Portal Tumor Thrombus Research Articles

Safety and efficacy of DEB-TACE in combination with lenvatinib and camrelizumab for the treatment of unresectable hepatocellular carcinoma (uHCC): a two-centre retrospective study.

The purpose of this study was to compare the safety and efficacy of drug-eluting bead (DEB) transarterial chemoembolization combined with lenvatinib and camrelizumab (DEB-TACE-Len-C) and DEB-TACE-Len for the treatment of unresectable hepatocellular carcinoma (uHCC). This retrospective study consecutively included uHCC patients who underwent DEB-TACE-Len-C or DEB-TACE-Len treatment at our hospital and Qujing Second People's Hospital from April 2020 to April 2022. In total, 85 patients were enrolled. There were 42 patients in the DEB-TACE-Len-C group and 43 patients in the DEB-TACE-Len group. The disease control rate (DCR), objective response rate (ORR), overall survival (OS), progression-free survival (PFS), and adverse events (AEs) were compared between the two groups, and the factors influencing OS and PFS were analysed. The ORR, DCR, PFS and OS were significantly greater in the DEB-TACE-Len-C group than in the DEB-TACE-Len group (ORR: 76.2% vs. 46.5%, P = 0.005; DCR: 88.1% vs. 67.8%, P = 0.039; PFS: 10 months vs. 6 months, P <0.0001; OS: 24 months vs. 16 months, P = 0.0038). Multivariate Cox proportional hazard regression analysis revealed that portal tumour thrombus (PVTT) and therapeutic approach were independent factors affecting PFS and OS. There were no statistically significant differences in the incidence of AEs between the two groups (P > 0.05). Compared with DEB-TACE-Len, DEB-TACE-Len-C is an effective treatment option that can improve the tumour therapeutic response and prolong the OS and PFS in uHCC patients.

Efficacy analysis of hepatic arterial infusion chemotherapy combined with targeted and immune therapy followed by 125I seeds implantation in the treatment of hepatocellular carcinoma with portal vain tumor thrombus

Objective: To investigate the safety and efficacy of Hepatic Arterial Infusion Chemotherapy(HAIC) combined with targeted and immune therapy followed by 125I seeds implantation in portal vain tumor thrombus (PVTT) in the treatment of hepatocellular carcinoma(HCC) with PVTT. Methods: A retrospective study was performed on the clinical data of 21 patients [ (11 men, 10 women) aged 34-73 (52.6±13.7) years] with HCC with PVTT in The First Affiliated Hospital of Zhengzhou University from October 2020 to October 2022, all of them were treated with HAIC plus targeted and immune therapy,and 125I seeds implanted into PVTT. The patients were followed up to January 2023, the efficacy was evaluated according to the modified version of the solid tumor efficacy evaluation criteria (mRECIST). The progression-free survival (PFS) rate, overall survival(OS) rate and portal tumor thrombus control rate at 3, 6, 12 and 18 months after treatment were recorded, and PFS and OS time were followed up. The changes of liver function, AFP, coagulation function and adverse events were observed. Results: Each patient received 2 to 7 (mean: 3.3±1.2) cycles of HAIC. 10-37 seeds (mean:16.6±6.7) were implanted per patients. The median follow-up time was 15 (range from 5 to 25) months.During the follow-up time, 15 patients showed progression and 6 patients died, and the PFS rates at 3, 6, 12, and 18 months after treatment were 90.5%, 71.4%, 42.9%, and 23.8%, respectively, and at 3, 6, 12, and 18-month OS rates were 100%, 100%, 81.0%, and 61.9%, respectively.The PVTT control rates at 3, 6, and 12 months were 90.5%, 90.5%, and 62.5%, respectively. Overall efficacy evaluation of CR rate 0, PR rate 47.6% (10/21), SD rate 38.1% (8/21), and PD rate 14.3% (3/21). The total incidence of treatment-related adverse events was 100%.Grade 3 treatment related adverse events were observed for 4 cases, the rest wereⅠtoⅡadverse events. Right upper abdominal pain, fever and hemorrhage in liver capsule related to the procedures were observed in 11(52.4%), 5(23.8%) and 3(14.3) patients, respectively. Conclusion: HAIC combined with targeted and immune therapy followed by 125I seeds implantation in PVTT is a safe and efficacy therapy for HCC with PVTT.

Intrahepatic Glisson Intrathecal Dissection via a Hepatic Parenchymal Transection-First Approach for Laparoscopic Anatomical Hemihepatectomy in Patients with Left/Right Glisson Pedicle Involvement.

