Radiation Segmentectomy and Subsegmentectomy of Hepatocellular Carcinoma

We present 2 cases of radiation segmentectomy with yttrium-90 in 2 elderly patients with biopsy-confirmed hepatocellular carcinoma. In the following clinical images report, we review the initial presentation, diagnostic work-up, procedural planning, intervention, and postintervention follow-up imaging of successful yttrium-90 therapy.

IO Learning. 2021;9:E24-E28. Epub 2021 October 21.

Key words: hepatocellular carcinoma, radiation segmentectomy, transarterial radioembolization.

CASE 1

A 71-year-old man with history of type 2 diabetes mellitus and gastric adenocarcinoma, status post gastroesophageal junction endoscopic biopsy and resection, presented with weakness, lethargy, and abdominal pain. The patient was incidentally diagnosed with a 6.2 cm lesion in segments 5 and 8. Magnetic resonance imaging (MRI) revealed a LR-5 lesion (Figure 1). Biopsy and pathology confirmed the diagnosis of hepatocellular carcinoma. The patient was not a surgical candidate and locoregional therapy was planned for him. Alpha-fetoprotein level (AFP) was 249.7 ng/mL at the time of diagnosis. Angiogram of the right hepatic artery during yttrium-90 (Y-90) mapping/planning study showed tumor blush supplied by 2 separate arteries from segments 5 and 8 (Figure 2A). After catheterization of segment 5 (Figure 2B) and segment 8 (Figure 2C) branches, a split dose of technetium (Tc-99m) macroaggregated albumin (MAA) was delivered. Post MAA delivery, single-photon emission computed tomography (SPECT) computed tomography (CT) scan showed localization of the MAA to the lesion in segments 5 and 8 (Figure 3A). Three days later, Y-90 therapy was administered from the same location, with follow-up SPECT-CT scan confirming successful delivery of Y-90 to the target area (Figure 3B). Three-month follow-up MRI showed a non-viable lesion in segments 5 and 8 (Figure 4), with the AFP decreased to 10.4 ng/mL. The patient had no immediate or long-term postoperative complications.

CASE 2

A 74-year-old woman with history of chronic hepatitis B on concurrent tenofovir, hyperlipidemia, coronary artery disease with non-ST segment elevation myocardial infarction, and status post drug-eluting stent placement presented with chest pain and dyspnea on exertion to the emergency room. Her CT of the chest incompletely visualized nodular liver contours suggestive of  liver cirrhosis. The patient had no sign or symptom of liver decompensation. Subsequent MRI (Figure 5) revealed 1.5 cm segment 5 and 1.2 cm segment 7 LR-5 lesions, concerning for hepatocellular carcinoma. The AFP level was 518.6 ng/mL. The biopsy confirmed hepatocellular carcinoma. The multidisciplinary tumor board discussion concluded that the patient was not a candidate for resection or transplant, and the plan was set for locoregional therapy. Y-90 radioembolization mapping and shunt study showed a single-artery supply to the target lesions in the segment 5 and 7 lesions (Figures 6A and 6B), confirmed on cone-beam CT scans (Figures 7A and 7B). SPECT-CT scan following MAA injection confirmed on-target delivery of the MAA (Figures 8A and 8B). One month later, the patient underwent Y-90 radioembolization from the same locations with immediate postradioembolization SPECT-CT scan confirming delivery of Y-90 glass beads to the expected targets (Figure 8C). Follow-up MRI at 3 months demonstrated non-viable lesions in segments 5 and 7 (Figure 9), with AFP level down-trended to 4.5 ng/mL. The patient had no immediate or long-term postoperative complications.