1. Liver Stiffness Measurement Using Acoustic Radiation Force Impulse (ARFI) Elastography and Effect of Necroinflammation Ki Tae Yoon, Sun Min Lim,Jun Yong Park, Do Young Kim, Sang Hoon Ahn, Kwang-Hyub Han, Chae Yoon Chon, Mong Cho, Jun Woo Lee, Seung Up Kim Dig Dis Sci 2012; DOI: 10.1007/s10620-012-2044-4 R2. Um Yujin Journal conference

2. BACKGROUND BACKGROUND liver biopsy : invasive noninvasive methods for assessing liver fibrosis 1)transient elastography (FibroScan [FS]) 2) acoustic radiation force impulse elastography (ARFI elastography) 3) serum fibrosis prediction indices : aspartate aminotransferase to platelet ratio index Prognosis, treatment strategy Degree of fibrosis chronic liver disease

3. BACKGROUND BACKGROUND liver stiffness measurement (LSM) by use of FS - widely applied procedure - unsatisfactory performance of FS : ascites, obesity, narrow intercostals spaces

4. BACKGROUND BACKGROUND Necroinflammatory activity : high alanine aminotransferase (ALT) level : the single most important confounder known to diminish the accuracy of LSM obtained by use of FS

5. BACKGROUND BACKGROUND ARFI (Acoustic radiation force impulse) elastography radiation force-based imaging method provided by conventional B-mode ultrasonography (Acuson S2000; SIEMENS Medical Solutions) Acoustic Radiation Force Impulse Elastography: A Non-Invasive Alternative to Liver Biopsy Hirokazu Takahashi1 et al automatically generates a pressure wave propagation speed increases with fibrosis operator selects the depth at which the liver elasticity is evaluated by placing ‘measuring box’ in the desired place supine position with the right arm in maximum abduction. Between the ribs in the right liver lobe to avoid cardiac motion Acoustic Radiation Force Impulse (ARFI) – a new modality for the evaluation of liver fibrosis Ioan Sporea, Roxana Şirli, Alina Popescu, Mirela Danilă

6. BACKGROUND BACKGROUND ARFI (Acoustic radiation force impulse)elastography - LSM in patients with ascites and obesity is feasible - enables LSM during a routine US evaluation of the abdomen - effect of ALT level on ARFI elastography remains to be determined. FS fixed ROI (region of interest ) at a fixed insertion depth ARFI flexible ROI ( 1 * 0.6 cm) at variable insertion depths

7. BACKGROUND BACKGROUND performance in assessing liver fibrosis vs - investigated the effects of necroinflammatory activity on ARFI elastography ARFI elastography aspartate aminotransferase -to-platelet ratio index (APRI) transient elastography by use of FS

8. METHODS METHODS Patients June 2010 and May 2011 104 consecutive patients161 patients liver biopsy (LB) ARFI elastography, and FS LB ARFI Severance Hospital, Yonsei University College of Medicine Pusan National University Yangsan Hospital.

9. METHODS METHODS Patients

10. METHODS METHODS LSM Using ARFI Elastography : real-time B-mode imaging : 10 mm * 5 mm region of interest (ROI) cursor : vessel-free liver parenchyma : held their breath for a moment and short-duration : generated a longitudinal acoustic pulse ->leading to localized tissue displacemen LSM Using Fibroscan results were expressed in kilopascals (kPa)

11. METHODS METHODS Liver Histology all patients (159 patients with CHB, and 19 patients with chronic hepatitis C) received antiviral treatment after LB. Fibrosis stageActivity grade F0 : no fibrosisA0 : no activity F1 : portal fibrosisA1 : minimal; F2 : periportal fibrosisA2 : mild F3 : septal fibrosisA3 : moderate F4 : cirrhosisA4 : severe

12. RESULTS RESULTS Patient Characteristics Table 1. Baseline characteristics of the patients

13. RESULTS RESULTS Histologic Information and Corresponding LSM Values obtained by use of ARFI Elastography Table 2 Histological information and LSM values obtained by use of ARFI elastography according to fibrosis stage and activity grade (n = 250)

14. RESULTS RESULTS LSM Values Using ARFI Elastography According to Fibrosis Stage Fig. 2 Distribution of LSM values obtained by use of ARFI elastography. 1.26 1.46 1.60 1.85 1.93

15. RESULTS RESULTS Correlation Between ARFI Elastography and Other Clinical Data Table 3. Correlations between LSM values obtained by use of ARFI elastography and other clinical data (n = 250)

16. RESULTS RESULTS Diagnostic Performance of ARFI Elastography and APRI Fig. 3 ROC curves of ARFI elastography and APRI for prediction of CF2 and F4 fibrosis stages for all 250 patients

17. RESULTS RESULTS Diagnostic Performance of ARFI Elastography and APRI Fig. 3 ROC curves of ARFI elastography and APRI for prediction of CF2 and F4 fibrosis stages for the 97 patients with reliable FS values

18. RESULTS RESULTS Effect of Alanine Aminotransferase Levels on LSM Table 4 Optimum cutoff values of ARFI elastography for each fibrosis stage and the effect of ALT level

19. CONCLUSIONS CONCLUSIONS Assessment of liver fibrosis using ARFI elastography : acceptable noninvasive tool : potentially minimizes the need for LB Elevated ALT levels : can lead to overestimation of liver fibrosis assessed by ARFI elastography => different cutoff LSM values are needed to diagnose the degree of liver fibrosis in patients with elevated ALT levels