Recent advances in noninvasive assessment of liver steatosis.

Due to the steatosis epidemic, noninvasive quantification of liver fat content is of great interest. Magnetic resonance (MR) techniques, including proton MR spectroscopy (MRS) and MR chemical shift imaging can quantify liver fat by measuring, directly or indirectly (the latter), the proton density fat fraction (PDFF). They have shown excellent diagnostic accuracy and are currently the reference standard for the noninvasive assessment of liver steatosis and are used in clinical trials for evaluating the change in liver fat over time. Using ultrasound (US), three different quantitative parameters can be obtained to estimate liver fat: attenuation coefficient, backscatter coefficient, and speed of sound. Controlled attenuation parameter (CAP), which estimates the attenuation of the US beam, was the first algorithm available and is performed with a non-imaging system. Currently, several other algorithms are available on B-mode imaging ultrasound systems, and they have shown an accuracy similar to or higher than the CAP. This article reports the current knowledge about their application in patients with metabolic dysfunction-associated steatotic liver disease.

MR and Ultrasound Elastography for Fibrosis Assessment in Children: Practical Implementation and Supporting Evidence-AJR Expert Panel Narrative Review.

Quantitative MRI and ultrasound biomarkers of liver fibrosis have become important tools in the diagnosis and clinical management of children with chronic liver disease (CLD). In particular, MR elastography (MRE) is now routinely performed in clinical practice to evaluate the liver for fibrosis. Ultrasound shear-wave elastography has also become widely performed for this purpose, especially in young children. These noninvasive methods are increasingly used to replace liver biopsy for the diagnosis, quantitative staging, and treatment monitoring of patients with CLD. Although ultrasound has advantages of portability and lower equipment cost, available evidence indicates that MRI may have greater reliability and accuracy in liver fibrosis evaluation. In this AJR Expert Panel Narrative Review, we describe how, why, and when to use MRI- and ultrasound-based elastography methods for liver fibrosis assessment in children. Practical approaches are discussed for adapting and optimizing these methods in children, with consideration of clinical indications, patient preparation, equipment requirements, acquisition technique, as well as pitfalls and confounding factors. Guidance is provided for interpretation and reporting, and representative case examples are presented.

Quantitative assessment of liver steatosis using ultrasound controlled attenuation parameter (Echosens).

Controlled attenuation parameter (CAP) is the algorithm available on the FibroScan system (Echosens, France) for quantification of liver steatosis. It assesses the ultrasound beam attenuation, which is directly related to liver fat content. The inter-observer reproducibility of the technique is high, with a reported concordance correlation coefficient of 0.82. Specific quality criteria for CAP measurements are not clearly defined yet, and there are conflicting results in the literature. Using liver biopsy as the reference standard, several studies have assessed the CAP performance in grading liver steatosis, and have reported that values are not affected by liver fibrosis. The cutoff for detection of liver steatosis reported in the literature ranges from 222 decibels per meter (dB/m) in a cohort of patients with chronic hepatitis C to 294 dB/m in a meta-analysis of nonalcoholic fatty liver disease (NAFLD) patients. CAP has been used as a tool to noninvasively evaluate the prevalence of NAFLD in groups at risk or in the general population; however, it should be underscored that different CAP cutoffs for steatosis detection (S > 0) were used in different studies, and this limits the robustness of the findings. CAP, alone or combined with other noninvasive indices or biomarkers, has been proposed as a tool for assessing nonalcoholic steatohepatitis or as a noninvasive predictor of prognosis in patients with chronic liver disease. CAP is easy to perform and has become a point-of-care technique. However, there is a large overlap of values between consecutive grades of liver steatosis, and cutoffs are not clearly defined.

Ultrasound liver elastography beyond liver fibrosis assessment.

Several guidelines have indicated that liver stiffness (LS) assessed by means of shear wave elastography (SWE) can safely replace liver biopsy in several clinical scenarios, particularly in patients with chronic viral hepatitis. However, an increase of LS may be due to some other clinical conditions not related to fibrosis, such as liver inflammation, acute hepatitis, obstructive cholestasis, liver congestion, infiltrative liver diseases. This review analyzes the role that SWE can play in cases of liver congestion due to right-sided heart failure, congenital heart diseases or valvular diseases. In patients with heart failure LS seems directly influenced by central venous pressure and can be used as a prognostic marker to predict cardiac events. The potential role of LS in evaluating liver disease beyond the stage of liver fibrosis has been investigated also in the hepatic sinusoidal obstruction syndrome (SOS) and in the Budd-Chiari syndrome. In the hepatic SOS, an increase of LS is observed some days before the clinical manifestations; therefore, it could allow an early diagnosis to timely start an effective treatment. Moreover, it has been reported that patients that were successfully treated showed a LS decrease, that reached pre-transplantation value within two to four weeks. It has been reported that, in patients with Budd-Chiari syndrome, LS values can be used to monitor short and long-term outcome after angioplasty.

