EUS diagnosis

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Agenda
Tissue harmonic imaging
Elastography
Compound Harmonic imaging
Sound speed compensation mode
Others

2
CH and THI
Basic characteristics of waves
There are 2 types of received waves; Fundamental and Harmonic.
 Harmonic waves have twice the frequency of fundamental waves and less artifacts(noise).
 Fundamental waves have lower frequency and thus more penetration.

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 CH and THI
□ B mode: Fundamental wave components are used to create images.

□ CH: Fundamental wave components and harmonic components are

compounded to create images.
(Compound harmonic)
□ THI: Harmonic components are used to create images.
(Tissue harmonic imaging)

Received wave
B mode
Incident wave

Fundamental wave
component
CH mode

THI mode
Harmonic component
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4
CH and THI
THI Tissue Harmonic Imaging

Uses harmonic(high frequency) received waves to

create images.

Example: Transmit 5 MHz and received 10 MHz

Advantage
 Increase resolution
 Reduce artifact

Disadvantage
 Less penetration
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 CH and THI
CH (Compound Harmonic Imaging)
Advantage : Combines good advantages of B-mode and high resolution
with High penetration (B mode) and high resolution (THI)
Disadvantage: Increases frame rate so is not suitable for continuous
observation with movement.

Penetration
B mode

Resolution Penetration
CH

Resolution
47 THI
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CH and THI
When are CH/THI used?
This function is most appreciated for diagnosis of pancreatic cystic lesions since it
provides detailed information with less artifacts. It visualizes septums, nodules and
inner structure of cysts more clearly.
A questionnaire answered by 10 expert Japanese facilities(usingEU-ME2)

Pancreatic cystic lesion

Pancreatic solid lesion

Early chronic pancreatitis Always useful

Bile duct stone Sometimes useful
Bile duct stricture Limited indication
Biliary cancer staging Not useful
Vol. 58 （ 7 ） , Jul. 2016
Ampullary cancer Gastroenterological Endoscopy
IMAGING OF PANCREATOBILIARY
Gallbladder adenomyosis DISEASES WITH NEW FUNCTIONS IN
ENDOSCOPIC ULTRASONOGRAPHY Akio
Gallbladder polyp KATANUMA, 　 Hiroyuki MAGUCHI, 　
Toshifumi KIN, Kei YANE AND Kuniyuki
TAKAHASHI
Gallbladder cancer
7
 CH and THI
If the deeper section is too dark in THI, we can switch to B mode or CH mode. However, if
are checking a targeted lesion, we may only need good resolution for the upper portion of
the image.
If CH is not moving smooth, we can change to B mode(remember; we have good B mode).

THI CH
(Tissue Harmonic Imaging) (Compound Harmonic)

47
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Agenda
Tissue harmonic imaging
Elastography
Compound Harmonic imaging
Sound speed compensation mode
Others

9
Elastography

What is elastography?
It calculates the amount of strain(=how much an object deforms) when an object is
compressed, and displays the amount of strain in different colors. Soft objects show large
strain(red) and hard objects so less strain(blue).

Elastography is a map of “strain”

High strain Low strain

(More deformation) (Less deformation) 10
Elastography
Clinical indication and limitations
Indications: Diagnosis of masses
 Diagnosis of malignant masses
 Diagnosis of chronic pancreatitis

Limitations: High sensitivity but low specificity

 Observer-dependent with operator bias in the selection of ROI and areas for
analysis
 It is difficult to control the tissue compression by the endosonographer, and
excessive pressure applied to the tissues can artificially increase their strain

Point: Elastography has issues and is not

considered to replace FNA. FNA is important
and we have a great scope for FNA.

