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Zhong X, Long H, Chen L, Xie Y, Shi Y, Peng J, Zheng R, Su L, Duan Y, Xie X, Lin M. Stiffness on shear wave elastography as a potential microenvironment biomarker for predicting tumor recurrence in HBV-related hepatocellular carcinoma. Insights Imaging 2023; 14:147. [PMID: 37697029 PMCID: PMC10495298 DOI: 10.1186/s13244-023-01505-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/16/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND To explore the pathologic basis and prognostic value of tumor and liver stiffness measured pre-operatively by two-dimensional shear wave elastography (2D-SWE) in hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) patients who undergo hepatic resection. METHODS A total of 191 HBV-infected patients with solitary resectable HCC were prospectively enrolled. The stiffness of intratumoral tissue, peritumoral tissue, adjacent liver tissue, and distant liver tissue was evaluated by 2D-SWE. The correlations between stiffness and pathological characteristics were analyzed in 114 patients. The predictive value of stiffness for recurrence-free survival (RFS) was evaluated, and Cutoff Finder was used for determining optimal cut-off stiffness values. Cox proportional hazards analysis was used to identify independent predictors of RFS. RESULTS Pathologically, intratumoral stiffness was associated with stroma proportion and microvascular invasion (MVI) while peritumoral stiffness was associated with tumor size, capsule, and MVI. Adjacent liver stiffness was correlated with capsule and liver fibrosis stage while distant liver stiffness was correlated with liver fibrosis stage. Peritumoral stiffness, adjacent liver stiffness, and distant liver stiffness were all correlated to RFS (all p < 0.05). Higher peritumoral stiffness (> 49.4 kPa) (HR = 1.822, p = 0.023) and higher adjacent liver stiffness (> 24.1 kPa) (HR = 1.792, p = 0.048) were significant independent predictors of worse RFS, along with tumor size and MVI. The nomogram based on these variables showed a C-index of 0.77 for RFS prediction. CONCLUSIONS Stiffness measured by 2D-SWE could be a tumor microenvironment and tumor invasiveness biomarker. Peritumoral stiffness and adjacent liver stiffness showed important values in predicting tumor recurrence after curative resection in HBV-related HCC. CLINICAL RELEVANCE STATEMENT Tumor and liver stiffness measured by two-dimensional shear wave elastography serve as imaging biomarkers for predicting hepatocellular carcinoma recurrence, reflecting biological behavior and tumor microenvironment. KEY POINTS • Stiffness measured by two-dimensional shear wave elastography is a useful biomarker of tumor microenvironment and invasiveness. • Higher stiffness indicated more aggressive behavior of hepatocellular carcinoma. • The study showed the prognostic value of peritumoral stiffness and adjacent liver stiffness for recurrence-free survival. • The nomogram integrating peritumoral stiffness, adjacent liver stiffness, tumor size, and microvascular invasion showed a C-index of 0.77.
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Affiliation(s)
- Xian Zhong
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Haiyi Long
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Lili Chen
- Department of Pathology, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Yuhua Xie
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Yifan Shi
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Jianyun Peng
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Ruiying Zheng
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Liya Su
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Yu Duan
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Xiaoyan Xie
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Manxia Lin
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, 510080, China.
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Zhang T, Zhang G, Deng X, Zeng J, Jin J, Zeping H, Wu M, Zheng R. APS (Age, Platelets, 2D Shear-Wave Elastography) Score Predicts Hepatocellular Carcinoma in Chronic Hepatitis B. Radiology 2021; 301:350-359. [PMID: 34427463 DOI: 10.1148/radiol.2021204700] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Two-dimensional (2D) shear-wave elastography (SWE) has been considered to be useful in predicting hepatocellular carcinoma (HCC) development in patients with chronic hepatitis B (CHB). Purpose To develop a risk model using 2D SWE to predict HCC in patients with CHB and to compare its predictive value with that of other models. Materials and Methods Patients with biopsy-proven CHB who underwent US and 2D SWE between April 2011 and December 2015 were enrolled in this study. After 2D SWE and biopsy were performed, the patients received regular follow-up for the detection of HCC. The scoring system was developed by dividing the parameters of the Cox proportional hazards model by the smallest parameter and simplifying the assigned points to integers. The predictive performance of the new score was compared with that of other scores. Results Among the 654 patients (mean age, 37 years; range, 30-43 years; 510 men), 26 developed HCC. The variables of age, platelet count, and liver stiffness measurement at 2D SWE were weighted to develop the so-called APS score, with a cutoff of 60 showing the best discrimination for HCC risk. The APS score (area under the receiver operating characteristic curve [AUC], 0.89) was superior to that of the Chinese University HCC prediction score constructed from age, albumin level, bilirubin level, hepatitis B virus (HBV) DNA level, and cirrhosis (AUC, 0.70; P = .005) and slightly higher than that of the guide with age, gender, HBV DNA level, core promoter mutations, and cirrhosis, or GAG-HCC score (AUC, 0.82; P = .052). In patients who underwent transient elastography, the AUC of the APS score was 0.79, compared with 0.82 for the modified risk estimation for HCC in CHB, or mREACH-B, score (P = .05). The APS score performed better in patients regardless of whether antiviral treatment was used, inflammation grade was low or high, or alanine aminotransferase levels were normal or high (all P > .05). Conclusion The APS score based on only the patient's baseline liver stiffness measurement at two-dimensional shear-wave elastography, age, and platelet count is valuable for predicting hepatocellular carcinoma in patients with chronic hepatitis B. © RSNA, 2021 Online supplemental material is available for this article.
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Affiliation(s)
- Ting Zhang
- From the Departments of Medical Ultrasonics (T.Z., J.Z., J.J., Z.H., M.W., R.Z.) and Infectious Disease (G.Z.), Third Affiliated Hospital of Sun Yat-Sen University, 600 TianHe Rd, Guangzhou 510630, China; and Department of Environmental Health Sciences, University at Albany, State University of New York, Rensselaer, NY (X.D.)
| | - Genglin Zhang
- From the Departments of Medical Ultrasonics (T.Z., J.Z., J.J., Z.H., M.W., R.Z.) and Infectious Disease (G.Z.), Third Affiliated Hospital of Sun Yat-Sen University, 600 TianHe Rd, Guangzhou 510630, China; and Department of Environmental Health Sciences, University at Albany, State University of New York, Rensselaer, NY (X.D.)
| | - Xinlei Deng
- From the Departments of Medical Ultrasonics (T.Z., J.Z., J.J., Z.H., M.W., R.Z.) and Infectious Disease (G.Z.), Third Affiliated Hospital of Sun Yat-Sen University, 600 TianHe Rd, Guangzhou 510630, China; and Department of Environmental Health Sciences, University at Albany, State University of New York, Rensselaer, NY (X.D.)
| | - Jie Zeng
- From the Departments of Medical Ultrasonics (T.Z., J.Z., J.J., Z.H., M.W., R.Z.) and Infectious Disease (G.Z.), Third Affiliated Hospital of Sun Yat-Sen University, 600 TianHe Rd, Guangzhou 510630, China; and Department of Environmental Health Sciences, University at Albany, State University of New York, Rensselaer, NY (X.D.)
| | - Jieyang Jin
- From the Departments of Medical Ultrasonics (T.Z., J.Z., J.J., Z.H., M.W., R.Z.) and Infectious Disease (G.Z.), Third Affiliated Hospital of Sun Yat-Sen University, 600 TianHe Rd, Guangzhou 510630, China; and Department of Environmental Health Sciences, University at Albany, State University of New York, Rensselaer, NY (X.D.)
| | - Huang Zeping
- From the Departments of Medical Ultrasonics (T.Z., J.Z., J.J., Z.H., M.W., R.Z.) and Infectious Disease (G.Z.), Third Affiliated Hospital of Sun Yat-Sen University, 600 TianHe Rd, Guangzhou 510630, China; and Department of Environmental Health Sciences, University at Albany, State University of New York, Rensselaer, NY (X.D.)
| | - Manli Wu
- From the Departments of Medical Ultrasonics (T.Z., J.Z., J.J., Z.H., M.W., R.Z.) and Infectious Disease (G.Z.), Third Affiliated Hospital of Sun Yat-Sen University, 600 TianHe Rd, Guangzhou 510630, China; and Department of Environmental Health Sciences, University at Albany, State University of New York, Rensselaer, NY (X.D.)
| | - Rongqin Zheng
- From the Departments of Medical Ultrasonics (T.Z., J.Z., J.J., Z.H., M.W., R.Z.) and Infectious Disease (G.Z.), Third Affiliated Hospital of Sun Yat-Sen University, 600 TianHe Rd, Guangzhou 510630, China; and Department of Environmental Health Sciences, University at Albany, State University of New York, Rensselaer, NY (X.D.)
