Open access peer-reviewed chapter
Comparison of ultrasound modes.
Abstract
This chapter offers a spotlight on the complex field of thyroid elastography, an innovative diagnostic tool performed on children with Hashimoto’s thyroiditis (HT). Navigating the intersection of technology and pediatric endocrinology, this chapter explores how elastography provides important information about thyroid tissue elasticity, offering a nuanced understanding of the disease’s progression. From unraveling the complexities of Hashimoto’s in the pediatric population to elucidating the diagnostic potential of elastography, this chapter serves as a beacon for clinicians and researchers alike. With a focus on precision and innovation, it promises to reshape our approach to diagnosing and managing thyroid disorders in the youngest patients, paving the way for enhanced pediatric thyroid care.
Keywords
- thyroid
- elastography
- strain elastography
- shear-wave elastography
- children
1. Introduction
Among medical conditions, thyroid diseases rank as some of the most widespread. The diverse manifestations of these conditions significantly differ from one region to another and are primarily influenced by the dietary supply of iodine. Iodine serves as a crucial component of the thyroid hormones thyroxine (T4) and triiodothyronine (T3), both synthesized by the thyroid gland [1].
This chapter will explore Hashimoto’s thyroiditis (HT), commonly known as chronic autoimmune thyroiditis (CAT), autoimmune thyroiditis, or chronic lymphocytic thyroiditis, representing an autoimmune thyroid condition encompassing thyroid enlargement, lymphocyte infiltration, and the detection of specific antibodies [2, 3]. Many factors, including the geographical region and time period, affect the incidence and prevalence of thyroiditis. Longitudinal, long-term follow-ups are not enough, even with the abundance of research on the frequency of autoimmune disorders. Over the previous 30 years, there has been a significant increase in both incidence and prevalence [4]. The frequency of HT varies from 4.8 to 25.8% in women and from 0.9 to 7.8% in males, depending on the area and socioeconomic class [5]. HT stands as the primary cause of hypothyroidism [6, 7]. Additionally, HT represents the most widespread autoimmune disease among the pediatric population. Approximately 4–10% of children are estimated to be affected by CAT [8, 9]. The diagnosis of CAT involves clinical examination, antithyroid antibodies, and imaging assays. Among these, serum antithyroid peroxidase antibodies (TPOAb) are considered the most crucial indicator of HT, with approximately 95% of patients exhibiting their presence [10, 11]. In contrast to TPOAb, antibodies against thyroglobulin (TgAb) exhibit lower sensitivity (se), being positive in only 60–80% of patients with HT. Additionally, these antibodies are less specific, with a higher percentage of positive results observed in healthy controls [12]. There are rarely any clinical symptoms or indicators. When symptoms do occur, they are usually associated with hypothyroidism (dry skin, weight gain, sensitivity to cold, constipation, etc.), but they may also result from the thyroid gland compressing surrounding tissues (dyspnea, dysphonia, dysphagia, etc.) [10].
Thyroid ultrasound (US) has been extensively used to diagnose thyroid lesions and has also proved to be helpful in CAT detection. The US examination of a patient with HT usually reveals either focal or diffuse enlargement of the thyroid, accompanied by a coarse, heterogeneous, and hypoechoic pattern in the parenchyma. Although echogenicity is often reduced because of the inflammatory cells infiltrating the thyroid tissue, it can be normal in certain circumstances [13]. Diminished brightness, or echogenicity, in comparison to normal thyroid tissues is known as diffuse hypoechogenicity. In CAT, a heterogeneous echotexture is among the most frequently observed US findings (Figure 1) [14, 15, 16, 17].
Figure 1.
B-mode US of a thyroid affected by HT; heterogeneous echotexture, hypoechogenicity; transverse plane.
The thyroid gland’s texture may appear irregular or uneven, but it might also appear macro- or micronodular. Thyroid pseudonodules are regions of the gland that show up as distinct nodules on ultrasonography; however, they are not actual thyroid nodules. There are two types of pseudonodules: micronodules and macronodules. Micro-pseudonodules are utterly small, sometimes less than one centimeter in diameter. These small pseudonodules usually do not need to be treated because they do not have any clinical significance. Usually, macro-pseudonodules are more than one centimeter in size. Several hypoechoic micronodules clearly suggest the presence of chronic thyroiditis. The external contour becomes more nodular as inflammation and fibrosis progress, and hyperechoic linear and curvilinear lines can appear with an uneven appearance. Fibrous septae can give the appearance that the parenchyma is pseudolobulated [18, 19, 20, 21]. There are various thyroid volume ranges: extremely small (atrophic gland), normal, or significantly increased (goiter) (Figure 2).
