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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 4  |  Page : 1764-1771

Study of the role of point shear wave elastography for characterization of focal liver lesions


Department of Tropical Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission04-Jul-2022
Date of Decision14-Aug-2022
Date of Acceptance22-Aug-2022
Date of Web Publication04-Mar-2023

Correspondence Address:
Mohammed E Ayad
Berket Elsabh, Menoufia Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_222_22

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  Abstract 


Objectives
This work aimed to evaluate the diagnostic role of point shear wave elastography (PSWE) for the differentiation of benign and malignant hepatic focal lesions (HFLs).
Background
Elastography is a medical imaging modality that maps the elastic properties and stiffness of soft tissue. The main applications of PSWE in the liver are assessment of fibrosis and characterization of HFLs.
Patients and methods
The current study included 135 patients in addition to 20 healthy volunteers. These participants were divided into four groups: group I (50 patients with nonmalignant HFLs), group II (70 patients with malignant HFLs), group III (15 patients with liver cirrhosis) and group IV (20 healthy volunteers as a control group). Demographic, laboratory, and imaging data were collected, and then elastographic assessment of the HFLs and the surrounding liver parenchyma using point quantification elastography (ElastPQ) (iU22x MATRIX, Philips) was done.
Results
ElastPQ (iU22x MATRIX, Philips) has shown respectable ability to differentiate between hepatocellular carcinoma and other malignant HFLs by calculation of SWE of HFL to SWE of surrounding liver parenchyma ratio (P < 0.001). ElastPQ has shown its ability to differentiate between regenerative liver nodule and different benign HFLs (P value <0.001). ElastPQ had the ability to differentiate between hemangioma and focal nodular hyperplasia (P < 0.001) and also hemangioma and hepatic abscess (P = 0.005). Cystic lesions demonstrated lower stiffness in comparison with hepatocellular carcinoma.
Conclusion
Although PSWE is a noninvasive quantitative and nonradiating safe imaging machine, it lacks sensitivity, specificity, and accuracy in differentiation between malignant and nonmalignant focal liver lesions.

Keywords: hepatic focal lesions, point shear wave elastography, stiffness


How to cite this article:
Mohammed HI, Abdelwahab RA, Ayad ME, El-Gazzarah AR. Study of the role of point shear wave elastography for characterization of focal liver lesions. Menoufia Med J 2022;35:1764-71

How to cite this URL:
Mohammed HI, Abdelwahab RA, Ayad ME, El-Gazzarah AR. Study of the role of point shear wave elastography for characterization of focal liver lesions. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:1764-71. Available from: http://www.mmj.eg.net/text.asp?2022/35/4/1764/370982




  Introduction Top


Conventional ultrasound (US) has been used as the first imaging modality to evaluate focal liver lesions (FLLs) [1]. Although MRI, computed tomography (CT), and contrast-enhanced US have a high level of diagnostic accuracy in assessing the morphology of FLLs [2], there are some limitations to each technology [3].

Elastography is a medical imaging modality that maps the elastic properties and stiffness of soft tissue [4]. The main idea is that whether the tissue is hard or soft, it will give diagnostic information about the presence or status of disease [5].

There are many techniques of US elastography. The most prominent techniques are quasistatic elastography [6], unidimensional transient elastography (FibroScan) [7], Acoustic Radiation Force Impulse imaging (ARFI) [8], and Supersonic Shear Imaging [9].

ARFI imaging is a new method for quantifying mechanical properties of tissue, without manual compression, by measuring the shear wave velocity induced by acoustic radiation and propagation in the tissue [10].

The main applications of ARFI in the liver are assessment of fibrosis [11] and characterization of hepatic tumors [12].

Recently published pilot studies on PSWE (ARFI technique) have revealed promising results for the evaluation of FLLs [13],[14].

So, this prospective study aimed to evaluate the role of PSWE in characterization of hepatic focal lesions and to show possible cutoff levels for diagnosis of these lesions.


