Patients with hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) have an extremely poor prognosis and relatively few treatment options.
During a consensus meeting, experts met to examine the published data for HCC treatment strategies in patients with PVTT.
Many treatment guidelines consider the presence of PVTT a contraindication to partial hepatectomy or liver transplantation. Transarterial chemoembolization (TACE) is associated with an increased risk of ischemic necrosis of liver and of treatment-related death in patients with PVTT, and is, therefore, limited to a select group of patients with good hepatic function and adequate collateral circulation around the occluded portal vein. Systemic sorafenib results in survival benefit in patients regardless of the presence of PVTT. However, side effects are common, and there are no effects on time-to-symptom progression or quality of life. Transarterial radioembolization (TARE) with yttrium-90 microspheres is emerging as a valuable strategy. A wider range of patients with PVTT are suitable for this procedure compared to TACE. TARE is as effective as TACE in HCC and has quality-of-life advantages.
In patients with HCC with PVTT, medical evidence suggests that TARE is a good choice of treatment.
"Almost all patients receiving sorafenib discontinued therapy (due to AEs or disease progression), while only one patient discontinued RT. Involvement of the main PVTT is associated with poor prognosis, possibly because of increased risk of tumor spread, elevated portal venous pressure causing variceal hemorrhage, and decreased portal flow resulting in ascites, jaundice, hepatic encephalopathy, and liver failure [7,9,23,26]. Sorafenib can compromise hepatic function by decreasing portal blood flow, as we previously demonstrated that sorafenib induced significant vasoconstriction of the portal venous area and significantly reduced portal venous flow, according to Doppler ultrasonography in patients with unresectable HCC . "
[Show abstract][Hide abstract] ABSTRACT: Background
This study investigated the survival benefits of sorafenib vs. radiotherapy (RT) in patients with unresectable hepatocellular carcinoma (HCC) and portal vein tumor thrombosis (PVTT) in the main trunk or the first branch.
Ninety-seven patients were retrospectively reviewed. Forty patients were enrolled by the Kanagawa Liver Study Group and received sorafenib, and 57 consecutive patients received RT in our hospital. Overall survival was compared between the two groups with PVTT by propensity score (PS) analysis. Factors associated with survival were evaluated by multivariate analysis.
The median treatment period with sorafenib was 45 days, while the median total radiation dose was 50 Gy. The Child-Pugh class and the level of invasion into hepatic large vessels were significantly more advanced in the RT group than in the sorafenib group. Median survival did not differ significantly between the sorafenib group (4.3 months) and the RT group (5.9 months; P = 0.115). After PS matching (n = 28 per group), better survival was noted in the RT group than in the sorafenib group (median survival, 10.9 vs. 4.8 months; P = 0.025). A Cox model showed that des-γ-carboxy prothrombin <1000 mAU/mL at enrollment and RT were significant independent predictors of survival in the PS model (P = 0.024, HR, 0.508; 95% CI, 0.282 to 0.915; and P = 0.007, HR, 0.434; 95% CI, 0.235 to 0.779; respectively).
RT is a better first-line therapy than sorafenib in patients who have advanced unresectable HCC with PVTT.
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