Figure 2.
Hyperechoic regenerative nodules in a hypoechoic thyroid parenchyma in a patient with HT - transverse view.
The thyroid tissue impacted by CAT may exhibit a moderate to considerable increase in vascularity, or it may exhibit normal vascularity, as revealed by Color Doppler Imaging (CDI). Increased vascularity appears to be associated with hypothyroidism, most likely as a result of thyroid-stimulating hormone’s (TSH) trophic stimulation [22]. Reduced or absent vascularization is frequently linked to the gland’s small size and atrophic state [23, 24].
Modern technologies, like elastography, have the potential to provide important information for the diagnostic methodology, hence increasing its quality and accuracy. Tissue strain is measured using elastography, a noninvasive US technique. Both shear-wave elastography (SWE) and strain elastography (SE) can accurately predict the probability of malignancies linked to increasing stiffness [25, 26, 27, 28, 29, 30, 31]. Less research has been done on diffuse thyroid pathology, with most studies centered on nodular thyroid pathology. However, there is evidence that suggests that HT-affected thyroid tissue is stiffer than normal thyroid tissue. Unfortunately, limited data is available regarding the pediatric population. In the next chapters, this subject will be covered in more detail.
2. Ultrasound features in pediatric patients
Thyroid US procedures for children are essentially quite similar to those for adults, with the exception of a few requirements on volume measuring accuracy. A change in gland volume is a common feature of almost all pediatric thyroid disorders. Regarding the normal size of the pediatric thyroid gland, opinions vary. Both the alternative thyroid formula, height x width x length x 0.47, and the ellipsoid formula, height x width x length x 0.523, have been used [32, 33, 34, 35]. A group of researchers compared various correction methods, including height, weight, a combination of height and weight, body surface area, and body mass index. Their study concluded that body surface area-corrected volume was the most reliable method for assessing thyroid volume in children aged 8–10 years [36]. Ozdikici conducted a study aimed at establishing normative reference values for thyroid volume in children, stratified by age and gender. This comprehensive investigation defined normal ranges of thyroid volume within a 95% confidence interval [37].
Pediatric thyroid size has been linked to somatometric characteristics, ethnicity, and local iodine intake [35, 38]. The World Health Organization (WHO) reference values for total thyroid volume, established in 2004, are limited to children aged 6–12 years from regions with long-standing iodine sufficiency, which does not accurately represent most European countries. For example, in German boys and girls, the 97th percentile thyroid volumes exceed the WHO standards by 33.4 and 28.5%, respectively—findings consistent with other contemporary European studies. These results suggest that the WHO reference values may be overly conservative and could be revised for use in other European countries with similar iodine histories [39]. Also, there may be variations in reported normal values as a result of these factors and variations in operator technique [34, 40]. Depending on gestational age, newborn thyroid volumes can range from 0.84 ± 0.38 mL to 1.62 ± 0.44 mL [41, 42]. Although highly important, research indicates that neither subjective nor objective assessments reliably predict whether congenital hypothyroidism (CH) is permanent or transient. Changes in gland shape may interfere with both methods and reduce the accuracy of standard formulas used to calculate lobe volume. Until more precise techniques for evaluating thyroid size are developed, the use of both subjective and objective assessments is advised in cases of CH [43]. The tracheal index is used in a simplified manner, and the usual range for the thyroid/trachea ratio is 1.7–2.4 [44]. The depth of the isthmus is typically not taken into account in situations where there is a noticeable rise in the overall volume of the thyroid lobes. The size of the isthmus can be estimated indirectly if the thyroid volume is close to the highest limit. In children under the age of 10 years, an isthmus thicker than 3 mm, and in adolescents, more than 5 mm, is considered an enlarged thyroid. The thyroid tissue’s echo density is measured in relation to the salivary gland in both children and adults. Normal thyroid tissue has a homogeneous echo structure [45].
Children with the diffuse sclerosing type of papillary carcinoma might present with an enlarged heterogeneous thyroid with echogenic regions that indicate microcalcifications, with the background of thyroiditis; this has to be diagnosed as such and requires a biopsy. It is important to distinguish this uneven look from thyroiditis’s micronodular pattern [46, 47, 48].
