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©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
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
ARTICLE HIGHLIGHTS
Case characteristics
A seventy years old patient presented with a segment IV liver tumor.
Clinical diagnosis
Due to the presence of alcohol-related cirrhosis, a diagnosis of hepatocellular carcinoma was suspected.
Differential diagnosis
Differential diagnosis included other solid liver tumors, primary or secondary.
Laboratory diagnosis
Laboratory data, including alpha-fetoprotein were not contributive.
Imaging diagnosis
Contrast-enhanced magnetic resonance imaging demonstrated a 40 mm mass in segment IV of the liver with vascular characteristics of hepatocellular carcinoma, such as arterial phase wash-in and portal phase wash-out and features of cirrhosis. Angiography demonstrated two separated left hepatic arteries, for segment IV and for segments II and III, allowing selective access to the tumor and to the future resected liver.
Pathological diagnosis
On operative specimen, pathology confirmed the diagnosis of hepatocellular carcinoma and a major response to preoperative radioembolization as indicated by less than 10% residual cancer cells.
Treatment
Left hepatectomy was preceded by sequential radioembolizations, delivering high-dose radiation to the tumor and then, lower dose to the future resected liver. This 2-steps approach aimed to maximize tumoricidal effect while limiting the risks for radiation-induced liver disease and liver insufficiency.
Related reports
In such cases of hepatocellular carcinoma requiring a major hepatectomy in patients with compensated cirrhosis, resectability is dramatically limited by the risk of postoperative liver insufficiency.
Experiences and lessons
This case indicates that, when arterial anatomy allows it, sequential radioembolizations with different radiation doses to the tumor and to the future resected liver could represent a new strategy to maximize the tumoricidal effect while preserving the atrophic effect but reducing the risk of radiation-induced liver injury.
