A novel, non-invasive model for diagnosing liver fibrosis stage in patients with hepatocellular carcinoma

The impact of hepatic and splenic volumetric assessment in imaging for chronic liver disease: a narrative review

Chronic liver disease is responsible for significant morbidity and mortality worldwide. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) can fully visualise the liver and adjacent structures in the upper abdomen providing a reproducible assessment of the liver and biliary system and can detect features of portal hypertension. Subjective interpretation of CT and MRI in the assessment of liver parenchyma for early and advanced stages of fibrosis (pre-cirrhosis), as well as severity of portal hypertension, is limited. Quantitative and reproducible measurements of hepatic and splenic volumes have been shown to correlate with fibrosis staging, clinical outcomes, and mortality. In this review, we will explore the role of volumetric measurements in relation to diagnosis, assessment of severity and prediction of outcomes in chronic liver disease patients. We conclude that volumetric analysis of the liver and spleen can provide important information in such patients, has the potential to stratify patients' stage of hepatic fibrosis and disease severity, and can provide critical prognostic information. CRITICAL RELEVANCE STATEMENT: This review highlights the role of volumetric measurements of the liver and spleen using CT and MRI in relation to diagnosis, assessment of severity, and prediction of outcomes in chronic liver disease patients. KEY POINTS: Volumetry of the liver and spleen using CT and MRI correlates with hepatic fibrosis stages and cirrhosis. Volumetric measurements correlate with chronic liver disease outcomes. Fully automated methods for volumetry are required for implementation into routine clinical practice.

Diagnostic performance of non-invasive liver fibrosis scores in patients with early-intermediate hepatocellular carcinoma

PURPOSE

Hepatocellular carcinoma (HCC) arises in individuals with underlying liver disease. Diagnosing the degree of hepatic fibrosis helps to determine the severity of the underlying liver disease and may influence therapeutic decisions in HCC patients. Non-invasive fibrosis scores can be used to estimate the degree of fibrosis in liver disease patients, but most of these scores were developed in patients with viral hepatitis and without HCC. This study explored the ability of the Fibrosis-4 Index (FIB-4), the AST/Platelet Ratio Index (APRI), and the AST/ALT ratio to diagnose or exclude advanced fibrosis (METAVIR F3/4 versus F0-2) in patients with early-intermediate, potentially resectable HCC.

METHODS

We retrospectively reviewed 119 patients who underwent hepatic resection for HCC at a tertiary centre (2007-2019), 75 of whom had advanced fibrosis (prevalence 63%). Histological assessment of the surgical liver specimen was used as a reference standard for the degree of fibrosis.

RESULTS

Overall diagnostic performance was highest for the FIB-4 Index, with an area under the receiver operating characteristic curve (AUROC) of 0.82, compared with 0.78 for APRI, and 0.56 for the AST/ALT ratio. Using established cut-off values, FIB-4 achieved a 90% positive predictive value at the higher cut-off (3.25) and a 90% negative predictive value at the lower cut-off (1.45).

CONCLUSION

The FIB-4 Index could reliably diagnose or exclude advanced fibrosis in patients with early-intermediate HCC, and may thus have a role in guiding therapeutic decisions in these patients.

A nomogram for predicting prognosis in patients with transjugular intrahepatic portosystemic shunt creation based on deep learning-derived spleen volume-to-platelet ratio

OBJECTIVES

The objective of our study was to develop a nomogram to predict post-transjugular intrahepatic portosystemic shunt (TIPS) survival in patients with cirrhosis based on CT images.

METHODS

This retrospective cohort study included patients who had received TIPS operation at the Wenzhou Medical University First Affiliated Hospital between November 2013 and April 2017. To predict prognosis, a nomogram and Web-based probability were developed to assess the overall survival (OS) rates at 1, 3, and 5 years based on multivariate analyses. With deep learning algorithm, the automated measurement of liver and spleen volumes can be realized. We assessed the predictive accuracy and discriminative ability of the nomogram using the concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).

