Prediction of posthepatectomy liver failure using the coefficient variation of relative liver enhancement on hepatobiliary phase images

Prediction of posthepatectomy liver failure using the coefficient variation of relative liver enhancement on hepatobiliary phase images Poster No.: C-0157 Congress: ECR 2015 Type: Scientific Exhibit Authors: S. Matsushima, Y. Sato, H. Yamaura, M. kato, S. Murata, Y. 1 2 1 2 1 1 1 1 1 1 2 Kinosada, S. Era, H. Ogura, Y. Inaba ; Nagoya/JP, Gifu/JP Keywords: Molecular imaging, Liver, Abdomen, MR, Contrast agentintravenous, Cancer DOI: 10.1594/ecr2015/C-0157 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 40

Aims and objectives Prediction of future remnant liver (FRL) function is crucial in the determination of whether a patient can safely undergo liver resection. A more reliable index for estimating postoperative liver failure is ICG clearance of the future remnant liver (ICG-Krem), which is calculated as the ratio of the FRL volume to the total liver volume (1,2). The threshold of ICG-Krem required for safe liver resection has been shown to be more than 0.05 (3). However, ICG-Krem assumes that uptake is homogeneous throughout the liver.gadoxetic acid disodium is a newly developed MR contrast agent for hepatocellular imaging; it can be used as a tracer for liver function testing (4-13). Recent reports suggest that gadoxetic acid disodium can also be used as a tracer for liver function testing (5, 6) and the relative liver enhancement (RLE) on hepatobiliary phase images is a potentially useful method for heterogeneous liver function (HLF) imaging by MRI (13,14). The purpose of this study is to predict posthepatectomy liver failure (PHLF) using gadoxetic acid-enhanced MRI with the measurement of relative liver enhancement (RLE) on hepatobiliary phase images, thereby facilitating safe liver resection.we tried to detect PHLF which was not able to be detected in ICG-Krem. We corrected ICGKrem for heterogeneous liver function (HLF) using a the coefficient variation of RLE value (RLE(Cv)). We conducted preoperative evaluation of PHLF using ICG-Krem while considering heterogeneous liver function (HLF-ICG-Krem). Page 2 of 40

Images for this section: Fig. 1: Title Page 3 of 40

Fig. 2: Abbreviations Page 4 of 40

Fig. 3: Background Page 5 of 40

Fig. 4: Background Page 6 of 40

Fig. 5: Background, Liver MRI-Function Image Page 7 of 40

Fig. 6: Background, Liver MRI-Function Image Page 8 of 40

Fig. 7: Purpose Page 9 of 40

Methods and materials Twenty patients underwent tumor excision surgery. PHLF was evaluated using the grading system of the International Study Group of Liver Surgery. A more reliable index for estimating PHLF is the indocyanine green clearance of future remnant liver (FRL) (ICG-Krem), which is calculated as the ratio of the FRL volume to the total liver volume. The threshold of ICG-Krem required for safe liver resection has been shown to be more than 0.05. However, ICG-Krem assumes homogenous uptake throughout the liver. The RLE value was defined as the percentage of signal gain between the precontrast and hepatocellular images. In the whole liver and FRL, the RLE value measured the tumor-free liver parenchyma in RLE images. The heterogeneous liver function (HLF) was evaluated using the coefficient variation of the RLE value [RLE(Cv)]. We corrected the ICG-Krem of FRL (ICG-Krem) for HLF using RLE(Cv); this corrected ICG-Krem (HLFICG-Krem) was defined as ICG-Krem [RLE(Cv) of the whole liver/rle(cv) of FRL]. Preoperative PHLF evaluation was predicted using RLE, FRL-RLE, ICG-Krem, and HLFICG-Krem. Page 10 of 40

Images for this section: Fig. 8: Design of this study Page 11 of 40

Fig. 9: Patients Page 12 of 40

Fig. 10: Patients Page 13 of 40

Fig. 11: Methods - MRI Technique Page 14 of 40

Fig. 12: Methods - MRI Technique Page 15 of 40

Fig. 13: Methods - RLE Page 16 of 40

Fig. 14: Methods - RLE image Page 17 of 40

Fig. 15: Methods - ROI and VOI Page 18 of 40

Fig. 16: Methods-ICG-Krem Page 19 of 40

Fig. 17: Methods-HLF-ICG-Krem Page 20 of 40

Fig. 18: Methods-PHLF Page 21 of 40

Fig. 19: Statistical analyses Page 22 of 40

Results Results Of the 20 evaluated patients, 5 (25%) had elevated INR values and serum bilirubin levels on postoperative day 5 and thus met the criteria for liver failure as proposed byisgls (Table 1). Of these 5 patients, 3 (60%) did not require specific treatment and were classified as PHLF grade A, whereas 2 (40%) required noninvasive treatment (PHLF grade B) (Table 1). ICG-Krem and HLF-ICG-Krem values correlated with INR after postoperative day 5 (r = #0.49 and #0.51, respectively; p < 0.05 for both) (Fig.1). HLF-ICG-Krem values of #0.05 could detect 2 patients with higher INRs (classified as PHLF grade B) after postoperative day 5 (Fig.1). ICG-Krem and HLF-ICG-Krem values were significantly lower in cases with PHLF (0.086 ± 0.033 and 0.075 ± 0.039, respectively) than in those without PHLF (0.129 ± 0.041 and 0.117 ± 0.034, respectively; p < 0.05 for both) (Table 1, 2). Only HLF-ICG-Krem values were significantly lower in cases with PHLF grade B (0.045 ± 0.004) than in those without PHLF (p < 0.05) (Table 1, 2). Discussion Liver volumetry is essential when evaluating patients who are candidates for partial liver resection because the postoperative course strongly depends on the liver remnant volume (20). In our study, we used the ICG-Krem value, which was calculated as the ratio of the FRL volume to the total liver volume, to estimate PHLF. However, ICGKrem does not consider HLF. We evaluated HLF using RLE(Cv) and corrected ICG-Krem values (HLF-ICG-Krem).Both ICG-Krem and HLF-ICG-Krem were significantly lower in cases with PHLF than in those without PHLF (p < 0.05), and only HLF-ICG-Krem was significantly lower in cases with PHLF grade B than in those without PHLF (p < 0.05). The ability to predict which patients will develop PHLF grade B prior to surgery is very clinically meaningful because the clinical management of such patients deviates from the regular course. Page 23 of 40

