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1.  Elastography for hepato-biliary-pancreatic surgery 
Surgery Today  2013;44(10):1793-1800.
Palpation is a subjective and non-sharable diagnostic method. Recently, palpation has been supported and replaced by elastography, which provides a novel parameter of “stiffness” as a visual representation or quantified value. Today, elastography is performed using two major modalities: strain elastography and shear wave elastography. Strain elastography converts the extent of deformation during external compression into colors, displaying these colors as a strain map in a motion picture representing the relative elasticity inside the region of interest. Shear wave elastography can quantify the elasticity of a target by calculating the velocity of shear waves generated by a probe. In addition to superficial organs, elastography has also been applied to upper abdominal organs, including the liver, pancreas and spleen. The visualization of the stiffness of focal lesions in the liver or the pancreas has enabled a more sensitive and specific depiction of small, non-palpable nodules, which are difficult to depict using B-mode ultrasonography. The quantification of stiffness also enables non-invasive estimates of liver fibrosis, the risk of postoperative liver insufficiency and the risk of recurrence of viral hepatitis after transplantation. In this article, we review the major reports that have recently been published describing the effective application of elastography to solid upper abdominal organs in a clinical setting.
doi:10.1007/s00595-013-0799-7
PMCID: PMC4162976  PMID: 24292652
Elastography; Liver; Intraoperative diagnosis; Palpation
2.  Diagnostic Value of Elastography Using Acoustic Radiation Force Impulse Imaging and Strain Ratio for Breast Tumors 
Journal of Breast Cancer  2014;17(1):76-82.
Purpose
The aim of this study was to determine whether the combination of B-mode ultrasonography (BUS), acoustic radiation force impulse (ARFI) elastography, and strain ratio (SR) provides better diagnostic performance of breast lesion differentiation than BUS alone.
Methods
ARFI elastography and SR evaluations were performed on patients with 157 breast lesions diagnosed by BUS from June to September 2013. BUS images were classified according to the Breast Imaging-Reporting and Data System. ARFI elastography was performed using Virtual Touch™ tissue imaging (VTI) and Virtual Touch™ tissue quantification (VTQ). In VTI mode, we evaluated the color-mapped patterns of the breast lesion and surrounding tissue. The lesions were classified into five categories by elasticity score. In VTQ mode, each lesion was assessed using shear wave velocity (SWV) measurements. SR was calculated from the lesion and comparable lateral fatty tissue. We compared the diagnostic performance of BUS alone and the combination of BUS, ARFI elastography, and SR evaluations.
Results
Among the 157 lesions, 40 were malignant and 117 were benign. The mean elasticity score (3.7±1.0 vs. 1.6±0.8, p<0.01), SWV (4.23±1.09 m/sec vs. 2.22±0.88 m/sec, p<0.01), and SR (5.69±1.63 vs. 2.69±1.40, p<0.01) were significantly higher for malignant lesions than benign lesions. The results for BUS combined with ARFI elastography and SR values were 97.5% sensitivity, 92.3% specificity, 93.6% accuracy, a 79.6% positive predictive value (PPV), and a 99.1% negative predictive value. The combination of the 3 radiologic examinations yielded superior specificity, accuracy, and PPV compared to BUS alone (p<0.01 for each).
Conclusion
ARFI elastography and SR evaluations showed significantly different mean values for benign and malignant lesions. Moreover, these two modalities complemented BUS and improved the diagnostic performance of breast lesion detection. Therefore, ARFI elastography and SR evaluations can be used as complementary modalities to make more accurate breast lesion diagnoses.
doi:10.4048/jbc.2014.17.1.76
PMCID: PMC3988346  PMID: 24744801
Breast neoplasms; Elasticity imaging techniques; Ultrasonography
3.  Quantitative Measurement of Elasticity of the Appendix Using Shear Wave Elastography in Patients with Suspected Acute Appendicitis 
PLoS ONE  2014;9(7):e101292.
Introduction
Shear wave elastography (SWE) has not been studied for diagnosing appendicitis. We postulated that an inflamed appendix would become stiffer than a normal appendix. We evaluated the elastic modulus values (EMV) by SWE in healthy volunteers, patients without appendicitis, and patients with appendicitis. We also evaluated diagnostic ability of SWE for differentiating an inflamed from a normal appendix in patients with suspected appendicitis.
Materials and Methods
Forty-one patients with clinically suspected acute appendicitis and 11 healthy volunteers were prospectively enrolled. Gray-scale ultrasonography (US), SWE and multi-slice computed tomography (CT) were performed. The EMV was measured in the anterior, medial, and posterior appendiceal wall using SWE, and the highest value (kPa) was recorded.
