Science to practice: Can T1rho imaging be used to diagnose and assess the severity of hepatic fibrosis?

Conventional and artificial intelligence-based computed tomography and magnetic resonance imaging quantitative techniques for non-invasive liver fibrosis staging

Chronic liver disease (CLD) ultimately develops into liver fibrosis and cirrhosis and is a major public health problem globally. The assessment of liver fibrosis is important for patients with CLD for prognostication, treatment decisions, and surveillance. Liver biopsies are traditionally performed to determine the stage of liver fibrosis. However, the risks of complications and technical limitations restrict their application to screening and sequential monitoring in clinical practice. CT and MRI are essential for evaluating cirrhosis-associated complications in patients with CLD, and several non-invasive methods based on them have been proposed. Artificial intelligence (AI) techniques have also been applied to stage liver fibrosis. This review aimed to explore the values of conventional and AI-based CT and MRI quantitative techniques for non-invasive liver fibrosis staging and summarized their diagnostic performance, advantages, and limitations.

A self-compensated spin-locking scheme for quantitative R1ρ dispersion MR imaging in ordered tissues

PURPOSE

To propose a self-compensated spin-locking (SL) method for quantitative R_1ρ dispersion imaging in ordered tissues.

METHODS

Two pairs of antiphase rotary-echo SL pulses were proposed in a new scheme with each pairs sandwiching one refocusing RF pulse. This proposed SL method was evaluated by Bloch simulations and experimental studies relative to three prior schemes. Quantitative R_1ρR dispersion imaging studies with constant SL duration (TSL = 40 ms) were carried out on an agarose (1-4% w/v) phantom and one in vivo human knee at 3 T, using six SL RF strengths ranging from 50 to 1000 Hz. The performances of these SL schemes were characterized with an average coefficient of variation (CV) of the signal intensities in agarose gels and the sum of squared errors (SSE) for quantifying in vivo R_1ρ dispersion of the femoral and tibial cartilage.

RESULTS

The simulations demonstrate that the proposed SL scheme was less prone to B₀ and B₁ field inhomogeneities. This theoretical prediction was supported by fewer image banding artifacts and less signal fluctuation signified by a reduced CV (%) on the phantom without R_1ρ dispersion (i.e., 4.04 ± 1.36 vs. 18.87 ± 4.46 or 6.66 ± 2.92 or 5.71 ± 2.05 for others), and further by mostly decreased SSE (*10^-3) for characterizing R_1ρ dispersion of the femoral (i.e., 0.3 vs. 1.2 or 0.4 or 0.1) and tibial (i.e., 0.4 vs. 7.2 or 3.2 or 2.8) cartilage.

CONCLUSION

The proposed SL scheme is less sensitive to B₀ and B₁ field artifacts for a wide range of SL RF strengths and thus more suitable for quantitative R_1ρ dispersion imaging in ordered tissues.

Diagnostic potential of T1ρ and T2 relaxations in assessing the severity of liver fibrosis and necro-inflammation

PURPOSE

To investigate the utility of T1ρ and T2 relaxations for assessing the severity of liver fibrosis (F stage) and necro-inflammation (A stage) in patients with chronic liver disease (CLD).

MATERIALS AND METHODS

We calculated T1ρ and T2 relaxations of the liver parenchyma in 82 patients who underwent liver surgery. F and A stages of enrolled patients were assessed by referring to surgically resected specimens. The relationships between T1ρ or T2 relaxation and F or A stage were assessed using one-way analysis of variance followed by Tukey's multiple comparison test, Spearman's rank correlation test and a receiver operating characteristic analysis.

RESULTS

The T1ρ and T2 values of the liver parenchyma were significantly increased as the F and A stages progressed. The T1ρ and T2 values showed significant differences between F0 and F4, between F1 and F4, and between F2 and F4. In addition, T1ρ values showed a significant difference between F0 and F3 as well. The highest diagnostic ability for fibrosis was obtained when differentiating ≥F3 from ≤F2 using T1ρ: the sensitivity was 82.8%, the specificity 79.2% and the area under the curve (AUC) 0.87. The sensitivity and AUC of T1ρ relaxation (46.9% and 0.67) were significantly higher than those of T2 relaxation (29.7% and 0.60) for differentiating ≥A1 from A0.

