ABSTRACT
Objective To compare the clinical features and surgical outcomes of hepatocellular carcinoma (HCC) combined with portal venous tumor thrombus (PVTT) and hepatic venous tumor thrombus (HVTT) or bile duct tumor thrombi (BDTT),and analyze the effects of different tumor thrombus (TT) types and different surgical methods for TT on prognosis.Methods The retrospective cross-sectional study was conducted.The clinical data of 220 HCC patients with lymphovascular invasion (LVI) who were admitted to the Affiliated Cancer Hospital of Guangxi Medical University between January 2004 and December 2014 were collected.Of 220 patients,140 were combined with PVTT,36 with HVTT and 44 with BDTT.According to patients' conditions,they underwent tumor and TT resection,and tumor resection + TT removal or single TT removal.Observation indicators:(1) comparisons of clinical features of HCC patients with PVTT or HVTT or BDTT;(2) surgical and postoperative situations;(3) follow-up and survival.Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to December 2015.Measurement data with normal distribution were represented as (x)±s.Comparisons among 3 indicators were analyzed using the one-way ANOVA,and comparisons between 2 indicators were analyzed using the t test.Comparisons of count data were analyzed using the chi-square test.The survival curve and rate were respectively drawn and calculated by the Kaplan-Meier method,and the Log-rank test was used for survival analysis.Results (1) Comparisons of clinical features of HCC patients with PVTT or HVTT or BDTT:number of patients with Child-pugh A,Child-pugh B and peritoneal effusion,tumor diameter and cases with tumor capsule were respectively detected in 133,7,23,(10±4)cm,91 in HCC patients with PVTT and 35,1,4,(9±4)cm,27 in HCC patients with HVTT and 35,9,16,(6±4)cm,15 in HCC patients with BDTT,with statistically significant differences (x2 =12.693,10.408,F=11.300,x2 =17.188,P＜ 0.05).(2) Surgical and postoperative situations:of 140 HCC patients with PVTT,51 underwent tumor and PVTT resection,89 underwent tumor resection + PVTT removal through incising portal vein;68 received postoperative transcatheter arterial chemoembolization (TACE).Thirty-six HCC patients with HVTT underwent tumor and HVTT resection;24 received postoperative TACE.Of 44 HCC patients with BDTT,23 underwent tumor and BDTT resection,21 underwent tumor resection + BDTT removal through incising common bile duct;29 received postoperative TACE.(3) Follow-up and survival:① 220 patients were followed up for 1-73 months,with a median time of 12 months.The median survival time,1-,3-and 5-year survival rates were respectively 12 months,48.2％,25.0％,15.4％ in 140 HCC patients with PVTT and 28 months,77.1％,45.6％,24.5％ in 36 HCC patients with HVTT and 36 months,88.6％,48.3％,24.6％ in 44 HCC patients with BDTT,with a statistically significant difference in survival (x2 =13.316,P＜0.05).② Of 140 HCC patients with PVTT,49 were in type Ⅰ PVTT,and median survival time,1-,3-and 5-year survival rates were respectively 20 months,60.3％,32.6％ and 17.1％;70 were in type Ⅱ PVTT,and median survival time,1-,3-and 5-year survival rates were respectively 13 months,51.4％,26.0％ and 17.3％;21 were in type Ⅲ PVTT,and median survival time,1-,3-and 5-year survival rates were respectively 7 months,9.5％,4.8％ and 0,showing a statistically significant difference in survival (x2=18.102,P＜0.05).The median survival time,1-,3-and 5-year survival rates were respectively 21 months,72.5％,42.5％,26.2％ in 51 patients undergoing tumor and TT resection and 9 months,40％,14.4％,0 in 89 patients undergoing tumor resection + PVTT removal through incising portal vein,showing a statistically significant difference in survival (x2=24.098,P＜0.05).③ Of 36 HCC patients with HVTT,17 were detected in right HVTT,and median survival time,1-,3-and 5-year survival rates were respectively 14 months,64.7％,20.2％ and 0;10 were detected in left HVTT,and median survival time,1-,3-and 5-year survival rates were respectively 53 months,80.0％,70.0％ and 38.9％;9 were detected in middle HVTT,and median survival time,1-,3-and 5-year survival rates were respectively 40 months,88.9％,61.0％ and 30.5％;showing no statistically significant difference in survival (x2 =5.951,P＞0.05).④ Of 44 HCC patients with BDTT,24,6 and 14 were respectively detected in type Ⅰ,Ⅱ and Ⅲ BDTTs,and median survival time,1-,3-and 5-year survival rates were respectively 38 months,87.5％,60.4％,34.9％ in type Ⅰ BDTT patients and 26 months,83.3％,16.7％,0 in type Ⅱ BDTT patients and 35 months,78.6％,50.0％,21.4％ in type Ⅲ BDTT patients,showing no statistically significant difference in survival (x2 =5.312,P＞0.05).Of 44 patients,median survival time,1-,3-and 5-year survival rates were respectively 38 months,91.3％,59.5％,34.3％ in 23 patients undergoing tumor and TT resection and 26 months,85.7％,35.7％,15.3％ in 21 patients undergoing tumor resection + TT removal through incising common bile duct,showing no statistically significant difference in survival (x2 =2.071,P＞0.05).Conclusions HCC patients with PVTT have larger tumor diameter and worse liver dysfunction,and are prone to peritoneal effusion.HCC patients with different LVI undergo surgery.There is better prognosis in HCC patients with BDTT,and good prognosis in patients with HVTT,while poorer prognosis in patients with PVTT.The postoperative survival of HCC patients with PVTT is associated with TT type,and patients will have better prognosis after tumor resection + TT removal if TT type is confirmed earlier.The postoperative survival of HCC patients with BDTT is not associated with TT type,tumor resection + TT removal maybe prolong postoperative survival time.