Volume–Function Analysis (LiMAx Test) in Patients with HCC and Cirrhosis Undergoing TACE—A Feasibility Study

Abstract

Background Transarterial chemoembolization (TACE) is an important therapy for hepatocellular carcinoma (HCC) in cirrhosis. In particular in advanced cirrhosis, post-TACE hepatic failure liver (PTHF) failure may develop. Currently, there is no standardization for the periinterventional risk assessment. The liver maximum capacity (LiMAx) test assesses the functional liver capacity, but has not been investigated in this setting. Aims The aim of this study was to prospectively evaluate periinterventional LiMAx and CT volumetry measurements in patients with cirrhosis and HCC undergoing repetitive TACE. Methods From 06/2016 to 11/2017, eleven patients with HCC and cirrhosis undergoing TACE were included. LiMAx measurements (n = 42) were conducted before and after each TACE. Laboratory parameters were correlated with the volume-function data. Results The median LiMAx levels before (276 ± 166 µg/kg/h) were slightly reduced after TACE (251 ± 122 µg/kg/h; p = 0.08). This corresponded to a median drop of 7.1%. Notably, there was a significant correlation between LiMAx levels before TACE and bilirubin (but not albumin nor albumin-bilirubin [ALBI] score) increase after TACE (p = 0.02, k = 0.56). Furthermore, a significantly higher increase in bilirubin in patients with LiMAx ≤ 150 µg/kg/h was observed (p = 0.011). LiMAx levels at different time points in single patients were similar (p = 0.2). Conclusion In our prospective pilot study in patients with HCC and cirrhosis undergoing multiple TACE, robust and reliable LiMAx measurements were demonstrated. Lower LiMAx levels before TACE were associated with surrogate markers (bilirubin) of liver failure after TACE. Specific subgroups at high risk of PTHF should be investigated. This might facilitate the future development of strategies to prevent occurrence of PTHF.

LiMAx Prior to Radioembolization for Hepatocellular Carcinoma as an Additional Tool for Patient Selection in Patients with Liver Cirrhosis

“…Recently, LiMAx ® was also investigated as an additional tool for patient selection prior to transjugular intrahepatic portosystemic shunt implantation [ 28 ]. In HCC patients, LiMAx ® has shown promising results in assessing liver function after TACE and was more accurate than the Child–Pugh score [ 12 , 13 ].…”

“…Similar findings were derived from a prospective study, where LiMAx ® was evaluated as an additional tool to predict the risk of hepatic failure caused by TACE. The authors reported that lower LiMAx ® values at baseline (<150 µg/kg/h) were associated with a significant increase in serum bilirubin levels after TACE [ 12 ]. This shows that the LiMAx ® measurement could predict even a minor deterioration in liver function due to locoregional therapy.…”

“…In a recently published prospective study, LiMAx ® was evaluated as an additional tool to predict the risk of hepatic failure related to TACE. The authors reported that lower LiMAx ® values at baseline (<150 µg/kg/h), representative of impaired liver synthesis function, were associated with a significant increase in serum bilirubin levels after TACE [ 12 ]. In another study, a considerable decrease in LiMAx ® could be observed one day after TACE, especially in patients with lower liver volume [ 13 ].…”

Liver Function—How to Screen and to Diagnose: Insights from Personal Experiences, Controlled Clinical Studies and Future Perspectives

“…Therefore, an adequate selection of patients suitable for a certain intervention is of fundamental importance. The LiMAx test was able to estimate prognosis with regard to liver surgery, transjugular intrahepatic portosystemic shunt (TIPS) or liver cancer therapies such as transarterial chemotherapy (TACE) or selective intra-arterial radiotherapy (SIRT; unpublished data) and decline from patients who will not benefit from these procedures [ 83 , 96 , 97 , 98 , 99 , 100 , 101 ]. However, it is not only possible to individually decide whether a certain intervention is possible but also to determine an appropriate timepoint.…”

Evaluation of liver function before and during therapy

“…Current investigations could demonstrate reliable and reproducible results for LiMAx measurements in detecting changes in liver function, even with regard to modulations caused by superselective procedures. Enzymatic liver function measured by the LiMAx test was superior to biochemical parameters and conventional scoring systems such as CPS or ALBI score, which were less specific in providing sufficient information on cellular dysfunction [18,19] . In conclusion, various modalities for the treatment of patients with HCC have become available over the last decades.…”