Adherence to quality criteria improves concordance between transient elastography and ElastPQ for liver stiffness assessment-A multicenter retrospective study.

BACKGROUND: Assessment of liver stiffness provides important diagnostic and prognostic information in patients with chronic liver disease. AIMS: To investigate whether the use of quality criteria (i) improves the concordance between transient elastography (TE) and a novel point shear wave elastography technique (ElastPQ®) and (ii) impacts on the performance of ElastPQ® for liver fibrosis staging using TE as the reference standard. METHODS: In this multicenter retrospective study, data of patients undergoing liver stiffness measurements (LSM) in five European centers were collected. TE was performed with FibroScan® (Echosens, France) and ElastPQ® with EPIQ® or Affiniti® systems (Philips, The Netherlands). The agreement between TE and ElastPQ® LSMs was assessed with Lin's concordance correlation coefficient (CCC). Diagnostic performance of ElastPQ® was assessed by the area under receiver operating characteristic (AUROC) curves. RESULTS: Overall, 664 patients were included: mean age: 54.8(13.5) years, main etiologies: viral hepatitis (83.1%) and NAFLD (7.5%). CCC increased significantly when LSMs with ElastPQ® were obtained with IQR/M ≤ 30% (p < 0.001). The diagnostic performance of ElastPQ® for fibrosis staging also increased if LSM values were obtained with IQR/M ≤ 30%. CONCLUSION: Quality criteria should be followed when using ElastPQ® for LSM, since the concordance with TE fibrosis staging was better at an ElastPQ® IQR/M ≤ 30.

Assessment of biopsy-proven liver fibrosis by two-dimensional shear wave elastography: An individual patient data-based meta-analysis.

Two-dimensional shear wave elastography (2D-SWE) has proven to be efficient for the evaluation of liver fibrosis in small to moderate-sized clinical trials. We aimed at running a larger-scale meta-analysis of individual data. Centers which have worked with Aixplorer ultrasound equipment were contacted to share their data. Retrospective statistical analysis used direct and paired receiver operating characteristic and area under the receiver operating characteristic curve (AUROC) analyses, accounting for random effects. Data on both 2D-SWE and liver biopsy were available for 1,134 patients from 13 sites, as well as on successful transient elastography in 665 patients. Most patients had chronic hepatitis C (n = 379), hepatitis B (n = 400), or nonalcoholic fatty liver disease (n = 156). AUROCs of 2D-SWE in patients with hepatitis C, hepatitis B, and nonalcoholic fatty liver disease were 86.3%, 90.6%, and 85.5% for diagnosing significant fibrosis and 92.9%, 95.5%, and 91.7% for diagnosing cirrhosis, respectively. The AUROC of 2D-SWE was 0.022-0.084 (95% confidence interval) larger than the AUROC of transient elastography for diagnosing significant fibrosis (P = 0.001) and 0.003-0.034 for diagnosing cirrhosis (P = 0.022) in all patients. This difference was strongest in hepatitis B patients. CONCLUSION: 2D-SWE has good to excellent performance for the noninvasive staging of liver fibrosis in patients with hepatitis B; further prospective studies are needed for head-to-head comparison between 2D-SWE and other imaging modalities to establish disease-specific appropriate cutoff points for assessment of fibrosis stage. (Hepatology 2018;67:260-272).

Noninvasive assessment of liver steatosis in children: the clinical value of controlled attenuation parameter.

