Virtual Touch Quantification using Acoustic Radiation Force Impulse Imaging Technology versus Transient Elastography for the Noninvasive Assessment of Liver Fibrosis in Patients with Chronic Hepatitis B or C using Liver Biopsy as the Gold Standard

AIMS

Our aim was to assess the diagnostic performance of transient elastography (TE) and Virtual Touch Quantification (VTQ), a point Shear Wave Elastography (pSWE) technique, using Acoustic Radiation Force Impulse (ARFI) technology, for liver fibrosis assessment, as compared to percutaneous liver biopsy (LB), in patients with chronic hepatitis B or C.

METHODS

We analyzed 157 patients (80 with chronic hepatitis B and 77 with chronic hepatitis C) with reliable liver stiffness (LS) measurements, in whom we compared TE and VTQ to the LB performed during the same session (evaluated according to the Metavir scoring system: F0-F4). LS was assessed by TE (FibroScan, EchoSens, Paris, France) and VTQ using the Siemens Acuson S2000TM ultrasound system (Siemens AG, Erlangen, Germany). We defined reliable LS measurements as the median value of 10 measurements with an IQR/M <30% for both TE (obtained using the M probe) and VTQ. The areas under receiver operating characteristic curves (AUROCs) were used to assess the diagnostic performance of TE and VTQ. Correlation analysis determined the relationship between LSM values and liver histology.

RESULTS

On LB 31 (19.7%) patients had no fibrosis, 35 (22.3%) had F1, 43 (27.4%) had F2, 28 (17.8%) had F3 and 20 (12.7%) had cirrhosis. The mean size of the liver specimen in LB was 27 mm. A strong, linear correlation (Spearman ρ=0.826; p<0.001) with 95% confidence interval for rho (0.769- 0.870), was found between the TE and VTQ measurements. By comparing the AUROC curves, TE and VTQ had similar predictive values for the presence of F≥1 Metavir: AUROC TE=0.876, AUROC VTQ=0.832, p=0.358, for F≥2 Metavir: AUROC TE=0.826, AUROC VTQ=0.862, p=0.313, for F≥3 Metavir: AUROC TE=0.907, AUROC VTQ=0.880, p=0.434 and for F=4 Metavir: AUROC TE=0.981, AUROC VTQ=0.974, p= 0.423.

CONCLUSIONS

Both methods, TE and VTQ (pSWE) offer excellent diagnostic accuracy for liver fibrosis assessment in patients with chronic hepatitis B or C with similar performance.

Nonalcoholic Fatty Liver Disease and the Need for Action

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Thyroid Pathology in End-Stage Renal Disease Patients on Hemodialysis

Objectives: Chronic kidney disease is a rising cause of morbidity and mortality in developed countries, including end-stage renal disease (ESRD). The prevalence of thyroid comorbidities in persons with chronic kidney disease is documented higher than in normal population. The study aims to investigate the prevalence of morphological and functional thyroid disorders in patients with chronic kidney disease, with renal replacement therapy (hemodialysis). Methods: A cross-sectional study was performed on 123 consecutive patients with chronic kidney disease stage 5, on hemodialysis during a period of one month (May 2019–June 2020). All patients were enrolled for maintenance hemodialysis in B Braun Hemodialysis Center Timisoara and were examined on conventional 2B ultrasound. Thyroid blood tests were done, including serum free thyroxin (FT4), free triiodothyronine (FT3) and thyroid-stimulating hormone (TSH) at the time of starting hemodialysis. Results: We evaluated 123 patients (male to female ratio 70/53) mean age 62.2 ± 11.01, mostly above 65 years old, enrolled in the end-stage renal disease program, on renal replacement therapy. From the cohort, 76/123 presented thyroid disease, including autoimmune hypothyroidism, nodular goiter or thyroid cancer. Among them, 63 patients presented nodular goiter, including 3 thyroid cancers, confirmed by surgery and histopathological result, 22 patients had thyroid autoimmune disease. The serum thyroid-stimulating hormone levels found in the cohort was 3.36 ± 2.313 mUI/mL, which was in the normal laboratory reference range. The thyroid volume was 13 ± 7.18 mL. A single patient in the cohort presented Graves Basedow disease, under treatment and three patients present subclinical hyperthyroidism. We have found that thyroid disease risk is increased by 3.4-fold for the female gender and also the increase of body mass index (BMI) with one unit raises the risk of developing thyroid disease with 1.083 times (p = 0.018). Conclusion: To conclude, this study aimed to quantify the prevalence of thyroid disease in end-stage kidney disease population, especially nodular goiter, important for differential diagnosis in cases with secondary hyperparathyroidism. Thyroid autoimmune disease can be prevalent among these patients, as symptoms can overlap those of chronic disease and decrease the quality of life. We have found that thyroid disease has a high prevalence among patients with end-stage renal disease on hemodialysis. Thyroid goiter and nodules in ESRD patients were more prevalent than in the general population. Clinical surveillance and routine screening for thyroid disorders can improve the quality of life in these patients.

