Increased future liver function after modified associating liver partition and portal vein ligation/embolization for staged hepatectomy

Background

The increasing ratio of functional future liver remnant (functional %FLR) after modified associating liver partition and portal vein ligation/embolization for staged hepatectomy (modified-ALPPS) compared with portal vein embolization (PVE) has not been comprehensively evaluated.

Purpose

To compare the increasing ratio of functional %FLR between modified-ALPPS and PVE via technetium-99 m-galactosyl human serum albumin single-photon emission computed tomography (^99mTc-GSA SPECT/CT) fusion imaging.

Material and Methods

Seven and six patients underwent modified-ALPPS (modified-ALPPS group) and PVE (PVE group) from 2015 to 2019. The functional %FLR on 99 mTc-GSA SPECT/CT fusion imaging was assessed before and 1 week (modified-ALPPS group) and 3 weeks (PVE group) after each procedure. The increasing ratio of functional %FLR (functional %FLR ratio) was calculated and compared between the two groups. Moreover, the hypertrophy ratio of future liver remnant volume (FLRV ratio) and atrophy ratio of embolized liver volume (.ELV ratio) were evaluated.

Results

The mean functional %FLR ratios of the modified-ALPPS group (1.47 ± 0.15) and the PVE group (1.49 ± 0.20) were comparable (p > .05). The median FLRV ratio of modified-ALPPS group (1.48) was higher than that of the PVE group (1.16), the median ELV ratio of the PVE group (0.81) was lower than that of the modified-ALPPS group (0.94), and the results significantly differed between the two groups (p < .05).

Conclusion

The increasing ratio of functional %FLR was comparable between modified-ALPPS and PVE. Compared with PVE, ALPPS was associated with a higher hypertrophy rate of the remnant liver but a lower atrophy rate of the embolized liver.

Case Report: Massive Hepatocellular Carcinoma Complete Surgical Resection After Portal Vein Embolization and Multimodality Therapy

A high proportion of massive patients with hepatocellular carcinoma (HCC) are not amenable for surgical resection at initial diagnosis, owing to insufficient future liver remnant (FLR) or an inadequate surgical margin. For such patients, portal vein embolization (PVE) is an essential approach to allow liver hypertrophy and prepare for subsequent surgery. However, the conversion resection rate of PVE only is unsatisfactory because of tumor progression while awaiting liver hypertrophy. We report here a successfully treated case of primary massive HCC, where surgical resection was completed after PVE and multimodality therapy, comprising hepatic artery infusion chemotherapy (HAIC), Lenvatinib plus Sintilimab. A pathologic complete response was achieved. This case demonstrates for the first time that combined PVE with multimodality therapy appears to be safe and effective for massive, potentially resectable HCC and can produce deep pathological remission in a primary tumor.

Associating liver partition and portal vein ligation for staged hepatectomy versus sequential transarterial chemoembolization and portal vein embolization in staged hepatectomy for HBV-related hepatocellular carcinoma: a randomized comparative study

Background

Both portal vein embolization (PVE) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) have merits and demerits when used in patients with unresectable liver cancers due to insufficient volumes in future liver remnant (FLR).

Methods

This study was a single-center, prospective randomized comparative study. Patients with the diagnosis of hepatitis B related hepatocellular carcinoma (HCC) were randomly assigned in a 1:1 ratio to the 2 groups. The primary endpoints were tumor resection and three-year overall survival (OS) rates.

Results

Between November 2014 to June 2016, 76 patients with unresectable HBV-related HCC due to inadequate volume of FLR were randomly assigned to ALPPS groups (n=38) and TACE + PVE groups (n=38). Thirty-seven patients (97.4%) in the ALPPS group compared with 25 patients (65.8%) in the TACE + PVE group were able to undergo staged hepatectomy (risk ratio 1.48, 95% CI: 1.17-1.87, P<0.001). The three-year OS rate of the ALPPS group (65.8%) (95% CI: 50.7-80.9) was significantly better than the TACE + PVE group (42.1%) (95% CI: 26.4-57.8) (HR 0.50, 95% CI: 0.26-0.98, two-sided P=0.036). However, no significant difference in the OS rates between patients who underwent tumor resection in the 2 groups of patients was found (HR 0.80, 95% CI: 0.35-1.83, two-sided P=0.595). Major postoperative complications rates after the stage-2 hepatectomy were 54.1% in the ALPPS group and 20.0% in the TACE + PVE group (risk ratio 2.70, 95% CI: 1.17-6.25, P=0.007).

