Hepatic resection is the optimum curative treatment for hepatocellular carcinoma (HCC). We often encounter situations in which large HCCs without distant metastasis are treated with transarterial chemoembolization (TACE) or hepatic arterial chemotherapy because of inadequate future remnant liver volume (%RLV) and functional liver volume (%RFLV) for curative hepatectomy. However, the prognosis of patients treated with TACE or hepatic arterial chemotherapy is markedly worse compared with that of patients who underwent hepatectomy,^1–3 indicating that a novel approach is required to enable hepatic resection for large HCCs by improving %RFLV and %RLV. Portal vein embolization (PVE) or obstruction induces hepatic hypertrophy in the nonembolized/unobstructed lobes; hence, it is an option for increasing %RLV and %RFLV.^4–6 On the other hand, there are some cases with borderline or insufficient %RLV and %RFLV for hepatic resection even after PVE or portal vein obstruction. In such cases, an additional approach is required to improve %RLV and %RFLV before hepatic resection. Here, we describe a case where %RFLV increased by a much greater amount than %RLV after induction by tumor compression–induced portal obstruction and selective TACE, resulting in successful resection of a large HCC.

Case Report

A 62-year-old, hepatitis B virus surface antigen–positive man was admitted for the treatment of a large hepatic tumor (16 × 14 cm). Plain computed tomography (CT) showed a heterogenous, hypodense tumor located in segment IV of the right lobe of the liver. The tumor showed contrast enhancement and washout in the arterial and late phases, respectively (Fig. 1). To relieve obstructive jaundice due to bile duct compression resulting from tumor expansion, a metal stent was placed from the right bile duct to the common hepatic duct in the hospital from which the patient had been referred to us. The level of alpha-fetoprotein, the Lens culinaris agglutinin–reactive fraction of alpha-fetoprotein, and the level of protein induced by vitamin K absence/antagonist II were 11.4 ng/mL, 14.2%, and 70,184 mAU/mL, respectively. Indocyanine green retention rate at 15 minutes was 7.5%. The patient was classified as having Child-Pugh class B liver function according to the following parameters: total bilirubin, 1.5 mg/dL; albumin, 3.1 g/dL; prothrombin activity, 68%; ascites, absent; and hepatic encephalopathy, absent. Uptake ratio of the liver to the liver plus heart at 15 minutes by ^99mTc–galactosyl human serum albumin (GSA) scintigraphy was 0.93. The HCC was located in segment IV of the right lobe, and a right trisectionectomy was initially planned as curative hepatectomy. We used ^99mTc-GSA scintigraphy single-photon emission computed tomography–computed tomography system (SPECT–CT fusion system AZE Virtual Place Lexus, AZE, Tokyo, Japan), which enables calculation of functional liver volume corresponding to liver volume using conventional CT volumetry.⁷ Calculated %RLV and %RFLV for the right trisectionectomy using this system were 31.2% and 41.3%, respectively. %RFLV showed marginal tolerability for curative hepatectomy, whereas %RLV was insufficient. We usually attempt PVE in such a situation according to our PVE criteria.⁷ However, portography had already shown that the right portal vein was completely obstructed because of compression by the expanding tumor (Fig. 2). As an alternative strategy, we chose TACE of the right lobe and segment IV including the tumor to selectively abolish liver function and decrease liver volume (Fig. 3). One month later, %RLV and %RFLV had markedly improved to 46.6% and 67.2%, respectively (Fig. 4 and Table 1). Based on the improvement in %RFLV, a right trisectionectomy was performed without any complications. The operation time was 416 minutes, and the intraoperative blood loss was 390 mL. No blood transfusion was required. The patient has recovered well with no recurrence 3 years after the surgery.

View Figure

• Download as Powerpoint
• Download Figure

View Figure

• Download as Powerpoint
• Download Figure

View Figure

• Download as Powerpoint
• Download Figure

View Figure

• Download as Powerpoint
• Download Figure

Table 1 Changes in liver volume and function before and after TACE

View Fullscreen

Discussion

In this report, we described the successful treatment of a large HCC by tumor compression–induced portal obstruction and additional TACE, which led to a marked increase in %RFLV compared with %RLV. Using the ^99mTc-GSA scintigraphy SPECT–CT fusion system, PVE or portal vein obstruction due to a large tumor has been shown to induce dissociation between %RFLV and %RLV (41.3% and 31.2%, respectively, in this patient).⁷ Because preoperative %RFLV showed a marginal tolerability, selective TACE was performed to abolish liver function and decrease the volume of the tumor-containing part of the liver. Thereafter, %RFLV remarkably increased to 67.2% at 1 month after TACE. Indeed, PVE and subsequent TACE have been reported to abolish the compensatory increase of hepatic arterial flow in portal-embolized liver, which can be a cause of insufficient hypertrophy or rapid tumor growth in nonembolized liver, as well as reported to prevent the progression of HCC.^8,9

Although the ^99mTc-GSA scintigraphy SPECT–CT fusion system is available only in a limited number of institutions now, the findings from this study promise to be of great value when planning preoperative management to improve %RFLV in patients with large HCCs waiting for curative hepatectomy.

In conclusion, tumor compression–induced portal obstruction and selective TACE increased %RFLV much more than %RLV using a ^99mTc-GSA scintigraphy SPECT–CT fusion system. The additional use of TACE in portal obstruction caused by large HCCs may be a useful approach in preoperative management to improve %RFLV before curative hepatectomy.