Published online Dec 28, 2017. doi: 10.4254/wjh.v9.i36.1372
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
A seventy years old patient presented with a segment IV liver tumor.
Due to the presence of alcohol-related cirrhosis, a diagnosis of hepatocellular carcinoma was suspected.
Differential diagnosis included other solid liver tumors, primary or secondary.
Laboratory data, including alpha-fetoprotein were not contributive.
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.
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.
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.
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.
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.