Four indices on Gd-EOB-DTPA-enhanced MRI can estimate liver functional reserve compared to ICG-R15: A systematic review and meta-analysis

AIMS

To evaluate the value of four indices of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced (Gd-EOB-DTPA) magnetic resonance as a potential imaging marker of liver functional reserve.

METHODS

PubMed/Medline, Embase, Cochrane Library, and Web of Science were searched for studies concerning the relationship between Gd-EOB-DTPA-enhanced MRI and liver functional reserve estimated by ICG-R15, Pooled correlation coefficient (r) and 95% confidence intervals (CIs) were calculated, Meanwhile, Sensitivity and subgroup analyses were performed along with Egger's test for the estimation of publication bias and potential heterogeneity.

RESULTS

14 publications with 1285 patients were included. The pooled r between relative liver enhancement (RLE), reduction rate of T1 relaxation time of the liver (rrT1), liver-to-spleen ratio (LSR), liver-to-muscle ratio (LMR), and ICG-R15 were -0.49 (95% CI, -0.56 to -0.41, p < 0.05), -0.47 (95% CI, -0.57 to -0.36, p < 0.05), -0.45 (95% CI, -0.55 to -0.34, p < 0.05), -0.50 (95% CI, -0.61 to -0.38, p < 0.05). moderate heterogeneity was observed between studies on rrT1, LSR, LMR, and ICG-R15 (p ≤ 0.05), but no significant heterogeneity was observed between RLE and ICG-R15. Further analysis shows that there was a notable heterogeneity between subgroup analysis of LSR and ICG-R15 stratified by years of publication, as well as rrT1 and LMR stratified by total patients and study design, the distribution funnel plots and the results of Egger's test showed no evidence of publication bias.

CONCLUSIONS

RLE, LSR, LMR, and rrT1 all correlated significantly with ICG-R15-estimated hepatic functional reserve. The four indices represent a promising imaging biomarker in the prediction of liver functional reserve.

The importance of liver functional reserve in the non-surgical treatment of hepatocellular carcinoma

The aim of any oncological treatment is not just to eliminate the tumour, but to maximise patient survival and quality of life. Since the liver has a vital function, any radical treatment that severely compromises liver function will result in a shortening of life expectancy, rather than a prolongation. Furthermore, even non-severe liver damage may prevent the delivery of further effective therapies. This is particularly important in the case of hepatocellular carcinoma (HCC), as it is associated with underlying cirrhosis in most patients - cirrhosis itself is not only a potentially lethal disease and independent prognostic factor in HCC, but it also makes liver function fragile. Accordingly, some information about liver dysfunction is included in most staging systems for HCC and can be used to guide the selection of treatments that the functional liver reserve can tolerate. Unfortunately, the prediction of functional damage to the liver in the case of antitumor treatments is very challenging and still suboptimal in any given patient. Moreover, while the assessment of functional reserve can now be used to avoid postoperative liver failure in the surgical setting, its use has been less well clarified for non-surgical therapies, which is of particular relevance today, as several lines of effective non-surgical treatments, including systemic therapies, have become available. The present article will a) critically review the implications of the assessment of liver functional reserve in patients with HCC, b) illustrate the available tools to assess liver functional reserve and c) discuss the role of functional assessment for each type of non-surgical therapy for HCC.

Onodera's prognostic nutritional index is a strong prognostic indicator for patients with hepatocellular carcinoma after initial hepatectomy, especially patients with preserved liver function

Background

Several inflammation-based scores are used to assess the surgical outcomes of hepatocellular carcinoma (HCC). The aim of the present study was to elucidate the prognostic value of the prognostic nutritional index (PNI) in HCC patients who underwent hepatectomy with special attention to preoperative liver functional reserve.

Methods

Preoperative demographic and tumor-related factors were analyzed in 189 patients with HCC undergoing initial hepatectomy from August 2005 to May 2016 to identify significant prognostic factors.

Results

Multivariate analysis for overall survival (OS) revealed that female sex (p = 0.005), tumor size (p < 0.001) and PNI (p = 0.001) were independent prognostic factors. Compared to the High PNI group (PNI ≥ 37, n = 172), the Low PNI group (PNI < 37, n = 17) had impaired liver function and significantly poorer OS (13% vs. 67% in 5-year OS, p = 0.001) and recurrence-free survival (RFS) (8 vs. 25 months in median PFS time, p = 0.002). In the subgroup of patients with a preserved liver function of LHL15 ≥ 0.9, PNI was also independent prognostic factor, and OS (21% vs. 70% in 5-year OS, p = 0.008) and RFS (8 vs. 28 months in median PFS time, p = 0.018) were significantly poorer in the Low PNI group than the High PNI group.

