Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology

Diagnostic Yield of Endoscopic Ultrasound-Guided Liver Biopsy in Comparison to Percutaneous Liver Biopsy: A Meta-Analysis of Randomized Controlled Trials and Trial Sequential Analysis

BACKGROUND

The efficacy of endoscopic ultrasound-guided liver biopsy (EUS-LB) compared to percutaneous liver biopsy (PC-LB) remains uncertain.

METHODS

Our data consist of randomized controlled trials (RCTs) comparing EUS-LB to PC-LB, found through a literature search via PubMed/Medline and Embase. The primary outcome was sample adequacy, whereas secondary outcomes were longest and total lengths of tissue specimens, diagnostic accuracy, and number of complete portal tracts (CPTs).

RESULTS

Sample adequacy did not significantly differ between EUS-LB and PC-LB (risk ratio [RR] 1.18; 95% confidence interval [CI] 0.58-2.38; p = 0.65), with very low evidence quality and inadequate sample size as per trial sequential analysis (TSA). The two techniques were equivalent with respect to diagnostic accuracy (RR: 1; CI: 0.95-1.05; p = 0.88), mean number of complete portal tracts (mean difference: 2.29, -4.08 to 8.66; p = 0.48), and total specimen length (mean difference: -0.51, -20.92 to 19.9; p = 0.96). The mean maximum specimen length was significantly longer in the PC-LB group (mean difference: -3.11, -5.51 to -0.71; p = 0.01), and TSA showed that the required information size was reached.

CONCLUSION

EUS-LB and PC-LB are comparable in terms of diagnostic performance although PC-LB provides longer non-fragmented specimens.

Banff 2022 Liver Group Meeting report: Monitoring long-term allograft health

The Banff Working Group on Liver Allograft Pathology met in September 2022. Participants included hepatologists, surgeons, pathologists, immunologists, and histocompatibility specialists. Presentations and discussions focused on the evaluation of long-term allograft health, including noninvasive and tissue monitoring, immunosuppression optimization, and long-term structural changes. Potential revision of the rejection classification scheme to better accommodate and communicate late T cell-mediated rejection patterns and related structural changes, such as nodular regenerative hyperplasia, were discussed. Improved stratification of long-term maintenance immunosuppression to match the heterogeneity of patient settings will be central to improving long-term patient survival. Such personalized therapeutics are in turn contingent on a better understanding and monitoring of allograft status within a rational decision-making approach, likely to be facilitated in implementation with emerging decision-support tools. Proposed revisions to rejection classification emerging from the meeting include the incorporation of interface hepatitis and fibrosis staging. These will be opened to online testing, modified accordingly, and subject to consensus discussion leading up to the next Banff conference.

Liver histology is associated with long-term clinical outcomes in patients with metabolic dysfunction-associated steatohepatitis

BACKGROUND

Few studies have examined the risk of long-term clinical outcomes in patients with metabolic dysfunction-associated steatohepatitis in relation to liver histology. We aimed to study this using a real-world cohort.

METHODS

Adults (N = 702) recorded on Vanderbilt University Medical Center's Synthetic Derivative database (1984-2021) with evidence of metabolic dysfunction-associated steatohepatitis on liver biopsy were followed from the first biopsy until the first clinical event or last database entry (median: 4.7 y). Risks of cirrhosis (N = 650), other noncirrhotic liver-related (N = 702) and cardiovascular-related outcomes (N = 660), and mortality due to liver, cardiovascular, or cancer events (N = 660) were determined as a function of baseline histology (fibrosis stage [F], lobular inflammation grade [LI], hepatocyte ballooning grade [HB], and steatosis score) adjusting for sex, age, diabetes, and weight-loss surgery.

RESULTS

Cirrhosis risk was reduced for lower versus higher fibrosis stage (HR: F0-1 vs. F3: 0.22 [95% CI: 0.12-0.42]), LI1 versus LI2-3 (0.42 [0.19-0.97]), and HB1 versus HB2 (0.20 [0.08-0.50]). Lower fibrosis stage was associated with significantly lower risks of liver-related outcomes versus F4 cirrhosis (eg, F0-1: 0.12 [0.05-0.25]), whereas no differences were seen across baseline lobular inflammation, hepatocyte ballooning, and steatosis grades/scores. Lower versus higher lobular inflammation grade was associated with lower risks for liver-related outcomes in patients with weight-loss surgery. There was a trend for lower risks for cardiovascular-related and any long-term outcomes with lower versus higher fibrosis stage.

CONCLUSIONS

Fibrosis stage and lobular inflammation and hepatocyte ballooning grades predict the risk of long-term outcomes, supporting the use of these histological features as potential surrogate markers of disease progression or clinical outcomes.

Liver respiratory-induced motion estimation using abdominal surface displacement as a surrogate: robotic phantom and clinical validation with varied correspondence models

PURPOSE

This work presents the implementation of an RGB-D camera as a surrogate signal for liver respiratory-induced motion estimation. This study aims to validate the feasibility of RGB-D cameras as a surrogate in a human subject experiment and to compare the performance of different correspondence models.

METHODS

The proposed approach uses an RGB-D camera to compute an abdominal surface reconstruction and estimate the liver respiratory-induced motion. Two sets of validation experiments were conducted, first, using a robotic liver phantom and, secondly, performing a clinical study with human subjects. In the clinical study, three correspondence models were created changing the conditions of the learning-based model.

RESULTS

The motion model for the robotic liver phantom displayed an error below 3 mm with a coefficient of determination above 90% for the different directions of motion. The clinical study presented errors of 4.5, 2.5, and 2.9 mm for the three different motion models with a coefficient of determination above 80% for all three cases.

CONCLUSION

RGB-D cameras are a promising method to accurately estimate the liver respiratory-induced motion. The internal motion can be estimated in a non-contact, noninvasive and flexible approach. Additionally, three training conditions for the correspondence model are studied to potentially mitigate intra- and inter-fraction motion.

A missed case of intraductal oncocytic papillary neoplasm associated with missed stones in extrahepatic bile duct: a case report

The pathological features of intraductal oncocytic papillary neoplasm (IOPN) of the bile duct include tumor cells that are rich in eosinophilic cytoplasm and arranged in papillary structures. Herein, we report a missed case of IOPN of the bile duct because of concomitant gallstones. A 70-year-old woman was hospitalized with upper abdominal discomfort. The primary diagnosis was choledocholithiasis following imaging examination. However, an unidentified mass was detected after the gallstones were removed. The mass appeared as many papillary protuberances surrounded by fish-egg-like mucosa when viewed by the choledochoscope and was confirmed as IOPN by pathological examination. The patient underwent choledochectomy and no recurrence was observed at the 6-month follow-up examination. In this report, peroral choledochoscopy demonstrated its advantages for the diagnosis of biliary diseases and acquisition of tissue specimens. Therefore, it may solve the challenge related to the lack of preoperative pathological evidence for bile duct tumors.

The Diagnostic Value of Liver Biopsy for Unexplained Liver Dysfunction: A Retrospective Study

Objective

To analyse clinical manifestations of unexplained abnormal liver function and perform hepatobiliary histopathology procedures on patients to evaluate the value of liver biopsy in diagnosing the aetiology of unexplained abnormal liver function.

Methods

A convenience sampling method was used to retrospectively collect the data of patients who were diagnosed with unexplained abnormal liver function and who received liver biopsy in the Pathology Department of Tianjin Second People's Hospital, China, between March 2022 and July 2023 to analyse liver pathology and clinical manifestations.

Results

A total of 1302 patients were included in this study, which mainly included 11 diseases: autoimmune liver disease (74 cases, 5.68%), drug-induced liver injury (DILI) (204 cases, 15.67%), cancer (237 cases, 18.20%), non-alcoholic fatty liver disease (104 cases, 7.99%), non-alcoholic steatohepatitis (74 cases, 5.68%), viral hepatitis (490 cases, 37.63%), other types of hepatitis (30 cases, 2.30%), cholestatic liver disease (17 cases, 1.31%), alcoholic liver disease (15 cases, 1.15%), hepatic cyst (5 cases, 0.38%) and Gilbert syndrome (4 cases, 0.31%). The success rate of liver biopsy sampling was 100%, and (1.52 ± 0.130) tissue strips were sampled. The average operating time was 11.52 minutes. The percutaneous liver biopsy did not significantly increase short-term liver function index values (serum γ-glutamyl transpeptidase, total bilirubin, alanine transaminase, aspartate aminotransferase, alkaline phosphatase). Ninety-two patients had a small amount of liver subcapsular fluid, but there was no progress after medical treatment.

Conclusion

Ultrasound-guided percutaneous liver biopsy has value in the diagnosis of unexplained abnormal liver function. Viral hepatitis, cancer and DILI are the most common causes of unexplained abnormal liver function. Liver biopsy does not aggravate the organic and functional impairment of the liver.

Steatotic Liver Disease: Pathophysiology and Emerging Pharmacotherapies

Steatotic liver disease (SLD) displays a dynamic and complex disease phenotype. Consequently, the metabolic dysfunction-associated steatotic liver disease (MASLD)/metabolic dysfunction-associated steatohepatitis (MASH) therapeutic pipeline is expanding rapidly and in multiple directions. In parallel, noninvasive tools for diagnosing and monitoring responses to therapeutic interventions are being studied, and clinically feasible findings are being explored as primary outcomes in interventional trials. The realization that distinct subgroups exist under the umbrella of SLD should guide more precise and personalized treatment recommendations and facilitate advancements in pharmacotherapeutics. This review summarizes recent updates of pathophysiology-based nomenclature and outlines both effective pharmacotherapeutics and those in the pipeline for MASLD/MASH, detailing their mode of action and the current status of phase 2 and 3 clinical trials. Of the extensive arsenal of pharmacotherapeutics in the MASLD/MASH pipeline, several have been rejected, whereas other, mainly monotherapy options, have shown only marginal benefits and are now being tested as part of combination therapies, yet others are still in development as monotherapies. Although the Food and Drug Administration (FDA) has recently approved resmetirom, additional therapeutic approaches in development will ideally target MASH and fibrosis while improving cardiometabolic risk factors. Due to the urgent need for the development of novel therapeutic strategies and the potential availability of safety and tolerability data, repurposing existing and approved drugs is an appealing option. Finally, it is essential to highlight that SLD and, by extension, MASLD should be recognized and approached as a systemic disease affecting multiple organs, with the vigorous implementation of interdisciplinary and coordinated action plans. SIGNIFICANCE STATEMENT: Steatotic liver disease (SLD), including metabolic dysfunction-associated steatotic liver disease and metabolic dysfunction-associated steatohepatitis, is the most prevalent chronic liver condition, affecting more than one-fourth of the global population. This review aims to provide the most recent information regarding SLD pathophysiology, diagnosis, and management according to the latest advancements in the guidelines and clinical trials. Collectively, it is hoped that the information provided furthers the understanding of the current state of SLD with direct clinical implications and stimulates research initiatives.

