Efficacy of radiofrequency ablation combined with sorafenib for treating liver cancer complicated with portal hypertension and prognostic factors

BACKGROUND Patients with liver cancer complicated by portal hypertension present complex challenges in treatment.AIM To evaluate the efficacy of radiofrequency ablation in combination with sorafenib for improving liver function and its impact on the prognosis of patients with this condition.METHODS Data from 100 patients with liver cancer complicated with portal hypertension from May 2014 to March 2019 were analyzed and divided into a study group(n=50)and a control group(n=50)according to the treatment regimen.The research group received radiofrequency ablation(RFA)in combination with sorafenib,and the control group only received RFA.The short-term efficacy of both the research and control groups was observed.Liver function and portal hypertension were compared before and after treatment.Alpha-fetoprotein(AFP),glypican-3(GPC-3),and AFP-L3 levels were compared between the two groups prior to and after treatment.The occurrence of adverse reactions in both groups was observed.The 3-year survival rate was compared between the two groups.Basic data were compared between the survival and non-surviving groups.To identify the independent risk factors for poor prognosis in patients with liver cancer complicated by portal hypertension,multivariate logistic regression analysis was employed.RESULTS When comparing the two groups,the research group's total effective rate(82.00%)was significantly greater than that of the control group(56.00%;P<0.05).Following treatment,alanine aminotransferase and aspartate aminotransferase levels increased,and portal vein pressure decreased in both groups.The degree of improvement for every index was substantially greater in the research group than in the control group(P<0.05).Following treatment,the AFP,GPC-3,and AFP-L3 levels in both groups decreased,with the research group having significantly lower levels than the control group(P<0.05).The incidence of diarrhea,rash,nausea and vomiting,and fatigue in the research group was significantly greater than that in the control group(P<0.05).The 1-,2-,and 3-year survival rates of the research group(94.00%,84.00%,and 72.00%,respectively)were significantly greater than those of the control group(80.00%,64.00%,and 40.00%,respectively;P<0.05).Significant differences were observed between the survival group and the non-surviving group in terms of Child-Pugh grade,history of hepatitis,number of tumors,tumor size,use of sorafenib,stage of liver cancer,histological differentiation,history of splenectomy and other basic data(P<0.05).Logistic regression analysis demonstrated that high Child-Pugh grade,tumor size(6–10 cm),history of hepatitis,no use of sorafenib,liver cancer stage IIIC,and previous splenectomy were independent risk factors for poor prognosis in patients with liver cancer complicated with portal hypertension(P<0.05).CONCLUSION Patients suffering from liver cancer complicated by portal hypertension benefit from the combination of RFA and sorafenib therapy because it effectively restores liver function and increases survival rates.The prognosis of patients suffering from liver cancer complicated by portal hypertension is strongly associated with factors such as high Child-Pugh grade,tumor size(6-10 cm),history of hepatitis,lack of sorafenib use,liver cancer at stage IIIC,and prior splenectomy.

Pancreaticoduodenectomy with portal vein/superior mesenteric vein resection for patients with pancreatic cancer with venous invasion

BACKGROUND： With the development of new surgical tech- niques, pancreaticoduodenectomy （PD） with portal vein or superior mesenteric vein （PV/SMV） resection has been used in the treatment of patients with borderline resectable pan- creatic cancer. However, opinions of surgeons differ in the effectiveness of this surgical technique. This study aimed to investigate the effectiveness of this approach in patients with pancreatic cancer. METHODS： Follow-up visits and retrospective analysis were carried out of 208 patients with pancreatic cancer who had undergone PD （PD group） and PD combined with PV/SMV resection and reconstruction （PDVR group） from June 2009 to May 2013 at our center. Statistical analysis was performed to compare the clinical features, the difference of survival time and risk factors of venous invasion in pancreatic cancer. Factors relating to postoperative survival time of pancreatic cancer were also investigated. RESULTS： In the PDVR group, which consisted of 42 cases, the 1-, 2- and 3-year survival rates were 70%, 41% and 16%, respective- ly and the median survival time was 20.0 months. Among the 166 patients in the PD group, the 1-, 2- and 3-year survival rates were 80%, 52%, and 12%, respectively with the median survival time of 26.0 months. No significant difference in survival time and R0 resection ratio was found between the two groups. Lum- bodorsal pain, tumor with pancreatic capsular invasion and bile duct infiltration were found to be independent risk factors for PV invasion in pancreatic cancer. In addition, non R0 resection,large tumor size （〉2 cm） and poorly differentiated tumor were independent risk factors for survival time in post-PD. CONCLUSIONS： The tumor has a higher chance of venous invasion if preoperative imagings indicate that it juxtaposes with the vessel. Lumbodorsal pain is the chief complaint. Pa- tients with pancreatic cancer associated with PV involvement should receive PDVR for R0 resection when preoperational assessment shows the chance for eradication.

