Proliferative Activity of Intrahepatic Colorectal Metastases After Preoperative Hemihepatic Portal Vein Embolization

Abstract

Although hemihepatic portal vein embolization (PVE) has been used preoperatively to extend indications for hepatectomy in patients with colorectal metastases, the effects of this procedure on tumor growth and outcome remain controversial. To address this issue, we assessed the proliferative activity of intrahepatic metastases after PVE and the long-term outcome of this procedure. Eighteen patients with colorectal metastases underwent preoperative PVE between 1996 and 2000 (PVE group). Twenty-nine patients who underwent major hepatic resection without PVE served as control (non-PVE group). The hepatic parenchymal fraction of the left lobe had significantly increased from 38.1 ؎ 3.2% to 45.9 ؎ 2.9% 3 weeks after PVE (؉20.5%, P < .0001). Tumor volume and percent tumor volume had also significantly increased from 223 ؎ 89 mL to 270 ؎ 97 mL (؉20.8%, P ‫؍‬ .016) and from 13.7 ؎ 4.3% to 16.2 ؎ 4.9% (؉18.5%, P ‫؍‬ .014), respectively. There was no apparent correlation between the increase in parenchymal volume and that in tumor volume. The Ki-67 labeling index of metastatic lesions was 46.6 ؎ 7.2% in the PVE group and 35.4 ؎ 12.6% in the non-PVE group (P ‫؍‬ .013). Long-term survival was similar in the PVE and non-PVE groups, however, disease-free survival was significantly poorer in the PVE group than in the non-PVE group (P ‫؍‬ .004). We conclude that PVE increases tumor growth and probably is associated with enhanced recurrence of disease. Although PVE is effective in extending indications for surgery, patient selection for PVE should be cautious. (HEPATOLOGY 2001;34:267-272.)Hepatic resection provides the only chance for cure in patients with colorectal metastases. To extend indications for hepatectomy, hemihepatic portal vein embolization (PVE) has been performed in selected patients. 1-3 PVE induces homolateral atrophy of the portion of the liver scheduled for resection and contralateral compensatory hypertrophy of the remnant liver, thus decreasing the risk of postoperative liver failure. PVE is indicated when the remnant liver is expected to be very small, i.e., about 40% smaller than preoperative liver volume, or when tumor spread requires a right hemihepatectomy with partial resection of the left side of the liver. 4,5 The positive effects of PVE on hepatic function must be weighed against recent evidence suggesting that this procedure may promote oncogenesis. Elias et al., have reported that after PVE liver metastases may grow more rapidly than liver parenchyma. 6 This assumption was based on a study of only 5 patients who had tumors in the nonembolized lobe of the liver, rather than the embolized lobe. In addition, they focused on tumor growth in the nonembolized lobe. Consequently, their findings were considered too premature to warrant contraindication of PVE in patients with colorectal metastases. 7,8 When used in combination with arterial chemoembolization, PVE suppresses growth of hepatocellular carcinoma (HCC). 9 Long-term results of HCC resection after PVE have recently been shown to be better than or...

Retraction: A systematic review and meta-analysis of feasibility, safety and efficacy of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) versus two-stage hepatectomy (TSH)

“…In our meta-analysis there wasn t any statistical difference between the two types of surgeries in regeneration volume. As reported previously, the hypertrophy of the FLR is negatively correlated with the pre-PVE FLR volume (10). Because hepatic parenchyma transection is usually performed along the umbilical fissure (the segmental border between left lateral lobe and segment 4) in ALLPS procedure (4,11) while PVE is usually performed on right hemi-liver in TSH procedure (12,13).…”

Effect of portal vein embolisation on the growth rate of colorectal liver metastases

“…PVE increases the anticipated future liver volume and allows surgery in patients who would otherwise be contraindicated for resection. The potential disadvantage of PVE is that earlier studies have suggested that it may stimulate tumour growth and lead to reduced long-term survival (Elias et al, 1999;Kokudo et al, 2001).…”

“…Tumour growth exceeding that of the normal liver parenchyma has been shown on imaging following PVE in patients with contra lateral lobe metastases (Elias et al, 1999), and the tumour-doubling time following PVE has been shown to be reduced from 92 to 76 days (Kokudo et al, 2001). There have been concerns that PVE may increase the risk of disease recurrence after curative resection (Kokudo et al, 2001;Pamecha et al, 2009). The influence of PVE on tumour growth characteristics on resected cancers has not been investigated.…”

Associating liver partition and portal vein ligation (ALPPS): Taking a view of trails

“…Therefore, several methods to increase the future remnant liver volume before major hepatectomy, including portal vein embolization (1), ligation (2), sequential arterial and portal vein embolizations (3), and two-staged hepatectomy (4), were introduced. These techniques, however, usually required 2-8 weeks interval before completing the entire clearance of tumor burden in the liver and the risk of tumor progression during the period might be critical especially among the patients with borderline resectable tumors or oncologically aggressive tumors (5,6).…”