title: Liver resection for metastatic disease after y90 radioembolization: a case series with long-term follow-up.
abstract: BACKGROUND
  There are only few reports of liver resections for metastatic disease in patients previously treated with Y-90 radioembolization (RE), and long-term outcome data are sparse. We reviewed our center's experience in patients undergoing hepatectomy after hepatic RE.
  
  
  METHODS
  A retrospective chart review of patients undergoing RE from 2004 to 2011 was performed. Demographic, clinicopathologic, operative, and long-term outcomes variables were collected. Independent pathologic review of tumor necrosis and normal liver tissue grading of fibrosis and inflammation after resection was performed. Data are expressed as medians and ranges.
  
  
  RESULTS
  RE was delivered to 106 patients with primary and metastatic disease of the liver, of whom 9 patients (6 males, 3 females, median age 54 (47-76) years) with metastatic disease ultimately underwent resection. RE was previously administered to the right liver in five, the left liver in one, and to the whole liver in three. Two patients had a second RE performed before resection. Six of the nine patients had previously received several infusions of cytotoxic therapy. The operations occurred at a median of 115 (56-245) days after RE and included right lobectomy (n = 5), left lobectomy (n = 1), left-lateral sectionectomy (n = 1), and bilobar wedge resections (n = 2). Extrahepatic sites were resected in three patients. Median blood loss was 900 (range 250-3600) ml. Grade 3 or higher complications occurred in seven cases (78 %). Follow-up was complete all nine patients. Three patients (33 %) died within 30 days of resection. All those surviving the operative period had disease recurrence (time to recurrence: 202 [range 54-315] days), and all have since died (overall survival: 584 [range 127-1230] days). Review of resected specimens demonstrated median tumor necrosis of 70 % (range 20-90 %). In nontumor-bearing liver, fibrosis grade (0-4) and inflammation score (0-4) was 2 or less in all specimens.
  
  
  CONCLUSIONS
  In this small cohort of highly selected and heavily pretreated patients, long-term survival in patients undergoing resection after RE appears possible, but the operations may carry substantial risks-highlighting the importance of careful patient selection for these resections. The etiology of morbidity and mortality is likely multifactorial and additional reports that include long-term outcomes will be necessary to identify more clearly the impact of RE on postoperative complications and death.
authors.affiliation: Division of Surgical Oncology, Indiana University Health, Goshen Center for Cancer Care, Goshen, IN, USA, lhenry@iuhealth.org.
authors.forename: Leonard R
authors.initials: LR
authors.lastname: Henry
authors.forename: Richard B
authors.initials: RB
authors.lastname: Hostetter
authors.forename: Brittany
authors.initials: B
authors.lastname: Ressler
authors.forename: Ingrid
authors.initials: I
authors.lastname: Bowser
authors.forename: Min
authors.initials: M
authors.lastname: Yan
authors.forename: Houman
authors.initials: H
authors.lastname: Vaghefi
authors.forename: John
authors.initials: J
authors.lastname: Abad
authors.forename: Seza
authors.initials: S
authors.lastname: Gulec
authors.forename: Roderich E
authors.initials: RE
authors.lastname: Schwarz
mesh_terms: D000368:Aged; D003131:Combined Modality Therapy; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000532:radiotherapy* / Q000556:secondary / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology; D009929:Organ Size; D013154:Spleen / Q000503:physiopathology; D015021:Yttrium Radioisotopes / Q000627:therapeutic use*
chemical_list: D015021:Yttrium Radioisotopes