Cavo-atrial thrombectomy combined with left hemi-hepatectomy for vascular invasion from hepatocellular carcinoma on diseased liver under hypothermic cardio-circulatory arrest

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.

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.

Hepatocellular carcinoma with right atrial tumor thrombus

BACKGROUND

 Hepatocellular carcinoma with right atrial tumor thrombus is uncommon but with a dismal prognosis.

METHODS

 By comprehensive retrieval of literature published between 2000 and 2019, 53 reports were obtained with 187 patients recruited into this study. The extracted data included patient characteristics, tumor characteristics, treatment, follow-up and outcomes. Statistical analyses applied were student t, Fisher exact and I² tests. Patients were devided into 6 groups according to treatment of choices: transarterial chemoembolization (TACE), surgery, radiotherapy, chemotherapy, interventional treatment and supportive care.

RESULTS

 The overall survival rate of this cohort was 40.8 %. The survival rate of patients receiving TACE was 33.3 % and that of surgical patients was 41.9 %. The survival time of patients with TACE was longer than surgical patients, but lack of a statistical significance. Patients had a follow-up of 15.7 ± 16.6 (median 10) months. The patients receiving radiotherapy had the longest follow-up among all groups. Intra- and/or extrahepatic recurrence of hepatocellular carcinoma was the major morbidity. The mortality rates in a decremental sequence for patients receiving different treatments were supportive care > radiotherapy > surgery > TACE > interventional treatment. No difference was found in mortality between patients reported from case reports and those from non-case reports.

CONCLUSIONS

 Advanced hepatocellular carcinoma with right atrial thrombus is an aggressive malignancy. Based on the results of median survival time, radiotherapy and TACE seemed to be associated with an improved prognosis and possible better survival.

Surgical treatment of extensive hepatic alveolar echinococcosis using a three-dimensional visualization technique combined with allograft blood vessels: A case report

RATIONALE

Hepatic alveolar echinococcosis (HAE) presents a high pathogenicity and case fatality rate. The main treatment for HAE is surgical resection. Giant lesions in the liver and invasion of the pathogen into the retrohepatic inferior vena cava are usually associated with a poor prognosis when radical resection cannot be performed.

PATIENT CONCERNS

A 56-year-old man who underwent hydatidectomy 7 years prior noted a recurrence of HAE. He was subsidized and admitted to our hospital for the purpose of surgical treatment.

DIAGNOSIS

By computed tomography, angiography and three-dimensional (3D) computed tomography reconstruction images, multiple, giant HAE with 75% stenosis was confirmed.

INTERVENTIONS

With the 3D visualization technique, we designed the surgical plan and performed radical resection of the lesions, including the invaded inferior vena cava, and maximized retention of normal liver tissue. The abdominal aorta of an organ donor was used for vascular allograft reconstruction.

OUTCOMES

The patient recovered gradually after the operation. He was followed up for 3 months, and the reconstructed vein patency was good.

LESSONS

The 3D visualization technique combined with a blood vessel allograft allowed us to expand indications for radical resection of extensive HAE.

Long-term survival after anterior approach right hepatectomy combined with inferior vena cava thrombectomy using trans-diaphragmatic intrapericardial inferior vena cava occlusion: a case report and review of the literature

Background

Presence of inferior vena cava tumor thrombosis (IVCTT) is an unfavorable factor to prognosis for patients with hepatocellular carcinoma (HCC).

Case presentation

Herein we report a case of HCC with IVC tumor thrombosis extending from the right hepatic vein (RHV) to the IVC, but it had not infiltrated the right atrium. Anterior approach right hepatectomy combined with IVC thrombectomy using trans-diaphragmatic IVC occlusion was performed for this patient. The patient is alive with disease-free at 32 months after treatment. A literature review was also performed. This case was demonstrated with the details and concepts of surgery.

Conclusion

This case suggested that surgical resection of HCC involving the IVC, but still outside the right atrium (RA), could offer satisfactory surgical outcomes in selected patients.

Right Atrium Invasion of Tumor Thrombus from Hepatocellular Carcinoma Incidentally Found on Transthoracic Echocardiogram

Hepatocellular carcinoma (HCC) is a highly aggressive malignancy in which tumor thrombus can invade portal and hepatic veins in late stages. However, an antemortem diagnosis of right atrial invasion by tumor thrombus is very rare and confers a poor prognosis. We report a patient with antemortem diagnosis of tumor thrombus in the right atrium incidentally found by transthoracic echocardiogram which was later confirmed with CT scan of abdomen with IV contrast. The patient was also noted to have an acute increase in alpha-fetoprotein (AFP). Our case suggests the importance of imaging studies and monitoring AFP levels in patients with long standing HCC.

HCC with tumor thrombus entering the right atrium and inferior vena cava treated by percutaneous ablation

Background

In the advanced stages of hepatocellular carcinoma (HCC), a tumor thrombus (TT) can form in the portal or hepatic vein. The management of patients with advanced HCC and a TT extending into the right atrium (RA) and inferior vena cava (IVC) is extremely difficult and risky.