  Patients and methods Top


Patients

This cross-sectional study included 120 patients with FLLs attending the radiology unit of National Liver Institute, Menoufia University, Egypt. In addition, 15 patients with liver cirrhosis without any focal lesion and 20 healthy volunteers were included as a control group. The included patients as well as the controls were divided into four groups: group I included 50 patients with benign FLLs diagnosed by US and triphasic CT abdomen or gadolinium-enhanced MRI and liver biopsy (if indicated). This group was subdivided into four subgroups: subgroup IA (20 patients had hemangioma), subgroup IB [10 patients had focal nodular hyperplasia (FNH)], subgroup IC (10 patients had cystic focal lesions as simple hepatic cyst, hydatid cyst, and hepatic abscess), and subgroup ID (10 patients had regenerative liver nodule). Group II included 70 patients with malignant FLLs diagnosed as group I. This group was subdivided into three subgroups: subgroup IIA [50 patients with hepatocellular carcinoma (HCC)], subgroup IIB (10 patients with metastatic FLLs), and subgroup IIC (10 patients with cholangiocarcinoma). Group III included 15 patients with hepatic cirrhosis (to compare it with median SWE of different hepatic parenchymas that surround malignant and nonmalignant groups) identified by U.S. and triphasic CT. Group IV included 20 healthy volunteers of matched age and sex (control group). This study was approved by the local ethics committee of the Faculty of Medicine, Menoufia University (approval No. 5/2017TROP) and was performed per Declaration of Helsinki. An informed consent was obtained from all participants and controls. Patients older than 18 years with FLLs that were clearly seen on conventional US were the inclusion criteria. Patients with lesions in the left lobe of the liver (oscillation of the left liver lobe by cardiac activity may interfere with stiffness measurements), lesions deeper than 8 cm, and patients who cannot hold their breath for 5 s were excluded from the study (as at least five measurements was done and every measurement may take 5 s).

Methods

Complete history taking was taken for every patient and controls, and also, they underwent a thorough clinical examination, which included a general examination (jaundice, pallor, and lower limb edema), as well as a local examination (ascites, hepatomegaly, and splenomegaly). The following investigation workup was done: (a) laboratory investigations such as (i) complete blood count; (ii) ESR; (iii) liver function tests, including alanine aminotransferase, aspartate aminotransferase, serum albumin, serum bilirubin (total and direct bilirubin), and international normalized ratio; (iv) alpha fetoprotein and CA 19-9 (only in suspected cases of cholangiocarcinoma); (v) blood glucose level; (vi) kidney function tests: serum urea and creatinine; (vii) HCVAb and HBsAg; and (viii) hydatid cyst Ab (ELISA) (in patients suspected to have hydatid disease). (b) Imaging included (i) US on abdomen (focal lesion site, size, number, and echopattern), (ii) multi-detector CT of abdomen (enhancement pattern of each focal lesion), (iii) gadolinium-enhanced MRI: in case of inconclusive triphasic CT, (iv) PET scan for metastatic lesions, and (v) stiffness assessment using PSWE technique, ElastPQ (Philips iu22 Healthcare, Andover, Massachusetts, USA). (c) US-guided biopsy and histopathology examination were done if triphasic CT and enhanced MRI was not conclusive and unknown primary (four cases had liver biopsy, three with FNH, and a case of metastatic liver lesion).

