David C. Madoff

Portal vein embolization before major hepatectomy and its effects on regeneration, resectability and outcome

This study evaluated the safety of portal vein embolization (PVE), its impact on future liver remnant (FLR) volume and regeneration, and subsequent effects on outcome after liver resection.

Three hundred and one consecutive extended right hepatectomies: evaluation of outcome based on systematic liver volumetry.

Objective(s):This study aimed to determine the effect of preoperative liver volumetry on postoperative outcomes after extended right hepatectomy. Primary end point was to evaluate whether future liver remnant (FLR)/standardized liver volume ratio (sFLR) >20% is sufficient for a safe hepatic resection. Secondary end point was to assess whether preoperative portal vein embolization (PVE) is associated with improved outcome in patients with initial sFLR ≤20%. Background Data:An sFLR >20% of the total liver volume has been proposed as sufficient for safe hepatic resection, but this concept has not been validated in a large series. In addition, recent reports suggest preoperative PVE is indicated for sFLR <30%. Methods:The impact of sFLR and PVE on short-term outcomes (postoperative complications, liver insufficiency, and 90-day mortality) was analyzed in 301 consecutive patients after extended right hepatectomy. Liver volumetry accounted for partial resection of segment IV. Liver insufficiency was defined as peak postoperative serum bilirubin >7 mg/dL. Predictors of liver insufficiency were identified by multivariate logistic regression. Results:Postoperative liver insufficiency occurred in 45 patients (15%) and accounted for 61% of deaths. Among 290 patients who underwent liver volumetry, sFLR was <20% in 38 patients, 20.1% to 30% in 144, and ≥30% in 108. Rates of postoperative liver insufficiency and death from liver failure were similar between patients with sFLR 20.1% to 30% and sFLR ≥30% but higher in patients with sFLR ≤20% (P < 0.05). Postoperative outcomes were similar between patients with increase in sFLR from ≤20% to >20% after PVE and patients with initial sFLR >20%. Multivariate analysis revealed that body mass index >25 kg/m2, intraoperative blood transfusion, and sFLR ≤20% (odds ratio = 3.18; 95% CI, 1.34–7.54) independently predicted postoperative liver insufficiency. Conclusions:Systematic measurement of FLR volume is important to select patients for PVE and extended right hepatectomy. A sFLR >20% is sufficient for safe hepatic resection and sFLR 20.1% to 30% is not an indication for preoperative PVE.

High Survival Rate After Two-Stage Resection of Advanced Colorectal Liver Metastases: Response-Based Selection and Complete Resection Define Outcome

PURPOSE Prolonged survival after two-stage resection (TSR) of advanced colorectal liver metastases (CLM) may be the result of selection of best responders to chemotherapy. The impact of complete resection in this well-selected group is controversial. PATIENTS AND METHODS Data on 890 patients undergoing resection and 879 patients who received only chemotherapy for CLM were collected prospectively. We used intent-to-treat analysis to evaluate the survival of patients who underwent TSR. Additionally, we evaluated a cohort of nonsurgically treated patients selected to mirror the TSR population: colorectal metastases with liver-only disease, objective response to chemotherapy, and alive 1 year after chemotherapy initiation. RESULTS Sixty-five patients underwent the first stage of TSR; 62 patients fulfilled the inclusion criteria for the medical group. TSR patients had a mean of 6.7 ± 3.4 CLM with mean size of 4.5 ± 3.1 cm. Nonsurgical patients had a mean of 5.9 ± 2.9 CLM with mean size of 5.4 ± 3.4 cm (not significant). Forty-seven TSR patients (72%) completed the second stage. Progression between stages was the main cause of noncompletion of the second stage (61%). After 50 months median follow-up, the 5-year survival rate was 51% in the TSR group and 15% in the medical group (P = .005). In patients who underwent TSR, noncompletion of TSR and major postoperative complications were independently associated with worse survival. CONCLUSION TSR is associated with excellent outcome in patients with advanced CLM as a result of both selection by chemotherapy and complete resection of metastatic disease.

Portal vein embolization in preparation for major hepatic resection: evolution of a new standard of care.

