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New macroscopic classification and back-flow thrombectomy for advanced hepatocellular carcinoma with portal vein tumor thrombus invading the contralateral second portal branch

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Abstract

Purpose

Patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT) invading the portal trunk (Vp4) are poor surgical candidates because of the technical difficulties involved. To overcome the limitations, we developed a technique of back-flow thrombectomy (BFT) based on the inherent portal hemodynamics and the macroscopic form of PVTT.

Methods

Forty-six patients with multiple HCC and Vp4 PVTT underwent hepatectomy with tumor thrombectomy. We used the BFT to treat 24 patients, 18 of whom had PVTT in the contralateral second portal branch. The form of PVTT was classified macroscopically into the floating and expansive types.

Results

The rate of complete removal by BFT of PVTT in the contralateral second portal branch was 89%. The patency rates at the thrombectomy site in all 46 patients and in the 24 BFT patients, 3 months after hepatectomy were 93 and 90%, respectively. The median OS of all 46 patients was 15 months, with 1- and 3-year OS rates of 58.5 and 17.1%, respectively. The median OS of the 24 patients treated with BFT vs. the 22 not treated with BFT was 14 and 15 months, respectively.

Conclusions

BFT can expand the therapeutic time window for patients with HCC and deep-seated PVTT and may improve their survival.

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References

  1. Okuda K, Ohtsuki T, Obata H, Tomimatsu M, Okazaki N, Hasegawa H, et al. Natural history of hepatocellular carcinoma and prognosis in relation to treatment. Study of 850 patients. Cancer. 1985;56(4):918–28.

    Article  CAS  PubMed  Google Scholar 

  2. Park KW, Park JW, Choi JI, Kim TH, Kim SH, Park HS, et al. Survival analysis of 904 patients with hepatocellular carcinoma in a hepatitis B virus-endemic area. J Gastroenterol Hepatol. 2008;23(3):467–73.

    Article  PubMed  Google Scholar 

  3. Llovet JM, Bustamante J, Castells A, Vilana R, Ayuso Mdel C, Sala M, et al. Natural history of untreated nonsurgical hepatocellular carcinoma: rationale for the design and evaluation of therapeutic trials. Hepatology. 1999;29(1):62–7.

    Article  CAS  PubMed  Google Scholar 

  4. Villa E, Moles A, Ferretti I, Buttafoco P, Grottola A, Del Buono M, et al. Natural history of inoperable hepatocellular carcinoma: estrogen receptors’ status in the tumor is the strongest prognostic factor for survival. Hepatology. 2000;32(2):233–8.

    Article  CAS  PubMed  Google Scholar 

  5. Bruix J, Sherman M, American Association for the Study of Liver D. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53(3):1020–2.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Llovet JM, Ricci S, Mazzaferro V, Hilgard P, Gane E, Blanc JF, et al. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med. 2008;359(4):378–90.

    Article  CAS  PubMed  Google Scholar 

  7. Cheng AL, Guan Z, Chen Z, Tsao CJ, Qin S, Kim JS, et al. Efficacy and safety of sorafenib in patients with advanced hepatocellular carcinoma according to baseline status: subset analyses of the phase III Sorafenib Asia-Pacific trial. Eur J Cancer. 2012;48(10):1452–65.

    Article  CAS  PubMed  Google Scholar 

  8. Bruix J, Raoul JL, Sherman M, Mazzaferro V, Bolondi L, Craxi A, et al. Efficacy and safety of sorafenib in patients with advanced hepatocellular carcinoma: subanalyses of a phase III trial. J Hepatol. 2012;57(4):821–9.

    Article  CAS  PubMed  Google Scholar 

  9. Torzilli G, Belghiti J, Kokudo N, Takayama T, Capussotti L, Nuzzo G, et al. A snapshot of the effective indications and results of surgery for hepatocellular carcinoma in tertiary referral centers: is it adherent to the EASL/AASLD recommendations?: an observational study of the HCC East-West study group. Ann Surg. 2013;257(5):929–37.

    Article  PubMed  Google Scholar 

  10. Wang JH, Changchien CS, Hu TH, Lee CM, Kee KM, Lin CY, et al. The efficacy of treatment schedules according to Barcelona Clinic Liver Cancer staging for hepatocellular carcinoma—Survival analysis of 3892 patients. Eur J Cancer. 2008;44(7):1000–6.

    Article  PubMed  Google Scholar 

  11. Changchien CS, Chen CL, Yen YH, Wang JH, Hu TH, Lee CM, et al. Analysis of 6381 hepatocellular carcinoma patients in southern Taiwan: prognostic features, treatment outcome, and survival. J Gastroenterol. 2008;43(2):159–70.

