\r\n\tThis book chapter’s main theme will be focused on transmission dynamics, pathogenesis, mechanisms of host interaction and response, epigenetics and markers, molecular diagnosis, RNA interacting proteins, RNA binding proteins, advanced development of tools for diagnosis, possible development of concepts for vaccines and anti drugs for RNA viruses, immunological mechanisms, treatment, prevention and control. \r\n\t
",isbn:"978-1-80355-667-3",printIsbn:"978-1-80355-666-6",pdfIsbn:"978-1-80355-668-0",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"52f8a3a1486912beae40b34ac557fed3",bookSignature:"Ph.D. Yogendra Shah",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11369.jpg",keywords:"HIV, Dengue, Zika, West Nile Virus, Chikungunya, Rabies, SARS-CoV2, MERS-CoV, Hanta Virus, Influenza, Whole Genome Sequencing, DNA Sequencing",numberOfDownloads:181,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 4th 2021",dateEndSecondStepPublish:"November 1st 2021",dateEndThirdStepPublish:"December 31st 2021",dateEndFourthStepPublish:"March 21st 2022",dateEndFifthStepPublish:"May 20th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"8 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:"Dr. Shah obtained his Ph.D. degree in Veterinary Medicine from Hokkaido University, Japan. He was awarded the Young Science and Technology Award from the Nepal Academy of Science and Technology (NAST) in 2019. His research interests include infectious diseases, zoonotic infectious diseases, and vector-borne diseases.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"278914",title:"Ph.D.",name:"Yogendra",middleName:null,surname:"Shah",slug:"yogendra-shah",fullName:"Yogendra Shah",profilePictureURL:"https://mts.intechopen.com/storage/users/278914/images/system/278914.jpg",biography:"Dr. Yogendra Shah is a consultant microbiologist/virologist, senior research microbiologist, and lecturer at Seti Provincial Hospital, COVID-19 PCR laboratory, National Zoonoses and Food Hygiene Research Center, and Kathmandu College of Science and Technology, Nepal. He obtained a Ph.D. in Veterinary Medicine (Bacteriology) from the Graduate School of Veterinary Medicine, Hokkaido University, Japan, in 2017. His research focuses on better understanding the molecular epidemiological features/transmission dynamics of infectious diseases and zoonotic infectious diseases in Nepal by employing molecular techniques like ELISA, polymerase chain reaction (PCR), loop-mediated isothermal amplification (LAMP), and DNA sequencing. He was awarded the Young Science and Technology Award from the Nepal Academy of Science and Technology (NAST) in 2019. His research interests include infectious diseases, zoonotic infectious diseases, and vector-borne diseases. 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1. Introduction
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare disease first described in 1997 when Keech & Creech published the first case report of anaplastic T-cell lymphoma in proximity to a saline-filled breast implant [1]. Following the initial report, additional case reports and case series of this entity have been published [2, 3, 4].
A possible association between breast implants and anaplastic large cell lymphoma was announced by the Food and Drug Administration (FDA) in 2011 [5], and in 2016, the World Health Organization (WHO) added BIA-ALCL as a provisionally recognized lymphoma to the family of existing ALCL [6].
In 2019 the FDA issued a safety communication stating, “all individuals who are considering a breast implant of any type be informed of the risk of developing BIA-ALCL”. At the time, most cases of BIA-ALCL were reported to have Allergan’s Biocell textured breast implants, thus, following an FDA recommendation, Allergan initiated a worldwide voluntary recall of their breast implant products in July 2019 [7].
The incidence of the disease has continued to increase with current estimates of the absolute risk for development of BIA-ALCL ranging from 1 in 3,817 to 1 in 30,000 [8].
BIA-ALCL is characterized by the development of peri-implant fluid collection that occurs >1 year after breast implant placement, and/or by a solid mass arising within the implant’s fibrous capsule [9]. Median time since implant placement at diagnosis is estimated at 8–10 years [9].
Overall, the disease has an excellent prognosis, particularly if diagnosed and fully treated at early stage [10]. It is therefore important to increase awareness about this disease amongst health care providers in general and amongst radiologists and provide them with the relevant information for early diagnosis, referral, and treatment.
2. Etiopathogenesis
Although the etiology of BIA-ALCL remains poorly understood, there is evidence demonstrating a preponderance of patients with BIA-ALCL to have been exposed to textured breast implants, developed in the 1980s to reduce implant contractures, which in turn provides clues as to the pathogenesis of this condition [11, 12].
Texturing of the implant shell may lead to a greater inflammatory response of the surrounding fibrous tissue capsule eliciting an increased chronic antigenic stimulation, which in turn could potentially be responsible for the development of ALCL [12]. Other potential causes of chronic inflammation which have been postulated include lipopolysaccharide endotoxin, trauma to the breast pocket, viral infection, and allergens [13].
Currently, there is not enough data to determine whether ALCL may be found more or less frequently in individuals with silicone-filled breast implants compared to individuals with saline-filled breast implants [14].
The presence of germline and somatic mutations, which can increase the susceptibility of the host to BIA-ALCL has been postulated as a contributing factor [12].
Recent molecular studies have identified novel, activating mutations in the Janus kinase (JAK), and signal transducer and activator of transcription factor (STAT3) pathway as a major risk factor for the development of BIA-ALCL (the presence of germline and somatic mutations, which can increase the susceptibility of the host to BIA-ALCL). Aberrant STAT3 signaling has been established as a mechanistic link between chronic inflammation in non–BIA-ALCL cancers, including B- and T-cell lymphomas, and amongst the latter systemic anaplastic large cell lymphomas (the presence of germline and somatic mutations, which can increase the susceptibility of the host to BIA-ALCL) and persistent STAT3 activation has been definitively linked to improved tumor survival and cell proliferation, increased angiogenesis, and tumor metastasis [13].
3. Epidemiology
Current estimates suggest that each year over 1.8 million people worldwide receive breast implants for cosmetic or reconstructive purposes [15]. In July of 2019 the number of BIA-ALCL reported cases worldwide reached 573, with 320 those cases reported in the US [16]. The estimated lifetime risk of BIA-ALCL in women with textured breast implants range from 1:1,000 to 1:30,000 [17]. A reported geographic variation of the risk is likely due to variable reporting and less likely to geographic or genetic predisposition [17].
4. Clinical features
Mean age at diagnosis is 53.2 ± 12.3 years [17]. Mean interval from implant placement to diagnosis is 10.7 ± 4.6 years [17]. However, this late-onset diagnoses may reflect delayed diagnosis or misdiagnosis.
Patients most commonly present with rapid onset of a spontaneous fluid collection (60–90%) or capsular mass (10–40%) [9]. Approximately 30% of patients report pain, and about 25% present with skin lesions, most commonly erythema, subcutaneous nodules, eruption, erosion, or ulcer [9].
Implant capsule contracture is present in approximately 30% of cases [9]. When this occurs, there is a preponderance of grade III and IV contracture, defined as clinically symptomatic and visible contracture of the implant capsule [18].
BIA-ALCL disseminates locally in a small proportion of cases [19]. When local dissemination takes place it most commonly involves the ipsilateral axillary lymph nodes [19]. The prevalence of lymphadenopathy at diagnosis ranges from 2–14% [19].
Distant disease is uncommon. There are case reports of and distant lymph nodes and bone marrow involvement [19]. Systemic symptoms, such as unexplained weight loss, fever, or night sweats, are also uncommon affecting approximately 8% of patients [19].
5. Radiologic features
5.1 Mammography
In general, mammography findings include nonspecific capsular thickening, and circumferential asymmetry around the implant (Figures 1 and 2) [19, 20].
Figure 1.
63-year-old female with history of saline breast implants with textured surface placed 19 years ago presented with pain and swelling throughout the right breast and a palpable abnormality in the posterior third of the right breast at 7 o’clock for 1 month. Bilateral digital mammogram shows bilateral retro glandular saline breast implants. The right breast is larger than the left and shows a homogeneous and circumferential area of increased density (arrow) surrounding the implant, including the area of palpable abnormality noted by triangular marker in the posterior third of the right breast lower quadrants (source: Collado-Mesa et al. [20]).
Figure 2.
54-year-old female status post left breast mastectomy for DCIS and right breast prophylactic mastectomy, followed by immediate bilateral breast silicone implant with textured surface reconstruction 11 years ago presented with sudden onset of right breast swelling and enlargement with associated discomfort. She denied fever or general symptoms. Bilateral mammogram shows irregular contours of the right breast silicone implant with associated focal-peri-implant increased density (arrows) (source: Collado-Mesa et al. [20]).
Unlike with primary breast cancer, mammography is not accurate for detection of either peri-implant effusion or mass-forming BIA-ALCL.
Overall, mammography has a lower sensitivity and specificity than both ultrasound and Magnetic Resonance Imaging (MRI) for any abnormality due to BIA-ALCL, at 73% and 50% respectively [21].
5.2 Ultrasound
Ultrasound (US) is the imaging exam of choice. Findings most commonly include a homogeneous peri implant effusion with inflammatory changes in the periprosthetic breast tissue (Figures 3 and 4).
Figure 3.
63-year-old female with history of saline breast implants with textured surface placed 19 years ago presented with pain and swelling throughout the right breast and a palpable abnormality in the posterior third of the right breast at 7 o’clock for 1 month. Grey scale ultrasound shows right breast peri-implant fluid collection (arrow) (source: Collado-Mesa et al. [20]).
Figure 4.
Effusion-only BIA-ALCL in a 55-year-old woman after mastectomy for breast cancer. The initial breast implant was exchanged after 9 years; 7 years later, she experienced sudden new marked implant-associated swelling. Transverse US image shows a large seroma with septa surrounding the intact implant (arrow). US-guided fine-needle aspiration yielded cloudy yellow fluid, cytologic analysis of which demonstrated ALK-negative BIA-ALCL (source: Sharma B et al. [19]).
When a solid mass is present, it frequently appears as an oval, hypoechoic, circumscribed mass, without hypervascularity (Figure 5) [19, 20]. Less frequently, it appears as a complex cystic and solid mass [19, 20].
Figure 5.
63-year-old female with history of saline breast implants with textured surface placed 19 years ago presented with pain and swelling throughout the right breast and a palpable abnormality in the posterior third of the right breast at 7 o’clock for 1 month. Grey scale ultrasound shows a 4 × 1.4 × 2.4 cm mixed echogenicity, oval, partially, indistinct mass (arrow) abutting the fibrous capsule in the right breast at 7 o’clock, 5 cm from the nipple, corresponding to palpable abnormality (source: Collado-Mesa et al. [20]).
Some cases may present with abnormal ipsilateral axillary lymph nodes, including the presence of nodal cortical thickening or diffusely hypoechoic without evident fatty hilus.
Amongst the commonly used breast imaging modalities, the highest sensitivity for detection of peri-implant fluid collection is reported for ultrasound (84%) [21]. Ultrasound is also reported to have the highest specificity for detection of solid mass (100%) [21].
5.3 Magnetic resonance imaging
Breast Magnetic Resonance Imaging (MRI) is the imaging test of choice after US, and it particularly add value when US results are indeterminate.
MRI findings include peri-implant tissue edema and effusion, as well as peri-implant mass lesions, including small-volume mass components not detected with US. Enhancement with intravenous gadolinium contrast material may also help with characterization of some findings (Figures 6–10) [19, 20].
