Outcomes of surgery for hepatocellular carcinoma with tumor thrombus in the inferior vena cava or right atrium

Fifteen-year survival of a hepatocellular carcinoma extending into the right atrium treated by surgical resection with the heart-first approach under cardiopulmonary bypass: a case report and review of the literature

Hepatocellular carcinoma with tumor thrombus in the inferior vena cava extending into the right atrium is rare and associated with poor prognosis in most cases. Although liver resection with thrombectomy is the only curative treatment, there is no consensus on the therapeutic options for managing these rare cases. The patient was a 67-year-old man with hepatocellular carcinoma with tumor thrombus in the right atrium. In February 2003, cavo-atrial thrombectomy was first performed using cardiopulmonary bypass with heparinization and cardiac arrest. After thrombectomy, right hepatectomy was performed. The total operative time was 10 h 48 min. Moreover, the total blood loss was 7267 mL. The patient recovered uneventfully except for right pleural effusion. He was cancer-free for approximately 9 years. A new lesion in the remnant liver was detected in March 2012. He underwent transcatheter arterial chemoembolization, followed by sequential administration of sorafenib and sunitinib. Radiation therapy was also administered. Eventually, the patient expired 6 years after recurrence. Cavo-atrial thrombectomy under cardiopulmonary bypass prior to hepatectomy for hepatocellular carcinoma with tumor thrombus in the right atrium could be performed safely. Aggressive surgery with the heart-first approach and multidisciplinary treatments even after recurrence led to long-term survival.

Right hepatectomy under cardiopulmonary bypass for hepatocellular carcinoma with inferior vena cava tumor thrombus: a case report

BACKGROUND

The prognosis of hepatocellular carcinoma (HCC) with vascular invasion is extremely poor, especially in patients with tumor thrombus (TT) of the inferior vena cava (IVC), which is an oncological emergency with a high risk of sudden death due to TT extension or migration. Herein, we describe a case of HCC with TT of the IVC that rapidly extended into the right atrium (RA), in which right hepatectomy was performed under cardiopulmonary bypass.

CASE PRESENTATION

A 64-year-old man was diagnosed with HCC with IVC TT, and right hepatic lobectomy was scheduled. While awaiting surgery, he complained of respiratory distress and rushed to the emergency room. The TT had reached the RA, and the patient was in a state of oncologic emergency. We requested the cooperation of the cardiovascular surgery department, and under artificial cardiopulmonary support, the right atrium was incised, and a part of the TT was removed. The IVC was clamped to prevent tumor dispersal, and right hepatic lobectomy was performed. The remaining thrombus was excised along with the right lobe of the liver by incising the IVC. There were no serious postoperative complications, and the patient is alive 1 year and 5 months postoperatively.

CONCLUSION

Hepatic resection with cardiopulmonary bypass could be an option for HCC with TT reaching the RA.

Liver Resection for Hepatocellular Carcinoma With Tumor Thrombus in the Inferior Vena Cava or Right Atrium: A Large-scale Multicenter Survey Conducted in Japan

OBJECTIVE

To clarify the short and long-term postoperative outcomes and surgical indications for patients accompanied by hepatocellular carcinoma with tumor thrombus (TT) in the inferior vena cava (IVC) or right atrium (RA).

BACKGROUND

These patients are known to have an extremely poor prognosis; however, the postoperative outcomes have not been fully verified because of the rarity of this disease.

METHODS

We contacted 211 specialized centers in Japan and collected data on liver resection for hepatocellular carcinoma with TT in the IVC or RA from centers with experience performing surgery for such patients. The patient characteristics, operative procedures, and surgical outcomes were then analyzed.

RESULTS

A total of 119 patients from 23 institutions were enrolled; 49 patients had TT in the IVC below the diaphragm (type I), 42 had TT in the IVC above the diaphragm (type II), and 28 had TT entering the RA (type III). The severity and frequency of postoperative complications did not differ among the 3 groups. There was one surgery-related death in the type III group. The median survival times were 2.47 years in the type I group, 1.77 years in the type II group, and 1.02 years in the type III group. Multivariate analysis identified an indocyanine green retention rate at 15 minutes >15% and ≥3 tumors as prognostic factors affecting survival, whereas the use of cardiopulmonary bypass and ≥3 tumors were risk factors for recurrence.