Background: Because of lack of an appropriate surgical approach, laparoscopic surgery in patients with left/right Glisson pedicle involvement is still rarely conducted. This study aimed to discusses the methods of intrahepatic Glisson intrathecal dissection via a hepatic parenchymal transection-first approach for laparoscopic hemihepatectomy in patients with left/right Glisson pedicle involvement. Materials and Methods: We retrospectively analyzed the clinical data of 21 patients who underwent laparoscopic hepatectomy in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from March 2021 to May 2022. Results: The mean age of the patients was 53.1 ± 11.6 years; mean operation time, 191.9 ± 22.3 minutes; median intraoperative blood loss, 205 mL (160-300 mL); and median length of hospital stay, 8 days (7-9 days). None of the patients underwent conversion to open procedure. Thirteen patients had pathologically confirmed hepatocellular carcinoma (HCC) with portal tumor thrombi (PVTT), and 8 was confirmed hepatolithiasis. Intraoperative frozen pathology and final pathology showed tumor free surgical margins in HCC with PVTT patients. After conservative treatment, all the complications such as postoperative liver section effusion, pleural effusion, pneumonia, intra-abdomen bleeding, and bile leak were cured. During outpatient follow-up examination, no other abnormality was detected. All HCC with PVTT patients were treated with a tyrosine kinase inhibitor after the operation and survived tumor-free. Conclusions: Proposed here is a more safe and feasible method of laparoscopic hemihepatectomy in patients with left/right Glisson pedicle involvement, but many problems still needs further exploration.

Robotic Left Trisectionectomy with Glissonian Approach (with Video)

BackgroundLeft hepatic trisectionectomy consists of the removal of liver segments 2, 3, 4, 5, and 8. This difficult surgical procedure may be required when the left liver and right anterior sector (segments 5 and 8) are involved. We present a video of a robotic anatomic left trisectionectomy with Glissonian approach to the left and right anterior sector pedicles. MethodsA 77-year-old man presented at a routine ultrasound with a large liver mass. Magnetic resonance imaging showed a bulky hepatocellular carcinoma occupying liver segments 2, 3, 4, 5, and 8, with a portal tumor thrombus in the right anterior sector. The patient had multiple comorbidities, including obesity, diabetes, hypertension, and coronariopathy. The multidisciplinary team decided to use immunotherapy with atezolizumab and bevacizumab. After 12 cycles, the patient showed an objective response, and left trisectionectomy was indicated. A robotic approach was proposed and consent was obtained. The Glissonian approach was used for anatomic control of the left and right anterior sector pedicles. ResultsThe operative time was 390 min with an estimated blood loss of 410 ml, and no transfusion was required during or after the procedure. Recovery was uneventful and the patient was discharged on postoperative day 8. No bile leak was observed, and the drain was removed on postoperative day 8. ConclusionsRobotic left trisectionectomy is safe and feasible. The Glissonian approach is useful for anatomic left liver trisectionectomy. This video can help gastrointestinal surgeons perform this complex procedure in a minimally invasive manner.

Full Laparoscopic Vascular Reconstruction for Portal Tumoral Invasion During a Right Hepatectomy Using the Caudal Approach

BackgroundLaparoscopic liver surgery has progressively evolved. Consequently, liver procedures are increasingly performed laparoscopically, particularly in experienced centers. However, vascular resection and reconstruction still are considered a limitation for laparoscopy1 due to the risk of bleeding and the technical difficulty.MethodsA 72-year-old woman with a history of colorectal cancer had a 10 cm metastasis diagnosed in the right hemiliver with tumoral invasion of the right portal branch and tumor thrombus advancing to the portal confluence. After adjuvant chemotherapy and with stable disease, surgical resection was planned.2,3 Tips to avoid portal stenosis were carefully followed.ResultsThe operation was performed with a fully laparoscopic procedure. To minimize manipulation, an in situ right hepatectomy was performed.4 The right hepatic artery was dissected and ligated. The liver transection was guided with a caudal approach of the middle hepatic vein.5 The right biliary duct was then divided, achieving an excellent exposure of the portal bifurcation. The main and left portal trunks were occluded with vascular clamps, and the right portal vein was sharply divided with scissors. The stump was sutured to minimize backflow bleeding and to cover the tumor thrombus. Then, the portal opening was transversally sutured with a 5/0 running suture. The clamps were released, and the authors observed no bleeding and an adequate caliber with no stenosis. The procedure was completed in the standard fashion. The postoperative course was uneventful, and the woman was discharged on postoperative day 3. No early or late complications were observed.6ConclusionsIn selected cases, patients who require vascular resection and reconstruction during hepatectomies can benefit from the advantages of a laparoscopic approach.