Whole-course management of interventional treatment in liver cancer patients with portal hypertension

Primary liver cancer often occurs in patients with hepatitis and cirrhosis.Some patients have portal hypertension due to cirrhosis,and present with varying degrees of collateral circulation,splenomegaly and hypersplenism,ascites,and liver dysfunction.It often interferes with the treatment of tumors and affects the disease prognosis.There are internationally recognized guidelines for interventional treatment of liver cancer and portal hypertension which will not be repeated in this paper.This paper focuses on how to treat portal hypertension and intervene with tumors in the treatment of liver cancer to optimize the management of patients with liver cancer and portal hypertension.We propose that the Interventional Management Mode of Liver Cancer with Portal Hypertension can improve the treatment of liver cancer patients with portal hypertension.

Postoperative inflammation as a possible cause of portal vein thrombosis after irreversible electroporation for locally advanced pancreatic cancer

Portal vein thrombosis(PVT) is a rare but serious postoperative complication associated with irreversible electroporation(IRE). We report a case of postoperative PVT in a 54-year-old woman who underwent IRE for locally advanced pancreatic cancer. Drain removal and discharge of the patient from the hospital were scheduled on postoperative day(POD) 7; however, a magnetic resonance imaging scan revealed the presence of PVT. We suspected postoperative inflammation in the pancreas as the main cause of PVT. However, the patient did not undergo any medical treatment because she did not have any clinical symptoms, and she was discharged on POD 8.

Associating liver partition and portal vein ligation for staged hepatectomy in the treatment of colorectal cancer liver metastases

Colorectal cancer(CRC)is a common malignancy of the digestive system.Colorectal liver cancer metastasis(CRLM)occurs in approximately 50%of the patients and is the main cause of CRC mortality.Surgical resection is currently the most effective treatment for CRLM.However,given that the remnant liver volume after resection should be adequate,only a few patients are suitable for radical resection.Since Dr.Hans Schlitt first performed the associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)for CRLM in 2012,ALPPS has received considerable attention and has continually evolved in recent years.This review explains the technical origin of the ALPPS procedure for CRLM and evaluates its efficacy,pointing to its favorable postoperative outcomes.We also discuss the patient screening strategies and optimization of ALPPS to ensure long-term survival of patients with CRLM in whom surgery cannot be performed.Finally,further directions in both basic and clinical research regarding ALPPS have been proposed.Although ALPPS surgery is a difficult and high-risk technique,it is still worth exploration by experienced surgeons.

Portal vein stenosis after pancreatectomy following neoadjuvant chemoradiation therapy for pancreatic cancer

Extrahepatic portal vein (PV) stenosis has various causes, such as tumor encasement, pancreatitis and as a postsurgical complication. With regard to post-pancreaticoduodenectomy, intraoperative radiation therapy with/ without PV resection is reported to be associated with PV stenosis. However, there has been no report of PV stenosis after pancreatectomy following neoadjuvant chemoradiation therapy (NACRT). Here we report the cases of three patients with PV stenosis after pancreatectomy and PV resection following gemcitabine-based NACRT for pancreatic cancer and their successful treatment with stent placement. We have performed NACRT in 18 patients with borderline resectable pancreatic cancer since 2005. Of the 15 patients who completed NACRT, nine had undergone pancreatectomy. Combined portal resection was performed in eight of the nine patients. We report here three patients with PV stenosis, and thus the ratio of post-operative PV stenosis in patients with PV resection following NACRT is 37.5% in this series. We encountered no case of PV stenosis among 22 patients operated with PV resection for pancreatobiliary cancer without NACRT during the same period. A relationship between PV stenosis and NACRT is suspected, but further investigation is required to determine whether NACRT has relevance to PV stenosis.

