Analysis of Preoperative Portal Vein Embolization Outcomes in Patients with Hepatocellular Carcinoma: A Single Center Experience
Researchers from Mt. Sinai recently presented their findings on a retrospective analysis of patients with well compensated hepatocellular cancer(HCC) who underwent preoperative portal vein embolization (PVE) that would allow surgical treatment (≤ 40% of functional liver remnant (FLR)) with curative intention was performed. 82 patients underwent PVE, 72(87.8%) were deemed surgical candidates and 69(84.1%) underwent surgical resection.
Embolization was performed using N-butyl cyanoacrylate glue mixed with lipoidol or sodium tetradecyl sulfate foam. Tumor progression, total liver volume (TLV), FLR, hypertrophy rate and the kinetic growth rate were evaluated 4-8 weeks after PVE. Resection was performed in 84% of patients. Post resection follow up protocol included serial imaging performed every 3 months for the first 2 years and every 6 months thereafter.
Rate of major adverse events were 11% which did not depend on the embolic material used. Median increase in the FLR, hypertrophy rate and kinetic growth rate were 14.6 and 10.5%, 9.7% respectively. Radiological progression of HCC occurred in 34.1% after PVE. Post-operative morbidity was 22.2% and mortality was 4.2%. Recurrence after surgical resection was 30.4% with a mean time to recurrence of 41.9 months. The mean survival after surgical resection was 42.8 months. No significant difference in the recurrence rate, time to recurrence and survival rates was observed between patients without and with tumor progression after PVE.
Fig 1. Comparison of predicted FLR before (upper image) and after (lower image) PVE.
Surgical resection is the procedure of choice for patient with Child A Cirrhosis who are not candidates for transplantation. The authors showed that in well selected patients PVE is a safe technique to improve the outcomes after surgical resection. Tumor progression while awaiting surgical resection can be as high as 34% and use of adjunct loco regional treatments while awaiting resection is a great option. Interestingly in this study, tumor progression after PVE did not have any influence in the recurrence rates, time to recurrence or survival after resection. Post-operative morbidity and mortality remains a concern for these patients. PVE should be considered for patients with HCC with good liver functions after carefully weighing the risks and benefits.
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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; 29:920-6.
Anil K Pillai, MD
Associate Professor and Section Chief
University of Texas Health Science Center