Sequential Transcatheter Arterial Chemoembolization and Portal Vein Embolization versus Portal Vein Embolization Only before Major Hepatectomy for Patients with Hepatocellular Carcinoma

Purpose

To evaluate the safety and efficacy of sequential transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE) prior to surgery in hepatocellular carcinoma (HCC) patients and to compare the clinical outcome of the combined procedure with that of a matched group of patients undergoing PVE alone.

Patients and Methods

From 1997 to 2008, 135 patients with HCC underwent sequential TACE and PVE (n = 71) or PVE alone (n = 64) before right hepatectomy. PVE was performed mean 1.2 months after TACE. In both groups, computed tomography (CT) and liver volumetry were performed before and 2 weeks after PVE to assess degree of left lobe hypertrophy.

Results

Baseline patient and tumor characteristics were similar in the two groups. After PVE, the chronological changes of liver enzymes were similar in the two groups. The mean increase in percentage future liver remnant (FLR) volume was higher in the TACE + PVE group (7.3%) than in the PVE-only group (5.8%) (P = 0.035). After surgery, incidence of hepatic failure was higher in the PVE-only group (12%) than in the TACE + PVE (4%) group (P = 0.185). Overall (P = 0.028) and recurrence-free (P = 0.001) survival rates were significantly higher in the TACE + PVE group than in the PVE-only group.

Conclusion

Sequential TACE and PVE before surgery is a safe and effective method to increase the rate of hypertrophy of the FLR and leads to longer overall and recurrence-free survival in patients with HCC.     

肝癌合并门静脉癌栓的外科处理

目的：研究肝细胞肝癌合并门静脉癌栓患者外科治疗的效果及影响因素。方法：对３１例肝癌合并门静脉主干及其大分支癌栓患者在电凝锐性解剖肝门的基础上,采用肝叶切除加癌栓清除、门静脉主干切开取栓等术式治疗,并对癌栓的临床病理学类型进行探讨。结果：与非治疗者相比,外科治疗明显延长了患者的术后生存期,疗效最好的方法是肝叶切除加取栓术,１８例术后平均存活时间１５个月,门静脉主干切开取栓术次之,８例平均存活８个月。所有取栓成功的患者术后均无食管静脉曲张破裂出血。癌栓的病理类型以增殖型最多见,机化型罕见,但由于癌栓与门静脉壁紧密粘连,不易清除,后者不宜外科治疗。结论：外科治疗有效地防止了肝癌合并门静脉癌栓的严重并发症──急性上消化道出血,并延长、改善了患者的生存期和生命质量。     

Preoperative Portal Embolization in Patients with Hepatocellular Carcinoma

The factors that contribute to the effect of portal vein embolization before hepatectomy for hepatocellular carcinoma are unclear. Sixty-six patients with hepatocellular carcinoma were enrolled in the study. Changes in liver function, portal vein pressure, and liver volume after embolization were examined. A multiple linear regression analysis was performed to identify factors that independently contributed to the effects of portal vein embolization. The acceptable volume ratio of the remnant liver was calculated from liver function and compared with the volume ratio of the non-embolized liver. No postoperative deaths were observed after portal vein embolization or hepatectomy. Serum total bilirubin and prothrombin time did not change significantly after portal vein embolization. In patients who underwent arterial embolization before portal vein embolization, aminotransferase levels increased significantly. The only factor that could significantly predict the atrophy effects of portal vein embolization was previous arterial embolization. The volume ratio of the non-embolized liver was smaller than the acceptable volume ratio of the remnant liver in 18 of 40 patients and increased over the acceptable volume ratio in all cases after portal vein embolization. Portal vein embolization induced atrophy or hypertrophy of the embolized or non-embolized liver sufficiently, even when the liver was dysfunctional or cirrhotic. The atrophy effects were significant, especially when arterial embolization had been performed before portal vein embolization.     

