An Appraisal of Liver and Portal Vein Resection for Hepatocellular Carcinoma With Tumor Thrombi Extending to Portal Bifurcation

Abstract

Background: The role of surgical resection for hepatocellular carcinoma with tumor thrombi involving the major portal vein is controversial because of a high operative risk and poor prognosis. Previously, a resection was performed only when the tumor thrombi were limited to the first branch of the portal vein without extension to the portal bifurcation. Hypothesis: Concomitant liver and portal vein resection may be beneficial in patients with hepatocellular carcinoma with tumor thrombi extending to portal bifurcation. Design: Retrospective review. Setting: University hospital, tertiary referral center. Patients: Among 368 patients with hepatocellular carcinoma who underwent a curative resection, portal vein involvement occurred in 112 patients. Fifteen of the 112 patients underwent a concomitant liver and portal vein resection owing to extension of tumor thrombi to the portal bifurcation (group 1). The remaining 97 patients did not need portal vein resection (group 2). Intervention: Surgical indications, procedures, and results of pathological examination of resected specimens were assessed in patients in group 1. The clinicopathological characteristics, operative morbidity and mortality, and operative results were compared between the 2 groups. Main Outcome Measures: Disease-free and actuarial survival rates. Results: Intramural tumor infiltration was found at the site of thrombi adhesion to the portal vein cuff in 11 of 15 patients in group 1. Owing to patient selection bias, patients in group 1 were significantly younger and had better liver function and greater resected liver weight. The operative time, postoperative hospitalization, operative blood loss, amount of blood transfusion, and operative morbidity and mortality did not differ significantly between the 2 groups. The 5-year disease-free survival rates of groups 1 and 2 were 21.6% and 20.4% (P=.19), respectively, while the actuarial survival rates were 26.4% and 28.5% (P =.33), respectively. Conclusion: Liver resection with partial resection of the portal vein is justified in selected patients with hepatocellular carcinoma with tumor thrombi extending to portal bifurcation.

Hepatic resection versus transcatheter arterial chemoembolization for the treatment of hepatocellular carcinoma with portal vein tumor thrombus

“…A median survival ranging from 8.9 to 33 months was reported for HCC with PVTT with surgical treatment. [13][14][15][16][17][18][19] Although these results seems to be superior to TACE, patients who received HR were highly selected. We, therefore, conducted this casematch-control study comparing HR with TACE in the treatment of HCC with PVTT.…”

“…In our study, after HR, there was one postoperative in-hospital death caused by postoperative liver failure (0.5%), and the major complication rate was 4.0% (8 of 201), our results were similar to the studies reported previously. [13][14][15][16][17][18][19][20][21][22] Therefore, HR is still a safe treatment for HCC with PVTT.…”

“…[9][10][11][12] To improve on the results of treatment of HCC with PVTT, attempts have been made to perform HR for these patients. [13][14][15][16][17][18][19][20][21][22] HCC with PVTT remains a contraindication to liver transplantation because of the high rate of tumor recurrence, and because of the severe shortage of donor organs. HR remains the only therapeutic option that may still offer a chance of cure.…”

“…More HCC with PVTT, which previously were considered as unresectable, have become resectable. [13][14][15][16][17][18][19][20][21][22] Recent studies have even shown favorable long-term survival outcomes of HR in well-selected cases of HCC with PVTT. 21,22 However, the survival outcomes of patients with HCC with PVTT treated with HR or with TACE have not been properly compared.…”

Living donor liver transplantation with extensive caval thrombectomy for acute-on-chronic Budd-Chiari syndrome

“…Reported 5-year survival reached around 40 % (1, 2). Right or left hemihepatectomy with segmental resection of the main portal vein has been applied for HCC with PVTT extending into the main portal trunk or the contralateral portal vein, using several modified surgical techniques (3,4). This procedure is considered to be an en bloc resection.…”