Images for this section: Fig. 20: Fig. 1 Correlation of the INR after postoperative day 5 and ICG-Krem, PLF-ICGKrem, RLE, FRL-REL Page 24 of 40

Fig. 21: Table 1. Summary of parameters for predicting PHLF grade Page 25 of 40

Fig. 22: Table 2. Summary of the significant difference in PHLF grade and the parameters for predicting PHLF grade Page 26 of 40

Fig. 23: Fig.2 RLE images Page 27 of 40

Fig. 24: Fig.3 RLE images Page 28 of 40

Fig. 25: Results 1 Page 29 of 40

Fig. 26: Results 2 Page 30 of 40

Fig. 27: Results 3 Page 31 of 40

Fig. 28: Discussion 1 Page 32 of 40

Fig. 29: Discussion 2 Page 33 of 40

Fig. 30: Limitations Page 34 of 40

Conclusion The HLF-ICG-Krem value incorporates HLF into the standard ICG-Krem value and thus provides a useful parameter that can evaluate PHLF more correctly. This MRI examination method thus provides morphological and functional information that can be used to optimize the preoperative selection of patients who can safely undergo liver resection. Page 35 of 40

Images for this section: Fig. 31: Conclusion Page 36 of 40

References 1.Kurumiya Y, Nagino M, Nozawa K, et al. Biliary bile acid concentration is a simple and reliable indicator for liver function after hepatobiliary resection for biliary cancer. Surgery 2003;133:512-520. 2.Uesaka K, Nimura Y, Nagino M. Changes in hepatic lobar function after right portal vein embolization. An appraisal by biliary indocyanine green excretion. Ann Surg 1996;223:77-83. 3.Nagino M, Kamiya J, Nishio H, Ebata T, Arai T, Nimura Y. Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up. Ann Surg 2006;243:364-372. 4.Albers I, Hartmann H, Bircher J, Creutzfeldt W. Superiority of the Child-Pugh classification to quantitative liver function tests for assessing prognosis of liver cirrhosis. Scand J Gastroenterol 1989;24:269-276. 5.Motosugi U, Ichikawa T, Sou H, et al. Liver parenchymal enhancement of hepatocytephase images in Gd-EOB-DTPA-enhanced MR imaging: which biological markers of the liver function affect the enhancement? J Magn Reson Imaging 2009;30:1042-1046. 6.Motosugi U, Ichikawa T, Tominaga L, et al. Delay before the hepatocyte phase of GdEOB-DTPA-enhanced MR imaging: Is it possible to shorten the examination time? Eur Radiol 2009;19:2623-2629. 7.Yamada A, Hara T, Li F, et al. Quantitative evaluation of liver function with use of gadoxetate disodium-enhanced MR imaging. Radiology 2011;260:727-733. 8.Ohwada S, Kawate S, Hamada K, et al. Perioperative real-time monitoring of indocyanine green clearance by pulse spectrophotometry predicts remnant liver functional reserve in resection of hepatocellular carcinoma. Br J Surg 2006;93:339-346. 9.Kwon AH, Ha-Kawa SK, Uetsuji S, Inoue T, Matsui Y, Kamiyama Y. Preoperative determination of the surgical procedure for hepatectomy using technetium-99mgalactosyl human serum albumin (99mTc-GSA) liver scintigraphy. Hepatology 1997;25:426-429. 10.Tajima T, Takao H, Akai H, et al. Relationship between liver function and liver signal intensity in hepatobiliary phase of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging. J Comput Assist Tomogr 2010;34:362-366. Page 37 of 40

11.Kim HY, Choi JY, Park CH, et al. Clinical factors predictive of insufficient liver enhancement on the hepatocyte-phase of Gd-EOB-DTPA-enhanced magnetic resonance imaging in patients with liver cirrhosis. J Gastroenterol 2013;48:1180-1187. 12.Yoneyama T, Fukukura Y, Kamimura K, et al. Efficacy of liver parenchymal enhancement and liver volume to standard liver volume ratio on Gd-EOB-DTPAenhanced MRI for estimation of liver function. Eur Radiol 2014;24:857-865. 13.Matsushima S, Sato Y, Yamaura H, et al. Visualization of liver uptake function using the uptake contrast-enhanced ratio in hepatobiliary phase imaging. Magn Reson Imaging 2014;32:654-659. 14.Kukuk GM, Schaefer SG, Fimmers R, et al. Hepatobiliary magnetic resonance imaging in patients with liver disease: correlation of liver enhancement with biochemical liver function tests. Eur Radiol 2014 Jul 17. [Epub ahead of print] 15.Rahbari NN, Garden OJ, Padbury R, et al. Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS). Surgery 2011;149:713-724. Page 38 of 40

Images for this section: Fig. 32: References Page 39 of 40

Fig. 33: References Page 40 of 40