Case Report
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Dec 28, 2017; 9(36): 1372-1377
Published online Dec 28, 2017. doi: 10.4254/wjh.v9.i36.1372
Sequential tumor-directed and lobar radioembolization before major hepatectomy for hepatocellular carcinoma
Michael Vouche, Thierry Degrez, Fikri Bouazza, Philippe Delatte, Maria Gomez Galdon, Alain Hendlisz, Patrick Flamen, Vincent Donckier
Michael Vouche, Philippe Delatte, Department of Radiology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels 1000, Belgium
Thierry Degrez, Department of Gastroenterology, CHR Sambre et Meuse, Namur 5000, Belgium
Fikri Bouazza, Department of Abdominal Surgery, Institut Jules Bordet, Université Libre de Bruxelles, Brussels 1000, Belgium
Maria Gomez Galdon, Department of Pathology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels 1000, Belgium
Alain Hendlisz, Department of Digestive Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels 1000, Belgium
Patrick Flamen, Department of Nuclear Medicine, Institut Jules Bordet, Université Libre de Bruxelles, Brussels 1000, Belgium
Vincent Donckier, Department of Abdominal Surgery, Institut Jules Bordet, Centre de Chirurgie Hépato-Biliaire de l’ULB (CCHB-ULB), Université Libre de Bruxelles, Brussels1000, Belgium
Author contributions: Degrez T, Bouazza F, Delatte P, Gomez Galdon M, Hendlisz A and Flamen P performed research; Vouche M and Donckier V performed research and wrote the paper.
Informed consent statement: An informed consent was obtained from the patient for surgery and potential publication of this case report and any accompanying images.
Conflict-of-interest statement: There is no conflict of interest. None of the authors received any financial support for this work.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Vincent Donckier, MD, PhD, Professor of Surgery, Department of Abdominal Surgery, Institut Jules Bordet, Université Libre de Bruxelles, Rue Héger-Bordet 1, Brussels 1000, Belgium. vincent.donckier@bordet.be
Telephone: +32-2-5417348 Fax: +32-2-5413141
Received: September 24, 2017
Peer-review started: September 25, 2017
First decision: October 9, 2017
Revised: November 20, 2017
Accepted: December 5, 2017
Article in press: December 5, 2017
Published online: December 28, 2017
Processing time: 93 Days and 18.7 Hours
Abstract

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.

Keywords: Hepatocellular carcinoma; Cirrhosis; Resectability; Radioembolization; Sequential; Efficacy; Safety

Core tip: Preoperative radioembolization may improve resectability of hepatocellular carcinoma in cirrhotic patient, inducing tumor downsizing, atrophy of radio-embolized sector and regeneration of non-embolized liver. We describe a patient with a segment IV hepatocellular carcinoma where the presence of two separated left hepatic arteries permitted to deliver sequentially high-dose 90Yttrium to the tumor and lower dose to future resected liver, allowing uneventful left hepatectomy 3 mo later. This observation suggests that, when different arterial accesses exist to tumor and future resected non-tumor liver, sequential radioembolization with different radiation doses could represent a new preoperative strategy, optimizing the tumoricidal effect while minimizing the risk of radiation-induced liver damage.