Figure 6.
63-year-old female with history of saline breast implants with textured surface placed 19 years ago presented with pain and swelling throughout the right breast and a palpable abnormality in the posterior third of the right breast at 7 o’clock for 1 month. Breast MRI axial T2-weighted fat-saturated sequence shows right breast peri-implant fluid collection (arrow) (source: Collado-Mesa et al. [20]).
Figure 7.
63-year-old female with history of saline breast implants with textured surface placed 19 years ago presented with pain and swelling throughout the right breast and a palpable abnormality in the posterior third of the right breast at 7 o’clock for 1 month. Breast MRI axial T1-weighted fat saturated postcontrast subtraction shows a 4 × 1.7 × 2 cm oval heterogeneously enhancing mass (arrow) arising from the fibrous capsule in the right lower outer quadrant (source: Collado-Mesa et al. [20]).
Figure 8.
Mass forming BIA-ALCL in a 29-year-old woman with a right upper inner breast mass 3 years after bilateral breast augmentation with TRF-520 implants (Allergan). Axial gadolinium enhanced fat-saturated breath-hold volume MR image shows a large implant-associated lobulated mass with a central necrotic area and intense rim enhancement (arrow) infiltrating the pectoralis major muscle and threatening the intercostal muscles. Biopsy demonstrated BIA-ALCL (source: Sharma B et al. [19]).
Figure 9.
BIA-ALCL with chest wall invasion in a 29-year-old woman who underwent bilateral breast augmentation with TRF-520 implants (Allergan) and developed a right upper inner breast lump 3 years after surgery. Axial fast spin-echo T2-weighted image with breath holding 4 months later shows irregular surface of the implant (blue arrow) and rapid enlargement (estimated at 7 cm axially) of the lobulated mass (red arrow), which is characterized by a central necrotic area. Biopsy demonstrated large atypical CD30-positive cells infiltrating the fibrous tissue. The final diagnosis was BIA-ALCL (source: Sharma B et al. [19]).
Figure 10.
BIA-ALCL with chest wall invasion in a 29-year-old woman who underwent bilateral breast augmentation with TRF-520 implants (Allergan) and developed a right upper inner breast lump 3 years after surgery. Sagittal short τ inversion-recovery (STIR) image obtained 4 months later shows the mass (arrow) infiltrating the pectoralis major muscle and threatening the intercostal muscles. Biopsy demonstrated large atypical CD30-positive cells infiltrating the fibrous tissue. The final diagnosis was BIA-ALCL (source: Sharma B et al. [19]).
MRI also serves to evaluate for the presence of implant rupture when there is a silicone implant [19].
MRI is the imaging modality with the second highest sensitivity for peri-implant fluid collection at 82% and with the second highest specificity for mass at 93% [21].
6. Diagnosis and histologic features
A high index of suspicion of BIA-ALCL is required to allow a timely diagnosis.
Breast ultrasound should be obtained in patients with suspicious signs and symptoms such as breast swelling, palpable mass, pain, and skin lesions which have developed more than one year after implant placement (average 8–10 years).
If a peri-implant effusion is noted, then fine needle aspiration of at least 50 ml should be performed [22]. In cases where a peri-implant mass is present, either core needle biopsy or surgical excisional biopsy should be performed [22].
In cases with inconclusive findings on ultrasound, a breast MRI should be obtained [22].
Samples should be sent for cytology, flow cytometry, immunohistochemistry for CD30 (Figures 11 and 12) and additional differentiation markers (CD2 – CD5, CD7, CD8, CD45, and ALK [19, 20, 22].
Figure 11.
Photomicrograph of ultrasound-guided core needle biopsy samples of solid mass showed in Figure 5 shows most of the cells to be strongly and uniformly positive for CD30 (CD30 immunohistochemistry, ×60) (Source: Collado-Mesa et al. [20]).
Figure 12.
Effusion-only BIA-ALCL in a 55-year-old woman after mastectomy, axillary node dissection, implant reconstruction, chemoradiotherapy, and immunotherapy. After 9 years, the implant was exchanged; 7 years later, sudden new marked swelling of the right breast developed. At US, a large seroma surrounded the intact right breast implant; diagnostic aspirate yielded cloudy yellow fluid, which was ALK-negative at cytologic analysis. Immunohistochemistry slides show that the infiltrate is positive for CD30 (source: Sharma B et al. [19]).
The presence of large neoplastic cells that have pleomorphic nuclei, abundant eosinophilic cytoplasm, and irregular cell membranes is required for diagnosis (Figure 13). Uniform CD30 expression, evidence of a single T-cell clone, and an absence of ALK expression are also observed [22]. Epithelial membrane antigen (EMA) is also often expressed by neoplastic cells [23]. “Hallmark cells” with eccentric kidney or horseshoe-shaped nuclei are not uncommonly seen [23].
Figure 13.
Photomicrograph of ultrasound-guided core needle biopsy samples of solid mass showed in Figure 5 shows large and pleomorphic neoplastic cells with irregular nuclei, large prominent nucleoli, conspicuous mitotic activity, and moderate cytoplasm (hematoxylin and eosin [H&E], ×60) (source: Collado-Mesa et al. [20]).
If results are indeterminate, a referral to a cancer center is recommended. If results are negative, then it should be treated as a benign seroma. Patients with positive results require a disease workup [22].
7. Staging
The traditional staging for all lymphoma is the Ann Arbor classification. However, BIA-ALCL is not a classical non-Hodgkin lymphoma and it usually progress locally and/or regionally like a solid tumor; thus, it is better suited to the TNM system for staging solid tumors.
The 2019 update of the National Comprehensive Cancer Network guidelines now include a TNM disease staging system based on clinical and pathological evaluation first proposed in 2016 by MD Anderson Cancer Center and which may be more applicable for predicting a prognosis and for evaluating treatment regimens in patients with BIA-ALCL [22].
In this TNM classification for BIA-ALCL the disease is considered extended (not localized) if there is tumor invasion beyond the fibrous capsule, spread to one or more regional lymph nodes, or spread to any organs/distant sites (Table 1).
TNM
Criteria
T: Tumor extent
T1
Confined to effusion or a layer on luminal side of capsule
T2
Early capsule infiltration
T3
Cell aggregates or sheets infiltrating the capsule
A surgical oncology consultation is not compulsory but may be beneficial for plastic surgeons unaccustomed to optimal surgical resection of a malignancy.
The goals of surgery are to remove the implant with the surrounding fibrous capsule and any associated capsule mass. Complete surgical excision prolongs both overall survival and event-free survival compared with all other therapeutic interventions [10].
All attempts should be made to gain complete surgical resection because retained or unresectable disease likely indicates the need for adjuvant treatments.
An estimated 2–4% of patients develop bilateral disease, and therefore surgeons may consider removal of the contralateral implant and capsule [10].
Currently, there is no clear role for radical mastectomy or sentinel lymph node biopsy. Full axillary dissection has been used rarely for gross involvement of multiple lymph nodes.
8.2 Adjuvant treatments
No data from prospective trials is available to guide management of patients with disseminated BIAS-ALCL. Current treatment is based on experiences from treating primary cutaneous and systemic ALCL.
Radiation therapy with 24–36 Gray (Gy) to the local or involved site is suggested for patients with local residual disease, positive margins, or unresectable disease with chest wall invasion [22].
Systemic therapy for patients with stage IIB-IV disease can be as combination anthracycline based chemotherapy or as a combination with brentuximab vedotin [22].
9. Surveillance and prognosis
In patients with complete response to treatment, surveillance should include history and physical exam and either a CT chest, abdomen, and pelvis with contrast or a whole-body PET-CT every 6 months for two years and then as clinically indicated (Figures 14 and 15) [22].
Figure 14.
63-year-old female with history of saline breast implants with textured surface placed 19 years ago presented with pain and swelling throughout the right breast and a palpable abnormality in the posterior third of the right breast at 7 o’clock for 1 month. Screen capture of a whole body 18F-FDG PET/CT shows FDG activity of SUV 10.56, corresponding to a soft tissue mass (arrow) in the lower outer quadrant of the right breast adjacent to the implant measuring 3.2 × 4.8 cm × 2.5 cm (source: Collado-Mesa et al. [20]).
Figure 15.
63-year-old female with history of saline breast implants with textured surface placed 19 years ago presented with pain and swelling throughout the right breast and a palpable abnormality in the posterior third of the right breast at 7 o’clock for 1 month. Screen capture of a whole body 18F-FDG PET/CT obtained 6 months after bilateral breast explantation and total capsulectomy shows no abnormality (source: Collado-Mesa et al. [20]).
BIA-ALCL has shown to have an excellent prognosis when the disease is diagnosed earlier (localized disease), and when complete surgery, consisting of explantation, capsulectomy, and removal of any associated capsule mass, is performed [9, 10].
Compared to stage I disease, stage II and stage III disease have a rate of disease events and recurrence which are 2.6-fold higher and 2.7-fold higher respectively [10].
Patients with T1–T3 disease have 0% rate of disease events following complete surgical excision as compared to T4 disease have a 14.3% in patients with T4 disease [10]. Local recurrence is most common if incomplete resection or partial capsulectomy took place [10].
A study of causes of death in patients diagnosed with BIA-ALCL showed that all the patients who died had incomplete surgical excision or did not receive targeted therapy [24]. The study also reported delay in diagnosis or treatment for an average of 1–2 years [24]. Direct extension into the chest wall leading to respiratory failure was a common cause of death [24]. Other less commonly reported causes of death included stem cell transplant complication and development of a second unrelated lymphoma [24].
10. Conclusion
In the absence of infection or trauma, the development of a new peri-implant effusion more than one year after breast implant placement should prompt consideration for the diagnosis of BIA-ALCL As the clinical symptoms are often nonspecific, radiologists, particularly those involved in breast imaging, play an important role in its diagnosis,. While mammography may demonstrate subtle abnormalities, ultrasound and MRI have higher sensitivity and specificity. Diagnosis requires sampling of peri-implant fluid or mass and or lymph node. Suspicion of BIA-ALCL should be communicated to the pathologist, and immunohistochemistry for CD30 ordered. Once diagnosed, oncology referral and multi-specialty team care including plastic surgery and radiation therapy is recommended. Prompt diagnosis and complete treatment appear to lead to excellent prognosis.