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Yang J, Li J, Ye G, Luo Y. Comparison of Visual Transient Elastography and Shear Wave Elastography in Evaluating Liver Fibrosis in Patients with Chronic Liver Disease. Int J Gen Med 2021; 14:3553-3561. [PMID: 34295181 PMCID: PMC8290848 DOI: 10.2147/ijgm.s319101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/30/2021] [Indexed: 02/05/2023] Open
Abstract
Purpose This study investigated the effectiveness and feasibility of shear wave elastography ((sound touch elastography) STE and (shear wave elastography) SWE) and visual transient elastography (ViTE) in the noninvasive quantitative diagnosis of liver fibrosis in chronic liver disease (CLD). Patients and Methods A total of 106 patients with CLD underwent STE, SWE and ViTE elastography evaluation. The Young’s modulus of the three elastography was valuated and the diagnostic performances of the three techniques for liver fibrosis staging were compared. The area under the receiver operating curve (ROC) for the diagnosis of liver fibrosis was compared. The final diagnosis was based on the histological findings on the liver biopsy. Results 1) The correlation between ViTE and SWE, ViTE and STE, SWE and STE stiffness values were 0.72, 0.75, 0.75 (P<0.001). 2) The relationship between the results of each elastography technique and the stage of pathological liver fibrosis showed that the more severe the liver fibrosis was, the higher the stiffness value was (all P <0.001). 3) When the three elastography techniques were used to detect the degree of liver fibrosis in different pathological stages, there was no statistical difference in the stabilities of the boxplots. 4) The ROCs of the three elastography techniques (ViTE, SWE and STE) were 0.88, 0.91, 0.92, F0 vs F1-3; 0.84, 0.84, 0.84, F0-1 vs F2-4; 0.80, 0.79, 0.77, F0-2 vs F3-4; 0.80, 0.76, 0.71, F0-3 vs 4; the AUC of ViTE was higher than the AUC of STE in the identification of F4, but there were no statistical differences in the AUCs of other groups. Conclusion ViTE has good stability for the liver stiffness measurement (LSM) and a high consistency with shear-wave elastography (SWE and STE). It is an effective tool for evaluating CLD, and its performance is comparable to SWE and STE. The combination of ViTE and STE can improve the specificity of disease diagnosis and do not add extra cost and may improve cost performance.
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Affiliation(s)
- Jiali Yang
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Jiawu Li
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Guilin Ye
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Yan Luo
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
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Popa A, Șirli R, Popescu A, Bâldea V, Lupușoru R, Bende F, Cotrău R, Sporea I. Ultrasound-Based Quantification of Fibrosis and Steatosis with a New Software Considering Transient Elastography as Reference in Patients with Chronic Liver Diseases. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1692-1703. [PMID: 33832824 DOI: 10.1016/j.ultrasmedbio.2021.02.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/30/2021] [Accepted: 02/23/2021] [Indexed: 06/12/2023]
Abstract
The goal of this study was to evaluate the performance of two new ultrasound-based techniques (ShearWave PLUS elastography [2-D-SWE PLUS], SSp PLUS Imaging [SSp PLUS]) implemented on the Aixplorer Mach 30 ultrasound system (Supersonic Imagine, Aix-en-Provence, France) for the non-invasive assessment of liver steatosis and fibrosis, using transient elastography (TE) with the controlled attenuation parameter (CAP) as reference. This monocentric cross-sectional study included 133 consecutive adult patients with chronic hepatopathies. Liver stiffness and steatosis were evaluated in the same session using the techniques mentioned above. An excellent correlation was observed between liver stiffness measurements obtained with 2-D-SWE PLUS and TE (r = 0.92, p < 0.0001). The best cutoff value of 2-D-SWE PLUS for predicting F≥2 was 6.8 kPa; for F≥3, 8.4 kPa; and for F4, 11 kPa. With respect to steatosis evaluation, a strong negative correlation between CAP and SSp PLUS values (r = -0.70, p < 0.0001) was obtained. The best SSp PLUS cutoff value for predicting steatosis was 1537 m/s.
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Affiliation(s)
- Alexandru Popa
- Department of Gastroenterology and Hepatology, ''Victor Babeș'' University of Medicine and Pharmacy, Timișoara, România
| | - Roxana Șirli
- Department of Gastroenterology and Hepatology, ''Victor Babeș'' University of Medicine and Pharmacy, Timișoara, România
| | - Alina Popescu
- Department of Gastroenterology and Hepatology, ''Victor Babeș'' University of Medicine and Pharmacy, Timișoara, România
| | - Victor Bâldea
- Department of Gastroenterology and Hepatology, ''Victor Babeș'' University of Medicine and Pharmacy, Timișoara, România.
| | - Raluca Lupușoru
- Department of Gastroenterology and Hepatology, ''Victor Babeș'' University of Medicine and Pharmacy, Timișoara, România; Department of Functional Science, "Victor Babeș" University of Medicine and Pharmacy Timișoara, Romania
| | - Felix Bende
- Department of Gastroenterology and Hepatology, ''Victor Babeș'' University of Medicine and Pharmacy, Timișoara, România
| | - Radu Cotrău
- Department of Gastroenterology and Hepatology, ''Victor Babeș'' University of Medicine and Pharmacy, Timișoara, România
| | - Ioan Sporea
- Department of Gastroenterology and Hepatology, ''Victor Babeș'' University of Medicine and Pharmacy, Timișoara, România
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Popa A, Bende F, Șirli R, Popescu A, Bâldea V, Lupușoru R, Cotrău R, Fofiu R, Foncea C, Sporea I. Quantification of Liver Fibrosis, Steatosis, and Viscosity Using Multiparametric Ultrasound in Patients with Non-Alcoholic Liver Disease: A "Real-Life" Cohort Study. Diagnostics (Basel) 2021; 11:diagnostics11050783. [PMID: 33926073 PMCID: PMC8146051 DOI: 10.3390/diagnostics11050783] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 04/20/2021] [Accepted: 04/25/2021] [Indexed: 12/17/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide. This study aimed to evaluate the performance of four ultrasound-based techniques for the non-invasive multiparametric (MPUS) assessment of liver fibrosis (LF), steatosis (HS), and inflammation in patients with NAFLD. We included 215 consecutive adult patients with NAFLD (mean age: 54.9 ± 11.7; 54.5% were male), in whom LF, HS, and viscosity were evaluated in the same session using four new ultrasound-based techniques embedded on the Aixplorer MACH 30 system: ShearWave Elastography (2D-SWE.PLUS), Sound Speed Plane-wave UltraSound (SSp.PLUS), Attenuation Plane-wave UltraSound (Att.PLUS), and Viscosity Plane-wave UltraSound (Vi.PLUS). Transient Elastography (TE) with Controlled Attenuation Parameter (CAP) (FibroScan) were considered as control. All elastographic measurements were performed according to guidelines. Valid liver stiffness measurements (LSM) were obtained in 98.6% of patients by TE, in 95.8% of patients by 2D-SWE.PLUS/Vi.PLUS, and in 98.1% of patients by Att.PLUS/SSp.PLUS, respectively. Therefore, 204 subjects were included in the final analysis. A strong correlation between LSMs by 2D-SWE.PLUS and TE (r = 0.89) was found. The best 2D-SWE.PLUS cut-off value for the presence of significant fibrosis (F ≥ 2) was 7 kPa. Regarding steatosis, SSp.PLUS correlated better than Att.PLUS with CAP values: (r = −0.74) vs. (r = 0.45). The best SSp.PLUS cut-off value for predicting the presence of significant steatosis was 1524 m/s. The multivariate regression analysis showed that Vi.PLUS values were associated with BMI and LSM by 2D-SWE.PLUS. In conclusion, MPUS was useful for assessing fibrosis, steatosis, and inflammation in a single examination in patients with NAFLD.
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Prieto Ortiz JE, Garzón-Orjuela N, Sánchez Pardo S, Prieto Ortíz RG, Ochoa Díaz AF, Soto-Ospina PH, Eslava-Schmalbach JH. Elastografía en tiempo real (Supersonic), experiencia de un centro en Bogotá. REVISTA COLOMBIANA DE GASTROENTEROLOGÍA 2021; 36:58-64. [DOI: 10.22516/25007440.594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
Abstract
Introducción: la elastografía en tiempo real, 2D-SWE (Supersonic), es una prueba no invasiva que se utiliza para determinar la elasticidad del hígado y, de esa forma, calcular el grado de fibrosis hepática. En Colombia, la prueba se introdujo en 2016 y no existen hasta el momento estudios del comportamiento de la prueba en todos los pacientes hepáticos, solo se han publicado en pacientes sanos y cirróticos.
Objetivo: analizar la experiencia de la aplicación de la elastografía en tiempo real, en sujetos atendidos en el centro de enfermedades hepáticas y digestivas de Bogotá, Colombia.
Materiales y métodos: estudio descriptivo retrospectivo de una cohorte de sujetos atendidos entre marzo de 2016 y julio de 2017. Se realizó una historia clínica completa y una prueba de elastografía en tiempo real (Supersonic).
Resultados: se incluyeron 654 sujetos, con una mediana de edad de 55 años (rango intercuartílico [RIC]: 45-64). La mediana de valores de fibrosis expresada en kilopascales (kPs) fue de 8,3, con un promedio de 5 mediciones. Se observó una diferencia significativa en el grado de fibrosis entre los grupos de edad y en relación con el diagnóstico final, donde se evidenció una mayor fibrosis en el grupo de enfermedades colestásicas (autoinmune, colangitis biliar primaria [CBP] y superposición autoinmune-CBP). La tasa global de fracaso fue menor al 1 %.
Conclusiones: es la primera descripción del comportamiento de la prueba a nivel nacional. Los valores de rigidez hepática observados en los diferentes estadios demuestran la utilidad de la prueba para la determinación de la fibrosis hepática en pacientes con diferentes patologías.
