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Purpose:  In this prospective, multicenter trial we evaluated whether additional shear wave elastography (SWE) for patients with BI-RADS 3 or 4 lesions on breast ultrasound could further refine the assessment with B-mode breast ultrasound for breast cancer diagnosis., Materials and Methods:  We analyzed prospective, multicenter, international data from 1288 women with breast lesions rated by conventional 2 D B-mode ultrasound as BI-RADS 3 to 4c and undergoing 2D-SWE. After reclassification with SWE the proportion of undetected malignancies should be < 2 %. All patients underwent histopathologic evaluation (reference standard)., Results:  Histopathologic evaluation showed malignancy in 368 of 1288 lesions (28.6 %). The assessment with B-mode breast ultrasound resulted in 1.39 % (6 of 431) undetected malignancies (malignant lesions in BI-RADS 3) and 53.80 % (495 of 920) unnecessary biopsies (biopsies in benign lesions). Re-classifying BI-RADS 4a patients with a SWE cutoff of 2.55 m/s resulted in 1.98 % (11 of 556) undetected malignancies and a reduction of 24.24 % (375 vs. 495) of unnecessary biopsies., Conclusion:  A SWE value below 2.55 m/s for BI-RADS 4a lesions could be used to downstage these lesions to follow-up, and therefore reduce the number of unnecessary biopsies by 24.24 %. However, this would come at the expense of some additionally missed cancers compared to B-mode breast ultrasound (rate of undetected malignancies 1.98 %, 11 of 556, versus 1.39 %, 6 of 431) which would, however, still be in line with the ACR BI-RADS 3 definition (< 2 % of undetected malignancies)., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Abstract: Polyorchidism, a very rare congenital anomaly, refers to the presence of more than 2 testes. It is often associated with many other pathologies including cryptorchidism, varicocele, testicular malignancy, and inguinal hernias.In this report, we describe a 40-year-old man who presented with an intermittently painful left groin, initially appearing as inguinal hernia. On ultrasound examination, a supernumerary testes and epididymis were found in the inguinal canal. The testes appeared sonographically normal with no evidence of associated pathologies. There was no evidence of an inguinal hernia containing fat or bowel.Ultrasound is essential in first-line diagnosis and classification of polyorchidism. Color Doppler ultrasound and magnetic resonance imaging can be used to clarify findings if sonographic images are inconclusive. We also review relevant literature as it pertains to classification, embryology, and treatment options. Patient treatment is based on imaging findings; if associated pathologies or malignancy is suspected, aggressive treatment such as surgical excision may be necessary. Otherwise, conservative treatment may be all that is needed., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Recently a series of papers was introduced describing on "how to do" certain techniques. More specifically we published on how to perform strain imaging using the transcutaneous and endoscopic ultrasound approach and shear wave elastography (SWE). In the first part we describe how to optimize the examination technique, discussing normal values, pitfalls, artefacts and specific tips for applying SWE to specific organs (liver, breast, thyroid, salivary glands) as part of a diagnostic US examination. In part II, the use of SWE in the pancreas, spleen, kidney, prostate, scrotum, musculoskeletal system, lymph nodes and future developments are discussed.

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide, with an estimated prevalence of up to 30% in the general population and higher in people with type 2 diabetes. The assessment of liver fat content is essential to help identify patients with or who are at risk for NAFLD and to follow their disease over time. The American Institute of Ultrasound in Medicine-RSNA Quantitative Imaging Biomarkers Alliance Pulse-Echo Quantitative Ultrasound Initiative was formed to help develop and standardize acquisition protocols and to better understand confounding factors of US-based fat quantification. The three quantitative US parameters explored by the initiative are attenuation, backscatter coefficient, and speed of sound. The purpose of this review is to present the current state of attenuation imaging for fat quantification and to provide expert opinion on examination performance and interpretation. US attenuation methods that need further study are outlined., (© RSNA, 2022.)

