Clinical Radiology 69 (2 0 1 4 ) 88 7 e 8 9 5

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Clinical Radiology
o! r nal " o#e$age % &&&'cl i n i cal r a di ol o g yo n l i ne' ne t
Revie&
C( vol!#etry o) t"e liver% *"ere does it stand
in clinical $ractice+
,'C' -i#
a.
/
. C'0' (an
a
. 1' Cai
b
. 1' 2"eng
b
. 3'*'C' 4o&
c
a
De$art#ent o) Diagnostic Radiology. (an (oc5 Seng 0os$ital. 11 1alan (an (oc5 Seng. Singa$ore 608466.
Singa$ore
b
Sc"ool o) Co#$!ter 7ngineering. 8anyang (ec"nological 9niversity. :loc5 84 8anyang 3ven!e ;02a<
62. Singa$ore 669798. Singa$ore
c
9niversity S!rgical Cl!ster. 8ational 9niversity 0os$ital. 5 -o&er 4ent Ridge Road. Singa$ore 119074. Singa$ore
art i cl e i n)or#at i on
3rticle "istory%
Received 2 =ctober 2016
Received in revised )or#
14 Dece#ber 2016
3cce$ted 17 Dece#ber 2016
>#aging<based vol!#etry "as been increasingly !tilised in c!rrent clinical $ractice to obtain
acc!rate #eas!re#ents o) t"e liver vol!#e' ("is is $artic!larly !se)!l $rior to #aor "e$atic
resection and living donor liver trans$lantation &"ere t"e si?e o) t"e re#nant liver and liver
gra)t. res$ectively. a))ects $roced!ral s!ccess and $osto$erative #ortality and #orbidity' ("e
!se o) i#aging<based vol!#etry. &it" e#$"asis on co#$!ted to#ogra$"y. &ill be revie&ed'
*e &ill e@$lore t"e vario!s tec"nical )actors t"at contrib!te to acc!rate vol!#etric #ea<
s!re#ents. and de#onstrate "o& t"e acc!racies o) t"ese tec"niA!es are inB!enced by
t"eir #et"odologies' ("e strengt"s and li#itations o) !sing anato#ical i#aging to esti#ate
liver vol!#e &ill be disc!ssed. in relation to laboratory and )!nctional i#aging
#et"ods o) assess#ent'
2014 ("e Royal College o) Radiologists' C!blis"ed by 7lsevier -td' 3ll rig"ts reserved'
>ntrod!ction
-iver vol!#e esti#ation is !nderta5en in t"e $reo$era<
tive assess#ent o) $atients !ndergoing liver resection or
liver trans$lantation' >n t"e assess#ent o) s!itability )or
s!rgery. 5ey considerations incl!de $reo$erative baseline
liver )!nction. $atient si?e. standardi?ed liver vol!#e (S-D).
and $osto$erative resid!al liver vol!#e ()!t!re liver
re#nant or E-R)' ("ese )actors are also a$$licable. in t"e
a$$ro$riate conte@t. )or a s!bset o) $atients &"o #ay
reA!ire $ortal vein e#boli?ation (CD7) to increase E-R vol<
!#e' Dol!#etry #ay also be i#$ortant )or $ost<t"era$y
assess#ent. s!c" as )ollo&ing liver trans$lant to assess
/ F!arantor and corres$ondent% ,'C' -i#. (an (oc5 Seng 0os$ital. 11 1alan
(an (oc5 Seng. Singa$ore 608466. Singa$ore' (el'% G65 66578111H )a@% G65
66578158'
7<#ail address% c"iti n 86I y a"oo'co#'sg (,'C' -i#)'
gra)t regeneration and treat#ent res$onse assess#ent o)
liver #alignancies'
Dol!#etric deter#ination s"o!ld be a #!ltidisci$linary
a$$roac"' ("e need )or close co##!nication bet&een t"e
s!rgeon and t"e radiologist is vital in t"e deter#ination o)
t"e c"oice o) s!rgical $lane (s!c" as "e#i<"e$atecto#y
vers!s e@tended "e#i<"e$atecto#y). assess#ent o)
resectability and t"e vis!ali?ation o) t!#o!r e@tent' Crior
care)!l assess#ent o) t"e liver )!nction is also vital. as a
diseased liver (e'g'. steatosis and cirr"osis) reA!ires signi)<
icantly #ore resid!al vol!#e as co#$ared to a nor#al
"ealt"y liver'
Co#$!ted to#ogra$"y (C() vol!#etry (C(D) "as been
&idely !sed as a #et"od )or t"e $reo$erative vol!#etric
