Extent Of Portal Vein Tumor Thrombus Research Articles

Association of Preoperative Coagulability With Incidence and Extent of Portal Vein Tumor Thrombus and Survival Outcomes in Hepatocellular Carcinoma After Hepatectomy: A Large-Scale, Multicenter Study.

BackgroundOccurrence of portal vein tumor thrombus (PVTT) worsens the outcomes of hepatocellular carcinoma (HCC) and imparts high economic burden on society. Patients with high risks of having hypercoagulation are more likely to experience thrombosis. Herein, we examined how preoperative international normalized ratio (INR) was related to the incidence and extent of PVTT, and associated with survival outcomes in HCC patients following R0 liver resection (LR).MethodsPatients with HCC and PVTT were enrolled from six major hospitals in China. The overall survival (OS) and recurrence-free survival (RFS) rates of individuals with different INR levels were assessed with Cox regression analysis as well as Kaplan-Meier method.ResultsThis study included 2207 HCC patients, among whom 1005 patients had concurrent PVTT. HCC patients in the Low INR group had a significantly higher incidence of PVTT and more extensive PVTT than the Normal and High INR groups (P<0.005). Of the 592 HCC subjects who had types I/II PVTT following R0 LR, there were 106 (17.9%), 342 (57.8%) and 144 (24.3%) patients in the High, Normal and Low INR groups, respectively. RFS and OS rates were markedly worse in patients in the Low INR group relative to those in the Normal and High INR groups (median RFS, 4.87 versus 10.77 versus 11.40 months, P<0.001; median OS, 6.30 versus 11.83 versus 12.67 months, P<0.001).ConclusionPreoperative INR influenced the incidence and extent of PVTT in HCC. Particularly, patients with HCC and PVTT in the Low INR group had worse postoperative prognosis relative to the High and Normal INR groups.

Challenging the Treatment Paradigm: Selecting Patients for Surgical Management of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus.

Portal vein tumor thrombus (PVTT) remains a common presentation in patients with hepatocellular carcinoma (HCC). Approximately 30–50% of patients newly diagnosed with HCC will present with a concomitant PVTT. Current guidelines recommend systemic therapy for treatment of HCC with PVTT. Real-world application of partial hepatectomy in HCC patients with PVTT has increased over the past two decades, as perioperative complications have declined. However, it is unclear if there is an association between the extent of PVTT and overall survival and rates of recurrence and whether the perioperative morbidity outweighs these potential benefits. Partial hepatectomy with en bloc resection of PVTT in second-order branches and distal can offer significant benefits in carefully selected patients; however, once the HCC-associated PVTT extends into first-order portal venous branches or more proximal into the superior mesenteric vein, the risks of surgical resection outweigh the benefits. The aim of this review is to determine which patients with HCC presenting with PVTT benefit from surgical resection. We will discuss the classification systems of PVTT and review both outcome and perioperative measures in patients undergoing partial hepatectomy with extirpation of HCC-related PVT.

Actual long-term survival in HCC patients with portal vein tumor thrombus after liver resection: a nationwide study.

Liver resection for hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT) offers a chance of cure, although survival is often limited. The actual 3-year survival and its associated prognostic factors have not been reported. A nationwide database of HCC patients with PVTT who underwent liver resection with 'curative' intent was analyzed. The clinicopathologic characteristics, the perioperative, and survival outcomes for the actual long-term survivors were compared with the non-long-term survivors (patients who died within 3years of surgery). Univariable and multivariable regression analyses were performed to identify predictive factors associated with long-term survival outcomes. The study included 1590 patients with an actuarial 3-year survival of 16.6%, while the actual 3-year survival rate was 11.7%. There were 171 patients who survived for at least 3years after surgery and 1290 who died within 3years of surgery. Multivariable regression analysis revealed that total bilirubin > 17.1μmol/l, AFP > 400ng/ml, types of hepatectomy, extent of PVTT, intraoperative blood loss > 400ml, tumor diameter > 5cm, tumor encapsulation, R0 resection, liver cirrhosis, adjuvant TACE, postoperative early recurrence (< 1year), and recurrence treatments were independent prognostic factors associated with actual long-term survival. One in nine HCC patients with PVTT reached the long-term survival milestone of 3years after resection. Major hepatectomy, controlling intraoperative blood loss, R0 resection, adjuvant TACE, and 'curative' treatment for initial recurrence should be considered for patients to achieve better long-term survival outcomes.