    Article  CAS  PubMed  Google Scholar 

  12. Inoue Y, Hasegawa K, Ishizawa T, Aoki T, Sano K, Beck Y, et al. Is there any difference in survival according to the portal tumor thrombectomy method in patients with hepatocellular carcinoma? Surgery. 2009;145(1):9–19.

    Article  PubMed  Google Scholar 

  13. Ikai I, Kudo M, Arii S, Omata M, Kojiro M, Sakamoto M, et al. Report of the 18th follow-up survey of primary liver cancer in Japan. Hepatol Res Off J Jpn Soc Hepatol. 2010;40:1043–59.

    Article  Google Scholar 

  14. General rules for the clinical and pathological study of primary liver cancer 3rd English editioned: Kanehara; 2010.

  15. TNM classification of malignant tumours International Union Against Cancer. 7th ed. Oxford: Wiley-Blackwell; 2009.

  16. Llovet JM, Bru C, Bruix J. Prognosis of hepatocellular carcinoma: the BCLC staging classification. Semin Liver Dis. 1999;19(3):329–38.

    Article  CAS  PubMed  Google Scholar 

  17. Ku Y, Fukumoto T, Tominaga M, Iwasaki T, Maeda I, Kusunoki N, et al. Single catheter technique of hepatic venous isolation and extracorporeal charcoal hemoperfusion for malignant liver tumors. Am J Surg. 1997;173(2):103–9.

    Article  CAS  PubMed  Google Scholar 

  18. Ku Y, Iwasaki T, Fukumoto T, Tominaga M, Muramatsu S, Kusunoki N, et al. Induction of long-term remission in advanced hepatocellular carcinoma with percutaneous isolated liver chemoperfusion. Ann Surg. 1998;227(4):519–26.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Ku Y, Iwasaki T, Tominaga M, Fukumoto T, Takahashi T, Kido M, et al. Reductive surgery plus percutaneous isolated hepatic perfusion for multiple advanced hepatocellular carcinoma. Ann Surg. 2004;239(1):53–60.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Ku Y, Fukumoto T, Iwasaki T, Tominaga M, Samizo M, Nishida T, et al. Clinical pilot study on high-dose intraarterial chemotherapy with direct hemoperfusion under hepatic venous isolation in patients with advanced hepatocellular carcinoma. Surgery. 1995;117(5):510–9.

    Article  CAS  PubMed  Google Scholar 

  21. Fukumoto T, Tominaga M, Kido M, Takebe A, Tanaka M, Kuramitsu K, et al. Long-term outcomes and prognostic factors with reductive hepatectomy and sequential percutaneous isolated hepatic perfusion for multiple bilobar hepatocellular carcinoma. Ann Surg Oncol. 2014;21(3):971–8.

    Article  PubMed  Google Scholar 

  22. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Katayama H, Kurokawa Y, Nakamura K, Ito H, Kanemitsu Y, Masuda N, et al. Extended Clavien-Dindo classification of surgical complications: Japan Clinical Oncology Group postoperative complications criteria. Surg Today. 2016;46(6):668–85.

    Article  PubMed  Google Scholar 

  24. Zhou J, Tang ZY, Wu ZQ, Zhou XD, Ma ZC, Tan CJ, et al. Factors influencing survival in hepatocellular carcinoma patients with macroscopic portal vein tumor thrombosis after surgery, with special reference to time dependency: a single-center experience of 381 cases. Hepato-gastroenterology 2006;53(68):275–80.

    PubMed  Google Scholar 

  25. Ohkubo T, Yamamoto J, Sugawara Y, Shimada K, Yamasaki S, Makuuchi M, et al. Surgical results for hepatocellular carcinoma with macroscopic portal vein tumor thrombosis. J Am Coll Surg. 2000;191(6):657–60.

    Article  CAS  PubMed  Google Scholar 

  26. Minagawa M, Makuuchi M, Takayama T, Ohtomo K. Selection criteria for hepatectomy in patients with hepatocellular carcinoma and portal vein tumor thrombus. Ann Surg. 2001;233(3):379–84.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Tanaka A, Morimoto T, Yamaoka Y. Implications of surgical treatment for advanced hepatocellular carcinoma with tumor thrombi in the portal vein. Hepato-gastroenterology 1996;43(9):637–43.

    CAS  PubMed  Google Scholar 

  28. Konishi M, Ryu M, Kinoshita T, Inoue K. Surgical treatment of hepatocellular carcinoma with direct removal of the tumor thrombus in the main portal vein. Hepato-gastroenterology 2001;48(41):1421–4.