Sonographic differentiation of diffuse liver cancer from portal cirrhosis

Objective: To differentiate diffuse liver cancer from portal cirrhosis by using ultrasonography. Methods: We analyzed the sonographic images of 15 patients with diffuse liver cancer and 30 patients with portal cirrhosis. Results: The patients with diffuse liver cancer showed enlarged liver and obvious echo of nodules. The rate of portal embolism and swelling of lymph nodes a- round the porta hepatis was high. The patients with portal cirrhosis showed diminished liver and the obvi- ous echo of fiber proliferation. The rates of spleen enlargement and ascites as well as gallbladder edema were high. Conclusions: To identify sonographic characteristics inside and outside of the liver. It is helpful in diffe- rentiating diffuse liver cancer from portal cirrhosis. The sonographic characteristics inside the liver in- clude surface and size, node echo, echo of fibrous tissue hyperplasia. They are difficult to identify when diffuse liver cancer merges with considerable cirrho- sis. The acoustic image characteristics of the two di- seases overlap. Hence attention should be paid to the size of the liver, proliferation of cells of diffuse liver carcinoma. In sonographic characteristics outside the liver, embolism of the portal vein and swelling of lymph nodes in the porta hepatis are particularly use- ful to identify diffuse liver cancer or diffuse liver cancer combined with liver cirrhosis in particular.

Clinical implications and perspectives of portal venous circulating tumor cells in pancreatic cancer

Despite recent improvements in the diagnosis and treatment of pancreatic cancer(PC),clinical outcomes remain dismal.Moreover,there are no effective prognostic or predictive biomarkers or options beyond carbohydrate antigen 19-9 for personalized and precise treatment.Circulating tumor cells(CTCs),as a member of the liquid biopsy family,could be a promising biomarker;however,the rarity of CTCs in peripheral venous blood limits their clinical use.Because the first venous drainage of PC is portal circulation,the portal vein can be a more suitable location for the detection of CTCs.Endoscopic ultrasound-guided portal venous sampling of CTCs is both feasible and safe.Several studies have suggested that the detection rate and number of CTCs may be higher in the portal blood than in the peripheral blood.CTC counts in the portal blood are highly associated with hepatic metastasis,recurrence after surgery,and survival.The phenotypic and genotypic properties measured in the captured portal CTCs can help us to understand tumor heterogeneity and predict the prognosis of PC.Small sample sizes and heterogeneous CTC detection methods limit the studies to date.Therefore,a large number of prospective studies are needed to corroborate portal CTCs as a valid biomarker in PC.

Management of small hepatocellular carcinoma in cirrhosis:Focus on portal hypertension

The incidence of hepatocellular carcinoma(HCC) is rising worldwide being currently the fifth most common cancer and third cause of cancer-related mortality.Early detection of HCC through surveillance programs have enabled the identification of small nodules with higher frequency,and nowadays account for 10%-15% of patients diagnosed in the West and almost 30% in Japan.Patients with small HCC can be candidates for potential curative treatments:liver transplantation,surgical resection and percutaneous ablation,depending on the presence of portal hypertension and co-morbidities.This review will analyze recent advancements in the clinical management of these individuals,focusing on issues related to the role of portal hypertension,the debate between resection and ablative therapies and the future impact of molecular technologies.

Preoperative high level of D-dimers predicts unresectability of pancreatic head cancer

AIM: To assess the value of D-dimer level in determining resectability of pancreatic cancer.

Portal vein thrombosis:Prevalence,patient characteristics and lifetime risk:A population study based on 23796 consecutive autopsies

AIM： TO assess the lifetime cumulative incidence of portal venous thrombosis （PVT） in the general population. METHODS： Between 1970 and 1982, 23 796 autopsies, representing 84% of all in-hospital deaths in the Malmo city population, were performed, using a standardised protocol including examination of the portal vein. PVT patients were characterised and the PVT prevalence at autopsy, an expression of life-time cumulative incidence, assessed in high-risk disease categories and expressed in terms of odds ratios and 95% CI. RESULTS： The population prevalence of PVT was 1.0%. Of the 254 patients with PVT 28% had cirrhosis, 23% primary and 44% secondary hepatobiliary malignancy, 10% major abdominal infectious or inflammatory disease and 3% had a myeloproliferative disorder. Patients with both cirrhosis and hepatic carcinoma had the highest PVT risk, OR 17.1 （95% CI 11.1-26.4）. In 14% no cause was found; only a minority of them had developed portal-hypertension-related complications. CONCLUSION： In this population-based study, PVT was found to be more common than indicated by previous clinical series. The markedly excess risk in cirrhosis and hepatic carcinoma should warrant an increased awareness in these patients for whom prospective studies of directed intervention might be considered.