CONCLUSIONS

As the postoperative prognosis of patients with type I or type II disease and of patients with no risk factors is relatively good, surgery should be considered for these patient populations.

Concomitant Hepatectomy and Atrial Thrombectomy under Cardiopulmonary Bypass versus Staged Hepatectomy in the Treatment for Hepatocellular Carcinoma with Large Right Atrial Tumor Thrombi

(1) Background: Hepatocellular carcinoma (HCC) with a large right atrium tumor thrombus (RATT) is a rare and critical presentation. Emergency hepatectomy and thrombectomy under cardiopulmonary bypass (CPB) is life-saving and potentially curative. The aim of this study is to propose an appropriate approach for this condition. (2) Methods: In period A (1998 to 2010, n = 7), hepatectomy and thrombectomy were concomitantly performed, and staged hepatectomy was performed in period B (2011 to 2018, n = 17). (3) Results: The median overall survival time (MOST) in the published studies was 14 months. Moreover, the blood loss, blood transfusion rate, length of ICU stays, and hospital costs were significantly reduced in period B. The MOSTs of patients in period A (n = 6) and period B (n = 17) were 14 vs. 18 months (p = 0.099). The median disease-free survival times (MDFTs) in period A (n = 6) and period B (n = 15) were 8 vs. 14 months (p = 0.073), while the MOSTs in period A and period B were 14 vs. 24 months (p = 0.040). (4) Conclusions: Emergency thrombectomy under CPB and staged hepatectomy 4–6 weeks later may be an appropriate approach for HCC with large RATT. However, the optimal waiting interval requires further investigation.

Simultaneous surgical treatment of hepatocellular carcinoma with tumor thrombus in the inferior vena cava and ischemic heart disease own research and literature review

<b> Introduction:</b> Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Tumor penetration into the inferior vena cava/right atrium is rare, as it occurs only in 34% of HCC patients. There are no clear guidelines for the management of this stage of disease. </br></br> <b>Aim:</b> This is a case report of a patient with HCC and tumor thrombus in the inferior vena cava and with advanced coronary artery disease. </br></br> <b> Materials and methods:</b> The patient was qualified for a simultaneous cardiac surgery and liver resection with removal of the tumor thrombus from the inferior vena cava due to a high risk of sudden cardiac death. The first stage involved aortocoronary bypass followed by a right-sided hemihepatectomy with removal of the tumor thrombus from the inferior vena cava (this part of the operation was performed by extracorporeal circulation). The postoperative period was uneventful. Surgical treatment is one of the therapeutic options that offers a chance to radically remove the tumor and extend the patient's life. From a standpoint, these operations are extremely difficult and carry a high risk of perioperative complications (up to 40%). At the same time, the patient is at risk of complications due to cancer, such as pulmonary embolism, tricuspid stenosis, and congestive heart failure, which should be considered when choosing a treatment method. A significant number of patients also suffer from chronic conditions that worsen the prognosis. Cardiac diseases combined with tumor thrombus in the inferior vena cava may cause sudden cardiac death. </br></br> <b>Conclusions:</b> Surgical treatment should be considered in patients with HCC and tumor thrombus in the inferior vena cava, especially in patients with cardiovascular disease burden, as it is not only a chance to prolong life, but also to protect them against life-threatening cardiac complications.

Heterotopic Ossification of the Inferior Vena Cava Wall: A Case Report and Literature Review

Masses of the inferior vena cava (IVC) are very diverse, most of which are thrombus and tumor thrombus, whereas heterotopic ossification of IVC has never been reported. Heterotopic ossification (HO) is the formation of mature lamellar bone outside normal bones and in soft tissues. Some researchers believe that HO is a manifestation of vascular calcification. Here we present a case of HO of the inferior vena cava (IVC) wall. A 68 year old female patient complaining hypertension and palpitation and diagnosed with a retroperitoneal mass was found to have a primary mass of the inferior vena cava wall during surgery. Histopathological examination after surgical resection revealed that the mass was mainly composed of mature bone tissues and hematopoietic tissues of bone marrow, there was no recurrence and the patient was symptom-free 15 months after the surgery. HO of the inferior vena cava wall is very rare, with large volume it can affect the circulation, and this case remind us that it can be cured by surgical resection.

