Is disease progression a contraindication for the strategy of portal vein embolization followed by hepatectomy for hepatocellular carcinoma?

Disability in perioperative activities of daily living is associated with worse survival outcomes following hepatic resection in patients with intrahepatic cholangiocarcinoma

AIM

Intrahepatic cholangiocarcinoma (ICC) is a rare disease; however, its incidence and mortality are increasing worldwide. The rapid aging of populations around the world is leading to an increased number of patients with cancer who develop disability in activities of daily living (ADL). This study was conducted to investigate the associations of perioperative ADL with patient survival after hepatic resection for ICC.

METHODS

We included 70 consecutive patients who underwent hepatectomy for ICC from 2010 to 2021 in the current study. Preoperative and postoperative ADL were evaluated based on the Barthel index, which yields a score of 0-100 points, with higher scores indicating greater independence. A preoperative or postoperative Barthel index score of <100 was defined as disability in perioperative ADL. Cox proportional hazards regression was used to calculate hazard ratios after adjusting for potential confounders.

RESULTS

Among the 70 patients, seven (10%) had a preoperative Barthel index score of <100, and 23 (33%) showed a postoperative Barthel index score of <100. Multivariate analyses revealed that disability in perioperative ADL was associated with shorter recurrence-free survival (multivariable hazard ratios 2.38, 95% confidence interval 1.22-4.57; p = 0.011) and overall survival (multivariable hazard ratio 2.49, 95% confidence interval 1.09-5.70; p = 0.031).

CONCLUSIONS

Disability in perioperative ADL is associated with shorter recurrence-free and overall survival after hepatic resection for ICC. Upon validation, perioperative measurement of ADL may improve risk assessment, and improvement of perioperative ADL may lead to favorable clinical outcomes in patients with ICC.

Impairment of perioperative activities of daily living is associated with poor prognosis following hepatectomy for hepatocellular carcinoma

BACKGROUND

The number of cancer patients with impairment of activities of daily living (ADLs) has increased. This study aimed to examine associations of perioperative Barthel index score, a validated measure of ADLs, with survival outcomes following hepatectomy for hepatocellular carcinoma (HCC).

METHODS

We analyzed data of 492 consecutive patients who underwent hepatectomy for HCC between 2010 and 2018. Pre- and postoperative ADLs were assessed using the Barthel index (range, 0-100; higher scores indicate greater independence). Preoperative Barthel index score ≤85 or postoperative Barthel index score ≤85 was defined as impairment of perioperative ADLs. Cox proportional hazards regression was used to calculate hazard ratios (HRs) after adjusting for potential confounders.

RESULTS

Among the 492 patients, 26 (5.2%) had a preoperative Barthel index score ≤85 and 95 (19%) had a postoperative Barthel index score ≤85. Impairment of perioperative ADLs was independently associated with shorter overall survival (multivariable HR: 1.75, 95% confidence interval [CI]: 1.06-2.81, p = 0.028). The association of impairment of perioperative ADLs with recurrence-free survival was not statistically significant.

CONCLUSION

Impairment of perioperative ADLs is associated with poor prognosis following hepatectomy for HCC. Maintenance and improvement of perioperative ADLs would be important to provide favorable long-term outcomes in patients with HCC.

Imaging-guided interventions modulating portal venous flow: evidence and controversies

Portal hypertension is defined by an increase in the portosystemic venous gradient. In most cases, increased resistance to portal blood flow is the initial cause of elevated portal pressure. More than 90% of cases of portal hypertension are estimated to be due to advanced chronic liver disease or cirrhosis. Transjugular intrahepatic portosystemic shunts, a non-pharmacological treatment for portal hypertension, involve the placement of a stent between the portal vein and the hepatic vein or inferior vena cava which helps bypass hepatic resistance. Portal hypertension may also be a result of extrahepatic portal vein thrombosis or compression. In these cases, percutaneous portal vein recanalisation restores portal trunk patency, thus preventing portal hypertension-related complications. Any portal blood flow impairment leads to progressive parenchymal atrophy and triggers hepatic regeneration in preserved areas. This provides the rationale for using portal vein embolisation to modulate hepatic volume in preparation for extended hepatic resection. The aim of this paper is to provide a comprehensive evidence-based review of the rationale for, and outcomes associated with, the main imaging-guided interventions targeting the portal vein, as well as to discuss the main controversies around such approaches.