Results
Patients were classified into appendicitis (n = 30) and no appendicitis groups (n = 11). One case of a negative appendectomy was detected. The median EMV was significantly higher in the appendicitis group (25.0 kPa) compared to that in the no appendicitis group (10.4 kPa) or in the healthy controls (8.3 kPa) (p<0.001). Among SWE and other US and CT features, CT was superior to any conventional gray-scale US feature or SWE. Either the CT diameter criterion or combined three CT features predicted true positive in 30 and true negative in 11 cases and yielded 100% sensitivity and 100% specificity. An EMV of 12.5 kPa for the stiffest region of the appendix predicted true positive in 28, true negative in 11, and false negative in two cases. The EMV (≥12.5 kPa) yielded 93% sensitivity and 100% specificity.
Conclusion
Our results suggest that EMV by SWE helps distinguish an inflamed from a normal appendix. Given that SWE has high specificity, quantitative measurement of the elasticity of the appendix may provide complementary information, in addition to morphologic features on gray-scale US, in the diagnosis of appendicitis.
doi:10.1371/journal.pone.0101292
PMCID: PMC4106760  PMID: 25051242
4.  Ultrasound elastography for thyroid nodules: recent advances 
Ultrasonography  2014;33(2):75-82.
Ultrasonography (US)-based elastography has been introduced as a noninvasive technique for evaluating thyroid nodules that encompasses a variety of approaches such as supersonic shear imaging and acoustic radiation force impulse imaging as well as real-time tissue elastography. However, the diagnostic performances for differentiating malignant thyroid nodules from benign ones with elastography as an adjunctive tool of gray-scale US is still under debate. In this review article, diagnostic performances of conventional US and a combination of conventional US and elastography are compared according to the type of elastography. Further, the interobserver variability of elastography is presented according to the type of elastography.
doi:10.14366/usg.13025
PMCID: PMC4058985  PMID: 24936499
Thyroid nodule; Ultrasonography; Elasticity imaging techniques
5.  Quantitative shear wave ultrasound elastography: initial experience in solid breast masses 
Breast Cancer Research : BCR  2010;12(6):R104.
Introduction
Shear wave elastography is a new method of obtaining quantitative tissue elasticity data during breast ultrasound examinations. The aims of this study were (1) to determine the reproducibility of shear wave elastography (2) to correlate the elasticity values of a series of solid breast masses with histological findings and (3) to compare shear wave elastography with greyscale ultrasound for benign/malignant classification.
Methods
Using the Aixplorer® ultrasound system (SuperSonic Imagine, Aix en Provence, France), 53 solid breast lesions were identified in 52 consecutive patients. Two orthogonal elastography images were obtained of each lesion. Observers noted the mean elasticity values in regions of interest (ROI) placed over the stiffest areas on the two elastography images and a mean value was calculated for each lesion. A sub-set of 15 patients had two elastography images obtained by an additional operator. Reproducibility of observations was assessed between (1) two observers analysing the same pair of images and (2) findings from two pairs of images of the same lesion taken by two different operators. All lesions were subjected to percutaneous biopsy. Elastography measurements were correlated with histology results. After preliminary experience with 10 patients a mean elasticity cut off value of 50 kilopascals (kPa) was selected for benign/malignant differentiation. Greyscale images were classified according to the American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS). BI-RADS categories 1-3 were taken as benign while BI-RADS categories 4 and 5 were classified as malignant.
Results
Twenty-three benign lesions and 30 cancers were diagnosed on histology. Measurement of mean elasticity yielded an intraclass correlation coefficient of 0.99 for two observers assessing the same pairs of elastography images. Analysis of images taken by two independent operators gave an intraclass correlation coefficient of 0.80. Shear wave elastography versus greyscale BI-RADS performance figures were sensitivity: 97% vs 87%, specificity: 83% vs 78%, positive predictive value (PPV): 88% vs 84%, negative predictive value (NPV): 95% vs 82% and accuracy: 91% vs 83% respectively. These differences were not statistically significant.
Conclusions
Shear wave elastography gives quantitative and reproducible information on solid breast lesions with diagnostic accuracy at least as good as greyscale ultrasound with BI-RADS classification.
doi:10.1186/bcr2787
PMCID: PMC3046449  PMID: 21122101
6.  Differentiating benign from malignant solid breast masses: value of shear wave elastography according to lesion stiffness combined with greyscale ultrasound according to BI-RADS classification 
British Journal of Cancer  2012;107(2):224-229.
Background:
The aim of this study was to assess the performance of shear wave elastography combined with BI-RADS classification of greyscale ultrasound images for benign/malignant differentiation in a large group of patients.
Methods:
One hundred and seventy-five consecutive patients with solid breast masses on routine ultrasonography undergoing percutaneous biopsy had the greyscale findings classified according to the American College of Radiology BI-RADS. The mean elasticity values from four shear wave images were obtained.
Results:
For mean elasticity vs greyscale BI-RADS, the performance results against histology were sensitivity: 95% vs 95%, specificity: 77% vs 69%, Positive Predictive Value (PPV): 88% vs 84%, Negative Predictive Value (NPV): 90% vs 91%, and accuracy: 89% vs 86% (all P>0.05). The results for the combination (positive result from either modality counted as malignant) were sensitivity 100%, specificity 61%, PPV 82%, NPV 100%, and accuracy 86%. The combination of BI-RADS greyscale and shear wave elastography yielded superior sensitivity to BI-RADS alone (P=0.03) or shear wave alone (P=0.03). The NPV was superior in combination compared with either alone (BI-RADS P=0.01 and shear wave P=0.02).