Endoscopic Ultrasound (EUS)

Elastography
Marc Giovannini
〈 MEDIX Suppl. 2007 〉 11
Elastography
When is elastography used?
Its main application is for pancreatic solid lesions. In the future, it is expected to be
more widely used for diagnosis of early chronic pancreatitis.
A questionnaire answered by 10 expert Japanese facilities(usingEU-ME2)

Pancreatic cystic lesion

Pancreatic solid lesion

Early chronic pancreatitis Always useful

Bile duct stone Sometimes useful
Bile duct stricture Limited indication
Biliary cancer staging Not useful
Vol. 58 （ 7 ） , Jul. 2016
Ampullary cancer
Gastroenterological Endoscopy IMAGING
OF PANCREATOBILIARY DISEASES WITH
Gallbladder adenomyosis NEW FUNCTIONS IN ENDOSCOPIC
ULTRASONOGRAPHY Akio KATANUMA, 　
Gallbladder polyp Hiroyuki MAGUCHI, 　 Toshifumi KIN, Kei
YANE AND Kuniyuki TAKAHASHI
Gallbladder cancer
12
 Elastography
Tips to adjust settings of elastography
-When the doctor says that elastography image does not appear-
 Fix the lesions with the scope by applying up angle with optimal(not too strong or
too week) degree. When the scope is moving elastography cannot function.
 Change the depth display to a minimal value that suits the lesion, so no
unnecessary information is processed.
 Set appropriate size of ROI to target lesion
 Lower the threshold value(elastography image will appear easier but accuracy will
drop)

Threshold value
can be lowered
down to -3

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Agenda
Tissue harmonic imaging
Elastography
Compound Harmonic imaging
Sound speed compensation mode
Others

14
Contrast Harmonic Imaging(CHI)
What is Contrast harmonic imaging?
Contrast harmonic imaging is a method of diagnosis in which microbubbles are
injected into the blood vessel. These micobubbles flow through the
bloodstream, vibrate and create strong harmonic component waves,
contributing to high resolution images of the blood stream.

CHI B mode

Strong
harmonic
component!
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 Contrast Harmonic Imaging(CHI)

Major Indications are…

Diagnosis of solid pancreatic lesions
Used for cases such as differentiation of pancreatic cancer and chronic pancreatitis(fig 1).

Diagnosis of IPMN(nodule or mucus?)

Evaluating mural nodules is important to predict malignancy of IPMN. However, IPMN
often includes mucus which is difficult to distinguish between nodules of tumors, without
contrast dye. If blood flow within the IPMN structure can be confirmed using contrast
dye, that is a sign that it is a nodule of a tumor.

Pancreatitis Necrosis after Pancreatic PNET

Utility of contrast―enhanced harmonic endoscopic ultrasonography pancreatitis, cancer
for diagnosis of pancreatic diseases Masayuki KITANO, T Cholesterol polyp 16
Contrast Harmonic Imaging(CHI)
When is CHI used?
This function is most appreciated for diagnosis of pancreatic solid lesions, cystic
lesions and gallbladder cancer.
A questionnaire answered by 10 expert Japanese facilities(usingEU-ME2)

Pancreatic cystic lesion

Pancreatic solid lesion

Early chronic pancreatitis Always useful

Bile duct stone Sometimes useful
Bile duct stricture Limited indication
Biliary cancer staging Not useful
Vol. 58 （ 7 ） , Jul. 2016
Ampullary cancer
Gastroenterological Endoscopy IMAGING
OF PANCREATOBILIARY DISEASES WITH
Gallbladder adenomyosis NEW FUNCTIONS IN ENDOSCOPIC
ULTRASONOGRAPHY Akio KATANUMA, 　
Gallbladder polyp Hiroyuki MAGUCHI, 　 Toshifumi KIN, Kei
YANE AND Kuniyuki TAKAHASHI
Gallbladder cancer
17
Contrast Harmonic Imaging(CHI)

When performing EUS-CHI, the doctor usually uses stores images and some
doctors take clips. The microbubbles are visualized effectively, 20 seconds after
being injected. For this reason, doctors pay attention to the time after injection.

Example of flow

If the doctor wants to take a

movie or carefully wants to
choose a good image.
Usual setting
Make sure clips can be recorded
for 1 minute. The keyboard cant
be controlled while taking clips.

