Mindray Elastography Solution

Ariana Jang
Clinical application specialist
General imaging in Global UIS Clinical Academic Department
Table of contents

• NTE (Natural touch elastography)

• STE (Sound touch elastography), STQ (Sound touch quantification)

• Clinical application
 NTE
Natural Touch Elastography

Strain Elastography
 NTE: Natural touch elastography

Strain elastography (also known as tissue strain elastography/static elastography/compression elastography)

Compression Strain map

1) Strain elastography
• Soft objects → High strain
reconstructs a ‘strain map
• Hard objects → Low strain
(elasticity map)’ by calculating
the deformations caused by a
static compression imposed by
the operator via the ultrasound
transducer

Soft Hard
Bigger deformation Smaller deformation
2) Lesion stiffness is expressed
on a color scale for qualitative
assessment

3) Strain imaging is a relative technique.

Reflects relative stiffness compared with other tissues in the
field of view (expressed as lesion-to-fat strain ratio “strain
ratio”) for semi-quantitative assessment.
Acquisition

Excitation Acquisition Analysis

Static compression imposed by Static elastography reconstructs 1) Elasticity score (Tsukuba score )
the operator via the ultrasound “elastogram” or ‘‘strain image’’ by
array calculating the deformations

Compression (Stress)
Score 1 2 3 4 5

Strain 2) Strain ratio

Relative numerical value to the stiffness
(tissue elasticity)
 Classification by interpretation

1. Elasticity score (Tsukuba score, Strain pattern )

• Based on color or grayscale elastography images, and a
diagnosis is made based on the assessed score.
• A five or four-point scale that visually grades the stiffness of a
mass.

2. EI/B ratio (width ratio, length ratio)

• Grayscale images from elastography are compared with B-
mode images, and a diagnosis is made based on the size ratio
of the target lesion

3. Strain ratio
• Relative numerical value to the stiffness (tissue elasticity) ROI A: Lesion, ROI B: Fat
B/A: fat-lesion ratio
• Semi-quantitative method for numerically evaluating how
many times stiffer a target mass is compared to subcutaneous
fat Breast Thyroid
Fat-lesion ratio (FLR) Parenchyma-to-nodule strain ratio (PNSR)
muscle-to-nodule strain ratio (MNSR)

Ref) WFUMB GUIDELINES AND RECOMMENDATIONS FOR CLINICAL USE OF ULTRASOUND ELASTOGRAPHY: PART 2: BREAST. PART 4: THYROID
 Classification by interpretation -Breast
Graphic depiction of the Tsukuba score (Elasticity score) (Itoh, Ueno et al. 2006)

This scale combines the size ratio changes and degree of stiffness of the lesion
▪ Scores of 1 to 3 are classified as probably benign
▪ It is recommended that lesions with scores of 4 or 5 be biopsied (Itoh,Ueno et al. 2006).

• Score1 : The lesion has a soft lesion

• Score2 : The Lesion has a mixed pattern
• Score3 : The lesion that is hard but smaller on the elastogram
• Score4 : The lesion is hard and the same size on elastography as in B-mode
• Score5 : The lesion is hard and larger on elastography
• A tri-laminar appearance of blue, green, and red (BGR) is identified in cysts (tri-color artifact)

Ref) WFUMB GUIDELINES AND RECOMMENDATIONS FOR CLINICAL USE OF ULTRASOUND ELASTOGRAPHY: PART 2: BREAST
 Classification by interpretation -Thyroid
Five-pattern scoring system for strain elastography (Itoh et al. 2006)

• Score 1 : The nodule is entirely soft (green)

• Score 2 : The nodule is mostly soft (green, with some blue areas)
• Score 3 : The nodule is only soft at the periphery (blue core, green periphery)
• Score 4 : The nodule is entirely rigid (blue)
• Score 5 : The nodule and the surrounding tissue is rigid (blue)

Four-pattern scoring system for strain elastography (Rago and Vitti 2008; Rago et al. 2007)

