Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy for Unresectable Hepatitis B Virus-related Hepatocellular Carcinoma: A Single Center Study of 45 Patients. Ann Surg. 2018;. [PMID: 29995681 DOI: 10.1097/sla.0000000000002942]

Pathological complete response after conversion therapy in unresectable hepatocellular carcinoma: a retrospective study

BACKGROUND

Hepatocellular carcinoma is a highly lethal tumor worldwide, and China has a correspondingly high incidence and mortality rate. For patients with unresectable hepatocellular carcinoma, the prognosis is often poor. The objective of this retrospective study was to investigate the effects of conversion therapies on these patients.

METHODS

The study included patients between the ages of 18 and 75 who were initially diagnosed with unresectable hepatocellular carcinoma and received conversion therapy. After completing surgery, the patients underwent pathological diagnosis, which showed complete necrosis. The study was conducted retrospectively at the First Affiliated Hospital, Zhejiang University School of Medicine, from January 2019 to December 2021. The main objectives of the study were to evaluate the overall survival and recurrence-free survival.

RESULTS

A total of 60 patients who met the inclusion criteria were enrolled. The median age of the patients was 56.6 ± 9.5 years, and 85% of them were male. The one-year overall survival rate (OS) was 98.3%, and the three-year OS was 95.6%. The one-year recurrence-free survival rate (RFS) was 81.1%, and the three-year RFS was 71.4%. In subgroup analysis, there was no statistically significant difference in RFS between patients with BCLC stages 0-A and BCLC stages B-C (p = 0.296). Additionally, there was no statistically significant difference in RFS between patients who received postoperative new adjuvant therapy and those who did not (p = 0.324).

CONCLUSIONS

Conversion therapy followed by surgical resection could be a promising treatment for patients with initially unresectable hepatocellular carcinoma, and the prognosis is good with a pathological complete response.

Liver fibrosis as a predictor of liver failure and outcome following ALPPS among patients with primary liver cancer

The influence of liver fibrosis on the rate of liver regeneration and complications following ALPPS has yet to be fully understood. This study aimed to scrutinize the effects of liver fibrosis on the postoperative complications, and prognosis subsequent to ALPPS. Clinical data were collected from patients with primary liver cancer who underwent ALPPS at Peking Union Medical College Hospital between May 2014 and October 2022. The degree of liver fibrosis was assessed using haematoxylin-eosin staining and Sirius red staining. This study encompassed thirty patients who underwent ALPPS for primary liver cancer, and there were 23 patients with hepatocellular carcinoma, 5 with cholangiocarcinoma, and 2 with combined hepatocellular-cholangiocarcinoma. The impact of severe liver fibrosis on the rate of liver regeneration was not statistically significant (P = 0.892). All patients with severe complications belonged to the severe liver fibrosis group. Severe liver fibrosis exhibited a significant association with 90 days mortality (P = 0.014) and overall survival (P = 0.012). Severe liver fibrosis emerges as a crucial risk factor for liver failure and perioperative mortality following the second step of ALPPS. Preoperative liver function impairment is an important predictive factor for postoperative liver failure.

Is ALPPS still appropriate for large or locally advanced hepatocellular carcinoma in an era of targeted agents and immunotherapy?

Therapeutic options for large or locally advanced hepatocellular carcinoma (HCC) have limited efficacy. This study investigated the efficacy and safety of drug-eluting beads trans-arterial chemo-embolization (dTACE), portal vein embolization (PVE), tyrosine kinase inhibitor (TKI), and immune checkpoint inhibitors (ICI) compared to Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) for large or locally advanced HCC.Data regarding clinicopathological details, safety, and oncological outcomes were reviewed for the quadruple therapy (dTACE-PVE-TKI-ICI) and compared with ALPPS.From 2019 to 2020, 10 patients with large or locally advanced HCC underwent future remnant liver (FRL) modulation (dTACE-PVE-TKI-ICI: 5; ALPPS: 5). All five dTACE-PVE-TKI-ICI cases responded well, with patients #4 and #5 achieving complete tumor necrosis. The overall response rate (ORR) was 5/5. Patients #1-4 underwent hepatectomy, while #5 declined surgery due to complete tumor necrosis. Mean FRL volume increased by 75.3% (range 60.0%-89.4%) in 2-4 months, compared to 104.6% (range 51.3%-160.8%) in 21-37 days for ALPPS (P = 0.032). Major postoperative complications occurred in 1/5 ALPPS patients. Resection rates were 4/4 for quadruple therapy and 5/5 for ALPPS. 2-year progression free survival for dTACE-PVE-TKI-ICI and ALPPS were 5/5 and 3/5, respectively.Quadruple therapy is a feasible, effective strategy for enhancing resectability by downsizing tumors and inducing FRL hypertrophy, with manageable complications and improved long-term prognosis. In addition, it provokes the re-examination of the application of ALPPS in an era of molecular and immune treatments.

Comparison of clinical efficacy between LAPS and ALPPS in the treatment of hepatitis B virus-related hepatocellular carcinoma

Background

Insufficient post-operative future liver remnant (FLR) limits the feasibility of hepatectomy for patients. Staged hepatectomy is an effective surgical approach that can improve the resection rate of hepatocellular carcinoma (HCC). This study aimed to compare the safety and efficacy of laparoscopic microwave ablation and portal vein ligation for staged hepatectomy (LAPS) and classical associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in the treatment of hepatitis B virus (HBV)-related HCC.

Methods

Clinical data of patients with HBV-related HCC who underwent LAPS or ALPPS in our institute between January 2017 and May 2022 were retrospectively analysed.

Results

A total of 18 patients with HBV-related HCC were retrospectively analysed and divided into the LAPS group (n = 9) and ALPPS group (n = 9). Eight patients in the LAPS group and eight patients in the ALPPS group proceeded to a similar resection rate (88.9% vs 88.9%, P = 1.000). The patients undergoing LAPS had a lower total comprehensive complication index than those undergoing ALPPS but there was not a significant different between the two groups (8.66 vs 35.87, P = 0.054). The hypertrophy rate of FLR induced by ALPPS tended to be more rapid than that induced by LAPS (24.29 vs 13.17 mL/d, P = 0.095). The 2-year recurrence-free survival (RFS) was 0% for ALPPS and 35.7% for LAPS (P = 0.009), whereas the 2-year overall survival for ALPPS and LAPS was 33.3% and 100.0% (P = 0.052), respectively.

Conclusions

LAPS tended to induce lower morbidity and FLR hypertrophy more slowly than ALPPS, with a comparable resection rate and better long-term RFS in HBV-related HCC patients.

Guidelines for the Diagnosis and Treatment of Primary Liver Cancer (2022 Edition)

Background

Primary liver cancer, of which around 75-85% is hepatocellular carcinoma in China, is the fourth most common malignancy and the second leading cause of tumor-related death, thereby posing a significant threat to the life and health of the Chinese people.

Summary

Since the publication of Guidelines for Diagnosis and Treatment of Primary Liver Cancer in China in June 2017, which were updated by the National Health Commission in December 2019, additional high-quality evidence has emerged from researchers worldwide regarding the diagnosis, staging, and treatment of liver cancer, that requires the guidelines to be updated again. The new edition (2022 Edition) was written by more than 100 experts in the field of liver cancer in China, which not only reflects the real-world situation in China but also may reshape the nationwide diagnosis and treatment of liver cancer.

Key Messages

The new guideline aims to encourage the implementation of evidence-based practice and improve the national average 5-year survival rate for patients with liver cancer, as proposed in the "Health China 2030 Blueprint."

A bibliometric and visualized analysis of preoperative future liver remnant augmentation techniques from 1997 to 2022

Background

The size and function of the future liver remnant (FLR) is an essential consideration for both eligibility for treatment and postoperative prognosis when planning surgical hepatectomy. Over time, a variety of preoperative FLR augmentation techniques have been investigated, from the earliest portal vein embolization (PVE) to the more recent Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and liver venous deprivation (LVD) procedures. Despite numerous publications on this topic, no bibliometric analysis has yet been conducted.

Methods

Web of Science Core Collection (WoSCC) database was searched to identify studies related to preoperative FLR augmentation techniques published from 1997 to 2022. The analysis was performed using the CiteSpace [version 6.1.R6 (64-bit)] and VOSviewer [version 1.6.19].

Results

A total of 973 academic studies were published by 4431 authors from 920 institutions in 51 countries/regions. The University of Zurich was the most published institution while Japan was the most productive country. Eduardo de Santibanes had the most published articles, and Masato Nagino was the most frequently co-cited author. The most frequently published journal was HPB, and the most cited journal was Ann Surg, with 8088 citations. The main aspects of preoperative FLR augmentation technique is to enhance surgical technology, expand clinical indications, prevent and treat postoperative complications, ensure long-term survival, and evaluate the growth rate of FLR. Recently, hot keywords in this field include ALPPS, LVD, and Hepatobiliary Scintigraphy.

