99mTc-GSA SPECT Research Articles

Indocyanine green plasma clearance rate and 99mTc-galactosyl human serum albumin single-photon emission computed tomography evaluated preoperative remnant liver.

BACKGROUNDPreoperative evaluation of future remnant liver reserves is important for safe hepatectomy. If the remnant is small, preoperative portal vein embolization (PVE) is useful. Liver volume analysis has been the primary method of preoperative evaluation, although functional examination may be more accurate. We have used the functional evaluation liver using the indocyanine green plasma clearance rate (KICG) and 99mTc-galactosyl human serum albumin single-photon emission computed tomography (99mTc-GSA SPECT) for safe hepatectomy.AIMTo analyze the safety of our institution’s system for evaluating the remnant liver reserve.METHODSWe retrospectively reviewed the records of 23 patients who underwent preoperative PVE. Two types of remnant liver KICG were defined as follows: Anatomical volume remnant KICG (a-rem-KICG), determined as the remnant liver anatomical volume rate × KICG; and functional volume remnant KICG (f-rem-KICG), determined as the remnant liver functional volume rate based on 99mTc-GSA SPECT × KICG. If either of the remnant liver KICGs were > 0.05, a hepatectomy was performed. Perioperative factors were analyzed. We defined the marginal group as patients with a-rem-KICG of < 0.05 and a f-rem-KICG of > 0.05 and compared the postoperative outcomes between the marginal and not marginal (both a-rem-KICG and f-rem-KICG > 0.05) groups.RESULTSAll 23 patients underwent planned hepatectomies. Right hepatectomy, right trisectionectomy and left trisectionectomy were in 16, 6 and 1 cases, respectively. The mean of blood loss and operative time were 576 mL and 474 min, respectively. The increased amount of f-rem-KICG was significantly larger than that of a-rem-KICG after PVE (0.034 vs 0.012, P = 0.0273). The not marginal and marginal groups had 17 (73.9%) and 6 (26.1%) patients, respectively. The complications of Clavian-Dindo classification grade II or higher and post-hepatectomy liver failure were observed in six (26.1%) and one (grade A, 4.3%) patient, respectively. The 90-d mortality was zero. The marginal group had no significant difference in postoperative outcomes (prothrombin time/international normalised ratio, total bilirubin, complication, post-hepatectomy liver failure, hospital stay, 90-d, and mortality) compared with the not-marginal group.CONCLUSIONFunctional evaluation of the remnant liver enabled safe hepatectomy and may extend the indication for hepatectomy after PVE treatment.

Validation of liver function and prediction scoring system

Introduction: Liver resection is performed for a variety of benign and malignant conditions. Despite advances in preoperative selection, surgical technique and perioperative management, posthepatectomy liver failure (PHLF) is still a leading cause of morbidity and mortality following liver resection. To avoid PHLF, we used various examination such as ICGR15, KICG, and estimated ICGR15 and KICG which are estimated by 99mTc-GSA SPECT, and functional liver volume estimated by 99mTc-GSA SPECT/MDCT fusion image, and used various prediction scoring system such as Makuuchi’s criteria, Prediction Score made by Hyogo college of medicine (PS), and Indocyanine green clearance of the future remnant liver (remKICG). The present study aimed to identify the risk factors for PHLF and validate these prediction formulas. Method: 329 patients who underwent hepatectomy without extrahepatic bile duct resection were retrospectively analyzed. Among 329 patients, major hepatectomy was performed in 79 patients (24%). Grade B and C PHLF based on ISGLS definition occurred in 11 patients (3.3%). Univariate and multivariate analyses were performed to identify the risk factors for PHLF. Result: The functional resection volume rate estimated by 99mTc-GSA SPECT/MDCT fusion image (%FRV), direct bilirubin and KICG were the risk factors according to multivariate analysis. Functional remKICG calculated by using %FRV and KICG which were obtained by multivariate analysis, had a sensitivity of 18.2%, a specificity of 100%, a positive prediction value of 100%, and a negative prediction value of 97.2%. Conclusion: %FRV, Direct bilirubin and KICG were the risk factor for PHLF. Functional remKICG was considered the most reliable prediction formula.

