Portal Vein Tumoral Thrombosis (PVTT) and management
We present a comprehensive overview of various diagnostic methods for PVTT detection, such as ultrasound, contrast-enhanced ultrasound, CT scans, MRI, and PET/CT, each offering unique insights into the extent and nature of the disease. Our focus then shifts to the nuanced world of TACE treatment, examining its efficacy across different PVTT stages as classified by Ikai et al. (LCSGJ) and other systems. We provide detailed tables summarizing key studies, highlighting patient cohorts, PVTT classifications, median survival times, and survival rates across different years. These tables offer valuable insights into the variable outcomes of TACE based on the PVTT stage and underline the potential benefits of combining TACE with other treatments.
Portal vein tumor thrombus classification:
| Liver Cancer Study Group of Japan (LCSGJ) | Description | Cheng et al | Description |
|---|---|---|---|
| - | - | Type I0 | Microscopic portal vein invasion |
| Vp1 | Presence of a tumor thrombus distal to the second-order branches of the portal vein | Type I | simillar to Vp1 and Vp2 |
| Vp2 | Invasion of the second-order branches of the portal vein | ||
| Vp3 | Presence of the thrombus in the first-order branches | Type II | simillar to Vp3 |
| Vp4 | Tumor thrombus in the main trunk of the portal vein and/or a portal vein branch contralateral to the primarily involved lobe | Type III | simillar to Vp4 |
| - | - | Type IV | involvement of superior mesenteric vein |
| Vv1 | Tumor thrombus in a branch of the hepatic vein | - | - |
| Vv2 | Tumor thrombus in the main trunk of the hepatic veins | - | - |
| Vv3 | Thrombus reaching the right atrium | - | - |
Diagnostic Methods for PVTT in HCC:
| Diagnostic Method | Sensitivity | Specificity | Notable Features |
|---|---|---|---|
| Ultrasound (US) | 80%-100% | - | Detects hypo/isoechoic thrombus, arterial neovascularization |
| Contrast Enhanced Ultrasound (CEUS) | 88%-100% | 94%-96% | Distinguishes neoplastic from benign PVT; rapid wash-in and wash-out phases |
| CT-Scan | 86% | 100% | Identifies thrombosis extension, collateral vessels |
| MRI | 100% | 90% | Differentiates neoplastic/non-neoplastic thrombosis |
| PET/CT | - | - | Identifies metabolic abnormalities before morphological changes |
Treatment Modalities for PVTT in HCC:
| Treatment Method | Efficacy | 1-Year Survival Rate (%) | Adverse Effects | Additional Notes |
|---|---|---|---|---|
| TACE | Varies by PVTT type | Up to 29 | Higher AE in TACE than conservative treatment | Effectiveness related to hepatic arterial supply to the thrombus |
| Sorafenib | Limited in advanced HCC | - | Dermatological, GI, constitutional AEs | Multi-tyrosine-kinase inhibitor; efficacy investigated in SHARP and Asia-Pacific Trials |
| Surgery | Superior to TACE in BCLC-B/C | Up to 62 | - | Hepatectomy, tumor thrombectomy, en-bloc resection |
| RT | Effective in selected patients | Up to 51.6 | Risk of severe liver damage, RILDS | Dose-related response; effectiveness in downstaging |
| Percutaneous Ablation | Effective in certain conditions | - | Risk of damaging nearby structures | Includes RFA, cryotherapy, ECT; limited by extension/location of PVTT |
| Liver Transplantation | Contraindicated in HCC with PVTT | - | High risk of tumor recurrence | Living-donor LT after successful downstaging considered in some cases |
Comparative Efficacy of Treatments for PVTT in HCC:
| Treatment Comparison | Study Reference | Findings | Survival Rates | Notes |
|---|---|---|---|---|
| TACE vs Conservative | Xue et al, Leng et al | TACE shows better survival rates | 6-mo and 1-year survival better in TACE group | - |
| Surgery vs TACE | Hyun et al | Surgery shows significant OS benefit in BCLC-B/C | 1-, 3-, 5-years survival higher for hepatectomy | HR = 0.59; 95%CI: 0.51-0.67 |
| Sorafenib vs Placebo | SHARP Trial, Asia-Pacific Trial | Slight prolongation of OS with sorafenib | - | More effective in Western population (SHARP) than in Asia-Pacific |
| TACE + Sorafenib vs Sorafenib Alone | Various Studies | Mixed results, some benefit in combination treatment | - | Combination may improve TTP but not OS |
Summary of Studies on TACE Efficacy in PVTT in HCC:
| Study (First Author, Year) | Patient Cohort (n) | PVTT Class (Vp) | Median Survival Time | Survival Rates (1-yr, 2-yr, 3-yr, 5-yr) |
|---|---|---|---|---|
| Okazaki M, 1991 | 163 | Vp2 (48), Vp3 (56), Vp4 (59) | 4.3, 4, 3.8 months | - |
| Chung JW, 1995 | 83 | Vp3, Vp4 (83) | 6 months | 30%, 18%, 9%, - |
| Georgiades CS, 2005 | 32 | Vp3, Vp4 (32) | 9.5 months | 25%, -, -, - |
| Luo J, 2011 | 84 | Vp1,2 (40), Vp3 (44) | 10.2, 5.3 months | 30.9%, 3.8%; 9.2%, 0%; -, - |
| Niu ZJ, 2012 | 115 | Vp1 (12), Vp2 (52), Vp3 (42), Vp4 (9) | 19, 11, 7.1, 4 months | 27.8%, 6%, -, - |
| Peng ZW, 2012 | 402 | Vp1 (54), Vp2 (136), Vp3 (166), Vp4 (46) | - | 41.1%, 37.9%, 36.1%, 30.4%; -, 8.9%, 6%, 4.2%, 4.3%; 3.6%, 0%, 0%, 0% |
| Ajit Y, 2014 | - | - | 6.2 months | -, 22%, -, - |
| Liu L, 2014 | 188 | Vp1,2 (98), Vp3 (90) | 6 months | 38%, 17%, 3%, - |
| Liu PH, 2014 | 181 | Vp1,2 (181) | - | 60%, -, 42%, 33% |
| Chern MC, 2014 | 50 | Vp1,2,3,4 | 6.2 months (range 1.7–50.9 months) | 22%, 10%, 8%, - |
| Tawada A, 2014 | 81 | Vp1,2,3,4 | NA | 45%, 23%, 20%, - |
| Ye JZ, 2014 | 338 | Vp1,2,3,4 (86 patients TACE) | 7.0 months | 17.5%, 0%, 0%, - |
| Tan X, 2015 | 116 | Type I, II, III (according to Shi et al) | 27.7 months (TACE+PVE) | 60.9%, 80.7%; 41%, 59%; 25%, 36.5%; 0%, 11.5% (TACE vs TACE+PVE) |
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