Hepatocellular carcinoma tumor thrombus entering the right atrium treated with combining percutaneous and intravenous high-dose-rate brachytherapy: a case report

The presented report describes a case of a Hepatocellular carcinoma (HCC) tumor thrombus (TT) infiltrating the inferior vena cava (IVC) and the right atrium (RA) in a 66-year old male patient who initially presented with TT related symptoms. CT-guided high-dose-rate brachytherapy (HDRBT) was performed for both, the intraparenchymal primary and the TT. A marked improvement of the tumor-related symptoms and shrinkage of the tumor mass were achieved six months after treatment initiation. The combination of intravascular and percutaneous HDRBT demonstrating a promising approach to palliate tumor-related symptoms in advanced HCC with macrovascular invasion.

Transmediastinal, intrapericardial inferior vena cava approach based on anatomical landmarks for hepatectomy using total hepatic vascular exclusion

BACKGROUND

Total hepatic vascular exclusion (THVE) is an essential technique to control hemorrhage during surgical treatment of advanced liver tumors or injury. However, surgeons often have difficulty securing the intrapericardial inferior vena cava (IVC) because few reports have described the anatomy around the supra-diaphragmatic IVC or the techniques and surgical outcomes for this procedure. This study presents our safe and feasible intrapericardial IVC approach, which is based on anatomical landmarks, and reports the surgical outcomes of this procedure.

METHODS

We performed THVE using our technique for hepatectomy, accompanied by resection of the hepatic vein confluence or tumor thrombectomy of the supra-hepatic IVC, in five patients between August 2011 and March 2018.

RESULTS

The mean operative time was 568 min (range: 240-820 min). The mean THVE time was 10 min (range: 5-15 min), with a mean blood loss of 1882 mL (range: 1010-3100 mL). Postoperatively, one patient was classified as Clavien-Dindo grade II due to medication for tachycardia, and two patients were classified as grade IIIa due to drainage of bile and pleural effusion, including one patient with tachycardia. The mean postoperative hospital stay was 26 days (range: 18-34 days). No patient exhibited decreased cardiac function during surgery or postoperatively, and no patient experienced thoracotomy or phrenic nerve paralysis.

CONCLUSIONS

Anatomical landmarks are important to ensure a safe approach to the intrapericardial IVC. Incising the pericardium does not lead to serious problems. The transmediastinal, intrapericardial IVC approach for THVE is a feasible method to secure the supra-diaphragmatic intrapericardial IVC.

Usefulness of a novel transarterial chemoinfusion plus external-beam radiation therapy for advanced hepatocellular carcinoma with tumor thrombi in the inferior vena cava and right atrium: Case study

Background

Invasion beyond inferior vena cava (IVC) to right atrium (RA) is a rare complication in patients with advanced hepatocellular carcinoma (HCC), and results in fatal oncologic emergencies, including pulmonary embolism and right heart failure.

Aim

As there is no gold standard treatment for unresectable HCC with tumor thrombi involving IVC and RA, we considered it valuable to assess safety and efficacy of a combination of hepatic arterial infusion chemoembolization (HAIC) therapy and external‐beam radiation therapy (EBRT).

Methods and results

The “New FP” was chosen as the HAIC therapy, in which the enhanced permeation and retention effect was achieved using a cisplatin‐Lipiodol suspension combined with continuous infusion of 5‐fluorouracil (5‐FU). Sixteen patients with HCC with tumor thrombi in IVC, RA, and pulmonary arteries were enrolled. modified response evaluation criteria in solid tumors‐based evaluation of response to the combination treatment was as follows: complete response, 6.2% (1 patient); partial response, 81.3% (13 patients); stable disease, 12.5% (2 patients); progressive disease, 0%. The median overall survival time (MST) was 19.0 months. Notably, MST of patients receiving sequential sorafenib monotherapy (39.0 months) was significantly longer than that of the rest (15.3 months).

Conclusion

The combination of New FP and EBRT is an efficacious treatment option for unresectable HCC involving IVC and RA, complicated with pulmonary embolism. Sequential administration of molecular‐targeted drugs may prolong survival in such patients.

