Can ultrasound strain elastography (USE) improve management of suspicious thyroid nodules measuring <10 mm? A systematic review (2023)


Volume 29, Issue 3,

May 2023

, Pages 661-667

Author links open overlay panel,



Current UK guidelines state that suspicious thyroid nodules <10mm do not require FNA. These are often followed up with serial ultrasound scans. Ultrasound Strain Elastography (USE) could provide a more accurate alternative and preclude the need for follow-up. Can USE identify nodules at greater risk of malignancy and streamline patient management?


Systematic review methodology used. Inclusion criteria are:

- Population: patients with suspicious thyroid nodules <10mm.- Intervention: USE.- Comparator: Ultrasound features of nodules.- Outcome measure: FNA or surgical removal of nodules. Searches performed on 6 commercial databases, along with grey literature anddissertation databases. The QUADAS-2 diagnostic study checklist used for quality assessment.


8 studies included and a narrative analysis performed due to heterogeneity of results. The mean USE sensitivity is 74.3%, mean specificity 80.5%. Mean overall ultrasound sensitivity is 80.4%, specificity 71.0%. Results suggest that USE is not superior to ultrasound for detecting malignancy. Some study limitations, particularly the heterogeneity of reporting the ultrasound features preclude meaningful conclusion from being drawn.


USE is more accurate at identifying benign nodules than ultrasound. Nodules appearing benign on USE could be excluded from serial ultrasound follow-up. No significant difference was found between USE and ultrasound at identifying malignant nodules.

(Video) Thyroid Elastography

Implications for practice

As FNA is not recommended for suspicious thyroid nodules <10mm, these are often followed up with multiple scans and clinician reviews. This increases pressure on healthcare systems and uncertainty for the patient. This review shows that USE is more accurate at identifying benign nodules than ultrasound alone, meaning that these nodules could potentially be excluded from serial follow up. This would streamline patient management, freeing-up vital resources in ENT and ultrasound departments.


Small suspicious thyroid nodules measuring less than 10mm present a management dilemma. The majority of these are papillary thyroid microcarcinoma (PTMC).1 Survival rates for PTMC is near 100% and they very rarely present with high-risk features such as lymph node metastasis, distant metastasis or extra-thyroid extension.1,2 The British Thyroid Association (BTA) recommend against FNA for nodules <10mm diameter to avoid overtreatment of clinically insignificant thyroid cancers unless there are high-risk features.1 A separate guideline on UK thyroid cancer management was published in 2016, based on the BTA guidelines, which further proscribed FNA of suspicious nodules <10mm unless there are associated pathological nodes.3

No guidance is given in either guideline on whether or not these nodules require monitoring. Whilst management can vary in different institutions, suspicious nodules <10mm in diameter are commonly followed-up with serial monitoring scans at 6 month intervals to assess for size increases or nodal metastasis that may change management.2 The scan interval may be increased to annually after two years if the nodule is shown to be stable.4 If a suspicious nodule increases in size >10mm or develops high-risk features, FNA is performed.1 These monitoring scans represent a burden on Imaging services and create uncertainty in patients who do not have a definite diagnosis.

Ultrasound strain elastography (USE) is not currently included in UK guidelines as a criterion for assessing thyroid nodules. USE is a qualitative ultrasound technique that measures tissue stiffness during application of pressure either with the ultrasound probe or physiological movement such as carotid artery pulsation. Tissue stiffness is indicated by a colour map, or elastogram, with different colours assigned to different stiffness levels5; increased stiffness of abnormal tissue compared to normal is associated with increased risk of malignancy.6 Different scoring systems have been suggested, such as a 5 point scale based on increasing stiffness of nodules.7

A drawback of USE is that it is potentially not suitable for all thyroid nodules, such as those containing internal macro-calcification or those with large cystic content.8 It may however be possible to assess complex nodules with USE as long as only the solid portion is assessed whilst ignoring artefacts caused by other contents.6

Several previous studies have been performed assessing USE effectiveness at diagnosing malignant thyroid nodules, including several systematic reviews and meta-analyses, most comparing USE to FNA, aiming to obviate the need for FNA9,10,.11 In this regard, USE is generally found to be inferior and so has not been integrated into routine practice.

