Predictive value of gadoxetic acid-enhanced MRI for posthepatectomy liver failure: a systematic review
Qiang Wang, Anrong Wang, Ernesto Sparrelid, Jiaxing Zhang, Ying Zhao, Kuansheng Ma & Torkel B. Brismar
European Radiology (2021). doi: 10.1007/s00330-021-08297-8
Postpancreatectomy liver failure (PHLF) is a major complication after liver resection and is the leading cause of perioperative morbidity and mortality. The reported incidence is typically around 10%, depending on different PHLF criteria and individual medical centre experience, however a frequency of 43% has also been reported [1,2]. For this reason, there is an urgent need for effective and non-invasive biomarkers to predict and avoid PHLF.
Common investigations and scoring models for the evaluation of liver function include, blood biochemical tests, indocyanine green (ICG) retention test, the LiMAx ® test, Child-Pugh score and the Model for End-Stage Liver Disease (MELD). Whilst these provide information on global liver function, they do not take into consideration the heterogeneous distribution of liver function amongst the different liver segments, which is especially significant in liver fibrosis or cirrhosis patients or after chemotherapy [3].
Gadoxetic acid (Primovist ®) enhanced magnetic resonance imaging (MRI) is used as a routine preoperative workup for the detection of liver lesions and their characterisation. 50% of the contrast medium is taken up by organic anion-transporting polypeptides (OATPs) or sinusoidal membrane of normal hepatocytes, and is then excreted into biliary ducts [4]. Enhancement of liver parenchyma is determined by the equilibrium of this transport mechanism.
Wang et al. carried out a systematic review which aims to evaluate the efficacy of gadoxetic acid-enhanced MRI-derived parameters as an imaging biomarker in preoperative prediction of PHLF. Studies evaluating the incidence of PHLF in patients who underwent preoperative liver function assessment using gadoxetic acid-enhanced MRI were included in a systematic literature search. The Quality In Prognostic Studies (QUIPS) tool was adopted to evaluate the risk of bias. Out of a total of 114 studies found in the systematic research search, 15 studies were considered eligible.
Most studies included were marked as low to moderate risk of bias in each domain of QUIPS. The most commonly used parameter was relative liver enhancement or its related parameters. The reported incidence of PHLF ranged from 3.9 to 40%, and the predictive sensitivity and specificity of gadoxetic acid-enhanced MRI parameters varied from 75 to 100% and from 54 to 93% in ten reported studies. A majority of the studies revealed that the gadoxetic acid-enhanced MRI parameter was a predictor for PHLF.
Risk factors for PHLF may result from patient aspects (namely age, body mass index, chronic diseases), liver quality (cirrhosis, hepatitis, neo-adjuvant chemotherapy), and factors related to the surgery itself (such as intraoperative blood loss, time of in-flow occlusion) [5].
The Authors highlight a number of limitations of this study, with the most significant limitation being the heterogeneity of the studies, both in the variance of MRI liver function parameters as well as in the indication and extent of liver resection. Other limitations include the fact that only less than half the studies had a large sample size, only one was prospectively designed, and just two studies included both a study cohort and a validation cohort.
Overall, this present systematic review provides evidence that quantitative liver function parameters derived from gadoxetic acid-enhanced MRI exhibit encouraging efficacy in the prediction of PHLF. Multicenter, prospective trials with large sample size and reliable, unified liver function parameters are required to validate the efficacy of individual liver function parameters.
References:
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- Guglielmi A, Ruzzenente A, Conci S, Valdegamberi A, Iacono C (2012) How much remnant is enough in liver resection? Dig Surg 29:6–17
- Van Beers BE, Pastor CM, Hussain HK (2012) Primovist, Eovist: what to expect? J Hepatol 57:421–429
- Guglielmi A, Ruzzenente A, Conci S, Valdegamberi A, Iacono C. How much remnant is enough in liver resection? Dig Surg. 2012;29(1):6-17. doi: 10.1159/000335713. Epub 2012 Mar 15. PMID: 22441614.
Dr. Maria Croucher is a first-year radiology resident at Mater Dei Hospital, Malta. She completed her undergraduate medical degree at the University of Malta in 2017 and joined the Medical Imaging Department in 2020 where she is undertaking training in diagnostic and interventional radiology. She is also currently studying for a Master's degree in Clinical Radiology at the University of Malta.
Comments may be sent to: mariacroucher@gmail.com