assess#ent o) t"e liver. )or t"e indications as described
above' ("e !se o) ot"er i#aging #et"ods. s!c" as #agnetic
resonance i#aging (,R>) and !ltraso!nd. "ave also been
e@$lored and "ave s"o&n reliable organ vol!#e #eas!re<
#ents &"en t"e a$$ro$riate scanning $rotocols are
0009<9260JK e see )ront #atter 2014 ("e Royal College o) Radiologists' C!blis"ed by 7lsevier -td' 3ll rig"ts reserved'
"tt$%JJd@'doi'orgJ 1 0 '1 0 1 6J'crad'2 0 1 6 '1 2'0 2 1
888
,'C' -i# et al' J Clinical Radiology 69 (2014) 887e895
e#$loyed' ("e strengt"s and li#itations o) t"e vario!s
i#aging #odalities )or liver vol!#e esti#ation are dis<
c!ssed s!bseA!ently'
Clinical a$$lications o)
C(D
-iver resection
>t is i#$erative to ac"ieve acc!rate deter#ination o) t"e
liver vol!#e. es$ecially in $atients &it" c"ronic liver dis<
ease or cirr"osis &"ere t"e si?e o) t"e re#nant liver be<
co#es even #ore i#$ortant as a $rognostic )actor' 3s t"e
$resence o) !nderlying liver disease can $otentially inB!<
ence t"e s!rgical resectability o) a lesion. acc!rate
deter< #ination o) any "e$atic $arenc"y#al disease
($artic!larly cirr"osis) is t"ere)ore vital' ("ere are #any
non<invasive #et"ods available in t"e eval!ation o) liver
cirr"osis. s!c"
as !ltrasonic transient elastogra$"y (Eibroscan)'
1
0o&ever.
"istological diagnosis via liver bio$sy re#ains t"e re)erence
standard )or t"e diagnosis o) liver cirr"osis. and s"o!ld be
considered in t"e s!bset o) $atients &it" eA!ivocal labo<
ratory and i#aging Lndings'
("e E-R<to<S-D ratio is !sed as an indicator in $redicting
t"e li5eli"ood o) $osto$erative liver )ail!re a)ter #aor "e<
$atic resection. $artic!larly in $atients &it" $re<e@isting
c"ronic liver disease' ("e S-D is based !$on t"e regression
analysis o) nor#al $o$!lation (ty$ically trans$lant donors).
and in &"ic" a )or#!la can be calc!lated eit"er )ro# a
$atientMs body &eig"t (:*) or body s!r)ace area (:S3)'
3 st!dy o) 601 e@tended rig"t "e$atecto#ies
de#onstrated an inverse correlation a#ongst s#all (N20O).
inter#ediate (20e60O). large (P60O) E-R vol!#es and
increasing ris5 )or
$osto$erative deat"s'
6
>n $atients &it" nor#al livers. an S-D N20O )ollo&ing
#aor s!rgical resection "as been )o!nd to be associated
&it" "ig"er $osto$erative #orbidity and liver ins!)Lciency.
incl!ding t"e lengt" o) stay in t"e intensive care !nit'
4
("e
e@act E-R can be $atient<s$eciLc and a range o) c!t<o))
$ercentages "ave been $ro$osed in vario!s $!blications'
Eor e@a#$le. in a $ros$ective st!dy. Eerrero and colleag!es
)o!nd t"at an E-R o) a$$ro@i#ately 26'5O is reA!ired )or
$atients &it" a "ealt"y liver'
5
0o&ever. )or $atients &it"
!nderlying liver disease. it is generally acce$ted t"at t"e E-R
reA!ired is considerably larger t"an t"ose &it" a nor#al
liver given t"e i#$aired baseline )!nction o) t"e "e$ato<
cytes' >n order to ens!re s!rgical s!ccess and to red!ce
signiLcant #orbidity and #ortality. a $atient &it" cirr"osis
&ill reA!ire an E-R o) P50O &"ereas t"e reA!ire#ent is
P40O in $atients &it" "ig"<grade steatosis'
2.5.6
(o overco#e
t"e $otentially lo& E-R a)ter liver resection. CD7 can be
$er)or#ed $reo$eratively to ind!ce contralateral "y$er<
tro$"y and. t"ere)ore. red!ce t"e loss o) liver #ass
)ollo&ing s!rgery'
2
Costo$erative in)ection is also a #aor ca!se o) #ortality'
