The Role of Sonoelastography in Breast Lesions

https://doi.org/10.1053/j.sult.2017.05.010Get rights and content

There is a large body of published material that supports the use of elastography, both strain and shear wave, for characterization of breast lesions. To a lesser extent, elastography can be used in the detection of breast abnormalities. This article reviews the principles of elastography regarding breast imaging, reviews the techniques to perform both strain and shear wave elastography, and reviews the literature and discusses how elastography can be used to improve the characterization of breast lesions to allow for decrease in the number of short-term follow-up examinations and benign biopsies.

Introduction

The use of palpation for the detection and characterization of disease states has been employed for thousands of years.1 The ancient Egyptians were known to use palpation to detect pathology. Many disease states cause a change in the stiffness of tissue, particularly in most malignancies. Elastography is the imaging equivalent to clinical palpation. Unlike manual palpation, ultrasound elastography can semiquantitate or quantitate the degree of stiffness of a mass or a tissue. It can also assess stiffness of deep tissues that may not be accessible for clinical palpation.

Ultrasound elastography has been employed in multiple tissues with varying levels of accuracy in detection and characterization of disease states. Organs where ultrasound elastography may improve assessment of disease states include breast, thyroid, liver, prostate, and tendons.2, 3, 4, 5, 6, 7 For focal lesions, the stiffness of malignant breast lesions is much greater than benign lesions with very little overlap allowing for high sensitivity and specificity in characterization of breast lesions as benign or malignant.5, 8, 9

Section snippets

Basic Principals

There are 2 types of ultrasound elastography, strain elastography (SE) and shear wave elastography (SWE). These techniques use different methods to determine tissue stiffness and are complementary techniques. Each has its advantages and disadvantages. The choice of which (or both) to use is dependent on the availability as well as which organ and disease being evaluated.2

Clinical Applications

Breast elastography can be used to characterize lesions as benign or malignant, identify multiple lesions that may appear as 1 lesion on B-mode, help characterize complex lesions, determine if a lesion is a fat lobule, determine if a lesion is a benign cystic lesion, and help facilitate where to biopsy a lesion.9

Techniques

As opposed to SE, SWE provides a quantitative value of stiffness expressed either in m/s or kPa (Fig. 7). For breast SWE, the transducer is placed on the breast with light pressure. No movement of the transducer is required; in fact that is contraindicated. Precompression is a major concern as it is in SE, and the discussion and methods to standardize light compression in SE apply to SWE.

Both p-SWE and 2D-SWE have been used to evaluate breast lesions. Breast masses, especially malignancies,

Combining SE and SWE

The difficulties with SE evaluation of breast lesions are usually in benign lesions as the stiffness value of benign lesions are similar to glandular tissue. Therefore, they are often difficult to visualize and the E/B ratio cannot be determined accurately (Fig. 8). In SWE difficulties usually occur in breast malignancies in that shear waves are not generated or are inadequate for accurate stiffness assessment (Fig. 9). Combining the 2 techniques may lead to improved accuracy. When both SE and

Guidelines

Guidelines recommending the use of elastography for characterizing breast lesions have been published by the European Federation Societies for Ultrasound in Medicine (EFSUMB)2 and the World Federation of Ultrasound in Medicine and Biology (WFUMB).5 Both guidelines recommend the addition of elastography to conventional ultrasound to improve the characterizations of breast lesions as benign or malignant. The WFUMB guidelines provide a detailed description of how to perform breast elastography,

Conclusions

The addition of elastography to a standard breast ultrasound (screening or diagnostic) can be performed in a few minutes. Both SE and SWE are highly sensitive and specific for characterizing breast lesions. The addition of elastography to a standard breast ultrasound will decrease the number of benign biopsies.

Disclosures

RGB has equipment grants from Siemens Ultrasound, Philips Ultrasound, SuperSonic Imagine, Hitachi-Aloka Ultrasound, and B and K Ultrasound; Speakers Bureau for Philips Ultrasound, Hitachi-Aloka, and Bracco Diagnostics; Advisory boards for Bracco Diagnostics and Lantheus Medical; and Royalties from Thieme Publishers.

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