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"breast implant-associated anaplastic large cell lymphoma, epidemiology, pathophysiology, diagnosis, treatment, prognosis, mammography, ultrasound, magnetic resonance imaging, fine needle aspiration, needle biopsy, positron emission tomography",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/79164.pdf",chapterXML:"https://mts.intechopen.com/source/xml/79164.xml",downloadPdfUrl:"/chapter/pdf-download/79164",previewPdfUrl:"/chapter/pdf-preview/79164",totalDownloads:77,totalViews:0,totalCrossrefCites:0,totalDimensionsCites:0,totalAltmetricsMentions:0,impactScore:0,impactScorePercentile:41,impactScoreQuartile:2,hasAltmetrics:0,dateSubmitted:"August 27th 2021",dateReviewed:"October 5th 2021",datePrePublished:"October 28th 2021",datePublished:"April 20th 2022",dateFinished:"October 28th 2021",readingETA:"0",abstract:"Breast implant-associated anaplastic large cell lymphoma is a rare disease first described in 1997. Since then, its incidence has continued to increase. Current estimated lifetime risk in women with textured breast implants range from 1:1000 to 1:30,000. Most cases present with rapid and dramatic breast swelling resulting from peri-implant fluid collection. Palpable mass, pain, and skin lesions also occur. A high index of suspicion in patients who develop a seroma around the breast implant more than one year after implant placement is required. The combination of clinical history, physical exam findings, and appropriate imaging workup can lead to a timely and accurate diagnosis. The disease has excellent prognosis when it is diagnosed earlier, and complete surgery is performed. Radiologists, particularly those involved in breast imaging, can play an essential role in early diagnosis. This chapter presents an overview of the disease, including relevant imaging findings.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/79164",risUrl:"/chapter/ris/79164",book:{id:"10790",slug:"lymphoma"},signatures:"Fernando Collado-Mesa",authors:[{id:"422382",title:"Associate Prof.",name:"Fernando",middleName:null,surname:"Collado-Mesa",fullName:"Fernando Collado-Mesa",slug:"fernando-collado-mesa",email:"fcollado@med.miami.edu",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Etiopathogenesis",level:"1"},{id:"sec_3",title:"3. Epidemiology",level:"1"},{id:"sec_4",title:"4. Clinical features",level:"1"},{id:"sec_5",title:"5. Radiologic features",level:"1"},{id:"sec_5_2",title:"5.1 Mammography",level:"2"},{id:"sec_6_2",title:"5.2 Ultrasound",level:"2"},{id:"sec_7_2",title:"5.3 Magnetic resonance imaging",level:"2"},{id:"sec_9",title:"6. Diagnosis and histologic features",level:"1"},{id:"sec_10",title:"7. Staging",level:"1"},{id:"sec_11",title:"8. Treatment",level:"1"},{id:"sec_11_2",title:"8.1 Surgical treatment",level:"2"},{id:"sec_12_2",title:"8.2 Adjuvant treatments",level:"2"},{id:"sec_14",title:"9. Surveillance and prognosis",level:"1"},{id:"sec_15",title:"10. Conclusion",level:"1"},{id:"sec_19",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Keech JA Jr, Creech BJ. Anaplastic T-cell lymphoma in proximity to a saline-filled breast implant. Plastic and Reconstructive Surgery. 1997;100:554-555'},{id:"B2",body:'Gaudet G, Friedberg JW, Weng A, Pinkus GS, Freedman AS. Breast lymphoma associated with breast implants: Two case reports and a review of the literature. Leukemia & Lymphoma. 2002;43(1):115-119'},{id:"B3",body:'Wong AK, Lopategui J, Clancy S, Kulber D, Bose S. Anaplastic large cell lymphoma associated with a breast implant capsule: A case report and review of the literature. The American Journal of Surgical Pathology. 2008;32(8):1265-1268'},{id:"B4",body:'Miranda RN, Lin L, Talwalkar SS, Manning JT, Medeiros LJ. Anaplastic large cell lymphoma involving the breast: A clinicopathologic study of 6 cases and review of the literature. Archives of Pathology & Laboratory Medicine. 2009;133(9):1383-1390'},{id:"B5",body:'Reports of Anaplastic Large Cell Lymphoma (ALCL) in Women with Breast Implants: FDA Safety Communication. 2011. Available from https://wayback.archive-it.org/7993/20170111070030/http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm240000.htm [Accessed: 2021-08-02]'},{id:"B6",body:'Swerdlow SH, Campo E, Pileri SA, Harris NL, Stein H, Siebert R, et al. The 2016 revision of the World Health Organization classification of lymphoid neoplasms. Blood. 2016;127(20):2375-2390'},{id:"B7",body:'US Food and Drug Administration. 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Complete surgical excision is essential for the management of patients with breast implant-associated anaplastic large cell lymphoma. Journal of Clinical Oncology. 2016;34(2):160-168'},{id:"B11",body:'Kadin ME, Deva A, Xu H, Morgan J, Khare P, MacLeod RA, et al. Biomarkers provide clues to early events in the pathogenesis of breast implant-associated anaplastic large cell lymphoma. Aesthetic Surgery Journal. 2016;36(7):773-781'},{id:"B12",body:'Rastogi P, Riordan E, Moon D, Deva AK. Theories of etiopathogenesis of breast implant-associated anaplastic large cell lymphoma. Plastic and Reconstructive Surgery. 2019;143(3S):23S-29S'},{id:"B13",body:'DeCoster RC, Clemens MW, Di Napoli A, Lynch EB, Bonaroti AR, Rinker BD, et al. Cellular and molecular mechanisms of breast implant-associated anaplastic large cell lymphoma. Plastic and Reconstructive Surgery. 2021;147(1):30e-41e'},{id:"B14",body:'US Food and Drug Administration. 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Plastic and Reconstructive Surgery. 2017;139(5):1042-1050'},{id:"B18",body:'Spear SL, Baker JL Jr. Classification of capsular contracture after prosthetic breast reconstruction. Plastic and Reconstructive Surgery. 1995;96(5):1119-1123'},{id:"B19",body:'Sharma B, Jurgensen-Rauch A, Pace E, Attygalle AD, Sharma R, Bommier C, et al. Breast implant-associated anaplastic large cell lymphoma: Review and multiparametric imaging paradigms. Radiographics. 2020;40(3):609-628'},{id:"B20",body:'Collado-Mesa F, Yepes MM, Net JM, Jorda M. Breast implant-associated anaplastic large cell lymphoma: Brief overview of current data and imaging findings. Breast Disease. 2021;40(1):17-23'},{id:"B21",body:'Adrada BE, Miranda RN, Rauch GM, Arribas E, Kanagal-Shamanna R, Clemens MW, et al. Breast implant-associated anaplastic large cell lymphoma: Sensitivity, specificity, and findings of imaging studies in 44 patients. 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University of Miami Miller School of Medicine, Miami, Florida, United States of America
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1. Introduction
In the sports medicine field, in order to evaluate musculoskeletal conditions such as muscle strain injury (MSI), magnetic resonance imaging (MRI) is commonly used in the diagnosis and prognosis of MSI. MRI uses the power of a magnetic field to determine the amount of water present in cells and tissues in the body.
The basic mechanism of MRI is that water has two hydrogen atoms, which are composed of a central proton and surrounding electrons. When a high-frequency current is pulsed to an object, the protons are stimulated and become imbalanced by acting against the gravitational pull of the magnetic field. When the radiofrequency field is turned off, the MRI sensors can detect the energy emitted when the protons rearrange to the magnetic field.
The time it takes for the protons to realign to a magnetic field depends on the environment and nature of the chemistry of the molecule to detect pathological changes [1]. MRI usually includes two types: T1-weighted and T2-weighted images, which are basically sets of settings. In T1-weighted images, the major adipose tissue appears white and the water and liquid components appear black. On the contrary, adipose tissue and fluid components appear white on T2-weighted images and can be used to detect the presence of pathological or morphological changes. Therefore, it can be used to assess fibrotic scar tissue when returning to sports or in the chronic phase of muscle injury to show anatomical features of the tissue [2].
While ultrasound (US) is used in musculoskeletal injury, the US uses high-frequency sound waves to evaluate organs and structures including muscle or other soft tissues. High-spatial-resolution modality provides details of a structure especially superficial area. There are some advantages of using both US and MRI evaluation. MRI is better in evaluating morphological changes, such as scar tissue and deep or large areas. On the other hand, the US is excellent at assessing small areas in detail. Because of its excellent contrast, high spatial resolution, and ability to view soft tissues with multiplanar evaluation, MRI currently appears to be the best imaging method for early-phase diagnosis and follow-up cases of muscle injuries. While the US can be a well-detected imaging method to assess adjunct tissues and can determine real-time conditions of muscle injuries.
1.1 Shear wave elastography
There are some kinds of diagnostic US, such as B mode US or shear wave elastography (SWE) for evaluating the musculoskeletal problems. B mode US is easy accessibility and relatively low cost, plus the possibility of real-time evaluation. Therefore, B mode US is widely used in the musculoskeletal field. However, B mode US cannot exactly investigate the biomechanical properties of tissues; therefore, it is difficult to assess the relationship with structural disorganization. In contrast, SWE is a novel noninvasive diagnostic ultrasound modality for analyzing the biomechanical properties of the soft tissues in healthy and pathological conditions.
Acoustic emission impulses are utilized to excite the tissue and measure the distribution of shear wave propagation speed by the shear wave as regards the mechanism of SWE [3]. SWE visualizes shear wave propagation and can quantify tissue stiffness based on the speed of propagation. SWE primarily assesses elasticity, also known as stiffness; the term of stiffness is basically recognized as the extent to which an object resists deformation in response to an applied force, and the speed of shear wave propagation is determined by both the elasticity and viscosity of the tissue [4]. As a result, it evaluates mechanical properties that indicate the deformity as an indicator of the quality of the object’s form and shape. Normal muscle is considered a linear relationship between shear wave modulus and muscle tone. Therefore, normal muscle shows optimal stiffness on SWE (Figure 1) [5]. However, the score of SWE is influenced by the components of collagenous fiber tissue such as epimysium or endomysium; therefore, the definitive optimal stiffness is difficult to determine.
Figure 1.
Normal calf muscles are seen with normal echotexture on SWE [3].
By contrast, B-mode US uses a monitor to convert the intensity of reflected waves into a two-dimensional tomographic image in the cross section parallel to the direction of the ultrasonic wave.
Because B-mode US is operator-independent, relatively reproducible, and quantitative method, SWE is currently considered as a promising real-time visualization tool for explicitly quantifying the mechanical properties of soft tissues in sports medicine [6].
B-mode US has a limitation that it is difficult to show the biomechanical properties of tissues.
Therefore, there is a difficulty to assess certain relationships between structural disorganization and clinical features [7]. On the other hand, SWE can obtain additional morphological information with elastic value of tissue structures and mechanical properties in regard to tissue degeneration, tissue healing, or injury in the wide variety of tissues and injury phases.
Soft tissues, which are referred to muscle, fat, fibrous tissue, blood vessels, or other supporting tissue of the body, are generally recognized viscoelastic, inhomogeneous, and anisotropic [8]. Viscoelastic tissues have both elastic and viscous fluid properties that vary from tissue to tissue [9]. In order to evaluate elasticity, it assumes linear, elastic, solid tissues, a first-order approximation is possible without the force from viscous fluid properties. Elastography systems are based on the prerequisite assumption that object material tissues are elastic, incompressible, homogeneous, and isotropic [10]. Since the elasticity of soft tissues is nonlinear and dependent on the tissue density, strain magnitude, or applied excitation frequency, the evaluation of soft tissues still has been challenging with using diagnostic US.
Utilization of SWE for the musculoskeletal system should be taken into several considerations. Firstly, in order to evaluate swear wave values, a transducer of SWE is put on the surface of the body. As musculoskeletal tissue is heterogeneity, skeletal muscle fibers are surrounded by fascial tissues and passed through by nerve, arteries, veins, and lymphatic vessels. Besides the skin, which is a relatively tight organ, and dermis are superficial to the skeletal muscle fibers [11].
Secondly, the individual muscle fibers are thought to be parallel or oblique to the long axis of the muscle. Muscle fiber types, pennate, unipennate, or multipennate, may affect shear wave measurements; therefore, transductor positioning should be taken according to the muscle fiber architecture.
