Downstaging with Localized Concurrent Chemoradiotherapy Can Identify Optimal Surgical Candidates in Hepatocellular Carcinoma with Portal Vein Tumor Thrombus

Locally advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) has a poor oncological outcome. This study evaluated the oncological outcomes and prognostic factors of surgical resection after downstaging with localized concurrent chemoradiotherapy (CCRT) followed by hepatic arterial infusion chemotherapy (HAIC). From 2005 to 2014, 354 patients with locally advanced HCC underwent CCRT followed by HAIC. Among these patients, 149 patients with PVTT were analyzed. Exclusion criteria included a total bilirubin >= 2 mg/dL, platelet count < 100,000/mu L, and indocyanine green retention test (ICG R15) > 20%. During the same study period, 18 patients with PVTT underwent surgical resection as the first treatment. Clinicopathological characteristics and oncological outcomes between groups were compared. Among 98 patients in the CCRT group, 26 patients (26.5%) underwent subsequent curative resection. The median follow-up period was 13 months (range 1-131 months). Disease-specific survival differed significantly between the resection after localized CCRT group and the resection-first group {median 62 months (95% confidence interval [CI] 22.99-101.01) versus 15 months (95% CI 10.84-19.16), respectively; P = 0.006}. Multivariate analyses showed that achievement of radiologic response was an independently good prognostic factor for both disease-specific survival (P = 0.039) and disease-free survival (P = 0.001) Localized CCRT could be an effective tool for identifying optimal candidates for surgical treatment with favorable tumor biology. Furthermore, with a 26.5% resection rate and 100% response in PVTT for resection after CCRT, our localized CCRT protocol may be ideal for PVTT.