Locoregional Therapies for Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis

Hepatocellular carcinoma is the fourth leading cause of cancer worldwide, and the fastest increasing cause of cancer mortality in the United States. Its propensity for vascular invasion leads to the presence of portal vein tumor thrombus in up to half of patients. PVTT results in a classification of advanced disease, given the risk recurrence secondary to intravascular spread, and formal guidelines recommend systemic therapy in these patients. However, recent advances in locoregional therapies including TACE, TARE, and ablation have demonstrated the potential to drastically improve overall survival in patients with HCC complicated by PVTT.

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Liver transplantation for hepatocellular carcinoma with portal vein tumor thrombosis

Journal of Liver Cancer ◽

10.17998/jlc.2021.03.17 ◽

2021 ◽

Vol 21 (2) ◽

pp. 105-112

Author(s):

Sang Jin Kim ◽

Jong Man Kim

Keyword(s):

Hepatocellular Carcinoma ◽

Liver Transplantation ◽

Radiation Therapy ◽

Portal Vein ◽

Alpha Fetoprotein ◽

Advanced Hepatocellular Carcinoma ◽

Portal Vein Tumor Thrombosis ◽

Donor Liver Transplantation ◽

Tumor Thrombosis ◽

Locoregional Therapies

Traditionally, liver transplantation for hepatocellular carcinoma with portal vein tumor thrombosis is not recommended. However, with recent developments in locoregional therapies for hepatocellular carcinoma, more aggressive treatments have been attempted for advanced hepatocellular carcinoma. Recently, various studies on locoregional therapies for downstaging followed by living donor liver transplantation reported inspiring overall survival and recurrence-free survival of patients. These downstaging procedures included three-dimensional conformal radiation therapy, trans-arterial chemoembolization, stereotactic body radiation therapy, trans-arterial radioembolization, hepatic arterial infusion chemotherapy and combinations of these therapies. Selection of the optimal downstaging protocol should depend on tumor location, biology and background liver status. The risk factors affecting outcome include pre-downstaging alpha-fetoprotein values, delta alpha-fetoprotein values, disappearance of portal vein tumor thrombosis on imaging and meeting the Milan criteria or not after downstaging. For hepatocellular carcinoma with portal vein tumor thrombosis, downstaging procedure with liver transplantation in mind would be helpful. If the reaction of the downstaged tumor is good, liver transplantation may be performed.

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Abstract No. 544 Locoregional therapies versus systemic therapy for hepatocellular carcinoma with portal vein tumor thrombus

Journal of Vascular and Interventional Radiology ◽

10.1016/j.jvir.2019.12.605 ◽

2020 ◽

Vol 31 (3) ◽

pp. S238

Author(s):

C. Chung ◽

M. Mitry ◽

M. Joshi ◽

M. Soliman ◽

R. Rosenblatt ◽

...

Keyword(s):

Hepatocellular Carcinoma ◽

Portal Vein ◽

Systemic Therapy ◽

Tumor Thrombus ◽

Portal Vein Tumor Thrombus ◽

Locoregional Therapies

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Transarterial Chemoembolization in Unresectable Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis: A Tertiary Care Center Experience

Indian Journal of Radiology and Imaging ◽

10.1055/s-0041-1734367 ◽

2021 ◽

Author(s):

Yashwant Patidar ◽

Amar Mukund ◽

Shiv K. Sarin ◽

Keyword(s):

Hepatocellular Carcinoma ◽

Prognostic Factors ◽

Liver Function ◽

Portal Vein ◽

Transarterial Chemoembolization ◽

Tumor Thrombus ◽

Portal Vein Tumor Thrombosis ◽

Main Portal Vein ◽

Portal Vein Invasion ◽

Tumor Thrombosis

Abstract Background Portal vein tumor thrombosis (PVTT) is a common complication of hepatocellular carcinoma (HCC) occurring in 30 to 40% of cases. The presence of PVTT in HCC is regarded as an advanced disease that confers poor prognosis and survival. Transarterial chemoembolization (TACE) has traditionally been considered to be contraindicated in cases of PVTT, due to the risk of hepatic infarction, and further deteriorate liver function. We evaluated safety, technical efficacy, and outcomes of TACE in HCC with PVTT. Methods From search results of the hospital database, out of 652 patients who underwent TACE for HCC, 73 patients of HCC with PVTT were retrospectively evaluated. Post-TACE tumor response by computed tomography (CT)/magnetic resonance imaging (MRI) imaging as per modified response evaluation criteria in solid tumors (mRECIST) criteria, if any occurrence of acute hepatic failure was assessed. Prognostic factors influencing survival were also determined. Results In our study population, the mean age of the patients was 58 years. The 12- and 24-month survival rates were 59 and 14%, respectively, with an overall median survival of 12.3 months. A total of 58.9% patients had branch portal vein tumor thrombus and 41.1% had tumor thrombus in the main portal vein. We did not encounter any mortality or acute liver failure following TACE in a 30-day period. Both univariate and multivariate analysis revealed Child–Pugh score (p = 0.01) and the extent of tumoral thrombus (p 0.004) as a significant prognostic factor. Patients with branch PVTT, no ascites, and Child–Pugh A had better survival than those having main portal vein tumor thrombus, ascites, and Child–Pugh B. Conclusion Our study concluded that TACE can achieve good disease control and improved survival in HCC with portal vein invasion despite being considered as a relative contraindication. Technical expertise, selection of patients, such as superselective catheterization and preserved liver function, are the key factors for a safe therapeutic procedure. Child–Pugh score and extent of portal vein invasion were the significant prognostic factors determining survival.

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