Dottorato in MEDICINA TRASLAZIONALE E ONCOLOGIA

Titolo della tesi: Liver resection in patients with HCC with major vascular invasion. ALPPS is a feasible option? Monocentric experience.

Patients with advanced hepatocellular carcinoma (HCC) and macrovascular invasion (MVI) have a poor prognosis and are typically directed toward systemic treatment or palliative care. To investigate the outcomes of patients with HCC and MVI undergoing the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure, demographic and operative data were prospectively and retrospectively examined. All types of hepatectomies and all ALPPS modifications were considered. MVI was categorized based on the Japanese Liver Cancer Study Group classification. A total of 46 patients were included. Viral etiology was the most common cause of chronic liver disease (65.2%). The median MELD score for cirrhotic patients was 9 (range 7-19). MVI involving the hepatic veins or inferior vena cava was diagnosed in 46.4% of patients, while portal vein involvement was present in 64.2% of cases. Bile duct involvement was diagnosed in four patients (11.3%). No patients died after Phase 1, but complications were observed in 17.4% of cases. After Phase 2, complications occurred in 54.3% of patients, with 10.9% experiencing major complications. Post-hepatectomy liver failure of Grade B and C occurred in twenty and four patients, respectively. Following a median follow-up of 22.9 months (range 0-65), the median survival was 29.4 months (range 0-64). Recurrence was observed in 34.8% of patients. The median overall survival (OS) for patients was 29.4 months (0-64); the MVI group with macrovascular infiltration had an OS of 25.6 months (range 0.1 - 64.4), while the NoMVI group had an OS of 30.3 months (range 5.7 - 53.7). The overall disease-free survival (DFS) after surgery was 19.7 months (range 1.6-63.4), with the MVI group at 19.9 months (range 1 - 63.4) and the NoMVI group at 18.9 months (range 3.3 - 51.1), respectively. The ALPPS procedure is an extreme rescue approach for patients with advanced HCC and MVI who would otherwise be considered inoperable. The procedure is associated with high morbidity and mortality, underscoring the importance of patient selection. The oncological outcomes appear promising and warrant further investigation.