Liver resection for hepatocellular carcinoma associated with hepatic vein invasion: A Japanese nationwide survey

Stereotactic body radiotherapy plus transcatheter arterial chemoembolization for inoperable hepatocellular carcinoma patients with portal vein tumour thrombus: A meta-analysis

Background

The efficacy and safety of stereotactic body radiotherapy (SBRT) plus transcatheter arterial chemoembolization (TACE) versus SBRT or TACE alone(monotherapy) for hepatocellular carcinoma (HCC) patients with portal vein tumour thrombus (PVTT) remains controversial. This meta-analysis was performed to provide more powerful evidence for clinical strategies in inoperable HCC with PVTT.

Methods

We searched the PubMed, EMBASE, Web of Science, Cochrane Library, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), VIP Journal Integration Platform (VIP), and WanFang databases for eligible studies. We pooled the results of 1- and 2-year overall survival rates (OSRs), objective response rates (ORRs), and adverse events (AEs) between the two groups and performed a subgroup meta-analysis for study type, control group, treatment order, and the interval between SBRT and TACE.

Results

Nine studies with 10 cohorts involving 938 patients were included in our meta-analysis. SBRT plus TACE yielded significantly higher 1-year OSR (RR, 1.52[95% CI, 1.33–1.74]), 2-year OSR (RR, 2.00 [95% CI: 1.48–2.70]), ORR (RR = 1.22 [95% CI, 1.08–1.37]), and a lower progression disease (PD) rate (RR = 0.45 [95% CI:0.26–0.79]) than monotherapy. No significant differences were detected in CR, PR, SD, or AEs between the two groups. Subgroup analysis regarding study type, control group, and treatment order indicated that compared with monotherapy, the combination of SBRT with TACE was associated with an increase in 1- and 2-year OSRs but not in ORR. In regard to the interval between SBRT and TACE, subgroup analysis found that the combination therapy for patients with an SBRT-TACE interval <28 days was preferable to monotherapy in the 1- and 2-year OSRs, and ORR. However, for patients with an SBRT-TACE interval ≥28 days, no obvious distinctions were observed in the 1-year OSR, 2-year OSR, or ORR between the two groups.

Conclusion

The combination of SBRT with TACE appears to be better than monotherapy in treating HCC with PVTT and should be recommended for inoperable HCC patients with PVTT.

Simultaneous surgical treatment of hepatocellular carcinoma with tumor thrombus in the inferior vena cava and ischemic heart disease own research and literature review

&lt;b&gt; Introduction:&lt;/b&gt; Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Tumor penetration into the inferior vena cava/right atrium is rare, as it occurs only in 34% of HCC patients. There are no clear guidelines for the management of this stage of disease. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Aim:&lt;/b&gt; This is a case report of a patient with HCC and tumor thrombus in the inferior vena cava and with advanced coronary artery disease. &lt;/br&gt;&lt;/br&gt; &lt;b&gt; Materials and methods:&lt;/b&gt; The patient was qualified for a simultaneous cardiac surgery and liver resection with removal of the tumor thrombus from the inferior vena cava due to a high risk of sudden cardiac death. The first stage involved aortocoronary bypass followed by a right-sided hemihepatectomy with removal of the tumor thrombus from the inferior vena cava (this part of the operation was performed by extracorporeal circulation). The postoperative period was uneventful. Surgical treatment is one of the therapeutic options that offers a chance to radically remove the tumor and extend the patient&apos;s life. From a standpoint, these operations are extremely difficult and carry a high risk of perioperative complications (up to 40%). At the same time, the patient is at risk of complications due to cancer, such as pulmonary embolism, tricuspid stenosis, and congestive heart failure, which should be considered when choosing a treatment method. A significant number of patients also suffer from chronic conditions that worsen the prognosis. Cardiac diseases combined with tumor thrombus in the inferior vena cava may cause sudden cardiac death. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Conclusions:&lt;/b&gt; Surgical treatment should be considered in patients with HCC and tumor thrombus in the inferior vena cava, especially in patients with cardiovascular disease burden, as it is not only a chance to prolong life, but also to protect them against life-threatening cardiac complications.

Successful conversion therapy and radical resection for huge Barcelona Clinic Liver Cancer stage C hepatocellular carcinoma: A case report

BACKGROUND

Conversion therapy play a key role in the treatment of Barcelona Clinic Liver Cancer stage C (BCLC-C) hepatocellular carcinoma.

CASE SUMMARY

We report a patient with BCLC-C hepatocellular carcinoma who underwent conversion therapy. Radical resection was executed consecutively after portal vein tumor thrombus regression.

CONCLUSION

Conversion therapy may provide an opportunity for curative therapy in patients with advanced hepatocellular carcinoma. More attention should be paid to systemic therapy in patients with initially unresectable tumors.

Transarterial Chemoembolization for Hepatocellular Carcinoma in Clinical Practice: Temporal Trends and Survival Outcomes of an Iterative Treatment

Background

Transarterial chemoembolization (TACE) is one of the most frequently applied treatments for hepatocellular carcinoma (HCC) worldwide. In this study, we aimed at evaluating whether and how TACE application and repetition, as well as the related outcome, have changed over the last three decades in Italy.

Methods

Data of 7,184 patients with HCC were retrieved from the Italian Liver Cancer (ITA.LI.CA) database. Patients were divided according to the period of diagnosis in six cohorts: P1 (1988–1993), P2 (1994–1998), P3 (1999–2004), P4 (2005–2009), P5 (2010–2014), and P6 (2015–2019). All the analyses were repeated in the overall patient population and in Barcelona Clinic Liver Cancer (BCLC) B patients, who are the subgroup of HCC patients originally supposed to receive TACE according to guidelines. TACE was defined as either the first or the main (more effective) treatment.

Results

The proportion of patients receiving TACE as first or main therapy declined over time, and less than 50% of BCLC B patients were treated with chemoembolization from P3 onward. Conversely, TACE was widely used even outside the intermediate stage. Survival of TACE-treated patients progressively increased from P1 to P6. Although TACE was performed only once in the majority of patients, there was an increasing proportion of those receiving 2 or ≥3 treatments sessions over time. The overall survival (OS) of patients undergoing repeated treatments was significantly higher compared to those managed with a single TACE (median OS 40.0 vs. 65.0 vs. 71.8 months in 1, 2, and ≥3 TACE groups, respectively; p < 0.0001). However, after a first-line TACE, the adoption of curative therapies provided longer survival than repeating TACE (83.0 vs. 42.0 months; p < 0.0001), which in turn was associated with better outcomes compared to systemic therapies or best supportive care (BSC).

Conclusions

Despite a decline in the percentage of treated patients over time, TACE has still an important role in the management of HCC patients. The survival of TACE-treated patients gradually improved over time, probably due to a better patient selection. Iterative TACE is effective, but an upward shift to curative therapies provides better outcomes while transition to systemic therapies and BSC leads to a worse prognosis.

Precision Medicine for Hepatocellular Carcinoma: Clinical Perspective

Hepatocellular carcinoma (HCC) is one of the major malignant diseases worldwide, characterized by growing incidence and high mortality rates despite apparent improvements in surveillance programs, diagnostic and treatment procedures, molecular therapies, and numerous research initiatives. Most HCCs occur in patients with liver cirrhosis, and the competing mortality risks from the tumor and the cirrhosis should be considered. Presently, previously identified risk factors, such as hepatitis virus infection, hepatic inflammation and fibrosis, and metabolic syndrome, may be used as chemoprevention targets. The application of precision medicine for HCC management challenges the one-size-fits-all concept; moreover, patients should no longer be treated entirely according to the histology of their tumor but based on molecular targets specific to their tumor biology. Next-generation sequencing emphasizes HCC molecular heterogeneity and aids our comprehension of possible vulnerabilities that can be exploited. Moreover, genetic sequencing as part of a precision medicine concept may work as a promising tool for postoperative cancer monitoring. The use of genetic and epigenetic markers to identify therapeutic vulnerability could change the diagnosis and treatment of HCC, which so far was based on Barcelona clinic liver cancer (BCLC) staging. In daily clinical practice, the shift from a stage-oriented to a therapeutic-oriented approach is needed to direct the choice of HCC treatment toward the potentially most effective option on an individual basis. The important factor in precision medicine is the promotion of patient management based on the individual approach, knowing that the final decision must be approved by a multidisciplinary expert team.

