Transcatheter arterial chemoembolization combined with PD-1 inhibitors and Lenvatinib for hepatocellular carcinoma with portal vein tumor thrombus

BACKGROUND Hepatocellular carcinoma(HCC)patients complicated with portal vein tumor thrombus(PVTT)exhibit poor prognoses and treatment responses.AIM To investigate efficacies and safety of the combination of PD-1 inhibitor,transcatheter arterial chemoembolization(TACE)and Lenvatinib in HCC subjects comorbid with PVTT.METHODS From January 2019 to December 2020,HCC patients with PVTT types Ⅰ-Ⅳ were retrospectively enrolled at Beijing Ditan Hospital.They were distributed to either the PTL or TACE/Lenvatinib(TL)group.The median progression-free survival(mPFS)was set as the primary endpoint,while parameters like median overall survival,objective response rate,disease control rate(DCR),and toxicity level served as secondary endpoints.RESULTS Forty-one eligible patients were finally recruited for this study and divided into the PTL(n=18)and TL(n=23)groups.For a median follow-up of 21.8 months,the DCRs were 88.9%and 60.9%in the PTL and TL groups(P=0.046),res-pectively.Moreover,mPFS indicated significant improvement(HR=0.25;P<0.001)in PTL-treated patients(5.4 months)compared to TL-treated(2.7 months)patients.There were no treatment-related deaths or differences in adverse events in either group.CONCLUSION A triplet regimen of PTL was safe and well-tolerated as well as exhibited favorable efficacy over the TL regimen for advanced-stage HCC patients with PVTT types Ⅰ-Ⅳ.

Conversion therapy of a giant hepatocellular carcinoma with portal vein thrombus and inferior vena cava thrombus:A case report and review of literature

BACKGROUND The prognosis of hepatocellular carcinoma(HCC)combined with portal and hepatic vein cancerous thrombosis is poor,for unresectable patients the combination of targeted therapy and immune therapy was the first-line recommended treatment for advanced HCC,with a median survival time of only about 2.7-6 months.In this case report,we present the case of a patient with portal and hepatic vein cancerous thrombosis who achieved pathologic complete response after conversion therapy.CASE SUMMARY In our center,a patient with giant HCC combined with portal vein tumor thrombus and hepatic vein tumor thrombus was treated with transcatheter arterial chemoembolization(TACE),radiotherapy,targeted therapy and immunotherapy,and was continuously given icaritin soft capsules for oral regulation.After 7 months of conversion therapy,the patient's tumor shrank and the tumor thrombus subsided significantly.The pathology of surgical resection was in complete remission,and there was no progression in the postoperative follow-up for 7 months,which provided a basis for the future strategy of combined conversion therapy.CONCLUSION In this case,atezolizumab,bevacizumab,icaritin soft capsules combined with radiotherapy and TACE had a good effect.For patients with hepatocellular carcinoma combined with hepatic vein/inferior vena cava tumor thrombus,adopting a high-intensity,multimodal proactive strategy under the guidance of multidisciplinary team(MDT)is an important attempt to break through the current treatment dilemma.

Comprehensive review of hepatocellular carcinoma with portal vein tumor thrombus:State of art and future perspectives

Background:Despite advances in the diagnosis of patients with hepatocellular carcinoma(HCC),70%-80%of patients are diagnosed with advanced stage disease.Portal vein tumor thrombus(PVTT)is among the most ominous signs of advanced stage disease and has been associated with poor survival if untreated.Data sources:A systematic search of MEDLINE(PubMed),Embase,Cochrane Library and Database for Systematic Reviews(CDSR),Google Scholar,and National Institute for Health and Clinical Excellence(NICE)databases until December 2022 was conducted using free text and MeSH terms:hepatocellular carcinoma,portal vein tumor thrombus,portal vein thrombosis,vascular invasion,liver and/or hepatic resection,liver transplantation,and systematic review.Results:Centers of surgical excellence have reported promising results related to the individualized surgical management of portal thrombus versus arterial chemoembolization or systemic chemotherapy.Critical elements to the individualized surgical management of HCC and portal thrombus include precise classification of the portal vein tumor thrombus,accurate identification of the subgroups of patients who may benefit from resection,as well as meticulous surgical technique.This review addressed five specific areas:(a)formation of PVTT;(b)classifications of PVTT;(c)controversies related to clinical guidelines;(d)surgical treatments versus non-surgical approaches;and(e)characterization of surgical techniques correlated with classifications of PVTT.Conclusions:Current evidence from Chinese and Japanese high-volume centers demonstrated that patients with HCC and associated PVTT can be managed with surgical resection with acceptable results.

