Surgical placement of biologic mesh spacers to displace bowel away from unresectable liver tumors followed by delivery of dose-intense radiation therapy.
OBJECTIVE
Delivery of radiation therapy (RT) to unresectable liver tumors is sometimes limited by proximity of radiosensitive bowel. We sought to determine if biologic mesh spacers (BMS) could be used in this situation.


METHODS
BMS composed of acellular human dermis were placed via a laparoscopic or open approach to displace bowel away from unresectable liver tumors in patients previously unable to receive radiation therapy (RT) due to risk of bowel toxicity.


RESULTS
In 1 year, 14 patients were treated. Median age was 64 years. Diagnoses included intrahepatic cholangiocarcinoma (n = 6), hepatocellular carcinoma (n = 3), and metastases (n = 5). A solitary lesion was present in 8 patients, while 4 patients had 2 lesions and 2 patients had 3 lesions. Median largest tumor size was 6.3 cm (range, 1.6-17.5 cm). Limited extrahepatic disease was present in 5 patients. The surgical approach was laparoscopic in 10 patients and open in 4 patients. Median length of stay was 2.5 days (1-8), and 3 patients developed low-grade complications. Folded, extra thick (2.3-3.3 mm) BMS, with a median area of 384 cm(2) (256-640 cm(2)), were used to displace stomach (n = 9), duodenum (7), colon (6), and small bowel (2). The mean displacement of these organs on postprocedure imaging was 23 mm, 23 mm, 24 mm, and 20 mm, respectively. Two patients did not receive RT due to extrahepatic disease progression. The remaining patients had 3-dimensional conformal proton RT (n = 5), stereotactic body RT (4), or intensity modulated RT (3). Median dose delivered was 54 Gy (40-58.5) in 5-15 fractions with only 1 patient with grade 3-4 toxicity. At short-term follow-up of at least 10 months, local disease control was obtained in 11 of 12 patients.


CONCLUSIONS
Initial dual institution experience with this novel strategy demonstrates feasibility, allowing previously untreatable liver tumor patients to receive high-dose RT.
Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. Electronic address: yoons@mskcc.org.
Sam S
SS
Yoon
Department of Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas.
Thomas A
TA
Aloia
Department of Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas.
Alex B
AB
Haynes
Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
Avinash
A
Kambadakone
Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas.
Harmeet
H
Kaur
Department of Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas.
Jean-Nicolas
JN
Vauthey
Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
Cristina R
CR
Ferrone
Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
Andrew X
AX
Zhu
Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
Jennifer Y
JY
Wo
Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
Christopher
C
Crane
Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
Theodore S
TS
Hong
D000368:Aged; D000369:Aged, 80 and over; D001688:Biological Products / Q000627:therapeutic use*; D003106:Colon / Q000601:surgery*; D005260:Female; D006801:Humans; D007421:Intestine, Small / Q000601:surgery*; D008113:Liver Neoplasms / Q000532:radiotherapy*; D008297:Male; D008875:Middle Aged; D011835:Radiation Protection / Q000379:methods*; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated; D012189:Retrospective Studies; D013270:Stomach / Q000601:surgery; D013526:Surgical Mesh
D001688:Biological Products