Prognostic value of future liver remnant LU15 index of 99mTc-galactosyl serum albumin scintigraphy for predicting posthepatectomy liver failure

Utility of Quantitative Assessment of Tc-99m-diethylenetriamine-penta-acetic acid-galactosyl Human Serum Albumin SPECT/CT in the Identification of Severe Liver Fibrosis: Its Complementary Diagnostic Value with Other Liver Function Indices

PURPOSE

To evaluate the value of Tc-99m-diethylenetriamine-penta-acetic acid-galactosyl human serum albumin (99mTc-GSA) single photon emission computed tomography (SPECT) for assessing liver fibrosis, and to assess its complementary value to other liver function indices such as fibrosis-4 (FIB-4) index and indocyanine green (ICG) clearance test parameters (ICG-R15 and ICG-K).

PROCEDURES

Seventy-eight patients with chronic liver disease and hepatocellular carcinoma who underwent 99mTc-GSA scintigraphy and other liver function tests including ICG test and FIB-4 index prior to hepatectomy were studied. 99mTc-GSA imaging was performed with SPECT/CT scanner (Discovery NM/CT 670). Immediately after injection of 99mTc-GSA, dynamic imaging was performed for 20 min, followed by SPECT data acquisition for 6 min. LHL15 which is a conventional index by 99mTc-GSA planar images, and liver uptake ration (LUR) was measured from 99mTc-GSA SPECT images. From the liver resection specimens, the degree of liver fibrosis was graded according to the Ludwig scale (F0-4).

RESULTS

Significant differences in LUR, LHL15, ICG-R15, ICG-K, platelet count and FIB-4 index were found between the F0-3 and F4 liver fibrosis patient groups (P < 0.05). Multivariate logistic regression analysis revealed that LUR and ICG-K were independent factors for identifying severe liver fibrosis (F4). Area under the curve of receiver operating curve analysis for the logistic regression model using LUR and ICG-K was 0.83. In the patient group with higher FIB-4 (≥ 3.16), the diagnostic performance of LUR for detecting severe liver fibrosis was significantly better than LHL15 (AUC: 0.83 vs. 0.75, P = 0.048). In the high FIB-4 index group, the sensitivity and specificity for identifying F4 was 88% and 85%, respectively, with LUR cutoff value of 41.2%.

CONCLUSIONS

LUR, measured by 99mTc-GSA SPECT, is a useful indicator for identifying sever liver fibrosis. Particularly in patients with high FIB-4 index (≥ 3.16), LUR can be a valuable indicator to identify severe liver fibrosis with high diagnostic accuracy.

Primary hepatic chronic expanding hematoma: a case report and literature review

Chronic expanding hematoma (CEH), first reported in 1968, is a hematoma that gradually enlarges over a long course of time after an initial period of bleeding. It can occur anywhere in the body; however, there are many reports of its occurrence in the thoracic cavity. Primary hepatic CEH is extremely rare. In this current study, we report on a case of primary hepatic CEH diagnosed preoperatively, with a review of the literature. A 68-year-old man presented with liver dysfunction. Abdominal computed tomography revealed a giant cystic tumor in the left lobe of the liver, with a longer axis of approximately 12 cm. Magnetic resonance imaging revealed a mosaic pattern with a mixture of high and low signals within the tumor on T1-weighted images and a high signal at the tumor margin on T2-weighted images. Based on these findings, primary hepatic CEH was suspected. However, other malignant tumors could not be excluded owing to tumor compression resulting in bile duct dilatation. Left trisectionectomy was performed, followed by bile duct drainage and percutaneous transhepatic portal vein embolization. Intraoperative hemorrhage was controlled by the Pringle maneuver and with temporary clamping of the inferior vena cava. Pathological examination revealed a pseudocyst containing a clot, consistent with CEH. In conclusions, the case report illustrates the potential to enhance preoperative diagnosis, inform surgical approaches, and minimize associated risks. Furthermore, it highlights the importance of increasing awareness and research on this condition for improved clinical decision-making and patient care.