BACKGROUND: To assess the clinical validity of controlled attenuation parameter (CAP) in the diagnosis of hepatic steatosis in a series of overweight or obese children by using the imperfect gold standard methodology. METHODS: Consecutive children referred to our institution for auxological evaluation or obesity or minor elective surgery were prospectively enrolled. Anthropometric and biochemical parameters were recorded. Ultrasound (US) assessment of steatosis was carried out using ultrasound systems. CAP was obtained with the FibroScan 502 Touch device (Echosens, Paris, France). Pearson's or Spearman's rank correlation coefficient were used to test the association between two study variables. Optimal cutoff of CAP for detecting steatosis was 249 dB/m. The diagnostic performance of dichotomized CAP, US, body mass indexes (BMI), fatty liver index (FLI) and hepatic steatosis index (HSI) was analyzed using the imperfect gold standard methodology. RESULTS: Three hundred five pediatric patients were enrolled. The data of both US and CAP were available for 289 children. Steatosis was detected in 50/289 (17.3%) children by US and in 77/289 (26.6%) by CAP. A moderate to good correlation was detected between CAP and BMI (r = 0.53), FLI (r = 0.55) and HSI (r = 0.56). In obese children a moderate to good correlation between CAP and insulin levels (r = 0.54) and HOMA-IR (r = 0.54) was also found. Dichotomized CAP showed a performance of 0.70 (sensitivity, 0.72 [0.64-0.79]; specificity, 0.98 [0.97-0.98], which was better than that of US (performance, 0.37; sensitivity, 0.46 [0.42-0.50]; specificity, 0.91 [0.89-0.92]), BMI (performance, 0.22; sensitivity, 0.75 [0.73-0.77]; specificity, 0.57 [0.55-0.60]) and FLI or HSI. CONCLUSIONS: For the evaluation of liver steatosis in children CAP performs better than US, which is the most widely used imaging technique for screening patients with a suspicion of liver steatosis. A cutoff value of CAP of 249 dB/m rules in liver steatosis with a very high specificity.

Accuracy of the ElastPQ Technique for the Assessment of Liver Fibrosis in Patients with Chronic Hepatitis C: a "Real Life" Single Center Study.

BACKGROUND AND AIMS: Noninvasive assessment of liver stiffness has been increasingly used to evaluate fibrosis instead of liver biopsy, especially in patients with chronic viral hepatitis. The aim of this study was to assess the performance in staging liver fibrosis of the updated ElastPQ® technique (EPIQ7 ultrasound system, Philips Healthcare, Bothell, WA, USA) in the "real life" setting by using the FibroScan as the reference standard and to understand whether the use of the quality criteria improves the performance of the technique. METHODS: This was a cross-sectional study: 278 patients affected by chronic hepatitis C referred for liver stiffness measurement with the FibroScan® 502 Touch device (Echosens, Paris, France) underwent measurements also with the ElastPQ® technique. For the assessment of significant fibrosis (F>/=2), advanced fibrosis (F>/=3) and cirrhosis (F=4), respectively, we used the cutoffs of 7.0, 9.5 and 12.0 kPa. The diagnostic performance of ElastPQ® was assessed using the area under the ROC (AUROC) curve analysis and was evaluated overall and for cases with (a) 10 measurements and IQR/M30%, (d) 5 measurements and IQR/M>30%. RESULTS: The optimal cutoffs of ElastPQ® for significant fibrosis, advanced fibrosis and cirrhosis were 6.43, 9.54 and 11.34 kPa, respectively. For measurements with an IQR/M/=2, F>/=3, and F=4, respectively). CONCLUSION: The ElastPQ® technique is reliable and accurate for staging liver fibrosis. The number of measurements does not affect the performance.

The clinical value of controlled attenuation parameter for the noninvasive assessment of liver steatosis.

BACKGROUND & AIMS: Ultrasound is the imaging modality most widely utilized in the general population for diagnostic purposes. Controlled attenuation parameter is a novel noninvasive method for assessing steatosis. Our aim was to investigate whether the clinical value of controlled attenuation parameter in patients referred for abdominal ultrasound examinations is affected by liver fibrosis. METHODS: Consecutive patients referred for abdominal ultrasound examinations were enrolled. Controlled attenuation parameter and liver stiffness were assessed with the FibroScan (Echosens, France). Liver fibrosis was staged according to published cutoffs of liver stiffness measurements. Pearson's or Spearman's rank correlation coefficient was used to test the association between two study variables. Optimal cutoff of controlled attenuation parameter for diagnosing liver steatosis (S≥2) was 256 dB/m. The diagnostic performance and accuracy of dichotomized controlled attenuation parameter, ultrasound and body mass index were analysed using the imperfect gold standard methodology. RESULTS: A total of 726 subjects (464 males and 262 females) were studied. Five hundred and eight-nine (81.1%) patients were affected by chronic viral hepatitis. Correlation of controlled attenuation parameter with ultrasound score was 0.48 and 0.57 in patients with and without chronic viral hepatitis respectively. In patients with chronic viral hepatitis, ultrasound, dichotomized controlled attenuation parameter and body mass index showed performance of 58.2%, 82.3% and 46.7%, respectively, whereas in patients without chronic viral hepatitis, the performance was 86.4%, 68.6% and 48.6% respectively. CONCLUSIONS: In patients with chronic viral hepatitis and advanced liver fibrosis, controlled attenuation parameter performs better than ultrasound for assessing liver steatosis, whereas in patients without viral hepatitis and with nonsignificant liver disease ultrasound shows the best performance.

