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.

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Based on our experience with 1,000 patients over 15 years, we have made a decision to adopt TARE as the first-line transarterial LRT for patients with HCC. Our decision was informed by prospective data and incrementally reported demonstrating outcomes stratified by BCLC, applied as either neoadjuvant or definitive treatment. (Hepatology 2017).

In this largest metastatic CRC series published to date, Y90 radioembolization was found to be safe; survival varied by prior therapy. Further studies are required to further refine the role of Y90 in metastatic CRC.

Aim To compare radiological and pathological changes and test the adjunct efficacy of Sorafenib to Y90 as a bridge to transplantation in HCC. Methods 15 patients with 16 HCC lesions randomized to Y90 without (Group A, n=9) or with Sorafenib (Group B, n=7). Size (WHO, RECIST), enhancement (EASL, mRECIST) and diffusion-weighted imaging criteria (ADC) measurements were obtained at baseline, 1 and every 3 months after treatment until transplantation. Percentage necrosis in explanted tumors was correlated with imaging findings. Results 100%, 50-99% and <50% pathological necrosis was observed in 6 (67%), 1 (11%) and 2 (22%) tumors in Group A and 3 (42%), 2 (28%) and 2 (28%) in Group B, respectively (p=0.81). While ADC (p=0.46) did not change after treatment, WHO (p=0.06) and RECIST (p=0.08) response at 1 month failed to reach significance, but significant responses by EASL (p<0.01/0.03) and mRECIST (p<0.01/0.03) at 1 and 3 months were observed. Response was equivalent by EASL or mRECIST. No difference in response rates were observed between groups A and B at 1 and 3 months by WHO, RECIST, EASL, mRECIST or ADC measurements. Despite failing to reach significance, smaller baseline size was associated with CPN (RECIST: p=0.07; WHO: p=0.05). However, a cut-off size of 35 mm was predictive of CPN (p=0.005). CPN could not be predicted by WHO (p=0.25 and 0.62), RECIST (p=0.35 and 0.54), EASL (p=0.49 and 0.46), mRECIST (p=0.49 and 0.60) or ADC (p=0.86 and 0.93). Conclusion The adjunct of Sorafenib did not augment radiological or pathological response to Y90 therapy for HCC. Equivalent significant reduction in enhancement at 1 and 3 months by EASL/mRECIST were noted. Neither EASL nor mRECIST could reliably predict CPN.

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