Is preoperative portal vein embolization effective in improving prognosis after major hepatic resection in patients with advanced-stage hepatocellular carcinoma?

Repeatability and reproducibility of deep-learning-based liver volume and Couinaud segment volume measurement tool

Purpose

Volumetric and health assessment of the liver is crucial to avoid poor post-operative outcomes following liver resection surgery. No current methods allow for concurrent and accurate measurement of both Couinaud segmental volumes for future liver remnant estimation and liver health using non-invasive imaging. In this study, we demonstrate the accuracy and precision of segmental volume measurements using new medical software, Hepatica™.

Methods

MRI scans from 48 volunteers from three previous studies were used in this analysis. Measurements obtained from Hepatica™ were compared with OsiriX. Time required per case with each software was also compared. The performance of technicians and experienced radiologists as well as the repeatability and reproducibility were compared using Bland–Altman plots and limits of agreement.

Results

High levels of agreement and lower inter-operator variability for liver volume measurements were shown between Hepatica™ and existing methods for liver volumetry (mean Dice score 0.947 ± 0.010). A high consistency between technicians and experienced radiologists using the device for volumetry was shown (± 3.5% of total liver volume) as well as low inter-observer and intra-observer variability. Tight limits of agreement were shown between repeated Couinaud segment volume (+ 3.4% of whole liver), segmental liver fibroinflammation and segmental liver fat measurements in the same participant on the same scanner and between different scanners. An underestimation of whole-liver volume was observed between three non-reference scanners.

Conclusion

Hepatica™ produces accurate and precise whole-liver and Couinaud segment volume and liver tissue characteristic measurements. Measurements are consistent between trained technicians and experienced radiologists.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00261-021-03262-x.

Oncological benefits of portal vein embolization for patients with hepatocellular carcinoma

Portal vein embolization (PVE) for hepatocellular carcinoma (HCC) was first introduced in 1986 and has been continuously developed throughout the years. Basically, PVE has been applied to expand the indication of liver resection for HCC patients of insufficient future liver remnant. Importantly, PVE can result in tumor progression in both embolized and non-embolized livers; however, long-term survival after liver resection following PVE is at least not inferior compared with liver resection alone despite the smaller future liver remnant volume. Five-year disease-free survival and 5-year overall survival were 17% to 49% and 12% to 53% in non-PVE patients, and 21% to 78% and 44% to 72% in PVE patients, respectively. At present, it has proven that PVE has multiple oncological advantages for both surgical and nonsurgical treatments. PVE can also enhance the anticancer effects of transarterial chemoembolization and can avoid intraportal tumor cell dissemination. Additional interventional transarterial chemoembolization and hepatic vein embolization as well as surgical two-stage hepatectomy and associated liver partition and portal vein ligation for staged hepatectomy can enhance the oncological benefit of PVE monotherapy. Taken together, PVE is an important treatment which we recommend for listing in the guidelines for HCC treatment strategies.

Is portal vein embolization safe and effective for patients with impaired liver function?

BACKGROUND AND OBJECTIVES

Portal vein embolization (PVE) is a safe and effective procedure used to increase the safety of extensive hepatectomy for selected patients. However, it is unknown whether PVE is safe for patients with impaired liver functional reserve.

METHODS

Patients who underwent PVE from April 2007 to September 2016 in our hospital were retrospectively assessed. According to indocyanine green retention rate at 15 min (ICG-R15), we divided patients into Group A (≤10%), Group B (10%-20%), and Group C (>20%). We described and compared the treatment course and the outcome among the three groups.

RESULTS

A total of 106 patients were assessed and divided into groups A (n = 46), B (n = 49), and C (n = 11). The morbidity and mortality after PVE showed no significant differences among the three groups (A:B:C = 37%:53%:64%, p = .16; A:B:C = 0%:0%:0%, p = 1.00, respectively). The morbidity and mortality after successive hepatectomy also showed no significant differences among the three groups (A:B:C = 55%:71%:78%, p = .19; A:B:C = 0%:2%:0%, p = 1.00, respectively).

CONCLUSION

A patient with impaired liver functional reserve (ICG-R15 > 20%) can be a candidate for PVE and successive hepatectomy, as safely as a patient with normal and slightly impaired liver functional reserve (ICG-R15 ≤ 20%).

Surgical Resection: Old Dog, Any New Tricks?

Patients with hepatocellular carcinoma (HCC) have many treatment options. For patients with surgical indication, consideration of future liver remnant and the surgical complexity of the procedure is essential. A new 3-level complexity classification categorizing 11 liver resection procedures predicts surgical complexity and postoperative morbidity better than reported classifications. Preoperative portal vein embolization can mitigate the risk of hepatic insufficiency. For small HCCs, both liver resection and ablation are effective. New medical treatment options are promising and perioperative use of these drugs may further improve outcomes for patients undergoing liver resection and lead to changes in current treatment guidelines.

Expanding the Surgical Pool for Hepatic Resection to Treat Biliary and Primary Liver Tumors

Surgical management of primary liver and biliary tract tumors has evolved over the past several decades, resulting in improved outcomes in these malignancies with historically poor prognoses. Expansion of patient selection criteria, progress in neoadjuvant and adjuvant therapies, development of techniques to increase future liver remnant, and the select utilization of liver transplantation have all contributed to increasing the patient pool for surgical intervention. Ongoing and future studies need to focus on improving multimodality treatment regimens and further refining the selection criteria for transplantation in order to optimize utilization of limited organ resources.

The role of portal vein embolization in the surgical management of primary hepatobiliary cancers. A systematic review

BACKGROUND

Primary liver and biliary cancers are very aggressive tumors. Surgical treatment is the main option for cure or long term survival. The main purpose of this systematic review is to underline the indications for portal vein embolization (PVE), in patients with inadequate future liver remnant (FLR) and to analyze other parameters such as resection rate, morbidity, mortality, survival after PVE and hepatectomy for primary hepatobiliary tumors. Also the role of trans-arterial chemoembolization (TACE) before PVE, is investigated.

METHODS

A systematic search of the literature was performed in Pub Med and the Cochrane Library from 01.01.1990 to 30.09.2015.

RESULTS

Forty articles were selected, including 2144 patients with a median age of 61 years. The median excision rate was 90% for hepatocellular carcinomas (HCCs) and 86% for hilar cholangiocarcinomas (HCs). The main indications for PVE in patients with HCC and presence of liver fibrosis or cirrhosis was FLR <40% when liver function was good (ICGR15 < 10%) and FLR < 50% when liver function was affected (ICGR15:10-20%). The combination of TACE and PVE increased hypertrophy rate and was associated with better overall survival and disease free survival and should be considered in advanced HCC tumors with inadequate FLR. In patients with HCs PVE was performed, after preoperative biliary drainage, when FLR was <40%, in the majority of studies, with very good post-operative outcome. However indications should be refined.

CONCLUSION

PVE before major hepatectomy allows resection in a patient group with advanced primary hepato-biliary tumors and inadequate FLR, with good long term survival.

Portal Vein Embolization Followed by Right-Side Hemihepatectomy for Hepatocellular Carcinoma Patients: A Japanese Multi-Institutional Study

BACKGROUND

Portal vein embolization (PVE) is useful to expand the indications of major hepatectomy; however, its oncologic effects are not fully understood. This study aimed to confirm the efficacy of preoperative PVE for hepatocellular carcinoma patients.

STUDY DESIGN

Between 2000 and 2012, five hundred and ten patients with hepatocellular carcinoma undergoing right-side hemihepatectomy were enrolled (PVE group, n = 162 and non-PVE group, n = 348). To equalize background factors, one-to-one propensity case-matched analysis and multivariate analysis were performed. Short- and long-term outcomes were evaluated.