Conclusion:
Together, BI-RADS assessment of greyscale ultrasound images and shear wave ultrasound elastography are extremely sensitive for detection of malignancy.
doi:10.1038/bjc.2012.253
PMCID: PMC3394981  PMID: 22691969
breast; ultrasound; elastography; shear wave; imaging
7.  Shear Wave Elastography May Add a New Dimension to Ultrasound Evaluation of Thyroid Nodules: Case Series with Comparative Evaluation 
Journal of Thyroid Research  2012;2012:657147.
Although elastography can enhance the differential diagnosis of thyroid nodules, its diagnostic performance is not ideal at present. Further improvements in the technique and creation of robust diagnostic criteria are necessary. The purpose of this study was to compare the usefulness of strain elastography and a new generation of elasticity imaging called supersonic shear wave elastography (SSWE) in differential evaluation of thyroid nodules. Six thyroid nodules in 4 patients were studied. SSWE yielded 1 true-positive and 5 true-negative results. Strain elastography yielded 5 false-positive results and 1 false-negative result. A novel finding appreciated with SSWE, were punctate foci of increased stiffness corresponding to microcalcifications in 4 nodules, some not visible on B-mode ultrasound, as opposed to soft, colloid-inspissated areas visible on B-mode ultrasound in 2 nodules. This preliminary paper indicates that SSWE may outperform strain elastography in differentiation of thyroid nodules with regard to their stiffness. SSWE showed the possibility of differentiation of high echogenic foci into microcalcifications and inspissated colloid, adding a new dimension to thyroid elastography. Further multicenter large-scale studies of thyroid nodules evaluating different elastographic methods are warranted.
doi:10.1155/2012/657147
PMCID: PMC3363142  PMID: 22685685
8.  Ductal Carcinoma In Situ Detected by Shear Wave Elastography within a Fibroadenoma 
Journal of Breast Cancer  2014;17(2):180-183.
Fibroadenoma is the most common breast tumor in women. Malignant transformation occurs rarely within fibroadenoma at older ages. Clinicians, radiologists, and pathologists need to be aware of malignant transformation within fibroadenomas. Radiologic studies play an important role in the diagnosis of fibroadenoma; however, radiologic findings are often nonspecific for malignancy and may appear completely benign. We detected an occult ductal carcinoma in situ that originated inside a fibroadenoma by using shear wave elastography. We report shear wave elastography findings of ductal carcinoma in situ within fibroadenoma and discuss the diagnostic role of this modality.
doi:10.4048/jbc.2014.17.2.180
PMCID: PMC4090322  PMID: 25013441
Carcinoma; Intraductal; Noninfiltrating; Elasticity imaging techniques; Fibroadenoma
9.  US in the assessment of acute scrotum 
Critical Ultrasound Journal  2013;5(Suppl 1):S8.
Background
The acute scrotum is a medical emergency . The acute scrotum is defined as scrotal pain, swelling, and redness of acute onset. Scrotal abnormalities can be divided into three groups , which are extra-testicular lesion, intra-testicular lesion and trauma. This is a retrospective analysis of 164 ultrasound examination performed in patient arriving in the emergency room for scrotal pain.
The objective of this article is to familiarize the reader with the US features of the most common and some of the least common scrotal lesions.
Methods
Between January 2008 and January 2010, 164 patients aged few month and older with scrotal symptoms, who underwent scrotal ultrasonography (US), were retrospectively reviewed. The clinical presentation, outcome, and US results were analyzed. The presentation symptoms including scrotal pain, painless scrotal mass or swelling, and trauma.
Results
Of 164 patients, 125 (76%) presented with scrotal pain, 31 (19%) had painless scrotal mass or swelling and 8 (5%) had trauma. Of the 125 patients with scrotal pain, 72 had infection,10 had testicular torsion, 8 had testicular trauma, 18 had varicocele, 20 had hydrocele, 5 had cryptorchidism, 5 had scrotal sac and groin metastases, and 2 had unremarkable results. In the 8 patients who had history of scrotal trauma, US detected testicular rupture in 1 patients, scrotal haematomas in 2 patients .
Of the 19 patients who presented with painless scrotal mass or swelling, 1 6 had extra-testicular lesions and 3 had intra-testicular lesions. All the extra-testicular lesions were benign. Of the 3 intra-testicular lesions, one was due to tuberculosis epididymo-orchitis, one was non-Hodgkin’s lymphoma, and one was metastasis from liposarcoma
Conclusions
US provides excellent anatomic detail; when color Doppler and Power Doppler imaging are added, testicular perfusion can be assessed
doi:10.1186/2036-7902-5-S1-S8
PMCID: PMC3711727  PMID: 23902859
scrotal trauma; scrotal disease; ultrasound of scrotum
10.  Quantitative assessment of the elasticity values of liver with shear wave ultrasonographic elastography 
Background & objectives:
Tissue stiffness in liver is related to tissue composition, which is changed by cirrhosis, hepatocellular carcinoma or metastases. Shear wave ultrasonographic elastography is a new imaging technique by which the elasticity of soft tissue can be measured quantitatively. The aim of this study was to measure the elasticity values of liver segments in healthy volunteers.
