Hepatic Radioembolization as a Bridge to Liver Surgery

Abstract

Treatment of oncologic disease has improved significantly in the last decades and in the future a vast majority of cancer types will continue to increase worldwide. As a result, many patients are confronted with primary liver cancers or metastatic liver disease. Surgery in liver malignancies has steeply improved and curative resections are applicable in wider settings, leading to a prolonged survival. Simultaneously, radiofrequency ablation (RFA) and liver transplantation (LTx) have been applied more commonly in oncologic settings with improving results. To minimize adverse events in treatments of liver malignancies, locoregional minimal invasive treatments have made their appearance in this field, in which radioembolization (RE) has shown promising results in recent years with few adverse events and high response rates. We discuss several other applications of RE for oncologic patients, other than its use in the palliative setting, whether or not combined with other treatments. This review is focused on the role of RE in acquiring patient eligibility for radical treatments, like surgery, RFA, and LTx. Inducing significant tumor reduction can downstage patients for resection or, through attaining stable disease, patients can stay on the LTx waiting list. Hereby, RE could make a difference between curative of palliative intent in oncologic patient management. Prior to surgery, the future remnant liver volume might be inadequate in some patients. In these patients, forming an adequate liver reserve through RE leads to prolonged survival without risking post-operative liver failure and minimizing tumor progression while inducing hypertrophy. In order to optimize results, developments in procedures surrounding RE are equally important. Predicting the remaining liver function after radical treatment and finding the right balance between maximum tumor irradiation and minimizing the chance of inducing radiation-related complications are still challenges.

90Y Hepatic Radioembolization: An Update on Current Practice and Recent Developments

“…Radioembolization before surgical resection, as in HCC and metastatic colorectal cancer, could be promising in intrahepatic cholangiocarcinoma as well. Downstaging occurs in 10%, and inducing contralateral hypertrophy seems feasible (65,72). In a small cohort combining radioembolization with chemotherapy, downstaging occurred in 22%, significant hypertrophy of the contralateral lobes was seen in all patients, and 18% were radically resected (74).…”

“…In HCC, the downstaging success rate with radioembolization is around 50% (range, 29%-67%), with a median time to downstaging of 3.1-4 mo (65). In downstaging HCC, radioembolization is a suitable alternative to TACE, but downstaging should not be restricted to HCC alone (65).…”

Treatment of Primary Liver Tumors and Liver Metastases, Part 1: Nuclear Medicine Techniques

“…In addition to salvage therapy and primary treatment of various malignancies for patients who have contraindications to surgery, 90 Y microspheres can be used as an adjunct to surgery (22). 90 Y microsphere therapy is efficacious in downstaging patients with hepatocellular carcinoma, metastatic colorectal cancer, and cholangiocarcinoma, making them more amenable to surgical resection (13,22). Radioembolization can also reduce tumor burden, slow disease progression, and provide a bridge to liver transplantation (22).…”

Transarterial Therapies for Hepatocellular Carcinoma

“…TARE using 90-Y-tagged glass beads has been shown to be safe and probably effective in patients with unresectable HCC [13][14][15]. A recent meta-analysis suggested that TARE is significantly better than TACE in terms of survival, time to progression, hospitalization time, and complication rates for patients with HCC [16]. A further role of TARE in advanced HCC patients is as a conversion treatment for patients considered otherwise unresectable or even as a bridge to transplantation [17].…”