Bridging and downstaging role of trans-arterial radio-embolization for expected small remnant volume before liver resection for hepatocellular carcinoma

Abstract

Backgrounds/aims: To evaluate our initial experience of bridging role of trans-arterial radio-embolization (TARE) before major hepatectomy for hepatocellular carcinoma (HCC) in risky patients with small expected remnant liver volume (ERLV).

Methods: We reviewed the data of patients with HCC who underwent major hepatectomy after TARE during the period between March and December 2017. Patients included had uni-lobar large HCC (＞5 cm) requiring major hepatectomy with small ERLV.

Results: Five patients were included in our study. All patients were Child Pugh class A. A single session of TARE was applied in all patients. None developed any adverse events related to irradiation. The mean tumor size at baseline was 8.4 cm and 6.1 cm after TARE (p=0.077). The mean % of tumor shrinkage was 24.5%. ERLV improved from 354.6 ml at baseline to 500.8 ml after TARE (p=0.012). ERLV percentage improved from 27.2% at baseline to 38.1% after TARE (p=0.004). The mean % of ERLV was 39.5%. The mean interval time between TARE and resection was 99.6 days. Four patients (80%) underwent right hemi-hepatectomy and one patient (20%) underwent extended right hemi-hepatectomy. The mean operation time was 151 minutes, and mean blood loss was 56 ml. The mean hospital stay was 13.8 days, and one patient (20%) developed postoperative morbidity. After a mean follow-up of 15 months, all patients were alive with no recurrence.

Conclusions: Yttrium-90 TARE can play a bridging role before major hepatectomy for borderline resectable HCC in risky patients with small ERLV.

Keywords: Major liver resection; Small remnant liver volume; Trans-arterial radio-embolization.

Fig. 1

Management algorithm of the study patients. TARE, trans-arterial radio-embolization; CT, computed tomography; LFT, liver function tests; AFP, alpha fetoprotein; PIVKA-II, protein induced by vitamin K absence or antagonist-II.

Fig. 2

(A-F) Computed tomography photos showing gradual tumor shrinkage (red line) and increased remnant liver volume (blue zone) after yettrium-90 trans- arterial radioembolization. (A and D) At baseline evaluation, (B and E) 4 weeks after trans-arterial radioembolization, and (C and F) before liver resection. (G-I) Operative view of right hemi-hepatectomy after yettrium-90 trans- arterial radioembolization. (G) Initial exposure with noted demarcation and inflammation on the right hemi-liver. (H) Pedicle dissection and individual control of inflow structures. (I) Parenchymatous division by cavitron ultrasonic suction aspirator.

Fig. 3

Changes in serum liver functions and tumor markers during management protocol. (A) Changes in serum bilirubin. (B) Changes in serum alanine aminotransferase (ALT). (C) Changes in serum aspartate aminotransferase (AST). (D) Changes in serum alpha fetoprotein (AFP). (E) Changes in serum protein induced by vitamin K absence or antagonist-II (PIVKA-II). TARE, trans-arterial radio-embolization; Op, operation.