A New Staging System for Hepatocellular Carcinoma Associated with Portal Vein Tumor Thrombus

Background. BCLC C stage does not identify patients homogeneous enough to be allocated to a single stage. A new staging system for patients with hepatocellular carcinoma (HCC) associated with portal vein tumor thrombus (PVTT) was developed by incorporating the good points of the BCLC classification of HCC, and by improving on the currently existing classifications of HCC with PVTT. Methods. Univariate and multivariate analysis with Wald χ2 test were used to determinate the clinical prognostic factors for overall survival (OS) in patients with HCC and PVTT in the training cohort. Then the conditional inference trees analysis was applied to establish a new staging system. Results. A training cohort of 2179 patients from the Eastern Hepatobiliary Surgery Hospital and a validation cohort of 1550 patients from four major liver centers in China were enrolled into establishing and validating a new staging system. The system was established by incorporating liver function, general health status, tumor resectability, extrahepatic metastasis and extent of PVTT. The median OS were 57.1 (37.2-76.9), 12.1 (11.0-13.2), 5.7 (5.1-6.2), 4.0 (3.3-4.6) and 2.5 (1.7-3.3) months for the stages 0 to IV, respectively (p<0.001) in the Training Cohort. The corresponding figures for the validation cohort were 37.6 (35.9-39.2) and 30.4 (27.4-33.4), 6.4 (4.9-7.9), 2.8 (1.3-4.4), and 1.5 (1.3-1.7) months for the stages 0 to IV, respectively (P<0.001). Conclusions. A new staging system was established which provided a good discriminatory ability to separate patients into different stages and substages after treatments. It can be used to supplement the other HCC staging systems. Funding: This work was supported by the grants of the National Science Foundation for Young Scientists of China (Grant No.81602523). The Science Fund for Creative Research Groups (No: 81221061); The National Key Basic Research Program 973 project (No: 2015CB554000); the China National Funds for Distinguished Young Scientists (No: 81125018). Declaration of Interest: There are no further declaration on financial disclosures, conflicts of interest, and/or acknowledgements to make. Ethical Approval: The study was approved by the Ethics Committees of all the five hospitals.

Surgical treatment of hepatocellular carcinoma with advanced portal vein tumor thrombus combined with pre-operative radiotherapy.

385 Background: Hepatocellular carcinoma (HCC) with advanced portal vein tumor thrombus (PVTT) in the main portal trunk (MPT) or the first branch of portal vein has poor prognosis. We attempted a multidisciplinary treatment to irradiate the PVTT prior to surgical resection. In this study, we evaluate the therapeutic effect of preoperative radiotherapy (Pre-RT) for HCC with advanced PVTT. Methods: The postoperative prognosis was retrospectively examined in 75 patients with advanced PVTT out of 1,045 patients who underwent hepatectomy for HCC between 1990 and 2015 in our institute. The treatment outcome was compared between the patients who underwent Pre-RT (30Gy/10fr) for PVTT before operation (RT group, n = 34) and patients not underwent Pre-RT (non-RT group, n = 41). Results: Among 75 patients with advanced PVTT, there was no difference in age, sex, extent of PVTT (MPT or first branch of PV), HBV, HCV, T-Bil, PT(%), ICG R15%, Child-Pugh classification, AFP, DCP, intra-operative blood loss, tumor size, tumor number, coexisting hepatic vein or bile duct tumor thrombus, presence of the residual tumor between RT and non-RT group other than adjuvant chemotherapy administration (p = 0.0009). The 5-year overall survival rate of all 75 cases was 18.5%. There was a significant overall survival extension in RT group with 29.4% compared to 16.2% in non-RT group (p = 0.039, log-rank test). Surgery without residual lesions was performed in 64 patients, of which the 5-year recurrence-free survival rate was 10.9%. The 5-year recurrence-free survival rate of RT group (n = 30) (16.1%) was significantly better than non-RT group (n = 34) (5.5%) (p = 0.027, log-rank test). Univariate analysis using Cox proportional hazard model demonstrated that the Pre-RT was the only significant prognostic factor (HR 0.595, 95% CI 0.356 - 0.981, p = 0.042) for overall survival, and the Pre-RT and tumor size over 10cm for recurrence-free survival among these patient’s factors. Conclusions: Multidisciplinary treatment combined preoperative radiotherapy to PVTT and subsequent surgical resection improve the prognosis for the patients of HCC with advanced PVTT extend to MPT or first branch of PV.

Surgical Resection Versus Conformal Radiotherapy Combined With TACE for Resectable Hepatocellular Carcinoma With Portal Vein Tumor Thrombus: A Comparative Study

The aim of this study was to compare the results of surgical resection with three-dimensional conformal radiotherapy (3D-CRT) in the treatment of resectable hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). Transarterial chemoembolization (TACE) was given to both groups of patients when possible. A retrospective study of 371 patients with resectable HCC with PVTT was conducted in two tertiary referral centers. The treatment of choice for these patients in one center was surgical resection. In the other center it was 3D-CRT. In the radiotherapy group (RG, n = 185), patients received 3D-CRT to the tumor and PVTT for a total radiation dose of 30-52 Gy (median 40 Gy). In the surgical group (SG, n = 186), patients underwent surgical resection. TACE was applied after surgery or 3D-CRT and then was repeated every 4-6 weeks if the patient tolerated the treatment. The median survival was 12.3 months for RG and 10.0 months for SG. The 1-, 2-, and 3-year overall survivals were 51.6, 28.4, and 19.9 %, respectively, for RG and 40.1, 17.0, and 13.6 %, respectively, for SG (p = 0.029). Stepwise multivariate analysis showed that the extent of PVTT and mode of treatment were independent risk factors of overall survival. The most common cause of death after treatment was liver failure as a consequence of progressive intrahepatic disease. 3D-CRT gave better survival than surgical resection for HCC with PVTT.

