I. What is the decision on whether to operate for liver cancer with portal vein thrombosis? What is portal vein thrombosis? What are the symptoms of such liver cancer patients? Many patients often ask me, “What exactly is portal vein cancer embolism?” Simply speaking, portal vein cancer embolism is a tumor cell that grows into the portal vein and forms a tumor embolism, which is called portal vein cancer embolism. If liver cancer patients have portal vein cancer thrombus, firstly, they will have symptoms related to liver cancer, such as nausea, abdominal pain (liver area), weakness, weight loss, jaundice, etc. Secondly, portal vein cancer thrombus will block blood vessels and affect the blood flow of portal vein, causing portal hypertension. Such patients will find enlarged spleen, hypersplenism, esophagogastric fundic varices, and some patients will vomit blood. Why is the portal vein prone to cancer clots? We know that 75% of the blood supply to the liver comes from the portal vein, and half of the liver’s oxygen is supplied through the portal vein. The portal vein is an important blood vessel connecting the liver with other organs in the abdominal cavity, and there are many branching vessels, through which cancer cells can easily enter the portal vein and form portal vein cancer embolism. If there is portal vein cancer embolism, is it advanced liver cancer? Is the patient’s condition more serious and complicated? According to the international BCLC staging (Barcelona Staging), liver cancer with portal vein embolism is classified as stage C (tumor has invaded blood vessels or metastasis has occurred), that is, advanced stage of liver cancer. The development of portal vein thrombosis means that the tumor is advanced, the disease is more complicated, and the treatment effect is worse. In foreign countries, surgery is often not done for patients with liver cancer with portal vein thrombosis. However, for Asian patients, if they do not undergo surgery, the treatment effect is not very good if they just take some targeted drugs. Moreover, targeted drugs are very expensive and too costly, which will be a heavy burden for families in general. Domestic doctors (when the patient’s condition allows) usually take surgery to improve the patient’s symptoms, quality of life and long-term treatment effect. Where does the cancerous embolus grow to and does it have any effect on the patient’s condition? The portal vein is like a tree trunk, which has many branching vessels, like branches, that supply blood and nutrients to the liver. According to the different places where the cancer thrombus grows, liver cancer with portal vein cancer thrombus is divided into different types, which has a great impact on the patient’s later treatment results. Nowadays, the common staging method of portal vein cancer embolism in China is Professor Cheng Shuqun’s programmed staging, which is divided into type I, type II, type III and type IV. If the cancer embolus grows to the secondary branch of portal vein (grows inside the twig), compared to the early stage, it is called portal vein cancer embolus type Ⅰ. Patients with type I embolism can usually be surgically removed. When the thrombus grows into the left or right branch (primary branch) of the portal vein (the two branches come together to form the portal vein), it is considered a type II portal vein thrombosis. In this case, surgery is performed to remove the cancerous thrombus and the associated portal vein at the same time as the liver tumor. Type III portal vein cancer embolism means that the cancer embolism grows to the confluence of the left and right branches of the portal vein, in which case it cannot be removed by surgery alone (tumor removal + portal vein cancer embolism removal). Because the confluence of the left and right branches of portal vein is an important large blood vessel (portal vein trunk), the liver tumor can only be removed through surgery and the portal vein cancer embolus can be removed at the same time, and further treatment will be needed later. Can surgery remove both liver cancer and portal vein thrombosis? What are the treatment methods for liver cancer with portal vein thrombosis? The treatment methods for liver cancer with portal vein thrombosis include surgery, chemotherapy and radiotherapy, etc. Surgery is the best way to remove liver cancer and portal vein thrombus at the same time. As mentioned earlier, for type I and type II portal vein thrombus, surgery can directly remove liver cancer and portal vein thrombus. For type III portal vein cancer thrombus, if it reaches the confluence of the left and right branches of the portal vein or even the main trunk, only the tumor can be removed and the portal vein cancer thrombus removed. For more serious patients – the cancer embolus has grown to the superior mesenteric vein along the portal vein, surgery is not possible, and chemotherapy and radiotherapy can only be used to prolong the life of the patient and improve the quality of life. How does surgery treat hepatocellular carcinoma with portal vein thrombosis? Take right hepatocellular carcinoma with portal vein thrombosis as an example, the tumor inside the right side of liver should be removed first, and part of the liver around the tumor should be removed at the same time to ensure that the edge of the cut tumor is free of cancer cells, and the tumor is completely removed, and the cancer thrombosis should be removed at the same time. to ensure that the surgery is complete and the patient is cured. For type III hepatocellular carcinoma with portal vein cancer embolus, surgery to remove the tumor and remove the cancer embolus cannot be called radical resection, and the patient’s recurrence rate will be very high and fast. Third, whether hepatocellular carcinoma with portal vein cancer embolism can be operated, please take the right seat! Can a patient with multiple lesions inside the liver and portal vein cancer embolism undergo surgery? If a patient has multiple tumor lesions inside the liver and portal vein cancer thrombus at the same time, whether surgery can be done in this case depends on the distribution of the tumor. If the patient is in good health and the