Twelve-Year Survival After Resection of Hepatocellular Carcinoma with Right Atrial Tumor Thrombus

INTRODUCTION

A large hepatocellular carcinoma (HCC) with macrovascular invasion is generally considered to have poor prognosis due to unfavorable tumor biology andsuch patients are relegated to palliative options. This report describes long term survival after surgery in a patient with HCC and tumor thrombus in the rightatrium.

METHODS

Case records of the patient, details of follow up visits and surveillance computed tomography scans performed were reviewed. A brief discussion of thesurgical strategy adopted along with outcome of similar cases in literature is presented.

RESULTS

A 60 year old man presented with a HCC in segments 4, 5 with extension of tumor into the middle, left hepatic veins, inferior vena cava and right atrium.Patient underwent extraction of the tumor thrombus from the right atrium under cardiopulmonary bypass along with extended left hepatectomy. He receivedthree cycles of adjuvant chemotherapy with Gemcitabine, Oxaliplatin and Interferon. There was a parietal wall recurrence after 1 year and 10 months whichwas excised. Since then he remains well and is on regular follow up for more than 12 years from his index surgery with no evidence of disease, making himthe longest known survivor with such an advanced presentation.

CONCLUSION

This is an unusual instance where aggressive resection for HCC with right atrial tumor thrombus has resulted in an exceptionally long survival.

Atrial reconstruction, distal gastrectomy with Ante-situm liver resection and autotransplantation for hepatocellular carcinoma with atrial tumor thrombus: A case report

RATIONALE

Hepatocellular with tumor thrombi extending into 3 hepatic veins (HVs) and right atrium presents as a real clinical challenge. We report the first documented case of surgical resection of an advanced hepatocellular carcinoma (HCC) with extensive invasion to distal stomach, atrium and hepatic vasculatures.

PATIENT CONCERNS

We present a case of 48-years old man with abdominal mass accompanying shortness of breath after activities.

DIAGNOSES

Preoperative examination revealed giant HCC with tumor thrombi extending into portal vein, HVs, inferior vena cava, and atrium.

INTERVENTIONS

Distal stomach involvement was confirmed at surgery and, distal gastrectomy, atrial reconstruction and ante-situm liver resection and autotransplantation under cardio-pulmonary bypass were performed.

OUTCOMES

The operation time was 490 minutes, extracorporeal circulation time 124 minutes, and anhepatic time 40 minutes. Postoperative follow-up revealed normal hepatic and cardiac function with no sign of recurrence.

LESSONS

This case illustrates that the extensive invasion of HCC to major vasculature and adjacent organs may not necessarily preclude the liver autotransplantation with multi-visceral resection as the treatment option of extremely advanced HCC patients.

Intrahepatic cholangiocarcinoma with a tumor thrombus extending from the inferior vena cava to the right atrium: a case report

Background

Vascular invasion involving a tumor thrombus in the inferior vena cava and/or right atrium is an unfavorable prognostic factor after intrahepatic cholangiocarcinoma resection. We report an intrahepatic cholangiocarcinoma case with a tumor thrombus extending from the left hepatic vein via the inferior vena cava to the right atrium.

Case presentation

A 58-year-old man with epigastralgia was referred to our hospital after an emergent transcatheter arterial embolization was done following the radiological diagnosis of a ruptured hepatic tumor. The serum concentrations of carcinoembryonic antigen, carbohydrate 19-9, duke pancreatic monoclonal antigen type 2, and cytokeratin-19 fragments were elevated; meanwhile those of alfa-fetoprotein and des-γ-carboxy prothrombin were within normal ranges. A contrast-enhanced computed tomography scan showed a heterogeneously enhanced tumor, 13 cm in diameter, in the left lobe of the liver, enlarged lymph nodes along the lesser curvature of the stomach, and a tumor thrombus extending from the left hepatic vein via the inferior vena cava to the right atrium. We performed a left hemihepatectomy and tumor thrombectomy under total hepatic vascular exclusion to reduce the risk of sudden death. After dissection of the liver parenchyma along the left side of the middle hepatic vein, except for the left hepatic vein, the inferior vena cava just below the right atrium could be clamped by pulling down the left lobe of the liver toward the caudal side. The thrombus could be removed by incising the inferior vena cava under total hepatic vascular exclusion. Microscopic examination showed a tubular adenocarcinoma. Immunohistochemical staining was positive for cytokeratin-7, cytokeratin-19, and epithelial membrane antigen, but negative for arginase-1, glypican-3, and hepatocyte. The patient was pathologically diagnosed with an intrahepatic cholangiocarcinoma with a tumor thrombus in the inferior vena cava. Adjuvant chemotherapy with tegafur/gimeracil/oteracil was administered for 1 year. The patient remained in good health without cancer recurrence for over 4 years after the operation.

