Quick Guide

NTE Natural
Touch
Elastography

Breast
STE Sound
Elastography Touch
Elastography

STQ Sound
Touch
Quantification
Mindray Tools

Natural Touch Elastography (NTE)

Strain Elastography (SE)
Stable real-time
Natural touch Pressure indicator Unique shell analysis
visualization
 No manual  High quality B/Elasto  Strain E Curve: Display  Provide the stiffness of
compression image the intensity and the surrounding tissue of
 Compression by  Relative strain in the stability of the pressure malignant breast lesions
respiratory movements tissue is displayed in for acquiring an  A good tool for
color coded image adequate elastography assessment of infiltrating
image breast tumor

Sound Touch Elastography(STE) & Sound Touch Quantification (STQ)

Shearwave Elastography(SWE)
High frame rate & Quantification
Real time imaging Quality control
Better penetration analysis
 More diagnostic  HFE (High frame rate  M-STB: Indicator for  E-Avg: Statistics of
information Elastography): Shear the stability of tissue multiple measurements
 Immediate results in a wave imaging obtains motion resulted from serial
real-time with good high frame rate for real-  RLB Map/Index: frames
reproducibility time Indicator of the reliability  Measurement results:

 Generate a real time  HQE (High quality of shear wave ROI depth, ROI size, E
quantitative map of Elastography):  Elasto bar: Elasticity mean/max/min
tissue stiffness Improvement in the analysis in multiple  Overall statistics:
penetration of shear frames to improve the Median, IQR,
wave, Diagnosis for hard, accuracy and reliability IQR/Median, Average,
deep and large tumors STD, STD/Average
 Shell quantification
toolbox
 Report

Natural Touch Sound Touch

Elastography Elastography
NTE Protocol

Use NTE enabled transducer and system, select Breast exam

Keep the probe lightly touching the skin and still, try not to apply pressure or give
“minimal vibration”

Touch the “Elasto” and choose “StrainE” on the touch screen

The ROI should partly include subcutaneous tissue and the pectoralis muscle

No need to hold the breath, Compression by respiratory movements

If necessary, adjust “Opacity” and “E scale” on the touch screen using knob button to
change the color transparency and elasticity

NTE Imaging needs to continue until the color of the entire target is completely stable

Freeze and select an optimal NTE image for interpretation

Press “Measure” button, choose strain ratio to classify lesions and save the result
(A: Lesion, B:Reference-Fat)

You can also classify lesions using visual scoring system which is a five-point scale that
visually grades the stiffness of a lesion (Tsukuba score=Elasticity score)

Go to the report

*Note: Features may vary depending on machine models/software version

STE/STQ Protocol

Use STE/STQ enabled transducer and system, select Breast exam

Keep the probe lightly touching the skin and still, try not to apply pressure

Touch the “Elasto” and choose “STE” on the Touch the “Elasto” and choose “STQ” on the
touch screen touch screen

The ROI should partly include subcutaneous Put the fixed ROI at the location of the
tissue and the pectoralis muscle desired measurement

Ask the patient to hold the breath Ask the patient to hold the breath

Acquire STE image when the image looks

constant and stable (Elasto bar looks Press “Update” to activate STQ
constant when Fixed-ROI is on)

Freeze image and select an optimal image, Freeze the image when the elasto bar looks
RLB index＞80% and M-STB stars show constant & stable and M-STB stars show
green green

Press “measure” button, choose “Mass” to Select a single or multiple frames using ”E
quantify maximum stiffness of the lesion Avg” knob button and save it

You can use “Shell thick” function to 5 to 10 measurements are needed to obtain
evaluate the infiltration of the lesion a median value
(2mm is recommended)

Go to the report and deselect any low

Repeat STE acquisition to get reliable result reliable result

Go to the report

*Note: Features may vary depending on machine models/software version

Guideline and Recommendations

Recommended imaging techniques

 Elastography should be performed and interpreted along with standard B-mode imaging.
 Obtain a good B-mode image to get a good elastography image.
 Keep the angle of the probe perpendicular to the skin.
 Strain Elastography
 Compression or vibration methods
• No Manual Compression - Keep the probe lightly touching the skin and try not to
apply pressure
• ‘‘minimal vibration’’ is recommended for elastography imaging of minute lesions. In
the case of deep lesions, however, ‘‘significant compression’’ may be better for
acquiring an adequate elastography image.
 ROI
• The ROI should partly include subcutaneous tissue and the pectoral muscle for a
more consistent scale range, and it should be expanded to its maximal width to
express relative values more accurately. Ribs and lungs should not be included.
 Imaging time
• Imaging needs to continue until the color of the entire target is completely stable in
order to acquire reliable results.
 Classification by interpretation
• Tsukuba score: five-point scale that visually grades the stiffness of a mass
• EI/B ratio : the ratio of the lesion size on elastography to the B-mode size
• Strain ratio: fat-lesion ratio (FLR), Numerical value to the stiffness
 Shear Wave Elastography
 Multiple measurements within the lesion and surrounding tissue need to be obtained
to acquire optimal measurements
 The best performing SWE features were the quantified maximum stiffness of the
lesions (inside or on the periphery) as E Max measurement
 Shear waves do not propagate in low viscosity liquids; therefore, simple cysts will not be
color-coded.
 Quality measure tools will help in eliminating possible false negative cases .
 Classification by interpretation: kPa (unit of stiffness), m/s (unit of shear wave speed)

Cautions
 SE should not be used if the lesion is larger than the FOV box.
 Accuracy of the SE differs between shallow sites and deep sites due to problems associated
with propagation of vibration energy.
 Elastography (SE or SWE) should not be used when a lesion is very superficial (<3 mm) from
the skin surface.