Panel discussion Portal Vein Embolization in preoperative Management

8th Annual Meeting of the Japanese Association of Hepato-Biliary-Pancreatic Surgery November 28–29, 1996, Osaka International House, Osaka, Japan President: Hiroaki Kinoshita Abstracts

Panel discussion Portal Vein Embolization in preoperative Management     

肝癌合并门静脉癌栓的研究进展

肝细胞癌(hepatocellular carcinoma,HCC;以下简称"肝癌")是世界上常见的恶性肿瘤之一,在我国已成为位列第2位的癌症杀手。文献和复旦大学中山医院肝癌研究所(以下简称"我所")资料均提示,肝癌各种疗法的5年生存率都已接近其高限,瓶颈主要是转移复发[1]。肝癌侵犯门静脉形成门静脉癌栓(portal vein tumor thrombus,PVTT)并导致肝内播散是其主要原因之一。根据尸检和影像学及病     

Transarterial Chemoembolization for Unresectable Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis: A Prospective Comparative Study

Background

For patients with hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT), the survival benefit of transarterial chemoembolization (TACE) compared with conservative treatment largely remains controversial. The objective of this study was to determine whether TACE confers a survival benefit to patients with HCC and PVTT, and to uncover prognostic factors.

Methods

Between July 2007 and July 2009, a prospective two-arm nonrandomized study was performed on consecutive patients with unresectable HCC with PVTT. In one arm, patients were treated by TACE using an emulsion of lipiodol and anticancer agents ± gelatin sponge embolization. In another arm, patients received conservative treatment.

Results

A total of 164 patients were recruited for the study (TACE group, n = 84; conservative treatment group, n = 80). Patients in the TACE group received a mean of 1.9 (range, 1–5) TACE sessions. The overall median survival for all patients was 5.2 months, and the 12- and 24-month overall survival rates were 18.3% and 5.6%, respectively. The 12- and 24-month overall survival rates for the TACE and conservative groups were 30.9%, 9.2%, and 3.8%, 0%, respectively. The TACE group had significantly better survivals than the conservative group (P < 0.001). On subgroup analysis of segmental and major PVTT, the TACE group also had significantly better survivals (P = 0.002, P = 0.002). The treatment type, PVTT extent, tumor size, and serum bilirubin were independent prognostic factors of survival on multivariate analysis.

Conclusions

TACE was safe and feasible in selected HCC patients with PVTT and it had survival benefit over conservative treatment.     

Surgical Treatment of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus

Background  

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.     

肝癌门静脉癌栓的外科治疗

肝细胞肝癌(简称肝癌)列全世界肿瘤发病率第5位，每年全世界的发病人数约564000，而死亡人数大致与其相似，在这些患者中，有一半以上在中国。虽然肝癌的早期诊断、外科技术和围手术期处理的进步以及肝移植等新技术的发展，肝癌的术后生存率明显提高，但从整个肝癌患者人群来说，总的5年生存率仍不足5％，其主要原因之一是门静脉癌栓(portal vein tumor thrombus，PVTT)的形成．根据尸检和影像学检查，门静脉癌栓的发生率约20％～70％。肝癌具有侵犯血管的特性，最多见门静脉，门静脉癌栓形成一方面引起肿瘤细胞的肝内播散和转移，另一方面可以加重肝硬变患者门脉高压而引起上消化道大出血，甚至导致肝功     

Surgical Outcomes in Hepatocellular Carcinoma Patients with Portal Vein Tumor Thrombosis

Background

Different approaches to surgical treatment of portal vein tumor thrombosis (PVTT) have been advocated. This study investigated the outcomes of different surgical approaches in hepatocellular carcinoma (HCC) patients with PVTT.

Methods

We reviewed prospectively collected data for all patients who underwent hepatectomy for HCC at our hospital between December 1989 and December 2010. Patients were excluded from analysis if they had extrahepatic disease, PVTT reaching the level of the superior mesenteric vein, or hepatectomy with a positive resection margin. The remaining patients were divided into three groups for comparison: group 1, with ipsilateral PVTT resected in a hepatectomy; group 2, with PVTT extending to or beyond the portal vein bifurcation, treated by en bloc resection followed by portal vein reconstruction; group 3, with PVTT extending to or beyond the portal vein bifurcation, treated by thrombectomy.