Technique: in PSWE, shear waves are produced by ARFI in the liver in a small (∼1 cm3) region of interest (ROI). B-mode imaging was used to monitor the liver tissue displacement owing to these waves. The displacements observed over time at different locations in response to the ARFI pulse are used to compute the shear wave speed in meters per second. The following assumptions can be used to convert the shear wave speed in meters per second to the Young modulus in kilopascals: E = 3(vS2•r), where E is the Young modulus, Vs is the shear wave speed, and r is the tissue density in homogeneous isotropic tissues. The density is assumed to be 1 g/ml [15]. According to World Federation of Ultrasound in Medicine and Biology guidelines, the best conditions for performing SWE are fasting, putting the patient in the dorsal decubitus position in a resting respiratory state (breath-hold without deep inspiration), placing the ROI beneath Glisson's capsule by about 1.5–2.0 cm to avoid reverberation artifacts and increased subcapsular stiffness, adjusting the ROI to avoid large liver blood vessels, and finally the median value of 5–10 measurements is considered [16].

Analytical statistics

Based on the past review of literature, the sample size was calculated at 95%, power 90%, and noninferiority margin 11%, where the required sample size was calculated to be not less than 10 patients per group [17]. STATA 14 software (College Station, Texas, USA) was used for data entry, validation, and analysis. Discrete variables are represented as number (percentage). The mean (SD) or median (interquartile range) is used to show summary statistics for continuous variables. Histograms, skewness, and kurtosis tests were used to determine the normality of continuous values. The skewness and kurtosis tests were used to determine whether a variable's distribution was normal or not. Those variables with a small P value less than 0.05 were considered not normally distributed. Every time it was appropriate, the Mann–Whitney test or the Student t test was used to compare two groups of data. Analysis of variance or the Kruskal–Wallis test was used to compare the three groups when necessary. Area under the curve and the receiver operating characteristics (ROC) curve were used to calculate the diagnostic performance. The highest sum of sensitivity and specificity was used to determine the cutoff value. ROC curve comparisons were used to determine the differences in diagnostic accuracy with value of stiffness and stiffness ratio. All statistical analyses were based on two-sided hypothesis tests, with a significance level of P less than 0.05.


  Results Top


A total of 135 patients, in addition to 20 healthy volunteers, were studied. The patients were divided into the following groups: group I included patients with benign FLLs, which included hemangioma, FNH, regenerative liver nodule, and cystic hepatic lesions such as hepatic abscess, hydatid cyst, and simple cyst. Group II included patients with malignant FLLs, which included HCC, cholangiocarcinoma, and metastatic liver lesions. Group III included patients with liver cirrhosis. In the HCC subgroup, males were significantly more in number (72%) when compared with that of the hemangioma subgroup (30%).

In the nonmalignant group, the hemangioma subgroup, most of the patients [14 (70%)] were females, and their mean age was 43 ± 7 years old. However, in the FNH subgroup, all patients were females, with a mean age of 36.5 ± 6 years, whereas in the regenerative nodule subgroup, males equals females, with a mean age of 58.2 ± 11 years and patients with cystic lesions were 40% males and 60% females with mean age of 47.1 ± 13. In the malignant group, the HCC subgroup, there were 36 (72%) males and 14 (28%) females, with a male to female ratio of 2.5: 1, with a mean age of 58.18 ± 7 years, whereas in the metastatic subgroup, 60% of the patients were males and 40% were females, with a mean age of 57.7 ± 6 years, and in the cholangiocarcinoma subgroup, 40% were males and 60% were females, with mean age of 60.1 ± 6. In the cirrhotic group, 66.6% were males, whereas 33.4% were females, with a mean age of 56.6 ± 8.7 years. Finally, in the control group, 60% were males and 40% were females, with a mean age of 50 ± 13.1 years [Table 1].
Table 1: Age and sex distribution among different patient subgroups

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Patients with hepatic cirrhosis showed a significant decrease in platelet count when compared with patients with malignant FLLs and a highly significant decrease in comparison with other patients with benign FLLs and the control group. Comparing patients with malignant FLLs and liver cirrhosis with those with benign lesions and the control group, hemoglobin levels of patients with malignant FLLs were significantly decreased. Patients with malignant FLLs showed a highly significant alpha fetoprotein level elevation when compared with patients with benign FLLs and liver cirrhosis. There was a highly significant difference between patients with malignant FLLs and patients with nonmalignant FLLs and control group regarding serum bilirubin, serum albumin, alanine aminotransferase, aspartate aminotransferase, and international normalized ratio [Table 2].
Table 2: Laboratory characteristics of studied patients and controls

