Caren van Roekel

64 Chapter 2 9.3. Radioembolization as a bridge to surgery Surgical resection of hepatic tumors offers the best chance of survival. Still, in many patients the future liver remnant (FLR) is deemed too small to preserve enough liver function, and often patients die because of liver failure. To overcome this hepatic failure, different strategies have been developed to increase the FLR, such as portal vein embolization (PVE). The FLR increases with 44-69% already 6-8 weeks after PVE. However, there are reports of patients developing tumors in the embolized and non-embolized lobes, which makes them ineligible for surgery. Radioembolization also induces hypertrophy of the untreated liver lobe, but this develops at a slower pace. This slower pace allows for the discovery of possible new lesions in the treated lobe and new lesions in the FLR (i.e. biological test of time). Furthermore, contrary to PVE, there is a tumoricidal effect in the treated lobe (141). Goebel et al. have found a mean increase of 36% in FLR volume in a series of 27 patients with HCC. A lower tumor burden, lower Child Pugh score and lower age were associated with a larger increase in FLR volume (142). An example of a patient who underwent radioembolization to induce hypertrophy of the FLR is shown in Figure 12a-d.