RESULTS

Propensity score-matched patients, 148 in each group, were selected. The percentage of resected liver volume on admission was significantly greater in the PVE group (60.5% vs 48.3%; p < 0.001), but decreased considerably after PVE, from 60.5% to 50.3% (p < 0.001). The 5-year cumulative recurrence-free survival (36.4% vs 35.3%) and overall survival (58.6% vs 52.8%) rates were comparable. Extrahepatic recurrences were less common in the PVE group (18.1% vs 38.8%; p = 0.004). Independent prognostic factors for recurrence-free survival were morbidity (hazard ratio [HR] = 1.56), multiple tumors (HR = 1.97), red cell concentrate administration (HR = 1.57), older age (HR = 2.09), and massive portal invasion (HR = 2.33); and those for overall survival were morbidity (HR = 2.37), multiple tumors (HR = 1.71), and massive hepatic venous invasion (HR = 3.49).

CONCLUSIONS

Even though hepatocellular carcinoma patients who underwent preoperative PVE and right-side hemihepatectomy had a significantly larger resected liver volume on admission, they have a comparable long-term prognosis as patients with up front hepatectomy. In addition, PVE might decrease extrahepatic recurrences.

Should ALPPS be Used for Liver Resection in Intermediate-Stage HCC?

BACKGROUND

Extended liver resections in patients with hepatocellular carcinoma (HCC) are problematic due to hepatitis, fibrosis, and cirrhosis. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has been promoted as a novel method to induce hypertrophy for patients with extensive colorectal liver metastases, but outcomes in HCC have not been well investigated.

METHODS

All patients registered in the international ALPPS Registry ( www.alpps.org ) from 2010 to 2015 were studied. Hypertrophy of the future liver remnant, perioperative morbidity and mortality, age, overall survival, and other parameters were compared between patients with HCC and patients with colorectal liver metastases (CRLM).

RESULTS

The study compared 35 patients with HCC and 225 patients with CRLM. The majority of patients undergoing ALPPS for HCC fall into the intermediate-stage category of the Barcelona clinic algorithm. In this study, hypertrophy was rapid and extensive for the HCC patients, albeit lower than for the CRLM patients (47 vs. 76 %; p < 0.002). Hypertrophy showed a linear negative correlation with the degrees of fibrosis. The 90-day mortality for ALPPS used to treat HCC was almost fivefold higher than for CRLM (31 vs. 7 %; p < 0.001). Multivariate analysis showed that patients older than 61 years had a significantly reduced overall survival (p < 0.004).

CONCLUSION

The ALPPS approach induces a considerable hypertrophic response in HCC patients and allows resection of intermediate-stage HCC, albeit at the cost of a 31 % perioperative mortality rate. The use of ALPPS for HCC remains prohibitive for most patients and should be performed only for a highly selected patient population younger than 60 years with low-grade fibrosis.

Hepatocellular Carcinoma: Review of Epidemiology, Screening, Imaging Diagnosis, Response Assessment, and Treatment

Hepatocellular carcinoma is a common malignancy for which prevention, screening, diagnosis, treatment, and surveillance demand a multidisciplinary approach. Knowledge of the underlying pathophysiology as well as advances in clinical management should be employed by radiologists to effectively communicate with hepatologists, surgeons, and oncologists. In this review article, we present recent developments in the clinical management of hepatocellular carcinoma.

Surgical resection after down-staging of locally advanced hepatocellular carcinoma by localized concurrent chemoradiotherapy

BACKGROUND

This study evaluated the down-staging efficacy and impact on resectability of concurrent chemoradiotherapy (CCRT) followed by hepatic arterial infusion chemotherapy (HAIC) in locally advanced hepatocellular carcinoma, and identified prognostic factors of disease-free survival (DFS) and overall survival (OS) after curative resection.

METHODS

DFS and OS were investigated using clinicopathologic variables. Functional residual liver volume (FRLV) was assessed before CCRT and again before surgery in patients with major hepatectomy. Tumor marker response was defined as elevated tumor marker levels at diagnosis but levels below cutoff values before surgery (α-fetoprotein < 20 ng/mL, protein induced by vitamin K absence or antagonist-II < 40 mAU/mL).

RESULTS

Of 243 patients who received CCRT followed by HAIC between 2005 and 2011, 41 (16.9 %) underwent curative resection. Tumor down-staging was demonstrated in 32 (78 %) of the resected patients. FRLV significantly increased from 47.5 to 69.9 % before surgery in patients who underwent major hepatectomy. In addition, the OS of the curative resection group was significantly higher than the OS of the CCRT followed by HAIC alone group (49.6 vs. 9.8 % at 5-year survival; p < 0.001). By multivariate analysis, the poor prognostic factors for DFS after curative resection were tumor marker non-response and the presence of a satellite nodule; however, tumor marker non-response was the only independent poor prognostic factor of OS.

CONCLUSIONS

CCRT followed by HAIC increased resectability by down-staging tumors and increasing FRLV. Curative resection may provide good long-term survival in tumor marker responders who undergo CCRT followed by HAIC.

Right portal vein embolization with absolute ethanol in major hepatic resection for hepatobiliary malignancy

BACKGROUND

This study aimed to evaluate the safety and efficacy of preoperative right portal vein embolization (PVE) with absolute ethanol in patients with hepatobiliary malignancies.

METHODS

PVE was performed via a percutaneous transhepatic ipsilateral approach, and the right portal branch was embolized with absolute ethanol. Technical success and complications following PVE, and changes in liver enzyme levels were evaluated. Changes in future liver remnant (FLR) and FLR/total functional liver volume ratio were calculated. Complications following hepatic resection were assessed.

RESULTS

A total of 83 patients with hepatobiliary malignancies (53 men, 30 women; mean age 68 years) underwent right PVE. Tumour types were hilar cholangiocarcinoma (37), liver metastases (14), gallbladder cancer (13), intrahepatic cholangiocellular carcinoma (10) and hepatocellular carcinoma (HCC) (9). PVE was performed successfully in all patients. Four patients (5 per cent) developed complications following PVE (liver abscess 2, left portal vein thrombosis 1, pseudoaneurysm 1), but this did not preclude hepatic resection. Liver enzyme levels rose transiently after PVE. The mean FLR and FLR/total functional liver volume increased after PVE (from 366 to 513 cm(3) and from 31 to 43 per cent respectively; both P < 0·001). Changes in the FLR and FLR/total functional liver volume ratio were comparable between patients with HCC and those with other malignancies (42 and 44 per cent, and 12 and 12 per cent, respectively). Sixty-nine of 83 patients underwent hepatic resection at a median of 25 days after PVE, with no postoperative mortality.

CONCLUSION

Preoperative right PVE with absolute ethanol is safe and effective for induction of selective hepatic hypertrophy in patients with hepatobiliary malignancy.

Enhanced tumor growth after portal vein embolization in a rabbit tumor model

BACKGROUND

Preoperative portal vein embolization (PVE) is used to increase future remnant liver volume through induction of hepatocellular regeneration. This event, however, potentially enhances tumor growth. The aim of our study was to assess tumor growth and liver regeneration after PVE in a rabbit hepatic tumor model. The VX2 carcinoma is derived from a virus-induced papilloma tumor in rabbits. The tumor grows rapidly, and its blood supply is similar to that of human hepatocellular carcinoma.

