Usefulness of examining hepatic functional volume using technetium-99m galactosyl serum albumin scintigraphy in hepatocellular carcinoma. Nucl Med Commun. 2013;34:478-488. [PMID: 23458853 DOI: 10.1097/mnm.0b013e32835f945f]

Current status of preoperative risk assessment for posthepatectomy liver failure in patients with hepatocellular carcinoma

Liver resection is an effective therapeutic option for patients with hepatocellular carcinoma. However, posthepatectomy liver failure (PHLF) remains a major cause of hepatectomy-related mortality, and the accurate prediction of PHLF based on preoperative assessment of liver functional reserve is a critical issue. The definition of PHLF proposed by the International Study Group for Liver Surgery has gained acceptance as a standard grading criterion. Liver function can be estimated using a variety of parameters, including routine blood biochemical examinations, clinical scoring systems, dynamic liver function tests, liver stiffness and fibrosis markers, and imaging studies. The Child-Pugh score and model for end-stage liver disease scores are conventionally used for estimating liver decompensation, although the alternatively developed albumin-bilirubin score shows superior performance for predicting hepatic dysfunction. Indocyanine green clearance, a dynamic liver function test mostly used in Japan and other Asian countries, serves as a quantitative estimation of liver function reserve and helps determine indications for surgical procedures according to the estimated risk of PHLF. In an attempt to improve predictive accuracy, specific evaluation of liver fibrosis and portal hypertension has gained popularity, including liver stiffness measurements using ultrasonography or magnetic resonance elastography, as well as noninvasive fibrosis markers. Imaging modalities, including Tc-99m-labeled galactosyl serum albumin scintigraphy and gadolinium-enhanced magnetic resonance imaging, are used for preoperative evaluation in combination with liver volume. This review aims to provide an overview of the usefulness of current options for the preoperative assessment of liver function in predicting PHLF.

Comparison of nuclear imaging techniques and volumetric imaging for the prediction of postoperative mortality and liver failure in patients undergoing localized liver-directed treatments: a systematic review

Background/aims

Although volumetric imaging by computed tomography (CT) is the gold standard for preoperative assessment of the future liver remnant, nuclear imaging studies have shown promising data. This systematic review summarized the results from trials investigating volumetric and nuclear medicine imaging for the prediction of postoperative mortality and liver failure (LF).

Methods

MEDLINE and Web of Science were searched for papers investigating nuclear imaging methods for the prediction of postoperative clinical outcomes in patients undergoing local, liver-directed treatments. Only papers investigating both preoperative nuclear imaging and CT or magnetic resonance imaging (MR) for the prediction of postoperative mortality and/or LF were included.

Results

Twenty-five trials were qualified for this review. All trials but two used technetium-based tracers for the nuclear imaging examination. Four papers used MR imaging and the remaining used CT for the volumetric evaluation. Overall, the studies were heterogeneous both in terms of methodology and imaging technique. Of the thirteen studies reporting on postoperative mortality, most were descriptive without detailed diagnostic data. A few with detailed data found that nuclear imaging had better predictive value than volumetric imaging. Nineteen studies investigated the prediction of postoperative LF of which seven papers investigated the predictive value of both modalities in multivariable regression analysis. Two papers found that only nuclear imaging parameters were predictive of LF, one paper found that the CT parameter was predictive, and four papers found that combined nuclear and CT/MR imaging parameters were predictive of LF.

Conclusion

Both methodologies were useful in the preoperative assessment of patients scheduled for liver interventions, especially in combination, but nuclear imaging demonstrated better predictive value for postoperative mortality and LF in a few trials. The overall technical and methodological heterogeneity of the included studies complicates the ability to directly compare the clinical utility of the two imaging techniques.

Nuclear imaging methods for the prediction of postoperative morbidity and mortality in patients undergoing localized, liver-directed treatments: a systematic review

Background

Several nuclear imaging methods may predict postoperative liver function and outcome, but none has achieved recommendations in clinical guidelines. The purpose of this systematic review was to summarize the existing knowledge on this topic.

Methods

MEDLINE and Web of Science were searched for studies investigating nuclear medicine imaging methods for the prediction of postoperative liver function in patients undergoing localized, liver-directed treatments. The postoperative endpoints were clinical outcome (morbidity and mortality) as well as measures of postoperative liver function, e.g., liver function assessed by biochemical tests or nuclear imaging.

Results

A total of 1352 references were identified, of which 82 fulfilled the eligibility criteria and were included in the review. Most studies (n = 63) were retrospective studies. The vast majority of studies assessed [^99mTc]Tc-galactosyl serum albumin (GSA) (n = 57) and [^99mTc]Tc-mebrofenin (n = 19). Liver resection was entirely or partly major (involved at least three segments) in 78 reports. There were notable variations in the research methodology, e.g., image acquisition, imaging variables, and endpoints. Thirty-seven studies reported on postoperative mortality, of which most reported descriptive data at the patient level. Of the four reports that performed multivariate analyses, two showed significant predictive results of isotope-based preoperative tests. Fifty-two papers presented data on postoperative liver failure. Multivariate predictive analyses were performed in eighteen trials, of which fifteen showed the significant value of nuclear medicine tests.