Prognostic Value of Microvascular Invasion in Eight Existing Staging Systems for Hepatocellular Carcinoma: A Bi-Centeric Retrospective Cohort Study

Background

Microvascular invasion (MVI) is a significant risk factor affecting survival outcomes of patients after R0 liver resection (LR) for hepatocellular carcinoma (HCC). However, whether the existing staging systems of hepatocellular carcinoma can distinguish the prognosis of patients with MVI and the prognostic value of MVI in different subtypes of hepatocellular carcinoma remains to be clarified.

Methods

A dual-center retrospective data set of 1,198 HCC patients who underwent R0 LR was included in the study between 2014 and 2016. Baseline characteristics and staging information were collected. Homogeneity and modified Akaike information criterion (AICc) were compared between each system. And the prognostic significance of MVI for overall survival (OS) was studied in each subgroup.

Results

In the entire cohort, there were no significant survival differences between Cancer of the Liver Italian Program (CLIP) score 2 and 3 (p = 0.441), and between Taipei Integrated Scoring System (TIS) score 3 and 4 (p = 0.135). In the MVI cohort, there were no significant survival differences between Barcelona Clinic Liver Cancer stages B and C (p=0.161), CLIP scores 2 and 3 (p = 0.083), TIS scores 0 and 1 (p = 0.227), TIS scores 2 and 3 (p =0.794), Tokyo scores 3 and 4 (p=0.353), and American Joint Committee on Cancer Tumor-Node-Metastasis 7^th stage I and II (p=0.151). Among the eight commonly used HCC staging systems, the Hong Kong Liver Cancer (HKLC) staging system showed the highest homogeneity and the lowest AICc value in both the entire cohort and MVI cohort. In each subgroup of the staging systems, MVI generally exhibited poor survival outcomes.

Conclusions

The HKLC staging system was the most accurate model for discriminating the prognosis of MVI patients, among the eight staging systems. Meanwhile, our findings suggest that MVI may be needed to be incorporated into the current HCC staging systems as one of the grading criteria.

Report of the 22nd nationwide follow-up Survey of Primary Liver Cancer in Japan (2012-2013)

In the 22nd Nationwide Follow-up Survey of Primary Liver Cancer in Japan, data from 21 155 newly registered patients and 43 041 previously registered follow-up patients were compiled from 538 institutions over a 2-year period from January 1, 2012 to December 31, 2013. Basic statistics compiled for patients newly registered in the 22nd survey were cause of death, past medical history, clinical diagnosis, imaging diagnosis, treatment-related factors, pathologic diagnosis, recurrence status and autopsy findings. Compared with the previous 21st survey, the population of patients with hepatocellular carcinoma (HCC) was older at the time of clinical diagnosis, had more female patients, more patients with non-B non-C HCC, smaller tumor diameter and was more frequently treated with hepatectomy. Cumulative survival rates were calculated for HCC, intrahepatic cholangiocarcinoma, and combined hepatocellular cholangiocarcinoma (combined HCC and intrahepatic cholangiocarcinoma) by treatment type and background characteristics for patients newly registered between 2002 and 2013 whose final outcome was survival or death. Median overall survival and cumulative survival rates for HCC were calculated by dividing patients by combinations of background factors (number of tumors, tumor diameter or Child-Pugh grade) and by treatment type (hepatectomy, radiofrequency ablation therapy, transcatheter arterial chemoembolization, hepatic arterial infusion chemotherapy and systemic therapy). The same values were also calculated according to registration date by dividing patients newly registered between 1978 and 2013 into five time period groups. The data obtained from this nationwide follow-up survey are expected to contribute to advancing clinical research and treatment of primary liver cancer worldwide.

Overview of Complications in Cirrhosis

BACKGROUND

Cirrhosis is the outcome of chronic liver disease of any etiology due to progressive liver injury and fibrosis. Consequently, cirrhosis leads to portal hypertension and liver dysfunction, progressing to complications like ascites, variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, cirrhotic cardiomyopathy, sarcopenia, hepatocellular carcinoma, and coagulation disorders. End-stage liver disease leads to an impaired quality of life, loss of social and economic productivity, and reduced survival.

METHODS

This narrative review explains the pathophysiology of complications of cirrhosis, the diagnostic approach and innovative management, with focus on data from India. A comprehensive literature search of the published data was performed in regard with the spectrum, diagnosis, and management of cirrhosis and its complications.

RESULTS

There is a change in the epidemiology of metabolic syndrome, lifestyle diseases, alcohol consumption and the spectrum of etiological diagnosis in patients with cirrhosis. With the advent of universal vaccination and efficacious long-term viral suppression agents for chronic hepatitis B, availability of direct-acting antiviral agents for chronic hepatitis C, and a booming liver transplantation programme across the country, the management of complications is essential. There are several updates in the standard of care in the management of complications of cirrhosis, such as hepatorenal syndrome, hepatocellular carcinoma, and hepatic encephalopathy, and new therapies that address supportive and palliative care in advanced cirrhosis.

CONCLUSION

Prevention, early diagnosis, appropriate management of complications, timely transplantation are cornerstones in the management protocol of cirrhosis and portal hypertension. India needs improved access to care, outreach of public health programmes for viral hepatitis care, health infrastructure, and disease registries for improved healthcare outcomes. Low-cost initiatives like immunization, alcohol cessation, awareness about liver diseases, viral hepatitis elimination, and patient focused decision-making algorithms are essential to manage liver disease in India.

Surgery for hepatocellular carcinoma with tumor thrombosis in inferior vena cava: A case report

BACKGROUND

Hepatocellular carcinoma (HCC) accompanied by a tumor thrombus is very common. However, the treatment strategy is controversial and varies by the location of the thrombus.

CASE SUMMARY

We report herein a case of HCC with a tumor thrombus in the suprahepatic inferior vena cava (IVC), which was successfully treated by hepatectomy combined with thrombectomy following sorafenib chemotherapy. A 47-year-old woman with chronic hepatitis was diagnosed with HCC. Computed tomography and magnetic resonance imaging showed that the tumor lesion was located in the right half of the liver, and a tumor thrombus was detected in the suprahepatic IVC near the right atrium. After multi-departmental discussion and patient informed consent, right major hepatectomy and total removal of the tumor thrombus were successfully performed under cardiopulmonary bypass. There were no serious complications after surgery. Following sorafenib treatment, no recurrence has been detected so far (11 mo later).

CONCLUSION

Surgical treatment followed by adjuvant sorafenib therapy might be an acceptable choice for HCC patients with tumor thrombosis in the IVC.

Surgery versus external beam radiotherapy for hepatocellular carcinoma involving the inferior vena cava or right atrium: A systematic review and meta-analysis

We investigated the efficacy and safety of surgery and external beam radiotherapy (EBRT), in patients with hepatocellular carcinoma (HCC) involving the inferior vena cava (IVC) and/or right atrium (RA) through a comparative meta-analysis. A systematic search of PubMed, MEDLINE, EMBASE, and the Cochrane library was performed for entries until July 2020. Eighteen studies with 22 cohorts were included, encompassing 755 patients. The pooled median overall survival (OS) and 1- and 2-year OS rates were 14.2 months, 55.6%, and 27.4%, respectively. The pooled median OS in the surgery and EBRT arms were 15.3 and 11.7 months, respectively. The pooled 1-year OS rate in the surgery arm was significantly higher than that in the EBRT arm (62.4%, 95% CI: 53.8%-70.3% vs 48.8%, 95% CI: 40.9-56.8, respectively; P = .023), while the 2-year OS rates were similar (27.5%, 95% CI: 19.7%-37.1% vs 26.9%, 95% CI: 20.7-34.2, respectively; P = .913). In the surgical arm, the perioperative mortality and grade ≥3 complication rates were 0%-7.6% and 3.9%-67%, respectively. Grade ≥3 complications and radiation-induced liver disease were rarely observed in the EBRT arm. Surgery could be an effective local modality for achieving the best survival rate, though it requires efforts to minimize morbidities and careful patient selection. EBRT, as a noninvasive modality, is a valid palliative option, especially for high-risk patients with a shorter life expectancy.