Conclusion

An aggressive surgical approach may be indicated for intrahepatic cholangiocarcinoma with a tumor thrombus in the inferior vena cava and/or right atrium to avoid the risk of impending death.

Hepatocellular carcinoma with atrial tumor thrombus presenting as myxoma: Resection under cardiopulmonary bypass

Surgical resection for Hepatocellular carcinoma (HCC) with atrial tumor thrombus is a rare life saving procedure. A case of left lateral segment liver tumor (HCC) with atrial tumor thrombus resected with use of cardio-pulmonary bypass is presented.

Long-Term Survival under Arterial Chemoembolization and Sorafenib of a Patient with Hepatocellular Carcinoma and Tumor Atrial Thrombus: A Case Report and Literature Review

Hepatocellular carcinoma (HCC) is considered to be the fourth most frequent cause of cancer-associated death globally. HCC might be associated, especially in advanced stages, with the formation of tumor thrombus (TT), which can be located in the portal vein, as well as in hepatic and/or inferior vena cava (IVC) veins. Nevertheless, the extension of TT to the right atrium (RA) is infrequent with an unfavorable prognosis. We present a rare case of a male patient with HCC and IVC TT extending to the RA. The atrial thrombus was the first manifestation of HCC diagnosed by cardiac ultrasound. So far, the patient has undergone 4 courses of transarterial chemoembolization in combination with systemic therapy with sorafenib, and under this therapeutic approach long-term survival has been achieved.

Transarterial Radioembolization for the Treatment of Advanced Hepatocellular Carcinoma Invading the Right Atrium

Hepatocellular carcinoma (HCC) has the tendency to invade the portal and/or hepatic venous system. The invasion of the right atrium is uncommonly observed and constitutes a treatment challenge. We report the case of a patient with HCC invading the right atrium treated with ⁹⁰Yttrium-transarterial radioembolization (⁹⁰Y-TARE). Following the treatment, organizing pneumonia secondary to nivolumab occurred, raising the question of an interaction between ⁹⁰Y-TARE and nivolumab.

Current trends in vena cava reconstructive techniques with major liver resection: a systematic review

PURPOSE

Historically, invasion of the inferior vena cava (IVC) represented advanced and often unresectable hepatic disease. With surgical and anesthetic innovations, IVC resection and reconstruction have become feasible in selected patients. This review assesses technical variations in reconstructive techniques and post-operative management.

METHODS

A comprehensive literature search was performed according to PRISMA. Inclusion criteria were (i) peer-reviewed articles in English; (ii) at least three cases; (iii) hepatic IVC resection and reconstruction (January 2015-March 2020). Primary outcomes were reconstructive technique, anti-thrombotic regimen, post-operative IVC patency, and infection. Secondary outcomes included post-operative complications and malignant disease survival.

RESULTS

Fourteen articles were included allowing for investigation of 351 individual patients. Analysis demonstrated significant heterogeneity in surgical reconstructive technique, anti-thrombotic management, and post-operative monitoring of patency. There was increased utilization of ex vivo approaches and decreased use of venovenous bypass compared with previously published reviews.

CONCLUSION

This review of literature published between 2015 and 2020 reveals persistent heterogeneity of hepatic IVC reconstructive techniques and peri-operative management. Increased utilization of ex vivo approaches and decreased use of venovenous bypass point towards improved operative techniques, peri-operative management, and anesthesia. In order to gain evidence for consensus on management, a registry would be beneficial.