Thirdly, shear wave value may not change with depth within superficial muscles; however, if the muscle is deeper than 4 cm, the unit of measurement will be difficult to normalize [12].
Lastly, shear wave value, stiffness, can be affected by muscle activities. Changes in SWS measurements with muscle activation are shown during muscle contraction [13]. Plus, SWE measurements are different between active and passive muscles [14]. The more increased tension in the tissue, the more stiffness is measured [15]. Controlling the muscle activation and sustaining the perfect resting positioning are difficult in human in vivo study; therefore, the positioning is special care due to technical errors.
Evaluating for stiffness in MSI used to be difficult because it required a high mechanical load in a view of safety for the participants; however, SWE can have a low invasive approach besides visible in a resting position. In this regard, SWE takes an advantage to other diagnostic tools.
Furthermore, the measurement can be affected by some internal factors. Shear wave values tend to be higher in men than women. In addition, shear wave values are gradually increased according to age [16].
2. Imaging of musculoskeletal injury
2.1 Musculoskeletal injury
The general process of most MSI cases, and it leads to the typical inflammatory process. Muscle inflammation basically occurs in the following three phases: damage, repair, and remodeling; especially repair and remodeling phases happen almost at the same time. Muscle inflammation is a normal and inevitable process, which is healing tissues, and ensures optimal tissue regeneration in order to lead to proper muscle function. In the inflammatory phase, it begins with the destruction of the injured tissue. This reaction leads to an influx of extracellular calcium and the activation of calcium-dependent proteases and phospholipases. Furthermore, this destructed reaction will secrete the serum proteins deriving from disrupted tissue increase as creatine kinase, present in the cytosol of the muscle cell, and found in excessive mechanical stress or muscle degenerative diseases.
In the regeneration phase, the fibrotic scar tissue formation is built and the mature tissue recovers its muscle function as normal reaction [17]. In this phase, an increase in elastography stiffness can occur.
Recovering functional muscle tissue depends on proper joint motion at the remodeling phase. Proper fiber alignment can be one of the important factors for muscle function.
Fibroblasts play an important role in muscle tissue repair by secreting extracellular matrix (ECM) proteins including: collagen types I and III, fibronectin, elastin, proteoglycans, laminin, and growth factors. However, if fibroblasts excessively secret in ECM, the tissue alters the mechanical characteristics of the muscle, which leads to the development of fibrosis and incomplete muscle recovery [18]. Fibrotic tissue such as fibrotic scar tissue is characterized by the accumulation of ECM, primarily type I collagen. Fibrotic scar tissue is usually induced by chronic connective tissue injuries; however, the relationship between scar tissue and injuries has been still controversial [19]. Therefore, this relationship should be required further investigation and considerations.
2.2 In acute phase on MRI
MRI is commonly used for the diagnosis and recovery of muscle injuries [20].
T2 mapping may be useful from a musculoskeletal injury. Using a series of diffusion-weighted images and subsequent muscle fiber tracking, diffusion tensor imaging provides diffusion quantification of anisotropic tissues such as muscle tissues.
It has been shown that diffusion tensor imaging can be useful for identifying muscle fiber direction, detecting the subclinical changes after a muscle injury, and differentiating injured muscles from normal control muscles [21].
In the general clinical practice especially in sports medicine, MRI observation is suggested to monitor recovery following the injury and decide to return to play. It is basically observed increased signal intensity on fluid-sensitive sequences consistent with edema may persist after resolution of clinical symptoms 6 weeks after the onset of injury. However, even though almost all athletes that are clinically recovered and successfully returned to play showed increased signal intensities on fluid-sensitive sequences, MRI feature only should not be the decision to return to play because it is moderate correlation between clinical assessment using functional tests and MRI findings, plus it showed that functional testing was more accurate than MRI assessment [22].
2.3 In acute phase on B mode US and SWE
B mode US offers dynamic muscle assessment in acute musculoskeletal injury. It is a fast, relatively inexpensive, easier tool for the injuries. And also, it allows serial evaluation for the healing process, and it can be used to perform real-time interventions. In addition, B mode US takes an advantage to MRI in regard that it can demonstrate relevant anatomy surrounding an injury. In acute injury, it is sometimes difficult to show the tissues on MRI images due to inflammation reactions such as an edema [23].
Normal muscle fibers are properly arranged in parallel to fibrofatty septa. The muscle fibers and fascicles are usually hypo echogenicity compared with adjacent fascial tissues. Thick hyperechoic areas are dense fibrous content, which basically contains collagen fiber.
B mode US shows that normal muscle is hypoechoic muscle bundles and the linear hyperechoic perimysium are arranged in layers (Figure 2).
Figure 2.
Normal calf muscles are seen with proper layered fiber arrangement on B mode US [3].
From a clinical perspective, in grade 1 MSI injuries, B mode US images may be either negative or exhibit focal or diffuse areas of increased echogenicity within the muscle at the site of injury. As Grade 1 MSI is known with or without actual fiber disruption, it may include injuries exhibiting minimal focal fiber disruption occupying less than 5% of the cross-sectional area of the muscle. The site of injury is represented by a well-defined focal hypoechoic or anechoic area within the muscle. However, there is no consensus about this definition. Therefore, the exact classification is unclear between grade 1 and grade 2 MSI [24]. In grade 2 MSI, the presence of areas of partial fiber disruption is less than 100% of the cross-sectional area of the muscle. Discontinuous fiber arrangement is usually seen in the echogenic perimysium striae around either the myotendon junction or the myofascial junction. Obvious intramuscular hematoma is normally seen in grade 2 MSI in initial almost 24–48 h. In this inflammation phase, hematomas may solidify and display increased echogenicity in comparison to the surrounding muscle. Up to 48 h, hematomas will develop into a well-defined hypoechoic fluid collection with an echogenic margin. In grade 3 MSI, total disruption or discontinuous fiber arrangement is observed on the B mode US. Perifascial fluid may be depicted on the B mode US and with hypoechoic area, which is the presence of extravascular blood in the inflammation phase.
The evaluation of B mode US should be careful because the linear configuration of the septae makes them susceptible to anisotropy artifact leading to decreased echogenicity or absence of conspicuity of septae.
The evaluation of SWE, when MSI occurred, the stiffness as shear wave value is decreased for 4–8 weeks. Then the stiffness is gradually increased, and it can generally return to a similar value as the uninjured side. This phenomenon is well explained that muscle tissue is properly in the acute phase of the healing process (Figures 3 and 4) [25].
Figure 3.
The healing process of gastrocnemius muscle imaging B mode US [25].
Figure 4.
The healing process of gastrocnemius muscle imaging and SWE [25].
Furthermore, another study shows that the stiffness of the postoperative tendon initially decreases and gradually increases following the recovery phases [26].
Improper healing tissue can be potential for re-injury; therefore; these results will be the parameter for return to play [27].
After MSI injury, MRI evaluation is basically used for injury evaluation in the acute phase.
Importantly, the T2 value is highest at 5 days on MRI while shear wave value is highest at 2 days on SWE.
2.4 In chronic phase on MRI
In the early stages of MSI, scar tissue formation can be visible as low signal intensity on T1-weighted images and high signal intensity on fluid-sensitive MRI. Scar tissue is observed almost 6 weeks after MSI, which can display low signal intensity on T1-weighted and high signal intensity on fluid-sensitive MRI at early stages.
It is typical for scar tissue to display as low signal intensity with MRI pulse sequences at the late stages. In the clinical practice, it may be misdiagnosed due to residual scar tissue and lead to over- or under-identification of new injuries [28].
During the healing phase up to a couple of months after MSI, differences in the hydrogen and proton environment due to obtained structural tissue changes including hemorrhage may contribute to susceptibility artifacts. It may be observed during follow-up evaluation. A study shows that MRI could evaluate morphologic changes of musculotendon remodeling following MSI by using quantification of the scar tissue volumes [29].
2.5 In chronic phase on B mode US
The US can observe the healing process of injured tissues depending on the nature of the original injury. The B mode US may appear hyperechogenic during the healing phase. Normal tissue healing is considered a reduction in size or resolution of the region of increased echogenicity [30]. Even though the B mode US can evaluate the chronic phase of injured tissue, it is less sensitive than MRI to residual morphologic changes after MSI for the higher soft-tissue contrast and high to extracellular fluid in MRI [31]. In clinical practice, the detection of small echogenic scar tissue by using the B mode US is difficult for a less experienced practitioner. As mentioned above, the relationship between demonstration of scar tissue and re-injury is still controversial. However, excessive scar tissue may be symptomatic that is described as “feeling tight.” It may disturb neural tension, which leads to re-injury [32].
Scar tissue is often shown as irregular thickening of the fascial tissue compared with the uninjured side on the B mode US [33].
Skeletal muscles are also composed of connective tissue, which resists and transmits the force generated by myofibrils to the tendon and bone structures to generate physical movement. When skeletal muscles are injured, any one of these components including fascial tissue can be damaged [18].
2.6 In chronic phase on SWE
SWE can take an advantage to evaluate tissue properties in chronic phase compared with B mode US. SWE can evaluate the absolute elasticity value of soft tissue structures and obtain useful quantitative information about the mechanical properties in the chronic phase.
In the chronic phase of MSI, the stiffness is significantly higher in the chronic phase compared with the acute phase [25].
In the chronic phase of tendon rupture injury, the stiffness of the tissue gradually increased following the healing process with or without surgical repair [34].
From these results, SWE can be a useful tool for evaluating in the phase of transition of acute to chronic phase.
Tendinopathy is considered to occur from mechanical, degenerative, and overuse diseases. It is associated with degeneration and disorganization of the collagenous structure, changes in the proteoglycan and water contents, increased cellularity, fatty infiltration, and neovascularization due to repetitive mechanical stress [35]. A study of tendinopathy shows tendon stiffness is correlated with the patients’ symptom scores, demonstrating the promise of shear wave elastography during follow-up for tendinopathies [36].
Interestingly, by evaluating SWE, injured area of fascial tissue increased stiffness between injured leg and uninjured leg in 11 injured professional rugby players, mean average of shear wave modulus on injured side (17.34 ± 9.04 kPa) and maximum shear wave modulus on injured side (33.53 kPa) compared with mean average of shear wave modulus on uninjured side (12.7 ± 4.96 kPa) and maximum shear wave modulus on uninjured side (20.86 kPa) (Figures 5 and 6) [37].
Figure 5.
The stiffness of fascial tissue of injured side by using Q box trace mode, and the unit was given automatically by machine in kilopascal units. Injured side stiffness is higher than that of uninjured side.
Figure 6.
The stiffness of fascial tissue of uninjured side by using Q box trace mode, and the unit was given automatically by machine in kilopascal units.
Chronic cumulative injury can affect the fascial tissue in addition to the chronic phase of direct trauma. Cumulative mechanical stress leads to fibrotic tissue, thickness of tendinous tissue could be related to the injury [38]. Repetitive cumulative stress, especially eccentric contraction, causes microscopic tissue damage and increases inflammation. ECM of tissue changes plays an important role in tissue stiffness changes [39]. Change in property of ECM by cumulative stress may affect the stiffness in the chronic musculoskeletal injury.
