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Surgical resection is considered first line and potentially curative for early stage hepatocellular carcinoma. However, many patients presenting with small tumors might not qualify as candidates for surgical resection given their small future liver remnant (FLR); such patients tend to undergo neoadjuvant therapies prior to resection to minimize the risk of hepatic decompensation after major hepatic resection. While there are several techniques for inducing FLR hypertrophy, a recent approach in hepatocellular carcinoma is Y90 radiation lobectomy (RL). RL was discovered serendipitously after noticing contralateral lobar hypertrophy in patients who had ipsilateral lobar Y90 radioembolization. This is now proactively used in bridging patients to surgical resection by inducing FLR hypertrophy. In this article we discuss the evolution of RL as an alternative to portal vein embolization which has been long used to induce FLR hypertrophy, albeit mostly in metastatic liver disease.

Purpose As an alternative to radical cystectomy (RC), tri-modality treatment (TMT) is an effective treatment approach for selected patients with muscle-invasive bladder cancer (MIBC). The purpose of this report is to contribute to the literature by summarizing institutional outcomes of a bladder-preserving TMT approach for patients with MIBC. Methods Patients treated with TMT for MIBC from 1998-2019 were identified. Patient, disease, and treatment factors were recorded. Overall survival (OS), disease-free survival (DFS), and bladder-preserved disease-free survival (bpDFS) were estimated with the Kaplan-Meier method. Prognostic factors were evaluated with Cox proportional hazards regression. Results Thirty-two patients treated with TMT to a median dose of 64.8Gy, for T2 (78%), T3 (19%) and T4 (3%) disease were followed for a median of 19 months (mean: 36, range 6 – 213); 31% had associated carcinoma-in-situ (CIS); 25% had associated hydronephrosis. Cisplatin was the most commonly used chemotherapeutic agent. OS rates were 84% at 1-yr and 61% at 5-yrs. DFS rates were 84% and 61% and bpDFS rates were 84% and 60% at 1-yr and 5-yrs, respectively. Salvage cystectomy rates at 1- and 5-yrs were 4% and 9%, respectively. Four patients had locally invasive recurrences at 8, 11, 34, and 37 months after initial MIBC diagnosis, two of whom underwent salvage radical cystectomy. Ten (31%) patients developed distant disease at a median of 13 months after diagnosis. Unlike local recurrence, distant recurrences were associated with worse OS, hazard ratios of 3.4 (p.=0.039) Conclusion OS and DFS were comparable to those of published data. Our outcomes support TMT as an effective option for carefully selected patients with MIBC. Summary In this series, we summarize the bladder preserving/trimodality treatment experiences at our institution in hopes of contributing to the literature. Our institutional experience with bladder preservation confirms previously reported oncologic control rates with 5-year DFS and OS of 61% (95% CI: 37 – 77%) and 61% (95% CI: 38 – 77%), despite a higher risk population comprising many patients with T3+ disease and/or incomplete TURBT. Trimodality treatment is underutilized as a viable radiation-based organ preservation approach.