Surgical management of hepatocellular carcinoma with tumor thrombi in the inferior vena cava or right atrium

Abstract

BackgroundThe prognosis for advanced hepatocellular carcinoma (HCC) with tumor thrombi in the inferior vena cava (IVC) or right atrium (RA) is poor, and there is no established effective treatment for this condition. Thus study aimed to evaluate the efficacy of surgical resection and prognosis after surgery for such cases.MethodsBetween January 1990 and December 2012, 891 patients underwent hepatectomy for HCC at our institution. Of these, 13 patients (1.5%) diagnosed with advanced HCC with tumor thrombi in the IVC or RA underwent hepatectomy and thrombectomy. Data detailing the surgical outcome were evaluated and recurrence-free and overall survival rates were calculated using the Kaplan-Meier method.ResultsSeven patients had an IVC thrombus and six had an RA thrombus. Extra-hepatic metastasis was diagnosed in 8 of 13 patients. Surgical procedures included three extended right lobectomies, three extended left lobectomies, five right lobectomies, and two sectionectomies. Right adrenal gland metastases were excised simultaneously in two patients. All IVC thrombi were removed under hepatic vascular exclusion and all RA thrombi were removed under cardiopulmonary bypass (CPB). Four patients (30.8%) experienced controllable postoperative complications, and there was no surgical mortality. The mean postoperative hospital stay for patients with IVC and RA thrombi was 23.6 ± 12.5 days and 21.2 ± 4.6 days, respectively. Curative resection was performed in 5 of 13 cases. The 1- and 3-year overall survival rates were 50.4%, and 21.0%, respectively, and the median survival duration was 15.3 months. The 1- and 3-year overall survival rates for patients who underwent curative surgical resection were 80.0% and 30.0%, respectively, with a median survival duration of 30.8 months. All patients who underwent curative resection developed postoperative recurrences, with a median recurrence-free survival duration of 3.8 months. The 1-year survival rate for patients who underwent noncurative surgery and had residual tumors was 29.2%, with a median survival duration of 10.5 months.ConclusionsAggressive surgical resection for HCC with tumor thrombi in the IVC or RA can be performed safely and may improve the prognoses of these patients. However, early recurrence and treatment for recurrent or metastatic tumors remain unresolved issues.

Liver resection versus transcatheter arterial chemoembolization for the treatment of patients with hepatocellular carcinoma and hepatic vein or inferior vena cava tumor thrombus: A propensity score matching analysis

“…Due to the paucity of data regarding the best management of HCC patients with HVTT or IVCTT, therapeutic options for this subgroup of patients are controversial. Currently, surgical resection of the primary tumor and the tumor thrombus and TACE with or without conformal radiotherapy have been reported, but there is no current credible evidence suggesting that these therapies offer benefits to patients, because all previous studies were either case reports or had a non‐control design . To our knowledge, this is the first large case series study to compare treatment outcomes among HCC patients with HVTT or IVCTT who were treated with LR or TACE using PSM analysis.…”

Surgery for Intermediate and Advanced Hepatocellular Carcinoma: A Consensus Report from the 5th Asia-Pacific Primary Liver Cancer Expert Meeting (APPLE 2014)

“…The resection of HCC with tumor thrombus extending into the right atrium is limited to case reports. Early recurrence within 6 months occurred in almost all patients, even if the patients underwent complete tumor resection [44]. However, surgical resection of metastasis to the right atrium may relieve associated symptoms.…”

Liver resection with thrombectomy for patients with hepatocellular carcinoma and tumour thrombus in the inferior vena cava or right atrium

“…Recently, Kokudo and colleagues 12 , in an analysis of data from the Liver Cancer Study Group of Japan database, reported excellent patient outcomes for patients with HCC and IVC TT who received systemic chemotherapy or HAIC, with a median OS of 15⋅4 months. In contrast, for surgical resection, promising median OS results in these patients have been reported as 16⋅7-30⋅8 months 8,12,13,15 . These reports imply that resection should be incorporated in the multidisciplinary treatment of this advanced disease.…”