MR Elastography MRE for... · Noninvasive Tests • Serum Biomarkers • Direct and Indirect •...
Transcript of MR Elastography MRE for... · Noninvasive Tests • Serum Biomarkers • Direct and Indirect •...
Richard L. Ehman, M.D.Richard L. Ehman, M.D.
SCBT·MR Annual CourseOctober 26, 2011
SCBT·MR Annual CourseOctober 26, 2011
MR Elastography:
Assessment of Diffuse Liver Disease
MR Elastography:
Assessment of Diffuse Liver Disease
The Mayo Clinic and the presenter have patent rights and a relevant financial interest.
The Mayo Clinic and the presenter have patent rights and a relevant financial interest.
Disclosure:Disclosure:
Compliant with oversight by the Mayo Clinic Conflict of Interest Review Board.Compliant with oversight by the Mayo Clinic Conflict of Interest Review Board.
Assurance:Assurance:
Importance of Chronic Liver Disease, Fibrosis, CirrhosisImportance of Chronic Liver Importance of Chronic Liver Disease, Fibrosis, CirrhosisDisease, Fibrosis, Cirrhosis
•• A leading cause of death worldA leading cause of death world--wide wide
•• Increasing prevalence of conditions that Increasing prevalence of conditions that cause hepatic fibrosiscause hepatic fibrosis•• Hepatitis C Hepatitis C -- 170 M people globally170 M people globally•• Hepatitis BHepatitis B•• Obesity / Fatty liver diseaseObesity / Fatty liver disease
•• Fibrosis can be reversed, if diagnosed Fibrosis can be reversed, if diagnosed early and treatedearly and treated
Progression of Liver DiseaseProgression of Liver Disease
Liver BiopsyStandard Diagnostic Procedure to rule-out Fibrosis
Liver BiopsyStandard Diagnostic Procedure to rule-out Fibrosis
• Risk of Complications
• Potential Sampling Errors
• Subjective Histology Grading
• Risk of Complications
• Potential Sampling Errors
• Subjective Histology Grading
NormalNormal FibrosisFibrosis
ReversibleSilent
ReversibleSilent
CirrhosisCirrhosis
IrreversibleHigh mortality
IrreversibleHigh mortality
Noninvasive TestsNoninvasive Tests
• Serum Biomarkers
• Direct and Indirect
• Conventional Imaging
• MRI, US, CT
• US Elastography
• Fibroscan
• ARFI
• MRI Techniques
• Contrast enhanced
• Diffusion-weighted
• MR Elastography
MR ElastographyMR Elastography
2.5cm2.5cm
ConventionalMR Image
ConventionalMR Image
Tissue-simulating gel phantom with
stiff inclusions
3. Inversion3. Inversion
800 40Shear Stiffness (kPa)Shear Stiffness (kPa)
ElastogramElastogram
1. Driver1. Driver(30-500 Hz)(30-500 Hz)
2. MRE Sequence2. MRE Sequence
-10
Wave ImagesWave Images
0 +10Displacement (m)Displacement (m)
Acoustic Driver System for MREAcoustic Driver System for MREAcoustic Driver System for MRE
MREAbdominal Driver
MREAbdominal Driver
MREVibration Source
MREVibration Source
Elastogram
Sh
ear
Sti
ffn
ess
(kP
a)S
hea
r S
tiff
nes
s (k
Pa)
0
10
4
6
8
2
MR Elastography:adds ~ 5 min
(15 second scan)
MR Elastography:adds ~ 5 min
(15 second scan)
Conventional MRIexam of Abdomen:
~ 45 min
Conventional MRIexam of Abdomen:
~ 45 min
2.1 kPa Normal
Shear Stiffness (kPa)Shear Stiffness (kPa)0 102 4 6 8
Liver FibrosisLiver FibrosisLiver FibrosisBiopsy:Stage F2Biopsy:Stage F2
3.5 kPa
Biopsy:Stage F1Biopsy:Stage F1
3.1kPa
Biopsy:Stage F3Biopsy:Stage F3
4.8 kPa
Biopsy:Stage F4Biopsy:Stage F4
10.8 kPa
2.1 kPa
Normal
MRE-Assessed Liver Stiffness
(5.31, 6.24)2.265.78944
(3.92, 4.73)1.934.32893
(3.32, 4.04)1.523.68702
(2.81, 3.21)0.873.01761
(2.59, 2.96)0.972.771090
95% CIStd Dev
MeanNo.Fibrosis Stage
438 patients with biopsy < 1 year
0
2
4
6
8
10
Mea
n L
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Sti
ffn
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a)
0 1 2 3 4Fibrosis Stage
Normal
Normal F1
F4F2
Shear Stiffness (kPa)0 84 62
F0
F3
Sensitivity and Specificity of MRE for Hepatic Fibrosis• Rouviere O, Yin M, Dresner MA, et al. MR elastography of the liver: preliminary results.