Portal vein (PV) embolization (PVE) is gaining acceptance in the preoperative management of patients selected for major hepatic resection. PVE redirects portal blood flow to the intended liver remnant to induce hypertrophy of the nondiseased portion of the liver and thereby reduce complications and shorten hospital stays after resection. This article reviews the rationale and existing literature on PVE, including the mechanisms of liver regeneration, the pathophysiology of PVE, the imaging techniques used to measure liver volumes and estimate functional hepatic reserve, and the technical aspects of PVE, including approaches and embolic agents used. In addition, the indications and contraindications for performing PVE in patients with and without chronic liver disease and the multidisciplinary approach required for the treatment of these complex cases are emphasized.

Hepatic artery embolization and chemoembolization for treatment of patients with metastatic carcinoid tumors: The M.D. Anderson experience

BACKGROUNDCarcinoid tumors have a predilection for metastasizing to the liver. The presence of liver metastases is associated with poor prognosis and also results in significant deterioration of patients quality of life. Several reports suggest that hepatic artery embolization or chemoembolization can be used for control of liver disease in these patients. We retrospectively reviewed our experience with the use of hepatic arterial embolization or chemoembolization in patients with liver-dominant metastatic carcinoid disease, evaluating the clinical and radiologic response rates, duration of response, and progression-free and overall survival rates of these patients. MATERIALS AND METHODSThe medical records of all patients with carcinoid tumors metastatic to the liver who underwent hepatic artery embolization or chemoembolization between January 1992 and December 2000 were reviewed. For the purposes of this study, we compared the follow-up computed tomography or magnetic resonance imaging with the baseline imaging to determine each patients objective tumor response. The interval between the dates of response and disease progression was considered the response duration. Progression-free survival duration was calculated from the date of initial treatment to the date disease progression was recorded or the date of death. Survival durations were calculated using the Kaplan-Meier method. RESULTSEighty-one patients (48 men and 33 women; age range, 38–79 years) were included in this study. The mean duration of disease from the initial discovery of liver metastases until embolization was 24.5 months. Fifty patients were treated with bland hepatic artery embolization, and 31 underwent chemoembolization. Of the 69 patients in whom radiologic response could be evaluated, partial response was observed in 46 patients (67%), minimal response (MR) in six (8.7%), stable disease in 11 (16%), and progressive disease in six (8.7%). The median duration of response in the 42 patients with partial response was 17 months (range, 4–51 months). Sixty-three percent of patients had a reduction in their tumor-related symptoms. The median progression-free survival duration was 19 months (95% confidence interval, 17–21 months); the probability of progression-free survival was 75%, 35%, and 11% at 1, 2, and 3 years, respectively. The median overall survival time was 31 months (95% confidence interval, 23–38 months); the survival probability was 93% at 1 year, 62% at 2 years, and 24% at 5 years. CONCLUSIONSHepatic arterial occlusive therapy using hepatic artery embolization or chemoembolization results in symptomatic and radiologic response in most patients with carcinoid metastases in the liver. The progression-free survival of 19 months achieved with embolization in our study is encouraging, given that most patients had extensive liver involvement and had shown disease progression while receiving systemic treatment.

Transhepatic Ipsilateral Right Portal Vein Embolization Extended to Segment IV: Improving Hypertrophy and Resection Outcomes with Spherical Particles and Coils

