Safe Hepatectomy after Arterial-Based Liver Directed Therapy

Presenter: Aneil Sood | Indiana University Background: Liver directed therapy (LDT) for primary and secondary liver cancer has been increasingly utilized in patients with technically unresectable liver tumors, or in patients with surgically prohibitive underlying liver disease or medical comorbidities. Recent studies have shown that transarterial radioembolization (TARE) may reduce tumor burden and permit hepatectomy for complete tumor clearance. The short- and long-term outcomes of patients undergoing hepatectomy following TARE are reported in this study. Methods: An observational study of patients undergoing partial hepatectomy after TARE with yttrium-90 (Y90) between 2013-2018 was performed. Demographics, comorbidities, TARE specific variables, perioperative outcomes, and long-term outcomes were recorded. Variables specific to TARE included the number of procedures, arterial selectivity of embolization, and total millicurie (mCi) dose. Operative variables included the extent of hepatectomy, estimated blood loss (EBL), duration of operation, major postoperative morbidity (Clavien-Dindo Grade III-V complications), hospital readmission, and 30-day mortality. Long-term outcomes were recorded as pattern of recurrence, disease-free survival, and overall survival. Results: Eight patients (6 females, 2 males; mean age 60.4 +/- 1.8 years) underwent TARE for initially unresectable liver cancer, including hepatocellular carcinoma (n = 5), metastatic cancer (pancreatic neuroendocrine n = 1, pulmonary neuroendocrine n = 1), and cholangiocarcinoma (n = 1). The mean total dose of Y90 was 86.1 +/- 14.4 mCi during a single procedure (n = 4) or over two procedures (n = 4). Selective TARE was performed in five patients (63%) and nonselective in three patients (38%). The mean time from TARE to hepatectomy was 12.4 +/- 4 months. Six of the 8 patients (75%) required major hepatectomy (all open technique). Mean EBL was 1056 +/- 294 mL, and mean operative time was 271 +/- 43 minutes. Postoperatively, major morbidity was seen in three patients (38%) and included organ-space surgical site infection (n = 1), pneumonia requiring reintubation (n = 1), and bile leak (n = 2). Readmission occurred in four patients (50%). There were no 30-day mortalities. After a median follow-up of 37 months, recurrence was observed in four patients (50%); three patients developed hepatic recurrence, and one patient developed peritoneal recurrence. The mean disease-free survival and overall survival were 18.1 +-/ 5.0 months and 33.8 +/- 8.4 months, respectively. Conclusion: Hepatectomy following liver-directed therapy with Y90 radioembolization appears to be a safe treatment paradigm for patients with advanced stage liver cancer and can result in good long-term outcomes.