Considering the results, in chronic musculoskeletal injury, it affects not only the muscle tissue but also a wide variety of tissues including fascial tissue. Even though a wide variety of ultrasound imaging has been used in fascial tissue, there is a lack of standardization [40]. SWE can be a more accurate diagnostic tool compared with B-mode, and the combination of SWE and B-US can be a strong diagnostic tool for fascial pathology [41].
To measure the fascial tissue, SWE provides the images reflecting the shear wave value as a tightness of the area of interest.
As considering the tissue property depending on viscoelastic property, utilization of SWE can be a useful tool for evaluating a wide variety of tissues in chronic musculoskeletal injury.
To explain fascial tissue, the term Fascia is used to be recognized as “a sheet or band of soft connective tissue that attaches, surrounds and separates internal organs and skeletal muscles.” However, according to the recognition of physiological and pathophysiological behaviors of a range of connective tissues, the definition is widely considered. With current understanding of mechanical aspects of connective tissue function, fascia is considered in the view of micro to macro as fibril to fascial system. From a morphological view, fascia is described as a sheet or any other dissectible aggregations of connective tissue that forms beneath the skin to attach, enclose, and separate muscles and other internal organs.
There are several types of fascial tissues in the fascial system. The fascial system consists of adipose tissue, adventitia, neurovascular sheaths, aponeuroses, deep and superficial fasciae, dermis, epineurium, joint capsules, ligaments, membranes, meninges, myofascial expansions, periostea, retinacula, septa, tendons. The fascial system is also considered to be included endotendon, peritendon, epitendon, and paratenson, visceral fasciae, and all the intramuscular and intermuscular connective tissues, including endomysium, perimysium, epimysium. The fascial system consists of various components, and it is built on three-dimensional soft seamless collagenous fibers. The loose and dense fibrous connective tissue fills the whole body and allows the integration of body systems.
With injured fascial tissues, it will have a very similar healing process to muscle injury. Micro or macro changes occurred by excessive or repetitive loading or direct trauma of fascial tissue. The pathological changes will modify mechanical function that compromises initial tissue or function. In the acute inflammation phase of fascial tissue, immune response proceeds by phagocytose from the injured cell. It releases proinflammatory cytokines and macrophages to promote immune cell infiltration. If the excessive loading is chronically prolonged, continuing inflammation develops, which leads to the presence of cytotoxic cytokines affected tissues. From this reaction, interleukin-1β, tumor necrosis factor (TNF) and transforming growth factor beta (TGFβ-1)) can promote fibrosis by excessive fibroblast proliferation and collagen matrix deposition that consequently develops fibrotic tissue. A study indicates that substance P stimulates TGFβ-1, which leads to fibrotic tissue development [42]. That phenomenon shows in the chronic phase of fascial injury.
Most pathological cases of fascial tissue demonstrated that a decreased tissue stiffness is present, while some cases demonstrated an increased stiffness due to fibrotic tissues.
However, the viscoelasticity is varied from tissue to tissue. The stiffness of tissue can be affected by the viscoelastic properties of ECM, especially the aponeurotic tissue containing loose connective tissue in which the ECM has ground substances, such as glycosaminoglycans (GAGs) especially hyaluronan (HA)-containing fluid between each layer [43]. The fascial component of the ECM is the main site of the inflammatory responses that occur in tissues. Thus, when the tissue reacts to an inflammatory response, the viscosity of the tissue can be increased, which could lead to increased viscoelasticity of the fascial tissue.
Evaluation of the stiffness of fascial tissue using SWE is considered as viscoelastic, inhomogeneous tissues [44]. The shear modulus value, stiffness, of fascial tissue is affected not only by the fibrotic tissue itself, but also ground substances and fluid components [45]. Therefore, stiffness is affected not only by pure elastic properties, but also by viscosity properties in the fascial tissue [46].
Fascial tissue can be affected by viscoelastic properties more than muscle [47].
Fascial tissue should include loose connective tissue, which contains rich ground substances between each layer. These properties affect the movement of loose connective tissue within and under the tissues [48].
In the chronic condition of MSI, the concentration and molecular weight of HA are altered. In this regard, binding interactions with other macromolecules may affect the sliding movement of fascial tissues [49]. Generally speaking, elastic tissues are hydrophilic and function using a tissue sliding system. However, fibrotic tissues exhibit an altered tissue sliding system, which affects the rehydration and expansion [50]. Therefore, in chronic MSI with scar tissue, there may be less function of rehydration; consequently, it will be stiffer tissue than healthy tissue. Even though SWE is considered not operator-dependent, the viscosity component will affect the results of measurement. Therefore, viscoelastic tissue such as fascial tissue must take special consideration in chronic musculoskeletal conditions.
This phenomenon may affect our daily activities for some reasons.
First, fascial tissues are rich in nerve receptors and free and encapsulated nerve endings including Pacinian corpuscles and Ruffini endings. Those receptors detect and react to mechanical stimulations [51]. As the tissue is stimulated, the nerve endings react and provide sensory feedback that translates into the human ability to detect and coordinate movement and achieve neuromuscular control. Chronic musculoskeletal issues, especially with fibrotic scar tissue, can alter the movement in daily activities.
Secondly, changes in the viscoelasticity of the tissues, basically modulated by ground substances, alter pain sensitivity as activation of nociceptors [48]. The more adhered tissue such as an inflamed tissue, the less lubricated that leads to the alteration of the tissue sliding. Thus, nociceptors can translate mechanical stimuli into pain sensation; consequently, incorrect sensory feedback will modify proprioceptors to nociceptors. Finally, myofascial network transmits to other tissues for muscle force [52]. Stiffened tissue affects this transmission and may change muscle mechanics [53]. Therefore, impaired myofascial force transmission by stiffened tissue may have a negative effect on the proper muscle biomechanics.
3. Conclusion
SWE is a newly developed diagnostic tool and is widely used in the musculoskeletal system.
SWE is a promising diagnostic modality for MSI and the accurate measurement of muscle and fascial tissues’ properties, which has a major impact in clinical practice. In this chapter, diagnostic tools of magnetic resonance imaging, B mode ultrasound, and shear wave elastography in both acute and chronic phases are compared. There are pros and cons for utilization between the tools; however, there is new insight by using SWE in MSI not only properties of muscle but also fascial tissues. SWE generally evaluates tissue stiffness as viscoelasticity. SWE visualizes the propagation of shear waves and can quantify tissue “stiffness” by the speed of propagation. In the chronic MSI cases, viscoelasticity comes from ground substances, which are contained more in fascial tissue. The stiffness increases in fascial tissue more than muscle; therefore, in the chronic case of MSI, not only muscle but also a wide variety of connective tissues can be considered. However, utilization of SWE should be careful due to technical pitfalls or internal factors. All in all, SWE is a promising diagnostic modality for MSI and the accurate measurement of muscle and fascial tissues properties, which has a major impact in clinical practice. There are few studies that investigate for chronic musculoskeletal problem including fascial tissue problem by using SWE especially in clinical trials. Furthermore, the shear wave value is different according to active muscle contraction. Therefore, further studies for chronic musculoskeletal problem will be expected in a wide variety of conditions.
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"shear wave elastography, muscle strain, connective tissue, fascia, chronic injury",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/80266.pdf",chapterXML:"https://mts.intechopen.com/source/xml/80266.xml",downloadPdfUrl:"/chapter/pdf-download/80266",previewPdfUrl:"/chapter/pdf-preview/80266",totalDownloads:41,totalViews:0,totalCrossrefCites:0,dateSubmitted:"November 26th 2021",dateReviewed:"December 14th 2021",datePrePublished:"January 31st 2022",datePublished:null,dateFinished:"January 30th 2022",readingETA:"0",abstract:"Shear wave elastography is a new noninvasive tool for the analysis of the biomechanical properties of the muscles in healthy and pathological conditions. Shear wave elastography is currently considered as a promising real-time visualization tool for quantifying explicitly the mechanical properties of soft tissues in sports medicine including muscle strain injury (MSI). This chapter shows utilizing diagnostic tools of magnetic resonance imaging, B mode ultrasound (US), and shear wave elastography in both acute and chronic phases. Also, the proposal for this chapter is to indicate the possibility of utilizing shear wave elastography for musculoskeletal injury, not only properties of the muscle but also fascial tissues. It introduces the relationship between previous muscle strain injury and local soft tissue stiffness, and we assessed the mechanical properties of soft tissues from a clinical perspective.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/80266",risUrl:"/chapter/ris/80266",signatures:"Tomonori Kawai",book:{id:"11250",type:"book",title:"Elastography - Applications in Clinical Medicine",subtitle:null,fullTitle:"Elastography - Applications in Clinical Medicine",slug:null,publishedDate:null,bookSignature:"Dr. Dana I Stoian and Dr. Alina Popescu",coverURL:"https://cdn.intechopen.com/books/images_new/11250.jpg",licenceType:"CC BY 3.0",editedByType:null,isbn:"978-1-78985-354-4",printIsbn:"978-1-78984-637-9",pdfIsbn:"978-1-78985-603-3",isAvailableForWebshopOrdering:!0,editors:[{id:"182103",title:"Dr.",name:"Dana",middleName:"I",surname:"Stoian",slug:"dana-stoian",fullName:"Dana Stoian"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_1_2",title:"1.1 Shear wave elastography",level:"2"},{id:"sec_3",title:"2. Imaging of musculoskeletal injury",level:"1"},{id:"sec_3_2",title:"2.1 Musculoskeletal injury",level:"2"},{id:"sec_4_2",title:"2.2 In acute phase on MRI",level:"2"},{id:"sec_5_2",title:"2.3 In acute phase on B mode US and SWE",level:"2"},{id:"sec_6_2",title:"2.4 In chronic phase on MRI",level:"2"},{id:"sec_7_2",title:"2.5 In chronic phase on B mode US",level:"2"},{id:"sec_8_2",title:"2.6 In chronic phase on SWE",level:"2"},{id:"sec_10",title:"3. Conclusion",level:"1"},{id:"sec_14",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Berger A. Magnetic resonance imaging. BMJ. 2002;324(7328):35. DOI: 10.1136/bmj.324.7328.35'},{id:"B2",body:'Verrall GM, Slavotinek JP, Barnes PG, Fon GT, Esterman A. Assessment of physical examination and magnetic resonance imaging findings of hamstring injury as predictors for recurrent injury. 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Faculty of Human Sciences, Department of Sports and Health Sciences, University of East Asia, Ichinomiya, Yamaguchi, Japan
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Furthermore, goals concerning the sustainable city increased design complexity, due to the involvement of different interrelated disciplines, which modified design processes by incorporating external contributions. In particular, environmental analyses are growing in importance and need to be reintegrated into the urban project at the conceptual stage. This ‘environmental awareness’ accompanies the history of the city, and numerous pieces of evidence clearly show the mutual and in‐depth relationship between urban form and local microclimates. Lessons from the ancients constituted the fundamentals in urban design until the Modern Movement, during which knowledge of the past also influenced the work of G. Vinaccia, an Italian pioneer in microclimatic urban design. After the World War II, most of the lessons had been forgotten in favour of technology systems that have since revealed their failures. The current design condition requires a discovery of past abilities, coupling them with contemporary scientific advances. This work introduces a methodology through which to integrate current urban design processes with environmental data and analyses. It is illustrated through a case study and is supported by software.",signatures:"Ilaria Giovagnorio and Giovanni M. Chiri",authors:[{id:"181928",title:"Ph.D.",name:"Ilaria",surname:"Giovagnorio",fullName:"Ilaria Giovagnorio",slug:"ilaria-giovagnorio",email:"ilaria.giovagnorio@gmail.com"},{id:"183198",title:"Prof.",name:"Giovanni",surname:"Chiri",fullName:"Giovanni Chiri",slug:"giovanni-chiri",email:"g.chiri@unica.it"}],book:{id:"5235",title:"Sustainable Urbanization",slug:"sustainable-urbanization",productType:{id:"1",title:"Edited Volume"}}}],collaborators:[{id:"25222",title:"Dr.",name:"Dong",surname:"Jiang",slug:"dong-jiang",fullName:"Dong Jiang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"180532",title:"Dr.",name:"Jingying",surname:"Fu",slug:"jingying-fu",fullName:"Jingying Fu",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"181037",title:"Dr.",name:"Gang",surname:"Lin",slug:"gang-lin",fullName:"Gang Lin",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"181928",title:"Ph.D.",name:"Ilaria",surname:"Giovagnorio",slug:"ilaria-giovagnorio",fullName:"Ilaria Giovagnorio",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Cagliari",institutionURL:null,country:{name:"Italy"}}},{id:"182038",title:"Dr.",name:"Gökçen",surname:"Kılınç Ürkmez",slug:"gokcen-kilinc-urkmez",fullName:"Gökçen Kılınç Ürkmez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Bursa Technical University",institutionURL:null,country:{name:"Turkey"}}},{id:"182126",title:"Dr.",name:"Gorkem",surname:"Gulhan",slug:"gorkem-gulhan",fullName:"Gorkem Gulhan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Pamukkale University",institutionURL:null,country:{name:"Turkey"}}},{id:"182298",title:"Dr.",name:"Ebru",surname:"Ersoy",slug:"ebru-ersoy",fullName:"Ebru Ersoy",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Adnan Menderes University",institutionURL:null,country:{name:"Turkey"}}},{id:"182370",title:"Dr.",name:"Simone",surname:"Teixeira",slug:"simone-teixeira",fullName:"Simone Teixeira",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidade de Pernambuco",institutionURL:null,country:{name:"Brazil"}}},{id:"185555",title:"Dr.",name:"Huseyin",surname:"Ceylan",slug:"huseyin-ceylan",fullName:"Huseyin Ceylan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"185732",title:"MSc.",name:"Daniele",surname:"Mariz",slug:"daniele-mariz",fullName:"Daniele Mariz",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null}]},generic:{page:{slug:"authorship-policy",title:"Authorship Policy",intro:'
',metaTitle:"Authorship Policy",metaDescription:"IN TECH's Authorship Policy is based on ICMJE criteria for authorship. In order to be identified as an Author, one must:",metaKeywords:null,canonicalURL:"/page/authorship-policy",contentRaw:'[{"type":"htmlEditorComponent","content":"
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Substantially contribute to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work
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Participate in drafting or revising the work
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Approve the final version of the work to be published.
