The technical part of these Guidelines and Recommendations, produced under the auspices of EFSUMB, provides an introduction to the physical principles and technology on which all forms of current commercially available ultrasound elastography are based. A difference in shear modulus is the common underlying physical mechanism that provides tissue contrast in all elastograms. The relationship between the alternative technologies is considered in terms of the method used to take advantage of this. The practical advantages and disadvantages associated with each of the techniques are described, and guidance is provided on optimisation of scanning technique, image display, image interpretation and some of the known image artefacts.

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EFSUMB Guidelines and Recommendations on the Clinical Use of Ultrasound Elastography. Part 1: Basic Principles and Technology

Conventional diagnostic ultrasound images of the anatomy (as opposed to blood flow) reveal differences in the acoustic properties of soft tissues (mainly echogenicity but also, to some extent, attenuation), whereas ultrasound-based elasticity images are able to reveal the differences in the elastic properties of soft tissues (e.g., elasticity and viscosity). The benefit of elasticity imaging lies in the fact that many soft tissues can share similar ultrasonic echogenicities but may have different mechanical properties that can be used to clearly visualize normal anatomy and delineate pathologic lesions. Typically, all elasticity measurement and imaging methods introduce a mechanical excitation and monitor the resulting tissue response. Some of the most widely available commercial elasticity imaging methods are 'quasi-static' and use external tissue compression to generate images of the resulting tissue strain (or deformation). In addition, many manufacturers now provide shear wave imaging and measurement methods, which deliver stiffness images based upon the shear wave propagation speed. The goal of this review is to describe the fundamental physics and the associated terminology underlying these technologies. We have included a questions and answers section, an extensive appendix, and a glossary of terms in this manuscript. We have also endeavored to ensure that the terminology and descriptions, although not identical, are broadly compatible across the WFUMB and EFSUMB sets of guidelines on elastography (Bamber et al. 2013; Cosgrove et al. 2013).

WFUMB guidelines and recommendations for clinical use of ultrasound elastography: Part 1: basic principles and terminology.

After 20 years of innovation in techniques that specifically image the biomechanical properties of tissue, the evolution of elastographic imaging can be viewed from its infancy, through a proliferation of approaches to the problem to incorporation on research and then clinical imaging platforms. Ultimately this activity has culminated in clinical trials and improved care for patients. This remarkable progression represents a leading example of translational research that begins with fundamentals of science and engineering and progresses to needed improvements in diagnostic and monitoring capabilities applied to major categories of disease, surgery and interventional procedures. This review summarizes the fundamental principles, the timeline of developments in major categories of elastographic imaging, and concludes with recent results from clinical trials and forward-looking issues.

https://iopscience.iop.org/article/10.1088/0031-9155/56/1/R01/pdf

Imaging the elastic properties of tissue: the 20 year perspective.

After X-radiography, ultrasound is now the most common of all the medical imaging technologies. For millennia, manual palpation has been used to assist in diagnosis, but it is subjective and restricted to larger and more superficial structures. Following an introduction to the subject of elasticity, the elasticity of biological soft tissues is discussed and published data are presented. The basic physical principles of pulse-echo and Doppler ultrasonic techniques are explained. The history of ultrasonic imaging of soft tissue strain and elasticity is summarized, together with a brief critique of previously published reviews. The relevant techniques—low-frequency vibration, step, freehand and physiological displacement, and radiation force (displacement, impulse, shear wave and acoustic emission)—are described. Tissue-mimicking materials are indispensible for the assessment of these techniques and their characteristics are reported. Emerging clinical applications in breast disease, cardiology, dermatology, gastroenterology, gynaecology, minimally invasive surgery, musculoskeletal studies, radiotherapy, tissue engineering, urology and vascular disease are critically discussed. It is concluded that ultrasonic imaging of soft tissue strain and elasticity is now sufficiently well developed to have clinical utility. The potential for further research is examined and it is anticipated that the technology will become a powerful mainstream investigative tool.

https://royalsocietypublishing.org/doi/pdf/10.1098/rsif.2011.0054

Medical ultrasound: imaging of soft tissue strain and elasticity

Elastography is a method that can ultimately generate several new kinds of images, called elastograms. As such, all the properties of elastograms are different from the familiar properties of sonograms. While sonograms convey information related to the local acoustic backscatter energy from tissue components, elastograms relate to its local strains, Young's moduli or Poisson's ratios. In general, these elasticity parameters are not directly correlated with sonographic parameters, i.e. elastography conveys new information about internal tissue structure and behavior under load that is not otherwise obtainable. In this paper we summarize our work in the field of elastography over the past decade. We present some relevant background material from the field of biomechanics. We then discuss the basic principles and limitations that are involved in the production of elastograms of biological tissues. Results from biological tissues in vitro and in vivo are shown to demonstrate this point. We conclude with some observations regarding the potential of elastography for medical diagnosis.

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Elastography: Imaging the elastic properties of soft tissues with ultrasound

A prototype freehand elastographic imaging system has been developed for clinical breast imaging. The system consists of a fast data acquisition system, which is able to capture sequences of intermediate frequency echo frames at full frame rate from a commercial ultrasound scanner whilst the breast is deformed using hand-induced transducer motion. Two-dimensional echo tracking was used in combination with global distortion compensation and multi-compression averaging to minimise decorrelation noise incurred when stress is applied using hand-induced transducer motion. Experiments were conducted on gelatine phantoms to evaluate the quality of elastograms produced using the prototype system relative to those produced using mechanically induced transducer motion. The strain sensitivity and contrast-to-noise ratio of freehand elastograms compared favourably with elastograms produced using mechanically induced transducer motion. However, better dynamic range and signal-to-noise ratio was achieved when elastograms were created using mechanically induced transducer motion. Despite the loss in performance incurred when stress is applied using hand-induced transducer motion, it was concluded that the prototype system performed sufficiently well to warrant clinical evaluation.

A freehand elastographic imaging approach for clinical breast imaging: system development and performance evaluation

Progress in freehand elastography of the breast. A digest is provided of work carried out at The Institute of Cancer Research to develop freehand elastography and apply it to breast investigations. Topics covered include the development of freehand elastography and its relationship to other methods, a description of the system for off-line clinical evaluation of the freehand method, comparison of the physical performances of freehand and mechanical elastography, early clinical results on 70 breast tumours, real-time imaging, quantitative elastography and psychophysical aspects of the detection and assessment; of elastic lesions. Progress in developing this new medical imaging modality is occurring rapidly throughout the world and its future looks promising.

Progress in Freehand Elastography of the Breast

We have demonstrated that despite the loss in performance incurred when hand-induced transducer motion are used as the source of tissue displacement, the quality of the elastograms are sufficiently high for creating clinically useful relative modulus images. Further work is currently been conducted to evaluate the performance of our quantitative freehand elastography system in vivo.

Frank G. Fuechsel

Papers

A freehand elastographic imaging approach for clinical breast imaging: system development and performance evaluation

Progress in Freehand Elastography of the Breast

Reconstructing Young’s Modulus Distributions within Soft Tissues From Freehand Elastograms