Transjugular intrahepatic portosystemic shunt for esophagogastric variceal bleeding in patients with hepatocellular carcinoma and portal vein tumor thrombus

BACKGROUND Whether hepatocellular carcinoma(HCC)with portal vein tumor thrombus(PVTT)and acute esophagogastric variceal bleeding(EGVB)can improve the success rate of endoscopic hemostasis and overall survival(OS)from transjugular intrahepatic portosystemic shunt(TIPS)remains controversial.AIM To compare the clinical outcomes between TIPS and standard treatment for such HCC patients.METHODS This monocenter,retrospective cohort study included patients diagnosed as HCC with PVTT and upper gastrointestinal bleeding.Patients were grouped by the treatment(TIPS or standard conservative treatment).The success rate of en-doscopic hemostasis,OS,rebleeding rates,and main causes of death were ana-lyzed.RESULTS Between July 2015 and September 2021,a total of 77 patients(29 with TIPS and 48 with standard treatment)were included.The success rate of endoscopic hemostasis was 96.6%in the TIPS group and 95.8%in the standard treatment group.All the 29 patients in TIPS group successful underwent TIPS procedure and had a better OS compared with standard treatment within the first 160 days after treatment(68 days vs 43 days,P=0.022),but shorter OS after 160 days(298 days vs 472 days, P = 0.022). Cheng’s Classification of PVTT, total bilirubin and Child-Pugh class wereindependently negative associated with OS (all P < 0.05). The main causes of death were liver failure or hepaticencephalopathy (75.9%) in the TIPS group and rebleeding (68.8%) in the standard treatment.CONCLUSIONTIPS could reduce the risk of early death due to rebleeding and prolong short-term survival in HCC patients withPVTT and acute EGVB, which deserves further investigation.

Upper extremity deep vein thrombosis:An intensivist’s perspective

Upper extremity deep vein thrombosis(UEDVT)is less common than lower extremity DVT but is a cause of significant morbidity and mortality in intensive care unit patients.Increasing cancer incidence,prolonged life expectancy and increasing use of intravascular catheters and devices has led to an increased incidence of UEDVT.It is also associated with high rates of complications like pulmonary embolism,post-thrombotic syndrome and recurrent thrombosis.Clinical prediction scores and D-dimer may not be as useful in identifying UEDVT;hence,a high suspicion index is required for diagnosis.Doppler ultrasound is commonly employed for diagnosis,but other tests like computed tomography and magnetic resonance imaging venography may also be required in some patients.Contrast venography is rarely used in patients with clinical and ultrasound findings discrepancies.Anticoagulant therapy alone is sufficient in most patients,and thrombolysis and surgical decompression is seldom indicated.The outcome depends on the cause and underlying comorbidities.

