Here are presented clinical cases in the format of 'Questions and Answers' concerning the emerging technology's applications of Shear Wave Elastography. So I’m grateful to all friends worldwide who shared their experiences and their doubts stimulating my mind to find plausible explanations based on my own still too ‘young’ experience. I trust that this kind of ‘debate’ is a very useful tool and in short time I’ll try to start on YouTube a dedicated channel where community can share doubts, questions, opinions and answers. This file, like all the other I’ve posted in Video format on YouTube, can be downloaded as PDF or PPSX file at my website www.masciotra.net or at www.researchgate.net at the following link https://www.researchgate.net/profile/Antonio_pio_Masciotra/?ev=hdr_xprf The vision will be large better if done at full screen.

1. Questions and answers emerging in the
approach to Shear Wave Elastography
Antonio Pio Masciotra
Campobasso – Molise – Italy
Website www.masciotra.net
YouTube channel
https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ

2. Questions and answers emerging in the
approach to Shear Wave Elastography
Antonio Pio Masciotra is the uptodate evolution of the Homo Aeserniensis
who lived more than 700.000 years ago in the land where I’ve born and then
generated my kids and grankids.
Hopefully Shear Wave Elastography will
require a large shorter time to reach its full
expression.
But like in the life of everyone, its evolution has
to pass through discussions and debates that
have to be always based on the ‘CURIOSITY’
Antonio Pio
Masciotra
Molise – Italy

3. Questions and answers emerging in the
approach to Shear Wave Elastography
So I’m grateful to all friends worldwide who shared their experiences and their doubts
stimulating my mind to find plausible explanations based on my own still too ‘young’
experience.
I trust that this kind of ‘debate’ is a very useful tool and in short time I’ll try to start on
YouTube
a dedicated channel where community can share doubts, questions, opinions and answers.
This file, like all the other I’ve posted in Video format on YouTube, can be downloaded as PDF
or PPSX file at my website www.masciotra.net or at www.researchgate.net at the following
link
https://www.researchgate.net/profile/Antonio_pio_Masciotra/?ev=hdr_xprf
The vision will be large better if done at full screen.

4. Case 1 - DCIS II
Why was this blue, if it’s malignant?
Why we can see black areas inside?
Could it be because of the wrong

5. Tissue/Organ
Breast
Young’s modulus
E (kPa)
18-24
Normal gland
28-66
Fibrous tissue
96-244
Carcinoma
22-560
Normal anterior gland
55-63
Normal posterior gland
(peripheral zone)
62-71
Benign Hyperplasia
36-41
Carcinoma
Prostate
Normal fat
Density
(kg/L)
96-241
1.0 ± 10%
~ Water
Why was this blue if it’s malignant?
 In the table above you can see that the elasticity of
breast cancer tissue is by itself highly variable (from
22 to 560 kPa!) and with large overlapping to the
values of normal breast tissues
 The same table shows that uptodate prostate is the only
organ in which there’s no overlapping of cancer
stiffness (96 - 241 kPa) on normal tissue elasticity
(36 – 71 kPa)

6. Why was this blue if it’s malignant?
Could it be because of the wrong settings?

7. Why was this blue if it’s malignant?
Could it be because of the wrong settings?

8. Why was this blue if it’s
malignant?
Could it be because of the wrong
settings?
Optimization of SWE™ map in acquisition
Resolution mode is for shallow and/or well
circumscribed lesions.
Excellent axial resolution and less persistence
is applied.
Improves clearing of fluid-filled lesion.
Standard default setting, to be used for
evaluation of the elasticity within the ROI.
More persistence is applied to create a
smoother appearance.
Penetration mode for deep, and/or large,
and/or anechoic or hypoechoic lesions with
posterior dropout.
Improves penetration at the cost of axial
resolution.

9. Why was this blue if it’s
malignant?
Could it be because of the wrong
settings?
28
Optimization of SWE™ map in postprocessing
Opacity
Its adjustment from 0 to 100% gives less and more priority to the
SWE map over the B-Mode image highlighting different features of
focal lesions like in this case of breast cancer

10. Why we can see black areas inside?

11. Why we can see black areas inside?
Phantom with liquid center
inside hard lesion
Shear Wave Elastography
Highly-localized estimation of tissue elasticity
• Especially, inside hard lesions
Shear Wave Elastography can “see” inside
the hard lesion, because the shear waves
can propagate through the hard shell.
Strain Elastography interprets the whole
lesion as hard, because the applied manual
compression cannot penetrate the hard shell.

12. Why we can see black areas inside?
SHEAR WAVE PROPAGATION

13. Case 2 - DCIS I
cribriform+solid, RE=90%,
RP=90%,
Her2=0, Ki67=5%
Why was this blue, if it’s malignant?
See the former slides.