Diagnosis, treatment and prognosis of hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus

Although tumor thrombus (TT) infringement of the inferior vena cava (IVC) and right atrium (RA) is rarely observed in hepatocellular carcinoma (HCC), the prognosis for this condition is extremely poor, with a median survival time of several months, given that the condition is often diagnosed at an advanced tumor stage or combined with multiple systemic metastases. Furthermore, there is no established effective treatment for the condition. However, some investigators insist that active treatment, including surgery, chemotherapy (systemic or intra-arterial), radiation therapy, best supportive care or a combination of these, may help prolong overall survival time in these patients. The management of patients with advanced HCC and a TT extending into the RA and IVC is extremely difficult and risky. To this end, the present review assessed the literature on the clinical features and treatments of this condition in recent years, with the aim of providing assistance for clinical work.

Nomogram for Predicting Long-Term Survival after Synchronous Resection for Hepatocellular Carcinoma and Inferior Vena Cava Tumor Thrombosis: A Multicenter Retrospective Study

Background

Although surgery for hepatocellular carcinoma (HCC) complicated with inferior vena cava tumor thrombus (IVCTT) may improve survival for some patients, prognostic markers remain elusive because of its rarity. We constructed a prognostic nomogram which predicts individualized survival benefit of curative-intent surgery for HCC patients with IVCTT.

Methods

According to abdominothoracic anatomy of inferior vena cava (IVC), IVCTT can be divided into 3 types: inferior diaphragmic (ID), superior diaphragmic (SD), and intracardiac type (IC). Data of 64 HCC patients with IVCTT who underwent curative-intent surgery between 2008 and 2015 in four centers in China were analyzed retrospectively. Univariate and multivariate Cox regression analyses were conducted to select variables for the construction of a prognostic nomogram. Predictive accuracy and discriminative ability were examined by concordance index (C-index) and calibration curve.

Results

Of 64 patients in the IVCTT classification, 37 (57.8%) were classified as ID type, 15 (23.4%) as SD type, and 12 (18.8%) as IC type. The 1-, 2-, 3-, and 5-year disease-specific survival (DSS) rates for patients in ID, SD, and IC groups were 94.4%, 55.6%, 71.4%, and 30.0%; 27.8%, 21.4%, 7.1%, and 0%; and 8.3%, 0%, 0%, and 0%, respectively. Independent factors included in the nomogram were ECOG performance status, AFP level ≥ 400 μg/L, tumor size ≥ 10 cm, portal vein tumor thrombosis, and IVCTT classification. The C-index of the nomogram was 0.812 (95% CI 0.761–0.873). The calibration plot for DSS probability showed excellent agreement between the prediction by nomogram and actual observation.

Conclusions

Curative-intent surgery should be carefully evaluated and suggested according to our novel IVCTT classification. We have developed a visual web-based nomogram model to predict oncological prognosis of curative-intent surgery for HCC patients with IVCTT.

Liver resection with thrombectomy for patients with hepatocellular carcinoma and tumour thrombus in the inferior vena cava or right atrium

Background

Hepatocellular carcinoma (HCC) with tumour thrombus (TT) in the inferior vena cava (IVC) or right atrium (RA) is a rare advanced disease state with a poor prognosis. The aim of this study was to examine survival after surgical resection.

Methods

Patients with HCC and TT of either the IVC or RA, who underwent liver resection between February 1997 and July 2017, were included. Their short‐ and long‐term outcomes and surgical details were analysed retrospectively.

Results

Thirty‐seven patients were included; 16 patients had TT in the IVC below the diaphragm, eight had TT in the IVC above the diaphragm, and 13 had TT entering the RA. Twelve patients had advanced portal vein TT (portal vein invasion (Vp) greater than Vp3 and Vp4), ten had bilobar disease, and 12 had extrahepatic disease. There were no in‐hospital deaths, although two patients died within 90 days. Median survival did not differ between patients who had resection with curative intent (18·7 months) and those with residual tumour in the lung only (20·7 months), but survival was poor for patients with residual tumour in the liver (8·3 months).

Conclusion

Liver resection with thrombectomy for advanced HCC with TT in the IVC or RA is safe and feasible, leading to moderate survival.

