Shear Wave Elasto-sonography in Gynecological Conditions: state of the art.

Shear Wave Elasto-sonography in Gynecological Conditions: state of the art. | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 25 March 2025 V1 Latest version Share on Shear Wave Elasto-sonography in Gynecological Conditions: state of the art. Authors : Amr Mohamed Abdelhady Sayed Abdelhady [email protected] , Mohamed Abdelhady Sayed** * , and Khalid Alloush Authors Info & Affiliations https://doi.org/10.22541/au.174288435.51403983/v1 261 views 172 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background: pathological changes in tissue lead to changes in elasticity and stiffness. Strain is deformation of tissue when exposed to pressure. Elasticity is return of tissue to original form when this pressure is removed. Palpation; a clinical method of examination used for thousands of years, is a method to test elasticity and stiffness of tissues. However, palpation is totally subjective and is not suitable for deeper tissues. Elastosonography; a new method to test tissue stiffness. It is suitable for deeper tissue, but it is subjective. Recently, SWE which is objective and quantitative has been developed to test for tissue stiffness. Shear Wave Elasto-sonography in Gynecological Conditions: state of the art. Amr Mohamed Abdelhady Sayed Abdelhady*, Mohamed Abdelhady Sayed**, Khalid Alloush*** * MD in Obstet & Gynaecol, MRCOG, Guy’s and St Thomas’ NHS foundation trust. ** MD in Obstet & Gynecology, Prof. of Obstet & Gynecology, Benha Faculty of Medicine, Benha, Egypt. *** Betsi Cadwaladr University Health Board. Correspondence to: Amr Mohamed Abdelhady Sayed Abdelhady: Guy’s and St Thomas’ Hospital, London, email: [email protected] Phone no: +447888339249 Background: pathological changes in tissue lead to changes in elasticity and stiffness. Strain is deformation of tissue when exposed to pressure. Elasticity is return of tissue to original form when this pressure is removed. Palpation; a clinical method of examination used for thousands of years, is a method to test elasticity and stiffness of tissues. However, palpation is totally subjective and is not suitable for deeper tissues. Elastosonography; a new method to test tissue stiffness. It is suitable for deeper tissue, but it is subjective. Recently, SWE which is objective and quantitative has been developed to test for tissue stiffness. Introduction: A new promising diagnostic method; elastosonography, is an ultrasound imaging technique that measures tissue strain due to stress applied to it (Stoelinga et al., 2014). It could be considered virtual palpation. According to Barr et al. (2012), sometimes elastography is called “method of visual palpation”. Palpation has been used in clinical examination for thousands of years; however, it is totally subjective and not suitable for deep organs or tissues. Elastosonography could be considered as a useful diagnostic tool because it is non-invasive, easy to perform, easy to interpret and has a short learning curve towards becoming skilled at the procedure (Tessarolo et al., 2011). It will add a few minutes to the time needed for conventional ultrasound. Acoustic radiation force impulse imaging (ARFI) is a recently developed non-invasive dynamic tissue imaging technique of quantitative elastography (Guros et al., 2021). Applying stress to tissue leads to tissue strain (displacement) which is detected and used for obtaining additional information beyond B-mode imaging (Beldaci et al., 2018) as shown in fig. 1 (Taljanovic et al., 2017). When the tissue is harder or stiffer, it strain more (measured in Kpa) and the shear wave moves faster, and its speed (m/s) provides information about tissue hardness (Bruno et al., 2016). Shear wave elastosonography is becoming an increasingly popular technique in the diagnosis of organs and system diseases (Cosgrove et al., 2013). SWE has been used clinically to assess many conditions such as liver diseases (Hu et al., 2019), thyroid nodules (Aghaghazvini et al., 2020), breast cancer (Zheng et al., 2020), preoperative evaluation of axillary lymph nodes status in early breast cancer diagnosis (Togawa et al., 2024), and other disorders. Recently, the use of sonoelastography has been reported in the evaluation of endometrium, myometrium, prediction of preterm labor, induction of labor success, pelvic endometriosis and cancer cervix (Stoelinga et al., 2016 – Beladaci et al., 2018 – Zhang et al., 2019 – Vora et al., 2022 – Simon et al., 2022). Hefeda and Zakaria (2020) and Wang et al. (2022) suggested that tissue elasticity measured by SWV is considered appropriate for obstetrics and gynecology. SWE should not replace conventional ultrasound imaging, but it is complementary to it (Ma et al., 2021). Polycystic Ovarian Disease (PCOD): Conventional U/S examination usually has difficulty presenting the overall morphology and structure of the ovary in patients with PCOS, as physicians can only observe follicles in a limited section of the ovary complicating the process of follicle count (He et al., 2025). The subjective judgement can easily result in misdiagnosis. Polycystic ovarian morphology can be seen by ultrasound examination in up to 25% of normal ovulating women in whom SWE will not be