Conclusion

This bibliometric analysis provides a comprehensive overview of preoperative FLR augmentation techniques, offering valuable insights and ideas for scholars in this field.

The Hong Kong consensus statements on unresectable hepatocellular carcinoma: narrative review and update for 2021

Background and Objective

Hong Kong, like many parts of Asia, faces a high burden of hepatocellular carcinoma (HCC) caused by high endemic rates of hepatitis B virus infection. Hong Kong clinicians have developed a high level of expertise in HCC treatment across surgical, transarterial, ablative, radiotherapeutic and systemic modalities. This publication summarizes the latest evidence-based recommendations on how these modalities should be used.

Methods

In two meetings held in 2020, a multidisciplinary panel of surgeons, oncologists and interventional radiologists performed a narrative review of evidence on the management of HCC, with an emphasis on treatment of HCC not amenable to surgical resection. Close attention was paid to new evidence published since the previous version of these statements in 2018.

Key Content and Findings

The expert panel has formulated 60 consensus statements to guide the staging and treatment of unresectable HCC. Since the previous version of these statements, considerable additions have been made to the recommendations on use of targeted therapies and immunotherapies because of the large volume of new evidence.

Conclusions

Our consensus statements offer guidance on how to select HCC patients for surgical or non-surgical treatment and for choosing among non-surgical modalities for patients who are not candidates for resection. In particular, there is a need for more evidence to aid physicians in the selection of second-line systemic therapies, as currently most data are limited to patients with disease progression on first-line sorafenib.

Case Report: The application of associating liver partition and portal vein ligation for staged hepatectomy in patients with hepatitis b virus-related hepatocellular carcinoma after undergoing treatment with an immune checkpoint inhibitor: a report of two cases

Hepatocellular carcinoma (HCC) is often diagnosed at an unresectable stage without opportunities for curative therapy. Future liver remnant (FLR) insufficiency limits the range of patients who can undergo radical resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can ultimately achieve short-term hypertrophy of the FLR in patients with viral hepatitis-related fibrosis/cirrhosis and R0 resection. However, the influence of immune checkpoint inhibitors (ICIs) on liver regeneration remains unknown. We report two patients diagnosed with Barcelona Clinic Liver Cancer (BCLC)-B stage hepatitis B virus (HBV)-related HCC who underwent pioneering ALPPS after immunotherapy without posthepatectomy liver failure (PHLF). ALPPS has been shown to be safe and feasible in patients with HCC who underwent immunotherapy previously for the first time and might provide an alternative salvage option for future conversion therapy of HCC.

Revival of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma: An international multicenter study with promising outcomes

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma has been considered to be contraindicated due to the initial poor results. Given the recent reports of improved outcomes, we aimed to collect the recent experiences of different centers performing associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma to analyze factors related to improved outcomes.

METHODS

This proof-of-concept study collected contemporary cases of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma and analyzed for morbidity, short and long-term survival, and factors associated with outcomes.

RESULTS

In total, 39 patients from 8 centers underwent associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma from 2010 to 2020. The median preoperative future liver remnant volume was 323 mL (155-460 mL). The median future liver remnant increase was 58.7% (8.9% -264.5%) with a median interstage interval of 13 days (6-60 days). Post-stage 1 and post-stage 2 biliary leaks occurred in 2 (7.7%) and 4 (15%) patients. Six patients (23%) after stage 1 and 6 (23%) after stage 2 experienced grade 3 or higher complications. Two patients (7.7%) died within 90 days after stage 2. The 1-, 3-, and 5-year survival was 92%, 69%, and 55%, respectively. A subgroup analysis revealed poor survival for patients undergoing additional vascular resection and lymph node positivity. Lymph node-negative patients showed excellent survival demonstrated by 1-, 3-, and 5-year survival of 86%, 86%, and 86%.

CONCLUSION

This study highlights that the critical attitude toward associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma needs to be revised. In selected patients with perihilar cholangiocarcinoma, associating liver partition and portal vein ligation for staged hepatectomy can achieve favorable survival that compares to the outcome of established surgical treatment strategies reported in benchmark studies for perihilar cholangiocarcinoma including 1-stage hepatectomy and liver transplantation.

Comparison of surgical resection and transcatheter arterial chemoembolization for large hepatocellular carcinoma: a systematic review and meta-analysis

INTRODUCTION AND OBJECTIVES

Large primary hepatocellular carcinoma (HCC) has a high mortality rate and a variety of treatments. Surgery and transcatheter arterial chemoembolization (TACE) are important treatments. Which could be better remain debatable. The objective of the study is to compare the long-term overall survival of surgical resection (SR) and the use of TACE in patients with large hepatocellular carcinoma.

MATERIALS AND METHODS

We assessed clinical trials through PubMed, Medline, Embase, and the Cochrane Library up to March 2022. Two researchers independently screened articles, extracted data, and assessed the study quality according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses)guidelines. The primary outcome was overall survival (OS). The secondary outcomes were OS after propensity scores matching (PSM) and progression-free survival (PFS).

RESULTS

A total of 14 studies, including 3609 patients, were enrolled in the meta-analysis. The meta-analysis indicated a significant improvement in the 1-year OS, 3-year OS, and 5-year OS favoring SR over TACE (OR = 2.19, 95% CI 1,60-3.00; OR = 3.47, 95% CI 2.47-4.88; OR = 2.72, 95% CI 2.03-3.64, p < 0.001, random model). The results were consistent across subgroups of tumor size and tumor numbers (p > 0.05). The pooled outcome indicated that 1-year OS, 3-year OS, and 5-year OS after PSM were higher in the SR group than in the TACE group (p < 0.001).

CONCLUSIONS

This meta-analysis indicates that among patients with large primary hepatocellular carcinoma, the overall survival rate of patients undergoing surgical resection was higher than that of patients undergoing TACE.

Mini-ALPPS-based multidisciplinary treatment leading to long-term survival in a patient with a large HCC: A case report

Background

The future liver remnant (FLR) induced by stage I associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) in hepatocellular carcinoma (HCC) might be limited due to liver fibrosis/cirrhosis or incomplete liver parenchymal transection.

Case presentation

A 51-year-old male with hepatitis B liver fibrosis was diagnosed with a large HCC (13.5 cm × 12.5 cm × 13.8 cm). The FLR of the patient was insufficient to permit one-stage tumor resection. Therefore, the two-stage ALPPS surgery was planned. Stage I ALPPS was performed with incomplete liver parenchymal transection due to bleeding (which is why we called it Mini-ALPPS). On postoperative day (POD) 18, CT revealed that the FLR hypertrophy was poor. The FLR/standard liver volume (SLV) had only increased from 22.00% to 34.63%. Salvage transhepatic arterial chemoembolization (TACE) was performed on POD 22 days to control possible tumor progression during the waiting period and to further facilitate FLR growth. About 16 days later, a CT reassessment of FLR revealed a 42.5% FLR/SLV. A right hepatectomy was then uneventfully performed. Although HCC recurred after 586 days, the patient survived for more than 1,920 days after stage II ALPPS.

Discussion

Damage control during a difficult conventional stage I ALPPS was important. TACE during the interstage and postoperative periods of this Mini-ALPPS was safe and beneficial. A multidisciplinary based on Mini-ALPPS treatment could provide patients long-term survival; however, Mini-ALPPS should not be selected as the primary solution for such patients today, as some other minimally invasive and effective strategies are available.

Should associating liver partition and portal vein ligation for staged hepatectomy be applied to hepatitis B virus-related hepatocellular carcinoma patients with cirrhosis? A multi-center study

BACKGROUND

It is unclear whether associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can be performed in hepatitis B virus-related hepatocellular carcinoma (HCC) patients with cirrhosis. We explored the efficacy of ALPPS in HCC patients.

METHODS

Data of 54 patients who underwent ALPPS between August 2014 and July 2020 at three centers were collected. Adverse factors affecting their prognosis were analyzed and subsequently compared with 184 patients who underwent transcatheter arterial chemoembolization (TACE).

RESULTS

Overall survival rates of the ALPPS group at 1, 3, and 5 years were 70.6%, 38.4%, and 31.7%, respectively; corresponding disease-free survival rates were 50.5%, 22.4%, and 19.2%, respectively. The ALPPS group had a significantly greater long-term survival rate than the TACE group (before propensity score matching, P < 0.001; after propensity score matching, P = 0.002). Multivariate analysis demonstrated that multifocal lesions (P = 0.018) and macroscopic vascular invasion (P = 0.001) were prognostic factors for HCC patients who underwent ALPPS. After the propensity score matching, the multifocal lesions (P = 0.031), macroscopic vascular invasion (P = 0.003), and treatment type (ALPPS/TACE) (P = 0.026) were the factors adversely affecting the prognosis of HCC patients.

