Shear Wave Elastography

SWM, ATT, Combi-Elasto

March 2019
Dawn Koo
Clinical Applications Manager
Ultrasound Solutions Division
HMSS
Liver diseases ~

According to WHO ( World Health Organization), 71 million people are

chronically infected with the hepatitis C.
In a study, approximately 230,500 Australians are living with chronic hepatitis C,
which is defined as having had the infection for longer than six months-of whom
85% have been diagnosed.
Approximately 10 000 new HCV infections occur in Australia per year, with 95%
due to injecting drug use-only 3760people with chronic HCV infection (less than
2%) are treated each year in Australia.

Hepatitis C
~ Develops after infected with Hepatitis C virus
~ No vaccination for Hepatitis C
~ Infection maybe acute or chronic
Liver disease
Clinical care for patients with liver disease has advanced over the years with
better understanding of the pathophysiology of the diseases and the
developments in diagnostic procedure and improvements in therapy and
prevention ~ EASL (The European Association for the Study of the Liver, 2018)

Push
pulse

Shear
Wave

Shear wave measurement

Liver diseases progression

~ Progression of liver disease~

NAFD ( Non-alcoholic fatty liver disease)

NASH ( Non- alcoholic steatohepatitis)

Liver Cirrhosis

Hepatocellular carcinoma
Evaluating Liver diseases by Combi-Elast
➢ A comprehensive, non-invasive method of evaluating diffuse liver
disease by integration of RTE & SWM
➢ Same acquisition position method as Real time Elastography
➢ Provides additional quantitative indices ~ Fibrosis F index ,
Inflammation A index & ATT index ,corresponding to dense fatty liver

© Hitachi Medical Systems (S) Pte Ltd. 2019. All rights reserved. 4
Combi Elasto

Measurement result display

History of measurement
F : F Index
A : A Index
M : Median of multiple measurements
IQR/M : IQR divided by median (%)

Measurement results

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Combi Elasto

Shorten examination with Workflow Automation

Elasto mode

Move ROI to measurement area

Combi-Elasto
Freeze

Select appropriate frame

Move ROI to
Set measurement ROI
measurement area
Press measurement button

Display LE INDEX

Freeze OFF UPDATE

SWM mode

Move ROI to measurement area

UPDATE
Display result Combi-Elasto
Display Vs 4 steps
Conventional Steps
12 steps

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New Advanced Features - Radiology

Liver disease
Fatty liver Hepatitis Fibrosis Cirrhosis
ATT A Index
F Index
LFI
Vs
Combi-Elasto can provide multiple information
related to liver condition by liver disease event.
• LFI : Liver fibrosis Index calculated from total amount of strain histogram
• Vs : Shear wave propagation velocity (median of the Vs)
• F Index: Index related to fibrosis stage calculated from combination of total amount of
strain histogram and Vs.
• A Index : Index related to activity grade calculated from combination of total amount of
strain histogram and Vs.
• ATT : Attenuation value (degree of attenuation)
© Hitachi Medical Systems (S) Pte Ltd. 2019. All rights reserved. 7
Combi-Elastography

A comprehensive evaluation of diffuse liver disease. Provides quantitative

indexes corresponding to fibrosis F value and inflammation A value (F index
and A index), plus Quantitative index corresponding to fat amount (ATT).

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Attenuation Measurement Function (ATT)

➢ Assess Hepatic fatty infiltration by estimating the attenuation coefficient,

represented by an index, ATT
➢ The higher the value is, the more severe fatty metamorphosis is.

Signal Intensity 50 % 25 %
75 %

0%

40 cm
Depth Below Skin

Attenuation of normal liver is

approx. 0.5～0.6 (dB/cm/MHz)
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Combi Elasto – Demo Experiences

Combi Elasto introduced in HMSE on December 2017

Principal evaluations in HMSE:
• Prof. Paul Sidhu – Head of Radiology dept. King’s College
Hospital London United Kingdom. He has published
extensively on many aspects of Ultrasound particularly in
relation to male health and liver transplantation, and has
pioneered the introduction of contrast-enhanced ultrasound in
the United Kingdom. He is recognised as a world authority in
the application of contrast-enhanced ultrasound in clinical
practice.
• Prof. JM Correas - Professor of Radiology at the Paris-
Descartes University and is vice-chairman of the Department of
Adult Radiology in Necker University Hospital, Paris, France.
He was deeply involved in the development of interventional
uroradiology and minimally invasive treatment of renal tumors.
He performed more than 400 ablative procedures of renal
masses. Speaker of the Hitachi Symposium at ECR