A new staging system for hepatocellular carcinoma associated with portal vein tumor thrombus

BACKGROUND

A new staging system for patients with hepatocellular carcinoma (HCC) associated with portal vein tumor thrombus (PVTT) was developed by incorporating the good points of the BCLC classification of HCC, and by improving on the currently existing classifications of HCC associated with PVTT.

METHODS

Univariate and multivariate analysis with Wald χ² test were used to determinate the clinical prognostic factors for overall survival (OS) in patients with HCC and PVTT in the training cohort. Then the conditional inference trees analysis was applied to establish a new staging system.

RESULTS

A training cohort of 2,179 patients from the Eastern Hepatobiliary Surgery Hospital and a validation cohort of 1,550 patients from four major liver centers in China were enrolled into establishing and validating a new staging system. The system was established by incorporating liver function, general health status, tumor resectability, extrahepatic metastasis and extent of PVTT. This staging system had a good discriminatory ability to separate patients into different stages and substages. The median OS for the two cohorts were 57.1 (37.2-76.9), 12.1 (11.0-13.2), 5.7 (5.1-6.2), 4.0 (3.3-4.6) and 2.5 (1.7-3.3) months for the stages 0 to IV, respectively (P<0.001) in the training cohort. The corresponding figures for the validation cohort were 6.4 (4.9-7.9), 2.8 (1.3-4.4), 10.8 (9.3-12.4), and 1.5 (1.3-1.7) months for the stages II to IV, respectively (P<0.001). The mean survival for stage 0 to 1 were 37.6 (35.9-39.2) and 30.4 (27.4-33.4), respectively (P<0.001).

CONCLUSIONS

A new staging system was established which provided a good discriminatory ability to separate patients into different stages and substages after treatment. It can be used to supplement the other HCC staging systems.

The characteristics of patients with macrovascular invasion in hepatocellular carcinoma: when East meets West

PURPOSE

To evaluate the prevalence and extension of macrovascular invasion (MaVI) in a large cohort of hepatocellular carcinoma (HCC) patients and analyze the association between MaVI and overall survival (OS).

METHODS

From 2011 to 2018, 2540 patients with newly diagnosed HCC who were managed in our institution were enrolled in this retrospective study. Tumor invasion of the intrahepatic branches of the portal or hepatic veins was defined as peripheral MaVI. Tumor invasion of the main portal vein or inferior vena cava was defined as central MaVI.

RESULTS

MaVI prevalence was 16.2% (n = 411). Among patients with Barcelona Clinic Liver Cancer (BCLC) stage C and Child-Pugh class A, 165 patients presented with peripheral MaVI and 89 patients with central MaVI. The median OS was 13.2 months (95% confidence interval [CI]: 11.4-15.4) in the peripheral MaVI group and 6.6 months (95% CI: 3.6-9.5) in the central MaVI group (p < 0.001). In patients with BCLC stage C and Child-Pugh class B or BCLC stage D, 68 patients presented with peripheral MaVI and 89 patients with central MaVI. The median OS was 3.6 months (95% CI: 3.1-4.2) in the peripheral MaVI group and 2.8 months (95% CI: 2.1-3.4) in the central MaVI group (p = 0.674).

CONCLUSION

The extension of MaVI significantly affected patient survival only in those with BCLC stage C and Child-Pugh class A. In patients with BCLC stage C and Child-Pugh class B or BCLC stage D, survival was poor irrespective of MaVI status.

Liver resection versus intensity-modulated radiation therapy for treatment of hepatocellular carcinoma with hepatic vein tumor thrombus: a propensity score matching analysis

Background

The presence of hepatic vein tumor thrombus (HVTT) is a major determinant of survival outcomes in hepatocellular carcinoma (HCC) patients. This study compared survival outcomes between liver resection (LR) and intensity-modulated radiation therapy (IMRT) in HCC patients with HVTT.

Methods

Data from patients who underwent LR or IMRT for HCC with HVTT at the Eastern Hepatobiliary Surgery Hospital were retrospectively analyzed. Their survival outcomes were compared before and after propensity score matching (PSM).

Results

Three hundred and seven HCC patients with HVTT who underwent either LR (n=140) or IMRT (n=167) were enrolled. PSM matched 82 pairs of patients. The overall survival (OS) and recurrence-free survival (RFS) rates were significantly higher for patients in the LR group than those in the IMRT group. On subgroup analysis, significantly better survival outcomes were obtained after LR than IMRT in patients with peripheral type of HVTT (pHVTT) and major type of HVTT (mHVTT). However, similar survival outcomes were obtained after LR and IMRT when the HVTT had developed into inferior vena cava tumor thrombus (IVCTT).

Conclusions

LR resulted in significantly better survival outcomes in HCC patients with HVTT when compared to IMRT. Once the HVTT had developed IVCTT, LR and IMRT resulted in similarly bad survival outcomes.

Changing the Treatment Paradigm for Hepatocellular Carcinoma Using Atezolizumab plus Bevacizumab Combination Therapy

Atezolizumab plus bevacizumab combination therapy was approved worldwide for use in 2020. A 30% objective response rate with 8% complete response (CR) was achieved in a phase 3 IMbrave150 trial. Here, the change in the treatment strategy for hepatocellular carcinoma (HCC) using atezolizumab plus bevacizumab combination therapy is reviewed. The phase 3 IMbrave150 clinical trial was successful because of the direct antitumor effect of bevacizumab, which shifted the suppressive immune microenvironment to a responsive immune microenvironment, in addition to its synergistic effects when combined with atezolizumab. The analysis of CR cases was effective in patients with poor conditions, particularly tumor invasion in the main portal trunk (Vp4), making the combination therapy a breakthrough for HCC treatment. The response rate of the combination therapy was 44% against intermediate-stage HCC. Such a strong tumor-reduction effect paves the way for curative conversion (ABC conversion) therapy and, therefore, treatment strategies for intermediate-stage HCC may undergo a significant shift in the future. As these treatment strategies are effective in maintaining liver function, even in elderly patients, the transition frequency to second-line treatments could also be improved. These strategies may be effective against nonalcoholic steatohepatitis-related hepatocellular carcinoma and WNT/β-catenin mutations to a certain degree.

Hepatocellular carcinoma with inferior vena cava and right atrium thrombus: A case report

BACKGROUND

Hepatocellular carcinoma (HCC) with inferior vena cava and right atrium thrombus is rare, accounting for approximately 1.4%-4.9% of cases. These patients are rarely reported, but the condition is being increasingly discovered with advances in imaging techniques, and their prognosis is extremely pessimistic with no current effective treatment. This condition is further associated with unexpected sudden death by cardiac arrest and acute large area pulmonary embolism.

CASE SUMMARY

A 34-year-old man with advanced HCC with a hepatic vein thrombus extending into the right atrium had a long-term, disease-free survival following 5-mo sequential treatment combined with transcatheter arterial chemoembolization and curative liver resection. No severe adverse effects were encountered, such as massive hemorrhage or pulmonary embolism. The proper selection of operative method is an important factor.

CONCLUSION

HCC with a tumor thrombus extending into the right atrium has a significant impact on the survival of patients. Thrombectomy combined with adjuvant therapy may be beneficial for these patients.