CONCLUSION

ALPPS was feasible in hepatitis B virus-related HCC patients with cirrhosis and resulted in better survival than TACE.

Impact of sarcopenia on the future liver remnant growth after portal vein embolization and associating liver partition and portal vein ligation for staged hepatectomy in patients with liver cancer: A systematic review

Purpose

The impact of sarcopenia on the future liver remnant (FLR) growth after portal vein occlusion, including portal vein embolization (PVE) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has gained increasing interest. This systematic review aimed to explore whether sarcopenia was associated with insufficient FLR growth after PVE/ALPPS stage-1.

Methods

A systematic literature search was performed in PubMed, Embase, Web of Science, and Cochrane Library up to 05 July 2022. Studies evaluating the influence of sarcopenia on FLR growth after PVE/ALPPS stage-1 in patients with liver cancer were included. A predefined table was used to extract information including the study and patient characteristics, sarcopenia measurement, FLR growth, post-treatment complications and post-hepatectomy liver failure, resection rate. Research quality was evaluated by the Newcastle-Ottawa Scale.

Results

Five studies consisting of 609 patients were included in this study, with a sample size ranging from 42 to 306 (median: 90) patients. Only one study was multicenter research. The incidence of sarcopenia differed from 40% to 67% (median: 63%). Skeletal muscle index based on pretreatment computed tomography was the commonly used parameter for sarcopenia evaluation. All included studies showed that sarcopenia impaired the FLR growth after PVE/ALPPS stage-1. However, the association between sarcopenia and post-treatment complications, post-hepatectomy liver failure, and resection rate remains unclear. All studies showed moderate-to-high quality.

Conclusions

Sarcopenia seems to be prevalent in patients undergoing PVE/ALPPS and may be a risk factor for impaired liver growth after PVE/ALPPS stage-1 according to currently limited evidence.

Systematic review registration

https://inplasy.com/, identifier INPLASY202280038.

Application of associating liver partition and portal vein ligation for staged hepatectomy for initially unresectable hepatocellular carcinoma

OBJECTIVE

To evaluate the safety and efficacy of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in the treatment of initially unresectable hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) and to preliminarily explore the mechanism of rapid growth of the future liver remnant (FLR).

METHODS

Twenty-four patients with HBV-associated HCC who underwent ALPPS in our hospital from August 2014 to January 2021 were retrospectively studied. Propensity score matching was used to compare oncologic outcomes of patients treated with ALPPS and transarterial chemoembolization (TACE). The expression of YAP and JNK in liver tissue after two stages of ALPPS were detected.

RESULTS

The median standard liver volume (SLV) was 1471.4 ml. Before second stage of ALPPS, the median FLR increased by 74.4%, and the median FLR/SLV increased from 26.1 to 41.6%. Twenty-two patients (91.7%) received staged hepatectomy after a median interval of 15 (9-24) d. The total incidence of postoperative complications in ALPPS group was 54.5%, and of Clavien-Dindo ≥ IIIb postoperative complications (requiring surgical, endoscopic or radiological intervention under general anesthesia) was 9.1%. There was no significant difference in total complications between ALPPS group and TACE group, but there were lower rate of above grade III complications in the TACE group than that in the ALPPS group. The incidence of complications was lower in laparoscopic-ALPPS than that in open surgery. In ALPPS group, the 1-year, 2-year and 5-year overall survival rate were respectively 71.4%, 33.3% and 4.8%. Interval time was an independent risk factor associated with overall survival rate. There was no significant difference in overall survival rate between ALPPS group and TACE group. For advanced HCC (BCLC stage B and C), ALPPS group was not superior to TACE group in overall survival rate. The expression of YAP and p-JNK in the residual liver tissue after second stage procedure was higher than that after first stage procedure, and the co-expression of YAP and p-JNK was observed in the residual liver tissue.

CONCLUSION

ALPPS is a safe and effective treatment for initially unresectable HBV-associated HCC. Laparoscopic technique might improve the effect of ALPPS. YAP and JNK pathway might take a role in rapid FLR increase in ALPPS procedure.

Lenvatinib plus anti-PD-1 therapy represents a feasible conversion resection strategy for patients with initially unresectable hepatocellular carcinoma: A retrospective study

Purpose

We aimed to investigate the feasibility of lenvatinib plus anti-PD-1 therapy as a conversion therapy for initially unresectable hepatocellular carcinoma (HCC).

Methods

Patients with initially unresectable HCC who received combined lenvatinib and anti-PD-1 antibody between May 2020 and Jan 2022 in Zhongshan Hospital were retrospectively analyzed. Tumor response and resectability were assessed by imaging every two months according to RECIST version 1.1 and modified RECIST (mRECIST) criteria.

Results

A total of 107 patients were enrolled. 30 (28%) of them received conversion surgery within 90.5 (range: 53-456) days after the initiation of lenvatinib plus anti-PD-1 therapy. At baseline, the median largest tumor diameter of these 30 patients was 9.2 cm (range: 3.5-15.0 cm), 26 patients had Barcelona Clinic Liver Cancer stage B-C, and 4 had stage A. Prior to surgery, all cases displayed tumor regression and 15 patients achieved objective response. Pathological complete response (pCR) was observed in 10 patients. No severe drug-related adverse events or surgical complications were observed. After a median follow-up of 16.5 months, 28 patients survived and 11 developed tumor recurrence. Survival analysis showed patients achieving tumor response before surgery or pCR had a longer tumor-free survival. Notably, patients with microvascular invasion (MVI) had significantly higher recurrence rate and poorer overall survival than patients without.

Conclusions

Lenvatinib combined with anti-PD-1 therapy represents a feasible conversion strategy for patients with initially unresectable HCC. Patients achieving tumor responses are more likely to benefit from conversion resection to access a longer term of tumor-free survival.

Application of systemic treatment in conversion therapy options for liver cancer

Radical hepatectomy is the main treatment method to improve the prognosis of patients with intermediate and early-stage liver cancer. Most liver cancer patients in China are in the advanced stage at the initial diagnosis, losing the opportunity for surgical treatment. Therefore, it is essential to down-stage unresectable liver cancer to resectable liver cancer clinically, which is an important way to improve patients’ survival and a hotspot of current clinical research. In recent years, with the increase in effective treatment methods for liver cancer, the resection rate of conversion surgery for unresectable advanced liver cancer has been significantly improved, and a growing number of patients benefit from conversion therapy. This article mainly reviews the connotation of conversion therapy for liver cancer, the patient selection, the selection of conversion strategy, the timing of sequential operations, the scheme and safety, etc.

Individualized Selection Criteria Based on Tumor Burden in Future Remnant Liver for Staged Hepatectomy of Advanced CRLM: Conventional TSH or ALPPS

Staged hepatectomy is a promising strategy for curative resection of advanced colorectal liver metastasis (CRLM) to prevent inadequate future remnant liver (FRL). However, the selection criteria for conventional two-stage hepatectomy (cTSH) and associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS) remain unclear. This study aimed to propose a selection criterion for determining the optimal staged hepatectomy for patients with advanced CRLM. A selection criterion based on the degree of metastatic tumors within the FRL was established to determine staged hepatectomy approaches. Generally, ALPPS is recommended for patients with ≤3 metastatic nodules and whose nodules do not measure >3 cm in the FRL. cTSH is performed for patients whose tumor burden in FRL beyond the selection criteria. Data of 37 patients who underwent staged hepatectomy and curative intent of CRLM were analyzed. The clinical characteristics and outcomes of the two approaches were compared. Overall, cTSH and ALPPS were performed for 27 (73.0%) and 10 (27.0%) patients, respectively. Of those, 20 patients in the cTSH group and all patients in the ALPPS group had completed staged hepatectomy. The 1-, 3-, and 5-year survival rates were 91.6%, 62.4%, and 45.4% for all patients, respectively. The outcomes of patients who had successfully completed the staged hepatectomy were significantly better than those of other patients who failed to achieve staged hepatectomy. However, no significant difference was observed in the overall survival of patients who underwent staged hepatectomy between the two groups, but those in the ALPPS group had 100% survival at the end of this study. The individualized selection criteria based on tumor burden in the FRL that could balance the operative risk and oncologic outcome appear to be a promising strategy for achieving complete staged hepatectomy in patients with advanced CRLM.

Conversion Therapy of Large Unresectable Hepatocellular Carcinoma With Ipsilateral Portal Vein Tumor Thrombus Using Portal Vein Embolization Plus Transcatheter Arterial Chemoembolization

Background

The study aimed to assess the safety and efficacy of conversion therapy with portal vein embolization (PVE) and transcatheter arterial chemoembolization (TACE) in patients with large unresectable hepatocellular carcinoma (HCC) and ipsilateral portal vein tumor thrombus (PVTT).

