Translator: Si Xiaocai (Shelia)

Reviewer: Yu Tunan 

A few days ago, Dr. Cai Xiujun’s team from Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, successfully conducted a case of using translational therapy concepts and "Cai’s ALPPS" technology at the same time to treat patients with complex liver cancer. It breaks the "forbidden area" once again in liver surgery and has become the world's first new attempt of "Cai's ALPPS" to combine translational therapy to save patients with advanced liver cancer.

 1.    Ten-year hepatitis B history after re-examination has been progressed to advanced liver cancer and deprived his opportunity for surgery

Han Ming came to Hangzhou more than ten years ago, working hard as a real estate agency employee. He lives happily with his wife and children. But what he didn't expect was that liver cancer relentlessly entered his life, almost imperceptibly.

Han Ming has always been in good health, and he has always been a "warm man" in the eyes of friends and family with his cheerful personality. In January last year, Han Ming suddenly felt pain in his lower abdomen, accompanied by fever, and his body temperature reached a maximum of 38.5°C. At first, Han Ming thought it was a common cold, and didn't particularly care about it. During the time of the COVID-19 epidemic, Han Ming was trapped in his hometown and did not go to the hospital for further examination. He just endured it when he had abdominal pain.

Later, when Han Ming returned to work in Hangzhou, his busy daily life made him almost forget the abdominal pain that occurred from time to time. It was not until August last year that his abdominal pain was so unbearable that he went to a municipal hospital in Hangzhou for treatment. The doctor recommended a CT examination of the abdomen. On the day after the examination results came out, Han Ming could not sleep the whole night long.

"The doctor told me that it’s the advanced stage of liver cancer. The tumor was huge, and the best chance of surgery had already been lost." Han Ming recalled that this result made him unacceptable. As the breadwinner of his family, he could not fall down, and his strong desire to survive made him start to seek treatment from many doctors.

On the recommendation of relatives and friends, he came to the General Surgery Department of SRRSH. After inquiring around, Han Ming found Professor Cai Xiujun, a famous expert in liver surgery, hoping to help him remove the tumor as soon as possible.

After reading Han Ming's CT report, Professor Cai Xiujun frowned. "The tumor of the right liver is large and multiple. The most important thing is that the tumor has grown into the portal vein. At this state, I am afraid that it is difficult to perform surgical treatment."

Han Ming suddenly felt very anxious. Seeing Han Ming’s longing eyes, Professor Cai thought for a moment and said, “We can try translational therapy first. If the tumor and the portal vein tumor thrombus shrinks, we still have the hope of surgical removal.” Professor Cai's words became the life-saving straw for Han Ming.

2.   Translational therapy brought a turnaround, but surgery faced new dilemmas

After being admitted to SRRSH, Han’s Chief Attending, Liang Xiao, the deputy director of General Surgery of the Dr. Cai’s team, conducted MDT discussions with experts in the Departments of Intervention, Oncology, Radiotherapy, Infectious Hepatology and Radiology. They developed an individualized translational treatment plan:

“Raltitrexed and oxaliplatin continuous hepatic arterial infusion chemotherapy (HAIC) to locally combat tumors, lenvatinib targeted therapy combined with teriprizumab (PD-1 inhibitor) to systemically control tumors, a multi-pronged approach to achieve tumor downgrading.”

According to reports, translational therapy is a treatment method that uses a multidisciplinary diagnosis and treatment model (MDT). It seeks to kill or inhibit tumors through a comprehensive treatment method that combines local and systemic methods to shrink tumors, reduce tumor activity, and reduce tumor staging. It is expected to turn unresectable tumors into resectable tumors.

Fortunately, the effect of translational therapy turns out very good for Han Ming. After a month of translational therapy, Han Ming's reexamination showed that the tumor in the liver significantly shrank, the portal vein tumor thrombus was reduced as well, and the AFP dropped significantly. This meant that Han Ming had a chance for surgery. This good news made Han Ming's family renew their courage to fight death.

However, another problem occurred in front of them. Dr. Cai’s team measured the patient’s three-dimensional reconstructed liver volume and found that if the patient undergoes liver resection, he will face the risk of liver failure due to insufficient remnant liver volume after surgery. Thus, is it possible to do the surgery?

3.   "Cai's ALPPS" surgery brings hope

Like Han Ming, Chief Attending Liang Xiao, who did not sleep all night, has been thinking about follow-up solutions. The next day, after the team's discussion and analysis, they finally decided to choose the "Cai's ALPPS" plan: the operation is divided into two steps.

ALPPS is currently a surgical method for the treatment of resectable liver cancer with insufficient remaining liver. Traditional ALPPS surgery is divided into two stages. The first stage is to divide the left and right livers with an ultrasonic knife, and tie up the blood vessels to allow blood to flow to the healthy side of the liver, so that the healthy side of the liver can be "brought up" and it can independently take the task of maintaining life. The second stage is to use surgery to remove the liver on the diseased side of the tumor. However, cutting the liver in the first stage of traditional ALPPS can cause biliary fistula on the liver section after surgery (reported incidence rate is 24%), which seriously affects the patient's recovery and the success rate of the second operation.

"Cai’s ALPPS" operation innovatively replaces the cut and separation of the left and right livers by using a band around the liver to block the blood flow of the left and right livers, so that the complication of bile leakage on the liver section after the first operation is completely eliminated. Moreover, the two operations of "Cai's ALPPS" are performed with minimally invasive methods, which reduces the trauma to the patient and enhances the further recovery of the patient after surgery.

The turning point appeared on November 11, 2020.

Han Ming underwent the first step of "Cai's ALPPS" operation. On the 7^th day after surgery, Han Ming’s liver on the healthy side increased by 60%, and the remaining liver volume on the healthy side reached the standard for Han Ming’s postoperative life needs.

On November 20, 2020, Han Ming underwent the second step of "Cai's ALPPS" surgery, which removed the tumor together with the liver on the diseased side. After the operation, Han Ming's liver function gradually improved after hepatoprotective treatment, and various indicators also recovered well. Finally he was discharged from the hospital smoothly.

Seeing from the reexamination two months later, Han Ming recovered very well. The tumor indicators returned to normal, and there is no signs of tumor recurrence via liver MRI. Currently Han Ming is having regular follow-up visits in the outpatient clinic.