The intrathyroidal thymus, an embryological remnant, is a specific US finding in infants. It appears as a well-defined hypovascular lesion, often measuring less than 1 cm, and sometimes has angulated borders with a starry-sky pattern. These lesions can occasionally show extrathyroidal extension, characterized by a thymic tissue protrusion toward the mediastinum or a thymus-lesion link. It is crucial to distinguish ectopic thymus from other nodular thyroid tumors [49, 50, 51].
3. Ultrasound-based elastography
3.1 General principles
Elastography, a noninvasive technique based on ultrasound, measures tissue strain. Its increasing use aims to enhance the differentiation of thyroid nodules. Both shear-wave elastography (SWE) and strain elastography (SE) have demonstrated effectiveness in predicting the risk of malignancy by identifying increased rigidity as a suspicion criterion [52, 53, 54]. US elastography evaluates tissue stiffness noninvasively by assessing the displacement of the tissue in response to internal or external mechanical pressure. Ultrasound elastography methods are categorized as quasi-static, or strain-based, and dynamic, or shear-wave-based [55, 56, 57]. A deformation occurs when the tissue is exposed to an external pressure, as in strain scanning, or to the shear-waves emitted by the US probe, as in SWE [58]. The capacity of a tissue to resist deformation in the presence of an external force and to return to its initial form upon removal of the force is known as its elasticity. Clinically observed loss of elasticity with palpation or elastography (virtual palpation) increases the possibility of a disease [59, 60]. A recent study compared two types of elastography—SWE and strain elastography—in evaluating children with Hashimoto’s thyroiditis, concluding that there were no significant differences between the methods. The authors recommend using either technique, depending on availability [61].
3.2 Shear-wave elastography
The SWE method relies on the generation and detection of shear-waves (SW), which are transverse components of particle displacement. Shear indicates a shape change, but volume does not change [25, 27]. The velocity of wave propagation is contingent on tissue elasticity, and shear-waves move through the tissue at a considerably slower speed than longitudinal waves [62]. Deformation of the tissue induced by wave generation leads to changes in the US pattern. The movement of tissue is monitored by using multiple locations of the ultrasound probe. Shear waves typically have a speed ranging from 1 to 50 m/s and are generated at frequencies between 10 and 2000 Hz [63, 64]. Because shear-wave elastography is less operator-dependent, it may be reproduced more precisely. Tissue elasticity may be evaluated both quantitatively and qualitatively by measuring the SW velocity [25, 65].
1-D monoplane: A common method for evaluating liver fibrosis is transient elastography, such as Echosens and Fibroscan. It is not accessible on normal US devices using standard US transducers. This device has a vibrating instrument in addition to a specialized ultrasonic transducer that uses an external vibrating “punch” to create shear-waves that penetrate the tissues [60].
Using push pulses that induce local tissue displacement perpendicular to the surface, the ARFI (acoustic radiation force impulse) physically stimulates the ROI’s (region of interest) tissue in monoplane SWE (point-SWE, pSWE). The operator can select the suitable acoustic window for assessments with the use of visual assistance in point shear-wave elastography. SW velocity (m/s) estimations may be achieved up to a maximum of 8 cm depth [60].
Using biplane SWE (2D SWE) and 3D SWE, a quantitative color elastogram is superimposed over 2B images in real time, and SW speed is determined. Supersonic shear-wave technology uses focused ultrasonic beams. These beams spread out over the imaging region and show the elasticity index (EI), which is measured in kilopascals (kPa), for each pixel of the ROI. This indicates the speed (m/s) of the SW. The mean, minimum, and maximum stiffness values, as well as the standard deviation (SD), may all be measured inside the ROI [25, 60].
Compared to SE, image acquisition is acknowledged as being easier to get accustomed to and more rapid. 2D SWE equipment provides results that are both quantitative and qualitative. Images are stored and assessed once the SWE map has stabilized, usually following an undisturbed exposure of five to seven seconds. Color-coded maps are supplied for each US machine, with different codes displayed on scales denoting soft-to-hard lesions.