MATERIALS AND METHODS

Two weeks after subcapsular implantation of a VX2 carcinoma in the cranial liver lobe, New Zealand White rabbits were allocated to a control or PVE group (n = 5 per group). In the PVE group, the portal vein branch to the cranial liver lobes (80%) was embolized using particles and coils, leaving the caudal liver lobe (20%) free. In the tumor control group, the liver was mobilized. Computed tomography volumetry was performed on days 3, 7, 10, and 14. Tumor growth rate (TGR), hepatocellular proliferation rate, and liver damage parameters were assessed before PVE and on days 1, 3, 7, 10, and 14.

RESULTS

Portography confirmed complete occlusion of the portal vein branch to the cranial liver lobes in all PVE rabbits. The hypertrophy response and proliferation rate in the nonembolized liver lobes were significantly higher in the PVE group, which was confirmed by liver-to-body weight index assessment. TGR was increased in both groups, with a significantly larger increase in the PVE group over time (day 14: mean, 34.4 ± 4.3 mL/d versus control: mean, 24.1 ± 7.2 mL/d; P < 0.05).

CONCLUSIONS

TGR was significantly increased after PVE in the rabbit tumor model. This finding supports the notion that PVE potentially enhances tumor growth, along with the regeneration of the nonembolized liver lobe.

Tzeng CW, Vauthey JN. Portal vein embolization for hepatocellular carcinoma

Portal vein embolization (PVE) improves the safety of major hepatectomy through hypertrophy of the future liver remnant (FLR), atrophy of the liver volume to be resected, and improvement in patient selection. Because most patients with hepatocellular carcinoma (HCC) have liver parenchymal injury due to underlying viral hepatitis or alcoholic liver fibrosis/cirrhosis, indication of PVE is relatively complex and sequential procedures, including transarterial chemoembolization, are required to maximize the effect of PVE as well as to minimize tumor progression due to increased arterial flow after PVE. PVE is currently indicated for patients with relatively well-preserved hepatic function [Child-Pugh A and indocyanine green tolerance test (ICG-R15) <20%) to achieve minimal FLR volume for safe major hepatectomy. FLR volume >40% is the minimal requirement for patients with chronic hepatitis or cirrhosis, and further strict criteria (FLR volume >50%) have been recommended for patients with marginal liver functional reserve (ICG-R15, 10-20%). Recent clinical results have suggested that PVE can be safely performed in patients with HCC and that it contributes to improved survival after major hepatectomy.

Role of portal vein embolization in hepatocellular carcinoma management and its effect on recurrence: a case-control study

Background

Liver regeneration that occurs after portal vein embolization (PVE) may have adverse effects on the microscopic tumor foci in the residual liver mass in patients with hepatocellular carcinoma (HCC).

Methods

Fifty-four HCC patients with inadequate functional residual liver volume were offered PVE during a seven-year period. Among them, 34 (63%) patients underwent curative resection. They were compared with a matched control group (n = 102) who underwent surgery without PVE. Postoperative complications, pattern of recurrence, and survival were compared between groups.

Results

In the PVE group, a pre-embolization functional residual liver volume of 23% (12–33.5%) improved to 34% (20–54%) (p = 0.005) at the time of surgery. When the two groups were compared, minor (PVE, 24%; control, 29%; p = 0.651) and major (PVE, 18%; control, 15%; p = 0.784) complications were similar. After a follow-up period of 35 months (standard deviation 25 months), extrahepatic recurrences were detected in 10 PVE patients (29%) and 41 control patients (40%) (p = 0.310). Intrahepatic recurrences were seen in 10 (29%) and 47 (46%) cases (p = 0.109) in the PVE and control groups, respectively. In the PVE group, 41% (n = 14) of the recurrences were detected before one year, compared with 42% (n = 43) in the control group (p = 1). Disease-free survival rates at 1, 3, and 5 years were 57, 29, and 26% in the control group and 60, 42, and 42% in the PVE group (log-rank, p = 0.335). On multivariate analysis, PVE was not a factor affecting survival (p = 0.821).

Conclusions

Portal vein embolization increases the resectability of initially unresectable HCC due to inadequate functional residual liver volume, and it has no deleterious oncological effect after major resection of HCC.

Liver hypertrophy and accelerated growth of implanted tumors in nonembolized liver of rabbit after left portal vein embolization

BACKGROUND

Portal vein embolization (PVE) has become a standard preoperative procedure to promote hypertrophy of the future remnant liver to reduce postoperative liver failure. Whether PVE accelerates tumor growth is still controversial. We developed a left PVE procedure and investigated its effect on liver hypertrophy and tumor growth in a rabbit liver tumor model.

MATERIALS AND METHODS

VX2 tumors were implanted in both the external left and right middle lobe (the bilateral group) or in the external left lobe only (the unilateral group) of rabbit liver. Both groups were further divided into a PVE or a sham/control group. Tumor volume and tumor growth rate as volume relative increase were determined by ultrasound. Liver volume-to-body weight index, an index for liver volume, was compared. Serum HGF was measured by ELISA.

RESULTS

In the bilateral PVE group, tumor volume and relative increase value in the nonembolized lobe were significantly (71% and 65%, respectively) greater than those in the control group at 5 d post-PVE. In the unilateral PVE group, liver volume-to-body weight index of the nonembolized lobes was significantly increased by 17%. Increase of serum HGF level after PVE was correlated well with both tumor growth and liver hypertrophy.

CONCLUSIONS

Left PVE promoted both the growth of implanted tumors and liver hypertrophy in the nonembolized liver, in which serum HGF might play an important role.

Sequential arterial and portal vein embolization in patients with cirrhosis and hepatocellular carcinoma: the hospital beaujon experience

When feasible, hepatic resection is the treatment of choice for large hepatocellular carcinoma (HCC). Because HCC is often developed on chronic liver disease, which is known to have limited regeneration capacity, major hepatic resections are often contraindicated. Portal vein embolization (PVE) has been introduced to extend the indications for major hepatic resection and to increase the safety of the surgical procedure. However, hypertrophy after PVE is often less than in normal liver. It has been suggested that preoperative sequential arterial embolization and PVE have a strong anticancer effect and could increase the rate of hypertrophy more than PVE alone. In our experience, sequential arterial embolization and PVE effectively increase the future liver remnant and induce a high rate of complete tumor necrosis. This combined procedure should broaden the indication for major resection in chronic liver disease.

Strategies for resection using portal vein embolization: hepatocellular carcinoma and hilar cholangiocarcinoma

Preoperative portal vein embolization (PVE) is increasingly used to optimize the volume and function of the future liver remnant (FLR) and to reduce the risk for complications of major hepatectomy for hepatocellular carcinoma (HCC) or hilar cholangiocarcinoma (CCA). In patients with HCC who are candidates for extended hepatectomy and in patients with HCC and well-compensated cirrhosis who are being considered for major hepatectomy, FLR volumetry is routinely performed, and PVE is employed in selected cases to optimize the volume and function of the FLR prior to surgery. Similarly, in patients with hilar CCA who are candidates for extended hepatectomy, careful preoperative preparation using biliary drainage, FLR volumetry, and PVE optimizes the volume and function of the FLR prior to surgery. Appropriate use of PVE has led to improved postoperative outcomes after major hepatectomy for these diseases and oncological outcomes similar to those in patients who undergo resection without PVE. Specific indications for PVE are being clarified. FLR volumetry is necessary for proper selection of patients for PVE. Analysis of the degree of hypertrophy of the FLR after PVE (a dynamic test of liver regeneration) complements analysis of the pre-PVE FLR volume (a static test). Together, FLR degree of hypertrophy and FLR volume are the best predictors of outcome after major hepatectomy in an individual patient, regardless of the degree of underlying liver disease. This article synthesizes the literature on the approach to patients with HCC and CCA who are candidates for major hepatectomy. The rationale and indications for FLR volumetry and PVE and outcomes following PVE and major hepatectomy for HCC and CCA are discussed.

