stiffness, a key characteristic of diseased tissue (that is often stiffer). The ACUSON Maple system offers strain imaging which is compatible with three transducers: 16L4, 14L4v and L10-5V Notes No. 11 Objectives SIEMENS . Healthineers ... • Explain Virtual Touch technologies • Demonstrate Strain imaging (eSie Touch elasticity imaging)* controls and techniques *Note: This presentation uses the term “Strain imaging” to refer to “eSie Touch elasticity imaging” displayed as “eSie Touch” under the “Elasticity” tab on the ultrasound 12 system. It also uses the term “Virtual Touch pSWE” to refer to “Virtual Touch quantification” displayed under the “Elasticity” tab on the ultrasound system. Unrestricted © Siemens Healthineers 2023 Speaker Notes: Next, we will discuss the Strain imaging controls and techniques. *Note: This presentation uses the term “Strain imaging” to refer to eSie Touch elasticity imaging displayed as eSie Touch under the “Elasticity” tab on the ultrasound system. Notes No. 12 Strain imaging SIEMENS . Healthineers ... High sensitivity, but difficulty defining the lesion size (boundaries) in isoelastic benign lesions, reduces specificity Site Total Lesion Malignant EI/B-mode Sensitivity Benign EI/B-mode Specificity Lesions Ratio≥1 Lesions Ratio<1 1 251 54 54 100% 197 188 95.4% 2 79 40 40 100% 39 26 66.7% 3 206 90 87 96.7% 116 100 86.2% 4 52 14 14 100% 38 29 76.3% 5 34 18 18 100% 16 12 75.0% 6 13 6 6 100% 7 6 85.7% Total 635 222 219 98.6% 413 361 87.4% Evaluation of Breast Lesions Using Ultrasound Elasticity Imaging: A Multi-centered Trial Barr RG, Destounis S, Lackey LB, Svensson WE, Balleyguier C, Smith C. Journal of Ultrasound in Medicine 2012 Feb; 31(2): 281-7 13 Unrestricted © Siemens Healthineers 2023 Speaker Notes: Strain imaging has been widely used in breast and thyroid imaging and is still relevant today as a highly sensitive indicator of relative tissue stiffness in focal lesions. In this multi-center study at six locations around the world, the reproducibility of strain imaging used in breast lesions yielded 97-100% sensitivity in all locations. Specificity was lower, primarily due to the difficulty in defining the lesion size (boundaries) in benign lesions, which are relatively isoelastic when compared to normal breast tissue. Notes No. 13 Strain imaging controls SIEMENS. Healthineers .. ₱ 13L4 Breast 5C1 1213 16L4 9MC3 CW8 4 Add Exam EI Color ? 2D Elasticity eSieScan Off eSie Touch > 1 364 Screen LUR Flip Split El Color Thyroid MI 1.03 Tr5 0.3 SC 2 UID Flip El Map Index EI Color DILI Mol U Tia 13.5 Mit 1 13 1pm Exit RIS 12 Tint 10 MultiHertz 10.0 MHZ Edge 1 Dyn R 65 dB Map D EI Color 2 14 Unrestricted © Siemens Healthineers 2023 Speaker Notes: The Virtual Touch elastography mode will display the dedicated elastography applications that are available for the selected transducer and exam preset. Each application has its own dedicated tab folder containing the controls that can be used to perform the application. When Strain imaging is activated, the B-mode image and elastogram display in a split format as shown here. If needed, the region of interest can be resized and repositioned over the area of interest. The image can be zoomed before or after acquisition. A color map can be selected to display the strain image in vibrant red to vibrant blue shades or in soft pink to soft red shades. Three different Map Index settings are available: 1 = Standard default map, 2 = Normalized map to compensate for non-uniform stress applied with the transducer, and 3 = Inverted map. Notes No. 14 Strain imaging techniques SIEMENS . Healthineers ... Avoid gray overlay box as shown here • Position patient to obtain perpendicular plane to skin • Minimal compression (use respirations or cardiac 1213 motion) TIS 0.2 TIB 0.2 SC 2 • Avoid lateral or rocking motion DTCE High Dyn R 88 dB THI 8.4 MHZ -2 dB • Quality Factor (QF) > 50 QF O • Optimize elastogram, then Freeze • Cine to obtain desired frames 15 Unrestricted © Siemens Healthineers 2023 Speaker Notes: Use best practice techniques when performing Strain imaging for reliable and repeatable results. First, optimize the scan direction by positioning the patient to obtain as much of a perpendicular plane to skin surface for good axial motion. Then, apply minimal compression. The natural compressions generated by a patient’s respirations and cardiac motion may be sufficient to generate the elastogram. If a gray overlay is displayed on the elastogram, as seen in this image of a breast lesion, it indicates one of the following conditions: Too much lateral movement or rocking motion, too little pressure, or too much pressure which causes the lesion to slip in and out of the plane. The system also displays a real-time Quality Factor score. Maintain a Quality Factor greater than 50 for optimal results. Optimize the