Some drawbacks of the ARFI method will be briefly highlighted. The first one has to do with the ROI’s predetermined fixed dimension. Additionally, nodules larger than 20 mm cause instability in SW speed. Lesions with liquid areas and intralesional calcifications cannot be examined since the ROI is hard to identify within the nodule. When utilizing point- and 2D-SWE, deep localization presents a major challenge; nodular structures deeper than 40–50 mm are inaccessible to the ARFI. Lesions on the thyroid isthmus are a challenge because of their position between the surface of the skin and the stiff trachea (Figures 3 and 4) [66, 67].
Figure 3.
2D-SWE of a healthy thyroid; homogeneous blue appearance; longitudinal view.
Figure 4.
2D-SWE - Thyroid affected by HT, stiffer thyroid tissue, heterogeneously blue and green appearance; longitudinal view.
3.3 Strain elastography
Initially, and most commonly, strain elastography is the technique employed. The external pressure is either created by an ARFI or the operator typically applies a minimally controlled external pressure. In recent years, the equipment has acquired the ability to identify even the smallest internal physiological motions, such as muscle contraction and vascular pulse [52, 59].
Devices equipped with strain elastography are unable to measure stress directly. Elastograms, which are based on signal differences before and after compression, show relative stiffness together with B-mode pictures on a dual-screen system or overlaid on the grayscale image. Usually, a continuous color map that ranges from red (soft) to green (equal strain or intermediate) to blue (hard) is used to depict the tissue stiffness. Several systems use an inverted color scale [60, 68, 69].
With the use of special software, strain elastography equipment generates an objective, semiquantitative assessment that yields a numerical value known as the strain ratio (SR). The measure used to evaluate stiffness is the parenchyma-to-nodule ratio (PTNR), which is the ratio of the strain in the thyroid parenchyma to the strain in the nodule, or the strain in the proximal strap muscle to the thyroid tissue. SR is thought to be more precise than evaluating qualitative elasticity (Table 1).
| Modality | Strengths | Limitations |
|---|---|---|
| B-mode US | Structural detail, widely available | Operator-dependent, does not provide information about elasticity |
| Color Doppler | Evaluates vascularity | Nonspecific for thyroiditis |
| Strain elastography | Qualitative, semiquantitative | Operator-dependent, less reproducible |
| Shear-wave elastography | Quantitative, reproducible | Equipment variability, deep lesions are problematic |
Table 1.
The average of the three consecutive measurements determines the final result. A number of recommendations need to be considered when determining where the ROI will be located. It should include the whole nodule and surrounding parenchyma as close to the transducer as possible. Strain depreciation with distance can be avoided by positioning the elastographic ROI as close to the transducer as is practical [66]. To increase the contrast between nodules and parenchyma in SE, it is imperative to include as much “normal” reference parenchyma as possible in the picture. Furthermore, the blood vessels (particularly the carotid), the esophagus, the trachea, the bones, and the muscles must all be removed from the ROI as much as possible. There is an important relevance to holding one’s breath and not speaking or swallowing. A large amount of gel and minimal skin contact are necessary. For this application, a probe stabilizer is inappropriate because of the neck’s anatomical particulars [70, 71]. Longitudinal sections are favored over transverse ones in the SE assessment. To improve reproducibility regarding the external, operator-dependent manual compression, each system offers suggestions on the ideal displacement quantity and frequency [66, 67].
The approach has several limitations, including subjectivity, operator dependence, and compressibility. It is believed that the size of the nodule has little impact on the accuracy of SE assessment, even though certain studies show that nodules less than 3 cm or greater than 3 cm perform differently. The World Federation for Ultrasound in Medicine and Biology (WFUMB) standards state that because of their deeper regions and absence of healthy surrounding tissue, nodules bigger than three centimeters cannot be examined appropriately. When coalescent nodules are present, the SE assessment is not accurate. Increased stiffness in benign lesions with calcifications or fibrosis can be detected, leading to false-positive findings. Identifying anterior lesions that extend to the capsule as soft may be an error due to the reference tissue being the strap muscles rather than the thyroid parenchyma. Isthmic lesions are challenging to assess because they are limited between two firm planes (the probe and the trachea) and lack reference tissue [72]. When external pressure is applied, carotid pulsations may interfere, especially in transverse sections. Real-time elastography (RTE) with external force is less suitable for transverse thyroid scans because it is more susceptible to carotid pulse interference. However, they have the benefit of internal force. Longitudinal scans offer greater thyroid reference tissue and are less affected by carotid pulsations. The surrounding reference parenchyma inside the ROI must exhibit at least 50% green color to determine an appropriate strain ratio. Lesions that are smaller than 5 mm, significant cystic components (only the solid part should be measured), nodules with peripheral rim calcification (which might inaccurately increase stiffness), and overweight individuals are some further limitations of SE (Figures 5 and 6) [27, 68].
