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Tissue Doppler and Strain Imaging for Evaluating Tissue Elasticity of Breast Lesions

Posted Apr 30, 2007 Updated Apr 7, 2023
By Anke Thomas MD , Mathias Warm MD , Markus Hoopmann MD , Felix Diekmann MD , Thomas Fischer MD
9 min read

Rationale and Objectives

Sonoelastography depicts the intrinsic elastic properties of a tissue which are characterized by the strain applied to achieve tissue deformation and the velocity at which tissue deformation occurs. The present study served to investigate whether the specificity of B-mode ultrasound (US) can be improved by combining B-mode imaging with tissue Doppler imaging (TDI) and offline analysis of tissue strain imaging (TSI).

Materials and Methods

Fifty women, 25 with malignant and 25 with benign focal breast lesions, were examined by US with a linear transducer (9 MHz, Aplio, Toshiba, Otawara, Japan). B-mode US views of the lesions were overlaid with color-coded TDI information and area quotients (AQ = area B-mode view/area TDI) were calculated. TSI views were reconstructed offline from the source data. This was done by placing a region of interest (ROI) in the target lesion and color-encoded display of the information. In addition, tissue elasticity was evaluated using a scale of 1–5 corresponding to the BI-RADS categories. Maximum strain (strain factor, SF) was determined in the ROI. All patients also underwent mammography. Sensitivities and specificities were calculated and statistical analysis was performed using Wilcoxon’s test.

Results

Sensitivity/specificity was 96%/68% for B-mode US, 100%/40% for combined B-mode US and mammography, and 96%/80% for TSI. The AQ of benign and malignant lesions was significantly different (p = .00008) as was the difference in SF (p = .0004). The readers considered TSI a feasible technique.

Conclusion

Evaluation of elasticity based on the quantification of strain factors improves characterization of focal breast lesions, especially the differentiation of BI-RADS 3 and 4 lesions. Surprisingly, significant results in characterizing breast lesions were obtained with the simple technique of TDI, showing a lower tissue displacement in malignant cases.

The search for a diagnostic test that allows reliable differentiation of benign and malignant breast lesions for timely initiation of therapy continues to be a challenge as reflected in the wide range of different modalities that have been proposed. While there have been advances in the individual modalities, the final diagnosis often relies on a combination of mammography, ultrasound, and magnetic resonance imaging, and histological confirmation is obtained before surgery is performed ( ).

The visualization of the pathophysiological changes in tissue properties associated with tumor development was the basis for the development of elasticity measurements, which began in the 1980s ( ). All elastography techniques combine a form of mechanical excitation with measurement of the resulting tissue motion ( ). Reconstruction of the elastic deformability (strain imaging) in real time is known as sonoelastography ( ). The deflections before and after tissue compression are measured semiquantitatively using the shear modulus (Young’s modulus), calculated using a model, and then displayed graphically in the form of an elastogram.

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Methods

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Ultrasound Technique

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Figure 1, Comparison of different ultrasound views of a benign focal breast lesion (fibroadenoma) in a 28-year-old woman. (A) The B-mode scan shows a smoothly marginated focal lesion of homogeneously low echogenicity. (B) TDI with plain B-image on the left and the image with superimposed, color-coded elasticity information on the right. The tumor is highly compressible, and there are no color gaps in the left image. (C) Typical appearance of benign lesion in the strain image. Strain field in the ROI placed around the lesion: there is a predominance of red and green as an indication of the moderate deformability of the lesion (score 3) (C, D) . (D) The curve on the right indicates the homogeneous compression and decompression cycle of the compressible tumor area to analyze the SF.

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Image Interpretation

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Image Analysis

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AQ=AreaB-mode/AreaTDI AQ

=

Area

B-mode

/

Area

TDI

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Mammography

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Histology

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Statistics

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Results

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Table 1

Histological Diagnoses of Benign and Malignant Breast Lesions

Benign Lesions (n = 25) No. Malignant Lesions (n = 25) No. Fibroadenoma 11 Invasive ductal carcinoma 19 Papilloma 3 Invasive lobular carcinoma 5 Fibrosis 5 Ductal carcinoma in situ 1 Fibrocystic mastopathy 5 Phyllodes tumor 1

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Mammography

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B-Mode Ultrasound

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Figure 2, Malignant breast lesion (52-year-old woman with invasive ductal cancer). (A) The B-mode scan shows a microlobulated lesion with an irregular margin. (B) TDI shows no color within the lesion. The area quotient of <1 indicates the larger tumor size of the malignant lesion in the TDI image in comparison to the B-mode scan. (C) Typical appearance of a score 5 tumor in the strain image. The black color indicates incompressibility. (D) The curves on the right indicate the compression and decompression of the tumor area with only a slight displacement, resulting in a high SF.

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Tissue Doppler Imaging

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Figure 3, Appearance of a BI-RADS 3 breast lesion (36-year-old woman, phyllodes tumor). Inhomogeneous focal lesion with smooth margin in B-mode scan (A) , BI-RADS 3, and little deformability in TDI (B) . Atypical strain image (C) with only little deformability, as indicated by the blue and green color, score of 4 (D) and the compression curve on the right (D) .

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Strain Imaging

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Subjective Evaluation

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Discussion

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Study Limitations

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Academic Radiology, Volume 14, Issue 5
Journals General Radiology
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