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Background: Existing studies suggest a positive correlation between high compliance with enhanced recovery programs (ERP) and improved outcomes. While individual outcome measures have advantages, composite benchmarks, such as textbook outcome (TO), offer a more comprehensive assessment of healthcare performance. Given the link between ERP and postoperative outcomes, this study aims to investigate the impact of ERP on TO attainment after liver surgery (LS)., Methods: A prospective multicenter cohort of patients undergoing LS and exposed to ERP from 2016 to 2022 in France was analyzed. The primary outcome was to compare the rates of TO achieved between patients with high ERP compliance (>70%) and those with low ERP compliance (<70%) after LS., Results: A total of 706 patients were included in the study, and 217 (30.7%) achieved TO: 170 patients with high ERP compliance (24%) versus 47 patients (6.6%) with low ERP compliance attained TO (p < 0.001). High ERP compliance was associated to an increased likelihood of achieving TO [odds ratio (OR) = 1.49 (95% CI: 1.01, 2.24); p = 0.049], while cholangiocarcinoma [OR = 0.11 (95% CI: 0.02, 0.39); p = 0.003], high complexity LS [OR = 0.22 (95% CI: 0.13, 0.36); p < 0.001], intraoperative hypotension requiring vasopressors [OR = 0.29 (95% CI: 0.10, 0.68); p = 0.010], and post-operative ileus [OR = 0.08 (95% CI: 0.00, 0.37); p = 0.013] were negatively associated to the likelihood of achieving TO., Conclusions: Patients with high ERP compliance after LS experience elevated rates of TO, compared to those with low ERP compliance., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Objectives: To evaluate if preoperative MRI can predict the most frequent HCC subtypes in North American and European patients treated with surgical resection., Methods: A total of 119 HCCs in 97 patients were included in the North American group and 191 HCCs in 176 patients were included in the European group. Lesion subtyping was based on morphologic features and immuno-histopathological analysis. Two radiologists reviewed preoperative MRI and evaluated the presence of imaging features including LI-RADS major and ancillary features to identify clinical, biologic, and imaging features associated with the main HCC subtypes., Results: Sixty-four percent of HCCs were conventional. The most frequent subtypes were macrotrabecular-massive (MTM-15%) and steatohepatitic (13%). Necrosis (OR = 3.32; 95% CI: 1.39, 7.89; p = .0064) and observation size (OR = 1.011; 95% CI: 1.0022, 1.019; p = .014) were independent predictors of MTM-HCC. Fat in mass (OR = 15.07; 95% CI: 6.57, 34.57; p < .0001), tumor size (OR = 0.97; 95% CI: 0.96, 0.99; p = .0037), and absence of chronic HCV infection (OR = 0.24; 95% CI: 0.084, 0.67; p = .0068) were independent predictors of steatohepatitic HCC. Independent predictors of conventional HCCs were viral C hepatitis (OR = 3.20; 95% CI: 1.62, 6.34; p = .0008), absence of fat (OR = 0.25; 95% CI: 0.12, 0.52; p = .0002), absence of tumor in vein (OR = 0.34; 95% CI: 0.13, 0.84; p = .020), and higher tumor-to-liver ADC ratio (OR = 1.96; 95% CI: 1.14, 3.35; p = .014) CONCLUSION: MRI is useful in predicting the most frequent HCC subtypes even in cohorts with different distributions of liver disease etiologies and tumor subtypes which might have future treatment and management implications., Key Points: • Representation of both liver disease etiologies and HCC subtypes differed between the North American and European cohorts of patients. • Retrospective two-center study showed that liver MRI is useful in predicting the most frequent HCC subtypes., (© 2022. The Author(s), under exclusive licence to European Society of Radiology.)

Objectives: To compare the performance of the quantitative analysis of the hepatobiliary phase (HBP) tumor enhancement in gadobenate dimeglumine (Gd-BOPTA)-enhanced MRI and of dual-tracer 18F-FDG and 18F-fluorocholine (FCH) PET/CT for the prediction of tumor aggressiveness and recurrence-free survival (RFS) in resectable hepatocellular carcinoma (HCC)., Methods: This retrospective, IRB approved study included 32 patients with 35 surgically proven HCCs. All patients underwent Gd-BOPTA-enhanced MRI including delayed HBP images, 18F-FDG PET/CT, and (for 29/32 patients) 18F-FCH PET/CT during the 2 months prior to surgery. For each lesion, the lesion-to-liver contrast enhancement ratio (LLCER) on MRI HBP images and the SUV max tumor-to-liver ratio (SUV T/L ) for both tracers were calculated. Their predictive value for aggressive pathological features-including the histological grade and microvascular invasion (MVI)-and RFS were analyzed and compared using area under receiver operating characteristic (AUROC) curves and Cox regression models, respectively., Results: The AUROCs for the identification of aggressive HCCs on pathology with LLCER, 18F-FDG SUV T/L , and 18F-FCH SUV T/L were 0.92 (95% CI 0.78, 0.98), 0.89 (95% CI 0.74, 0.97; p = 0.70), and 0.64 (95% CI 0.45, 0.80; p = 0.035). At multivariate Cox regression analysis, LLCER was identified as an independent predictor of RFS (HR (95% CI) = 0.91 (0.84, 0.99), p = 0.022). LLCER - 4.72% or less also accurately predicted moderate-poor differentiation grade (Se = 100%, Sp = 92.9%) and MVI (Se = 93.3%, Sp = 60%) and identified patients with poor RFS after surgical resection (p = 0.030)., Conclusions: HBP tumor enhancement after Gd-BOPTA injection may help identify aggressive HCC pathological features, and patients with reduced recurrence-free survival after surgical resection., Key Points: • In patients with resectable HCC, the quantitative analysis of the HBP tumor enhancement in Gd-BOPTA-enhanced MRI (LLCER) accurately identifies moderately-poorly differentiated and/or MVI-positive HCCs. • After surgical resection for HCC, patients with LLCER - 4.72% or less had significantly poorer recurrence-free survival than patients with LLCER superior to - 4.72%. • Gd-BOPTA-enhanced MRI with delayed HBP images may be suggested as part of pre-surgery workup in patients with resectable HCC.

