Complication Rate after Percutaneous Liver Biopsy Using a Real-time Ultrasound Approach and Introducing a Uniform Methodology: A Brief Report

Following the initial liver biopsy attempts, several techniques using a wide range of methodologies and materials were developed. Many studies on the evaluation of post-liver biopsy complications were conducted. However, their fundamental limitation was significant variance in patient demographics and methodology, which might account for the inconsistent outcomes. Therefore, a uniform methodology to perform percutaneous liver biopsies that result in comparable outcomes around the world is required. This study aimed to determine the precise complication rate following percutaneous liver biopsy using a consistent method in all individuals. It also aimed to establish a consistent operating procedure for a percutaneous liver biopsy that yielded comparable outcomes. Between July 2018 and July 2019, 116 patients were enrolled in this retrospective study for percutaneous liver biopsy. All individuals underwent a biopsy using the same procedure. There was an attempt to exclude elements that could have an impact on the complication rate. For this purpose, the same type and size of needle were utilized. Moreover, a single needle pass, a subcostal approach, deep inspiration breath holding, identical pre- and post-biopsy preparation, real-time ultrasonography guidance, the use of a single operator, and the absence of sedation or general anesthesia were the other approaches that were used to minimize the impact of variables that could raise complication rates. The overall complication rate was 19.8%, of which 18.9% of patients experienced pain and mild bleeding, and one patient (0.9%) experienced hematoma necessitating precautionary hospitalization. The overall percentage of patients who experienced pain was 13.8%. No further complications were observed. The findings of this study could provide an accurate estimate of the post-liver biopsy complication rate. Furthermore, due to a lower complication rate than other practiced procedures, this uniform methodology could be an attractive alternative in clinical practice. However, more research is required to confirm these results.

Accuracy and concordance of two-dimensional shear-wave elastography using transient elastography as the reference in chronic viral hepatitis and HIV infection in Rio de Janeiro, Brazil

OBJECTIVES

Evaluate the accuracy and agreement of two-dimensional shear-wave elastography (2D-SWE) LOGIQ-S8 with transient elastography in patients from Rio de Janeiro, Brazil.

METHOD

This retrospective study compared liver stiffness measurements (LSMs) using transient elastography (M and XL probes) and 2D-SWE GE-LOGIQ-S8 performed by a single experienced operator on the same day in 348 consecutive individuals with viral hepatitis or HIV infection. Suggestive and highly suggestive compensated-advanced chronic liver disease (c-ACLD) were defined by transient elastography-LSM ≥10 kPa and ≥15 kPa, respectively. Agreement between techniques and accuracy of 2D-SWE using transient elastography-M probe as the reference was assessed. Optimal cut-offs for 2D-SWE were identified using the maximal Youden index.

RESULTS

Three hundred five patients [61.3% male, median age = 51 [interquartile range (IQR), 42-62] years, 24% with hepatitis C virus (HCV) ± HIV; 17% with hepatitis B virus (HBV) ± HIV; 31% were HIV mono-infected and 28% had HCV ± HIV post-sustained virological response] were included. The overall correlation (Spearman's ρ ) was moderate between 2D-SWE and transient elastography-M ( ρ  = 0.639) and weak between 2D-SWE and transient elastography-XL ( ρ  = 0.566). Agreements were strong ( ρ  > 0.800) in people with HCV or HBV mono-infection, and poor in HIV mono-infected ( ρ  > 0.400). Accuracy of 2D-SWE for transient elastography-M ≥ 10 kPa [area under the receiver operating characteristic (AUROC) = 0.91 (95% confidence interval [CI], 0.86-0.96); optimal cut-off = 6.4 kPa, sensitivity = 84% (95% CI, 72-92), specificity = 89% (95% CI, 84-92)] and for transient elastography-M ≥ 15 kPa [AUROC = 0.93 (95% CI, 0.88-0.98); optimal cut-off = 7.1 kPa; sensitivity = 91% (95% CI, 75-98), specificity = 89% (95% CI, 85-93)] were excellent.

CONCLUSION

2D-SWE LOGIQ-S8 system had a good agreement with transient elastography and an excellent accuracy to identify individuals at high risk for c-ACLD.

Assessment of Liver Function With MRI: Where Do We Stand?

