Liver resection for hepatocellular carcinoma associated with portal vein tumor thrombus

We would like to thank to Cheng et al. for their comments on our recently published article, which demonstrated the survival benefit of hepatic resection for hepatocellular carcinoma (HCC) associated with portal vein tumor thrombus (PVTT) through an analysis of the Japanese nationwide survey (1). The authors supported our findings that PVTT is not a contraindication to liver resection. In addition, they summarized the recent advances in the treatment of HCC with PVTT.

PVTT is considered to be a contraindication to liver resection in Western guidelines and the only proposed treatment option is palliative sorafenib therapy (2). For decades, Eastern centers have repeatedly reported a survival benefit of liver resection in patients with PVTT (3-5). In addition, several recent Western reports have also demonstrated a preferable prognosis after liver resection for HCC patients with PVTT (6,7). Taken together with our study, the literature shows that PVTT should not be considered a contraindication to curative resection especially for PVTT limited to the first-order branch.

However, whether there is a survival benefit of surgical resection for PVTT invading the main trunk or contralateral branch is controversial (1,4). Even after curative resection, patient outcomes for this extremely advanced disease remain dismal, and additional treatment is necessary. According to our data, perioperative transcatheter arterial chemoembolization did not show better survival (1). As mentioned by Cheng et al., perioperative radiotherapy may be a possible treatment modality to improve outcome for PVTT invading the main trunk or contralateral branch. Further prospective study is needed with special consideration of radiological liver damage.

Surgical procedure is another important issue to consider. The superiority of en bloc resection to thrombectomy is still controversial (8,9). If an en bloc resection is technically feasible without additional procedures or damage to non-cancerous parenchyma, it should certainly be considered first. However, in patients with impaired liver function or PVTT invading the main trunk or contralateral branch, an en bloc resection may be difficult due to the risk of postoperative liver failure and additional procedures, such as segmental resection of the portal vein, may be necessary. In these cases, thrombectomy may be an appropriate procedure to avoid fatal postoperative complications, without impairing the oncological outcomes (8).

Although the survival benefit of surgical resection is evident in patients with PVTT, the prognosis is not satisfactory with high rates of recurrence. Future study focusing on adjuvant treatments and surgical techniques is essential to improve the outcome of this advanced disease.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned and reviewed by Editor-in-Chief Eric Y. Chuang (Professor and Director, Graduate Institute of Biomedical Electronics and Bioinformatics, NTU YongLin Biomedical Engineering Center, National Taiwan University, Taipei, Taiwan).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/tcr.2017.05.01). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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