tumors are concentrated in one lobe or one section of the liver, for example, in the left or right half of the liver, the tumors and thrombus can be removed surgically. After the tumor is removed, the remaining liver is sufficient to maintain the patient’s body. If the patient has a large number of tumor lesions in the liver and they are scattered, then radical resection is not possible and surgery is not suitable in this case. If diffuse hepatocellular carcinoma with portal vein thrombosis, is surgery still possible? If diffuse hepatocellular carcinoma with portal vein thrombosis is present, surgery is generally not possible. If the whole liver is filled with tumor lesions, regardless of the size of the tumor, as long as the distribution is particularly scattered, it cannot be removed. If there is also portal vein thrombosis, it is recommended that the patient should undergo radiation therapy, and then rest for a period of time before liver intervention, and then consider other treatment options. Is surgery suitable for patients with liver cancer with portal vein thrombosis who have cirrhosis and gastric bleeding? Patients with hepatocellular carcinoma with portal vein cancer thrombosis who have cirrhosis and gastric bleeding should be treated for gastric bleeding first. Only after the stomach bleeding has stopped and the hematocrit level is normal can we decide whether to operate according to the location and condition of the tumor. Can a patient with hepatocellular carcinoma with portal vein thrombosis still undergo surgery when liver failure has already occurred? Patients with hepatocellular carcinoma with portal vein thrombosis who have liver failure, jaundice, ascites, poor eating and other symptoms are not suitable for surgery. Patients should be given albumin and amino acid infusion to provide nutritional support so that their physical condition can be improved; meanwhile, diuretic and anti-yellowness drugs should be used to reduce jaundice and improve liver function so that they can have the chance of further treatment. Can a patient with hepatocellular carcinoma with portal vein thrombosis who is older, too weak to stand, and in obvious pain operate in this case? Some patients are older and weak or even unable to stand, and their families ask if they can have surgery. Generally speaking, doctors do surgery because they want the patient to get better. For this kind of elderly patients who are not in good health, it is difficult to bear the blow of surgery, so they should do supportive treatment first, and wait until the patient’s liver function is better, his physical condition is also better, and the pain is obviously improved, then they can consider whether they can do other treatments. Surgery is definitely inappropriate. Can a patient with hepatocellular carcinoma with portal vein thrombosis who has bone metastasis still have surgery? Surgery is generally not recommended for patients with hepatocellular carcinoma with portal vein thrombosis who have bone metastasis. The occurrence of bone metastasis means that the patient has distant metastasis, so surgery only removes liver tumor and portal vein cancer embolus is not significant, and patients are recommended to have systemic chemotherapy for better effect. Can patients with hepatocellular carcinoma with portal vein thrombosis not have surgery if they have portal hypertension? Generally speaking, liver cancer patients with portal vein cancer embolism often have portal hypertension, which is not a contraindication to surgery. Gastroscopy can be performed to see the degree of varices in the fundus of the patient to determine the situation of portal hypertension and then formulate a treatment plan. 4.How to see the patient efficiently for liver cancer with portal vein cancer embolism? How to regularly review patients with hepatocellular carcinoma with portal vein cancer thrombosis? The treatment of liver cancer with portal vein cancer embolism is like a candy cane, surgery is just one of them, and there are many other treatments to follow. One month after surgery, patients should return to the hospital for review, including liver function, blood count, B-ultrasound, and possibly enhanced CT or even MRI, depending on the patient’s condition; B-ultrasound, MRI and other imaging examinations can show whether there is tumor residue or tumor recurrence in the liver. If there is neither tumor residue nor recurrence, the next review and treatment plan will be decided according to the patient’s surgical method at that time. If the surgery removed the tumor and portal vein thrombus, the patient is advised to follow up closely after surgery; if the surgery only removed the tumor and removed the thrombus, the patient is asked to start the follow-up radiotherapy and interventional treatment. What should patients with hepatocellular carcinoma with portal vein thrombosis pay attention to in daily life and diet? There are no special requirements for daily life of patients with liver cancer with portal vein thrombosis. However, it should be noted that if patients have portal hypertension, they may have gastroesophageal varices. Patients should be advised to eat soft, high-protein and other easy-to-digest foods as much as possible, and some high-fiber and coarse foods should be controlled to avoid food damage to esophageal veins and even bleeding. For patients with hepatocellular carcinoma with portal vein thrombosis who want to consult online whether they can have surgery or treatment plan, what examination information should be provided? If a patient with hepatocellular carcinoma with portal vein thrombosis wants to consult online for treatment plan, it is recommended to provide detailed medical history and all the information on hand, such as whether you have had hepatitis, the status of hepatitis virus, the duration of the disease, liver function, etc.; you should upload the ultrasound, CT, MRI and other examination films and reports. These examination data can help doctors make better diagnosis and treatment. Now there is also 3D digital imaging of the liver, which can clearly see the location and extent of portal vein cancer clots, which is helpful for diagnosis and treatment.