Bridging and downstaging role of trans-arterial radio-embolization for expected small remnant volume before liver resection for hepatocellular carcinoma

Abstract

Backgrounds/Aims: To evaluate our initial experience of bridging role of trans-arterial radio-embolization (TARE) before major hepatectomy for hepatocellular carcinoma (HCC) in risky patients with small expected remnant liver volume (ERLV). Methods: We reviewed the data of patients with HCC who underwent major hepatectomy after TARE during the period between March and December 2017. Patients included had uni-lobar large HCC (＞5 cm) requiring major hepatectomy with small ERLV. Results: Five patients were included in our study. All patients were Child Pugh class A. A single session of TARE was applied in all patients. None developed any adverse events related to irradiation. The mean tumor size at baseline was 8.4 cm and 6.1 cm after TARE (p=0.077). The mean % of tumor shrinkage was 24.5%. ERLV improved from 354.6 ml at baseline to 500.8 ml after TARE (p=0.012). ERLV percentage improved from 27.2% at baseline to 38.1% after TARE (p=0.004). The mean % of ERLV was 39.5%. The mean interval time between TARE and resection was 99.6 days. Four patients (80%) underwent right hemi-hepatectomy and one patient (20%) underwent extended right hemi-hepatectomy. The mean operation time was 151 minutes, and mean blood loss was 56 ml. The mean hospital stay was 13.8 days, and one patient (20%) developed postoperative morbidity. After a mean follow-up of 15 months, all patients were alive with no recurrence. Conclusions: Yttrium-90 TARE can play a bridging role before major hepatectomy for borderline resectable HCC in risky patients with small ERLV.

Biochemical Safety of Ablative Yttrium-90 Radioembolization for Hepatocellular Carcinoma as a Function of Percent Liver Treated

“…Notably, OS was not significantly different in any study group when comparing those treated for <14.5% vs ≥14.5% of the liver. For patients with a baseline ALBI 2, grade increases by 3 months were additionally associated with a treatment angiosome volume ≥246 cm 3 , treatment activity ≥2.61 GBq, and total sphere number ≥3.6 million (p<0.05).…”

“…Transarterial radioembolization (TARE) with Yttrium-90 ( 90 Y) has emerged as a versatile treatment for patients with hepatocellular carcinoma (HCC), with neoadjuvant, definitive, and palliative applications. [1][2][3][4][5] Selective delivery of high dose TARE to ≤2 hepatic segments (ie, radiation segmentectomy) has shown local tumor control and survival outcomes comparable to other modalities with curative intent. [6][7][8] Radiation segmentectomy with a single compartment Medical Internal Radiation Dose (MIRD) ≥190 Gy correlates with pathologic tumor necrosis with little to no exposure to the adjacent non-target normal parenchyma.…”

Liver Transplantation for Hepatocellular Carcinoma beyond the Milan Criteria: A Specific Role for Living Donor Liver Transplantation after Neoadjuvant Therapy

“…LDLT can therefore be used for selected patients to enable those patients to undergo a transplant. Patients were selected on the basis of tumour biology markers such as AFP levels [ 27 , 28 , 29 ], tumour differentiation [ 30 , 31 ], response to bridging therapy [ 5 , 9 , 19 ] and the presence of cancer-related symptoms [ 15 ].…”

“…Bridging procedures such as transcatheter arterial chemoembolization and selective internal radiotherapy have been able to further improve oncological outcomes in patients with HCC, and new therapeutic approaches such as immunotherapy have been established [ 5 , 6 , 7 , 8 , 9 , 10 ]. Even if immune checkpoint inhibition is currently not implemented in the bridging of patients with HCC on the waiting list, it is encouraging that this approach has the potential to further improve bridging therapy in combination with conventional bridging methods [ 8 , 11 , 12 , 13 ].…”

Indications for Surgery in Cirrhotic Patients

“…10.1); preoperative transarterial chemoembolization (TACE) alone (Fig. 10.2), or followed by PVE [19]; combined hepatic vein embolization and PVE (liver venous deprivation) [20]; radioembolization with yttrium-90 microspheres [21]; portal vein ligation for staged hepatectomy (ALPPS) procedure [22].…”