14. Case 3 - CDI + CDIS
Why was this blue, if it’s malignant?
Why black areas inside?

15. Case 3 - CDI + CDIS
Why was this blue, if it’s malignant?
Why black areas inside?
See the former slides and then :
1) Here the focal zone is between 19 and 32 mm
deep
2) The lower limit of the focal zone is far out
(lower) of the lower border of the color box
(ROI)
3) The center of the lesion is 10 mm deep ,
far outside the upper limit of the focal zone

16. Case 4 - CDI
NST
I
Why different results for the same
lesion?

17. Why different results for the same
Case 4 - CDI NST I
lesion?
1) Here the focal zone is between 19 and 32 mm deep
2) The lower limit of the focal zone is far out (lower) of the
lower border of the color box (ROI)
3) The center of the lesion is 20 mm deep ,
almost outside the upper limit of the focal zone
1) Here the focal zone is between 11 and 24 mm deep
2) The lower limit of the focal zone is well inside the lower
border of the color box (ROI)
3) The center of the lesion is 18 mm deep,
well inside the focal zone
The differences are due to the huge differences in the 2 acquisitions with malpositioning
of both the focal zone and the colorbox in the first case.
A good SWE image for a reliable stiffness representation and quantification does always require :
 The best quality of the B scan image (like in the second sampling)
 The accurate positioning of the focal zone and the color box
having the lesion in the middle of both
 The right time to stabilize the SW signal with the least possible probe pressure

18. Case 5 - ???
Why blue?
See the former slides (colorscale
adjustment)

19. Case 6 - Fibroadenoma
Why black?

20. Why was this blue if it’s malignant?
Could it be because of the wrong settings?
We need to learn that in SW Elastography the colorscale adjustments have to been used with the
same principles we use the greyscale in CT images viewing (acting on the window width choice and
window’s center positioning when in the same scan we want to see better bone, lung, mediastinum
or other structures).

21. Why do we have red inside the benign
lesion?

22. Why do we have red inside the benign
lesion?
Because the colorscale range setting here was between 0 (blue) and 40 kPa (red).
The quantification of the red spot in fact corresponds to a maximum stiffness of only 33 kPa (which
is not hard).
In a colorscale setting as usual (0 blue -180 Kpa red) all the world would seem been blue!

23. Why was this blue if it’s malignant?
Could it be because of the wrong settings?
We need to learn that in SW Elastography the colorscale adjustments have to been
used with the same principles we use the greyscale in CT images viewing (acting on
the window width choice and window’s center positioning according if in the same scan
we want to see better bone, lung, mediastinum or other structures).

24. Please explain to us, with examples if
possible!

25. Please explain to us, with examples if
possible!
Same nodule with 3 different modes
acquisition

26. CONCLUSIONS
Sono-Elastography adds valuable information to the study of all organs, potentially resulting in
“a virtual biopsy” .
This final aim will be achieved when further improvement of Shear Wave Elastography technology
(the only actually capable to quantify elasticity or stiffness) will give us the right consistency of the
quantitative measurements of tissue elasticity that up todate is still lacking.
Hence the RSNA initiative of ‘Quantitative Imaging Biomarkers Alliance’ applied to
Sono-Elastography too.
This means that if the intrinsic elasticity of the testis is 2 kPa all the measurements have to give this
value, not depending on the probe’s frequency or on other variables.
When this requirement will be accomplished we’ll can really establish the cutoff value between
normal and abnormal tissues both in focal and in diffuse diseases.
Therefore we’ll can rely on it at same extent we actually rely on the use a thermometer to check
the behavior of the fever during an infection (if it’s responding to the treatment).
Then let’s go on!
Lessons need to be drawn from two great men of the past who had the
vision to preparing for the future.

27. Galileo Galilei
"Any problem that wants
to be solved
starts with curiosity."
Johann Wolfgang von Goethe
"Knowing is not enough,
we must apply.
Willing is not enough,
we must do."

28. Questions and answers emerging in the
approach to Shear Wave Elastography
Again a lot of thanks to all friends worldwide who shared their experiences and their doubts
stimulating my mind to find plausible explanations based on my own still too ‘young’
experience.
I trust that this kind of ‘debate’ is a very useful tool and in short time I’ll try to start on
YouTube
a dedicated channel where community can share doubts, questions, opinions and answers.
This file, like all the other I’ve posted in Video format on YouTube, can be downloaded as PDF
or PPSX file at my website www.masciotra.net or at www.researchgate.net at the following
link
https://www.researchgate.net/profile/Antonio_pio_Masciotra/?ev=hdr_xprf
The vision will be large better if done at full screen.