Eligibility Assessment for Hepatic Resection in Primary and Metastatic Liver Tumors
Hepatic resection eligibility is determined by a combined oncologic resectability assessment and a multidimensional liver function/reserve assessment that includes liver function, portal hypertension, expected future liver remnant (FLR), and planned extent of resection. EASL 2018 HCC Guideline
For patients with underlying liver disease, preoperative assessment should be performed using standardized volume-based and functional criteria, often with a stepwise risk-stratification framework integrating FLR, portal hypertension measures, and functional testing. Innsbruck Preoperative Liver Function Assessment Consensus
Preoperative Clinical and Laboratory Assessment
Performance status and comorbidities are incorporated into the surgical candidacy decision. EASL 2018 HCC Guideline
Routine blood-based liver function and portal hypertension–related surrogates are used to identify patients at risk for clinically relevant post-hepatectomy liver failure (PHLF). Innsbruck Preoperative Liver Function Assessment Consensus
Non-tumoral liver biopsy is not recommended routinely as part of preoperative functional assessment because it is not an adequate test for preoperative liver function. Innsbruck Preoperative Liver Function Assessment Consensus
Imaging Modalities for Tumor Staging and Resectability Mapping
Primary lesion mapping and response assessment
Multiphasic contrast-enhanced CT or MRI is recommended to assess response after resection and after loco-regional or systemic therapies in HCC workflows. EASL 2018 HCC Guideline
Operative planning for primary and metastatic disease
For colorectal liver metastases (CLM), preoperative imaging is used to characterize:
- Number and distribution of intrahepatic lesions
- Tumor burden and locations within the liver
- Extrahepatic disease and peritoneal/pelvic metastases when relevant to surgical planning
[1]
Multiphasic cross-sectional imaging is the mainstay for staging and resection planning, with multiparametric MRI having higher sensitivity than CT for detecting and characterizing focal liver lesions in CLM. [2]
Intrahepatic anatomy confirmation
Intraoperative ultrasound is used to confirm preoperative findings and to detect previously undiagnosed lesions, supporting safe resection planning. [1]
Functional Liver Reserve Framework
Volumetry of the FLR is the foundation of risk assessment in preoperative liver function evaluation. [3]
Functional assessment is recommended when the FLR is borderline, when underlying liver disease is suspected, or when surgery is complex, using one of several available functional tests (often combined with FLR volumetry). Innsbruck Preoperative Liver Function Assessment Consensus
Functional Testing Modalities Used to Estimate Hepatic Reserve
Indocyanine green (ICG)
ICG clearance is used as a functional assessment method that can be combined with FLR volumetry for estimating remnant functional capacity. Innsbruck Preoperative Liver Function Assessment Consensus
Hepatocyte-function MRI with hepatobiliary contrast agents
Functional MRI using hepatocyte-specific hepatobiliary contrast media (eg, gadoxetic acid) is considered to provide estimation of FLR function and to improve prediction of PHLF. Innsbruck Preoperative Liver Function Assessment Consensus
Nuclear medicine scintigraphy
- ^99mTc-labeled galactosyl human serum albumin (GSA) scintigraphy and ^99mTc-labeled mebrofenin scintigraphy (including SPECT/CT approaches) are used as functional liver assessment methods. Innsbruck Preoperative Liver Function Assessment Consensus
- These modalities can provide functional assessment integrated with volumetric information for FLR risk stratification. Innsbruck Preoperative Liver Function Assessment Consensus
LiMAx® (metabolism-based functional test)
LiMAx® is used to estimate overall liver function and should be combined with volumetry to estimate remnant liver function. Innsbruck Preoperative Liver Function Assessment Consensus
Hepatic venous pressure gradient (HVPG)
HVPG measurement can be considered in selected patients with cirrhosis when scheduled for liver resection. Innsbruck Preoperative Liver Function Assessment Consensus
Functional Liver Reserve Criteria Used for Eligibility Decisions
Portal hypertension thresholds
Significant portal hypertension is defined within the consensus framework using:
- Liver stiffness measurement (LSM) > 25 kPa and/or
- HVPG ≥ 10 mmHg
Innsbruck Preoperative Liver Function Assessment Consensus
In the presence of significant portal hypertension, non-surgical strategies or transplant should be considered. Innsbruck Preoperative Liver Function Assessment Consensus
FLR thresholds by expected remnant capacity
Within the consensus clinical algorithm, eligibility is operationalized with FLR thresholds combined with qualitative/quantitative assessment of function:
- Proceed with surgery when:
- FLR ≥ 40% and adequate function, or
- FLR ≥ 30% with mild dysfunction, or
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FLR 20–30% with adequate function
Innsbruck Preoperative Liver Function Assessment Consensus -
Consider risk-mitigation/augmentation strategies when intermediate risk is present:
-
Clinically relevant PHLF (CR-PHLF) risk is in the intermediate range (CR-PHLF ≥ 3 to 5%)
Innsbruck Preoperative Liver Function Assessment Consensus -
Consider non-surgical treatment or transplant when high portal hypertension physiology and/or high-risk stratification is present within the framework:
- Significant portal hypertension (LSM > 25 kPa or HVPG ≥ 10 mmHg)
- High CR-PHLF risk (CR-PHLF ≤ 40%) as shown in the algorithm figure
Innsbruck Preoperative Liver Function Assessment Consensus
Stepwise Preoperative Assessment Algorithm Used in Practice-Oriented Workflows
A stepwise approach is applied:
- Determine FLR volume from imaging. Innsbruck Preoperative Liver Function Assessment Consensus
- Screen for portal hypertension using LSM and/or HVPG when indicated by underlying liver disease context. Innsbruck Preoperative Liver Function Assessment Consensus
- Add functional testing when FLR is borderline or when underlying liver dysfunction is suspected, using ICG, LiMAx®, hepatobiliary MRI, liver scintigraphy, or other locally available modalities. Innsbruck Preoperative Liver Function Assessment Consensus
- Combine these results with planned extent of hepatectomy and overall patient risk tolerance for the final eligibility decision. EASL 2018 HCC Guideline