Efficacy of Local Treatments for Hepatocellular Carcinoma Involving the Inferior Vena Cava and/or Right Atrium

Abstract

Major vessel invasion is frequently observed in locally advanced hepatocellular carcinoma (HCC). The most commonly involved major vessel is the portal vein; however, approximately 4% of patients with HCC have inferior vena cava (IVC) and/or right atrium (RA) invasion. Although these conditions have dismal prognoses, local treatments have not been regularly administered because they may affect systemic circulation. Owing to recent technological advances, various local treatments including surgery and external radiotherapy have increasingly been performed in these patients. Since irradiating tumorous lesions in the liver while preserving normal tissues is possible and major vessels are relatively resistant to radiation, external radiotherapy has been a feasible palliative modality for treating vessel-invasive HCC. In addition, systemic fatal complications that were initially a cause of concern have become rare after radiotherapy. While invasive procedures such as extracorporeal circulation or hepatic vascular exclusion may be required, pioneering surgeons have performed surgical resections in selected patients and have obtained promising results. Surgery has shown the best survival outcomes compared to other treatment options including radiotherapy, but the possibility of perioperative morbidity should be considered. In addition, a combination of local treatment and novel systemic agents, which demonstrated better survival and response rates than sorafenib, is expected to maximize therapeutic effects. In this review, we have discussed the most recent treatments for HCC with IVC and/or RA involvement and have provided information intended to guide therapeutic decisions and facilitate future research.

The inferior vena cava: anatomical variants and acquired pathologies

“…Patients typically have concomitant liver dysfunction, poor prognosis and high rate of recurrence; therefore, HCC with IVC invasion is considered an absolute contraindication to liver transplantation and managed non-surgically. However, recent studies have shown that sorafenib, external beam radiotherapy and surgery with careful patient selection can improve clinical outcomes [ 98 , 99 ].

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Transarterial Radioembolization Treatment of Advanced Hepatocellular Carcinoma Invading the Right Atrium

“…However, due to the risk of circulatory failure and the poor general status of patients with HCC RA TT, this approach is not compatible with all patients. Likewise, External beam radiation therapy is also not suitable for all patients due to the associated severe adverse effects and liver toxicity that may result from radiation doses exceeding 35 Gy [3,4,12].…”

“…Conventional TACE is the most commonly used locoregional treatment for the management of HCC and is the recommended standard therapy for intermediate-stage HCC [12]. However, TACE is generally contraindicated for cases of HCC with IVC and RA TT due to the high number of associated complications which include: high-risk ischemic hepatic necrosis, pulmonary embolization, and metastasis [10].…”