Patient selection for surgical management of primary and metastatic liver cancers: current perspectives

The surgical management of liver malignancies remains a mainstay in the treatment of such patients, and has benefited from dramatic advancements over the last two decades. Improvements in surgical technique, better understanding of hepatic anatomy, and improvement in anesthesiological supportive care has resulted in a decline in perioperative morbidity and operative mortality. Proper patient selection for surgical and nonsurgical treatment currently employs a multidisciplinary approach in our institution. This review will focus on the surgical treatment options for both primary and secondary liver cancers.

Safety and efficacy of trisectionectomy for hepatocellular carcinoma

BACKGROUND

Right or left trisectionectomy represents the most extensive and difficult type of hepatic resection, and carries an unfavourably high morbidity and mortality. This retrospective study aimed to evaluate the safety and efficacy of trisectionectomy for hepatocellular carcinoma (HCC).

METHODS

From January 2000 to December 2008, 35 patients with HCC were treated with trisectionectomy. The treatment outcomes of these patients were retrospectively analysed.

RESULTS

Twenty-three right and 12 left trisectionectomies were performed. The overall operative morbidity and mortality were 42.8% (n= 15) and 2.8% (n= 1), respectively. The 1-, 3-, and 5-year overall survival rates were 82.9%, 51.4% and 23.8%, while the 1-, 3- and 5-year disease-free survival rates were 71.4%, 42.9% and 12.9%, respectively.

CONCLUSIONS

With careful patient selection and meticulous surgical technique, trisectionectomy can be performed safely and is associated with long-term survival in a subset of patients with HCC.

Impact of portal vein embolization on expression of cancer stem cell markers in regenerated liver and colorectal liver metastases

OBJECTIVE

Little is known about the expression of stem cell markers in normal liver and colorectal liver metastases (CLM). The aim of this paper is to assess whether patterns of stem cell marker expression differ between normal liver tissue and CLM and to determine whether a clinical model of liver regeneration induced by portal vein embolization (PVE) has any influence on these patterns of expression in both regenerated liver tissue and cancer.

MATERIALS AND METHODS

Immunohistochemistry was used to provide semi-quantitative analysis of patterns of expression in tissue samples of liver and tumor tissue pre- and post-PVE in 23 patients with CLM. CD133, CD44 and Oct4 were studied.

RESULTS

There was no expression of CD133, CD44 or Oct4 in normal liver tissue before PVE but there was high expression of CD133 and CD44 in CLM. PVE had no significant influence on stem cell marker expression either in regenerated liver tissue or in tumor when compared with pre-PVE samples.

CONCLUSION

Liver regeneration following PVE does not seem to involve stem cells. Stem cell marker expression by CLM supports the stem cell theory of carcinogenesis which is not influenced by PVE.

Portal vein embolization: rationale, outcomes, controversies and future directions

Portal vein embolization (PVE) is now considered the standard of care to improve safety for patients undergoing extensive hepatectomy with an anticipated small future liver remnant (FLR). PVE is used to induce contralateral liver hypertrophy in preparation for major liver resection. Optimal patient selection is essential to maximize the clinical benefits of PVE. Computed tomography volumetry is used to calculate a standardized FLR and determine the need for preoperative PVE. Percutaneous PVE can be performed via the transhepatic ipsilateral or contralateral approaches, depending on operator preference. Several different embolic agents are available to the interventional radiologist, all with similar effectiveness in inducing hypertrophy. When an extended hepatectomy is planned, right PVE should include segment 4, in order to maximize FLR hypertrophy. Multiple studies have demonstrated the beneficial outcomes of PVE in both patients with healthy livers and with underlying liver diseases. Novel improvements to PVE should expand its scope to patients who were previously not candidates for the procedure.

Uses and limitations of portal vein embolization for improving perioperative outcomes in hepatocellular carcinoma

Hepatic resection remains the only curative option for the majority of patients with hepatocellular carcinoma (HCC) who do not meet criteria for transplantation or local ablative options. As the majority of patients with HCC also have underlying chronic liver disease and cirrhosis, post-hepatectomy complications can be significant, and in some prohibitive. The technique of portal vein embolization (PVE) has evolved to increase the candidacy of patients for major hepatectomy, as well as improve postoperative outcomes and safety. This review will focus on PVE and discuss our institution's experience with uses and limitations of this technique for HCC.

Major hepatic resection for hepatocellular carcinoma with or without portal vein embolization: Perioperative outcome and survival

BACKGROUND

Preoperative portal vein embolization (PVE) is performed to minimize perioperative risks of major hepatic resection for hepatocellular carcinoma (HCC), but its effects on tumor growth are ill defined. Perioperative outcome and survival after major hepatic resection for HCC, with and without PVE, were investigated.

METHODS

Patients that underwent major hepatic resection (> or =3 segments) for HCC between January 1998 and May 2007 were analyzed retrospectively. Preoperative PVE was performed when the remnant liver volume was predicted to be insufficient.

RESULTS

A total of 54 patients underwent major hepatic resection for HCC: 21 patients with PVE before resection (PVE group) and 33 patients without PVE (non-PVE group). PVE and non-PVE groups had similar rates of fibrosis or cirrhosis, hepatitis C virus, hepatitis B virus, American Joint Committee on Cancer stage, preoperative transarterial chemoembolization, overall postoperative complications, and positive margin (P = nonsignificant for all rates). There were no perioperative deaths in the PVE group and 6 (18%) deaths in the non-PVE group (P = .038). Median follow-up was 21 months. Excluding perioperative deaths, overall survival rates at 1, 3, and 5 years were 94%, 82%, and 72%, respectively, in the PVE group and 93%, 63%, and 54%, respectively, in the non-PVE group (P = .35). Similarly, disease-free survival (DFS) rates were not significantly different between the groups, with 1-, 3-, and 5-year DFS rates of 84%, 56%, and 56%, respectively, in the PVE group and 66%, 49%, and 49%, respectively, in the non-PVE group (P = .38).

CONCLUSION

PVE before major hepatic resection for HCC is associated with improved perioperative outcome. Excluding perioperative mortality, overall survival and DFS rates were similar between patients with and without preoperative PVE.

Portal vein embolization using a nitinol plug (Amplatzer vascular plug) in combination with histoacryl glue and iodinized oil: adequate hypertrophy with a reduced risk of nontarget embolization

The purpose of this study was to assess whether portal vein embolization (PVE) using a nitinol vascular plug in combination with histoacryl glue and iodinized oil minimizes the risk of nontarget embolization while obtaining good levels of future liver remnant (FLR) hypertrophy. Between November 2005 and August 2008, 16 patients (8 females, 8 males; mean age, 63 +/- 3.6 years), each with a small FLR, underwent right ipsilateral transhepatic PVE prior to major hepatectomy. Proximal PVE was initially performed by placement of a nitinol vascular plug, followed by distal embolization using a mixture of histoacryl glue and iodinized oil. Pre- and 6 weeks postprocedural FLR volumes were calculated using computed tomographic imaging. Selection for surgery required an FLR of 0.5% of the patient's body mass. Clinical course and outcome of surgical resection for all patients were recorded. At surgery, the ease of hepatectomy was subjectively assessed in comparison to previous experience following PVE with alternative embolic agents. PVE was successful in all patients. Mean procedure time was 30.4 +/- 2.5 min. Mean absolute increase in FLR volume was 68.9% +/- 12.0% (p = 0.00005). There was no evidence of nontarget embolization during the procedure or on subsequent imaging. Nine patients proceeded to extended hepatectomy. Six patients demonstrated disease progression. One patient did not achieve sufficient hypertrophy in relation to body mass to undergo hepatic resection. At surgery, the hepatobiliary surgeons observed less periportal inflammation compared to previous experience with alternative embolic agents, facilitating dissection at extended hepatectomy. In conclusion, ipsilateral transhepatic PVE using a single nitinol plug in combination with histoacryl glue and iodinized oil simplifies the procedure, offering short procedural times with minimal risk of nontarget embolization. Excellent levels of FLR hypertrophy are achieved enabling safe extended hepatectomy.