• Score 1 : The nodule is entirely green

• Score 2 : The nodule is mostly green, with some blue areas
• Score 3 : The nodule is mostly blue, with some green areas
• Score 4 : The nodule is entirely blue
Ref) WFUMB GUIDELINES AND RECOMMENDATIONS FOR CLINICAL USE OF ULTRASOUND ELASTOGRAPHY: PART 4: THYROID
 NTE Mindray technology highlights

Excitation Acquisition Analysis

Natural Touch Pressure indicator Shell Analysis

▪ No manual compression ▪ Strain E Curve: Display the intensity and ▪ Provide the stiffness of the surrounding
▪ Compression by carotid pulsation, stability of the pressure for acquiring an tissue of malignant breast lesions
respiratory movements adequate elastography image ▪ A good tool for assessment of infiltrating
breast tumor

• Clinical application: Breast, Thyroid, MSK, Prostate, Uterus

Clinical Images

Strain ratio in Thyroid Parenchyma-to-nodule strain Strain ratio in Breast fat-lesion strain ratio (FLR))
ratio (PNSR) and muscle-to-nodule strain ratio (MNSR)
ROI A: Lesion, ROI B: Fat, B/A: fat-lesion ratio
ROI A: Nodule, ROI B: Parenchyma, B/A: Parenchyma-
to-nodule strain ratio (PNSR)
Cutoff values: Breast, Thyroid

▪ Shanghai Jiaotong University Ruijin Hospital Affiliated to school of Medicine

▪ Use of Resona7, L11-3U
▪ 5-point scoring: 1-3 points-Benign, 4-5 points-Malignant
▪ Strain ratio

Breast
Strain ratio: > 3.73 points, suggesting malignancy

Thyroid
Longitudinal section
Strain ratio: >1.90 (all nodules); >1.95 (≥ 1cm nodule)
 STE
Sound Touch Elastography

STQ
Sound Touch Elastography Quantification

Shear Wave Elastography

Shearwave elastography
Shear wave elastography (SWE) is a new elastic imaging technology, which can quantitatively measure tissue
hardness with adequate repeatability

1) SWE uses an acoustic radiation force pulse

sequence to generate shear waves, which
propagate perpendicular to the ultrasound
beam, causing transient displacements.

Acoustic
radiation
force

2) Shear waves propagate faster 3) These measurements can be expressed in elasticity (kPa) or
Shear wave
through stiffer contracted tissue shearwave velocity (cm/s). Advantages of this technique are the
independence of tissue compression, the presence of quantitative
data and the direct assessment of elasticity
 Shear wave Elastography

Point shear wave (STQ) 2D shear wave (STE)

Excitation in Single focal location In multiple focal zones

Elastogram Does not show an image of stiffness Real time visualization of a color box; quantitative
elastogram superimposed on a B-mode image
stiffness information

Became available in 2008 Currently newest SWI method

Acquisition

Excitation Acquisition Analysis

Specific focused beams with high Display speed of shear wave Stiffness and Shear wave speed
intensity，lead to acoustic and/or elasticity map
▪ Quantitative values calculated for the
radiance force and act as the Shear wave speed determined by stiffness
source of shear wave with high- in Shear Wave Elastography
quality.
▪ kPa (unit of stiffness), m/s (unit of SWS)

Acoustic
radiation
force

Shear wave
Interpretation -Breast, Thyroid

SWE has been shown to be useful for differentiating benign

breast lesions from malignant breast lesions and in
detecting malignant thyroid nodules
• kPa (unit of stiffness), m/s (unit of SWS) :Quantitative values
calculated for the Shear wave speed determined by stiffness in Shear
Wave Elastography system.

•The best performing SWE features are the quantified maximum

stiffness of the lesions (inside or on the periphery)
Interpretation -Liver

Shear wave elastography is a non-invasive method to assess

the staging, progression, prognosis, and follow-up of liver
fibrosis with good sensitivity and reproducibility
• For STQ, the median value of at least 10 measurements should be used.