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Lee DH, Lee ES, Bae JS, Lee JY, Han JK, Yi NJ, Lee KW, Suh KS, Kim H, Lee KB, Choi BI. 2D shear wave elastography is better than transient elastography in predicting post-hepatectomy complication after resection. Eur Radiol 2021; 31:5802-5811. [PMID: 33459859 DOI: 10.1007/s00330-020-07662-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/11/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Both transient elastography (TE) and 2D shear wave elastography (SWE) are accurate methods to evaluate liver fibrosis. We aimed to evaluate the diagnostic performance of 2D-SWE in predicting post-hepatectomy complication and to compare it with TE. METHODS We prospectively enrolled 125 patients with liver tumors. Liver stiffness (LS) (kilopascal [kPa]) was measured using both TE and 2D-SWE before surgery. All post-operative complication was evaluated using the comprehensive complication index (CCI), and CCI ≥ 26.2 was defined as severe complication. Logistic regression analysis was performed to identify predictive factors for severe complication. Receiver operating characteristic analysis was used to evaluate the diagnostic performance of TE/2D-SWE in detecting liver fibrosis and severe complication. RESULTS Severe complication developed in 18 patients. The median LS in patients with severe complication was significantly higher for both 2D-SWE (11.4 kPa vs. 7.0 kPa, p < 0.001) and TE (8.9 kPa vs. 6.2 kPa, p = 0.009). LS obtained from 2D-SWE was a significant factor correlated with severe complication (odds ratio: 1.27 per kPa [1.10-1.46], p = 0.001). The diagnostic performance of 2D-SWE was significantly higher than that of TE in detecting both ≥F3 (p = 0.024) and F4 (p = 0.048). The area under the curve of 2D-SWE to predict severe complication was 0.854, significantly higher than 0.692 of TE (p = 0.004). The optimal cut-off LS from 2D-SWE to predict severe complication was 8.6 kPa, with sensitivity of 88.9% (16/18) and specificity of 73.8% (79/107). CONCLUSION LS obtained from 2D-SWE was a significant predictive factor for severe complication, and 2D-SWE showed significantly a better diagnostic performance than TE in detecting liver fibrosis and severe complication. KEY POINTS • The diagnostic performance of 2D-SWE was significantly higher than that of TE in detecting both ≥ F3 (AUC: 0.853 vs. 0.779, p = 0.024) and F4 (AUC: 0.929 vs. 0.872, p = 0.048). • Liver stiffness value obtained from 2D-SWE was a significant factor correlated with the development of severe complication defined as CCI ≥ 26.2 after hepatic resection for liver tumors (odds ratio: 1.27 per kPa [1.10-1.46], p = 0.001). • 2D-SWE provided significantly a better diagnostic performance in predicting severe complication after hepatic resection than TE (AUC for 2D-SWE: 0.853 vs. AUC for TE: 0.692, p = 0.004).
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Affiliation(s)
- Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul, 03080, South Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, South Korea
| | - Eun Sun Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, South Korea.,Department of Radiology, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Jae Seok Bae
- Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul, 03080, South Korea
| | - Jae Young Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul, 03080, South Korea. .,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, South Korea. .,Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea.
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul, 03080, South Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, South Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung Bun Lee
- Department of Pathology, Seoul National University College of Medicine, Seoul, South Korea
| | - Byung Ihn Choi
- Department of Radiology, Chung-Ang University Hospital, Seoul, South Korea
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Brattain LJ, Ozturk A, Telfer BA, Dhyani M, Grajo JR, Samir AE. Image Processing Pipeline for Liver Fibrosis Classification Using Ultrasound Shear Wave Elastography. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:2667-2676. [PMID: 32622685 PMCID: PMC7483774 DOI: 10.1016/j.ultrasmedbio.2020.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 05/28/2023]
Abstract
The purpose of this study was to develop an automated method for classifying liver fibrosis stage ≥F2 based on ultrasound shear wave elastography (SWE) and to assess the system's performance in comparison with a reference manual approach. The reference approach consists of manually selecting a region of interest from each of eight or more SWE images, computing the mean tissue stiffness within each of the regions of interest and computing a resulting stiffness value as the median of the means. The 527-subject database consisted of 5526 SWE images and pathologist-scored biopsies, with data collected from a single system at a single site. The automated method integrates three modules that assess SWE image quality, select a region of interest from each SWE measurement and perform machine learning-based, multi-image SWE classification for fibrosis stage ≥F2. Several classification methods were developed and tested using fivefold cross-validation with training, validation and test sets partitioned by subject. Performance metrics were area under receiver operating characteristic curve (AUROC), specificity at 95% sensitivity and number of SWE images required. The final automated method yielded an AUROC of 0.93 (95% confidence interval: 0.90-0.94) versus 0.69 (95% confidence interval: 0.65-0.72) for the reference method, 71% specificity with 95% sensitivity versus 5% and four images per decision versus eight or more. In conclusion, the automated method reported in this study significantly improved the accuracy for ≥F2 classification of SWE measurements as well as reduced the number of measurements needed, which has the potential to reduce clinical workflow.
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Affiliation(s)
- Laura J Brattain
- MIT Lincoln Laboratory, Lexington, Massachusetts, USA; Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Arinc Ozturk
- Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Manish Dhyani
- Department of Radiology, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA
| | - Joseph R Grajo
- Abdominal Imaging Division, Department of Radiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Anthony E Samir
- Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Lee DH, Lee ES, Lee JY, Bae JS, Kim H, Lee KB, Yu SJ, Cho EJ, Lee JH, Cho YY, Han JK, Choi BI. Two-Dimensional-Shear Wave Elastography with a Propagation Map: Prospective Evaluation of Liver Fibrosis Using Histopathology as the Reference Standard. Korean J Radiol 2020; 21:1317-1325. [PMID: 32729274 PMCID: PMC7689142 DOI: 10.3348/kjr.2019.0978] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/08/2020] [Accepted: 04/13/2020] [Indexed: 02/06/2023] Open
Abstract
Objective The aim of this study was to prospectively evaluate whether liver stiffness (LS) assessments, obtained by two-dimensional (2D)-shear wave elastography (SWE) with a propagation map, can evaluate liver fibrosis stage using histopathology as the reference standard. Materials and Methods We prospectively enrolled 123 patients who had undergone percutaneous liver biopsy from two tertiary referral hospitals. All patients underwent 2D-SWE examination prior to biopsy, and LS values (kilopascal [kPa]) were obtained. On histopathologic examination, fibrosis stage (F0–F4) and necroinflammatory activity grade (A0–A4) were assessed. Multivariate linear regression analysis was performed to determine the significant factors affecting the LS value. The diagnostic performance of the LS value for staging fibrosis was assessed using receiver operating characteristic (ROC) analysis, and the optimal cut-off value was determined by the Youden index. Results Reliable measurements of LS values were obtained in 114 patients (92.7%, 114/123). LS values obtained from 2D-SWE with the propagation map positively correlated with the progression of liver fibrosis reported from histopathology (p < 0.001). According to the multivariate linear regression analysis, fibrosis stage was the only factor significantly associated with LS (p < 0.001). The area under the ROC curve of LS from 2D-SWE with the propagation map was 0.773, 0.865, 0.946, and 0.950 for detecting F ≥ 1, F ≥ 2, F ≥ 3, and F = 4, respectively. The optimal cut-off LS values were 5.4, 7.8, 9.4, and 12.2 kPa for F ≥ 1, F ≥ 2, F ≥ 3, and F = 4, respectively. The corresponding sensitivity and specificity of the LS value for detecting cirrhosis were 90.9% and 88.4%, respectively. Conclusion The LS value obtained from 2D-SWE with a propagation map provides excellent diagnostic performance in evaluating liver fibrosis stage, determined by histopathology.
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Affiliation(s)
- Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Eun Sun Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Jae Young Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea.
| | - Jae Seok Bae
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - Kyung Bun Lee
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - Su Jong Yu
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eun Ju Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young Youn Cho
- Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Ihn Choi
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
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Jamialahmadi T, Nematy M, Jangjoo A, Goshayeshi L, Rezvani R, Ghaffarzadegan K, Nooghabi MJ, Shalchian P, Zangui M, Javid Z, Doaei S, Rajabzadeh F. Measurement of Liver Stiffness with 2D-Shear Wave Elastography (2D-SWE) in Bariatric Surgery Candidates Reveals Acceptable Diagnostic Yield Compared to Liver Biopsy. Obes Surg 2020; 29:2585-2592. [PMID: 31077025 DOI: 10.1007/s11695-019-03889-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is common among severely obese patients. Two-dimensional shear wave elastography (2D-SWE) has been validated as a noninvasive diagnostic tool for liver stiffness measurement. However, the technical feasibility and accuracy of this method in severely obese patients are still under debate. OBJECTIVE We aimed to assess the diagnostic accuracy of 2D-SWE in bariatric surgery candidates in comparison with the gold standard liver biopsy. METHODS Ninety severely obese candidates for bariatric surgery were included. Liver stiffness was measured using 2D-SWE 14 days before liver biopsy. Liver biopsy was taken on the day of surgery. The area under the receiver operating curve (AUROC) was calculated for the staging of liver fibrosis. RESULTS 2D-SWE was performed in 97.3% of patients successfully. Histologic stages of fibrosis (F0-F4) were detected in 34.2%, 36%, 6.3%, 3.6%, and 0.9% of patients, respectively. The AUROC for 2D-SWE was 0.77 for F1, 0.72 for F2, 0.77 for F3, and 0.70 for F4. In univariate analysis, 2D-SWE values were correlated with BMI, waist circumference, NAFLD activity score (NAS), and steatosis, whereas these components did not affect liver stiffness in multivariate analysis. CONCLUSION Two-dimensional shear wave elastography of the liver can be feasible and has good accuracy in severely obese candidates for bariatric surgery. Therefore, 2D-SWE may be a good option for assessing liver fibrosis, especially in the early stages of fibrosis to lessen complications of surgery in this population. However, this method should be applied on a larger scale for late stage of fibrosis.
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Affiliation(s)
- Tannaz Jamialahmadi
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, 9177948564, Iran
| | - Mohsen Nematy
- Biochemistry and Nutrition Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, 9177948564, Iran
| | - Ali Jangjoo
- Surgical Oncology Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, 9177948564, Iran
| | - Ladan Goshayeshi
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.,Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, 9177948564, Iran
| | - Reza Rezvani
- Biochemistry and Nutrition Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, 9177948564, Iran
| | - Kamran Ghaffarzadegan
- Pathology Department, Education and Research Department, Razavi Hospital, Mashhad, 9177948564, Iran
| | - Mehdi Jabbari Nooghabi
- Department of Statistics, Faculty of Mathematical Sciences, Ferdowsi University of Mashhad, Mashhad, 9177948944, Iran
| | - Payman Shalchian
- Hazrat Zahra Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahtab Zangui
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, 9177948564, Iran
| | - Zeinab Javid
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, 9177948564, Iran
| | - Saeid Doaei
- Research Center of Health and Environment, Guilan University of Medical Sciences, Rasht, 1313973476, Iran
| | - Farnood Rajabzadeh
- Department of Radiology, Faculty of Medicine, Islamic Azad University-Mashhad Branch, Mashhad, 9137714639, Iran.
