Liver surgery after radioembolization (RE) entails highly demanding and challenging procedures due to the frequent combination of large tumors, severe RE-related adhesions, and the necessity of conducting major hepatectomies. Laparoscopic liver resection (LLR) and its associated advantages could provide benefits, as yet unreported, to these patients. The current study evaluated feasibility, morbidity, mortality, and survival outcomes for major laparoscopic liver resection after radioembolization.

In this retrospective, single-center study patients diagnosed with hepatocellular carcinoma, intrahepatic cholangiocarcinoma or metastases from colorectal cancer undergoing major laparoscopic hepatectomy after RE were identified from institutional databases. They were matched (1:2) on several pre-operative characteristics to a group of patients that underwent major LLR for the same malignancies during the same period but without previous RE.

From March 2011 to November 2020, 9 patients underwent a major LLR after RE. No differences were observed in intraoperative blood loss (50 vs. 150 ml; p = 0.621), operative time (478 vs. 407 min; p = 0.135) or pedicle clamping time (90.5 vs 74 min; p = 0.133) between the post-RE LLR and the matched group. Similarly, no differences were observed on hospital stay (median 3 vs. 4 days; p = 0.300), Clavien–Dindo ≥ III complications (2 vs. 1 cases; p = 0.250), specific liver morbidity (1 vs. 1 case p = 1.000), or 90 day mortality (0 vs. 0; p = 1.000).

The laparoscopic approach for post radioembolization patients may be a feasible and safe procedure with excellent surgical and oncological outcomes and meets the current standards for laparoscopic liver resections. Further studies with larger series are needed to confirm the results herein presented.

The online version contains supplementary material available at 10.1007/s00423-022-02474-z.

• Colorectal liver metastases
• Hepatocellular carcinoma
• Intrahepatic cholangiocarcinoma
• Laparoscopic liver resection
• Radioembolization

• Radioembolization
• major hepatectomy
• post hepatectomy liver failure (PHLF)
• radiation lobectomy

• Case report
• Colorectal liver metastases
• Radioembolization
• Selective internal radiation therapy
• Trans-arterial
• Two-stage hepatectomy
• Yttrium90

Selective internal radiotherapy (SIRT) with yttrium-90 (Y-90) is an intra-arterial therapy for hepatic malignancy in patients who are unsuitable for surgical resection. This treatment is considered palliative, although some patients can demonstrate a response that is adequate to facilitate surgical resection with curative intent.

All patients who underwent liver resection post SIRT were reviewed. Data gathered included patient demographics, tumor type, surgical details, and post-operative outcomes.

Twelve patients underwent SIRT followed by liver resection (7 males and 5 females). Pathologies were hepatocellular carcinoma (n = 5), metastatic colorectal cancer (n = 5), and neuroendocrine tumor (n = 2). Lesional response (size, volume, and RECIST (response evaluation criteria in solid tumors)) was calculated and where appropriate functional liver remnant (FLR) is presented. Mean FLR increase was 264cm³ (range − 123 to 909), and all cases demonstrated a partial response according to RECIST with a mean largest lesion volume reduction of 475cm³ (range 14–1632). No post-SIRT complications were noted. Hepatectomy occurred at a mean of 322 days from SIRT treatment. Ninety-day morbidity was 67% (n = 6), complications post-surgery were analyzed according to the Clavien-Dindo classification scale; a total of 15 events occurred in 6 patients. Ninety-day mortality of 11% (n = 1).

In selected cases, liver resection is possible post SIRT. As this can represent a potentially curative option, it is important to reconsider resection in the follow-up of patients undergoing SIRT. Post-operative complications are noted following major and extended liver resection. Therefore, further studies are needed to improve patient selection.