Análise de custo do uso oral de Valganciclovir para tratamento de viremia por citomegalovírus / Cost analysis of oral use of Valganciclovir for treatment of cytomegalovirus viremia

INTRODUÇÃO: Citomegalovírus (CMV) pertence à família dos Herpesvírus, e possui a característica de se manter no hospedeiro por tempo prolongado, como uma infecção latente, após a resolução da fase aguda, com maior risco para indivíduos imunossuprimidos. A soroprevalência do CMV oscila conforme a área geográfica, idade e se mostra mais alta em países desenvolvidos, com uma taxa de 50% na população adulta dos EUA. A doença por CMV não apresenta um quadro clínico específico, podendo se manifestar por meio de febre, leucopenia, mononucleose, trombocitopenia, hepatite, encefalite ou infecção do trato gastrointestinal. Os meios de transmissão do vírus ocorrem por contato sexual, ou por exposição ao sangue e tecidos, como no caso dos transplantes de órgãos sólidos de doadores positivos. Grande parte dos casos não estão associados a nenhum sintoma em hospedeiros imunocompetentes. E nos casos de pacientes com infecção por CMV sintomática, como a síndrome de mononucleose, a doença se apresenta auto-limitada, com recuperação completa ao longo de um período de dias a semanas. Nesses casos a terapia antiviral nem está comumente indicada. A infecção por CMV é uma importante causa de morbidade e mortalidade em receptores de transplantes de órgãos sólidos, nos primeiros seis meses pós-transplante, devido à imunossupressão. E tem sido bem descrita como a complicação de maior ocorrência em transplantes, com um risco cinco vezes aumentado para mortalidade global e onze vezes para óbito associado à infecção por CMV. Portanto, prevenção e tratamento da infecção e doença por CMV é de extrema importância para assegurar o sucesso de um transplante. A prevalência da doença em pacientes transplantados oscila entre 30% e 50%, dependendo do tipo de órgão sólido. Pode ocorrer em aproximadamente 60% dos transplantados categorizados como de alto risco, onde o receptor é negativo e o doador soropositivo. Mas também no grupo de receptores com sorologia positiva pré-transplante, onde o risco de infecção por reativação da doença é de 10% a 30%. Além de estar associada a aumentado risco de rejeição do enxerto em transplantes. TECNOLOGIAS Valganciclovir (VG) é um medicamento antiviral, pró-fármaco do ganciclovir. Atua por inibição da síntese do DNA viral. Aprovado em 2001 pela Food and Drug Administration (FDA), e com registro na Agência Nacional de Vigilância Sanitária (ANVISA) sob a forma de comprimidos revestidos de 450 mg. Indicado para o tratamento de retinite em pacientes portadores do HIV/Aids e para a prevenção da doença por CMV em pacientes transplantados de rim, coração e pâncreas. A recomendação para a profilaxia da doença pelo CMV, em pacientes pós transplante de rim, coração e pâncreas é de 900 mg por dia, via oral. E para o tratamento da infecção ou terapia preemptiva é de 900 mg 2 x ao dia por 21 dias. Ganciclovir (GC) é um análogo do nucleosídeo 2'-desoxiguanosina, com uma estrutura semelhante à do aciclovir. Sua atividade inibidora dos Herpesvírus tem especial ação contra o CMV. Eliminação renal elevada necessitando de ajuste da dose em pacientes com insuficiência renal. Possui baixa biodisponibilidade por via oral (6% a 9%) e tem sido comercializado sob a forma endovenosa, na concentração de 1 mg/ml com registro autorizado pela ANVISA. Indicado para o tratamento e prevenção de infecções por CMV em imunodeprimidos (transplantes). A dose recomendada é de 5 mg/Kg 2 x ao dia, por 14 ou 21 dias. PERGUNTA CLÍNICA: O medicamento Valganciclovir na apresentação oral para o tratamento de pacientes pós-transplante cardíaco com diagnóstico de viremia por citomegalovírus é mais custo-efetivo comparado ao tratamento padrão com Ganciclovir na apresentação endovenosa? ANÁLISE DA EVIDÊNCIA: Evidências descritas pelo demandante: -Eficácia no tratamento de viremia por CMV e na doença órgão específico por via oral, com boa biodisponibilidade e tolerância; -O tratamento por via oral possibilita a liberação do paciente para o domicílio e possui menor risco de complicações em comparação ao uso endovenoso (acesso vascular, internação); -Pequeno número de pacientes com indicação.MÉTODO: O demandante solicitou a avaliação de custos do medicamento Valganciclovir por via oral, como opção ao uso endovenoso do Galvanciclovir. E como justificativa descreveu a possibilidade de evitar a internação e os riscos inerentes ao uso de medicação endovenosa para os pacientes em pós-operatório de transplante cardíaco, que apresentam sorologias positivas para CMV durante o acompanhamento ambulatorial e necessitam de tratamento para a viremia. DISCUSSÃO: O Valganciclovir é um medicamento largamente indicado, como opção dentre as estratégias de terapia preemptiva para a doença por CMV, sendo mais utilizado em pacientes submetidos ao transplante de órgãos sólidos, apesar de seu alto custo. Uma das principais razões para sua popularidade está associada à sua apresentação por via oral, que demonstrou maior eficácia e biodisponibilidade do que os demais antivirais disponíveis. Diversos estudos demonstram eficácia semelhante do Valganciclovir comparado aos demais antivirais. Entretanto, poucos estudos compararam diretamente VG ao GC, e alguns ainda classificaram profilaxia como terapia preemptiva. No entanto, recentemente uma revisão sistemática com metanálise comparou o uso do VG oral ao GC em sua apresentação endovenosa, confirmando similar eficácia entre os dois medicamentos, o que permite garantir um tratamento mais confortável para o paciente imunossuprimido. As diferentes estratégias de prevenção do CMV e algumas questões relativas à eficácia e economia permanecem em discussão. Importante salientar que, uma das indicações de uso para o valganciclovir é o paciente ambulatorial, que se submeteu a um transplante de órgão sólido e, dessa forma pode evitar uma internação hospitalar relativamente longa, com os riscos já conhecidos para um paciente imunossuprimido, mantido em um acesso venoso. Sem considerar os benefícios intangíveis, como o stress pelo afastamento familiar, o risco de qualquer intercorrência durante sua internação e a oportunidade de utilizar o leito hospitalar para outro paciente. O custo incremental entre os dois tratamentos foi elevado, no entanto o impacto orçamentário anual não foi grande, face a uma baixa prevalência de casos positivos (2 casos/ano), pode ser considerado favorável ao se ponderar que o benefício ao paciente pós transplante cardíaco será a prevenção de doença por CMV e suas possíveis complicações em pacientes transplantados sucesso do paciente transplantado representa um benefício institucional e já implica em uma grande utilização de recursos prévia. RECOMENDAÇÃO: Recomendação fraca a favor da Incorporação do Valganciclovir com controle de dispensação conforme protocolo.

