The portal is closing, beam me up!

Top Line: Hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is typically considered a textbook unresectable case.
The Study: In many Asian countries where patients with hepatitis B-related HCC often have better overall liver function, surgery is often considered if the tumor is resectable in all aspects minus the PVTT. The big challenge there is accomplishing a resection of the vein and tumor thrombus en bloc with the primary tumor. As a result, there is interest in neoadjuvant therapies to increase the success rate of HCC+PVTT resection. This multicenter randomized trial explored the utility of +/- neoadjuvant radiation prior to resection of primary HCC plus right, left, or main portal vein thrombosis. Importantly, patients with hepatitis C or other reasons for inoperability were excluded. In the radiation cohort, the GTV was defined as all arterially-enhancing primary tumor plus the portal venous filling defect, with a 5-10 mm CTV and 5-10 mm PTV. This final volume was prescribed 3 Gy x 6 using 3DCRT followed by surgery 4 weeks later. While there were 0% complete and only 21% partial response rates, there was a significant improvement in overall and disease-free survival among patients who received radiation. The main toxicity was a mild elevation in liver enzymes.
TBL: Despite relatively low response rates, neoadjuvant radiation for HBV-related HCC with portal vein thrombosis intriguingly appears to improve survival outcomes. | Wei, J Clin Oncol 2019


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