Comparing 3 mm and 5 mm laparoscopic liver biopsy samples in dogs

OBJECTIVE

To determine whether 3 mm cup biopsy forceps (CBF) provide equivalent diagnostic samples to 5 mm CBF for histopathologic diagnosis, bacterial culture, and copper quantification.

STUDY DESIGN

Clinical prospective study.

ANIMALS

Ten client-owned dogs, presenting for laparoscopic liver biopsy (LLB).

METHODS

Dogs underwent LLB, and paired samples were collected using 3 and 5 mm CBF. Portal triad and hepatic lobule counts, crush and fragmentation artifacts, copper concentration, bacterial culture results, and agreement on histopathologic diagnosis were compared.

RESULTS

Both CBF sizes allowed for easy sample collection and resulted in minimal hemorrhage. An average of 12.13 (confidence limit (CL): 9.4-14.9) and 17.84 (CL: 15.1-20.6) portal triads were obtained using a 3 and 5 mm CBF, respectively (p = .0003). A portal triad count of 11 or more was achieved in 73.3% of the 3 mm and 93.3% of the 5 mm samples. Gwets AC1 coefficient showed a high level of agreement (0.8) for overall histopathologic diagnosis (p < .0001). The 3 mm CBF crush scores were higher (median of the differences: -1; range: -1 to 1) (p = .035). There was no difference in fragmentation scores (p = .935).

CONCLUSION

The 3 mm CBF yielded smaller samples in terms of size and portal triad count compared with the 5 mm CBF. However, the portal triad count was sufficient in a majority of samples and histologic agreement with the 5 mm CBF was excellent.

CLINICAL SIGNIFICANCE

In dogs, a 3 mm CBF yields adequate samples for histopathologic interpretation, copper quantification, and bacterial culture.

Comparison of Diagnostic Accuracy and Diagnostic Adequacy Between Endoscopic Ultrasound-Guided and Percutaneous Liver Biopsies: A Meta-Analysis of Randomized Controlled Trials and Observational Studies

A liver biopsy (LB) is a crucial diagnostic tool for evaluating liver diseases and is traditionally performed percutaneously under ultrasound guidance (PC-LB). However, endoscopic ultrasound-guided liver biopsy (EUS-LB) has emerged as an alternative approach, offering potential advantages over conventional techniques. This systematic review and meta-analysis aimed to compare the effectiveness and safety of EUS-LB using modern core biopsy needles with PC-LB. A comprehensive literature search identified nine studies involving 785 patients that met the inclusion criteria. The meta-analysis evaluated three primary endpoints: diagnostic adequacy, diagnostic accuracy, and adverse event rates. The results indicated no significant difference in overall diagnostic adequacy (odds ratio: 0.446, 95% CI: 0.192-1.031) or diagnostic accuracy (odds ratio: 1.646, 95% CI: 0.224-12.09) between EUS-LB and PC-LB. Furthermore, the combined occurrence of adverse events did not differ significantly between the two procedures (odds ratio: 0.653, 95% CI: 0.298-1.431). However, PC-LB demonstrated superiority in obtaining a higher number of complete portal tracts (mean difference: -0.985, 95% CI: -1.753 to -0.218), indicating better specimen quality. While both EUS-LB and PC-LB exhibited similar diagnostic performance and safety profiles, PC-LB provided higher-quality specimens, which may be advantageous in cases where accurate diagnosis and staging are critical, such as the evaluation of liver fibrosis. Clinicians should consider factors like specimen quality, procedural preferences, and local expertise when selecting the appropriate biopsy approach tailored to individual patient needs and clinical circumstances.

Validation of FIB-6 score in assessment of liver fibrosis in chronic hepatitis B

BACKGROUND

We recently developed a simple novel index called fibrosis 6 (FIB-6) using machine learning data analysis. We aimed to evaluate its performance in the diagnosis of liver fibrosis and cirrhosis in chronic hepatitis B (CHB).

METHODS

A retrospective observational analysis of data was obtained from seven countries (Egypt, Kingdom of Saudi Arabia (KSA), Turkey, Greece, Oman, Qatar, and Jordan) of CHB patients. The inclusion criteria were receiving an adequate liver biopsy and a complete biochemical and hematological data. The diagnostic performance analysis of the FIB-6 index was conducted and compared with other non-invasive scores.

RESULTS

A total of 603 patients were included for the analysis; the area under the receiver operating characteristic curve (AUROC) of FIB-6 for the discrimination of patients with cirrhosis (F4), compensated advanced chronic liver disease (cACLD) (F3 and F4), and significant fibrosis (F2-F4) was 0.854, 0.812, and 0.745, respectively. The analysis using the optimal cut-offs of FIB-6 showed a sensitivity of 70.9%, specificity of 84.1%, positive predictive value (PPV) of 40.3%, and negative predictive value (NPV) of 95.0% for the diagnosis of cirrhosis. For the diagnosis of cACLD, the results were 71.5%, 69.3%, 40.8%, and 89.2%, respectively, while for the diagnosis of significant fibrosis, the results were 68.3%, 67.5%, 59.9%, and 75.0%, respectively. When compared to those of fibrosis 4 (FIB-4) index, aspartate aminotransferase (AST)-to-platelet ratio index (APRI), and AST-to-alanine aminotransferase (ALT) ratio (AAR), the AUROC for the performance of FIB-6 was higher than that of FIB-4, APRI, and AAR in all fibrosis stages. FIB-6 gave the highest sensitivity and NPV (89.1% and 92.4%) in ruling out cACLD and cirrhosis, as compared to FIB-4 (63.8% and 83.0%), APRI (53.9% and 86.6%), and AAR (47.5% and 82.3%), respectively.

CONCLUSIONS

The FIB-6 index could be used in ruling out cACLD, fibrosis, and cirrhosis with good reliability.

Performance of MAST, FAST, and MEFIB in predicting metabolic dysfunction-associated steatohepatitis

BACKGROUND AND AIM

To identify individuals with metabolic dysfunction-associated steatohepatitis (MASH) or "at-risk" MASH among patients with metabolic dysfunction-associated steatotic liver disease (MASLD), three noninvasive models are available with satisfactory efficiency, which include magnetic resonance imaging [MRI]- AST (MAST), FibroScan-AST (FAST score), and magnetic resonance elastography [MRE] plus FIB-4 (MEFIB). We aimed to evaluate the most accurate approach for diagnosing MASH or "at-risk" MASH.

METHODS

We included 108 biopsy-proven MASLD patients who underwent simultaneous assessment of MRE, MRI proton density fat fraction (MRI-PDFF), and FibroScan scans. Compared with the histological diagnosis, we analyzed the AUC of each model and assessed the accuracy.

RESULTS

Our study cohort consisted of 64.8% of MASH and 25.9% of "at-risk" MASH. When analyzing the performance of each model for the diagnostic accuracy of MASH, we found that the AUC [95% CI] of MAST was comparable to FAST (0.803 [0.719-0.886] vs 0.799 [0.707-0.891], P = 0.930) and better than MEFIB (0.671 [0.571-0.772], P = 0.005). Similar findings were observed in the "at-risk" MASH patients. The AUCs [95% CI] for MAST, FAST, and MEFIB were 0.810 [0.719-0.900], 0.782 [0.689-0.874], and 0.729 [0.619-0.838], respectively. The models of MAST and FAST had comparable AUCs (P = 0.347), which were statistically significantly higher than that of MEFIB (P = 0.041). Additionally, the cutoffs for diagnosis of MASH were lower than "at-risk" MASH.

CONCLUSION

MAST and FAST performed better than MEFIB in diagnosing "at-risk" MASH and MASH using lower cutoff values. Our findings provided evidence for selecting the most accurate noninvasive model to identify patients with MASH or at-risk MASH.

NAFLD in the 21st Century: Current Knowledge Regarding Its Pathogenesis, Diagnosis and Therapeutics

Non-alcoholic fatty liver disease (NAFLD) is a major public health issue worldwide. It is the most common liver disease in Western countries, andits global prevalence is estimated to be up to 35%. However, its diagnosis may be elusive, because liver biopsy is relatively rarely performed and usually only in advanced stages of the disease. Therefore, several non-invasive scores may be applied to more easily diagnose and monitor NAFLD. In this review, we discuss the various biomarkers and imaging scores that could be useful in diagnosing and managing NAFLD. Despite the fact that general measures, such as abstinence from alcohol and modulation of other cardiovascular disease risk factors, should be applied, the mainstay of prevention and management is weight loss. Bariatric surgery may be suggested as a means to confront NAFLD. In addition, pharmacological treatment with GLP-1 analogues or the GIP agonist tirzepatide may be advisable. In this review, we focus on the utility of GLP-1 analogues and GIP agonists in lowering body weight, their pharmaceutical potential, and their safety profile, as already evidenced inanimal and human studies. We also elaborate on other options, such as the use of vitamin E, probiotics, especially next-generation probiotics, and prebiotics in this context. Finally, we explore future perspectives regarding the administration of GLP-1 analogues, GIP agonists, and probiotics/prebiotics as a means to prevent and combat NAFLD. The newest drugs pegozafermin and resmetiron, which seem to be very promising, arealso discussed.