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11
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Saloux E, Gauthier M, Buklas D, Saplacan V, Denoyer A, Labombarda F, Raitiere O, Criton A, Milliez P, Bauer F. Direct measurement of cardiac stiffness using echocardiographic shearwave imaging during open-chest surgery: A pilot study in human. Echocardiography 2020; 37:722-731. [PMID: 32388915 DOI: 10.1111/echo.14626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/30/2020] [Accepted: 02/16/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Cardiac stiffness is a marker of diastolic function with a strong prognostic significance in many heart diseases that is not measurable in clinical practice. This study investigates whether elastometry, a surrogate for organ stiffness, is measurable in the heart using ShearWave Imaging. METHODS In 33 anesthetized patients scheduled for cardiac surgery, ShearWave imaging was acquired epicardially using a dedicated ultrasound machine on the left ventricle parallel to the left anterior descending coronary artery in a loaded heart following the last cardiac beat. Cardiac elastometry was measured offline using the Young modulus with customized software. RESULTS Overall, the ejection fraction was 61 ± 10%. E/A and E/e' ratios were 1.0 ± 0.5 and 10.5 ± 4.1, respectively. Cardiac elastometry averaged 15.3 ± 5.3 kPa with a median of 18 kPa. Patients with high elastometry >18 kPa were older (P = .04), had thicker (P = .02) but smaller LV (P = .004), had larger left atria (P = .05) and a higher BNP level (P = .04). We distinguished three different transmural elastometry patterns: higher epicardial, higher endocardial, or uniformly distributed elastometry. CONCLUSION Elastometry measurement was feasible for the human heart. This surrogate for cardiac stiffness dichotomized patients with low and high elastometry, and provided three different phenotypes of transmural elastometry with link to diastolic function.
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Affiliation(s)
- Eric Saloux
- Department of cardiology and Caen Basse-Normandie University, Caen University Hospital, Caen, France
| | - Michael Gauthier
- Department of cardiology, Caen University Hospital, Caen, France
| | - Dimitrios Buklas
- Department of cardiac surgery, Caen University Hospital, Caen, France
| | - Vladimir Saplacan
- Department of cardiac surgery, Caen University Hospital, Caen, France
| | | | - Fabien Labombarda
- Department of cardiology and Caen Basse-Normandie University, Caen University Hospital, Caen, France
| | - Olivier Raitiere
- Department of cardiology, Rouen University Hospital, Rouen, France
| | | | - Paul Milliez
- Department of cardiology and Caen Basse-Normandie University, Caen University Hospital, Caen, France
| | - Fabrice Bauer
- Pulmonary Hypertension and Advanced Heart Failure Clinic, Department of Cardiac Surgery, INSERM U1096, Rouen University Hospital, Rouen, France
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12
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Wei H, Jiang HY, Li M, Zhang T, Song B. Two-dimensional shear wave elastography for significant liver fibrosis in patients with chronic hepatitis B: A systematic review and meta-analysis. Eur J Radiol 2020; 124:108839. [PMID: 31981878 DOI: 10.1016/j.ejrad.2020.108839] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE To determine the diagnostic performance and cutoff value of two-dimensional shear wave elastography (2D SWE) for detecting significant liver fibrosis in patients with chronic hepatitis B (CHB). METHODS A systematic literature search of the PubMed, EMBASE, Cochrane Library databases and Web of Science was conducted. Bivariate modelling and summary receiver-operating-characteristic (ROC) modelling were constructed to summarize the diagnostic performance of 2D SWE. Meta-regression analyses were performed to explore the source of heterogeneity. RESULTS Eleven eligible studies with 2623 patients were included. 2D SWE showed a summary sensitivity of 88 % (95 % CI: 83-91), specificity of 83 % (95 % CI: 78-88) and area under the ROC curve of 0.92 (95 % CI: 0.89-0.94) for detecting significant fibrosis in CHB patients. The mean threshold of 2D SWE was 7.91 kPa (range: 6.73-10.00 kPa). Notably, the cutoffs of studies excluding patients with history of prior antiviral therapy were generally lower than that of studies without excluding those who had received antiviral treatment, with an average of 7.15 kPa and 8.87 kPa, respectively (p < 0.01). Meta-regression analysis revealed that enrollment of consecutive patients was the only significant factor influencing heterogeneity (p < 0.01). Specifically, studies recruiting consecutive patients with CHB had significantly lower sensitivity than those with absence of consecutive enrolment (0.83 vs 0.92, p < 0.01). CONCLUSIONS 2D SWE is an excellent modality for predicting significant liver fibrosis in CHB populations. Further work is required to establish the cutoffs that account for antiviral treatment as a potential confounding factor.
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Affiliation(s)
- Hong Wei
- Department of Radiology, Sichuan University West China Hospital, Chengdu, Sichuan Province, China
| | - Han-Yu Jiang
- Department of Radiology, Sichuan University West China Hospital, Chengdu, Sichuan Province, China
| | - Mou Li
- Department of Radiology, Sichuan University West China Hospital, Chengdu, Sichuan Province, China
| | - Tong Zhang
- Department of Radiology, Sichuan University West China Hospital, Chengdu, Sichuan Province, China
| | - Bin Song
- Department of Radiology, Sichuan University West China Hospital, Chengdu, Sichuan Province, China.
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Performance of B-mode ratio and 2D shear wave elastography for the detection and quantification of hepatic steatosis and fibrosis after liver transplantation. Eur J Gastroenterol Hepatol 2020; 32:222-230. [PMID: 31464783 DOI: 10.1097/meg.0000000000001500] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate the diagnostic performance of B-mode ratio and shear wave elastography (SWE) for the assessment of steatosis and liver fibrosis after liver transplantation. MATERIALS AND METHODS Patients hospitalized for a systematic check-up after liver transplantation underwent the same day hepatic ultrasound with B-mode ratio and SWE, followed by liver biopsy and biological examinations. Steatosis was measured using hepatorenal sonographic index of B-mode ratio and liver stiffness using SWE. Liver biopsy, used as gold standard, graded steatosis S0(<5%), S1(5-<33%), S2(33-<66%), or S3(≥66%) and liver fibrosis according to the Metavir score. The results were tested against two external validation cohorts. RESULTS Fifty-eight patients were included. Mean B-ratio value was significantly higher in patients with steatosis (0.95 ± 0.13 versus 1.39 ± 0.41, P < 0.001). A B-mode ratio cutoff values at least 0.985 was found optimal for steatosis' detection [area under the receiver operating characteristic curve (AUROC) 0.902 ± 0.05, sensitivity 95%, specificity 79%]. A B-mode ratio value below 0.9 ruled out steatosis and above 1.12 ruled in steatosis. Mean SWE value for patients without significant fibrosis (≤F1) was 15.90 ± 9.2 versus 19.27 ± 7.7 kPa for patients with fibrosis (P = 0.185). A 2D-SWE value below 7.85 kPa ruled out significant fibrosis and above 26.35 kPa ruled it in. CONCLUSION The B-mode ratio is an efficient and accurate tool for the noninvasive diagnostic of steatosis in postliver transplantation patients. Yet, because liver stiffness is higher in postliver transplantation patients, 2D-SWE is not reliable in the diagnosis of significant fibrosis after liver transplantation.
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Assessment of Fibrosis in Liver Transplant Recipients: Diagnostic Performance of Shear Wave Elastography (SWE) and Correlation of SWE Findings With Biopsy Results. AJR Am J Roentgenol 2019; 213:W264-W271. [PMID: 31573849 DOI: 10.2214/ajr.19.21160] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE. Liver transplant patients are monitored for rejection and hepatic fibrosis and often undergo liver biopsies. The purpose of the present study is to determine whether noninvasive shear wave elastography (SWE) can quantify fibrosis in liver transplant recipients, with the aim of decreasing and possibly eliminating unnecessary biopsies for patients with suspected or progressive hepatic fibrosis. MATERIALS AND METHODS. Between May 1, 2015, and December 31, 2017, our prospective study evaluated 111 adult liver transplant patients (age range, 23-79 years) who underwent 147 ultrasound (US) SWE examinations of the right hepatic lobe followed by biopsies. SWE values were compared with the histologic fibrosis (Metavir) scores of the biopsy samples. SWE threshold values were determined using classification and regression tree analysis by anchoring to the degree of fibrosis. The sensitivity, specificity, positive predictive value, and negative predictive value (with 95% CIs) were calculated on the basis of the threshold value. Overall prediction accuracy was estimated using the AUC value from the ROC curve. RESULTS. From the 147 US SWE examinations and liver biopsies, consistent threshold values were identified for patients with no or minimal fibrosis (Metavir scores of F0 and F1, respectively) compared with significant fibrosis (Metavir scores of F2, F3, or F4). A median SWE value of 1.76 m/s or less denoted no or minimal fibrosis, whereas a value greater than 1.76 m/s denoted significant fibrosis. The sensitivity of US SWE examinations in classifying fibrosis was 0.77 (95% CI, 0.5-0.93). The specificity, positive predictive value, and negative predictive value were 0.79 (95% CI, 0.71-0.86), 0.33 (95% CI, 0.19-0.49), and 0.96 (95% CI, 0.91-0.99), respectively. CONCLUSION. Liver transplant patients may avoid liver biopsy if US SWE examination shows a median shear wave velocity of 1.76 or less, which corresponds to a Metavir score of F0 or F1, denoting no or minimal fibrosis.
