Left hepatectomy with concomitant cavo-atrial and biliary tumor thrombectomy for invasive hepatocellular carcinoma: a video report

HCC accounts for 90% of primary hepatic malignancies. Its 5-year survival rate has been estimated to be as low as 5% in the subpopulation of non-transplantable patients (2). HCC is endowed with a highly aggressive potential, possibly giving rise to tumor growth within blood vessels and resulting in neoplastic thrombosis of major vasculature, due to its remarkable vascular affinity. Widely reported in literature is the involvement of the portal system, variably described as an autoptic finding in 26–80% of HCCs, carrying a well-defined negative prognostic value (1,6). In contrast, IVC or right atrium involvement via the hepatic veins is a less frequent occurrence, displaying an incidence of 0.53% and noted in merely 6% of post-mortem autopsies (2). At present, no definitive global consensus or agreement has been reached regarding the management of HCC with IVC or cardiac tumor thrombosis. This is possibly due to the fact that patients with vascular neoplastic involvement, hence an advanced disease stage, do not meet traditional criteria for surgery because of reportedly poor postoperative outcomes. A surgical approach, associating liver resection with thrombectomy is apparently the sole possibility, among the available therapeutic armamentarium, for a radical tumor removal (6). Patients presenting with extensive tumor thrombus extension to the right atrium or further, may require a multidisciplinary approach inclusive of extracorporeal circulation. Surgery represents a potential treatment in cases where the primary tumor has characteristics of resectability and the estimated future liver remnant is sufficient to prevent postoperative hepatic failure. Nonetheless, effective oncological advantages in terms of overall survival after surgical treatment are currently uncertain. Available evidence predominantly includes case series and reports which do not allow to draw unbiased results and make definitive conclusions regarding survival advantages in this subgroup of patients (1,6). In conclusion, the prevalence of HCC is likely to rise due to the broad increase of worldwide obesity, with particular distribution within Western countries. Therapeutic and life-lengthening management options are various, although not all are endowed with curative intent. Nevertheless, treatment of HCC with vascular or bile duct extension poses further challenges. Amongst therapeutic approaches, hepatic resection associated with vascular and biliary thrombectomy displays a potentially favorable outcome in terms of overall survival and represents a viable option in selected patients. Nonetheless, randomized controlled trials are essential in order to validate treatment modality choice.