Noninvasive tests maintain high accuracy for advanced fibrosis in chronic hepatitis B patients with different nomenclatures of steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a new nomenclature proposed in 2023. We aimed to compare the diagnostic efficacy of noninvasive tests (NITs) for advanced fibrosis under different nomenclatures in patients with chronic hepatitis B (CHB). A total of 844 patients diagnosed with CHB and concurrent steatotic liver disease (SLD) by liver biopsy were retrospectively enrolled and divided into four groups. The performances of fibrosis-4 (FIB-4), gamma-glutamyl transpeptidase to platelet ratio index (GPRI), aspartate aminotransferase to platelet ratio index (APRI), and liver stiffness measurement (LSM) were compared among the four groups. The four NITs showed similar diagnostic efficacy for nonalcoholic fatty liver disease (NAFLD), MASLD, and metabolic dysfunction-associated fatty liver disease (MAFLD) in patients with CHB with advanced fibrosis. LSM showed the most stable accuracy for NAFLD (AUC = 0.842), MASLD (AUC = 0.846), and MAFLD (AUC = 0.863) compared with other NITs (p < 0.05). Among the four NITs, APRI (AUC = 0.841) and GPRI (AUC = 0.844) performed best in patients with CHB & MetALD (p < 0.05). The cutoff value for GPRI in patients with CHB & MetALD was higher than that in the other three groups, while further comparisons of NITs at different fibrosis stages showed that the median GPRI of CHB & MetALD (1.113) at F3-4 was higher than that in the CHB & MASLD group (0.508) (p < 0.05). Current NITs perform adequately in patients with CHB and SLD; however, alterations in cutoff values for CHB & MetALD need to be noted.

Mistakes in utilising histopathology for the management of liver disease

INTRODUCTION

Liver biopsy has become selective due to its invasiveness, potential adverse effects, patient acceptance and cost. Furthermore, the emergence of noninvasive tests (NITs) has challenged the necessity of liver biopsies in specific clinical situations. However, liver biopsy continues to play a crucial role in disease diagnosis, prognosis, and evaluating treatment compliance and response in selected patients.

AREAS COVERED

In this narrative review, we discuss the errors and the shortcomings that can occur at various stages, from the initial patient selection for a liver biopsy to the final reporting phase, and strategies to address them. Clinicians and pathologists must take all necessary precautions to mitigate potential shortcomings that could compromise the value of liver biopsies.

EXPERT OPINION

The increasing sophistication of NITs offers a safer, more convenient, and potentially more cost-effective approach to diagnosing chronic liver disease, especially for assessing the degree of liver fibrosis. As NITs continue to evolve, liver biopsy will likely transition to a more targeted role, ensuring optimal patient care in the ever-changing field of hepatology. However, liver biopsy will continue to have a pivotal role in assessing acute liver disease where the diagnostic yield of the liver biopsy still outweighs that of NITs.

Quantitative Measurement of Serum HBcrAg Can Be Used to Assess the Feasibility of Safe Discontinuation of Antiviral Therapy for Chronic Hepatitis B

Hepatitis B virus (HBV) infection is a serious global health problem, and chronic HBV infection significantly increases the risk of liver fibrosis, cirrhosis, and even hepatocellular carcinoma in patients. Current first-line therapeutics such as nucleos(t)ide analogues and interferons are unable to completely clear cccDNA, so the vast majority of patients need to take long-term or even lifelong medication. However, long-term virological and biochemical responses can be achieved in some patients after drug withdrawal. Successfully screening these patients with drug withdrawal advantages is difficult. Hepatitis-B-core-related antigen (HBcrAg) is a new HBV serological marker that which can reflect the level and transcription activity of cccDNA in hepatocytes. Therefore, HBcrAg has potential value in guiding patients in drug withdrawal. This review summarizes previous reports on HBcrAg and evaluates the application value of HBcrAg in safe drug discontinuation.

Liver Stiffness Determined by Transient Elastography Is a Simple and Highly Accurate Predictor for Presence of Liver Cirrhosis in Clinical Routine

INTRODUCTION

Early detection of patients with advanced chronic liver disease is critical for the prevention of complications and inclusion in surveillance programs for hepatocellular carcinoma. In daily clinical care, it remains challenging to differentiate early cirrhosis from lower fibrosis grades without performing a liver biopsy. The aim of the present study was to assess the performance of different non-invasive detection tools to differentiate cirrhosis from lower fibrosis grades.

METHODS

Data of 116 patients (51 male, 65 female) with chronic liver disease of various origins undergoing liver biopsy was analyzed. Routine laboratory values, liver stiffness measurement (LSM) by transient elastography, and histological liver assessment were collected.

RESULTS

Robust and significant correlations with the histological fibrosis stage were identified for LSM (r = 0.65), the FAST score (0.64), the FIB-4 (0.48), serum aspartate aminotransferase (AST) concentration (0.41), NFS (0.33), international normalized ratio (INR; 0.30), methacetin breath test results (-0.40), and serum albumin concentration (-0.29) by spearman rank correlation. Receiver operating characteristic curves were built for these parameters to separate patients with cirrhosis from those with any other fibrosis stage. The highest AUC was achieved by LSM (0.9130), followed by the FAST score (0.8842), the FIB-4 (0.8644), the NFS (0.8227), INR (0.8142), serum albumin (0.7710), and serum AST (0.7620). The most promising clinical applicability would be an LSM value of 12.2 kPa, achieving 95.7% sensitivity and 75.3% specificity.

CONCLUSION

LSM and FAST score seem to be robust non-invasive measurements for liver fibrosis. LSM and FAST scores may have the potential to reliably detect patients with liver cirrhosis in clinical routine settings.

Expert opinion on bleeding risk from invasive procedures in cirrhosis

Background & Aims

Despite several recent international guidelines, no consensus exists on the bleeding risk nor haemostatic parameter thresholds that define the safety of invasive procedures in patients with cirrhosis. The aim of this study was to establish a position paper on the bleeding risk associated with invasive procedures in patients with cirrhosis among the experts involved in various guidelines.

Methods

All experts involved in recent guidelines on the management of invasive procedures in patients with cirrhosis were invited to classify 80 procedures as "high risk" or "low risk" with respect to bleeding. Procedures were considered high risk when the estimated risk of major bleeding was 1.5% or more, or when even minor bleeding might lead to significant morbidity or death. The experts were also asked to choose safety thresholds for laboratory test values at which elective invasive procedures could be safely performed. The predetermined threshold considered as "consensus" was ≥75% agreement.

Results

Fifty-two experts participated in the study. Out of 80 procedures, a consensus opinion was reached for 52 procedures (65%): 17 procedures were classified as "high risk", primarily interventional endoscopic procedures, percutaneous organ biopsies, or procedures involving the central nervous system; and 35 as "low risk", primarily "diagnostic" procedures. The lowest platelet counts at which performance of a low-risk procedure or a high-risk procedure/surgery were deemed acceptable were 30 × 109/L and 50 × 109/L, respectively. Experts did not believe that international normalised ratio should be considered before performing low-risk procedures; 71% also indicated that it should not be considered before performing high-risk procedures.

Conclusions

This experience-based classification may be helpful to refine future study designs and to guide clinical decision making regarding invasive procedures in patients with cirrhosis.

Impact and implications

Several risk classifications and management guidelines for invasive procedures in patients with cirrhosis have been proposed, but with conflicting recommendations. By providing a position paper, based on the opinion of a broad panel of experts, on the bleeding risk associated with 52 invasive procedures in patients with cirrhosis, this survey will help to provide a framework for future study design. The consensus on platelet count, international normalised ratio, fibrinogen and activated partial thromboplastin time identified in this survey will inform physicians regarding the laboratory test values considered acceptable by the experts prior to the performance of an elective invasive procedure in patients with cirrhosis.

Impact of CT texture analysis on complication rate in CT-guided liver biopsies

Aim of the study

Texture analysis derived from computed tomography (CT) involves quantitative imaging parameters characterizing possible valuable associations with clinical purposes. Their prognostic capability in patients undergoing percutaneous CT-guided liver biopsy to identify associations with postinterventional bleeding complications and biopsy success is not sufficiently explored.

Material and methods

Three hundred fifteen patients (124 female, 39%) with a mean age of 62.5 ±10.2 years underwent percutaneous CT-guided liver biopsy and were analyzed regarding clinical, procedure-related, and CT texture features.

Results

Thirty patients (9.5%) presented with bleeding after biopsy (including two requiring interventional treatment), whereas 46 patients (14.6%) had negative biopsy successes. Distance of lesion from liver capsule was statistically significantly different in patients with and without bleeding (p = 0.015). Several texture features were statistically significantly different between the groups, S(0,1)SumAverg having the highest significance (p = 0.004). Regarding unsuccessful biopsy results, liver fibrosis was the only clinical feature with statistical significance (p = 0.049). Only two texture features (S(4,-4)InvDfMom and Teta3) were statistically different between the groups according to the biopsy result.

Conclusions

Several CT texture features of the target lesion and the length from the capsule to the lesion were associated with bleeding complications after CT-guided percutaneous liver biopsy. This could be used to identify patients at risk at the beginning of the procedure.

Chronic liver disease-associated severe thrombocytopenia in Spain: Results from a retrospective study using machine learning and natural language processing

BACKGROUND

Patients with chronic liver disease (CLD) often develop thrombocytopenia (TCP) as a complication. Severe TCP (platelet count<50×109/L) can increase morbidity and complicate CLD management, increasing bleeding risk during invasive procedures.

OBJECTIVES

To describe the real-world scenario of CLD-associated severe TCP patients' clinical characteristics. To evaluate the association between invasive procedures, prophylactic treatments, and bleeding events in this group of patients. To describe their need of medical resource use in Spain.