Methods:
One hundred twenty seven healthy volunteers (89 women, 38 men; mean age 37, 72 ± 9.11 yr, range 17-63 yr) were examined on shear wave elastography and ultrasonography by using convex probe with a frequency of 3 MHz. Individuals with liver hepatosteatosis, cirrhosis, chronic liver disease, or focal liver lesions were excluded from the study.
Results:
The mean elasticity values of right posterior, right anterior, left medial and left lateral segments of the liver was determined as 4 (±2.2), 3.3 (±2.1), 3.8 (±2.1), and 3.7 (±1.9) kPa for each segments, respectively. There was no significant difference in liver elasticity values between men and women.
Interpretation & conclusions:
In this preliminary study the elasticity values of liver segments were measured by shear wave ultrasonographic elastography in normal healthy volunteers. Further studies, comparing elasticity values of normal and pathologic tissues are needed to detect the diagnostic role of this new technique.
PMCID: PMC3734682  PMID: 23760376
Elasticity; elastography; liver; shear wave ultrasoun
11.  Acoustic radiation force impulse of the liver 
Acoustic radiation force impulse (ARFI) imaging is a new and promising ultrasound-based diagnostic technique that, evaluating the wave propagation speed, allows the assessment of the tissue stiffness. ARFI is implemented in the ultrasound scanner. By short-duration acoustic radiation forces (less than 1 ms), localized displacements are generated in a selected region of interest not requiring any external compression so reducing the operator dependency. The generated wave scan provides qualitative or quantitative (wave velocity values) responses. Several non-invasive methods for assessing the staging of fibrosis are used, in order to avoid liver biopsy. Liver function tests and transient elastography are non-invasive, sensitive and accurate tools for the assessment of liver fibrosis and for the discrimination between cirrhotic and non-cirrhotic liver. Many published studies analyse ARFI performance and feasibility in studying diffuse liver diseases and compare them to other diagnostic imaging modalities such as conventional ultrasonography and transient elastography. Solid focal liver lesions, both benign and malignant, are common findings during abdominal examinations. The accurate characterization and differential diagnosis are important aims of all the imaging modalities available today. Only few papers describe the application of ARFI technology in the study of solid focal liver lesions, with different results. In the present study, the existing literature, to the best of our knowledge, about ARFI application on diffuse and focal liver pathology has been evaluated and results and statistical analyses have been compared, bringing to the conclusion that ARFI can be used in the study of the liver with similar accuracy as transient elastography in diagnosing significant fibrosis or cirrhosis and has got some advantages in respect to transient elastography since it does not require separate equipment, better displays anatomical structures and measurements can be successfully carried out almost in every patient.
doi:10.3748/wjg.v19.i30.4841
PMCID: PMC3740413  PMID: 23946588
Acoustic radiation force impulse imaging; Sonoelastography; Diffuse liver pathology; Focal liver lesion
12.  Role of Color Doppler in Scrotal Lesions 
Color Doppler USG of the scrotum has been demonstrated to be useful in the diagnosis of scrotal lesions. Gray-scale USG characterizes the lesions as testicular or extratesticular and, with color Doppler and power Doppler, flow and perfusion can also be assessed. Color Doppler is particularly helpful in acute painful conditions, where it can differentiate testicular ischemia from inflammatory conditions and thus prevent unnecessary surgical explorations. With color Doppler, useful information can be gained about vascularity in testicular malignancies. Color Doppler also has high sensitivity and high specificity in the diagnosis of lesions like varicoceles.
doi:10.4103/0971-3026.54874
PMCID: PMC2766882  PMID: 19881082
Color Doppler; testicular torsion; epididymo-orchitis; varicoceles
13.  Comb-push Ultrasound Shear Elastography (CUSE) for Evaluation of Thyroid Nodules: Preliminary In vivo Results 
In clinical practice, an overwhelming majority of biopsied thyroid nodules are benign. Therefore, there is a need for a complementary and noninvasive imaging tool to provide clinically relevant diagnostic information about thyroid nodules to reduce the rate of unnecessary biopsies. The goal of this study was to evaluate the feasibility of utilizing Comb-push Ultrasound Shear Elastography (CUSE) to measure the mechanical properties (i.e., stiffness) of thyroid nodules and use this information to help classify nodules as benign or malignant. CUSE is a fast and robust 2D shear elastography technique in which multiple laterally distributed acoustic radiation force beams are utilized simultaneously to produce shear waves. Unlike other shear elasticity imaging modalities, CUSE does not suffer from limited field of view (FOV) due to shear wave attenuation and can provide a large FOV at high frame rates. To evaluate the utility of CUSE in thyroid imaging, a preliminary study was performed on a group of 5 healthy volunteers and 10 patients with ultrasound (US)-detected thyroid nodules prior to fine needle aspiration biopsy (FNAB). The measured shear wave speeds in normal thyroid tissue and thyroid nodules were converted to Young's modulus (E), indicating a measure of tissue stiffness. Our results indicate an increase in E for thyroid nodules compared to normal thyroid tissue. This increase was significantly higher in malignant nodules compared to benign. The Young's modulus in normal thyroid tissue, benign and malignant nodules were found to be 23.2±8.29 kPa, 91.2±34.8 kPa, and 173.0±17.1 kPa, respectively. Results of this study suggest the utility of CUSE in differentiating between benign and malignant thyroid nodules.