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In the current study, there was no significant difference between median SWE stiffness of HCC and both cholangiocarcinoma and metastatic liver lesions [Table 3]. On the contrary, there was a highly significant increase in the median stiffness of regenerative nodule when compared with hemangioma and hepatic abscess, and also there was a highly significant increase in the median stiffness of FNH when compared with hemangioma and hepatic abscess [Figure 1].
Table 3: Shear wave elastography of the focal liver lesion among each type of malignant group

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Figure 1: SWE of the FLLs among each type of nonmalignant group: P1 = dysplastic nodule and hemangioma (<0.001**), P2 = dysplastic nodule and FNH (<0.001**), P3 = dysplastic nodule and abscess (0.005**), P4 = dysplastic nodule and simple cyst (0.011*), P5 = dysplastic nodule and hydatid cyst (0.011*), P6 = hemangioma and FNH (<0.676), P7 = hemangioma and abscess (0.587), P8 = hemangioma and simple cyst (0.411), P9 = hemangioma and hydatid cyst (0.584), P10 = FNH and abscess (0.572), P11 = FNH and simple cyst (0.49), P12 = FNH and hydatid cyst (0.398), P13 = abscess and simple cyst (0.48), P14 = abscess and hydatid cyst (1.0), and P15 = simple cyst and hydatid cyst (0.827). **highly significant; *significant). FLL, focal liver lesion; FNH, focal nodular hyperplasia.

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There was a highly significant decrease in stiffness value profile (SWE of FLL/SWE of surrounding parenchyma ratio) of HCC when compared with metastatic liver lesions, and also a significant decrease in stiffness value profile of HCC when compared with that of cholangiocarcinoma. Moreover, there was a highly significant decrease in the stiffness value profile of regenerative nodule when compared with FNH, a highly significant decrease in the stiffness value profile of hemangioma when compared with that of FNH, and a highly significant increase of the stiffness value profile of FNH when compared with that of the hepatic abscess [Figure 2].
Figure 2: Stiffness value profiles of focal hepatic lesions/surrounding parenchyma in malignant and nonmalignant groups. P1 = HCC and metastatic (<0.001**), P2 = HCC and CCC (0.004**), P3 = metastatic and CCC (0.002**), P4 = dysplastic nodule and hemangioma (0.039*), P5 = dysplastic nodule and FNH (<0.001**), P6 = hemangioma and FNH (0.006**), P7 = hemangioma and abscess (0.011*), P8 = FNH and abscess (0.005**), P9 = abscess and simple cyst (0.48), and P10 = simple cyst and hydatid cyst (0.513). **highly significant; *significant. CCC, cholangiocarcinoma; FNH, focal nodular hyperplasia; HCC, hepatocellular carcinoma.

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The present study showed that the best cutoff point was 6.19 kPa for differentiation between malignant and nonmalignant FLLs, with apparent low sensitivity, specificity, and accuracy (52.2, 46, and 50%, respectively). Moreover, much more apparent decrease in sensitivity (28.6%), specificity (20%), and accuracy (25%) was reported at a cutoff point of stiffness value profile of (0.57) [Table 4]. This is shown in the ROC curve in [Figure 3].
Table 4: Validity of point shear wave elastography to predict cutoff points for malignancy detection

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Figure 3: ROC curve for validity of SWE for a possible cutoff point for malignancy detection. ROC, receiver operating characteristics; SWE, shear wave elastography.

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[Figure 4] shows a case report of patients with HCC with characteristic CT findings of HCC and shear wave stiffness taken by ElastPQ.
Figure 4: Right: triphasic CT findings of HCC. Left: PSWE of HCC by ElastPQ. CT, computed tomography; HCC, hepatocellular carcinoma; PSWE, point shear wave elastography.