Conclusion

There is sparse evidence supporting the significant value of nuclear medicine imaging methods in predicting postoperative mortality. In contrast, a notable number of trials showed a significant prediction of liver failure in multivariate analyses. The research methodology was heterogeneous and exploratory in most trials. Documentation of nuclear medicine tests in this setting awaits the results of properly designed, prospective trials with the standardization of both the nuclear medicine test and endpoints.

Hepatectomy for gallbladder-cancer with unclassified anomaly of right-sided ligamentum teres: A case report and review of the literature

Right-sided ligamentum teres (RSLT) is a congenital anomaly in which the right umbilical ligament becomes dominant and anomalous ramifications of the hepatic vessels and biliary system are present. A male patient in his 70s was diagnosed with advanced gallbladder cancer directly infiltrating the right hepatic duct (RHD), together with RSLT. Preoperative three-dimensional simulation of the liver based on multiple detector computed tomography images after cholangiography revealed ramifications of all segmental portal veins from the portal trunk and discordance of the arterial and biliary branching patterns of segment 8. Fusion analysis of the biliary architecture and segmental volumetry showed that the RHD drained segments 1r, 5, 6, and 7. We successfully performed a modified right-sided hepatectomy sparing segment 8 (i.e., resection of the RHD drainage territory), with negative surgical margins. This report is the first to describe major hepatectomy for advanced gallbladder cancer with RSLT.

Comparison of physical parameter measurements between peripheral and portal blood samples in patients with portal hypertension

BACKGROUND

Measuring portal venous pressure is necessary to examine, diagnose, and treat portal hypertension, but current methods are invasive.

OBJECTIVE

This study aimed to determine whether a noninvasive peripheral blood measurement could be used to estimate portal venous pressure by investigating correlations between certain physical parameter measurements in the peripheral blood with those obtained in portal blood samples.

METHODS

A total of 128 peripheral and portal blood samples from patients (n= 128) were analyzed for blood rheology and routine blood parameters.

RESULTS

The mean peripheral and portal whole blood viscosities under the shear rates of 200 s-1 (BV 200 s-1) were 2.97 ± 0.50 mPa.s and 3.06 ± 0.39 mPa.s. The mean peripheral and portal BV 30 s-1 values were 3.96 ± 0.79 mPa.s and 4.16 ± 0.64 mPa.s. We observed strong correlations between peripheral and portal blood measurements of BV 200 s-1 (r2= 0.9649), BV 30 s-1 (r2= 0.9622), BV 5 s-1 (r2= 0.9610), and BV 1 s-1 (r2= 0.9623).

CONCLUSIONS

Our results indicate that peripheral blood can be used to evaluate certain parameters in portal blood for use in biofluid mechanics studies, and to provide noninvasive measurement of portal venous pressure.

99mTc-GSA肝受体显像在肝功能评估临床研究应用及进展

我国是肝病大国, 各种肝病严重影响人民健康, 手术是多种肝病的重要治疗手段之一. 术前肝功能评估对于手术方案制定发挥极为重要价值, 其中尤以三维定量肝功能成像技术备受临床关注. 近年来分子影像突飞猛进, 恰巧这也是核医学分子影像技术的优势所在. 大量研究证实新型肝细胞去唾液酸糖蛋白受体显像剂^99mTc-半乳糖基人血清白蛋白(^99mTc-galactosyl-human serum albumin, ^99mTc-GSA)能够于无创条件下较为准确地反映肝功能状态, 但现有研究尚处于初始阶段, 仍待深入的临床研究. 本文旨在系统阐述^99mTc-GSA单光子发射计算机断层成像肝受体显像基础上, 结合已有临床研究及新进展, 探索其潜在临床应用前景及未来发展动向.

Prediction of postoperative liver failure using gadoxetic acid-enhanced magnetic resonance imaging in patients with hepatocellular carcinoma

BACKGROUND

We intended to determine the usefulness of gadoxetic acid-enhanced magnetic resonance (MR) imaging on preoperative prediction of the risk of postoperative liver failure (PLF) using measurement of relative liver enhancement (RLE) in patients who underwent surgical resection of hepatocellular carcinoma (HCC).

METHODS

A total of 121 HCC patients who had underwent gadoxetic acid-enhanced MRI before surgery between January 2012 and April 2015 at our hospital was retrospectively analyzed. RLE was calculated as the ratio of signal intensity measurements of the liver parenchyma in each liver segment before and 20 min after intravenous administration of gadoxetic acid. PLF was defined based on the "50-50 criteria" (prothrombin time <50% and serum bilirubin >5 mg/dL on 5 days after surgery).

