Whole-Liver Automatic Function Scoring System from Gadoxetic Acid-Enhanced MRI in Predicting Post-Hepatectomy Liver Failure in Hepatocellular Carcinoma

Abstract Objective This study evaluates the effectiveness of the Functional Automated Whole-Liver Score (FAWLS), derived from gadoxetic acid-enhanced MRI, in predicting post-hepatectomy liver failure (PHLF) in patients who with hepatocellular carcinoma (HCC). Materials and Methods A retrospective study included 183 patients who had 3-Tesla liver MRI and indocyanine green (ICG) testing for liver function evaluation between January 2022 and November 2024. PHLF was recorded according to international surgical group standard criteria. To identify independent predictors of PHLF, both univariate and multivariate binary logistic regression analyses were conducted.The diagnostic efficacy of the FAWLS parameter, ICG R15, and PHLF outcomes were assessed using ROC curves and Delong tests. Result A cohort of 129 patients (mean age 57.038 ± 9.964; 103 males) was studied, with 34 (26.4%) developing PHLF. Univariate analysis revealed significant differences between the non-PHLF and PHLF groups in various parameters. Multivariate analysis identified the FAWLS index (OR = 0.438; p < 0.05) and rLV Liver (OR = 0.997; p < 0.05) as independent predictors of PHLF. Diagnostic performance for PHLF was similar between FAWLS parameters and ICG R15 (p > 0.05). The combination of rLVLiver and FAWLS index had an area under the ROC curve of 0.781 (95% CI: 0.699–0.863), with 94.1% sensitivity and 50.5% specificity. Conclusion FAWLS index and rLV Liver predict PHLF in HCC. FAWLS system predicts PHLF comparably to ICG R15. Combining rLV Liver with FAWLS enhances predictive accuracy, aiding preoperative risk assessment and surgical planning.