doi:10.1109/TMI.2014.2346498
PMCID: PMC4280299  PMID: 25122532
Cancer; Elasticity; In vivo; Shear Wave Elastography; Thyroid; Ultrasound
14.  Breast Sonography – 2D, 3D, 4D Ultrasound or Elastography? 
Breast Care  2011;6(2):98-103.
Summary
The aim of this publication is to give an answer to the question whether 2D, 3D and 4D sonography of the breast can be replaced by elastography or whether elastography is an adjunct tool to B-mode imaging. The Breast Imaging and Reporting Data System (BI-RADS) ultrasound (US) descriptors of a lesion besides vascularity are based on B-mode imaging. US elastography displays the mechanical tissue properties. This information can be obtained by freehand compression and decompression. Acoustic radiation force impulse imaging (ARFI) produces stress with low-frequency push pulses. Manual compression by the transducer is not necessary. Shear wave elastography (SWE) is the combination of ARFI and the measurement of the consecutive shear wave propagations in the tissue. A quantification of the elasticity in kilopascal (kPa) is offered. Discussing B-mode imaging and elastography combined with the literature, elastography is seen as an addition to B-mode imaging with the potential to increase the specificity of the B-mode imaging-based BI-RADS assessment. In spite of additional elasticity information, the sensitivity remains high. A time-saving diagnostic algorithm for 2D, 3D US and elastography is described. In conclusion, it must be said that elasticity is not a stand-alone US modality able to replace 2D and 3D sonography.
doi:10.1159/000327504
PMCID: PMC3104899  PMID: 21673819
Breast; Ultrasound; Three-dimensional imaging; Elastography; Breast Diseases
15.  Endoscopic ultrasound elastography 
Endoscopic Ultrasound  2012;1(1):8-16.
Endoscopic ultrasound (EUS) is a reference technique for diagnosing and staging several different diseases. EUS-guided biopsies and fine needle aspirations are used to improve diagnostic performance of cases where a definitive diagnosis cannot be obtained through conventional EUS. However, EUS-guided tissue sampling requires experience and is associated with a low but not negligible risk of complications. EUS elastography is a non-invasive method that can be used in combination with conventional EUS and has the potential for improving the diagnostic accuracy and reducing the need for EUS-guided tissue sampling in several situations. Elastography measures tissue stiffness by evaluating changes in the EUS image before and after the application of slight pressure to the target tissue by the ultrasonography probe. Pathologic processes such as cancerization and fibrosis alter tissue elasticity and therefore induce changes in elastographic appearance. Qualitative elastography depicts tissue stiffness using different colors, whereas quantitative elastography renders numerical results expressed as a strain ratio or hue histogram mean. EUS elastography has been proven to differentiate between benign and malignant solid pancreatic masses, as well as between benign and malignant lymph nodes with a high accuracy. Studies have also demonstrated that the early changes of chronic pancreatitis can be distinguished from normal pancreatic tissues under EUS elastography. In this article, we review the technical aspects and current clinical applications of qualitative and quantitative EUS elastography and emphasize the potential additional indications that need to be evaluated in future clinical studies.
doi:10.7178/eus.01.003
PMCID: PMC4062202  PMID: 24949330
endoscopic ultrasound; elastography; pancreatic tumors; lymph nodes
16.  Early Exploration in the Management of Acute Scrotum in Children 
Iranian Journal of Pediatrics  2010;20(4):466-470.
Objective
Acute scrotal conditions are a common clinical setting that present with pain and swelling of the hemiscrotum. The aim of our study has been to evaluate the findings in boys operated on acute scrotum.
Methods
A descriptive study was conducted on 100 patients with acute scrotum admitted to Mofid Children's Hospital from March 1993 to March 2007. Data included history, age, primary symptoms, definite diagnosis, side involvement, paraclinical tests, imaging modalities, medical or surgical management and type of the surgery.