The assessment of functional remnant liver rate for the hepatectomy based on the fusion image of 3DCT and 99mTc-GSA SPECT

Introduction: Preoperative assessment of future remnant liver (FRL) function is critical for major hepatectomy to avoid postoperative liver failure (PLF).Indocyanine green clearance of the FRL (Krem), which is calculated as the ratio of FRL volume to total liver volume by CT, is reliable index for estimating PLF and its threshold is 0.05. However, Krem assumes homogenous uptake throughout the liver.For damaged livers with functional heterogeneity, fusion images combining 99mTc-GSA SPECT and 3D-CT are helpful to estimate the functional reserve of the FRL. Our aim was to determine the utility of functional Krem (F-Krem) by comparing volumetric Krem (V-Krem). Methods: Between July 2015 to December 2017, 45 patients received preoperative dynamic CT and 99mTc-GSA SPECT and underwent major hepatectomy. We constructed fusion image of 3D-CT and 99mTc-GSA SPECT. V-Krem by CT volumetry and F-Krem by fusion image were compared in each patient to estimate which is more reliable. Results: In 88.9% of the patients, F-Krem was bigger than V-Krem (Figure). The ratio of F-Krem/V-Krem (F/V) was 1.116±0.12 (mean±SD). In the patients with portal vein occlusion (PVO) or large tumor (LT) of 500ml or more, F/V ratio was significantly bigger than that of the other patients: 1.181±0.082 (n=8, PVO)vs.1.097±0.118 (n=37, non-PVO), 1.306±0.174 (n=4,LT)vs.1.11±0.097 (n=41, non-LT), (p=0.01, respectively). There were significantly correlation between F-Krem and postoperative-parameters (T-Bil and platelets counts in POD1,3,7). In 5 patients with V-Krem less than 0.05,a patient had F-Krem more than 0.05, resulting in good post-operative course. Conclusion: In almost patients who need major hepatectomy, F-Krem is bigger than V-Krem, because liver function of the diseased side is impaired compared with residual side. F-Krem is a more reliable index than V-Krem.

ICG Clearance Test and 99mTc-GSA SPECT/CT Fusion Images

Preoperative estimation of future remnant liver function is critical for major hepatic surgery to avoid postoperative morbidity and mortality. Among several liver function tests, the indocyanine green (ICG) clearance test is still the most popular dynamic method. The usefulness of ICG clearance test parameters, such as ICGR15, K_ICG, or PDR_ICG, has been reported by many investigators. The transcutaneous non-invasive pulse dye densitometry system has made the ICG clearance test more convenient and attractive, even in Western countries. The concept of future remnant K_ICG (rem K_ICG), which combines the functional aspect and the volumetric factor of the future remnant liver, seems ideal for determining the maximum extent of major hepatic resection that will not cause postoperative liver failure. For damaged livers with functional heterogeneity among the hepatic segments, fusion images combining technetium-99m-diethylenetriaminepentaacetic acid-galactosyl human serum albumin single photon emission computed tomography (99mTc-GSA SPECT) and X-ray CT are helpful to precisely estimate the functional reserve of the future remnant liver. Another technique for image-based liver function estimation, gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid(Gd-EOB)-enhanced magnetic resonance imaging, may be an ideal candidate for the preoperative determination of future remnant liver function. Using these methods effectively, morbidity and mortality after major hepatic resection could be reduced.

Assessment of liver function by 99mTc-GSA SPECT scintigraphy after laparoscopic liver resection

Assessment of liver function by 99mTc-GSA SPECT scintigraphy after laparoscopic liver resection

Quantitative Analysis for Assessing the Post Therapeutic Hepatic Function Reserve by Using 99mTc-GSA SPECT

Quantitative Analysis for Assessing the Post Therapeutic Hepatic Function Reserve by Using 99mTc-GSA SPECT

99mTc-GSA SPECT analysis was clinically useful to evaluate the effect of interferon in a patient with interferon non-responsive chronic hepatitis C

We describe a 62-year-old woman with advanced chronic hepatitis C who showed no response to low-dose long-term interferon-beta monotherapy (3MU, three times a week). The interferon monotherapy was continued for 2years and 9months. Despite this lack of response to interferon, the patient's clinical course was good and liver function assessed by (99m)Tc-galactosyl human serum albumin single photon emission computed tomography ((99m)Tc-GSA SPECT) analysis improved significantly. Improvement of the data obtained by (99m)Tc-GSA SPECT analysis justified continuation of the treatment. (99m)Tc-GSA SPECT analysis was clinically useful to evaluate the effect of interferon in a patient with interferon non-responsive chronic hepatitis C, despite a lack of reduction of the ALT level and HCV-RNA titer.