Inhibiting MMP13 Attenuates Deep Vein Thrombosis in a Mouse Model by Reducing the Expression of Pdpn

Objective:Matrix metalloproteinase 13(MMP13)is an extracellular matrix protease that affects the progression of atherosclerotic plaques and arterial thrombi by degrading collagens,modifying protein structures and regulating inflammatory responses,but its role in deep vein thrombosis(DVT)has not been determined.The purpose of this study was to investigate the potential effects of MMP13 and MMP13-related genes on the formation of DVT.Methods:We altered the expression level of MMP13 in vivo and conducted a transcriptome study to examine the expression and relationship between MMP13 and MMP13-related genes in a mouse model of DVT.After screening genes possibly related to MMP13 in DVT mice,the expression levels of candidate genes in human umbilical vein endothelial cells(HUVECs)and the venous wall were evaluated.The effect of MMP13 on platelet aggregation in HUVECs was investigated in vitro.Results:Among the differentially expressed genes,interleukin 1 beta,podoplanin(Pdpn),and factor VIII von Willebrand factor(F8VWF)were selected for analysis in mice.When MMP13 was inhibited,the expression level of PDPN decreased significantly in vitro.In HUVECs,overexpression of MMP13 led to an increase in the expression level of PDPN and induced platelet aggregation,while transfection of PDPN-siRNA weakened the ability of MMP13 to increase platelet aggregation.Conclusions:Inhibiting the expression of MMP13 could reduce the burden of DVT in mice.The mechanism involves downregulating the expression of Pdpn through MMP13,which could provide a novel gene target for DVT diagnosis and treatment.

Prevention and management of postoperative deep vein thrombosis in lower extremities of patients with gastrointestinal tumor

BACKGROUND Deep vein thrombosis(DVT)is a significant postoperative concern,particularly in patients undergoing surgery for gastrointestinal(GI)cancers.These patients often present multiple risk factors,including advanced age and elevated body mass index(BMI),which can increase the likelihood of thromboembolic events.Effec-tive prophylaxis is crucial in this high-risk population to minimize complications such as DVT and pulmonary embolism(PE).This study investigates a compre-hensive DVT prevention protocol,combining mechanical and pharmacological strategies alongside early mobilization,to evaluate its effectiveness and safety in reducing postoperative thrombosis rates among GI cancer surgery patients.AIM To evaluate the effectiveness and safety of postoperative DVT prevention strate-gies in patients with GI cancer.METHODS A prospective cohort study was conducted involving 100 patients who underwent surgery for GI tumors between January and December 2022.All patients received a standardized DVT prevention protocol,which included risk assessment,mecha-nical prophylaxis,pharmacological prophylaxis,and early mobilization.The primary endpoint was the incidence of DVT within 30 days postoperatively.Se-condary outcomes included the occurrence of PE,bleeding complications,and adherence to the protocol.RESULTS The overall incidence of DVT was 7%(7/100 patients).One patient(1%)deve-loped PE.The adherence rate to the prevention protocol was 92%.Bleeding complications were observed in 3%of patients.Significant risk factors for DVT development included advanced age[odds ratio(OR):1.05;95%confidence interval(95%CI):1.01-1.09],higher BMI(OR:1.11;95%CI:1.03-1.19),and longer operative time(OR:1.007;95%CI:1.001-1.013).CONCLUSION Implementing a comprehensive DVT prevention and management protocol for patients undergoing GI tumor surgery resulted in a lower incidence.Strict adherence and individualized risk assessment are crucial for optimizing outcomes.

Malnutrition Assessed Using the Geriatric Nutritional Risk Index Is Associated with Preoperative Incidence of Deep Vein Thrombosis in Japanese Patients Undergoing Total Knee Arthroplasty