Purpose: This study was conducted in order to evaluate if iso- or hyperintensity of HCAs on HBP is systematically related to a high uptake of hepatospecific contrast agent, using a quantitative approach., Methods: This bicentric retrospective study included all patients with histologically confirmed and subtyped HCA from 2009 to 2017 who underwent MRI with HBP after Gd-BOPTA injection and who showed iso- or hyperintensity on HBP. The signal intensity of tumors on pre- and postcontrast images and the presence of hepatic steatosis were noted. Contrast uptake on HBP was quantified using the liver-to-lesion contrast enhancement ratio (LLCER) and compared between HCA subtypes (Wilcoxon signed-rank test). Categorical variables were compared using chi-square tests., Results: Twenty-four HCAs showed iso- or hyperintensity on HBP, specifically 17 inflammatory (IHCAs) and 7 β-catenin HCAs (BHCAs). Eighteen HCAs (75%) (17 IHCAs and 1 BHCAs) had a LLCER < 0% (median - 13.6%, group 1), of which 94% were hyperintense on precontrast T1-W images, with background hepatic steatosis. Six HCAs (25%) had LLCER ≥ 0% (median 2.9%, group 2), and all were BHCAs. A LLCER ≥ 1.6% was associated with the diagnosis of BHCA with a sensitivity of 86% and a specificity of 100%., Conclusion: In conclusion, iso- or hyperintensity of hepatocellular adenomas on HBP does not necessarily correspond to an increased hepatospecific contrast-agent uptake. In IHCA, tumor hyperintensity on precontrast images and the underlying steatosis likely explain such iso- or hyperintensity, which do show reduced HBP contrast-agent uptake. On the other hand, marked contrast uptake can be observed, especially in BHCA., Key Points: • Iso- or hyperintensity on HBP does not necessarily reflect a high uptake of hepatospecific contrast agent. • Discrepancies between qualitative signal intensity and quantitative hepatospecific contrast uptake can be explained in IHCA by a combination of tumor hyperintensity on precontrast images and underlying hepatic steatosis. • In BHCA, iso- or hyperintensity on HBP does actually correspond to a greater contrast uptake than that of the liver, demonstrated by an increased lesion-to-liver contrast enhancement ratio (LLCER).

Purpose: The purpose of our study was to correlate the quantitative analysis of benign hepatocellular tumor uptake on delayed hepatobiliary phase (HBP) imaging with the quantitative level of OATP expression., Methods: This single-center retrospective study, which took place between September 2009 and March 2015, included 20 consecutive patients with a proven pathologic and immunohistochemical (IHC) diagnosis of FNH or HCA, including quantification of the OATP expression. The patients underwent Gd-BOPTA-enhancement MRI, including an HBP. The analysis of HBP uptake was performed using the liver-to-lesion contrast enhancement ratio (LLCER). Mean LLCER and OATP expressions were compared between FNH and HCA, and the expression of OATP was correlated with the LLCER value., Results: Of the 23 benign hepatocellular tumors, 9 (39%) were FNH and 14 (61%) were HCA, including 6 inflammatory, 2 HNF1a inactivated, 3 β-catenin-mutated and 3 unclassified HCAs. On HBP, 100% of the FNH appeared hyper- or isointense, and 79% of the adenomas appeared hypointense. The mean OATP expression of FNH (46.67 ± 26.58%) was significantly higher than that of HCA (22.14 ± 30.74%) (p = 0.0273), and the mean LLCER of FNH (10.66 ± 7.403%) was significantly higher than that of HCA (-13.5 ± 12.25%) (p < 0.0001). The mean LLCER of β-catenin-mutated HCA was significantly higher than that of other HCAs (p = 0.011). Significant correlation was found between the OATP expression and LLCER values (r = 0.661; p = 0.001)., Conclusion: In benign hepatocellular tumors, the quantitative analysis of hepatobiliary contrast agent uptake on HBP is correlated with the level of OATP expression and could be used as an imaging biomarker of the molecular background of HCA and FNH., Key Points: • Gd-BOPTA uptake on HBP correlates with the OATP level in benign hepatocellular tumors • FNH and β-catenin-mutated HCA showed an increased lesion-to-liver contrast enhancement ratio (LLCER) • Increased LLCER may be explained by activation of the Wnt β-catenin pathway.