CONCLUSION

T1ρ and T2 relaxations have potential as a biochemical marker for assessing the severity of liver fibrosis and necro-inflammation. T1ρ relaxation may be slightly superior to T2 relaxation in terms of diagnostic ability for liver fibrosis and necro-inflammation.

Evaluation of liver fibrosis and cirrhosis on the basis of quantitative T1 mapping: Are acute inflammation, age and liver volume confounding factors?

PURPOSE

To evaluate potential confounding factors in the quantitative assessment of liver fibrosis and cirrhosis using T1 relaxation times.

METHODS

The study population is based on a radiology-information-system database search for abdominal MRI performed from July 2018 to April 2019 at our institution. After applying exclusion criteria 200 (59 ± 16 yrs) remaining patients were retrospectively included. 93 patients were defined as liver-healthy, 40 patients without known fibrosis or cirrhosis, and 67 subjects had a clinically or biopsy-proven liver fibrosis or cirrhosis. T1 mapping was performed using a slice based look-locker approach. A ROI based analysis of the left and the right liver was performed. Fat fraction, R2*, liver volume, laboratory parameters, sex, and age were evaluated as potential confounding factors.

RESULTS

T1 values were significantly lower in healthy subjects without known fibrotic changes (1.5 T MRI: 575 ± 56 ms; 3 T MRI: 857 ± 128 ms) compared to patients with acute liver disease (1.5 T MRI: 657 ± 73 ms, p < 0.0001; 3 T MRI: 952 ± 37 ms, p = 0.028) or known fibrosis or cirrhosis (1.5 T MRI: 644 ± 83 ms, p < 0.0001; 3 T MRI: 995 ± 150 ms, p = 0.018). T1 values correlated moderately with the Child-Pugh stage at 1.5 T (p = 0.01, ρ = 0.35).

CONCLUSION

T1 mapping is a capable predictor for detection of liver fibrosis and cirrhosis. Especially age is not a confounding factor and, hence, age-independent thresholds can be defined. Acute liver diseases are confounding factors and should be ruled out before employing T1-relaxometry based thresholds to screen for patients with liver fibrosis or cirrhosis.

Collagen deposition in the liver is strongly and positively associated with T1rho elongation while fat deposition is associated with T1rho shortening: an experimental study of methionine and choline-deficient (MCD) diet rat model

BACKGROUND

A number of questions concerning the histological mechanism of elongated T1rho in liver fibrosis remain unanswered. Using a rat model of non-alcoholic fatty liver disease (NAFLD) induced with methionine and choline-deficient (MCD) diet, the primary aim of this study is to clarify whether collagen deposition per se causes liver T1rho elongation.

METHODS

There were 45 rats in the NAFLD model group and 8 rats in the control group. NAFLD model rats were fed MCD diet for 1, 2, 4, 6, 8, or 10 weeks, respectively. At the endpoint, the rats had in vivo MRI at 3.0 T and followed by histology. For T1rho data acquisition, a rotary echo spin-lock pulse was implemented in a three-dimensional fast field echo sequence with frequency selective fat suppression. The spin-lock frequency was set to 500 Hz, and the spin-lock times of 5, 10, 40, and 50 ms were used. Liver specimens were processed with hematoxylin-eosin staining for steatosis and inflammation evaluation, and Masson's trichrome staining for collagen visualization. The semiquantitative histopathological evaluation was based on NASH Clinical Research Network criteria. Histomorphometric analysis calculated percentages of fat and collagen accumulations in the livers.

RESULTS

A strong (r=0.82) and significant (P<0.0001) positive correlation between liver collagen content and liver T1rho was observed. Rats with no or minimal inflammation could have very long T1rho value. Among experimental rats without a positive fibrosis grading, five rats did not have an inflammation score (i.e., had minimal inflammation or no inflammation) while four had a positive inflammation score; the difference in liver T1rho between these two types of rats was minimal. Eight control rat livers and 15 stage-1 fibrosis rat livers were separated by liver T1rho completely. When four subgroups of experiment rats were selected where the liver collagen had a very narrow range within these subgroups, all these four subgroups showed a trend of negative correlation between liver fat and liver T1rho.

CONCLUSIONS

Collagen deposition in the live strongly contributes to liver T1rho elongation, while fat deposition contributes to T1rho shortening. In a well-controlled experimental setting, T1rho measure alone allows separation of healthy livers and stage-1 liver fibrosis in the MCD rat liver model.

