WFUMB Course Book 33.

ELASTOGRAPHY

33. Elastography B) Shear-waves elastography (SWE) is a quantitative method that assesses the shear-
Roxana Șirli, Giovanna Ferraioli waves speed generated into the tissue by a mechanical stimulus, which is directly
applied on the skin, as in Transient Elastography (TE) or into the body by the push-
Keywords: elastography, stiffness, liver, thyroid, breast, prostate pulse of focused ultrasound beams, as in the ARFI based techniques, i.e. pSWE and
2D-SWE. pSWE evaluates the shear-waves speed at the focal point of the US beam, in
33.1. Basics of elastography a small and region of interest (ROI) of fixed size, whereas 2D-SWE is based on multiple
ARFI lines in a large field of view (FOV) that is usually user-adjustable.
Elasticity is an intrinsic physical property of materials and tissues: to deform when an
external force is applied upon them and to return to their original shape after removing
the force that caused the deformation. A complementary concept is stiffness, defined View enlarged image
as the resistance opposed by an elastic material to deformation.
In order to perform elasticity measurements, a mechanical excitation of the tissue is
needed. It can be obtained by manual compression (by hand or using cardiovascular
pulsations or respiratory motions), by electronically controlling the ultrasound transducer
to create focused acoustic radiation force impulse (ARFI) at a controlled depth (ARFI
imaging and shear wave elastography with ARFI-based techniques), or by external
mechanical vibrations. The mechanical excitation induces longitudinal deformation, Fig 33.1a
assessed by strain imaging or ARFI imaging, and shear-waves that propagate inside SE of the liver – Hitachi
the tissue, whose speed can be measured. Stiffer tissues show less longitudinal Aloka system. From F1
displacement and higher shear-waves’ speed. Elastography techniques are classified to F4 fibrosis stage, color
variation of the SE increases
by international guidelines according to the measured physical quantity, the excitation
- low strain regions
method, and the method used to display the measured quantity:
(LFI=1.68) in a patient with
F1
A) Strain elastography (SE) and ARFI imaging are based on the qualitative assessment
of the axial displacement. Strain elastography evaluates the percentage of displacement
induced into the tissue by a quasi-static force applied by manual compression (by hand View enlarged image

or using cardiovascular pulsations or respiratory motions). ARFI imaging assesses the

displacement without any further processing. They are qualitative and semi-quantitative
methods that differentiate hard (stiff) tissues from soft ones, either by a color-coded
image or by gray scale tones. Image analysis tools are available for most systems.
Quasi-static strain imaging techniques, including Strain Elastography (SE) and Strain
Rate Imaging (SRI) are implemented on most ultrasound machines. Acoustic Radiation
Fig 33.1b
Force Impulse Imaging (ARFI imaging) is implemented on Siemens ultrasound
SE of the liver – Hitachi
equipments.
Aloka system. From F1
to F4 fibrosis stage, color
variation of the SE increases
Remember
- a patched image pattern
• Stiffer tissues show less longitudinal displacement and higher shear-waves’ speed (LFI=4.19) in a patient with
F4