Indeterminate renal masses are a common clinical problem. CEUS has several advantages to characterize both cystic and solid renal masses including thin slice thickness, excellent background subtraction, and real-time imaging with a high frame rate. The ultrasound contrast agents are not nephrotoxic and can be used in patients with renal insufficiency and obstruction. The Bosniak classification has been developed for use in CT and MRI. A CEUS Bosniak classification has not yet been developed. This meta-analysis reviews the results of renal mass characterization using Lumason/Sonovue in characterizing renal solid and cystic masses. For complex cystic renal lesions (419 patients; 436 lesions), the pooled sensitivity and specificity of CEUS were 95% (95% CI: 91%, 99%) and 84% (95% CI: 77%, 90%) and for solid lesions (331 patients; 341 lesions), the pooled sensitivity and specificity of CEUS were 98% (95% CI: 95%, 100%) and 78% (95% CI: 68%, 88%), respectively., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

BACKGROUND. Supplemental screening breast ultrasound (US) detects additional cancers in women with dense breasts but identifies many BI-RADS 3 lesions that result in short-term follow-up and biopsies. OBJECTIVE. The purpose of this study was to evaluate outcomes in patients recommended for return to routine screening for lesions assessed as BI-RADS 3 on supplemental automated whole-breast US. METHODS. This prospective study invited patients with BI-RADS 1 or 2 on screening mammography and breast density C or D to undergo supplemental automated breast US (ABUS). ABUS was interpreted as BI-RADS 1, 2, 3, or 0. Return to routine screening was recommended for ABUS BI-RADS 1, 2, or 3. ABUS BI-RADS 0 lesions underwent targeted handheld US. Remaining patients were followed for 2 years. Malignancy rates were compared using Fisher exact tests. RESULTS. A total of 2257 women (mean age, 58.0 ± 11.2 [SD] years) were included. Supplemental ABUS was scored as BI-RADS 1 in 1186 (52.5%) women, BI-RADS 2 in 591 (26.2%), BI-RADS 3 in 395 (17.5%), and BI-RADS 0 in 85 (3.8%). A total of 394 patients with ABUS BI-RADS 3 had 2-year follow-up, during which no cancer (0%; 95% CI, 0.0-0.9%) was diagnosed in the quadrant of the lesion. Among patients with 2-year follow-up, breast cancer was diagnosed in 4/1117 (0.4%) with ABUS BI-RADS 1, 2/556 (0.4%) with ABUS BI-RADS 2, and 2/394 (0.5%) with ABUS BI-RADS 3 (cancer in other quadrant than the lesion). Malignancy rates were not different between ABUS BI-RADS 1, 2, and 3 ( p = .28). The ABUS recall rate was 3.8% (85/2257; 95% CI, 3.6-4.0%). If short-term follow-up had been recommended for ABUS BI-RADS 3, the ABUS recall rate would have been 21.3% (480/2257, 95% CI 19.6-23.0%). The biopsy rate was 0.5% (12/2257; 95% CI, 0.3-0.9%); the positive biopsy rate was 58.3% (7/12). One of seven cancers diagnosed by initial supplemental ABUS and none of eight cancers diagnosed during subsequent follow-up were node-positive cancer. CONCLUSION. Return to routine screening for ABUS BI-RADS 3 lesions results in a substantial decrease in recall rate and is unlikely to result in an adverse outcome. CLINICAL IMPACT. This prospective study supports a recommendation for routine annual follow-up for BI-RADS 3 lesions at supplemental ABUS. TRIAL REGISTRATION. ClinicalTrials.gov NCT02650778.

