Hitachi

Real-time Tissue Elastography (RTE)

Clinical Applications

RTE is compatible with over 20 different transducers and its diagnostic value has been proven in a variety of different clinical areas, notably breast, urology, pancreas and lymph nodes.

Linear Arrays (Example EUP-L74M)
Echo endoscopes (Example EG-3870UTK)
Endocavity (Example EUP-V53W)
Laparoscopic (Example EUP-OL-531)
Endocavity (Example EUP-R54AW)
Intraoperative (Example EUP-O54J)

In breast applications, RTE has a complementary diagnostic role to the conventional B-mode:

  • The assessment of elasticity can be made in real-time
  • The Tsukuba score classification is simple to use and suitable for routine clinical use (see figure 3)
  • RTE is proven in multicentre studies to be an effective and reproducible US modality and is not time-consuming
  • RTE offers increased specificity afforded by the addition of new benign criteria
  • RTE has the potential to eliminate unnecessary benign core biopsies especially in breast masses categorized as BI-RADS categories 3 and 4
  • The Fat to Lesion Ratio (Strain Ratio) can provide greater objectivity in assessing the elastography image



Two hypoechoic lesions with rounded shape on conventional B-mode:


[1] Elastography Score 4 ?
invasive ductal ca

[2] Elastography Score 1 ? fibroadenoma

[3] Tsukuba Elasticity Score Classification

RTE of the prostate offers a new approach for the detection and visualization of cancer:

  • RTE can detect prostate cancer foci with good accuracy
  • It allows the estimation of tumour location and extent
  • The cancer yield with RTE – guided targeted biopsies can equal that of systematic biopsy for less than half the number of cores

RTE can also improve the detection and differentiation of testicular masses

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HI-RTE shows a small blue (stiff) lesion on the right side of the prostate which was confirmed as prostate cancer

HI-RTE used to target a suspicious area in the left peripheral zone of the prostate for biopsy

Leydig Cell Tumour of testis
  • Endoscopic RTE allows the characterisation and differentiation of benign and malignant lymph nodes with a high sensitivity, specificity and accuracy
  • It provides better targeting for fine needle aspiration (FNA) procedures in patients with multiple enlarged lymph nodes
  • Mapping of the tissue elasticity distribution can provide more information for differentiation of focal pancreatic masses
  • RTE can be used to target EUS-FNA biopsy into stiffer regions of the pancreas suspicious for malignancy

HI-RTE illustrates the malignant nature of this large upper mediastinal lymph node (patient with oesophageal ca)

Large pancreatic cancer visualised using the linear echoendoscope

A ductal adenocarcinoma of the pancreas as visualised using the Real-time Tissue Elastography mode with ultrasound endoscopy

Thyroid nodules are very common, but less than 5% are malignant. Conventional US can predict malignancy with high specificity in less than 20% patients.

  • RTE can provide quick and easy characterisation of thyroid nodules thereby allowing identification of patients at high risk of malignancy
  • A low elasticity score on RTE (stiff lesion) has been shown to be highly predictive of malignancy
  • An entirely elastic nodule pattern has been observed only in relation to benign nodules, in which case the indication for a biopsy is questionable
  • In a multinodular goiter, high true positive results have been achieved when RTE is used to target a particular nodule for biopsy which is hard on RTE



Complex multinodular thyroid glands showing mixed elasticity patterns. High true positive results have been achieved when RTE is used to target a particular nodule for biopsy which is hard on RTE:




Hitachi’s Real-time Tissue Elasticity is the only elastography with the dynamic range necessary to provide strain images with the subtle detail you require.

Examples of other clinical areas where preliminary studies have shown RTE to be a promising diagnostic tool are shown below, all acquired using standard ultrasound imaging transducers.


Musculoskeletal: HI-RTE is emerging as a promising method for the diagnosis of acute muscle injury and support for the clinical and therapeutic follow-up of muscular lesions. Here HI-RTE illustrates the complex appearance of a resolving tear, 2 months old, in the left pectoral muscle.

Musculoskeletal: HI-RTE has been shown to be a sensitive method for assessment of intratendinous Achilles tendon alterations in achillodynia and correlates well with MRI and US. Here an example of Achilles tendinopathy in the sagittal view.


Liver: Biopsy proven Metavir stage F0. Real time elastography is a new and promising method for the characterization of liver fibrosis in chronic hepatic diseases.

Liver: Biopsy proven Metavir stage F4. The strain image becomes patchy with an increasing number and size of blue (stiff) areas with increasing fibrosis.


Endo-anal: Differences in the tissue elasticity of the internal anal sphincter can be imaged by HI-RTE, with red representing normal soft tissue, and blue representing a sphincter defect as seen in the upper left quadrant.

Cervix: The normal cervix has been shown to be 'softer' on elastography when compared with patients with cancer of the cervix, and in pregnancy, first results point to a 'softer' cervix in cases of insufficiency as shown above