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.

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.

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.

Prostatic small cell carcinoma with resultant tumor thrombus to the right iliac vein

Dear Editor,Prostatic small cell carcinoma(SCC)is a rare,deadly tumor with an overall median survival of fewer than 12 months[[1],[2],[3],[4],[5]].Here we describe a unique case of a patient with prostatic SCC who developed a concurrent tumor thrombus in the right iliac vein.

Analysis of vascular thrombus and clinicopathological factors in prognosis of gastric cancer:A retrospective cohort study

BACKGROUND Gastric cancer(GC)is one of the most common malignant tumors in the world,and its prognosis is closely related to many factors.In recent years,the incidence of vascular thrombosis in patients with GC has gradually attracted increasing attention,and studies have shown that it may have a significant impact on the survival rate and prognosis of patients.However,the specific mechanism underlying the association between vascular thrombosis and the prognosis of patients with GC remains unclear.AIM To analyze the relationships between vascular cancer support and other clinicopathological factors and their influence on the prognosis of patients with GC.METHODS This study retrospectively analyzed the clinicopathological data of 621 patients with GC and divided them into a positive group and a negative group according to the presence or absence of a vascular thrombus.The difference in the 5-year cumulative survival rate between the two groups was compared,and the relationships between vascular cancer thrombus and other clinicopathological factors and their influence on the prognosis of patients with GC were analyzed.RESULTS Among 621 patients with GC,the incidence of vascular thrombi was 31.7%(197 patients).Binary logistic regression analysis revealed that the degree of tumor differentiation,depth of invasion,and extent of lymph node metastasis were independent influencing factors for the occurrence of vascular thrombi in GC patients(P<0.01).The trend of the χ^(2) test showed that the degree of differentiation,depth of invasion,and extent of lymph node metastasis were linearly correlated with the percentage of vascular thrombi in GC patients(P<0.01),and the correlation between lymph node metastasis and vascular thrombi was more significant(r=0.387).Univariate analysis revealed that the 5-year cumulative survival rate of the positive group was significantly lower than that of the negative group(46.7%vs 73.3%,P<0.01).Multivariate analysis revealed that age,tumor diameter,TNM stage,and vascular thrombus were independent risk factors for the prognosis of GC patients(all P<0.05).Further stratified analysis revealed that the 5-year cumulative survival rate of stage Ⅲ GC patients in the thrombolase-positive group was significantly lower than that in the thrombolase-negative group(36.1%vs 51.4%;P<0.05).CONCLUSION Vascular cancer status is an independent risk factor affecting the prognosis of patients with GC.The combination of vascular cancer suppositories and TNM staging can better judge the prognosis of patients with GC and guide more reasonable treatment.

Individualized anti-thrombotic therapy for acute myocardial infarction complicated with left ventricular thrombus: A case report

BACKGROUND Presently,there is no established standard anti-blood clot therapy for patients facing acute myocardial infarction(AMI)complicated by left ventricular thrombus(LVT).While vitamin K antagonists are the preferred choice for oral blood thinning,determining the best course of blood-thinning medication remains challenging.It is unclear if non-vitamin K antagonist oral blood thinners have different effectiveness in treating LVT.This study significantly contributes to the medical community.CASE SUMMARY The blood-thinning treatment of a patient with AMI and LVT was analyzed.Triple blood-thinning therapy included daily enteric-coated aspirin tablets at 0.1 g,daily clopidogrel hydrogen sulfate at 75 mg,and dabigatran etexilate at 110 mg twice daily.After 15 d,the patient’s LVT did not decrease but instead increased.Clinical pharmacists comprehensively analyzed the cases from the perspective of the patient’s disease status and drug interaction.The drug regimen was reformulated for the patient,replacing dabigatran etexilate with warfarin,and was administered for six months.The clinical pharmacist provided the patient with professional and standardized pharmaceutical services.The patient’s condition was discharged after meeting the international normalized ratio value(2-3)criteria.The patient fully complied with the follow-up,and the time in the therapeutic range was 78.57%,with no serious adverse effects during pharmaceutical monitoring.CONCLUSION Warfarin proves to be an effective drug for patients with AMI complicated by LVT,and its blood-thinning course lasts for six months.