Liver Transplantation for Diffuse Hepatic Epithelioid Hemangioendothelioma

Hepatic epithelioid hemangioendothelioma (HEHE) is an extremely rare vascular tumor. His treatment is not clearly defined. In diffuse HEHE, liver transplantation (LT) is the only possible surgery. Male, 60 years old, medical history: allergic to acetylsalicylic acid and hiatal hernia, presents anorexia, asthenia, weight loss and abdominal distension. Ultrasound, abdominal CT, MRI and PET-CT showed multiple bilobar nodules that diffusely affect liver parenchyma, ascites without portal thrombosis and no extrahepatic disease. FNAC: HEHE. The patient presents clinical and liver function worsening due to thrombosis of the central and right portal branch. He was evaluated in the Transplant Committee and listed with MELD 27. In July 2021, he underwent LT with vena cava preservation. Cold ischemia time (275 minutes), warm ischemia (32 minutes) and total surgery (288 minutes). A portal thrombectomy and hilar lymphadenectomy was also performed. Immunosuppression is started with corticosteroids, mycophenolate, and basiliximab (single dose). On the third day started with Advagraf®. He was discharged on the 11th day post-LT without Clavien-Dindo≥ IIIa complications. Pathology: diffuse HEHE with intrahepatic venous invasion and gallbladder wall; portal tumor thrombus and metastases in 5 /23 lymph nodes excised. Positivity for CD31, CD34 and negative for CKAE1/AE3. Low proliferative activity with Ki67:3%. Diffuse HEHE is an extraordinary rare tumor. The survival of HEHE after LT, according to the ELTR, is 88.6% and 79.5% at 1-year and 5-years respectively. 25% of LT patients have recurrence (median:18 months). The results obtained with LT are excellent, although the risk of recurrence is not negligible.

Brachytherapy with Iodine-125 seeds for treatment of portal vein-branch tumor thrombus in patients with hepatocellular carcinoma

BackgroundThere is currently no widely-accepted consensus for the management of hepatocellular carcinoma with portal vein tumor thrombus. We evaluate the safety and efficacy of ultrasound-guided percutaneous brachytherapy with iodine-125 seeds for the treatment of hepatocellular carcinoma with portal vein-branch tumor thrombus (PVBTT).MethodsSixty-nine hepatocellular carcinoma patients with PVBTT were enrolled; 34 received transarterial chemoembolization (TACE) combined with iodine-125 seeds implanted in the PVBTT; 35 were treated with TACE alone. Adverse events, objective response rate, disease control rate, progression-free survival, and overall survival were compared between the two groups. Tumor responses of PVBTT and intrahepatic tumor were correlated. Multivariate and subgroup analyses were conducted for overall survival.ResultsNo grade 3 or 4 adverse events were recorded, and there was no difference in grade 1 or 2 adverse events between the two groups. Objective response rate and disease control rate for PVBTT were 58.9 and 91.2%, respectively, in the combined treatment group, which were significantly greater than the 5.7 and 54.3% rates, respectively, in the TACE-alone group (both p’s ≤ 0.001). Intrahepatic tumor response was positively correlated with the PVBTT response (γ = 0.782, p < 0.01). Survival outcomes were better in the combined treatment group than in the TACE-alone group: the median progression-free survival for PVBTT was 9 months versus 3 months (HR = 0.187 [95% CI: 0.101, 0.345], p < 0.001), and the median overall survival was 11 months versus 7 months (HR = 0.448 [95% CI: 0.265, 0.758], p = 0.003). Multivariate analysis revealed that application of brachytherapy and lower grade PVBTT (Vp1 + Vp2 vs. Vp3) were protective predictors of overall survival. In stratified analysis, the benefit of overall survival was more significant in the subgroup of PVBTT Vp1 + Vp2 rather than in Vp3.ConclusionsThe combination of iodine-125 seed brachytherapy guided by ultrasound and TACE is a convenient, safe, and effective treatment for patients with HCC and PVBTT, conferring a better survival benefit than TACE alone.

The Efficacy and Safety of Hypofractionated Radiation Therapy With Tomotherapy for Advanced or Recurrent Hepatocellular Carcinoma.

The effects of radiotherapy on hepatocellular carcinoma (HCC) still remain to be further proved. The dose of radiotherapy is generally 2Gy*25f. In the current study, we prospectively investigated the clinical outcomes of advanced or recurrent HCC patients who received hypofractionated radiotherapy at a dose of 5Gy*10f with tomotherapy. A study involving hypofractionated radiotherapy (5Gy*10f) based on TOMO was conducted in HCC patients with Child-Pugh grade A or B who were unsuitable candidates for resection or radiofrequency ablation or with residual disease after transarterial chemoembolization (TACE). The prescription dose was 50 grays in 10 fractions. From Sep. 2016 and Dec. 2017, 65 patents were evaluated with a median follow-up of 24 months (range: 7–41 months). 10 patients were treatment-naïve (failure to undergo surgery or intervention due to the presence of a portal or portal branch tumor thrombus), 15 patients were treated for residual HCC after TACE as salvage therapy, and 40 cases were treated for recurrent HCC. The median overalls survival (OS) of these patients was 18 months. Among them, 27 patients classified as BCLC stage B had a median OS of 22 months. Moreover, 28 patients classified as BCLC stage C had a median OS of 14 months. None of the patients experienced recurrence in the area of radiotherapy. The local control rate of primary tumor at 3 months, 6 months, 1 year and 2 years was 100%. The 3-month survival rate was 100%, the 6-month survival rate was 100%, the 1-year survival rate was 75.4%, and the 2-year survival rate was 43%. In addition, 14 patients had the opportunity to continue the treatment of PD-1 antibody after the disease progression, and their prognosis was not surprisingly better compared with the patients who did not receive PD-1 antibody treatment (NR vs. 15 months, P=0.04). No serious side effect was found in all patients during and after radiotherapy. Hypofractionated radiotherapy (5Gy*10f) based on TOMO achieved high local control rate and OS with tolerable toxicities for HCC patients. TOMO therapy could be used to effectively against HCC in treatment-naive, intrahepatic failure, residual disease, and recurrent settings.