Preoperative Y-90 microsphere selective internal radiation treatment for tumor downsizing and future liver remnant recruitment: a novel approach to improving the safety of major hepatic resections

Background

Extended liver resections are being performed more liberally than ever. The extent of resection of liver metastases, however, is restricted by the volume of the future liver remnant (FLR). An intervention that would both accomplish tumor control and induce compensatory hypertrophy, with good patient tolerability, could improve clinical outcomes.

Case presentation

A 53-year-old woman with a history of cervical cancer presented with a large liver mass. Subsequent biopsy indicated poorly differentiated carcinoma with necrosis suggestive of squamous cell origin. A decision was made to proceed with pre-operative chemotherapy and Y-90 microsphere SIRT with the intent to obtain systemic control over the disease, downsize the hepatic lesion, and improve the FLR. A surgical exploration was performed six months after the first SIRT (three months after the second). There was no extrahepatic disease. The tumor was found to be significantly decreased in size with central and peripheral scarring. The left lobe was satisfactorily hypertrophied. A formal right hepatic lobectomy was performed with macroscopic negative margins.

Conclusion

Selective internal radiation treatment (SIRT) with yttrium-90 (Y-90) microspheres has emerged as an effective liver-directed therapy with a favorable therapeutic ratio. We present this case report to suggest that the portal vein radiation dose can be substantially increased with the intent of inducing portal/periportal fibrosis. Such a therapeutic manipulation in lobar Y-90 microsphere treatment could accomplish the end points of PVE with avoidance of the concern regarding tumor progression.

Use of bioluminescence imaging to detect enhanced hepatic and systemic tumor growth following partial hepatectomy in mice

BACKGROUND

The impact of partial hepatectomy on intra-hepatic and distant tumor growth is a matter of controversy. Utilizing a highly sensitive tumor imaging strategy, we sought to demonstrate whether this growth-acceleration occurs, and to develop an animal model with which to investigate potential therapeutic strategies.

METHODS

Mice bearing constitutively-active luciferase-expressing tumor cells were subjected to either 70% partial hepatectomy (PH; n=10) or a sham operation (n=11). Mice were sacrificed 14 days later and remnant livers (or anatomic equivalents in the control group) and lungs harvested for bioluminescence detection.

RESULTS

Remnant liver weights were significantly increased in PH compared to equivalent lobes in sham-operated animals (t-test; p=0.005). Tumor burden as measured by bioluminescence was significantly higher in both liver and lung specimens in the PH group (Wilcoxon's Rank Sum test; p=0.01 and 0.004, respectively).

CONCLUSIONS

Following PH, enhanced metastatic growth was depicted regionally and systemically with bioluminescence imaging providing an objective measure of tumor burden. This preclinical model can help to identify adjuvant therapies that can influence both tumor growth and liver regeneration.

Outcomes and prognostic factors of cirrhotic patients with hepatocellular carcinoma after radical major hepatectomy

BACKGROUND

Radical major hepatectomy (RMH) has been suggested as one of main options for cure of large/advanced hepatocellular carcinoma (HCC). However, its operative risk remains high and its effectiveness is still controversial, especially for patients with liver cirrhosis. The present study aims to investigate short- and long-term outcomes and to identify prognostic factors for cirrhotic patients with HCC after RMH.

MATERIALS AND METHODS

Prospectively collected clinicopathological data of 81 consecutive cirrhotic HCC patients who underwent RMH were reviewed retrospectively. The Kaplan-Meier method was adopted for evaluating long-term survival. Prognostic factors were identified by univariate and multivariate analyses.

RESULTS

After RMH, perioperative mortality, overall morbidity, and life-threatening morbidity were 1.2%, 24.7%, and 12.3%, respectively. Overall and disease-free 5-year survival rates were 39.4% and 28.1%, respectively. Univariate analysis showed that presence of portal vein tumor thrombosis (PVTT) and satellite nodules, late TNM staging, high Edmondson-Steiner grading, and blood transfusion was associated with worsened prognosis. Of them, Edmondson-Steiner grading was identified as the sole independent prognostic factor for both overall and disease-free survival by multivariate analysis, whereas blood transfusion and the presence of PVTT independently predicted unfavorable overall or disease-free survival, respectively.

CONCLUSIONS

These data indicated that RMH was safe and appeared to be effective in treating cirrhotic patients with HCC. Some tumor-related and clinical variables influenced long-term outcome of these patients after RMH.

Trans-ileocecal portal vein embolization as a preoperative treatment for right trisegmentectomy with caudate lobectomy

BACKGROUND AND OBJECTIVES

The indication of preoperative portal vein embolization (PVE) has been expanded to hepatocellular carcinoma, cholangiocellular carcinoma (CCC), hepatic metastasis, and gallbladder (GB) cancer as well as hilar cholangiocarcinoma (hCC). However, biliary cancers sometimes cause peritoneal dissemination.

PATIENTS AND METHODS

We performed our preoperative trans-ileocecal-vein PVE (TIPE) method on 14 (3 GB cancer, 1 CCC, and 10 hCC), whose estimated residual liver volume was <30%.

RESULTS

Out of 14 patients, peritoneal dissemination was encountered in two patients with GB cancer and one with hCC (21.4%) during our procedure. The estimated residual liver volume was 37.4 +/- 2.7% at 14 days after PVE in patients without predisposing cholangitis, while those in patients with cholangitis was 29.3 +/- 1.3% (P = 0.0002). No major complication due to the procedure was encountered in this series.

CONCLUSIONS

PTPE could be the first choice for patients with hCC, hepatocellular carcinoma, and hepatic metastases. Although the TIPE proposed here has some potential disadvantages, we would recommend it especially for patients with GB cancer because of its high potential to cause cancerous peritonitis. When a patient had predisposing cholangitis, radical operation should be scheduled on >21 days after PVE rather than on 14 days.

Preoperative Portal Vein Embolization and Surgical Resection in Patients with Hepatocellular Carcinoma and Small Future Liver Remnant Volume: Comparison with Transarterial Chemoembolization

BACKGROUND

Preoperative portal vein embolization (PVE) increases the future liver remnant (FLR) volume, thus enabling surgical resection in patients with small FLR volume. It is unclear, however, if this approach can enhance survival in patients with hepatocellular carcinoma (HCC). We therefore compared the outcomes of preoperative PVE and surgical resection with transarterial chemoembolization (TACE).

METHODS

Changes in FLR volumes were analyzed in 32 HCC patients who underwent preoperative PVE and surgical resection. Long-term outcomes were compared with 64 TACE-treated patients matched for gender, Child-Turcotte-Pugh class, tumor size and number, serum alpha-fetoprotein levels, and UICC stage.

RESULTS

In the PVE group, the baseline ratio of FLR/total estimated liver volumes (TELV) was 27.6 +/- 7.2%. Following PVE, FLR volume increased 34% (336.5 vs 449.4 mL, P < .001) and the ratio of FLR/TELV increased from 27.6 +/- 7.2 to 36.9 +/- 8.1% (P < .001). There was no mortality associated with PVE or surgical resection. The 5-year survival rate was significantly higher in the PVE group than in the TACE group (71.9% vs 45.6%, P = .03). Multivariate analysis showed that treatment modality was an independent predictive factor for survival (odds ratio 2.05, 95% confidence interval 1.01-4.16, P = .046).

