The Next Step

Presented By:

Niyas Ummer
1st Year MDS Department of Oral Medicine & Radiology

Elastography: The Next Step
Debdutta Das, Monika Gupta, Harkamal Kaur and Aman Kalucha
Department of Oral and Maxillofacial Surgery, M. M. College of Dental Sciences and Research, Haryana, India Department of Oral Medicine and Radiology, M. M. College of Dental Sciences and Research, Haryana, India Journal of Oral Science, Vol. 53, No. 2, 137-141, 2011

• Cervical metastasis - most important prognostic factor in oral cancer • Management requires careful staging of regional lymphatics to accurately determine disease progression • Lymph node enlargement:
 Part of our body’s normal immune response  Drug reactions, infection, immunologic disorders, malignancies, and several other disorders of unknown etiology

lung.first symptom in patients with malignancies of the head and neck. differentiation between reactive and metastatic lymphadenopathy is vital . breast.• Metastatic cervical lymphadenopathy .one of the differentiating criteria is lymph node hardness (elasticity) . and other sites • Hence.

grey-scale and color Doppler imaging .• Ultrasound (US) imaging:  Dynamic. and patient-friendly  Useful in examination of superficial structures  Nonionizing imaging modality  Rapid acquisition of images with minimal artifacts  Used to guide needle biopsies (fine needle and core biopsies)  Highly specific diagnostic tool  Preoperative localization of impalpable neck masses • Fully digital. readily available. real-time. handheld devices capable of highresolution.

• Ophir (1991) .measures the characteristics of tissue compliance • Allows assessment of  Elasticity distribution  Differences in hardness between diseased tissue and normal tissus .promising new ultrasound technique “Elastography” .

liver. breast.• Promising results in differential diagnosis of diseases of the thyroid. prostate and pancreas • May prove to be immensely useful in assessing lymph nodes in the maxillofacial region .

• Aim of this Review:  Highlight possible applications of elastography in examining cervical lymph nodes  Describe the mechanics of this method  Limitations of this technique briefly discussed .

Principles • Tissue compression produces strain (displacement) within the tissue • Strain is lower in harder tissues than in softer tissues • By measuring tissue strain induced by compression .estimate tissue hardness .

blue  Soft areas .red • Provide clinical information that permits observation of tissue stiffness .malignant tissue is generally harder than normal surrounding tissue • Helpful addition to findings on palpation .• Tissue elasticity resulting from compression is displayed as an image (elastogram)  Hard areas .

Mechanics of Elastography • Assessment of elastic properties of tissues • Images obtained are compared before and after compression • Elasticity varies  in different tissues  In the same tissue during different pathologic states • Tissue stiffness tends to change (usually increase) with disease .

• Imaged by measuring the tissue distortion under an applied stress by an ultrasound transducer • Resulting high contrast images can lead to early detection of disease processes • Data compared using a cross-correlation technique • Determine amount of displacement each small region of tissue undergoes in response to the compression applied .

level of strain in that element will be higher or lower • Stiffer tissue element . all points in the elastic medium experience a resulting level of longitudinal strain • Greatest effect in components along the axis of compression • If one or more of the tissue elements has a different stiffness parameter .less strain .• Upon application of stress (or displacement).

set of echo lines from the same region of interest . post-compression.• Longitudinal (axial and lateral) strains .estimated from the analysis of ultrasonic signals • Accomplished by  acquiring a set of digitized radio-frequency echo lines from the tissue  compressing the tissue by a small amount with the ultrasonic transducer along the axis of ultrasonic radiation  acquiring a second.

• Data from these two echo lines undergo processing • Elastographic image (elastogram) ultimately appears on the monitor • Two types of elastograms:  Grayscale • Hard areas . yellow.dark • Soft areas .bright  Color • Increasing tissue hardness appears. and blue . in ascending order. as red. green.


conservative neck dissection. or suprahyoid lymph node extirpation .Elastography in Cervical Lymphadenopathy • Why assess cervical lymph nodes ?  Prognosis and treatment planning  Anamnesis and clinical investigations – less reliable  Lymph node status .criterion for radical neck dissection.

effective but is invasive .prone to sampling and analytic error .• Current Scenario:  Gold Standard .open cervical lymph node biopsy combined with pathologic examination  Fine Needle Aspiration Cytology .

early detection of cancer recurrence  Risk of over or understaging lymph nodes in the head and neck – prevented by elastography .• Role of Elastography?  Not yet used in routine clinical practice  Useful in differential diagnosis of breast. and prostate cancers  Neck lymph nodes . thyroid.easily accessible and efficiently compressed against underlying anatomic structures  Guidance of percutaneous biopsy and nodal dissection  Improve patient follow up .

 Alam et al. .• Other Uses?  Measure masseter stiffness for the purpose of massage  Evaluate focal lesions in major salivary glands • Elastography in Action?  Lyshchik et al.

Histologic nodal findings • Benign nodes had same brightness as surrounding anatomic structures .not clearly visible • Metastatic lymph nodes appeared darker • Margin delineation was better . • Accuracy of sonoelastography • Differentiating benign and metastatic cervical lymph nodes in patients suspected of having thyroid or hypopharyngeal cancer • Reference standard .margins of metastatic lymph nodes were more regular and distinct .Lyshchik et al.

Alam et al. • Diagnostic performance of sonographic elastography and B-mode sonography • Assessing enlarged cervical lymph nodes • Elastography significantly improved the performance of sonography .

uses radiation impulses to induce localized displacement of tissues .Limitations • Inability to control the extent of tissue compression by the transducer • Application of strong pressure – misdiagnosis • Suggestions:  Acoustic radiation force impulse (ARFI) imaging .monitor dynamic response of tissues .

excludes surrounding tissue • Cervical lymph nodes close to great vessels .• Suboptimal images of large lymph nodes .artifacts • Regions of interest in large lymph nodes include only the nodes themselves .probe contact may not be adequate • Movement of surrounding tissues and vessels during compression .pulse affects the technique • Suggestions:  Re-examined after tilting the probe .

equalize the necessary pressure .• Interobserver variability • Suggestions:  Force adjusted using a visual compression indicator on the screen  Balloon systems indicating the force of compression integrated into the probes .

Recommendations • Use of volumetric measurement to assess the stiffness of the whole lymph node .increase the diagnostic performance • Study its use in the characterization of small lesions .

which then eventually require a new technique to address them • With its high specificity . ultrasonography .easier for general dental practitioners • With continued development.Future Perspectives • Good techniques are instrumental in producing desirable results.more objective diagnostic tool .much progress is needed • Colored images .can improve the performance of sonography • Although elastography has progressed rapidly .

like MRI. or of 3D Elastography .Critical Review • Merits:     Up to date and comprehensive sources Brief description of concept and mechanics Included limitations and suggestions to overcome them Discussed future perspectives and alternatives • Demerits:      Plagiarism No discussion about cervical lymph nodes or lymphadenopathy No staging of nodes or identification of malignant changes No images for equipments or elastograms of cervical nodes No mention of other modalities of Elastography.

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