METHODS

This is a retrospective, multicenter study including patients who had confirmed diagnosis of CLD and severe TCP in four hospitals within the Spanish National Healthcare Network from January 2014 to December 2018. We analyzed the free-text information from Electronic Health Records (EHRs) of patients using Natural Language Processing (NLP), machine learning techniques, and SNOMED-CT terminology. Demographics, comorbidities, analytical parameters and characteristics of CLD were extracted at baseline and need for invasive procedures, prophylactic treatments, bleeding events and medical resources used in the follow up period. Frequency tables were generated for categorical variables, whereas continuous variables were described in summary tables as mean (SD) and median (Q1-Q3).

RESULTS

Out of 1,765,675 patients, 1787 had CLD and severe TCP; 65.2% were male with a mean age of 54.7 years old. Cirrhosis was detected in 46% (n=820) of patients and 9.1% (n=163) had hepatocellular carcinoma. Invasive procedures were needed in 85.6% of patients during the follow up period. Patients undergoing procedures compared to those patients without invasive procedures presented higher rates of bleeding events (33% vs 8%, p<0.0001) and higher number of bleedings. While prophylactic platelet transfusions were given to 25.6% of patients undergoing procedures, TPO receptor agonist use was only detected in 3.1% of them. Most patients (60.9%) required at least one hospital admission during the follow up and 14.4% of admissions were due to bleeding events with a hospital length of stay of 6 (3, 9) days.

CONCLUSIONS

NLP and machine learning are useful tools to describe real-world data in patients with CLD and severe TCP in Spain. Bleeding events are frequent in those patients who need invasive procedures, even receiving platelet transfusions as a prophylactic treatment, increasing the further use of medical resources. Because that, new prophylactic treatments that are not yet generalized, are needed.

Oxidative stress in metabolic dysfunction-associated steatotic liver disease (MASLD): How does the animal model resemble human disease?

Despite decades of research, the pathogenesis of metabolic dysfunction-associated steatotic liver disease (MASLD) is still not completely understood. Based on the evidence from preclinical models, one of the factors proposed as a main driver of disease development is oxidative stress. This study aimed to search for the resemblance between the profiles of oxidative stress and antioxidant defense in the animal model of MASLD and the group of MASLD patients. C57BL/6J mice were fed with the Western diet for up to 24 weeks and served as the animal model of MASLD. The antioxidant profile of mice hepatic tissue was determined by liquid chromatography-MS3 spectrometry (LC-MS/MS). The human cohort consisted of 20 patients, who underwent bariatric surgery, and 6 controls. Based on histological analysis, 4 bariatric patients did not have liver steatosis and as such were also classified as controls. Total antioxidant activity was measured in sera and liver biopsy samples. The hepatic levels of antioxidant enzymes and oxidative damage were determined by Western Blot. The levels of antioxidant enzymes were significantly altered in the hepatic tissue of mice with MASLD. In contrast, there were no significant changes in the antioxidant profile of hepatic tissue of MASLD patients, except for the decreased level of carbonylated proteins. Decreased protein carbonylation together with significant correlations between the thioredoxin system and parameters describing metabolic health suggest alterations in the thiol-redox signaling. Altogether, these data show that even though the phenotype of mice closely resembles human MASLD, the animal-to-human translation of cellular and molecular processes such as oxidative stress may be more challenging.

Liver Biopsy Handling of Metabolic-Associated Fatty Liver Disease (MAFLD): the Children's Hospital of Eastern Ontario grossing protocol

Metabolic-(non-alcoholic) associated fatty liver disease (MAFLD/NAFLD) has increasingly become a worldwide epidemic. It has been suggested that renaming NAFLD to MAFLD is critical in identifying patients with advanced fibrosis and poor cardiovascular outcomes. There are concerns that the progression to non-alcoholic steatohepatitis (NASH) may become a constant drive in the future healthcare of children and adolescents. There is a necessity to tackle the emerging risk factors for NASH-associated hepatocellular carcinoma (HCC). In this narrative review, we present the current protocol of liver biopsy separated between pre-analytical, analytical, and post-analytical handling. Genetic association investigations have identified single nucleotide polymorphisms implicated in the progression of MAFLD-HCC, many of which seem to belong to the lipid metabolism pathways. PNPLA3 rs738409 variant, TM6SF2 rs58542926 variant, MBOAT7 rs641738 variant, and GCKR variants seem to be significantly associated with NAFLD disease susceptibility. In disclosing the current comprehensive protocol performed at the Children's Hospital of Eastern Ontario, Ottawa, ON, Canada, we support the most recent Kulkarni-Sarin's pledge to rename NAFLD to MAFLD. Grossing of the liver biopsy is key to identifying histologic, immunophenotypical, and ultrastructure data and properly preserving tissue for molecular genomics data.

Unraveling the Role of Maternal Serum Ferritin Levels in Preterm Delivery: A Comprehensive Review

Preterm delivery remains a critical global health concern, with numerous adverse consequences for both neonate and healthcare systems. Understanding the relationship between maternal ferritin levels, as a marker of iron status, and the risk of preterm birth is the focal point of this comprehensive review. We provide insights into the multifaceted nature of this connection, highlighting factors that influence maternal ferritin levels, including dietary intake, genetic and physiological variations, comorbidities, and iron supplementation. While evidence suggests an association between low maternal ferritin levels and preterm birth, causality remains elusive, necessitating further research with robust study designs. The potential mechanisms linking maternal iron status to preterm birth, such as inflammation, infection, and oxidative stress, are explored, underscoring the need for in-depth investigations. This comprehensive review emphasizes the clinical importance of assessing and monitoring maternal ferritin levels in prenatal care and advocates for public health initiatives to raise awareness and provide targeted interventions, particularly in high-risk populations. As we strive to address these unanswered questions and embark on innovative research directions, the aim is to ultimately enhance our understanding of the complex relationship between maternal iron status and preterm birth, leading to improved maternal and child health outcomes.

Use of the gun-sight technique to create a parallel transjugular intrahepatic portosystemic shunt

A parallel shunt (PS) is often necessary to regain portal decompression in a dysfunctional transjugular intrahepatic portosystemic shunt (TIPS). Here, we successfully utilized the gun-sight technique to create a PS. An 81-year-old male with decompensated NASH cirrhosis and recent TIPS placement presents with recurrent ascites and pleural effusions in the setting of a persistent portosystemic gradient. Due to a lack of access to endovascular ultrasound and complex patient anatomy, a gun-site technique was approached to create a PS (left portal vein [PV] to left hepatic vein [HV]). After the right HV and existing TIPS were accessed via the right internal jugular vein access, the left HV was accessed. Following a left portal venogram, 10 mm snares were placed into the left HV and the left PV. An 18-gauge needle was then fluoroscopically placed through and through both snares. A 0.035 Glidewire was snared with the help of both snares, establishing access from the left HV via the left PV to the right PV. After serial dilation, a roadrunner wire and catheter were placed into the main PV and superior mesenteric vein, followed by stent dilation. Post-TIPS portal venogram showed prompt flow of contrast from the main PV to the right atrium without any stenosis through both TIPS stents in the left and right PVs. Initial and postprocedural TIPS gradients were 24 mm Hg and 6 mm Hg, respectively. Gun-site technique is a valuable technique in creating a parallel TIPS shunt.

Prospective comparison of an 18-gauge versus 16-gauge needle for percutaneous liver core-needle biopsy in children

PURPOSE

The objective of this study was to analyzed the impact of needle gauge (G) on the adequacy of specimens and hemorrhagic complications in pediatric patients undergoing ultrasound (US)-guided transplanted liver biopsies.

METHODS

The study included 300 consecutive biopsies performed in 282 pediatric patients (mean age 6.75 ± 3.82 years, range 0.84-17.90) between December 2020 and April 2022. All pediatric patients that referred to our institution for US-guided core-needle liver biopsy (CNLB) were randomized to undergo 16-G or 18-G CNLB. Hemorrhagic complications were qualitatively evaluated. The number of complete portal tracts (CPTs) per specimen was counted and specimen adequacy was assessed based on the American Association for the Study of Liver Diseases guidelines.

RESULTS

The incidence of bleeding was 7.00% (n = 21) and adequate specimens for accurate pathological diagnosis were obtained from 98.33% (n = 295) of patients. There was no significant difference in the incidence or amount of bleeding between the 16-G and 18-G groups (11 vs 10, p = 0.821; 35.0 mL vs 31.3 mL, p = 0.705). Although biopsies obtained using a 16-G needle contained more complete portal tracts than those obtained using an 18-G needle (20.0 vs 18.0, p = 0.029), there was no significant difference in specimen inadequacy according to needle gauge (2 vs 3, p = 1.000).

CONCLUSIONS

Biopsy with a 16-G needle was associated with a greater number of CPTs but did not increase the adequate specimen rate. There was no significant difference in the complication rate between 16-G biopsy and 18-G biopsy.

Pulmonary Pathology Society Survey on Practice Approaches in the Histologic Diagnosis of Fibrotic Interstitial Lung Disease: Consensus and Opportunities

CONTEXT.—

The pathologic diagnosis of usual interstitial pneumonia (UIP) remains a challenging area, and application of histologic UIP guidelines has proved difficult.

OBJECTIVE.—

To understand current practice approaches by pulmonary pathologists for the histologic diagnosis of UIP and other fibrotic interstitial lung diseases (ILDs).

DESIGN.—

The Pulmonary Pathology Society (PPS) ILD Working Group developed and sent a 5-part survey on fibrotic ILD electronically to the PPS membership.

RESULTS.—

One hundred sixty-one completed surveys were analyzed. Of the respondents, 89% reported using published histologic features in clinical guidelines for idiopathic pulmonary fibrosis (IPF) in their pathologic diagnosis; however, there was variability in reporting terminology, quantity and quality of histologic features, and the use of guideline categorization. Respondents were very likely to have access to pulmonary pathology colleagues (79%), pulmonologists (98%), and radiologists (94%) to discuss cases. Half of respondents reported they may alter their pathologic diagnosis based on additional clinical and radiologic history if it is pertinent. Airway-centered fibrosis, granulomas, and types of inflammatory infiltrates were considered important, but there was poor agreement on how these features are defined.

