DOI: 10.1097/SLA.0b013e3181cb8940

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Issn Print: 0003-4932

Publication Date: 2010/02/01


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Preoperative Transarterial Chemoembolization for Resectable Large Hepatocellular Carcinoma

Wan Yee Lau; Eric C. H. Lai; Meng-chao Wu; Wei-ping Zhou

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There are 3 published randomized controlled trials in the medical literature, including our current study, on neoadjuvant transarterial chemoembolization (TACE) before “curative” partial hepatectomy for hepatocellular carcinoma (HCC).1–3 Both Wu et al and Yamasaki et al used TACE with doxorubicin. Our study used TACE with an emulsion of 5-fluorouracil, mitomycin C, cisplatin, and lipiodol.2,3 Wu et al randomized 52 patients with large but resectable HCC (>10 cm), and they showed a decreased overall survival and a higher extrahepatic recurrence rate (57% vs. 23%) when compared with the control group.2 Yamasaki et al randomized 97 patients with small HCC (from 2 to 5 cm), and they showed that neoadjuvant therapy had no impact on disease-free and overall survivals.3 Our study randomized 108 patients with resectable HCC (≥5 cm) and we also showed that neoadjuvant therapy had no impact on disease-free and overall survivals.1 There is no evidence to suggest efficacy of neoadjuvant therapy. Arguments against the use of neoadjuvant TACE include: (1) the associated complications of preoperative TACE, such as perihepatic adhesions, which renders liver resection more difficult; (2) the increased risk of liver failure; (3) a delay in definitive surgery, which can be detrimental if the tumor fails to respond to the therapy and continues to grow, eventually becoming unresectable; (4) an increased difficulty in future transarterial treatment for recurrent HCC as a result of the development of collateral neoplastic feeding vessels after embolization of hepatic arteries; and (5) the partial tumor necrosis induced by neoadjuvant TACE, causing the remaining tumor cells to become less firmly attached and more likely to dislodge and travel into the bloodstream during liver resection.4
The prognosis of patients with HCC accompanied by portal vein tumor thrombus (PVTT) is generally poor.5,6 However, the optimal treatment for HCC with gross vascular invasion remains controversial. Tumor extension into the portal vein remains a contraindication to liver transplantation because of early tumor recurrence. Liver resection remains the only therapeutic option that may offer a chance of cure in HCC with PVTT. Most surgeons select patients for liver resection when the tumor thrombus is confined to the primary or second branches of the main portal vein. In these patients, the tumor can still be removed completely by liver resection combined with resection of the ipsilateral portal venous system containing the tumor thrombus. When the tumor thrombus has extended to beyond the portal bifurcation or the main trunk, surgical resection becomes controversial. To improve the efficacy of surgical resection for HCC with PVTT, neoadjuvant/adjuvant therapies have also been evaluated. However, portal vein thrombosis is considered by some as a contraindication to TACE for HCC.7 The theoretical concern is that as the blood supply to the liver has already been compromised by portal vein thrombosis, embolization of the hepatic artery may result in hepatic infarct or acute hepatic failure. However, there is evidence to support the contrary, which is likely to be due to the development of collateral circulation or portal vein recanalization. Adjustments to the TACE protocol are, however, necessary by lessening the degree of embolization and by carrying out superselective TACE. Isolated good results from retrospective cohort studies using neoadjuvant selective TACE to the liver segments with PVTT followed by liver resection need to be confirmed by randomized controlled trials because of the possibility of patient selection bias. A subgroup analysis in our study failed to demonstrate any efficacy of neoadjuvant TACE on patients with PVTT.
Based on the available evidence, liver resection with resection of PVTT is justified in selected patients with resectable HCC with PVTT. Neoadjuvant therapy is not recommended for HCC with or without PVTT.

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