Screening for Liver Fibrosis and Steatosis in a Large Cohort of Patients with Type 2 Diabetes Using Vibration Controlled Transient Elastography and Controlled Attenuation Parameter in a Single-Center Real-Life Experience

BACKGROUND

Type 2 diabetes mellitus (T2DM), obesity, hyperlipidemia, and hypertension are considered risk factors for developing non-alcoholic fatty liver disease (NAFLD). This study aims to assess steatosis and fibrosis severity in a cohort of T2DM patients, using vibration controlled transient elastography (VCTE) and controlled attenuation parameter (CAP).

MATERIAL AND METHOD

We performed a prospective study in which, in each patient, we aimed for 10 valid CAP and liver stiffness measurements (LSM). To discriminate between fibrosis stages, we used the following VCTE cut-offs: F ≥ 2-8.2 kPa, F ≥ 3-9.7 kPa, and F4 - 13.6 kPa. To discriminate between steatosis stages, we used the following CAP cut-offs: S1 (mild) - 274 dB/m, S2 (moderate) - 290dB/m, S3 (severe) - 302dB/m.

RESULTS

During the study period, we screened 776 patients; 60.3% had severe steatosis, while 19.4% had advanced fibrosis. Female gender, BMI, waist circumference, elevated levels of AST, total cholesterol, triglycerides, blood glucose, and high LSM were associated with severe steatosis (all p-value < 0.05). BMI, waist circumference, elevated levels of AST, HbA1c, and CAP were associated with advanced fibrosis (all p-values < 0.05).

CONCLUSION

Higher BMI (obesity) comprises a higher risk of developing severe steatosis and fibrosis. Individualized screening strategies should be established for NAFLD according to different BMI.

TI-RADS Diagnostic Performance: Which Algorithm is Superior and How Elastography and 4D Vascularity Improve the Malignancy Risk Assessment

Given the increased prevalence of thyroid nodules in the general population (~50%), the real challenge resides in correctly recognizing the suspicious ones. This study proposes to compare four important Thyroid Imaging and Reporting Data Systems (TI-RADS) and evaluate the contribution of elastography and 4D Color Doppler assessment of vascularity in estimating the risk of malignancy. In the study, 133 nodules with histopathological examination were included. Of these, 35 (26.31%) proved to be malignant. All nodules were classified using the four selected systems and our proposed improved score. The American College of Radiology (ACR) and EU TI-RADS had good sensitivity (94.28%, 97.14%) and NPV (93.33%, 95.83%), but fairly poor specificity (31.81%, 23.46%) and PPV (35.48%, 31.19%), with an accuracy of 42.8% and 45.8%, respectively. Horvath TI-RADS had better accuracy of 66.9% and somewhat improved specificity (62.24%), but poorer sensitivity (80%). Russ’ French TI-RADS includes elastography in the risk assessment strategy. This classification proved superior in all aspects (Se: 91.42%, Sp:82.65%, NPV:96.42%, PPV:65.30%, and Acc of 84.96%). The mean strain ratio (SR) value for malignant lesions was 5.56, while the mean SR value for benign ones was significantly lower, 2.54 (p < 0.05). It also correlated well with the response variable: histopathological result (p < 0.001). Although, adding 4D vascularity to the French score generated a similar calculated accuracy and from a statistical point of view, the parameter itself proved beneficial for predicting the malignancy risk (p < 0.001) and may add important knowledge in uncertain situations. Advanced ultrasound techniques definitely improved the risk estimation and should be used more extensively.