Purpose: Few studies have evaluated the association between malnutrition and the risk of preoperative deep vein thrombosis (DVT) in patients undergoing primary total joint arthroplasty. This study aimed to investigate the prevalence of preoperative DVT in Japanese patients undergoing total knee arthroplasty (TKA) and the importance of malnutrition in the risk of preoperative DVT. Methods: We retrospectively analyzed 394 patients admitted for primary TKA at our institution between January 2019 and December 2023. All patients scheduled for TKA at our institution had serum D-dimer levels measured preoperatively. Lower-limb ultrasonography was examined to confirm the presence of DVT in patients with D-dimer levels ≥ 1.0 µg/mL or who were considered to be at high risk of DVT by the treating physician. Based on the results of lower-limb ultrasonography, all patients were divided into the non-DVT and DVT groups. The incidence of and risk factors for preoperative DVT were investigated, as well as the correlation of DVT with the patient’s nutritional parameters. We used two representative tools for nutritional assessment: the Geriatric Nutritional Risk Index (GNRI) and Controlling Nutritional Status Score. Results: The mean age was 77.8 ± 6.9 years. Preoperative DVT was diagnosed in 57 of the 394 (14.5%) patients. Multivariate logistic regression analysis showed that advanced age and malnutrition status, assessed using the GNRI, were independent risk factors for preoperative DVT. Conclusion: A high incidence of preoperative DVT was observed in patients who underwent TKA. Malnutrition status, as assessed using the GNRI, increased the risk of preoperative DVT. Our findings suggest that clinicians should consider these factors when tailoring preventive strategies to mitigate DVT risk in patients undergoing TKA.

Diagnostic Value of the Padua Score Combined with Thrombotic Biomarker Tissue Plasminogen Activator Inhibitor-1 (tPAI-1) Detection for the Risk of Deep Vein Thrombosis in Patients with Pulmonary Heart Disease

This study explores the diagnostic value of combining the Padua score with the thrombotic biomarker tissue plasminogen activator inhibitor-1(tPAI-1)for assessing the risk of deep vein thrombosis(DVT)in patients with pulmonary heart disease.These patients often exhibit symptoms similar to venous thrombosis,such as dyspnea and bilateral lower limb swelling,complicating differential diagnosis.The Padua Prediction Score assesses the risk of venous thromboembolism(VTE)in hospitalized patients,while tPAI-1,a key fibrinolytic system inhibitor,indicates a hypercoagulable state.Clinical data from hospitalized patients with cor pulmonale were retrospectively analyzed.ROC curves compared the diagnostic value of the Padua score,tPAI-1 levels,and their combined model for predicting DVT risk.Results showed that tPAI-1 levels were significantly higher in DVT patients compared to non-DVT patients.The Padua score demonstrated a sensitivity of 82.61%and a specificity of 55.26%at a cutoff value of 3.The combined model had a significantly higher AUC than the Padua score alone,indicating better discriminatory ability in diagnosing DVT risk.The combination of the Padua score and tPAI-1 detection significantly improves the accuracy of diagnosing DVT risk in patients with pulmonary heart disease,reducing missed and incorrect diagnoses.This study provides a comprehensive assessment tool for clinicians,enhancing the diagnosis and treatment of patients with cor pulmonale complicated by DVT.Future research should validate these findings in larger samples and explore additional thrombotic biomarkers to optimize the predictive model.

Analysis of risk factors for postoperative deep vein thrombosis after craniotomy and nomogram model construction

BACKGROUND Deep vein thrombosis(DVT)of the lower extremity is one of the most common postoperative complications,especially after craniocerebral surgery.DVT may lead to pulmonary embolism,which has a devastating impact on patient prognosis.This study aimed to investigate the incidence and risk factors of DVT in the lower limbs following craniocerebral surgery.AIM To identify independent risk factors for the development of postoperative DVT and to develop an effective risk prediction model.METHODS The demographic and clinical data of 283 patients who underwent craniocerebral surgery between December 2021 and December 2022 were retrospectively analyzed.The independent risk factors for lower extremity DVT were identified by univariate and multivariate analyses.A nomogram was created to predict the likelihood of lower extremity DVT in patients who had undergone craniocerebral surgery.The efficacy of the prediction model was determined by receiver operating characteristic curve using the probability of lower extremity DVT for each sample.RESULTS Among all patients included in the analysis,47.7%developed lower extremity DVT following craniocerebral surgery.The risk of postoperative DVT was higher in those with a longer operative time,and patients with intraoperative intermittent pneumatic compression were less likely to develop postoperative DVT.CONCLUSION The incidence of lower extremity DVT following craniocerebral surgery is significant,highlighting the importance of identifying independent risk factors.Interventions such as the use of intermittent pneumatic compression during surgery may prevent the formation of postoperative DVT.

