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Page 2 of 9 Malerba et al. Hepatoma Res 2021;7:19 I http://dx.doi.org/10.20517/2394-5079.2020.131

INTRODUCTION
Liver resection represents the most oncologically effective treatment for many hepatic tumors. When a liver
resection is planned, a strict balance between oncological efficacy and surgical safety has to be respected.
While oncological efficacy depends on the complete removal of the tumor, with negative surgical margins,
surgical safety is based on a number of factors including the remnant liver volume (RLV) and its functional
reserve, both essential to avoid one of the most feared and serious complications in liver surgery, namely
post-hepatectomy liver failure (PHLF).

While the risk of developing PHLF is strictly related to the future liver remnant (FLR) volume [1-3] ,
integration between FLR volumetric data and liver parenchyma quality, commonly evaluated through
[4-6]
the indocyanine green (ICG) clearance test , is mandatory to achieve a correct estimation of the FLR
functional reserve and of the risk for PHLF development. In this context, patients requiring a liver resection
for hepatocellular carcinoma (HCC) represent a peculiar patient subgroup, because HCC development
is in the majority of cases related to chronic liver disease affecting liver tissue quality, decreasing hepatic
functional reserve, limiting the extension of feasible liver resection, and increasing the FLR volume
[7]
required to perform a safe liver resection .

Among many strategies aiming to optimize the FLR volume for patients requiring a major liver resection,
preoperative portal vein embolization (PVE) is the most popular and validated [8-11] . More recently, the
associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure has been
proposed for patients with a very small FLR volume or a PVE failure . ALPPS was initially criticized for
[12]
the initial suboptimal short term results, but later, following progressive methodologic variations and better
[13]
patient selection, it proved to be safe and effective . Moreover, the most recent reports have highlighted
the potential role of hepatic vein embolization (HVE), synchronous or subsequent to PVE, in inducing
additional parenchymal hypertrophy to further increase the pool of patients that may benefit from surgical
[14]
treatment .

We herein report a case where the sequential adoption of all the aforementioned approaches was necessary
to allow a radical resection of a large right liver HCC in a patient affected by chronic liver disease and with
a small FLR.

CASE REPORT
2
In March 2020, a 72-year-old obese (BMI = 34.48 kg/m ) male, complaining of right upper quadrant pain,
was diagnosed with an 11-cm tumor in the right liver on abdominal ultrasound. On subsequent contrast-
enhanced computed tomography (CT), the lesion, approximately 10 cm × 11 cm × 9 cm in size, was located
very close to the right Glissonian pedicle and showed enhancement in the arterial phase and washout in
the portal and delayed phases [Figure 1]: such findings were consistent with a diagnosis of large right liver
HCC. The patient had a history of asymptomatic hepatitis B. All the clinical findings were normal with no
signs of cirrhosis. His tumour markers including α-fetoprotein and carcinoembryonic antigen were normal.
Other laboratory tests showed: HBsAg (+), HBcAb (-), HBV DNA 251 IU/mL, AST 76 U/L (normal level: <
9
35), ALT 68 U/L (normal level < 60 U/L) and GGT 74 U/L (normal level: < 70 U/L), PLT 238 × 10 /L (normal
level 130-459 × 10 /L), albumin 4.4 g/dL (normal level: 3.1-5.2 g/dL), bilirubin 0.8 mg/dL (normal level: <
9
1.2 mg/dL). Colonoscopy and gastroscopy did not show any pathological findings.

The case was presented at our multidisciplinary tumor board (MDT), and a right hemi-hepatectomy was
indicated. However, due to a small FLR volume (26%), a right PVE was recommended and was performed
on day 1.