Radiation-Associated Lymphopenia and Outcomes of Patients with Unresectable Hepatocellular Carcinoma Treated with Radiotherapy

BackgroundThe immune system plays a crucial role in cancer surveillance. Previous studies have shown that lymphopenia associated with radiotherapy (RT) portends a poor prognosis. We sought to differentiate the effects of proton and photon RT on changes in absolute lymphocyte count (ALC) for patients with hepatocellular carcinoma (HCC).Patients and MethodsPatients with HCC treated with definitive RT from 2006 to 2016 were studied. Serial ALCs were graded according to CTCAE v4.0. Overall survival (OS), disease-free survival, and distant metastasis-free survival were analyzed using the Kaplan–Meier method. Univariable and multivariable Cox-proportional hazards analyses were used to identify predictors of OS. A cohort analysis matched for treatment volume was performed to investigate differences in ALC dynamics between photon and proton therapy.ResultsOf 143 patients identified, the median age was 66 (range, 19–90) years. The treatment modality was photon in 103 (72%) and proton in 40 (28%). Median follow-up was 17 months (95% confidence interval, 13–25 months). The median time to ALC nadir after initiation of RT was 17 days with a median relative decrease of 67%. Those who received proton RT had a higher median ALC nadir (0.41 vs 0.32 k/µL, p=0.002) and longer median OS (33 vs 13 months, p=0.002) than those who received photon RT. Matched cohort analyses revealed a larger low-dose liver volume in the photon group, which correlated with lower ALC. On multivariable Cox analysis, Grade 3 or higher lymphopenia prior to or after RT, portal venous tumor thrombus, larger planning target volumes, Child-Pugh (CP) Class B, and increased CP score after RT were associated with a higher risk of death, whereas the use of proton therapy was associated with lower risk.ConclusionGrade 3 or higher lymphopenia may be associated with poorer outcomes in patients receiving RT for HCC. Protons may mitigate lymphopenia compared with photons, potentially due to reduced dose exposure of sites of lymphopoiesis.

Safety and efficacy of endovascular implantation of a portal vein stent combined with iodine-125 seed-strips followed by transcatheter arterial chemoembolization with sorafenib for the treatment of hepatocellular carcinoma with portal vein tumor thrombosis.

To assess the safety and efficacy of endovascular implantation of a portal vein stent combined with iodine-125 seed-strips followed by transcatheter arterial chemoembolization with sorafenib (PVS-125I-TACE-S) for the treatment of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT). Between January 2015 and July 2017, 18 patients with PVTT caused by HCC that were treated with PVS-125I-TACE-S were reviewed. The technical success, complications, changes in liver function from baseline values due to subsequent endovascular implantation of a portal vein stent combined with iodine-125 seed-strips (PVS-125I), time-to-tumor progression (TTP) and overall survival (OS) were observed. The technical success rate was 100%. Adverse events (AEs) were managed successfully, with no occurrence of procedure-related deaths. Liver function test values after PVS-125I were not significantly different than baseline values (P＞0.05). The median TTP was 7.0 months (range: 4.2-9.9 months). In Vp3 PVTT, the TTP was 9.7 months (range: 8.8-10.5 months), and in Vp4 PVTT, the TTP was 4.2 months (range: 2.8-5.6 months). The median OS was 10.0 months (range: 7.0-13.1 months). In Vp3 PVTT, OS was 11.9 months (range: 9.2-14.5 months), and in Vp4 PVTT, OS was 7.2 months (range: 3.8-10.7 months). PVS-125I-TACE-S is safe for patients with HCC with PVTT and may extend the TTP and survival of patients with Vp4 PVTT. PVS implantation promptly restored flow in the obstructed portal vein, which can reduce the risk of hepatic failure and upper gastrointestinal bleeding. Implantation of iodine-125 seed-strips may directly expose the portal tumor thrombus to radiation and kill cancer cells. Their combined use with TACE-S has a strong scientific rationale.