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WFUMB Course Book
33.2. Liver elastography
SWE techniques have been accepted as a reliable substitute of liver biopsy in
several clinical scenarios.
Liver elastography is a highly reproducible method with a short learning curve,
however training is needed in order to obtain reliable results. Feasibility is also very
good, but variable for different systems and experience in ultrasound increases
feasibility, especially for 2D-SWE.
LS measurements should be performed in patients fasting for at least 4 hours,
in the right liver lobe through the intercostal spaces, with the patient in dorsal
decubitus with the right arm in maximal abduction, during an intermediate breath
hold to minimize motion.
Fibrosis is not the only factor influencing liver stiffness (LS). Thus, LS measurements
should be interpreted with caution in patients with liver congestion (heart failure,
obstructive jaundice), in patients with aminotransferases flares (>5 times the upper
limit of normal) – indicative of inflammation, and in cases of infiltrative diseases. LS
values obtained by different systems and techniques are not superimposable.
33.2.1 Strain elastography (SE) for liver fibrosis assessment
Strain elastography is a qualitative method which assesses echo signals before and
under slight compression. Older systems used hand compression as mechanical
stimulus, while newer systems use the heart and respiratory movements as stimulus.
Several algorithms were used to quantify SE data, such as Elastic Ratio, Elastic
Index, Elasticity Score and Liver Fibrosis Index (LFI). SE for the liver was evaluated
mostly in Asian studies using Hitachi Aloka systems (Fig 33.1a, b). The results of
two published meta-analyses showed that LFI could not be applied to accurately
differentiate F2 versus F0-1 nor F=4 versus F0-3, with summary sensitivities and
specificities roughly 0.80.
33.2.2. Shear-waves elastography (SWE) for liver fibrosis assessment
33.2.2.1. Transient elastography (TE)
TE, performed with the FibroScan® device (EchoSens), is undoubtedly the most
studied elastographic technique used to assess liver fibrosis (Fig 33.2). For reliable
LS measurements by TE, 10 valid shots should be obtained with an interquartile
range (IQR) less than 0.3 of the median. The median value of the 10 valid shots is
calculated, the result being expressed in Young’s modulus units (kilopascal, kPa).
2
33. ELASTOGRAPHY
TE is considered failed if no valid shots can be obtained. TE is not feasible in patients
with ascites, while failed and unreliable measurements are mostly correlated with
obesity. Three types of probes are available according to BMI: S probe for pediatric
patients, M probe – normal weight patients and XL probe for obese.
View enlarged image
Fig 33.2
TE measurement by
FibroScan in a normal liver.
LS values in orange (median
of 10 measurements = 3.9
kPa and IQR/M =7%). In
blue estimation of steatosis
by controlled attenuation
parameter (CAP)
In patients with chronic viral hepatitis or NAFLD, the “rule of 5” has been
proposed: LS ≤ 5 kPa has a high probability of being normal; LS < 10 kPa in the
absence of other known clinical signs rules out compensated advanced chronic
liver disease (cACLD), i.e. F3-F4 stages; values between 10 and 15 kPa are
suggestive of cACLD but need further tests for confirmation; values > 15 kPa are
highly suggestive of cACLD; values ≥ 20-25 kPa can rule in clinically significant
portal hypertension.
LS values in patients with chronic viral hepatitis decrease after successful antiviral
treatment. However, if the patient had LS values consistent with cirrhosis before
treatment, he/she should be considered cirrhotic and followed up as such, even if
LS after treatment decreases below cirrhosis cut-offs. This holds true also for the
ARFI-based techniques.
WFUMB Course Book 33. ELASTOGRAPHY

33.2.2.2. ARFI-based techniques View enlarged image

As opposed to TE, they can be performed also in patients with ascites (Fig 33.3). For
reliable measurements, the measurement box should be placed at least 1.5 cm below
the liver capsule, avoiding large vessels, bile ducts and masses, with the transducer
perpendicular to the liver capsule. The median of 10 measurements with pSWE and
5 measurements with 2D-SWE is calculated, the results are expressed either in m/s,
or converted into kPa. For reliable measurements, the IQR/M should be less than Fig 33.3
0.30 if the result is given in kPa or less than 0.15 if the result is given in m/s. pSWE 2D-SWE measurement by
techniques are available from several vendors (Fig 33.4 - 7). the Aixplorer (Supersonic
With 2D-SWE, local tissue elasticity is displayed in a “real time” color map (elastogram) Imagine) system in a patient
superimposed on a B-mode image. Within the FOV, LS is measured in a measurement with ascites. Mean LS value
box whose size and position can be changed by the operator. Guidelines recommend inside the ROI is 15.1 kPa.
Measurement made in the
to perform only one measurement in each frozen image. Most systems also have
most homogeneous area of
quality criteria to ensure accurate LS measurements (Fig 33.8 – 14). the elastogram

In patients with chronic viral hepatitis or NAFLD, the “rule of 4” has been proposed:
LS ≤ 5 kPa has high probability of being normal; LS < 9 kPa, in the absence of
other known clinical signs, rules out cACLD; values between 9 kPa and 13 kPa are
suggestive of cACLD but may need further tests for confirmation; and values > 13
kPa are highly suggestive of cACLD. There is a probability of clinically significant portal
hypertension with LS values > 17 kPa, but additional tests may be required. In some
patients with NAFLD, the cut-off values for cACLD may be lower and follow-up or
additional testing in those with values between 7 and 9 kPa is recommended. Using
these cutoffs each manufacturer’s technique will have its own sensitivity and specificity.

