Abstract
Background: Return to intended oncologic treatment (RIOT) has been suggested as an important outcome for hepatic tumors. Resection of multifocal, bilobar liver tumors through extended hepatectomy often necessitates liver molding for an adequate future liver remnant (FLR), however a delay to surgery and the morbidity of liver molding could impact RIOT. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has been shown to stimulate faster FLR regeneration compared to portal vein embolization (PVE) which could reduce the chemotherapy-free interval and improve RIOT. This study aims to evaluate RIOT after liver molding with ALPPS compared to PVE with trisectionectomy. Methods: A retrospective review was conducted on all patients undergoing trisectionectomies (right or left) for liver tumors from 2008–2018 in a single tertiary institution. Tumor biology, chemotherapy treatment, operative and oncologic outcomes were compared between trisectionectomies with and without liver molding (ALPPS or PVE). FLR regeneration time was defined as the duration between portal vein occlusion (first ALPPS stage or PVE) and hepatic resection (second ALPPS stage or trisectionectomy). The chemotherapy-free interval (CFI) for RIOT was calculated for patients planned for neoadjuvant and adjuvant chemotherapy, including patients who died prior to receiving intended adjuvant treatment. Results: Of the 51 patients who underwent trisectionectomy, 25 (49%) required liver molding (11 ALPPS, 14 PVE). Median FLR regeneration time was 11 days for ALPPS and 44 days for PVE (p < 0.001). Patients who did not have adjuvant chemotherapy indicated (n = 15) or were lost to follow up shortly after surgery (n = 3) were not considered for RIOT. Successful RIOT was achieved in 89% (16/18) with liver molding and 87% (13/15) with trisectionectomy alone (p = 0.85). Patients receiving neoadjuvant and adjuvant chemotherapy had a shorter CFI when trisectionectomy did not require liver molding (110 vs 228 days, p = 0.014). For patients requiring liver molding, RIOT was similar between ALPPS (7/8) and PVE with trisectionectomy (9/10) (p = 0.87). Specifically for colorectal metastases requiring liver molding prior to resection, there was a 90-day difference in mean resumption of chemotherapy (CFI) between ALPPS and PVE (183 vs 273 days, p = 0.28). Conclusion: Liver molding for patients undergoing extended liver resections does not reduce the ability to achieve RIOT. While liver molding in general expectedly increases the CFI, the shorter FLR regeneration time in ALPPS may help to reduce the CFI compared to traditional PVE with trisegmentectomy.
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