No previous systematic review can be identified concentrating solely on USE assessment of thyroid nodules <10mm diameter compared to ultrasound alone. However, as FNA is not recommended in these cases, alternative techniques to ultrasound may provide more accurate assessment of risk of malignancy.

The objective of this review is to consider the scope of USE in identifying nodules at greater risk of malignancy, and whether it could further inform the decision-making process regarding follow-up of these nodules. This could streamline patient management and reduce the burden of multiple follow-up appointments on ENT services, ultrasound departments and, ultimately, patients.

Section snippets


This study used a systematic review methodology in line with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement.12 Searches were performed on the following commercial databases: Pubmed, CINAHL, Scopus, Wiley Online Library and the Cochrane Library. Searches were also performed on ‘grey literature’ and dissertation databases: Open Grey, EThOS and Open Dissertations. Search terms were tailored to each database using boolean operators, including key terms and


Searches returned 1953 non-duplicated studies, with 261 deemed relevant following title and abstract screening. These proceeded to full text screening, with 11 studies meeting inclusion criteria (see PRISMA chart, Fig.1). During quality assessment, results reporting was deemed inaccurate in 1 of the 11 studies; this study was excluded.14 A further two were excluded due to poor reporting of results. One study only provided sensitivities for ultrasound appearances and not specificities19;

Quality assessment

Several issues were identified during quality assessment. Cohorts were poorly described in all cases; it was unclear why patients were under investigation or what presenting symptoms were. One study stated inclusion criteria as a thyroid nodule measuring <10mm during physical examination – this is unusual as these are not reliably palpable.15

Two studies demonstrated potential selection bias; Xing etal.16 and Wang, Dan & Dan etal.17 Both only included patients already selected for thyroid

Analysis of results

Ultrasound features reported in the studies as suspicious for malignancy varied. All studies reported microcalcifications and irregular margins. Other features were variably reported across different studies: taller>wide morphology,16,21,23, 24, 25 hypoechogenicity,16,18,21,23, 24, 25 internal blood flow16,17,18,21, loss of halo,18,24 extra-thyroid extension22 or disrupted rim calcification.22

In isolation, individual ultrasound features show significant inconsistency. The mean sensitivity of


The aim of this review was to investigate the effectiveness of USE in identifying malignancy in suspicious thyroid nodules <10mm. In this regard, no significant difference is seen between the accuracy of USE and ultrasound as ultrasound is shown to have a higher sensitivity than USE for thyroid nodule malignancy. However, one significant outcome of the review is that USE has a higher specificity than ultrasound for excluding thyroid malignancy, suggesting that USE is more accurate at


The results of this systematic review show that USE is more accurate at identifying a benign nodule than ultrasound features alone. This could improve management of these patients, as it means that nodules appearing benign on USE assessment, particularly indeterminate nodules (U3), do not require FNA and could be excluded from serial follow up, reducing the scan burden on ENT and ultrasound services. It is still recommended that any decisions regarding patient management take into account the

Declaration of interest

There is no conflict of interest to declare.


Peter Cogings and Barry Stevens for invaluable advice and guidance whilst carrying out and writing up the research.

This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

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    (Video) Ultrasound Elastography Explained: Strain and Shear

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    How do you treat highly suspicious thyroid nodules? ›

    A common treatment for cancerous nodules is surgical removal. In the past, it was standard to remove a majority of thyroid tissue — a procedure called near-total thyroidectomy. However, today more limited surgery to remove only half of the thyroid may be appropriate for some cancerous nodules.

    What is the most accurate tool in the evaluation of thyroid nodules? ›

    Thyroid FNA biopsy is the most reliable, safe, and cost-effective diagnostic tool used in the evaluation of thyroid nodules.

    How can I shrink my thyroid nodules without surgery? ›

    Radiofrequency ablation (RFA) is an effective alternative – no surgery or hormone therapy required. In the U.S., nearly half the population will develop a thyroid nodule by age 60. Thyroid nodules are solid or fluid-filled lumps that form within your thyroid, a butterfly shaped gland located at the base of your neck.

    What is the single most important test in the evaluation of thyroid nodules? ›

    Fine needle aspiration biopsy (FNAB) is the most important step in the workup of the thyroid nodule, as cytology is the primary determinant in whether thyroidectomy is indicated. FNAB is widely available and well tolerated, with a low risk of complications.