Purpose:  To evaluate the diagnostic performance of strain elastography (SE) and 2 D shear wave elastography (SWE) and SE/SWE combination in comparison with conventional multiparametric ultrasound (US) with respect to improving BI-RADS classification results and differentiating benign and malignant breast lesions using a qualitative and quantitative assessment., Materials and Methods:  In this prospective study, 130 histologically proven breast masses were evaluated with baseline US, color Doppler ultrasound (CDUS), SE and SWE (Toshiba Aplio 500 with a 7-15 MHz wide-band linear transducer). Each lesion was classified according to the BIRADS lexicon by evaluating the size, the B-mode and color Doppler features, the SE qualitative (point color scale) and SE semi-quantitative (strain ratio) methods, and quantitative SWE. Histological results were compared with BIRADS, strain ratio (SR) and shear wave elastography (SWE) all performed by one investigator blinded to the clinical examination and mammographic results at the time of the US examination. The area under the ROC curve (AUC) was calculated to evaluate the diagnostic performance of B-mode US, SE, SWE, and their combination., Results:  Histological examination revealed 47 benign and 83 malignant breast lesions. The accuracy of SR was statistically significantly higher than SWE (sensitivity, specificity and AUC were 89.2 %, 76.6 % and 0.83 for SR and 72.3 %, 66.0 % and 0.69 for SWE, respectively, p = 0.003) but not higher than B-mode US (B-mode US sensitivity, specificity and AUC were 85.5 %, 78.8 %, 0.821, respectively, p = 1.000)., Conclusion:  Our experience suggests that conventional US in combination with both SE and SWE is a valid tool that can be useful in the clinical setting, can improve BIRADS category assessment and may help in the differentiation of benign from malignant breast lesions, with SE having higher accuracy than SWE., Competing Interests: Cantisani: Speaker, Canon Medical Systems Corporation, Speaker, Bracco Group, Speaker, Samsung Electronics Co, Ltd; Barr: Consultant, Siemens AG Speakers Bureau, Siemens AG Research Grant, Siemens AG Consultant, Koninklijke Philips NV Speakers Bureau, Koninklijke Philips NV Consultant, Canon Medical Systems Corporation Research Grant, SuperSonic Imagine Research Grant, Bracco Group Research Grant, Esaote SpA Research Grant, BK Ultrasound Research Grant, Hitachi, Ltd; Radzina: Lecturer honoraria (Bayer, Canon, Bracco); Pediconi: Lecturer (bracco, Bayer, Siemens)., (Thieme. All rights reserved.)

Contrast-enhanced ultrasound (CEUS) has become an established modality in various clinical indications for liver diseases. SonoVue ® , a pure blood pure agent, and Sonazoid ® , which exhibits an additional Kupffer phase, are contrast agents approved for liver imaging. This review discusses and compares the current clinical evidence for these two ultrasound contrast agents in the characterization and detection of focal liver lesions in the non-cirrhotic and cirrhotic liver, as well as for the use in interventional procedures such as liver biopsy guidance, and local ablation treatment monitoring. Reference is made to clinical studies which evaluated the accuracy of CEUS using a standard of reference, its safety, or to comparative studies of these two agents.

On October 24, 2017, in Chicago, the Society of Radiologists in Ultrasound convened a panel of specialists in contrast-enhanced ultrasound (CEUS) to arrive at a white paper regarding the use of CEUS in noncardiac applications in North America. Recommendations are based on analysis of the current literature and common practice strategies. They represent a reasonable approach to introduce the advantages of this safe and noninvasive technique for the benefit of our patients. Characterization of liver nodules with CEUS, as the approval indication worldwide, is the major focus of this endeavor. In addition, many off label uses are reviewed and literature supporting these indications provided.Key Points(1) Contrast-enhanced ultrasound (CEUS) allows cross-sectional imaging of the liver, kidneys and multiple other solid and hollow viscera, providing excellent characterization of identified focal mass lesions.(2) Performed with the injection of a microbubble contrast agent, CEUS provides a safe and readily available imaging technique which requires no ionizing radiation, making it appropriate for use in all ages, in those with renal insufficiency and when a portable examination is needed.(3) The CEUS can be considered in abdominal imaging whenever blood flow information is of value to diagnosis.(4) Dynamic real-time acquisition and the use of a purely intravascular contrast agent are the 2 most essential technical aspects of CEUS imaging which distinguish it from both computed tomography and magnetic resonance scan.

