Zhu YB, Qin JY, Zhang TT, Zhang WJ, Ling Q. Reassessment of palliative surgery in conversion therapy of previously unresectable hepatocellular carcinoma: Two case reports and review of literature. World J Gastrointest Surg 2024; 16(10): 3312-3320 [DOI: 10.4240/wjgs.v16.i10.3312]
Corresponding Author of This Article
Qi Ling, PhD, Chief Doctor, Chief Physician, Professor, Surgeon, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou 310003, Zhejiang Province, China. lingqi@zju.edu.cn
Research Domain of This Article
Surgery
Article-Type of This Article
Case Report
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (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: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastrointest Surg. Oct 27, 2024; 16(10): 3312-3320 Published online Oct 27, 2024. doi: 10.4240/wjgs.v16.i10.3312
Reassessment of palliative surgery in conversion therapy of previously unresectable hepatocellular carcinoma: Two case reports and review of literature
Yang-Bo Zhu, Wen-Jin Zhang, Qi Ling, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
Yang-Bo Zhu, Wen-Jin Zhang, Qi Ling, Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
Jia-Yi Qin, Department of Clinical Pharmacy, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
Ting-Ting Zhang, Department of Medical Imaging, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
Co-first authors: Yang-Bo Zhu and Jia-Yi Qin.
Author contributions: Zhu YB and Qin JY designed and performed the research, managed the data curation, prepared and revised the draft; Zhang TT prepared images for submission; Zhang WJ provided the patient with informed consent and validated the research; Ling Q reviewed and edited the manuscript. All authors have read and approved the final manuscript. Zhu YB and Qin JY contributed equally to this work as co-first authors.
Supported byZhejiang Medical Science and Technology Project, No. 2023KY704; Zhejiang Traditional Chinese Medicine Science and Technology Project, No. 2023ZR107 and No. 2024ZF094; Special Research Fund for Hospital Pharmacy of Zhejiang Pharmaceutical Association, No. 2021ZYY08; and Zhejiang Medical Association Clinical Research Fund, No. 2021ZYC-A64 and No. 2021ZYC-A67.
Informed consent statement: The informed consent was obtained from all subjects and/or their legal guardian(s).
Conflict-of-interest statement: All authors stated that there was no potential conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
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: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Qi Ling, PhD, Chief Doctor, Chief Physician, Professor, Surgeon, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou 310003, Zhejiang Province, China. lingqi@zju.edu.cn
Received: April 19, 2024 Revised: August 30, 2024 Accepted: September 9, 2024 Published online: October 27, 2024 Processing time: 161 Days and 4.2 Hours
Abstract
BACKGROUND
Most patients with hepatocellular carcinoma (HCC) have lost the opportunity for direct surgery at the time of diagnosis. Transarterial chemoembolization (TACE) combined with immune checkpoint inhibitors or tyrosine kinase inhibitors (TKI) can partially transform some unresectable HCC and improve the prognosis effectively. However, based on the promising prospects of combined targeted and immunotherapy for the effective treatment of HCC, the positive role of palliative surgery in the conversion treatment of advanced HCC urgently needs further intensive re-assessment.
CASE SUMMARY
In this study, we describe two successful cases of "conversion therapy for unresectable HCC" achieved mainly by palliative surgery combined with TACE plus immunotherapy and TKIs. A 48-year-old patient with newly diagnosed HCC, presenting with a 6-cm mass in the segment VII/VIII of the right liver with multiple intrahepatic metastases, could not undergo one-stage radical surgical resection. He underwent palliative surgery with radiofrequency of metastatic lesions and the palliative resection of the primary mass, and received subsequent TACE treatments twice in the early postoperative period (2 weeks and 6 weeks), in addition to targeted and immune combination therapy with sintilimab injection and oral lenvatinib. No evidence of recurrence was observed during the 11-month follow-up period after surgery. The other patient was a 47-year-old patient with massive HCC (18 cm × 15 cm × 4.5 cm) in the left liver with severe cirrhosis. The left portal branch was occluded and a tumor thrombus formed, and the tumor partly involved the middle hepatic vein. The patient underwent palliative surgery of left hemihepatectomy (including resection of the middle hepatic vein) for HCC, followed by three TACE procedures and oral TKIs 2 weeks after surgery. Six months later, the re-examination via computed tomography revealed no tumour activity in the remaining right liver, while magnetic resonance imaging revealed slight local tumor enhancement in the caudate lobe of the liver considered, TACE was performed once again, and during the next follow-up of 10 months did not reveal new intrahepatic lesions or distant metastases.
CONCLUSION
These cases demonstrate that the addition of palliative surgery to conversion therapy in a selected population with a high tumor burden could benefit patients with initially unresectable HCC.
Core Tip: We herein present two successful cases of "conversion Therapy for unresectable hepatocellular carcinoma (HCC)" achieved mainly by palliative surgery combined with transarterial chemoembolization (TACE) plus immunotherapy and tyrosine kinase inhibitors. For some selected advanced HCC with a high risk of tumor overload and metastasis, if liver function permits, early palliative surgery combined with local subsequent TACE, along with targeted and immunotherapy, may be a tolerable and effective strategy, which may provide the opportunity for the ultimate cure for the initially unresectable HCC and effectively improve the long-term survival based on the promising prospects of combined targeted and immunotherapy.