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15
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Simkin P, Rattansingh A, Liu K, Hudson JM, Atri M, Jang HJ, Kim TK, Khalili K. Reproducibility of 2 Liver 2-Dimensional Shear Wave Elastographic Techniques in the Fasting and Postprandial States. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:1739-1745. [PMID: 30536401 DOI: 10.1002/jum.14862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 10/11/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The purpose of this study was to compare the reliability and agreement of 2 methods of 2-dimensional (2D) shear wave elastography (SWE) on liver stiffness in healthy volunteers. We also assessed effects of the prandial state and operator experience on measurements. METHODS Two operators, 1 experienced and 1 novice, independently examined 20 healthy volunteers with 2D SWE on 2 ultrasound machines (Aixplorer [SuperSonic Imagine, Aix-en-Provence, France] and Aplio 500 [Canon Medical Systems Corporation, Otawara, Japan]). Volunteers were scanned 8 times by the operators using both machines in fasting and postprandial states. Agreement was evaluated by a Bland-Altman analysis, and the correlation was assessed by the Pearson correlation and intraclass correlation coefficients (ICCs). An analysis of variance was conducted to determine the contribution of the machine, prandial state, and operator experience to the variability. RESULTS Agreement assessed by Bland-Altman plots showed no statistically significant difference in measured liver stiffness between the machines (mean difference, -0.8%; 95% confidence interval, -3.7%, 2.1%), with a critical difference of 1.36 kPa. The correlation was good to excellent for both the crude overall Pearson coefficient and the ICC, both measuring 0.88 (95% confidence interval, 0.82, 0.92). Subclass ICCs for the fasting state, postprandial state, novice operator, and experienced operator were 0.89, 0.88, 0.90, and 0.86, respectively. The 2-way mixed effect analysis of variance showed that the volunteers accounted for 86.3% of variation in median liver stiffness, with no statistically significant contribution from operator experience, the prandial state, or the machine (P = .108, .067, and .296, respectively). CONCLUSIONS Our study showed that the 2D SWE techniques had a high degree of reliability and agreement in measurement of liver stiffness in a healthy population. Operator experience and the prandial state did not impart significant variability to stiffness measurements.
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Affiliation(s)
- Paul Simkin
- Departments of Medical Imaging, Toronto, Ontario, Canada
| | | | - Kuan Liu
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Mostafa Atri
- Departments of Medical Imaging, Toronto, Ontario, Canada
| | - Hyun-Jung Jang
- Departments of Medical Imaging, Toronto, Ontario, Canada
| | - Tae Kyoung Kim
- Departments of Medical Imaging, Toronto, Ontario, Canada
| | - Korosh Khalili
- Departments of Medical Imaging, Toronto, Ontario, Canada
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Jian ZC, Long JF, Liu YJ, Hu XD, Liu JB, Shi XQ, Li WS, Qian LX. Diagnostic value of two dimensional shear wave elastography combined with texture analysis in early liver fibrosis. World J Clin Cases 2019; 7:1122-1132. [PMID: 31183343 PMCID: PMC6547320 DOI: 10.12998/wjcc.v7.i10.1122] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 03/19/2019] [Accepted: 04/09/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Staging diagnosis of liver fibrosis is a prerequisite for timely diagnosis and therapy in patients with chronic hepatitis B. In recent years, ultrasound elastography has become an important method for clinical noninvasive assessment of liver fibrosis stage, but its diagnostic value for early liver fibrosis still needs to be further improved. In this study, the texture analysis was carried out on the basis of two dimensional shear wave elastography (2D-SWE), and the feasibility of 2D-SWE plus texture analysis in the diagnosis of early liver fibrosis was discussed.
AIM To assess the diagnostic value of 2D-SWE combined with textural analysis in liver fibrosis staging.
METHODS This study recruited 46 patients with chronic hepatitis B. Patients underwent 2D-SWE and texture analysis; Young's modulus values and textural patterns were obtained, respectively. Textural pattern was analyzed with regard to contrast, correlation, angular second moment (ASM), and homogeneity. Pathological results of biopsy specimens were the gold standard; comparison and assessment of the diagnosis efficiency were conducted for 2D-SWE, texture analysis and their combination.
RESULTS 2D-SWE displayed diagnosis efficiency in early fibrosis, significant fibrosis, severe fibrosis, and early cirrhosis (AUC > 0.7, P < 0.05) with respective AUC values of 0.823 (0.678-0.921), 0.808 (0.662-0.911), 0.920 (0.798-0.980), and 0.855 (0.716-0.943). Contrast and homogeneity displayed independent diagnosis efficiency in liver fibrosis stage (AUC > 0.7, P < 0.05), whereas correlation and ASM showed limited values. AUC of contrast and homogeneity were respectively 0.906 (0.779-0.973), 0.835 (0.693-0.930), 0.807 (0.660-0.910) and 0.925 (0.805-0.983), 0.789 (0.639-0.897), 0.736 (0.582-0.858), 0.705 (0.549-0.883) and 0.798 (0.650-0.904) in four liver fibrosis stages, which exhibited equivalence to 2D-SWE in diagnostic efficiency (P > 0.05). Combined diagnosis (PRE) displayed diagnostic efficiency (AUC > 0.7, P < 0.01) for all fibrosis stages with respective AUC of 0.952 (0.841-0.994), 0.896 (0.766-0.967), 0.978 (0.881-0.999), 0.947 (0.835-0.992). The combined diagnosis showed higher diagnosis efficiency over 2D-SWE in early liver fibrosis (P < 0.05), whereas no significant differences were observed in other comparisons (P > 0.05).
CONCLUSION Texture analysis was capable of diagnosing liver fibrosis stage, combined diagnosis had obvious advantages in early liver fibrosis, liver fibrosis stage might be related to the hepatic tissue hardness distribution.
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Affiliation(s)
- Zhao-Cheng Jian
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
- Medical Imaging Center, Affiliated Hospital of Weifang Medical University, Weifang 261031, Shandong Province, China
| | - Jin-Feng Long
- Medical Imaging Center, Affiliated Hospital of Weifang Medical University, Weifang 261031, Shandong Province, China
| | - Yu-Jiang Liu
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Xiang-Dong Hu
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Ji-Bin Liu
- Institute of Ultrasound, Thomas Jefferson University Hospital, Philadelphia, PA 19107, United States
| | - Xian-Quan Shi
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Wei-Sheng Li
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Lin-Xue Qian
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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17
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Zhang W, Zhu Y, Zhang C, Ran H. Diagnostic Accuracy of 2-Dimensional Shear Wave Elastography for the Staging of Liver Fibrosis: A Meta-analysis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:733-740. [PMID: 30171621 PMCID: PMC7379518 DOI: 10.1002/jum.14760] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/01/2018] [Accepted: 06/29/2018] [Indexed: 05/12/2023]
Abstract
OBJECTIVES To evaluate the overall accuracy of 2-dimensional shear wave elastography (SWE) for the staging of liver fibrosis. METHODS Literature databases and conference abstracts were searched from 2000 to September 2017. Sensitivity, specificity, and other information were extracted from the included studies. Methodological quality was assessed with Quality Assessment of Diagnostic Accuracy Studies 2 tools. Data were synthesized by a bivariate hierarchical model. RESULTS The summary sensitivity and specificity were 0.85 (95% confidence interval [CI], 0.80-0.89) and 0.79 (95% CI, 0.72-0.85) for fibrosis stage F≥2, 0.90 (95% CI, 0.87-0.93) and 0.85 (95% CI, 0.80-0.89) for F≥3, and 0.89 (95% CI, 0.84-0.93) and 0.92 (95% CI, 0.89-0.95) for F=4, respectively. The areas under the summary receiver operating characteristic curve for F≥2, F≥3, and F=4 was 0.81, 0.77, and 0.84. CONCLUSIONS Two-dimensional SWE is a good noninvasive method for the diagnosis of substantial liver fibrosis and cirrhosis. Further studies are needed to assess severe fibrosis and to perform head-to-head comparisons of 2-dimensional SWE and other imaging modalities for the evaluation of liver fibrosis.
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Affiliation(s)
- Wei Zhang
- Institute of Ultrasound Imaging and Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ultrasound Molecular ImagingChongqingChina
| | - Ya Zhu
- Department of Obstetrics and Gynecology, Dong Feng Affiliated HospitalHubei University of MedicineShiyanChina
| | - Cuncheng Zhang
- Institute of Ultrasound Imaging and Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ultrasound Molecular ImagingChongqingChina
| | - Haitao Ran
- Institute of Ultrasound Imaging and Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ultrasound Molecular ImagingChongqingChina
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18
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Dhyani M, Xiang F, Li Q, Chen L, Li C, Bhan AK, Anthony B, Grajo JR, Samir AE. Ultrasound Shear Wave Elastography: Variations of Liver Fibrosis Assessment as a Function of Depth, Force and Distance from Central Axis of the Transducer with a Comparison of Different Systems. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:2209-2222. [PMID: 30143339 PMCID: PMC6594152 DOI: 10.1016/j.ultrasmedbio.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 06/25/2018] [Accepted: 07/05/2018] [Indexed: 05/10/2023]
Abstract
We evaluated variation in fibrosis staging caused by depth, pre-load force and measurement off-axis distance on different ultrasound shear wave elastography (SWE) systems prospectively in 20 patients with diffuse liver disease. Shear wave speed (SWS) was measured with transient elastography, acoustic radiation force impulse (ARFI) and 2-D shear wave elastography (SWE). ARFI and 2-D-SWE measurements were obtained at different depths (3, 5 and 7 cm), with different pre-load forces (4, 7 and 10N and variable) and at 0, 2 and 4cm off the central axis of the transducer. A single, blinded pathologist staged fibrosis using the METAVIR system (F0-F4). Area under the receiver operating characteristic curve was charted to differentiate significant fibrosis (F ≥ 2). Depth was the only factor found to influence ARFI-derived values; no acquisition factors were found to affect 2-D-SWE SWS values. ARFI and 2-D-SWE for diagnosis of significant fibrosis at a depth of 7cm along the central axis had good diagnostic performance (areas under the receiver operating characteristic curve: 0.92 and 0.82, respectively), comparable to that of transient elastography. Further investigation of this finding will likely be of interest.
