Changes in Liver and Spleen Stiffness by Virtual Touch Quantification Technique after Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices and Exacerbation of Esophageal Varices: A Preliminary Study.

PURPOSE: To assess liver stiffness (LS) and spleen stiffness (SS) values measured by virtual touch quantification (VTQ) technique in the monitoring of portal pressure and their usefulness for the prediction of the exacerbation of esophageal varices (EV) in patients with gastric varices undergoing balloon-occluded retrograde transvenous obliteration (B-RTO). MATERIALS AND METHODS: The LS, SS, and hepatic venous pressure gradient (HVPG) were measured in 20 patients both before and after B-RTO. The change in each parameter between the two groups (EV exacerbation and non-exacerbation groups) was compared by analysis of variance. The efficacy of the parameters for the prediction of the exacerbation of EV was analyzed using a receiver operating characteristic (ROC) curve analysis. RESULTS: 9 patients (40.9 %) exhibited an exacerbation of EV within 24 months after B-RTO. Significant changes were observed in the HVPG and SS after B-RTO between the two groups (EV exacerbation group vs. non-exacerbation group: HVPG before 12.7 ±â€Š4.4 mmHg vs. 11.0 ±â€Š4.4 mmHg; HVPG after 19.6 ±â€Š6.0 mmHg vs. 13.6 ±â€Š3.1 mmHg P = 0.003; SS before 3.40 ±â€Š0.50 m/s vs. 3.20 ±â€Š0.51 m/s; SS after 3.74 ± 0.53 m/s vs. 3.34 ±â€Š0.43 m/s P = 0.016). However, no significant changes in LS were observed between the two groups. The area under the ROC curves of elevation in HVPG and SS for the prediction of the exacerbation of EV after B-RTO were 0.833 and 0.818, respectively. CONCLUSION: Elevation of the HVPG and SS measured by VTQ after B-RTO was useful for the prediction of the exacerbation of EV.

Measurement of Spleen Stiffness With Acoustic Radiation Force Impulse Imaging Predicts Mortality and Hepatic Decompensation in Patients With Liver Cirrhosis.

BACKGROUND & AIMS: Hepatic venous pressure gradient can predict mortality and hepatic decompensation in patients with cirrhosis. Measurement of hepatic venous pressure gradient requires an invasive procedure; therefore, prognostic markers are needed that do not require invasive procedures. We investigated whether measurements of spleen stiffness, made by acoustic radiation force impulse (ARFI) imaging, associated with mortality and decompensation in patients with cirrhosis, compared with liver stiffness and other markers. METHODS: We measured spleen stiffness in 393 patients diagnosed with cirrhosis (based on histologic or physical, laboratory, and radiologic findings) at a hospital in Japan from September 2010 through August 2013 (280 patients with compensated and 113 patients with decompensated cirrhosis). Patients underwent biochemical, ARFI, ultrasonography, and endoscopy evaluations every 3 or 6 months to screen for liver-related complications until their death, liver transplantation, or the end of the study period (October 2015). The primary outcome was the accuracy of spleen stiffness in predicting mortality and decompensation, measured by Cox proportional hazards model analysis. We compared spleen stiffness with other noninvasive parameters using the Harrell's C-index analysis. RESULTS: During a median follow-up period of 44.6 months, 67 patients died and 35 patients developed hepatic decompensation. In the multivariate analysis, spleen stiffness was an independent parameter associated with mortality, after adjustment for levels of alanine aminotransferase and serum sodium, and the model for end-stage liver disease score (P < .001). Spleen stiffness was associated independently with decompensation after adjustment for Child-Pugh score and model for end-stage liver disease score (P < .001). Spleen stiffness predicted mortality and decompensation with greater accuracy than other parameters (C-indexes for predicting mortality and decompensation were 0.824 and 0.843, respectively). A spleen stiffness cut-off value of 3.43 m/s identified the death of patients with a 95.3% negative predictive value and 75.8% accuracy. A spleen stiffness cut-off value of 3.25 m/s identified patients with decompensation with a 98.8% negative predictive value and 68.9% accuracy. CONCLUSIONS: Spleen stiffness, measured by ARFI imaging, can predict death of patients with cirrhosis with almost 76% accuracy and hepatic decompensation with almost 70% accuracy. It might be a useful noninvasive test to predict patient outcome. UMIN Clinical Trials Registry no. UMIN000004363.