>ncreased ris5 o) severe in)ection is inversely correlated
&it" E-R'
7
>n t"e st!dy o) Sc"indl et al'
7
on 104 $atients
&"o
!nder&ent liver resection. analysis o) t"e s!bgro!$ o) $a<
tients &it" s#aller relative resid!al liver vol!#e s"o&ed a
signiLcant relation bet&een severe "e$atic dys)!nction and
in)ection. s!ggesting t"at t"ere #ay be a relations"i$ be<
t&een liver )!nction. innate i##!nity. and s!sce$tibility to
in)ections'
-iving donor liver trans$lantation
("e liver vol!#e is also a 5ey )actor in t"e selection o)
t"e a$$ro$riate individ!al )or living donor liver trans<
$lantation (-D-()' >#aging o) t"e reci$ient s"o!ld be
car< ried o!t as close to t"e ti#e o) $lanned
trans$lantation as $ossible so as to obtain an acc!rate
reBection o) t"e re< ci$ientMs disease state. $artic!larly i)
t"ere is !nderlying #alignancy as t!#o!r can ra$idly
$rogress' 3ny vasc!lar invasion or t"ro#bosis s"o!ld be
readily identiLed. as t"is inB!ences t"e $la!sibility o)
trans$lantation' 3dditionally. $ro@i#ity o) t"e t!#o!r to
t"e #ain "e$atic and $ortal vasc!lat!re as &ell as t"e
central bile d!cts s"o!ld be "ig"lig"ted' >n $atients
&it" end<stage cirr"osis. i#aging s"o!ld actively see5 to
e@cl!de "e$atocell!lar carcino#a (0CC)' C( o) t"e t"ora@
and abdo#en s"o!ld be acA!ired at t"e sa#e sitting to
r!le o!t #etastatic disease or conco#< itant e@tra<"e$atic
$ri#ary #alignancy. s"o!ld a "e$atic t!#o!r be $resent'
3lt"o!g" t"e i#aging Lndings o) t"e reci$ient "ave no
signiLcant i#$act on donor selection. $recise assess#ent
o) t"e donor liver vol!#e is cr!cial in deter#ining
&"et"er t"e donor is s!itable )or -D-( to ens!re sa)ety )or
bot" donor and reci$ient' Creo$erative i#aging is reA!ired
to ens!re t"ere is no !nderlying )ocal or di))!se liver dis<
ease t"at #ay #a5e trans$lantation !ns!itable. s!c" as
steatosis. cirr"osis. and )ocal benign or #alignant
neo$las#s'
Eor acc!rate liver vol!#e esti#ation. a good !nder<
standing o) intra"e$atic vasc!lar and biliary anato#y is
i#$ortant' So!nd 5no&ledge o) t"e s!rgical $roced!re is
reA!ired )or acc!rate eval!ation o) t"e donor liver vol!#e'
("e 5ey anato#ical variants t"at #ay $otentially inB!ence
t"e s!rgical tec"niA!es s"o!ld be "ig"lig"ted'
8
Eor
e@a#$le. ty$ical anato#y o) t"e "e$atic arterial is only seen
in 55e61O o) t"e $o$!lation' Co##on variants incl!de
re$laced le)t "e$atic artery )ro# t"e le)t gastric artery and
re$laced rig"t "e$atic artery )ro# t"e s!$erior #esenteric
artery as &ell as accessory rig"t or le)t "e$atic arteries'
9
Crecise details o) t"e vasc!lar anato#y and its associated
territories can be obtained via angiogra$"y or t"ro!g" t"e
!se o) $ersonali?ed co#$!ter analysis so)t&are. s!c" as t"e
-iver3naly?er (,eDis Distant Services. ,eDis ,edical So<
l!tions. :re#en. Fer#anyH Eig 1)'
9sing C(D t"ere is generally good correlation o) t"e
esti#ated vol!#e &it" gra)t &eig"t obtained'
10
3 st!dy by
8a5aya#a et al'
11
s"o&ed t"at t"e #ean &eig"t o) an ad!lt
liver &as 881'1 249'8 g. &"ereas t"e #ean #eas!red
vol!#e o) t"e liver &as 956'99 280'1 c#
6
'
11
Eor an ad!lt donor. a re#nant liver vol!#e o) 60O )or
t"e donor is considered to be t"e #ini#!# t"res"old
)or trans$lantation to $roceed. $roviding t"at t"ere is
no
steatosis or ot"er !nderlying liver disease'
12
S#all<)or<si?e