Reference: WFUMB GUIDELINES AND RECOMMENDATIONS FOR CLINICAL USE OF ULTRASOUND ELASTOGRAPHY: PART 2:
BREAST
Analysis

NTE STE & STQ

Interpretation 1) Elasticity score (Tsukuba score )
• A five-point scale that visually grades the
stiffness of a mass.
• If a lesion is classified between 1 and 3, it is
considered benign; if classified 4 or 5, it is
considered to be malignant.
Interpretation) Stiffness and Shear wave speed
• 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.

Score 1 Deformability of the entire lesion
Score 2 Deformability of most of the lesion
with some small stiff areas
• The best performing SWE features are the
quantified maximum stiffness of the lesions
(inside or on the periphery)

Score 3 Deformability of the peripheral • A : Mass area, Shell: Shell area,

portion of the lesion with stiff tissue A/Shell: A-Shell ratio, A’: Mass + Shell area
in the center

Score 4 Stiffness of the entire lesion

Score 5 Stiffness of the entire lesion and

surrounding tissue

Interpretation 2) Strain ratio

• Relative numerical value to the stiffness
(tissue elasticity)
• fat-lesion ratio (FLR)
• ROI A: Lesion, ROI B: Fat, B/A: fat-lesion ratio

Mindray Building, Keji 12th Road South, High-tech Industrial Park, Nanshan, Shenzhen 518057, P.R. China
Tel: +86 755 8188 8998 Fax: +86 755 26582680 E-mail: intl-uis@mindray.com www.mindray.com
© 2018 Shenzhen Mindray Bio-Medical Electronics Co., Ltd. All rights reserved. Contents are subject to changes without prior notice.
 Quick Guide

NTE Natural
Touch
Elastography

Thyroid
STE Sound
Elastography Touch
Elastography

STQ Sound
Touch
Quantification
Mindray Tools

Natural Touch Elastography(NTE)

Strain Elastography (SE)
Stable real-time
Natural touch Pressure indicator Unique shell analysis
visualization

 No manual  High quality B/Elasto  Strain E Curve:  Provide the stiffness

compression image Display the intensity of the surrounding
 Compression by  Relative strain in the and stability of the tissue of malignant
carotid pulsation tissue is displayed in pressure for acquiring lesions
color coded image an adequate
elastography image

Sound Touch Elastography(STE) &Sound Touch Quantification(STQ)

Shearwave Elastography(SWE)
High frame rate & Quantification
Real time imaging Quality control
Better penetration analysis

 More diagnostic  HFE (High frame rate  M-STB: Indicator for  E-Avg: Statistics of
information Elastography): Shear the stability of tissue multiple
 Immediate results in wave imaging obtains motion measurements
a real-time with good high frame rate for  RLB Map/Index: resulted from serial
reproducibility real-time Indicator of the frames
 Generate a real time  HQE (High quality reliability of shear  Measurement results:

quantitative map of Elastography): wave ROI depth, ROI size, E

tissue stiffness Improvement in the  Elasto bar: Elasticity mean/max/min
penetration of shear analysis in multiple  Overall statistics:
wave, Diagnosis for frames to improve the Median, IQR,
hard, deep and large accuracy and reliability IQR/Median, Average,
tumors STD, STD/Average
 Shell quantification
toolbox
 Report

Natural Touch Sound Touch

Elastography Elastography
NTE Protocol

Use NTE enabled transducer and system, select Thyroid exam

Keep the probe lightly touching the skin and still, try not to apply pressure or give
“minimal vibration”

Touch the “Elasto” and choose “StrainE” on the touch screen

Set the ROI as large as possible, covering the nodule together with adjacent
normal thyroid tissue

Ask the patient to hold the breath

If necessary, adjust “Opacity” and “E scale” on the touch screen using knob
button to change the color transparency and elasticity

NTE Imaging needs to continue until the color of the entire target is completely
stable

Freeze and select an optimal NTE image for interpretation

Press “Measure” button, choose strain ratio to classify lesions and save the result
(A: Lesion, B:Reference-Normal parenchyma/muscle)

Repeat at least 1 time of the SE acquirement

You can also classify lesions using visual scoring system such as Elasticity Tsukuba
score which is a five-point scale that visually grades the stiffness of a lesion