Determination of Risk Factors for Pain After Transarterial Chemoembolization with Drug-Eluting Beads for Hepatocellular Carcinoma.

PurposeTo identify risk factors for pain after transarterial chemoembolization with drug-eluting beads (DEB-TACE) for hepatocellular carcinoma (HCC).Patients and MethodsIn this retrospective study, a total of 118 consecutive patients who underwent DEB-TACE between June 2016 and May 2019 with post-TACE pain were included. The patients were divided into three groups based on the severity of post-TACE pain according to the distribution of pain Visual Analogue Scale/Score (VAS). Potential risk factors for post-TACE pain were primarily analyzed using the chi-square test, one-way analysis of variance, or Kruskal–Wallis test (if appropriate). For multivariate analysis, an ordinal logistic regression model was utilized. Variables with P<0.10 in the univariate analysis were included in a multivariate model to identify independent risk factors for post-TACE pain. A multivariate analysis was also performed by means of a decision tree using the Classification and Regression Tree (CART) algorithm.ResultsThe univariate analysis showed that elderly patients or patients with portal venous tumor thrombus (PVTT) were more likely to have severe post-TACE pain than young patients or those without PVTT (P=0.028 and <0.001, respectively). However, in the ordinal logistic regression, nonsuperselective chemoembolization and presence of PVTT were independent risk factors of severe post-TACE pain (P=0.046 and <0.001, respectively). In addition, the CART showed that nonsuperselective chemoembolization and PVTT could increase the probability of severe post-TACE pain.ConclusionNonsuperselective chemoembolization and PVTT are independent risk factors for pain after DEB-TACE. Therefore, these factors should be taken into full consideration for the relief of pain.

Computed Tomography and Magnetic Resonance Imaging in the Diagnosis of Primary Neuroendocrine Tumors of the Liver

We selected 992 patients who presented to our hospital for treatment and were diagnosed with a neuroendocrine tumor (NET) between January 1, 2008, and December 31, 2018, of whom 17 were diagnosed with primary hepatic neuroendocrine neoplasm. The clinical data were analyzed to study the clinical value of computed tomography (CT) and magnetic resonance imaging data in the diagnosis of the disease. Nine tumors (52.9%) were in the right lobe of the liver, and 9 tumors (52.9%) were single. On imaging, the arterial phase, venous phase, and delayed phase continued to be slightly enhanced, showing low-density change relative to the liver and no portal tumor thrombus formation. Four patients (23.5%) had distant metastases, including adrenal glands, portal interstitial lymph nodes, retroperitoneal lymph nodes, and the gallbladder and peritoneum. In terms of pathological grade, there were 3 cases of NET G2, 2 cases of NET G3, 10 cases of neuroendocrine carcinoma (NEC; including 2 cases of large-cell NEC and 3 cases of small-cell NEC), and 2 cases of hepatocellular carcinoma and small-cell NEC. Seven patients were treated with surgery alone, 4 patients were treated with transcatheter arterial chemoembolization (TACE), and 2 patients were treated with other therapies. Three patients were not treated with surgery and were treated with TACE, etoposide and cisplatin, and octreotide acetate. One patient was discharged automatically. The tumor density on CT images was lower than that of the liver parenchyma; medium-high enhancement was seen in the arterial enhancement phase, and continuous enhancement was seen in the venous phase, but the degree of enhancement was reduced, and rarely with portal tumor thrombosis. Currently, surgery is the main treatment method; however, postoperative combined TACE is superior to surgery in combination with microwave ablation, chemotherapy, and other treatments.

Prognostic factors of radical resection on patients with intrahepatic cholangiocarcinoma and impact of abdominal lymph node dissection on prognosis

Objective To study factors affecting prognosis of patients with intrahepatic cholangiocarcinoma (ICC), focusing on the correlation between extent of lymph node dissection and prognosis of patients with ICC. Methods The clinical data of ICC patients who underwent radical resection at the Hepatobiliary and Pancreatic Surgery of Affiliated Cancer Hospital of Zhengzhou University from October 2013 to October 2017 were retrospectively analyzed. According to the extent of lymph node dissection, the patients were divided into the non-dissected lymph node group, the routine dissection lymph node group and the extended lymph node dissection group. The prognoses of the three groups were compared. The Cox stepwise regression model was used to analyze the independent risk factors for prognosis of patients with ICC. Results The 178 patients included 109 males and 69 females. Their ages ranged from 30 to 81 years (average 59 years). There were 80 patients in the non-dissected group, 34 patients in the routine lymph node dissection group, and 64 patients in the extended lymph node dissection group. The overall survival rates of the 178 patients at 3 years after liver resection was 29.2%(52/178), overall median survival 25.8 months. The 3-year survival rates of the non-dissected group, routine dissection group, and extended dissection group were 10.0%(8/80), 52.9%(18/34), 40.6%(26/64), respectively. The differences among the three groups were significant (P 0.05). There was a significant difference in survival rates between the non-dissected group and the extended lymph node dissection group (P<0.05). Univariate analysis showed that CA19-9, tumor diameter, portal tumor thrombus, and lymph node dissection were related to prognosis of patients with ICC (P<0.05). Multivariate analysis showed CA19-9, tumor diameter, and extent of lymph nodes clearance were related to patient survival (P<0.05). Conclusions CA19-9, tumor diameter, and extent of lymph node dissection were independent risk factors of survival in patients with ICC. For patients with ICC who undergo surgical resection, conventional laparoscopic lymph node dissection can achieve good results, and there is no need to extend lymph node dissection. Key words: Cholangiocarcinoma; Lymph node excision; Prognosis analysis