elastogram and then press “Freeze” on the Control Panel. At this point, you would review the cine to obtain desired frames and then choose a frame that contains several consecutive frames with the same Quality Factor score. Notes No. 15 Effects of precompression SIEMENS . Healthineers .. • Too much pressure substantially changes elastographic results • Soft tissue can appear hard • Minimize precompression by using minimal pressure + .......................... HD D 14.1 mm 16 Unrestricted © Siemens Healthineers 2023 Speaker Notes: It is important to utilize proper scan technique to minimize the effect of precompression. If too much pressure is applied with the transducer, elastographic results can substantially change. Fat can appear to have the same elasticity as cancer when too much pressure is applied. In this image of a breast cyst, the soft tissue in the near field appears to show an increase in stiffness due to the effect of precompression. Precompression is a substantial factor in obtaining accurate results with elastography. Precompression should be minimized in obtaining clinical images.* *Barr, R. G. and Zhang, Z. (2012), Effects of Precompression on Elasticity Imaging of the Breast. Journal of Ultrasound in Medicine, 31: 895-902. doi:10.7863/jum.2012.31.6.895 Notes No. 16 Shadow measurement SIEMENS . Healthineers ... Breast Testis Penile Thyroid Style 1213 ? Breast Right Left None Tx Power 100% MI 1.06 TIS 0.2 TIB 0.2 SC 2 Rt Mass 1 Rt Mass 2 Rt Mass 3 Rt Mass 4 Rt Mass 5 DICE High Dyn R 68 dB THI 8.4 MHZ 0 CB Rt Cyst 1 Rt Cyst 2 Rt Cyst 3 Rt Cyst 4 Rt Cyst 5 13 fps OF 90 Clear Screen Rt LN 1 Rt LN 2 Rt LN 3 Rt LN 4 Rt LN 5 Hide Patient Shadow Image Param End Exam O % Distance Ellips Spline Cross Angle ol 3 Dis Strain Ratio More Undo/Redo MDA Summarize MDA Report Delete Exam Font Size On Small Parts 17 Unrestricted © Siemens Healthineers 2023 Speaker Notes: When the Shadow measurement is active, the system duplicates and displays the measurement on the adjacent image for a comparison of lesion size and/or location. To perform a Shadow measurement, select Split, if needed, and then press Caliper on the Control Panel to enter the measurement menu. Select Shadow on the Touch Screen to activate and measure either image. The measurement displays in the measured results, as shown here in the image of a breast cyst. Notes No. 17 Strain ratio measurement SIEMENS . Healthineers ... Strain Ratio = ROI 1 (Ref) / ROI 2 (Mass) • Place ROI 1 (Ref) in tissue • Place ROI 2 (Mass) in lesion (same size and Strain Ratio at same depth) • Results: > 1 = Lesion is harder than the 1213 surrounding tissue Breast Tx Power 100% MI 1.17 TIS 0.2 • Results: ≤ 1 = Lesion is softer or the same TIB 0.2 as the surrounding tissue SC 2 DTCE High C Dyn R 68 dB THI 8.4 MHZ 0 dB 11 fps ROI1 (Ref) 0.03 % ROI2 (Mass) 0.03 % Strain Ratio 0.92 18 Unrestricted © Siemens Healthineers 2023 Speaker Notes: Strain ratio compares the relative stiffness of tissue within two ROIs. The strain ratio is the result of dividing ROI 1 (Ref) by ROI 2 (Mass). When the first ROI is placed in the surrounding tissue and the second ROI is placed in the lesion, a strain ratio greater than 1 indicates that the lesion is harder than the surrounding tissue. A strain ratio less than or equal to 1 indicates that the lesion is softer or the same as the surrounding tissue. The strain ratio and the average strain percentage for both regions of interest are displayed in the measured results. The strain ratio and average strain (%) for both ROIs are displayed. Notes No. 18 Elasticity imaging/B-mode (EI/B) ratio SIEMENS . Healthineers ... Testis 13L4 Breast Style MI 0.56 TIS 0.2 TIB 0.2 ? SC 2 Right Left Non Open Tra Open Spline 2 Distance 3 Distance DTCE Med Dyn R 65 dB THI 10.0 MHZ X 0 GB Rt Mass 1 Rt Mass ? Auto Stenosis -%Stenosi A- 5%Stenosis Cross Angle 16 fps QF 95 Rt Cyst 1 Rt Cyst 2 O Trace spline esioCales Wp Angle d:D Ratio OFF Clear Screen RI LN 2 Dist Ratio Vol Ratio 6 Hide Area Ratio Strain Rati 8.91 mm Patient 8.91 mm 1.00 image BIA 1.00 Param Vol 1 Dist Val 2 Dis Vol 3 Dist Ellipse Vol 1E + 10 Dick Trac Dick (A-BVA 0.00 X Lindokeds MDA Summarize MDA Report Delete Exam Font Size Small Parts 19 Unrestricted © Siemens Healthineers 2023 Speaker Notes: One of the most sensitive indicators for the likelihood of breast lesion malignancy is the ratio of the lesion size in the elastogram compared to the lesion size in the B-mode image. Research has shown that suspicious breast lesions appear measurably larger with elasticity imaging versus B-mode imaging. It is hypothesized that this is due to the detection of tentacle formation and/or desmoplasia, which is the growth of fibrous or connective tissue. When the ratio is >1, the probability of malignancy is increased.