CT-derived liver and spleen volume accurately diagnose clinically significant portal hypertension in patients with hepatocellular carcinoma

Abstract

Background & aims: Clinically significant portal hypertension (CSPH) is a landmark in the natural history of cirrhosis, influencing clinical decisions in patients with hepatocellular carcinoma (HCC). Previous small series suggested that splanchnic volume measurements may predict portal hypertension. We aimed to evaluate whether volumetry obtained by standard multidetector computerised tomography (MDCT) can predict CSPH in patients with HCC.

Methods: We included 175 patients with HCC, referred for hepatic venous pressure gradient (HVPG) evaluation, in whom contemporary MDCT was available. Liver volume, spleen volume (SV) and liver segmental volume ratio (LSVR: volume of the segments I-III/volume of the segments IV-VIII) were calculated semi-automatically from MDCT. Other non-invasive tests (NITs) were also employed.

Results: Volume parameters could be measured in almost 100% of cases with an excellent inter-observer agreement (intraclass correlation coefficient >0.950). SV and LSVR were independently associated with CSPH (HVPG ≥10 mmHg) and did not interact with aetiology. The volume Index (VI), calculated as the product of SV and LSVR, predicted CSPH (AUC 0.83; 95% CI 0.77-0.89). Similar results were observed in an external cohort (n = 23) (AUC 0.87; 95% CI 0.69-1.00). Setting a sensitivity and specificity of 98%, VI could have avoided 35.9% of HVPG measurements. The accuracy of VI was similar to that of other NITs. VI also accurately predicted HVPG greater than 12, 14, 16 and 18 mmHg (AUC 0.81 [95% CI 0.74-0.88], 0.84 [95% CI 0.77-0.91], 0.85 [95% CI 0.77-0.92] and 0.87 [95% CI 0.79-0.94], respectively).

Conclusions: Quantification of liver and spleen volumes by MDCT is a simple, accurate and reliable method of CSPH estimation in patients with compensated cirrhosis and HCC.

Impact and implications: An increase in portal pressure strongly impacts outcomes after surgery in patients with early hepatocellular carcinoma (HCC). Direct measurement through hepatic vein catheterization remains the reference standard for portal pressure assessment, but its invasiveness limits its application. Therefore, we evaluated the ability of CT scan-based liver and spleen volume measurements to predict portal hypertension in patients with HCC. Our results indicate that the newly described index, based on quantification of liver and spleen volume, accurately predicts portal hypertension. These results suggest that a single imaging test may be used to diagnose and stage HCC, while providing an accurate estimation of portal hypertension, thus helping to stratify surgical risks.

Keywords: CSPH, clinically significant portal hypertension; DAAs, direct-acting antivirals agents; HCC, hepatocellular carcinoma; HVPG, hepatic venous pressure gradient; LSPS, liver stiffness-spleen size-to-platelet ratio score; LSVR, liver segmental volume; LV, liver volume; LV/SV, liver/spleen volume ratio; MAFLD, metabolic dysfunction-associated fatty liver disease; MDCT, multidetector computerised tomography; NITs, non-invasive tests; PSR, platelet count to spleen diameter ratio; SV, spleen volume; TE, transient elastography; VI, volume index; cirrhosis; cross-sectional imaging; hepatocellular carcinoma; non-invasive test; organ size; portal hypertension; predictive model.

Graphical abstract

Fig. 1

Patient flowchart. HCC, hepatocellular carcinoma; HVPG, hepatic venous pressure gradient; LT, liver transplantation; MDCT, multidetector computerised tomography; SV, spleen volume.

Fig. 2

Prediction of CSPH using the volume index (n = 167). (A) ROC curve and (B) calibration plot (Hosmer-Lemeshow goodness-of-fit test) for the prediction of CSPH using the volume index (n = 167). CSPH, clinically significant portal hypertension.

Fig. 3

Distribution of volume index according to the presence of CSPH (n = 167). Cut-off points of volume index (79.14 cc. and 359.48 cc) for sensitivity and specificity = 98%. CSPH, clinically significant portal hypertension.

Fig. 4

Comparison of the diagnostic accuracy for clinically significant portal hypertension of the volume index and other non-invasive measures. Diagnostic accuracy (AUC [95% CI]) of the volume index and (A) transient elastography, (B) transient elastography and platelets, (C) PSR, (D) LSPS and (E) PHRS. (DeLong test for comparing AUCs). LSPS, liver stiffness-to-spleen platelet score; PHRS, portal hypertension risk score; Pl, platelets; PSR, platelet-to-spleen ratio; TE, transient elastography; VI, volume index.