• Hepatic malignancy
• Radioembolization
• Resection after SIRT
• SIRT
• Selective internal radiotherapy
• Surgical resection
• Y90

• liver neoplasm
• post-hepatectomy safety
• surgical oncology

Radioembolization with ⁹⁰Y-microspheres has been reported to induce contralateral liver hypertrophy with simultaneous ipsilateral control of tumor growth. The aim of the present systematic review was to summarize the evidence of contralateral liver hypertrophy and oncological outcome following unilateral treatment with radioembolization. A systematic literature search using the MEDLINE, EMBASE, and Cochrane libraries for studies published between 2008 and 2020 was performed. A total of 16 studies, comprising 602 patients, were included. The median kinetic growth rate per week of the contralateral liver lobe was 0.7% and declined slightly over time. The local tumor control was 84%. Surgical resection after radioembolization was carried out in 109 out of 362 patients (30%). Although the available data suggest that radioembolization prior to major hepatectomy is safe with a promising oncological outcome, the definitive role of radioembolization requires assessment within controlled clinical trials.

• SIRT
• hepatectomy
• liver resections
• neoadjuvant
• preconditioning
• selective internal radiation therapy

• brachytherapy
• hepatectomy
• interventional oncology
• trans-arterial radio-embolisation

• multidisciplinary team
• overall survival
• primary tumor resection
• resectable metastases
• synchronous colorectal cancer metastases

• Hepatectomy
• Hepatocellular carcinoma
• Postoperative bile leakage
• Stereotactic body radiotherapy

• Adult
• Aged
• Bile
• Biliary Tract Diseases/epidemiology
• Biliary Tract Diseases/etiology
• Carcinoma, Hepatocellular/surgery
• Female
• Hepatectomy/adverse effects
• Humans
• Incidence
• Liver Neoplasms/surgery
• Male
• Middle Aged
• Multivariate Analysis
• Operative Time
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Retrospective Studies
• Risk Factors

• Aged
• Aged, 80 and over
• Carcinoma, Hepatocellular/mortality
• Carcinoma, Hepatocellular/radiotherapy
• Carcinoma, Hepatocellular/surgery
• Female
• Hepatectomy/statistics & numerical data
• Humans
• Japan/epidemiology
• Liver Neoplasms/mortality
• Liver Neoplasms/radiotherapy
• Liver Neoplasms/surgery
• Male
• Middle Aged
• Neoplasm Recurrence, Local/epidemiology
• Propensity Score
• Radiosurgery/statistics & numerical data
• Retrospective Studies

Preoperative radioembolization may improve the resectability of liver tumor by inducing tumor shrinkage, atrophy of the embolized liver and compensatory hypertrophy of non-embolized liver. We describe the case of a cirrhotic Child-Pugh A patient with a segment IV hepatocellular carcinoma requiring a left hepatectomy. Preoperative angiography demonstrated 2 separated left hepatic arteries, for segment IV and segments II-III. This anatomic variant allowed sequential radioembolizations, delivering high-dose ⁹⁰Yttrium (160 Gy) to the tumor, followed 28 d later by lower dose (120 Gy) to segments II-III. After 3 mo, significant tumor response and atrophy of the future resected liver were obtained, allowing uneventful left hepatectomy. This case illustrates that, when anatomic disposition permits it, sequential radioembolizations, delivering different ⁹⁰Yttrium doses to the tumor and the future resected liver, could represent a new strategy to prepare major hepatectomy in cirrhotic patients, allowing optimal tumoricidal effect while reducing the toxicity of the global procedure.

• Hepatocellular carcinoma
• Cirrhosis
• Resectability
• Radioembolization
• Sequential
• Efficacy
• Safety

• Colorectal cancer
• Hepatocellular cancer
• Liver metastasis
• Liver neoplasms
• Liver resection
• Video

Radioembolization (RE) is an emerging treatment strategy for patients with primary hepatic malignancies and metastatic liver disease. Though RE is primarily performed in the palliative setting, a shift toward the curative setting is seen. Currently, hepatic resection and in selected cases liver transplantation are the only curative options for patients with a hepatic malignancy. Unfortunately, at diagnosis most patients are not eligible for liver surgery due to the imbalance between the necessary liver resection and the remaining liver remnant. However, in borderline resectable cases, tumor volume reduction and/or increasing the future liver remnant can lead to a resectable situation. The combination of selective tumor treatment, the induction of hypertrophy of untreated liver segments, and its favourable toxicity profile make RE an appealing strategy for downstaging. The present review discusses the possibilities for RE in the preoperative setting as a downstaging tool or as a bridge to liver transplantation.

• Bridge to transplant
• Downstaging
• Future liver remnant
• Radioembolization