View enlarged image

Remember
• SWE can be used as a first-line method to assess liver fibrosis severity
• Confounding factors for SWE are liver congestion (cardiac insufficiency,
obstructive jaundice), inflammation (aminotransferases flares, acute alcoholic
hepatitis), infiltrative diseases, and non-fasting conditions. All of them can lead
to overestimation of fibrosis severity
• Stiffness values for different stages of fibrosis are system specific
Fig 33.4
• In patients with chronic viral hepatitis undergoing successful antiviral treatment, pSWE measurement of LS
LS values may significantly decrease; however, patients with pretreatment LS by Virtual Touch
values suggestive for advanced liver disease should be followed-up as such, Quantification (VTQ)
even if LS values decrease technique from Siemens.
Measurement value 1.25 m/s

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WFUMB Course Book
View enlarged image
Fig 33.5
pSWE measurement of LS
by ElastPQ technique from
Philips. Measurement value
5.82 kPa
View enlarged image
Fig 33.6
LS measurement by
S-Shearwave Imaging
technique from Samsung-
Medison. Measurement
value is 4.4 kPa
4
33. ELASTOGRAPHY
View enlarged image
Fig 33.7
LS measurement by pSWE
technique from Hitachi. Ten
measurements made, their
median value is 1.71 m/s
(8.75 kPa)
View enlarged image
Fig 33.8
2D-SWE measurement by
the Aixplorer (Supersonic
Imagine) system in a patient
with cirrhosis. Mean LS
value inside the ROI is 13.8
kPa. Measurement made in
the most homogeneous area
of the elastogram
WFUMB Course Book
View enlarged image
Fig 33.9
LS measurement by
2D-SWE from General
Electric in a patient with
cirrhosis. Mean LS value
inside the ROI is 13.8 kPa.
Measurement made in the
most homogeneous area of
the elastogram
View enlarged image
Fig 33.10
LS measurement by
2D-SWE from General
Electric in a patient with
cirrhosis. Left side of the
image – confidence map.
Right side of the image –
elasticity map. Measurement
made in the most
homogeneous area
5
33. ELASTOGRAPHY
View enlarged image
Fig 33.11
2D-SWE measurement of
LS by ElastQ technique
from Philips. Measurements
made in the most
homogeneous areas.
Left side of the image:
confidence map.
View enlarged image
Fig 33.12
2D-SWE measurement of
LS by S-Shearwave Imaging
technique from Samsung-
Medison.
WFUMB Course Book
View enlarged image
Fig 33.13
LS measurement by
2D-SWE from Mindray.
Left side of the image –
reliability map. Right side of
the image – elasticity map.
Measurement made in the
most homogeneous area,
mean value in the ROI 8.05
kPa
View enlarged image
Fig 33.14
LS measurement by
2D-SWE from Canon.
Left side of the image –
elastogram. Right side of
the image – propagation
map. Measurement made in
the area with parallel lines,
mean value in the ROI 5.2
kPa
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33. ELASTOGRAPHY
33.3. Breast elastography
Cancer nodules are stiffer than the normal surrounding tissue and the stiffening
process begins in the early cancer stages. Both strain (SE) and shear-waves
elastography (SWE) techniques can be used for breast assessment. In order to
obtain reliable elastographic measurements a good gray-scale US image of the
lesion is mandatory, and the probe should be maintained perpendicularly on the
skin. SE compression technique for each elastography system should be known
and applied. The ROI should include various tissue types (fat, glandular tissue,
muscle) and the lesion should account for maximum ¼ of the ROI.
33.3.1 Strain elastography (SE) for breast nodules assessment
The Tsukuba score is a five-point scale based on the colors (balance of green and
blue) inside the tumor and the surrounding tissue, a higher score being associated
with malignancy (Fig 33.15). Tsukuba score had 86.5% sensitivity, 89.9% specificity,
and 88.3% accuracy for differentiating benign vs. malignant breast nodules.
EI/B ratio, width ratio, length ratio assessment started from the observation that the
elastogram of benign lesions is smaller than the corresponding B-mode image that
of malignant lesions is larger. In a multicenter trial, the EI/B-mode ratio criterion of
<1.0 as benign and ≥1.0 as malignant had 99% sensitivity and 87% specificity in
differentiating benign vs. malignant breast lesions.
Lesion to fat ratio (LFR) compares the strain in the breast mass to the one in
subcutaneous fat. Reported cut-offs of 2.8 to 4.5 are used to rule-out and rule-in
malignant lesions, respectively (Fig 33.16 - 20).
33.3.2. SWE measurement and imaging for breast nodules
Stiffness measurements should be used in addition to the Breast Imaging Reporting
and Data System (BI-RADS) classification. The maximum stiffness of the lesion
should be taken into consideration. Low stiffness values (< 20 kPa or <2.6 m/s) can
be used to rule-out malignancy, while high stiffness values (> 80 kPa or 5.2 m/s)
can be used to rule-in malignancy (Fig 33.21-22).
Remember
• Malignant breast nodules are stiffer than the surrounding tissue
• Breast elastography should be used in addition to BI-RADS criteria for breast
nodules
WFUMB Course Book
View enlarged image
Fig 33.15
Tsukuba score. 1- soft lesion
(green); 2 - mixed pattern;
3 - hard lesion (blue), but
smaller on the elastogram
than on B-mode US; 4 - hard
lesion and the same size on
elastography as in B-mode;
5 – lard lesion and larger on
elastography
View enlarged image
Fig 33.16
BIRADS 3 (low risk)
nodule in gray scale US:
solid pattern, hypoechoic,
regular margins, posterior
enhancement, oval shape.
SE (Hitachi) color code map
1 – low stiffness. Strain ratio
= 0.99 – Fibroadenoma
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33. ELASTOGRAPHY
View enlarged image
Fig 33.17
BIRADS 4a (Intermediate
risk) nodule in gray scale
US: solid pattern, intense
hypoechoic, spiculated
margins, oval shape. SE
(Hitachi) color code map 2
– isolated point of increased
stiffness. Strain ratio = 1.32
Lobar hyperplasia
View enlarged image
Fig 33.18
BIRADS 5 (high risk) nodule
in gray scale US: solid
pattern, intense hypoechoic,
irregular margins, posterior
shadowing, infiltration,
taller than wide shape. SE
(Hitachi) color code map 4 –
increased stiffness area that
equals the gray scale image.
Strain ratio = 8.78 - Breast
cancer
WFUMB Course Book
View enlarged image
Fig 33.19
BIRADS 3 (low risk) nodule
in gray scale US: solid
pattern, mild hypoechoic,
oval shape, clear margins,
no posterior phenomenon,
oval shape, partially
inhomogeneous. SE
(Philips) color code map 32
– predominant low strain
View enlarged image
Fig 33.20
BIRADS 4A (intermediate
risk) nodule in gray
scale US: solid pattern,
intense hypoechoic, oval
shape, clear margins, no
posterior phenomenon,
inhomogeneity. SE (Philips)
color code map 3 –
predominant stiff image =
risk upgrade (4B)
8
33. ELASTOGRAPHY
View enlarged image
Fig 33.21
BIRADS 3 (low risk) nodule
in gray scale US: solid
pattern, hypoechoic, regular
shape, clear margins,
oval shape, homogenous,
no calcification, posterior
enhancement. 2D-SWE
(Mac 30 Aixplorer) color
code map 1 – complete
low stiffness area. Mean
elasticity 43 kPa –
Fibroadenoma
View enlarged image
Fig 33.22
BIRADS 5 (high risk)
nodule in gray scale US:
solid pattern, irregular
shape, intense hypoechoic,
posterior shadowing, unclear
margins. 2D-SWE (Mac 30
Aixplorer) color code map
4 – complete stiff area.
Mean elasticity = 109.4 kPa
- Breast cancer
WFUMB Course Book 33. ELASTOGRAPHY