Methods

This retrospective study evaluated consecutive patients with initially large (≥5 cm) unresectable HCC with ipsilateral PVTT who underwent PVE + TACE at our center between June 2016 and September 2020 (Group A). Clinically equivalent patients from three centers who were receiving tyrosine kinase inhibitors (TKIs) + TACE (Group B) were included. The survival times were evaluated and compared between the two therapeutic groups.

Results

In Group A (n = 33), the median tumor diameter was 14 cm (range, 5–18 cm) and 19 (57.6%) patients underwent radical resection 18–95 days after PVE. Radical liver resection was not performed because of inadequate hypertrophy (n = 11), pulmonary metastasis (n = 1), lack of consent for surgery (n = 1), and the rupture of the HCC (n = 1). There were no patients who underwent radical resection in Group B (n = 64) (P = 0.000). The mean and median overall survival (OS) were 736.5 days and 425.0 days in Group A and 424.5 days and 344.0 days in Group B, respectively. Compared with TKIs + TACE, treatment with PVE + TACE prolonged OS (P = 0.023).

Conclusions

This study shows that conversion therapy was safe and effective in patients with initially large unresectable HCC with ipsilateral PVTT treated with PVE + TACE. Moreover, PVE + TACE conferred more favorable outcomes than treatment with TKIs + TACE.

Evolution of associating liver partition and portal vein ligation for staged hepatectomy from 2012 to 2021: A bibliometric analysis. Review

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has become increasingly popular during the past few decades, and its indications have extended from patients with normal liver to post-chemotherapy patients and even patients with cirrhosis. However, few studies have assessed the publications in relation to ALPPS.

METHODS

Web of Science was searched to identify studies related to ALPPS published from 2012 to 2021. The analysis was performed using the bibliometric package (Version 3.1.0) in R software.

RESULTS

In total, 486 publications were found. These articles were published in 159 journals and authored by 2157 researchers from 694 organizations. The most prolific journal was Annals of Surgery (24 articles and 1170 citations). The most frequently cited article was published in Annals of Surgery (average citations, 72.7; total citations, 727). China was the most productive country for ALPPS publications but had comparatively less interaction with other countries. Both thematic evolution and co-occurrence network analysis showed low numbers of topics such as failure, resection, and safety among the publications but large numbers of highly cited papers on outcomes, prediction, mechanisms, multicenter analysis, and novel procedures such as liver venous deprivation. A total of 196 studies focused the clinical application of ALPPS, and most studies were IDEAL Stages I and II. The specific mechanism of ALPPS liver regeneration remains unclear.

CONCLUSIONS

This is the first bibliometric analysis offering an overview of the development of ALPPS research publications. Our findings identified prominent studies, countries, institutions, journals, and authors to indicate the future direction of ALPPS research. The role of ALPPS in liver regeneration and the long-term results of ALPPS need further study. Future research directions include comparison of ALPPS with portal vein embolization, liver venous deprivation, and other two-stage hepatectomies as well as patients' quality of life after ALPPS.

Chinese expert consensus on conversion therapy for hepatocellular carcinoma (2021 edition)

Recent advances in systemic and locoregional treatments for patients with unresectable or advanced hepatocellular carcinoma (HCC) have resulted in improved response rates. This has provided an opportunity for selected patients with initially unresectable HCC to achieve adequate tumor downstaging to undergo surgical resection, a 'conversion therapy' strategy. However, conversion therapy is a new approach to the treatment of HCC and its practice and treatment protocols are still being developed. Review the evidence for conversion therapy in HCC and develop consensus statements to guide clinical practice. Evidence review: Many research centers in China have accumulated significant experience implementing HCC conversion therapy. Preliminary findings and data have shown that conversion therapy represents an important strategy to maximize the survival of selected patients with intermediate stage to advanced HCC; however, there are still many urgent clinical and scientific challenges for this therapeutic strategy and its related fields. In order to summarize and learn from past experience and review current challenges, the Chinese Expert Consensus on Conversion Therapy for Hepatocellular Carcinoma (2021 Edition) was developed based on a review of preliminary experience and clinical data from Chinese and non-Chinese studies in this field and combined with recommendations for clinical practice. Sixteen consensus statements on the implementation of conversion therapy for HCC were developed. The statements generated in this review are based on a review of clinical evidence and real clinical experience and will help guide future progress in conversion therapy for patients with HCC.

Sequential Portal Vein Embolization and Percutaneous Radiofrequency Ablation for Future Liver Remnant Growth: A Minimally Invasive Alternative to ALPPS Stage-1 in Treatment of Hepatocellular Carcinoma

Background: To evaluate the feasibility and efficacy of sequential portal vein embolization (PVE) and radiofrequency ablation (RFA) (PVE+RFA) as a minimally invasive variant for associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) stage-1 in treatment of cirrhosis-related hepatocellular carcinoma (HCC).

Methods: For HCC patients with insufficient FLR, right-sided PVE was first performed, followed by percutaneous RFA to the tumor as a means to trigger FLR growth. When the FLR reached a safe level (at least 40%) and the blood biochemistry tests were in good condition, the hepatectomy was performed. FLR dynamic changes and serum biochemical tests were evaluated. Postoperative complications, mortality, intraoperative data and long-term oncological outcome were also recorded.

Results: Seven patients underwent PVE+RFA for FLR growth between March 2016 and December 2019. The median baseline of FLR was 353 ml (28%), which increased to 539 (44%) ml after 8 (7–18) days of this strategy (p < 0.05). The increase of FLR ranged from 40% to 140% (median 47%). Five patients completed hepatectomy. The median interval between PVE+RFA and hepatectomy was 19 (15–27) days. No major morbidity ≥ III of Clavien-Dindo classification or in-hospital mortality occurred. One patient who did not proceed to surgery died within 90 days after discharge. After a median follow-up of 18 (range 3–50) months, five patients were alive.

Conclusion: Sequential PVE+RFA is a feasible and effective strategy for FLR growth prior to extended hepatectomy and may provide a minimally invasive alternative for ALPPS stage-1 for treatment of patients with cirrhosis-related HCC.

A Prospective Study of Liver Regeneration After Radiotherapy Based on a New (Su'S) Target Area Delineation

Background

In this study, we designed a new (Su’S) target area delineation to protect the normal liver during liver regeneration and prospectively evaluate liver regeneration after radiotherapy, as well as to explore the clinical factors of liver regeneration and established a model and nomogram.

Methods

Thirty patients treated with preoperative downstaging radiotherapy were prospectively included in the training cohort, and 21 patients treated with postoperative adjuvant radiotherapy were included in the validation cohort. The cut-off points of each optimal predictor were obtained using receiver-operating characteristic analysis. A model and nomogram for liver regeneration after radiotherapy were developed and validated.

Results

After radiotherapy, 12 (40%) and 13 (61.9%) patients in the training and validation cohorts experienced liver regeneration, respectively. The risk stratification model based on the cutoffs of standard residual liver volume spared from at least 20 Gy (SVs20 = 303.4 mL/m²) and alanine aminotransferase (ALT=43 u/L) was able to effectively discriminate the probability of liver regeneration. The model and nomogram of liver regeneration based on SVs20 and ALT showed good prediction performance (AUC=0.759) in the training cohort and performed well (AUC=0.808) in the validation cohort.

Conclusions

SVs20 and ALT were optimal predictors of liver regeneration. This model may be beneficial to the constraints of the normal liver outside the radiotherapy-targeted areas.

Hepatic Arterioportal Fistula Is Associated with Decreased Future Liver Remnant Regeneration after Stage-I ALPPS for Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) patients often developed hepatic arterioportal fistula (APF). The aim of this study is to evaluate the impact of APF on future liver remnant (FLR) regeneration and surgical outcomes after the first stage of associating liver partition and portal vein ligation for staged hepatectomy (stage-I ALPPS).

METHODS

Consecutive HCC patients who underwent ALPPS at our center between March 2017 and May 2019 were retrospectively studied. Data for the association between APF and clinicopathological details, liver volume, and surgical outcomes were analyzed.

RESULTS

The enrolled 35 HCC patients were divided into three groups: 15 patients with preoperative APF were classified as the APF I group, 10 patients developed APF after stage-I ALPPS as the APF II group, whereas the other 10 patients without APF before and after stage-I ALPPS as the control group. After stage-I ALPPS, patients in the APF I and APF II groups had lower kinetic growth rate (KGR) of FLR volume (6.1±3.2%, 11.4±8.4%, 25.0±8.8% per week, respectively, P<0.001) and took longer median time to reach the sufficient FLR volume for stage-II ALPPS (17.5 days, 12 days, 6 days, respectively, P<0.001) than those in the control group. Meanwhile, the incidence of posthepatectomy liver failure (PHLF) in the APF I and APF II groups was significantly higher than that of the control group (P=0.007). There are 27 (77.1%) patients who completed stage-II ALPPS. The overall survival (OS) rates at 1 and 3 years were 59.3% and 35.1%, whereas the disease-free survival (DFS) rates at 1 and 3 years were 44.4% and 22.9%, respectively.