Outcome of Patients with Lower Limbs Deep Vein Thrombosis at the University Hospital of Brazzaville (The Republic of the Congo)

The aim of this study was to describe the characteristics of patients with deep vein thrombosis (DVT) of the pelvic limbs at the time of diagnosis, and their course after hospitalization, in order to improve the management of DVT in our context. This was a descriptive longitudinal study, based on cases of deep vein thrombosis recorded between 1 January 2015 and 30 September 2018, in the cardiology and internal medicine department of the Brazzaville University Hospital Centre. During the study period, 4678 patients were hospitalized, including 52 with DVT. Thirty-three were reassessed. The frequency of DVT was 1.1% and the average hospitalization rate was 13.9 cases/year. The 33 patients were divided into 20 women and 13 men (sex ratio: 0.65). The mean age of the patients was 51.4 ± 17.8 years (extremes: 16 and 85 years). The main aetiological factors were cancer (19.1%), sickle cell disease (3%) and HIV immunosuppression (3%). The predominant risk factors were: prolonged immobilization (42.9%), pregnancy, long travel and obesity in the same number of cases (n = 3, i.e. 14.2%). The DVT involved the left pelvic limb in 75.8% of cases. Anticoagulants were administered in all patients, and compression stockings were worn in 97% of cases. The mean time to re-evaluation was 10.9 ± 9.4 months (extremes: three and 35 months). The mean measurements of the limb where the thrombosis had occurred at diagnosis and reassessment showed a significant difference. Venous Doppler showed compressible veins (60.6%), varicosities (36.3%), incompressible veins (30.3%) and thrombus (21.2%). Complications were: post-phlebitic disease (42.4%), death (21.2%), pulmonary embolism (18.2%), recurrence (18.2%). The DVT remains relatively rare, and its conventional therapeutic management is satisfactory. Systematic venous Doppler ultrasound reassessment should enable patients at risk of recurrence to be identified.

Analysis and Literature Review of Deep Vein Thrombosis Related Phlegmasia Cerulea Dolens Diagnosis in Critically Patients

Goal: The purpose of this research is to analyze the clinical characteristics, diagnosis, treatment, and prognosis of critical care patients with phlegmasia cerulea dolens (PCD) caused by deep vein thrombosis. Our goal is to improve both awareness and early diagnosis and treatment of rare clinical diseases. Furthermore, we aim to examine advancements in the diagnosis and treatment of deep vein thrombosis. Method: The clinical information of patients with PCD received in 2022 was subject to retrospective analysis. The author conducted a search of 191 publications with a focus on PCD, from January 2010 to July 2022, from databases such as the China National Knowledge Infrastructure (CNKI), Wanfang Data, PubMed, etc. The results were used to summarize the examinations, diagnostic criteria, and treatment progress of PCD patients. Additionally, the author conducted another search using keywords such as “Venous thromboembolism” and “Anticoagulant drugs” to summarize research progress in anticoagulant drugs and the treatment of VTE. The search was limited to relevant. Outcome: Six months prior to admission, the patient, a 68-year-old female, developed sunken edema and cyanosis in both her lower extremities and was diagnosed with lower extremity deep vein thrombosis complicated by PCD, lower extremity ischemic necrosis, and septicemia. This diagnosis was made using a combination of CT and lower extremity vascular ultrasound-related examinations, as well as a significantly elevated D-dimer value. Despite active treatment and aggressive measures, such as anti-infection, organ function maintenance, anticoagulation, and improvement of microcirculatory disorders, the patient’s family declined corresponding surgical treatment and interventional surgery for the lower extremity due to objective factors, and the patient ultimately succumbed to her illness. The clinical characteristics of this patient were similar to those of the 14 cases of PCD reported by Xie Fei et al. in 2022. Conclusion: For patients with malignancy, it is crucial to start anticoagulation and physical prevention of DVT early on. Patients with DVT complicated by PCD have a variety of surgical options available to them, including surgical embolization or PMT (percutaneous mechanical thrombus ablation), CDT (catheter contact thrombolysis), and fascial ventriculotomy decompression [1]. Additionally, it may be necessary to place an inferior venous filter. Although the incidence of this disease is low accounting for approximately 5% of all patients with iliofemoral deep vein thrombosis [2], the prognosis is poor, as the mortality rate can reach up to 40% - 60% due to venous gangrene, with an overall mortality rate of 20% - 40% [3]. To increase the survival rate, it is important to diagnose and treat this disease as early as possible.

