# Anatomical Quantitative Volumetric Evaluation of Liver Segments in Hepatocellular Carcinoma Patients Treated with Selective Internal Radiation Therapy: Key Parameters Influencing Untreated Liver Hypertrophy

## TL;DR

This study identifies factors like younger age and treatment specifics that influence liver growth after radiation therapy for liver cancer.

## Contribution

The study introduces an anatomical volumetric approach to evaluate liver changes after SIRT and identifies key parameters influencing untreated liver hypertrophy.

## Key findings

- Younger patients with smaller spleen volume and higher 90Y activity showed greater untreated liver hypertrophy.
- The amount of treated liver strongly impacts relative untreated liver volume increase.
- Liver function stability post-SIRT correlates with increased untreated liver hypertrophy.

## Abstract

Selective internal radiation therapy (SIRT) is widely used for hepatocellular carcinoma (HCC) treatment. Following SIRT, complex morphological changes in the liver occur, with hypertrophy of the untreated liver and atrophy of the treated liver. However, the factors affecting these morphological changes are still unclear. This study aimed to investigate liver volume changes after SIRT for HCC with different levels of treatment selectivity and to evaluate the parameters affecting these changes using a segmentation-based 3D software relying on liver vascular anatomy. Our results, based on a cohort of 88 HCC patients treated with SIRT, showed that younger patients with smaller spleen volume, higher administered 90Y activity, and larger amount of treated liver had a higher degree of untreated liver hypertrophy. When SIRT is used in potential surgical candidates, these parameters should be considered to improve patient selection.

Background: Factors affecting morphological changes in the liver following selective internal radiation therapy (SIRT) are unclear, and the available literature focuses on non-anatomical volumetric assessment techniques in a lobar treatment setting. This study aimed to investigate quantitative changes in the liver post-SIRT using an anatomical volumetric approach in hepatocellular carcinoma (HCC) patients with different levels of treatment selectivity and evaluate the parameters affecting those changes. This retrospective, single-institution, IRB-approved study included 88 HCC patients. Whole liver, liver segments, tumor burden, and spleen volumes were quantified on MRI at baseline and 3/6/12 months post-SIRT using a segmentation-based 3D software relying on liver vascular anatomy. Treatment characteristics, longitudinal clinical/laboratory, and imaging data were analyzed. The Student’s t-test and Wilcoxon test evaluated volumetric parameters evolution. Spearman correlation was used to assess the association between variables. Uni/multivariate analyses investigated factors influencing untreated liver volume (uLV) increase. Results: Most patients were cirrhotic (92%) men (86%) with Child–Pugh A (84%). Absolute and relative uLV kept increasing at 3/6/12 months post-SIRT vs. baseline (all, p ≤ 0.005) and was maximal during the first 6 months. Absolute uLV increase was greater in Child–Pugh A5/A6 vs. ≥B7 at 3 months (A5, p = 0.004; A6, p = 0.007) and 6 months (A5, p = 0.072; A6, p = 0.031) vs. baseline. When the Child–Pugh class worsened at 3 or 6 months post-SIRT, uLV did not change significantly, whereas it increased at 3/6/12 months vs. baseline (all p ≤ 0.015) when liver function remained stable. The Child–Pugh score was inversely correlated with absolute and relative uLV increase at 3 months (rho = −0.21, p = 0.047; rho = −0.229, p = 0.048). In multivariate analysis, uLV increase was influenced at 3 months by younger age (p = 0.013), administered 90Y activity (p = 0.003), and baseline spleen volume (p = 0.023). At 6 months, uLV increase was impacted by younger age (p = 0.006), whereas treatment with glass microspheres (vs. resin) demonstrated a clear trend towards better hypertrophy (f = 3.833, p = 0.058). The amount (percentage) of treated liver strongly impacted the relative uLV increase at 3/6/12 months (all f ≥ 8.407, p ≤ 0.01). Conclusion: Liver function (preserved baseline and stable post-SIRT) favored uLV hypertrophy. Younger patients, smaller baseline spleen volume, higher administered 90Y activity, and a larger amount of treated liver were associated with a higher degree of untreated liver hypertrophy. These factors should be considered in surgical candidates undergoing neoadjuvant SIRT.