Surgical Strategy for Hepatocellular Carcinoma Patients with Portal/Hepatic Vein Tumor Thrombosis

Abstract

BackgroundPortal/hepatic vein tumor thrombosis (PVTT/HVTT) in hepatocellular carcinoma (HCC) is a sign of advanced stage disease and is associated with poor prognosis. This study investigated the surgical outcomes of patients with HCC and PVTT/HVTT to determine the most appropriate surgical treatment strategy for these patients.Materials and MethodsThe study population included 77 HCC patients from January 2004 to June 2009 who underwent hepatectomy in our department and were diagnosed with PVTT/HVTT based on pathological examination. The patients were divided into two groups: in group 1, PVTT/HVTT was located in the hepatic resection area and removed with the tumor en bloc (38 cases); in group 2, PVTT/HVTT was beyond the resection line and removed by suction or thrombectomy (39 cases). Concerning the factor of surgical margins, the patients were further divided into four subgroups: group 1A: patients in group 1 with surgical margins ≤1 cm (28 cases); group 1B: patients in group 1 with surgical margins >1 cm (9 cases); group 2A: patients in group 2 with surgical margins ≤1 cm (28 cases); and group 2B: patients in group 2 with surgical margins >1 cm (9 cases).ResultsMost of the characteristics of groups 1 and 2 were similar. Patients in group 2 had significantly higher median blood loss (p=0.002) and higher blood transfusion rate (p=0.002) during the operation, which were not considered prognostic factors (p=0.323 and 0.571, respectively). The median overall survival (OS) duration in group 1 was significantly longer than that in group 2 (14.3 vs. 10.4 months, p=0.047). The median OS durations in groups 1A, 1B, 2A, and 2B were 14.3, 42.7, 7.5, and 18.0 months, respectively, which were significantly different(p=0.018).ConclusionsWhen PVTT/HVTT is located in the hepatic resection area and removed with the tumor en bloc, the median OS duration is longer. Based on this finding, widening the surgical margins when technically possible may increase OS.

Optimal surgical strategy for hepatocellular carcinoma with portal vein tumor thrombus: A propensity score analysis

“…For HCC patients with PVTT, anatomical resection showed no advantage compared with non-anatomical resection regarding postoperative outcomes in our study, consistent with previous studies [31, 32]. The resection margin has also been evaluated as a prognostic factor for long-term outcomes after HCC resection; however, the significance of this variable also remains controversial [19, 32, 33]. Our previous study explored patterns of intrahepatic micrometastasis using large pathological sections of liver resection specimens from 113 patients with solitary HCC [34].…”

“…These findings suggest that en bloc resection may be superior to peeling off resection as an operative procedure for HCC patients with PVTT. Although three previous studies have compared the survival outcomes between en bloc and peeling off resections for HCC with PVTT, to our knowledge, our study comprises the largest study population and presents the longest follow-up data reported to date [17–19]. In addition, the current findings, which were obtained after balancing patient demographics, liver function reserves, and tumor characteristics between the en bloc and peeling off groups, provide important data that may be used to establish an optimal surgical strategy for the management of HCC patients with PVTT.…”

“…One study demonstrated the superiority of en bloc resection compared with peeling off resection for PVTT [19], although other investigators have questioned the validity of this finding because no differences in HCC recurrence or overall survival (OS) rates were identified between the two groups following resection with a curative intent [17, 18]. Unfortunately, the statistical power of these previously reported studies was limited, and no case-matched or randomized clinical trials have compared the outcomes of peeling off and en bloc resection for HCC with PVTT.…”

Indication for surgical resection in patients with hepatocellular carcinoma with major vascular invasion

“…Some studies showed that hepatic resection for MVI may be advantageous in terms of avoiding liver failure secondary to tumor thrombus (13)(14)(15)(16)(17). However, the indications for hepatic resection and transarterial therapy in HCC cases with MVI differ among institutions (2,3,12,(18)(19)(20).…”

Complete response with sorafenib and transcatheter arterial chemoembolization in unresectable hepatocellular carcinoma

“…According to the American Association for the Study of the Liver Disease/Barcelona Clinic for Liver Cancer Staging System and treatment guidelines, the only proposed treatment option for HCC patients with PVTT is sorafenib chemotherapy[4]. In Asia, various treatments including hepatectomy and transcatheter arterial chemoembolization (TACE) have been attempted and possible prolongation of overall survival (OS) has been repeatedly reported[5]. We herein report the first case of a patient with an initially unresectable advanced HCC with PVTT who underwent curative hepatectomy after sorafenib and TACE, showing complete histological response.…”