Assessing outcomes of patients with HCC who undergo portal vein embolization

Portal vein embolization (PVE) is a technique used to redirect portal vein flow to induce growth of healthy liver in a patient who has primary or metastatic hepatocellular carcinoma (HCC). An initially insufficient future liver remnant (FLR) can preclude major liver resection. PVE can potentially increase opportunities for surgery in patients with initially unresectable liver cancer.

Researchers at the Icahn School of Medicine at Mount Sinai in New York City analyzed the outcomes of all HCC patients who underwent preoperative PVE that would allow surgical treatment with curative intent, reporting their findings in July issue of the Journal of Vascular and Interventional Radiology.

Eighty-two patients underwent PVE. The patients ranged from 57 to 68 years old and were predominantly male (83%), with hepatitis B infection as the main cause for underlying liver disease. Thirty-three patients had undergone transarterial chemoembolization before PVE, and two patients had other procedures.

Lead author Josep Marti, MD, PhD, and colleagues said that all patients had Child-Pugh A status and/or minimal clinical evidence of portal hypertension along with resectable HCC. However, a ratio of FLR to total liver volume equal to or greater than 40% after complete resection of the tumor was doubtful. For this reason, the patients underwent PVE with the aim to increase an insufficient FLR, with 69 patients ultimately undergoing resection with curative intent.

PVE procedures were performed by board-certified interventional radiologists. Patients had a chest computed tomography (CT) every 90 days following surgery and either CT or magnetic resonance imaging (MRI) of the abdomen for the first two years. Eighteen patients were lost to follow-up.

Patients who had surgical resection had a neoplastic recurrence rate of 30.4% and a median survival of 43 months. Patients who did not undergo surgery had a median survival after PVE of 12 months. The authors wrote that “if a sufficient FLR can be attained, PVE offers a chance for surgical resection with good results in terms of survival and neoplastic recurrence to selected patients with HCC exceeding liver transplantation criteria.”

They said that while concerns exist that PVE can impair the previous abnormal liver function and that already damaged liver tissue may not attain a sufficient FLR, this did not occur with their patient cohort. “In most of the patients of the present series, PVE did not impair liver function and it allowed planning for a safe liver resection with an acceptable complications rate in patients undergoing surgery,” the authors wrote. The authors attributed this in part to frequent imaging surveillance of the FLR to enable patients to have surgical resection as soon as feasible. They acknowledged that PVE can be associated with neoplastic progression, but that the risk can be overcome with close surveillance.

REFERENCE

1. Marti J, Giacca M, Alshebeeb K, et al. Analysis of preoperative portal vein embolization outcomes in patients with hepatocellular carcinoma: A single-center experience. J Vasc Interv Radiol. 2018; 29(7):920-92.