PURPOSE To analyze outcomes after right portal vein embolization extended to segment IV (right PVE + IV) before extended right hepatectomy, including liver hypertrophy, resection rates, and complications after embolization and resection, and to assess differences in outcomes with two different particulate embolic agents. MATERIALS AND METHODS Between 1998 and 2004, transhepatic ipsilateral right PVE + IV with particles and coils was performed in 44 patients with malignant hepatobiliary disease, including metastases (n = 24), biliary cancer (n = 14), and hepatocellular carcinoma (n = 6). Right PVE + IV was considered if the future liver remnant (FLR; segments II/III with or without I) was less than 25% of the total estimated liver volume (TELV). Tris-acryl microspheres (100-700 microm; n = 21) or polyvinyl alcohol (PVA) particles (355-1,000 microm; n = 23) were administered in a stepwise fashion. Smaller particles were used to occlude distal branches, followed by larger particles to occlude proximal branches until near-complete stasis. Coils were then placed in secondary portal branches. Computed tomographic volumetry was performed before and 3-4 weeks after right PVE + IV to assess FLR hypertrophy. Liver volumes and postembolization and postoperative outcomes were measured. RESULTS After right PVE + IV with PVA particles, FLR volume increased 45.5% +/- 40.9% and FLR/TELV ratio increased 6.9% +/- 5.6%. After right PVE + IV with tris-acryl microspheres, FLR volume increased 69.0% +/- 30.7% and FLR/TELV ratio increased 9.7% +/- 3.3%. Differences in FLR volume (P = .0011), FLR/TELV ratio (P = .027), and resection rates (P = .02) were statistically significant. Seventy-one percent of patients underwent extended right hepatectomy (86% after receiving tris-acryl microspheres, 57% after receiving PVA). Thirteen patients (29%) did not undergo resection (extrahepatic spread [n = 9], inadequate hypertrophy [n = 3], other reasons [n = 1]). No patient developed postembolization syndrome or progressive liver insufficiency after embolization or resection. One death after resection occurred as a result of sepsis and hemorrhage. Median hospital stays were 1 day after right PVE + IV and 7 days after resection. CONCLUSION Transhepatic ipsilateral right PVE + IV with use of particles and coils is a safe, effective method for inducing contralateral hypertrophy before extended right hepatectomy. Embolization with small spherical particles provides improved hypertrophy and resection rates compared with larger, nonspherical particles.

Yttrium 90 Resin Microspheres for the Treatment of Unresectable Colorectal Hepatic Metastases after Failure of Multiple Chemotherapy Regimens: Preliminary Results

PURPOSE Responses to liver-directed therapy with yttrium 90 microspheres (SIR-Spheres) and adjuvant intraarterial chemotherapy have occurred in patients with unresectable colorectal hepatic metastases who had received less than one chemotherapy regimen. Now, SIR-Spheres are being used to treat patients with advanced disease who have received multiple chemotherapy regimens. A retrospective analysis was performed to determine the technical feasibility of SIR-Sphere treatment in this population. MATERIALS AND METHODS The medical records of 12 patients with hepatic metastatic disease and intrahepatic progression after multiple chemotherapy regimens for unresectable colorectal hepatic metastases who were treated with one or two infusions of SIR-Spheres were retrospectively analyzed for demographics, tumor characteristics, treatment details, response, and survival. RESULTS Twelve patients underwent 17 outpatient infusions of SIR-Spheres. Percent hepatic tumor volume was less than 25% in four patients, 25%-50% in three, and more than 50% in five. Treatment in 11 patients with bilobar disease was accomplished via single infusions in six cases and sequential unilobar infusions in five patients. A single infusion was used to treat unilobar disease in the remaining patient. Median prescribed dose was 39.6 mCi (mean, 37.2 mCi; range, 17-67.5 mCi); the prescribed dose exceeded the delivered dose in six infusions (35%) as a result of embolic arterial occlusion. Radiologic response was stable in five of nine patients. Carcinoembryonic antigen levels decreased in four of seven patients. Four patients received chemotherapy concomitantly or after completion of treatment. Gastric ulceration in one patient was managed nonoperatively. Median survival times from diagnosis and treatment were 24.6 and 4.5 months, respectively. CONCLUSIONS Treatment with SIR-Spheres induces responses in patients with advanced unresectable colorectal hepatic metastases after multiple chemotherapy regimens. Inability to deliver the prescribed dose is related to the embolic effect of SIR-Spheres.

Update on the management of neuroendocrine hepatic metastases

Neuroendocrine tumors (NETs) are rare and represent a diverse collection of malignancies that occur in many organ systems throughout the body, including the gastrointestinal and respiratory tracts. Unfortunately, the majority of patients with NETs have hepatic metastases at the time of diagnosis. Although some patients may be asymptomatic, others have unusual clinical presentations and variable tumor growth patterns. Although many patients have long indolent courses, without treatment, most patients die within 5 years of diagnosis. This article reviews the care of patients with NETs and hepatic metastases, with emphasis on the increasingly important role of oncologic image-guided interventions.