Indocyanine-green fluorescence guided anatomical segmentectomy for HCC with portal thrombosis: the counter-fluorescence technique.

A surgical technique to intra-operatively define segmental boundaries by US-guided bimanual liver compression has been described by the authors, but this procedure is contraindicated in case of portal tumor thrombus. A technique to overcome this limitation is described. A patient with a single hepatocarcinoma nodule and segment 8 (S8) portal branch thrombosis was submitted to the procedure. Anatomical demarcation of S8 was achieved by hilar clamping of the common hepatic artery, intravenous injection of indocyanine green (ICG), and fluorescence imaging analyses of the liver. The procedure was feasible and the demarcation of S8 was visible within 2min from the iv injection of ICG in a counterstaining fashion. Then S8 segmentectomy was safely carried out. This novel approach seems feasible, providing a reliably anatomical and conservative removal of HCC with portal branch tumor thrombus.

Conventional versus drug-eluting beads chemoembolization for infiltrative hepatocellular carcinoma: a comparison of efficacy and safety

BackgroundTo compare the efficacy and safety between conventional transarterial chemoembolization (cTACE) and drug-eluting beads TACE (DEB-TACE) in patients with infiltrative hepatocellular carcinoma (iHCC).MethodsA total of 89 iHCC patients who were treated with either cTACE (n = 33) or DEB-TACE (n = 56) between April 2013 and September 2017 were included in this retrospective study. Patients with the situations that might have a poor outcome were defined as advanced disease including Child-Pugh class B, bilobar lesions, tumor size greater than 10 cm, ECOG 1–2, tumor burden of 50–70%, and the presence of ascites, arterioportal shunt (APS), and portal venous tumor thrombus (PVTT). The tumor response was measured 1-month and 3-month after the procedure. Progression-free survival (PFS) was calculated. Toxicity was graded by Common Terminology Criteria for Adverse Events v5.0 (CTCAE v5.0). The differences in tumor response, PFS, and toxicity were compared between the DEB-TACE group and cTACE group.ResultsAt 1-month and 3-month after the procedure, the objective response rate (ORR) in the overall study population was similar in DEB-TACE group and cTACE group. The disease control rate (DCR), at 1-month after the procedure, was significantly higher in the patients treated with DEB-TACE relative to those treated with cTACE (P = 0.034), while after 3 months, the difference did not differ between two groups. DEB-TACE showed a higher DCR than cTACE in patients with tumor size greater than 10 cm (P = 0.036) or associated with APS (P = 0.030) at 1-month after the procedure, while after 3 months, the difference was only noted in patients with APS (P = 0.036). The median PFS in DEB-TACE group was 96 days, while in cTACE group was 94 days, and there was no difference in PFS between two groups (P = 0.831). In the side effect analysis, abdominal pain (P = 0.034) and fever (P = 0.009) were more frequently present in the cTACE group than DEB-TACE group, but there was no difference in high grade liver toxicity between the two groups.ConclusionsCompared to cTACE, DEB-TACE offers slightly better DCR and tolerability for iHCC patients, particularly in patients associated with APS and large tumor size. However, DEB-TACE does not provide higher PFS than cTACE.

IL-37b suppresses epithelial mesenchymal transition in hepatocellular carcinoma by inhibiting IL-6/STAT3 signaling

BackgroundInterleukin-37b (IL-37b), a vital negative regulator of the innate immune system, has been reported to be a tumor inhibitor in different type of cancers. However, little is known about the relationship between IL-37b and hepatocellular carcinoma (HCC). The present study aimed to investigate the potential roles of IL-37b in HCC progression. MethodsSubjects (n = 237) were recruited, and serum IL-37b was measured using ELISA. The tumor-suppressive capacity and underlying mechanisms of IL-37b in HCC were investigated in vitro and in vivo. ResultsCompared to healthy controls, serum IL-37b levels were elevated in chronic hepatitis B (CHB) patients but decreased significantly in HBV-HCC patients, especially for those with portal venous tumor thrombus. Low level serum IL-37b in HBV-HCC patients correlated with high HCC stage and poor overall survival and disease-free survival. In vitro and in vivo, recombinant human IL-37b inhibited proliferation and metastasis in HCC cells. Furthermore, IL-37b inhibited epithelial mesenchymal transition in HCC cells in vitro by downregulating IL-6, pSTAT3 (Y705), N-cadherin, and vimentin expression and by upregulating E-cadherin expression. These effects were partially reversed by transfection of adenovirus encoding human IL-6. ConclusionsIL-37b inhibits HCC growth, metastasis and epithelial mesenchymal transition by regulating IL-6/STAT3 signaling. Serum IL-37b may be a biomarker for HBV-HCC and its staging.