Go to the report

*Note: Features may vary depending on machine models/software version

STE/STQ Protocol

Use an STE/STQ enabled transducer and system, select Thyroid exam mode

Keep the probe lightly touching the skin and still, try not to apply pressure

Touch the “Elasto” and choose “STE” on the Touch the “Elasto” and choose “STQ” on the
touch screen touch screen

Set the ROI, covering the nodule together Put the fixed ROI at the location of the
with adjacent normal thyroid tissue desired measurement

Ask the patient to hold the breath

Ask the patient to hold the breath

Press “Update” to activate STQ

Acquire STE image when the image looks
constant and stable (Elasto bar looks
constant when Fixed-ROI is on)
Freeze the image when the elasto bar looks
constant & stable and M-STB stars show
Freeze image and select an optimal image, green
RLB index＞80% and M-STB stars show
green
Select a single or multiple frames using ”E
Avg” knob button and save it
Press “measure” button, choose “Mass” to
quantify stiffness of the lesion

5 to 10 measurements are needed to obtain

5 to 10 measurements are needed to obtain a median value
a median value

Go to the report and deselect any low

Go to the report reliable result

*Note: Features may vary depending on machine models/software version

Guideline and Recommendations

Recommended imaging techniques

 Use a 12 to 15 MHz linear probe. For SWE, a lower-frequency transducer could be used
sometimes.
 Obtain a good B-mode image to get a good elastography image.
 Use longitudinal plane parallel to the long axis of the carotid could improve the consistency
and enhance the quality of elstograms.
 Keep the probe perpendicular to the skin and tell the patients to hold breath during
acquiring the elastography.
 Customization of the displayed scale according to the stiffness of the material scanned is
imperative to obtain quality elastograms.
 Strain Elastography
 Longitudinal scans are useful for strain ratio; however, if carotid pulsation is used,
transverse scans should be employed.
 Set the ROI as large as possible, preferably covering the nodule together with
adjacent normal thyroid tissue and avoid the inclusion of big vessel, bones.
 In patients without adjacent normal thyroid tissue, a surrounding muscle can be used
for the strain ratio.
 A strain quality indicator is very helpful in obtaining good strain elastograms.
 Each nodule should undergo at least two SE acquisitions.
 Strain ratio: parenchyma-to-nodule strain ratio (PNSR)/ muscle-to-nodule strain ratio
(MNSR)
 Shearwave Elastography
 The operator exerts only minimal pressure with the probe during image acquiring.
 The quality indicator or map will guide the optimum position of the ROI.
 Obtain accurate measurements up to 4–5 cm in depth. Deeper than this, the ARFI
pulses are attenuated, and the tissue displacement is too small
 A standard ROI of 5-6 mm should be placed inside the nodule, avoiding cystic or
calcified areas.
 Five to ten measurements are needed to obtain a median value yielding reliable
accuracy.
Cautions
 SE displays the relative strain of the structures in the ROI. The numeric value of SE is
inappropriate to compare two lesions or two individuals .
 Nodules in the isthmus,close to the carotid artery, and those that are large or deeply located
may be more difficult for SE.
 For SWE, pressure applied by the probe increases the tissue’s stiffness.
 Nodules in the isthmus are difficult for SWE, because they are trapped between the skin and
the stiff trachea.

Reference: WFUMB GUIDELINES AND RECOMMENDATIONS FOR CLINICAL USE OF ULTRASOUND ELASTOGRAPHY: PART 4:
THYROID
Analysis

NTE STE & STQ

Interpretation 1) Elasticity score (Tsukuba score ) Interpretation) Stiffness and Shear wave speed
• A five-point scale that visually grades the stiffness
of a mass.
• kPa (unit of stiffness), m/s (unit of SWS)
Score 1 The nodule is entirely soft (green)
: Quantitative values calculated for the Shear
Score 2 The nodule is mostly soft (green, with wave speed determined by stiffness in Shear
some blue areas)
Wave Elastography system.
Score 3 The nodule is only soft at the
periphery (blue core, green periphery) • A quantitative stiffness value of the maximum
or mean stiffness value of the nodule for
Score 4 The nodule is entirely rigid (blue)
characterization is usually used.
Score 5 The nodule and the surrounding
tissue is rigid (blue)

• Four-pattern scoring system for strain elastography

of thyroid nodules.
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

Interpretation 2) Strain ratio

• Relative numerical value to the stiffness (tissue
elasticity)
• Parenchyma-to-nodule strain ratio (PNSR) and
muscle-to-nodule strain ratio (MNSR)
• ROI A: Lesion, ROI B: Fat, B/A: fat-lesion ratio

Mindray Building, Keji 12th Road South, High-tech Industrial Park, Nanshan, Shenzhen 518057, P.R. China
Tel: +86 755 8188 8998 Fax: +86 755 26582680 E-mail: intl-uis@mindray.com www.mindray.com
© 2018 Shenzhen Mindray Bio-Medical Electronics Co., Ltd. All rights reserved. Contents are subject to changes without prior notice.