Evaluation of the living donor for liver transplantation is a complex process involving such invasive studies as liver biopsy and angiography. It is important to establish the likelihood and extent of hepatic steatosis in living donors by clinical, imaging, and biochemical parameters to avoid performing a liver biopsy, if possible. In this study, the predictive value of body mass index (BMI), liver chemistry tests, and imaging studies was compared with liver histological examination in 33 potential living donors. Patients were grouped and compared based on their BMI (<25, 25 to 28, >28). No patient with a BMI less than 25 had hepatic steatosis. Of patients with a BMI of 25 to 28, steatosis was found on biopsy in 3 of 9 patients. Thirteen of 17 patients (76%) with a BMI greater than 28 had hepatic steatosis on liver biopsy. There was a significant correlation between BMI and overall grade of steatosis (R ‫؍‬ 0.49). All subjects with steatosis detected on magnetic resonance imaging (MRI) or computed tomography (CT) had steatosis on biopsy, and all but 2 such patients had greater than 10% steatosis on biopsy. Conversely, 30% of patients in the MRI group and 24% of patients in the CT group failed to show hepatic steatosis when it was present on biopsy. Thus, it appears that liver biopsy could be avoided in subjects with a normal BMI and absence of risk factors. Individuals with a high BMI should undergo liver biopsy because biochemical and imaging data are currently inadequate to determine the extent of steatosis. Future studies should aim at improving the sensitivity of imaging techniques in the diagnosis of steatosis. (Liver Transpl 2001;7:409-414.)

Background & Aims Portal vein embolization (PVE) is a standard technique for patients not amenable to liver resection due to small future liver remnant ratio (FLR). Radiation lobectomy (RL) with 90Y-loaded microspheres (Y90) is hypothesized to induce comparable volumetric changes in liver lobes, while potentially controlling the liver tumor and limiting tumor progression in the untreated lobe. We aimed at testing this concept by performing a comprehensive time-dependent analysis of liver volumes following radioembolization. Methods 83 patients with right unilobar disease with hepatocellular carcinoma (HCC; N = 67), cholangiocarcinoma (CC; N = 8) or colorectal cancer (CRC; N = 8) were treated by Y90 RL. The total liver volume, lobar (parenchymal) and tumor volumes, FLR and percentage of FLR hypertrophy from baseline (%FLR hypertrophy) were assessed on pre- and post-Y90 CT/MRI scans in a dynamic fashion. Results Right lobe atrophy (p = 0.003), left lobe hypertrophy (p <0.001), and FLR hypertrophy (p <0.001) were observed 1 month after Y90 and this was consistent at all follow-up time points. Median %FLR hypertrophy reached 45% (5–186) after 9 months (p <0.001). The median maximal %FLR hypertrophy was 26% (−14→86). Portal vein thrombosis was correlated to %FLR hypertrophy (p = 0.02). Median Child-Pugh score worsening (6→7) was seen at 1 to 3 months (p = 0.03) and 3 to 6 months (p = 0.05) after treatment. Five patients underwent successful right lobectomy (HCC N = 3, CRC N = 1, CC N = 1) and 6 HCCs were transplanted. Conclusions Radiation lobectomy by Y90 is a safe and effective technique to hypertrophy the FLR. Volumetric changes are comparable (albeit slightly slower) to PVE while the right lobe tumor is treated synchronously. This novel technique is of particular interest in the bridge-to-resection setting.

Resection and radiofrequency ablation (RFA) are treatment options for hepatocellular carcinoma (HCC) <3 cm; there is interest in expanding the role of ablation to 3-5 cm. RFA is considered high-risk when the lesion is in close proximity to critical structures. Combining microcatheter technology and the localized emission properties of Y90, highly selective radioembolization is a possible alternative to RFA in such cases. We assessed the efficacy (response, radiology-pathology correlation, survival) of radiation segmentectomy in solitary HCC not amenable to RFA or resection. Patients with treatment-na€ ıve, unresectable, solitary HCC £ 5 cm not amenable to RFA were included in this multicenter study. Administered dose, response rate, time-to-progression (modified Response Evaluation Criteria in Solid Tumors [mRECIST]), radiology-pathology correlation and long-term survival were assessed. In all, 102 patients were included in this study. mRECIST complete response (CR), partial response (PR), and stable disease (SD) were 47/99 (47%), 39/99 (39%), and 12/99 (12%), respectively. Median time-to-disease-progression was 33.1 months. In all, 33/ 102 (32%) patients were transplanted with a median (interquartile range [IQR]) time-totransplantation of 6.3 months (3.6-9.7). Pathology revealed 100% and 50-99% necrosis in 17/33 (52%) and 16/33 (48%), respectively. Median overall survival was 53.4 months. Univariate analysis demonstrated a survival benefit for Eastern Cooperative Oncology Group (ECOG) 0 patients. In the multivariate model, age <65, ECOG 0, and Child-Pugh A were characteristics associated with longer survival. Conclusion: Radiation segmentectomy is an effective technique with a favorable risk profile and radiology-pathology outcomes for solitary HCC £ 5 cm. This approach may allow for treatment of HCC in difficult locations. Since RFA and resection are not options given tumor location, there appears to be a strong rationale for this technique as second choice. (HEPATOLOGY 2014;60:192-201) H epatocellular carcinoma (HCC) is a health problem of global proportions that has a wide variety of treatment options. Tumor location, size, number of lesions, liver function, and clinical symptoms all play a role in weighing various treatment modalities. Although liver transplantation and resection are considered curative, scarce transplant availability and patient/tumor characteristics limit Abbreviations: AASLD, American Association for the Study of the Liver; AFP, alpha