Quantitative assessment of liver function with whole-liver T1rho mapping at 3.0T

OBJECTIVES

To assess the segmental liver function in healthy subjects and liver cirrhosis (LC) patients with different Child-Pugh grades using whole-liver T1rho mapping at 3.0T.

METHODS

Thirty-three healthy volunteers and 33 patients with clinically diagnosed LC were examined using a three-dimensional (3D) whole-liver coverage T1rho mapping. T1rho maps were calculated from five respiratory-triggered sequences with different spin-lock durations (0, 10, 20, 40, and 60ms). The patients were classified into group A with Child-Pugh A cirrhosis and group B with Child-Pugh B or C cirrhosis. The hepatic T1rho values in different segments of the healthy volunteers and LC patients were compared, and receiver operating characteristic curves (ROC) were plotted to determine the performance of T1rho.

RESULTS

The median T1rho value of the patients (Child-Pugh class A: 47.07ms; Child-Pugh classes B and C: 51.09ms) was significantly higher than that of the healthy volunteers (39.37ms, P<0.001). No remarkable variations among different hepatic segments in LC patients with various Child-Pugh grades were found (P>0.05). The T1rho values of the liver parenchyma were significantly correlated with albumin (r=-0.590, P<0.001) and prothrombin time (r=0.601, P<0.001). The T1rho values in patients increased with an increase in the Child-Pugh classification (r=0.574, P<0.001).

CONCLUSIONS

The whole-liver coverage T1rho sequence at 3.0T was feasible for the assessment of segmental liver function. T1rho relaxation might be a potential biomarker for the estimation of liver function in LC patients.

Multiparametric or practical quantitative liver MRI: towards millisecond, fat fraction, kilopascal and function era

New advances in liver magnetic resonance imaging (MRI) may enable diagnosis of unseen pathologies by conventional techniques. Normal T1 (550-620 ms for 1.5 T and 700-850 ms for 3 T), T2, T2* (>20 ms), T1rho (40-50 ms) mapping, proton density fat fraction (PDFF) (≤5%) and stiffness (2-3kPa) values can enable differentiation of a normal liver from chronic liver and diffuse diseases. Gd-EOB-DTPA can enable assessment of liver function by using postcontrast hepatobiliary phase or T1 reduction rate (normally above 60%). T1 mapping can be important for the assessment of fibrosis, amyloidosis and copper overload. T1rho mapping is promising for the assessment of liver collagen deposition. PDFF can allow objective treatment assessment in NAFLD and NASH patients. T2 and T2* are used for iron overload determination. MR fingerprinting may enable single slice acquisition and easy implementation of multiparametric MRI and follow-up of patients. Areas covered: T1, T2, T2*, PDFF and stiffness, diffusion weighted imaging, intravoxel incoherent motion imaging (ADC, D, D* and f values) and function analysis are reviewed. Expert commentary: Multiparametric MRI can enable biopsyless diagnosis and more objective staging of diffuse liver disease, cirrhosis and predisposing diseases. A comprehensive approach is needed to understand and overcome the effects of iron, fat, fibrosis, edema, inflammation and copper on MR relaxometry values in diffuse liver disease.

An experimental study on the assessment of rabbit hepatic fibrosis by using magnetic resonance T1ρ imaging

OBJECTIVE

To explore the correlation between the T1ρ values of liver and liver fibrosis by using magnetic resonance (MR) T1ρ imaging.

MATERIALS AND METHODS

The study consisted of the control group and the hepatic fibrosis (HF) group. Carbon tetrachloride (CCl4) injection was performed once a week for 10 weeks (week 1-10) in the HF group which was divided into 5 subgroups and underwent MR examinations at weeks 4, 5, 6, 10, and 15 respectively post the first CCl4 injection (week 1). According to Scheuer Classification, the stage of HF of all rabbits was classified as S0-S4. Mann-Whitney U test was performed to compare the T1ρ values, and p<0.05 was considered statistically significant.

RESULTS

The control group included 11 rabbits and the HF group included 46 rabbits. The T1ρ values in the HF group tended to increase with the increase of CCl4 injection duration or in higher HF stages. The T1ρ values were significantly lower (p=0.036) in the control group (or the stage S0 group) (23.5±4.0 ms) compared to the whole HF group (or S1-S4 group) (26.1±3.7 ms), and dropped at week 15 (p=0.043) after the CCl4 injection was stopped at week 10.