Conclusions

PNI was an independent prognostic factor for HCC patients who underwent hepatectomy. Patients with PNI lower than 37 were at high risk for early recurrence and poor patient survival, especially in the patients with preserved liver function of LHL ≥ 0.9.

Correlation between Liver Elasticity by Ultrasound Elastography and Liver Functional Reserve

No worldwide consensus on the assessment tool for liver functional reserve is currently available. The aim of this study was to evaluate the correlation between liver elasticity of both hepatic lobes and liver functional reserve tests. This prospective observational study comprised 40 patients scheduled for hepatectomy. Liver elasticity was assessed by Virtual Touch Quantification (VTQ). The mean VTQ value for the right and left lobes was defined as the mVTQ. Liver functional reserve was measured with technetium-99m-diethylenetriaminepentaacetic acid-galactosyl-human serum albumin scintigraphy as LHL15 and HH15 and the indocyanine green (ICG) excretion test as ICG-R15 and ICG-K. All examinations were measured after biliary decompression confirmed serum a total bilirubin level ≤2 mg/dL. Mean VTQ values were moderately correlated with LHL15 (r = -0.42, p < 0.01), HH15 (r = 0.48, p < 0.01), ICG-R15 (r = 0.53, p < 0.01) and ICG-K (r = -0.61, p < 0.01) values. In conclusion, the liver elasticity determined by VTQ would be a useful predictor of liver functional reserve in patients scheduled for hepatectomy.

Design of liver functional reserve monitor based on three-wavelength from red light to IR

BACKGROUND

The preoperative evaluation of liver functional reserve is very important to determine the excision of liver lobe for the patients with liver cancer. There already exist many effective evaluation methods, but these ones have many disadvantages such as large trauma, complicated process and so on.

OBJECTIVE

Therefore, it is essential to develop a fast, accurate and simple detection method of liver functional reserve for the practical application in the clinical engineering field.

METHODS

According to the principle of spectrophotometry, this paper proposes a detection method of liver functional reserve based on three-wavelength from red light to infrared light (IR), in which the artery pulse, the vein pulse and the move of tissue are taken into account.

RESULTS

By using photoelectric sensor technology and excreting experiment of indocyanine green, a minimally invasive, fast and simple testing equipment is designed in this paper.

CONCLUSIONS

The testing result shows this equipment can greatly reduce the interference from human body and ambient, realize continuous and real-time detection of arterial degree of blood oxygen saturation and liver functional reserve.

Preoperative portal vein embolization for hepatocellular carcinoma: Consensus and controversy

Thirty years have passed since the first report of portal vein embolization (PVE), and this procedure is widely adopted as a preoperative treatment procedure for patients with a small future liver remnant (FLR). PVE has been shown to be useful in patients with hepatocellular carcinoma (HCC) and chronic liver disease. However, special caution is needed when PVE is applied prior to subsequent major hepatic resection in cases with cirrhotic livers, and volumetric analysis of the liver segments in addition to evaluation of the liver functional reserve before PVE is mandatory in such cases. Advances in the embolic material and selection of the treatment approach, and combined use of PVE and transcatheter arterial embolization/chemoembolization have yielded improved outcomes after PVE and major hepatic resections. A novel procedure termed the associating liver partition and portal vein ligation for staged hepatectomy has been gaining attention because of the rapid hypertrophy of the FLR observed in patients undergoing this procedure, however, application of this technique in HCC patients requires special caution, as it has been shown to be associated with a high morbidity and mortality even in cases with essentially healthy livers.

Use of magnetic resonance elastography for assessing liver functional reserve: A clinical study

AIM: To investigate the value of magnetic resonance elastography (MRE) with regard to assessing liver functional reserve.

METHODS: Data from inpatients diagnosed with a liver tumor at an interventional radiology department from July 2013 to June 2014 were analyzed. A 3.0 Tesla magnetic resonance unit was used to scan 32 patients with confirmed diagnoses of hepatocellular carcinoma (HCC); an MRE sequence was added to the protocol, and the data were reconstructed and analyzed by two attending radiologists. Regions of interest were identified in different slices of the non-tumor liver parenchyma to measure average stiffness. In addition, the indocyanine green (ICG) test was performed no more than 1 wk before or after the magnetic resonance examination for all 32 patients; the ICG retention rate at 15 min (ICGR-15) and the ICG plasma clearance rate (ICG-K) were recorded. Correlational analyses were performed between the liver stiffness values and the ICGR-15 as well as between the liver stiffness values and the ICG-K.