Systematic Reviews and Meta-Analyses of Portal Vein Embolization, Associated Liver Partition and Portal Vein Ligation, and Radiation Lobectomy Outcomes in Hepatocellular Carcinoma Patients

PURPOSE OF REVIEW

To understand portal vein embolization (PVE), associated liver partition and portal vein ligation (ALPPS) and radiation lobectomy (RL) outcomes in hepatocellular carcinoma (HCC) patients. Systematic reviews of future liver remnant (FLR) percent hypertrophy, proportion undergoing hepatectomy and proportion with major complications following PVE, ALPPS, and RL were performed by searching Ovid MEDLINE, Ovid EMBASE, The Cochrane Library, and Web of Science. Separate meta-analyses using random-effects models with assessment of study heterogeneity and publication bias were performed whenever allowable by available data.

RECENT FINDINGS

Of the 10,616 articles screened, 21 articles with 636 subjects, 4 articles with 65 subjects, and 4 articles with 195 subjects met the inclusion criteria for systematic reviews and meta-analyses for PVE, ALPPS, and RL, respectively. The pooled estimate of mean percent FLR hypertrophy was 30.9% (95%CI: 22-39%, Q = 4034.8, p < 0.0001) over 40.3 +/- 26.3 days for PVE, 54.9% (95%CI: 36-74%, Q = 73.8, p < 0.0001) over 11.1 +/- 3.1 days for ALPPS, and 29.0% (95%CI: 23-35%, Q = 56.2, p < 0.0001) over 138.5 +/- 56.5 days for RL. The pooled proportion undergoing hepatectomy was 91% (95%CI: 83-95%, Q = 43.9, p = 0.002) following PVE and 98% (95%CI: 50-100%, Q = 0.0, p = 1.0) following ALPPS. The pooled proportion with major complications was 5% (95%CI: 2-10%, Q = 7.3, p = 0.887) following PVE and 38% (95%CI: 18-63%, Q = 10.0, p = 0.019) following ALPPS. Though liver hypertrophy occurs following all three treatments in HCC patients, PVE balances effective hypertrophy with a short time frame and low major complication rate.

Novel Approach via the Round Ligament in Portal Vein Embolization

BACKGROUND

The objective of this study was to describe the detailed technique and clinical outcomes of portal vein embolization via the round ligament (RL-PVE) prior to major hepatectomy.

METHODS

Between January 2010 and March 2020, a total of 50 portal vein embolization (PVE) procedures were performed in 50 patients. Of them, seven patients who underwent RL-PVE were enrolled in this study. Percutaneous transhepatic portal vein embolization (PTPE) was not indicated due to the following reasons: bile duct dilation (n = 4), difficulty in visualizing the portal vein on ultrasonography because of severe fatty liver (n = 1), large tumor size (n = 1), and combined surgery with staging laparoscopy (n = 1). The following were reasons for avoiding trans-ileocecal PVE: past laparotomy (n = 5), difficulty in accessing the portal vein due to a large tumor (n = 1), and purpose of preventing small intestinal adhesions before hepatopancreatoduodenectomy (n = 1). The percentage of functional hepatic remnant rates was calculated before and after RL-PVE.

RESULTS

Technical success was achieved in all cases. Five patients underwent embolization of the right portal vein, while two underwent embolization of the left portal vein. The median operative time and blood loss during RL-PVE were 181 min and 33 g, respectively. Morbidity and mortality related to RL-PVE were not observed. The median functional hepatic remnant rate before and after PVE was 55.6% and 63.2%, respectively. Liver functions including Child-Pugh classification were equivalent before and after RL-PVE.

CONCLUSIONS

The RL-PVE technique may be useful in elective cases for which it is difficult to safely perform PTPE or trans-ileocecal approaches.

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.

