Portal vein tumor thrombus is a bottleneck in the treatment of hepatocellular carcinoma

The effect of portal vein tumor thrombus(PVTT) on the prognosis of patients with hepatocellular carcinoma has become clear over the past several decades. However, identifying the mechanisms and performing the diagnosis and treatment of PVTT remain challenging. Therefore, this study aimed to summarize the progress in these areas. A computerized literature search in Medline and EMBASE was performed with the following combinations of search terms: "hepatocellular carcinoma" AND "portal vein tumor thrombus." Although several signal transduction or molecular pathways related to PVTT have been identified, the exact mechanisms of PVTT are still largely unknown. Many biomarkers have been reported to detect microvascular invasion, but none have proved to be clinically useful because of their low accuracy rates. Sorafenib is the only recommended therapeutic strategy in Western countries. However, more treatment options are recommended in Eastern countries, including surgery, radiotherapy(RT), transhepatic arterial chemoembolization(TACE), transarterial radioembolization(TARE), and sorafenib. Therefore, we established a staging system based on the extent of portal vein invasion. Our staging system effectively predicts the long-term survival of PVTT patients. Currently, several clinical trials had shown that surgery is effective and safe in some PVTT patients. RT,TARE, and TACE can also be performed safely in patients with good liver function. However, only a few comparative clinical trials had compared the effectiveness of these treatments. Therefore, more randomized controlled trials examining the extent of PVTT should be conducted in the future.

A new classification for hepatocellular carcinoma with hepatic vein tumor thrombus

Background:Hepatic vein tumor thrombus(HVTT)is a significant poor risk factor for survival outcomes in hepatocellular carcinoma(HCC)patients.Currently,the widely used international staging systems for HCC are not refined enough to evaluate prognosis for these patients.A new classification for macroscopic HVTT was established,aiming to better predict prognosis.Methods:This study included 437 consecutive HCC patients with HVTT who underwent different treatments.Overall survival(OS)and time-dependent receiver operating characteristic(ROC)curve area analysis were used to determine the prognostic capacities of the new classification when compared with the different currently used staging systems.Results:The new HVTT classification was defined as:type I,tumor thrombosis involving hepatic vein(HV),including microvascular invasion;type II,tumor thrombosis involving the retrohepatic segment of inferior vena cava;and type III,tumor thrombosis involving the supradiaphragmatic segment of inferior vena cava.The numbers(percentages)of patients with types I,II,and III HVTT in the new classification were 146(33.4%),143(32.7%),and 148(33.9%),respectively.The 1-,2-,and 3-year OS rates for types I to III HVTT were 79.5%,58.6%,and 29.1%;54.8%,23.3%,and 13.8%;and 24.0%,10.0%,and 2.1%,respectively.The time-dependent-ROC curve area analysis demonstrated that the predicting capacity of the new HVTT classification was significantly better than any other staging systems.Conclusions:A new HVTT classification was established to predict prognosis of HCC patients with HVTT who underwent different treatments.This classification was superior to,and it may serve as a supplement to,the commonly used staging systems.

A new staging system for hepatocellular carcinoma associated with portal vein tumor thrombus

Background:A new staging system for patients with hepatocellular carcinoma(HCC)associated with portal vein tumor thrombus(PVTT)was developed by incorporating the good points of the BCLC classification of HCC,and by improving on the currently existing classifications of HCC associated with PVTT.Methods:Univariate and multivariate analysis with Waldχ2 test were used to determinate the clinical prognostic factors for overall survival(OS)in patients with HCC and PVTT in the training cohort.Then the conditional inference trees analysis was applied to establish a new staging system.Results:A training cohort of 2,179 patients from the Eastern Hepatobiliary Surgery Hospital and a validation cohort of 1,550 patients from four major liver centers in China were enrolled into establishing and validating a new staging system.The system was established by incorporating liver function,general health status,tumor resectability,extrahepatic metastasis and extent of PVTT.This staging system had a good discriminatory ability to separate patients into different stages and substages.The median OS for the two cohorts were 57.1(37.2-76.9),12.1(11.0-13.2),5.7(5.1-6.2),4.0(3.3-4.6)and 2.5(1.7-3.3)months for the stages 0 to IV,respectively(P<0.001)in the training cohort.The corresponding figures for the validation cohort were 6.4(4.9-7.9),2.8(1.3-4.4),10.8(9.3-12.4),and 1.5(1.3-1.7)months for the stages II to IV,respectively(P<0.001).The mean survival for stage 0 to 1 were 37.6(35.9-39.2)and 30.4(27.4-33.4),respectively(P<0.001).Conclusions:A new staging system was established which provided a good discriminatory ability to separate patients into different stages and substages after treatment.It can be used to supplement the other HCC staging systems.

Liver resection versus intensity-modulated radiation therapy for treatment of hepatocellular carcinoma with hepatic vein tumor thrombus:a propensity score matching analysis

Background:The presence of hepatic vein tumor thrombus(HVTT)is a major determinant of survival outcomes in hepatocellular carcinoma(HCC)patients.This study compared survival outcomes between liver resection(LR)and intensity-modulated radiation therapy(IMRT)in HCC patients with HVTT.Methods:Data from patients who underwent LR or IMRT for HCC with HVTT at the Eastern Hepatobiliary Surgery Hospital were retrospectively analyzed.Their survival outcomes were compared before and after propensity score matching(PSM).Results:Three hundred and seven HCC patients with HVTT who underwent either LR(n=140)or IMRT(n=167)were enrolled.PSM matched 82 pairs of patients.The overall survival(OS)and recurrence-free survival(RFS)rates were significantly higher for patients in the LR group than those in the IMRT group.On subgroup analysis,significantly better survival outcomes were obtained after LR than IMRT in patients with peripheral type of HVTT(pHVTT)and major type of HVTT(mHVTT).However,similar survival outcomes were obtained after LR and IMRT when the HVTT had developed into inferior vena cava tumor thrombus(IVCTT).Conclusions:LR resulted in significantly better survival outcomes in HCC patients with HVTT when compared to IMRT.Once the HVTT had developed IVCTT,LR and IMRT resulted in similarly bad survival outcomes.