Are there different cut-off values for staging liver fibrosis using 2D-SWE implemented on different systems from the same manufacturer?

AIM

To evaluate the range of liver stiffness (LS) cut-off values for predicting different stages of liver fibrosis (LF) for 2D-SWE-GE implemented on three different systems from General Electric Healthcare (LOGIQ E9, LOGIQ S8, LOGIQ P9).

MATERIAL AND METHOD

We performed a comparative study evaluating the performance of 2D-SWE-GE (LOGIQ E9, S8, P9) for predicting different stages of LF using Transient Elastography (TE) as the reference method. All patients (with or without chronic hepatopathies) were evaluated by TE, 331 patients were included in the LOGIQ E9 study, 179 in the LOGIQ S8 study and 234 in the LOGIQ P9 study. Reliable liver stiffness measurements (LSM) were defined for TE as the median value of 10 measurements with an interquartile range/median ratio (IQR/M)≤0.30 and for 2D-SWE-GE as the median value of 10 measurements and IQR/M≤0.30.

RESULTS

Reliable LSM was obtained by both methods in 91.5% subjects of the LOGIQ E9 group, in 95.5% subjects from the LOGIQ S8 group and in 87.6% subjects in the LOGIQ P9 group. The performance of 2DSWE-GE for predicting F≥2 with LOGIQ E9, LOGIQ S8 and LOGIQ P9 systems were: cut-offs 6.7 kPa, 6.9 kPa and 6.8 kPa; AUCs 0.95, 0.92 and 0.93. For predicting F≥3, the performances were: cut-offs - 8.2 kPa, 8.2 kPa and 7.6 kPa; AUCs - 0.97, 0.93 and 0.94. For predicting F4, the performances were: cut-offs - 9.3 kPa, 9.3 kPa and 9.3 kPa; AUCs - 0.96, 0.91 and 0.91.

CONCLUSION

The LS cut-off values for 2D-SWE-GE implemented on different systems for predicting F≥2, F≥3 and F=4 are not significantly different.

Comparative study between pSWE and 2D-SWE techniques integrated in the same ultrasound machine, with Transient Elastography as the reference method

AIM

To evaluate the feasibility of two elastographic methods, point Shear Wave Elastography (pSWE) and two dimensional Shear Wave Elastography (2D-SWE), integrated in the same ultrasound machine, for liver fibrosis (LF) assessment, using Transient Elastography (TE) as the reference method.

MATERIAL AND METHODS

We included in the study 115 subjects in which LF was evaluated in the same session by TE (FibroScan, EchoSens), pSWE and 2D-SWE (Samsung-Medison RS85). Reliable liver stiffness (LS) measurements were defined: for TE the median value of 10 measurements with interquartile range (IQR/M)≤30%,while for pSWE and 2D-SWE the median value of 10 measurements, with a reliability measurement index (RMI)≥0.5 and IQR/M≤30%. For classification of LF severity we used TE as the reference method with the following cut-offs: F2≥7kPa, F3≥9.5kPa and F4≥12kPa.

RESULTS

Reliable measurements by TE were obtained in 98.2% of cases (113/115), by pSWE in 93.9% of cases (108/115) and by 2D-SWE in 92.1% of cases (106/115), so the final analysis included 101 patients. We divided the cohort into 3 groups: fibrosis 5.9 kPa [AUROC=0.95, 95%CI(0.89;0.98), p<0.0001, Se=94.1%, Sp=89.5%, PPV=82.1%, NPV=96.8%]; F4 LS >8 kPa [AUROC=0.98, 95%CI(0.94;0.99), p<0.0001, Se=94.4%, Sp=95.1%, PPV=81%, NPV=98.7%], while for 2D-SWE they were: F≥2 LS >6.1 kPa [AUROC=0.93, 95%CI(0.86;0.97), p<0.0001, Se=91.1%, Sp=80.6%, PPV=70.5%, NPV=94.7%]; F4 LS >7.6 kPa [AUROC=0.98, 95%CI(0.93;0.99), p<0.0001, Se=100%, Sp=91.5%, PPV=72%, NPV=100%]. We observed strong correlations between LS values obtained by TE and 2D-SWE (r=0.85), between TE and pSWE (r=0.88) and between pSWE and 2D-SWE (r=0.90) (p=0.37), respectively. There were no significant differences between the mean values obtained by pSWE and 2D-SWE (p=0.96).

