Selection criteria for hepatectomy in patients with hepatocellular carcinoma and portal vein tumor thrombus

Abstract

Objective: To examine the usefulness of the authors' method involving preoperative transcatheter arterial chemoembolization followed by hepatectomy.

Summary background data: The presence of portal vein tumor thrombus in a patient with hepatocellular carcinoma is one of the most significant factors for a poor prognosis. No standard therapy has been established.

Methods: Forty-five of 455 patients with hepatocellular carcinoma (10%) from 1989 to 1998 were included in this study. These patients had gross portal vein tumor thrombus but no distant metastases. The 23 patients (50%) who had indications for surgery received preoperative transcatheter arterial chemoembolization: 18 underwent hepatic resection and 5 underwent ligation of the hepatic artery or portal vein on laparotomy. Among the remaining 22 patients who did not have indications for hepatectomy, 10 received regional chemotherapy and 12 underwent transcatheter arterial chemoembolization.

Results: The mean duration of survival was 3.4 +/- 2.7 years in the 18 patients who received transcatheter arterial chemoembolization and hepatectomy and 0.36 +/- 0.26 years in the 27 patients who did not receive hepatectomy. The survival rate of the 18 patients who received hepatic resection with preoperative transcatheter arterial chemoembolization was 82% at 1 year, 42% at 3 years, and 42% at 5 years. Portal trunk occlusion by tumor thrombus, three or more primary nodules, an indocyanine green retention rate at 15 minutes of 20% or worse, and therapeutic choice other than hepatectomy were significant predictors of a poor prognosis on univariate analysis. Hepatectomy was the only factor that was significant on multivariate analysis.

Conclusions: Patients may enjoy long-term survival if they receive hepatectomy with preoperative transcatheter arterial chemoembolization, when the number of primary nodules is no more than two, the portal trunk is not occluded by tumor thrombus, and the indocyanine green retention rate at 15 minutes is better than 20%.

Figure 1. Overall survival of patients grouped according to whether they underwent hepatic resection. There was a statistically significant difference in survival (P < .0001).

Figure 2. Survival rates of patients who did not undergo hepatectomy stratified according to the therapeutic modalities: regional chemotherapy vs. transcatheter arterial chemoembolization, regional chemotherapy vs. ligation, and transcatheter arterial chemoembolization vs. ligation. There were no significant differences.

Figure 3. On the plain computed tomography scan taken 2 weeks after transcatheter arterial chemoembolization, an iodized oil accumulated in portal vein tumor thrombus located at the right portal vein (arrow), and also in a nodule of hepatocellular carcinoma.