RESULTS

Age, total bilirubin, and spleen volume-to-platelet ratio (SVPR) were identified as the independent risk factors for OS. The nomogram was constructed based on the above risk factors. The C-index (0.80, 0.74, 0.70), ROC curve (area under curve: 0.828, 0.761, 0.729), calibration curve, and DCA showed that nomogram good at predictive value, stability, and clinical benefit in the prediction of 1-, 3-, 5-year OS in patients with TIPS creation.

CONCLUSIONS

We constructed a nomogram for predicting prognosis in patients with TIPS creation based on risk factors. The nomogram can help clinicians in identifying patients with poor prognosis, eventually facilitating earlier treatment and selecting suitable patients before TIPS.

ADVANCES IN KNOWLEDGE

This study developed the first nomogram based on SVPR to predict the prognosis of patients treated with TIPS. The nomogram could help clinician in non-invasive decision-making.

Spleen to non-cancerous liver volume ratio predicts liver cirrhosis in hepatocellular carcinoma patients

PURPOSE

To investigate the performance of spleen to non-cancerous liver volume ratio (STnLR) for diagnosing liver cirrhosis in patients with hepatocellular carcinoma (HCC) during preoperative evaluation.

METHODS

Patients were randomly divided into experiment group and validation group. Patients were grouped into cirrhosis group and non-cirrhosis group according to Scheuer staging. Patients' routine image data were reconstructed using a three-dimensional system. STnLR, spleen to liver volume ratio (STLR), spleen volume, aspartate aminotransferase to platelet ratio index (APRI), and fibrosis index based on the four factors (FIB-4) were calculated. Correlations between indices and cirrhosis were measured by Spearman correlation analysis. Diagnostic performance was assessed and compared using receiver operating characteristic analysis. Accuracies of the models were analyzed in validation group.

RESULTS

No statistical difference in demographic and clinical characteristics was observed between groups. In experiment group, STnLR had the strongest correlation (r = 0.5399, P < 0.0001), and STLR, spleen volume, APRI, and FIB-4 had moderate correlations (r = 0.4583, 0.4123, 0.3648, and 0.3405, P < 0.0001, < 0.0001, < 0.0001, and = 0.0002) with liver cirrhosis stage. AUROC of STnLR (0.8326) was not statistically higher than that for spleen volume (0.7542, P = 0.09832) and STLR (0.8046, P = 0.3034), but was significantly higher than that for APRI (0.7099, P = 0.02046) and FIB-4 (0.7294, P = 0.03987). In validation group, STnLR showed the highest AUROC value (0.8538) and highest Youden index (0.5869) among all models.

CONCLUSION

STnLR is an accurate and stable volumetric model to diagnose hepatic cirrhosis in the HCC population, which is superior to APRI and FIB-4.

A nomogram for predicting post-hepatectomy liver failure in patients with hepatocellular carcinoma based on spleen-volume-to-platelet ratio

BACKGROUND AND OBJECTIVES

Post-hepatectomy liver failure (PHLF) is one of the most serious complications after hepatectomy in patients with hepatocellular carcinoma (HCC), and has an association with high morbidity and mortality. This study aimed to explore the risk factors of PHLF and to establish and validate a nomogram to predict PHLF.

METHODS

We retrospectively analyzed 971 HCC patients undergoing major liver resection at the Eastern Hepatobiliary Surgery Hospital between 2011 and 2016, and established a nomogram based on multivariate analyses for predicting PHLF. The predictive accuracy and discriminative ability of the nomogram were evaluated by concordance index (C-index) and calibration curve. The predictive ability of PHLF of this nomogram was compared with conventional models using receiver operating characteristic (ROC) curves.

RESULTS

The incidence of PHLF was 18.8%. Multivariate analysis identified age, BMI, preoperative ascites, preoperative prealbumin, spleen volume-to-platelet ratio, total bilirubin, and intraoperative blood loss as independent predictors of PHLF. The area under ROC curve (AUROC) of the predictive model was 0.668 and was higher than that of the albumin-bilirubin score (ALBI). The optimal cut-off value of the model was 124.

CONCLUSIONS

We constructed a nomogram for predicting PHLF based on risk factors. The nomogram can assist clinicians in identifying patients with high-risk PHLF, eventually facilitating earlier interventions and improving clinical outcomes.

