The post-SIR-Spheres surgery study (P4S): analysis of outcomes following hepatic resection of patients previously treated with selective internal radiation therapy (SIRT), with or without exposure to future liver remnant (FLR)

Abstract

Purpose: Patients with liver tumors may not be candidates for curative resection if their future liver remnant (FLR) is inadequate. We aimed to assess outcomes in patients who underwent 90 Y radiation lobectomy (RL) with the intent to hypertrophy the FLR prior to resection. Materials and Methods: With IRB approval and following multidisciplinary tumor board discussion, right lobar þ/segment 4 90 Y treatments were performed prior to right hepaticlobectomy/tri-segmentectomy in patients with hepatic tumor, preserved liver function, but inadequate FLR. Based on 3-D reconstructions, parenchymal/tumor volumes were calculated from pre/post-RL imaging; FLR and %FLR hypertrophy were determined. Common Terminology Criteria for Adverse Events were used to assess post-resection toxicity. Statistical comparisons were made with ANOVA and paired t-tests; p-values o0.05 were considered significant. Results: 11 patients (HCC n¼8, cholangiocarcinoma n¼2, mCRC n¼1) underwent 14 therapies with 90 Y glass microspheres (Therasphere, BTG, London, UK). The median right lobe radiation dose was 141 Gy (111-298 Gy). The median time between RL and imaging to calculate FLR was 36 days (23-124 days), while the median time to resection was 55 days (30-143 days). Median FLR increased significantly after RL [pre: 32% (22-41%); post: 42% (29-58%), po0.01]. The median %FLR hypertrophy was 29% (4-46%); there was no significant change in tumor volume (median decrease 9%). All patients successfully underwent resection; the median hospital stay was 3 days (2-10 days). Transaminase/albumin toxicities were statistically significant in the first post-operative week (po0.01), but were unchanged from baseline 1-month post surgery (AST: p¼0.42, ALT: p¼0.33, albumin: p¼0.29). Grade 3/4 bilirubin elevation was present in only 1 patient at 1 month; the patient had primary sclerosing cholangitis. An HCC patient died 603 days after resection. The median follow-up time of the remaining patients was 465 days (136-1045 days). Conclusion: Radiation lobectomy results in significant hypertrophy of the future liver remnant while treating right lobe tumors; this may allow for safe resection in patients initially presenting with a small FLR.

Radioembolization as an adjunct therapy to the resection of liver tumors

“…Finally, the potential induction of subclinical liver function loss could impair the quality of the remaining liver after resection and impact on surgical safety. A recent study has focused on the safety of surgical resection after RE and the results are reassuring [26,27]. This multicenter retrospective study analyzed perioperative and 90-day postoperative morbidity and mortality among 71 patients mainly with HCC (32%) and liver metastases from CRC (43%) treated with resection after an average of 8.7 months post-RE.…”

“…HCC patients were more likely to have FLR-sparing RE than patients with liver metastasis but overall there were no significant differences in outcomes (including liver complications) between resected patients with irradiated FLR and those with an FLR spared from radiation. Nevertheless, sparing the FLR remains a common practice when RE is performed with a clear intention to rescue patients for liver resection [27].…”