    What is the most efficient first line evaluation for thyroid nodules? ›

    Fine-needle aspiration (FNA) is the most accurate and cost-effective method for evaluating thyroid nodules (3).

    How often should thyroid nodules be checked with ultrasound? ›

    The ATA Guidelines recommend that thyroid nodules be followed with a repeat ultrasound 6–18 months after an initial benign cytology. False‐negative results of up to 2% may occur with ultrasound‐guided FNAB 22 . This may be higher for nodules with suspicious ultrasound features 22 .

    What makes a thyroid nodule highly suspicious? ›

    There are certain factors that make a nodule suspicious for thyroid cancer. For example, nodules that do not have smooth borders or have little bright white spots (micro-calcifications) on the ultrasound would make your doctor suspicious that there is a thyroid cancer present.

    What percentage of highly suspicious thyroid nodules are cancerous? ›

    The majority of thyroid nodules are benign, with 5% to 15% being malignant [1].

    What is the gold standard investigation for thyroid nodule? ›

    Thyroid ultrasonography is the recognized “gold standard” for an accurate and reliable assessment of gland volume and thyroid nodules. Many endocrinologists refer patients for surgical treatment because of detection of growth of thyroid nodules.

    What is the gold standard test for thyroid nodule? ›

    Fine needle aspiration biopsy (FNA) is the gold standard for the examination of thyroid nodules, but with decreasing sensitivity in multinodular goiter, thyroid nodules >4 ml or follicular tumors (Haugen et al.

    Can ultrasound be wrong for thyroid nodules? ›

    In the case of thyroid ultrasound, the resulting mistakes may be due to a faulty examination technique, or the similarity of the neighboring anatomical structures to the abnormal changes within the gland.

    What is the alternative to surgery for thyroid nodules? ›

    Your doctor can discuss options with you. If a thyroid nodule is filled with fluid, the fluid can be drained out with a needle. This can provide temporary relief but the cyst almost always recurs. This is a similar procedure to aspiration and can be used for simple liquid-filled nodules.

    What medication reduces size of thyroid nodules? ›

    Thyroid hormone medication (L-thyroxine)

    This synthetic form of thyroid hormone can help to shrink an enlarged thyroid and treat an underactive thyroid. Hypothyroid symptoms usually start to improve within the first week of starting the medication, and disappear within a few months.

    What is a moderately suspicious thyroid nodule? ›

    “Moderately suspicious” or TR4 nodules are 4 to 6 points, and TR5 nodules or “highly suspicious” have sums of 7 points or more. For TR4 nodules, the guidelines recommend fine-needle aspiration if the nodule is 1.5cm or larger, and follow-ups if larger than 1cm.

    What is the single best test to screen for abnormal thyroid gland function? ›

    The TSH test is often done first because it's the best way to initially test thyroid function. It determines whether a person has hyperthyroidism or hypothyroidism.

    Which is the most helpful test in diagnosis thyroid malignancy? ›

    A radioactive iodine scan uses a radioactive form of iodine and a special camera to detect thyroid cancer cells in your body. It's most often used after surgery to find any cancer cells that might remain. This test is most helpful for papillary and follicular thyroid cancers.

    What is the best test to confirm thyroid malignancy? ›

    Biopsy. The actual diagnosis of thyroid cancer is made with a biopsy, in which cells from the suspicious area are removed and looked at in the lab. If your doctor thinks a biopsy is needed, the simplest way to find out if a thyroid lump or nodule is cancerous is with a fine needle aspiration (FNA) of the thyroid nodule ...

    Should a 7mm thyroid nodule be biopsied? ›

    According to the Society of Radiologists in Ultrasound, biopsy should be performed on a nodule 1 cm in diameter or larger with microcalcifications, 1.5 cm in diameter or larger that is solid or has coarse calcifications, and 2 cm in diameter or larger that has mixed solid and cystic components, and a nodule that has ...

    What is the most sensitive first line screening test for suspected thyroid abnormalities? ›

    A TSH test is the recommended first-line test for suspected thyroid disease; if results are abnormal, the TSH test should be repeated along with a serum free T4 measurement.