33.4. Thyroid elastography View enlarged image

33.4.1 Elastographic assessment of thyroid nodules

Both strain (SE) and shear-waves elastography (SWE) techniques can be used.
They should be used in combination with Thyroid Imaging Reporting and Data
System (TI-RADS) to increase accuracy. Operator training and experience are
essential for adequate SE, while the use of strain quality indicator is helpful for Fig 33.23
assessing the quality of compression. Four-pattern scoring system
for SE of thyroid nodules: 1 -
33.4.1.1. Strain elastography for thyroid nodules entirely green nodule (soft);
Visual scores. The Tsukuba five-pattern visual scoring system (Fig 33.15) can 2 - mostly green nodule, with
some blue areas; 3 – mostly
be used for thyroid nodules (PPV 100%, NPV 98% for scores 4 and 5 to predict
blue nodule, with some
malignancy). The four-pattern scoring system for RTE of thyroid nodules is an
green areas; 4 - entirely blue
alternative [Fig.33.23). nodule (hard)

Strain ratio (SR) is a semi-quantitative method that compares the ratio between
strain in adjacent tissue vs. thyroid nodule, either normal thyroid parenchyma
(parenchyma-to-nodule SR), or adjacent strap muscle (muscle-to-nodule SR) (Fig
33.24 - 26). There is no consensus on which cut-off to use. Caveat in non-papillary View enlarged image
thyroid carcinomas which can be soft and also in underlying Hashimoto disease
where the thyroid parenchyma is hard.