Findings
Diagnosis was made mainly by clinical signs and symptoms and surgical exploration. Torsion of testis (n=31) was the most common cause of acute scrotum followed by incarcerated inguinal hernia (n=30), torsion of testicular appendage (n=27), epididymo-orchitis (n=7), idiopathic scrotal edema (n=4) and hematocele (n=1). Most (34%) of the patients were in the first year of life and the mean age was 5.4 years. The commonest signs were pain and swelling (62%) followed by pain, swelling and redness (21%) and pain alone (16%). 83 patients consisting of 31 with torsion of testis, 14 with torsion of testicular appendage, 30 with incarcerated hernia and 7 with epididymo–orchitis underwent surgical exploration after careful physical examination. 10 of 31 patients with torsion of testis had orchiectomy and orchiopexy of contra–lateral testis and the rest had detorsion and bilateral orchiopexy. 80% of patients were referred to the hospital after 12 hours of clinical onset of symptoms.
Conclusion
Early exploration of scrotum based on careful physical examination excludes the risk of misdiagnosis by diagnostic procedures and unnecessary delay by diagnostic techniques. Exploration of scrotum is a relatively safe and simple procedure with good cosmetic results, it also allows an accurate diagnosis to be made.
PMCID: PMC3446083  PMID: 23056747
Scrotum; Testicular Torsion; Scrotal Swelling; Epididymitis; Orchitis
17.  Role of Ultrasound with Color Doppler in Acute Scrotum Management 
Background and Objective:
An acute scrotum is defined as acute pain with or without scrotal swelling, may be accompanied by local signs or general symptoms. Acute scrotal pain is a medical emergency. Depending on cause, the management is entirely different. Torsion of testis and strangulated hernia are surgical emergency; whereas, epididymo-orchitis is treated by medicines. Testicular trauma and obstructed hernia can be differentiated by taking history from patient. Physical examination adds only a little information. Color Doppler ultrasound (US) is the modality of choice to differentiate testicular torsion from inflammatory conditions and can thus help in avoiding unnecessary surgical explorations.
Subjects and Methods:
A study on 50 patients was conducted who were referred with history of acute scrotal pain to our department between January 2013 and January 2014. Trauma and scrotal mass were excluded from the study. The clinical presentation, outcome, and US results were analyzed.
Results:
Color Doppler sonography yielded a positive and negative predictive value (PPV and NPV) of 100% each for torsion, whereas, 93.9 and 70.6% for epididymo-orchitis, respectively; a sensitivity and specificity of 100% for torsion, whereas, for epididymo-orchitis it was found to be 86.1 and 85.7%, respectively. In cases of incomplete or early torsion, some residual perfusion may be detected leading to false-negative results.
Conclusion:
We therefore conclude that color Doppler sonography can reliably rule out testicular torsion and can thus help in avoiding unnecessary surgical explorations. Hence, it can significantly improve outcome and decrease morbidity of patient. It is an accurate, rapid, nonexpensive, nonionizing, important adjunct to clinical assessment of scrotum.
doi:10.4103/2249-4863.148130
PMCID: PMC4311353  PMID: 25657954
Color Doppler in acute scrotum; sonographic evaluation of acute scrotum; torsion of testis
18.  Sonoelastography – A Useful Adjunct for Parotid Gland Ultrasound Assessment in Patients Suffering from Chronic Inflammation 
Background
Shear wave elastography (SWE) is widely used in breast, liver, prostate and thyroid evaluations. Elastography provides additional information if used to assess parotid gland pathology. We assessed parotid glands by means of SWE to compare the parenchyma properties in different types of inflammation.
Material/Methods
Prospective analysis included 78 consecutive patients with parotid gland pathology: sialolithiasis (33), Stensen’s duct stenosis (15), chronic inflammation (10), and primary Sjögren syndrome (pSS) (20) treated at the Department of Otolaryngology, Head and Neck Surgery of PUMS. The primary predictor variable was type of parotid pathology, and secondary predictor variables were patient age and the duration and intensity of complaints. Ultrasound pictures were compared with elastography values of parotid parenchyma.
Results
Mean elasticity values for pSS (111 Kilopascals (kPa), Stensen’s duct stenosis (63 kPa), sialolithiasis (82 kPa), and chronic inflammation (77 kPa) were significantly higher than the mean value for healthy patients (24 kPa). Elasticity increased proportionally to the intensity of complaints: mild (51 kPa), moderate (78 kPa), and strong (90 kPa). Increased elasticity did not correspond with ultrasonographic pictures. In pSS the parenchyma was almost twice as stiff as in chronic inflammation (p=0.02), although subjective complaints were mostly mild or moderate, and the ultrasonographic picture did not present features of fibrosis.
