Outcomes of Surgical Resection after Radioembolization for Hepatocellular Carcinoma
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.
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.
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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.
Daniel P. Sheeran, MD
Department of Radiology and Medical Imaging
Division of Vascular and Interventional Radiology
University of Virginia