Surgical Resection of a Recurrent Hepatocellular Carcinoma with Portal Vein Thrombosis: Is It a Good Treatment Option? A Case Report and Systematic Review of the Literature

Background: Hepatocellular carcinoma (HCC) is the sixth most frequent diagnosed tumor
worldwide and the third leading cause of cancer related death. According to the EASL Guidelines,
HCC with portal vein tumor thrombosis (PVTT) is classified as an advanced stage (BCLC stage C)
and the only curative option is represented by systemic therapy. Therefore, treatment of HCC
patients with PVTT remains controversial and debated. In this paper, we describe the case of a 66‐
year‐old man with a recurrent HCC with PVTT who underwent surgical resection. A systematic
review of the literature, comparing surgical resection with other choices of treatment in HCC
patients with PVTT, is reported. Methods: A systematic review of the literature regarding all
prospective and retrospective studies comparing the survival outcomes of HCC patients with PVTT
treated with surgical resections (SRs) or other non‐surgical treatments (n‐SRs) has been conducted.
Case presentation: A 66‐year‐old Caucasian man with a history of Hepatitis C Virus (HCV) related
liver cirrhosis and previous hepatocellular carcinoma of the VI segment treated with percutaneous
ethanol infusion (PEI) seven years before presented to our clinics. A new nodular hypoechoic lesion
in the VI hepatic segment was demonstrated on follow‐up ultrasound examination. A
hepatospecific magnetic resonance imaging (MRI) scan confirmed also the presence of a 18 × 13 mm
nodular lesion in the V hepatic segment with satellite micronodules associated with V‐VIII sectoral
portal branch thrombosis. The case was then discussed at the multidisciplinary team meeting, and
it was decided to perform a right hepatectomy. The postoperative course was regular and
uneventful, and the discharge occurred seven days after the surgery. At eight‐month follow‐up,
there was no clinical nor radiological evidence of neoplastic recurrence, with well‐preserved liver
function (Child‐Pugh A5). Results: Nine studies were included in the review. Median Overall
Survaival (OS) ranged from 8.2 to 30 months for SRs patients and from 7 to 13.3 for n‐SRs patients.
In SR patients, one‐year survival ranged from 22.7% to 100%, two‐year survival from 9.8% to 100%,
and three‐year survival from 0% to 71%. In n‐SRs patients, one‐year survival ranged from 11.8% to
77.6%, two‐year survival from 0% to 47.8%, and three‐year survival from 0% to 20.9%. Conclusion:
The present systematic literature review and the case presented demonstrated the efficacy of
surgery as a first‐line treatment in well‐selected HCC patients with PVTT limited or more distal to
the right and left portal branches. However, further studies, particularly randomized trials, need to
be conducted in future to better define the surgical indications.