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WFUMB Guidelines and Recommendations on the Clinical Use of Ultrasound Elastography| Volume 43, ISSUE 1, P1-3, January 01, 2017

Foreword to the Second Set of WFUMB Guidelines and Recommendations on the Clinical Use of Ultrasound Elastography

      With the increased number of publications on elastography, the World Federation for Ultrasound in Medicine and Biology (WFUMB) leadership decided to take initiative to create guidelines in August 2011. The first consensus meeting was held in March 2013 and led to the development of guidelines for basic science (
      • Shiina T.
      • Nightingale K.R.
      • Palmeri M.L.
      • Hall T.J.
      • Bamber J.C.
      • Barr R.G.
      • Castera L.
      • Choi B.I.
      • Chou Y.H.
      • Cosgrove D.
      • Dietrich C.F.
      • Ding H.
      • Amy D.
      • Farrokh A.
      • Ferraioli G.
      • Filice C.
      • Friedrich-Rust M.
      • Nakashima K.
      • Schafer F.
      • Sporea I.
      • Suzuki S.
      • Wilson S.
      • Kudo M.
      WFUMB Guidelines and Recommendations on the Clinical Use of Ultrasound Elastography: Part 1: Basic Principles and Terminology.
      ), breast (
      • Barr R.G.
      • Nakashima K.
      • Amy D.
      • Cosgrove D.
      • Farrokh A.
      • Schafer F.
      • Bamber J.C.
      • Castera L.
      • Choi B.I.
      • Chou Y.H.
      • Dietrich C.F.
      • Ding H.
      • Ferraioli G.
      • Filice C.
      • Friedrich-Rust M.
      • Hall T.J.
      • Nightingale K.R.
      • Palmeri M.L.
      • Shiina T.
      • Suzuki S.
      • Sporea I.
      • Wilson S.
      • Kudo M.
      WFUMB Guidelines and Recommendations on the Clinical Use of Ultrasound Elastography: Part 2: Breast.
      ) and liver (
      • Ferraioli G.
      • Filice C.
      • Castera L.
      • Choi B.I.
      • Sporea I.
      • Wilson S.R.
      • Cosgrove D.
      • Dietrich C.F.
      • Amy D.
      • Bamber J.C.
      • Barr R.G.
      • Chou Y.H.
      • Ding H.
      • Farrokh A.
      • Friedrich-Rust M.
      • Hall T.J.
      • Nakashima K.
      • Nightinggale K.R.
      • Palmeri M.L.
      • Schafer F.
      • Shiina T.
      • Suzuki S.
      • Kudo M.
      WFUMB Guidelines and Recommendations on the Clinical Use of Ultrasound Elastography: Part 3: Liver.
      ) elastography. With the increasing number of publications and interest in thyroid and prostate elastography, WFUMB convened a panel of worldwide experts to provide guidelines for these applications of elastography.
      It is anticipated that additional guidelines will be forthcoming as elastography technology evolves and more clinical studies and new applications are developed. With this set of guidelines, a standardized format including grading of recommendations was instituted, which will be used for forthcoming guidelines. Guidelines for individual organ systems will be updated as additional literature and technology dictate. These guidelines provide guidance to both novice and expert uses in performing elastography.