A Review of the Appropriateness of the Current Italian Guidelines for Noninvasive Imaging Assessment of Focal Liver Lesions.

In 2007 the Italian National Institute of Health issued Guidelines for the use of diagnostic imaging techniques in the detection and the characterization of focal liver lesions. Since the publication of these guidelines in 2008, several studies relating to this topic have been published. Thus, we felt the need to assess whether interval research and new advancements in diagnostic imaging have yielded new evidence that should modify the recommendations that were previously issued. The literature search confirmed the appropriateness of the current guidelines. Although most modalities did not show substantial changes, interval introduction of DW-MRI is a valuable technique with a high diagnostic accuracy in the detection and characterization of FLLs, and its sensitivity is higher when combined with MRI.

Elastography Assessment of Liver Fibrosis: Society of Radiologists in Ultrasound Consensus Conference Statement.

The Society of Radiologists in Ultrasound convened a panel of specialists from radiology, hepatology, pathology, and basic science and physics to arrive at a consensus regarding the use of elastography in the assessment of liver fibrosis in chronic liver disease. The panel met in Denver, Colo, on October 21-22, 2014, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies and are thought to represent a reasonable approach to the noninvasive assessment of diffuse liver fibrosis.

Ultrasound point shear wave elastography assessment of liver and spleen stiffness: effect of training on repeatability of measurements.

