Associating liver partition and portal vein ligation or combined transarterial chemo-embolisation and portal vein embolisation for staged hepatectomy for HBV-related hepatocellular carcinoma

Abstract

Many patients with hepatocellular carcinoma are diagnosed with large tumours at an advanced stage. In addition, conditions such as liver fibrosis, cirrhosis, portal hypertension, viral load, and portal vein thrombosis due to either non-neoplastic or portal vein tumour thrombus limit the indications for surgical management to a select subset of individuals (1). In fact, based on the American Association for the study of the liver (AASLD) and European Association for the study of the liver (EASL) guidelines surgical management is generally limited to patients with Barcelona Clinical Liver Cancer Criteria (BCLC) stage A disease (2). However, several centres of hepatobiliary surgical centers of excellence in East Asian countries have demonstrated the potential benefit of hepatic resection for patients with BCLC stage B and C disease. In turn, based data derived from these centers, new guidelines have been proposed that push expand operability criteria (3-5).In considering the data, the principal aim of any multimodality treatment strategy should be to identify the subgroups of individuals and the specific individual patients who may benefit from surgical resection. Hepatic resection for patients with extensive disease can typically be defined into three categories: (I) single hepatic resection with or without modulation of functional liver remnant (FLR), (II) two stage or multistage hepatectomy usually with modulation of FLR and (III) parenchyma-sparing hepatic resection (6-8). In the late 1990s, a paradigm shift occurred with data demonstrating that these surgical approaches could achieve a complete resection with acceptable morbidity (9). In turn, multimodality treatment has increasingly focused on the prevention of postoperative liver failure secondary to an insufficient FLR complete (Ro) resection rather than tumour-related parameters such as size, number, or location (10-13).

Inflammatory indicators such as systemic immune inflammation index (SIII), systemic inflammatory response index (SIRI), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) as prognostic factors of curative hepatic resections for hepatocellular carcinoma

“…For the subset of patients who present with tumor and liver-related features amenable to surgery, hepatic resection—in addition to transplantation—offers the best chance at curative-intent therapy. Resection can be associated, however, with risk of complications and perioperative death especially among individuals with concomitant portal hypertension, liver fibrosis, cirrhosis, and portal vein thrombosis ( 1 - 3 ). Post-resection liver failure is also a major concern and can be a devasting complication following hepatic resection ( 4 , 5 ).…”

“…Overall survival following hepatic resection of HCC ranges from only 30–50%, and recurrence can be common depending on the stage of disease. In turn, there is considerable interest in identifying markers to help stratify patients relative to risk of recurrence and prognosis to define which groups of patients may benefit the most from hepatic resection of HCC ( 1 - 5 ).…”