Liver function assessment using 99mTc-GSA single-photon emission computed tomography (SPECT)/CT fusion imaging in hilar bile duct cancer: A retrospective study

doi:10.1016/j.surg.2016.02.009

Surgery

Volume 160, Issue 1, July 2016, Pages 118-126

https://doi.org/10.1016/j.surg.2016.02.009 Get rights and content

Background

The objective of this study was to determine the utility of Tc-99m-diethylenetriamine-penta-acetic acid-galactosyl human serum albumin (^99mTc-GSA) single-photon emission computed tomography (SPECT)/CT fusion imaging for posthepatectomy remnant liver function assessment in hilar bile duct cancer patients.

Methods

Thirty hilar bile duct cancer patients who underwent major hepatectomy with extrahepatic bile duct resection were retrospectively analyzed. Indocyanine green plasma clearance rate (KICG) value and estimated KICG by ^99mTc-GSA scintigraphy (KGSA) and volumetric and functional rates of future remnant liver by ^99mTc-GSA SPECT/CT fusion imaging were used to evaluate preoperative whole liver function and posthepatectomy remnant liver function, respectively. Remnant (rem) KICG (= KICG × volumetric rate) and remKGSA (= KGSA × functional rate) were used to predict future remnant liver function; major hepatectomy was considered unsafe for values <0.05. The correlation of remKICG and remKGSA with posthepatectomy mortality and morbidity was determined.

Results

Although remKICG and remKGSA were not significantly different (median value: 0.071 vs 0.075), functional rates of future remnant liver were significantly higher than volumetric rates (median: 0.54 vs 0.46; P < .001). Hepatectomy was considered unsafe in 17% and 0% of patients using remKICG and remKGSA, respectively. Postoperative liver failure and mortality did not occur in the patients for whom hepatectomy was considered unsafe based on remKICG. remKGSA showed a stronger correlation with postoperative prothrombin time activity than remKICG.

Conclusion

^99mTc-GSA SPECT/CT fusion imaging enables accurate assessment of future remnant liver function and suitability for hepatectomy in hilar bile duct cancer patients.

Section snippets

Patients

Thirty HBDC patients who underwent major hepatectomy with extrahepatic bile resection between April 2009 and July 2014 were enrolled in the retrospective study. Preoperative liver function was assessed in all HBDC patients using the ICG test and ^99mTc-GSA SPECT/CT fusion imaging. The study was approved by an institutional review board, with waiver of informed consent.

^99mTc-GSA SPECT/CT fusion examination

All patients underwent preoperative biliary drainage. ^99mTc-GSA SPECT/CT fusion examination was performed after patients had

Clinical characteristics

The clinical characteristics of the 30 patients are shown in the Table. The patient population comprised 17 males and 13 females with a median age of 71 years (range, 42–84 years). All 30 patients showed obstructive jaundice and received preoperative biliary drainage limited to the future remnant lobe. As a result, biliary decompression in the future remnant lobe and biliary dilatation in the future resected lobe were admitted in 25 (83%) patients. In the remaining 5 patients, biliary

Discussion

Preoperative remnant liver function assessment is crucial to avoid posthepatectomy liver dysfunction.1, 7 Few studies have investigated remnant liver function as indication for hepatectomy in HBDC. Two notable studies demonstrated the utility of remKICG value in predicting outcome after major hepatectomy for biliary cancer patients.1, 2 A remKICG value <0.05 was reported to be a useful and reliable cut-off value in selecting HBDC patients for hepatectomy.1, 2 This index, which is based on