Liver disease and hepatocellular carcinoma (HCC) have become a global health burden. For this reason, the determination of liver function plays a central role in the monitoring of patients with chronic liver disease or HCC. Furthermore, assessment of liver function is important, e.g., before surgery to prevent liver failure after hepatectomy or to monitor the course of treatment. Liver function and disease severity are usually assessed clinically based on clinical symptoms, biopsy, and blood parameters. These are rather static tests that reflect the current state of the liver without considering changes in liver function. With the development of liver-specific contrast agents for MRI, noninvasive dynamic determination of liver function based on signal intensity or using T1 relaxometry has become possible. The advantage of this imaging modality is that it provides additional information about the vascular structure, anatomy, and heterogeneous distribution of liver function. In this review, we summarized and discussed the results published in recent years on this technique. Indeed, recent data show that the T1 reduction rate seems to be the most appropriate value for determining liver function by MRI. Furthermore, attention has been paid to the development of automated tools for image analysis in order to uncover the steps necessary to obtain a complete process flow from image segmentation to image registration to image analysis. In conclusion, the published data show that liver function values obtained from contrast-enhanced MRI images correlate significantly with the global liver function parameters, making it possible to obtain both functional and anatomic information with a single modality.

Evaluation of Rabbits Liver Fibrosis Using Gd-DTPA-BMA of Dynamic Contrast-Enhanced Magnetic Resonance Imaging

Objective

To evaluate the different pharmacokinetic parameters of the DCE-MRI method on diagnosing and staging of rabbits' liver fibrosis.

Methods

We had performed DCE-MRI for rabbits that had been divided into the experiment group and the control group. Then, rabbits' images were transferred to a work station to get three parameters such as K _trans, K _ep, and V _e, which had been measured to calculate. After data were analyzed, ROC analyses were performed to assess the diagnostic performance of K _trans, K _ep, and V _e to judge liver fibrosis.

Results

The distribution of the different liver fibrosis group was as follows: F1, n = 8; F2, n = 9; F3, n = 6; F4, n = 5. No fibrosis was deemed as F0, n = 6. K _ep is statistically significant (P < 0.05) for F0 and mild liver fibrosis stage, and the K _ep shows AUC of 0.814. Three parameters are statistically significant for F0 and advanced liver fibrosis stage (K _trans and K _ep, P < 0.01; V _e, P < 0.05), and the K _trans shows AUC of 0.924; the K _ep shows AUC of 0.909; the V _e shows AUC of 0.848; K _trans and K _ep are statistically significant for mild and advanced liver fibrosis stages (K _trans, P < 0.01; K _ep, P < 0.05), and the K _trans shows AUC of 0.840; the K _ep shows AUC of 0.765. Both K _trans and K _ep are negatively correlated with the liver fibrosis stage. V _e is positively correlated with the liver fibrosis stage.

Conclusion

K _trans is shown to be the best DCE parameter to distinguish the fibrotic liver from the normal liver and mild and advanced fibrosis. On the contrary, K _ep is moderate and V _e is worst. And K _ep is a good DCE parameter to differentiate mild fibrosis from the normal liver.

Evolution of the liver biopsy and its future

Liver biopsies are commonly used to evaluate a wide variety of medical disorders, including neoplasms and post-transplant complications. However, its use is being impacted by improved clinical diagnosis of disorders, and non-invasive methods for evaluating liver tissue and as a result the indications of a liver biopsy have undergone major changes in the last decade. The evolution of highly effective treatments for some of the common indications for liver biopsy in the last decade (e.g., viral hepatitis B and C) has led to a decline in the number of liver biopsies in recent years. At the same time, the emergence of better technologies for histologic evaluation, tissue content analysis and genomics are among the many new and exciting developments in the field that hold great promise for the future and are going to shape the indications for a liver biopsy in the future. Recent advances in slide scanners now allow creation of "digital/virtual" slides that have image of the entire tissue section present in a slide [whole slide imaging (WSI)]. WSI can now be done very rapidly and at very high resolution, allowing its use in routine clinical practice. In addition, a variety of technologies have been developed in recent years that use different light sources and/or microscopes allowing visualization of tissues in a completely different way. One such technique that is applicable to liver specimens combines multiphoton microscopy (MPM) with advanced clearing and fluorescent stains known as Clearing Histology with MultiPhoton Microscopy (CHiMP). Although it has not yet been extensively validated, the technique has the potential to decrease inefficiency, reduce artifacts, and increase data while being readily integrable into clinical workflows. Another technology that can provide rapid and in-depth characterization of thousands of molecules in a tissue sample, including liver tissues, is matrix assisted laser desorption/ionization (MALDI) mass spectrometry. MALDI has already been applied in a clinical research setting with promising diagnostic and prognostic capabilities, as well as being able to elucidate mechanisms of liver diseases that may be targeted for the development of new therapies. The logical next step in huge data sets obtained from such advanced analysis of liver tissues is the application of machine learning (ML) algorithms and application of artificial intelligence (AI), for automated generation of diagnoses and prognoses. This review discusses the evolving role of liver biopsies in clinical practice over the decades, and describes newer technologies that are likely to have a significant impact on how they will be used in the future.

