Elastosonography in the Differential Diagnosis of Musculoskeletal Soft Tissue Tumors: A Systematic Review

Background: Soft tissue tumors (STTs) represent a heterogeneous group of rare lesions that frequently mimic bone sarcomas in both clinical and radiologic appearance. Accurate differentiation between benign and malignant lesions is critical for appropriate treatment planning, yet conventional imaging often remains inconclusive. Ultrasound (US) elastography, a non-invasive method that quantifies tissue stiffness, has recently emerged as a potential adjunct to standard musculoskeletal imaging for improving diagnostic confidence and guiding biopsy. Methods: A systematic review was conducted in accordance with PRISMA guidelines. PubMed, Web of Science, and Cochrane Library were searched using the keywords "elastography", "sonoelastography", and "soft tissue tumor". Twelve studies encompassing 1554 patients met the inclusion criteria, assessing the diagnostic accuracy of strain, compression, and shear wave elastography for differentiating benign from malignant STTs. Results: Elastography alone demonstrated limited specificity when used as a single diagnostic technique. However, its integration into multiparametric ultrasound approaches-combining grayscale, Doppler, and contrast-enhanced imaging-significantly improved diagnostic performance. Several studies reported sensitivities and specificities exceeding 85% when elastographic parameters were incorporated into composite diagnostic scores. Conclusions: Ultrasound elastography shows promise as a quantitative imaging biomarker for the preoperative evaluation of musculoskeletal tumors, particularly in distinguishing soft tissue from bone-related lesions. Although not a substitute for histopathological confirmation, its application within multimodal ultrasound protocols may reduce unnecessary biopsies, enhance diagnostic accuracy, and facilitate tailored management of bone and soft tissue sarcomas.