Reassessment of palliative surgery in conversion therapy of previously unresectable hepatocellular carcinoma: Two case reports and review of literature

BACKGROUND Most patients with hepatocellular carcinoma(HCC)have lost the opportunity for direct surgery at the time of diagnosis.Transarterial chemoembolization(TACE)combined with immune checkpoint inhibitors or tyrosine kinase inhibitors(TKI)can partially transform some unresectable HCC and improve the prognosis ef-fectively.However,based on the promising prospects of combined targeted and immunotherapy for the effective treatment of HCC,the positive role of palliative surgery in the conversion treatment of advanced HCC urgently needs further in-tensive re-assessment.CASE SUMMARY In this study,we describe two successful cases of"conversion therapy for un-resectable HCC"achieved mainly by palliative surgery combined with TACE plus immunotherapy and TKIs.A 48-year-old patient with newly diagnosed HCC,presenting with a 6-cm mass in the segment VII/VIII of the right liver with mul-tiple intrahepatic metastases,could not undergo one-stage radical surgical resection.He underwent palliative surgery with radiofrequency of metastatic lesions and the palliative resection of the primary mass,and received subsequent TACE treatments twice in the early postoperative period(2 weeks and 6 weeks),in addition to targeted and immune combination therapy with sintilimab injection and oral lenvatinib.No evidence of recurrence was observed during the 11-month follow-up period after surgery.The other patient was a 47-year-old patient with massive HCC(18 cm×15 cm×4.5 cm)in the left liver with severe cirrhosis.The left portal branch was occluded and a tumor thrombus formed,and the tumor partly involved the middle hepatic vein.The patient underwent palliative surgery of left hemihepatectomy(including resection of the middle hepatic vein)for HCC,followed by three TACE procedures and oral TKIs 2 weeks after surgery.Six months later,the re-examination via computed tomography revealed no tumour activity in the remaining right liver,while magnetic resonance imaging revealed slight local tumor enhancement in the caudate lobe of the liver considered,TACE was performed once again,and during the next follow-up of 10 months did not reveal new intrahepatic lesions or distant metastases.CONCLUSION These cases demonstrate that the addition of palliative surgery to conversion therapy in a selected population with a high tumor burden could benefit patients with initially unresectable HCC.

Predictive value of tumor markers in patients with recurrent hepatocellular carcinoma in different vascular invasion pattern

BACKGROUND： Four tumor markers for hepatocellular carcinoma（HCC）, alpha-fetoprotein（AFP）, glypican-3（GPC3）, vascular endothelial growth factor（VEGF） and des-gammacarboxy prothrombin（DCP）, are closely associated with tumor invasion and patient＇s survival. This study estimated the predictability of preoperative tumor marker levels along with pathological parameters on HCC recurrence after hepatectomy.METHODS： A total of 140 patients with HCC who underwent hepatectomy between January 2012 and August 2012 were enrolled. The demographics, clinical and follow-up data were collected and analyzed. The patients were divided into two groups： patients with macroscopic vascular invasion（Ma VI ＋） and those without Ma VI（Ma VI-）. The predictive value of tumor markers and clinical parameters were evaluated by univariate and multivariate analysis.RESULTS： In all patients, tumor size（〉8 cm） and Ma VI were closely related to HCC recurrence after hepatectomy. For Ma VI＋ patients, VEGF（〉900 pg/m L） was a significant predictor for recurrence（RR=2.421; 95% CI： 1.272-4.606; P=0.007）. The 1- and 2-year tumor-free survival rates for Ma VI＋ patients with VEGF ≤900 pg/m L versus for those with VEGF 〉900 pg/m L were 51.5% and 17.6% versus 19.0% and 4.8%（P〈0.001）. For Ma VI- patients, DCP 〉445 m Au/m L and tumor size 〉8 cm were two independent risk factors for tumor recurrence（RR=2.307, 95% CI： 1.132-4.703, P=0.021; RR=3.150, 95% CI： 1.392-7.127, P=0.006; respectively）. The 1- and 2-year tumor-free survival rates for the patients with DCP ≤445 m Au/m L and those with DCP 〉445 m Au/m L were 90.4% and 70.7% versus 73.2% and 50.5% respectively（P=0.048）. The 1-and 2-year tumor-free survival rates for the patients with tumor size ≤8 cm and 〉8 cm were 83.2% and 62.1% versus 50.0% and 30.0%, respectively（P=0.003）.CONCLUSIONS： The Ma VI＋ patients with VEGF ≤900 pg/m L had a relatively high tumor-free survival than those with VEGF 〉900 pg/m L. In the Ma VI- patients, DCP 〉445 m Au/m L and tumor size 〉8 cm were predictive factors for postoperative recurrence.

Impact of intra-operative cholangiography and parenchymal resection to donor liver function in living donor liver transplantation

BACKGROUND: Living donor liver transplantation(LDLT)has been widely accepted over the past decade, and hepatic dysfunction often occurs in the donor in the early stage after liver donation. The present study aimed to evaluate the effect of intraoperative cholangiography(IOC) and parenchymal resection on liver function of donors in LDLT, and to assess the role of IOC in influencing the biliary complications and improving the overall outcome.METHODS: Data from 40 patients who had donated their right lobes for LDLT were analyzed. Total bilirubin(TB), alanine aminotransferase(ALT), aspartate aminotransferase(AST),alkaline phosphatase(ALP) and γ-glutamyl transpeptidase(GGT)at different time points were compared, and the follow-up data and the biliary complications were also analyzed.RESULTS: The ALT and AST values were significantly increased after IOC(P<0.001) and parenchymal resection(P<0.001).However, the median values of TB, ALP and GGT were not significantly influenced by IOC(P>0.05) or parenchymal resection(P>0.05). The biochemical changes caused by IOC or parenchymal resection were not correlated with the degree of post-operative liver injury or the recovery of liver function. The liver functions of the donors after operation were stable, and none of the donors suffered from biliary stenosis or leakage during the follow-up.CONCLUSIONS: IOC and parenchymal resection may induce a transient increase in liver enzymes of donors in LDLT, but do not affect the recovery of liver function after operation. Moreover,the routine IOC is helpful to clarify the division line of the hepatic duct, thus reducing the biliary complication rate.