CONCLUSIONS

Preoperative PVE enables surgical resection in HCC patients with small FLR volume and improves patient survival compared with TACE.

Surgical resection of hilar cholangiocarcinoma: analysis of survival and postoperative complications

BACKGROUND

Surgery is the only potentially curative treatment for hilar bile duct cancer. This study sought to evaluate the efficacy and feasibility of surgical management of hilar bile duct carcinoma, including radical hepatectomy, at a single institution.

METHODS

We performed a retrospective review of 49 consecutive patients who underwent surgery at our hospital between 1990 and 2003.

RESULTS

Altogether, 44 of 49 patients underwent radical hepatectomy combined with caudate lobectomy and lymphadenectomy. One and four patients underwent partial hepatectomy or bile duct resection, respectively. No patients underwent preoperative portal vein embolization. The 5-year survival rate was 39.7%, with a median survival time of 3.75 years. The postoperative morbidity and mortality rates were 46.8% and 2.0%, respectively. Cox's proportional hazard model revealed that lymph node status and the residual tumor factor were independent prognostic factors. Multivariate analysis revealed that preoperative hyperbilirubinemia, postoperative complications, and extended surgical procedures were independently associated with postoperative hyperbilirubinemia. After potentially curative resection, 39.4% of patients suffered from disease recurrence. In 60% of the total cases, the sites of recurrence were distant metastases.

CONCLUSION

Surgery, including radical hepatectomy combined with caudate lobectomy and lymph node dissection, is a feasible, effective treatment for hilar bile duct cancer.

Prognosis and results after resection of very large (>or=10 cm) hepatocellular carcinoma

INTRODUCTION

Few potentially curative treatment options exist besides resection for patients with very large (>or=10 cm) hepatocellular carcinoma (HCC). We sought to examine the outcomes and risk factors for recurrence after resection of >or=10 cm HCC.

METHODS

Perioperative and long-term outcomes were examined for 189 consecutive patients from 1993 to 2004 who underwent potentially curative resection of HCC >or=10 cm (n = 24; 13%) vs. those with HCC <10 cm (n = 165; 87%). Disease-free survival (DFS) and overall survival (OS) were determined by Kaplan-Meier analysis and patient, tumor, and treatment characteristics were compared using univariate and multivariate analysis.

RESULTS

Median follow-up was 34 months. Tumors >or=10 cm were more likely to be symptomatic, of poorer grade, and have vascular invasion (p < 0.05). Twelve patients (50%) underwent an extended resection of more than four hepatic segments or resection of adjacent organs for oncologic clearance (diaphragm-2, inferior vena cava (IVC)-2, median sternotomy-1). Postoperative complications were more common after resection of >10 cm HCC (12/24, 50% vs. 35/165, 21%; p = 0.04). Median DFS was significantly shorter in patients with large HCC (>or=10 cm) group compared to patients with smaller HCC (8.4 vs. 38 months; p = 0.001), but overall survival was not different between the two groups (5-year survival 54% vs. 53%; p = 0.43). Seventeen patients (71%) with very large HCC developed recurrences (12 intrahepatic, five systemic); eight of these patients (47%) underwent additional therapy (resection-4, TACE-3, RFA-1). Pathological positive margins and vascular invasion were significant determinants of DFS in tumors >or=10 cm (p < 0.05), but only vascular invasion was an independent risk factor for recurrence after multivariate analysis (HR 0.17; 95% CI: 0.04-0.8). Median OS after recurrence was 24 months.

CONCLUSION

Surgical resection is the optimal therapy for very large (>or=10 cm) HCC. Although recurrences are common after resection of these tumors, overall survival was not significantly different from patients after resection of smaller HCC in this series.

Portal Vein Embolization with N-Butyl Cyanoacrylate before Partial Hepatectomy in Patients with Hepatocellular Carcinoma and Underlying Cirrhosis or Advanced Fibrosis

PURPOSE

To describe the safety, complications, and liver regeneration associated with the left liver after embolization of the right portal vein (PV) in patients with hepatocellular carcinoma (HCC) developed in the setting of advanced liver fibrosis and cirrhosis.

MATERIALS AND METHODS

Forty patients (31 men, nine women; mean age, 62 years) with HCC underwent PV embolization over a 4-year period. Embolization was performed from a left PV percutaneous access with use of n-butyl cyanoacrylate (NBCA) mixed with iodized oil. Computed tomography (CT) volumetry was performed before and 1 month after PV embolization to measure the left lobe volume as well as the functional liver ratio defined by the ratio between the left lobe and the total liver volume minus tumoral volume. PV pressure and liver enzyme levels were compared before and 1 month after the procedure and complications were registered. Factors potentially affecting regeneration (age, sex, diabetes, chemoembolization, functional liver ratio before PV embolization, and Knodell histologic score) were evaluated by one-way and stepwise regression analysis.

RESULTS

PV embolization could be achieved successfully in all cases. Two patients had partial PV thrombosis on the 1-month follow-up CT and two patients developed transient ascites after PV embolization. The left lobe volume increase was 41% +/- 32% after PV embolization and the functional liver ratio increased from 28% +/- 10% to 36% +/- 10% (P < .0001). Hypertrophy of the left lobe was greater in patients with a low functional liver ratio before PV embolization and those with an F3 fibrosis score. Other factors had no influence on left lobe regeneration.

CONCLUSION

PV embolization with use of NBCA is feasible in patients with advanced fibrosis and cirrhosis. Hypertrophy of the left lobe of the liver after PV embolization has a statistically significant correlation with lower functional liver ratio and lower degrees of fibrosis.

Tumor growth-promoting cellular host response during liver atrophy after portal occlusion

BACKGROUND/AIMS

Clinical observations suggest cancer progression after preoperative segmental portal vein occlusion, a procedure to prevent liver failure after major hepatic resections. The aim of this study was to determine whether portal occlusion induces host reactions which promote cancer invasion and angiogenesis.

METHODS

The rat model of portal branch ligation (PBL) was compared with partial hepatectomy (PH) and sham operation (SO) and evaluated for the expression of heat shock protein-70 (hsp70), heme oxygenase-1 (hmox1), early growth response gene-1 (Egr-1) and urokinase-type plasminogen activator (uPA), its inhibitor (PAI-1) and receptor (uPAR).

RESULTS

Portal deprivation after PBL was associated with a regression of liver tissue to 25% of its original mass within 8 days with only modest fibrotic changes. During the progression of atrophy, there were significant inductions of hsp70-, hmox1- and Egr-1-mRNA in comparison with regenerating liver tissue. PAI-1-specific mRNA was transiently elevated at 3 - 48 h after PBL in the atrophying lobes, whereas uPA and uPAR were unaffected in comparison with PH or SO.

CONCLUSION

Hepatic atrophy caused by PBL is associated with increased expression of genes known to promote tumor growth. These host events represent a possible explanation for the tumor progression after portal occlusion and require further evaluation.

The continuing challenge of hepatic cancer in Asia

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world. The number of new cases is estimated to be 564,000 per year. About 80% of all cases are found in Asia. The goal of HCC management is "cancer control"--a reduction in its incidence and mortality as well as an improvement in the quality of life of patients with HCC and their family. Overall, 80% of HCC can be attributed to chronic hepatitis B and C infection. Prevention of infection with hepatitis B and C virus is the key strategy to reduce the incidence of HCC in Asia. Liver resection and liver transplantation remain the options that give the best chance of a cure. In the past two decades, operative mortality and surgical outcome of liver resection and liver transplantation for HCC have improved. Progress also has been made in multi-modality therapy which can increase the chance of survival and improve the quality of life for patients with advanced HCC. Many challenges are still present in Asia, such as the high prevalence of chronic hepatitis, the low resection rate of HCC, the high postoperative recurrence and the severe shortage of cadaveric organ donor. This article aims to discuss the development and challenges in the prevention and management of HCC in Asia.