Portal Hypertension in Patients with Liver Cirrhosis: Diagnostic Accuracy of Spleen Stiffness.

PURPOSE: To evaluate the accuracy of spleen stiffness (SS) and liver stiffness (LS) measured by using acoustic radiation force impulse imaging in the diagnosis of portal hypertension in patients with liver cirrhosis, with the hepatic venous pressure gradient (HVPG) as a reference standard. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained for this prospective single-center study. From February 2012 to August 2013, 60 patients with liver cirrhosis (mean age, 70.8 years; age range, 34-88 years; 34 men, 26 women) with HVPG, LS, and SS measurements and gastrointestinal endoscopy and laboratory data were included if they met the following criteria: no recent episodes of gastrointestinal bleeding, no history of splenectomy, no history of partial splenic embolization, no history of ß-blocker therapy, and absence of portal thrombosis. The efficacy of the parameters for the evaluation of portal hypertension was analyzed by using the Spearman rank-order correlation coefficient and receiver operating characteristic (ROC) curve analysis. RESULTS: The correlation coefficient between SS and HVPG (r = 0.876) was significantly better than that between LS and HVPG (r = 0.609, P < .0001). The areas under the ROC curve of SS for the identification of clinically important portal hypertension (HVPG ≥ 10 mm Hg), severe portal hypertension (HVPG ≥ 12 mm Hg), esophageal varices (EVs), and high-risk EVs were significantly higher (0.943, 0.963, 0.937, and 0.955, respectively) than those of LS, spleen diameter, platelet count, and platelet count to spleen diameter ratio (P < .05 for all). SS could be used to accurately rule out the presence of clinically important portal hypertension, severe portal hypertension, EVs, and high-risk EVs (negative likelihood ratios, 0.051, 0.056, 0.054, and 0.074, respectively). CONCLUSION: SS is reliable and has better diagnostic performance than LS for identifying portal hypertension in liver cirrhosis.

Planning Sonography Using Real-time Virtual Sonography and Contrast-enhanced Sonography for Radiofrequency Ablation of Inconspicuous Hepatocellular Carcinoma Nodules.

BACKGROUND/AIMS: Determining whether planning sonography, using real-time virtual sonography (RVS) and contrast-enhanced sonography (CEUS), enables the identification of inconspicuous HCC nodules on conventional sonography (US), during percutaneous radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC). METHODOLOGY: We examined the factors associated with poor conspicuity, identification rate of inconspicuous HCC nodules in planning US using RVS and CEUS, the success rate of RFA for such nodules and local recurrence rates. RESULTS: Sixty inconspicuous HCC nodules were analyzed. Factors associated with poor conspicuity included location of the nodules for 34 nodules, US findings of HCC nodules for 24 nodules, US findings of surrounding hepatic parenchyma for 26 nodules and local recurrence for 18 nodules. Fifty-five (90.0%) HCC nodules were identified with RVS. Of the remaining five HCC nodules, three were visualized with CEUS. Thus, 96.7% (58/60) of the inconspicuous HCC nodules were identified. Forty-six (79.3%) identified HCC nodules, were treated with RFA; the success rate was 95.7% (44/46). The cumulative local recurrence rates were 0%, 2.7% and 9.4% at 12, 24 and 36 months, respectively. CONCLUSIONS: This study suggested that planning US using RVS and CEUS permits the identification of most inconspicuous HCC nodules, thereby improving the success rate of RFA.

Measurement of spleen stiffness by acoustic radiation force impulse imaging identifies cirrhotic patients with esophageal varices.