Conclusions
Sonoelastography, by improving routine ultrasonographic assessment, might be a useful tool for parotid evaluations during the course of chronic inflammation. An extraordinarily high degree of stiffness was revealed in pSS despite lack of fibrosis by ultrasonography and moderate subjective complaints, suggesting that sonoelastography could be a valuable diagnostic tool.
doi:10.12659/MSM.890678
PMCID: PMC4245104  PMID: 25398237
Elasticity Imaging Techniques; Sialadenitis; Ultrasonography
19.  Torsion of a seminoma in an intrascrotal testis: A case report and review of the literature 
An intrascrotal testicular torsion with malignant testicular tumour is extremely rare. We report a case of a 26-year-old male who was diagnosed with testicular torsion by magnetic resonance imaging and with testicular seminoma after orchiectomy. Through this case, we found that if the possibility of testicular torsion remains during the diagnosis of acute scrotum cases, additional examination adding to colour Doppler sonography should be performed. Furthermore, we should be aware of the possibility of testicular tumours during the diagnosis and treatment of acute scrotums. If the affected testis is preserved in the treatment of testicular torsion, a postoperative examination by ultrasound and/or tumour markers for the remaining testis is essential to confirm the absence of testicular tumour.
doi:10.5489/cuaj.248
PMCID: PMC3650797  PMID: 23671497
20.  Breast elastography: A literature review 
Journal of Ultrasound  2012;15(3):192-198.
Breast elastography is a new sonographic imaging technique which provides information on breast lesions in addition to conventional ultrasonography (US) and mammography. Elastography provides a noninvasive evaluation of the stiffness of a lesion. Today, two technical solutions are available for clinical use: strain elastography and shear wave elastography. Initial evaluations of these techniques in clinical trials suggest that they may substantially improve the possibility of differentiating benign from malignant breast lesions thereby limiting recourse to biopsy and considerably reducing the number of benign breast biopsy diagnoses. This article reviews the basics of this technique, how to perform the examination, image interpretation and the results of major clinical studies. Although elastography is easy to perform, training and technical knowledge are required in order to obtain images permitting a correct interpretation. This paper will highlight the technique and point out common pitfalls.
doi:10.1016/j.jus.2012.06.009
PMCID: PMC3558110  PMID: 23449849
Sonoelastography; Breast elastography; Breast lesions
21.  Shear Wave Velocity Imaging Using Transient Electrode Perturbation: Phantom and ex vivo Validation 
This paper presents a new shear wave velocity imaging technique to monitor radio-frequency and microwave ablation procedures, coined electrode vibration elastography. A piezoelectric actuator attached to an ablation needle is transiently vibrated to generate shear waves that are tracked at high frame rates. The time-to-peak algorithm is used to reconstruct the shear wave velocity and thereby the shear modulus variations. The feasibility of electrode vibration elastography is demonstrated using finite element models and ultrasound simulations, tissue-mimicking phantoms simulating fully (phantom 1) and partially ablated (phantom 2) regions, and an ex vivo bovine liver ablation experiment. In phantom experiments, good boundary delineation was observed. Shear wave velocity estimates were within 7% of mechanical measurements in phantom 1 and within 17% in phantom 2. Good boundary delineation was also demonstrated in the ex vivo experiment. The shear wave velocity estimates inside the ablated region were higher than mechanical testing estimates, but estimates in the untreated tissue were within 20% of mechanical measurements. A comparison of electrode vibration elastography and electrode displacement elastography showed the complementary information that they can provide. Electrode vibration elastography shows promise as an imaging modality that provides ablation boundary delineation and quantitative information during ablation procedures.
doi:10.1109/TMI.2010.2091412
PMCID: PMC3066053  PMID: 21075719
Electrode vibration elastography; radio-frequency (RF) ablation; shear wave tracking; time-to-peak; ultrasound
22.  Impact of Acoustic Radiation Force Impulse Imaging in Clinical Practice of Patients after Orthotopic Liver Transplantation 
Background
Acoustic radiation force impulse (ARFI) elastography is a reliable diagnostic device for quantitative non-invasive assessment of liver fibrosis in patients with chronic liver disease. The aim of our prospective study was to evaluate the impact of ARFI in patients after orthotopic liver transplantation (OLT). Therefore, we compared ARFI shear wave velocities with clinical features, non-invasive markers, and the histology of patients following OLT.
Material/Methods
Post-transplant patients underwent a clinical examination and blood samples were taken. B-mode and Doppler ultrasound (US) of the portal vein and the hepatic artery were performed. Subsequently, a minimum of 10 valid ARFI values were measured in the left and right liver lobe. Liver biopsy was performed if indicated.
Results
Between May 2012 and May 2014, 58 Patients after OLT were included in the prospective study. Laboratory markers and aspartate aminotransferase-to-platelet ratio index (APRI) correlated with ARFI values (r=0.44, p<0.001). The histological (n=22) fibrosis score (Ludwig) was significantly correlated with the ARFI of the biopsy site (r=0.55, p=0.008). The mean shear-wave velocities were significantly increased in advanced fibrosis (F≤2 1.57±0.57 m/s; F≥3 2.85±0.66 m/s; p<0.001), obstructive cholestasis and active viral hepatitis. The area under the receiver operating characteristic (AUROC) curves for the accuracy of ARFI were 74% (F≥1), 73% (F≥2), 93% (F≥3), and 80% (=F4).