Highly metabolic thrombus of the portal vein:^(18)F fluorodeoxyglucose positron emission tomography/computer tomography demonstration and clinical significance in hepatocellular carcinoma

AIM： To assess the ability of ^18F-fluorodeoxyglucose positron emission tomography/computer tomography （^18F-FDG PET/CT） to differentiate between benign and malignant portal vein thrombosis in hepatocellular carcinoma （HCC） patients.METHODS： Five consecutive patients who had HBV cirrhosis, biopsy-proven HCC, and thrombosis of the main portal vein and/or left/right portal vein on ultrasound （US）, computer tomography （CT） or magnetic resonance imaging （MRI） were studied with ^18F-FDG PET/CT. The presence or absence of a highly metabolic thrombus on ^18F-FDG PET/CT was considered diagnostic for malignant or benign portal vein thrombosis, respectively. All patients were followed-up monthly with US, CT or MRI. Shrinkage of the thrombus or recanalization of the vessels on US, CT or MRI during follow-up was considered to be definitive evidence of the benign nature of the thrombosis, whereas enlargement of the thrombus, disruption of the vessel wall, and parenchymal infiltration over follow-up were considered to be consistent with malignancy. ^18SF-FDG PET/CT, and US, CT or MRI results were compared.RESULTS： Follow-up （1 to 10 mo） showed signs of malignant thrombosis in 4 of the 5 patients. US, CT or MRI produced a true-positive result for malignancy in 4 of the patients, and a false-positive result in 1. ^18F-FDG PET/CT showed a highly metabolic thrombus in 4 of the 5 patients. ^18F-FDG PET/CT achieved a true-positive result in all 4 of these patients, and a true-negative result in the other patient. No false-positive result was observed using ^18F-FDG PET/CT.CONCLUSION： ^18F-FDG PET/CT may be helpful in discriminating between benign and malignant portal vein thrombi. Patients may benefit from ^18F-FDG PET/CT when portal vein thrombi can not be diagnosed exactly by US, CT or MRI.

Multi-slice Spiral CT Three-dimensional Portography in Portal Vein Tumor Thrombus of Hepatic Cancer

Objective: To study the clinical significance of multi-slice spiral CT 3-dimensional (3D) portography in portal vein tumor thrombosis of hepatocellular cacinoma.Methods: 57 cases undergoing 3D portography were collected, of which 6 cases were normal, 5 cases were subjected to cirrhosis and hypertension of portal vein, 42 cases had portal tumor thrombus of hepatic cancer, and the remaining 4 cases showed lymph node enlargment in hilar of liver. All data of the patients came from conventional multi-slice spiral CT double phase of liver. Contrast media was 1.5–2 ml/kg with the injection rate being 2.5–3 ml/s. Axis and 3D portography was analyzed and compared in 42 cases of portal tumor thrombus of hepatic cancer.Results: According to portal tumor thrombus position, 42 cases were fallen into three categories: left (13 cases), right (20 cases), main (9 cases) of potal vein. There was no difference between axis and 3D portography in displaying portal tumor thrombus of hepatic cancer (P>0.05), but 3D portography showing collateral branches was better than axis portography after main portal vein thrombus.Conclusion: Multi-slice spiral CT 3D portography can display the position and types of portal tumor thrombus of hepatic cancer. 3D combined with axis portography can better evaluate the portal tumor thrombus of hepatic cancer and guide to select the therapies. Key words portal vein - tumor thrombus - multi-slice CT - 3 dimension imaging