Role of Liver Resection for Hepatocellular Carcinoma with Vascular Invasion: Emerging Evidence from Western Countries

Patients with advanced hepatocellular carcinoma (HCC) with macrovascular invasion, that is, tumor thrombosis in the portal vein or hepatic vein, are generally considered not eligible for liver resection in Western countries, and only systemic therapy is recommended. However, there is a subgroup of patients who can survive long after surgical treatment despite having a very advanced stage of the disease. Some Asian surgical centers and a few Western surgical centers have been using surgery to treat BCLC stage C HCC as long as it is operable, and those centers have reported acceptable outcomes. In this issue of Liver Cancer, Govalan et al. report on the superiority of surgical resection over other treatments for patients with vascular invasion based on data from the National Cancer Database. This is a first report analyzing a large set of contemporary US cohort data, and its findings may catch the attention of many hepatologists in Western countries who are hesitant about sending eligible patients to surgeons. In this era of advanced systemic therapy using molecular targeted agents and immuno-check point inhibitors, a combination of promising systemic therapy and surgery may be a future path to improve survival for patients with this very advanced disease.

Treatment for hepatocellular carcinoma with tumor thrombosis in the hepatic vein or inferior vena cava: A comprehensive review

Hepatocellular carcinoma (HCC) is the most common type of liver cancer with a high mortality rate worldwide. The percentage of HCC patients with vascular invasion is high. However, tumor thrombus in the hepatic vein (HVTT) has a lower incidence than tumor thrombus in the portal vein (PVTT). Conventionally, HCC patients with HVTT are treated the same as HCC patients with PVTT and offered sorafenib or other systemic agents. However, according to recent studies, it is evident that HCC with HVTT shows different outcomes when classified into different subgroups. In this review, we discuss the recent progress and changes in treatment of HCC with HVTT.

Transmediastinal, intrapericardial inferior vena cava approach based on anatomical landmarks for hepatectomy using total hepatic vascular exclusion

BACKGROUND

Total hepatic vascular exclusion (THVE) is an essential technique to control hemorrhage during surgical treatment of advanced liver tumors or injury. However, surgeons often have difficulty securing the intrapericardial inferior vena cava (IVC) because few reports have described the anatomy around the supra-diaphragmatic IVC or the techniques and surgical outcomes for this procedure. This study presents our safe and feasible intrapericardial IVC approach, which is based on anatomical landmarks, and reports the surgical outcomes of this procedure.

METHODS

We performed THVE using our technique for hepatectomy, accompanied by resection of the hepatic vein confluence or tumor thrombectomy of the supra-hepatic IVC, in five patients between August 2011 and March 2018.

RESULTS

The mean operative time was 568 min (range: 240-820 min). The mean THVE time was 10 min (range: 5-15 min), with a mean blood loss of 1882 mL (range: 1010-3100 mL). Postoperatively, one patient was classified as Clavien-Dindo grade II due to medication for tachycardia, and two patients were classified as grade IIIa due to drainage of bile and pleural effusion, including one patient with tachycardia. The mean postoperative hospital stay was 26 days (range: 18-34 days). No patient exhibited decreased cardiac function during surgery or postoperatively, and no patient experienced thoracotomy or phrenic nerve paralysis.

CONCLUSIONS

Anatomical landmarks are important to ensure a safe approach to the intrapericardial IVC. Incising the pericardium does not lead to serious problems. The transmediastinal, intrapericardial IVC approach for THVE is a feasible method to secure the supra-diaphragmatic intrapericardial IVC.

Combined Chemoembolization and Radiotherapy Versus Chemoembolization Alone for Hepatocellular Carcinoma Invading the Hepatic Vein or Inferior Vena Cava

PURPOSE

To evaluate the efficacy and safety of transarterial chemoembolization (TACE) plus radiotherapy compared with TACE alone for patients with hepatocellular carcinoma (HCC) invading the hepatic vein (HV) or inferior vena cava (IVC).

MATERIALS AND METHODS

Data from 79 patients who underwent TACE plus radiotherapy as a first-line treatment for non-metastatic HCC invading the HV or IVC between 2006 and 2018 were retrospectively evaluated. These findings were compared with data from a historical control group, consisting of 80 patients who received TACE alone between 2000 and 2006.

RESULTS

Baseline characteristics were similar in both groups. Median progression-free survival (PFS) (8.1 vs. 4.4 months, P = 0.003) and overall survival (OS) (18.3 vs. 9.5 months, P = 0.002) were longer in the TACE plus radiotherapy than in the TACE alone group. Multivariate analysis showed that PFS and OS were significantly associated with treatment type. Subgroup analyses found that TACE plus radiotherapy showed better OS than TACE alone in patients with Child-Pugh class A, maximal tumor size < 9 cm, tumor number < 4, serum alpha-fetoprotein level ≥ 400 ng/mL, infiltrative tumor, IVC tumor thrombus, and combined portal vein invasion. The major complication rates were similar between the TACE plus radiotherapy (16.5%) and the TACE alone (13.8%) group (P = 0.664) CONCLUSION: Both TACE plus radiotherapy and TACE alone showed similar safety in treating non-metastatic HCC invading the HV or IVC. TACE plus radiotherapy seems effective to prolong OS and PFS compared to TACE alone in this specific patient group.

A prediction model for overall survival after transarterial chemoembolization for hepatocellular carcinoma invading the hepatic vein or inferior vena cava

OBJECTIVES

An effective therapeutic option has not yet been established for hepatocellular carcinoma (HCC) invading the hepatic vein (HV) or inferior vena cava (IVC). This study aimed to determine the therapeutic effect of transarterial chemoembolization (TACE) in HCC patients with HV or IVC invasion, and to build a risk prediction model.

METHODS

Data from patients who underwent TACE as a first-line treatment for HCC invading the HV or IVC between 1997 and 2019 were retrospectively evaluated.

RESULTS

Data from 296 patients were included (1997-2006 comprised the training cohort, n = 174; 2007-2019 comprised the validation cohort, n = 122). The median post-TACE survival was 7.3 months and an objective tumor response was achieved in 34.1% of patients. Multivariable Cox analysis of the training cohort identified five pretreatment factors (maximal tumor size > 10 cm, infiltrative HCC, combined portal vein invasion, extrahepatic metastasis, and ECOG performance status 1), which were used to create predictive models for overall survival. Median overall survival times in the validation cohort were 14 and 4.2 months for the low (sum of risk score: 0-3)- and high-risk (sum of risk score: 4-7) groups, respectively (p < 0.001). Time-dependent ROC curves for the predictive models for overall survival applied to the validation cohort showed acceptable AUC values (0.723 and 0.667 at 6 months and 1 year).

CONCLUSIONS

TACE seems effective for selected patients with HCC invading the HV or IVC. The predictive model may help to identify candidates most likely to benefit from TACE.

KEY POINTS

• To develop a risk prediction model for patients with HCC with HV or IVC invasion treated with TACE, five factors were selected from a multivariate Cox regression model for overall survival. • The combination of these factors helped to identify two prognostic categories: low- and high-risk. • The predictive model can help to select candidates who will benefit most from TACE in this patient group.

Hepatic vein tumor thrombosis in patients with hepatocellular carcinoma: Prevalence and clinical significance

BACKGROUND

There is strong evidence that portal vein tumor thrombosis (PVTT) is associated with poor survival in patients with hepatocellular carcinoma (HCC). However, data regarding the clinical significance of hepatic vein tumor thrombosis (HVTT) is rare, particularly in Western patients.

OBJECTIVE

To determine the HVTT prevalence in a Western patient population and its impact on survival.

METHODS

We included 1310 patients with HCC treated in our tertiary referral center between January 2005 and December 2016. HVTT and PVTT were diagnosed with contrast-enhanced cross-sectional imaging. Overall survival (OS) was calculated starting from the initial HCC diagnosis, and in a second step, starting from the first appearance of vascular invasion.

