Effective treatment strategies other than sorafenib for the patients with advanced hepatocellular carcinoma invading portal vein

Table 1 Clinical outcomes for hepatocellular carcinoma patients accompanying portal vein tumor thrombosis following surgical resection

Ref.	PVTT status1	No. of patients	Survival2
			Median (mo)	1-yr (%)	3-yr (%)
Shi et al[49]	Vp2	139	NR	52.1	25.1
	Vp3	169		38.2	17.78
	Vp4	78		24.7	3.6
	Beyond Vp4	20		18.3	0
Lin et al[50]	Vp2
	Vp3	63	NR	52.1	16
	Vp4	5		33.1	0
Chen et al[78]	Vp2-4	88	9	31.1	15.2
Matono et al[79]	Vp3-4	29	16.9	62.1	24.1

¹Beyond Vp4 = extending to superior mesenteric vein;

²Intrahepatic recurred lesions were treated by percutaneous ethanol injection therapy, radiofrequency ablation, transarterial chemoembolization, or systemic chemotherapy based on their hepatic functional reserve and the pattern of intrahepatic recurrence. NR: Not reported; PVTT: Portal vein tumor thrombosis.

Table 2 Comparing various treatment strategies for hepatocellular carcinoma patients accompanying portal vein tumor thrombosis

	Indication	Advantages	Disadvantages
Sorafenib	BCLC stage C	Showing survival benefit	Modest efficacy compared to placebo control
		in infiltrative type HCC	Hand-foot skin reaction
TACE	Nodular type HCC up to Vp4	Wide indication	Post TACE syndrome
	Child A liver function		Potential risk of liver failure
TARE	Tumor extension ≤ 50% of liver volume	Down-staging allowing	Requiring additional lung shunt study
	Unilobar	liver transplantation	due to the risk of lung injury
	Nodular type
	Up to Vp4
RFA	Single medium-sized HCCs (3-5 cm)	Less invasive	If the intraparenchymal tumor was not completely ablated by RFA, complete effects on the thrombus probably would not be produced
Surgery	Up to Vp4	Less expensive technic	Invasive and expensive technic
	Single medium-sized HCCs ( ≤ 7 cm)	Better outcomes than other patients	Potential risk of liver failure
	Up to Vp4	with HCC who are BCLC stage C
	No HV/IVC invasion	with Child A liver function
External beam	AFP ≤ 30 ng/mL	Combined to multimodal strategies	Potential risk of radiation induced liver disease
radiotherapy	Tumor extension ≤ 60% of liver volume		Potential risk of GI tract toxicities

BCLC: Barcelona clinic liver cancer; HCC: Hepatocellular carcinoma; TACE: Transarterial chemoembolization; TARE: Transarterial radioembolization; RFA: Radiofrequency ablation; HV: Hepatic vein; IVC: Inferior vena cava; AFP: Alpha-fetoprotein; GI: Gastrointestinal.