found increased. Gursu et al. (2021) conducted a study to give insights into the elasticity pattern and SWV in PCOS ovaries compared to ovaries in non-PCOS women. They concluded that easy application of quantitative sonoelastography measurements (SWE) provides significant findings about PCOS. They added that the widespread application of SWE in PCOS diagnosis is not a must, but it can be a beneficial diagnostic tool for clinicians. Also, He et al. (2025) demonstrated that patients with PCOS (n=59) showed an increased SWV (mean & max) compared to controls (n=56) as shown in fig 2. Uterine Adenomyosis: The most commonly used non-invasive tools to diagnose uterine adenomyosis in clinical practice are: 1) TVS (Dueholm, 2006), and 2) MRI (Bazot et al., 2001). According to Acar et al. (2016), the subjective nature of B-mode imaging interpretation is a recognized limitation of U/S as a diagnostic modality of this problem and is undoubtedly the cause of wide accuracy range (38.4% to 86.4%). MRI has a good accuracy to diagnose uterine adenomyosis (Bazot et al., 2001). However, the routine use of MRI is limited by its high cost and less availability. Acar et al. (2016) concluded that SWE was accurate to diagnose uterine adenomyosis. Endometrial and sub endometrial lesions: Endometrial diseases pose a diagnostic challenge due to their nonspecific clinical presentation and features on primary imaging assessment (Soliman et al., 2024). SWE can assess the mechanical properties of the endometrial lesions and provide a quantitative measure of tissue stiffness and so aids in differentiating different endometrial pathologies (Soliman et al., 2024). TVS is the first line imaging modality in premenopausal patients with AUB. SWE does not replace conventional TVS, but it is complementary to it (Ma et al., 2021). Vora et al. (2022) conducted a pilot study to assess the role of SWE in characterizing endometrial and sub endometrial pathologies (endometrial hyperplasia, endometrial polyp, endometrial carcinoma, submucosal leiomyoma and focal adenomyoma). They concluded that SWE is a potential adjunct to ultrasound that provides an additional paradigm to characterize endometrial and sub endometrial lesions. TV-SWE is an effective additional method of differentiating benign and malignant endometrial lesions when combined with conventional U/S (Soliman et al., 2024). Uterine fibroid and fibrosarcoma: Samanci and Onal (2020) investigated the role of SWE in the evaluation of response to uterine artery embolization (UAE)in patients having uterine leiomyomas. The post UAE 1.5 month stiffness measurements after the procedure were significantly lower than the pre UAE measures. This could be explained by ischemic coagulative necrosis. They concluded that SWE values after UAE, significantly decreased. They added that SWE, with its high reproducibility, could become a useful tool in the follow up of uterine leiomyomas after UAE. Ovarian cysts: Ciledag et al. (2013) conducted a pilot study to determine the appearance of various cystic ovarian lesions on transvaginal real-time ultrasonographic elastography and to investigate its potential in the differential diagnosis of these lesions. They concluded that this diagnostic technique may be used in differentiation of benign and malignant ovarian masses. So unnecessary interventions could be available for benign cysts with solid components. The method used by Ciledag et al. is strain elastography (SE) which is subjective qualitative one. Application of the objective quantitative SWE could be more accurate regarding this issue. Cervical lesions, fig 3: \RL pathological changes \RL leading to increased stiffness are associated with increased risk of malignancy (Bota et al., 2012). Investigations done by Bakay and Golovko, 2015) demonstrated that SE included into the ultrasound studies extended the diagnostic possibilities of these methods, allowed to increase the information at examination of cancer process staging. They added that, currently elastography techniques is in the process of development and requires further studies. Fu et al. (2020) conducted a study to explore the value of SWE in the differential diagnosis of cervical disease and to evaluate the infiltration of cervical cancer, between October 2014 and January 2017. The mean value of SWS for cervical cancer was significantly higher than that of cervical benign lesions and normal cervix. Also, they concluded that SWE may be used to differentiate between cervical benign lesions and cervical cancer and that SWE is able to evaluate the infiltration of cervical cancer. Perineal body (PB): stress urinary incontinence (SUI) is a significant health problem for women, negatively affecting their quality of life (Sangsawang and Sangsawang, 2013). PB, which serves as the anchor of pelvis\RL, is a functional and anatomic complex tissue that maintains urinary continence (Woodman and Graney, 2002). The current state of knowledge about correlation of PB and SUI is limited and further studies are needed to understand the role of PB in SUI pathogenesis (Li et al., 2024). The latter authors conducted a study to evaluate the elasticity of PB by SWE in parous women to compare PB elasticity between healthy women and patients with SUI. They found