Timer is activated when

microbubbles are injected

Flush is sometimes used to

send ultrasound signals to
destroy bubbles, which can Doctors may use to choose
make bubbles vibrate even good images with current view.
after a few minutes. . 18
Agenda
Tissue harmonic imaging
Elastography
Compound Harmonic imaging
Sound speed compensation mode
Others

19
Sound speed compensation mode 47

Sound speed of each organ

□ General ultrasound devices create images based on the assumption that the sound
speed in the body is always 1,540 m/sec.
(=>Actually, the sound speed varies slightly depending on the organ.)
1,540
m/sec 0 1,000 2,000 3,000 4,000
Air: 330
Water: 1,480
Fat: 1,450
Brain: 1,540
Kidney: 1,560
Liver: 1,570
Blood: 1,570
Skull: 4,080
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 Sound speed compensation mode 47

Evaluation of sharpness Same sound speed

Signal intensity
Different sound speed

□ When the sound speed is set to the same value as

the actual speed, sharp images are obtained.
(=>Clear images) Azimuth
direction
Sharpness of images obtained at various sound speeds is evaluated
=> The sound speed for the most sharp image is identified

Specified sound speed: … 1450 m/s … 1540 m/s … 1580 m/s …

Image: … … … …
Signal intensity

Signal intensity
Signal intensity

Sharpness: … … … …
Azimuth direction Azimuth direction Azimuth direction

Used as the compensated

sound speed value
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Sound speed compensation mode 47

Before sound speed After sound speed

compensation compensation
Specified sound speed is not optimal Specified sound speed is optimal

Signals are Signals are sharply

blurred displayed

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Sound speed compensation mode 47

Chronic pancreatitis

Optimize
Update

The optimal sound speed in the ROI is indicated in green

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Agenda
Tissue harmonic imaging
Elastography
Compound Harmonic imaging
Sound speed compensation mode
Others

24
 Others 47

Pulse Wave

FR ： 12.0Hz B FB ： 7.5M G ： 48 DR ： 55 1540m/s E:2 P:2 M:G7 SR:2 S:2 PW 4.0M G ： 55 DR:70 WF ： M:G3
5 A:0°

□ The graph shows the change of doppler information (flow speed) over time
at a specific point (sample gate).
□ The touch pad enables the doppler cursor and the sample gate
to be moved. Touch pad
Cursor

Gate Steady flow => Vein

Toward

Flow
speed
Time
Away
Regular pulsation => Artery
* The above photos are simulated images. 25
 Others
Color Doppler

C 4.0M G ： 43 WF ： 3 P:1 M:VD1 FC:2 CB:3

FR ： 10.9Hz B FB ： 7.5M G ： 48 DR ： 55 1540m/s E:2 P:2 M:G7 SR:2 S:2

□ Intensity and direction of the blood flow are displayed with colors.
(Red: toward the transducer/ Blue: away from the transducer)
□ This mode is used for diagnosis of blood vessel information and
determination of the puncture line for FNA.

Color doppler status

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* The above photos are simulated images. 26
 Any papers?
Randomized Controlled Trial Comparing the Usefulness of
Endoscopic Ultrasound Processor
Hiroki Koda,* Kazuya Matsumoto,* Yohei Takeda,* Takumi Onoyama,* Soichiro Kawata,* Hiroki Kurumi,* Taro
Yamashita,* Hisashi Noma,† and Hajime Isomoto*

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6437413/

Study about..
Usefulness between EU-ME2/GF-UCT260 and SU-1/EG-580UT compared

Conclusion
“SU-1/EG-580UT demonstrated superior performance compared to EU-ME2/GF-
UCT260 during ultrasonic endoscopic GI observation, operability, and ultrasonic image
quality. We believe that the result of the superior ultrasound imaging quality of
SU-1/EG-580UT EUS will aid in the identification of small pancreatic malignancies with
unclear borders and prove useful in evaluating mural nodules of intraductal papillary
mucinous neoplasm in detail.”

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