    What is the Kim criteria for thyroid nodules? ›

    According to the Kim criteria, a nodule should have at least one of the following findings: marked hypoechogenicity, irregular or microlobulated margins, microcalcifications, or length greater than width.

    Can a highly suspicious thyroid nodule be benign? ›

    A nodule can be benign, or noncancerous; toxic, meaning it produces too much thyroxine; or cancerous. Doctors at NYU Langone are experts in determining what type you have and choosing the appropriate treatment. About 90 to 95 percent of thyroid nodules are benign.

    When do they decide to remove thyroid nodules? ›

    Doctors may also recommend surgery to manage a thyroid nodule if a biopsy shows it's cancerous or if genetic testing shows it's likely to be cancerous. Your NYU Langone endocrinologist and endocrine surgeon determine the most effective and least invasive treatment or type of surgery based on diagnostic test results.

    What is the treatment for cancerous thyroid nodules? ›

    Most cancers are treated with removal of the thyroid gland (thyroidectomy), although small tumors that have not spread outside the thyroid gland may be treated by just removing the side of the thyroid containing the tumor (lobectomy).

    Should a moderately suspicious thyroid nodule be biopsied? ›

    If a Thyroid Nodule is Visualized, What Next? Typically, nodules that represent a risk of malignancy should be biopsied. That is one way to avoid over-treatment. However, all thyroid nodules do not need a biopsy.

    What are the features of malignant thyroid nodules on ultrasound? ›

    Ultrasound can detect the presence, site, size, and number of thyroid nodules, and there have been reports of US characteristics of malignancy, such as ill-defined margin, irregular shape, hypoechogenicity, heterogeneity, absence of cystic lesion and/or the halo sign, the presence of calcification, and invasion to ...

    Is a 10 mm thyroid nodule large? ›

    large (> 10 mm) nodules, but still clinically relevant in absolute terms. Although the prognosis of small (< 10 mm) papillary thyroid cancer (so-called microcarcinoma) is usually excellent, some may progress classically to clinically evident or even aggressive disease, occasionally with a fatal outcome [8, 10].

    What size is suspicious thyroid nodule? ›

    A small nodule with a diameter of less than 1cm is often benign, but if it reaches a size greater than 2 cm, there is an increased risk of cancer. Thyroid nodules greater than 4 cm in diameter have a 15% likelihood of becoming cancerous, according to one study cited by The American Thyroid Association.

    How fast can a cancerous thyroid nodule grow? ›

    Malignant nodules, especially higher-risk phenotypes, grow faster than benign nodules. As growth >2 mm/y predicts malignant compared with benign disease, this clinical parameter can contribute to the assessment of thyroid cancer risk.

    What is a diagnostic workup for thyroid nodules? ›

    Thyroid nodules come to clinical attention when noted by the patient; by a clinician during routine physical examination; or during a radiologic procedure, such as carotid ultrasonography, neck or chest computed tomography (CT), or positron emission tomography (PET) scanning.

    What is the gold standard test for Hashimoto? ›

    An elevated serum anti-thyroid peroxidase (TPOAb) is widely considered the best serological marker of Hashimoto's thyroiditis, and it is detectable in about 95% of patients with clinical Hashimoto's thyroiditis as defined by the spontaneous onset of hypothyroidism when neither surgery nor radioiodine ablation has been ...

    Should an 8mm thyroid nodule be biopsied? ›

    On the basis of ultrasound features, thyroid nodules may be categorized into three groups: low, intermediate and high malignancy risk. FNAB should be considered for nodules ≤10 mm diameter only when suspicious signs are present, while nodules ≤5 mm should be monitored rather than biopsied.

    What is the best biopsy for thyroid nodule? ›

    A fine needle aspiration biopsy of a thyroid nodule is a simple and safe procedure performed in the doctor's office. Typically, the biopsy is performed under ultrasound guidance to ensure accurate placement of the needle within the thyroid nodule.

    Which thyroid nodule meets criteria for FNA? ›

    FNA needle biopsy of thyroid nodules is generally done on any thyroid nodules that is big enough to be felt. This means that they are larger than about 1 centimeter (about 1/2 inch) across. FNA biopsy is indicated on any thyroid nodule that causes symptoms.