* In this example, the elasticity imaging to B-mode ratio diameter measurement has been used to compare the size of a lesion visualized in the elastogram with the size of the same lesion visualized in the B-mode image. The ratio of the elastogram measurement divided by the B-mode measurement is displayed as 1.00 in the measured results, indicating that the lesion size is measuring the same in both the elastogram and the B-mode image. *Barr, R. G., De Silvestri, A. , Scotti, V. , Manzoni, F. , Rebuffi, C. , Capittini, C. and Tinelli, C. (2019), Diagnostic Performance and Accuracy of the 3 Interpreting Methods of Breast Strain Elastography: A Systematic Review and Meta-analysis. J Ultrasound Med, 38: 1397-1404. doi:10.1002/jum.14849 Notes No. 19 “Bull’s-eye” appearance in cysts SIEMENS . Healthineers ... • Dark ring surrounding echogenic center 11L4 Breast MI 1.16 with posterior white spot TIS 0.4 TIB 0.4 SC 2 • Clinical marker for cysts DTCE High Dyn R 65 dB THI 9.4 MHZ • Applies to all organs 5 dB 14 fps QF 80 • Occurs from decorrelation between HD images caused by fluid movement in cyst D 4.2 mm ............ 3.5 cm Z 20 Unrestricted © Siemens Healthineers 2023 Speaker Notes: A characteristic of Strain imaging is the “bull’s-eye” appearance in cysts. As shown in this image of a breast cyst, the “bull’s-eye” appears as a dark ring surrounding a bright, echogenic center with a posterior white spot. It is a useful clinical marker for cysts in any organ imaged with Strain imaging. The bull’s-eye occurs from decorrelation between images caused by fluid movement in the cyst. Notes No. 20 Solid, complex cyst or complicated cyst SIEMENS . Healthineers ... • Lesion with internal echoes on B-mode image 12L3 Breast Tx Power 100% • Solid, complex cyst or complicated cyst MI 1.06 TIS 0.2 TIB 0.2 • Bull’s-eye appearance on elastogram SC 2 DICE High Dyn R 68 dB THI 8.4 MHZ 0 dB 13 fps OF 90 3 cm Z_ YA Fr217 21 Unrestricted © Siemens Healthineers 2023 Speaker Notes: Complicated cysts contain low level internal echos or internal debris which may produce an appearance similar to that of a solid mass or a complex cyst (containing both solid and cystic components). It is important to differentiate a complicated cyst from a complex cyst or a solid mass to best assess lesion management for follow-up, aspiration or biopsy. This slide shows how Strain imaging can be used to support the differential diagnosis between a solid mass, a complex cyst or a complicated cyst. Notes No. 21 Shadowing SIEMENS . Healthineers ... Shadowing displayed on B-mode image • Difficult to distinguish or measure borders of lesion • Shadowing does not affect the elastogram • Borders and size can be more confidently determined Sonographic Mechanical properties properties 22 Unrestricted © Siemens Healthineers 2023 Speaker Notes: In this example, the B-mode image displays acoustic shadowing, characterized by the loss of signal around the lateral and posterior borders of a breast lesion due to strong absorption or reflection of the ultrasound waves. Shadowing makes it difficult to distinguish or measure the borders of this lesion. Notice how shadowing does not affect the elastogram. The B-mode image displays the sonographic properties of the image while the strain image displays the mechanical properties of the image. The borders of the lesion can be identified on the strain image, and the size of the lesion can be determined with greater confidence. Notes No. 22 Siemens Healthineers Virtual Touch technologies SIEMENS . Healthineers ... Clinical evidence • Siemens Healthineers first to have ARFI-based technologies Radiology Thyroid • Worldwide adoption since 2008 • Several hundred papers • Multiple specialties • Nearly 1,000 sites worldwide JOURNAL OF HEPATOLOGY IRSNA 23 Unrestricted © Siemens Healthineers 2023 Speaker Notes: When you expand your clinical offering with a critical new technology such as elastography, it is important to choose a partner that has industry-leading advanced elastography solutions with strong clinical validation so that you can be confident of its adoption into personalized clinical pathways. Siemens Healthineers provides this partnership with confidence, leading the way with over 400 publications since the introduction of elastography in 2008. We encourage you to investigate and discover for yourself the clinical validity of our technology at the third-party research database at www.mendeley.com. Notes No. 23 SIEMENS . Trademarks and Disclaimers Healthineers ... ACUSON Maple, eSie Touch elasticity imaging and Virtual Touch technologies are trademarks of Siemens Medical Solutions USA, Inc. 24 Unrestricted © Siemens Healthineers 2023 Speaker Notes: No speaker notes. Notes No. 24 Thank you for your enthusiasm! SIEMENS . Healthineers ... Questions? 25 Unrestricted © Siemens Healthineers 2023 Speaker Notes: No speaker notes. Notes No. 25