Treatment of hepatocellular carcinoma in patients with portal vein tumor thrombosis: Beyond the known frontiers

Abstract

Hepatocellular carcinoma is one of the most frequent malignant tumors worldwide: Portal vein tumor thrombosis (PVTT) occurs in about 35%-50% of patients and represents a strong negative prognostic factor, due to the increased risk of tumor spread into the bloodstream, leading to a high recurrence risk. For this reason, it is a contraindication to liver transplantation and in several prognostic scores sorafenib represents its standard of care, due to its antiangiogenetic action, although it can grant only a poor prolongation of life expectancy. Recent scientific evidences lead to consider PVTT as a complex anatomical and clinical condition, including a wide range of patients with different prognosis and new treatment possibilities according to the degree of portal system involvement, tumor biological aggressiveness, complications caused by portal hypertension, patient’s clinical features and tolerance to antineoplastic treatments. The median survival has been reported to range between 2.7 and 4 mo in absence of therapy, but it can vary from 5 mo to 5 years, thus depicting an extremely variable scenario. For this reason, it is extremely important to focus on the most adequate strategy to be applied to each group of PVTT patients.

Identification of APEX2 as an oncogene in liver cancer

“…The deficiency of powerful drugs and acquired drug resistance are the main reasons. Sorafenib is the only approved targeted drug for LIHC, and it is commonly reported that the drug resistance would be acquired in the process of therapy[ 31 ]. Although researchers have been trying their best to find underlying the mechanisms, there are much more unknown.…”

Living donor liver transplantation for patients with advanced hepatocellular carcinoma

“…A summary of treatment strategies according to PVTT is provided in Figure 1 [26,34,35,38,41] . In terms of LDLT, within the scope of the present review, recent studies demonstrated LDLT is a viable option to improve [37] , Japan's PVTT portal vein invasion (VP) classification [34,35] . HAIC: hepatic arterial infusion chemotherapy; IFN-alpha 2b: interferon alfa-2b; LT: liver transplantation; RT: radiation therapy; TACE: transarterial chemoembolization; TARE: transarterial radioembolization; 5-FU: 5-fluorouracil.…”

“…However, two classifications are currently valid to effectively assess prognosis and provide guidance for surgical treatment [34] . The Liver Cancer Study Group of Japan differentiates PVTT in four main categories of portal vein invasion, VP1, VP2, VP3, and VP4 [34][35][36] . In a similar fashion, Cheng et al [34] proposed a four-category classification, with the distinction of a category for microscopic portal vein invasion and the allusion of the extension of PVTT involving the superior mesenteric vein or inferior vena cava [37,38] [ Figure 1].…”

“…HAIC: hepatic arterial infusion chemotherapy; IFN-alpha 2b: interferon alfa-2b; LT: liver transplantation; RT: radiation therapy; TACE: transarterial chemoembolization; TARE: transarterial radioembolization; 5-FU: 5-fluorouracil. *Under certain conditions; **not enough support [26,34,35,38,37,40,41] long-term survival outcomes among carefully selected patients under specific criteria such as: (a) PVTT in a segmental branch, (b) AFP level < 100ng/mL, (c) low AP score, and (d) patients with HCC and PVTT who were successfully downstaged [36,42,43] .…”

Value of surgical resection compared to transarterial chemoembolization in the treatment of hepatocellular carcinoma with portal vein tumor thrombus: A meta-analysis of hazard ratios from five observational studies

“…In particular, HCC with portal vein tumor thrombosis (PVTT) is believed to be a negative prognostic factor because it increases the likelihood of tumor cell spread into the bloodstreams, resulting in higher chances of recurrence. 5 Previous studies have stated that HCC patients with portal vein invasion have a median survival period of 2.7-4 months without any treatment. 6,7 However, as per recent studies, depending on the patient's baseline performance status, hepatic function, tumor characteristics, the type of therapy could increase the survival duration from 5 months to 5 years.…”