Preoperative evaluation of liver regeneration following hepatectomy in hepatocellular carcinoma using magnetic resonance elastography

BACKGROUND

For patients with hepatocellular carcinoma (HCC) undergoing hepatectomy, insufficient remnant liver regenerative capacity can lead to liver failure. The aim of this study was to evaluate the potential role of magnetic resonance elastography (MRE) for the preoperative prediction of liver regeneration in patients with HCC after partial hepatectomy (PH).

METHODS

A total of 54 patients with HCC undergoing MRE prior to PH were retrospectively included. The total functional liver, volume of preoperative future liver remnant (LVpre), and volume of postoperative liver remnant (LVpost), respectively, were measured, and the regeneration index (RI) and parenchymal hepatic resection rate (PHRR) were manually calculated. Univariate and multivariate logistic regression analyses were conducted to identify factors associated with a high RI, and receiver operating characteristic (ROC) curves were employed to evaluate the diagnostic performance of the liver stiffness (LS) values. Patients were classified into three subgroups based on the value of PHRR: low PHRR (<30%), intermediate PHRR (30-50%), and high PHRR (>50%). Subsequently, Spearman correlation analysis was used to investigate the relationship between LS values and RI in the subgroups.

RESULTS

Multivariable analysis revealed a low LS value was associated with greater odds of a high RI [odds ratio (OR), 0.049; 95% confidence interval (CI): 0.002 to 0.980]. An optimal cutoff value of 3.30 kPa was used to divide all patients into a low RI group and a high RI group with an area under the curve (AUC) value of 0.882 (95% CI: 0.767 to 0.996). A significant negative relationship between RI and LS values (r=-0.799; P<0.001) was observed in the intermediate PHRR subgroup.

CONCLUSIONS

The LS values based on MRE may serve as a potential preoperative predictor of liver regeneration for patients with HCC undergoing PH.

A novel index for staging hepatitis B related liver cirrhosis in patients with hepatocellular carcinoma

Information on the stage of liver cirrhosis is essential for prognostication and decisions on surgical planning for hepatocellular carcinoma (HCC) patients. But a non-invasive liver cirrhosis staging model is still lacking. The aim of our study was to develop a non-invasive model based on routine clinical parameters to evaluate the severity of cirrhosis in hepatitis B related HCC patients. A total of 226 HCC patients with chronic hepatitis B virus (HBV) infection who had liver resection were analyzed in this retrospective study. We found that platelets, prothrombin activity, maximum oblique diameter of right hepatic lobe and spleen length were the independent predictors of liver cirrhosis in HCC patients. By cumulating the weight of risk scores of independent variables, we constructed the PPMS (PLT/PTA/maximum oblique diameter of right hepatic lob/spleen length) index. The areas under the receiver operating characteristic curves (AUROC) of PPMS index were 0.820, 0.667, and 0.650 in predicting ≥cirrhosis 1 (C1), ≥cirrhosis 2 (C2), and ≥cirrhosis 3 (C3), respectively. The optimal cut-off value of the PPMS index for predicting ≥C1, ≥C2, and ≥C3 was 4.392, 4.471, and 4.784, respectively. And the corresponding sensitivity was 63.1%, 63.2%, and 64.7%, the corresponding specificity was 89.4%, 64.3%, and 62.5%, respectively. Our study constructed a non-invasive liver cirrhosis index (PPMS) could distinguish patients from different stages of liver cirrhosis, which might add more preoperative information for HCC patients.

Safe standard remnant liver volume after hepatectomy in HCC patients in different stages of hepatic fibrosis

Background

To determine the standard remnant liver volume (SRLV) threshold to avoid postoperative hepatic insufficiency inpatients in different stages of hepatic fibrosis who undergo right hemi-hepatectomy.

Methods

Data for 85 patients at our single medical center were analysed prospectively to examine whether the following factors differed significantly between those who experienced postoperative hepatic insufficiency and those who did not: height, prothrombin time, remnant liver volume, SRLV or hepatic fibrosis stage.