Diffuse liver disease is a substantial world-wide problem. With the combination of conventional ultrasound of the abdomen and elastography-appropriate staging of the patient can be assessed. This information allows for the detection of fibrosis as well as prognosis, surveillance, and prioritization for treatment. With the potential for reversibility with appropriate treatment, accurate assessment for the stage of chronic liver disease is critical., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Strain ratio (SR) is a semiquantitative parameter in differentiating benign from malignant tumors in breast ultrasound elastography. Currently, SR is computed manually and, thus, user dependent. The objective of this study was to evaluate the performance of a new tool assist strain ratio (ASR) and determine how it performs compared with an expert sonologist., Methods: Ninety-one patients scheduled for breast biopsy were included in this institutional review board-approved/Health Insurance Portability and Accountability Act-compliant study. For manual strain ratio (MSR), fat and lesion were manually outlined, whereas for ASR, the clinician indicated the lesion center and the fat-to-lesion ratio is computed automatically. Three measurements were obtained for each lesion. The same raw data were used to calculate the MSR and ASR., Results: The SR thresholds to differentiate benign from malignant tumors were determined using the Youden index. For MSR, the cutoff was 2.7, and for ASR was 2.8. The MSR showed a sensitivity of 88%, specificity of 64%, accuracy of 77%, positive predictive value of 72%, and negative predictive value of 92.1%. Corresponding ASR showed a sensitivity of 86%, specificity of 76%, accuracy of 81%, positive predictive value of 79%, and negative predictive value of 84%. The areas under the curve for the MSR and ASR were 0.83 and 0.85, respectively. The average coefficients of variation for the MSR and ASR measurements were 43% and 30%, respectively., Conclusion: Assist strain ratio demonstrated similar diagnostic performance compared with MSR. In addition, the coefficient of variation of ASR is lower, implying lower intraoperator dependency. Thus, ASR may aid less-experienced scanners in obtaining improved results.

Aim:  The primary aim of this study was to determine the inter-system variability of liver stiffness measurements (LSMs) in patients with varying degrees of liver stiffness. The secondary aim was to determine the inter-observer variability of measurements., Materials and Methods:  21 individuals affected by chronic hepatitis C and 5 healthy individuals were prospectively enrolled. The assessment of LSMs was performed using six ultrasound (US) systems, four of which with point shear wave elastography (p-SWE) and two with 2 D shear wave elastography (2D-SWE) systems. The Fibroscan (Echosens, France) was used as the reference standard. Four observers performed the measurements in pairs (A-B, C-D). The agreement between different observers or methods was calculated using Lin's concordance correlation coefficient. The Bland-Altman limits of agreement (LOA) were calculated as well., Results:  There was agreement above 0.80 for all pairs of systems. The mean difference between the values of the systems with 2D-SWE technique was 1.54 kPa, whereas the maximum mean difference between the values of three out of four systems with the pSWE technique was 0.79 kPa. The intra-patient concordance for all systems was 0.89 (95 % CI: 0.83 - 0.94). Inter-observer agreement was 0.96 (95 % CI: 0.94 - 0.98) for the pair of observers A-B and 0.93 (95 % CI: 0.89 - 0.96) for the pair of observers C-D., Conclusion:  The results of this study show that the agreement between LSMs performed with different US systems is good to excellent and the overall inter-observer agreement in "ideal conditions" is above 0.90 in expert hands., Competing Interests: A conflict of interest has been declared by the author(s)., (© Georg Thieme Verlag KG Stuttgart · New York.)

With the recent FDA approval for characterization of focal liver lesions (FLL) in both pediatric and adult patients using Lumason (sulfur hexafluoride microbubbles), increased use of ultrasound contrast for routine clinical use is expected. This agent has been available for many years in Europe and Asia, and a large body of literature is available regarding the sensitivity and specificity of this agent. In addition, a few studies have directly compared CEUS to CECT and CEMRI for the characterization of focal liver lesions. This paper reviews the literature to provide a background to investigators in the United States as to the accuracy of CEUS in the characterization of FLL. This paper reviews the literature regarding sulfur hexafluoride microbubbles (Lumason in the USA and Sonovue in the rest of the world) since it is the only FDA approved agent in the USA for characterization of FLL. The results of other ultrasound contrast agents which are not FDA approved for abdominal indications (approval for cardiac indications) most likely will have similar results.