BACKGROUND & AIMS: We evaluated whether spleen stiffness (SS), measured by acoustic radiation force impulse imaging, can identify patients who have esophageal varices (EVs); those without EVs would not require endoscopic examination. METHODS: In a prospective study, we measured SS and liver stiffness (LS) in 340 patients with cirrhosis undergoing endoscopic screening for EVs and 16 healthy volunteers (controls) at the Kurashiki Central Hospital in Okayama, Japan. The diagnostic accuracy of SS for the presence of EVs was compared with that of other noninvasive parameters (LS, spleen diameter, and platelet count). Optimal cutoff values of SS were chosen to confidently rule out the presence of varices. RESULTS: Patients with cirrhosis had significantly higher SS and LS values than controls (P < .0001 and P < .0001, respectively). Levels of SS were higher among patients with EVs (n = 132) than controls, and values were highest among patients with high-risk EVs (n = 87). SS had the greatest diagnostic accuracy for the identification of patients with EVs or high-risk EVs compared with other noninvasive parameters, independent of the etiology of cirrhosis. An SS cutoff value of 3.18 m/s identified patients with EVs with a 98.4% negative predictive value, 98.5% sensitivity, 75.0% accuracy, and 0.025 negative likelihood ratio. An SS cutoff value of 3.30 m/s identified patients with high-risk EVs with a 99.4% negative predictive value, 98.9% sensitivity, 72.1% accuracy, and 0.018 negative likelihood ratio. SS values less than 3.3 m/s ruled out the presence of high-risk varices in patients with compensated or decompensated cirrhosis. SS could not be measured in 16 patients (4.5%). CONCLUSIONS: Measurements of SS can be used to identify patients with cirrhosis with EVs or high-risk EVs. A cutoff SS was identified that could rule out the presence of varices and could be used as an initial noninvasive screening test; UMIN Clinical Trials Registry number, UMIN000004363.

Needle electrode position assessed using three-dimensional ultrasonography and outcome of radiofrequency ablation in hepatocellular carcinoma.

BACKGROUND/AIMS: Radiofrequency ablation (RFA) is an established curative therapy for early-stage hepatocellular carcinoma (HCC). We assessed the positions of inserted needle electrodes using three-dimensional ultrasonography (3D-US) and examined the association between the electrode position and outcomes of RFA. METHODOLOGY: Forty-seven patients with 49 HCC nodules treated with a cooled-tip RFA system were enrolled. Immediately after the first insertion of electrodes, 3D volume data were acquired. After RFA completion, the electrode position was assessed using the data. RESULTS: There were 18 central and 31 marginal pattern nodules. The total number of electrode insertions was significantly greater for the marginal nodules than for the central nodules (p=0.032). In the first session of RFA, 36 HCC nodules (central, n=14; marginal, n=22) were treated with single insertion of electrodes. The ratio of incompletely ablated nodules after the first session was greater for the marginal nodules than for the central nodules (p=0.025). CONCLUSIONS: Our study demonstrated that inserted electrode positions assessed using 3D-US are closely associated with outcomes of RFA and the number of electrode insertions.

Acoustic radiation force impulse imaging for reactive and malignant/metastatic cervical lymph nodes.

The aim of this study was to compare lymph node stiffness using acoustic radiation force impulse (ARFI) imaging in patients with cervical lymph node swelling. Forty-two cervical lymph nodes (reactive, n = 22; metastatic, n = 20) from 19 patients (13 men, 6 women; mean age, 63.68 ± 14.9 y; range, 23-85 y) were examined between September 2011 and March 2012. The shear wave velocity (SWV, m/s) of each lymph node was evaluated by ARFI imaging. SWV of reactive lymph nodes was 1.52 ± 0.48 m/s, and that of metastatic/malignant lymph nodes was 2.46 ± 0.75 m/s. A SWV > 1.9 m/s was very useful metastatic lymph node classification, with 95.0% specificity, 81.8% sensitivity and 88.0% overall accuracy. The area under the receiver operating characteristic curve was 0.923 (95% confidence interval, 0.842-1.000). ARFI imaging can be useful in the differentiation of reactive and malignant/metastatic cervical lymph nodes.