ALPPS procedure for hepatocellular carcinoma with macrovascular thrombosis: A new opportunity?
Authors: Giovanni Battista Levi Sandri, Quirino Lai, Michel Rayar, Laurent Sulpice
Journal: Journal of Hepatology (2014)

Surgical treatment of hepatocellular carcinoma associated with hepatic vein tumor thrombosisJournal of HepatologyVol. 61Issue 3PreviewPresence of hepatic vein tumor thrombosis (HVTT) in patients with hepatocellular carcinoma (HCC) is regarded as signaling an extremely poor prognosis. However, little is known about the prognostic impact of surgical treatment for HVTT. Full-Text PDF Reply to: “ALPPS procedure for hepatocellular carcinoma with macrovascular thrombosis: A new opportunity?”Journal of HepatologyVol. 62Issue 1PreviewWe would like to thank Levi Sandri and colleagues for their comments regarding our recently published article [1]. The authors support our result that neither tumour thrombosis in a major hepatic vein (mHVTT) nor portal vein tumour thrombosis, not invading the main portal trunk, is a contraindication for liver resection. In addition, they proposed further an aggressive strategy for unresectable hepatocellular carcinoma (HCC), i.e., associating liver partition and portal vein ligation in a staged hepatectomy (ALPPS) [2]. Full-Text PDF Open Access We read with interest the recent article entitled, “Surgical treatment of hepatocellular carcinoma associated with hepatic vein tumour thrombosis” published by Kokudo et al. [[1]Kokudo T. Hasegawa K. Yamamoto S. Shindoh J. Takemura N. Aoki T. et al.Surgical treatment of hepatocellular carcinoma associated with hepatic vein tumor thrombosis.J Hepatol. 2014; 61: 583-588Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar]. We congratulate the authors for their study, based on an experience of over 1500 liver resections. The authors conclude that surgical treatment of patients with tumour thrombosis, involving major hepatic veins (mHVTT), does not differ in terms of mortality, length of hospital stay and frequency of complications compared with patients with microscopic invasion (pHVTT). We agree with the authors’ conclusion. Major hepatectomy was performed in 67% of the cases in the mHVTT group, including four where right extended or left hepatectomy was required. We would like to draw attention to those selected patients. Since the first two-staged hepatectomy reports [[2]Adam R. Laurent A. Azoulay D. Castaing D. Bismuth H. Two-stage hepatectomy: a planned strategy to treat irresectable liver tumors.Ann Surg. 2000; 232: 777-785Crossref PubMed Scopus (634) Google Scholar], liver resection indications have been implemented with new surgical treatments, such as the Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) procedure. Vennarecci et al. [[3]Vennarecci G. Laurenzi A. Santoro R. Colasanti M. Lepiane P. Ettorre G.M. The ALPPS procedure: a surgical option for hepatocellular carcinoma with major vascular invasion.World J Surg. 2014; 38: 1498-1503https://doi.org/10.1007/s00268-013-2296-yCrossref PubMed Scopus (39) Google Scholar] described the ALPPS procedure for hepatocellular carcinoma (HCC) with major vascular invasion and concluded that this technique may increase the rate of curative liver resections for tumours previously considered unresectable. Kokudo et al. [[1]Kokudo T. Hasegawa K. Yamamoto S. Shindoh J. Takemura N. Aoki T. et al.Surgical treatment of hepatocellular carcinoma associated with hepatic vein tumor thrombosis.J Hepatol. 2014; 61: 583-588Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar] considered surgical resection of cases where preoperative characteristics jeopardize oncological radicality, only with the intent to prevent embolic complications or tumour rupture. The authors suggested that this aggressive surgical approach should be considered only in Child-Pugh class A patients, in which liver function is still acceptable. We agree with this statement. A multicentre analysis recently confirmed that the ALPSS procedure offers a better chance for complete resection in patients with primarily unresectable liver tumours [[4]Schadde E. Ardiles V. Slankamenac K. Tschuor C. Sergeant G. Amacker N. et al.ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors compared with conventional-staged hepatectomies: results of a multicenter analysis.World J Surg. 2014; 38: 1510-1519https://doi.org/10.1007/s00268-014-2513-3Crossref PubMed Scopus (207) Google Scholar]. In another study, ALPPS has been described for cirrhotic patients with HCC [[5]Vennarecci G. Laurenzi A. Levi Sandri G.B. Busi Rizzi E. Cristofaro M. Montalbano M. et al.The ALPPS procedure for hepatocellular carcinoma.Eur J Surg Oncol. 