Complexity in interpreting cardiac valve-associated thrombus from tumors in Li-Fraumeni syndrome

Li-Fraumeni syndrome(LFS)is a well-defined autosomal dominant predisposition syndrome due to TP53 germline mutation that causes many cancer malig-nancies.This early-onset syndrome poses a state of widespread malignancy.Such an inherited condition possessing defective p53,guardian of the genome,in the germline has the potential to cause multiple cancers by predominantly affecting mesenchyme(connective tissues,blood cells),breast,brain,and adrenal cortex organs.The tumors initially identified in LFS can eventually propagate to cause secondary malignancies.LFS contributes to multiple cancers in individuals with defective p53 inheritance.When suspected to possess any mass,patients with other co-morbidities,in particular those with certain cardiovascular conditions,undergo screening using high-throughput techniques like transthoracic and transesophageal echocardiography or cardiothoracic magnetic resonance imaging to locate and interpret the size of the mass.In LFS cases,it is certain to presume these masses as cancers and plan their management employing invasive surgeries after performing all efficient diagnostic tools.There are only poor predictions to rule out the chances of any other pathology.This criterion emphasizes the necessity to speculate alternative precision diagnostic methods to affirm such new growth or masses encountered in LFS cases.Moreover,it has all the possibilities to ultimately influence surgical procedures that may be invasive or complicate operative prognosis.Hence,it is essential to strategize an ideal protocol to diagnose any new unexplored mass in the LFS community.In this editorial,we discuss the importance of diagnostic approaches on naïve pristine masses in LFS.

Relationship of inflammatory indices with left atrial appendage thrombus or spontaneous echo contrast in patients with atrial fibrillation

BACKGROUND Inflammatory indices derived from complete blood tests have been reported to be associated with poor outcomes in patients with atrial fibrillation(AF).The data about the relationship between inflammatory indices and left atrial appendage thrombus(LAAT)or dense spontaneous echo contrast(SEC)are limited.AIM To explore the value of inflammatory indices for predicting the presence of LAAT or dense SEC in nonvalvular AF patients.METHODS A total of 406 patients with nonvalvular AF who underwent transesophageal echocardiography were included and divided into two groups based on the presence(study group)or absence(control group)of LAAT or dense SEC.Inflammatory indices,including the neutrophil-to-lymphocyte ratio(NLR),platelet–tolymphocyte ratio(PLR),and lymphocyte-to-monocyte ratio(LMR),were calculated from complete blood analysis.The associations of inflammatory indices RESULTS LAAT and dense SEC were detected in 11(2.7%)and 42(10.3%)patients,respectively.The PLR only showed an association with LAAT/dense SEC in the univariate model.Elevated NLR(odds ratio[OR]=1.48,95%confidence interval[CI]:1.11-1.98,P=0.007)and reduced LMR(OR=0.59,95%CI:0.41-0.83,P=0.003)were found to be independent risk factors for the presence of LAAT/dense SEC.The areas under the NLR and LMR curves for predicting LAAT/dense SEC were 0.73(95%CI:0.66-0.80,P<0.001)and 0.73(95%CI:0.65-0.81,P<0.001),respectively,while the cutoff values were 2.8(sensitivity:69.8%;specificity:64.0%)and 2.4(sensitivity:71.7%;specificity:60.6%),respectively.CONCLUSION Increased NLR and decreased LMR may predict LAAT/dense SEC in patients with nonvalvular AF.

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.

Surgical treatment of left-sided renal carcinoma with grade II inferior vena cava tumour thrombus: a report and review of the literature

The surgical removal of renal cancer,along with the thrombectomy of the inferior vena cava tumour thrombus,represents a remarkable milestone in urological surgery.This procedure is not only technically demanding but also requires a high level of surgical expertise.Managing renal cancer combined with a vena cava tumour thrombus poses significant challenges,especially when dealing with combined grade Ⅱ-Ⅳ inferior vena cava tumour thrombus.The complexity of these cases is further exacerbated by the delicate anatomical structures involved and the need to preserve critical vessels while effectively removing the tumour.The Upper Urethral Tumour Treatment Centre of Weifang People's Hospital successfully treated a challenging case of left renal tumour combined with grade II inferior vena cava tumour thrombus.The surgical team,led by experienced urological surgeons,meticulously planned and executed the procedure,ensuring minimal trauma to the patient and complete removal of the tumour.This achievement not only demonstrates the hospital's commitment to providing state-of-the-art surgical care but also highlights the importance of continued research and training in urological oncology.The successful outcome of this case is a testament to the expertise and dedication of the medical team and offers hope to patients facing similar complex surgical challenges.