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All contributors who meet these criteria are listed as Authors. Their exact contributions should be described in the manuscript at the time of submission.
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Conversely, all contributors who do not meet these criteria should be listed in the Acknowledgments section of the manuscript, along with a short description of their specific contributions.
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CHANGES IN AUTHORSHIP
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If it is felt necessary to make changes to the list of Authors after a manuscript has been submitted or published, it is the responsibility of the Author concerned to provide a valid reason to amend the published list. Additionally, all listed Authors must verify and approve the proposed changes in order for any amendments to be made.
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AFFILIATION
\\n\\n
Authors are responsible for ensuring all addresses and emails provided are correct. Under affiliation(s) all Authors should indicate where the research was conducted. Please note that no changes to the affiliation(s) can be made after the chapter has been published.
Substantially contribute to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work
\n\t
Participate in drafting or revising the work
\n\t
Approve the final version of the work to be published.
\n
\n\n
All contributors who meet these criteria are listed as Authors. Their exact contributions should be described in the manuscript at the time of submission.
\n\n
Conversely, all contributors who do not meet these criteria should be listed in the Acknowledgments section of the manuscript, along with a short description of their specific contributions.
\n\n
CHANGES IN AUTHORSHIP
\n\n
If it is felt necessary to make changes to the list of Authors after a manuscript has been submitted or published, it is the responsibility of the Author concerned to provide a valid reason to amend the published list. Additionally, all listed Authors must verify and approve the proposed changes in order for any amendments to be made.
\n\n
AFFILIATION
\n\n
Authors are responsible for ensuring all addresses and emails provided are correct. Under affiliation(s) all Authors should indicate where the research was conducted. Please note that no changes to the affiliation(s) can be made after the chapter has been published.
\n\n
Policy last updated: 2017-05-29
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Küden"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},subject:{topic:{id:"951",title:"Solid-State Physics",slug:"metals-and-nonmetals-solid-state-physics",parent:{id:"158",title:"Metals and Nonmetals",slug:"metals-and-nonmetals"},numberOfBooks:5,numberOfSeries:0,numberOfAuthorsAndEditors:117,numberOfWosCitations:85,numberOfCrossrefCitations:72,numberOfDimensionsCitations:127,videoUrl:null,fallbackUrl:null,description:null},booksByTopicFilter:{topicId:"951",sort:"-publishedDate",limit:12,offset:0},booksByTopicCollection:[{type:"book",id:"6801",title:"Ferroelectrics and Their Applications",subtitle:null,isOpenForSubmission:!1,hash:"ce5ff2c700cc6d73c62c2f6541226248",slug:"ferroelectrics-and-their-applications",bookSignature:"Husein Irzaman",coverURL:"https://cdn.intechopen.com/books/images_new/6801.jpg",editedByType:"Edited by",editors:[{id:"193016",title:"Dr.",name:"Husein",middleName:null,surname:"Irzaman",slug:"husein-irzaman",fullName:"Husein Irzaman"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5982",title:"Soldering Materials",subtitle:null,isOpenForSubmission:!1,hash:"017cb7a95fde498c01fe35c735bc15cf",slug:"recent-progress-in-soldering-materials",bookSignature:"Ahmad Azmin Mohamad",coverURL:"https://cdn.intechopen.com/books/images_new/5982.jpg",editedByType:"Edited by",editors:[{id:"199509",title:"Dr.",name:"Ahmad Azmin",middleName:null,surname:"Mohamad",slug:"ahmad-azmin-mohamad",fullName:"Ahmad Azmin Mohamad"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5850",title:"New Research on Silicon",subtitle:"Structure, Properties, Technology",isOpenForSubmission:!1,hash:"9dd26e7154c656a641230200a3a37724",slug:"new-research-on-silicon-structure-properties-technology",bookSignature:"Vitalyi Igorevich Talanin",coverURL:"https://cdn.intechopen.com/books/images_new/5850.jpg",editedByType:"Edited by",editors:[{id:"103029",title:"Prof.",name:"Vitalyi Igorevich",middleName:null,surname:"Talanin",slug:"vitalyi-igorevich-talanin",fullName:"Vitalyi Igorevich Talanin"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5223",title:"Non-Destructive Testing",subtitle:null,isOpenForSubmission:!1,hash:"1cd0602adf345e3f19f63dfbf81651d0",slug:"non-destructive-testing",bookSignature:"Fausto Pedro Garcia Marquez, Mayorkinos Papaelias and Noor Zaman",coverURL:"https://cdn.intechopen.com/books/images_new/5223.jpg",editedByType:"Edited by",editors:[{id:"22844",title:"Prof.",name:"Fausto Pedro",middleName:null,surname:"García Márquez",slug:"fausto-pedro-garcia-marquez",fullName:"Fausto Pedro García Márquez"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1794",title:"Nondestructive Testing Methods and New Applications",subtitle:null,isOpenForSubmission:!1,hash:"0200bcd5a85a22f3111c1776f71ccd3a",slug:"nondestructive-testing-methods-and-new-applications",bookSignature:"Mohammad Omar",coverURL:"https://cdn.intechopen.com/books/images_new/1794.jpg",editedByType:"Edited by",editors:[{id:"13368",title:"Dr.",name:"Mohammad",middleName:null,surname:"Omar",slug:"mohammad-omar",fullName:"Mohammad Omar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:5,seriesByTopicCollection:[],seriesByTopicTotal:0,mostCitedChapters:[{id:"30285",doi:"10.5772/35547",title:"Magnetic Adaptive Testing",slug:"magnetic-adaptive-testing",totalDownloads:2231,totalCrossrefCites:12,totalDimensionsCites:25,abstract:null,book:{id:"1794",slug:"nondestructive-testing-methods-and-new-applications",title:"Nondestructive Testing Methods and New Applications",fullTitle:"Nondestructive Testing Methods and New Applications"},signatures:"Ivan Tomáš and Gábor Vértesy",authors:[{id:"104936",title:"Dr.",name:"Ivan",middleName:null,surname:"Tomas",slug:"ivan-tomas",fullName:"Ivan Tomas"},{id:"104983",title:"Dr.",name:"Gabor",middleName:null,surname:"Vertesy",slug:"gabor-vertesy",fullName:"Gabor Vertesy"}]},{id:"54505",doi:"10.5772/67730",title:"Silicon‐Germanium (SiGe) Nanostructures for Thermoelectric Devices: Recent Advances and New Approaches to High Thermoelectric Efficiency",slug:"silicon-germanium-sige-nanostructures-for-thermoelectric-devices-recent-advances-and-new-approaches-",totalDownloads:2367,totalCrossrefCites:8,totalDimensionsCites:15,abstract:"Silicon and germanium present distinct and interesting transport properties. However, composites made of silicon‐germanium (SiGe) have resulted in a breakthrough in terms of their transport properties. Currently, these alloys are used in different applications, such as microelectronic devices and integrated circuits, photovoltaic cells, and thermoelectric applications. With respect to thermoelectricity, in the last decades, Si0.8Ge0.2 has attracted significant attention as an energy harvesting material, for powering space applications and other industrial applications. This chapter focuses on the recent advances and new approaches in silicon‐germanium (Si1−xGex) nanostructures for thermoelectric devices with high thermoelectric efficiency obtained through magnetron sputtering.",book:{id:"5850",slug:"new-research-on-silicon-structure-properties-technology",title:"New Research on Silicon",fullTitle:"New Research on Silicon - Structure, Properties, Technology"},signatures:"Jaime Andrés Pérez‐Taborda, Olga Caballero‐Calero and Marisol\nMartín‐González",authors:[{id:"193020",title:"Dr.",name:"Jaime Andres",middleName:null,surname:"Perez Taborda",slug:"jaime-andres-perez-taborda",fullName:"Jaime Andres Perez Taborda"},{id:"202004",title:"Dr.",name:"Marisol",middleName:null,surname:"Martin Gonzalez",slug:"marisol-martin-gonzalez",fullName:"Marisol Martin Gonzalez"},{id:"202119",title:"Dr.",name:"Olga",middleName:null,surname:"Caballero Calero",slug:"olga-caballero-calero",fullName:"Olga Caballero Calero"}]},{id:"50085",doi:"10.5772/62408",title:"Non-Destructive Techniques Applied to Monumental Stone Conservation",slug:"non-destructive-techniques-applied-to-monumental-stone-conservation",totalDownloads:2195,totalCrossrefCites:8,totalDimensionsCites:13,abstract:"Non-destructive techniques have always been used in the study of built cultural heritage because of the high cultural value of the concerned objects and the need to preserve them as intact as possible. In this chapter, different non-destructive techniques applied to the conservation of historical building are presented. The selected techniques concern the measurement of some physical properties of the building materials measured at the surface: water absorption, permeability, water content, cohesion, hardness and so on; the actual conditions of the building: stress state, deformation, crack growth and so on; and in-depth physical properties: mechanical properties, inner structure of walls, damp location and salt content. Some of these techniques are used for inspection of the building at a given time, whereas others can be applied for long periods of time to investigate the evolution of the building or of one of its parts (e.g., crack propagation) with time.",book:{id:"5223",slug:"non-destructive-testing",title:"Non-Destructive Testing",fullTitle:"Non-Destructive Testing"},signatures:"Beatriz Menéndez",authors:[{id:"178332",title:"Dr.",name:"Beatriz",middleName:null,surname:"Menendez",slug:"beatriz-menendez",fullName:"Beatriz Menendez"}]},{id:"61619",doi:"10.5772/intechopen.77388",title:"BaTiO3-Based Lead-Free Electroceramics with Their Ferroelectric and Piezoelectric Properties Tuned by Ca2+, Sn4+ and Zr4+ Substitution Useful for Electrostrictive Device Application",slug:"batio3-based-lead-free-electroceramics-with-their-ferroelectric-and-piezoelectric-properties-tuned-b",totalDownloads:1436,totalCrossrefCites:3,totalDimensionsCites:9,abstract:"Dense microstructure BaTiO₃ (BT) ceramic with c/a ~1.0144 and average grain size ~7.8 μmis developed by achieving the ferroelectric parameters Psat. = 24.13 μC/cm2 and Pr = 10.42 μC/cm2 with lower coercive field of Ec = 2.047 kV/cm. For BT ceramic, the “sprout” shape nature is observed for strain-electric field measurements with remnant strain ~ 0.212%, converse piezoelectric constant ~376.35 pm/V and electrostrictive coefficient Q33~ 0.03493 m4/C2. To tune the piezoelectric properties of BT ceramic, the substitutions of Ca2+ and Sn4+, Zr4+ are done for Ba2+ and Ti4+ sites respectively. The Ba0.7Ca0.3Ti1-xSnxO3 (x = 0.00, 0.025, 0.050, 0.075, and 0.1, BCST) system was studied with ferroelectric, piezoelectric and electrostrictive properties. The electrostrictive coefficient (Q33) ~ 0.0667 m4/C2 was observed for x = 0.075 and it is higher than the lead-based electrostrictive materials. Another (1-X) Ba0.95Ca0.05Ti0.92Sn0.08O3 (BCST) – (X) Ba0.95Ca0.05Ti0.92Zr0.08O3 (BCZT), ceramics (x = 0.00, 0.25, 0.50, 0.75, and 1) is studied. The BCST-BCZT ceramic system shows the increase of polymorphic phase transition temperatures toward the room temperature by Ca2+, Sn4+ and Zr4+ substitution. For BCST-BCZT system the composition x = 0.75 exhibits the d33, and Q33 values of 310 pC/N, 385 pm/V and 0.089 m4/C2 respectively which is greater than BT ceramics.",book:{id:"6801",slug:"ferroelectrics-and-their-applications",title:"Ferroelectrics and Their Applications",fullTitle:"Ferroelectrics and Their Applications"},signatures:"Bharat G. Baraskar, Pravin S. Kadhane, Tulshidas C. Darvade, Ajit R.