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Affiliation(s)
- Manish Dhyani
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Feixiang Xiang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China.
| | - Qian Li
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Luzeng Chen
- Peking University First Hospital Ultrasound Center, Beijing, China
| | - Changtian Li
- Department of Ultrasound, The Southern Building, Chinese PLA General Hospital, Beijing, China
| | - Atul K Bhan
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian Anthony
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Joseph R Grajo
- Department of Radiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Anthony E Samir
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Gonzales E, Matarazzo L, Franchi-Abella S, Dabadie A, Cohen J, Habes D, Hillaire S, Guettier C, Taburet AM, Myara A, Jacquemin E. Cholic acid for primary bile acid synthesis defects: a life-saving therapy allowing a favorable outcome in adulthood. Orphanet J Rare Dis 2018; 13:190. [PMID: 30373615 PMCID: PMC6206929 DOI: 10.1186/s13023-018-0920-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 09/24/2018] [Indexed: 02/08/2023] Open
Abstract
Background Oral cholic acid (CA) replacement has been shown to be an effective therapy in children with primary bile acid synthesis defects, which are rare and severe genetic liver diseases. To date there has been no report of the effects of this therapy in children reaching adulthood. The aim of the study was to evaluate the long-term effectiveness and safety of CA therapy. Methods Fifteen patients with either 3β-hydroxy-Δ5-C27-steroid oxidoreductase (3β-HSD) (n = 13) or Δ4–3-oxosteroid 5β-reductase (Δ4–3-oxo-R) (n = 2) deficiency confirmed by mass spectrometry and gene sequencing received oral CA and were followed prospectively. Results The median age at last follow-up and the median time of follow-up with treatment were 24.3 years (range: 15.3–37.2) and 21.4 years (range: 14.6–24.1), respectively. At last evaluation, physical examination findings and blood laboratory test results were normal in all patients. Liver sonograms were normal in most patients. Mean daily CA dose was 6.9 mg/kg of body weight. Mass spectrometry analysis of urine showed that excretion of the atypical metabolites remained low or traces in amount with CA therapy. Liver fibrosis scored in liver biopsies or assessed by elastography in 14 patients, after 10 to 24 years with CA therapy, showed a marked improvement with disappearance of cirrhosis (median score < F1; range: F0-F2). CA was well tolerated in all patients, including five women having 10 uneventful pregnancies during treatment. Conclusions Oral CA therapy is a safe and effective long-term treatment of 3β-HSD and Δ4–3-oxo-R deficiencies and allows affected children to reach adulthood in good health condition without the need for a liver transplantation.
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Affiliation(s)
- Emmanuel Gonzales
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, National Reference Centre for rare pediatric liver diseases and Filfoie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris, France.,Faculty of Medicine Paris - Sud, University Paris - Sud / Paris - Saclay, Paris, France.,INSERM UMR-S1174 and Hepatinov, University Paris -Sud / Paris - Saclay, Orsay, France.,Service d'Hépatologie et de Transplantation Hépatique Pédiatriques, Hôpital Bicêtre, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, France
| | | | - Stéphanie Franchi-Abella
- Faculty of Medicine Paris - Sud, University Paris - Sud / Paris - Saclay, Paris, France.,Pediatric Radiology Unit, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Alain Dabadie
- Department of Pediatrics, Hôpital Sud, Rennes, France
| | - Joseph Cohen
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, National Reference Centre for rare pediatric liver diseases and Filfoie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Dalila Habes
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, National Reference Centre for rare pediatric liver diseases and Filfoie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sophie Hillaire
- Hepatology Unit, Hôpital Foch, and Hôpital Beaujon, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Catherine Guettier
- Faculty of Medicine Paris - Sud, University Paris - Sud / Paris - Saclay, Paris, France.,Pathology Unit, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Anne-Marie Taburet
- Pharmacy Unit, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Anne Myara
- Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Emmanuel Jacquemin
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, National Reference Centre for rare pediatric liver diseases and Filfoie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris, France. .,Faculty of Medicine Paris - Sud, University Paris - Sud / Paris - Saclay, Paris, France. .,INSERM UMR-S1174 and Hepatinov, University Paris -Sud / Paris - Saclay, Orsay, France.
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20
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Grgurevic I, Bokun T, Salkic NN, Brkljacic B, Vukelić-Markovic M, Stoos-Veic T, Aralica G, Rakic M, Filipec-Kanizaj T, Berzigotti A. Liver elastography malignancy prediction score for noninvasive characterization of focal liver lesions. Liver Int 2018; 38:1055-1063. [PMID: 29028279 DOI: 10.1111/liv.13611] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/03/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS To analyse elastographic characteristics of focal liver lesions (FLL)s and diagnostic performance of real-time two-dimensional shear-wave elastography (RT-2D-SWE) in order to differentiate benign and malignant FLLs. METHODS Consecutive patients diagnosed with FLL by abdominal ultrasound (US) underwent RT-2D-SWE of FLL and non-infiltrated liver by intercostal approach over the right liver lobe. The nature of FLL was determined by diagnostic work-up, including at least one contrast-enhanced imaging modality (MDCT/MRI), check-up of target organs when metastatic disease was suspected and FLL biopsy in inconclusive cases. RESULTS We analysed 196 patients (median age 60 [range 50-68], 50.5% males) with 259 FLLs (57 hepatocellular carcinomas, 17 cholangiocarcinomas, 94 metastases, 71 haemangiomas, 20 focal nodular hyperplasia) of which 70 (27%) were in cirrhotic liver. Malignant lesions were stiffer (P < .001) with higher variability in intralesional stiffness (P = .001). The best performing cut-off of lesion stiffness was 22.3 kPa (sensitivity 83%; specificity 86%; positive predictive value [PPV] 91.5%; negative predictive value [NPV] 73%) for malignancy. Lesion stiffness <14 kPa had NPV of 96%, while values >32.5 kPa had PPV of 96% for malignancy. Lesion stiffness, lesion/liver stiffness ratio and lesion stiffness variability significantly predicted malignancy in stepwise logistic regression (P < .05), and were used to construct a new Liver Elastography Malignancy Prediction (LEMP) score with accuracy of 96.1% in validation cohort (online calculator available at http://bit.do/lemps). CONCLUSION The comprehensive approach demonstrated in this study enables correct differentiation of benign and malignant FLL in 96% of patients by using RT-2D-SWE.
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Affiliation(s)
- Ivica Grgurevic
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, University of Zagreb School of Medicine and Faculty of Pharmacy and Biochemistry, Zagreb, Croatia
| | - Tomislav Bokun
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, University of Zagreb School of Medicine and Faculty of Pharmacy and Biochemistry, Zagreb, Croatia
| | - Nermin N Salkic
- Department of Gastroenterology and Hepatology, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | - Boris Brkljacic
- Department of Diagnostic and Interventional Radiology, University Hospital Dubrava, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Mirjana Vukelić-Markovic
- Department of Diagnostic and Interventional Radiology, University Hospital Dubrava, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Tajana Stoos-Veic
- Department of Pathology and Cytology, University Hospital Dubrava, Zagreb, Croatia.,Faculty of Medicine, University "J.J. Strossmayer", Osijek, Croatia
| | - Gorana Aralica
- Department of Pathology and Cytology, University Hospital Dubrava, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Mislav Rakic
- Department of Abdominal Surgery, University Hospital Dubrava, Zagreb, Croatia
| | - Tajana Filipec-Kanizaj
- Department of Gastroenterology and Hepatology, University Hospital Merkur, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Annalisa Berzigotti
- Hepatology, Swiss Liver Center, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Berne, Berne, Switzerland
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21
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Xie LT, Yan CH, Zhao QY, He MN, Jiang TA. Quantitative and noninvasive assessment of chronic liver diseases using two-dimensional shear wave elastography. World J Gastroenterol 2018; 24:957-970. [PMID: 29531460 PMCID: PMC5840471 DOI: 10.3748/wjg.v24.i9.957] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/01/2018] [Accepted: 02/09/2018] [Indexed: 02/06/2023] Open
Abstract
Two-dimensional shear wave elastography (2D-SWE) is a rapid, simple and novel noninvasive method that has been proposed for assessing hepatic fibrosis in patients with chronic liver diseases (CLDs) based on measurements of liver stiffness. 2D-SWE can be performed easily at the bedside or in an outpatient clinic and yields immediate results with good reproducibility. Furthermore, 2D-SWE was an efficient method for evaluating liver fibrosis in small to moderately sized clinical trials. However, the quality criteria for the staging of liver fibrosis are not yet well defined. Liver fibrosis is the main pathological basis of liver stiffness and a key step in the progression from CLD to cirrhosis; thus, the management of CLD largely depends on the extent and progression of liver fibrosis. 2D-SWE appears to be an excellent tool for the early detection of cirrhosis and may have prognostic value in this context. Because 2D-SWE has high patient acceptance, it could be useful for monitoring fibrosis progression and regression in individual cases. However, multicenter data are needed to support its use. This study reviews the current status and future perspectives of 2D-SWE for assessments of liver fibrosis and discusses the technical advantages and limitations that impact its effective and rational clinical use.
