Hepatocellular carcinoma with hepatic vein invasion should not be considered a contraindication for liver resection

Supported by grants from the National Key Basic Research Program “973 project” (2015CB554000), the Science Fund for Creative Research Groups (81521091), the China National Funds for Distinguished Young Scientists (81125018), the ChangJiang Scholars Program (2013) of the Chinese Ministry of Education, the Shanghai Science and Technology Committee (134119a0200, SHDC12015106), the National Natural Science Foundation of China (8160110271), and the SMMU Innovation Alliance for Liver Cancer Diagnosis and Treatment (2012). Potential conflict of interest: Nothing to report. To the editor: Because symptoms of hepatocellular carcinoma (HCC) often are imperceptible in earlier stages of this disease, most HCC patients with a portal vein tumor thrombus or hepatic vein tumor thrombus (HVTT) diagnosis have already reached an advanced stage, stage C according to the Barcelona Clinic for Liver Cancer staging system and treatment guidelines.1 Based on official guidelines in the United States and Europe, oral sorafenib was the only recommended treatment for HCC patients associated with macroscopic vascular invasion.2 However, liver resection (LR) should not be offered for patients with HVTT. Kokudo et al.3 compare the survival of 540 Child‐Pugh A HCC patients with HVTT without inferior vena cava invasion who underwent LR and 481 Japanese patients who received other treatments. The median survival time in the LR group was 2.89 years, significantly longer than that in the non‐LR group (P < 0.001). Similarly, they found that the median survival time was 1.61 years longer than that in the non‐LR group (P = 0.023) in a propensity score–matched cohort. However, there was no survival benefit between patients with HVTT in the peripheral hepatic vein and those with HVTT in the major hepatic vein. This is a great exploration with the largest number of HCC patients with HVTT to recommend LR for some select patients. Their recent findings echo a previous study published in the Journal of Hepatology in 2014 from the same group, indicating that LR was associated with a good prognosis in HCC patients with microscopic or major HVTT when R0 resection was feasible.4 Other studies from Asian countries equally confirmed that widening the surgical margins when technically possible may increase overall survival of patients with HCC and HVTT.5 From previous studies, official treatment guidelines should recognize that LR may be a therapeutic option for some select patients with advanced HCC with HVTT. Liver surgeons should not shy away from LR for select HVTT patients under recent advances in surgical techniques and perioperative management. Precision therapy and combined treatments should be applied to HCC patients with different types of HVTT. It is imperative to design multicenter randomized controlled trials to assess LR in some select HVTT patients.