CONCLUSIONS

Hepatic APF is significantly associated with decreased FLR regeneration and a higher risk of PHLF after stage-I ALPPS. HCC patients who are to undergo ALPPS may benefit from the timely perioperative intervention of APF.

Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Registry: What Have We Learned?

In 2007, the first associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure was performed in Regensburg, Germany. ALPPS is a variation of two-stage hepatectomy to induce rapid liver hypertrophy allowing the removal of large tumors otherwise considered irresectable due to a too small future liver remnant. In 2012, the international ALPPS registry was created, and it now contains more than 1,000 cases. During the past years, improved patient selection and refinements in operative techniques, in particular, less invasive approaches such as Partial ALPPS, Tourniquet ALPPS, Ablation-assisted ALPPS, Hybrid ALPPS or Laparoscopic or Robotic approaches, have resulted in significant improvements in safety. The most frequent indication for ALPPS is colorectal liver metastases. In the first randomized controlled study, ALPPS provided a higher resectability rate than conventional two-stage hepatectomy, with similar complication rates. Long-term outcome data are still missing. The initial results of ALPPS for hepatocellular carcinoma and for perihilar cholangiocarcinoma were devastating, but with progress in surgical technic and better patient selection, ALPPS could serve as a treatment alternative in carefully selected cases, even for these tumors. ALPPS has enlarged the armamentarium of hepato-pancreato-biliary surgeons, but there is still discussion regarding how to use this novel technique, which may allow resection of tumors that are otherwise deemed irresectable.

Downstaging and Resection of Initially Unresectable Hepatocellular Carcinoma with Tyrosine Kinase Inhibitor and Anti-PD-1 Antibody Combinations

BACKGROUND

Combined therapy with tyrosine kinase inhibitors (TKIs) and anti-PD-1 antibodies has shown high tumor response rates for patients with unresectable hepatocellular carcinoma (HCC). However, using this treatment strategy to convert initially unresectable HCC to resectable HCC was not reported.

METHODS

Consecutive patients with unresectable HCC who received first-line therapy with combined TKI/anti-PD-1 antibodies were analyzed. Tumor response and resectability were evaluated via imaging every 2 months (±2 weeks) using RECIST v1.1. Resectability criteria were (1) R0 resection could be achieved with sufficient remnant liver volume and function; (2) intrahepatic lesions were evaluated as partial responses or stable disease for at least 2 months; (3) no severe or persistent adverse effects occurred; and (4) hepatectomy was not contraindicated.

RESULTS

Sixty-three consecutive patients were enrolled. Of them, 10 (15.9%) underwent R0 resection in 3.2 months (range: 2.4-8.3 months) after the initiation of combination therapy. At baseline, these 10 patients had a median largest tumor diameter of 9.3 cm, 7 had Barcelona Clinic Liver Cancer stage C (vascular invasion) disease, 2 had stage B, and 1 had stage A. Before surgery, 6 patients were evaluated as a partial response, 3 stable disease, and 1 partial response in the intrahepatic lesion but a new metastatic lesion in the right adrenal gland. Six patients (60%) achieved a pathological complete response. One patient died from immune-related adverse effects 2.4 months after hepatectomy. After a median follow-up of 11.2 months (range: 7.8-15.9 months) for other 9 patients, 8 survived without disease recurrence, and 1 experienced tumor recurrence.

CONCLUSIONS

Combination of TKI/anti-PD-1 antibodies is a feasible conversion therapy for patients with unresectable HCC to become resectable. This study represents the largest patient cohort on downstaging role of combinational systemic therapy on TKI and PD-1 antibody for HCC.

Conversion to Resectability Using Transarterial Chemoembolization Combined With Hepatic Arterial Infusion Chemotherapy for Initially Unresectable Hepatocellular Carcinoma

Objective

To evaluate whether this conversion rate to resectability could be increased when patients are treated with transarterial chemoembolization and hepatic arterial infusion chemotherapy (TACE-HAIC) using oxaliplatin plus fluorouracil/leucovorin.

Background

Conventional TACE (c-TACE) is a common regimen for initially unresectable hepatocellular carcinoma (HCC), which converts to curative-intent resection in about 10% of those patients. It is urgent need to investigated better regimen for those patients.

Methods

The data of 83 initially unresectable HCC patients were examined, including 41 patients in the TACE-HAIC group and 42 patients in the c-TACE group. Their response rate, conversion rate to resection, survival outcome, and adverse events were compared.

Results

The conversion rate was significantly better in the TACE-HAIC group than in the c-TACE group (48.8% vs 9.5%; P < 0.001). The TACE-HAIC had marginal superiority in overall response rate as compared to c-TACE (14.6% vs 2.4%; P = 0.107 [RECIST]; 65.9% vs 16.7%; P < 0.001 [mRECIST], respectively). The median progression-free survival was not available and 9.2 months for the TACE-HAIC and cTACE groups, respectively (hazard rate [HR]: 0.38; 95% confidence interval [CI], 0.20-0.70; P = 0.003). The median overall survival was not available and 13.5 months for the TACE-HAIC and c-TACE groups, respectively (HR, 0.63; 95% CI, 0.34-1.17; P = 0.132). The 2 groups had similar rates of grade 3/4 adverse events (all P > 0.05).

Conclusions

TACE-HAIC demonstrated a higher conversion rate and progression-free survival benefit than c-TACE and could be considered as a more effective regimen for patients with initially unresectable HCC. Future prospective randomized trials are needed to confirm it.

Rescue radiofrequency ablation or percutaneous ethanol injection: a strategy for failed RALPPS stage-1 in patients with cirrhosis-related hepatocellular carcinoma

Background

The future liver remnant (FLR) faces a risk of poor growth in patients with cirrhosis-related hepatocellular carcinoma (HCC) after stage-1 radiofrequency-assisted ALPPS (RALPPS). The present study presents a strategy to trigger further FLR growth using supplementary radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI).

Methods

At RALPPS stage-1 the portal vein branch was ligated, followed by intraoperative RFA creating a coagulated avascular area between the FLR and the deportalized lobes. During the interstage period, patients not achieving sufficient liver size (≥ 40%) within 2–3 weeks underwent additional percutaneous RFA/PEI of the deportalized lobes (rescue RFA/PEI) in an attempt to further stimulate FLR growth.

Results

Seven patients underwent rescue RFA/PEI after RALPPS stage-1. In total five RFAs and eight PEIs were applied in these patients. The kinetic growth rate (KGR) was highest the first week after RALPPS stage-1 (10%, range − 1% to 15%), and then dropped to 1.5% (0–9%) in the second week (p < 0.05). With rescue RFA/PEI applied, KGR increased significantly to 4% (2–5%) compared with that before the rescue procedures (p < 0.05). Five patients proceeded to RALPPS stage-2. Two patients failed: In one patient the FLR remained at a constant level even after four rescue PEIs. The other patient developed metastasis. Except one patient died after RALPPS stage-2, no severe complications (Clavien-Dindo ≥ IIIb) occurred among remaining six patients.

Conclusions

Rescue RFA/PEI may provide an alternative to trigger further growth of the FLR in patients with cirrhosis-related HCC showing insufficient FLR after RALPPS stage-1.

Trial registration Retrospectively registered.

Evolutions in the Management of Hepatocellular Carcinoma over Last 4 Decades: An Analysis from the 100 Most Influential Articles in the Field

INTRODUCTION

Over the past 4 decades, the management of hepatocellular carcinoma (HCC) has changed dramatically. The publications that have had the most significant impact on HCC management have not been quantitatively analyzed. In this article, we analyzed the 100 most influential articles over the past 4 decades using bibliometric citation analysis to characterize the evolution in HCC treatment.

METHODS

The top-cited publications were identified and analyzed from the Clarivate Analytics Web of Science Core Collection database.

RESULTS

The 100 most cited articles were identified with an average of 738 citations (range: 349-6,799). There was an increase in the number of influential articles in the late 1990s, which was paralleled by an increase in reports focused on locoregional treatment of HCC. Most top 100 articles came from the USA (n = 35), followed by Italy (n = 28), mainland China (n = 26), and Japan (n = 24). The surgical management was the most studied topic (n = 33). The Annals of Surgery published the highest number of papers (n = 26) with 13,978 citations. While other 3 topics (surgical management, locoregional treatment, and outcome prediction) declined among publications beginning in the 2000s, there was an emergence of highly cited papers on targeted drugs and immune checkpoint inhibitors with a concomitant increase in the number of publications on systemic therapy.