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  Discussion Top


In clinical and radiological practice, it is frequently difficult to characterize FLLs. Early diagnosis of these lesions is crucial for developing the best treatment plan and improving patient outcomes [18].

Elastography is an imaging technique that determines the elasticity of the tissue. SWE is a technique that uses a transducer to remotely generate brief mechanical stresses that are then applied to tissues. Quantitative elasticity maps are produced by imaging the shear waves that emerge from it, using the same transducer at an ultrafast imaging sequence [9].

In this study, we attempted to clarify the elasticity characterization of various FLLs and their surrounding liver parenchyma to investigate the diagnostic role of stiffness value and ratio (lesion to parenchyma) as determined by PSWE in characterization of various types of FLLs in a cohort of 155 Egyptian patients and controls.

The present study revealed that the median stiffness of malignant FLLs collectively was 6.34 kPa, with no significant difference (P = 0.58) when compared with median stiffness of benign lesions collectively, which was 6.79 kPa. Few studies reported collective median stiffness for all malignant or benign FLLs. Gerber et al.[19] reported higher values for malignant and benign FLLs (36 and 16.4 kPa, respectively) [19].

The present study revealed that HCC had the lowest median stiffness value in malignant group (6.03 kPa), whereas metastatic lesions had the highest value (7.98 kPa) with no significant difference between different malignancies (P = 0.77). These results agreed with Choong et al.[20] and Gad et al. [14] who reported nonsignificant differences in the stiffness values between HCC and liver metastasis [14],[20]. On the contrary, Park et al.[21] reported significantly higher stiffness in HCC compared with secondaries [21]. Moreover, Gerber et al.[19] and Abdel-Latif et al.[22] reported highest SWE values in cholangiocarcinoma group (70.7 and 35.9 kPa, respectively) [19],[22]. Okamoto et al.[23] and Sirica [24] explained the higher median stiffness in cholangiocarcinoma to considerable fibrotic component and significant malignant progression [23],[24].

Regarding median stiffness values of PSWE of benign FLLs, the present study revealed a highly significant difference between different benign FLLs (P < 0.001). The highest median stiffness values were regenerative nodule, FNH, and hepatic hemangioma (9.95, 8.65, and 4.8 kPa, respectively), whereas the lowest values were simple cyst (1.4 kPa), hepatic abscess (2.71 kPa), and hydatid cyst (2.8 kPa).

The median stiffness value in the hemangioma subgroup (20 patients) in the present study was 4.8 kPa, which agreed with Hasab Allah et al.[17] and Gad et al.[14], who reported very close median stiffness values (4.94 and 4.91 kPa, respectively) [14],[17], whereas Guibal et al.[25] and Gerber et al.[19] reported apparently higher median stiffness values (13.8 and 16.35 kPa, respectively) [19],[25].

The median stiffness value in the FNH subgroup (10 patients) in the present study was 8.65 kPa, which agreed with Hasab Allah et al.[17] and Gad et al.[14], who reported very close median stiffness values of 9.2 and 8.87 kPa, respectively [14],[17], whereas Gerber et al.[19] reported apparently higher median stiffness values (16.55 kPa) [19]. This can be explained by Hussain et al.[26], who attributed high fibrotic content of FNH to vascular malformations, fibrous septa that radiate from a central scar, and also tortuous feeding arteries [26].

