Clinical Outcomes of Hepatic Resection after Combined Radiotherapy and Transarterial Chemoembolization in Patients with Advanced Hepatocellular Carcinoma Showing Macroscopic Vascular Invasion

Abstract

Although most hepatocellular carcinoma (HCC) with macroscopic vascular invasion (MVI) is not considered resectable, some patients can receive subsequent curative surgical resection owing to downstaging by combined radiotherapy and transarterial chemoembolization (TACE). This study aims to analyze the long-term survival outcomes of patients with HCC showing MVI who underwent hepatic resection after combined radiotherapy and TACE. Between January 2010 and February 2016, a total of 652 HCC patients with macroscopic vascular invasion received combined radiotherapy plus TACE as a first-line treatment. Of these, the patients who underwent hepatic resection were retrospectively analyzed. Surgical resectability after combined treatment was determined by the hepatobiliary and transplant surgeons in the multidisciplinary team for liver cancer depended on the downstaging status and liver function. Forty-two patients (6.4%) received hepatic resection after combined treatment. Thirty-eight (90.5%) were male and median tumor size was 9.2 cm (range, 3.1 – 30.4) at diagnosis. The extent of portal vein tumor thrombus was as follows: Vp2 in 12 patients, Vp3 in 16, and Vp4 in 11. Three patients had tumor invasion to the hepatic vein or inferior vena cava. The median interval between the combined treatment and surgical resection was 7 months (range, 1 – 36). Median follow-up periods for all patients and for survivals were 38 months (range, 7 – 109) and 81 months (range, 44 – 109), respectively. Five-year overall survival and progression-free survival rates were 47.5%, and 24.2%, respectively. A major surgical complication was observed in 1 patient (hematoma), however, this was managed well with subsequent surgery. No mortality after surgery was observed in any patient. After combined radiotherapy and TACE, curative hepatic resection could be performed in selected patients with advanced HCC showing MVI, enabling long-term patient survival. Our findings suggest that hepatic resection might be considered after successful downstaging by combined treatment in patients with advanced HCC.