Oncological Outcomes of Portal Vein Embolization Without Tumor Clearance in Bilateral CRLM

Overview

This study compared portal vein embolization without prior tumor clearance followed by one-stage hepatectomy (PVE-OSH) to two-stage hepatectomy with PVE (TSH-PVE) and ALPPS in patients with bilateral colorectal liver metastases. PVE-OSH showed comparable postoperative outcomes and overall survival, with a lower rate of unsuccessful resections than TSH-PVE. ALPPS induced the fastest liver hypertrophy but was associated with a higher risk of liver recurrence.

Background

Resectable bilateral colorectal liver metastases (CRLM) often require major hepatectomy with adequate future liver remnant (FLR) volume to ensure safety. Portal vein embolization (PVE) is commonly used to induce hypertrophy of the FLR before resection. Traditional two-stage hepatectomy involves clearing tumors in the FLR before PVE, but this prolongs treatment time. An alternative approach is upfront PVE without prior tumor clearance, followed by a one-stage hepatectomy (PVE-OSH), potentially reducing surgical burden. However, the oncological safety and outcomes of this approach compared to established two-stage procedures remain unclear.

Data Highlights

Key Findings

• PVE-OSH patients had a lower unsuccessful resection rate (11%) compared to TSH-PVE (21%) but higher than ALPPS (4%).
• ALPPS induced the most rapid liver hypertrophy, followed by PVE-OSH, then TSH-PVE.
• The median interval from first intervention to major resection was shortest for ALPPS (1 week), intermediate for PVE-OSH (6 weeks), and longest for TSH-PVE (9 weeks).
• Postoperative outcomes including liver failure, mortality, and overall survival were similar across all three groups.
• Multivariable analysis identified the number of metastases and undergoing ALPPS as independent risk factors for liver recurrence.
• PVE-OSH can be safely performed in patients with limited tumor burden in the FLR, potentially avoiding the need for two-stage procedures.

Clinical Implications

PVE-OSH offers a viable and oncologically safe alternative to traditional two-stage hepatectomy approaches in selected patients with bilateral CRLM and limited tumor burden in the FLR. This strategy may reduce the overall treatment time and surgical burden without compromising postoperative outcomes or survival. Careful patient selection remains critical, especially considering the increased liver recurrence risk associated with ALPPS.

Conclusion

Upfront PVE without prior tumor clearance followed by one-stage hepatectomy is a safe and effective approach for managing bilateral colorectal liver metastases with limited tumor burden in the FLR. It provides comparable oncological outcomes to established two-stage procedures while potentially simplifying surgical management.

References

1. Original Study Authors 2024 -- Oncological Implications of Portal Vein Embolization Without Tumor Clearance Prior to One-Stage Hepatectomy for Bilateral Colorectal Liver Metastases