Effective treatment strategies other than sorafenib for the patients with advanced hepatocellular carcinoma invading portal vein

Abstract

Patients with hepatocellular carcinoma (HCC) accompanying portal vein tumor thrombosis (PVTT) have relatively few therapeutic options and an extremely poor prognosis. These patients are classified into barcelona clinic liver cancer stage C and sorafenib is suggested as the standard therapy of care. However, overall survival (OS) gain from sorafenib is unsatisfactory and better treatment modalities are urgently required. Therefore, we critically appraised recent data for the various treatment strategies for patients with HCC accompanying PVTT. In suitable patients, even surgical resection can be considered a potentially curative strategy. Transarterial chemoembolization (TACE) can be performed effectively and safely in a carefully chosen population of patients with reserved liver function and sufficient collateral blood flow nearby the blocked portal vein. A recent meta-analysis demonstrated that TACE achieved a substantial improvement of OS in HCC patients accompanying PVTT compared with best supportive care. In addition, transarterial radioembolization (TARE) using yttrium-90 microspheres achieves quality-of-life advantages and is as effective as TACE. A large proportion of HCC patients accompanying PVTT are considered to be proper for TARE. Moreover, TACE or TARE achieved comparable outcomes to sorafenib in recent studies and it was also reported that the combination of radiotherapy with TACE achieved a survival gain compared to sorafenib in HCC patients accompanying PVTT. Surgical resection-based multimodal treatments, transarterial approaches including TACE and TARE, and TACE-based appropriate combination strategies may improve OS of HCC patients accompanying PVTT.

Videolaparoscopic microwave ablation in patients with HCC at a European high‐volume center: Results of 815 procedures

“…The upper nodule size limit adopted at our center was chosen on the strength of previous experiences with percutaneous MWA, which achieved 75% of complete ablations in HCC up to 5 cm in size . VLA was used in 188 carefully selected patients with BCLC C: 122 of them were classified as such due to a PS 1, which we do not consider a contraindication to minimally invasive approaches; the other 66 had a type Vp1 portal thrombosis (of the peripheral branches) . The aim of VLA was to completely ablate the invaded area.…”

“…122 of them were classified as such due to a PS 1, which we do not consider a contraindication to minimally invasive approaches; the other 66 had a type Vp1 portal thrombosis (of the peripheral branches). 22,23 The aim of VLA was to completely ablate the invaded area. The available data on localized infiltrative HCC 24 or HCC with portal thrombosis being treated with percutaneous ablation indicate that the procedure is safe and that patient survival is longer than with no treatment.…”

Refining prognosis after trans‐arterial chemo‐embolization for hepatocellular carcinoma

“…In previous models published, the inclusion of patients with portal vein tumour thrombosis (PVTT) represents the second concern . PVTT is generally considered a contraindication for TACE because of concerns that interruption to hepatic arterial blood supply could result in a massive hepatic necrosis in patients whose blood supply is already compromised . In addition, it is well known that vascular invasion is probably the most negative prognostic indicator in HCC prognosis .…”

The possibility of radiotherapy as downstaging to living donor liver transplantation for hepatocellular carcinoma with portal vein tumor thrombus

“…There were trials attempting downstaging in these patients using TARE with Yttrium-90 or multimodal treatment with sorafenib, but the results were still not satisfactory. (15,16) The role of RT had been restricted in the past due to radiation-induced liver disease caused by low tolerance of the liver to radiation but after the introduction of CRT, excessive radiation exposure to the liver and adjacent organs could be avoided, and radiation treatment has become a safer treatment modality. (17,18) Despite the small number of patients, our data suggest the possible role of RT as a new treatment modality for downstaging patients with PVTT.…”