Isolated Right Ventricular Metastasis in a Woman with Advanced Hepatocellular Carcinoma after Palliative Therapy

Hepatocellular carcinoma (HCC) with cardiac metastasis represents a group of rarity and poor prognosis. Few case reports have described this patient entity, and it remains unclear regarding the optimal treatment and predicted outcome for these patients. In our case, we represented a 67-year-old female patient with presentations of dyspnea and heart murmur, which conducted to the diagnosis of advanced HCC with isolated right ventricular metastasis. Because of multiple comorbidities regarding cardiac and pulmonary systems, she received best supportive care and survived 2 months after initial diagnosis. A systemic literature review of 80 published cases (including our patient) since the 1950s was also performed from PubMed, and the data were gathered from the medical record and literature reviews. In our review, patients with advanced HCC and cardiac metastasis involved the right heart mainly with a predominance of right atrium (53%). Meanwhile the overall 3-month survival rate in our review was 70.7%. In subgroup analysis, the overall 3-month survival was highest (97%) in patients treated with surgery and other therapies, and lowest (27%) in patients with best supportive care. To our knowledge, this is the first comprehensive literature review addressing the epidemiology, optimal treatment, and prognosis for advanced-stage HCC with cardiac metastasis. We suggest that abnormal cardiac murmur in patients with history of HCC should prompt investigation for tumor involvement of the heart. We also emphasize individualized treatment as well as prognostic measurement accordingly.

Proton beam therapy for hepatocellular carcinoma associated with inferior vena cava tumor thrombus

PURPOSE

Hepatocellular carcinoma (HCC) with inferior vena cava tumor thrombus (IVCTT) is rare and regarded as an advanced disease stage with poor prognosis. Treatment effect data regarding HCC with IVCTT is scarce and clear evidence has not been established. This study, therefore, aims to examine the safety and effectiveness of proton beam therapy (PBT) for HCC patients with IVCTT.

METHODS

From January 2005 to December 2014, a total of 21 HCC patients with IVCTT were analyzed. The total irradiation doses ranged from 50 to 74 (median 72.6) gray relative biological effectiveness.

RESULTS

The follow-up period was 4-120 (median 21) months. Regarding acute toxicities, dermatitis of grade 1-2 was observed in all patients, while no grade 3 or higher late toxicity events were encountered. The overall survival (OS) rates for all patients were 62%, 33%, and 19% at 1, 2, and 3 years, respectively. No local recurrences for the treated lesions, including IVCTT, were observed. According to univariate analysis, IVCTT extension type was not associated with prognosis, but only tumor number significantly affected the OS rate (p = 0.003). For 10 single lesion patients, the longest survival time was 120 months with OS rates of 82%, 64%, and 36% at 1, 2, and 3 years, respectively.

CONCLUSION

PBT is safe and effective for HCC patients with IVCTT, especially those with single lesion status. PBT is an important treatment option for HCC patients with IVCTT.

Progress in research of hepatocellular carcinoma with tumor thrombus

Hepatocellular carcinoma (HCC) with tumor thrombus is a hot and difficult issue in the study of HCC, and many key issues concerning this condition are still controversial. Clinical guidelines and treatment recommendations vary widely between the East and the West, and efficacy remains unsatisfactory. In recent years, with the progress of comprehensive tumor treatment concept and the rapid development of surgical techniques, perioperative management, interventional therapy, radiotherapy, targeted therapy, and other treatment methods, the overall survival rate of HCC with tumor thrombus has been significantly extended and encouraging efficacy has been achieved. However, the core issues on how to select individualized treatment to achieve optimal treatment and how to prevent postoperative recurrence still need to be studied and discussed. This article reviews the progress in the research of hepatic carcinoma with portal vein thrombus, inferior vena cava thrombus, or bile duct thrombus.

Stereotactic body radiotherapy as the initial treatment for hepatocellular carcinoma with extensive inferior vena cava and atrium tumor thrombus

Hepatocellular carcinoma (HCC) with inferior vena cava (IVC) tumor thrombus rarely occurs, its prognosis is extremely poor. A 49-year-old locally advanced HCC male with tumor thrombus extension into the IVC and the right atrium was successfully treated with stereotactic body radiotherapy (SBRT). A radiation dose of 40 Gy/5 fractions was delivered to the thrombus in 5 days. Contrast-enhanced magnetic resonance imaging one month after SBRT demonstrated no thrombus in IVC and the right atrium, and the huge lesion on right lobe also shrank. No severe adverse effect, eg, pulmonary embolism, was encountered. After controlling the thrombus, this patient has the opportunity to receive subsequent transarterial chemoembolization procedure in time, and avoided disease progression outside the irradiation volume. We reported a HCC case with extensive IVC and atrium tumor thrombus successfully treated by SBRT, the effectiveness and potential severe adverse effects were discussed.