Radiology. 2006;240:440-448.
• Huwart L, Peeters F, Sinkus R, et al. Liver fibrosis: non-invasive assessment with MR elastography. NMR Biomed. 2006;19:173-179.
• Yin M, Woollard J, Wang X, et al. Quantitative assessment of hepatic fibrosis in an animal model with magnetic resonance elastography. Mag Reson Med. 2007;58:346-353.
• Salameh N, Peeters F, Sinkus R, et al. Hepatic viscoelastic parameters measured with MR elastography. 2007;26:956-962.
• Yin M, Talwalkar JA, Glaser KJ, et al. Assessment of hepatic fibrosis with magnetic resonance elastography. Clin Gastroenterol Hepatol. 2007;5:1207-1213.
• Huwart L, Sempoux C, Salameh N, et al. Liver fibrosis: Noninvasive assessment with MR elastography versus aspartate aminotransferase-to-platelet ratio index. Radiology. 2007;245:458-466.
• Huwart L, Salameh N, ter Beek L, et al. MR elastography of liver fibrosis: preliminary results comparing spin-echo and echo-planar imaging. Eur Radiol. 2008;18:2535-2541.
• Huwart L, Sempoux C, Vicaut E, et al. Magnetic resonance elastography for the noninvasive staging of liver fibrosis. Gastroenterology. 2008;135:32-40.
• Salameh N, Larrat B, Abarca-Quinones J, et al. Early detection of steatohepatitis in fatty rat liver by using MR elastography. Radiology. 2009;253:90-97.
• Asbauch P, Klatt D, Schlosser B, et al. Viscoelasticity-based staging of hepatic fibrosis with multifrequency MR elastography. Radiology. 2010;257:80-86.
Comparability to Transient Ultrasound Elastography• Oudry J, Chen J, Glaser KJ, et al. Cross-validation of magnetic resonance
elastography and ultrasound-based transient elastography: a preliminary phantom study. J Magn Reson Imaging. 2009;30:1145-50.
Reproducibility• Hines CD, Bley TA, Lindstrom MJ, Reeder SB. Repeatability of magnetic
resonance elastography for quantification of hepatic stiffness. J Magn ResonImaging. 2010;31:725-731.
• Motosugi U, Ichikawa T, Sano K, et al. Magnetic resonance elastography of the liver: preliminary results and estimation of inter-rater reliability. Jpn J Radiol. 2010;28:623-627.
• Hines CD, Lindstrom MJ, Varma AK, Reeder SB. Effects of postprandial state and mesenteric blood flow on the repeatability of MR elastography in asymptomatic subjects. J Magn Reson Imaging. 2011;33:239-244.
• Shire NJ, Yin M, Chen J, et al. Test-Retest Reproducibility of Magnetic Resonance Elastography for Non-Invasive Liver Fibrosis Assessment in Hepatitis C. Submitted.
Safety• Ehman EC, Rossman PJ, Kruse SA, Sahakian AV, Glaser KJ. Vibration safety
limits for magnetic resonance elastography. Phys Med Biol. 2008;53:925-935.