Case presentation

We report the case of a patient with HCC and a large TT (85 × 45 mm) extending into the RA through the hepatic vein and IVC, which is very rare. We performed percutaneous microwave ablation of the TT and the two intrahepatic tumors (maximum diameter, 57 mm). The treatment shrank the tumors, and the patient is in good condition and has survived for 16 months thus far. A literature review was also performed. This is the first such case to be treated with percutaneous microwave ablation.

Conclusion

The outcomes in this case suggest that percutaneous ablation is useful for the treatment of TT extending into the RA and IVC in patients with HCC.

Surgical resection of recurrent extrahepatic hepatocellular carcinoma with tumor thrombus extending into the right atrium under cardiopulmonary bypass: a case report and review of the literature

Background

Recurrent hepatocellular carcinoma accompanied by a right atrial tumor thrombus is rare. No standard treatment modality has been established. Surgical treatment may be the only curative treatment; however, surgery has been considered high risk. We herein describe a patient who underwent resection of a recurrent right atrial tumor thrombus under normothermic cardiopulmonary bypass on a beating heart.

Case presentation

A 60-year-old man underwent a right hepatectomy for hepatocellular carcinoma with diaphragm invasion. During the preoperative cardiac screening, he was diagnosed with an old myocardial infarction with triple-vessel coronary disease. Percutaneous coronary intervention was performed for the left anterior descending artery and left circumflex coronary artery. High-grade stenosis remained in his right coronary artery. Nine months later, computed tomography showed recurrent hepatocellular carcinoma in the diaphragm and a tumor thrombus extending from the suprahepatic inferior vena cava into the right atrium. Surgical resection of the recurrent tumor was performed through a right subcostal incision with xiphoid extension and median sternotomy. The recurrent tumor was incised with the diaphragm and pericardium. Intraoperative ultrasonography revealed that the tumor thrombus was free from right atrium wall invasion and that the right atrium could be clamped just proximal to the tumor thrombus. The right atrium, infrahepatic vena cava, left and middle hepatic veins, and hepatoduodenal ligament were encircled. Cardiopulmonary bypass was performed to prevent ischemic heart disease caused by intraoperative hypotension. Total hepatic vascular exclusion was then performed under normothermic cardiopulmonary bypass on heart beating. The inferior vena cava wall was incised. The tumor thrombus with the diaphragmatic recurrent tumor was resected en bloc. The patient had a favorable clinical course without any complications.

Conclusion

The recurrent hepatocellular carcinoma in the diaphragm and the right atrial tumor thrombus were safely resected using normothermic cardiopulmonary bypass on heart beating.

Hepatocellular carcinoma on cirrhosis complicated with tumoral thrombi extended to the right atrium: results in three cases treated with major hepatectomy and thrombectomy under hypothermic cardiocirculatory arrest and literature review

Background

Hepatocellular carcinoma (HCC) with the presence of tumor thrombus in hepatic veins and vena cava, until the atrium (RATT), is correlated with poor prognosis and with risk of tricuspid valve occlusion, congestive heart failure, and pulmonary embolism.

Methods

Three patients with HCC on cirrhotic liver with RATT were studied. Operative technique, pre-operative and post-operative liver function tests, blood loss and transfusions, post-operative morbidity and mortality, and the overall survival and the disease free survival were analyzed.

Results

Mean operative time was 336 ± 66 min. Intra-operative blood loss was 926.6 ± 325.9 ml. No major complications occurred. The times of hospital stay were 10, 21, and 19 days, respectively. The survival times were 90, 161, and 40 days, and the disease-free survival times were 30, 141, and 30 days, respectively.

Conclusions

The complete removal of HCC with RATT may be achieved with cardiopulmonary by-pass (CPB) and total hepatic vascular exclusion (THVE). Adding the hypothermic cardiocirculatory arrest (HCCA) to the use of CPB allowed us to have minimal blood loss and hemostasis of the resectional plane. So the use of CPB and HCCA should be considered a good therapeutic alternative to the normothermic CPB with THVE.

Hepatocellular Carcinoma With Tumor Thrombus Occupying the Right Atrium and Portal Vein: A Case Report and Literature Review

Hepatocellular carcinoma (HCC) patients with tumor thrombus extended through the major hepatic veins and inferior vena cava into the right atrium (RA) are rare, and most cases are considered as the advanced stage with a poor prognosis.We report a case of HCC with a tumor thrombus extending into the RA and a tumor thrombus in the portal vein. A literature search for case reports was performed on PubMed.Compared with the published literature, our case is one of the youngest patients, but with the most advanced HCC that invades both the hepatic inflow and outflow vasculature. For this patient, we resected the tumor thrombus in the RA with the use of cardiopulmonary bypass, and then removed the tumor thrombus in the portal vein and ligated the left branch of portal vein. Because of insufficient remnant liver volume, microwave ablation and transcatheter arterial chemoembolization were performed to control the growth of HCC. The patient survived 6 months after surgery.This case suggests that for patients with extension of HCC into the RA and portal vein, surgery is a useful therapeutic modality, even in case that liver tumor cannot be resected.

