Florian Bösch1,2, Harun Ilhan2,3, Vanessa Pfahler2,4, Michael Thomas1,2, Thomas Knösel2,5, Valentin Eibl1,2, Sebastian Pratschke1,2, Peter Bartenstein2,3, Max Seidensticker2,4, Christoph J Auernhammer2,6, Christine Spitzweg2,6, Markus O Guba1,2, Jens Werner1,2, Martin K Angele1,2. 1. Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany. 2. Interdisciplinary Center of Neuroendocrine Tumors of the GastroEnteroPancreatic System, Ludwig-Maximilians-University Munich, Munich, Germany. 3. Department of Nuclear Medicine, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany. 4. Department of Radiology, Ludwig-Maximilians-University Munich, Munich, Germany. 5. Institute of Pathology, Ludwig-Maximilians-University Munich, Munich, Germany. 6. Department of Internal Medicine 4, Ludwig-Maximilians-University Munich, Munich, Germany.
Abstract
BACKGROUND: Radioembolization (RE) is well established in the treatment of neuroendocrine liver metastases. However surgery is rarely performed after RE, although liver resection is the gold standard in the treatment of localized neuroendocrine liver metastases. Therefore, aim of the present study was to evaluate the safety and feasibility of liver resection after RE in a homogenous cohort. METHODS: From a prospective surgical (n=494) and nuclear medical (n=138) database patients with NELM who underwent liver resection and/or RE were evaluated. Between September 2011 and December 2017 eight patients could be identified who underwent liver resection after RE (mean therapeutic activity of 1,746 Mbq). Overall and progression free survival were evaluated as well as epidemiological and perioperative factors. The surgical specimens were analyzed for necrosis, fibrosis, inflammation, and steatosis. RESULTS: The mean hepatic tumor load of patients, who had liver surgery after RE, was 31.4% with a mean Ki-67 proliferation index of 5.9%. The majority of these patients (7/8) received whole liver RE prior to liver resection, which did not increase morbidity and mortality compared to a surgical collective. Indications for RE were oncological (6/8) or carcinoid syndrome associated reasons (2/8). Mean overall survival was 25.1 months after RE and subsequent surgery. Tumor necrosis in radioembolized lesions was 29.4% without evidence of fibrosis and inflammation in hepatic tissue. CONCLUSIONS: This is the first study analyzing the multimodal therapeutic approach of liver resection following whole liver RE. This treatment algorithm is safe, does not lead to an increased morbidity and is associated with a favorable oncological outcome. Nonetheless, patient selection remains a key issue. 2020 Hepatobiliary Surgery and Nutrition. All rights reserved.
BACKGROUND: Radioembolization (RE) is well established in the treatment of neuroendocrine liver metastases. However surgery is rarely performed after RE, although liver resection is the gold standard in the treatment of localized neuroendocrine liver metastases. Therefore, aim of the present study was to evaluate the safety and feasibility of liver resection after RE in a homogenous cohort. METHODS: From a prospective surgical (n=494) and nuclear medical (n=138) database patients with NELM who underwent liver resection and/or RE were evaluated. Between September 2011 and December 2017 eight patients could be identified who underwent liver resection after RE (mean therapeutic activity of 1,746 Mbq). Overall and progression free survival were evaluated as well as epidemiological and perioperative factors. The surgical specimens were analyzed for necrosis, fibrosis, inflammation, and steatosis. RESULTS: The mean hepatic tumor load of patients, who had liver surgery after RE, was 31.4% with a mean Ki-67 proliferation index of 5.9%. The majority of these patients (7/8) received whole liver RE prior to liver resection, which did not increase morbidity and mortality compared to a surgical collective. Indications for RE were oncological (6/8) or carcinoid syndrome associated reasons (2/8). Mean overall survival was 25.1 months after RE and subsequent surgery. Tumor necrosis in radioembolized lesions was 29.4% without evidence of fibrosis and inflammation in hepatic tissue. CONCLUSIONS: This is the first study analyzing the multimodal therapeutic approach of liver resection following whole liver RE. This treatment algorithm is safe, does not lead to an increased morbidity and is associated with a favorable oncological outcome. Nonetheless, patient selection remains a key issue. 2020 Hepatobiliary Surgery and Nutrition. All rights reserved.
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