Hepatocellular carcinoma with macrovascular invasion treated with yttrium-90 radioembolization prior to transplantation

Abstract

Background: Yttrium-90 microspheres radioembolization (Y90-RE) has shown to be an effective and safe treatment of primary liver tumors. According to the staging system of the Barcelona Clinic Liver Cancer (BCLC), patients with macrovascular invasion are staged as BCLC-C. This paper comprises a presentation of the results following application of the procedure.Methods: From January 2002 to December 2015, 367 patients were transplanted at the San Camillo Hospital Center. One hundred and forty-three patients were transplanted for hepatocellular carcinoma (HCC) and in 22 cases patients were treated with Y90-RE before liver transplantation (LT), of them 4 with macrovascular invasion were included in this study. Results:The four patients had a complete response for the thrombosis, and were included in the waiting list within the Milan criteria. Means interval time between Y90-RE and LT was 15.86 months. No patient death was observed at Y90-RE procedure or at LT. We obtain a free-survival of 39.1 (range, 6-76) months.In all four cases the complete thrombosis regression was observed. Conclusions:We reported a short series of patients transplanted after Y90-RE in patients with BCLC stage C. In our experience we achieved acceptable overall and disease-free survival. Eventually, Y90-RE seems to have a place in the downstaging strategy for LT candidates.

Liver Transplantation for Locally Advanced Hepatocellular Carcinoma

“…A case series from Italy reported that DS for those with portal vein tumor thrombosis was attempted using Yttrium-90 radioembolization, and these patients were successfully downstaged and could undergo liver transplantation. 66 Two similar cases were reported by the Yale group, and both of them had no tumor recurrence posttransplant. 67 Although these were very limited cases, the development of a multidisciplinary approach could have the possibility to cure even portal vein tumor thrombosis cases.…”

Hepatocellular carcinoma: when is liver transplantation oncologically futile?

“…Although absolute numbers were small, none of the patients with complete response to neoadjuvant treatment had HCC recurrence. This "oncologically favourable" outcome has been recently confirmed by several case series (19)(20)(21)(22). Of a total of 21 patients who underwent LT with macrovascular invasion, 8 patients developed HCC recurrence.…”

Radioembolization in the setting of liver transplantation: great expectations or hard times?

“…In a recent study by Levi Sandri et al, four cases even presenting initial tumor-related PVT were first downstaged and then efficaciously transplanted (9). Interestingly enough, these four cases corresponded to approximately 20% of all the cases down-staged using TARE, further suggesting that the systematic use of TARE should present a non-marginal role in improving the number of potentially transplantable patients.…”

“…It is clear that the opportunity to use TARE for efficaciously down-stage advanced and not-transplantable cases, even initially presenting macrovascular invasion, represents an attractive opportunity for liver transplantation (LT) physicians (7)(8)(9). A study comparing 172 HCC cases initially bridged/down-staged with different approaches (TARE =93; TACE =79) and then undergoing LT showed a trend towards better recurrence-free survivals in downstaged patients treated with TARE (7).…”