that PB stiffness during Valsalva maneuver in healthy women was higher than in women having SUI. Pelvic organ prolapse (POP): Assuming that changes of extracellular matrix of connective tissue have specifically contributed to the incidence of POP, it seems reasonable that sonoelastography could be useful tool to evaluate the elasticity of pelvic floor tissue in patients with POP and compare it to those without POP (Garcia-Mejido et al., 2024). The latter authors did a pilot study to determine if there are differences in elasticity of the levator ani Muscle (LAM) and vaginal tissue between patients with and without POP. They detected a higher elasticity (lesser stiffness) of the LAM and vaginal tissue in patients with POP than in healthy controls. Conclusion: Palpation, used in clinical examination for thousands of years is based on detection of changes in elasticity and stiffness of tissue due to pathological conditions. Palpation is subjective and is not suitable for deeper tissues. Elastography, a novel diagnostic modality has been developed to overcome the disadvantages of palpation. Strain elastography was developed first, but it is still subjective and operator dependent. So, SWE has been developed as an objective and quantitative diagnostic modality. It has been studied in many conditions including obstetric and gynecological problems. SWE is easy to perform and interpret, reproducible and add few minutes to the conventional ultrasound examination. More studies are recommended in this area. Author Contributions: AA and KA participated in writing the paper. All three authors (AA, MS, and KA) participated in revising and editing the manuscript. Funding Statement: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Acknowledgements: The authors would like to thank the reviewers for their valuable comments and suggestions. Ethical Statement: This review article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors. REFERENCES: Acar S, Miller E, Mitkova M and Mitkov V et al. (2016): Value of ultrasound shear wave elastography in the diagnosis of adenomyosis. Ultrasound; 24(4): 205-13. Aghaghazvini L, Maheronnaghash R, Soltani A et al. (2020): Diagnostic value of shear wave sonoelastography in differentiation of benign from malignant thyroid nodules. Eur J Radiol; 126:108926. Bakay OA and Golovko TS (2015): Use of Elastography for Cervical Cancer Diagnostics. Exp Oncol; 37: 139-45. 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Wang K, Lu X, Zhou H et al. (2019): Deep learning radiomics of shear wave elastography significantly improved diagnostic performance for assessing liver fibrosis in chronic hepatis B: A prospective multicenter study. Gut; 68: 729-41. Youk JH, Gweon HM and Son EJ (2017): Shear-wave elastography in breast ultrasonography. The state of the art. Ultrasonography; 36: 300-9. Zhang X, Huang Y, Liu Y et al. (2020): Shear-wave elastography of the breast: added value of a quality map in diagnosis and prediction of the biological characteristics of the biological characteristics of breast cancer. Korean J Radiol; 2: 172-80. (B) Fig 1: A) Basic physics of SWE from Taljanovic et al. (2017). In step 1; shear waves are generated using ARF that propagate perpendicular to the primary U/S wave at a lower velocity. In step 2; fast plane wave excitation is used to track displacement and velocity as shear waves propagate, and tissue displacement is calculated using a speckle tracking algorithm. In step 3; tissue displacement is used to calculate shear wave velocity (Cs) and shear modulus (G). (B) Relationship between shear wave velocity and shear modulus expressed as a color bar, which assume es, in this case, tissue density equals that of water (1g/cm3). Actual density estimates will vary for different types of tissue and can also be found using values published in the literature. Fig 2: Sinus follicle counts and images of Young’s modulus of ovarian medulla in PCOS patients and healthy controls. From He et al. (2025). Fig 3: Cancer cervix stage IIa stage (Fu et al., 2020). Elastography of endophytic tumor which significantly affects the cervix stroma and invades uterine body without leaving its margin. There is a clear border line between dark blue tumor and green colored unchanged stroma. postoperative specimen confirms absence of invasion outside the uterus. Information & Authors Information Version history V1 Version 1 25 March 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords adenomyosis: diagnosis imaging radiological imaging: ultrasound reproductive science: polycystic ovary syndrome Authors Affiliations Amr Mohamed Abdelhady Sayed Abdelhady [email protected] Guy's and St Thomas' NHS Foundation Trust View all articles by this author Mohamed Abdelhady Sayed** * Benha University Faculty of Medicine View all articles by this author Khalid Alloush NHS Wales Betsi Cadwaladr University Health Board View all articles by this author Metrics & Citations Metrics Article Usage 261 views 172 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Amr Mohamed Abdelhady Sayed Abdelhady, Mohamed Abdelhady Sayed** *, Khalid Alloush. Shear Wave Elasto-sonography in Gynecological Conditions: state of the art.. Authorea . 25 March 2025. 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