Surgical therapy of hepatocellular carcinoma

There is no worldwide consensus of an algorithm for the radical treatment of hepatocellular carcinoma (HCC). Surgical resection, liver transplantation and, recently, local ablation therapies achieve high curative rates in selected patients. However, recurrence of HCC remains a major problem. This review provides an overview of the current surgical treatment options available for patients with HCC.

Transhepatic Ipsilateral Right Portal Vein Embolization Extended to Segment IV: Improving Hypertrophy and Resection Outcomes with Spherical Particles and Coils

PURPOSE

To analyze outcomes after right portal vein embolization extended to segment IV (right PVE + IV) before extended right hepatectomy, including liver hypertrophy, resection rates, and complications after embolization and resection, and to assess differences in outcomes with two different particulate embolic agents.

MATERIALS AND METHODS

Between 1998 and 2004, transhepatic ipsilateral right PVE + IV with particles and coils was performed in 44 patients with malignant hepatobiliary disease, including metastases (n = 24), biliary cancer (n = 14), and hepatocellular carcinoma (n = 6). Right PVE + IV was considered if the future liver remnant (FLR; segments II/III with or without I) was less than 25% of the total estimated liver volume (TELV). Tris-acryl microspheres (100-700 microm; n = 21) or polyvinyl alcohol (PVA) particles (355-1,000 microm; n = 23) were administered in a stepwise fashion. Smaller particles were used to occlude distal branches, followed by larger particles to occlude proximal branches until near-complete stasis. Coils were then placed in secondary portal branches. Computed tomographic volumetry was performed before and 3-4 weeks after right PVE + IV to assess FLR hypertrophy. Liver volumes and postembolization and postoperative outcomes were measured.

RESULTS

After right PVE + IV with PVA particles, FLR volume increased 45.5% +/- 40.9% and FLR/TELV ratio increased 6.9% +/- 5.6%. After right PVE + IV with tris-acryl microspheres, FLR volume increased 69.0% +/- 30.7% and FLR/TELV ratio increased 9.7% +/- 3.3%. Differences in FLR volume (P = .0011), FLR/TELV ratio (P = .027), and resection rates (P = .02) were statistically significant. Seventy-one percent of patients underwent extended right hepatectomy (86% after receiving tris-acryl microspheres, 57% after receiving PVA). Thirteen patients (29%) did not undergo resection (extrahepatic spread [n = 9], inadequate hypertrophy [n = 3], other reasons [n = 1]). No patient developed postembolization syndrome or progressive liver insufficiency after embolization or resection. One death after resection occurred as a result of sepsis and hemorrhage. Median hospital stays were 1 day after right PVE + IV and 7 days after resection.

CONCLUSION

Transhepatic ipsilateral right PVE + IV with use of particles and coils is a safe, effective method for inducing contralateral hypertrophy before extended right hepatectomy. Embolization with small spherical particles provides improved hypertrophy and resection rates compared with larger, nonspherical particles.

Current role of portal vein embolization/hepatic artery chemoembolization

This article has reviewed indications, methods, and results of PVE and TACE for hepatobiliary tumors. PVE is applied mainly to increase the safety of major hepatic resection in patients with hilar cholangiocarcinoma, HCC, or metastatic liver tumors. Hepatic arterial embolization causes selective ischemia of the liver tumor and enhances the cytotoxicity of the chemotherapeutic agent administered concomitantly. A survival benefit of TACE in patients with unresectable or recurrent HCC has been demonstrated. The significance of preoperative TACE is still controversial. TACE is routinely performed before PVE in HCC patients.

[Treatment of hepatocellular carcinoma in the cirrhotic liver]

The incidence of hepatocellular carcinoma (HCC) in cirrhotic patients is increasing. Despite advances in imaging and laboratory screening which allow earlier diagnosis, the surgeon is all too often confronted with an HCC of advanced stage or arising in the setting of severe cirrhosis; this severely limits the treatment possibilities. Treatment options are constrained not only by the characteristics of the tumor but also by hepatocellular reserve, severity of portal hypertension, and the general condition of the host. "Curative treatments" envisage the complete eradication of the malignancy; they include liver transplantation, resection, or tumor destruction by radiofrequency or alcohol ablation. They are most effective in the early stages of HCC. Total hepatectomy and transplantation, by far the most complex surgical therapy, also has the best results avoiding the all-too-frequent local recurrence of HCC in the residual liver. Other medical and interventional treatments (chemo-embolization, radiotherapy with lipiodol) can only slow the progress of the HCC. Goals for the future include more precise and directed screening of the population at risk, and better chemopreventive and chemotherapeutic treatments.

Role of neoadjuvant chemotherapy in the treatment of multiple colorectal metastases to the liver

BACKGROUND

The role of neoadjuvant chemotherapy for patients with multiple (five or more) bilobar hepatic metastases irrespective of initial resectability is still under scrutiny. The purpose of this study was to compare the outcome of hepatectomy alone with that of hepatectomy after neoadjuvant chemotherapy for multiple bilobar hepatic metastases from colorectal cancer.

METHODS

Retrospective data were collected from 71 patients after hepatectomy for five or more bilobar liver tumours. The outcome of 48 patients treated by neoadjuvant chemotherapy followed by hepatectomy was compared with that of 23 patients treated by hepatectomy alone.

RESULTS

Patients who received neoadjuvant chemotherapy had better 3- and 5-year survival rates from the time of diagnosis than those who did not (67.0 and 38.9 versus 51.8 and 20.7 per cent respectively; P = 0.039), and required fewer extended hepatectomies (four segments or more) (39 of 48 versus 23 of 23; P = 0.027). Multivariate analysis showed neoadjuvant chemotherapy to be an independent predictor of survival.

CONCLUSION

In patients with bilateral multiple colorectal liver metastases, neoadjuvant chemotherapy before hepatectomy was associated with improved survival and enabled complete resection with fewer extended hepatectomies.

Preoperative portal vein embolization for extended hepatectomy

OBJECTIVE

To examine the authors' experience with preoperative ipsilateral portal vein embolization (PVE) and assess its role in extended hepatectomy.

SUMMARY BACKGROUND DATA

Extended hepatectomy (five or more liver segments) has been associated with higher complication rates and increased postoperative liver dysfunction than have standard hepatic resections involving lesser volumes. Recently, PVE has been used in patients who have a predicted (postresection) future liver remnant (FLR) volume less than 25% of total liver volume in an attempt to increase the FLR and reduce complications.

METHODS

Sixty patients from 1996 to 2002 were reviewed. Thirty-nine patients had PVE preoperatively. Eight patients who had PVE were not resected either due to the discovery of additional unresectable disease after embolization but before surgery (n = 5) or due to unresectable disease at surgery (n = 3). Therefore, 31 patients who had PVE subsequently underwent extended hepatic lobectomy. A comparable cohort of 21 patients who had an extended hepatectomy without PVE were selected on the basis of demographic, tumor, and liver volume characteristics. Patients had colorectal liver metastases (n = 30), hepatocellular carcinoma (n = 15), Klatskin tumors (n = 9), peripheral cholangiocarcinoma (n = 3), and other tumors (n = 3). The 52 resections performed included 42 extended right hepatectomies, 6 extended left hepatectomies, and 4 right hepatectomies extended to include the middle hepatic vein and the caudate lobe but preserving the majority of segment 4. Concomitant vascular reconstruction of either the inferior vena cava or hepatic veins was performed in five patients.