Stents combined with iodine-125 implantation to treat main portal vein tumor thrombus

AIM To evaluate the efficacy of main portal vein stents combined with iodine-125(^(125)Ⅰ) to treat main portal vein tumor thrombus.METHODS From January 1, 2010 to January 1, 2015, 111 patients were diagnosed with liver cancer combined with main portal vein tumor thrombus. They were non-randomly assigned to undergo treatment with transarterial chemoembolization(TACE)/transarterial embolization(TAE) + portal vein stents combined with ^(125)Ⅰ implantation(Group A) and TACE/TAE + portal vein stents only(Group B). After the operation, scheduled follow-up was performed at 6, 12 and 24 mo. The recorded information included clinical manifestations, survival rate, and stent restenosis rate. Kaplan–Meier curves, log-rank test and Cox regression were used for data analyses. RESULTS From January 1, 2010 to January 1, 2015, 54 and 57 patients were allocated to Groups A and B, respectively. The survival rates at 6, 12 and 24 mo were 85.2%, 42.6% and 22.2% in Group A and 50.9%, 10.5% and 0% in Group B. The differences were significant [log rank P < 0.05, hazard ratio(HR): 0.37, 95%CI: 0.24-0.56]. The rates of stent restenosis were 18.5%, 55.6% and 83.3% in Group A and 43.9%, 82.5% and 96.5% in Group B. The differences were significant(log rank P < 0.05, HR: 0.42, 95%CI: 0.27-0.63). Cox regression identified that treatment was the only factor affecting survival rate in this study.CONCLUSION Main portal vein stents combined with ^(125)Ⅰ can significantly improve survival rate and reduce the rate of stent restenosis.

Current surgical treatment for bile duct cancer

Since extrahepatic bile duct cancer is difficult to diagnose and to cure, a safe and radical surgical strategy is needed. In this review, the modes of infiltration and spread of extrahepatic bile duct cancer and surgical strategy are discussed. Extended hemihepatectomy, with or without pancreatoduodenectomy （PD）, plus extrahepatic bile duct resection and regional lyrnphadenectomy has recently been recognized as the standard curative treatment for hilar bile duct cancer. On the other hand, PD is the choice of treatment for middle and distal bile duct cancer. Major hepatectomy concomitant with PD （hepatopancreatoduodenectomy） has been applied to selected patients with widespread tumors. Preoperative biliary drainage （BD） followed by portal vein embolization （PVE） enables major hepatectomy in patients with hilar bile duct cancer without mortality. BD should be performed considering the surgical procedure, especially, in patients with separated intrahepatic bile ducts caused by hilar bile duct cancer. Right or left trisectoriectomy are indicated according to the tumor spread and biliary anatomy. As a result, extended radical resection offers a chance for cure of hilar bile duct cancer with improved resectability, curability, and a 5-year survival rate of 40%. A 5-year survival rate has ranged from 24% to 39% after PD for middle and distal bile duct cancer.

Portal vein embolization for induction of selective hepatic hypertrophy prior to major hepatectomy: rationale,techniques, outcomes and future directions

The ability to modulate the future liver remnant(FLR) is a key component of modern oncologic hepatobiliary surgery practice and has extended surgical candidacy for patients who may have been previously thought unable to survive liver resection. Multiple techniques have been developed to augment the FLR including portal vein embolization(PVE), associating liver partition and portal vein ligation(ALPPS), and the recently reported transhepatic liver venous deprivation(LVD). PVE is a well-established means to improve the safety of liver resection by redirecting blood flow to the FLR in an effort to selectively hypertrophy and ultimately improve functional reserve of the FLR. This article discusses the current practice of PVE with focus on summarizing the large number of published reports from which outcomes based practices have been developed. Both technical aspects of PVE including volumetry, approaches, and embolization agents; and clinical aspects of PVE including data supporting indications, and its role in conjunction with chemotherapy and transarterial embolization will be highlighted. PVE remains an important aspect of oncologic care; in large part due to the substantial foundation of information available demonstrating its clear clinical benefit for hepatic resection candidates with small anticipated FLRs.

Hepatic resection beyond barcelona clinic liver cancer indication:When and how

Hepatocellular carcinoma(HCC)is the main common primary tumour of the liver and it is usually associated with cirrhosis.The barcelona clinic liver cancer(BCLC)classification has been approved as guidance for HCC treatment algorithms by the European Association for the Study of Liver and the American Association for the Study of Liver Disease.According to this algorithm,hepatic resection should be performed only in patients with small single tumours of 2-3 cm without signs of portal hypertension(PHT)or hyperbilirubinemia.BCLC classification has been criticised and many studies have shown that multiple tumors and large tumors,as wide as those with macrovascular infiltration and PHT,could benefit from liver resection.Consequently,treatment guidelines should be revised and patients with intermediate/advanced stage HCC,when technically resectable,should receive the opportunity to be treated with radical surgical treatment.Nevertheless,the surgical treatment of HCC on cirrhosis is complex:The goal to be oncologically radical has always to be balanced with the necessity to minimize organ damage.The aim of this review was to analyze when and how liver resection could be indicated beyond BCLC indication.In particular,the role of multidisciplinary approach to assure a proper indication,of the intraoperative ultrasound for intraoperative restaging and resection guidance and of laparoscopy to minimize surgical trauma have been enhanced.