Red blood cell transfusions and the survival in patients with cancer undergoing curative surgery: a systematic review and meta-analysis

Allogenic red blood cell transfusions exert a potential detrimental effect on the survival when delivered to cancer patients undergoing surgery with curative intent. We performed a systematic review and meta-analysis to assess the association between perioperative allogenic red blood cell transfusions and risk of death as well as relapse after surgery for localized solid tumors. PubMed, the Cochrane Library, and EMBASE were searched from inception to March 2019 for studies reporting the outcome of patients receiving transfusions during radical surgery for non-metastatic cancer. Risk of death and relapse were pooled to provide an adjusted hazard ratio with a 95% confidence interval [hazard ratio (HR) (95% confidence interval {CI})]. Mortality and relapse associated with perioperative transfusion due to cancer surgery were evaluated among participants (n = 123 studies). Overall, RBC transfusions were associated with an increased risk of death [HR = 1.50 (95% CI 1.42-1.57), p < 0.01] and relapse [HR = 1.36 (95% CI 1.26-1.46), p < 0.01]. The survival was reduced even in cancer at early stages [HR = 1.45 (1.36-1.55), p < 0.01]. In cancer patients undergoing surgery, red blood cell transfusions reduced the survival and increased the risk of relapse. Transfusions based on patients' blood management policy should be performed by applying a more restrictive policy, and the planned preoperative administration of iron, if necessary, should be pursued.

Is Portal Vein Embolization Followed by Hepatectomy for Hepatocellular Carcinoma Justified in Patients with Impaired Liver Function?

BACKGROUND

Portal vein embolization (PVE) was developed for patients with insufficient future liver remnant volume and function and has gained relevant support worldwide before major hepatectomy. However, the efficacy of preoperative PVE for hepatocellular carcinoma (HCC) patients with impaired liver function remains uncertain.

PATIENTS AND METHODS

Ninety-seven HCC patients who were scheduled for PVE followed by hepatectomy were enrolled in this study. Their short- and long-term outcomes were investigated, according to the liver damage classification defined by the Liver Cancer Study Group of Japan.

RESULTS

Of 97 patients who underwent preoperative PVE, 30 (32.4%) could not undergo subsequent hepatectomy. Dropout rate from treatment strategy was significantly higher in patients with liver damage B (n = 13, 61.5%) than in those with liver damage A (n = 84, 26.2%) (P = 0.014). Among the 67 patients who underwent planned hepatectomy after PVE, 53 were categorized to liver damage A, and 14 were categorized to liver damage B at the point of hepatectomy. Although major complication and mortality rates were comparable between the two groups, the cumulative overall survival (OS) and disease-free survival (DFS) after hepatectomy were markedly worse in patients with liver damage B than in those with liver damage A (5-year OS rate: 23.1% vs 74.6%, P = 0.014, 5-year DFS rate: 7.8% vs 33.5%, P = 0.054, respectively).

CONCLUSIONS

The treatment strategy of PVE followed by hepatectomy might be a contraindication for HCC patients with impaired liver function categorized as liver damage B because of the higher dropout rate and poorer long-term outcomes after hepatectomy.

The transjugular approach is a safe and effective alternative for performing portal vein embolization

To evaluate the safety and efficacy of the novel technique, transjugular portal vein embolization (TPVE).A single-center retrospective review of 18 patients (12 males and 6 females; mean age, 62 years) who underwent TPVE between January 2012 and January 2013 was conducted. The technical success rate, future liver remnant (FLR) volume, total liver volume (TLV) and FLR/TLV ratio after PVE were analyzed. Liver function, including total bilirubin (TB), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and International Normalized Ratio (INR), was assessed before and after PVE. Any complications of TPVE and liver resection after TPVE were recorded.TPVE was performed on 18 patients before right hepatic resection for both primary and secondary hepatic malignancies (10 hepatocellular carcinomas, 4 cases of colorectal liver metastasis, and 4 cholangiocarcinomas). Technical success was achieved in 100% of patients (18 of 18). The mean FRL significantly increased to 580 ± 155 mL (P < .001) after PVE. The mean FLR/TLV ratio (%) significantly increased to 34 ± 4 (P < .001) after PVE. One patient suffered septicemia after TPVE. A small number patients experienced mild to moderate abdominal pain during TPVE. No other major complications occurred after TPVE in our study. The patient who developed septicemia died 3 days after the surgery as a result of this complication and subsequent multiple organ dysfunction syndrome (MODS).Transjugular portal vein embolization is a safe, efficacious, and promising novel technique to induce hypertrophy of the FLR.