Portal vein embolization versus radiation lobectomy as pre-treatment for major liver resection for colorectal liver metastases: functional assessment of the future liver remnant

Abstract

Introduction: Insufficiency of the future liver remnant (FLR) precludes surgery for liver tumors as it is associated with post-hepatectomy liver failure (PHLF). A common strategy to induce pre-operative FLR hypertrophy is portal vein embolization of the tumor bearing liver lobe. More recently, transarterial radio-embolization (radiation lobectomy, RL) has been employed. Direct functional assessment using 99mTc-mebrofenin-hepatobiliary-scintigraphy (HBS) predicts FLR sufficiency more accurately than conventional volume assessment. However, studies describing dynamic functional assessment of the FLR after RL as induction for surgery are currently lacking. This study aims to compare FLR functional changes after PVE and RL. Methods: This non-interventional retrospective single-center cohort study was performed between 2016 and 2024. Patients with colorectal liver metastases (CRLM) who underwent PVE or RL because of an insufficient FLR (HBS < 2.7%/min/m2) were included. Induction of sufficient FLR function was the primary outcome. Results: Ten PVE- and ten RL-treated patients were included. The median duration to achieve sufficient FLR function was longer for RL- than PVE-treated patients (75 days (64–85) vs 31 days (28–54.5), p = 0.002). RL showed a non-significant higher median functional increase (58.6% vs 51.1%, p = 0.940) and a significantly higher voluminal increase (65.7% vs 36.8%, p = 0.049) compared to PVE. PHLF and resection margins were comparable among groups. There was no 90 day mortality. Conclusion: RL represents a feasible alternative to PVE with comparable functional outcomes, particularly in patients with lower baseline FLR function or need for simultaneous tumor control. This warrants prospective studies with optimized RL protocols to better define the functional outcomes and clinical applications of RL versus PVE.