CONCLUSIONS.—

There is significant consensus among the PPS membership on the importance of histologic guidelines/features of UIP. There are unmet needs for (1) consensus and standardization of diagnostic terminology and incorporation of recommended histopathologic categories from the clinical IPF guidelines into pathology reports, (2) agreement on how to incorporate into the report relevant clinical and radiographic information, and (3) defining the quantity and quality of features needed to suggest alternative diagnoses.

Reproducibility and Repeatability of Intravoxel Incoherent Motion MRI Acquisition Methods in Liver

BACKGROUND

Intravoxel incoherent motion (IVIM) diffusion weighted MRI (DWI) has potential for evaluating hepatic fibrosis but image acquisition technique influence on diffusion parameter estimation bears investigation.

PURPOSE

To minimize variability and maximize repeatably in abdominal DWI in terms of IVIM parameter estimates.

STUDY TYPE

Prospective test-retest and image quality comparison.

SUBJECTS

Healthy volunteers (3F/7M, 29.9 ± 12.9 years) and Family Study subjects (18F/12M, 51.7 ± 16.7 years), without and with liver steatosis.

FIELD STRENGTH/SEQUENCE

Abdominal single-shot echo-planar imaging (EPI) and simultaneous multi-slice (SMS) DWI sequences with respiratory triggering (RT), breath-holding (BH), and navigator echo (NE) at 3 Tesla.

ASSESSMENT

SMS-BH, EPI-NE, and SMS-RT data from twice-scanned healthy volunteers were analyzed using 6 × b-values (0-800 s⋅mm-2 ) and lower (LO) and higher (HI) b-value ranges. Family Study subjects were scanned using SMS and standard EPI sequences. The biexponential IVIM model was used to estimate fast-diffusion coefficient (Df ), fraction of fast diffusion (f), and slow-diffusion coefficient (Ds ). Scan time, estimated signal-to-noise ratio (eSNR), eSNR per acquisition, and distortion ratio were compared.

STATISTICAL TESTS

Coefficients of variation (CoV) and Bland Altman analyses were performed for test-retest repeatability. Interclass correlation coefficient (ICC) assessed interobserver agreement with P < 0.05 deemed significant.

RESULTS

Within-subject CoVs among volunteers (N = 10) for f and Ds were lowest in EPI-NE-LO (11.6%) and SMS-RT-HI (11.1%). Inter-observer ICCs for f and Ds were highest for EPI-NE-LO (0.63) and SMS-RT-LO (0.76). Df could not be estimated for most subjects. Estimated eSNR (EPI = 21.9, SMS = 4.7) and eSNR time (EPI = 6.7, SMS = 16.6) were greater for SMS, with less distortion in the liver region (DR-PE: EPI = 23.6, SMS = 13.1).

DATA CONCLUSION

Simultaneous multislice acquisitions had significantly less variability and higher ICCs of Ds , higher eSNR, less distortion, and reduced scan time compared to EPI.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 1.

Translating the potential of the urine steroid metabolome to stage NAFLD (TrUSt-NAFLD): study protocol for a multicentre, prospective validation study

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) affects approximately one in four individuals and its prevalence continues to rise. The advanced stages of NAFLD with significant liver fibrosis are associated with adverse morbidity and mortality outcomes. Currently, liver biopsy remains the 'gold-standard' approach to stage NAFLD severity. Although generally well tolerated, liver biopsies are associated with significant complications, are resource intensive, costly, and sample only a very small area of the liver as well as requiring day case admission to a secondary care setting. As a result, there is a significant unmet need to develop non-invasive biomarkers that can accurately stage NAFLD and limit the need for liver biopsy. The aim of this study is to validate the use of the urine steroid metabolome as a strategy to stage NAFLD severity and to compare its performance against other non-invasive NAFLD biomarkers.

METHODS AND ANALYSIS

The TrUSt-NAFLD study is a multicentre prospective test validation study aiming to recruit 310 patients with biopsy-proven and staged NAFLD across eight centres within the UK. 150 appropriately matched control patients without liver disease will be recruited through the Oxford Biobank. Blood and urine samples, alongside clinical data, will be collected from all participants. Urine samples will be analysed by liquid chromatography-tandem mass spectroscopy to quantify a panel of predefined steroid metabolites. A machine learning-based classifier, for example, Generalized Matrix Relevance Learning Vector Quantization that was trained on retrospective samples, will be applied to the prospective steroid metabolite data to determine its ability to identify those patients with advanced, as opposed to mild-moderate, liver fibrosis as a consequence of NAFLD.

ETHICS AND DISSEMINATION

Research ethical approval was granted by West Midlands, Black Country Research Ethics Committee (REC reference: 21/WM/0177). A substantial amendment (TrUSt-NAFLD-SA1) was approved on 26 November 2021.

TRIAL REGISTRATION NUMBER

ISRCTN19370855.

Liver biopsy for assessment of suspected drug-induced liver injury in metabolic dysfunction-associated steatohepatitis clinical trials: Expert consensus from the Liver Forum

BACKGROUND

Causality assessment of suspected drug-induced liver injury (DILI) during metabolic dysfunction-associated steatohepatitis (MASH) clinical trials can be challenging, and liver biopsies are not routinely performed as part of this evaluation. While the field is moving away from liver biopsy as a diagnostic and prognostic tool, information not identified by non-invasive testing may be provided on histology.

AIM

To address the appropriate utilisation of liver biopsy as part of DILI causality assessment in this setting.

METHODS

From 2020 to 2022, the Liver Forum convened a series of webinars on issues pertaining to liver biopsy during MASH trials. The Histology Working Group was formed to generate a series of consensus documents addressing these challenges. This manuscript focuses on liver biopsy as part of DILI causality assessment.

RESULTS

Expert opinion, guidance and recommendations on the role of liver biopsy as part of causality assessment of suspected DILI occurring during clinical trials for a drug(s) being developed for MASH are provided. Lessons learned from prior MASH programs are reviewed and gaps identified.

CONCLUSIONS

Although there are no pathognomonic features, histologic evaluation of suspected DILI during MASH clinical trials may alter patient management, define the pattern and severity of injury, detect findings that favour a diagnosis of DILI versus MASH progression, identify prognostic features, characterise the clinicopathological phenotype of DILI, and/or define lesions that influence decisions about trial discontinuation and further development of the drug.

Endoscopic procedures in hepatology: Current trends and new developments

Gastrointestinal endoscopy has long been a reliable backbone in the diagnosis and management of hepatobilary disorders and their complications. However, with evolving non-invasive testing, personalised medicine has reframed the utility and necessity of endoscopic screening. Conversely, the growing interest and use of endoscopic ultrasound (EUS) and advanced endoscopy within gastrointestinal units has also opened novel diagnostic and therapeutic avenues for patients with various hepatobiliary diseases. The integration of "advanced endoscopy" within the practice of hepatology is nowadays referred to as "endo-hepatology". In essence, endo-hepatology consists of two pillars: one focusing primarily on disorders of the liver parenchyma, vascular disorders, and portal hypertension, which is mainly captured via EUS, while the other targets the hepatobiliary tract via endoscopic retrograde cholangiopancreatography and advanced imaging. Applications under the umbrella of endo-hepatology include, amongst others, EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, coil and glue embolisation of gastric varices as well as cholangioscopy. As such endo-hepatology could become an attractive concept wherein advanced endoscopy might reinforce the medical management of patients with hepatobiliary disorders and their complications after initial basic work-up. In this review, we discuss current trends and future developments within endo-hepatology and the remaining hurdles to overcome.

Comparison of the Safety of Transjugular and Percutaneous Liver Biopsies

PURPOSE

To compare adverse events (AEs) between the transjugular liver biopsy (TJLB) and percutaneous liver biopsy (PLB) approaches.

MATERIALS AND METHODS

A total of 1,300 patients who underwent liver biopsy between July 1, 2014 and January 31, 2018, were examined, and bivariate and multivariate analyses were used to determine predictors of the biopsy method used and AEs. To reduce bias in the comparison of the AE rates between patients who had TJLB or PLB, propensity score matching was used to control for baseline disease severity.

RESULTS

PLB and TJLB were performed in 601 and 699 patients, respectively. The mean Charlson Comorbidity Index score was 3 (±2), and antiplatelet or anticoagulation therapy at the time of biopsy was used in <10% of patients. Patients with suspected cirrhosis or portal hypertension (odds ratio [OR], 9.9), an international normalized ratio of >1.5 (OR, 5.9), or a platelet count of <100 × 103/mL (OR, 3.9) were more likely to undergo TJLB. After propensity matching, which identified a population of patients with a mean international normalized ratio of <1.5 and platelet count of >150 × 103/mL, the only difference in the AE rate was for pain, which was present in 8% and 10% of patients after TJLB and PLB, respectively (P < .001). Bleeding requiring transfusion occurred in 2 patients who underwent TJLB and 1 patient who underwent PLB. There was 1 case of death occurring after TJLB.

CONCLUSIONS

Severe/life-threatening AEs occurring after liver biopsy were uncommon, and the 2 liver biopsy approaches appeared to have similar safety profiles for low-risk patients. After matching for underlying disease severity, pain was the AE that was more likely to occur in patients who underwent PLB.

Combined impact of myosteatosis and liver steatosis on prognosis in stage I-III colorectal cancer patients

BACKGROUND

Myosteatosis and liver steatosis (LS) have been recognized as patient-derived image biomarkers that correlate with prognosis in colorectal cancer (CRC) patients. However, the significance of considering fat deposition in multiple body areas simultaneously has been underestimated. This study aimed to investigate the combined effect of myosteatosis and LS in stage I-III CRC patients.

METHODS

A total of 616 stage I-III CRC patients were included in the study. Myosteatosis was assessed using skeletal muscle radiodensity (SMD), and LS was estimated by calculating the Hounsfield unit of the liver and spleen ratio (LSR). Cox proportional hazard models were utilized to evaluate disease-free survival (DFS). A combination of myosteatosis and LS was proposed, and its discriminatory performance was compared using the C-index.