2014; (pii: S0748-7983(14)00397-7)https://doi.org/10.1016/j.ejso.2014.04.002Abstract Full Text Full Text PDF Scopus (48) Google Scholar], in which all resected cases had preserved liver function (Child-Pugh class A). An increase in the future liver remnant (FLR) from 33% to 43% was observed within one week; this increase reached 54% after hepatectomy. These important results suggest that it is possible to achieve R0 resection in patients with mHVTT as long as patients present preserved liver function. Notwithstanding, ALPPS represents a suitable indication only in a small number of patients with portal vein thrombosis (PVT). In fact, patients treatable with ALPPS should be carefully selected and evaluated in order to draw a benefit in terms of survival. Model for end-stage liver disease (MELD) and portal hypertension (PHT) are two crucial factors in decision making for surgical resection, especially when major liver resection or the ALPPS procedure are contemplated. As previously described, liver resection in cirrhotic patients with MELD score >14 is not recommended [[6]Hofmann W.P. Rädle J. Moench C. Bechstein W. Zeuzem S. Prediction of perioperative mortality in patients with advanced liver disease and abdominal surgery by the use of different scoring systems and tests.Z Gastroenterol. 2008; 46: 1283-1289Crossref PubMed Scopus (17) Google Scholar], and when the score is >9 other treatment modalities should be considered [[7]Teh S.H. Christein J. Donohue J. Que F. Kendrick M. Farnell M. et al.Hepatic resection of hepatocellular carcinoma in patients with cirrhosis: Model of End-Stage Liver Disease (MELD) score predicts perioperative mortality.J Gastrointest Surg. 2005; 9: 1207-1215Crossref PubMed Scopus (197) Google Scholar]. PHT was for a long time considered an absolute contraindication for liver resection. However, recent experiences suggest that liver surgery can be safety achieved also in the presence of PHT, mainly in the case of limited hepatic resections in patients with Child-Pugh A [8Cucchetti A. Ercolani G. Vivarelli M. Cescon M. Ravaioli M. Ramacciato G. et al.Is portal hypertension a contraindication to hepatic resection?.Ann Surg. 2009; 250: 922-928https://doi.org/10.1097/SLA.0b013e3181b977a5Crossref PubMed Scopus (193) Google Scholar, 9Santambrogio R. Kluger M.D. Costa M. Belli A. Barabino M. Laurent A. et al.Hepatic resection for hepatocellular carcinoma in patients with Child-Pugh’s A cirrhosis: is clinical evidence of portal hypertension a contraindication?.HPB (Oxford). 2013; 15: 78-84https://doi.org/10.1111/j.1477-2574.2012.00594Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 10Shi J. Lai E.C. Li N. Guo W.X. Xue J. Lau W.Y. et al.A new classification for hepatocellular carcinoma with portal vein tumor thrombus.J Hepatobiliary Pancreat Sci. 2011; 18: 74-80Crossref PubMed Scopus (130) Google Scholar]. Nevertheless, we believe that PHT must remain a contraindication for ALPPS procedure as well as for major hepatic resections. According to the classification of PVT by Shi et al. [[10]Shi J. Lai E.C. Li N. Guo W.X. Xue J. Lau W.Y. et al.A new classification for hepatocellular carcinoma with portal vein tumor thrombus.J Hepatobiliary Pancreat Sci. 2011; 18: 74-80Crossref PubMed Scopus (130) Google Scholar] we suggest type III-IV as contraindications for the ALPPS procedure, whilst type I-II can be safely approached with this surgical technique. The suboptimal effect on the regeneration of truncal with respect to segmental/subsegmental PVT must also be taken into account. Various grades of liver atrophy consequent to truncal/main PVT can be preoperatively evaluated with volumetric computed tomography (volCT), calculating in this way the liver remnant to body weight ratio (BWR). The volCT scan can be repeated after the first surgical step, starting from postoperative day 7. Patients can be scheduled for the second step when a liver remnant to BWR of 0.8 was achieved. Consistent with these arguments, ALPPS seems to be an intriguing strategy, which should be explored in the next future. ALLPS can represent a valid approach also in patients with mHVTT, with the intent to increase the surgical indications. In conclusion, we hope that further studies will focus their attention on patients with HCC that are presently considered unresectable. Multicentre studies are aimed to better define indications for HCC in cirrhotic patients with hepatic vein tumour thrombosis. The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.