Conclusions

ALPPS resulted in significantly better intermediate-term OS outcomes, at the expenses of a significantly higher perioperative morbidity rate compared with TACE + PVE in patients who had initially unresectable HBV-related HCC.

Sequential Portal Vein Embolization and Percutaneous Radiofrequency Ablation for Future Liver Remnant Growth: A Minimally Invasive Alternative to ALPPS Stage-1 in Treatment of Hepatocellular Carcinoma

Background: To evaluate the feasibility and efficacy of sequential portal vein embolization (PVE) and radiofrequency ablation (RFA) (PVE+RFA) as a minimally invasive variant for associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) stage-1 in treatment of cirrhosis-related hepatocellular carcinoma (HCC).

Methods: For HCC patients with insufficient FLR, right-sided PVE was first performed, followed by percutaneous RFA to the tumor as a means to trigger FLR growth. When the FLR reached a safe level (at least 40%) and the blood biochemistry tests were in good condition, the hepatectomy was performed. FLR dynamic changes and serum biochemical tests were evaluated. Postoperative complications, mortality, intraoperative data and long-term oncological outcome were also recorded.

Results: Seven patients underwent PVE+RFA for FLR growth between March 2016 and December 2019. The median baseline of FLR was 353 ml (28%), which increased to 539 (44%) ml after 8 (7–18) days of this strategy (p < 0.05). The increase of FLR ranged from 40% to 140% (median 47%). Five patients completed hepatectomy. The median interval between PVE+RFA and hepatectomy was 19 (15–27) days. No major morbidity ≥ III of Clavien-Dindo classification or in-hospital mortality occurred. One patient who did not proceed to surgery died within 90 days after discharge. After a median follow-up of 18 (range 3–50) months, five patients were alive.

Conclusion: Sequential PVE+RFA is a feasible and effective strategy for FLR growth prior to extended hepatectomy and may provide a minimally invasive alternative for ALPPS stage-1 for treatment of patients with cirrhosis-related HCC.

Current Surgical Management of Peri-Hilar and Intra-Hepatic Cholangiocarcinoma

Cholangiocarcinoma accounts for approximately 10% of all hepatobiliary tumors and represents 3% of all new-diagnosed malignancies worldwide. Intrahepatic cholangiocarcinoma (i-CCA) accounts for 10% of all cases, perihilar (h-CCA) cholangiocarcinoma represents two-thirds of the cases, while distal cholangiocarcinoma accounts for the remaining quarter. Originally described by Klatskin in 1965, h-CCA represents one of the most challenging tumors for hepatobiliary surgeons, mainly because of the anatomical vascular relationships of the biliary confluence at the hepatic hilum. Surgery is the only curative option, with the goal of a radical, margin-negative (R0) tumor resection. Continuous efforts have been made by hepatobiliary surgeons in order to achieve R0 resections, leading to the progressive development of aggressive approaches that include extended hepatectomies, associating liver partition, and portal vein ligation for staged hepatectomy, pre-operative portal vein embolization, and vascular resections. i-CCA is an aggressive biliary cancer that arises from the biliary epithelium proximal to the second-degree bile ducts. The incidence of i-CCA is dramatically increasing worldwide, and surgical resection is the only potentially curative therapy. An aggressive surgical approach, including extended liver resection and vascular reconstruction, and a greater application of systemic therapy and locoregional treatments could lead to an increase in the resection rate and the overall survival in selected i-CCA patients. Improvements achieved over the last two decades and the encouraging results recently reported have led to liver transplantation now being considered an appropriate indication for CCA patients.

How should liver hypertrophy be stimulated? A comparison of upfront associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and portal vein embolization (PVE) with rescue possibility

Background

The role of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in comparison to portal vein embolization (PVE) is debated. The aim of this study was to compare successful resection rates (RR) with upfront ALPPS vs. PVE with rescue ALPPS on demand and to compare the hypertrophy of the liver between ALPPS and PVE plus subsequent rescue ALPPS.

Methods

A retrospective analysis of all patients treated with PVE for colorectal liver metastasis (CRLM) or ALPPS (any diagnosis, rescue ALPPS included) at five Scandinavian university hospitals during the years 2013-2016 was conducted. A Chi-square test and a Mann-Whitney U test were used to assess the difference between the groups. A successful RR was defined as liver resection without a 90-day mortality.

