Elsevier

Journal of Surgical Research

Volume 266, October 2021, Pages 269-283
Journal of Surgical Research

Outcomes of Hepatic Resection for Hepatocellular Carcinoma Associated with Portal Vein Invasion

https://doi.org/10.1016/j.jss.2021.04.011Get rights and content

Highlights

  • Hepatocellular carcinoma has a very high tendency to portal vein invasion.

  • Surgical management of selected advanced hepatocellular carcinomas with macroscopic portal vein invasion is feasible.

  • It associated with comparable disease-free survival but poorer overall survival.

  • Surgical management should be considered to improve the survival rates compared to other palliative modalities.

ABSTRACT

Background

To evaluate our experience of liver resection for hepatocellular carcinoma (HCC) patients associated with macroscopic portal vein invasion (PVI).

Methods

Consecutive HCC patients who underwent liver resection for HCC between November 2009 & June 2019 were included. To overcome selection bias between patients with and without macroscopic PVI, we performed 1:1 match using propensity score matching (PSM).

Results

Macroscopic PVI was detected in 37 patients (12.8%). We divided our patients into two groups according to the presence of macroscopic PVI. After PSM, 36 patients of PVI group were matched with 36 patients from Non-PVI group. After PSM, both groups were well balanced regarding tumor site, number, liver resection extent and type. Longer operation time and more blood loss were noted in PVI group. Higher incidence of post-operative morbidities occurred in PVI group especially, post-hepatectomy liver dysfunction. The 1-, 2-, and 3-y overall survival rates for Non-PVI group were 85.3%, 64.6%, and 64.6% & 69.8%, 42%, and 0% for PVI group, respectively (P = 0.009). There were no significant differences regarding the recurrence rate, site, and its management. The 1-, 2-, and 3-y disease-free survival (DFS) rates for Non-PVI group were 81.7%, 72.3%, and 21.7% & 67.7%, 42.3%, and 0% for PVI group, respectively (P = 0.172).

Conclusion

Surgical management of advanced HCCs with macroscopic PVI is feasible, and associated with comparable DFS but poorer overall survival, compared to patients without PVI.

Introduction

Hepatocellular carcinoma (HCC) is one of the commonest malignancies all over the world and it is the second most common etiology of tumor associated mortalities.1,2 The overall incidence of HCC is rising continuously among Egyptian patients as a result of the high prevalence of hepatitis C viral (HCV) infection (genotype 4). Nowadays, it is considered as the most challenging health care problem by Egyptian health authorities.3

HCC has a very high tendency to portal vein invasion (PVI). The presence of macroscopic PVI is heterogenous among different studies and it is found in about 30%-62% of advanced HCC cases4, 5, 6, 7; however, the incidence is undoubtedly underestimated. The presence of macroscopic PVI is always regarded as a very strong negative prognostic factor for HCC patients, due to the high risk of dissemination of the malignant cancer cells into the blood stream and metastasis to the liver and other organs. The median survival of untreated HCC patients with macroscopic PVI has been reported to be around 2.7 – 4 mo.8,9

The American Association for the Study of the Liver Disease and/or Barcelona Clinic for Liver Cancer (BCLC) Staging System of HCC classified patients with macroscopic PVI as an advanced stage of HCC (stage C) with no chance for curative treatment.10,11 They recommended that systemic therapy (sorafenib) is the best management strategy for HCC patients with macroscopic PVI. However, systemic therapy can permit a very poor extension of the life expectancy for those advanced patients. The reported median survival time of almost 10 mo after systemic therapy for HCC patients with macroscopic PVI.12,13 Consequently, the management of advanced HCC patients associated with macroscopic PVI remains a controversial issue.

Surgical resection may have a role in the management of selected patients of HCC associated with macroscopic PVI. Recent advancements of the surgical techniques and perioperative care allowed liver resections to be performed easily and safely. Some studies from tertiary high-volume centers had shown that aggressive liver resection for selected patients with macroscopic PVI is beneficial to prevent hepatic decompensation from tumor thrombosis.5,6,13, 14, 15 However, the outcomes had been heterogenous among different studies especially regarding the long-term survival outcomes and tumor recurrence.

The aim of this study was to evaluate our center experience of liver resection for HCC patients associated with macroscopic PVI. We aimed to compare the short-term and the survival outcomes after liver resection between two matched groups of HCC patients with and without macroscopic PVI utilizing propensity score matching (PSM).

