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