RESULTS

We observed macrovascular invasion (MVI) in 519 patients who suffered from either isolated HVTT (n = 40), isolated PVTT (n = 352), or both combined (HVTT + PVTT) (n = 127). Calculated from the initial HCC diagnosis, the median OS for patients with isolated HVTT was significantly shorter than that of patients without MVI (13.3 vs. 32.5 months, p < 0.001). Calculated from the first appearance of MVI, the median OS was similar among patients with isolated HVTT (6.5 months), isolated PVTT (5 months), and HVTT + PVTT (5 months). Multivariate analysis confirmed HVTT as an independent risk factor for poor survival.

CONCLUSIONS

HVTT may be more common than typically reported. In most patients, it was accompanied by PVTT. Isolated HVTT occurred less frequently and later than isolated PVTT; however, once developed, it had the same deleterious impact on survival. Therefore, patients with HVTT should be classified as advanced stage of HCC.

Management of Hepatocellular Carcinoma in Japan: JSH Consensus Statements and Recommendations 2021 Update

The Clinical Practice Manual for Hepatocellular Carcinoma was published based on evidence confirmed by the Evidence-based Clinical Practice Guidelines for Hepatocellular Carcinoma along with consensus opinion among a Japan Society of Hepatology (JSH) expert panel on hepatocellular carcinoma (HCC). Since the JSH Clinical Practice Guidelines are based on original articles with extremely high levels of evidence, expert opinions on HCC management in clinical practice or consensus on newly developed treatments are not included. However, the practice manual incorporates the literature based on clinical data, expert opinion, and real-world clinical practice currently conducted in Japan to facilitate its use by clinicians. Alongside each revision of the JSH Guidelines, we issued an update to the manual, with the first edition of the manual published in 2007, the second edition in 2010, the third edition in 2015, and the fourth edition in 2020, which includes the 2017 edition of the JSH Guideline. This article is an excerpt from the fourth edition of the HCC Clinical Practice Manual focusing on pathology, diagnosis, and treatment of HCC. It is designed as a practical manual different from the latest version of the JSH Clinical Practice Guidelines. This practice manual was written by an expert panel from the JSH, with emphasis on the consensus statements and recommendations for the management of HCC proposed by the JSH expert panel. In this article, we included newly developed clinical practices that are relatively common among Japanese experts in this field, although all of their statements are not associated with a high level of evidence, but these practices are likely to be incorporated into guidelines in the future. To write this article, coauthors from different institutions drafted the content and then critically reviewed each other's work. The revised content was then critically reviewed by the Board of Directors and the Planning and Public Relations Committee of JSH before publication to confirm the consensus statements and recommendations. The consensus statements and recommendations presented in this report represent measures actually being conducted at the highest-level HCC treatment centers in Japan. We hope this article provides insight into the actual situation of HCC practice in Japan, thereby affecting the global practice pattern in the management of HCC.

Comparison of Surgical Resection and Systemic Treatment for Hepatocellular Carcinoma with Vascular Invasion: National Cancer Database Analysis

INTRODUCTION

Small studies from outside of the USA suggest excellent outcomes after surgical resection for hepatocellular carcinoma (HCC) with vascular invasion. The study aims to (1) compare overall survival after surgical resection and systemic therapy among patients with HCC and vascular invasion and (2) determine factors associated with receipt of surgical resection in a US population.

METHODS

HCC patients with AJCC clinical TNM stage 7th T3BN0M0 diagnosed between 2010 and 2017 from the National Cancer Database were analyzed. Cox and logistic regression analyses identified factors associated with overall survival and receipt of surgical resection.

RESULTS

Of 11,259 patients with T3BN0M0 HCC, 325 (2.9%) and 4,268 (37.9%) received surgical resection and systemic therapy, respectively. In multivariable analysis, surgical resection was associated with improved survival compared to systemic therapy (adjusted hazard ratio: 0.496, 95% confidence interval: 0.426-0.578) with a median survival of 21.4 and 8.1 months, respectively. Superiority of surgical resection was observed in noncirrhotic and cirrhotic subgroups and propensity score matching and inverse probability of treatment weighting adjusted analysis. Asians were more likely to receive surgical resection, whereas Charlson comorbidity ≥3, elevated alpha-fetoprotein, smaller tumor size, care in a community cancer program, and the South or West region were associated with a lower likelihood of surgical resection.

CONCLUSION

HCC patients with vascular invasion may benefit from surgical resection compared to systemic therapies. Demographic and clinical features of HCC patients and region and type of treating facility were associated with surgical resection versus systemic treatment.

Systemic treatment of HCC in special populations

Recent years have seen significant progress in the systemic treatment of hepatocellular carcinoma (HCC), including the advent of immunotherapy. While several large phase III trials have provided the evidence for a multi-line treatment paradigm, they have focused on a highly selected group of patients by excluding potentially confounding comorbidities. As a result, high quality evidence for the systemic treatment of HCC in patients with various comorbidities is missing. This review summarises current knowledge on the use of approved medicines in patients with HIV, autoimmune disease, cardiovascular disease, diabetes, fibrolamellar HCC, mixed HCC-cholangiocarcinoma, decompensated cirrhosis (Child-Pugh B and C), a significant bleeding history, vascular invasion or portal vein thrombosis, as well as the elderly, those on haemodialysis, and those after solid organ transplantation. The article highlights relevant knowledge gaps and current clinical challenges. To improve the safety and efficacy of HCC treatment in these subgroups, future trials should be designed to specifically include patients with comorbidities.

Development and validation of an individualized prediction calculator of postoperative mortality within 6 months after surgical resection for hepatocellular carcinoma: an international multicenter study

BACKGROUND

Evidence-based decision-making is critical to optimize the benefits and mitigate futility associated with surgery for patients with malignancies. Untreated hepatocellular carcinoma (HCC) has a median survival of only 6 months. The objective was to develop and validate an individualized patient-specific tool to predict preoperatively the benefit of surgery to provide a survival benefit of at least 6 months following resection.

METHODS

Using an international multicenter database, patients who underwent curative-intent liver resection for HCC from 2008 to 2017 were identified. Using random assignment, two-thirds of patients were assigned to a training cohort with the remaining one-third assigned to the validation cohort. Independent predictors of postoperative death within 6 months after surgery for HCC were identified and used to construct a nomogram model with a corresponding online calculator. The predictive accuracy of the calculator was assessed using C-index and calibration curves.

RESULTS

Independent factors associated with death within 6 months of surgery included age, Child-Pugh grading, portal hypertension, alpha-fetoprotein level, tumor rupture, tumor size, tumor number and gross vascular invasion. A nomogram that incorporated these factors demonstrated excellent calibration and good performance in both the training and validation cohorts (C-indexes: 0.802 and 0.798). The nomogram also performed better than four other commonly-used HCC staging systems (C-indexes: 0.800 vs. 0.542-0.748).

CONCLUSIONS

An easy-to-use online prediction calculator was able to identify patients at highest risk of death within 6 months of surgery for HCC. The proposed online calculator may help guide surgical decision-making to avoid futile surgery for patients with HCC.

Report of the 21st Nationwide Follow-up Survey of Primary Liver Cancer in Japan (2010-2011)

In the 21st Nationwide Follow-up Survey of Primary Liver Cancer in Japan, data from 22,134 new patients and 41,956 previously followed patients were compiled from 546 institutions over a 2-year period from 1 January 2010 to 31 December 2011. Basic statistics compiled for patients newly registered in the 21st survey were cause of death, medical history, clinical diagnosis, imaging diagnosis, treatment-related factors, pathological diagnosis, recurrence status, and autopsy findings. Compared with the previous 20th survey, the population of patients with hepatocellular carcinoma (HCC) was older at the time of clinical diagnosis, had more female patients, had more patients with non-B non-C HCC, had smaller tumor diameter, and was more frequently treated with hepatectomy and with radiofrequency ablation. Cumulative survival rates were calculated for HCC, intrahepatic cholangiocarcinoma, and combined hepatocellular cholangiocarcinoma (combined HCC and intrahepatic cholangiocarcinoma) by treatment type and background characteristics for patients newly registered between 1998 and 2011 whose final outcome was survival or death (excluding unknown). Cumulative survival rates for HCC were calculated by dividing patients by combinations of background factors (number of tumors, tumor diameter, and Child-Pugh grade) and by treatment type (hepatectomy, local ablation therapy, transcatheter arterial chemoembolization, and hepatic arterial infusion chemotherapy). The same values were also calculated according to registration date by dividing patients newly registered between 1978 and 2011 into four time-period groups. The data obtained from this nationwide follow-up survey are expected to contribute to advancing clinical research and treatment of primary liver cancer.