33.4.1.2. SWE measurement and imaging for thyroid nodules

Both pSWE and 2D-SWE can be used in addition to B-mode US to differentiate
between malignant and benign nodules, with cut-offs varying from 2.4 to 4.7 m/s
for malignancy (34.5–66 kPa) (Fig 33.27 - 28). Fig 33.24
Low risk thyroid nodule in
gray scale US: solid pattern,
33.4.2. Elastographic assessment of diffuse thyroid diseases
oval shape, isoechoic, clear
The thyroid tissue becomes stiffer in chronic diseases; therefore, SWE can be used
margins, regular shape, no
in addition to clinical and biologic criteria for the diagnosis. Focal inflammatory posterior phenomenon. SE
areas should be included in the differential diagnosis of carcinoma because they (Hitachi Preirus) color code
are stiffer than the surrounding tissue. 1 – low. Strain ratio = 1.14

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WFUMB Course Book
View enlarged image
Fig 33.25
Intermediate risk thyroid
nodule in gray scale US:
solid pattern, taller than
wide shape clear margins,
no calcification, no posterior
phenomenon. SE (Hitachi
Preirus) color code 3 –
increased stiffness - risk
upgrade. Strain ratio = 4.5
View enlarged image
Fig 33.26
High risk thyroid nodule
in gray scale US: solid
pattern, irregular margins,
inhomogeneous, posterior
partial attenuation. SE
(Hitachi Preirus) color code
4 – increased stiffness
- ads risk to the nodule’
evaluation. Strain ratio =
3.42
10
33. ELASTOGRAPHY
View enlarged image
Fig 33.27
Low risk thyroid nodule in
gray scale US: solid pattern,
oval shape, isoechoic, clear
margins, regular shape,
no posterior phenomenon,
cystic degeneration.
2D-SWE (Mac 30 Aixplorer)
color code 1 – low stiffness
- reconfirmation of low risk
category. Mean elasticity =
14.9 kPa
View enlarged image
Fig 33.28
High risk thyroid nodule in
gray scale US: solid pattern,
intense hypoechoic, irregular
margins, inhomogeneous.
2D-SWE (Mac 30 Aixplorer)
color code 4 – increased
stiffness - upgrade to
very high category. Mean
elasticity = 100.4 kPa. Strain
Ration = 16.4
WFUMB Course Book 33. ELASTOGRAPHY

View enlarged image

Remember
• Malignant thyroid nodules are stiffer than the surrounding tissue (caveat
papillary carcinomas that can be soft)
• Elastography should be used in addition to gray-scale B-mode US to increase
diagnosis accuracy in differentiating benign vs. malignant thyroid nodules
• Thyroid stiffness increases in chronic thyroid diseases

Fig 33.29
SE of a hyperechoic
33.5. Prostate elastography prostate nodule. Stiffness
in the entire hyperechoic
nodule is hard, Kamoi score
Cancerous tissue in the prostate is stiffer (Fig 33.29) as compared with benign 5, prostate adenocarcinoma
tissue (Fig 33.30). US elastography improves prostate nodules characterization
but also cancer detection by disclosing lesions on the elasticity map not visible on
conventional trans-rectal US (TRUS) imaging or MRI.
Prostate elastography should be always performed after standard TRUS, with
minimal pre-compression, the FOV including the prostate capsule and periprostatic
tissues, excluding the bladder. The measurement box should be placed in the
center of FOV.

33.5.1. Trans-rectal strain elastography (TRSE)

Several visual scores have been proposed for interpretation of TRSE (Kamoi
score, Innsbruck score) with equal value. Also Strain Ratio (SR) and peak strain View enlarged image

ratio index (normal prostate tissue vs. peak stiffest region in the lesion) can be
used for prostate nodule characterization.
TRSE can be used for target biopsy guidance in addition to systematic biopsies.
Addition of TRSE can improve staging of prostate cancer as compared to TRUS
alone, but it cannot exclude capsular or extracapsular extension.