    How to tell if thyroid nodule is cancerous with ultrasound? ›

    A malignant thyroid nodule tends to have ill-defined margins on ultrasound (Fig. 1). A peripheral halo of decreased echogenicity is seen around hypoechoic and isoechoic nodules and is caused by either the capsule of the nodule or compressed thyroid tissue and vessels [31].

    Can you tell if a thyroid nodule is benign from an ultrasound? ›

    The vast majority — more than 95% — of thyroid nodules are benign (noncancerous). If concern arises about the possibility of cancer, the doctor may simply recommend monitoring the nodule over time to see if it grows. Ultrasound can help evaluate a thyroid nodule and determine the need for biopsy.

    Can you tell if a nodule is benign from an ultrasound? ›

    Ultrasound can usually help differentiate between benign and malignant tumours based on shape, location, and a number of other sonographic characteristics. If the ultrasound is inconclusive, your doctor may request follow-up ultrasound to monitor the tumor or a radiologist may recommend a biopsy.

    Can cancerous thyroid nodules be removed without surgery? ›

    A thin needle is inserted through the skin and guided using ultrasound to the nodule. The tip of the needle heats up, destroying (ablating) it from the inside. The normal thyroid tissue around the nodule is not affected. The ablated nodule turns into scar tissue, shrinking over time.

    Can cancerous thyroid nodules be treated without surgery? ›

    Now we know there can be success in removing only part of the thyroid gland, or sometimes avoiding surgery entirely.” In the past 10 to 20 years, more than 85% of patients who chose active surveillance never needed surgery—their tumors did not grow or spread to their lymph nodes.

    What vitamins are good for thyroid nodules? ›

    Selenium and zinc are beneficial in improving thyroid function and hormone levels. According to a study in Hormones: The Journal of Endocrinology and Metabolism, zinc improves T3 levels significantly. Food sources of zinc include shellfish, mollusks, meat, legumes, and nuts.

    Can you decrease the size of thyroid nodules? ›

    Most solid thyroid nodules will not shrink on their own. In such cases, your doctor may prescribe medicine or recommend surgery to remove the nodules or shrink a nodule by removing fluid from it with a thin needle.

    Can selenium shrink thyroid nodules? ›

    Selenium deficiency is also a potential cause of nodules, as studies suggest that selenium supplementation can result in improved thyroid ultrasound features and smaller nodules (25).

    What is the average size of a malignant thyroid nodule? ›

    Thyroid nodules ranged in size from 0.5 to 8.8 cm with a mean (SD) size of 2.0 (1.4) cm (Table 1).

    What is the most sensitive thyroid function test? ›

    The blood test for TSH, which is the most sensitive marker of your thyroid status, is used as a biochemical marker to ensure that your thyroid hormone replacement is adequate. It is recommended that patients on thyroid hormone replacement should keep their TSH within the reference range.

    What is the first line evaluation for thyroid nodules? ›

    Scintigraphy is the first-line study for assessing a hyperfunctioning nodule.

    What is the most common well differentiated thyroid malignancy? ›

    Follicular thyroid cancer and papillary thyroid cancer are the most common differentiated thyroid cancers. They are very often curable, especially when found early and in people younger than 50. Together, follicular and papillary thyroid cancers make up about 95% of all thyroid cancer.

    What is the imaging of choice for thyroid carcinoma? ›

    The mainstay for primary diagnosis thyroid cancer is high-resolution ultrasound of the thyroid gland including ultrasound-guided fine needle biopsy (FNB) of any suspect thyroid nodules.

    What causes thyroid nodules to grow? ›

    Thyroid nodules are caused by an overgrowth of cells in the thyroid gland. These growths can be: Not cancer (benign), thyroid cancer (malignant), or very rarely, other cancers or infections.

    What is the least common thyroid malignancy? ›

    Anaplastic thyroid cancer

    This is the least common and most serious thyroid cancer. Less than 1 out of every 100 thyroid cancers (less than 1%) are this type. Anaplastic thyroid cancer is usually diagnosed in older people and is more common in women.

    What is the minimum size of a thyroid nodule to biopsy? ›

    This nodule is classified as category TR3 (mildly suspicious) according to American College of Radiology (ACR) guidelines. ATA and KTA/KSThR guidelines recommend biopsy at size threshold of 1.5 cm or larger, whereas ACR does not recommend biopsy with size threshold of 2.5 cm or larger.

