Interventional Oncology

Session: Educational Exhibit Presentations - Station 6: Interventional Oncology

Radiation Lobectomy Versus Portal Vein Embolization Versus Liver Venous Deprivation. Which Is Best for Maximizing Future Liver Remnant?

Monday, March 6, 2023

5:40 PM – 5:45 PM

Location: Phoenix Convention Center, North Ballroom 120ABC, Poster Hall

Abstract Presenter(s)

Brendan Carney, DO (he/him/his)

Resident
University of Iowa Hospitals and Clinics

Disclosure(s): No financial relationships to disclose

Author/Co-author(s)

CC

Colton Clymer, BS

Student
University of Iowa
MA

Mohammad Amarneh, MD

Clinical Assistant Professor
University of Iowa Hospitals and Clinics

Disclosure(s):

Brendan Carney, DO: No financial relationships to disclose

Learning Objectives: Compare and contrast the current interventional radiology options for future liver remnant (FLR) hypertrophy.

Background: Surgical resection is the gold standard treatment for patients with liver malignancies who are not transplant candidates. Surgery may require the assistance of IR for FLR hypertrophy before a large-volume resection. Current IR options include radiation lobectomy (RL), portal vein embolization (PVE), and liver venous deprivation (LVD).

Clinical Findings/Procedure Details: PVE is currently the standard of care for maximizing FLR. PVE involves the injection of embolic material into the portal vein with the goal of redirecting flow to the FLR, resulting in hypertrophy [1]. One disadvantage of PVE is that FLR hypertrophy can occur four or more weeks after PVE, which can lead to tumor progression and cancellation of surgery. [2, 3]. PVE can lead to increased tumor growth secondary to increased arterial flow to the tumor, termed hepatic artery buffer response [4]. LVD can potentially reduce the time to surgical resection. LVD involves concomitant embolization of the portal vein and the hepatic vein. There is evidence that LVD can lead to accelerated FLR hypertrophy and function compared to PVE [5]. This is theoretically due to decreased portal collateralization, antegrade portal venous flow, and hepatic arterial flow. RL involves the injection of radiation-coated microparticles into the hepatic artery. RL offers hypertrophy of the FLR, with an animal study showing similar FLR hypertrophy to PVE at 3-6 months [6]. Unlike PVE and LVD, RL provides the benefit of tumor necrosis, which allows for better tumor control or downstaging. RL allows for a “test of time” approach, which creates better patient selection prior to surgery. For example, a patient undergoing PVE or LVD may lose their surgical candidacy despite adequate FLR hypertrophy. This may be secondary to tumor progression or the development of major systemic illness. Non-surgical candidates who underwent RL would have local tumor control. In contrast, a similar patient who underwent PVE or LVD would have limited future treatment options [7].

Conclusion and/or Teaching Points: PVE is currently the standard of care when attempting to maximize FLR hypertrophy. Drawbacks to PVE include tumor progression leading to surgery cancellation. The evidence suggests that LVD stimulates accelerated FLR hypertrophy compared to PVE, which may lead to faster surgical resection. RL provides FLR hypertrophy, albeit at a slower rate than PVE and LVD. Benefits of RL over PVE and LVD include tumor necrosis allowing for tumor control or downstaging, and the test of time benefit.