OBJECTIVES: To evaluate reproducibility of measurements of spleen stiffness (SS) and liver stiffness (LS) at several sites by using point shear wave elastography (pSWE) and to investigate any training effect. METHODS: Healthy volunteers were consecutively enrolled. Measurements of SS and LS were performed by an expert (observer 1) and a novice (observer 2) at three different sites of liver and spleen. To assess the effect of training the study was conducted in two periods (period 1 and period 2). Concordance correlation coefficient was used to assess intra-observer and inter-observer reproducibility. RESULTS: A total of 92 subjects (67 men and 25 women) were enrolled in the study. Both intra-observer and inter-observer agreement were higher for the liver than for the spleen. Overall, the highest intra-observer and inter-observer agreement were obtained for the assessment of LS through intercostal space, and for measurements at this site there was a significantly better performance of observer 2 after the training period. For both observers, training improved the repeatability of SS measurements at all sites. A good intra-observer agreement was obtained only for measurements at the spleen lower pole. CONCLUSIONS: The results of this study show that a learning curve in pSWE acquisition should be taken into account both for SS and LS measurements. KEY POINTS: Reproducibility of SS measurements depends on the expertise of the operator. To achieve good reproducibility between measurements a training period is required. A learning curve in pSWE acquisition should be taken into account. SS measurements are less reproducible than LS measurements.

Performance of real-time strain elastography, transient elastography, and aspartate-to-platelet ratio index in the assessment of fibrosis in chronic hepatitis C.

OBJECTIVE: The purpose of this article is to evaluate the diagnostic performance of transient elastography, real-time strain elastography, and aspartate-to-platelet ratio index in assessing fibrosis in patients with chronic hepatitis C by using histologic Metavir scores as reference standard. SUBJECTS AND METHODS: Consecutive patients with chronic hepatitis C scheduled for liver biopsy were enrolled. Liver biopsy was performed on the same day as transient elastography and real-time strain elastography. Transient elastography and real-time strain elastography were performed in the same patient encounter by a single investigator using a medical device based on elastometry and an ultrasound machine, respectively. Diagnostic performance was assessed by using receiver operating characteristic curves and area under the receiver operating characteristic curve (AUC) analysis. RESULTS: One hundred thirty patients (91 men and 39 women) were analyzed. The cutoff values for transient elastography, real-time strain elastography, and aspartate-to-platelet ratio index were 6.9 kPa, 1.82, and 0.37, respectively, for fibrosis score of 2 or higher; 7.3 kPa, 1.86, and 0.70, respectively, for fibrosis score of 3 or higher; and 9.3 kPa, 2.33, and 0.70, respectively, for fibrosis score of 4. AUC values of transient elastography, real-time strain elastography, aspartate-to-platelet ratio index were 0.88, 0.74, and 0.86, respectively, for fibrosis score of 2 or higher; 0.95, 0.80, and 0.89, respectively, for fibrosis score of 3 or higher; and 0.97, 0.80, and 0.84, respectively, for fibrosis score of 4. A combination of the three methods, when two of three were in agreement, showed AUC curves of 0.93, 0.95, and 0.95 for fibrosis scores of 2 or higher, 3 or higher, and 4, respectively. CONCLUSION: Transient elastography, real-time strain elastography, and aspartate-to-platelet ratio index values were correlated with histologic stages of fibrosis. Transient elastography offered excellent diagnostic performance in assessing severe fibrosis and cirrhosis. Real-time elastography does not yet have the potential to substitute for transient elastography in the assessment of liver fibrosis.

Italian guidelines for noninvasive imaging assessment of focal liver lesions: development and conclusions.

OBJECTIVES: To develop guidelines for the noninvasive imaging assessment of focal liver lesions comparing different imaging modalities focused on (i) evaluating the imaging techniques in terms of (a) diagnostic accuracy; (b) role in the management of oncologic patients; (c) follow-up of benign lesions; and (ii) developing standard procedure for their use in patients with focal liver lesions that require targeted diagnostic characterization. METHODS: An explicit search strategy was used to conduct a systematic review of the literature in the English language from January 2000 to October 2007; the search covered PubMed, Embase, Pascal, SciSearch, and Cochrane Library databases. A panel of experts evaluated the selected studies and conveyed their view. RESULTS: The online search yielded 4960 titles and abstracts from which 176 studies were considered suitable for the final adherence-to-guidelines topic evaluation. An evidence grading system was not used as the guideline topic and the heterogeneity of the collected data did not fit with the currently used hierarchy of evidence. A panel of experts formulated several recommendations with grade and level which were expressed narratively and nonschematically. CONCLUSION: The recommendations reported in the study are based on an extensive literature evaluation and were developed by considering the appropriateness of the choice of the imaging techniques while noninvasively detecting and characterizing focal liver lesions.