Extended Right Hepatectomy and Inferior Vena Cava Graft Replacement for En Bloc Resection of Hepatocellular Carcinoma with Cavo-Hepatic Venous Confluence Invasion

BackgroundHepatocellular carcinoma (HCC) associated with tumor extension in the portal vein, hepatic vein, or inferior vena cava (IVC) is traditionally considered an advanced stage of disease to which palliative radiotherapy or sorafenib chemotherapy is proposed.(1,2) Recent studies have shown a significant survival benefit in patients treated with R0 liver resection.(3-5)MethodsWe describe the case of a 45-year-old female patient presenting with a voluminous HCC developed in a non-cirrhotic liver with a tumor thrombus obstructing the retrohepatic IVC and the middle hepatic vein termination. Initial treatment included two cycles of selective internal radiation therapy with Yttrium 90 and sorafenib treatment for 1year. Re-evaluation revealed a significant reduction of the tumor and compensative hypertrophy of the left liver lobe, enabling surgical resection.ResultsThe procedure included anatomic right hepatic trisectionectomy with caudate lobectomy and retrohepatic IVC graft replacement. Total liver vascular exclusion with intrapericardial IVC control enabled en bloc R0 resection of the tumor and the floating tumor thrombus in the cavo-hepatic venous confluence. Total liver vascular exclusion duration was 20min, for a total warm liver ischemia of 40min. The duration of the operation was 240min and blood loss was 700mL. The patient was discharged on postoperative day 15 and was free of disease 6months post-surgery.ConclusionLiver surgery with complex vascular resections for HCC with major vascular invasion should be considered a valid therapeutic option in high-volume hepatobiliary centers.