Preoperative ⁶⁸Ga-FAPI-04 PET/CT-derived liver fibrosis quantification independently predicts post-hepatectomy liver failure: a histologically validated study

Purpose: Accurate preoperative risk stratification for post-hepatectomy liver failure (PHLF) is crucial. This study aimed to investigate whether, in patients deemed eligible for safe resection by conventional clinical criteria, ⁶⁸Ga-FAPI-04 PET/CT-based quantitative assessment of liver fibrosis could serve as a non-invasive predictor for PHLF.

Methods: In this retrospective study, 107 patients with liver Cancer underwent preoperative ⁶⁸Ga-FAPI-04 PET/CT. Quantitative parameters, including liver SUVmax, SUVmean, SUVpeak, and liver-to-aorta SUV ratios (TBRs), were measured. These imaging metrics were correlated with histopathological fibrosis stage (S0-S4) and analyzed alongside clinical and surgical variables to identify independent predictors of PHLF.

Results: PHLF occurred in 30 (28.0%) patients. All PET parameters significantly increased with advancing fibrosis stage (all P < 0.05). Multivariable logistic regression identified TBRmax (odds ratio [OR] = 4.590, 95% CI 1.439 to 14.637, P = 0.010), prothrombin time (OR = 1.566, 95% CI 1.009 to 2.428, P = 0.045), and major hepatectomy (OR = 2.857, 95% CI 1.065 to 7.665, P = 0.037) as independent predictors of PHLF. A nomogram incorporating these three variables demonstrated good predictive performance, with an area under the curve of 0.780, satisfactory calibration, and positive net benefit on decision curve analysis.

Conclusion: Preoperative ⁶⁸Ga-FAPI-04 PET/CT offers a histologically confirmed, non-invasive method to quantify liver fibrosis. This hypothesis-generating model offers a promising approach for preoperative risk stratification, warranting further validation in independent cohorts.