Regarding median stiffness values of PSWE, the present study had the ability to differentiate between hemangioma and FNH, as there was a highly significant difference between hemangioma and FNH (P < 0.001). This is in agreement with Hassab Allah et al.[17], who report that FNHs had the highest stiffness values (9.96 kPa), whereas hemangiomas had the lowest stiffness values (4.91 kPa), with highly significant difference [17] and also in agreement with Abdel-Latif et al.[22], who showed that the median stiffness value of FNH was 26.7 kPa, whereas that of hemangioma was 10.5 kPa [22]. The fibrous septa and central scar are primarily responsible for the increase in FNH stiffness [27]. Hemangiomas, on the contrary, are mostly made of numerous flexible vascular channels that are filled with blood [28]. However, these results do not agree with Gerber et al.[19], who reported that there was no significant difference in stiffness values between the different nonmalignant FLLs, as hemangioma had a median stiffness value of 16.35 kPa and FNH had a median stiffness value of 16.55 kPa [19].

The present study revealed that the median stiffness of FHL/surrounding parenchyma ratio in the HCC group (0.43) was highly significantly lower (P = 0.004) than that of cholangiocarcinoma group (0.54) and also highly significantly lower (P < 0.001) than of metastatic group (1.81). These results agreed with DeWall et al.[29] and Park et al.[21], who reported lower median stiffness ratio in the HCC group in comparison with other malignancy [21],[29]. On the contrary, Dong et al.[13] reported increase in the median stiffness ratio in the HCC group compared with the metastatic group [13]. Moreover, Abdel-Latif et al. [22] reported apparently higher stiffness ratio in HCC, secondaries, and cholangiocarcinoma (1.37, 4.2, and 4.6, respectively) when compared with our results [22].

The present study revealed that the median stiffness of FLL/surrounding parenchyma ratio in the FNH group (1.73) was highly significantly higher in comparison with other benign groups (P = 0.002). These results agreed with Hassab Allah. et al.[17], who reported high lesion/parenchyma ratio of FNH (2.93) in comparison with hemangioma (0.89) [17], and Abdel-Latif et al.[22], who reported high lesion/parenchyma ratio of FNH in comparison with other benign lesions. This may be attributed to high stiffness value of FNH in comparison with normal surrounding liver parenchyma [22].

The present study revealed that the sensitivity, specificity, and accuracy of SWE using the ROC curve at cutoff of 6.19 kPa for differentiation of malignant from nonmalignant focal lesions were 52.2, 46, and 50%, respectively. Moreover, much more apparent decreases in sensitivity (28.6%), specificity (20%), and accuracy (25%) were reported at a cutoff point of stiffness value profile of 0.57. These results disagree with previous reports such as Gerber et al.[19], who reported higher sensitivity (79.7%) and specificity (62%) at a much higher cutoff point of SWE (20.7 kPa) [19], and Abdel-Latif et al.[22], who reported very high sensitivity (98.1%), accuracy (92%), and specificity (78.3%) at a cutoff of 14.2 kPa [22]. Moreover, Hassab Allah et al. [17] reported that stiffness ratio was superior to stiffness value in differentiation of HCCs from metastases (AUROC, 0.91 vs. 0.51 respectively, P < 0.001) [17]. These differences from our results may be attributed to different patient populations and different machines used.

The results of our study suggested that the diagnostic performance of ElastPQ (Philips iU 22x MATRIX) was not accurate and lacked sensitivity and specificity in differentiation between malignant and benign FLLs as well as the differentiation between different hepatic malignancy. On the contrary, other reports confirmed more advantages of 2D SWE in comparison with ElastPQ [30]. Moreover, magnetic resonance elastography adds more advantages over 2D SWE as it enables the examination of very large areas of the liver with very low failure rate, which may be related to certain conditions such as iron overload, obesity, and claustrophobia; however, magnetic resonance elastography has many limitations over elastography [30].


