Outcomes of Surgical Resection after Radioembolization for Hepatocellular Carcinoma

Summary

This is a retrospective study evaluating all patients who underwent both radioembolization (TARE) and subsequent hepatic resection in the setting of hepatocellular carcinoma (HCC). The study population (31 patients) was derived from 155 patients with HCC who underwent TARE but were also potential surgical resection candidates [preserved liver function, unilobar disease (or bilobar within Milan), no portal vein thrombus, no metastases]. The remaining patients, of the 155, were either transplanted (33) or considered for transplant (91).

The study population was made of 94% CP A and 77% BCLC Stage A disease. Technique of TARE was either lobar at a median dose of 128 Gy or segmental ablative at a medium dose of 254 Gy. 27/31 patients had a single treatment. There were no radiation-induced complications.

In addition to surgical outcomes, the authors looked extensively at the future liver remnant (FLR) following Y-90 therapy, as 25/31 patients underwent a major hepatic resection. FLR was calculated from the pre-TARE to the pre-surgical imaging. FLR increased significantly from 35% to 45% in those who received lobar Y-90 (20/25) and from 32% to 34% in those who received segmentectomy (5/25).

EASL response rates after TARE were evaluated. Stable disease was present in 39%, partial response 29%, and complete response 29%. Surgical resection after TARE occurred a median of 2.9 months after initial therapy. 24/31 patients had > 90% necrosis based on pathologic specimens.

In follow-up, 9/31 patients developed either a systemic or liver recurrence (all of whom had primary tumors > 5 cm), preferentially so in those who were EASL stable disease or had less pathologic necrosis. These findings yielded hazard ratios to develop recurrence for EASL responders of 0.18 (CI 0.5-0.7) and for 50-99% pathologic necrosis patients of 0.12 (CI 0.02-0.6). Median time to recurrence was 34 months. Median survival time was 96% at 1 and 2 years in the setting of a median follow-up time of 13 months.

Commentary

From a large number of TARE patients, this study was able to parse out a subset who underwent both TARE and subsequent surgical resection. The authors successfully demonstrate acceptable outcomes of surgical resection in the setting of prior radioembolization. They also effectively elucidate that response after Y-90 therapy by both imaging and pathologic criteria is a harbinger of future risk of recurrence after surgery.

Indirectly, this article seems to also be about the use of radioembolization to increase FLR, thus allowing surgical resection. The authors mention the potential benefits of this use, i.e. allowing local tumor control and mitigating the potential increase in local tumor growth, should one use for example portal vein embolization.

Currently TARE is often utilized in the setting non-operative HCC candidates. The authors expanded its use in this study, it seems using it as a potential bridge to resection for those in whom the FLR was insufficient to allow for surgical resection. Directly addressing this potential use of Y-90 would be helpful in future studies, as the current data only reflects the outcomes of those who successfully underwent surgery. Indeed, perhaps the success of this procedure in terms of FLR growth is much lower than theorized.

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Gabr A, Abouchaleh N, Ali R, et al. Outcomes of surgical resection after radioembolization for hepatocellular carcinoma. J Vasc Interv Radiol. 2018; 29(11): 1502-1510.

Post Author:
Daniel P. Sheeran, MD
Assistant Professor
Department of Radiology and Medical Imaging
Division of Vascular and Interventional Radiology
University of Virginia