Remedial radiofrequency ablation or portal vein embolization combined with radiofrequency ablation-assistant associating liver partition and portal vein ligation for staged hepatectomy in the treatment of patients with hepatocellular carcinoma with cirrhosis

Abstract

Objective To explore the clinical effect of remedial radiofrequency ablation (RFA) or portal vein embolization (PVE) combined with radiofrequency ablation-assistant associating liver partition and portal vein ligation for staged hepatectomy (RALPPS) in the treatment of patients with insufficient future liver remnant (FLR) after the first staged operation and hepatocellular carcinoma (HCC) with cirrhosis. Methods The retrospective and descriptive cross-sectional study was adopted. The clinical data of 5 patients with insufficient FLR after the first staged of RALPPS and HCC with cirrhosis who underwent remedial RFA or PVE at the Southwest Hospital of the Third Military Medical University between September 2014 and February 2016 were collected. Standard liver volume (SLV)=613.0×body surface area (BSA)+ 162.8, BSA=0.007 1×height+ 0.013 3×body mass. Patients with FLR<40% received RALPPS. In the first staged operation, RFA was used to cauterize a coagulated avascular area between the FLR and contralateral lobe, and then right branch of portal vein was ligated. After the operation, remedial RFA or PVE was performed in patients with insufficient FLR. Once the FLR achieved the target value, the second staged RALPPS was performed. Observation indicators included (1) perioperative complications and death, complications in stage IIIa and above of Clavien-Dindo as main complications, (2) changes of FLR and tumor progression, (3) intraoperative situation, (4) follow-up. The follow-up using outpatient examination was performed up to February 2016, including laboratory examination, tumor markers and imaging examinations (enhanced scan of computed tomography in the epigastric region or ultrasound). Measure-ment data with normal distribution were represented as ±s. Results (1) Perioperative complications and death: of 5 patients, 2 didn′t receive second staged RALPPS and 3 completed both stages. Five patients had no postoperative main complications and 1 died of renal failure and pulmonary infection after second staged RALPPS. (2) Changes of FLR and tumor progression: the average FLR and percentage of FLR to SLV were (329±80)cm3 , 25%±5% in 5 patients before first staged operation and (533±45)cm3, 43%±3% in 3 patients before second staged operation, with an average growth rate of 44%-113%. The average interval time of 5 patients was (29.0±2.2)days. For the 3 patients which completed both stages, the 1-week increased percentage of FLR was 33.5%-68.9% after first staged operation, 1.2%-14.3% and 9.7%-29.8% before and after remedial RFA or PVE. Two patients didn′t undergo the second staged operation, 1 patient was due to not reach standard of safe resection after 4 times remedial PVE, and 1 patient was due to tumor metastasis during intermittent stage after remedial RFA with average FLR after 2 weeks and average 1-week increased percentage of 762.0 cm3 and 10.6%. (3) Intraoperative situations: 1 patient underwent laparoscopic-assisted first staged RALPPS and 1 underwent RFA in the left lobe of liver. The first staged operation time, RFA time and volume of intraoperative blood loss were (240±43)minutes, (15±8)minutes and (190±136)mL, and no patient had blood transfusion. After first staged operation, 5 patients received 5 times remedial PVE and 7 times RFA. Two patients underwent right hemihepatectomy and 1 patient underwent hepatic trisegmentectomy in the second staged operation. The second staged operation time and volume of intraoperative blood loss of 3 patients were (257±33)minutes and (303±73)mL, and 3 patients received R0 resection and no intraoperative blood transfusion. (4) Follow-up: 1 patient was dead during hospitalization and 4 patients were followed up for 1-12 months with a median time of 6 months. Of 2 patients without second staged operation, 1 continued to undergo interventional treatment and then was dead after half year, and 1 continued to undergo transcatheter arterial chemoembolization (TACE) and had good survival up to the end of follow-up. Of the other 2 patients, 1 with tumor recurrence at postoperative month 2 received interventional treatment and traditional Chinese medicine and then was dead after 6 months, and 1 had no tumor recurrence and metastasis during the follow-up. Conclusion For the patients with HCC with cirrhosis who had insufficient FLR after the first staged RALPPS, remedial RFA or PVE could promote further regeneration of FLR and thus improve the completion rate of both stages. Key words: Liver neoplasms; Cirrhosis; Associating liver partition and portal vein ligation for staged hepatectomy; Radiofrequency ablation; Portal vein embolization; Future liver remnant