CONCLUSION

The pSWE and 2D-SWE are feasible methods for assessing liver fibrosis, both techniques strongly correlating with TE results.

Shear Wave Elastography in Diagnosing Secondary Hyperparathyroidism

This study evaluates the diagnostic value of two-dimensional shear wave elastography (2 D-SWE) technique in the evaluation of hyperplastic parathyroid glands in cases with secondary and tertiary hyperparathyroidism. A total of 59 patients (end-stage renal disease, under supplemental dialysis program) with visible parathyroid hyperplastic glands on ultrasound, confirmed by biochemical assay and scintigraphy, were enrolled; they were examined on grayscale ultrasound and 2 D shear wave elastography. We determined the elasticity index (EI) in the parathyroid gland, thyroid parenchyma and surrounding muscles, and the elasticity ratio of hyperplastic parathyroid glands compared to muscle, specifically sternocleidomastoid muscle. Patients presented fibrocystic bone disease with secondary hyperparathyroidism induced by end-stage chronic kidney disease; being on prolonged chronic dialysis therapy, they had positive sestamibi scintigraphy and high values of serum parathormone (1141.04 pg/mL). Nodules placed posterior to the thyroid capsule that were cystic, had a hypoechoic aspect, and were homogenous with an independent afferent artery were found. Mean EI in the parathyroid gland was 7.83 kPa, the median value in thyroid parenchyma was 13.76 kPa, and mean muscle EI value was 15.78 kPa. The observed mean parathyroid/muscle SWE ratio was 0.5356 and the value for parathyroid/normal thyroid parenchyma was 0.5995. Using receiver operating characteristic (ROC) analysis, we found that EI below 9.74 kPa correctly identifies parathyroid tissue, with a sensitivity of 94.8%, specificity of 90.7%, and accuracy of 92.26% when compared to normal thyroid tissue. Compared with the muscle tissue, we identified that EI below 9.98 kPa has a sensitivity, specificity, and accuracy of 93.8%, 90.7%, and 91.75%, respectively. Ultrasound elastography is a helpful tool in identifying parathyroid hyperplasia in patients with chronic kidney disease. A cutoff value of 9.98 kPa can be used in 2 D-SWE for accurate diagnosis of parathyroid disease.

US4all (Ultrasound for all)

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Clinical elastography

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Comparative study between four ultrasound Shear Waves Elastographic methods for liver fibrosis assessment

AIMS

Non-invasive methods to assess the severity of chronic liver diseases have become more and more popular. The aim of our study was to evaluate the correlation of four Shear Waves Elastographic methods in a cohort of patients with chronic liver diseases of mixed etiologies and to compare their performances for liver fibrosis evaluation.

MATERIAL AND METHODS

 A prospective study was conducted on 127 consecutive patients with chronic liver diseases of mixed etiologies. LS measurements were performed in all subjects, in one session, during the same day, by means of 4 elastographic methods: Transient Elastography (TE), Virtual Touch Quantification (VTQ), ElastPQ and 2D-SWE.SSI. The diagnosis accuracies of VTQ, ElastPQ, 2D-SWE.SSI were then compared using TE as reference method.

RESULTS

Valid LS measurements by all four shear waves ultrasound elastographic methods were obtained in 116/127 subjects with VTQ, in 108/127 subjects with 2D-SWE.SSI, in 111/127 with TE and in 109/127 with ElastPQ, so the final analysis included 82/127 subjects (64.5%). A good and significant correlation was found between all 4 elastographic methods. The diagnostic accuracy of VTQ, 2D-SWE.SSI and ElastPQ for the diagnosis of significant and severe fibrosis (F2/F3), and liver cirrhosis were similar for all elastographic techniques: VTQ vs 2D-SWE.SSI vs ElastPQ: 84.1% vs 85.3% vs. 84% (p>0.05); 93.9% vs 94% vs 94% (p>0.05).

CONCLUSION

considering TE as the reference method for liver fibrosis evaluation, VTQ, ElastPQ, and 2D-SWE.SSI obtained similar accuracies for diagnosing at least significant fibrosis (F≥2) and liver cirrhosis.