Section snippets

Materials and methods

We retrospectively review the data of patients who underwent curative liver resection for pathologically confirmed HCC at Gastrointestinal Surgery Center, Mansoura University, Egypt during the period between November 2009 till June 2019. Patient data were retrieved from a prospectively maintained database for all patients undergoing liver resection.

An informed consent was obtained from each patient prior to surgical intervention for participation in the study. The study was approved by

Results

During the study period, 288 consecutive patients underwent curative liver resection for pathologically confirmed HCC at Gastrointestinal Surgery Center, Mansoura University, Egypt.

Macroscopic PVI was detected in 37 patients (12.8%). According to classification system of Liver Cancer Study Group of Japan, Vp0 was found in 251 patients (87.2%), Vp1 was found in 3 patients (1%), Vp2 was found in 12 patients (4.2%), Vp3 was found in 20 patients (6.9%), and Vp4 was found in 2 patients (0.7%).

We

Discussion

Patients with advanced stage HCC associated with macroscopic PVI have been reported to have an extremely poor prognosis.4, 5, 6, 7,26 The median survival of untreated HCC patients with macroscopic PVI has been reported to be around 2.7-4 mo after diagnosis.8,9,27,28 The presence of macroscopic PVI can cause severe portal hypertension and esophageal varices, hepatic decompensation from occlusion of hepatic portal inflow, and dissemination of the malignant cancer cells into the blood stream and

Authors’ Contribution

The conception and design of the manuscript: Shehta A, Farouk A, Fouad A.

The acquisition, analysis, or interpretation of data of the manuscript: Shehta A, Farouk A.

Drafting the manuscript: all authors.

Revision of the manuscript critically for important intellectual content: all authors.

Final approval of the version of the manuscript to be published: all authors.

Disclosure

All authors declare no conflicts of interest.

Acknowledgment

No external funding resources or grants.

References (55)

  • T Ohkubo et al.

    Surgical results for hepatocellular carcinoma with macroscopic portal vein tumor thrombosis

    J Am Coll Surg

    (2000)
  • N Li et al.

    Hepatocellular carcinoma with main portal vein tumor thrombus: a comparative study comparing hepatectomy with or without neoadjuvant radiotherapy

    HPB (Oxford)

    (2016)
  • JH Zhong et al.

    Controversies and evidence of hepatic resection for hepatocellular carcinoma

    BBA Clin

    (2016)
  • LA Torre et al.

    Global cancer statistics, 2012

    CA Cancer J Clin

    (2015)
  • J Ferlay et al.

    Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012

    Int J Cancer

    (2015)
  • I Waked et al.

    Screening and treatment program to eliminate hepatitis C in Egypt

    N Engl J Med

    (2020)
  • Q Zhou et al.

    Prognostic analysis for treatment modalities in hepatocellular carcinomas with portal vein tumor thrombi

    Asian Pac J Cancer Prev

    (2011)
  • G Torzilli et al.

    A snapshot of the effective indications and results of surgery for hepatocellular carcinoma in tertiary referral centers: Is it adherent to the EASL/AASLD recommendations? An observational study of the HCC East-West study group

    Ann Surg

    (2013)
  • M Minagawa et al.

    Treatment of hepatocellular carcinoma accompanied by portal vein tumor thrombus

    World J Gastroenterol

    (2006)
  • JM Llovet et al.

    Natural history of untreated nonsurgical hepatocellular carcinoma: rationale for the design and evaluation of therapeutic trials

    Hepatology

    (1999)
  • JM Llovet et al.

    Sorafenib in advanced hepatocellular carcinoma

    N Engl J Med

    (2008)
  • T Higaki et al.

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

    Bioscience trends

    (2017)
  • Y Yamamoto et al.

    Post-hepatectomy survival in advanced hepatocellular carcinoma with portal vein tumor thrombosis

    World J Gastroenterol

    (2015)
  • MA Wahab et al.

    Predictors of recurrence in hepatitis C virus related hepatocellular carcinoma after hepatic resection: a retrospective cohort study

    Eurasian J Med

    (2014)
  • M Abdel-Wahab et al.

    Prognostic factors affecting survival and recurrence after hepatic resection for hepatocellular carcinoma in cirrhotic liver

    Langenbecks Arch Surg

    (2010)
  • SM Strasberg et al.

    The Brisbane 2000 terminology of liver anatomy and resections

    HPB Surg

    (2000)
  • I Ikai et al.

    Report of the 17th nationwide follow up survey of primary liver cancer in Japan

    Hepatol Res

    (2007)
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