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Moreover, 99mTc-GSA uptake is not dependent on the bilirubin serum level, which makes it applicable even in cholestatic patients. Several reports from Eastern countries highlighted its usefulness to predict post-hepatectomy liver failure in patients with PHC [112,115]. Despite it widespread in South-East Asia, 99mTc-GSA is unfortunately not available in most European countries.
Perihilar cholangiocarcinoma (PHC) is a common and highly intractable malignancy of the main biliary tree confluence. PHC is associated with a poor prognosis because of its insidious local spread that makes it challenging to diagnose and assess. Surgical resection remains the standard curative treatment (up to 50% 5-year overall survival after negative-margin resection). More aggressive surgical approaches have recently emerged, pushing the boundaries of PHC resectability at the cost of a higher morbidity. As such, adequate preoperative preparation (i.e., biliary drainage, venous embolization) is now regarded as a critical issue to increase the number of patients amenable to extended liver resection. Thorough imaging plays a pivotal role in the preoperative setting in both PHC resectability assessment and patient preparation to surgery. Despite recent improvement in PHC imaging, its assessment remains challenging and only 50–60% of patients who are scheduled to undergo surgery are ultimately amenable to curative resection. Therefore, a knowledge of available diagnostic and interventional imaging techniques is important to improve PHC management. Herein, we review the various imaging techniques and preoperative radiological interventions such as biliary drainage, portal vein embolization and liver venous deprivation that are available in PHC management focusing on the anatomical and oncological considerations that are crucial to prepare and guide curative surgical resection.
<sup>99m</sup>Tc-GSA scintigraphy for assessing the functional volume ratio of the future liver remnant in the routine practice of liver resection
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As shown in Fig 6, A, when comparing CT- and GSA-based FLR% measurements before PVE with those after PVE in paired samples, we noticed that the rate of increase in FLR% was larger for GSA-based than CT-based values. This result is consistent with previously reported studies documenting the importance of 99mTc-GSA scintigraphy in the assessment of FLR% [21,22]. Nonetheless, it should be borne in mind that the rise in the GSA-based FLR% after PVE does not necessarily indicate an actual increase in the number of liver cells in response to PVE, but rather, it is partly due to a decrease in the uptake of 99mTc-GSA molecules by the embolized liver [23].
The significance of incorporating regional functional heterogeneity assessment by liver scintigraphy into the calculation of the future liver remnant has been reported. However, liver scintigraphy entails additional costs and radiation exposure. Nevertheless, studies describing when liver scintigraphy demonstrates an actual benefit over computed tomography liver volumetry are lacking. Thus, we evaluated the degree of agreement between future liver remnant % values calculated by technetium ^99mTc diethylenetriaminepentaacetic acid-galactosyl human serum albumin scintigraphy (galactosyl human serum albumin–based future liver remnant %) and those by computed tomography volumetry and investigated the practical impact of performing regional functional heterogeneity assessment.
The Bland–Altman method was used to retrospectively analyze the agreement between computed tomography– and galactosyl human serum albumin–based future liver remnant % measurements in 84 patients.
In ordinary patients with a computed tomography–based future liver remnant % greater than 50%, there was a good agreement between both measurements. However, in cases with a computed tomography–based future liver remnant % less than 40%, galactosyl human serum albumin–based measurements were significantly smaller than computed tomography–based values, with 88% of these patients exhibiting a galactosyl human serum albumin–based future liver remnant % less than 30%. After portal vein embolization, galactosyl human serum albumin–based measurements were primarily greater than or in agreement with computed tomography–based values, even in cases with a computed tomography–based future liver remnant % less than 40%.
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This retrospective study included 335 HCC patients who underwent anatomical hepatectomy at eight institutions between 2013 and 2017. Risk factors, including volume-associated liver-estimating parameters, for PHLF grade B–C were analyzed in a training set (n = 122) via multivariate analysis, and a PHLF prediction model was developed. The utility of the model was evaluated in a validation set (n = 213).
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: The authors have no conflicts of interest to declare.

: This work was supported by the Kochi Organization for Medical Reformation and Renewal.

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HepatoBilioPancreaticLiver function assessment using 99mTc-GSA single-photon emission computed tomography (SPECT)/CT fusion imaging in hilar bile duct cancer: A retrospective study

Background

Methods

Results

Conclusion

Section snippets

Patients

99mTc-GSA SPECT/CT fusion examination

Clinical characteristics

Discussion

J Am Coll Surg

Surgery

Surgery

J Gastrointest Surg

Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up

Ann Surg

Value of indocyanine green clearance of the future liver remnant in predicting outcome after resection for biliary cancer

Br J Surg

Functional discrepancy between two liver lobes after hemilobe biliary drainage in patients with jaundice and bile duct cancer: an appraisal using (99m)Tc-GSA SPECT/CT fusion imaging

Radiology

Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections

Ann Surg

Role of preoperative biliary drainage in jaundiced patients who are candidates for pancreatoduodenectomy or hepatic resection: highlights and drawbacks

Ann Surg

Preoperative estimation of asialoglycoprotein receptor expression in the remnant liver from CT/99mTc-GSA SPECT fusion images correlates well with postoperative liver function parameters

J Hepatobiliary Pancreat Sci

Preoperative estimation of remnant hepatic function using fusion images obtained by (99m)Tc-labelled galactosyl-human serum albumin liver scintigraphy and computed tomography

Br J Surg

CT/99mTc-GSA SPECT fusion images demonstrate functional differences between the liver lobes

World J Gastroenterol

Preoperative evaluation of hepatic functional reserve following hepatectomy by technetium-99m galactosyl human serum albumin liver scintigraphy and computed tomography

Eur J Nucl Med

99mTc-DTPA-galactosyl-human-serum-albumin liver scintigraphy for evaluating hepatic functional reserve before hepatectomy in a patient with indocyanine green excretory defect: report of a case

Surg Today

HepatoBilioPancreatic
Liver function assessment using 99mTc-GSA single-photon emission computed tomography (SPECT)/CT fusion imaging in hilar bile duct cancer: A retrospective study

^99mTc-GSA SPECT/CT fusion examination