RESULTS

There were no differences between PVE and non-PVE groups in terms of tumor number, tumor size, tumor type, surgical margin status, complexity of operation, or perioperative red cell transfusion requirements. The predicted FLR was similar between PVE and non-PVE groups at presentation. After PVE the FLR was higher than in the non-PVE group. No complications were observed after PVE before resection. There was no difference in postoperative mortality, with one death from liver failure in the non-PVE group and no operative mortality in the PVE group. Postoperative peak bilirubin was higher in the non-PVE than the PVE group, as were postoperative fresh-frozen plasma requirements. Liver failure (defined as the development of encephalopathy, ascites requiring sustained diuretics or paracentesis, or coagulopathy unresponsive to vitamin K requiring fresh-frozen plasma after the first 24 hours postresection) was higher in the non-PVE patients than the PVE patients. The hospital stay was longer in the non-PVE than the PVE group.

CONCLUSIONS

Preoperative PVE is a safe and effective method of increasing the remnant liver volume before extended hepatectomy. Increasing the remnant liver volume in patients with estimated postresection volumes of less than 25% appears to reduce postoperative liver dysfunction.

Hepatocellular carcinoma metastasis in the pituitary gland: case report and review of the literature

Symptomatic pituitary metastases are uncommon and have been reported mainly in autopsy series. Although all types of malignancies can metastasize to the pituitary gland, a review of the literature has indicated that lung and breast carcinomas are the most frequent primary tumors while hepatocellular carcinoma metastasis has only recently been described. A 59-year-old man with abdominal pain and fever was admitted to our hospital. Hepatosplenomegaly was present without signs of ascites. Laboratory tests showed only abnormal hepatic biochemistry while the radiological studies revealed a solid mass occupying the left hepatic lobe. The patient underwent excision of the left hepatic lobe and was closely followed-up. Six months later he readmitted with headache and visual disturbances. MRI revealed a solid mass in the sella region pressing the optic chiasma. Transsphenoidal excision of the pituitary mass was followed and the histological examination of the tumor was compatible with hepatocellular carcinoma. Symptomatic pituitary metastases are uncommon and may be difficult to differentiate from pituitary adenomas. The present case emphasizes on the capricious nature of hepatocellular carcinoma and on the importance of the individualized therapeutic approach.

Preoperative portal vein embolization for extended hepatectomy

OBJECTIVE

To examine the authors' experience with preoperative ipsilateral portal vein embolization (PVE) and assess its role in extended hepatectomy.

SUMMARY BACKGROUND DATA

Extended hepatectomy (five or more liver segments) has been associated with higher complication rates and increased postoperative liver dysfunction than have standard hepatic resections involving lesser volumes. Recently, PVE has been used in patients who have a predicted (postresection) future liver remnant (FLR) volume less than 25% of total liver volume in an attempt to increase the FLR and reduce complications.

METHODS

Sixty patients from 1996 to 2002 were reviewed. Thirty-nine patients had PVE preoperatively. Eight patients who had PVE were not resected either due to the discovery of additional unresectable disease after embolization but before surgery (n = 5) or due to unresectable disease at surgery (n = 3). Therefore, 31 patients who had PVE subsequently underwent extended hepatic lobectomy. A comparable cohort of 21 patients who had an extended hepatectomy without PVE were selected on the basis of demographic, tumor, and liver volume characteristics. Patients had colorectal liver metastases (n = 30), hepatocellular carcinoma (n = 15), Klatskin tumors (n = 9), peripheral cholangiocarcinoma (n = 3), and other tumors (n = 3). The 52 resections performed included 42 extended right hepatectomies, 6 extended left hepatectomies, and 4 right hepatectomies extended to include the middle hepatic vein and the caudate lobe but preserving the majority of segment 4. Concomitant vascular reconstruction of either the inferior vena cava or hepatic veins was performed in five patients.

RESULTS

There were no differences between PVE and non-PVE groups in terms of tumor number, tumor size, tumor type, surgical margin status, complexity of operation, or perioperative red cell transfusion requirements. The predicted FLR was similar between PVE and non-PVE groups at presentation. After PVE the FLR was higher than in the non-PVE group. No complications were observed after PVE before resection. There was no difference in postoperative mortality, with one death from liver failure in the non-PVE group and no operative mortality in the PVE group. Postoperative peak bilirubin was higher in the non-PVE than the PVE group, as were postoperative fresh-frozen plasma requirements. Liver failure (defined as the development of encephalopathy, ascites requiring sustained diuretics or paracentesis, or coagulopathy unresponsive to vitamin K requiring fresh-frozen plasma after the first 24 hours postresection) was higher in the non-PVE patients than the PVE patients. The hospital stay was longer in the non-PVE than the PVE group.

CONCLUSIONS

Preoperative PVE is a safe and effective method of increasing the remnant liver volume before extended hepatectomy. Increasing the remnant liver volume in patients with estimated postresection volumes of less than 25% appears to reduce postoperative liver dysfunction.

Portal vein embolization with polyvinyl alcohol particles and coils in preparation for major liver resection for hepatobiliary malignancy: safety and effectiveness--study in 26 patients

PURPOSE

To evaluate whether preoperative portal vein embolization (PVE) with polyvinyl alcohol (PVA) particles and coils is safe and effective for inducing lobar hypertrophy in patients with hepatobiliary malignancy.

MATERIALS AND METHODS

PVE was performed in 26 patients. All patients had malignancy: metastases (n = 11), cholangiocarcinoma (n = 9), hepatocellular carcinoma (n = 5), and gallbladder carcinoma (n = 1). One patient had underlying liver disease caused by hepatitis. PVE was performed if the future liver remnant (FLR) was estimated to be less than 25% of the total liver volume. PVE was performed with a percutaneous transhepatic approach (right, 25 patients; left, one patient). PVA particles and coils were used to occlude the right portal system and veins supplying segment IV to promote FLR hypertrophy (segments I-III +/- IV). FLR hypertrophy was assessed with comparison of computed tomographic scans obtained before and 2-4 weeks after PVE. Effectiveness evaluation was based on changes in absolute FLR size and ratio of FLR to total estimated liver volume (TELV). Safety of PVE and hepatic resection was determined with postprocedure complication rate and median hospital stay.

RESULTS

Sixteen patients underwent hepatic resection (right trisegmentectomy [n = 13], right lobectomy [n = 3]) without mortality. Ten patients did not undergo resection (complete remission after medical therapy [n = 1], lack of regeneration [n = 2], extrahepatic disease undetected prior to PVE [n = 7]). Six patients had biliary obstruction; five were treated percutaneously before PVE. No patient developed postembolization syndrome or signs of fulminant hepatic insufficiency after PVE or resection. Two patients had complications after PVE that did not preclude successful resection. Median hospital stays were 1 day (PVE) and 7 days (liver resection). Mean absolute FLR increased from 325.0 to 458.6 cm3 (increase, 41.1%). Mean TELV was 1,784.8 cm3. FLR/TELV ratio increase was 8%.

CONCLUSION

Preoperative PVE with PVA particles and coils is safe and effective for inducing lobar hypertrophy in patients with advanced hepatobiliary malignancy.

Indications for and limitations of portal vein embolization before major hepatic resection for hepatobiliary malignancy

Portal vein embolization is a promising adjunctive tool in liver surgery; however, the understanding of liver regeneration and PVE is still in its infancy. Refinement in patient selection criteria and methods to evaluate hepatic hypertrophy and function should increase the potential indications for PVE and expand the field of major liver surgery.