Results

Logistic regression showed SRLV and hepatic fibrosis stage to be independent risk factors for postoperative hepatic insufficiency. The threshold SRLV for predicting insufficiency was 203.2 ml/m² across all patients [area under receiver operating characteristic curve (AUC) 0.778, sensitivity 66.67%, specificity 83.64%, p<0.0001), 193.8 ml/m² for patients with severe hepatic fibrosis (AUC 0.938, sensitivity 91.30%, specificity 85.71%, p<0.0001), and 224.3 ml/m² for patients with cirrhosis (AUC 0.888, sensitivity 100%, specificity 64.29%, p<0.0001).

Conclusions

Right hemi-hepatectomy may be safer in Chinese patients when the standard remnant liver volume is more than 203.2 ml/m² in the absence of hepatic fibrosis or cirrhosis, 193.8 ml/m² in the presence of severe hepatic fibrosis or 224.3 ml/m² in the presence of cirrhosis.

Liver fibrosis is a major risk factor for liver regeneration: A comparison between healthy and fibrotic liver

BACKGROUND

Blood flow factors, such as congestion or ischemia after hepatectomy, have a significant impact on liver regeneration, but with the popularization of precise hepatectomy technology, segmental hepatectomy without congestion or ischemia has become the preferred treatment. Our aim is to investigate the factors affecting liver regeneration after hepatectomy without blood flow changes, and to provide clinical evidence for surgeons on the timing of second hepatectomy for cirrhosis patients with hepatocellular carcinoma (HCC).

METHODS

This study retrospectively analyzed data from patients who underwent right hepatectomy without middle hepatic vein (MHV) in West China Hospital between January 2016 and January 2018. Eighteen living-donors without MHV as normal group and 45 HCC patients, further classified into 3 subgroups based on the severity of fibrosis using the Scheure system. Demographic data, pre- and postoperative liver function indexes, and remnant liver volume (RLV) were retrospectively compared. We also analyzed the remnant liver regeneration rate (RLRR) post-operatively in each group. The significant indexes in univariate analysis were further analyzed using both receiver operating characteristic (ROC) analysis and multivariate regression analysis.

RESULTS

Liver regeneration occurred in both living-donor and HCC groups after hepatectomy; the RLRRs at 1 month were 59.46 ± 10.39% and 57.27 ± 4.77% (P = .509), respectively. Regeneration in the cirrhosis group occurred more slowly and less completely compared with that in other groups. The regeneration rate in the first 6 months showed rapid increase and the RLRR reached above 70% in cirrhosis group. Multivariate and ROC analyses revealed that Alb and the hepatic fibrosis grade in the early postoperative period were significant predictors of remnant liver regeneration.

CONCLUSION

The liver regenerated in all HCC patients; however, regeneration was significantly slower and less complete compared with the normal liver, especially in the patients with cirrhosis. Therefore, it can be concluded that the degree of liver fibrosis is a major predictor of liver regeneration. Furthermore, the optimal time for second resection in recurrent HCC patients with cirrhosis was 6 months after the first operation.

Dgat2 reduces hepatocellular carcinoma malignancy via downregulation of cell cycle-related gene expression

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related deaths worldwide, mainly due to the absence of effective diagnostic biomarkers and therapeutic targets. Therefore, novel molecular targets are urgently needed, in order to formulate novel therapeutic approaches for this devastating disease. In the present study, we demonstrated that diacylglycerol acyltransferase 2 (Dgat2) was downregulated in human HCC tissues compared with in matched normal tissues. Furthermore, its high expression was significantly associated with longer survival. In addition, Dgat2 overexpression significantly suppressed HCC cell proliferation. in vivo studies, we revealed that the weight and volume of the tumors derived from Balb/c nude mice was markedly decreased when using HCC cells overexpressing Dgat2. Mechanism analysis demonstrated that cell cycle-related gene expressions were significantly downregulated in HCC cells overexpressing Dgat2. Taken together, these data suggest that Dgat2 is an important regulator of HCC cell proliferation, and could represent a potential anticancer target and diagnostic biomarker for HCC.