Chinese tree shrews as a primate experimental animal eligible for the study of alcoholic liver disease: characterization and confirmation by MRI

There has been a lack of suitable fatty liver models and characterization techniques for histopathological evaluation of alcoholic fatty liver (AFL). This work aimed to exploit an magnetic resonance imaging (MRI) technique for characterizing an alcohol-induced fatty liver model established in tree shrews (Tupaia belangeri chinese). The animals were treated with 15% alcohol for two weeks instead of drinking water to induce AFL. Blood alanine aminotransferase (ALT), aspartate aminotransferase (AST), alcohol, and liver malondialdehyde (MDA) concentrations were determined, and the histopathology of the liver was checked by hematoxylin & eosin (HE) and Oil red O staining on day 0 and on the 4th, 7th and 14th days after alcohol feeding. MRI was used to trace the histopathological changes in the liver of tree shrews in real time. Compared with the control group, the levels of ALT, AST, and MDA significantly increased in the alcohol-induced group and were positively correlated with the induction time. HE and Oil red O staining revealed that a moderate fatty lesion occurred in the liver on the 4th day and that a serious AFL was successfully induced on the 14th day. MRI further confirmed the formation of AFL. MRI, as noninvasive examination technique, provides an alternative tool for accurate characterization of AFL in live subjects. It is comparable to HE or Oil red O staining for histopathological examination, but is more suitable by virtue of its high flexibility and compliance. The AFL model of tree shrews combined with MRI characterization can work as a platform for studying fatty liver diseases and medications for their treatment.

Ultrasound Shear Wave Elastography: Variations of Liver Fibrosis Assessment as a Function of Depth, Force and Distance from Central Axis of the Transducer with a Comparison of Different Systems

We evaluated variation in fibrosis staging caused by depth, pre-load force and measurement off-axis distance on different ultrasound shear wave elastography (SWE) systems prospectively in 20 patients with diffuse liver disease. Shear wave speed (SWS) was measured with transient elastography, acoustic radiation force impulse (ARFI) and 2-D shear wave elastography (SWE). ARFI and 2-D-SWE measurements were obtained at different depths (3, 5 and 7 cm), with different pre-load forces (4, 7 and 10N and variable) and at 0, 2 and 4cm off the central axis of the transducer. A single, blinded pathologist staged fibrosis using the METAVIR system (F0-F4). Area under the receiver operating characteristic curve was charted to differentiate significant fibrosis (F ≥ 2). Depth was the only factor found to influence ARFI-derived values; no acquisition factors were found to affect 2-D-SWE SWS values. ARFI and 2-D-SWE for diagnosis of significant fibrosis at a depth of 7cm along the central axis had good diagnostic performance (areas under the receiver operating characteristic curve: 0.92 and 0.82, respectively), comparable to that of transient elastography. Further investigation of this finding will likely be of interest.

Utility of rapid on-site evaluation for needle core biopsies and fine-needle aspiration cytology done for diagnosis of mass lesions of the liver

BACKGROUND

Fine-needle aspiration (FNA) and core biopsy (CB) are used to diagnose liver lesions. Rapid onsite evaluation (ROSE) can improve the adequacy of the procedures and help triage diagnostic material appropriately. There are very few studies evaluating the role of ROSE for CB and FNA of mass lesions of the liver.

METHODS

Liver cases with ROSE material from 2007 to 2017 were retrieved and reviewed. The ROSE material was re-evaluated by 2 cytopathologists who were blinded to the final diagnosis. Data including age, number of lesions, number of passes, adequacy assessed at time of procedure, and diagnosis made by cytopathologist on ROSE material at time of re-review was compiled.