Courtesy of Luca G. HMSE

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Combi Elasto

Combi Elasto introduced in HMSE on December 2017

Principal evaluations in HMSE:
• Prof. Christoph F. Dietrich – Caritas-Krankenhaus Bad
Merghentheim – Germany. Head of the 2nd Department of Medicine.
• He is a specialist in gastroenterology & proctology, hematology
oncology & palliative care, pneumology and geriatric medicine.
His scientific career is focused on endoscopy and ultrasound
(EUS) CEUS and Elastography. Editor of 13 books translated
and published in German, English, Spanish and Czech. He is
author of more than 600 scientific papers and book chapters.
President of the German Association for Endoscopy (DGEBV)
and President of the European Federation of Societies in
Ultrasound Medicine and Biology (EFSUMB). He is currently
member of the WFUMB Administrative Council. Christoph F.
Dietrich is Professor honoris causa at Zhengzhou university,
China and honorary member of the Polish Society of
Ultrasound.

Courtesy of Luca G. HMSE

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Clinical Findings ~ SWM of Liver

“Shear wave elastography with a new reliability indicator” ~

Christoph F.Dietrich, Yi Dong
Mass Push Mass
pulse
~ Data can be reliably measured in 92% of
subjects Shear
Wave
~ Healthy subjects shows values < 7.1 kPa;
Liver cirrhosis cases >13.8kPa
~ Cutoff Results correspond well with other Hitachi Shear Wave Measurement

equipment from Siemens, GE, Supersonic

~ Significant overlap of results in lower
fibrosis patient ( similar to other vendor)
~ Use of a reliability indicator is reproducible
in the studies, even for very stiff tissues
~ Journal of Ultrasonography 2016
Combi Elasto

Combi Elasto introduced in HMSE demos on January 2018

Principal evaluations in HMSE:
• Dr. Giovanna Ferraioli - Infectious Diseases Dept., IRCSS Policlinico
S. Matteo, University of Pavia, Italy
• She is actually one of the principal researcher about new
ultrasound techniques in liver fibrosis. She has a a very strong
reputation at international level. Member of international board
of WFUMB for elastography, The department is focused in
Liver Elasto (Transient, Shear Wave, Strain), He is one of the
author of the elastography compendium book. They were
involved in many clinical trials for Hitachi. She is currently
leading the clinical project of establishing cut off values for
Combi Elasto. She was the speaker at Hitachi Symposium at
ECR to launch the new method.
• Main target of the study: Clinical validation of the method and
creation of the Cut Off values for Combi Elasto (E, ATT, LFI, F
Index and A Index)

Courtesy of Luca G. HMSE

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Clinical Findings~ SWM of Liver
“Non-invasive staging of liver fibrosis in patients with chronic viral hepatitis:
performance of a shear wave measurement method ” ~ G.Ferraioli, L.Maiocchi, R.
Lissandrin, A.De Silvestri, C.Tinelli,C.Filice; Pavia/IT

A study on 411 patients with majority of them affected by Chronic Hepatitis C

High correlation between Velocity Shear wave (Vs) of SWM with FibroScan results.
Cutoff kPa: F#2~6.44; F#3 ~7.82; F=4~ 8.4.
Results show that SWM is a useful tool for staging liver fibrosis non-invasively in
patients with chronic viral hepatitis

The ARUOC of the SWM method for the staging

of significant fibrosis F#2 & Liver cirrhosis F=4
Courtesy of Dr. Norihisa Yada, et all
 Clinical Findings –SWM of Liver

Median values of liver stiffness

Study based on 445 patients
Reliability index VsN > 50% improves diagnostic performance of SWM

SWM, kPa Ruling-

Fibrosis Stage Ruling-in Ruling-in Ruling-out
(interquartile range) out
F≥2 F=4 F=4
F≥2
(95% CI) (95% CI) (95% CI)
(95% CI)
Mild/No fibrosis (F0-F1) 4.8 (4.0-5.7)

