Sequential tumor-directed and lobar radioembolization before major hepatectomy for hepatocellular carcinoma

Abstract

Preoperative radioembolization may improve the resectability of liver tumor by inducing tumor shrinkage, atrophy of the embolized liver and compensatory hypertrophy of non-embolized liver. We describe the case of a cirrhotic Child-Pugh A patient with a segment IV hepatocellular carcinoma requiring a left hepatectomy. Preoperative angiography demonstrated 2 separated left hepatic arteries, for segment IV and segments II-III. This anatomic variant allowed sequential radioembolizations, delivering high-dose ⁹⁰Yttrium (160 Gy) to the tumor, followed 28 d later by lower dose (120 Gy) to segments II-III. After 3 mo, significant tumor response and atrophy of the future resected liver were obtained, allowing uneventful left hepatectomy. This case illustrates that, when anatomic disposition permits it, sequential radioembolizations, delivering different ⁹⁰Yttrium doses to the tumor and the future resected liver, could represent a new strategy to prepare major hepatectomy in cirrhotic patients, allowing optimal tumoricidal effect while reducing the toxicity of the global procedure.

Keywords: Cirrhosis; Efficacy; Hepatocellular carcinoma; Radioembolization; Resectability; Safety; Sequential.

Figure 1

Preoperative imaging. A and B: Baseline contrast-enhanced magnetic resonance imaging (MRI). Contrast-enhanced MRI demonstrated a 40 mm mass in segment IV of the liver with arterial wash-in (A) and wash-out on the portal venous phase (B) and features of cirrhosis (irregular surface, relative hypertrophy of segment I); C and D: Selective intra-tumor deposition of 90Y microspheres after first SIRT session (C) and deposition of 90Y microspheres to segments II and III after the second SIRT session (D).

Figure 2

Intra- and postoperative images. A: Intraoperative view showing the cirrhosis and the post-selective internal radiotherapy (SIRT) relative atrophy of the left liver; B: Resected specimen showing small residual cancer cells foci with the necrotic and fibrotic zone targeted by segment IV high-dose SIRT; C: Pathological view showing massive necrosis and fibrosis together with the presence of microspheres; D: Pathological view showing a residual hepatocellular carcinoma focus, surrounded by necrosis and fibrosis together with the presence of microspheres.