Figure 5.
SE (left) and B-mode US (right) of a normal thyroid; SR = 1.07; longitudinal view.
Figure 6.
SE (left) and B-mode US (right) of a thyroid affected by HT; longitudinal view.
3.4 Thyroid elastography in children with HT – current perspective
3.4.1 Shear-wave elastography
There has been limited research on the pediatric population. Elasticity scores were measured in 107 healthy children, and a median value of 6.38 ± 1.97 kPa was suggested as the norm for a healthy thyroid [73]. Additional studies on children with healthy thyroids have revealed similar findings, with thyroid stiffness (TS) values ranging from 8.2 ± 2.82 kPa [74] to 11.24 ± 1.99 kPa [75]. Normal elasticity scores were reported as 10.9 ± 1.78 kPa [76], 9.36 ± 1.63 kPa [77], 10.41 ± 2.01 kPa [78], or 10.6 kPa [79] in several articles. Given the wide range of variability, more expansive cohorts of children must be investigated. The evaluation should also consider the ROI’s depth and size.
The cut-off value with the best diagnostic accuracy for elasticity values was 12.3 kPa (sensitivity 86.4%, specificity 96.3%) in research with 59 pediatric patients with CAT diagnoses and 26 healthy controls [79]. Twenty healthy volunteers and 74 patients with diffuse thyroid diseases (DTD) participated in another study on children with graves’ disease (GD), HT, and simple goiter. It was discovered that 12.8 kPa was the optimal SWE cut-off value for distinguishing between DTD and a normal thyroid [76]. Another research that showed a se of 82% and a sp of 88% determined a cut-off value of 12.2 kPa for the mean SWE value in predicting CAT in children. A cut-off value of 13.13 kPa for the highest SWE value obtained a sensitivity of 80% and a specificity of 92% in accurately differentiating between children with CAT and healthy participants [78]. A group of Egyptian researchers found similar results after studying 64 children. The elasticity values of the CAT patients were significantly higher than those of the control group (9.35 kPa vs. 35.6 kPa). In addition to having a sensitivity of 96.9% and a specificity of 100%, the test was found to have a threshold value for elasticity of 12.317 kPa [77]. Koca et al. assessed 46 children who were recently given a diagnosis of CAT and 46 healthy individuals. Mean SWE values of 12.5 ± 5.1 kilopascals (kPa) were observed in children with euthyroid CAT, whereas healthy controls exhibited mean SWE values of 8.2 ± 2.82 kPa (p < 0.001). With a sensitivity of 68%, a specificity of 72%, a positive predictive value of 70%, and a negative predictive value of 69%, they determined a cut-off value of 9.68 kPa for diagnosing HT [74]. In a different study, the thyroid glands of 18 children (5 boys and 13 girls) with newly diagnosed HT and 27 healthy controls (21 boys and 6 girls) were assessed using grayscale ultrasound followed by SWE. The median SWE value in the HT group was 20.6 kPa, compared to 10.7 kPa in the control group. This difference was statistically significant (W = 438.5,
There was no association observed between thyroid elasticity levels and TSH levels [78, 82, 83]. However, one study reported a mild negative correlation between the two parameters [80]. Furthermore, two studies reported a weak to mildly positive correlation between thyroid elasticity level and TPOAb [78, 79] but no link between TS and TGAb [79]. A weak positive correlation was seen in another analysis between TS and TGAb, but no link was discovered between TS and TPOAb [84].
Additionally, it was verified if children with CAT diagnoses who were getting levothyroxine hormone replacement therapy had different TS than those who were not. Nevertheless, no noticeable differences in elasticity were seen between these two youth patient categories [78]. However, research by Magri found that there were significant differences in thyroid elasticity between individuals receiving medication and those who were not, although it is important to highlight that Magri’s study included adult participants [85].