RESULTS

Among the 616 participants, the median (interquartile) age was 64 (55-72) years, and 240 (38.9%) were female. The median and interquartile range of LSR were determined as 1.106 (0.967-1.225). The optimal cutoff value for LSR was identified as 1.181, leading to the classification of patients into low (410, 66.5%) and high LSR (206, 33.4%) groups. Among the patients, 200 were categorized into the low SMD group, while 416 were allocated to the high SMD group. Both myosteatosis and LS were identified as independent prognostic factors in the multivariable analysis. The combination of these two variables resulted in a three-group classification: high SMD with low LSR group, high SMD with high LSR group, and low SMD group. When comparing the C-index values, the three-group classification exhibited superior discriminatory performance compared with considering myosteatosis and LS separately.

CONCLUSIONS

Myosteatosis was associated with poorer survival, while the presence of LS was linked to a better prognosis in non-metastatic CRC patients. Simultaneously considering fat infiltration can serve as a more effective prognosticator in non-metastatic CRC patients.

Does amyloid β precursor protein gene expression have a role in diagnosis of biliary atresia?

Aim of the study

Biliary atresia (BA) is an important cause of surgical jaundice. Although the precise etiology is unknown, β-amyloid (Aβ) has been observed around the bile ducts in BA livers. It is unclear whether Aβ plays a role in the pathogenesis of this disease. This study aims to assess the amyloid β precursor protein (APP) gene expression in infants with BA in comparison with other causes of neonatal cholestasis. This could help explore the role of Aβ in the pathogenesis and diagnosis of BA.

Material and methods

A prospective study was conducted at the outpatient clinic of Paediatric Hepatology, Gastroenterology, and Nutrition Department, National Liver Institute, Menoufia University, Shebin El Kom, Menoufia, Egypt during the period March 2022 to December 2022. Clinical data were gathered and laboratory and radiological investigations were conducted including β precursor protein gene expression measured in liver biopsies of the three groups using quantitative real-time PCR (qPCR).

Results

Gene expression of APP was considerably higher in the BA group (p = 0.0001) compared to neonatal cholestasis (NC) patients. Gamma glutamyl transferase (GGT) and APP had a positive correlation (p = 0.001). No significant association was found between APP and fibrosis. APP was noticeably higher in BA than NC other than BA. Also, APP in BA was higher (statistically significant, p = 0.0001) than the control. There was no statistically significant difference among NC, BA, and control groups regarding APP (p = 0.07). Both males and females did not show significant differences as regards APP (p = 0.851). Age did not have a statistically significant correlation with APP (p = 0.532). Also, there were no correlations between APP and alkaline phosphatase (ALP), aspartate transaminase (AST), or total bilirubin (TB) (p > 0.05).

Conclusions

We concluded that the development and identification of BA may depend on the liver expression of serum APP. Surgeons may be able to carry out early intraoperative cholangiography for BA confirmation if the combination of APP with GGT and other hepatic function parameters exhibits a high predictive potential as a diagnostic test for BA. To evaluate this hypothesis, more research with sizable sample numbers is necessary.

MAGPIX and FLEXMAP 3D Luminex platforms for direct detection of miR-122-5p through dynamic chemical labelling

MicroRNAs (miRs) have emerged as promising biomarkers for diagnosing and predicting the prognosis of liver injury. This study aimed to compare the performance of two Luminex platforms, MAGPIX and FLEXMAP 3D, utilizing the innovative Dynamic Chemical Labelling (DCL) technology for direct detection and analysis of miR-122-5p in serum samples from patients with liver injury. Serum samples were collected from four patients with liver injury and four healthy controls. The levels of miR-122-5p were measured using the DCL method on both MAGPIX and FLEXMAP 3D platforms. The performance evaluation included the limit of detection (LOD), intra-assay and inter-assay precision, as well as accuracy. The results demonstrated that both platforms exhibited high sensitivity and specificity in detecting miR-122-5p in serum samples from patients with liver injury. However, FLEXMAP 3D indicated a lower LOD compared to MAGPIX. The precision of miR-122-5p detection was similar between the two platforms. In conclusion, both MAGPIX and FLEXMAP 3D Luminex platforms, in conjunction with DCL reagents, proved to be reliable and sensitive tools for detecting miR-122-5p in serum samples from patients with liver injury. Although both platforms were effective, FLEXMAP 3D exhibited slightly better performance, suggesting its preference for miR detection in clinical settings. These findings offer valuable insights for selecting the appropriate Luminex platform for miR detection in patients with liver injury and beyond.

A lethal case of massive hemorrhage after percutaneous liver biopsy in a patient with thrombasthenia

Percutaneous needle liver biopsy is an important procedure in the diagnosis of and assessment of the severity of liver diseases. Although liver biopsy is considered to be a relatively safe procedure, there are occasional cases of death due to massive bleeding after liver biopsy. Thrombasthenia is a disease in which bleeding occurs in the mucosa and skin due to platelet dysfunction. A 60-year-old female was admitted for a liver biopsy for further investigation after an abnormal liver function test. She was diagnosed with thrombasthenia and was being treated with oral tranexamic acid and carbazochrome. Blood tests showed little decrease of platelet count and no abnormalities of blood coagulability. Approximately ten hours after the liver biopsy, the patient complained of nausea and lightheadedness, followed by decreased blood pressure and decreased consciousness. An emergent abdominal CT scan showed a large amount of blood in the abdominal cavity. The patient died despite multidisciplinary treatment, and a forensic autopsy was performed. At internal examination, approximately 2,620 mL of dark red blood was accumulated in the abdominal cavity. A puncture wound led 1.8 cm into the liver from the surface of the liver, and no major vascular damage was observed. The cause of death was considered to be blood loss due to bleeding from the puncture wound. Even if the platelet count is normal, such as in a case of thrombasthenia, the risk of bleeding should not be underestimated. Careful attention should be paid when performing liver biopsy in a patient with risk factors.

Distinct ways to perform a liver biopsy: The core technique setups and updated understanding of these modalities

There is dramatically increased incidence of several liver diseases worldwide; thus, an unmet need to diagnose and stage these pathological entities heralds the wide application of liver biopsy (LB) techniques. The ways of LB are versatile, including percutaneous LB, transjugular LB, and more recently an approach of minimal invasiveness, that is, EUS-guided LB (EUS-LB). In this review article, we come to the conclusion that EUS-LB may serve as a feasible, reliable, and safe alternative to percutaneous LB and transjugular LB in terms of improved diagnostic yield, excellent sampling performance, and controlled adverse events among patients with focal, infiltrative, and parenchymal liver diseases. Furthermore, extensive efforts have been made to optimize and refine several technical pillars within EUS-LB modality such as the selection of needle size/type, priming manner of biopsy needle, and choice of pass/actuation technique, all of which aim at obtaining better specimen quantity and quality. Another advantageous aspect and unique property pertinent to EUS-guided modality indicate that multiple screening, surveillance, and intervention procedures can be combined into one single endoscopic session. Accordingly, some pilot studies have clarified the clinical usefulness by integrating EUS-LB with simultaneous measurement of portal pressure gradient or examination of liver stiffness. However, more studies, in particular, randomized controlled trials or real-world evidence, are practically warranted to elucidate the validity and safety of EUS-LB as a regular/routine part of managing liver diseases.

Quality of Tissue Samples Obtained by Endoscopic Ultrasound-Guided Liver Biopsy: A Randomized, Controlled Clinical Trial

INTRODUCTION

Liver biopsy (LB) remains essential for the diagnosis and staging of parenchymal liver diseases. Endoscopic ultrasound-guided LB (EUS-LB) has emerged as an attractive alternative to percutaneous and transjugular routes. We aimed at comparing the adequacy of samples obtained by EUS-LB with percutaneous LB.

METHODS

A single-center, randomized, controlled clinical trial was designed. Patients undergoing LB were randomly assigned to EUS-LB or percutaneous LB groups. EUS-LB was performed with a 19-gauge Franseen core needle through a transduodenal and transgastric route. Percutaneous LB was performed with a 16-gauge Tru-Cut needle. The main outcome was the percentage of adequate samples obtained. Secondary outcomes were the percentage of accurate histologic diagnosis, number of complete portal tracts (CPT), total and longest specimen length (TSL and LSL), sample fragmentation, adverse events, and patients' satisfaction. An adequate specimen was defined as TSL ≥20 mm and including ≥11 CPT.

RESULTS

Ninety patients were randomized (44 to EUS-LB and 46 to percutaneous LB) and included in the analysis. The percentage of adequate tissue samples was 32.6% and 70.4% for percutaneous LB and EUS-LB, respectively ( P < 0.001). A final histologic diagnosis was provided in all cases but one. TSL was longer after EUS-LB (23.5 vs 17.5 mm, P = 0.01), whereas the number of CPT was similar in both groups. Sample fragmentation occurred more often after EUS-LB ( P < 0.001). No differences in adverse events were found. Satisfaction reported with both procedures was high.

DISCUSSION

EUS-LB is safe and accurate and may be considered an alternative to percutaneous LB for the evaluation of parenchymal liver diseases.

Technical Success, Sample Adequacy, and Complications of Pediatric Transjugular Liver Biopsy: A Systematic Review and Meta-Analysis

BACKGROUND

Transjugular liver biopsy (TJLB) procedurally samples liver tissue through the internal jugular vein. It is indicated in the presence of coagulopathies and/or ascites.

AIMS

This meta-analysis aimed to assess the safety and efficacy of TJLB in children.

METHODS

A literature search of several databases was conducted from inception to August 2022. Eligible studies reported pediatric patients (< 18 years old) who underwent TJLB. The pooled proportion was analyzed using a random-effects model. This review was registered in PROSPERO (CRD42022354421).

RESULTS

From 921 initial studies screened, eight met the eligibility criteria, with a total of 361 pediatric patients who underwent 374 TJLBs. All eight studies reported pooled rates of technical success at 99.1% (95% CI 0.982, 1.001; I2 = 0%) and histological adequacy of sampling at 97.5% (95% CI 0.954, 0.995; I2 = 27.66%). A total of 49 complications were reported across six studies, the most common being bleeding from the entry site (38.78%), fevers for less than 24 h (12.24%), red blood cells transfusion requirement (10.2%), supraventricular tachycardia (8.16%), and pain requiring analgesia (8.16%).