• For STE, the analysis box should be set to at least 10 mm, preferably 15
mm or more. A round shape is usually chosen.

• For STE, a minimum of 3 measurements should be obtained and the

final result should be expressed as the median together with the
interquartile range.

• An IQR/Med < 30 % of the measurements is the most important

reliability criterion
 STE / STQ Mindray technology highlights

Excitation Acquisition Analysis

High frame rate STE Quality control Quantification analysis
▪ Allows fast detection of all necessary ▪ M-STB: Indication for the stability of ▪ Shell analysis for Breast: A good
shear wave information in the ROI. tissue motion tool for assessment of infiltrating
▪ Excellent penetration capability, which ▪ RLB Map & Index: Indication of the breast tumor
ensures better elasticity images and reliability of shear wave ▪ Measurement results: ROI depth,
measurement results. ▪ Elasto bar: Elasticity analysis in ROI size, E mean/max/min
▪ onsistent STE brings more confidence in multiple frames to improve the ▪ Overall statistics: Median, IQR,
clinical diagnosis accuracy and reliability IQR/Median, Average, STD,
STD/Average
HQE Mode A’ A Shell
▪ Dedicated modes for Better penetration

• Clinical application: Breast, Thyroid, MSK, Liver, Prostate

 STE / STQ -Quality map Mindray technology highlights

M-STB index (Motion Stability Index) RLB Map, RLB Index and RLB View
helps to monitor the image stability, which can help the user intuitively and quantitatively
may be affected by patient’s respiration and verify the quality of shear wave elastography.
transducer movement during STE acquisition.
RLB Map: Purple area indicates a
region of low reliability

RLB View: Automatically

hollow an unreliable
region in STE map (e.g.
blood vessel)
→ Measurement result
is not affected by the
hollowed region.

M-STB Green stars-better motion stability, Red stars-poor motion stability The RLB index >80%
provides a more
reliable image
STQ image STE image
Clinical Images

Malignant tumor in breast with hard shell Cirrhosis of liver with elastic modulus more than 21 KPa
Cutoff values: Liver
STE/STQ Diagnostic Reference Standard for Liver Fibrosis Staging in Chronic Viral Hepatitis B patients

Mindray and the Intervention Group of Chinese Society of Ultrasound Medicine of Chinese Medical
Association co-sponsored a large sample study, in collaboration with 26 centers and units throughout China,
and collected 510 qualified cases. After analysis is made in accordance with the golden standard (namely,
liver biopsy pathology METAVIR staging), the following STE/STQ diagnostic standard for staging of liver fibrosis
in chronic viral hepatitis B patients is recommended as a reference.
Notes
1. In the study, Youden Index analysis is applied to
1. Normal liver stiffness reference criteria: acquire the optimal cutoff values for diagnostic threshold
in F0, F2 and F4.
STE LSM< 6.5 kPa, STQ LSM <7.4 kPa 2. Median value of Young's modulus is applied for fibrosis
staging.
3. The prerequisite of above reference criteria: ALT < 2
2.Liver stiffness diagnosis > F2 (significant liver fibrosis) reference criteria: times upper limit.
STE LSM> 8.3 kPa, STQ LSM >8.5 kPa 4. Apart from the diagnostic reference criteria above,
clinical diagnosis should be made in combination with
clinical data.
3. Liver stiffness diagnosis F4 (cirrhosis) reference criteria: 5. The Liver Stiffness Measurement (LSM) may be
affected by jaundice, ascites, intestinal gas, obesity and
STE LSM> 10.3 kPa, STQ LSM >11.7 kPa other factors. The criteria above are only for a reference
while physicians make diagnosis in combination with
clinical evaluation.
Cutoff values: Breast, Thyroid

▪ Shanghai Jiaotong University Ruijin Hospital Affiliated to school of Medicine

▪ Use of Resona7, L11-3U
▪ STE cutoff values

Breast
Shell 2mm, Emax > 98.66kPa suggesting malignancy

Thyroid
Shell1mm, ≥1cm, Emax ≥45.5kPa, Emean ≥39.3kPa
Clinical application
Breast
MSK
Liver
Prostate
 Breast -Paper

• Used system: Mindray, Philips ,Siemens, GE, SuperSonic and B&K

• In our experience, the 2D SWE systems from multiple vendors provide similar
results with less inter vendor variability compared with SE.

