Kawano Fumihiro, Lim Megan A, Kemprecos Helen J, Tsai Kathryn, Cheah Daniel, Tigranyan Annie, Kaviamuthan Kanakaraju, Pillai Arundhati, Chen Jaime, Polites Gregory, Brummett Tim, Solai Killivalavan, Bellini Michel, Mise Yoshihiro, Leite Leandro, Cohen Mark, Saiura Akio, Conrad Claudius
Carle Illinois College of Medicine University of Illinois Urbana-Champaign, 509 W University Ave, Urbana, IL, 61801, USA.
Juntendo University Hospital, Tokyo, Japan.
Ann Surg Oncol. 2025 Sep 6. doi: 10.1245/s10434-025-18079-x.
The liver cone unit (Tokyo 2020 terminology) of the peripheral portal vein territory represents the smallest anatomical and functional unit of the liver. While this unit enables anatomical, subsegmental resection, particularly in patients with cirrhosis, the tumor-bearing cone unit can be challenging to identify intraoperatively. PATIENTS AND METHODS: A 58-year-old man with hepatitis C-related cirrhosis (Child-Pugh B) was diagnosed with a subcapsular hepatocellular carcinoma (HCC) in segment 8. While ablation can achieve excellent outcomes in small HCC, owing to the superficial- (risk of seeding) and posterior-superior location (possible transdiaphragmatic access) as well as the presence of ascites, resection was offered. Preoperative three-dimensional (3D) reconstruction identified the tumor-bearing cone unit. Owing to cirrhosis-related shunting with its impact on Indocyanine Green (ICG) tumor staining, selective artery embolization of the branch feeding the neighboring cone unit and subsequent ICG injection into the tumor bearing cone unit was performed. This allowed for laparoscopic, anatomical ICG-guided resection along the tumor-bearing cone unit's boundaries.
Cone unit-based planning and targeted embolization enabled accurate localization and resection of the tumor-bearing area. Despite impaired ICG uptake due to cirrhosis, fluorescence imaging provided visualization for precise anatomical transection with minimal bleeding.
This case demonstrates a novel combined interventional radiology/surgical approach for precise cone unit resection, leading to minimal intraoperative blood loss and function-preserving hepatectomy in a patient with advanced cirrhosis. This conceptional framework can serve as a complement to ultrasound guided cone unit identification in patients with advanced cirrhosis, which can be highly challenging intraoperatively.
外周门静脉区域的肝圆锥单位（2020东京术语）代表肝脏最小的解剖和功能单位。虽然该单位可实现解剖性亚段切除，尤其是在肝硬化患者中，但术中识别有肿瘤的圆锥单位可能具有挑战性。
一名58岁丙型肝炎相关性肝硬化（Child-Pugh B级）男性被诊断为肝段8的包膜下肝细胞癌（HCC）。虽然消融术对小肝癌可取得良好效果，但由于肿瘤位于表浅位置（有种植风险）、后上方位置（可能经膈肌入路）以及存在腹水，故建议进行手术切除。术前三维（3D）重建确定了有肿瘤的圆锥单位。由于肝硬化相关分流对吲哚菁绿（ICG）肿瘤染色有影响，对邻近圆锥单位供血分支进行了选择性动脉栓塞，随后将ICG注入有肿瘤的圆锥单位。这使得能够在腹腔镜下沿有肿瘤的圆锥单位边界进行解剖性ICG引导下切除。
基于圆锥单位的规划和靶向栓塞能够准确定位和切除有肿瘤的区域。尽管由于肝硬化导致ICG摄取受损，但荧光成像为精确的解剖横断提供了可视化，出血极少。
本病例展示了一种新颖的联合介入放射学/手术方法，用于精确的圆锥单位切除，在晚期肝硬化患者中实现了术中失血最少和保留功能的肝切除术。这一概念框架可作为晚期肝硬化患者超声引导下圆锥单位识别的补充，后者在术中可能极具挑战性。