RESULTS

Of the 121 patients, 74 (61.2%) patients had liver cirrhosis, clinically. Median tumor size 2.8 cm (range, 1-14 cm), 106 (87.6%) patients had a single HCC, and 101 (83.5%) patients had HCC within Milan criteria. Based on the "50-50 criteria", PLF was observed in 7 (5.8%) patients. Mean RLE was significantly lower in patients with PLF than those without it (55.9% vs 85.5%, P < 0.01). In a multivariate analysis, decreased RLE was a significant independent risk factor for PLF in HCC patients (odds ratio 0.97, P = 0.03). Optimal cut-off RLE value was 82.36.

CONCLUSIONS

RLE was significantly lower in patients with PLF than those without it. Measurement of RLE using gadoxetic acid-enhanced MR imaging before surgery can be useful for prediction of PLF in HCC patients who receive surgical treatment.

Significance of functional hepatic resection rate calculated using 3D CT/99mTc-galactosyl human serum albumin single-photon emission computed tomography fusion imaging

AIM: To evaluate the usefulness of the functional hepatic resection rate (FHRR) calculated using 3D computed tomography (CT)/^99mTc-galactosyl-human serum albumin (GSA) single-photon emission computed tomography (SPECT) fusion imaging for surgical decision making.

METHODS: We enrolled 57 patients who underwent bi- or trisectionectomy at our institution between October 2013 and March 2015. Of these, 26 patients presented with hepatocellular carcinoma, 12 with hilar cholangiocarcinoma, six with intrahepatic cholangiocarcinoma, four with liver metastasis, and nine with other diseases. All patients preoperatively underwent three-phase dynamic multidetector CT and ^99mTc-GSA scintigraphy. We compared the parenchymal hepatic resection rate (PHRR) with the FHRR, which was defined as the resection volume counts per total liver volume counts on 3D CT/^99mTc-GSA SPECT fusion images.

RESULTS: In total, 50 patients underwent bisectionectomy and seven underwent trisectionectomy. Biliary reconstruction was performed in 15 patients, including hepatopancreatoduodenectomy in two. FHRR and PHRR were 38.6 ± 19.9 and 44.5 ± 16.0, respectively; FHRR was strongly correlated with PHRR. The regression coefficient for FHRR on PHRR was 1.16 (P < 0.0001). The ratio of FHRR to PHRR for patients with preoperative therapies (transcatheter arterial chemoembolization, radiation, radiofrequency ablation, etc.), large tumors with a volume of > 1000 mL, and/or macroscopic vascular invasion was significantly smaller than that for patients without these factors (0.73 ± 0.19 vs 0.82 ± 0.18, P < 0.05). Postoperative hyperbilirubinemia was observed in six patients. Major morbidities (Clavien-Dindo grade ≥ 3) occurred in 17 patients (29.8%). There was no case of surgery-related death.

CONCLUSION: Our results suggest that FHRR is an important deciding factor for major hepatectomy, because FHRR and PHRR may be discrepant owing to insufficient hepatic inflow and congestion in patients with preoperative therapies, macroscopic vascular invasion, and/or a tumor volume of > 1000 mL.

Correlation between morphological and functional liver volume in each sector using integrated SPECT/CT imaging by computed tomography and technetium-99m galactosyl serum albumin scintigraphy in patients with various diseases who had undergone hepatectomy

OBJECTIVES

The aim of the study was to accurately examine the functional volume (RI-vol) of the hepatic segments on single photon emission computed tomography/computed tomography (CT) fusion imaging by technetium-99m galactosyl human serum albumin scintigraphy and compare it with the RI-vol and morphological volume obtained on computed tomography (CT-vol).

METHODS

In 60 patients with various liver background statuses who had undergone hepatectomy, the RI-vol and CT-vol were examined in each sector using imaging analysis. The values from a control group (n=91) were used as reference data.

RESULTS

The mean RI-vol and CT-vol of the right liver were 64 ± 10 and 63 ± 6%, respectively, whereas the values for the left liver were 36 ± 10 and 37 ± 6%, respectively. Compared with the control group, the ratios in each hemiliver were similar. The mean RI-vol and CT-vol for each sector were also similar, and significant positive correlations were identified between the two volumes (P<0.01). In four patients with hepatic tumors involving the main hepatic vessels or the bile duct and in 10 patients who had undergone portal vein embolization, the actual RI-vol in the injured sector was significantly decreased compared with CT-vol (P<0.05). There were marked changes in functional volume in segment 6+7 and segment 2+3 after portal vein embolization (P<0.05).

CONCLUSION

Volumetric measurement using single photon emission computed tomography/CT imaging with technetium-99m galactosyl human serum albumin scintigraphy is useful for evaluating the functional volume in separated livers and offers a good reflection of the background liver status.