INTERVENTIONAL ONCOLOGY Hepatic Resection in the Era of Liver - Directed Therapies

O ver the last decade, there have been dramatic increases in the use of transarterial embolotherapies for the treatment of hepatic malignancies. Although palliative treatments remain the main driving force behind this trend, part of the increased utilization is the result of expanding indications. Increasingly, transarterial therapies are being performed in the neoadjuvant and adjuvant settings, to downstage tumors, bridge patients to liver transplant, and improve postoperative survival. Over this same period of time, advances in preand postoperative management, as well as surgical techniques, have expanded the number of patients who can benefit from surgical resection. As the concomitant use of liver-directed therapies and surgical resection continue to evolve, it is imperative that both the interventional radiologist and surgeon understand the implications of patients sequentially undergoing each treatment modality. This article briefly explores the sequential use of transarterial therapies before and after major liver resection. TRANSARTERIAL THERAPY BEFORE LIVER RESECTION Surgical resection and ablation are considered the treatments of choice for most resectable liver cancers. Although the role of neoadjuvant transarterial chemoembolization (TACE) in the setting of resectable tumors has been explored with an abundance of data verifying its safety and efficacy, this role remains controversial and not widely adopted,1 as no clear survival benefit has been proven in this setting. For the majority of patients, surgery is not initially an option for a variety of reasons, including advanced tumor stage, significant comorbidities, inadequate future liver remnant (FLR), or poor performance status. Furthermore, certain patients are deemed unresectable due to the size or location of their hepatic tumors. This subset of patients may potentially be resectable or eligible for transplantation if their tumors can be adequately downsized.2,3 As early as 1993, Yu et al demonstrated the benefits and safety of performing surgery What every interventional radiologist and surgeon needs to know.