CONCLUSIONS

Based on bibliometric analysis of the literature over the last 40 years, a comprehensive analysis of the most historically significant HCC management articles highlighted the key contributions made to the evolution and advancement of this specialist field. The data should provide clinicians and researchers insight into future directions relative to the advancement of HCC management.

Mitochondrial dysfunction attenuates rapid regeneration in livers with toxin-induced fibrosis

BACKGROUND

The mechanism of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)-induced rapid liver regeneration remains poorly documented, especially in patients with fibrosis. Therefore, this study aims to investigate the underlying mechanism of ALPPS-induced accelerated regeneration in toxin-induced fibrosis models.

METHODS

The ALPPS-induced regeneration model was established in livers with thioacetamide (TAA)-induced fibrosis to determine the regenerative pathways involved in rapid regeneration. Confirmatory experiments were performed in transforming growth factor beta 1 (TGFβ1)-treated AML12 cells and mice with carbon tetrachloride (CCl4)-induced fibrosis. Finally, mitochondrial dysfunction was validated in fibrotic/non-fibrotic patients.

RESULTS

In TAA-induced fibrotic mice, ALPPS-induced regeneration was significantly inferior to that of the control group (P=0.027 at day 2 and P<0.001 at day 7). Furthermore, mitochondria-associated genes were significantly downregulated in TAA-challenged mice. Accordingly, the reduced production of ATP and elevated levels of malondialdehyde indicated disturbances in intracellular energy metabolism during the ALPPS-induced regenerative process after TAA treatment. Further investigations were performed in TGF-β1-treated AML12 cells and CCl4-treated mice, which indicated that mitochondrial dysfunction attenuated the capacity for rapid regeneration after ALPPS.

CONCLUSIONS

In summary, this study revealed that mitochondrial dysfunction led to inferior regeneration in livers with toxin-induced fibrosis and identified new therapeutic targets to improve the feasibility and safety of the ALPPS procedure. Further studies in human patients are required in the future.

Efficacy of the association liver partition and portal vein ligation for staged hepatectomy for the treatment of solitary huge hepatocellular carcinoma: a retrospective single-center study

BACKGROUND

The feasibility of association liver partition and portal vein ligation for staged hepatectomy (ALPPS) for solitary huge hepatocellular carcinoma (HCC, maximal diameter ≥ 10 cm) remains uncertain. This study aims to evaluate the safety and the efficacy of ALPPS for patients with solitary huge HCC.

METHODS

Twenty patients with solitary huge HCC who received ALPPS during January 2017 and December 2019 were retrospectively analyzed. The oncological characteristics of contemporaneous patients who underwent one-stage resection and transcatheter arterial chemoembolization (TACE) were compared using propensity score matching (PSM).

RESULTS

All patients underwent complete two-staged ALPPS. The median future liver remnant from the ALPPS-I stage to the ALPPS-II stage increased by 64.5% (range = 22.3-221.9%) with a median interval of 18 days (range = 10-54 days). The 90-day mortality rate after the ALPPS-II stage was 5%. The 1- and 3-year overall survival (OS) rates were 70.0% and 57.4%, respectively, whereas the 1- and 3-year progression-free survival (PFS) rates were 60.0% and 43.0%, respectively. In the one-to-one PSM analysis, the long-term survival of patients who received ALPPS was significantly better than those who received TACE (OS, P = 0.007; PFS, P = 0.011) but comparable with those who underwent one-stage resection (OS, P = 0.463; PFS, P = 0.786).

CONCLUSION

The surgical outcomes of ALPPS were superior to those of TACE and similar to those of one-stage resection. ALPPS is a safe and effective treatment strategy for patients with unresectable solitary huge HCC.

Inhibition of TGFβ1 accelerates regeneration of fibrotic rat liver elicited by a novel two-staged hepatectomy

Aims: Emerging evidence is demonstrating that rapid regeneration of remnant liver elicited by associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) may be attenuated in fibrotic livers. However, the molecular mechanisms responsible for this process are largely unknown. It is widely acknowledged that the TGFβ1 signaling axis plays a major role in liver fibrosis. Therefore, the aims of this study were to elucidate the underlying mechanism of liver regeneration during ALPPS with or without fibrosis, specifically focusing on TGFβ1 signaling. Approach: ALPPS was performed in rat models with N-diethylnitrosamine-induced liver fibrosis and no fibrosis. Functional liver remnant regeneration and expression of TGFβ1 were analyzed during the ALPPS procedures. Adeno-associated virus-shTGFβ1 and the small molecule inhibitor LY2157299 (galunisertib) were used separately or in combination to inhibit TGFβ1 signaling in fibrotic rats. Results: Liver regeneration following ALPPS was lower in fibrotic rats than non-fibrotic rats. TGFβ1 was a key mediator of postoperative regeneration in fibrotic liver. Interestingly, AAV-shTGFβ1 accelerated the regeneration of fibrotic functional liver remnant and improved fibrosis, while LY2157299 only enhanced liver regeneration. Moreover, combination treatment elicited a stronger effect. Conclusions: Inhibition of TGFβ1 accelerated regeneration of fibrotic liver, ameliorated liver fibrosis, and improved liver function following ALPPS. Therefore, TGFβ1 is a promising therapeutic target in ALPPS to improve fibrotic liver reserve function and prognosis.

Surgical Treatments of Hepatobiliary Cancers

Hepatobiliary cancers which include hepatocellular carcinoma (HCC) and biliary tract cancers (i.e., cholangiocarcinoma and gallbladder carcinoma) are associated with significant morbidity and mortality based on the stage of the disease at presentation. With improved screening for hepatobiliary malignancies in patients with risk factors and with widespread use of laparoscopic cholecystectomy, hepatobiliary malignancies, including incidental diagnosis of gallbladder carcinoma, are on the rise. Definitive treatment of hepatobiliary malignancies include surgical resection, ablation, and liver transplantation. However, management of these cancers is challenging due to the complex hepatobiliary anatomy and the need for meticulous perioperative management especially in patients with advanced liver disease. The management and prognosis of hepatobiliary malignancies vary widely based on the stage of presentation, with surgical options providing the possibility of definitive cure in patients presenting with early-stage disease. Surgical resection for HCC results in good outcomes if performed in ideal candidates. For patients with early HCC who are not candidates for surgical resection, ablation and liver transplantation should be considered. Similarly, surgical resection is also the definitive treatment for biliary tract cancers, and liver transplantation can be curative in selected patients with perihilar cholangiocarcinoma after neoadjuvant chemoradiotherapy. The role of routine adjuvant chemotherapy and radiotherapy is not clearly established, but adjuvant therapies can offer better outcomes in patients with advanced disease at presentation. Outcomes of surgical management of hepatobiliary cancers seem to be improving. Given the complex decision-making process involved, multidisciplinary evaluation is essential to provide and coordinate the best treatments for these patients.

Conversion hepatectomy for advanced hepatocellular carcinoma after right portal vein transection and lenvatinib therapy

Background

Lenvatinib is a novel tyrosine kinase inhibitor that exhibits an antitumor effect on hepatocellular carcinoma (HCC). An established strategy that involves surgery and usage of lenvatinib for advanced HCC remains elusive.

Case presentation

A 58-year-old male patient with advanced HCC and untreated hepatitis B was referred to our hospital. The tumor at the right lobe was 10 cm in diameter with right portal vein thrombus. Because of the possible lung metastasis and concern about the remaining hepatic function after extended right hepatectomy, lenvatinib was initiated before surgery. After the confirmation of a sharp decrease of tumor markers during the 3-week lenvatinib therapy, only a right portal vein transection was done leaving the enlargement of the left lobe for improved post-hepatectomy liver function while lenvatinib therapy was continued. The laparotomy revealed that the tumor was invading the right diaphragm. After 7 weeks of lenvatinib administration after right portal vein transection, an extended right hepatectomy with resection of the tumor-invaded diaphragm was successfully done. The lung nodules that were suspected as metastases had disappeared. The patient has been doing well without any sign of recurrence for 1 year.

Conclusion

The strategy involving the induction of lenvatinib to conversion hepatectomy including the portal vein transection was effective for advanced HCC.

Guidelines for the Diagnosis and Treatment of Hepatocellular Carcinoma (2019 Edition)

BACKGROUND

Primary liver cancer, around 90% are hepatocellular carcinoma in China, is the fourth most common malignancy and the second leading cause of tumor-related death, thereby posing a significant threat to the life and health of the Chinese people.

SUMMARY

Since the publication of Guidelines for Diagnosis and Treatment of Primary Liver Cancer (2017 Edition) in 2018, additional high-quality evidence has emerged with relevance to the diagnosis, staging, and treatment of liver cancer in and outside China that requires the guidelines to be updated. The new edition (2019 Edition) was written by more than 70 experts in the field of liver cancer in China. They reflect the real-world situation in China regarding diagnosing and treating liver cancer in recent years.