RESULTS: Magnetic resonance imaging, including an MRE sequence and the ICG test, was performed successfully in all 32 enrolled patients. None of the patients developed complications. The mean ± SD of the elasticity values measured by the two attending radiologists were 4.7 ± 2.2 kPa and 4.7 ± 2.1 kPa, respectively. The average liver stiffness value of the non-tumor parenchyma measured using MRE in HCC patients was 4.7 ± 2.2 kPa. The average ICGR-15 was 0.089 ± 0.077, and the average ICG-K was 0.19 ± 0.07. We found that the liver stiffness value of the non-tumor parenchyma was significantly and positively related to the ICGR-15 (r = 0.746, P < 0.01) as well as significantly and negatively related to the ICG-K (r = -0.599, P < 0.01). The ICGR-15 was significantly and negatively related to the ICG-K (r = -0.852, P < 0.01).

CONCLUSION: MRE is accurate and non-invasive; furthermore, it can be used to effectively assess the liver functional reserve of HCC patients.

Comprehensive Predictors of Portal Pressure from Functional Liver Reserve in Patients Who Underwent Hepatectomy

Portal hypertension is a major risk factor for hepatic failure or intestinal bleeding in patients with liver disease but cannot be measured indirectly. We attempted to comprehensively evaluate preoperative parameters of functional liver reserve that correlated with portal pressure (PP) in patients with various liver diseases. We examined 93 patients in whom portal pressure was directly measured during preoperative portal vein embolization (PVE) or operation. Background liver included chronic viral liver disease in 43 patients, obstructive jaundice in 29 patients, and normal liver in 21. Multivariate logistic analysis and linear regression analysis were applied to create a predictive formula for PP. Mean PP was 13.4 ± 4.9 cm H2O, and PP was significantly associated with severity of liver injury, hepatic fibrosis, intraoperative blood loss, and post-hepatectomy morbidity (p < 0.05 each). Mean PP after PVE (22.5 ± 7.8 cm H2O) was significantly increased compared to that before embolization (13.1 ± 4.7 cm H2O; p < 0.01). Univariate analysis identified seven significant parameters of preoperative liver function associated with PP: indocyanine green (ICG) test result, liver uptake and clearance index (HH15) on (99m)Tc-galactosyl serum albumin liver scintigraphy, total bilirubin level, prothrombin activity, and hyaluronate level. Using multiple linear regression analysis, the predictive formula using ICG and HH15 was as follows: Y (estimated PP) = 0.273 + 0.086 × ICGR15 + 0.193 × HH15. The calculated PP (11.5 ± 4.6 cm H2O (-1.9 cm H2O)) was lower than true PP, which was significantly associated with post-hepatectomy morbidity (p < 0.05). The correlation between true and calculated PP was weak, and prediction using the conventional liver functional parameters was limited at present and, however, estimating PP appears to be useful in evaluating portal hypertension and post-hepatectomy morbidity.

13C-methacetin breath test for evaluation of liver functional reserve and treatment effectiveness in patients with liver cirrhosis

AIM: To evaluate the value of ¹³C-methacetin breath test in diagnosis and treatment of liver cirrhosis and the association between Child-Pugh score and ¹³C-MBT, and to analyze their advantages and disadvantages.

METHODS: Eighty-eight inpatients and 10 healthy volunteers were enrolled. All of them received ¹³C-MBT and Child-Pugh scoring. According to ¹³C-MBT levels, 88 patients with liver cirrhosis were divided into three subgroups: levelsⅠ(n = 21), Ⅱ(n = 36), and Ⅲ (n = 31). According to Child-Pugh score, the patients were also divided into three subgroups: grade A in 16 cases, grade B in 41 cases and grade C in 31 cases. Liver function changes between before and after treatment were assessed. Sensitivity, specificity and time required to achieve efficacy between two groups were compared.