    CAS  PubMed  Google Scholar 

  29. Ikai I, Hatano E, Hasegawa S, Fujii H, Taura K, Uyama N, et al. Prognostic index for patients with hepatocellular carcinoma combined with tumor thrombosis in the major portal vein. J Am Coll Surg. 2006;202(3):431–8.

    Article  PubMed  Google Scholar 

  30. Pawlik TM, Poon RT, Abdalla EK, Ikai I, Nagorney DM, Belghiti J, et al. Hepatectomy for hepatocellular carcinoma with major portal or hepatic vein invasion: results of a multicenter study. Surgery. 2005;137(4):403–10.

    Article  PubMed  Google Scholar 

  31. Shi J, Lai EC, Li N, Guo WX, Xue J, Lau WY, et al. A new classification for hepatocellular carcinoma with portal vein tumor thrombus. J Hepato biliary Pancreat Sci. 2011;18(1):74–80.

    Article  Google Scholar 

  32. Yamamoto K, Takenaka K, Kawahara N, Shimada M, Shirabe K, Itasaka H, et al. Indications for palliative reduction surgery in advanced hepatocellular carcinoma. The use of a remnant tumor index. Arch Surg. 1997;132(2):120–3.

    Article  CAS  PubMed  Google Scholar 

  33. Wakabayashi H, Ushiyama T, Ishimura K, Izuishi K, Karasawa Y, Masaki T, et al. Significance of reduction surgery in multidisciplinary treatment of advanced hepatocellular carcinoma with multiple intrahepatic lesions. J Surg Oncol. 2003;82(2):98–103.

    Article  PubMed  Google Scholar 

  34. Yamaoka Y, Kumada K, Ino K, Takayasu T, Shimahara Y, Mori K, et al. Liver resection for hepatocellular carcinoma (HCC) with direct removal of tumor thrombi in the main portal vein. World J Surg. 1992;16(6):1172–6. (discussion 7).

    Article  CAS  PubMed  Google Scholar 

  35. Kumada K, Ozawa K, Okamoto R, Takayasu T, Yamaguchi M, Yamamoto Y, et al. Hepatic resection for advanced hepatocellular carcinoma with removal of portal vein tumor thrombi. Surgery. 1990;108(5):821–7.

    CAS  PubMed  Google Scholar 

  36. Chung JW, Park JH, Han JK, Choi BI, Han MC. Hepatocellular carcinoma and portal vein invasion: results of treatment with transcatheter oily chemoembolization. AJR Am J Roentgenol. 1995;165(2):315–21.

    Article  CAS  PubMed  Google Scholar 

  37. Kim KM, Kim JH, Park IS, Ko GY, Yoon HK, Sung KB, et al. Reappraisal of repeated transarterial chemoembolization in the treatment of hepatocellular carcinoma with portal vein invasion. J Gastroenterol Hepatol. 2009;24(5):806–14.

    Article  PubMed  Google Scholar 

  38. Roayaie S, Jibara G, Taouli B, Schwartz M. Resection of hepatocellular carcinoma with macroscopic vascular invasion. Ann Surg Oncol. 2013;20(12):3754–60.

    Article  PubMed  Google Scholar 

  39. Tang QH, Li AJ, Yang GM, Lai EC, Zhou WP, Jiang ZH, et al. Surgical resection versus conformal radiotherapy combined with TACE for resectable hepatocellular carcinoma with portal vein tumor thrombus: a comparative study. World J Surg. 2013;37(6):1362–70.

    Article  PubMed  Google Scholar 

  40. Kokudo T, Hasegawa K, Matsuyama Y, Takayama T, Izumi N, Kadoya M, et al. Survival benefit of liver resection for hepatocellular carcinoma associated with portal vein invasion. J Hepatol. 2016;65(5):938–43.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan

    Takumi Fukumoto, Masahiro Kido, Atsushi Takebe, Motofumi Tanaka, Hisoka Kinoshita, Kaori Kuramitsu, Shohei Komatsu, Daisuke Tsugawa, Tadahiro Goto, Sadaki Asari, Hirochika Toyama, Tetsuo Ajiki & Yonson Ku

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  1. Takumi Fukumoto
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  2. Masahiro Kido
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Correspondence to Takumi Fukumoto.

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Fukumoto, T., Kido, M., Takebe, A. et al. New macroscopic classification and back-flow thrombectomy for advanced hepatocellular carcinoma with portal vein tumor thrombus invading the contralateral second portal branch. Surg Today 47, 1094–1103 (2017). https://doi.org/10.1007/s00595-017-1507-9

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