Predictive value of Tc-99m galactosyl human serum albumin liver SPECT on the assessment of functional recovery after partial hepatectomy: a comparison with CT volumetry

Predicting liver functional reserve is important before partial hepatectomy. However, it is difficult to predict using morphologic imaging modalities, such as CT and MRI. In this study, we assess the usefulness of galactosyl human serum albumin (GSA) scintigraphy in predicting liver function recovery. We performed 99mTc-GSA scintigraphy before operation in 56 patients. Each patient was administered 185 MBq of 99mTc-GSA by intravenous injection. Serial images were taken immediately after the administration for 40 min. SPECT images were obtained to make a functional map. We calculated the functioning parameter residual GSA-Rmax (GSA-RL) using analysis software developed by Dr.N. Shuke. In addition, we compared GSA-RL with the morphological parameter residual liver volume (RLV-CT) calculated by conventional CT and serum albumin (Alb) or cholinesterase (ChE). We analyzed the correlation between imaging parameters and the postoperative recovery periods of serum albumin (r-Alb) and cholinesterase (r-ChE) and the values at 1 and 3 months for serum albumin (1M-Alb, 3M-Alb) and cholinesterase (1M-ChE, 3M-ChE). We found significant correlations between GSARL and r-Alb, r-ChE, 1M-Alb, 3M-Alb, 1M-ChE and 3M-ChE, but not between RLV-CT and the same parameters. The GSA-RL calculated by 99mTc GSASPECT was a useful parameter for predicting postoperative liver function recovery that should be implemented before partial hepatectomy.

99mTc-GSA Scintigraphy with SPECT for Assessment of Hepatic Function and Functional Volume During Liver Regeneration in a Rat Model of Partial Hepatectomy

Small-animal models are crucial to gain insights in the complex recovery mechanisms of liver function during liver regeneration. (99m)Tc-Mebrofenin hepatobiliary scintigraphy (HBS) has been introduced for noninvasive assessment of liver function in the clinical setting as well as in experimental research. However, HBS is restricted to planar modalities in small animals because hepatic kinetics are generally too fast for SPECT acquisition. (99m)Tc-DTPA-galactosyl serum albumin (where DTPA is diethylenetriaminepentaacetic acid) ((99m)Tc-GSA) scintigraphy is an alternative, receptor-mediated, noninvasive liver function test. After hepatic uptake, (99m)Tc-GSA remains trapped in the liver, which readily enables additional SPECT for the assessment of both liver function and liver functional volume within one test. In this study we evaluated the use of (99m)Tc-GSA scintigraphy combined with SPECT for the assessment of liver function and liver functional volume in normal and regenerating rat livers. The reproducibility of (99m)Tc-GSA scintigraphy and SPECT was investigated by repeated measurements within the same rat. For the assessment in a regenerating liver, (99m)Tc-GSA scintigraphy with SPECT was performed on 1, 3, 5, and 7 d (n = 6 rats per time point) after 70% partial hepatectomy (PH). The correlation between repeated (99m)Tc-GSA measurements was strong (r = 0.75, P = 0.019). In normal rat livers, there was a strong, significant correlation between liver functional volume and conventional liver volume (r = 0.93; < 0.0001). The correlation between (99m)Tc-GSA uptake and liver volume was moderate (r = 0.62, P = 0.043). During the regeneration process, (99m)Tc-GSA uptake was significantly lower compared with both liver volume (P < 0.001) and liver functional volume (P < 0.001), when expressed as a percentage of baseline levels. There was a strong correlation between liver functional volume and conventional liver volume in the regenerating liver (r = 0.92, P < 0.0001). (99m)Tc-GSA scintigraphy combined with SPECT is a feasible, noninvasive method to assess hepatic functional volume in normal rat liver as well as in the regenerating rat liver. However, the hepatic (99m)Tc-GSA uptake as a liver function test seems to underestimate hepatic regeneration in comparison to liver volume.