Chronic liver disease is a substantial world-wide problem. Its major consequence is increasing deposition of fibrous tissue within the liver leading to the development of cirrhosis with its consequences of portal hypertension, hepatic insufficiency, and hepatocellular carcinoma. The stage of liver fibrosis is important to determine prognosis, surveillance, prioritize for treatment, and potential for reversibility. The process of fibrosis is dynamic and regression of fibrosis is possible with treatment of the underlying conditions. Previously, the only method of staging the degree of fibrosis was liver biopsy. The recent development of ultrasound elastography techniques allows a non-invasive method of estimating the degree of liver fibrosis. Transient elastography (TE) is a non-imaging elastographic technique, while point shear wave (p-SWE) and 2D-SWE combine imaging with elastography. The evidence at this time suggests that p-SWE is as accurate as but more reliable than TE, while 2D-SWE is more accurate than TE. This review discusses the background of chronic liver disease, the types of ultrasound elastography, how to perform an examination, and how to interpret the results.

Purpose To assess the performance of computer-aided diagnosis (CAD) systems and to determine the dominant ultrasonographic (US) features when classifying benign versus malignant focal liver lesions (FLLs) by using contrast material-enhanced US cine clips. Materials and Methods One hundred six US data sets in all subjects enrolled by three centers from a multicenter trial that included 54 malignant, 51 benign, and one indeterminate FLL were retrospectively analyzed. The 105 benign or malignant lesions were confirmed at histologic examination, contrast-enhanced computed tomography (CT), dynamic contrast-enhanced magnetic resonance (MR) imaging, and/or 6 or more months of clinical follow-up. Data sets included 3-minute cine clips that were automatically corrected for in-plane motion and automatically filtered out frames acquired off plane. B-mode and contrast-specific features were automatically extracted on a pixel-by-pixel basis and analyzed by using an artificial neural network (ANN) and a support vector machine (SVM). Areas under the receiver operating characteristic curve (AUCs) for CAD were compared with those for one experienced and one inexperienced blinded reader. A third observer graded cine quality to assess its effects on CAD performance. Results CAD, the inexperienced observer, and the experienced observer were able to analyze 95, 100, and 102 cine clips, respectively. The AUCs for the SVM, ANN, and experienced and inexperienced observers were 0.883 (95% confidence interval [CI]: 0.793, 0.940), 0.829 (95% CI: 0.724, 0.901), 0.843 (95% CI: 0.756, 0.903), and 0.702 (95% CI: 0.586, 0.782), respectively; only the difference between SVM and the inexperienced observer was statistically significant. Accuracy improved from 71.3% (67 of 94; 95% CI: 60.6%, 79.8%) to 87.7% (57 of 65; 95% CI: 78.5%, 93.8%) and from 80.9% (76 of 94; 95% CI: 72.3%, 88.3%) to 90.3% (65 of 72; 95% CI: 80.6%, 95.8%) when CAD was in agreement with the inexperienced reader and when it was in agreement with the experienced reader, respectively. B-mode heterogeneity and contrast material washout were the most discriminating features selected by CAD for all iterations. CAD selected time-based time-intensity curve (TIC) features 99.0% (207 of 209) of the time to classify FLLs, versus 1.0% (two of 209) of the time for intensity-based features. None of the 15 video-quality criteria had a statistically significant effect on CAD accuracy-all P values were greater than the Holm-Sidak α-level correction for multiple comparisons. Conclusion CAD systems classified benign and malignant FLLs with an accuracy similar to that of an expert reader. CAD improved the accuracy of both readers. Time-based features of TIC were more discriminating than intensity-based features. © RSNA, 2017 Online supplemental material is available for this article.

