Pushing the Limits: Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy for Advanced Hepatocellular Carcinoma with Macrovascular Invasion

Abstract

INTRODUCTION: Patients with advanced hepatocellular carcinoma and macrovascular invasion (MVI) have dismal prognosis and are referred to systemic treatment or palliation. The aim of this study is the investigation the outcomes of patients with HCC and MVI undergoing operation in the form of the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure. METHODS: Demographics and operative data as well as follow-up were retrospectively reviewed. All types of hepatectomy and all types of ALPPS modification were included. MVI was categorized according to the Japanese Liver Cancer Study Group classification. RESULTS: A total of 28 patients were included in the study. Viral etiology was the most common cause of chronic liver disease (89.3%); 85.7% of patients were cirrhotic, with a median Model for End-Stage Liver Disease score of 9 (7 to 10). MVI of the hepatic veins or inferior vena cava was diagnosed in 46.4% of patients, and portal vein involvement was present in 64.2% of cases. Four patients (14.2%) were diagnosed with bile duct involvement. No patients died after step 1, although complication occurred in 21.4% of cases. After step 2, 3 patients (11.5%) died and 20 (69.2%) developed complication. Grade B and C after hepatectomy liver failure occurred in 57.6% and 11.5% of patients, respectively. After a median follow-up of 18 months (7 to 35), median survival was 22 months (3 to 40). Eleven patients (39.3%) experienced recurrence. Median disease-free survival was 15 months (5 to 26). CONCLUSION: The ALPPS procedure is an extreme rescue approach in otherwise inoperable advanced HCC with MVI. The procedure is associated with high morbidity and mortality and patient selection is pivotal. Oncologic outcomes are safe and should be further investigated.