Results

A total of 88 patients, with a median age of 54 years, were included in the analysis. Group 2 patients were younger, with a median age of 43.5 years versus 57 in group 1 and 49 in group 3 (p = 0.017). Group 1 patients had higher preoperative serum alpha-fetoprotein levels, with a median of 8,493 ng/mL versus 63.25 in group 2 and 355 in group 3 (p = 0.004), and shorter operation time, with a median of 467.5 min versus 663.5 in group 2 and 753 in group 3 (p = 0.018). No patient had thrombus in the main portal vein. Two (2.8 %) hospital deaths occurred in group 1 and one (10 %) in group 2, but none in group 3 (p = 0.440). The rates of complication in groups 1, 2, and 3 were 31.9, 50.0, and 71.4 %, respectively (p = 0.079). The median overall survival durations were 10.91, 9.4, and 8.58 months, respectively (p = 0.962), and the median disease-free survival durations were 4.21, 3.78, and 1.51 months, respectively (p = 0.363). The groups also had similar patterns of disease recurrence (intrahepatic: 33.8 vs. 28.6 vs. 40.0 %; extrahepatic: 16.9 vs. 14.3 vs. 0 %; both: 28.2 vs. 42.9 vs. 40.0 %; no recurrence: 21.1 vs. 14.3 vs. 20.0 %; p = 0.836).

Conclusions

The three approaches have similar outcomes in terms of survival, complication, and recurrence. Effective adjuvant treatments need to be developed to counteract the high incidence of recurrence.     

合并门静脉癌栓的肝细胞癌外科治疗策略

<正>肝细胞肝癌位列全世界肿瘤发病率第5位,在我国,其发病率及病死率均居恶性肿瘤的第2位,此外,肝癌术后5年的累计复发率为77%～100%[1]。门静脉癌栓(portal vein tumor thrombus,PVTT)形成是肝癌的生物学特征之一,也是肝癌术后复发和肝内播散的主要原因。临床报道肝癌合并PVTT发生率为44.0%～62.2%[2],无干预情况下中位生存期仅为2.7个月[3]。对于该类患者的处理,以往     

Preoperative Portal Vein Embolization and Surgical Resection in Patients with Hepatocellular Carcinoma and Small Future Liver Remnant Volume: Comparison with Transarterial Chemoembolization

BACKGROUND: Preoperative portal vein embolization (PVE) increases the future liver remnant (FLR) volume, thus enabling surgical resection in patients with small FLR volume. It is unclear, however, if this approach can enhance survival in patients with hepatocellular carcinoma (HCC). We therefore compared the outcomes of preoperative PVE and surgical resection with transarterial chemoembolization (TACE). METHODS: Changes in FLR volumes were analyzed in 32 HCC patients who underwent preoperative PVE and surgical resection. Long-term outcomes were compared with 64 TACE-treated patients matched for gender, Child-Turcotte-Pugh class, tumor size and number, serum alpha-fetoprotein levels, and UICC stage. RESULTS: In the PVE group, the baseline ratio of FLR/total estimated liver volumes (TELV) was 27.6 +/- 7.2%. Following PVE, FLR volume increased 34% (336.5 vs 449.4 mL, P < .001) and the ratio of FLR/TELV increased from 27.6 +/- 7.2 to 36.9 +/- 8.1% (P < .001). There was no mortality associated with PVE or surgical resection. The 5-year survival rate was significantly higher in the PVE group than in the TACE group (71.9% vs 45.6%, P = .03). Multivariate analysis showed that treatment modality was an independent predictive factor for survival (odds ratio 2.05, 95% confidence interval 1.01-4.16, P = .046). CONCLUSIONS: Preoperative PVE enables surgical resection in HCC patients with small FLR volume and improves patient survival compared with TACE.     

