A functional liver imaging score for preoperative prediction of liver failure after hepatocellular carcinoma resection
Ningbin Luo, Xiangyang Huang, Yinan Ji, Guanqiao Jin, Yunying Qin, Bangde Xiang, Danke Su, Weizhong Tang
European Radiology. 2022. DOI: 10.1007/s00330-022-08656-z
Monica Milazzo (radiology resident, University of Palermo, Palermo/IT) and
Roberto Cannella (radiologist and researcher, University of Palermo, Palermo/IT)
Hepatocellular carcinoma (HCC) accounts for about 75-85% of all primary liver cancers, representing one of the most important causes of cancer death worldwide [1]. Surgical resection is widely accepted as the most effective treatment option for HCC in patients with preserved liver function. Despite the improvements of post-hepatectomy mortality rates due to the advances in surgical technique and postoperative management, morbidity remains high. The post-hepatectomy liver failure (PHLF) is one of the most severe and challenging complications. It is related to the insufficient residual liver function and it represents a leading cause of hepatectomy-related mortality and increased cost of hospitalization [2, 3]. The incidence of PHLF ranges from 1,2% to 32% according to different definitions, characteristics of study population, and surgical procedures. Several predictors of PHLF have been explored in recent years with inconstant results to improve long-term survival in patients with HCC.
Bastati et al. [4] proposed and validated the functional liver imaging score (FLIS), a visual 6-point score, based on three imaging characteristics on gadoxetic acid-enhancement MRI: 1) liver parenchymal enhancement; 2) biliary contrast excretion; and 3) portal vein sign. The FLIS is calculated on the 20-minutes hepatobiliary phase after the administration of gadoxetic acid by summing semiquantitative assessment of each parameter, scored on an ordinal 0-2 scale. The FLIS reflects the residual hepatic function in patients with advanced chronic liver disease and it turned out to be an independent predictor for mortality in both patient with compensated and decompensated advanced chronic liver disease [5, 6].
A recent study by Luo and colleagues [7] assessed the potential of the FLIS to predict PHLF in patients with HCC in comparison with other routine liver functional parameters. This study included a large cohort of 502 patients (422 men and 80 women), who underwent hepatic resection and had a histologically confirmed HCC. In this cohort, the most common etiology of the chronic liver disease was hepatitis B virus in 425 (84.7%) patients. A total of 90 patients experienced PHLF and this was associated with a higher risk of 30-day and 90-day mortality (OR of 3.4 and 2.6, respectively). The gadoxetic acid-enhanced MRI exams were acquired within 1 month before surgery and they were assessed independently by two abdominal radiologists which assigned the FLIS to each patient.
The main study results demonstrate that PHLF was associated with cirrhosis, ascites, aspartate aminotransferase, platelet count, model for end-stage liver disease (MELD) score, albumin–bilirubin (ALBI) score, FLIS, and major hepatic resection. Interestingly, multivariate analyses revealed that only the FLIS and mayor hepatectomy were independently associated with the risk of PHLF. Particularly, a higher FLIS was associated with a lower risk of PHLF (OR 0.452) [7]. Importantly, the FLIS demonstrated a higher accuracy for the prediction of PHLF compared to other clinical scores including the MELD, ALBI score, and the indocyanine green 15-min retention rate. A FLIS lower than 4 predicted the PHFL with a sensitivity of 61% and a specificity of 79% [7].
The results of this study are relevant for the preoperative management of patients with HCC, as gadoxetic acid-enhanced MRI is often acquired for the preoperative HCC diagnosis and staging. In this setting, the assessment of FLIS on the hepatobiliary phase images can provide an additional functional information for the optimal selection of candidates to surgical resection. Moreover, the FLIS demonstrated an excellent reproducibility between different radiologists, and it may have the advantage to be easily assessed compared to other quantitative liver imaging functional parameters. Indeed, this visual assessment does not require complex equations or specific software for measurement of signal intensity. The main limitations of this retrospective study are the lack of comparison between different grades of PHLF and the low number of patients without viral hepatitis (14,5%), such as nonalcoholic fatty liver disease.
In conclusion, PHLF remains a challenging and life-threatening complication in patients with chronic liver disease. The FLIS score could help the preoperative assessment of patients with HCC at risk of PHLF, improving their management and allowing to select the appropriate surgical strategies. Furthermore, the FLIS is confirmed a simple, noninvasive, and reproducible score. Therefore, it has the potential to be easily implemented in clinical practice and to be used for future applications supported by further studies.
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- Luo N, Huang X, Ji Y, Jin G, Qin Y, Xiang B, Su D, Tang W. A functional liver imaging score for preoperative prediction of liver failure after hepatocellular carcinoma resection. Eur Radiol. 2022. doi: 10.1007/s00330-022-08656-z.
Dr. Monica Milazzo is a second-year young radiology resident at the University of Palermo (Italy). Dr. Milazzo graduated from the University of Palermo in March 2019. Her main interest is abdominal and gastrointestinal radiology, with particular attention to hepatobiliary disease, and she is currently engaged in a multidisciplinary oncology group.
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