syndro#e occ!rs &"en t"e gra)t si?e is too s#all )or t"e
,'C' -i# et al' J Clinical Radiology 69 (2014) 887e895 889
Eig!re 1 (a) De$iction o) "e$atic vasc!lar anato#y (!sing -iver3naly?er)' >#age on t"e le)t s"o&s "e$atic arteries and $ortal veins &"ereas
i#age on t"e rig"t s"o&s t"e "e$atic veins' (b) Cro$osed resection o) t"e rig"t lobe gra)t. &"ic" incl!des t"e territory s!$$lied by t"e rig"t
#iddle "e$atic vein (!sing -iver3naly?er)' ("e esti#ated gra)t &eig"t is 717 g'
reci$ient. and #ay #ani)est in t"e )or# o) $osto$erative
c"olestasis. $oor bile $rod!ction. re)ractory ascites. and
$rolonged $rot"ro#bin ti#e' 3 #ini#!# gra)t<to<
reci$ient &eig"t ratio o) 0'8 "as been reco##ended by
so#e a!t"ors to $revent s#all<)or<si?e syndro#e. and t"e
!se o) vol!#etry calc!lator &ill "el$ to deter#ine t"e ad<
eA!acy o) t"e $otential liver gra)t'
16
0o&ever. it is i#$ortant to note t"at gra)t )!nction and
s!rvival are not only inB!enced by gra)t si?e. b!t can also
be a))ected by $re<e@isting disease in t"e donorMs liver $rior
to trans$lantation' S$eciLcally. "e$atic steatosis is a
co##on Lnding in develo$ed co!ntries and can "ave
signiLcant i#$act on s!rgical o!tco#e in t"e trans$lant' >n
t"e st!dy o)
DM3lessandro et al'
14
involving 124 donor livers )or trans<
$lantation. t"ere &as a signiLcantly "ig"er rate o) $ri#ary
non<)!nction and initial $oor )!nction in $atients &"o
&ere s"o&n to "ave received livers &it" severe "e$atic
steatosis on donor liver bio$sy. co#$ared to t"ose &"o
received
livers &it" none or lesser degrees o) "e$atic steatosis'
14
9$on identiLcation o) a $otentially steatotic liver in t"e
donor. ,R> o) t"e liver can "el$ to )!rt"er A!anti)y t"e
degree o) steatosis'
Cre<o$erative increase o) re#nant liver vol!#e
(ransarterial c"e#oe#boli?ation ((3C7) involves t"e
ad#inistration o) a c"e#ot"era$e!tic agent into t"e
"e$atic artery )ollo&ed by "e$atic artery e#boli?ation
(037)' (3C7 "as been s"o&n to be e))ective in do&nsi?ing
0CCs as t"ese t!#o!rs $re)erentially obtain t"eir blood
s!$$ly )ro# t"e "e$atic artery' =ccl!sion o) t"e "e$atic
artery res!lts in selective isc"ae#ia o) t"e t!#o!r and en<
"ances t"e cytoto@ic e))ect o) t"e c"e#ot"era$e!tic agent'
(3C7 is )reA!ently $er)or#ed be)ore CD7 in $atients &it"
0CCs to $revent t!#o!r gro&t" d!ring t"e ti#e interval o)
CD7 and sc"ed!led resection (Eig 2)'
15
>n addition. (3C7
bloc5s t"e arterio<$ortal s"!nts t"at are co##only
enco!ntered in 0CC &"ose $resence co!ld $otentially
atten!ate t"e e))ects o) CD7'
CD7 ca!ses red!ction in t"e si?e o) t"e e#boli?ed "e<
$atic lobe and "ence ind!ces co#$ensatory "y$ertro$"y
o) t"e re#nant $ortion o) t"e liver (Eig 6)' CD7 "as been
&idely regarded as an e))ective #eans to increase t"e E-R
vol!#e. $artic!larly in $atients &it" inadeA!ate re#nant
liver vol!#e &"o reA!ire #aor or e@tended "e$atec<
to#y'
16.17
("is i#$lies t"at a "ig"er $ro$ortion o) $atients
&it" $revio!sly !nresectable disease can no& beneLt
)ro# s!rgery )ollo&ing a s!ccess)!l CD7 $roced!re'
18
=t"er t"an !st increasing t"e E-R vol!#e. CD7 $er<
)or#ed $rior to resection "as been s"o&n to decrease t"e
$eri<o$erative #ortality'
19.20
("e increase in E-R a)ter CD7
#ay also be !sed )or $rognostication' 3n increase o) P5O
in E-R #ay indicate lo& ris5 )or liver )ail!re a)ter #aor
resection'
21