The EFSUMB Guidelines and Recommendations for the Clinical Practice of Elastography in Non-Hepatic Applications: Update 2018.

This manuscript describes the use of ultrasound elastography, with the exception of liver applications, and represents an update of the 2013 EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) Guidelines and Recommendations on the clinical use of elastography.

Integrating anatomy, radiology, pathology, and surgery: An alternative approach in resecting multifocal and multicentric breast carcinoma.

The sick lobe hypothesis provides the basis for a lobar approach in radiology, pathology, and surgical treatment of breast cancer. This approach aims to remove the tumor together with the surrounding field of genetic aberrations. Detailed preoperative lobar imaging that properly maps the disease and assesses its extent guides the parenchymal resection. Integration of our knowledge of breast anatomy and pathology with the results of preoperative radiological mapping is critical in assessing the eligibility of patients with multifocal and/or multicentric breast cancer for breast conservation treatment. Through an appropriately selected incision, a multisegment resection of the diseased lobe(s) is performed, which leaves the residual parenchyma in a formation that allows dovetailing of one part into the other, like the way pieces of a jigsaw puzzle fit together. Detailed pathologic analysis of the surgical specimen provides valuable feedback to the radiologist, establishes the completeness of surgical intervention, and generates predictive information for therapeutic decisions. Our approach is a step in continuous search for ideal tailored therapy to avoid under or over-treatment of breast cancer patients.

A 2-D anatomic breast ductal computer phantom for ultrasonic imaging.

Most breast cancers (85%) originate from the epithelium and develop first in the ductolobular structures. In screening procedures, the mammary epithelium should therefore be investigated first by the performing of an anatomically guided examination. For this purpose (mass screening, surgical guidance), we developed a two-dimensional anatomic phantom corresponding to an axial cross section of the ductolobular structures, which makes it possible to better understand the interactions between the breast composition and ultrasound. The various constitutive tissues were modeled as a random inhomogeneous continuum with density and sound speed fluctuations. Ultrasonic pulse propagation through the breast computer phantom was simulated using a finite element time domain method (the phantom can be used with other propagation codes). The simulated ductal echographic image is compared with the ductal tomographic (DT) reconstruction. The preliminary results obtained show that the DT method is more satisfactory in terms of both the contrast and the resolution.

The lobar approach to breast ultrasound imaging and surgery.

Breast cancer is a lobar disease in the sense that, at the earliest stages, the cancer is structurally confined to a single sick lobe. The subgross morphology of breast carcinoma is often complex, as multiple invasive foci are frequently present and the ductal system often contains an extensive in situ component. Adequate preoperative visualization of all of the malignant structures within the affected breast and preoperative mapping of the lesions in relation to the surrounding normal structures are essential for successful image-guided breast surgery and therefore are key factors in assuring adequate local control of the disease. We advocate use of the lobar approach in ultrasound imaging (ducto-radial echography) and breast-conserving surgery based on the lobar anatomy of the breast, the sick lobe theory, our extensive clinical experience with the approach, and favorable long-term patient outcomes. Despite abundant evidence demonstrating the advantages of the lobar approach, the number of breast centers using it in practice is still limited. In this review, we aim to call attention to the advantages of the lobar approach from the theoretical, imaging, and surgical points of view.

WFUMB guidelines and recommendations for clinical use of ultrasound elastography: Part 2: breast.

The breast section of these Guidelines and Recommendations for Elastography produced under the auspices of the World Federation of Ultrasound in Medicine and Biology (WFUMB) assesses the clinically used applications of all forms of elastography used in breast imaging. The literature on various breast elastography techniques is reviewed, and recommendations are made on evidence-based results. Practical advice is given on how to perform and interpret breast elastography for optimal results, with emphasis placed on avoiding pitfalls. Artifacts are reviewed, and the clinical utility of some artifacts is discussed. Both strain and shear wave techniques have been shown to be highly accurate in characterizing breast lesions as benign or malignant. The relationship between the various techniques is discussed, and recommended interpretation based on a BI-RADS-like malignancy probability scale is provided. This document is intended to be used as a reference and to guide clinical users in a practical way.

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

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 3: liver.

The World Federation for Ultrasound in Medicine and Biology (WFUMB) has produced these guidelines for the use of elastography techniques in liver disease. For each available technique, the reproducibility, results, and limitations are analyzed, and recommendations are given. Finally, recommendations based on the international literature and the findings of the WFUMB expert group are established as answers to common questions. The document has a clinical perspective and is aimed at assessing the usefulness of elastography in the management of liver diseases.

Tissue harmonic imaging: utility in breast sonography.

OBJECTIVE: To determine the impact of tissue harmonic imaging on visualization of focal breast lesions and to compare gray scale contrast between focal breast lesions and fatty tissue of the breast between tissue harmonic imaging and fundamental frequency sonography. METHODS: A prospective study was performed on 219 female patients (254 lesions) undergoing sonographically guided fine-needle biopsy. The fundamental frequency and tissue harmonic images of all lesions were obtained on a scanner with a wideband 7.5-MHz linear probe. Twenty-three breast carcinomas, 6 suspect lesions, 9 fibroadenomas, 1 papilloma, 1 phyllodes tumor, 162 unspecified solid benign lesions, and 40 cysts were found. In 12 cases the fine-needle aspiration did not yield sufficient material. The gray scale intensity of the lesions and adjacent fatty tissue was measured with graphics software, and the gray scale contrast between lesions and adjacent fatty tissue was calculated. RESULTS: Tissue harmonic imaging improved the gray scale contrast between the fatty tissue and breast lesions in 230 lesions (90.6%; P < .001) compared with fundamental frequency images. The contrast improvement was bigger in breasts with predominantly fatty or mixed (fatty/glandular) composition than in predominantly glandular breasts. The overall conspicuity, lesion border definition, lesion content definition, and acoustic shadow conspicuity were improved or equal in the harmonic mode for all lesions. CONCLUSIONS: The tissue harmonic imaging technique used as an adjunct to conventional breast sonography may improve lesion detectability and characterization.