Clinical impact of liver stiffness measurement on the prediction of surgical outcomes in hepatocellular carcinoma: which instrument performs better?

Ultrasound (US)-based or magnetic resonance elastography (MRE) have been developed to noninvasively measure tissue stiffness and help diagnose and monitor various conditions (1). US-based elastography has been used to diagnose various types of cancer, such as breast (2), prostate (3), and thyroid (4) cancers, facilitating the differentiation of malignant lesions from benign lesions. In the field of hepatic diseases, US-based elastography and MRE have been used to assess chronic liver diseases, accurately diagnosing liver fibrosis without pathological evaluation based on core needle biopsy (5).

US-based elastography includes strain elastography (SE), shear wave elastography (SWE), and transient elastography (TE). SWE assesses the stiffness of deep tissue using shear waves produced by US. TE, a one-dimensional technique performed with the FibroScan^® system (Echosens, Paris, France), is the most common elastography technique, and both the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of the Liver (EASL) practice guidelines recommend the assessment of liver fibrosis using US-based elastography (6,7).

Determination of the fibrosis grade in patients with chronic liver diseases is important for predicting the risk of developing hepatocellular carcinoma (HCC) and the occurrence of complications after invasive procedures. Many reports have demonstrated that liver stiffness measurement (LSM) using US-based elastography or MRE is a significant factor for the surgical outcomes of patients with HCC (8-10).

Vibration-controlled TE (VCTE), a patented technology of the FibroScan^®, is a simple method compared with SWE (11). Therefore, although VCTE is relatively inaccurate compared with other types of elastography, it should be performed before surgery to predict postoperative complications or recurrence of HCC. In a meta-analysis, Yu et al. evaluated the utility of VCTE for predicting the recurrence of HCC after surgery based on five papers from an Asian cohort [most patients had chronic hepatitis B (HB)] and postoperative complications based on eight papers {six from an Asian cohort and two from a European cohort [most of the patients had chronic hepatitis C (HC) or fatty liver disease]} (12).

HCC recurrence after liver resection was estimated based on the recurrence rate affected by the follow-up period (median, 38 months; range: 25–56 months). Consequently, despite of low values of I² (0.00%) and P value for heterogeneity, there was a wide range of LSM (12 kPa; range: 7.4–13.4 kPa) and areas under receiver operating characteristics curves (AUCs) were relatively low (0.656; range: 0.638–0.676), suggesting the low reliability of VCTE for predicting HCC recurrence. Conversely, the meta-analysis of complications after liver resection was heterogeneous (I²=85.03%) and had a wide range of LSM cutoff values for the occurrence of postoperative complications (15.65 kPa; range: 12–25.6 kPa). This can be mainly attributed to the various definitions of postoperative complications depending on the article, which include grade 3 or greater grades based on the modified Clavien-Dindo classification and liver failure, such as refractory ascites or hyperbilirubinemia. However, AUCs in papers included in this study were relatively high (0.815; range: 0.65–0.902), suggesting that VCTE is more useful for predicting postoperative complications than for recurrence of HCC.

The number of reports on the surgical outcomes based on LSM by VCTE is limited, and most include small patient cohorts. Therefore, this meta-analysis had heterogeneity and low reliability. However, MRE (10,13) and two-dimensional (2D)-SWE (14) showed the high accuracy of prediction model of surgical outcomes. Based on LSM using MRE or 2D-SWE, patients undergoing liver resection of HCC could be classified into three groups, including low-, moderate-, and high-risk for recurrence of HCC. MRE also accurately predicted major postoperative complications related to blood loss during liver transection (AUC, 0.810) (9). In Baveno VII workshop, it was advocated that LSM is available to stratify the risk of portal hypertension in patients with compensated advanced chronic liver disease (15). Furthermore, direct comparison for assessment of liver fibrosis in patients with chronic liver diseases using VCTE and 2D-SWE demonstrated the superior diagnostic performance of the latter (11). Thus, in addition to the diagnosis of liver fibrosis, the prediction of surgical outcomes using LSM measured by VCTE is not superior to that of other types of elastography. This is partly because VCTE is carried out without checking US images; therefore, measuring LSM in a liver region of interest is difficult, whereas positional accuracy is easy in 2D-SWE. In addition, measurement of LSM is impossible in patients with severe obesity and ascites.

Nevertheless, this meta-analysis showed that VCTE can predict the recurrence of HCC and occurrence of complications after surgery, which is consistent with previous reports. Consequently, VCTE is useful, similar to 2D-SWE and MRE by the following reasons. Compared with 2D-SWE and MRE, VCTE is a simple, cost-effective examination and can be performed by a US laboratory technician or an inexperienced doctor. Conversely, 2D-SWE requires more technical expertise, is more time-consuming, and is typically conducted by experienced physicians. MRE assesses the 2D displacement vector but involves a high cost and can be performed only in a limited number of medical institutions.

LSM measured by VCTE is not as accurate as that measured by SWE or MRE; however, VCTE can be easily performed in many hospitals and can provide a prediction model for the surgical outcomes of patients with HCC, which is consistent with those of SWE and MRE. Consequently, LSM determined by VCTE, SWE, or MRE can serve as a valuable variable in decision-making for liver surgery in patients with HCC.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, HepatoBiliary Surgery and Nutrition. The article has undergone external peer review.

Peer Review File: Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-505/prf

Funding: This work was mainly supported by a Grant-in-Aid for Scientific Research (C) 21K08807 from the Ministry of Education, Culture, Sports, Science and Technology (MEXT), Japan. The funding body has no role in the design of the study and analysis and interpretation of data and in writing the manuscript.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-505/coif). The author has no conflicts of interest to declare.

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