Liver resection with thrombectomy as a treatment of hepatocellular carcinoma with major vascular invasion: results from a retrospective multicentric study

BACKGROUND

The role of liver resection (LR) of hepatocellular carcinoma with macroscopic vascular thrombosis (MVT) remains controversial. The aim of this study is to evaluate whether the presence of MVT should still be considered a contraindication for LR.

METHODS

Retrospective study was carried out on 62 patients who underwent LR and thrombectomy for hepatocellular carcinoma complicated by MVT. Of the 62 patients, 15 (36.5%) had tumor thrombus (TT) in the peripheral portal vein (Vp1), 5 (12.2%) in second branch (Vp2), and 21 (51.3%) in the first branch/portal vein trunk (Vp3), while on the hepatic/cava vein side, 8 (12.9%) had TT in the main trunk of the hepatic veins (Vv2) and 3 (4.8%) had TT reaching the vena cava/right atrium (Vv3).

RESULTS

Perioperative major morbidity was 14.5%, while in-hospital mortality was 4.8%. Overall, 1, 3, and 5-year survival rates were 53.3%, 30.1%, and 20%, and disease-free survival rates were 31.7%, 20.8%, and 15.6%, respectively. There were no differences in survival about the MVT localized in Vp1, Vp2, or Vp3 (P = .77), while we found a statistical trend between patients with Vv2 and Vv3 (P = .06).

CONCLUSION

Surgical resection seems to be justified in these patients, and the presence of MVT should no longer be considered an absolute contraindication for LR.

Isolated metastases of hepatocellular carcinoma in the left atrium, unresponsive to treatment with sorafenib

Isolated metastases in the left atrium that are discontinuous with an intrahepatic hepatocellular carcinoma (HCC) are extremely rare. This is the case report of a 46-year-old male patient with pulmonary metastases from HCC, who presented with a tumor in the left lung, extending to the left atrium through the left pulmonary vein. Two weeks after the initiation of treatment with sorafenib, the tumor metastasized to the left parietal cerebral lobe, with an intracranial hemorrhage. Although the patient underwent gamma knife radiosurgery for the metastatic brain tumor, his condition gradually deteriorated and he succumbed to multiple organ failure 4 months later. Given the severe complications that have been reported in patients with this type of metastasis, immediate multidisciplinary treatment, including surgical resection, should be considered.

Cavoatrial thrombectomy in hepatocellular carcinoma with tumor thrombus in the vena cava and atrium without the use of cardiopulmonary bypass

BACKGROUND

Hepatocellular carcinoma (HCC) with tumor thrombus (TT) in hepatic vein, inferior vena cava (IVC), and right atrium (RA) portends a poor prognosis because of intravascular extension leading to rapid distal metastases. En bloc resection of cavoatrial TT without the use of cardiopulmonary bypass (CPB) is challenging. We describe a new method of vascular occlusion for thrombus entering into the RA without the need for CPB as shown in echocardiography.

METHODS AND RESULTS

Retrospective analysis was carried out in 1 HCC patient, who had undergone hepatectomy with TT extension into IVC and RA. The infrahepatic IVC was occluded with vascular tape and the right atrial appendage was controlled with a Satinsky clamp proximal to the TT. The IVC wall was incised under direct vision from the infrahepatic IVC cranially. The tumor and thrombus were then removed en bloc under direct vision. Thus, cavoatrial thrombectomy was performed under total hepatic vascular exclusion without the use of CPB. He survived for 6 months and died of tumor recurrence.

CONCLUSIONS

Using this technique, advanced HCC with cavoatrial TT can be resected safely without CPB and thereby avoid dislodgement of TT and air embolism.

Survival benefit of surgical treatment for hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus: results of a retrospective cohort study

BACKGROUND

The significance of surgery in the treatment of hepatocellular carcinoma (HCC) extending into the inferior vena cava (IVC)/right atrium (RA) is currently unclear. We sought to clarify whether surgical treatment can improve survival in such patients.

METHODS

A retrospective review was undertaken of patients with HCC and IVC/RA tumor thrombus who were potential candidates for surgery but who were finally treated surgically and nonsurgically between September 2000 and October 2010. The patients were subdivided according to therapeutic modalities, and the results for each group were compared.

RESULTS

A total of 56 patients were included in this study. They were divided into three groups. Twenty-five patients underwent hepatectomy plus thrombectomy (surgical group), with minor morbidity and no mortality; the patients in this group had 1-, 3-, and 5-year survival rates of 68.0, 22.5, and 13.5%, respectively, with a median survival of 19 months. Twenty patients were treated with transcatheter arterial chemoembolization, with 1- and 3-year survival rates of 15.0 and 5.0%, respectively (median survival 4.5 months). Eleven patients received symptomatic treatment only, and no one in this group survived longer than 1 year (median survival 5 months). The patients in surgical group survived significantly longer than the patients in the other two groups (p < 0.001).

CONCLUSIONS

Although technically challenging, surgery for HCC with IVC/RA tumor thrombus can be safely performed and should be considered in patients with resectable primary tumor and sufficient hepatic reservoir because compared with transcatheter arterial chemoembolization or symptomatic treatment, it significantly improved patient survival.