CONCLUSION

Pediatric TJLB demonstrates high rates of technical success and adequate liver core biopsy samples, with a low rate of complications. These results suggest that TJLB is an effective method for diagnostic yield and postprocedural outcomes, especially in patients with preexisting coagulopathies and ascites where percutaneous liver biopsy is contraindicated. Additional studies evaluating larger groups of pediatric patients may provide further support for the use of TJLB in this population.

Hospital discharge after percutaneous liver biopsy - less is more?

INTRODUCTION

Liver biopsy is a technique frequently performed in clinical practice. However, the recommended surveillance period after the procedure is not established in the guidelines. The aim of this study was to assess the safety and patient satisfaction of hospital discharge 2 h after a percutaneous liver biopsy.

METHODS

Prospective monocentric study which included all patients who underwent percutaneous liver biopsy between December 2020 and November 2022. Individuals were discharged 2 h after the procedure according to a protocol that was implemented in our institution.

RESULTS

A total of 200 patients were included, the majority male (52.0%), with a median age of 52 years old (interquartile range (IQR) 40-60). Forty-two (21.0%) individuals had mild adverse events at the time of or within 2 h of the procedure. Most (90.4%) occurred in the first hour after the liver biopsy. Only 5 (2.5%) patients were kept under observation for 4 h due to abdominal/shoulder pain. There were no serious complications and no patient required subsequent admission. The majority of patients reported being satisfied/very satisfied (99.4%) and felt safe (98.9%) with this protocol. Most of the individuals showed a preference for early hospital discharge (97.3%).

CONCLUSION

We showed that patients requiring percutaneous liver biopsy can be safely discharged 2 h after the procedure.

Advances in Endohepatology

Over the past decade, the number of endoscopic procedures relevant to patients with liver disease not only increased but also altered and expanded in terms of indications and applications. "Endohepatology" refers to the integration of advanced endoscopy within the practice of hepatology with endoscopic ultrasound as one of the main pillars. Current applications under the umbrella of endohepatology focus on advanced diagnostics and oncological, vascular, and metabolic interventions. These involve, among others, endoscopic ultrasound (EUS)-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided coil and glue embolization of gastric varices. In addition to its conceptually attractive technical and innovative characteristics, endohepatology is also an appealing practical option for daily practice because it can be offered as a "one-stop clinic" intervention where comprehensive endoscopic diagnostic and/or therapeutic testing is performed in a single outpatient visit. In this review, we will discuss current trends and future developments within endohepatology and the remaining hurdles to overcome.

Comparison of Radiologists and Deep Learning for US Grading of Hepatic Steatosis

Background Screening for nonalcoholic fatty liver disease (NAFLD) is suboptimal due to the subjective interpretation of US images. Purpose To evaluate the agreement and diagnostic performance of radiologists and a deep learning model in grading hepatic steatosis in NAFLD at US, with biopsy as the reference standard. Materials and Methods This retrospective study included patients with NAFLD and control patients without hepatic steatosis who underwent abdominal US and contemporaneous liver biopsy from September 2010 to October 2019. Six readers visually graded steatosis on US images twice, 2 weeks apart. Reader agreement was assessed with use of κ statistics. Three deep learning techniques applied to B-mode US images were used to classify dichotomized steatosis grades. Classification performance of human radiologists and the deep learning model for dichotomized steatosis grades (S0, S1, S2, and S3) was assessed with area under the receiver operating characteristic curve (AUC) on a separate test set. Results The study included 199 patients (mean age, 53 years ± 13 [SD]; 101 men). On the test set (n = 52), radiologists had fair interreader agreement (0.34 [95% CI: 0.31, 0.37]) for classifying steatosis grades S0 versus S1 or higher, while AUCs were between 0.49 and 0.84 for radiologists and 0.85 (95% CI: 0.83, 0.87) for the deep learning model. For S0 or S1 versus S2 or S3, radiologists had fair interreader agreement (0.30 [95% CI: 0.27, 0.33]), while AUCs were between 0.57 and 0.76 for radiologists and 0.73 (95% CI: 0.71, 0.75) for the deep learning model. For S2 or lower versus S3, radiologists had fair interreader agreement (0.37 [95% CI: 0.33, 0.40]), while AUCs were between 0.52 and 0.81 for radiologists and 0.67 (95% CI: 0.64, 0.69) for the deep learning model. Conclusion Deep learning approaches applied to B-mode US images provided comparable performance with human readers for detection and grading of hepatic steatosis. Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Tuthill in this issue.

Tips for Preparing and Practicing Thermal Ablation Therapy of Hepatocellular Carcinoma

Thermal ablation therapy, including radiofrequency ablation (RFA) and microwave ablation (MWA), is considered the optimal locoregional treatment for unresectable early-stage hepatocellular carcinomas (HCCs). Percutaneous image-guided ablation is a minimally invasive treatment that is being increasingly performed because it achieves good clinical outcomes with a lower risk of complications. However, the physics and principles of RFA and MWA markedly differ. Although percutaneous thermal ablation under image guidance may be challenging in HCC cases with limited access or a risk of thermal injury, a number of ablative techniques, each of which may be advantageous and disadvantageous for individual cases, are available. Furthermore, even when a HCC is eligible for ablation based on tumor selection and technical factors, additional patient factors may have an impact on whether it is the appropriate treatment choice. Therefore, a basic understanding of the advantages and limitations of each ablation device and imaging guidance technique, respectively, is important. We herein provide an overview of the basic principles of tissue heating in thermal ablation, clinical and laboratory parameters for ablation therapy, preprocedural management, imaging assessments of responses, and early adverse events. We also discuss associated challenges and how they may be overcome using optimized imaging techniques.

The Efficacy of Anthropometric Indicators in Predicting Non-Alcoholic Fatty Liver Disease Using FibroScan® CAP Values among the Taiwanese Population

The controlled attenuation parameter (CAP) measurement obtained from FibroScan® is a low-risk method of assessing fatty liver. This study investigated the association between the FibroScan® CAP values and nine anthropometric indicators, including the abdominal volume index (AVI), body fat percentage (BFP), body mass index (BMI), conicity index (CI), ponderal index (PI), relative fat mass (RFM), waist circumference (WC), waist-hip ratio (WHR), and waist-to-height ratio (WHtR), and risk of non-alcoholic fatty liver disease (fatty liver). We analyzed the medical records of adult patients who had FibroScan® CAP results. CAP values <238 dB/m were coded as 0 (non- fatty liver) and ≥238 dB/m as 1 (fatty liver). An individual is considered to have class 1 obesity when their body mass index (BMI) ranges from 30 kg/m2 to 34.9 kg/m2. Class 2 obesity is defined by a BMI ranging from 35 kg/m2 to 39.9 kg/m2, while class 3 obesity is designated by a BMI of 40 kg/m2 or higher. Out of 1763 subjects, 908 (51.5%) had fatty liver. The BMI, WHtR, and PI were found to be more strongly correlated with the CAP by the cluster dendrogram with correlation coefficients of 0.58, 0.54, and 0.54, respectively (all p < 0.0001). We found that 28.3% of the individuals without obesity had fatty liver, and 28.2% of the individuals with obesity did not have fatty liver. The BMI, CI, and PI were significant predictors of fatty liver. The BMI, PI, and WHtR demonstrated better predictive ability, indicated by AUC values of 0.72, 0.68, and 0.68, respectively, a finding that was echoed in our cluster group analysis that showed interconnected clustering with the CAP. Therefore, of the nine anthropometric indicators we studied, the BMI, CI, PI, and WHtR were found to be more effective in predicting the CAP score, i.e., fatty liver.

A Machine Learning Method to Identify the Risk Factors for Liver Fibrosis Progression in Nonalcoholic Steatohepatitis

AIM

Nonalcoholic fatty liver disease (NAFLD) is a silent epidemy that has become the most common chronic liver disease worldwide. Nonalcoholic steatohepatitis (NASH) is an advanced stage of NAFLD, which is linked to a high risk of cirrhosis and hepatocellular carcinoma. The aim of this study is to develop a predictive model to identify the main risk factors associated with the progression of hepatic fibrosis in patients with NASH.

METHODS

A database from a multicenter retrospective cross-sectional study was analyzed. A total of 215 patients with NASH biopsy-proven diagnosed were collected. NAFLD Activity Score and Kleiner scoring system were used to diagnose and staging these patients. Noninvasive tests (NITs) scores were added to identify which one were more reliable for follow-up and to avoid biopsy. For analysis, different Machine Learning methods were implemented, being the eXtreme Gradient Booster (XGB) system the proposed algorithm to develop the predictive model.

RESULTS

The most important variable in this predictive model was High-density lipoprotein (HDL) cholesterol, followed by systemic arterial hypertension and triglycerides (TG). NAFLD Fibrosis Score (NFS) was the most reliable NIT. As for the proposed method, XGB obtained higher results than the second method, K-Nearest Neighbors, in terms of accuracy (95.05 vs. 90.42) and Area Under the Curve (0.95 vs. 0.91).

CONCLUSIONS

HDL cholesterol, systemic arterial hypertension, and TG were the most important risk factors for liver fibrosis progression in NASH patients. NFS is recommended for monitoring and decision making.

Diagnostic efficacy of endoscopic ultrasound-guided liver biopsy for diffuse liver diseases and its predictors - a multicentric retrospective analysis

Aim of the study

Endoscopic ultrasound (EUS)-guided liver biopsy (LB) has become an increasingly popular method of tissue acquisition for evaluating liver diseases. Despite its advantages, EUS-LB has not been widely adopted in clinical practice due to concerns regarding efficacy and safety. Present data on EUS-LB from India are scarce. We aimed to study the diagnostic outcome and safety of EUS-guided liver biopsy.

Material and methods

This is a retrospective analysis of prospectively maintained data from January 2021 to October 2022 of consecutive patients undergoing EUS-LB at four tertiary care centers in India. The primary outcome was sample adequacy, while secondary outcomes were rate of successful pathological diagnoses and incidence of adverse events (AE).

