Women's Health

4D
4D imaging is supported on all platforms by dedicated lightweight, ergonomic transducers to cover the full gestational range. Features that increase the diagnostic value of this modality include Real-time high definition 3D, advanced modes such as MPR / MULTISCAN, and easy storage and retrieval of 3D volume data.
Real-time Tissue Elastography (RTE)
In breast applications, Real-time Tissue Elastography has been shown to improve the accuracy in differentiating between benign and malignant tumours, especially for tumours less than 1 cm, and to improve the specificity compared to US BIRADS classification for benign lesions. As a result, elastography can reduce the biopsy rate in atypical cysts, and may suggest appropriate workup for cancers with an atypical presentation. Preliminary data has shown that the normal cervix is “softer” on elastography in comparison with patients with cancer of the cervix.
Radial Ductal Echography
The role of ultrasound in breast investigation is limited by different factors: its analysis and interpretation present several difficulties, the results are often not easily reproduced, and the quality is highly dependent on the skill of the operator. Moreover, in conventional breast ultrasound, transverse and longitudinal scans are performed perpendicularly to the ductal course.
This mode of scanning cannot match the radial arrangement of the breast anatomy. Cancers are detected only when they have sufficient volume, show abnormal contrast and are perceptible whatever the orientation of the sweep.
An anatomically led method of investigation based on the identification of the internal mammary structures, Ductal Echography, was introduced in 1987 by Dr Teboul. This technique is based on radial scanning with scans performed along the ductal axis. With this technique, the observer actively investigates the epithelial structures by systematically following the ductal system in each mammary lobe. Ductal Echography allows the practitioner to visualize, delineate and hence to differentiate the lobe, Cooper’s ligaments, the fasciae (superficialis and pectoralis), the fat tissue and the chest wall.
This technique offers huge advantages:

• Understanding of the anatomy
• Analysis of any changes in the lobes or ducts
• Detection of pre-tumoural or suspicious lesions at a very early stage
• Good reproducibility
• Accurate localisation of the lesion

To perform a radial scanning technique around the nipple, a long linear, high frequency transducer, such as the L53L is the best choice. In addition, a fixed waterbag is available providing:

• Perfect contact between the skin and the transducer as the water-bag conforms to the shape of the breast.
• Reduction of artefacts from the skin and shadowing behind the Cooper’s ligaments.
• Better visualization of the ducts within the nipple and good visualization behind the areolar region
• Improved contrast resolution

1. Ami O., Lamazou F., Mabille M., et al. Real-time transvaginal elastosonography of uterine fibroids. Ultrasound Obstet Gynecol 2009; 34: 486–488
2. Cho N., Moon W.K., Park J.S., et al. Nonpalpable breast masses: evaluation by US elastography. Korean J Radiol, March 1, 2008; 9(2): 111-8.
3. Cho N., ., Moon W.K., Park J.S. Real-time US elastography in the differentiation of suspicious microcalcifications on mammography. Eur Radiol. 2009 Jul;19(7):1621-8.
4. Cho N., Moon W.K., Kim H.Y., et al. Sonoelastographic strain index for differentiation of benign and malignant nonpalpable breast masses. . J Ultrasound Med 2010; 29:1–7
5. Chung SY, Moon WK, Choi JW, et al. Differentiation of benign from malignant nonpalpable breast masses: a comparison of computer-assisted quantification and visual assessment of lesion stiffness with the use of sonographic elastography. Acta Radiol. 2010 Feb;51(1):9-14.
6. Farrokh A,Wojcinski S, Degenhardt F. Diagnostic value of strain ratio measurement in the differentiation of malignant and benign breast lesions. Ultraschall Med. 2010 Apr 27.
7. Havre R.F.,Elde E., Gilja O.H., et al. Freehand real-time elastography: impact of scanning parameters on image quality and in vitro intra- and interobserver validations. Ultrasound Med Biol. 2008 Oct;34(10):1638-50.
8. Itoh A., Ueno E., Tohno E., et al. Breast disease: clinical application of US elastography for diagnosis. Radiology 2006;239:341-350
9. Moon W.K., Huang C-S., Shen W-C., et al. Analysis of elastographic and B-mode features at sonoelastography for breast tumor classification. Ultrasound Med Biol, 2009 Nov;35(11):1794-802
10. Raza S., Odulate A., Ong E., et al. Using real-time tissue elastography for breast lesion evaluation. Our initial experience. J Ultrasound Med 2010; 29:551–563
11. Scaperrotta G., Ferranti C., Costa C., et al. Role of sonoelastography in non-palpable breast lesions. Eur Radiol. 2008:18 (11); 2381 - 9
12. Tan S.M., Teh H.S., Kent Mancer J.F., et al. Improving B mode ultrasound evaluation of breast lesions with real-time ultrasound elastography- a clinical approach.The Breast; 17 (2008):252 – 257
13. Thomas A., Fischer T., Frey H., et al. Real-time elastography - an advanced method of ultrasound: first results in 108 patients with breast lesions. Ultrasound Obstet Gynecol 2006, Sep;28 (3): 335-340
14. Thomas A.Picture of the month: Imaging of the cervix using sonoelastography. Ultrasound Obstet Gynecol 2006, Sep;28 (3): 356-357
15. Thomas A., Kümmel S., Fritzsche F., et al. Real-time sonoelastography performed in addition to B-mode ultrasound and mammography: improved differentiation of breast lesions? Acad Radiol. 2006 Dec;13(12):1496-504
16. Thomas A., Kümmel S., Gemeinhardt O., et al. Real-time sonoelastography of the cervix: tissue elasticity of the normal and abnormal cervix. Acad Radiol 2007; 14:193–200
17. Thomas A, Degenhardt F, Farrokh A, et al. Significant differentiation of focal breast lesions: calculation of strain ratio in breast sonoelastography. Acad Radiol. 2010 May;17(5):558-63. Epub 2010 Feb 20.
18. Wojcinski S, Farrokh A, Weber S, et al. Multicenter study of ultrasound real-time tissue elastography in 779 cases for the assessment of breast lesions: improved diagnostic performance by combining the BI-RADS®-US classification system with sonoelastography. Ultraschall Med. 2010 Apr 20.
19. Yamaguchi S., Kamei Y., Kozuma S., et al. Tissue elastography imaging of the uterine cervix during pregnancy. JMed Ultrasonics (2007) 34:209–210 Ultrasound image of the month
20. Zhi H., Ou B., Luo B., et al. Comparison of ultrasound elastography, mammography, and sonography in the diagnosis of solid breast lesions. J Ultrasound Med 2007; 26: 807–815
21. Zhi H., Xiaa XY., Yang H-Y., et al. Semi-quantitating stiffness of breast solid lesions in ultrasonic elastography. Acad Radlol 2008; 15:1347-1353
22. Recommended reading:
    M. Teboul, Practical ductal echography, guide to intelligent and intelligible ultrasonic imaging of the breast, editorial Medgen, 2004, pp. 15-98