Management of hepatocellular carcinoma patients with portal vein tumor thrombosis:A narrative review

Background: Hepatocellular carcinoma(HCC) is one of the main reasons for malignancy-related death. Portal vein tumor thrombosis(PVTT) is the most common form of macrovascular invasion related to HCC occurring in 10%-60% of patients. HCC with PVTT is usually characterized by worsening liver function, vulnerability to blood metastasis, higher incidence of complications associated with portal hypertension, and intolerance to treatment when compared with that without PVTT. If only treated with supportive care, the median survival of HCC with PVTT is about 2.7 months. In the past, sorafenib was the only recommended therapy by guidelines with limited effectiveness. This narrative review aimed to describe the current management options for HCC with PVTT. Data sources: We have reviewed literature from Pub Med on the treatment of HCC with PVTT and compiled evidence-based facts on effective therapies available for different types of PVTT. Results: Sorafenib monotherapy is not much effective, but combining it with other methods can improve survival. Each type of PVTT can beneft from the combination of transarterial chemoembolization and sorafenib than sorafenib monotherapy. The tumor downstaging can be realized possibly after transarterial chemoembolization, but tumor invasion into the main trunk of the portal vein greatly impairs efficacy. Although surgery is a curative approach, it is often not recommended for Vp4 PVTT. Some new methods can broaden the indication, but further explorations are needed. Radiotherapy can decrease the possibility of Vp3 progression to Vp4, but building a forecast model of best radiation dose and response is necessary. Systemic chemotherapy, hepatic arterial infusion chemotherapy, radiofrequency ablation, portal stenting, and traditional Chinese medicine are also benefcial in Vp3-4 PVTT. The accurate diagnosis of PVTT can be made by radiomics, and prognostic classifcation models can be used to design personalized treatments. The application of new treatment methods such as the atezolizumab plus bevacizumab scheme may increase survival.

Endoscopic papillary large balloon dilation with or without sphincterotomy for large bile duct stones removal:Short-term and long-tem outcomes

To the Editor:Simplifying the endoscopic procedures and reducing the procedure time are necessary,while guaranteeing that the stone retrieval efficacy is an important prerequisite for minimizing the risk of complications after endoscopic retrograde cholangiopancreatography(ERCP).Compared with endoscopic sphincterotomy(EST),which can effectively extract common bile duct stones,endoscopic papillary balloon dilatation(EPBD)causes less bleeding and perforation and preserves the function of sphincter of Oddi[1,2].However,in comparison with EST,EPBD is related to a higher risk of pancreatitis[2,3].Retrieving large bile duct stones(≥10 mm)using the conventional techniques EST and EPBD is difficult.The use of EST combined with endoscopic papillary large balloon dilation(EPLBD)for bile duct stone removal was first introduced by Ersoz et al.[4],and this innovation has become useful in patients with large or difficult stones.In addition,removing the bile duct stones should be considered urgent.Especially,EPLBD procedure is appropriate for patients with unfavorable anatomy for EST,such as those who underwent Roux-en-Y or Billroth II gastrectomy[5].