Although only limited long-term studies evaluating thermal ablation of renal masses have been performed, it appears that thermal ablation has a comparable 5-year success rate to that of partial or total nephrectomy. This technique is often used in patients who are not good candidates for partial or total nephrectomy. Contrast-enhanced ultrasound (CEUS) has been recently approved by the Food and Drug Administration for characterization of focal liver lesions in adults and pediatric patients. CEUS can be used off label for renal applications and has been used for years in Europe and Asia. It has several advantages over contrast-enhanced computed tomography for use as the technique to guide and evaluate efficacy of thermal ablation of renal masses. These include the ability to visualize small amounts of enhancement, repeat dosing to evaluate efficacy of an ablation during a procedure, thin slice thickness, and real-time visualization. Ultrasound contrast is also non-nephrotoxic and non-hepatotoxic, allowing evaluation of patients with renal insufficiency. This article reviews the use of CEUS for the guidance and follow-up of thermal ablative procedures of renal masses.

There is a large body of published material that supports the use of elastography, both strain and shear wave, for characterization of breast lesions. To a lesser extent, elastography can be used in the detection of breast abnormalities. This article reviews the principles of elastography regarding breast imaging, reviews the techniques to perform both strain and shear wave elastography, and reviews the literature and discusses how elastography can be used to improve the characterization of breast lesions to allow for decrease in the number of short-term follow-up examinations and benign biopsies., (Copyright © 2018 Elsevier Inc. All rights reserved.)

"How to perform contrast-enhanced ultrasound (CEUS)" provides general advice on the use of ultrasound contrast agents (UCAs) for clinical decision-making and reviews technical parameters for optimal CEUS performance. CEUS techniques vary between centers, therefore, experts from EFSUMB, WFUMB and from the CEUS LI-RADS working group created a discussion forum to standardize the CEUS examination technique according to published evidence and best personal experience. The goal is to standardise the use and administration of UCAs to facilitate correct diagnoses and ultimately to improve the management and outcomes of patients.

Tissue stiffness assessed by palpation for diagnosing pathology has been used for thousands of years. Ultrasound elastography has been developed more recently to display similar information on tissue stiffness as an image. There are two main types of ultrasound elastography, strain and shear wave. Strain elastography is a qualitative technique and provides information on the relative stiffness between one tissue and another. Shear wave elastography is a quantitative method and provides an estimated value of the tissue stiffness that can be expressed in either the shear wave speed through the tissues in meters/second, or converted to the Young's modulus making some assumptions and expressed in kPa. Each technique has its advantages and disadvantages and they are often complimentary to each other in clinical practice. This article reviews the principles, technique, and interpretation of strain elastography in various organs. It describes how to optimize technique, while pitfalls and artifacts are also discussed.

The World Federation for Ultrasound in Medicine and Biology (WFUMB) has produced guidelines for the use of elastography techniques, including basic science, breast, liver and thyroid elastography. Here we present elastography in prostate diseases. For each available technique, procedure, reproducibility, results and limitations are analyzed and recommendations are given. Finally, recommendations are given based on the level of evidence of the published literature and on the WFUMB expert group's consensus. This document has a clinical perspective and is aimed at assessing the usefulness of elastography in the management of prostate diseases., (Copyright © 2016 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

This article reviews the clinical applications of current ultrasound elastography methods in non-hepatic conditions including thyroid nodules, prostate cancer, chronic kidney disease, solid renal lesions, pancreatic lesions, and deep vein thrombosis. Pathophysiology alters tissue mechanical properties via ultrastructural changes including fibrosis, increased cellularity, bleeding, and necrosis, creating a target biomarker, which can be imaged qualitatively or quantitatively with US elastography. US elastography methods can add information to conventional US methods and improve the diagnostic performance of conventional US in a range of disease processes.

Breast elastography is a new sonographic technique that provides additional characterization information on breast lesions over conventional sonography and mammography. This technique provides information on the strain or hardness of a lesion, similar to a clinical palpation examination. Two techniques are now available for clinical use: strain (compression-based elastography) and shear wave elastography. Initial evaluation of these techniques in clinical trials suggests that they may substantially improve the characterization of breast lesions as benign or malignant. This improvement may substantially reduce the number of benign biopsies performed. Elastography can be performed by several methods and is now available from several manufactures. This article reviews the basics of this technique, how to perform the examination, image interpretation, and artifacts. Although easy to perform, technique is critical to obtain adequate images for interpretation. This primer will highlight the technique and point out common pitfalls.