CONCLUSION

T1ρ imaging is closely associated with the severity of HF and may play an important role in the early diagnosis of HF.

T₁ρ MRI of human musculoskeletal system

Magnetic resonance imaging (MRI) offers the direct visualization of the human musculoskeletal (MSK) system, especially all diarthrodial tissues including cartilage, bone, menisci, ligaments, tendon, hip, synovium, etc. Conventional MRI techniques based on T1 - and T2 -weighted, proton density (PD) contrast are inconclusive in quantifying early biochemically degenerative changes in MSK system in general and articular cartilage in particular. In recent years, quantitative MR parameter mapping techniques have been used to quantify the biochemical changes in articular cartilage, with a special emphasis on evaluating joint injury, cartilage degeneration, and soft tissue repair. In this article we focus on cartilage biochemical composition, basic principles of T1ρ MRI, implementation of T1ρ pulse sequences, biochemical validation, and summarize the potential applications of the T1ρ MRI technique in MSK diseases including osteoarthritis (OA), anterior cruciate ligament (ACL) injury, and knee joint repair. Finally, we also review the potential advantages, challenges, and future prospects of T1ρ MRI for widespread clinical translation.

Evaluation of fibrotic liver disease with whole-liver T1ρ MR imaging: a feasibility study at 1.5 T

PURPOSE

To test at 1.5 T whether T1ρ magnetic resonance (MR) imaging of fibrotic liver disease is feasible, to investigate whether liver T1ρ imaging allows assessment of the severity of liver cirrhosis, and to assess the normal liver T1ρ range in healthy patients.

MATERIALS AND METHODS

This prospective study was approved by the institutional ethics committee. Written informed consent was obtained. Healthy volunteers (n = 25) and patients (n = 34) with cirrhosis underwent whole-liver T1ρ MR imaging at 1.5 T. Mean T1ρ values were calculated from liver regions of interest. Mean T1ρ values were correlated to clinical data and histopathologic analysis by analysis of variance. Receiver operating characteristic curves were calculated to determine the accuracy of mean T1ρ values for the assessment of Child-Pugh class.

RESULTS

Mean T1ρ values of volunteers (mean, 40.9 msec ± 2.9 [standard deviation]; range, 33.9-46.3 msec) were significantly lower than those of patients who were Child-Pugh class A (P < .004), B (P < .001), or C (P < .001), and significant differences were found between each Child-Pugh stage (A vs B, P < .002; B vs C, P < .009; A vs C, P < .001). Liver cirrhosis was confirmed via histologic analysis in all patients with liver biopsy. Mean T1ρ values did not correlate with necroinflammatory activity (r = 0.31; P = .23), degree of steatosis (r = -0.016; P = .68), or presence of iron load (r = 0.22; P = .43). Mean T1ρ values performed well by assessing the Child-Pugh stage, with receiver operating characteristic areas of 0.95-0.98. Intraclass correlation coefficient values ranged between 0.890 and 0.987, which indicated excellent imaging and reimaging reproducibility and interobserver and intraobserver variability.

CONCLUSION

Whole-liver T1ρ MR imaging at 1.5 T to detect and assess human liver cirrhosis is feasible. Further investigation and optimization of this technique are warranted to cover the entire spectrum of fibrotic liver disease.

Experimental evaluation of accelerated T1rho relaxation quantification in human liver using limited spin-lock times

Objective

It was reported lately that to obtain consistent liver T1rho measurement, at 3T MRI using six spin-lock times (SLTs), is feasible. In this study, the feasibility of using three or two SLT points to measure liver T1rho relaxation time was explored.

Materials and Methods

Seventeen healthy volunteers underwent 36 examinations. Three representative axial slices were selected to cut through the upper, middle, and lower liver. A rotary echo spin-lock pulse was implemented in a 2D fast field echo sequence. Spin-lock frequency was 500 Hz and the spin-lock times of 1, 10, 20, 30, 40, and 50 milliseconds (ms) were used for T1rho mapping. T1rho maps were constructed by using all 6 SLT points, three SLT points of 1, 20, and 50 ms, or two SLTs of 1 and 50 ms, respectively. Intra-class correlation coefficient (ICC) and Bland and Altman plot were used to assess the measurement agreement.