Is there a correlation between kidney shear wave velocity measured with VTQ and histological parameters in patients with chronic glomerulonephritis? A pilot study

AIM

To analyze the relationship between shear wave velocity in the kidney measured by point shear wave elastography using Virtual Touch Quantification (VTQ) (Siemens Acuson S2000) and histological parameters obtained from renal biopsies, in patients with chronic glomerulonephritis (CGN).

MATERIAL AND METHODS

The study group included 20 patients (mean age 47.95±13.59 years) with different types of CGN, that had underwent renal biopsy and 57 normal controls (mean age 38.07±17.32 years). In all patients, five valid stiffness measurements were obtained in each kidney, with the patient in lateral decubitus. Regarding the histological results, we assessed the presence or absence of glomerulosclerosis, interstitial fibrosis, and arteriolo-hyalinosis.

RESULTS

In patients with CGN we obtained the following mean values of VTQ values: right kidney: 2.12±0.81 m/s, left kidney 1.65±0.54 m/s, while in the normal controls significantly higher VTQ values were obtained: right kidney 2.69±0.72 m/s (p=0.004), left kidney 2.48±0.73 m/s (p<0.0001). In patients with CGN no statistically significant correlations between VTQ values and eGFR (r=0.37, p=0.12) or proteinuria (r=0.2, p=0.37) were found. We found significantly lower VTQ values in patients with interstitial fibrosis (1.46 vs. 1.99 m/s, p<0.05) and also in patients with arteriolo-hyalinosis (1.55 vs. 2.47 m/s, p<0.05).

CONCLUSION

Our pilot study shows that shear wave velocity values in patients with CGN are significantly lower compared to normal controls, and there is a tendency to decrease with the decrease of eGFR, with the presence of interstitial fibrosis and of arteriolo-hyalinosis.

Romanian National Guidelines on Contrast Enhanced Ultrasound in clinical practice

Contrast-enhanced ultrasound (CEUS) allows a real-time assessment of the vascular pattern of different types of lesions, as it has no renal or liver toxicity, it lacks radiation exposure and it is also cheaper than other imaging methods, having a diagnostic capability that matches contrast-enhanced CT or MRI. In Romania CEUS is used more and more, especially by clinicians, and since some centres have extensive experience in this domain, we felt the need to disseminate our expertise in order to implement this method in as many centres as possible. These Guidelines present the clinical applications of CEUS in the liver, spleen, pancreas, kidney, testis, bowel, intra-cavitary and endoscopic ultrasound, as well as other applications.

The Future of Liver Elastography in the Field of Hepatology

Ultrasound-based liver elastography is being increasingly used in clinical practice to help clinicians assess prognosis and recommend the most appropriate treatment in hepatology patients. In coming years liver elastography will probably be increasingly used as part of "point of care" ultrasonography.

Performance of 2D-SWE.GE for predicting different stages of liver fibrosis, using Transient Elastography as the reference method

AIM

To evaluate the performance of 2D shear-wave elastography from General Electric (2D-SWE.GE) for the noninvasiveassessment of liver fibrosis and to identify liver stiffness (LS) cut-off values for predicting different stages of fibrosisusing Transient Elastography (TE) as the reference method.

MATERIAL AND METHOD

We included 331 consecutive subjectswith or without chronic hepatopathies in whom LS was evaluated in the same session by means of 2 elastographic techniques:TE and 2D-SWE.GE. Reliable LS measurements were defined for TE as the median value of 10 measurements with a successrate of ≥60% and an interquartile range (IQR)<30% and for 2D-SWE.GE as the median value of 10 measurements acquiredin a homogenous area and an IQR<30%. To discriminate between TE fibrosis stages we used the following cut-offs: F2- 7;F3- 9.5 and F4- 12kPa.

RESULTS

Reliable LS measurements were obtained in 95.8% subjects by 2D-SWE.GE, and 94.2%by TE (p=0.44). Based on TE cut-off values we divided our cohort into four groups: F<2: 30.1%; F=2: 10.2%; F=3: 12.2%;F=4: 47.5%. A strong correlation was found between the LS values obtained by the 2 methods: r=0.83, p<0.0001.LS valuesobtained by 2D-SWE.GE were significantly lower than those obtained by TE: 10.14±4.24 kPa vs. 16.72±13.4 kPa (p<0.0001).The best cut-off value for F≥2, F≥3 and for F=4 were 6.7, 8.2 and 9.3 kPa.