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Affiliation(s)
- Li-Ting Xie
- Department of Ultrasound, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Chun-Hong Yan
- Department of Ultrasound, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Qi-Yu Zhao
- Department of Ultrasound, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Meng-Na He
- Department of Ultrasound, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Tian-An Jiang
- Department of Ultrasound, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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22
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Abstract
Liver fibrosis is an important pathological precondition for hepatocellular carcinoma. The degree of hepatic fibrosis is positively correlated with liver cancer. Liver fibrosis is a series of pathological and physiological process related to liver cell necrosis and degeneration after chronic liver injury, which finally leads to extracellular matrix and collagen deposition. The early detection and precise staging of fibrosis and cirrhosis are very important for early diagnosis and timely initiation of appropriate therapeutic regimens. The risk of severe liver fibrosis finally progressing to liver carcinoma is >50%. It is known that biopsy is the gold standard for the diagnosis and staging of liver fibrosis. However, this method has some limitations, such as the potential for pain, sampling variability, and low patient acceptance. Furthermore, the necessity of obtaining a tissue diagnosis of liver fibrosis still remains controversial. An increasing number of reliable non-invasive approaches are now available that are widely applied in clinical practice, mostly in cases of viral hepatitis, resulting in a significantly decreased need for liver biopsy. In fact, the non-invasive detection and evaluation of liver cirrhosis now has good accuracy due to current serum markers, ultrasound imaging, and magnetic resonance imaging quantification techniques. A prominent advantage of the non-invasive detection and assessment of liver fibrosis is that liver fibrosis can be monitored repeatedly and easily in the same patient. Serum biomarkers have the advantages of high applicability (>95%) and good reproducibility. However, their results can be influenced by different patient conditions because none of these markers are liver-specific. The most promising techniques appear to be transient elastography and magnetic resonance elastography because they provide reliable results for the detection of fibrosis in the advanced stages, and future developments promise to increase the reliability and accuracy of the staging of hepatic fibrosis. This article aims to describe the recent progress in the development of non-invasive assessment methods for the staging of liver fibrosis, with a special emphasize on computer-aided quantitative and deep learning methods.
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Affiliation(s)
- Chengxi Li
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Rentao Li
- Department of Hepatobiliary Surgery, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Wei Zhang
- Department of Hepatobiliary Surgery, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
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23
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Deng H, Qi X, Zhang T, Qi X, Yoshida EM, Guo X. Supersonic shear imaging for the diagnosis of liver fibrosis and portal hypertension in liver diseases: a meta-analysis. Expert Rev Gastroenterol Hepatol 2018; 12:91-98. [PMID: 29186994 DOI: 10.1080/17474124.2018.1412257] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The meta-analysis aimed to summarize the technical success rate of supersonic shear imaging (SSI) and to evaluate the diagnostic performance of liver and spleen stiffness measurement (LSM and SSM) with SSI for the detection of liver fibrosis, portal hypertension, and gastroesophageal varices in liver diseases. METHODS PubMed, EMBASE, and Cochrane Library databases were searched. Technical success rate of SSI was pooled. Area under curve (AUC), sensitivity, and specificity with corresponding 95% confidence interval (CI) were calculated. RESULTS Included studies regarding the diagnostic performance of SSI for liver fibrosis, portal hypertension, and esophageal varices numbered 28, 4, and 4 respectively. The pooled technical success rates of LSM and SSM were 95.3% and 75.5%, respectively. The AUC, sensitivity, and specificity of LSM/SSM for different stages of liver fibrosis were 0.85-0.94, 0.7-0.89, and 0.82-0.92, respectively. The AUC, sensitivity, and specificity of LSM were 0.84 (95%CI = 0.8-0.86), 0.79 (95%CI = 0.7-0.85), and 0.82 (95%CI = 0.72-0.88) for clinically significant portal hypertension, 0.85 (95%CI = 0.82-0.88), 0.8 (95%CI = 0.68-0.88), and 0.8 (95%CI = 0.6-0.92) for any varices, and 0.86 (95%CI = 0.83-0.89), 0.86 (95%CI = 0.76-0.92), and 0.61 (95%CI = 0.35-0.83) for high-risk varices, respectively. CONCLUSIONS LSM with SSI had a high diagnostic accuracy for liver fibrosis, but a moderate diagnostic accuracy for portal hypertension and esophageal varices.
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Affiliation(s)
- Han Deng
- a Yuebei People's Hospital , Shaoguan , China
| | - Xingshun Qi
- b Liver Cirrhosis Study Group, Department of Gastroenterology , General Hospital of Shenyang Military Area , Shenyang , China
- c Chinese Portal Hypertension Noninvasive Diagnosis Study (CHESS) Group , China
| | - Tiansong Zhang
- d Department of Traditional Chinese Medicine , Jing'an District Central Hospital , Shanghai , China
| | - Xiaolong Qi
- c Chinese Portal Hypertension Noninvasive Diagnosis Study (CHESS) Group , China
- e Institute of Hepatology, Nanfang Hospital, Southern Medical University , Guangdong Provincial Research Center for Liver Fibrosis , Guangzhou , China
| | - Eric M Yoshida
- f Division of Gastroenterology , Vancouver General Hospital , Vancouver , Canada
| | - Xiaozhong Guo
- b Liver Cirrhosis Study Group, Department of Gastroenterology , General Hospital of Shenyang Military Area , Shenyang , China
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24
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Paul SB, Das P, Mahanta M, Sreenivas V, Kedia S, Kalra N, Kaur H, Vijayvargiya M, Ghosh S, Gamanagatti SR, Gupta SD, Acharya SK. Assessment of liver fibrosis in chronic hepatitis: comparison of shear wave elastography and transient elastography. Abdom Radiol (NY) 2017. [PMID: 28643136 DOI: 10.1007/s00261-017-1213-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To evaluate the diagnostic accuracy of shear wave elastography (SWE) and transient elastography (TE) in the evaluation of liver fibrosis in chronic hepatitis B (CHB) and C (CHC) patients taking liver biopsy as gold standard. METHODS Ethics committee approved this prospective cross-sectional study. Between October 2012 and December 2014, consecutive CHB/CHC patients fulfilling the inclusion criteria were included-age more than 18 years, informed written consent, willing and suitable for liver biopsy. SWE, TE, and biopsy were performed the same day. Liver stiffness measurement (LSM) cut-offs for various stages of fibrosis were generated for SWE and TE. AUC, sensitivity, specificity, and positive/negative predictive values were estimated individually or in combination. RESULTS CH patients (n = 240, CHB 172, CHC 68), 176 males, 64 females, mean age 32.6 ± 11.6 years were enrolled. Mean LSM of patients with no histological fibrosis (F0) was 5.0 ± 0.7 and 5.1+1.4 kPa on SWE and TE, respectively. For differentiating F2 and F3-4 fibrosis on SWE, at 7.0 kPa cut-off, the sensitivity was 81.3% and specificity 77.6%. For TE, at 8.3 kPa cut-off, sensitivity was 81.8% and specificity 83.1%. For F3 vs. F4, SWE sensitivity was 83.3% and specificity 90.7%. At 14.8 kPa cut-off, TE showed similar sensitivity (83.3%) but specificity increased to 96.5%. Significant correlation between SWE and TE was observed (r = 0.33, p < 0.001). On combining SWE and TE, a drop in sensitivity with increased specificity for all stages of liver fibrosis occured. CONCLUSION SWE is an accurate technique for evaluating liver fibrosis. SWE compares favorably with TE especially for predicting advanced fibrosis/cirrhosis. Combining SWE and TE further improves specificity.
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Affiliation(s)
- Shashi B Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Mousumi Mahanta
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Vishnubhatla Sreenivas
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Nancy Kalra
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Harpreet Kaur
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Maneesh Vijayvargiya
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Shouriyo Ghosh
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Shivanand R Gamanagatti
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Siddhartha Dutta Gupta
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Subrat K Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029, India
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25
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Imaging biomarkers in liver fibrosis. RADIOLOGIA 2017; 60:74-84. [PMID: 29108657 DOI: 10.1016/j.rx.2017.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 08/29/2017] [Accepted: 09/03/2017] [Indexed: 02/07/2023]
Abstract
There is a need for early identification of patients with chronic liver diseases due to their increasing prevalence and morbidity-mortality. The degree of liver fibrosis determines the prognosis and therapeutic options in this population. Liver biopsy represents the reference standard for fibrosis staging. However, given its limitations and complications, different non-invasive methods have been developed recently for the in vivo quantification of fibrosis. Due to their precision and reliability, biomarkers' measurements derived from Ultrasound and Magnetic Resonance stand out. This article reviews the different acquisition techniques and image processing methods currently used in the evaluation of liver fibrosis, focusing on their diagnostic performance, applicability and clinical value. In order to properly interpret their results in the appropriate clinical context, it seems necessary to understand the techniques and their quality parameters, the standardization and validation of the measurement units and the quality control of the methodological problems.
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26
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Lee ES, Lee JB, Park HR, Yoo J, Choi JI, Lee HW, Kim HJ, Choi BI, Park HJ, Park SB. Shear Wave Liver Elastography with a Propagation Map: Diagnostic Performance and Inter-Observer Correlation for Hepatic Fibrosis in Chronic Hepatitis. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:1355-1363. [PMID: 28431795 DOI: 10.1016/j.ultrasmedbio.2017.02.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/12/2017] [Accepted: 02/13/2017] [Indexed: 06/07/2023]
Abstract
The aim of this study was to determine the performance of shear wave elastography (SWE) with a propagation map in the diagnosis of hepatic fibrosis, and to assess its reliability with transient elastography (TE) as the reference standard. Our prospective study included 115 consecutive patients with suspected or alleged chronic hepatitis. Patients underwent SWE by two different operators and TE by sonographers on the same day. The correlation coefficient of the intra-class correlation test between an experienced radiologist and a third-year radiology resident was 0.878. There was a moderate correlation between SWE and TE (r = 0.511) in the diagnosis of hepatic fibrosis. The best cutoff values predicting significant hepatic fibrosis and liver cirrhosis by SWE were >1.78 m/s (area under the receiver operating characteristic curve [AUROC] = 0.777) and >2.24 m/s (AUROC = 0.935), respectively. SWE with a propagation map is a reliable method for predicting hepatic fibrosis regardless of operator experience.