KEY MESSAGES

Most importantly, the new guidelines were endorsed and promulgated by the Bureau of Medical Administration of the National Health Commission of the People's Republic of China in December 2019.

Modern therapeutic approaches for the treatment of malignant liver tumours

Malignant liver tumours include a wide range of primary and secondary tumours. Although surgery remains the mainstay of curative treatment, modern therapies integrate a variety of neoadjuvant and adjuvant strategies and have achieved dramatic improvements in survival. Extensive tumour loads, which have traditionally been considered unresectable, are now amenable to curative treatment through systemic conversion chemotherapies followed by a variety of interventions such as augmentation of the healthy liver through portal vein occlusion, staged surgeries or ablation modalities. Liver transplantation is established in selected patients with hepatocellular carcinoma but is now emerging as a promising option in many other types of tumour such as perihilar cholangiocarcinomas, neuroendocrine or colorectal liver metastases. In this Review, we summarize the available therapies for the treatment of malignant liver tumours, with an emphasis on surgical and ablative approaches and how they align with other therapies such as modern anticancer drugs or radiotherapy. In addition, we describe three complex case studies of patients with malignant liver tumours. Finally, we discuss the outlook for future treatment, including personalized approaches based on molecular tumour subtyping, response to targeted drugs, novel biomarkers and precision surgery adapted to the specific tumour.

The role of associating liver partition and portal vein ligation for staged hepatectomy in unresectable hepatitis B virus-related hepatocellular carcinoma

Background

The role of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for hepatocellular carcinoma (HCC) remains controversial.

Methods

The records of 23 consecutive patients with hepatitis B virus (HBV)-related HCC who underwent ALPPS at our center between November 2013 and June 2018 were retrospectively reviewed. Oncological results were compared between patients who received ALPPS and those that received transarterial chemoembolization (TACE) using propensity score matching (PSM) analysis.

Results

In patients with a single tumor (n=12) the median tumor diameter was 13.0 (range: 5.1–20.0) cm, whereas in patients with multiple tumors (n=11) the median total tumor diameter was 6.3 (range: 2.3–26.0) cm. After the stage-1 ALPPS, the median future liver remnant (FLR) increased by 50.0%. The stage-2 ALPPS was completed in 20 patients (87.0%) after a median of 12 days. The 90-day mortality rate was 13% (3/23). The overall survival (OS) rates at 1-, 2-, and 5-year were 61.1%, 34.9%, and 8.7%, respectively, whereas the disease-free survival (DFS) rates at 1-, 2-, and 5-year were 27.8%, 27.8%, and 0.0%, respectively. PSM analysis showed no difference in OS between patients who underwent ALPPS and those that received TACE [P=0.178, Barcelona Clinic Liver Cancer (BCLC) stage A–C patients; P=0.241, BCLC stage B and C patients].

Conclusions

ALPPS is a safe and effective treatment option for unresectable HBV-related HCC. However, for HBV-related intermediate and advanced HCC patients, ALPPS may not be superior to TACE.

Interpretation of guidelines for the diagnosis and treatment of primary liver cancer (2019 edition) in China

Primary liver cancer (PLC) is currently the fourth most common malignancy and accounts for the second most cancer-related deaths in China. Since 2017, a great deal of high-level evidence, and particularly evidence based on Chinese studies and practice, has emerged in terms of diagnosis, staging, and treatment. A new version of the guidelines for the management of PLC specifying the diagnosis and treatment of PLC (2019 edition) has recently been published. The guidelines feature major changes in the techniques for early diagnosis, the combination of surgery, local therapy, and systemic treatment, and the use of traditional Chinese medicine. The guidelines need to be further implemented in clinical practice to demonstrate their validity.

Safety, feasibility, and efficacy of associating liver partition and portal vein ligation for staged hepatectomy in treating hepatocellular carcinoma: a systematic review

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) allows radical resection of colorectal liver metastasis (CRLM). However, the effect of ALPPS on hepatocellular carcinoma (HCC) is not completely understood. This systematic review aimed to examine the existing data on the safety, feasibility, and oncologic effect of ALPPS on HCC. Electronic databases, including PubMed, Web of Science, and Embase, were systemically searched to identify articles on ALPPS and HCC. Additional articles were identified manually. The feasibility (liver hypertrophy between two stages), safety (90-day mortality), and therapeutic effect (long-term survival) were analyzed. Nine published articles that satisfied the retrieval standards were included, and these studies involved 176 patients. The evidence level of the enrolled studies was low, among which, the greatest Oxford evidence level was 2c. Additionally, the average median increase in future liver volume was 178 mL, the average interval between two stages was 11.2 days, the interval was remarkably longer in radiofrequency-assisted ALPPS (RALPPS) patients (28 days), and the average 90-day mortality was 17.6% (range, 0–50%). However, the oncological outcomes were not well documented. Survival following ALPPS was evidently improved compared with that after transcatheter arterial chemoembolization (TACE). This value was comparable to that following the one-stage hepatectomy and portal vein embolization (PVE), and it was similar to that in CRLM patients over the long term. Publication biases caused by case series and single-center reports are common in the review. It is concluded in this review that ALPPS is a safe and feasible approach to treat selected patients with unresectable HCC, but its oncological outcome requires further study. RALPPS is not recommended for HCC patients because of the long waiting time between the two stages.

Minimally Invasive Stage 1 to Protect Against the Risk of Liver Failure: Results from the Hepatocellular Carcinoma Series of the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy Italian Registry

Introduction: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been described to treat hepatocellular carcinoma (HCC) but burdened, in its pioneering phase, by high morbidity and mortality. With the advent of minimally invasive (MI) techniques in liver surgery, surgical complications, including posthepatectomy liver failure (PHLF), have been dramatically reduced. The primary endpoint of this study was to compare the short-term outcomes of MI- versus open-ALPPS for HCC, with specific focus on PHLF. Methods: Data of patients submitted to ALPPS for HCC between 2012 and 2020 were identified from the ALPPS Italian Registry. Patients receiving an MI Stage 1 (MI-ALPPS) constituted the study group, whereas the patients who received an open Stage 1 (open-ALPPS) constituted the control group. Results: Sixty-six patients were enrolled from 12 Italian centers. Stage 1 of ALPPS was performed in 14 patients using an MI approach (21.2%). MI-ALPPS patients were discharged after Stage 1 at a significantly higher rate compared with open-ALPPS (78.6% versus 9.6%, P < .001). After Stage 2, major morbidity after MI-ALPPS was 8.3% compared with 28.6% reported after open-ALPPS. Mortality was nil after MI-ALPPS. Length of hospital stay was significantly shorter in MI-ALPPS (12 days versus 22 days, P < .001). Univariate logistic regression analysis (Firth method) found that both MI-ALPPS (odds ratio [OR] = 0.05, P = .040) and partial parenchymal transection (OR = 0.04, P = .027) were protective against PHLF. Conclusion: This national multicenter study showed that a less invasive approach to ALPPS first stage was associated with a lower overall risk of PHLF.

Conventional Two-Stage Hepatectomy or Associating Liver Partitioning and Portal Vein Ligation for Staged Hepatectomy for Colorectal Liver Metastases? A Systematic Review and Meta-Analysis

Background: Pushing the surgical limits for initially unresectable colorectal liver metastases (CRLM) are two approaches for sequential liver resection: two-stage hepatectomy (TSH) and associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS). However, the role of each treatment modality remains ill-defined. The present meta-analysis was designed to compare the safety, efficacy, and oncological benefits between ALPPS and TSH in the management of advanced CRLM.

Methods: A systematic literature search was conducted from online databases through to February 2020. Single-arm synthesis and cumulative meta-analysis were performed.

Results: Eight studies were included, providing a total of 409 subjects for analysis (ALPPS: N = 161; TSH: N = 248). The completions of the second stage of the hepatectomy [98 vs. 78%, odds ratio (OR) 5.75, p < 0.001] and R0 resection (66 vs. 37%; OR 4.68; p < 0.001) were more frequent in patients receiving ALPPS than in those receiving TSH, and the waiting interval was dramatically shortened in ALPPS (11.6 vs. 45.7 days, weighted mean difference = −35.3 days, p < 0.001). Nevertheless, the rate of minor complications was significantly higher in ALPPS (59 vs. 18%, OR 6.5, p < 0.001) than in TSH. The two treatments were similar in 90-day mortality (7 vs. 5%, p = 0.43), major complications (29 vs. 22%, p = 0.08), posthepatectomy liver failure (PHLF; 9 vs. 9%, p = 0.3), biliary leakage (11 vs. 14%, p = 0.86), length of hospital stay (27.95 vs. 26.88 days, p = 0.8), 1-year overall survival (79 vs. 84%, p = 0.61), 1-year recurrence (49 vs. 39%, p = 0.32), and 1-year disease-free survival (34 vs. 39%, p = 0.66). Cumulative meta-analyses indicated chronological stability for the pooled effect sizes of resection rate, 90-day mortality, major complications, and PHLF.