Management of Hepatocellular Carcinoma Recurrence After Liver Transplantation

Management of patients with hepatocellular carcinoma (HCC) recurrence after liver transplantation (OLT) is not well established. We conducted a retrospective analysis of our results in the treatment of HCC recurrence after OLT Patients. The 23 HCC recurrences developed after 182 OLT performed for HCC within Milan criteria, had an average follow-up of 60 months.

Results

The median time to recurrence was 23.4 months. Surgical resection of the recurrence was possible in 11 patients, but an R-0 resection was obtained in 8 patients. Four of these 8 patients developed another recurrence, with 3 succumbing due to tumor recurrence and 1 alive at 12 months with recurrence. The other 4 patients without recurrences, include 3 who are alive at 19, 31, and 86 months and 1 who died at 32.6 months due to hepatitis C recurrence. The 3 patients with palliative resections developed recurrences. Twelve patients were rejected for surgery: 8 were treated symptomatically, 2 with systemic chemotherapy, and 2 with everolimus and sorafenib. This last treatment was also prescribed for 2 patients after R-0 surgery who are alive at 19 and 31 months and for 1 patient after R-1 surgery who is alive at 19 months. Of 15 patients who died, 13 succumbed to HCC recurrence. The average survival from transplantation was 61.7 ± 37.5 and 48 ± 34.3 months for patients without and with recurrence, respectively (P < .001). The survival from the recurrence was significantly higher among patients with R-0 surgery: 32.3 ± 21.5 versus 11.9 ± 6.9 months (P = .006).

Conclusions

HCC recurrence after OLT of patients within Milan criteria was low but had a great impact on survival. Few cases are amenable to R-0 resection, but when possible it was associated with a significantly increased survival, although with an high incidence of a new recurrence. There is a rationale for the use of sorafenib and mammalian target of rapamycin based immunosuppression, which warrants randomized studies.     

门静脉癌栓分型与治疗选择

临床实践及文献[1,2]报道均提示,晚期肝癌患者有40.0%～90.2%在门静脉主干或主要分支内形成癌栓。即使是小肝癌,门静脉内形成癌栓的比例也相当高。2003年Chau等[3]报道37例直径<2 cm的肝癌手术切除标本中镜下门静脉癌栓发生率为40.5%,而115例直径为2.1～4.0 cm的肝癌手术切除标本中门静脉癌栓发生率高达49.6%。癌栓不仅发生率高,而且也是影响肝癌预后的一个主要因素。近年来,肝癌的治疗已有了长足的进步,但     

Efficacy of Postoperative Transarterial Chemoembolization and Portal Vein Chemotherapy for Patients with Hepatocellular Carcinoma Complicated by Portal Vein Tumor Thrombosis—a Randomized Study

Objectives The aim of this single, randomized study was to explore the efficacy of postoperative transarterial chemoembolization (TACE) and portal vein chemotherapy (PVC) for patients with hepatocellular carcinoma (HCC) complicated by portal vein tumor thrombosis (PVTT) and to evaluate prognostic factors. Methods The study cohort consisted of 112 patients with HCC and PVTT randomly divided into three groups: Group A (37 patients), operation only; Group B (35 patients), operation plus TACE; Group C (40 patients), operation plus TACE and PVC. Disease-free survival rates and prognostic factors were analyzed. Results Most of the side effects and complications were related to the operation, catheters, and local chemotherapy and included liver decompensation (15.0%), catheter obstruction (11.6%), and nausea and loss of appetite (22.1%). The disease-free survival curve was significantly different among the three groups, as estimated by the Kaplan-Meier method (both P < 0.05). Group C showed a significantly higher disease-free survival rate than Group A (P < 0.05), but no statistical differences were found between group A and group B, and group B and group C (both P > 0.05). Tumor size, tumor number, PVTT location, and treatment modalities were independent prognostic factors (P < 0.05). Conclusion Postoperative TACE combined with PVC may benefit the survival of patients with HCC complicated by PVTT in the short-term (less than 60 months), but long-term efficacy is not yet certain and needs to be confirmed by further studies.     

