Shirabe K, Shimada M, Gion T et al 1999 Postoperative liver failure after major hepatic resection for hepatocellular carcinoma in the modern era with special reference to remnant liver v
Trang 1HCC in patients with cirrhosis PVE was performed when the FLR volume was pre-dicted to be less than 40% and led to significant increases in the FLR volumes in all embolized patients Importantly, none of 10 patients who underwent PVE had liver failure or death following resection whereas three of 19 patients in the non-PVE group suffered liver failure and one patient died Overall survival (44% non-PVE
vs 53% no PVE), disease-free survival (21% PVE vs 17% no PVE), and com-plication rates (56% PVE vs 57% no PVE) were similar with or without PVE Importantly, Wakabayashi and colleagues found that overall and disease-free sur-vival rates remain similar between the groups even after adjustment for HCC stage (overall survival: 40% PVE vs 46% no PVE; disease-free survival: 28% PVE vs.
13% no PVE; both P = NS) Tanaka and colleagues [108] reported several benefits
of PVE in a larger study of patients with HCC and cirrhosis Disease-free survival rates were similar, but cumulative survival rates were significantly higher in the PVE group than in the non-PVE group In addition, patients with recurrence fol-lowing PVE plus resection were more often candidates for further treatments such
as chemoembolization, an additional benefit of PVE in the long term (Table 11.2) [109–111].
Another study validated residual volume as the key to prediction of postopera-tive liver function and posthepatectomy course and the utility of PVE in patients with HCC Palavecino and colleagues [112] evaluated 54 patients that underwent major hepatic resection for HCC between 1998 and 2007 and PVE was performed
when the FLR volume was predicted to be insufficient [PVE group (n = 21),
non-PVE group (n = 33)] Both groups had similar rates of fibrosis or cirrhosis, HCV, HBV, American Joint Committee on Cancer stage, preoperative
chemoemboliza-tion, overall postoperative complications and positive margin (P all non-significant).
There were no perioperative deaths in the PVE group and six (18%) in the non-PVE
group (P = 0.038) Excluding these perioperative deaths, the overall survival rates at
1, 3, and 5 years were 94, 82, and 72% in the PVE group and 93, 63, and 54% in
the non-PVE group, respectively (P = 0.35) Similarly, disease-free survival was not significantly different between the groups, with 1-, 3- and 5-year disease-free survival of 84, 56, and 56% in the PVE group and 66%, 49% and 49% in the
non-PVE group, respectively (P = 0.38) The authors concluded that PVE before major hepatectomy for HCC is associated with improved perioperative outcome Further, excluding perioperative mortality, overall survival and disease-free survival rates were similar between patients with and without preoperative PVE.
Some data suggest that not only PVE provides an outcome benefit in patients with cirrhosis but the greatest outcome benefit may occur within the patient subset with worse liver function In one study, multivariate analysis revealed that preoperative PVE was an independent predictor of survival following resection in patients with preoperative indocyanine green retention ≤ 13 (5-year overall survival rate, 52%
PVE vs 20% no PVE; P = 0.002) [108].
The combination of chemoembolization of the tumor followed by PVE before hepatectomy may further improve long-term outcomes after major resection for HCC Aoki and colleagues reported on their experience with this strategy in
17 patients and found 5-year overall and disease-free survival rates of 56 and 47%,
Trang 2Major hepatectomy (%)
complica- tions/hepatic insuf
3 7
50 16
Trang 3respectively In a similar retrospective study, Ogata and colleagues [93] found that chemoembolization followed by PVE led to complete necrosis of the tumor in more than 80% of patients, compared to 5% with PVE alone They also found that chemoembolization followed by PVE was associated with better 5-year disease-free
survival rates than PVE alone (37% vs 19%; P = 0.04), primarily due to lower rates
of early recurrence in the liver.
The outcome from PVE and subsequent resection may be even more closely linked to the PVE technique in patients with otherwise normal livers than in patients with chronically diseased livers In patients with cirrhosis, RPVE (without seg-ment 4) is the most common technique used since extended hepatectomy is rarely indicated or possible In patients without cirrhosis who have HCC [113], extended right or less commonly left hepatectomy is often indicated In the case of extended right hepatectomy, owing to the consistently small volume of the left lateral liver (segments 2/3), preoperative PVE is frequently needed [69].
A recent report from M.D Anderson Cancer Center considered 127 consecu-tive extended hepatectomies using standardized liver volume calculations to select patients for PVE [6] In this series that was not limited to patients with HCC,
31 (24.4%) of the patients underwent PVE prior to extended hepatectomy Only six patients (5%) experienced significant postoperative liver insufficiency (total bilirubin level >10 mg/dL or international normalized ratio >2) The postoperative complication rate was 30.7% (39/127), and only one patient (0.8%) died after hepa-tectomy The median survival was 41.9 months, and the overall 5-year survival rate was 26% for the entire group The low mortality rate following extended hepatec-tomy in this series reflects many factors, among which was the systematic attention
to FLR volume and the use of PVE based on the indications reviewed above.
Conclusions
PVE is now a validated technique to increase the volume and function of the rem-nant liver prior to resection of hepatobiliary cancer PVE increases the safety of major resection in patients with liver disease and extends the option of resection
to patients with multiple hepatic metastases and limited parenchymal sparing from metastatic disease Careful attention to key factors, such as the presence or absence
of underlying liver disease, adjustment of liver size to patient size using proper techniques to measure the liver remnant, and recognition of the physiologic effect
of the type of hepatic and extrahepatic procedure planned, permits the appropriate selection of patients for PVE The FLR should be measured and standardized to the patient using the calculated FLR/TELV ratio, because this method produces a reproducible, accurate index of posthepatectomy liver function Currently recom-mended thresholds prompting consideration of preoperative PVE are FLR/TELV ratios of ≤20% for patients with an otherwise normal liver, ≤30% for patients who have received high-dose chemotherapy, and <40% for patients with chronic liver
Trang 4disease Continued critical analysis of the factors affecting liver hypertrophy in par-allel with improvements in oncologic treatments will further improve the selection and outcomes of patients with liver cancer considered for PVE.
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