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Affiliation(s)
- Eun Sun Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, Republic of Korea; College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Jong Beum Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, Republic of Korea; College of Medicine, Chung-Ang University, Seoul, Republic of Korea.
| | - Hwi Ryong Park
- Department of Radiology, Chung-Ang University Hospital, Seoul, Republic of Korea; College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Jeongin Yoo
- Department of Radiology, Chung-Ang University Hospital, Seoul, Republic of Korea; College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Ji In Choi
- Department of Radiology, Chung-Ang University Hospital, Seoul, Republic of Korea; College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Hyun Woong Lee
- College of Medicine, Chung-Ang University, Seoul, Republic of Korea; Division of Gastroenterology and Hepatology, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Hyung Joon Kim
- College of Medicine, Chung-Ang University, Seoul, Republic of Korea; Division of Gastroenterology and Hepatology, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Byung Ihn Choi
- Department of Radiology, Chung-Ang University Hospital, Seoul, Republic of Korea; College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Hyun Jeong Park
- Department of Radiology, Chung-Ang University Hospital, Seoul, Republic of Korea; College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Sung Bin Park
- Department of Radiology, Chung-Ang University Hospital, Seoul, Republic of Korea; College of Medicine, Chung-Ang University, Seoul, Republic of Korea
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27
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Dhyani M, Grajo JR, Bhan AK, Corey K, Chung R, Samir AE. Validation of Shear Wave Elastography Cutoff Values on the Supersonic Aixplorer for Practical Clinical Use in Liver Fibrosis Staging. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:1125-1133. [PMID: 28341490 PMCID: PMC5610928 DOI: 10.1016/j.ultrasmedbio.2017.01.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/14/2017] [Accepted: 01/26/2017] [Indexed: 05/12/2023]
Abstract
The purpose of this study was to determine the validity of previously established ultrasound shear wave elastography (SWE) cut-off values (≥F2 fibrosis) on an independent cohort of patients with chronic liver disease. In this cross-sectional study, approved by the institutional review board and compliant with the Health Insurance Portability and Accountability Act, 338 patients undergoing liver biopsy underwent SWE using an Aixplorer ultrasound machine (SuperSonic Imagine, Aix-en-Provence, France). Median SWE values were calculated from sets of 10 elastograms. A single blinded pathologist evaluated METAVIR fibrosis staging as the gold standard. The study analyzed 277 patients with a mean age of 48 y. On pathologic examination, 212 patients (76.5%) had F0-F1 fibrosis, whereas 65 (23.5%) had ≥F2 fibrosis. Spearman's correlation of fibrosis with SWE was 0.456 (p < 0.001). A cut-off value of 7.29 kPa yielded sensitivity of 95.4% and specificity of 50.5% for the diagnosis of METAVIR stage ≥F2 liver fibrosis in patients with liver disease using the SuperSonic Imagine Aixplorer SWE system.
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Affiliation(s)
- Manish Dhyani
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Joseph R Grajo
- Department of Radiology, Division of Abdominal Imaging, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Atul K Bhan
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen Corey
- Department of Hepatology, Liver and GI Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond Chung
- Department of Hepatology, Liver and GI Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony E Samir
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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28
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Procopet B, Berzigotti A. Diagnosis of cirrhosis and portal hypertension: imaging, non-invasive markers of fibrosis and liver biopsy. Gastroenterol Rep (Oxf) 2017; 5:79-89. [PMID: 28533906 PMCID: PMC5421457 DOI: 10.1093/gastro/gox012] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/15/2017] [Indexed: 12/12/2022] Open
Abstract
The concept of ‘cirrhosis’ is evolving and it is now clear that compensated and decompensated cirrhosis are completely different in terms of prognosis. Furthermore, the term ‘advanced chronic liver disease (ACLD)’ better reflects the continuum of histological changes occurring in the liver, which continue to progress even after cirrhosis has developed, and might regress after removing the etiological factor causing the liver disease. In compensated ACLD, portal hypertension marks the progression to a stage with higher risk of clinical complication and requires an appropriate evaluation and treatment. Invasive tests to diagnose cirrhosis (liver biopsy) and portal hypertension (hepatic venous pressure gradient measurement and endoscopy) remain of crucial importance in several difficult clinical scenarios, but their need can be reduced by using different non-invasive tests in standard cases. Among non-invasive tests, the accepted use, major limitations and major benefits of serum markers of fibrosis, elastography and imaging methods are summarized in the present review.
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Affiliation(s)
- Bogdan Procopet
- University of Medicine and Pharmacy 'Iuliu Hatieganu', 3rd Medical Clinic and Hepatology Department, Regional Institute of Gastroenterology and Hepatology 'O Fodor', Cluj-Napoca, Romania
| | - Annalisa Berzigotti
- Swiss Liver Center, Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
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29
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Srinivasa Babu A, Wells ML, Teytelboym OM, Mackey JE, Miller FH, Yeh BM, Ehman RL, Venkatesh SK. Elastography in Chronic Liver Disease: Modalities, Techniques, Limitations, and Future Directions. Radiographics 2016; 36:1987-2006. [PMID: 27689833 DOI: 10.1148/rg.2016160042] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Chronic liver disease has multiple causes, many of which are increasing in prevalence. The final common pathway of chronic liver disease is tissue destruction and attempted regeneration, a pathway that triggers fibrosis and eventual cirrhosis. Assessment of fibrosis is important not only for diagnosis but also for management, prognostic evaluation, and follow-up of patients with chronic liver disease. Although liver biopsy has traditionally been considered the reference standard for assessment of liver fibrosis, noninvasive techniques are the emerging focus in this field. Ultrasound-based elastography and magnetic resonance (MR) elastography are gaining popularity as the modalities of choice for quantifying hepatic fibrosis. These techniques have been proven superior to conventional cross-sectional imaging for evaluation of fibrosis, especially in the precirrhotic stages. Moreover, elastography has added utility in the follow-up of previously diagnosed fibrosis, the assessment of treatment response, evaluation for the presence of portal hypertension (spleen elastography), and evaluation of patients with unexplained portal hypertension. In this article, a brief overview is provided of chronic liver disease and the tools used for its diagnosis. Ultrasound-based elastography and MR elastography are explored in depth, including a brief glimpse into the evolution of elastography. Elastography is based on the principle of measuring tissue response to a known mechanical stimulus. Specific elastographic techniques used to exploit this principle include MR elastography and ultrasonography-based static or quasistatic strain imaging, one-dimensional transient elastography, point shear-wave elastography, and supersonic shear-wave elastography. The advantages, limitations, and pitfalls of each modality are emphasized. ©RSNA, 2016.
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Affiliation(s)
- Aparna Srinivasa Babu
- From the Departments of Radiology of Mercy Catholic Medical Center, Darby, Pa (A.S.B., O.M.T., J.E.M.); Mayo Clinic, 200 First St SW, Rochester, MN 55905 (M.L.W., R.L.E., S.K.V.); Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); and University of California-San Francisco School of Medicine, San Francisco, Calif (B.M.Y.)
| | - Michael L Wells
- From the Departments of Radiology of Mercy Catholic Medical Center, Darby, Pa (A.S.B., O.M.T., J.E.M.); Mayo Clinic, 200 First St SW, Rochester, MN 55905 (M.L.W., R.L.E., S.K.V.); Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); and University of California-San Francisco School of Medicine, San Francisco, Calif (B.M.Y.)
| | - Oleg M Teytelboym
- From the Departments of Radiology of Mercy Catholic Medical Center, Darby, Pa (A.S.B., O.M.T., J.E.M.); Mayo Clinic, 200 First St SW, Rochester, MN 55905 (M.L.W., R.L.E., S.K.V.); Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); and University of California-San Francisco School of Medicine, San Francisco, Calif (B.M.Y.)
| | - Justin E Mackey
- From the Departments of Radiology of Mercy Catholic Medical Center, Darby, Pa (A.S.B., O.M.T., J.E.M.); Mayo Clinic, 200 First St SW, Rochester, MN 55905 (M.L.W., R.L.E., S.K.V.); Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); and University of California-San Francisco School of Medicine, San Francisco, Calif (B.M.Y.)
| | - Frank H Miller
- From the Departments of Radiology of Mercy Catholic Medical Center, Darby, Pa (A.S.B., O.M.T., J.E.M.); Mayo Clinic, 200 First St SW, Rochester, MN 55905 (M.L.W., R.L.E., S.K.V.); Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); and University of California-San Francisco School of Medicine, San Francisco, Calif (B.M.Y.)
| | - Benjamin M Yeh
- From the Departments of Radiology of Mercy Catholic Medical Center, Darby, Pa (A.S.B., O.M.T., J.E.M.); Mayo Clinic, 200 First St SW, Rochester, MN 55905 (M.L.W., R.L.E., S.K.V.); Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); and University of California-San Francisco School of Medicine, San Francisco, Calif (B.M.Y.)
| | - Richard L Ehman
- From the Departments of Radiology of Mercy Catholic Medical Center, Darby, Pa (A.S.B., O.M.T., J.E.M.); Mayo Clinic, 200 First St SW, Rochester, MN 55905 (M.L.W., R.L.E., S.K.V.); Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); and University of California-San Francisco School of Medicine, San Francisco, Calif (B.M.Y.)
| | - Sudhakar K Venkatesh
- From the Departments of Radiology of Mercy Catholic Medical Center, Darby, Pa (A.S.B., O.M.T., J.E.M.); Mayo Clinic, 200 First St SW, Rochester, MN 55905 (M.L.W., R.L.E., S.K.V.); Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); and University of California-San Francisco School of Medicine, San Francisco, Calif (B.M.Y.)
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