A Troika of Tricuspid Valve Thrombus, Bilateral Upper Extremity Deep Venous Thrombosis and Pulmonary Embolism

Background: Tricuspid valve thrombus with concomitant bilateral pulmonary embolism (PE) and right heart strain poses a significant risk of hemodynamic instability and increased mortality. Case Report: We report the unique case of a female who presented with dyspnea and tachycardia, and was subsequently found to have a structure attached to the tricuspid valve. Concomitantly, she also had bilateral upper extremity deep venous thrombosis (UEDVT) and bilateral sub-massive PE. Thorough clinical assessment, and diagnostic and risk stratification tools were applied to guide the management and disposition. Tricuspid valve thrombus resolved after unfractionated heparin therapy followed by oral anticoagulation as seen on repeat transthoracic echocardiography. We think the readership will benefit from our experience of managing an uncommon and critical clinical presentation of tricuspid valve thrombus in the setting of extensive venous thromboembolism. Conclusion: Careful clinical assessment, risk stratification tools, and close monitoring are needed to guide the management of tricuspid valve thrombus with concomitant bilateral PE and UEDVT.

Better surgical treatment method for hepatocellular carcinoma with portal vein tumor thrombus

Hepatocellular carcinoma(HCC) with portal vein tumor thrombus(PVTT) is a disease that is not uncommon, but the treatments vary drastically between Eastern and Western countries. In Europe and America, the first line of treatment is systemic therapy such as sorafenib and the surgical treatment is not a recommend option. While an increasing number of studies from China and Japan have suggested that surgical treatment results in better outcomes when compared to transcatheter arterial chemoembolization(TACE), sorafenib, or other nonsurgical treatments, and two classification systems, Japanese Vp classification and Chinese Cheng's classification, were very useful to guide the surgical treatment. We have also found that surgical treatment may be more effective, as we have performed surgical treatment for HCC-PVTT patients over a period of approximately 15 years and achieved good results with the longest surviving time being 13 years and onward. In this study, we review the efficacy and principles of current surgical treatments and introduce our new, more effective surgical technique named "thrombectomy first", which means the tumor thrombus in the main portal vein, the bifurcation or the contralateral portal vein should be removed prior to liver resection. Thus, compression and crushing of PVTT during the operation could be avoided and new intrahepatic metastases caused by tumor thrombus to the remnant liver minimized. The new technique is even beneficial to the prognosis of Cheng's classification Types Ⅲ and Ⅳ PVTT. The vital tips and tricks for the surgical approach are described.

Comprehensive treatments for hepatocellular carcinoma with tumor thrombus in major portal vein

AIM: To evaluate the efficacy of transcatheter arterial chemoembolisation (TACE) compared with surgical intervention and sorafenib for treatment of hepatocellular carcinoma (HCC) in patients with tumor thrombus extending to the main portal vein.METHODS: From 2009 to 2013, a total of 418 HCC patients with tumor thrombus extending to the main portal vein were enrolled in this study and divided into four groups. These groups underwent different treatments as follows: TACE (n = 307), surgical intervention (n = 54), sorafenib (n = 15) and palliative treatment (n = 42). Overall survival rates were determined by Kaplan-Meier method, and differences between the groups were identified through log-rank analysis. Cox&#x02019;s proportional hazard model was used to identify the risk factors for survival.RESULTS: The mean survival periods for patients in the TACE, surgical intervention, sorafenib and palliative treatment groups were 10.39, 4.13, 5.54 and 2.82 mo, respectively. For the TACE group, the 3-, 6-, 12- and 24-mo survival rates were 94.1%, 85.9%, 51.5% and 0.0%, respectively. The corresponding rates were 60.3%, 22.2%, 0.0% and 0.0% for the surgical intervention group and 50.9%, 29.5%, 0.0% and 0.0% for the sorafenib group. Evidently, the results in the TACE group were significantly higher than those in the other groups (P &#x0003c; 0.0001). Furthermore, no significant difference among survival rates was observed between TACE with/without sorafenib (10.22 mo vs 10.52 mo, P = 0.615). No significant difference in survival rates was also found among the surgical intervention, sorafenib and palliative treatment groups (P &#x0003e; 0.05). These values significantly increased after TACE with/without sorafenib compared with other treatments (P &#x0003c; 0.05).CONCLUSION: For HCC patients with tumor thrombus extending to the main portal vein, TACE can yield a higher survival rate than surgical intervention or sorafenib treatment.