Role of endoscopic ultrasound in anticancer therapy:Current evidence and future perspectives

The digestive system is one of the most common sites of malignancies in humans.Since gastrointestinal tumors represent a massive global health burden both in terms of morbidity and health care expenditures,scientists continuously develop novel diagnostic and therapeutic methods to ameliorate the detrimental effects of this group of diseases.Apart from the well-established role of the endoscopic ultrasound(EUS)in the diagnostic course of gastrointestinal and hepatobiliary malignancies,we have recently become acquainted with a vast array of its therapeutic possibilities.A multitude of previously established,evidence-based methods that might now be guided by the EUS emerged:Radiofrequency ablation,brachytherapy,fine needle injection,celiac plexus neurolysis,and endoscopic submucosal dissection.In this review we endeavored to provide a comprehensive overview of the role of these methods in different malignancies of the digestive system,primarily in the treatment and symptom control in pancreatic cancer,and additionally in the management of hepatic,gastrointestinal tumors,and pancreatic cysts.

Isolated gastric variceal bleeding related to non-cirrhotic portal hypertension following oxaliplatin-based chemotherapy:A case report

BACKGROUND Sinusoidal obstruction syndrome has been reported after oxaliplatin-based chemotherapy,but liver fibrosis and non-cirrhotic portal hypertension(NCPH)are rarely reported.CASE SUMMARY Here,we describe the case of a 64-year-old woman who developed isolated gastric variceal bleeding 16 mo after completing eight cycles of oxaliplatin combined with capecitabine chemotherapy after colon cancer resection.Surprisingly,splenomegaly and thrombocytopenia were not accompanied by variceal bleeding,which has been reported to have predictive value for gastric variceal formation.However,a liver biopsy showed fibrosis in the portal area,suggesting NCPH.The patient underwent endoscopic treatment and experienced no further symptoms.CONCLUSION It is necessary to guard against long-term complications after oxaliplatin-based chemotherapy.Sometimes splenic size and platelet level may not always accurately predict the occurrence of portal hypertension.

Hepatectomy for gallbladder-cancer with unclassified anomaly of right-sided ligamentum teres: A case report and review of the literature

Right-sided ligamentum teres(RSLT) is a congenital anomaly in which the right umbilical ligament becomes dominant and anomalous ramifications of the hepatic vessels and biliary system are present. A male patient in his 70 s was diagnosed with advanced gallbladder cancer directly infiltrating the right hepatic duct(RHD), together with RSLT. Preoperative three-dimensional simulation of the liver based on multiple detector computed tomography images after cholangiography revealed ramifications of all segmental portal veins from the portal trunk and discordance of the arterial and biliary branching patterns of segment 8. Fusion analysis of the biliary architecture and segmental volumetry showed that the RHD drained segments 1 r, 5, 6, and 7. We successfully performed a modified right-sided hepatectomy sparing segment 8(i.e., resection of the RHD drainage territory), with negative surgical margins. This report is the first to describe major hepatectomy for advanced gallbladder cancer with RSLT.

Pylephlebitis—a rare complication of a fish bone migration mimicking metastatic pancreatic cancer:A case report

BACKGROUND Pylephlebitis is a rare condition,poorly recognized by clinicians and with few references.In this case,the clinical appearance resembled the clinical course of a pancreatic cancer and was originated by the ingestion of a fish bone,making the case more interesting and rare.CASE SUMMARY A 79-year-old female presented to the emergency department with fever,loss of appetite and jaundice.Tenderness in the right upper quadrant was present.Inflammation marker were high.A computed tomography(CT)scan revealed gallstones and aspects compatible with acute pancreatitis.The patient was admitted to surgery ward and has her condition aggravated.A magnetic resonance revealed multifocal liver lesions.Later,a cholangiopancreatography and an endoscopic ultrasound(US)were able to diagnose the condition.Specific treatment was implemented and the patient made a complete recovery.CONCLUSION In conclusion,this case report demonstrates for the first time the diagnosis of an unusual case of pylephlebitis complicated by the migration of a fish bone,mimicking metastatic pancreatic cancer.Clinical presentation and traditional imaging studies,such as transabdominal US and CT,remain the standard for diagnosing this condition.