A recent meta-analysis was conducted to evaluate the utility of two-dimensional shear-wave elastography (2D-SWE) in children with Hashimoto’s thyroiditis. Although the analysis included only five studies, all reported that the method is useful for diagnosing children with Hashimoto’s thyroiditis. However, larger studies are needed to reach a consensus on standardized cut-off values [86].
3.4.2 Strain elastography
It was found that the stiffness of several thyroid diseases in adults may be ranked in ascending order using a list as follows: control group < hyperthyroidism< HT < subacute thyroiditis (SAT) [87]. SE can be a useful tool in distinguishing cases of SAT from healthy individuals as well as between several autoimmune diseases, including GD and HT [88]. Real-time elastography is a viable technique for differential diagnosis when thyroid nodules and CAT coexist, and SR evaluation could be a helpful predictor [89, 90].
Until this point, there has been limited research conducted on thyroid elastography specifically focused on pediatric individuals diagnosed with thyroiditis. The existing body of literature concerning this subject is currently scarce.
In a study including 54 healthy children, Yurttutan et al. evaluated the SR of normal thyroid parenchyma. Their suggested mean value is 0.54 +/− 0.38. Their analysis found no evidence of a significant association between SR and gender (r = 0.007; p = 0.96) or age (r = 0.22; p = 0.15) [91].
A study that included 47 children without thyroid conditions and 63 children with HT revealed differences between the two groups (1.75 ± 1.46 vs. 0.26 ± 0.77; p < 0.001). For CAT presence, the cut-off value was 0.31 (92.1% sensitivity (se), 66% sp, and AUROC of 0.828) [92]. A different study with 76 teenagers with HT and 46 without thyroid disease suggested using SR >0.98 (se of 83%, sp of 93%, AUROC 0.929) as the cut-off value for CAT diagnosis. The children with CAT had mean SR values of 1.2 ± 0.2, which were considerably higher than the control participants’ mean SR values of 0.77 ± 0.18 (p < 0.01) [93].
In another study, 22 children without thyroid pathology and 52 children with CAT diagnoses were included. When comparing the control group to the CAT group, the mean SR values were considerably lower (0.68 ± 0.2 vs. 1.19 ± 0.25; p < 0.0001). For CAT, a mean value greater than 0.9 was determined to be predictive, with AUROC 0.9, 84.62% se, 95.45% sp, 97.8% PPV, and 72.4% NPV [94].
Regarding the relationships between different variables and tissue elasticity level, there is no consensus in the literature. Positive correlations between SR and TPOAb (r = 6.85) were noted by Ozturk et al., but no evaluation was done into the possible association between SR and TGAb [92]. Similar findings were made by Çekiç et al.; they found no association between SR and TGAb but a correlation between SR and TPOAb (r = 0.439, p < 0.01) [93]. Additionally, Cepeha et al. found a mildly positive association (r = 0.29) between SR and TGAb levels and a strong correlation (r = 0.65) between SR and TPOAb values [94].
Only one study addressed the differences between patients receiving treatment and those who did not need it. There were no significant differences noticed between children receiving levothyroxine therapy and those who were not [94]. Given the disparities between treated and untreated patients seen in previous adult population studies [69], this line of inquiry deserves more examination.
4. Conclusions
Elastography has emerged as a promising tool in the evaluation and follow-up of children with HT. Although the number of studies in pediatric populations is still relatively limited, the existing research shows encouraging results regarding the accuracy and usefulness of this technique. Both SWE and strain elastography have demonstrated the ability to noninvasively measure thyroid stiffness, offering additional information that complements conventional ultrasound. Some studies even suggest that elastography may help in grading disease severity, although clear differences between all stages have not been consistently observed.
Despite these promising results, some limitations remain. The small number of large studies, differences in examination methods, and the lack of clear reference values mean that elastography is not yet fully standardized for routine use in clinical practice.
In clinical settings, elastography provides a unique benefit by reducing the need for invasive procedures and allowing for easy, repeatable monitoring over time, an important consideration when dealing with children. Its role should be viewed as complementary to conventional ultrasound techniques, including grayscale and Doppler imaging, to provide a more complete picture of thyroid health.
Looking ahead, further research is essential to define normal reference ranges for children, establish standard protocols, and clarify the potential of elastography in tracking disease progression and treatment response. With continued advances in ultrasound technology and growing experience among clinicians, elastography may become an even more reliable and routine part of thyroid imaging in pediatric patients.
Conflict of interest
The authors declare no conflict of interest.
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