RESULTS: There was a good consistency (Kappa = 0.84, P < 0.05) between ¹³C-MBT levels (levels Ⅰ, Ⅱ and Ⅲ) and Child-Pugh score (grades A, B and C). Sensitivity and specificity of 13C-MBT were similar to those of Child-Pugh score (93.8%, 75.6%, 87.1% vs 91.7%, 89.4%, 93.0%). Concerning the time required to achieve efficacy, according to Child-Pugh score, there was no statistic significance among three subgroups of patients (P > 0.05), while according to ¹³C-MBT levels, a statistic significance was observed among the three subgroups of patients (P < 0.05). The higher the ¹³C-MBT level, the shorter the time required to achieve efficacy.

CONCLUSION: ¹³C-MBT is a simple, safe and reliable technique, representing a complementary method for Child-Pugh scoring.

Index of convexity: A novel liver function index using Tc-GSA scintigraphy

AIM: To investigate the clinical usefulness of a newly developed index, the “index of convexity (IOC)”, for evaluating liver functional reserve using technetium-99m-diethylenetriaminepentaacetic acid-galactosyl-human serum albumin (Tc-GSA scintigraphy).

METHODS: In total, 349 patients underwent Tc-GSA scintigraphy. Dynamic planner images were obtained, and time activity curves of the liver and heart were generated and analyzed. Our focus was on the convex shape of the liver accumulation curve. We developed a method for evaluating the extent of convexity and calculated an index that we named the IOC. Clearance index and receptor index were also calculated. The correlations between each GSA index with other liver function tests and liver histopathology were evaluated.

RESULTS: Among the 3 indices generated by Tc-GSA, the IOC had the highest correlation with all other liver function tests (indocyanine green R15, albumin, prothrombin time, cholinesterase level, platelet count, and total bilirubin level). IOC can also differentiate between normal liver, chronic hepatitis, and liver cirrhosis with highest F ratio among GSA indices as determined by one-way analysis of variance. Receiver operating characteristic analysis demonstrated high diagnostic performance of IOC in the diagnosis of cirrhosis.

CONCLUSION: IOC is a very simple and reliable index for assessing liver functional reserve, which may prove to be useful in combination with the indocyanine green test for preoperative assessment of hepatic resection.

Correlation between liver functional reserve and hepatic fibrosis in patients with chronic liver disease

AIM: To investigate the correlation between liver functional reserve and hepatic fibrosis in patients with chronic liver disease.

METHODS: Sixty patients with chronic HBV infection were divided into two groups: patients with chronic hepatitis B and those with compensated cirrhosis. Indocyanine green (ICG) excretion test [plasma clearance (K) and retention rate at 15 min (R₁₅)] was conducted with the Pulse Dye Densitograph Analyzer (DDG). The degree of liver fibrosis was determined by FibroScan.

RESULTS: With the increase in the degree of liver fibrosis, K values decreased (184.786 ± 69.34 vs 93.826 ± 51.50, t = 5.216, P < 0.01) and R₁₅ values increased (9.536% ± 8.823% vs 30.304% ± 20.24%, t = 4.576, P < 0.01). A negative correlation was noted between K values and liver fibrosis scores (r = -0.712), while a positive correlation was observed between R15 values and liver fibrosis scores (r = 0.794).

CONCLUSION: Liver functional reserve decreases with the aggravation of liver fibrosis in patients with chronic liver disease.

Clinical value of IRIS 13C-methacetin breath test in assessing liver function in patients with cirrhosis

AIM: To investigate the clinical value of ¹³C-methacetin breath test in the assessment of liver function by comparing with Child-Pugh classification and measurement of liver and spleen volume by CT in patients with cirrhosis.

METHODS: Seventy-one patients with liver cirrhosis, 17 patients with hepatitis, and 10 healthy controls were included in this study. Patients with cirrhosis were divided into three groups according to Child-Pugh classification: patients with Child-Pugh A liver function, those with Child-Pugh B, and those with C. All patients received ¹³C-methacetin breath test to compare the breath test parameters with liver function parameters and liver and spleen volume.

RESULTS: Depending on the severity of liver damage, the parameters MVmax40, CUM40, and CUM120 were obviously reduced. There is a significant correlation between ¹³C-methacetin breath test classification and Child-Pugh classification (κ = 0.57, P < 0. 05). In cirrhotic patients, the above three parameters were negatively correlated with TBIL, Child-Pugh score, and spleen volume (all P < 0.005), positively with PTA and DALB (both P < 0.05), but not with ALB, ALT, and liver volume (all P > 0.05).

CONCLUSION: ¹³C-methacetin breath test is a helpful tool for measurement of hepatocyte injury and liver functional reserve in patients with cirrhosis.