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.

Establishment and Internal Validation of a Prognostic Score for Post-hepatectomy Liver Failure Based on Functional Liver Parameters Estimated via TC-99m GSA

Background The 99mTc-galactosyl human serum albumin (Tc-99m GSA) scintigraphy evaluates the future remnant liver function, which is an important prognostic factor for post-hepatectomy liver failure (PHLF). This study aimed to establish a new prognostic score for PHLF, including the functional liver parameters evaluated by Tc-99m GSA scintigraphy. Materials and methods This study reviewed a single-center, retrospective 368-patient database of those who underwent open and laparoscopic hepatectomy in Meiwa Hospital from January 2016 to October 2021. Moreover, 102 patients who underwent Tc-99m GSA scintigraphy following hepatectomy were analyzed. The index of blood clearance of the tracer was calculated from the uptake ratio of heart at 15 minutes to that at 3 minutes (HH15) and the index of hepatic accumulation was calculated from the uptake ratio of liver to liver plus heart at 15 minutes after the injection (LHL15) were calculated for the general functional parameters. The maximal removal rate of Tc-99m GSA (GSARmax) was also calculated, then the GSARmax of the remnant liver (GSARmax-RL) was estimated as the future remnant liver function depending on the hepatectomy. Multivariate analysis was conducted to identify the PHLF predictor, and then a risk-scoring system was established with the 1,000-times bootstrapped validation. Results PHLF (grade ≥ B) was observed in 13 of 102 patients. Multivariate analysis revealed that PHLF was independently predicted by GSARmax-RL (<0.26 mg/min) and LHL15 (<0.89). The risk score was assigned to each item and then classified into four subgroups, with a predicted PHLF of 3.7%, 14.4%, 42.8%, and 76.8%. Receiver operating characteristic (ROC) curve analysis demonstrated good discrimination (adjusted area under the curve (AUC) after bootstrapped validation, 0.779). The ROC curve analysis compared with other prognostic scores showed that the new model had the highest AUC values for accuracy. Conclusions The new prognostic score based on Tc-99m GSA scintigraphy could recognize patients with a high risk of progressing to PHLF and be helpful in planning therapeutic strategies.

Cortisol in Peripheral Blood Predicts the Severity and Prognosis in Patients with Liver Failure at 90 Days

Objective

To investigate the cortisol level in peripheral blood in evaluating the severity and prognosis of patients with liver failure.

Methods

A total of 211 inpatients with liver failure were enrolled in Beijing You ‘an Hospital affiliated with Capital Medical University, from September 2018 to January 2020. They were divided into three groups according to the severity of liver failure: early-stage liver failure, medium-stage liver failure and end-stage liver failure. In all patients, peripheral venous blood was gathered to detect the level of peripheral cortisol and related biochemical indexes. Logistic regression was used to screen the risk factors affecting the prognosis of patients at 90 days. A receiver operating curve (ROC) was used to reflect the value of cortisol on the prognosis of patients at 90 days. A model for end-stage liver disease (MELD) was accessed.

Results

Among these 211 patients with liver failure, aged from 19 to 70 years, the average level of cortisol was 351.26 ± 129.78 nmol/L for 101 cases with early-stage liver failure, 281.05 ± 81.31 nmol/L for 58 cases with medium-stage liver failure, and 189.21 ± 89.27 nmol/L for 52 cases with end-stage liver failure (P < 0.05). The level of cortisol in the survival group and the non-survival group was 339.26 ± 121.19 nmol/L and 192.71 ± 67.23 nmol/L, respectively (P < 0.05). The results of logistics regression analysis showed that the odds ratio (OR) and 95% confidence intervals (CI) of cortisol were 1.025 and 1.013–1.038 nmol/L (P < 0.05). MELD results showed that patients with higher MELD scores had lower cortisol content.

Conclusion

The level of cortisol is correlated with the severity of liver failure and decreases with the aggravation of liver failure, suggesting that the level of cortisol could be used as one of the indicators to evaluate the prognosis in patients with liver failure at 90 days.