Palliating Symptoms in Patients With Hepatocellular Carcinoma Involving the Inferior Vena Cava With External Beam Radiation Therapy

Introduction

Patients with hepatocellular carcinoma (HCC) involving the inferior vena cava (IVC) and/or right atrium (RA) often experience debilitating symptoms, including lower extremity edema, dyspnea on exertion, shortness of breath at rest, chest pain, and ascites, that impact quality of life. The efficacy of external beam radiation therapy (EBRT) in palliating these symptoms is unclear. Thus, we sought to assess the effectiveness of EBRT in the palliation of symptoms and treatment outcomes in this patient population.

Materials and methods

All patients with HCC that compressed or invaded the IVC, received EBRT, and had a two-month follow-up visit to assess clinical response at our institution between 2010 and 2018 were analyzed. Patient demographics and clinical features were retrieved from the electronic medical record. Local control, local progression-free survival, and overall survival (OS) were measured from the last day of EBRT and calculated using the Kaplan-Meier method.

Results

Twenty-six patients with invasion or compression of the IVC were identified, 11 of whom (42%) had involvement of the RA. The median follow-up was 3.6 months. Five patients (19%) were treated with stereotactic body radiation therapy (SBRT) (all with five fractions) and 21 patients (81%) were treated with fractionated radiation therapy (range 10-16 fractions), both to a median dose of 3,000 cGy (range 2500-4000 cGy for SBRT, 2500-3750 cGy for fractionated radiation therapy). Significant proportions of patients experienced symptomatic relief from peripheral edema (54%), dyspnea on exertion (57%), shortness of breath (83%), chest pain (67%), and ascites (25%) after receiving EBRT. Additionally, they experienced few toxicities, with zero experiencing grade three or higher toxicities. One-year and two-year local control rates were 11.5% and 7.7%, respectively, and the median local progression-free survival was 4.8 months. One-year and two-year OS rates were 38.4% and 38.4%, respectively.

Conclusions

Our results suggest that EBRT should be considered as a potential treatment option for patients with HCC invading or compressing the IVC with or without involvement of the RA. EBRT was very well-tolerated and effectively palliated a variety of symptoms in patients with advanced disease.

A Pre-Operative Prognostic Score for Patients With Advanced Hepatocellular Carcinoma Who Underwent Resection

BACKGROUND

Previous studies demonstrated a promising prognosis in advanced hepatocellular carcinoma (HCC) patients who underwent surgery, yet a consensus of which population would benefit most from surgery is still unreached.

METHOD

A total of 496 advanced HCC patients who initially underwent liver resection were consecutively collected. Least absolute shrinkage and selection operator (LASSO) regression was performed to select significant pre-operative factors for recurrence-free survival (RFS). A prognostic score constructed from these factors was used to divide patients into different risk groups. Survivals were compared between groups with log-rank test. The area under curves (AUC) of the time-dependent receiver operating characteristics was used to evaluate the predictive accuracy of prognostic score.

RESULT

For the entire cohort, the median overall survival (OS) was 23.0 months and the median RFS was 12.1 months. Patients were divided into two risk groups according to the prognostic score constructed with ALBI score, tumor size, tumor-invaded liver segments, gamma-glutamyl transpeptidase, alpha fetoprotein, and portal vein tumor thrombus stage. The median RFS of the low-risk group was significantly longer than that of the high-risk group in both the training (10.1 vs 2.9 months, P<0.001) and the validation groups (13.7 vs 4.6 months, P=0.002). The AUCs of the prognostic score in predicting survival were 0.70 to 0.71 in the training group and 0.71 to 0.72 in the validation group.

CONCLUSION

Surgery could provide promising survival for HCC patients at an advanced stage. Our developed pre-operative prognostic score is effective in identifying advanced-stage HCC patients with better survival benefit for surgery.

The Recent Development of the Surgical Treatment for Hepatocellular Carcinoma

The optimal treatment for hepatocellular carcinoma (HCC) should be selected based on tumor conditions, liver functional reserve, and performance status. Surgical treatment, such as liver resection and liver transplantation, is the most favorable treatment method; however, its indication criteria differ according to each country’s guidelines. In Western countries, liver resection is indicated only for early-stage HCC patients with Barcelona-Clinic Liver Cancer staging classification (BCLC) 0/A. While in Asian countries, liver resection is one of the treatment options for advanced HCC, such as BCLC B/C. Recently, the treatment of HCC is about to enter a drastic transitional period. It started with the widespread use of minimally invasive surgery for HCC, followed by a high rate of hepatitis C virus eradication with the advent of direct acting antivirals and developing a multidisciplinary treatment for highly advanced HCC. As a result, the importance of liver resection for HCC is increasing, and it is time to reconsider the criteria for selecting treatment methods for HCC patients. This article outlines current topics in the surgical treatment of HCC.

A new classification for hepatocellular carcinoma with hepatic vein tumor thrombus

Background

Hepatic vein tumor thrombus (HVTT) is a significant poor risk factor for survival outcomes in hepatocellular carcinoma (HCC) patients. Currently, the widely used international staging systems for HCC are not refined enough to evaluate prognosis for these patients. A new classification for macroscopic HVTT was established, aiming to better predict prognosis.

Methods

This study included 437 consecutive HCC patients with HVTT who underwent different treatments. Overall survival (OS) and time-dependent receiver operating characteristic (ROC) curve area analysis were used to determine the prognostic capacities of the new classification when compared with the different currently used staging systems.

Results

The new HVTT classification was defined as: type I, tumor thrombosis involving hepatic vein (HV), including microvascular invasion; type II, tumor thrombosis involving the retrohepatic segment of inferior vena cava; and type III, tumor thrombosis involving the supradiaphragmatic segment of inferior vena cava. The numbers (percentages) of patients with types I, II, and III HVTT in the new classification were 146 (33.4%), 143 (32.7%), and 148 (33.9%), respectively. The 1-, 2-, and 3-year OS rates for types I to III HVTT were 79.5%, 58.6%, and 29.1%; 54.8%, 23.3%, and 13.8%; and 24.0%, 10.0%, and 2.1%, respectively. The time-dependent-ROC curve area analysis demonstrated that the predicting capacity of the new HVTT classification was significantly better than any other staging systems.

Conclusions

A new HVTT classification was established to predict prognosis of HCC patients with HVTT who underwent different treatments. This classification was superior to, and it may serve as a supplement to, the commonly used staging systems.

Treatment of Hepatocellular Carcinoma in the Precision Medicine Era: From Treatment Stage Migration to Therapeutic Hierarchy

Treatment allocation is extremely complex in patients with hepatocellular carcinoma (HCC) because this neoplasm arises, in most cases, in patients with cirrhosis and additional comorbidities. The "stage hierarchy" approach, which involves linking each stage (or substage) of the disease to a specific treatment, has become the main proposed treatment strategy for the clinical management of HCC, particularly in the West. The Barcelona Clinic Liver Cancer (BCLC) scheme serves as the main example of the application of this strategy. In an attempt to increase the plasticity of the "stage hierarchy" approach as well as its adaptability to the requirements of real-world clinical practice, the latest versions of European and American guidelines have introduced certain relevant elements of flexibility, which were not intrinsic to the original BCLC scheme. These elements are as follows: the "treatment stage migration" strategy, which allows moving to another treatment (generally the one that is associated with the subsequent stage) if the approach linked with the current stage proves to be unfeasible, and the "treatment stage alternative" approach, which proposes further therapeutic options for each BCLC-defined stage. In regard to most of the solid cancers, another potential strategy is to consider the treatment decision to be hierarchically dictated by the efficacy of each therapy with complete or partial independence from the tumor stage. This concept of "therapeutic hierarchy" has been historically endorsed by the Asia-Pacific treatment algorithm as well as by the recent Italian multisociety guidelines. The present review provides a critical analysis of the different conceptual approaches to HCC management, highlighting their advantages and disadvantages and focusing on the remarkable differences between the stage-guided and the hierarchical strategies.