33.5.2. Trans-rectal shear waves elastography (TRSWE)

Results of TRSWE can be expressed in m/s or kPa or as ratios between the lesion Fig 33.30
and normal prostate tissue. A stiffness value greater than 35 kPa is suggestive of SE of a hyperechoic
a malignancy (Fig 33.31). prostate nodule. Stiffness
TRSWE can be used for target biopsy guidance in addition to systematic biopsies. in the entire hyperechoic
Addition of TRSWE can improve staging of prostate cancer as compared to TRUS nodule is soft, benign
alone, but it cannot exclude capsular or extracapsular extension prostate hypertrophy

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WFUMB Course Book 33. ELASTOGRAPHY

View enlarged image View enlarged image

Fig 33.31
2D-SWE of the prostate. Fig 33.32
Both measured values are Spleen stiffness
higher than 35 kPa. Biopsy measurement by pSWE
should be targeted in the (VTQ technique from
stiffer area (98 kPa) Siemens)

Remember
• Prostate cancer nodules are stiffer than the surrounding tissue
• Elastography should be used in addition to TRUS to increase diagnosis
accuracy
• Prostate elastography can be used for targeting biopsy guidance in addition to
systematic biopsies
View enlarged image

33.6. Other applications

The best results of spleen elastography are for predicting portal hypertension (PH).
Spleen stiffness (SS) is correlated to hepatic vein portal gradient (HVPG), and has
an excellent diagnostic accuracy for predicting clinically significant PH, regardless
of the technique (AUROC 0.92). TE measurement of SS with a dedicated software
is superior to classic TE software for predicting significant esophageal varices.
Point SWE (Fig 33.32) and 2D-SWE (Fig 33.33) techniques have shown mixed Fig 33.33
results for predicting the presence and severity of esophageal varices. Spleen stiffness
Pancreas elastography (SE and SWE) can be done either by transabdominal approach measurement by 2D-SWE
or by ecoendoscopy. It can be used as an additional tool to characterize chronic (Aixplorer System from
pancreatitis, but it cannot differentiate focal pancreatitis from pancreatic tumors. Supersonic Imaging)

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WFUMB Course Book
Acknowledgements
• Images of SE of the liver courtesy of Larisa Sandulescu from the University of
Medicine and Pharmacy form Craiova, Romania.
• Images of breast and thyroid elastography courtesy of Dana Stoian from the
“Victor Babes” University of Medicine and Pharmacy Timisoara, Romania.
• Images of prostate elastography courtesy of Sorin Dudea from the “Iuliu
Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania
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33. ELASTOGRAPHY
Recommended reading
• Barr RG, Cosgrove D, Brock M et al. WFUMB Guidelines and Recommendations
on the Clinical Use of Ultrasound Elastography: Part 5. Prostate. Ultrasound
Med Biol. 2017 Jan;43(1):27-48.
• Barr RG, Ferraioli G, Palmeri ML, et al. Elastography Assessment of Liver
Fibrosis: Society of Radiologists in Ultrasound Consensus Conference
Statement. Radiology. 2015;276(3):845-861.
• Barr RG, Nakashima K, Amy D, et al. WFUMB guidelines and recommendations
for clinical use of ultrasound elastography: Part 2: breast. Ultrasound Med Biol.
2015 May;41(5):1148-60.
• Barr RG, Wilson SR, Rubens D, Garcia-Tsao G, Ferraioli G. Update to the
Society of Radiologists in Ultrasound Liver Elastography Consensus Statement.
Radiology. 2020;296(2):263-274.
• Cosgrove D, Barr R, Bojunga J et al. WFUMB Guidelines and Recommendations
on the Clinical Use of Ultrasound Elastography: Part 4. Thyroid. Ultrasound
Med Biol. 2017 Jan;43(1):4-26.
• Dietrich CF, Bamber J, Berzigotti A et al. EFSUMB Guidelines and
Recommendations on the Clinical Use of Liver Ultrasound Elastography,
Update 2017. Ultraschall Med. 2017 Aug;38(4):e48.
• Ferraioli G, Filice C, Castera L et al. WFUMB guidelines and recommendations
for clinical use of ultrasound elastography: Part 3: liver. Ultrasound Med Biol.
2015 May;41(5):1161-79.
• Ferraioli G, Wong VW, Castera L, et al. Liver Ultrasound Elastography: An
Update to the World Federation for Ultrasound in Medicine and Biology
Guidelines and Recommendations. Ultrasound Med Biol. 2018;44(12):2419-
2440.
• Săftoiu A, Gilja OH, Sidhu PS et al.The EFSUMB Guidelines and
Recommendations for the Clinical Practice of Elastography in Non-Hepatic
Applications: Update 2018. Ultraschall Med. 2019 Aug;40(4):425-453.
• Shiina T, Nightingale KR, Palmeri ML et al. WFUMB guidelines and
recommendations for clinical use of ultrasound elastography: Part 1: basic
principles and terminology. Ultrasound Med Biol. 2015 May;41(5):1126-47.