RESULTS

A total of 82 cases were identified; 33 were primary lesions (group A) and 49 were metastatic lesions (group B). ROSE done by cytotechnologist at time of procedure showed an adequacy rate of 84%. During re-review of ROSE material by cytopathologists, the overall adequacy rates were similar, although the adequacy rates in group B increased (to 100% from 92%) and it dropped in group A (from 73% to 52%). The overall accuracy rate was 90%. Hepatocellular adenoma, regenerative nodules, well-differentiated hepatocellular carcinoma, and angiosarcoma were not possible to diagnose on smears alone during ROSE.

CONCLUSIONS

ROSE for liver lesions is useful for assessing adequacy. Certain lesions cannot be accurately diagnosed on ROSE alone. ROSE material when assessed by cytopathologist can improve adequacy rate and possibly decrease number of nondiagnostic specimens in group A, though the cost effectiveness needs to be assessed.

Association between serum S100A9 levels and liver necroinflammation in chronic hepatitis B

BACKGROUND

S100A9 protein, which is recently classified as a novel damage associated molecular pattern, is released from stressed cells undergoing necrosis or secreted by living cells undergoing a stress that act as endogenous danger signal associated with infection, tissue damage and cancer. Here, we evaluated the relationship of serum S100A9 with viral replication and liver necroinflammation in patients with chronic hepatitis B (CHB) infection.

METHODS

A total of one hundred and eighty-three recruited patients with CHB infection underwent liver biopsy for grading of necroinflammation (G) and staging of fibrosis (S). Forty-nine healthy individuals were included as healthy controls (HCs). Serum S100A9 levels were determined by enzyme-linked immunosorbent assay. Correlations of serum S100A9 with viral replication and liver necroinflammation were analyzed. The receiver operating characteristic curve was used to assess the discriminating power of serum S100A9 to grade liver necroinflammation (G). Liver normal L02 cells were transfected with a HBV plasmid, and S100A9 levels were determined.

RESULTS

Serum S100A9 levels were increased in CHB patients compared to HCs. Intrahepatic immunoreactivity for S100A9 was enhanced in liver sample from CHB patients. Infection of HBV also resulted in an elevated S100A9 expression in L02 cells. Serum S100A9 was correlated with the serum HBV DNA levels. CHB patients with moderate-to-severe liver necroinflammation (G ≥ 2) showed significantly higher serum S100A9 levels than those without or with mild necroinflammation (G < 2). In patients with normal ALT levels, the area under the curve (AUC) of S100A9 for discriminating patients with moderate-to-severe necroinflammation (G ≥ 2) was 0.791 [95% confidence interval (CI), 0.670-0.913] with 91.7% sensitivity, 65.0% specificity and 78.3% accuracy. In patients with an alanine aminotransferase (ALT) < 2 upper limit of normal, the AUC of S100A9 for discriminating patients with moderate-to-severe necroinflammation (G ≥ 2) was 0.826 (95% CI, 0.729-0.923) with 87.9% sensitivity, 72.5% specificity and 80.2% accuracy.

CONCLUSIONS

HBV infection may enhance S100A9 expression. Serum S100A9 levels are correlated with viral load. Serum S100A9 has potential to discriminate the grades of liver necroinflammation, particularly in CHB patients with normal or mildly increased ALT levels.

Hepatic gadoxetic acid uptake as a measure of diffuse liver disease: Where are we?

MRI has emerged as the most comprehensive noninvasive diagnostic tool for focal liver lesions and diffuse hepatobiliary disorders. The introduction of hepatobiliary contrast agents, most notably gadoxetic acid (GA), has expanded the role of MRI, particularly in the functional imaging of chronic liver diseases, such as nonalcoholic fatty liver disease (NAFLD). GA-enhanced MRI (GA-MRI) may help to distinguish between the two subgroups of NAFLD, simple steatosis and nonalcoholic steatohepatitis. Furthermore, GA-MRI can be used to stage fibrosis and cirrhosis, predict liver transplant graft survival, and preoperatively estimate the risk of liver failure should major resection be undertaken. The amount of GA uptake can be estimated, using static images, by the relative liver enhancement, hepatic uptake index, and relaxometry of T1-mapping during the hepatobiliary phase. On the contrary, the hepatic extraction fraction and liver perfusion can be measured on dynamic imaging. Importantly, there is currently no clear consensus as to which of these MR-derived parameters is the most suitable for assessing liver dysfunction. This review article aims to describe the current role of GA-enhanced MRI in quantifying liver function, primarily in diffuse hepatobiliary disorders.

LEVEL OF EVIDENCE

3 J. Magn. Reson. Imaging 2017;45:646-659.