Hepatocellular carcinoma with atrial tumor thrombus presenting as myxoma: Resection under cardiopulmonary bypass

Surgical resection for Hepatocellular carcinoma (HCC) with atrial tumor thrombus is a rare life saving procedure. A case of left lateral segment liver tumor (HCC) with atrial tumor thrombus resected with use of cardio-pulmonary bypass is presented.

What liver surgeons have achieved in the recent decade for patients with hepatocellular carcinoma?

In the past decade, there has been remarkable progress in surgical treatment for hepatocellular carcinoma (HCC) based on evidence created by epoch-making prospective trials or national registry big data analysis. A head-to-head randomized controlled trial comparing liver resection and local ablation for small oligo HCCs (SURF trial) demonstrated comparable recurrence-free survival provided both modalities are feasible. Survival benefit of liver resection for HCC with vascular invasion was demonstrated by two propensity scored matched analyses based on Japanese national data. Furthermore, expanded HCC criteria for living donor liver transplantation were developed based on Japanese national data, and this "5-5-500 rule" was accepted by the social insurance system in Japan. The recent remarkable progress in promising new anti-HCC agents may open the door for effective neoadjuvant or adjuvant treatment in combination with surgery.

Analysis of Patient Outcome after Non-curative Resection for Hepatocellular Carcinoma Using Nationwide Survey Data in Japan

BACKGROUND

Non-curative (debulking) hepatic resection for hepatocellular carcinoma (HCC) is occasionally applied for selected cases with bulky tumors or for oncologic emergency cases; however, the clinical usefulness of this procedure has not yet been fully evaluated. The aim of the present study was to evaluate the patient outcomes of non-curative hepatic resections for HCC using data from bi-annual nationwide surveys conducted in Japan.

METHOD

Data of 1084 non-curative hepatic resections for HCC were collected. The patient outcomes were compared with those of curative resections, transcatheter arterial chemoembolization (TACE), and hepatic arterial infusion chemotherapy (HAIC).

RESULTS

Patient survival after the non-curative resection was poorer than that after curative resection (P < 0.001) and was especially dismal in cases with extrahepatic tumor spread (lymph node metastasis, peritoneal seeding, or distant metastasis). As compared to cases receiving TACE without surgery, non-curative resections for multiple intrahepatic tumors were applied to cases with advanced tumors with good liver functional reserve. The survival outcomes were significantly more favorable in the TACE group, but the results became similar after propensity score matching of the patients. The survival outcome of patients receiving non-curative resections was better than that of cases treated by HAIC, with median survival times of 26.0 months and 10.0 months, respectively.

CONCLUSION

The indications for non-curative hepatic resection in patients with HCC should be judged cautiously, especially in patients with extrahepatic tumor spread. This treatment approach may be beneficial for selected patients with intermediate- or advanced-stage HCC limited in liver and with good liver functional reserve.

Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion

A broad range of abdominal and pelvic tumors can manifest with or develop intraluminal venous invasion. Imaging features at cross-sectional modalities and contrast-enhanced US that allow differentiation of tumor extension within veins from bland thrombus include the expansile nature of tumor thrombus and attenuation and enhancement similar to those of the primary tumor. Venous invasion is a distinctive feature of hepatocellular carcinoma and renal cell carcinoma with known prognostic and treatment implications; however, this finding remains an underrecognized characteristic of multiple other malignancies-including cholangiocarcinoma, adrenocortical carcinoma, pancreatic neuroendocrine tumor, and primary venous leiomyosarcoma-and can be a feature of benign tumors such as renal angiomyolipoma and uterine leiomyomatosis. Recognition of tumor venous invasion at imaging has clinical significance and management implications for a range of abdominal and pelvic tumors. For example, portal vein invasion is a strong negative prognostic indicator in patients with hepatocellular carcinoma. In patients with rectal cancer, diagnosis of extramural venous invasion helps predict local and distant recurrence and is associated with worse survival. The authors present venous invasion by vascular distribution and organ of primary tumor origin with review of typical imaging features. Common pitfalls and mimics of neoplastic thrombus, including artifacts and anatomic variants, are described to help differentiate these findings from tumor in vein. By accurately diagnosing tumor venous invasion, especially in tumors where its presence may not be a typical feature, radiologists can help referring clinicians develop the best treatment strategies for their patients. ^©RSNA, 2020.

Radiofrequency ablation versus laparoscopic hepatectomy for treatment of hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

Several randomized controlled trials (RCTs) compared the effects of laparoscopic hepatectomy (LH) and radiofrequency ablation (RFA) for the treatment of hepatocellular carcinoma (HCC), but the results have remained inconsistent. Hence, a meta-analysis and a systematic review of these treatment modalities are necessary to evaluate their efficacy and safety for HCC treatment.

METHODS

From the inception of this meta-analysis and review until August 31, 2019, we searched Medline, PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, Wanfang Database, and China Biomedical Literature Database for RCTs involving LH and RFA treatments of patients with HCC. The studies were screened and the data from these articles were extracted independently by two authors. Summary odd ratios (OR) or mean differences (MD) with 95% confidence intervals (CI) were calculated for each outcome with a fixed- or random-effect model. The outcomes for effectiveness evaluations included duration of surgery, estimated bleeding volume, incidence of blood transfusion during surgery, duration of hospital stay, and the outcome for safety included the incidence of cancer recurrence.

RESULTS

Seven RCTs with a total of 615 patients were identified, 312 and 303 of which underwent RFA and LH treatments, respectively. The duration of surgery (MD = -99.04; 95% CI: -131.26--66.82), estimated bleeding volume (MD = -241.97; 95% CI: -386.93--97.02), incidence of blood transfusion during surgery (OR = 0.08; 95% CI: 0.02-0.37), and duration of hospital stay (MD = -3.4; 95% CI: -5.22--1.57) in RFA treatment were significantly lower than those of LH treatment. However, the incidence of cancer recurrence was significantly higher for RFA treatment compared with LH treatment (OR = 2.68; 95% CI: 1.72-4.18).

CONCLUSIONS

LH treatment is preferred over RFA treatment with a better radical effect, but RFA treatment is more beneficial with smaller trauma, development of less complications, and shorter operating time when compared with HCC treatment.

Diagnosis, treatment and prognosis of hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus

Although tumor thrombus (TT) infringement of the inferior vena cava (IVC) and right atrium (RA) is rarely observed in hepatocellular carcinoma (HCC), the prognosis for this condition is extremely poor, with a median survival time of several months, given that the condition is often diagnosed at an advanced tumor stage or combined with multiple systemic metastases. Furthermore, there is no established effective treatment for the condition. However, some investigators insist that active treatment, including surgery, chemotherapy (systemic or intra-arterial), radiation therapy, best supportive care or a combination of these, may help prolong overall survival time in these patients. The management of patients with advanced HCC and a TT extending into the RA and IVC is extremely difficult and risky. To this end, the present review assessed the literature on the clinical features and treatments of this condition in recent years, with the aim of providing assistance for clinical work.

New frontiers in liver resection for hepatocellular carcinoma

Liver resection is one of the main curative options for early hepatocellular carcinoma (HCC) in patients with cirrhosis and is the treatment of choice in non-cirrhotic patients. However, careful patient selection is required to balance the risk of postoperative liver failure and the potential benefit on long-term outcomes. In the last decades, improved surgical techniques and perioperative management, as well as better patient selection, have enabled the indications for liver resection to be expanded. In this review, we aim to describe the main indications for liver resection in the management of HCC, its role compared to percutaneous ablation and liver transplantation in the therapeutic algorithm, as well as the recent advances in liver surgery that could be used to improve the prognosis of patients with HCC.

