The use of neoadjuvant radioembolization prior to resection of hepatic malignancies

Abstract

Introduction: Arterial radioembolization with yttrium-90 (Y-90) has demonstrated efficacy for hepatic malignancies. Little is known about use of Y-90 in a neoadjuvant fashion. We describe our use of unilobar Y-90 therapy for liver directed treatment and hepatic conditioning in preparation for resection. Methods: 14 patients undergoing Y-90 therapy with subsequent surgical resection from 2007 to 2017 were reviewed. Patients underwent mapping angiography with angiosomal analysis via cone beam CT and hepatic arterial Tc-MAA SPECT CT. Dosimetry was accomplished using MIRD and BSA for glass and resin spheres respectively. Results: Patient descriptions are given in Table 1. The mean age was 62.7 and included hepatocellular carcinoma, cholangiocarcinoma, and liver metastasis in 5 (36%), 3 (21%), and 6 (43%) respectively. All patients were non-surgical candidates due to insufficient contralateral volume or high risk biology prior to treatment. Mean contralateral hypertrophy with neoadjuvant Y-90 alone resulted in a 549 ml to 789 ml (30% to 45%) in 9 patients within a median 202 days. Y-90 with PVE in 5 patients resulted in 531 ml to 710 mL (38% to 54%) hypertrophy within a median 190 days. Liver resection included right hepatectomy, left hepatectomy, and trisegmentectomy in 9 (64%), 2 (14%) and 3 (22%) respectively with a mean length of stay of 8.5 days and major morbidity of 14%. No perioperative mortality occurred.FP08-09 TableCharacteristics and post hepatectomy outcomes in patients with previous Y-90 for liver malignancy.PtAge/SexDiagnosisTumor size (cm)/NPVEY-90Dosage (Gy)Y-90 – surgery(days)FLRVPre /post Y-90(ml) (%)Type of SurgeryLOS90-Day Complications (CD-grade)173/MHCC10.0/1Yes101190514(19%)/786(31%)Open TRS6Pleural effusion, (Cl–I)259/MHCC6.3/1No118210517(30%)/875(49%)HA RH22Bile leak, (Cl–IIIb)367/FMCA3.2/multipleNo105217421(33%)/627(56%)Lap. RH7Subcortical infarct (Cl-II)460/MHCC11.0/1No122.7202625(25%)/789(36%)Open RH6Anemia, (Cl-II)566/FHCC13.0/1No106122447(35%)/631(48%)Open TRS6None668/MCCA4.0/1No116.7167310(16%)/535(35%)Open TRS20DVT, PE (Cl-IIIb)727/FMMA6.0/1Yes110126530(34%)/527(43%)Lap. RH4None872/MMCA2.8/multipleYes117153411(43%)/372(53%)Open RH6None970/FMCA3.8/multipleYes113481733(58%)/854(68%)Open LH6Anemia, (Cl-II)1061/FCCA11.0/1No369141598(31%)/1046(47%)Open RH6None1163/MMCA2.0/multipleYes104459469(34%)/1012(73%)Open RH8Ileus, (Cl-II)1244/MCCA8.8/multipleNo2252431008(43%)/934(47%)Lap. LH8Anemia, (Cl-II)1361/MMCA2.3/1No231182469(34%)/808(49%)Open RH5None1487/MHCC9.8/1No412259543(27%)/855(41%)HA RH8N/AAbbreviations: HCC, hepatocellular carcinoma; MCA, metastatic carcinoma; MCA, metastatic melanoma; TRS, trisegmentectomy; HA, hand assisted; RH, right hepatectomy; LH, left hepatectomy; Cl, Clavien-Dindo classification; LOS, length of stay; DVT, deep vein thrombosis; PE, pulmonary embolism; PVE, portal vein embolization; CD, Clavien-Dindo-Score. Open table in a new tab Abbreviations: HCC, hepatocellular carcinoma; MCA, metastatic carcinoma; MCA, metastatic melanoma; TRS, trisegmentectomy; HA, hand assisted; RH, right hepatectomy; LH, left hepatectomy; Cl, Clavien-Dindo classification; LOS, length of stay; DVT, deep vein thrombosis; PE, pulmonary embolism; PVE, portal vein embolization; CD, Clavien-Dindo-Score. Conclusion: Neoadjuvant radioembolization contributes to contralateral hypertrophy and tumor control during surviellance in patients with aggressive biology. Surgical intervention after Y-90 is feasible without adding morbidity.