Conclusions
ARFI elastography correlates well with laboratory values and with noninvasive and invasive markers of fibrosis in patients after OLT. In this regard, elevated ARFI-velocities should be interpreted with caution in the context of obstructive cholestasis and active viral disease.
doi:10.12659/MSM.891126
PMCID: PMC4218901  PMID: 25342166
Elasticity Imaging Techniques; Liver Cirrhosis; Liver Transplantation; Ultrasonography
23.  Noncontact depth-resolved micro-scale optical coherence elastography of the cornea 
Biomedical Optics Express  2014;5(11):3807-3821.
High-resolution elastographic assessment of the cornea can greatly assist clinical diagnosis and treatment of various ocular diseases. Here, we report on the first noncontact depth-resolved micro-scale optical coherence elastography of the cornea achieved using shear wave imaging optical coherence tomography (SWI-OCT) combined with the spectral analysis of the corneal Lamb wave propagation. This imaging method relies on a focused air-puff device to load the cornea with highly-localized low-pressure short-duration air stream and applies phase-resolved OCT detection to capture the low-amplitude deformation with nano-scale sensitivity. The SWI-OCT system is used here to image the corneal Lamb wave propagation with the frame rate the same as the OCT A-line acquisition speed. Based on the spectral analysis of the corneal temporal deformation profiles, the phase velocity of the Lamb wave is obtained at different depths for the major frequency components, which shows the depthwise distribution of the corneal stiffness related to its structural features. Our pilot experiments on ex vivo rabbit eyes demonstrate the feasibility of this method in depth-resolved micro-scale elastography of the cornea. The assessment of the Lamb wave dispersion is also presented, suggesting the potential for the quantitative measurement of corneal viscoelasticity.
doi:10.1364/BOE.5.003807
PMCID: PMC4242019  PMID: 25426312
(170.4460) Ophthalmic optics and devices; (170.4500) Optical coherence tomography; (120.5050) Phase measurement
24.  Clinical oncology for pancreatic and biliary cancers: Advances and current limitations 
In the early 2000s, the main stream of endoscopic ultrasonography (EUS) changed from a mechanical scanning method to electronic radial or linear scanning methods. Subsequently, useful applications in trans-abdominal ultrasonography came within reach of EUS. In particular, contrast-enhanced EUS (CE-EUS) and EUS-elastography became cutting-edge diagnostic modalities for pancreatic disorders. Each type of pancreatic disorder has characteristic hemodynamics. CE-EUS uses color Doppler flow imaging and harmonic imaging to classify pancreatic lesions. EUS-elastography can assess tissue hardness by measuring its elasticity. This parameter appears to correlate with the malignant potential of the lesions. Tissue elasticity studies can provide information on both its pattern and distribution. The former is the conventional method of morphological diagnosis, but it is restricted to observations made in a region of interest (ROI). The latter is an unbiased analysis that can be performed by image analysis software and is theoretically constant, regardless of the ROI. Though EUS-fine needle aspiration (FNA) is also a very useful diagnostic tool, there are several limitations. Diagnostic EUS-FNA of pancreatic cystic lesions has marginal utility mainly due to low sensitivity. Therefore, in particular, endoscopists should keep this limitation in mind.
doi:10.5306/wjco.v2.i5.217
PMCID: PMC3100497  PMID: 21611098
Contrast-enhanced endoscopic ultrasonography; Endoscopic ultrasonography-elastography; Endoscopic ultrasonography-fine needle aspiration; Pancreatic cystic lesions; Dissemination; Track seeding; Marginal utility for pancreatic cystic lesions of endoscopic ultrasonography-fine needle aspiration
25.  Can Doppler or contrast-enhanced ultrasound analysis add diagnostically important information about the nature of breast lesions? 
Clinics  2014;69(2):87-92.
OBJECTIVES:
Despite evidence suggesting that Doppler ultrasonography can help to differentiate between benign and malignant breast lesions, it is rarely applied in clinical practice. The aim of this study was to determine whether certain vascular features of breast masses observed by duplex Doppler and color Doppler ultrasonography (before and/or after microbubble contrast injection) add information to the gray-scale analysis and support the Breast Imaging-Reporting and Data System (BI-RADS) classification.
METHODS:
Seventy solid lesions were prospectively evaluated with gray-scale ultrasonography, color Doppler ultrasonography, and contrast-enhanced ultrasonography. The morphological analysis and lesion vascularity were correlated with the histological results.
RESULTS:
Percutaneous core biopsies revealed that 25/70 (17.5%) lesions were malignant, while 45 were benign. Hypervascular lesions with tortuous and central vessels, a resistive index (RI)≥0.73 before contrast injection, and an RI≥0.75 after contrast injection were significantly predictive of malignancy (p<0.001).
CONCLUSION:
The combination of gray-scale ultrasonography data with unenhanced or enhanced duplex Doppler and color Doppler US data can provide diagnostically useful information. These techniques can be easily implemented because Doppler devices are already present in most health centers.
doi:10.6061/clinics/2014(02)03
PMCID: PMC3912319  PMID: 24519198
Breast Ultrasonography; Ultrasonography, Doppler, Duplex; Breast Cancer; Contrast Media; Microbubbles

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