\nJames and Rahul C. Kambale",authors:[{id:"243834",title:"Dr.",name:"Rahul",middleName:null,surname:"Kambale",slug:"rahul-kambale",fullName:"Rahul Kambale"},{id:"243837",title:"Mr.",name:"Bharat",middleName:null,surname:"Baraskar",slug:"bharat-baraskar",fullName:"Bharat Baraskar"},{id:"243838",title:"Dr.",name:"Pravin",middleName:"Sadashiv",surname:"Kadhane",slug:"pravin-kadhane",fullName:"Pravin Kadhane"},{id:"243839",title:"Dr.",name:"Ajit",middleName:null,surname:"James",slug:"ajit-james",fullName:"Ajit James"},{id:"243840",title:"Mr.",name:"Tulshidas",middleName:null,surname:"Darvade",slug:"tulshidas-darvade",fullName:"Tulshidas Darvade"}]},{id:"30282",doi:"10.5772/35650",title:"Neutron Radiography",slug:"neutron-radiography",totalDownloads:5422,totalCrossrefCites:2,totalDimensionsCites:7,abstract:null,book:{id:"1794",slug:"nondestructive-testing-methods-and-new-applications",title:"Nondestructive Testing Methods and New Applications",fullTitle:"Nondestructive Testing Methods and New Applications"},signatures:"Nares Chankow",authors:[{id:"105317",title:"Associate Prof.",name:"Nares",middleName:null,surname:"Chankow",slug:"nares-chankow",fullName:"Nares Chankow"}]}],mostDownloadedChaptersLast30Days:[{id:"54430",title:"Self-Adjusting Electrochemical Etching Technique for Producing Nanoporous Silicon Membrane",slug:"self-adjusting-electrochemical-etching-technique-for-producing-nanoporous-silicon-membrane",totalDownloads:1660,totalCrossrefCites:3,totalDimensionsCites:4,abstract:"This chapter presents the technique in producing the nanoporous silicon membrane using electrochemical etching technique. Electrochemical etching technique is a self-adjusting technique due to its ability to control transfer of ion to form pore by manipulating certain parameters. There are several parameters that have been manipulated to study the effect of each parameter to the pore formation by characterizing each component. The project starts with fabrication of silicon membrane and then continues with characterization of HF concentration, current density, doping and also alcohol diluents using field emission scanning electron microscopy (FESEM). The effect of each parameter is discussed in terms of pore size, pore formation and pore structure. Finally, the pore with size less than 100 nm and columnar structure has formed using this technique. The star-shaped structure is also formed through this experimental setup. Improved nanoporous silicon membrane can be applied for filtration and separating particles, especially in an artificial kidney.",book:{id:"5850",slug:"new-research-on-silicon-structure-properties-technology",title:"New Research on Silicon",fullTitle:"New Research on Silicon - Structure, Properties, Technology"},signatures:"Norhafizah Burham, Azrul Azlan Hamzah and Burhanuddin Yeop\nMajlis",authors:[{id:"187754",title:"Dr.",name:"Azrul",middleName:"Azlan",surname:"Hamzah",slug:"azrul-hamzah",fullName:"Azrul Hamzah"},{id:"194384",title:"Dr.",name:"Jumril",middleName:null,surname:"Yunas",slug:"jumril-yunas",fullName:"Jumril Yunas"},{id:"194385",title:"Prof.",name:"Burhanuddin Yeop",middleName:null,surname:"Majlis",slug:"burhanuddin-yeop-majlis",fullName:"Burhanuddin Yeop Majlis"},{id:"200506",title:"Dr.",name:"Norhafizah",middleName:null,surname:"Burham",slug:"norhafizah-burham",fullName:"Norhafizah Burham"}]},{id:"56959",title:"Low Melting Temperature Solder Materials for Use in Flexible Microelectronic Packaging Applications",slug:"low-melting-temperature-solder-materials-for-use-in-flexible-microelectronic-packaging-applications",totalDownloads:1758,totalCrossrefCites:1,totalDimensionsCites:3,abstract:"The increasing application of heat-sensitive microelectronic components such as a multitude of transistors, polymer-based microchips, and so on, and flexible polymer substrates including polyethylene terephthalate (PET) and polyimide (PI), among others, for use in wearable devices has led to the development of more advanced, low melting temperature solders (<150°C) for interconnecting components in various applications. However, the current low melting temperature solders face several key challenges, which include more intermetallic compound formation (thus become more brittle), cost issues according to the addition of supplementary elements to decrease the melting point temperature, an increase in the possibility of thermal or popcorn cracking (reliability problems), and so on. Furthermore, the low melting temperature solders are still required to possess rapid electronic/electrical transport ability (high electrical conductivity and current density) and accompany strong mechanical strength sustaining the heavy-uploaded microelectronic devices on the plastic substrates, which are at least those of the conventional melting temperature solders (180–230°C). Thus, the pursuit of more advanced low melting temperature solders for interconnections is timely. This review is devoted to the research on three methods to improve the current properties (i.e., electrical and thermomechanical properties) of low melting temperature solders: (i) doping with a small amount of certain additives, (ii) alloying with a large amount of certain additives, and (iii) reinforcing with metal, carbon, or ceramic materials. In this review, we also summarize the overall recent progress in low melting temperature solders and present a critical overview of the basis of microscopic analysis with regard to grain size and solid solutions, electrical conductivity by supplementation with conductive additives, thermal behavior (melting point and melting range) according to surface oxidation and intermetallic compound formation, and various mechanical properties.",book:{id:"5982",slug:"recent-progress-in-soldering-materials",title:"Soldering Materials",fullTitle:"Recent Progress in Soldering Materials"},signatures:"Sang Hoon Kim and Sangsun Yang",authors:[{id:"203384",title:"Dr.",name:"Sang Hoon",middleName:null,surname:"Kim",slug:"sang-hoon-kim",fullName:"Sang Hoon Kim"},{id:"203387",title:"Dr.",name:"Sangsun",middleName:null,surname:"Yang",slug:"sangsun-yang",fullName:"Sangsun Yang"}]},{id:"61508",title:"Preparation and Device Applications of Ferroelectric β-PVDF Films",slug:"preparation-and-device-applications-of-ferroelectric-pvdf-films",totalDownloads:1298,totalCrossrefCites:5,totalDimensionsCites:6,abstract:"Organic ferroelectric materials have unique characters comparing to their inorganic counterparts in electronics because they show the advantages such as low cost, lightweight, small thermal budget, flexible and nontoxic characteristics. The ferroelectric poly(vinylidene fluoride) (PVDF) is mostly desired for memory devices due to its polar phase. To obtain the ferroelectric memory devices for data storage, ultrathin PVDF films are required to allow for low operation voltages with both small roughness and free of pin-holes. Micron-meter thick films of ferroelectric phase PVDF can be easily achieved by many preparation methods. But the nanofilms could be mainly fabricated by coating method and Langmuir–Blodgett deposition technique. Meanwhile, according to the structure of devices, four types of organic memory cells using ferroelectric phase PVDF films were introduced, such as memory based on metal/organic semiconductor/metal ferroelectric tunnel junctions, organic capacitors, field effect transistor and organic diodes. The research has been mainly done in Zhang’s laboratory from September 2016 to explore the preparation and potential applications of ferroelectric PVDF films. In this chapter, we summarize several device investigations and show the PVDF films have the promising memory applications.",book:{id:"6801",slug:"ferroelectrics-and-their-applications",title:"Ferroelectrics and Their Applications",fullTitle:"Ferroelectrics and Their Applications"},signatures:"Liuxia Ruan, Donghai Zhang, Junwei Tong, Jianli Kang, Yufang\nChang, Lianqun Zhou, Gaowu Qin and Xianmin Zhang",authors:[{id:"221551",title:"Prof.",name:"Xianmin",middleName:null,surname:"Zhang",slug:"xianmin-zhang",fullName:"Xianmin Zhang"},{id:"264044",title:"Dr.",name:"Liuxia",middleName:null,surname:"Ruan",slug:"liuxia-ruan",fullName:"Liuxia Ruan"},{id:"264045",title:"Dr.",name:"Donghai",middleName:null,surname:"Zhang",slug:"donghai-zhang",fullName:"Donghai Zhang"},{id:"264046",title:"Dr.",name:"Junwei",middleName:null,surname:"Tong",slug:"junwei-tong",fullName:"Junwei Tong"},{id:"264047",title:"Dr.",name:"Jianli",middleName:null,surname:"Kang",slug:"jianli-kang",fullName:"Jianli Kang"},{id:"264048",title:"Dr.",name:"Yufang",middleName:null,surname:"Chang",slug:"yufang-chang",fullName:"Yufang Chang"},{id:"264049",title:"Dr.",name:"Lianqun",middleName:null,surname:"Zhou",slug:"lianqun-zhou",fullName:"Lianqun Zhou"},{id:"264050",title:"Dr.",name:"Gaowu",middleName:null,surname:"Qin",slug:"gaowu-qin",fullName:"Gaowu Qin"}]},{id:"50028",title:"Mechanical Behavior Analysis and Testing of Marine Riser in Deepwater Drilling",slug:"mechanical-behavior-analysis-and-testing-of-marine-riser-in-deepwater-drilling",totalDownloads:2020,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"In this chapter, the mechanical model and control equation have been established to analyse the mechanical behaviour of marine riser in working condition. The control equation has been solved by weighted residual method, and the analysis model has been verified by finite element method (FEM) in ABAQUS framework. Based on this, the deformation and stress distribution of the marine riser have been acquired. Then, a simulation experimental system has been introduced, and the system composition, functions and operational approach of the experimental setup have been stated in detail. After that, a tubular sample has been manufactured to simulate the marine riser, and the simulation experiments have been carried out based on this setup, where the experimental procedures, key aspects, difficult points of the experiment and its corresponding solutions have been elaborated. At last, the strain value of the specimen has been measured successfully