Significant fibrosis (F2) 7.2 (5.7-9.0) Cutoff, KPa 6.78 5.55 9.15 8.41

Advanced fibrosis (F3) 8.5 (6.7-9.5) Sensitivity 76.9 90.6 83.3 90.6

Liver cirrhosis (F4) 14.0 (11-17) Specificity 90.3 72.2 90.1 82.2

Ferraioli et al., J Gastrointestin Liver Dis, 2017

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 Clinical Findings~ SWM of Liver
“A Newly Developed Shear Wave Elastography Modality : With a Unique
Reliability Index” ~ Norihisa Yada, Toshiharu Sakurai Tomohiro Minami etc
Oncology 2015

High correlation between Velocity Shear wave (Vs) of SWM with Vs from different
devices. High success rate of measuring SWM for 168 patients @ 97.6 %.

VsN Allows user to determine the reliability of the measurement, resulting in greater
accuracy

The absolute average value of the difference between Vs of SWM and other companies Vs.
Courtesy of Dr. Norihisa Yada, et all
 Clinical Findings~ SWM of Liver
“Usefulness of SWM /ATT considered from a clinical standpoint ”
~ Clinical Report

Hitachi’s diagnostic system can evaluate fatty liver and

liver fibrosis non-invasively and easily by simultaneously
measure SWM & ATT. Extremely useful clinically to
monitor progression of liver disease from fatty liver to
fibrotic stages.

Having Vsn as a reliability index, an error processing

technology makes it possible to evaluate liver tissue with
reliability and reproducibility. An index, ATT ,a measurement
indicator for fatty liver can be easily obtained with the
superior operability of system.
Validation test ~ATT
Validation Test Using Phantoms
Method
1. Measure attenuation coefficient values of five reference phantoms* (Types A-E) at ten
scanning planes by using ATT. * OST’s Model SOPT-068 with attenuation coefficient
of them were controlled prior to the test.
2. Calculate the following based on the data taken:
- Average values of the attenuation coefficient
- %CV which is calculated from standard deviation divided by average value and
determines reproducibility.
- ΔATT which shows difference between the attenuation coefficient value and the
actual data measured by the phantom vendor
Condition Device: ARIETTA 850, Probe: C251, Measuring depth: 40 mm – 100 mma

Average attenuation coefficient %C V AND ΔAT T

Vendor Measured value %CV [%] ΔATT [%]
value
メーカー実測値 平均値(10回計測） 変動係数 %CV [%]

[dB/cm/MHz] [dB/cm/MHz] メーカー実測値との誤差 ⊿ATT [%]

2 30 30
25
ATT [dB/cm/MHz]

%CV [%]

ΔATT [%]
20
15 10
1 10
5
0 -10
0 Type Type Type Type Type
Type A Type B Type C Type D Type E A B C D E

Phantom Type
Phantom Type

Test results: Precision (%CV): 7-15%, ΔATT: within ±10%.

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 Combi Elasto

Provides the comprehensive evaluation of diffuse liver diseases.

P<0.001 P<0.001
The F Index to estimate liver fibrosis
showed a significant upward trend with
fibrosis stage.
The A Index estimating the level of
inflammation also showed a similar trend as
the activity grade.

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Combi Elasto
Combi-Elastography (SWM + RTE) on Liver
The combined use of RTE and SWM offers a new approach to noninvasive
assessment of liver fibrosis. Combining these 2 methods allow
comprehensive diagnosis of liver disease.

SWM (Vs / kPa) RTE (LF Index)

▪ Shear Wave Speed ❖ Strain Imaging method.

Measurement method.
❖ LFI reflects the progression of liver
▪ SWM is influenced not fibrosis and is not significantly
only by fibrosis but also influenced by inflammation,
inflammation, jaundice or jaundice or congestion
congestion

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© Hitachi Medical Systems (S) Pte Ltd. 2019. All rights reserved.
Shear Wave Measurement ~ Thyroid & MSK

Thyroid gland MSK

Courtesy of Peter Belov, Russia

© Hitachi Medical Systems (S) Pte Ltd. 2019. All rights reserved. 21
Thank you

© Hitachi Medical Systems (S) Pte Ltd. 2019. All rights reserved. 23