Preoperative functional liver imaging score in hepatocellular carcinoma resection: systematic review and meta-analysis

Objectives To synthesize the evidence on the association between the preoperative functional liver imaging score (FLIS) and post-hepatectomy liver failure (PHLF), overall survival (OS), and the discriminative performance of FLIS for PHLF prediction, in patients undergoing hepatectomy for hepatocellular carcinoma (HCC). Materials and methods PubMed, Embase, and Web of Science were searched through February 2026 for studies of preoperative FLIS on gadoxetic acid–enhanced MRI in HCC hepatectomy. Risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool. DerSimonian-Laird random-effects meta-analyses pooled the odds ratio (OR) per FLIS point for PHLF and the area under the receiver operating characteristic curve (AUC) for PHLF prediction. Results Five studies comprising 1832 patients (1740 in HCC-specific analyses) were included. In the exploratory meta-analysis (k = 2; potential cohort overlap), higher FLIS reduced PHLF odds (pooled OR: 0.55; 95% confidence interval (CI) 0.37–0.83; p = 0.004; I² = 82.5%). Pooled AUC for PHLF was 0.73 (95% CI: 0.70–0.76), exceeding MELD (0.557–0.558), ALBI (0.609), and ICG-R15 (0.605–0.624) in contributing studies. In the only study evaluating OS, low FLIS was associated with worse 5-year OS (42.4% vs. 76.4%; p < 0.001). QUIPS rated two studies as low and three as high risk of bias. Conclusion FLIS showed associations with PHLF and OS after hepatectomy for HCC, with moderate discriminative ability for PHLF prediction. As findings derive from two studies for PHLF and one for OS with potential cohort overlap, they should be interpreted as exploratory and require prospective multicenter validation. Key Points Question Preoperative risk stratification for hepatectomy in hepatocellular carcinoma relies on biochemical scores that do not incorporate imaging-derived assessment of hepatocyte function. Findings In an exploratory meta-analysis (k = 2), each FLIS point increase was associated with 45% lower odds of post-hepatectomy liver failure (odds ratio 0.55). Relevance statement FLIS showed associations with post-hepatectomy liver failure and survival in hepatocellular carcinoma based on two studies for PHLF and one study for overall survival, with moderate discriminative performance.