Results

A total of 189 patients were included. Successful RR was in 84.5% of the patients with ALPPS upfront and in 73.3% of the patients with PVE and rescue ALPPS on demand (P=0.080). The hypertrophy of the future liver remnants (FLRs) with ALPPS upfront was 71% (48-97%) compared to 96% (82-113%) after PVE and rescue ALPPS (P=0.010).

Conclusions

Upfront ALPPS offers a somewhat higher successful RR than PVE with rescue ALPPS on demand. The sequential combination of PVE and ALPPS leads to a higher overall degree of hypertrophy than upfront ALPPS.

Applications of transcatheter embolotherapy in preparation for liver transplantation and resection

Although the liver-directed therapies offered by interventional radiology are often treated as alternatives to surgery, the roles they can play in preparation for surgical intervention are less often appreciated and thus underutilized. Locoregional therapies (LRT) can help establish and maintain candidacy for transplantation in patients with early-stage disease, and in those who are candidates for partial hepatectomy can improve post-resection outcomes. Appropriate patient selection is essential to realizing the maximal potential benefit, and herein we provide an overview of the options available and the indications for their use in the pre-operative period.

ALPPS for hepatocarcinoma under cirrhosis: a feasible alternative to portal vein embolization

Hepatocellular carcinoma (HCC) is one of the most common and malignant tumors. Preoperative portal vein embolization (PVE) is currently the most accepted treatment before major hepatic resection for HCC in patients with liver fibrosis or cirrhosis and associated insufficient future liver remnant (FLR). In the last decade, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique has been described to obtain an increase of volume regarding PVE and a decrease of drop out. The initial excessive morbidity and mortality of this technique have decreased drastically due to a better selection of patients, the learning curve and the use of less aggressive variations of the original technique in the first stage. For both techniques a complete preoperative assessment of the FLR is the most important issue and only patients with and adequate FLR should be resected. ALPPS could be a feasible technique in very selected patients with HCC and cirrhosis. As long as it is performed in an experienced center could be used as a first choice technique versus PVE or could be used as a rescue technique in case of PVE failure.

Liver-directed therapies in metastatic colorectal cancer

Colorectal cancer (CRC) is a major health concern in the United States (US) with over 140,000 new cases diagnosed in 2012. The most common site for CRC metastases is the liver. Hepatic resection is the treatment of choice for colorectal liver metastases (CLM), with a 5-year survival rate ranging from 35% to 58%. Unfortunately, only about 20% of patients are eligible for resection. There are a number of options for extending resection to more advanced patients including systemic chemotherapy, portal vein embolization (PVE), two stage hepatectomy, ablation and hepatic artery infusion (HAI). There are few phase III trials comparing these treatment modalities, and choosing the right treatment is patient dependent. Treating hepatic metastases requires a multidisciplinary approach and knowledge of all treatment options as there continues to be advances in management of CLM. If a patient can undergo a treatment modality in order to increase their potential for future resection this should be the primary goal. If the patient is still deemed unresectable then treatments that lengthen disease-free and overall-survival should be pursued. These include chemotherapy, ablation, HAI, chemoembolization, radioembolization (RE) and stereotactic radiotherapy.

Therapeutic value of transcatheter arterial chemoembolization combined with portal vein embolization for primary hepatocellular carcinoma with portal vein tumor thrombus: a pilot study

AIM

To compare clinical outcome and safety of transcatheter arterial chemoembolization (TACE) + portal vein embolization (PVE) with TACE alone in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT).

METHODS

We retrospectively collected patients of HCC with PVTT treated with TACE (5-FU, oxaliplatin and mitomycin) or TACE + PVE (doxorubicin) between October 2000 and July 2008. Outcomes evaluated include overall survival, response to treatment and side effects.

RESULTS

One hundred and sixteen patients were assessed. The median follow-up of TACE group and TACE + PVE group was 83 and 85 months, respectively. The tumor response rates were respectively 48/64 and 49/52. The 1-, 3- and 5-year overall survival rates for the TACE and TACE + PVE groups were 39/64, 16/64, 0/64 and 42/52, 19/52, 6/52 respectively (P = 0.015, 0.046 and 0.002, respectively). Three factors were shown as the risk factors which affect the survival of patients: treated by TACE + PVE or TACE; type of PVTT; and absence of cirrhosis.

CONCLUSION

TACE + PVE may be better than TACE alone to treat primary HCC with PVTT.