Modified Radiation Lobectomy: An Evolving Paradigm to Convert Patients to Liver Resection Candidacy

Surgical resection is regarded as the first-line curative treatment for early-stage hepatocellular carcinoma (HCC). However, the lack of sufficient future liver remnant (FLR) in many patients would preclude them from surgical candidacy. Yttrium-90 radiation lobectomy (RL) has been established over the past decade as an effective method to achieve tumor control as well as achieving FLR hypertrophy, while embedding a test-of-time. Most recently, Yttrium-90 radiation segmentectomy (RS) has been proven potentially curative in early-stage HCC. In this article, we highlight a modified radiation lobectomy (mRL) which is a combined approach of RL and RS that aims at concurrent achievement of complete tumor necrosis and FLR hypertrophy.

Radioembolization has historically been employed in the salvage setting for the treatment of unresectable hepatic malignancies. In this approach, lobar hepatic therapies have been found to offer palliative intent.[1] Observations of an atrophy–hypertrophy complex following this lobar therapy have led to a concept termed “radiation lobectomy”; the treated hepatic lobe will atrophy following radioembolization and the contralateral, untreated, hepatic lobe provides compensatory hypertrophy. This finding has allowed for the application of RL as an alternative to portal vein embolization (PVE), particularly in HCC, which can provide concurrent cancer therapy while promoting hypertrophy of the contralateral FLR for planned surgical resection in patients initially presenting with an FLR insufficient to sustain hepatic function postoperatively.[2] [3] [4]

Described in 2010, RS[5] is a technique increasingly used to treat liver tumors in a segmental rather than lobar fashion. RS has demonstrated safety and efficacy, with good imaging response rates, long time to tumor progression posttreatment, and high rates of explant complete pathologic necrosis.[6] [7] More recently, segmental radioembolization with glass microspheres has been described with curative intent in patients with unresectable HCC.[8]

In this article, we highlight a modified approach to RL combining both lobar and segmental Y90 delivery to promote curative tumor therapy while inducing contralateral hypertrophy to facilitate surgical resection. These approaches have been most commonly performed and reported in the literature employing glass microsphere radioembolization (TheraSphere, Biocompatibles UK Ltd) for patients with unresectable HCC.[9]

• References

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• 9 TheraSphere^® Yttrium-90 Glass Microspheres [package insert]. Farnham, Surrey, UK: Biocompatibles UK Ltd., Rev 14. Available at: https://www.btg-im.com/BTG/media/TheraSphere-Documents/PDF/TheraSphere-Package-Insert_USA_Rev-14.pdf . Accessed September 5, 2019
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