Treatment of hepatocellular carcinoma accompanied by portal vein tumor thrombus

The prognosis of patients with hepatocellular cardnorna （HCC） accompanied by portal vein tumor thrombus （PVTT） is generally poor if leo untreated： a median survival time of 2.7-4.0 mo has been reported. Furthermore, while transcatheter arterial chemoembolization （TACE） has been shown to be safe in selected patients, the median survival time with this treatment is still only 3.8-9.5 mo. Systemic single-agent chemotherapy for HCC with PVTT has failed to improve the prognosis, and the response rates have been less than 20%. While regional chemotherapy with low-dose cisplatin and 5-fluorouracil or interferon and 5-fluorouracil via hepatic arterial infusion has increased the response rate, the median survival time has not exceeded 12 （range 4.5-11.8） mo. Combined treatment consisting of radiation for PVTT and TACE for liver tumor has achieved a high response rate, but the median survival rates have still been only 3.8-10.7 mo. With hepatic resection as monotherapy, the 5-year survival rate and median survival time were reportedly 4%-28.5% and 6-14 mo. The most promising results were reported for combined treatments consisting of hepatectomy and TACE, chemotherapy, or internal radiation. The reported 5-year survival rates and median survival times were 42% and 31 mo for TACE followed by hepatectomy; 36.3% and 22.1 mo for hepatectomy followed by hepatic arterial infusion chemotherapy; and 56% for chemotherapy or internal radiation followed by hepatectomy.

Application of cystoscope in surgical treatment of hepatocellular carcinoma with portal vein tumor thrombus

Development of portal vein tumor thrombus deteriorates the prognosis of hepatocellular carcinoma, while surgical treatment can offer a promising prognosis for selected patients. However, the possibility of residual lesions in portal vein after conventional thrombectomy is a main risk factor leading to postoperative recurrence. Therefore, ensuring the complete removal of tumor thrombus during operation is critical to improve prognosis. For the first time, we report here one case of hepatocellular carcinoma with portal vein tumor thrombus in which cystoscope was successfully applied as a substitute of intravascular endoscope to visualize the cavity of the portal vein. The patient was a 61-year-old man with a 7-cm tumor in the right lobe of the liver, with tumor thrombus invading the right branch and adjacent to the conjunction of the portal vein. After removal of the tumor, the Olympus CYF-VA2 cystoscope was used to check the portal vein from the opening stump of the right branch of the portal vein. In this case, residual thrombus tissue was found near the opening stump and the conjunction of the portal vein. The residual lesion was carefully retrieved from the stump after retraction of the cystoscope. The procedure was repeated until no residual lesion was found. The whole duration time of thrombectomy was 22.5(15 + 7.5) min. The patient was free from recurrence at 8 months after the procedure. Our work indicated that the cystoscope is a suitable substitute, with a proper size and function to check the portal vein system and ensure the curability of thrombectomy. Although welldesigned clinic trails are still needed, this procedure may further improve the postoperative prognosis of hepatocellular carcinoma with portal vein tumor thrombus.

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.