Imaging-Based Liver Function Tests – Past, Present and Future

 

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Abstract

Preoperative assessment of liver function and prediction of postoperative functional reserve are important in patients scheduled for liver resection. While determination of absolute liver function currently mostly relies on laboratory tests and clinical scores, postoperative remnant liver function is estimated volumetrically using imaging data obtained with computed tomography (CT) or magnetic resonance imaging (MRI). Accurate estimation of hepatic function is also relevant for intensive care patients, oncologic patients, and patients with diffuse liver disease. The indocyanine green (ICG) test is still the only established test for estimating true global liver function. However, more recent tools such as the LiMAx test also allow global assessment of hepatic function. These tests are limited when liver function is inhomogeneously distributed, which is the case in such conditions as unilateral cholestasis or after portal vein embolization. Imaging-based liver function tests were first developed in nuclear medicine and, compared with laboratory tests, have the advantage of displaying the spatial distribution of liver function. Nuclear medicine scans are obtained using tracers such as 99mTc galactosyl and 99mTc mebrofenin. Liver function is typically assessed using planar scintigraphy. However, three-dimensional volumetry is possible with single-photon emission computed tomography (SPECT-CT). Another technique for image-based liver function estimation is Gd-EOB-enhanced MRI. While metabolization of Gd-EOB in the body is similar to that of ICG and mebrofenin, its distribution in the liver can be displayed by MRI with higher temporal and spatial resolution. Moreover, MRI-based determination of liver function can be integrated into routine preoperative imaging. This makes MRI an ideal candidate for preoperative determination of liver function, though the best pulse sequence and the parameter to be derived from the image information remain to be identified. Another question to be answered is how the results may be affected by renal function and the presence of hyperbilirubinemia. As more results from clinical evaluation including comparison with postoperative liver function data become available, image-based liver function tests, especially with use of Gd-EOB as the contrast medium, have the potential to add another dimension to preoperative imaging.

Key Points:

• Liver function consists of a multitude of subfunctions such as biotransformation, excretion and storage.

• Global liver function tests are score-based tests such as Child-Pugh or MELD as well as the ICG- and LiMAx-test.

• Imaging-based liver function tests add spatial information. Current clinical standard is the 99mTc-Mebrofenin-scintigraphy.

• MRI-based function tests with Gd-EOB-DTPA have the potential to integrate seamlessly into clinical workup, feature a higher temporal and spatial resolution and do not rely on ionizing radiation.

Citation Format:

• Geisel D, Lüdemann L, Hamm B et al. Imaging-Based Liver Function Tests – Past, Present and Future. Fortschr Röntgenstr 2015; 187: 863 – 871

Zusammenfassung

Die Bestimmung der Leberfunktion und die Abschätzung der postoperativen Leberfunktion spielt insbesondere vor leberresezierenden Eingriffen eine große Rolle. Zur Bestimmung der absoluten Funktion werden gegenwärtig überwiegend laborchemische Parameter bzw. klinische Scores angewandt, die Abschätzung der postoperativen Funktion erfolgt dann über eine Volumetrie anhand von CT oder MRT-Daten. Auch in der Intensivmedizin, der Onkologie oder bei diffusen Lebererkrankungen hat die Bestimmung der Leberfunktion eine Relevanz. Als echter globaler Leberfunktionstest konnte sich bisher nur der ICG-Test durchsetzen, neuere Entwicklungen wie beispielsweise der LiMAx-Test können ebenfalls die Gesamtkapazität der Leberfunktion abschätzen. An ihre Grenzen kommen diese Methoden bei einer inhomogenen Funktionsverteilung wie beispielsweise bei einer einseitigen Cholestase oder nach einer Pfortaderembolisation. Bildgestützte Leberfunktionstests stammen ursprünglich aus der Nuklearmedizin und haben gegenüber laborchemischen Tests den Vorteil, dass die räumliche Verteilung der Leberfunktion mitabgebildet werden kann. Als nuklearmedizinische Tracer stehen 99mTc-Galaktosyl und 99mTc-Mebrofenin zur Verfügung, überwiegend erfolgt die Darstellung mittels planarer Szintigraphie, jedoch ist auch eine dreidimensionale Messung mittels SPECT-CT möglich. Eine weitere Möglichkeit zur bildgestützten Leberfunktionsmessung ist das Gd-EOB-verstärkte MRT. Gd-EOB wird vergleichbar zur ICG und Mebrofenin verstoffwechselt, lässt sich aber durch die MRT zeitlich und räumlich höher aufgelöst darstellen und in die präoperative Routinebildgebung integrieren. Dies prädestiniert es zur Evaluation der Leberfunktion, jedoch muss die optimale Sequenz und der hieraus abgeleitete Parameter noch gefunden werden. Offene Fragen bestehen darüber hinaus im Einfluß der Nierenfunktion und einer Hyperbilirubinämie. Mit zunehmender klinischer Evaluierung und dem Vergleich mit postoperativen Funktionsdaten haben bildgestützte Leberfunktionstests, insbesondere mit Gd-EOB, das Potential, die präoperative Bildgebung um eine weitere Dimension zu bereichern.

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