  Conclusion Top


Although PSWE is a noninvasive quantitative and nonradiating safe imaging machine, it lacks sensitivity, specificity, and accuracy in differentiation between malignant and nonmalignant FLLs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Trillaud H, Bruel JM, Valette PJ, Vilgrain V, Schmutz G, Oyen R, et al. Characterization of focal liver lesions with SonoVue®-enhanced sonography: international multicenter-study in comparison to CT and MRI. World J Gastroenterol 2009; 15:3748.  Back to cited text no. 1
    
2.
Semelka RC, Martin DR, Balci C, Lance T. Focal liver lesions: comparison of dual-phase CT and multisequence multiplanar MR imaging including dynamic gadolinium enhancement. J Magn Reson Imaging 2001; 13:397–401.  Back to cited text no. 2
    
3.
Xu HX, Lu MD, Liu LN. Discrimination between neoplastic and nonneoplastic lesions in cirrhotic liver using contrast-enhanced ultrasound. Br J Radiol 2012; 85:1376–1384.  Back to cited text no. 3
    
4.
Wells PN, Liang HD. Medical ultrasound: imaging of soft tissue strain and elasticity. J R Soc Interface 2011; 8:1521–1549.  Back to cited text no. 4
    
5.
Sarvazyan A, Hall TJ, Urban MW, Fatemi M, Aglyamov SR, Garra BS. An overview of elastography – an emerging branch of medical imaging. Curr Med Imaging Rev 2011; 7:255–282.  Back to cited text no. 5
    
6.
Parker KJ, Doyley M, Rubens DJ. Imaging the elastic properties of tissue: the 20 year perspective. Phys Med Biol 2011; 56:513–515.  Back to cited text no. 6
    
7.
Sandrin L, Tanter M, Gennisson JL, Catheline S, Fink M. Shear elasticity probe for soft tissues with 1-D transient elastography. IEEE Trans Ultrason Ferroelectr Freq Control 2002; 49:436–446.  Back to cited text no. 7
    
8.
Nightingale KR, Palmeri ML, Nightingale RW, Trahey GE. On the feasibility of remote palpation using acoustic radiation force. J Acoust Soc Am 2001; 110:625–634.  Back to cited text no. 8
    
9.
Bercoff J, Tanter M, Fink M. Supersonic shear imaging: a new technique for soft tissue elasticity mapping. IEEE Trans Ultrason Ferroelectr Freq Control 2004; 51:396–409.  Back to cited text no. 9
    
10.
Sporea I, Şirli R, Popescu A, Danilă M. Acoustic Radiation Force Impulse (ARFI) – a new modality for the evaluation of liver fibrosis. Med Ultrasonogr 2010; 12:26–31.  Back to cited text no. 10
    
11.
Sporea I, Şirli R, Bota S, Fierbinţeanu-Braticevici C, Petrişor A, Badea R, et al. Is ARFI elastography reliable for predicting fibrosis severity in chronic HCV hepatitis?. World J Radiol 2011; 3:188.  Back to cited text no. 11
    
12.
Guo LH, Wang SJ, Xu HX, Sun LP, Zhang YF, Xu JM, et al. Differentiation of benign and malignant focal liver lesions: value of virtual touch tissue quantification of acoustic radiation force impulse elastography. Med Oncol 2015; 32:1.  Back to cited text no. 12
    
13.
Dong Y, Wang WP, Xu Y, Cao J, Mao F, Dietrich CF. Point shear wave speed measurement in differentiating benign and malignant focal liver lesions. Med Ultrasonogr 2017; 19:259–264.  Back to cited text no. 13
    
14.
Gad MA, Eraky TE, Omar HM, Abosheaishaa HM. Role of real-time shear-wave elastogarphy in differentiating hepatocellular carcinoma from other hepatic focal lesions. Eur J Gastroenterol Hepatol 2021; 33:407–414.  Back to cited text no. 14
    
15.
Barr RG, Ferraioli G, Palmeri ML, Goodman ZD, Garcia-Tsao G, Rubin J, et al. Elastography assessment of liver fibrosis: society of radiologists in ultrasound consensus conference statement. Radiology 2015; 276:845–861.  Back to cited text no. 15
    
16.
Ferraioli G, Barr RG, Pameri ML. Elastography assessment of liver fibrosis: society of radiologists in ultrasound consensus conference statement. Radiology 2015; 276:845–861.  Back to cited text no. 16
    