Conclusions: Compared with TSH, ALPPS for advanced CRLM resulted in superior surgical efficacy with comparable perioperative mortality rate and short-term oncological outcomes, while this was at the cost of increased perioperative minor complications.

New frontiers in liver resection for hepatocellular carcinoma

Liver resection is one of the main curative options for early hepatocellular carcinoma (HCC) in patients with cirrhosis and is the treatment of choice in non-cirrhotic patients. However, careful patient selection is required to balance the risk of postoperative liver failure and the potential benefit on long-term outcomes. In the last decades, improved surgical techniques and perioperative management, as well as better patient selection, have enabled the indications for liver resection to be expanded. In this review, we aim to describe the main indications for liver resection in the management of HCC, its role compared to percutaneous ablation and liver transplantation in the therapeutic algorithm, as well as the recent advances in liver surgery that could be used to improve the prognosis of patients with HCC.

2019 Chinese clinical guidelines for the management of hepatocellular carcinoma: updates and insights

Importance

Approximately half of newly-diagnosed hepatocellular carcinoma (HCC) cases in the world occur in China, with hepatitis B virus (HBV) infection being the predominant risk factor. Recently, the guidelines for the management of Chinese HCC patients were updated.

Objective

The past decade has witnessed a great improvement in the management of hepatocellular carcinoma (HCC). This study reviews the recommendations in the 2019 Chinese guidelines and makes comparison with the practices from the Western world.

Evidence Review

The updated recommendations on the surveillance, diagnosis, and treatment algorithm of HCC in the 2019 Chinese guidelines were summarized, and comparisons among the updated Chinese guidelines, the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) guidelines were made.

Findings

Besides imaging and pathological diagnoses, novel biomarkers like the seven-micro-RNA panel are advocated for early diagnoses and therapeutic efficacy evaluation in the updated Chinese guidelines. The China liver cancer (CNLC) staging system, proposed in the 2017 guidelines, continues to be the standard model for patient classification, with subsequent modifications and updates being made in treatment allocations. Compared to the Barcelona Clinic Liver Cancer (BCLC) system, the CNLC staging system employs resection, transplantation, and transarterial chemoembolization (TACE) for more progressed HCC. TACE in combination with other regional therapies like ablation or with systemic therapies like sorafenib are also encouraged in select patients in China. The systemic treatments for HCC have evolved considerably since lenvatinib, regorafenib, carbozantinib, ramucirumab and immune checkpoint inhibitors (ICIs)were first prescribed as first-line or second-line agents.

Conclusions and Relevances

Novel biomarkers, imaging and operative techniques are recommended in the updated Chinese guideline. More aggressive treatment modalities are suggested for more progressed HBV-related HCC in China.

Correlation of clinical features with inferior right hepatic vein incidence: a three-dimensional reconstruction-based study

PURPOSE

The correlation between right hepatic vein (RHV) diameter and inferior RHV (IRHV) incidence and that between IRHV incidence and other clinical features remain unclear. We investigated factors correlated with IRHV incidence as well as provide a simple and reliable method for predicting IRHV presence preoperatively.

METHODS

We obtained computed tomography (CT) imaging data of 1980 patients from the Department of Radiology, Qingdao Municipal Hospital, from July 1, 2016, to July 1, 2017. We excluded patients with heart disease, inferior vena cava (IVC) disease, history of liver surgery or trauma, space-occupying lesions in the liver, and other diseases, which can cause hepatic hemodynamic changes. CT images of patients were three-dimensionally reconstructed. We measured RHV and IRHV diameter as well as the angle between the RHV and the IVC.

RESULTS

Data on 299 patients were included in this study; the incidence of IRHV was 34.44%. Sex, age, and the angle between the RHV and IVC did not correlate with IRHV incidence. RHV diameter negatively correlated with IRHV incidence (P < 0.05). The area under the receiver-operating characteristic curve for IRHV incidence was 0.878. The diagnostic threshold value of RHV diameter was 8.86 mm.

CONCLUSION

A negative correlation was found between RHV diameter and IRHV incidence, suggesting that IRHV is absent with RHV diameter > 8.86 mm, but is present with RHV diameter < 8.86 mm. This suggests that measuring only RHV diameter can predict the presence of an IRHV when IRHV-related hepatectomy and IRHV preserved living donor liver transplantation are needed.

A better route to ALPPS: minimally invasive vs open ALPPS

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has gained both interest and controversy, as an alternative to portal vein embolisation (PVE) by inducing future liver remnant hypertrophy in patients at risk of liver failure following major hepatectomy. Open ALPPS induces more extensive hypertrophy in a shorter timespan than PVE; however, it is also associated with higher complication rates and mortality. Minimally invasive surgery (MIS), with its known benefits, has been applied to ALPPS in the hope of reducing the surgical insult and improving functional recovery time while preserving the extensive FLR hypertrophy.

METHODS

A search of the PubMed, Medline, EMBASE and Cochrane Library databases was conducted on 10 July 2019. 1231 studies were identified and screened. 19 open ALPPS studies, 3 MIS ALPPS and 1 study reporting on both were included in the analysis.

RESULTS

1088 open and 46 MIS-ALPPS cases were included in the analysis. There were significant differences in the baseline characteristic: open ALPPS patients had a more diverse profile of underlying pathologies (p = 0.028) and comparatively more right extended hepatectomies (p = 0.006) as compared to right hepatectomy and left extended hepatectomy performed. Operative parameters (time and blood loss) did not differ between the two groups. MIS ALPPS had a lower rate of severe Clavien-Dindo complications (≥ IIIa) following stage 1 (p = 0.063) and significantly lower median mortality (0.00% vs 8.45%) (p = 0.007) compared to open ALPPS.

CONCLUSION

Although MIS ALPPS would seem to be better than open ALPPS with reduced morbidity and mortality rates, there is still limited evidence on MIS ALPPS. There is a need for a higher quality of evidence on MIS ALPPS vs. open ALPPS to answer whether MIS ALPPS can replace open ALPPS.

Acute kidney injury after associating liver partition and portal vein ligation for staged hepatectomy for hepatocellular carcinoma: two case reports and a literature review

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is used for avoiding postoperative live failure caused by insufficient future liver remnant (FLR) after major liver resection. However, ALPPS accompanied by high morbidity and mortality. The surgeons focus their attention mainly on the common complications such as bile leak, bleeding, infection and liver failure. Acute kidney injury (AKI) is a relatively rare postoperative complication, and get less attention. However, once AKI occurred after the surgery, it will seriously affect the prognosis of patients. We firstly report two cases of postoperative AKI after ALPPS in hepatocellular carcinoma with liver cirrhosis. Case 1, a 61-year-old male, chief complaint upper abdominal pain for half a month, medical examination found a huge liver space-occupying lesion. The clinical diagnosis was liver cancer, and ALPPS was performed. After the first step of surgery, delayed renal replacement therapy (RRT) was initiated when stage 3 AKI diagnosed. Although the second step surgery completed successfully, the patient eventually died of multiple organ dysfunction syndrome (MODS) induced by gastrointestinal bleeding. Case 2, a 64-year-old male chief complaint right liver mass present to our hospital, with a small FLR. Stage 2 AKI was diagnosed after the first step of ALPPS, early RRT was started immediately. Renal function gradually recovered, and the second step surgery was completed. The patient discharged with a good condition, found no recurrence in the latest follow-up. ALPPS for hepatocellular carcinoma with liver cirrhosis cases, more likely to happen AKI. More strict patient screening criteria, early RRT may improve the prognosis.

ALPPS for hepatocarcinoma under cirrhosis: a feasible alternative to portal vein embolization

Hepatocellular carcinoma (HCC) is one of the most common and malignant tumors. Preoperative portal vein embolization (PVE) is currently the most accepted treatment before major hepatic resection for HCC in patients with liver fibrosis or cirrhosis and associated insufficient future liver remnant (FLR). In the last decade, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique has been described to obtain an increase of volume regarding PVE and a decrease of drop out. The initial excessive morbidity and mortality of this technique have decreased drastically due to a better selection of patients, the learning curve and the use of less aggressive variations of the original technique in the first stage. For both techniques a complete preoperative assessment of the FLR is the most important issue and only patients with and adequate FLR should be resected. ALPPS could be a feasible technique in very selected patients with HCC and cirrhosis. As long as it is performed in an experienced center could be used as a first choice technique versus PVE or could be used as a rescue technique in case of PVE failure.