CT features of hepatic epithelioid angiomyolipoma: differentiation from hepatocellular carcinoma in patients with noncirrhotic livers.

Hepatic epithelioid angiomyolipoma (HEA) shares some similarities with other hepatic tumors, such as hepatocellular carcinoma (HCC). Thus, establishing a definite diagnosis of HEA based on medical imaging is often difficult. In this study, we evaluated multiphasic computed tomography (CT) imaging to differentiate HEA from HCC in patients with noncirrhotic livers. We retrospectively analyzed the clinical and imaging data of both contrast and non-contrast enhanced CT scans from 25 patients with HEA and 50 patients with HCC in noncirrhotic livers. CT features, including lesion position, size, shape, interior content, border, enhancement degree, and enhancement pattern, were independently evaluated by two radiologists. Intratumoral blood vessels, peripheral supply vessels, the early display of the hepatic vein, peripheral abnormal perfusion, peripheral washout sign, pseudocapsule, and portal tumor thrombus were also evaluated. Next, we quantitatively analyzed difference within results of clinical and CT characteristics between the HEA and HCC groups. The number of female HEA patients is more than male (76% vs. 24%), with a mean age of 49.44±10.33 years (from 30 to 68 years). The majority (64%) of HEA patients were asymptomatic, without hepatitis (88%). On non-contrast enhanced CT, HEA mainly manifested as a round (92%), hypodense mass (100%) with little fat (12%) and rare complications, such as hemorrhage (4%) and calcification (4%). HEA all manifested as an intensely enhanced mass on contrast-enhanced CT. The differences between HEA and HCC were significant in the imaging characteristics of the early display of the hepatic vein (32% vs. 0%, P=0.000), intratumoral blood vessels during the nonarterial phase (36% vs. 8%, P=0.003), washout enhancement (52% vs. 86%, P=0.001), and prolonged enhancement (40% vs. 4%, P=0.000). Although HEA is an uncommon hepatic tumor, clinical and CT manifestation may be indicative. Clinical and CT characteristics including asymptomatic, non-hepatic, fat-deficient, early display of the hepatic vein, intratumoral blood vessels during the nonarterial phase and prolonged enhancement are selected to improve the recognition of HEA, supporting for a differential diagnosis from HCC.

Surgical effect analysis of hepatocellular carcinoma with different lymphovascular invasion