Hepatocellular Carcinoma with Tumor Thrombus Extending from the Portal Vein to the Right Atrium

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors. Tumor thrombus formation in advanced HCC stages is common and usually involves the hepatic or portal veins. The formation of tumor thrombus is considered a poor prognostic factor. Herein, we report a rare case wherein the thrombus extended to the inferior vena cava (IVC) reaching the right atrium without affecting the hemodynamic status. This is a 59-year-old male who presented with melena. He was found to have grade 3 esophageal varices with findings suggestive of recent bleeding associated with a large amount of blood in the gastric body that required banding. Computed tomography (CT) of the abdomen and pelvis showed multiple liver masses with an intraluminal IVC mass extending from the hepatic vein into the right atrium. A CT scan of the chest confirmed the presence of a tumor thrombus in the IVC extending to the right atrium. The patient declines surgical intervention and he was discharged. Unfortunately, he passed after a short period of time. In conclusion, tumor thrombus formation is common in HCC. However, expansion of the thrombus to IVC and right atrium is rare and indicates poor prognosis.

Cavo-atrial thrombectomy prior to hepatectomy for hepatocellular carcinoma with tumor thrombus in the right atrium: a case report

BACKGROUND

Hepatocellular carcinoma (HCC) with tumor thrombus (TT) in the right atrium is a critical condition. The general consensus is to perform hepatectomy prior to cavo-atrial thrombectomy because of the risk of uncontrollable bleeding during the liver transection after heparinization. However, sudden cardiac arrest due to the ball-valve effect and pulmonary embolism have been reported in cases of TT. Cavo-atrial thrombectomy prior to hepatectomy for HCC with TT in the right atrium was successfully performed to prevent sudden cardiac arrest and pulmonary embolism.

CASE PRESENTATION

Tumor thrombectomy under cardiopulmonary bypass with heparin and electrical ventricular fibrillation prior to hepatectomy was successfully performed to prevent sudden cardiac arrest or pulmonary embolism in a 75-year-old woman with a huge HCC and TT in the right atrium. After the neutralization of heparin, right hepatectomy with tumor thrombectomy in the inferior vena cava was performed. The total operation time was 9 h, and the total blood loss was 8200 mL. The patient's postoperative course was uneventful, and she was discharged 14 days after surgery. One year after surgery, she is alive with HCC recurrence in the lung.

CONCLUSIONS

Cavo-atrial thrombectomy prior to hepatectomy for HCC with TT in the right atrium can be performed safely to prevent sudden cardiac arrest and pulmonary embolism by collaboration of cardiovascular surgeons and gastroenterological surgeons.

Long non-coding RNA FENDRR inhibits proliferation and invasion of hepatocellular carcinoma by down-regulating glypican-3 expression

Long non-coding RNA FENDRR is implicated in progression of several cancers, but its exact role and mechanism in hepatocellular carcinoma (HCC) are largely unknown. In this study, we investigated the expression and biological roles of FENDRR in HCC tissues and cell lines. We found that the expression levels of FENDRR were significantly down-regulated in HCC tissues and cells. FENDRR overexpression could inhibit the growth of HCC cells in vitro and in vivo. Moreover, up-regulation of FENDRR suppressed the migration and invasion of HCC cells. Mechanistically, we demonstrated that FENDRR interacted directly with Glypican-3 (GPC3) promoter and methylated GPC3 promoter, which led to down-regulation of GPC3 expression. Ectopic expression of GPC3 ablated the inhibitory effects of FENDRR on HCC cell proliferation, migration and invasion. Taken together, we provided the first evidence for the inhibitory activity of FENDRR in HCC, which is causally linked to targeting GPC3 at the epigenetic level. Restoration of FENDRR may be a potential approach to prevent HCC progression and metastasis.