0.5
0.6
0.7
0.8
0.9
1.0
F≥1 F≥2 F≥3 F≥4
Fibrosis StageFibrosis StageFibrosis Stage
Huwart L et al. Gastroenterology 235 (2008) – 141 Patients Huwart L et al. Gastroenterology 235 (2008) – 141 Patients
UTEUTEUTE
MREMREMRE
Diagnostic Performance: APRI, UTE, & MREDiagnostic Performance: APRI, UTE, & MREDiagnostic Performance: APRI, UTE, & MRE
100% Correct100% Correct100% Correct
WorthlessWorthlessWorthless
Area underROC CurveArea underArea underROC CurveROC Curve
APRIAPRIAPRI
AST to platelet
ratio index
AST to AST to platelet platelet
ratio ratio indexindex
TechnicalSuccess
TechnicalSuccess
94%94%94%
84%84%84%
• Biopsy : No fibrosis• Biopsy : No fibrosisShear Stiffness (kPa)
80 4
2.3
41 yo Patient – Fatty Liver Disease 41 41 yoyo Patient Patient –– Fatty Liver Disease Fatty Liver Disease
• Biopsy : Stg. 3 fibrosis• Biopsy : Stg. 3 fibrosisShear Stiffness (kPa)
80 4
7.5
69 69 yoyo Patient Patient -- Fatty Liver Disease Fatty Liver Disease
Steatosis Does Not Affect Liver StiffnessSteatosisSteatosis Does Not Affect Liver StiffnessDoes Not Affect Liver Stiffness
Liv
er S
tiff
nes
s (k
Pa)
Liv
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tiff
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s (k
Pa)
Liv
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tiff
nes
s (k
Pa)
22
44
66
88
1010
1212
1414
00 55 1010 1515 2020 2525
Fat / Water RatioFat / Water RatioFat / Water Ratio
0.680.68
NormalNormal
Stage 0Stage 0
Stage 1Stage 1
Stage 2Stage 2
Stage 3Stage 3
Stage 4Stage 4
Liv
er P
atie
nt
Liv
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atie
nt
How Early Can MRE Demonstrate NASH in Patients with Fatty Liver Disease?
How Early Can MRE Demonstrate NASH in How Early Can MRE Demonstrate NASH in Patients with Fatty Liver Disease?Patients with Fatty Liver Disease?
Liver stiffness measurement (kPa)
Liver biopsy findings
cp484 cp765cp685 cp910 cp478 cp958
InflammGrade 0 0 1 1 2 1
Fibrosis Stage 0 0 0 0 4 4
MR Elastograms
2.02 2.05 4.38 3.59 10.24 7.52
Detection of Detection of SteatohepatitisSteatohepatitisbeforebefore the onset of Fibrosisthe onset of Fibrosis
• Biopsy: Not performedShear Stiffness (kPa)
80 4
11.7
55 55 yoyo Patient Patient –– Chronic Hepatitis C Chronic Hepatitis C
• Biopsy : Stg. 4 fibrosisShear Stiffness (kPa)
80 4
6.0
59 59 yoyo Patient Patient –– Alcohol Alcohol
76 76 yoyo Patient Patient -- AlcoholAlcoholShear Stiffness (kPa)
80 4
5.5
3.4
Abstinent
9 months later
47 47 yoyo female with Autoimmune Hepatitisfemale with Autoimmune Hepatitis
8/14/07 6/18/09
Mean Liver Stiffness: 4.0 kPa
Liver Biopsy Score = F0Liver Biopsy Score = F2Mean Liver Stiffness: 2.9 kPa
Sh
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Sti
ffn
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(kP
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4
MR ElastographyMR MR ElastographyElastography
•• Emerging as a reliable nonEmerging as a reliable non--invasive invasive method for diagnosing hepatic fibrosismethod for diagnosing hepatic fibrosis
•• Safer, less expensive, and less affected Safer, less expensive, and less affected by sampling error than liver biopsyby sampling error than liver biopsy
•• Other potential applications (heart, lung, Other potential applications (heart, lung, pancreas, breast) are being exploredpancreas, breast) are being explored