In conclusion,
both high sensitivity and specificity for breast lesion characterization can be obtained by
combining results from SE and 2D SWE, which has important implications for patient
treatment, with the potential for substantially decreasing the number of breast biopsies with
negative results, thereby improving patient care, reducing patient anxiety,
and saving health care dollars.
Knowledge of false-positive and false-negative lesions also improves the accuracy of
interpretation.

Received August 5, 2019, from the Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio,
USA; and Southwoods Imaging, Youngstown, Ohio, USA. Manuscript accepted for publication September 9, 2019.
Breast -2021 Mindray Breast elastography webinar

Conclusion

▪ Both SE and SWE provide additional information on breast lesion

characterization. Technique is critical. Always done in conjunction
with B-mode.
▪ Strain has the highest sensitivity
▪ Shearwave has the highest specificity
▪ There is a significant improvement in the sensitivity of SWE with the
addition a Quality map.
▪ The combination of SE and SWE may increase confidence and
accuracy.
 Breast -Webinar lecture

NTE
Natural Touch
Elastography

STE with
Reliability map
(Quality map)
Sound Touch
Elastography
Breast -Webinar lecture

Tips to use Elastography on Resona7

Breast -2021 Mindray Breast elastography webinar
MSK -2021 Mindray MSK elastography webinar
• Used Linear transducers
• Both Strain & Shearwave Elastography can be used
Strain imaging Shear wave imaging
FOV includes several layers of tissues FOV is similar to strain imaging
Avoid bone No pre-compression
A standoff gel pad if needed Repeat 2-3times to acquire reliable result
No pre-compression Adjust stiffness scale

• Not all part of MSK

✓ Tendons: Achilles tendon/PT/CET
✓ Muscle: Biceps/MHG (dynamic during muscle contraction)
✓ Ligaments, fascia
✓ Nerves
• Main topic at this session is about Tendon/Muscle
• Conclusion
- Both strain and shearwave elastography have been shown to
improve understanding properties of MSK lesions
- Both techniques have advantage and disadvantage (very operator
dependent)
Achilles tendon in Strain & Shearwave elastography imaging - Further work is needed
Liver -SRU Recommendation

This statement is an update recommendations on the

use of ARFI to the SRU SWE for the assessment of
fibrosis in patients with diffuse liver disease, as a guide
for performing and interpreting the examination, taking
into account the interim technology advances and
published studies.
 Liver -SRU Recommendation

Cut off values

Recommends a vendor-neutral rule of four for interpretation for ARFI
techniques.
Rule of four (5, 9, 13, 17 kPa) for the ARFI techniques
Used system: Mindray, Philips , Siemens, Toshiba, Hitachi, Samsung, Supersonic

STE with quality criteria on Resona7 system

• Indicated by stars (with the highest stability
Motion stability shown with five green stars)
(M-STB) index • The stars are an indicator of motion during the
acquisition
Reliability (RLB) • From purple to green
map • Green color indicating the highest reliability.
Prostate - Mindray White paper

High diagnostic accuracy of shear wave elastography (SWE) for the detection of prostate cancer

• STE available on prostate application of V11-3HU, DE10-3WU endocavity probe and ELC13-4U* biplane transrectal probe

Benign prostatic hyperplasia Prostate cancer

It shows the normal prostate gland. From the cross section, STE image of the prostate in the longitudinal section using
the inner gland is stiffer than the peripheral zone, and the Biplane transrectal probe
boundary between the inner gland and peripheral zone is
clear

*ELC13-4U biplane transrectal probe

The end