      Methodology

      A steering committee was appointed to define the general content of the guidelines, with subsequent invitation of experts from each of the member organizations of WFUMB, based on their publications records and expertise in the different fields, to partake in guideline development. Two author subgroups (thyroid and prostate) were established with specific responsibility for each section of the WFUMB guidelines. Section leaders were selected from the steering committee; the section leaders defined the subsections and key topics of the 2 new guideline sections (thyroid and prostate).
      A literature search was performed systematically in PubMed using predefined key words and MeSH terms and, in addition, by a complimentary “hand search” using reference lists of articles retrieved by systematic searches, books and reviews. The literature search was in principle restricted to English language papers, and in particular to guidelines, meta-analyses and systematic reviews; original research articles (randomized controlled trials, prospective studies, retrospective studies, case series of more than 6 cases); and results of clinical registries and surveys. English abstracts and single case studies were included only in selected circumstances.
      Evidence tables were generated for each key topic. The Oxford Centre for Evidence-Based Medicine Levels of Evidence (March 2009 edition) was used to judge the level of evidence (LoE) and grade of recommendations (GoR) (
      • Burns P.B.
      • Rohrich R.J.
      • Chung K.C.
      The levels of evidence and their role in evidence-based medicine.
      ). Drafts of the overview, recommendations and comments were provided by three authors for each section and revised by the members of the steering committee. After approval by the steering committee, the revised drafts were submitted to the whole expert group approximately 2 weeks before the expert meeting, held in Chicago, IL, USA on December 3 and 4, 2016. Vendors were asked to participate in the meeting and were allowed to comment, but they did not write or edit the guidelines. At the expert meeting, each of the three authors presented their overviews to the entire organ-specific group. All recommendations were discussed and improved, and a draft document was developed. The steering committee reviewed and revised the draft document for consistency and accuracy. The draft document was distributed to each member of the expert panels subject to a vote for each of the recommendations by the expert panel. Consensus was graded using a simple system: strong consensus, >95% of experts' votes; broad agreement, >75%–95% of experts' votes; majority consensus, 50%–75% of experts' votes; dissent, <50% of experts' votes in favor of the respective recommendation. Only recommendations with strong consensus or broad agreement were included in the final version of the guidelines. Following the consensus meeting, comments were adapted to the final recommendations and shortened. The LoE and GoR were checked by the authors and steering committee.
      For many important recommendations reported in these guidelines, the strength of evidence may appear relatively weak in comparison to the value of the recommendation based on clinical expert judgment. Often new and valid methods are so obviously of benefit that randomized controlled trials comparing older technology are not performed. Investigators can use the LoE to identify areas in need of additional studies.
      Vendors were asked to provide a listing of the types elastography they provide and which transducers are available for each type of elastography they provide. The results are presented in Table 1.
      Table 1Elastography methods. Each column shows methods and measured parameters for elastography. Each row shows a method for inducing displacement. Each cell shows a type of elastography
      Measured

      Physical quantity
      Strain or displacement Shear wave speed
      Methods

      Excitation method
      Strain imagingShear wave imaging
      • (A)
        Manual compression
        • -
          Palpation
        • -
          Cardiovascular
        • -
          Pulsation
        • -
          Respiration
      Strain elastography
      -eSieTouch Elasticity ImagingSiemens
      -Real-time tissue elastographyHitachi Aloka
      -ElastographyGE

      Philips

      Toshiba

      Zonare
      -ElastoScanSamsung

      BK Ultrasound

      CareStream
      • (B)
        Acoustic Radiation Force
      Acoustic Radiation Force Impulse (ARFI) ImagingPoint Shear Wave Elastography

      (Average shear wave speed in local region)
      -Virtual Touch Imaging (VTI)

      Siemens-Virtual Touch Quantification (VTQ)

      -ElastPQ

      -QelaXto

      -S-Shearwave (RS80A with Prestige)

      Siemens

      Philips

      Esaote

      Samsung
      Shear wave elastography

      (Shear wave speed imaging)
      -ShearWave Elastography:SWE

      -Virtual Touch Image Quantification (VTIQ)
      SSI

      Siemens

      GE

      Toshiba
      • (C)
        Mechanical Impulse
      Transient Elastography

      (Average shear wave speed measurement)
      -FibroScan

      Echosens
      “Point” measurement denotes the fact that measurements are performed in a small region of interest, typically 1 cm2, compared to the field of view in the image.
      As with the first set of guidelines, this international cooperative project lends more strength to these documents. The publications of these documents underscores the worldwide recognition of the use of elastography, both strain and shear wave techniques, in the evaluation of thyroid and prostate pathology. These guidelines expand on the guidelines published by the European Federation for Ultrasound in Medicine and Biology (EFSUMB) published in 2013 (
      • Cosgrove D.
      • Piscaglia F.
      • Bamber J.
      • Bojunga J.
      • Correas J.-M.
      • Gilja O.H.
      • Klauser A.S.
      • Sporea I.
      • Calliada F.
      • Cantisani V.
      • D'Onofrio M.
      • Drakonaki E.E.
      • Fink M.
      • Friedrich-Rust M.
      • Fromageau J.
      • Havre R.F.
      • Jensses C.
      • Ohlinger R.
      • Saftoiu A.
      • Schaefer F.
      • Dietrich C.F.
      EFSUMB Guidelines and Recommendations on the Clinical Use of Ultrasound Elastography. Part 2: Clinical Applications.
      ). These guidelines should be a major reference for both novices and experts performing elastography of the thyroid and prostate.

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