Results

A total of 74 patients (median age: 44.5 years, 50.0% males) were included. The majority of the patients underwent left-lobe biopsy (62/74, 83.7%), and a 19-G Franseen FNB needle was most commonly used (61/74, 82.4%). Wet heparin suction was used in most cases (60/74, 81.1%). There were five mild AEs observed (one case of self-limited bleeding and four cases of post-procedural pain). Adequate and optimal samples were obtained in 71 (95.9%) and 49 (66.2%) cases, with a conclusive diagnosis being made in 97.3% (72/74) of the patients. On multivariate analysis, the presence of ascites was a negative predictor of optimal sample (odds ratio [OR] = 0.128, 95% CI: 0.017-0.96).

Conclusions

EUS-LB is a safe and viable alternative to percutaneous liver biopsy, achieving diagnosis in > 95% of cases. EUS-LB can be performed safely even in patients with mild ascites, although ascites reduces the chances of getting an optimal sample.

Liver Biopsy: To Do or Not to Do - A Single-Center Study

INTRODUCTION

A variety of liver disorders are associated with characteristic histopathological findings that help in their diagnosis and treatment. However, percutaneous liver biopsy (PLB) is prone to limitations and complications. We evaluated all PLBs done in our hospital in a 13-year period, aiming to assess PLB's utility and complications.

METHODS

All PLBs conducted in an internal medicine department of a tertiary university hospital in Athens, Greece, during a 13-year period were reviewed. Recorded data included demographic characteristics, laboratory results acquired on biopsy day, indication for liver biopsy, and occurrence of side effects. All patients were followed for 1 month post-hospital discharge for possible PLB-related complications.

RESULTS

A total of 261 patients underwent PLB during the study period. The commonest indication of PLB was investigation of liver mass, followed by transaminasemia. PLB assisted in setting a diagnosis in 218 patients and was unhelpful in only 43, in 14 of them due to inadequate or inappropriate biopsy specimen. Complications attributable to PLB were rare, with 10 patients exhibiting pain, either at biopsy site or in the right shoulder, and 3 having bleeding episodes; no deaths were noted.

CONCLUSIONS

Our study shows that PLB is still a powerful diagnostic tool in everyday practice, provided it is used when indicated.

Refining Liver Biopsy in Hepatocellular Carcinoma: An In-Depth Exploration of Shifting Diagnostic and Therapeutic Applications

The field of hepatocellular carcinoma (HCC) has faced significant change on multiple levels in the past few years. The increasing emphasis on the various HCC phenotypes and the emergence of novel, specific therapies have slowly paved the way for a personalized approach to primary liver cancer. In this light, the role of percutaneous liver biopsy of focal lesions has shifted from a purely confirmatory method to a technique capable of providing an in-depth characterization of any nodule. Cancer subtype, gene expression, the mutational profile, and tissue biomarkers might soon become widely available through biopsy. However, indications, expectations, and techniques might suffer changes as the aim of the biopsy evolves from providing minimal proof of the disease to high-quality specimens for extensive analysis. Consequently, a revamped position of tissue biopsy is expected in HCC, following the reign of non-invasive imaging-only diagnosis. Moreover, given the advances in techniques that have recently reached the spotlight, such as liquid biopsy, concomitant use of all the available methods might gather just enough data to improve therapy selection and, ultimately, outcomes. The current review aims to discuss the changing role of liver biopsy and provide an evidence-based rationale for its use in the era of precision medicine in HCC.

Transjugular liver biopsy: enlarge the indications for liver biopsy with reliable diagnostic quality

BACKGROUND

Complications and diagnostic efficiency for liver biopsy are main concerns for clinicians. This study aimed to assess the safety and efficacy of transjugular liver biopsy (TJLB) compared with percutaneous liver biopsy (PLB) when patients had equal level of liver function and number of passes, using propensity score matching (PSM).

METHODS

The clinical and pathological data of patients who received TJLB or PLB between January 2012 and October 2022 were collected. Matching factors included age, gender, cirrhosis, portal hypertension, liver function, creatinine, number of passes, hemodialysis, history of anti-coagulation and anti-platelet, and comorbidities. Coagulation indexes were not considered as matching factors due to different indications of the two techniques.

RESULTS

2711 PLBs and 30 TJLBs were evaluated. By PSM, 75 patients (50 PLBs, 25 TJLBs) were matched. The complication rates for TJLB and PLB were 4.0% (1/25) and 10.0% (5/50) (P > 0.05). Two PLBs had hepatic hemorrhage, one of which required only close monitoring (Grade 1) and the other needed hemostasis and rehydration therapy (Grade 2). The other 3 cases presented with mild abdominal pain (Grade 1). And only one TJLB presented with mild pain. The median number of complete portal tracts were 6.0 and 10.0 for TJLBs and PLBs (P < 0.05). Moreover, the median length of sample for TJLBs and PLBs were 10.0 and 16.5 mm (P < 0.05). The diagnostic efficiency of hepatopathy of unknown etiology of TJLB versus PLB groups before and after matching were 96.4% vs. 94.1% and 95.7% vs. 93.2%, respectively (P > 0.05).

CONCLUSION

TJLB is an effective invasive diagnostic procedure that expands indications for liver biopsy with reliable diagnostic quality.

MRI-guided thoraco-abdominal percutaneous needle biopsy: our initial experience

OBJECTIVE

The aim of this study is to describe the technique and to report early results of thoraco-abdominal biopsies in the Interventional Magnetic Resonance Imaging Suite (IMRIS).

MATERIALS AND METHODS

We prospectively evaluated patients with indications for MRI-guided biopsy between January 2021 and May 2022. Exclusion criteria were indication for US-/CT-guided biopsy, contraindication to percutaneous biopsy, inability to lie flat for at least 30 min, claustrophobic, severe obesity, or non-MRI compatible devices. Biopsies were performed by 3 interventional radiologists, with at least 8 years of experience in oncological interventional radiology. Epidemiological, clinical, procedural, and histopathological data were retrospectively collected.

RESULTS

From an initial population of 117 patients, 57 patients (32 male, mean age 64 ± 8 y) were finally enrolled. All 57 patients suspected thoraco-abdominal malignant lesions finally underwent MRI-guided percutaneous biopsy. The mean duration of the entire procedure was 37 min (range 28-65 min); the mean duration of the total needle-in-patient time was 10 min (range 6-19 min). Technical and clinical success were obtained for all the biopsies performed. Malignancy was demonstrated in 47/57 (82%) cases and benignancy in the remaining 10/57 (18%) cases. No major complications were detected after the biopsies; two minor compliances (severe pain) occurred and were managed conservatively.

CONCLUSION

Our initial experience demonstrated the technical feasibility and the accuracy of MRI-guided biopsies of thoraco-abdominal masses. The reported data associated with the best comfort for the patient and for the operator make the use of MRI a valid alternative to other methods, especially in lesions that are difficult to approach via US or CT.

CLINICAL RELEVANCE STATEMENT

Interventional MRI is one of the most important innovations available for interventional radiologists. This method will broaden the diagnostic and therapeutic possibilities, allowing treatment of lesions up to now not approachable percutaneously. For this, it is necessary to start publishing the data of the few groups that are developing the method.

KEY POINTS

• To evaluate the use of MRI as a guide for percutaneous biopsies of various districts. • Our preliminary experience confirms experience demonstrated the technical feasibility and the accuracy of MRI-guided biopsies of thoraco-abdominal masses. • Interventional MRI can become the reference method for percutaneous biopsies in particular for lesions with difficult percutaneous approach.

A deep learning model with data integration of ultrasound contrast-enhanced micro-flow cines, B-mode images, and clinical parameters for diagnosing significant liver fibrosis in patients with chronic hepatitis B

OBJECTIVE

To develop and investigate a deep learning model with data integration of ultrasound contrast-enhanced micro-flow (CEMF) cines, B-mode images, and patients' clinical parameters to improve the diagnosis of significant liver fibrosis (≥ F2) in patients with chronic hepatitis B (CHB).

METHODS

Of 682 CHB patients who underwent ultrasound and histopathological examinations between October 2016 and May 2020, 218 subjects were included in this retrospective study. We devised a data integration-based deep learning (DIDL) model for assessing ≥ F2 in CHB patients. The model contained three convolutional neural network branches to automatically extract features from ultrasound CEMF cines, B-mode images, and clinical data. The extracted features were fused at the backend of the model for decision-making. The diagnostic performance was evaluated across fivefold cross-validation and compared against the other methods in terms of the area under the receiver operating characteristic curve (AUC), with histopathological results as the reference standard.

RESULTS

The mean AUC achieved by the DIDL model was 0.901 [95% CI, 0.857-0.939], which was significantly higher than those of the comparative methods, including the models trained by using only CEMF cines (0.850 [0.794-0.893]), B-mode images (0.813 [0.754-0.862]), or clinical data (0.757 [0.694-0.812]), as well as the conventional TIC method (0.752 [0.689-0.808]), APRI (0.792 [0.734-0.845]), FIB-4 (0.776 [0.714-0.829]), and visual assessments of two radiologists (0.812 [0.754-0.862], and 0.800 [0.739-0.849]), all ps < 0.01, DeLong test.

CONCLUSION

The DIDL model with data integration of ultrasound CEMF cines, B-mode images, and clinical parameters showed promising performance in diagnosing significant liver fibrosis for CHB patients.

KEY POINTS

• The combined use of ultrasound contrast-enhanced micro-flow cines, B-mode images, and clinical data in a deep learning model has potential to improve the diagnosis of significant liver fibrosis. • The deep learning model with the fusion of features extracted from multimodality data outperformed the conventional methods including mono-modality data-based models, the time-intensity curve-based recognizer, fibrosis biomarkers, and visual assessments by experienced radiologists. • The interpretation of the feature attention maps in the deep learning model may help radiologists get better understanding of liver fibrosis-related features and hence potentially enhancing their diagnostic capacities.