Is hepatectomy safe following Yttrium-90 therapy? A multi-institutional international experience.

BACKGROUND: Single institution reports demonstrate variable safety profiles when liver-directed therapy with Yttrium-90 (Y-90) is followed by hepatectomy. We hypothesized that in well-selected patients, hepatectomy after Y90 is feasible and safe. METHODS: Nine institutions contributed data for patients undergoing Y90 followed by hepatectomy (2008-2017). Clinicopathologic and perioperative data were analyzed, with 90-day morbidity and mortality as primary endpoints. RESULTS: Forty-seven patients were included. Median age was 59 (20-75) and 62% were male. Malignancies treated included hepatocellular cancer (n = 14; 30%), colorectal cancer (n = 11; 23%), cholangiocarcinoma (n = 8; 17%), neuroendocrine (n = 8; 17%) and other tumors (n = 6). The distribution of Y-90 treatment was: right (n = 30; 64%), bilobar (n = 14; 30%), and left (n = 3; 6%). Median future liver remnant (FLR) following Y90 was 44% (30-78). Resections were primarily right (n = 16; 34%) and extended right (n = 14; 30%) hepatectomies. The median time to resection from Y90 was 196 days (13-947). The 90-day complication rate was 43% and mortality was 2%. Risk factors for Clavien-Dindo Grade>3 complications included: number of Y-90-treated lobes (OR 4.5; 95% CI1.14-17.7; p = 0.03), extent of surgery (p = 0.04) and operative time (p = 0.009). CONCLUSIONS: These data demonstrate that hepatectomy following Y-90 is safe in well-selected populations. This multi-disciplinary treatment paradigm should be more widely studied, and potentially adopted, for patients with inadequate FLR.

New scoring system for resectable hepatocellular carcinoma with a maximum tumor size of ≤5 cm based on preoperative tumor factors.

BACKGROUND: The aim of this study was to establish a new scoring system for hepatocellular carcinoma (HCC) that can be used to predict the postoperative prognosis of HCC patients. METHODS: A total of 359 HCC patients who underwent hepatectomy were included in this study. All eligible patients were randomly allocated to derivation cohort or validation cohort samples. We assigned one point each for preoperative factors identified in the derivation cohort, and the sum of the scores was used to classify the patients into high-risk and low-risk groups. The scoring system established using the derivation cohort was fitted to the validation cohort. RESULTS: The prognosis of the high-risk group was significantly poorer than that of the low-risk group in both the derivation and validation samples (p = 0.04, p < 0.01, respectively). In the high-risk group, major hepatectomy resulted in a significantly better prognosis than minor hepatectomy in both samples (p = 0.04, p = 0.03, respectively). On the other hand, the extent of hepatectomy did not influence the prognosis of the low-risk group in either sample (p = 0.14, p = 0.34, respectively). CONCLUSION: Our new scoring system can predict the treatment outcome of patients undergoing curative hepatectomy for HCC and could help determine the optimal extent of resection.

Predictive factors for long-term survival in patients with clinically significant portal hypertension following resection of hepatocellular carcinoma.

BACKGROUND: Hepatic resection for hepatocellular carcinoma (HCC) is not currently recommended for patients with clinically significant portal hypertension (PHT); however, recent studies have shown similar post-operative outcomes between patients with and without clinically significant PHT. AIM: To clarify the post-operative prognostic relevance of clinically significant PHT in Child-Pugh A cirrhotic patients. METHODS: A total of 100 Child-Pugh A cirrhotic patients who underwent curative resection of HCC were eligible for this analysis. Patients were divided into two groups: PHT group (n=47) and non-PHT group (n=53). RESULTS: Clinicopathological variables showed no significant differences except for prothrombine time. Liver-related complications were significantly higher in the PHT group (P=0.015), and the 5-year overall survival rate was significantly higher in the non-PHT group (78.7 vs. 37.9%, P<0.001). The proportion of patients who died because of complications of cirrhosis was significantly higher in the PHT group (P=0.001). Multivariate analysis indicated that the presence of clinically significant PHT was the most powerful adverse prognostic factor for overall survival. Multivariate analysis of the 47 patients with clinically significant PHT indicated that gross vascular invasion and non-single nodular type were poor prognostic factors. The 5-year survival rate of patients with single nodular type and without gross vascular invasion (n=17) was 78.4%. CONCLUSIONS: In Child-Pugh A cirrhotic patients, the presence of clinically significant PHT was significantly associated with post-operative hepatic decompensation and poor prognosis after resection of HCC. However, in patients with clinically significant PHT, those with single nodular tumours lacking gross vascular invasion may be good surgical candidates.