    What is the gold standard for thyroid nodule examination? ›

    Thyroid ultrasonography is the recognized “gold standard” for an accurate and reliable assessment of gland volume and thyroid nodules.

    What is the gold standard for diagnosis of thyroid nodules? ›

    Fine needle aspiration biopsy (FNA) is the gold standard for the examination of thyroid nodules, but with decreasing sensitivity in multinodular goiter, thyroid nodules >4 ml or follicular tumors (Haugen et al.

    What makes a thyroid nodule mildly suspicious? ›

    There are certain factors that make a nodule suspicious for thyroid cancer. For example, nodules that do not have smooth borders or have little bright white spots (micro-calcifications) on the ultrasound would make your doctor suspicious that there is a thyroid cancer present.

    Can thyroid nodules go away with medication? ›

    Toxic nodules and multinodular goiters, which cause hyperthyroidism, can often be managed with antithyroid agents before turning to treatments such as radioactive iodine therapy or surgery. Antithyroid medications, which include methimazole and propylthiouracil, reduce the amount of hormone produced by the thyroid.

    What are the options for removing thyroid and nodules? ›

    Thyroid nodule removal surgery may use a lobectomy or a total thyroidectomy to remove a section or all of the thyroid containing the nodule. In a lobectomy, the surgeon removes only the section — called a lobe — that contains the lump. In a total thyroidectomy, the surgeon removes the entire thyroid.

    Should a suspicious thyroid nodule be removed? ›

    Most noncancerous, or benign, thyroid nodules do not need treatment unless they are a cosmetic concern or cause symptoms including problems with swallowing, breathing, or speaking and neck discomfort.

    Can cancerous thyroid nodules be treated? ›

    Thyroid nodules — even the occasional cancerous ones — are treatable.

    Can an ultrasound tell if a thyroid nodule is cancerous? ›

    Occasionally, a CT scan is needed early in the evaluation phase, but an ultrasound is always a pillar of the diagnosis of thyroid cancer. As noted above, ultrasound is also used to guide and perform a needle biopsy of a nodule to diagnose thyroid cancer.

    How fast do cancerous thyroid nodules grow? ›

    More importantly, most nodules, whether they are benign or cancerous, either are stable or grown <2 mm/year. This is helpful in the long term management of thyroid nodules. Thyroid nodule: an abnormal growth of thyroid cells that forms a lump within the thyroid.

    Can a radiologist tell if a thyroid nodule is cancerous? ›

    The only way to definitively determine if a thyroid nodule is cancerous is to examine it under a microscope. The most common method is called fine need aspiration (FNA) biopsy, where a very small needle is inserted into the thyroid nodule and cells are removed for microscopic examination.

    When should thyroid nodules be removed? ›

    Any nodule that is 4 cm or larger should be removed with thyroid nodule surgery. Thyroid surgery is also very frequently needed for nodules that have atypical or suspicious cells on biopsy. This allows for a definitive diagnosis and cure. Many thyroid nodules that are benign on biopsy may be observed.

    What size thyroid nodule should be biopsied? ›

    According to the Society of Radiologists in Ultrasound, biopsy should be performed on a nodule 1 cm in diameter or larger with microcalcifications, 1.5 cm in diameter or larger that is solid or has coarse calcifications, and 2 cm in diameter or larger that has mixed solid and cystic components, and a nodule that has ...

    What foods to avoid if you have thyroid nodules? ›

    So if you do, it's a good idea to limit your intake of Brussels sprouts, cabbage, cauliflower, kale, turnips, and bok choy, because research suggests digesting these vegetables may block the thyroid's ability to utilize iodine, which is essential for normal thyroid function.


    1. Thyroid ultrasound & TI-RAD
    2. Effect of Thyroid Nodule Location on Risk of Thyroid Cancer with Dr. Sina Jasim
    (THANC Foundation)
    3. ACR TI-RADS Webinar Part I: This Is How We Do It
    4. Sonographic Evaluation of Diffuse Thyroid Disease
    (Radiology Video - radiology made esay)
    5. Thyroid Nodules What We Know and What We Don't Ultrasound Video
    (Radiology Video - radiology made esay)
    6. Ultrasound updates : Elasticity , elastography
    (Radiology Video - radiology made esay)


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