Imaging biomarkers of liver hypertrophy after portal vein embolization in patients with liver tumors: cholestasis, arterial hyperperfusion, and splenic response

PURPOSE: To identify imaging and clinical factors associated with future liver remnant (FLR) hypertrophy after portal vein embolization (PVE) prior to major hepatectomy. MATERIALS AND METHODS: This retrospective single-center study included 98 patients (mean age 61 ± 14 years, 56 female) with benign or malignant liver tumors who underwent PVE between 2019 and 2024 before planned major liver resection. 10 patients also received liver venous deprivation (LVD). FLR volumes were measured on cross-sectional imaging before and after PVE. Embolic agent, cholestasis, arterial perfusion patterns, signal intensities in MRI, spleen volume, and venous diameters were assessed. RESULTS: Mean FLR growth was 35.6 ± 22.2% (628.9 ± 256.2 to 979.6 ± 313.8 ml (p < 0.001)). Patients undergoing combined LVD demonstrated significantly greater FLR hypertrophy (mean FLR growth 61.3 ± 23.1%, 422 ± 97 ml; p < 0.001) compared with PVE alone. Arterial hyperperfusion of the embolized liver lobe was found to be associated with increased FLR growth (p = 0.036). Isolated cholestasis confined to the embolized lobe was also associated with greater FLR hypertrophy (p = 0.038), whereas cholestasis involving the FLR was associated with impaired growth (p = 0.042). No significant difference in FLR hypertrophy was observed regarding the used embolic agent (p = 0.11). Splenic volume increased significantly following PVE (311.9 ± 146.5 mL after PVE vs. 271.3 ± 118.5 mL prior to PVE, p < 0.001). CONCLUSION: Imaging features such as arterial hyperperfusion and cholestasis of the embolized liver lobe, and postinterventional splenic enlargement are associated with larger FLR-growth. These findings may provide valuable early indicators of regenerative response and could help refine patient selection for PVE and hepatectomy, warranting further prospective evaluation.