Proposal of selection criteria for operative resection of hepatocellular carcinoma with inferior vena cava tumor thrombus incorporating hepatic arterial infusion chemotherapy.

BACKGROUND: Because operative resection of hepatocellular carcinoma with inferior vena cava tumor thrombus has been associated with a substantial risk of recurrence and postoperative morbidity, adequate patient selection for resection is necessary. Our aim was to propose selection criteria for resection of hepatocellular carcinoma with inferior vena cava tumor thrombus.

METHODS: Long-term outcomes were analyzed retrospectively in 39 operative cases of hepatocellular carcinoma with inferior vena cava tumor thrombus (1996-2015). Since 2003, preoperative hepatic arterial infusion chemotherapy instead of immediate resection has been performed in patients with advanced inferior vena cava tumor thrombus, defined as those patients with suspected extrahepatic metastasis, who will need extracorporeal circulation, or who have marginal liver function and/or multiple bilobar tumors. Indication for resection has been based on the tumor response to hepatic arterial infusion chemotherapy thereafter.

RESULTS: The median survival time for all patients was 15.2 months. Multivariate analysis revealed that preoperative hepatic arterial infusion chemotherapy (hazard ratio: 0.30), use of extracorporeal circulation (3.12), and extrahepatic metastasis (2.67) were independent prognostic factors for overall survival. Among patients with initially advanced inferior vena cava tumor thrombus, preoperative hepatic arterial infusion chemotherapy was associated with a much more favorable prognosis compared with no hepatic arterial infusion chemotherapy (median survival time: unreached vs 8.3 months, P = .007). Overall survival was significantly worse in patients with uncontrolled, advanced inferior vena cava tumor thrombus than in those without advanced inferior vena cava tumor thrombus or with advanced inferior vena cava tumor thrombus controlled by preoperative hepatic arterial infusion chemotherapy (median survival time: 10.4 vs 26.1 months, P = .039).

CONCLUSION: An effective response to hepatic arterial infusion chemotherapy and subsequent operative resection salvaged patients with initially advanced inferior vena cava tumor thrombus. Our results suggest that operative resection should be indicated only in patients without advanced inferior vena cava tumor thrombus or with advanced inferior vena cava tumor thrombus controlled by preoperative hepatic arterial infusion chemotherapy.