Separate analysis of asialoglycoprotein receptors in the right and left hepatic lobes using 99mTc-GSA SPECT in patients with acute hepatic damage

The asialoglycoprotein receptor (ASGPR) is abundantly expressed on the sinusoidal surfaces of hepatocytes. However, regional expression and clinical significance of the ASGPR in acute hepatic damage is presently unknown. Our aim was to clarify the clinical significance of the regional expression of ASGPR in human livers with acute hepatitis (AH) and fulminant hepatic failure (FHF). Eighteen volunteers, 42 patients with AH and 10 with FHF were studied using a newly developed, conventional (99m)Tc-GSA SPECT analysis. Using Cantlie's line as a guide, ASGPR expression was analyzed separately in the right and left hepatic lobes, as well as in the whole liver, using novel indices (the liver uptake ratio [LUR] and liver uptake density [LUD], which reflect the amount and density of ASGPRs in the liver, respectively). Mean LUR and LUD values for the whole liver and the right and left lobes decreased in accordance with the severity of acute hepatic damage. In the FHF group, the reduction in LUR and LUD values in the right lobes was more significant than in the left lobes. The LUR and LUD values for the whole liver correlated well with hepatic functional reserve and total bilirubin levels. The right LUR and LUD values in particular correlated well with these parameters. A time-course observation of 13 patients with either AH or FHF revealed that the expression of ASGPRs in the right lobe recovered faster than in the left. We first evaluated the regional expression of AGSPRs by (99m)Tc-GSA SPECT analysis in both AH and FHF patients, which is a clinically useful and reliable indicator for assessing the severity of regional hepatic damage and evaluating regional liver regeneration.

Quantitative analysis for assessing regional function of liver by using 99mTc-GSA SPECT.

In the present study, we developed quantitative index for evaluating regional liver function using 99mTc diethylenetriamine-pentaacetic acid galactosyl human serum albumin (GSA). A three head SPECT equipped with a low energy high resolution parallel hole collimator was used. Used pre-filter was Butterworth and axial images were reconstructed by a ramp filter without attenuation correction. Correlation between SPECT counts and net concentration of activity of radioisotopes was evaluated in basic consideration using LKS and Nine-Ball phantoms. SPECT Counts = 0.6 x RI concentration. There was a simple correlation among GSA receptor amounts (Cr), injected GSA amounts (S), free GSA amounts (Cf), and intra hepatic receptor ratio ((Cr ratio)). Cr = S - Cf. (Cr ratio) = Cr/S, 0 < (Cr ratio) < 1. Injected GSA amounts can be calculated from injected net RI counts. Free GSA amounts can be evaluated from counts of the heart. GSA receptor amounts can be assumed by performing SPECT three times in series. Regional GSA receptor amounts can be evaluated from the ratio between the region's counts and whole counts. In clinical SPECT images, we could evaluate the regional GSA receptor amounts before and after chemolipiodolization. In conclusion, our method is a simple quantitative index of analyzing regional GSA receptor amounts.

Evaluation of preoperative portal embolization for safe hepatectomy, with special reference to assessment of nonembolized lobe function with 99mTc-GSA SPECT scintigraphy

Background. Preoperative portal embolization (PE) is used to stimulate liver hypertrophy in the nonembolized lobe. We studied liver volume and function with computed tomography and technetium-99m-galactosyl human serum albumin (99mTc-GSA) scintigraphy before PE and at 1 or 2 weeks after PE. Methods. Right PE was performed in 30 patients. Morphologic and functional hypertrophy in the left lobe after PE was determined and related to the presence or absence of cholestasis, biliary drainage of the embolized lobe, and postoperative liver failure. Results. The volume of the left lobe and 99mTc-GSA uptake increased rapidly for the first week after PE, but no significant increase was seen during the second week. Morphologic hypertrophy was less pronounced in patients with jaundice (P =.03). When PE was performed at a total bilirubin level above 2 mg/dL, the interval between PE and surgery was prolonged because of cholangitis and liver abscess formation. The net morphologic hypertrophy ratio was significantly higher in livers that had undergone left lobe drainage only (9.1% ± 0.9%) compared with those in which there was drainage of the embolized lobes (5.7% ± 0.9%; P =.03). The volume and 99mTc-GSA uptake of the left lobe in the second week after PE was significantly smaller in patients with postoperative liver failure (33.7% ± 2.4% and 18.0% ± 2.1%, respectively) than in patients without liver failure (46.2% ± 1.4% and 38.4% ± 2.3%; P =.003 and P =.01, respectively). Conclusion. In the nonembolized lobe, the functional increase in 99mTc-GSA uptake is more pronounced than suggested by the degree of morphologic hypertrophy. Whenever possible, biliary drainage should not be performed in the lobe undergoing hepatectomy. 99mTc-GSA SPECT scintigraphy is useful for the evaluation of postoperative liver failure. (Surgery 2003;133:495-506.)