CONCLUSIONS

The best 2D-SWE.GE cut-off valuesfor predicting F≥2, F≥3 and F=4 were 6.7, 8.2 and 9.3kPa.

The new EFSUMB Guidelines on Liver Elastography 2017: why and for whom?

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Proposed score for the self-assessment of an endoscopy department performance in colonoscopy screening

The aim of the paper was to propose a score for performance evaluation in colonoscopy units.

METHOD

We proposed a score (CDCD score - Cecal intubation, polyp Detection rate, Cleansing and Documentation of cecal intubation) based on the following parameters that assess the quality of colonoscopy units: total colonoscopies rate, polyp detection rate, rate of cecal intubation photo record, rate of recorded Boston bowel preparation scale (BBPS) (rated 1 to 5 stars). The mean score obtained based on the above mentioned criteria was used as a quality parameter of the endoscopy unit. We applied and calculated this score in all screening colonoscopies performed in our Endoscopy Department during the last 4 years.

RESULTS

The study group included 856 screening colonoscopies. The rate of total colonoscopies was 92.1% (789/856 cases) and the polyp detection rate was 23.9%. Regarding the quality of bowel preparation, the BBPS was recorded in 51.1% cases. The cecal intubation was photo recorded in 44% of cases. We considered that of the 4 parameters, the highest weight for an excellent quality belonged to the cecal intubation rate, followed by the polyp detection rate, because they evaluate the endoscopic technique, while the other 2 are more administrative. Thus, for the unit's assessment we used the following equation: UNIT'S QUALITY CDCD SCORE = (3×cecal intubation rate+3×polyp detection rate+1×photo documentation+1×BBPS documentation)/8. Thus, the CDCD Score for our unit was ≈4 stars (3.7 stars).

CONCLUSION

The proposed CDCD score may be an objective tool for the quality assessment in different endoscopy units.

Ultrasound: "one stop shop" in hepatology

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Why isn't Contrast Enhanced Ultrasound for Focal Liver Lesions used more in daily practice?

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Liver elastography - where are we now?

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One or more elastographic methods for liver fibrosis assessment?

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Comparative study between two point Shear Wave Elastographic techniques: Acoustic Radiation Force Impulse (ARFI) elastography and ElastPQ

AIM

To compare the feasibility and the liver stiffness (LS) values obtained by means of the two available point Shear Wave Elastographic (pSWE) techniques: ARFI elastography and ElastPQ technique.

MATERIAL AND METHODS

Our study included 176 subjects with or without chronic liver disease, in which LS was evaluated in the same session by means of ARFI elastography and ElastPQ.

RESULTS

Ten valid measurements were obtained in all subjects by means of ARFI elastography and in 97.7% cases by means of ElastPQ (p=0.12). Reliable LS measurements by means of ARFI elastography were obtained in 170/176 subjects (96.5%), so the final analysis included 166/176 subjects (94.3%). The mean LS values by ARFI were significantly higher than those obtained by ElastPQ: 1.46+/-0.69 m/s vs. 1.32+/-0.52 m/s, p=0.0004. For a LS cut-off value >1.4 m/second, ARFI elastography had 83.1%accuracy (AUROC=0.822) to differentiate between subjects with or without chronic liver disease, while the best ElastPQ cut-off value to discriminate between these two categories of subjects was >1.23 m/second, with 83.7% accuracy (AUROC=0.851).

CONCLUSIONS

Both available pSWE techniques have very good feasibility for the non-invasive liver fibrosis assessment and a good performance for predicting the presence of liver pathology. LS values obtained by Elast PQ technique are significant lower than those obtained by ARFI elastography.

Romanian national guidelines and practical recommendations on liver elastography

The use of liver elastography has substantially developed in the past few years; the introduction of novel elastographic methods (Transient Elastography, point Shear Wave Elastography, Real Time Shear Wave Elastography, Strain Elastography) has changed the perspective in the evaluation of liver disease. The ongoing research in this area is mainly focused on diffuse liver diseases and for predicting liver cirrhosis complication. This guideline created under the auspice of Romanian Society of Ultrasound in Medicine and Biology is intended to accustomize the clinician with the current practical use of liver elastography and has been issued to help in maximizing the clinical benefit for the patients with chronic liver diseases.