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Chan et al. Hepatoma Res 2018;4:5  I  http://dx.doi.org/10.20517/2394-5079.2017.49                                                  Page 5 of 17


               Table 2. Summary of median overall survival of large/multifocal high-burden hepatocellular carcinoma treated with
               surgery
                                                     Moderately-large/multifocal  Huge/multifocal
                                  Solitary large tumor                                           Overall
                                                        (≥ 5 cm and < 10 cm)     (≥ 10 cm)
                1-year survival (%)     87.2                  73.0                 70.0           74.3
                3-year survival (%)     63.2                  55.1                 45.0           51.2
                5-year survival (%)     56.1                  50.8                 36.0           39.2


               Table 3. Recent studies on the efficacy of surgical resection in the management of high-burden hepatocellular carcinoma with
               portal vein invasion
                Year    Place    Authors   Type   Size:   Size:   Number of   1-year   3-year   5-year   Median   Recruitment
                                          (S/A) ≥ 5 cm 5-10  patients (n) survival  survival  survival   survival   year
                                                      cm             (%)    (%)    (%)   (months)
                2010  Taiwan  Lin et al. [20]  A  78   -    78       39     2      -      15.8   2001-2007
                2011  China   Luo et al. [26]  A  -    83   83       67.2   26     18.9   19.5   2004-2006
                2014  China   Yin et al. [34]  A  -    85   85       51.8   18.1   -      14     2008-2010
                2014  China   Jianyong et al. [69]  S  190  -  190   87.9   76.3   57.9   -      2002-2008
                2014  China   Jianyong et al. [69]  A  139  -  490   68.4   46     40.8   -      2002-2008
                2015  South Korea  Lee et al. [70]  S  68  -  68     89.8   72.8   49.6   -      -
                2016  Japan   Kudo et al. [56]  A  -   -    1576     82.2   40.2   21.1   -      1997-2006
                2016  Taiwan  Liu et al. [37]  S  229  -    229      74     44     35     -      -
                2017  South Korea  Jin et al. [39]  A  489  -  489   67.7   38.2   27.2   -      2003-2010
                2017  Japan   Nouso et al. [71]  A  76  -   76       -      47.3   21.4   72     2001-2015

               A: studies consider large tumors (≥ 5 cm) with or without multifocal tumors as one single population group; S: studies only consider
               solitary large tumors

               Table 4. Classification of portal vein invasion
               Degree of invasion
               Vp0: no evidence of tumor thrombus invasion
               Vp1: tumor thrombus distal to but not in the second-order branches
               Vp2: tumor thrombus in the second-order branches
               Vp3: tumor thrombus in the first-order branches
               Vp4: tumor thrombus in the main trunk or contralateral or both


               Table 5. Summary of median overall survival of high-burden hepatocellular carcinoma with portal vein invasion treated with
               surgery
                                            Vp1 and Vp2            Vp3 and Vp4              Overall
                1-year survival (%)             69.1                  52.8                   61.0
                3-year survival (%)             42.2                  23.4                   32.9
                5-year survival (%)             38.7                  14.6                   27.0


               survival rates were higher: 87.9%, 72.8%, and 49.6%. In this group of high-burden HCC, TACE appeared to
               be inferior to surgical resection in prolonging survival. However, if we focus on solitary large HCC (≥ 5 cm)
               only, TACE appeared to outperform surgical resection [Table 7]. Therefore, it appears that surgery should
               be the choice of treatment when the tumor is “resectable”, while TACE could be considered in the case of
               solitary large tumor.


               TACE is commonly considered contraindicated in HCC with portal vein invasion due to the potential risk
               of acute liver failure resulting from post-TACE ischemia, as the normal liver parenchymal blood supply from
               the portal vein is already compromised. However, this contraindication has not been validated in large trials.
               On the contrary, a number of small retrospective studies have shown that TACE could be performed safely
               in patients with portal vein tumor thrombus (PVTT), provided that there was adequate liver reserve and the
               establishment of collateral blood circulation around the obstructed PVTT was sufficient [72,73] .
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