Transarterial chemoembolization compared with conservative treatment for advanced hepatocellular carcinoma with portal vein tumor thrombus: using a new classification

We aimed to compare the survival benefit of transarterial chemoembolization (TACE) with conservative treatment for patients with advanced hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT), furthermore, to reveal which PVTT types benefit from TACE treatment. From August 2007 to January 2010, a prospective controlled study was performed on consecutive patients with advanced HCC and PVTT. Of a total of 150 patients, 115 were treated with TACE (lipiodol and anticancer agents ± gelatin sponge embolization), and 35 who refused to accept the procedure were treated with conservative treatment. We performed survival analysis of the two treatment groups and then stratified by a new classification of PVTT that was divided into four types. Overall survival was significantly better in the TACE group than in the conservative group (8.67 months vs. 1.4 months, P<0.001). The overall median survival for types I-IV PVTT were 12.0, 8.3, 5.0, and 2.43 months (P<0.01). On subgroup analysis of PVTT, the median survival in the TACE group compared with conservative group for type I, II, III, and IV PVTT was 19.0 months versus 4.0 months, 11.0 months versus 1.43 months, 7.1 months versus 1.3 months, and 4.0 months versus 1.0 months, respectively (P<0.01). The TACE group had significantly better survival than the conservative group for different extent of PVTT. TACE is an effective treatment mode compared with conservative treatment for HCC and PVTT and may provide a significantly better survival benefit for different extent of PVTT.

Surgical Treatment of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus

The role of liver resection in patients with hepatocellular carcinoma (HCC) accompanying with portal vein tumor thrombus (PVTT) remains controversial. This article aimed to evaluate the significance of different location and extent of PVTT on surgical outcomes after liver resection for HCC. A retrospective study was carried out on patients who underwent partial hepatectomy with or without portal thrombectomy for HCC with PVTT in a single tertiary center from January 2001 to December 2003. According to the extent, PVTT was divided into 4 types (I-segmental/sectoral branches of portal vein, II-left and/or right portal vein, III-main portal vein trunk, and IV-superior mesenteric vein). A total of 406 patients with HCC and PVTT who underwent partial hepatectomy were studied. The complication rate and hospital mortality rate were 32.8 and 0.2%, respectively. After a median follow-up of 6.4 months, 128 patients (31.5%) died. The 1- and 3-year overall survival rates were 34.4 and 13.0%, respectively. The 1- and 3-year disease-free survival rates were 13.3 and 4.7%, respectively. Patients with PVTT located in the segmental, sectoral, or right and/or left portal veins (types I and II) showed significantly better survival than those with PVTT extended to the main trunk of the portal vein or the superior mesenteric vein (types III and IV). Liver resection is justified in selected patients with PVTT located in the segmental or sectoral branches of the portal vein. However, surgical resection for PVTT involving the portal bifurcation or the main trunk is still controversial.

Effects of Location and Extension of Portal Vein Tumor Thrombus on Long-Term Outcomes of Surgical Treatment for Hepatocellular Carcinoma

The role of surgical resection and thrombectomy for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) is controversial. This study aimed to evaluate the effects of the location and extent of PVTT on the long-term outcomes of surgical treatment for HCC. A total of 438 patients with HCC and PVTT underwent liver resection with or without thrombectomy. These 438 patients were divided into 2 groups: in group A, PVTT was located in the hepatic resection area or protruded into the first branch of the main portal vein beyond the resection line for < 1 cm (286 patients), and in group B, PVTT extended into the main portal vein (152 patients). Concomitant thrombectomy was performed in 147 patients (51.4%) of group A and in all patients of group B. PVTT recurrence within 6 months after surgery in group B was significantly higher than that in group A: 76.9% vs. 11.3%. Remnant liver recurrence within 1 year after surgery was 45.0% in group A and 78.8% in group B. The cumulative 1-, 2-, 3-, and 5-year overall survival rates were 58.7%, 39.9%, 22.7%, and 18.1% for group A and 39.5%, 20.4%, 5.7%, and 0% for group B, respectively. The overall survivals were significantly better in group A than group B (P < .02). Liver resection with thrombectomy yielded better outcomes in the HCC patients with PVTT confined to the first or second branch of the main portal vein compared with PVTT extending into the main portal vein.