17.
Hasab Allah M, Salama RM, Marie MS, Mandur AA, Omar H. Utility of point shear wave elastography in characterisation of focal liver lesions. Exp Rev Gastroenterol Hepatol 2018; 12:201–207.  Back to cited text no. 17
    
18.
Nagolu H, Kattoju S, Natesan C, Krishnakumar M, Kumar S. Role of acoustic radiation force impulse elastography in the characterization of focal solid hepatic lesions. J Clin Imaging Sci 2018; 8:21–23.  Back to cited text no. 18
    
19.
Gerber L, Fitting D, Srikantharajah K, Weiler N, Kyriakidou G, Bojunga J, et al. Evaluation of 2D-shear wave elastography for characterisation of focal liver lesions. J Gastrointest Liver Dis 2017; 26:11–12.  Back to cited text no. 19
    
20.
Choong KL, Abdullah BJJ, Kumar G. Shear wave elastography characterization of liver tumours. Poster presented at ECR 2014/C–1921.  Back to cited text no. 20
    
21.
Park HS, Kim YJ, Yu MH, Jung SI, Jeon HJ. Shear wave elastography of focal liver lesion: intraobserver reproducibility and elasticity characterization. Ultrasound Q 2015; 31:262–271.  Back to cited text no. 21
    
22.
Abdel-Latif M, Fouda N, Shiha OA, Rizk AA. Role of shear wave sono-elastography (SWE) in characterization of hepatic focal lesions. Egypt J Radiol Nucl Med 2020; 51:1–5.  Back to cited text no. 22
    
23.
Okamoto K, Tajima H, Ohta T, Nakanuma S, Hayashi H, Nakagawara H, et al. Angiotensin II induces tumor progression and fibrosis in intrahepatic cholangiocarcinoma through an interaction with hepatic stellate cells. Int J Oncol 2010; 37:1251–1259.  Back to cited text no. 23
    
24.
Sirica AE. The role of cancer-associated myofibroblasts in intrahepatic cholangiocarcinoma. Nat Rev Gastroenterol Hepatol 2012; 9:44–54.  Back to cited text no. 24
    
25.
Guibal A, Boularan C, Bruce M, Vallin M, Pilleul F, Walter T, et al. Evaluation of shearwave elastography for the characterisation of focal liver lesions on ultrasound. Eur Radiol 2013; 23:1138–1149.  Back to cited text no. 25
    
26.
Hussain S, Zondervan P, Schalm S, Krestin G, de Man R, IJzermans J. Benign versus malignant hepatic nodules: MR imaging findings with pathologic correlation. Radiographics 2002; 1:5–9.  Back to cited text no. 26
    
27.
Buetow PC, Pantongrag-Brown L, Buck JL, Ros PR, Goodman ZD. Focal nodular hyperplasia of the liver: radiologic-pathologic correlation. Radiographics 1996; 16:369–388.  Back to cited text no. 27
    
28.
Kim JE, Lee JY, Bae KS, Han JK, Choi BI. Acoustic radiation force impulse elastography for focal hepatic tumors: usefulness for differentiating hemangiomas from malignant tumors. Korean J Radiol 2013; 14:743–753.  Back to cited text no. 28
    
29.
DeWall RJ, Bharat S, Varghese T, Hanson ME, Agni RM, Kliewer MA. Characterizing the compression-dependent viscoelastic properties of human hepatic pathologies using dynamic compression testing. Phys Med Biol 2012; 57:2273.  Back to cited text no. 29
    
30.
Friedrich-Rust M, Poynard T, Castera L. Critical comparison of elastography methods to assess chronic liver disease. Nat Rev Gastroenterol Hepatol 2016; 13:402–411.  Back to cited text no. 30
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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  In this article
Abstract
Introduction
Patients and methods
Results
Discussion
Conclusion
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