Results

Two examinations were excluded, due to motion artifact at the SLT of 50 ms. With the remaining 34 examinations, the ICC for 6-SLT vs. 3-SLT T1rho measurements was 0.922, while the ICC for 6-SLT vs. 2-SLT T1rho measurement was 0.756. The Bland and Altman analysis showed a mean difference of 0.19 (95% limits of agreement: -1.34, 1.73) for 6-SLT vs. 3-SLT T1rho measurement, and the mean difference of 0.89 (95% limits of agreement: -1.67, 3.45) for 6-SLT vs. 2-SLT T1rho measurement. The scan re-scan reproducibility ICC (n = 11 subjects) was 0.755, 0.727, and 0.528 for 6-SLT measurement, 3-SLT measurement, and 2-SLT measurement, respectively.

Conclusion

Adopting 3 SLTs of 1, 20, and 50 ms can be an acceptable alternative for the liver T1rho measurement, while 2 SLTs of 1 and 50 ms do not provide reliable measurement.

Liver T1ρ MRI measurement in healthy human subjects at 3 T: a preliminary study with a two-dimensional fast-field echo sequence

OBJECTIVES

The aim of this study was to explore the technical feasibility of T(1)ρ MRI for the liver, and to determine the normal range of liver T(1)ρ in healthy subjects at clinical 3 T.

METHODS

There were 15 healthy volunteers. Three representative axial slices were selected to cut through the upper, middle and lower liver. A rotary echo spin-lock pulse was implemented in a two-dimensional fast-field echo sequence. Spin-lock frequency was 500 Hz, and the spin-lock times of 1, 10, 20, 30, 40 and 50 ms were used for T(1)ρ mapping. The images were acquired slice by slice during breath-holding. Regions of interest (ROIs; n=5) were manually placed on each slice of the liver parenchyma region, excluding artefacts and vessels. The mean value of these ROIs (n=15) was regarded as the liver T(1)ρ value for the subject. Six subjects were scanned once at fasting status; six subjects were scanned once 2 h post meal; three subjects were scanned twice at fasting status; and seven subjects were scanned twice 2 h post meal.

RESULTS

When two readers measured the same 10 data sets, the interreader reproducibility (ICC: intraclass correlation coefficient) was 0.955. With the 10 subjects scanned twice, the ICC for scan-rescan reproducibility was 0.764. There was no significant difference for the liver T(1)ρ value at the fasting status (43.08±1.41 ms) and post-meal status (42.97±2.38 ms, p=0.867). Pooling together all the 32 scans in this study, the normal liver T(1)ρ value ranged from 38.6 to 48.3 ms (mean 43.0 ms, median 42.6 ms).

CONCLUSION

It is feasible to obtain consistent liver T(1)ρ measurement for human subjects at 3 T.

MR T1ρ as an imaging biomarker for monitoring liver injury progression and regression: an experimental study in rats with carbon tetrachloride intoxication

OBJECTIVES

Recently it was shown that the magnetic resonance imaging (MRI) T1ρ value increased with the severity of liver fibrosis in rats with bile duct ligation. Using a rat carbon tetrachloride (CCl(4)) liver injury model, this study further investigated the merit of T1ρ relaxation for liver fibrosis evaluation.

METHODS

Male Sprague-Dawley rats received intraperitoneal injection of 2 ml/kg CCl(4) twice weekly for up to 6 weeks. Then CCl(4) was withdrawn and the animals were allowed to recover. Liver T1ρ MRI and conventional T2-weighted images were acquired. Animals underwent MRI at baseline and at 2 days, 2 weeks, 4 weeks and 6 weeks post CCl(4) injection, and they were also examined at 1 week and 4 weeks post CCl(4) withdrawal. Liver histology was also sampled at these time points.

RESULTS

Liver T1ρ values increased slightly, though significantly, on day 2, and then increased further and were highest at week 6 post CCl(4) insults. The relative liver signal intensity change on T2-weighted images followed a different time course compared with that of T1ρ. Liver T1ρ values decreased upon the withdrawal of the CCl(4) insult. Histology confirmed the animals had typical CCl(4) liver injury and fibrosis progression and regression processes.

CONCLUSIONS

MR T1ρ imaging can monitor CCl(4)-induced liver injury and fibrosis.

KEY POINTS

• MR T1ρ is a valuable imaging biomarker for liver injury/fibrosis. • Liver T1ρ was only mildly affected by oedema and acute inflammation. • Liver MR T1ρ decreased when liver fibrosis and injury regressed.