Resection of recurrent hepatocellular carcinoma with thrombi in the inferior vena cava, right atrium, and phrenic vein: a report of three cases

Background

Prognosis for patients with advanced hepatocellular carcinoma with a tumor thrombus in the inferior vena cava or right atrium is extremely poor due to cancer progression, pulmonary embolism, and congestion of the circulatory system caused by right heart failure. Surgical resection of the tumor thrombi may potentially yield better results than non-surgical treatments through prevention of sudden death. However, the benefits of surgical resection in patients with hepatocellular carcinoma and a tumor thrombus extending to the inferior vena cava, right atrium, and potentially in the phrenic vein are unclear. Here, we report three such cases.

Case presentation

Of the total 136 patients who underwent hepatectomies for hepatocellular carcinoma in our institution, three patients with prior hepatectomies and recurrent hepatocellular carcinoma had tumor thrombi in the inferior vena cava, right atrium, and phrenic vein. Surgical resections were performed, as there was a possibility of sudden death, despite the risk of leaving residual tumor. For all patients, we performed resection of the tumor thrombi in the inferior vena cava and right atrium and combined diaphragm resection. Surgical resection was performed using the total hepatic vascular exclusion technique in all cases. Additional passive veno-venous bypass was also performed in two cases, in which complete tumor resections could not be achieved. The microscopic surgical margins of the combined resected diaphragms were positive in all cases. Progression-free survival was 20.2, 3.8, and 9.5 months for case 1, 2, and 3, respectively. The respective overall postoperative survival was 98.0, 38.9, and 30.9 months. The patients died due to liver cirrhosis, acute heart failure, and hepatocellular carcinoma, respectively. Sudden death did not occur for any of the patients.

Conclusion

Surgical resections may extend prognosis for patients with recurrent hepatocellular carcinoma with tumor thrombi in the inferior vena cava, right atrium, and phrenic vein, although the indications should be considered carefully.

Insulin-Like Growth Factor Binding Protein-2 Promotes Proliferation and Predicts Poor Prognosis in Hepatocellular Carcinoma

Background

Insulin-like growth factor binding protein-2 (IGFBP2) levels are significantly increased in the plasma of hepatocellular carcinoma (HCC) patients. However, the correlation between IGFBP2 levels and clinical parameters and the exact role of IGFBP2 in HCC are unclear. In this study, we identified the role and potential molecular mechanisms of IGFBP2 in HCC.

Materials and Methods

ELISA assays were used to detect plasma IGFBP2 levels in HCC patients and healthy controls, and the correlations with patients’ clinicopathological data were analyzed. The CCK8 assay was used to explore cell proliferation. Luciferase reporter, co-immunoprecipitation, and immunofluorescence assays were used to demonstrate the molecular mechanism of IGFBP2 in HCC.

Results

Plasma IGFBP2 levels were determined blindly in 37 HCC patients and 37 matched healthy controls. The mean plasma IGFBP2 concentrations in HCC patients were higher than in healthy controls, and IGFBP2 levels in HCC were positively correlated with the degree of differentiation, tumor size, metastasis, and portal venous invasion. Exogenous IGFBP2 activated integrin β1 and thus induced the combination and colocalization of activated integrin β1 and p-FAK, which promoted the phosphorylation of FAK, Erk, and Elk1, eventually inducing EGR1-mediated proliferation of the HCC cell lines HepG2 and HCCLM3. Meanwhile, neutralization of integrin β1 inhibited IGFBP2-induced FAK, Erk, Elk1, and EGR1 activation.

Conclusion

Taken together, these results indicated that exogenous IGFBP2 promoted the integrin β1/FAK/Erk/Elk1/EGR1 pathway, which stimulated the proliferation of HCC cells. Plasma IGFBP2 could be a novel prognostic biomarker for HCC patients.

Alpha-fetoprotein and 18F-FDG standard uptake value predict tumor recurrence after liver transplantation for hepatocellular carcinoma with portal vein tumor thrombosis: Preliminary experience

BACKGROUND

Portal vein tumor thrombosis (PVTT) is regarded as a contraindication for liver transplantation (LT) in hepatocellular carcinoma (HCC). However, some of these patients may have a favorable prognosis after LT. In this study, we evaluated the biological behavior of HCC with PVTT using tumor biomarker (alpha-fetoprotein, AFP) and ¹⁸F-FDG positron emission tomography (tumor standard uptake value) to identify a subset of patients who may be suitable for LT.

METHODS

Seventy-five HCC-PVTT liver recipients transplanted during February 2016 and June 2018 were analyzed. Different pre-transplant prognostic factors were identified by univariate and multivariate analyses. PVTT status was identified following Vp classification (Vp1-Vp4).

RESULTS

Three-year recurrence-free survival and overall survival rates were 40% and 65.4% in Vp2-Vp3 PVTT patients, 21.4% and 30.6% in Vp4 PVTT patients (P < 0.05). Total tumor diameter >8 cm, pre-transplant AFP level >1000 ng/mL and intrahepatic tumor maximal standard uptake value (SUVmax-tumor >5) were independent risk factors for HCC recurrence and overall survival after LT in Vp2-3 PVTT patients. Low risk patients were defined as total tumor diameter ≤8 cm; or if total tumor diameter more than 8 cm, with both pre-transplant AFP level less than 1000 ng/mL and intrahepatic tumor SUVmax less than 5, simultaneously. Twenty-two Vp2-3 PVTT HCC patients (46.8%) were identified as low risk patients, and their 3-year recurrence-free and overall survival rates were 67.6% and 95.2%, respectively.

CONCLUSIONS

Patients with segmental or lobar PVTT and biologically favorable tumors defined by AFP and ¹⁸F-FDG SUVmax might be suitable for LT.

Nomogram for Predicting Long-Term Survival after Synchronous Resection for Hepatocellular Carcinoma and Inferior Vena Cava Tumor Thrombosis: A Multicenter Retrospective Study

Background

Although surgery for hepatocellular carcinoma (HCC) complicated with inferior vena cava tumor thrombus (IVCTT) may improve survival for some patients, prognostic markers remain elusive because of its rarity. We constructed a prognostic nomogram which predicts individualized survival benefit of curative-intent surgery for HCC patients with IVCTT.

Methods

According to abdominothoracic anatomy of inferior vena cava (IVC), IVCTT can be divided into 3 types: inferior diaphragmic (ID), superior diaphragmic (SD), and intracardiac type (IC). Data of 64 HCC patients with IVCTT who underwent curative-intent surgery between 2008 and 2015 in four centers in China were analyzed retrospectively. Univariate and multivariate Cox regression analyses were conducted to select variables for the construction of a prognostic nomogram. Predictive accuracy and discriminative ability were examined by concordance index (C-index) and calibration curve.

Results

Of 64 patients in the IVCTT classification, 37 (57.8%) were classified as ID type, 15 (23.4%) as SD type, and 12 (18.8%) as IC type. The 1-, 2-, 3-, and 5-year disease-specific survival (DSS) rates for patients in ID, SD, and IC groups were 94.4%, 55.6%, 71.4%, and 30.0%; 27.8%, 21.4%, 7.1%, and 0%; and 8.3%, 0%, 0%, and 0%, respectively. Independent factors included in the nomogram were ECOG performance status, AFP level ≥ 400 μg/L, tumor size ≥ 10 cm, portal vein tumor thrombosis, and IVCTT classification. The C-index of the nomogram was 0.812 (95% CI 0.761–0.873). The calibration plot for DSS probability showed excellent agreement between the prediction by nomogram and actual observation.

Conclusions

Curative-intent surgery should be carefully evaluated and suggested according to our novel IVCTT classification. We have developed a visual web-based nomogram model to predict oncological prognosis of curative-intent surgery for HCC patients with IVCTT.