原发性肝癌切除术后门静脉血栓形成的预防及治疗

目的探讨原发性肝癌切除术后门静脉血栓形成的可能原因及防治方法。方法回顾分析我科自2013年1月~2014年10月8例原发性肝癌患者行肝部分切除术后门静脉血栓形成的临床资料,包括患者的一般资料、手术部位、术后临床化验指标、相关的影像学检查结果、临床处理及预后。结果原发性肝癌切除术后门静脉血栓形成的发生率为2.05%(8/389),均发生在术后10天内,临床表现以腹胀、腹部不适、腹水形成、谷丙转氨酶、谷草转氨酶、总胆红素、直接胆红素和乳酸脱氢酶在短时间内急剧升高为初发表现。除3例门静脉血栓早期予抗凝、溶栓治疗后存活;其余5例门静脉主干血栓者经抗凝及溶栓治疗无效,均于血栓形成2周左右死亡。结论门静脉血栓形成是原发性肝癌切除术后一种少见的,但却是相当的严重的并发症,其确切的发病机制、有效的预防及治疗方法需重视和进一步研究。     

门静脉栓塞的临床应用现状与进展

目的总结门静脉栓塞（PVE）的应用现状以及研究进展。方法通过检索国内外关于PVE的相关文献并作综述。结果PVE可以有效提高肝切除围手术期的安全性。然而,目前在PVE材料、剂量使用及临床操作方法的最佳选择上还存在一定争议。结论PVE作为一种诱导肝功能代偿的方法,在增加肝脏大部切除术的安全性、提高患者的生存率等方面具有明显的作用;而改进PVE的方法及技术,从而更快、更好地促进剩余肝脏组织的增生代偿,尚需要进一步研究。     

肝癌术后门静脉血流障碍的处理

目的观察原发性肝癌切除术后门静脉血流障碍的可能原因及防治方法。方法回顾分析上海东方肝胆外科医院16例原发性肝癌切除术后门静脉血流障碍患者的临床资料,含手术方式、术后临床化验指标、相关的影像学检查结果、临床处理及预后。结果原发性肝癌切除术后发生门静脉血流障碍16例,其中门静脉血栓13例,血流变慢3例,均发生在术后3天,以谷丙转氨酶、谷草转氨酶和乳酸脱氢酶短时间内急剧升高为初发表现;3例血流变慢及6例门静脉分支部分血栓形成予抗凝治疗后存活;4例门静脉主干血栓未行抗凝治疗,3例门静脉主干血栓者经抗凝治疗无效,均于血栓形成1周内死亡。结论门静脉血流障碍是原发性肝癌切除术后一种少见并发症,死亡率高,其发病原因不明,目前缺乏有效的预防及治疗方法。     

肝癌术后门静脉血流障碍的处理

目的观察原发性肝癌切除术后门静脉血流障碍的可能原因及防治方法。方法回顾分析上海东方肝胆外科医院16例原发性肝癌切除术后门静脉血流障碍患者的临床资料,含手术方式、术后临床化验指标、相关的影像学检查结果、临床处理及预后。结果原发性肝癌切除术后发生门静脉血流障碍16例,其中门静脉血栓13例,血流变慢3例,均发生在术后3天,以谷丙转氨酶、谷草转氨酶和乳酸脱氢酶短时间内急剧升高为初发表现;3例血流变慢及6例门静脉分支部分血栓形成予抗凝治疗后存活;4例门静脉主干血栓未行抗凝治疗,3例门静脉主干血栓者经抗凝治疗无效,均于血栓形成1周内死亡。结论门静脉血流障碍是原发性肝癌切除术后一种少见并发症,死亡率高,其发病原因不明,目前缺乏有效的预防及治疗方法。