Percutaneous radiofrequency ablation of renal tumors: technique, complications, and outcomes.

PURPOSE To report the safety, technical success, and effectiveness of percutaneous radiofrequency (RF) ablation for renal tumors. MATERIALS AND METHODS The authors retrospectively reviewed the medical records and imaging studies of 29 consecutive patients (18 men, 11 women; mean age, 65 ± 2.62 years) with 30 renal tumors (mean diameter, 3.5 ± 0.24 cm) who underwent percutaneous RF ablation at their institution from September 2001 to March 2004. All procedures were performed with computed tomography guidance with general anesthesia, and all patients were admitted to the hospital for overnight observation. Technical success, complications, and their management were recorded. Technique effectiveness was assessed by imaging and clinical follow up. RESULTS Overall, 88 overlapping ablations were performed (mean, 2.6 ± 0.16 ablations per tumor per session) in 34 sessions. There were four major complications (12%). Three patients had gross hematuria and urinary obstruction, all were successfully treated. One patient had persistent anterior abdominal wall weakness. There were also two minor complications (6%) without significant clinical sequelae. One patient had gross hematuria which resolved spontaneously, another patient had transient paresthesia of the anterior abdominal wall. There were no significant changes in renal function after RF ablation. The intent of RF ablation was eradication of the primary tumor in 27 patients and treatment of gross hematuria in the other two. Technical success was achieved in all cases. Follow-up images were available for 26 patients. The primary tumor was completely ablated in 23 of 24 patients (96%) in whom eradication of the primary tumor was attempted (follow up period: mean, 10 months, median 7 months). The two patients treated for hematuria remained asymptomatic for 6 and 27 months each. CONCLUSION Percutaneous RF ablation for renal tumors is safe and well tolerated. High technical success rates are expected. Early reports of the techniques effectiveness are promising.

Nonoperative Management of Traumatic Splenic Injuries: Is There a Role for Proximal Splenic Artery Embolization?

OBJECTIVE The objective of our study was to evaluate our experience with transcatheter proximal (i.e., main) splenic artery embolization (TPSAE) in the nonsurgical management of patients with grade III-V splenic injuries, according to the American Association for the Surgery of Trauma (AAST) guidelines, and patients with splenic injuries associated with CT evidence of active contrast extravasation or blush (or cases meeting both criteria). MATERIALS AND METHODS The records of patients with traumatic splenic injuries admitted during a 52-month period were retrospectively reviewed for patient age and sex, mechanism of injury, injury severity score (ISS), RBC transfusion requirements, AAST splenic injury CT grade, presence of active contrast extravasation or blush on CT examination, and amount of hemoperitoneum on CT examination. Demographics, CT findings, transfusion requirements, and outcome were compared using the Students t test or chi-square test in patients undergoing standard nonoperative management and nonoperative management TPSAE-that is, TPSAE followed by nonoperative management. RESULTS Of the 79 identified patients with splenic trauma, 67 were managed nonoperatively. Thirty-seven patients (28 men, nine women; mean age, 40 years; mean ISS, 28.8) underwent nonoperative management TPSAE and 30 patients (27 men, three women; mean age, 37 years; mean ISS, 25.1) underwent nonoperative management. Age, sex, and ISS were not significantly different between the two groups. TPSAE was always technically feasible. Splenic injuries were significantly more severe in the nonoperative management TPSAE group than in the nonoperative management group with respect to the mean splenic injury AAST CT grade (3.7 vs 2, respectively; p < 0.0001), active contrast extravasation or blush (38% [14/37] vs 3% [1/30], respectively; p = 0.0005), and hemoperitoneum grade (1.6 vs 0.8, respectively; p = 0.0006). Secondary splenectomy rate was lower in the nonoperative management TPSAE group (2.7% [1/37] vs 10% [3/30]). No procedure-related complications were encountered during early and delayed clinical follow-up. CONCLUSION TPSAE is a feasible and safe adjunct to observation in the nonoperative management of severe traumatic splenic injuries. The secondary splenectomy rate using nonoperative management TPSAE (2.7%) is among the lowest reported despite a selection of severe injuries.