Right hepatectomy for advanced hepatocellular carcinoma (cT4N0M0) with inferior vena cava invasion: challenges and curative surgical strategies

Abstract

Advanced hepatocellular carcinoma (HCC) with major vascular involvement remains a surgical challenge, particularly in cases classified as cT4N0M0. Inferior vena cava (IVC) invasion significantly increases operative complexity and perioperative risk. However, in selected patients with preserved liver function and adequate future liver remnant (FLR), curative-intent hepatectomy may still be considered. A 46-year-old male presenting with persistent right upper quadrant pain. Imaging studies including contrast-enhanced CT scan and three-phase whole abdominal CT demonstrated a right lobe liver mass consistent with malignant tumor, staged as cT4N0M0. Multidisciplinary evaluation was performed. FLR was 80%, and portal vein embolization was not indicated. The patient underwent open right hepatectomy with Pringle maneuver, right Glissonean pedicle ligation, and cholecystectomy. Intraoperatively, tumor involvement led to two ruptures of the IVC, which were managed with primary repair. Advanced HCC (cT4N0M0) with macrovascular invasion, including portal vein or IVC involvement, has traditionally been associated with poor prognosis; however, recent meta-analyses and nationwide cohort studies demonstrate that curative-intent liver resection can achieve meaningful survival benefits, with 1 and 3 year overall survival rates exceeding those of non-surgical therapy in carefully selected patients. Right hepatectomy with IVC repair can be performed safely in selected patients with advanced HCC (cT4N0M0) and sufficient FLR. Careful preoperative planning, multidisciplinary evaluation, and meticulous vascular control are critical to achieving curative resection in complex cases involving major vascular structures.