after the experiment, and the stress state of the specimen has been obtained based on the analysis.",book:{id:"5223",slug:"non-destructive-testing",title:"Non-Destructive Testing",fullTitle:"Non-Destructive Testing"},signatures:"Yanbin Wang, Deli Gao and Jun Fang",authors:[{id:"178322",title:"Ph.D.",name:"Yanbin",middleName:null,surname:"Wang",slug:"yanbin-wang",fullName:"Yanbin Wang"},{id:"183856",title:"Prof.",name:"Deli",middleName:null,surname:"Gao",slug:"deli-gao",fullName:"Deli Gao"},{id:"183857",title:"Dr.",name:"Jun",middleName:null,surname:"Fang",slug:"jun-fang",fullName:"Jun Fang"}]},{id:"54345",title:"Study on the Preparation of Solar Grade Silicon by Metallurgical Method",slug:"study-on-the-preparation-of-solar-grade-silicon-by-metallurgical-method",totalDownloads:2231,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The global PV industry has rapidly developed over the past decade, which has led to a large demand for silicon materials. Solar cells are currently fabricated from a variety of silicon‐based materials. However, current market is difficult to ensure a steady supply for this material. Development of a new process to produce silicon at low cost is definitely necessary. Metallurgical grade silicon (MG‐Si) with the purity of 98%, which is produced by carbothermic reduction in electric arc furnaces, has been considered as a cheap starting material for conversion to purity of 99.99%. Many alternative methods for purifying MG‐Si to Solar grade silicon (SoG‐Si) have been explored, for example, (1) pyro metallurgical processes, (2) hydrometallurgical processes and (3) electrochemical methods. Metallurgical route is recognized as a promising process to meet market demand for solar energy silicon material, which is different from the traditional Siemens process. This chapter focuses on the introduction of three kinds of typical impurity removal methods in metallurgical process, and the impurity removal effect of different processes was analysed and discussed.",book:{id:"5850",slug:"new-research-on-silicon-structure-properties-technology",title:"New Research on Silicon",fullTitle:"New Research on Silicon - Structure, Properties, Technology"},signatures:"Dawei Luo",authors:[{id:"197504",title:"Dr.",name:"Dawei",middleName:null,surname:"Luo",slug:"dawei-luo",fullName:"Dawei Luo"}]}],onlineFirstChaptersFilter:{topicId:"951",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:0,limit:8,total:null},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:90,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:320,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:133,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:17,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"24",title:"Sustainable Development",doi:"10.5772/intechopen.100361",issn:null,scope:"
\r\n\tTransforming our World: the 2030 Agenda for Sustainable Development endorsed by United Nations and 193 Member States, came into effect on Jan 1, 2016, to guide decision making and actions to the year 2030 and beyond. Central to this Agenda are 17 Goals, 169 associated targets and over 230 indicators that are reviewed annually. The vision envisaged in the implementation of the SDGs is centered on the five Ps: People, Planet, Prosperity, Peace and Partnership. This call for renewed focused efforts ensure we have a safe and healthy planet for current and future generations.
\r\n
\r\n\t
\r\n
\r\n\tThis Series focuses on covering research and applied research involving the five Ps through the following topics:
\r\n
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\r\n\t1. Sustainable Economy and Fair Society that relates to SDG 1 on No Poverty, SDG 2 on Zero Hunger, SDG 8 on Decent Work and Economic Growth, SDG 10 on Reduced Inequalities, SDG 12 on Responsible Consumption and Production, and SDG 17 Partnership for the Goals
\r\n
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\r\n\t2. Health and Wellbeing focusing on SDG 3 on Good Health and Wellbeing and SDG 6 on Clean Water and Sanitation
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\r\n\t3. Inclusivity and Social Equality involving SDG 4 on Quality Education, SDG 5 on Gender Equality, and SDG 16 on Peace, Justice and Strong Institutions
\r\n
\r\n\t
\r\n
\r\n\t4. Climate Change and Environmental Sustainability comprising SDG 13 on Climate Action, SDG 14 on Life Below Water, and SDG 15 on Life on Land
\r\n
\r\n\t
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\r\n\t5. Urban Planning and Environmental Management embracing SDG 7 on Affordable Clean Energy, SDG 9 on Industry, Innovation and Infrastructure, and SDG 11 on Sustainable Cities and Communities.
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\r\n\tThe series also seeks to support the use of cross cutting SDGs, as many of the goals listed above, targets and indicators are all interconnected to impact our lives and the decisions we make on a daily basis, making them impossible to tie to a single topic.
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Usha has been a keynote speaker as well as an invited speaker at national and international conferences, seminars and workshops. Her teaching experience includes teaching in Asian countries. She has advised Austrade, APEC, national, state and local governments. She serves as a reviewer and a member of the scientific committee for national and international refereed journals and refereed conferences. She is on the editorial board for refereed journals and has worked on Special Issues. Usha has served and continues to serve on the Boards of several not-for-profit organisations and she has also served as panel judge for a number of awards including the Premiers Sustainability Award in Victoria and the International Green Gown Awards. Usha has published over 100 publications, including research and consulting reports. Her publications cover a wide range of scientific and technical research publications that include edited books, book chapters, refereed journals, refereed conference papers and reports for local, state and federal government clients. She has also produced podcasts for various organisations and participated in media interviews. She has received state, national and international funding worth over USD $25 million. Usha has been awarded the Quarterly Franklin Membership by London Journals Press (UK). Her biography has been included in the Marquis Who's Who in the World® 2018, 2016 (33rd Edition), along with approximately 55,000 of the most accomplished men and women from around the world, including luminaries as U.N. Secretary-General Ban Ki-moon. 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He is a full professor of signal processing and pattern recognition and is head of the Signals and Communications Department at ULPGC, teaching from 2001 on subjects on signal processing and learning theory. His research lines are biometrics, biomedical signals and images, data mining, classification system, signal and image processing, machine learning, and environmental intelligence. He has researched in 52 international and Spanish research projects, some of them as head researcher. He is co-author of 4 books, co-editor of 27 proceedings books, guest editor for 8 JCR-ISI international journals, and up to 24 book chapters. He has over 450 papers published in international journals and conferences (81 of them indexed on JCR – ISI - Web of Science). He has published seven patents in the Spanish Patent and Trademark Office. He has been a supervisor on 8 Ph.D. theses (11 more are under supervision), and 130 master theses. He is the founder of The IEEE IWOBI conference series and the president of its Steering Committee, as well as the founder of both the InnoEducaTIC and APPIS conference series. He is an evaluator of project proposals for the European Union (H2020), Medical Research Council (MRC, UK), Spanish Government (ANECA, Spain), Research National Agency (ANR, France), DAAD (Germany), Argentinian Government, and the Colombian Institutions. He has been a reviewer in different indexed international journals (<70) and conferences (<250) since 2001. He has been a member of the IASTED Technical Committee on Image Processing from 2007 and a member of the IASTED Technical Committee on Artificial Intelligence and Expert Systems from 2011. \n\nHe has held the general chair position for the following: ACM-APPIS (2020, 2021), IEEE-IWOBI (2019, 2020 and 2020), A PPIS (2018, 2019), IEEE-IWOBI (2014, 2015, 2017, 2018), InnoEducaTIC (2014, 2017), IEEE-INES (2013), NoLISP (2011), JRBP (2012), and IEEE-ICCST (2005)\n\nHe is an associate editor of the Computational Intelligence and Neuroscience Journal (Hindawi – Q2 JCR-ISI). He was vice dean from 2004 to 2010 in the Higher Technical School of Telecommunication Engineers at ULPGC and the vice dean of Graduate and Postgraduate Studies from March 2013 to November 2017. 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His research interests include computer/machine vision, machine learning, pattern recognition, computational intelligence. \nDr. Papakostas served as a reviewer in numerous journals, as a program\ncommittee member in international conferences and he is a member of the IAENG, MIR Labs, EUCogIII, INSTICC and the Technical Chamber of Greece (TEE).",institutionString:null,institution:{name:"International Hellenic University",institutionURL:null,country:{name:"Greece"}}},editorTwo:null,editorThree:null},{id:"25",title:"Evolutionary Computation",coverUrl:"https://cdn.intechopen.com/series_topics/covers/25.jpg",isOpenForSubmission:!0,editor:{id:"136112",title:"Dr.",name:"Sebastian",middleName:null,surname:"Ventura Soto",slug:"sebastian-ventura-soto",fullName:"Sebastian Ventura Soto",profilePictureURL:"https://mts.intechopen.com/storage/users/136112/images/system/136112.png",biography:"Sebastian Ventura is a Spanish researcher, a full professor with the Department of Computer Science and Numerical Analysis, University of Córdoba. 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(Eng.) in Telematics from the Universidad de Colima, Mexico. He obtained both his M.Sc. and Ph.D. from the University of Liverpool, England, in the field of Intelligent Systems. He is a full professor at the Universidad Autonoma de Queretaro, Mexico, and a member of the National System of Researchers (SNI) since 2009. Dr. Aceves Fernandez has published more than 80 research papers as well as a number of book chapters and congress papers. He has contributed in more than 20 funded research projects, both academic and industrial, in the area of artificial intelligence, ranging from environmental, biomedical, automotive, aviation, consumer, and robotics to other applications. He is also a honorary president at the National Association of Embedded Systems (AMESE), a senior member of the IEEE, and a board member of many institutions. 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