Background & Aims Portal vein embolization (PVE) is a standard technique for patients not amenable to liver resection due to small future liver remnant ratio (FLR). Radiation lobectomy (RL) with 90Y-loaded microspheres (Y90) is hypothesized to induce comparable volumetric changes in liver lobes, while potentially controlling the liver tumor and limiting tumor progression in the untreated lobe. We aimed at testing this concept by performing a comprehensive time-dependent analysis of liver volumes following radioembolization. Methods 83 patients with right unilobar disease with hepatocellular carcinoma (HCC; N = 67), cholangiocarcinoma (CC; N = 8) or colorectal cancer (CRC; N = 8) were treated by Y90 RL. The total liver volume, lobar (parenchymal) and tumor volumes, FLR and percentage of FLR hypertrophy from baseline (%FLR hypertrophy) were assessed on pre- and post-Y90 CT/MRI scans in a dynamic fashion. Results Right lobe atrophy (p = 0.003), left lobe hypertrophy (p <0.001), and FLR hypertrophy (p <0.001) were observed 1 month after Y90 and this was consistent at all follow-up time points. Median %FLR hypertrophy reached 45% (5–186) after 9 months (p <0.001). The median maximal %FLR hypertrophy was 26% (−14→86). Portal vein thrombosis was correlated to %FLR hypertrophy (p = 0.02). Median Child-Pugh score worsening (6→7) was seen at 1 to 3 months (p = 0.03) and 3 to 6 months (p = 0.05) after treatment. Five patients underwent successful right lobectomy (HCC N = 3, CRC N = 1, CC N = 1) and 6 HCCs were transplanted. Conclusions Radiation lobectomy by Y90 is a safe and effective technique to hypertrophy the FLR. Volumetric changes are comparable (albeit slightly slower) to PVE while the right lobe tumor is treated synchronously. This novel technique is of particular interest in the bridge-to-resection setting.

Resection and radiofrequency ablation (RFA) are treatment options for hepatocellular carcinoma (HCC) <3 cm; there is interest in expanding the role of ablation to 3-5 cm. RFA is considered high-risk when the lesion is in close proximity to critical structures. Combining microcatheter technology and the localized emission properties of Y90, highly selective radioembolization is a possible alternative to RFA in such cases. We assessed the efficacy (response, radiology-pathology correlation, survival) of radiation segmentectomy in solitary HCC not amenable to RFA or resection. Patients with treatment-na€ ıve, unresectable, solitary HCC £ 5 cm not amenable to RFA were included in this multicenter study. Administered dose, response rate, time-to-progression (modified Response Evaluation Criteria in Solid Tumors [mRECIST]), radiology-pathology correlation and long-term survival were assessed. In all, 102 patients were included in this study. mRECIST complete response (CR), partial response (PR), and stable disease (SD) were 47/99 (47%), 39/99 (39%), and 12/99 (12%), respectively. Median time-to-disease-progression was 33.1 months. In all, 33/ 102 (32%) patients were transplanted with a median (interquartile range [IQR]) time-totransplantation of 6.3 months (3.6-9.7). Pathology revealed 100% and 50-99% necrosis in 17/33 (52%) and 16/33 (48%), respectively. Median overall survival was 53.4 months. Univariate analysis demonstrated a survival benefit for Eastern Cooperative Oncology Group (ECOG) 0 patients. In the multivariate model, age <65, ECOG 0, and Child-Pugh A were characteristics associated with longer survival. Conclusion: Radiation segmentectomy is an effective technique with a favorable risk profile and radiology-pathology outcomes for solitary HCC £ 5 cm. This approach may allow for treatment of HCC in difficult locations. Since RFA and resection are not options given tumor location, there appears to be a strong rationale for this technique as second choice. (HEPATOLOGY 2014;60:192-201) H epatocellular carcinoma (HCC) is a health problem of global proportions that has a wide variety of treatment options. Tumor location, size, number of lesions, liver function, and clinical symptoms all play a role in weighing various treatment modalities. Although liver transplantation and resection are considered curative, scarce transplant availability and patient/tumor characteristics limit Abbreviations: AASLD, American Association for the Study of the Liver; AFP, alpha

No abstract

Based on our experience with 1,000 patients over 15 years, we have made a decision to adopt TARE as the first-line transarterial LRT for patients with HCC. Our decision was informed by prospective data and incrementally reported demonstrating outcomes stratified by BCLC, applied as either neoadjuvant or definitive treatment. (Hepatology 2017).

No abstract