急性心肌梗死高血栓负荷影响因素分析及应用ThrombusterⅡ血栓抽吸导管改善心肌灌注观察

目的 分析急性ST段抬高型心肌梗死（STEMI）高血栓负荷的影响因素及应用ThrombusterⅡ血栓抽吸导管对心肌灌注的影响.方法 选择首次因STEMI行急诊PCI患者110例,据血栓积分分为高血栓负荷组和低血栓负荷组,再依据术中选择分为血栓抽吸组及标准PCI组,分别比较两组患者临床基线情况、冠状动脉造影、心肌灌注及心电图ST段回落情况.以血栓积分≥2分为因变量采用Logistic回归模型分析高血栓负荷的独立危险因素.结果 同低血栓负荷组相比,高血栓负荷组吸烟者比例较高（59.4％比44.9％,P＜0.05）,症状开始至再灌注时间较长[（7.9±4.7）h比（5.4±3.5）h,P＜0.05],术中应用GPⅡb/Ⅲa比例高（93.8％比80.1％,P＜0.05）.与标准PCI组相比较,血栓抽吸组TMPG达3级者较多（P＜0.05）,TMPG≤2级者比例更低,CTFC帧数较少（P＞0.05）.多因素分析示,年龄＞75岁、吸烟、症状开始至再灌注时间＞6 h是STEMI患者高血栓负荷的独立危险因素.结论年龄＞75岁、吸烟、症状开始至再灌注时间＞6 h是STEMI患者高血栓负荷的独立危险因素.应用ThrombusterⅡ血栓抽吸导管可减少STEMI患者PCI后无复流及慢血流的发生,改善心肌组织灌注.

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

急性STEMI应用ThrombusterⅡ抽吸导管联合冠状动脉内注射替罗非班的疗效观察

目的 观察对急性ST段抬高型心肌梗死（STEMI）患者行直接经皮冠状动脉介入（PCI）手术中应用血栓抽吸导管联合冠状动脉内注射替罗非班的疗效.方法 选择因STEMI行直接PCI并于术中应用Thrombuster Ⅱ血栓抽吸导管联合冠状动脉内推注替罗非班的患者65例作为治疗组,以基础临床资料和冠状动脉影像特征相似并单纯行直接PCI的60例患者作为对照组,观察临床疗效.结果 治疗组在TIMI 3级血流、校正TIMI帧数、术后2 h ST段回落程度、酶峰值和峰值时间以及梗死相关血管（IRA）无复流发生率均优于对照组（P＜0.05或 0.01）.治疗组术后3个月左心室射血分数（LVEF）、左心室舒张末径（LVEDd）、左心室收缩末径（LVESd）及主要不良心血管事件（MACE,包括死亡、再梗死、再次靶血管重建）的发生率少于对照组（P＜0.05）,而术后1周时两组差异无统计学意义（P ＞0.05）.结论 STEMI患者行直接PCI过程中应用血栓抽吸导管联合冠状动脉内推注替罗非班可减少无复流的发生,改善心肌再灌注水平及左心室功能.

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.

Diagnosis of bile duct hepatocellular carcinoma thrombus without obvious intrahepatic mass

AIM:To study the diagnosis of hepatocellular carcinoma(HCC)presenting as bile duct tumor thrombus with no detectable intrahepatic mass.METHODS:Six patients with pathologically proven bile duct HCC thrombi but no intrahepatic mass demonstrated on the preoperative imaging or palpated intrahepatic mass during operative exploration,were collected.Their clinical and imaging data were retrospectively analyzed.The major findings or signs on comprehensive imaging were correlated with the surgical and pathologic findings.RESULTS:Jaundice was the major clinical symptom of the patients.The elevated serum total bilirubin,direct bilirubin and alanine aminotransferase levels were in concordance with obstructive jaundice and the underlying liver disease.Of the 6 patients showing evidence of viral hepatitis,5 were positive for serum alpha fetoprotein and carbohydrate antigen 19-9,and 1 was positive for serum carcinoembryonic antigen.No patient was correctly diagnosed by ultrasound.The main features of patients on comprehensive imaging were filling defects with cup-shaped ends of the bile duct,with large filling defects presenting as casting moulds in the expanded bile duct,hypervascular intraluminal nodules,debris or blood clots in the bile duct.No obvious circular thickening of the bile duct walls was observed.CONCLUSION:Even with no detectable intrahepatic tumor,bile duct HCC thrombus should be considered in patients predisposed to HCC,and some imaging signs are indicative of its diagnosis.

