Reply to: “ALPPS procedure for hepatocellular carcinoma with macrovascular thrombosis: A new opportunity?”
Authors: Takashi Kokudo, Kiyoshi Hasegawa, Norihiro Kokudo
Journal: Journal of Hepatology (2014)

ALPPS procedure for hepatocellular carcinoma with macrovascular thrombosis: A new opportunity?Journal of HepatologyVol. 62Issue 1PreviewWe read with interest the recent article entitled, “Surgical treatment of hepatocellular carcinoma associated with hepatic vein tumour thrombosis” published by Kokudo et al. [1]. 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). Full-Text PDF Open AccessSurgical 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 We would like to thank Levi Sandri and colleagues for their comments regarding our recently published article [[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 (105) Google Scholar]. 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]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: 1510-1519Crossref PubMed Scopus (214) Google Scholar]. HCC with macroscopic vascular invasion is a challenging situation for surgical resection [[3]Bruix J. Sherman M. Management of hepatocellular carcinoma.Hepatology. 2005; 42: 1208-1236Crossref PubMed Scopus (5123) Google Scholar], and major hepatic resection is often required [1Kokudo 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 (105) Google Scholar, 4Inoue Y. Hasegawa K. Ishizawa T. Aoki T. Sano K. Beck Y. et al.Is there any difference in survival according to the portal tumor thrombectomy method in patients with hepatocellular carcinoma?.Surgery. 2009; 145: 9-19Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 5Minagawa M. Makuuchi M. Takayama T. Ohtomo K. Selection criteria for hepatectomy in patients with hepatocellular carcinoma and portal vein tumor thrombus.Ann Surg. 2001; 233: 379-384Crossref PubMed Scopus (203) Google Scholar]. Considering the progressive nature of the disease, an urgent operation is also required. These situations complicate the decision-making process, and many cases miss their chance for a curative resection. Since ALPPS is reportedly associated with a rapid hypertrophy of the remnant liver [[2]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: 1510-1519Crossref PubMed Scopus (214) Google Scholar], this technique may be a promising strategy for treating HCC with macroscopic vascular invasion. We have never attempted ALLPS in this setting. Instead, we have proposed preoperative portal vein embolization (PVE) as a possible strategy in cases with an insufficient postoperative remnant liver volume [[6]Imamura H. Shimada R. Kubota M. Matsuyama Y. Nakayama A. Miyagawa S. et al.Preoperative portal vein embolization: an audit of 84 patients.Hepatology. 1999; 29: 1099-1105Crossref PubMed Scopus (334) Google Scholar]. Actually, among 14 patients who underwent a major hepatic resection for mHVTT, 4 patients (29%) underwent preoperative PVE [[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 (105) Google Scholar]. At present, PVE may be a standard strategy with an acceptable morbidity rate [[7]Aoki T. Imamura H. Hasegawa K. Matsukura A. Sano K. Sugawara Y. et al.Sequential preoperative arterial and portal venous embolizations in patients with hepatocellular carcinoma.Arch Surg. 2004; 139: 766-774Crossref PubMed Scopus (161) Google Scholar]. The presence of portal hypertension and impaired liver function (a 15 min indocyanine green retention rate of more than 20%) are contraindications for PVE [[8]Seyama Y. Kokudo N. Assessment of liver function for safe hepatic resection.Hepatol Res. 2009; 39: 107-116Crossref PubMed Scopus (154) Google Scholar]. These safety restrictions should also be applied to ALPPS, since it is a more aggressive strategy. As Levi Sandri et al. proposed, the Child-Pugh score and the model for end-stage liver disease score may be useful for making treatment-related decisions. Data on this attractive approach are now being accumulated through a worldwide registry system. However, the available evidence remains insufficient to support the use of ALPPS in cirrhotic patients with HCC [2Schadde 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: 1510-1519Crossref PubMed Scopus (214) Google Scholar, 9Vennarecci 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; 40: 982-988Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar]. Most of the evidence regarding ALPPS is based on patients with colorectal liver metastases, in whom the liver function has not been severely damaged. We expect further reports on the role of the ALPPS procedure for HCC patients requiring major hepatectomy. The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.