Objective To compare the clinical features and surgical outcomes of hepatocellular carcinoma (HCC) combined with portal venous tumor thrombus (PVTT) and hepatic venous tumor thrombus (HVTT) or bile duct tumor thrombi (BDTT), and analyze the effects of different tumor thrombus (TT) types and different surgical methods for TT on prognosis. Methods The retrospective cross-sectional study was conducted. The clinical data of 220 HCC patients with lymphovascular invasion (LVI) who were admitted to the Affiliated Cancer Hospital of Guangxi Medical University between January 2004 and December 2014 were collected. Of 220 patients, 140 were combined with PVTT, 36 with HVTT and 44 with BDTT. According to patients′ conditions, they underwent tumor and TT resection, and tumor resection + TT removal or single TT removal. Observation indicators: (1) comparisons of clinical features of HCC patients with PVTT or HVTT or BDTT; (2) surgical and postoperative situations; (3) follow-up and survival. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to December 2015. Measurement data with normal distribution were represented as ±s. Comparisons among 3 indicators were analyzed using the one-way ANOVA, and comparisons between 2 indicators were analyzed using the t test. Comparisons of count data were analyzed using the chi-square test. The survival curve and rate were respectively drawn and calculated by the Kaplan-Meier method, and the Log-rank test was used for survival analysis. Results (1) Comparisons of clinical features of HCC patients with PVTT or HVTT or BDTT: number of patients with Child-pugh A, Child-pugh B and peritoneal effusion, tumor diameter and cases with tumor capsule were respectively detected in 133, 7, 23, (10±4)cm, 91 in HCC patients with PVTT and 35, 1, 4, (9±4)cm, 27 in HCC patients with HVTT and 35, 9, 16, (6±4)cm, 15 in HCC patients with BDTT, with statistically significant differences (χ2=12.693, 10.408, F=11.300, χ2=17.188, P 0.05). ④ Of 44 HCC patients with BDTT, 24, 6 and 14 were respectively detected in type Ⅰ, Ⅱ and Ⅲ BDTTs, and median survival time, 1-, 3- and 5-year survival rates were respectively 38 months, 87.5%, 60.4%, 34.9% in type Ⅰ BDTT patients and 26 months, 83.3%, 16.7%, 0 in type Ⅱ BDTT patients and 35 months, 78.6%, 50.0%, 21.4% in type Ⅲ BDTT patients, showing no statistically significant difference in survival (χ2=5.312, P>0.05). Of 44 patients, median survival time, 1-, 3- and 5-year survival rates were respectively 38 months, 91.3%, 59.5%, 34.3% in 23 patients undergoing tumor and TT resection and 26 months, 85.7%, 35.7%, 15.3% in 21 patients undergoing tumor resection + TT removal through incising common bile duct, showing no statistically significant difference in survival (χ2=2.071, P>0.05). Conclusions HCC patients with PVTT have larger tumor diameter and worse liver dysfunction, and are prone to peritoneal effusion. HCC patients with different LVI undergo surgery. There is better prognosis in HCC patients with BDTT, and good prognosis in patients with HVTT, while poorer prognosis in patients with PVTT. The postoperative survival of HCC patients with PVTT is associated with TT type, and patients will have better prognosis after tumor resection + TT removal if TT type is confirmed earlier. The postoperative survival of HCC patients with BDTT is not associated with TT type, tumor resection + TT removal maybe prolong postoperative survival time. Key words: Carcinoma, hepatocellular; Portal venous tumor thrombus; Hepatic venous tumor thrombus; Bile duct tumor thrombus; Surgical procedures, operative; Prognosis; Overall survival rate

Intra-arterial ethanol embolization augments response to TACE for treatment of HCC with portal venous tumor thrombus

BackgroundThe prognosis of hepatocellular carcinoma with portal vein tumor thrombus remains extremely poor. This pilot study aimed to evaluate the technical feasibility, effectiveness and safety of transcatheter chemoembolization for tumors in the liver parenchyma plus intra-arterial ethanol embolization for portal vein tumor thrombus.MethodsA pilot study was carried out on 31 patients in the treatment group (transcatheter chemoembolization plus intra-arterial ethanol embolization) and 57 patients in the control group (transcatheter chemoembolization alone). Enhanced computed tomography/magnetic resonance images were repeated 4 weeks after the procedure to assess the response. Overall survival and complications were assessed until the patient died or was lost to follow-up.ResultsMedian survival was 10.5 months in the treatment group (2.4 ± 1.7 courses) and 3.9 months in the control group (1.9 ± 1 courses) (P = 0.001). Patients in the treatment group had better overall survival (at 3, 6 and 12 months, respectively), compared to patients in the control group (90.3% vs. 59.6%, 64.5% vs. 29.8%, and 41.9% vs. 10.6%; p = 0.001). Furthermore, the rate of portal vein tumor thrombus regression was higher in the treatment group (93.1%) than in the control group (32.1%) (P < 0.001).ConclusionsBased on the results of this study, transcatheter chemoembolization combined with intra-arterial ethanol embolization may be more effective than transcatheter chemoembolization alone for treating hepatocellular carcinoma with portal vein tumor thrombus. Intra-arterial ethanol embolization for treating portal vein tumor thrombus is safe, feasible and prolongs overall survival.

Predictive Factors for Treatment Failure after Peritoneovenous Shunt for Hepatic Ascites

Peritoneovenous shunt (PVS) is used to treat refractory ascites. Here, we identify predictive factors for inhospital death after PVS placement. Thirty-five patients with refractory ascites related to liver cirrhosis and/or hepatocellular carcinoma (HCC) who underwent PVS placement between February 2005 and February 2013 were included in the study. Group A comprised 13 patients for whom the PVS placement outcome was inhospital death. Group B comprised 22 patients who were discharged after PVS placement without complications. Patient background and laboratory data were analyzed to identify risk factors for inhospital death. HCC prevalence in Groups A and B was 92 and 55 per cent, respectively (P = 0.02) and that of portal venous tumor thrombus (PVTT) was 54 and 9 per cent, respectively (P = 0.003). The mean des-γ-carboxy prothrombin (DCP) level in both groups was 15,553 ± 49,330 and 787 ± 2600 mAU/mL, respectively (P = 0.009). Multivariate analysis revealed that the presence of PVTT was the only independent predictor of inhospital death (P = 0.007). The presence of PVTT, HCC, and elevated des-γ-carboxy prothrombin levels are predictors of inhospital death after PVS placement. Therefore, PVS should not be used to treat refractory ascites in patients with these predictors, particularly with PVTT.