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.

Surgical treatment of hepatocellular carcinoma with inferior vena cava tumor thrombus: a new classification for surgical guidance

BACKGROUND: Hepatic resection is the main treatment modality for hepatic tumors. Advances in diagnostic technique, preoperative preparation, surgical technique, and postoperative management increased the success rate. The present study aimed to evaluate hepatectomy and resection of inferior vena cava tumor thrombus (IVCTT) in patients with hepatocellular carcinoma, and the relationship between IVCTT classification and selection of surgical technique. METHODS: We retrospectively reviewed 13 patients with hepatocellular carcinoma who had undergone hepatectomy with IVCTT resection between May 1997 and August 2009. Age, gender, diagnosis, findings of physical examination, results of preoperative laboratory investigations, radiological examination, criteria for resection, postoperative pathological results, incisions, operative technique, intraoperative transfusion, drains, and intraoperative and postoperative complications were evaluated for all patients. RESULTS: Type Ⅰ IVCTT (10 patients) was posterior to the liver and below the diaphragm; type Ⅱ IVCTT (2 patients) was above the diaphragm but still outside the atrium; and type Ⅲ IVCTT (1 patient) was above the diaphragm and in the right atrium. Type Ⅰ was treated by radical hepatectomy and removal of IVCTT with total hepatic vascular exclusion. Type Ⅱ was treated by radical hepatectomy and removal of IVCTT by incision of the diaphragm. Type Ⅲ was treated by hepatectomy and resection of the thrombus from the right atrium under cardiopulmonary bypass. There were no surgical complications and one patient has been survived for 4 years with cancer-free status. The median survival time was 18.2 months, and the 1-and 2-year survival rates were 53.8% and 15.4%, respectively. CONCLUSION: Surgical treatment is safe and feasible for treatment of IVCTT in patients with hepatocellular carcinoma, and surgical resectability can be judged according to the classification of tumor thrombus.

Prognosis of hepatocellular carcinoma with bile duct tumor thrombus after R0 resection:a matched study

BACKGROUND： Hepatocellular carcinoma （HCC） with bile duct tumor thrombus （BDTT） is rare. The present study aimed to determine post-surgical prognoses in HCC patients with BDTT, as outcomes are currently unclear. METHODS： We compared the prognoses of 110 HCC patients without BDTT （group A） to 22 cases with BDTT （group B）. The two groups were matched in age, gender, tumor etiology, size, number, portal vascular invasion, and TNM stage. Additionally, 28 HCC patients with BDTT were analyzed to identify prognostic risk factors. RESULTS： The 1-, 3-, and 5-year overall survival rates were 90.9%, 66.9%, and 55.9% for group A and 81.8%, 50.0%, and 37.5% for group B, respectively. The median survival time in groups A and B was 68.8 and 31.4 months, respectively （P=0.043）. The patients for group B showed higher levels of serum total bilirubin, alanine aminotransferase and gammaglutamyl transferase, a larger hepatectomy range, and a higher rate of anatomical resection. In subgroup analyses of patients with BDTT who underwent R0 resection, TNM stage Ⅲ-Ⅳ was an independent risk factor for overall survival; these patients had worse prognoses than those with TNM stage Ⅰ-Ⅱ after R0 resection （hazard ratio=6.056, P=0.014）. Besides, univariate and multivariate analyses revealed that non-R0 resection and TNM stage Ⅲ-Ⅳ were independent risk factors for both disease-free survival and overall survival of 28 HCC patients with BDTT. The median overall survival time of patients with BDTT who underwent R0 resection was longer than that of patients who did not undergo R0 resection （31.0 vs 4.0 months, P=0.007）.CONCLUSIONS： R0 resection prolonged survival time in HCC patients with BDTT, although prognosis remains poor. For such patients, R0 resection is an important treatment that determines long-term survival.

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.