Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 21, 2022; 28(7): 704-714
Published online Feb 21, 2022. doi: 10.3748/wjg.v28.i7.704
Will the collaboration of surgery and external radiotherapy open new avenues for hepatocellular carcinoma with portal vein thrombosis?
Jung Wan Choe, Hye Yoon Lee, Chai Hong Rim
Jung Wan Choe, Department ofInternal Medicine, Korea University Ansan Hospital, Ansan 15355, South Korea
Hye Yoon Lee, Department of Surgery, Korea University Ansan Hospital, Ansan 15355, South Korea
Chai Hong Rim, Department of Radiation Oncology, Korea University Ansan Hospital, Ansan 15355, South Korea
Author contributions: Rim CH contributed to conceptualization; Lee HY supervised the study; Choe JW and Rim CH wrote the original draft; Choe JW, Lee HY and Rim CH reviewed and edited the manuscript; All authors have read and agreed to the published version of the manuscript.
Supported by the National Research Fund of Korea, No. NRF-2021R1I1A2047475.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Chai Hong Rim, MD, PhD, Assistant Professor, Department of Radiation Oncology, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan 15355, South Korea.
Received: October 28, 2021
Peer-review started: October 28, 2021
First decision: December 12, 2021
Revised: December 17, 2021
Accepted: January 19, 2022
Article in press: January 19, 2022
Published online: February 21, 2022

Portal invasion of hepatocellular carcinoma (HCC) occurs in 12.5%-40% of patients diagnosed with cancer and yields poor clinical outcomes. Since it is a common cause of inoperability, sorafenib was regarded as the standard treatment for HCC in the Barcelona Clinic of Liver Cancer guidelines. However, the median survival of the Asian population was only approximately 6 mo, and the tumor response rate was less than moderate (< 5%). Various locoregional modalities were performed, including external beam radiotherapy (EBRT), transarterial chemoembolization, hepatic arterial infusion chemotherapy, and surgery, alone or in combination. Among them, EBRT is a noninvasive method and can safely treat tumors involving the major vessels. Palliative EBRT has been commonly performed, especially in East Asian countries, where locally invasive HCC is highly prevalent. Although surgery is not commonly indicated, pioneering studies have demonstrated encouraging results in recent decades. Furthermore, the combination of neo- or adjuvant EBRT and surgery has been recently used and has significantly improved the outcomes of HCC patients, as reported in a few randomized studies. Regarding systemic modality, a combination of novel immunotherapy and vascular endothelial growth factor inhibitor showed results superior to that of sorafenib as a first-line agent. Future clinical trials investigating the combined use of these novel agents, surgery, and EBRT are expected to improve the prognosis of HCC with portal invasion.

Keywords: Surgery, Hepatocellular carcinoma, Radiotherapy, Systemic treatment

Core Tip: The prognosis of hepatocellular carcinoma with portal vein involvement is poor, and there had been few available local modalities. However, with the development of radiotherapy techniques, the 1-year survival rate has been reported to be close to 45%-50% after palliation. Recently, a surgical approach has also been attempted showing encouraging results. Furthermore, the combination of surgery and radiation therapy showed effective results in studies including randomized studies. The combination of these two modalities are expected to increase efficacy of treating hepatocellular carcinoma with portal invasion.