A logical approach to hepatocellular carcinoma presenting with jaundice

Typing of biliary tumor thrombus influences the prognoses of patients with hepatocellular carcinoma

OBJECTIVE

To establish a new classification of biliary tumor thrombus (BTT).

METHODS

Overall survival of patients with BTT was first used to determine whether it correlated with current hepatocellular carcinoma staging systems. Univariate and multivariate analyses were used to determine factors affecting the overall survival (OS) to form the basis of our new classification for BTT.

RESULTS

All 6 international staging systems showed overlapping survival curves. Univariate followed by multivariate analyses showed that total bilirubin and intrahepatic/extrahepatic BTT were significant risk factors of OS. Based on these data, a new BTT classification was defined as: Type I: intrahepatic BTT; and Type II: extrahepatic BTT involving a common bile duct or common hepatic duct. Type I was further subdivided into type Ia: BTT involving a second-order intrahepatic duct or above, and type Ib: BTT involving a first-order intrahepatic duct. Type II was further subdivided into type IIa and type IIb using a cut-off total bilirubin (TB) > 300 μmol/L. The numbers (percentages) of patients with types I and II BTT were 69 (34.2%) and 133 (65.8%), respectively. The median OS of type I patients was significantly higher than that of type II patients (37.5 months vs. 23.2 months; P = 0.002). Using subgroup analyses, OS outcomes were significantly different between the subgroups of type IIb and type IIa, although there was no significant difference between the type Ia and type Ib subgroups (P = 0.07).

CONCLUSIONS

A new BTT classification was established to predict prognoses of HCC patients with BTT who underwent liver resection.

The effect of bile duct tumor thrombus on the long-term prognosis of hepatocellular carcinoma patients after liver resection: a systematic review and meta-analysis

Background

The effect of bile duct tumor thrombus (BDTT) on the postoperative long-term prognosis of hepatocellular carcinoma (HCC) patients is still under debate.

Methods

The PubMed, Embase, Cochrane Library, Web of Science databases were systematically searched to collect the clinicopathologic characteristics, perioperative indices, and postoperative survival outcomes in the BDTT and non-BDTT groups of HCC patients from inception to February 1, 2020. The study outcomes were extracted by two independent investigators.

Results

A total of 15 studies involving 6,484 patients were included. The meta-analysis revealed that the levels of serum total bilirubin and alkaline phosphatase were notably higher in patients with HCC and BDTT than those without BDTT. Meanwhile, HCC patients with BDTT had more aggressive biological characteristics, such as poor tumor differentiation, macrovascular invasion, and lymph node metastasis, as compared to patients without BDTT. The 1-year [odds ratio (OR) 0.39, 95% confidence interval (CI): 0.31–0.48, P<0.01], 3-year (OR 0.33, 95% CI: 0.22–0.51, P<0.01) and 5-year overall survival (OS) rates (OR 0.31, 95% CI: 0.20–0.49, P<0.01) of the BDTT group were significantly worse than those of the non-BDTT group. The hazard ratio of HCC with BDTT was 4.27 (95% CI: 3.47–5.26, P<0.01) within 5 years after hepatectomy.

Conclusions

HCC patients with BDTT had worse OS compared to patients free of BDTT after surgery. BDTT may be a potential prognostic factor for HCC patients.

Comparison of different surgical interventions for hepatocellular carcinoma with bile duct tumor thrombus: a systematic review and meta-analysis

Background

The optimal surgical modality for hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) remains controversial, especially regarding deciding whether to perform concurrent bile duct resection (BDR).

Methods

PubMed, EMBASE, Cochrane Library, Web of Science and Scopus databases were systematically searched from inception to February 2020, in order to compare overall survival (OS) and recurrence-free survival (RFS) rates of HCC patients with BDTT who had either received hepatectomy with extrahepatic bile duct resection (BDR group) or hepatectomy without bile duct resection (NBDR group). Relevant outcomes were extracted by two investigators.

Results

A total of 12 studies involving 355 patients was included. The 1-, 3- and 5-year OS rates were similar in the BDR and NBDR groups (OR =0.58, 95% CI: 0.31-1.09, P=0.09; OR =0.74, 95% CI: 0.43-1.28, P=0.28; OR =0.63, 95% CI: 0.36-1.11, P=0.11, respectively). However, the BDR group had better 1-, 3- and 5-year RFS rates than the NBDR group (OR =0.38, 95% CI: 0.22-0.65, P<0.01; OR =0.40, 95% CI: 0.22-0.72, P<0.01; OR =0.37, 95% CI: 0.19-0.71, P<0.01, respectively).

Conclusions

Concomitant bile duct resection results in decreased postoperative recurrence in HCC patients with BDTT. However, the OS rates were similar whether or not patients underwent bile duct resection.

Nomogram for prediction of the international study Group of Liver Surgery (ISGLS) grade B/C Posthepatectomy liver failure in HBV-related hepatocellular carcinoma patients: an external validation and prospective application study

BACKGROUND

To develop a nomogram for predicting the International Study Group of Liver Surgery (ISGLS) grade B/C posthepatectomy liver failure (PHLF) in hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) patients.

METHODS

Patients initially treated with hepatectomy were included. Univariate regression analysis and stochastic forest algorithm were applied to extract the core indicators and reduce redundancy bias. The nomogram was then constructed by using multivariate logistic regression, and validated in internal and external cohorts, and a prospective clinical application.

RESULTS

There were 900, 300 and 387 participants in training, internal and external validation cohorts, with the morbidity of grade B/C PHLF were 13.5, 11.0 and 20.2%, respectively. The nomogram was generated by integrating preoperative total bilirubin, platelet count, prealbumin, aspartate aminotransferase, prothrombin time and standard future liver remnant volume, then achieved good prediction performance in training (AUC = 0.868, 95%CI = 0.836-0.900), internal validation (AUC = 0.868, 95%CI = 0.811-0.926) and external validation cohorts (AUC = 0.820, 95%CI = 0.756-0.861), with well-fitted calibration curves. Negative predictive values were significantly higher than positive predictive values in training cohort (97.6% vs. 33.0%), internal validation cohort (97.4% vs. 25.9%) and external validation cohort (94.3% vs. 41.1%), respectively. Patients who had a nomogram score < 169 or ≧169 were considered to have low or high risk of grade B/C PHLF. Prospective application of the nomogram accurately predicted grade B/C PHLF in clinical practise.

CONCLUSIONS

The nomogram has a good performance in predicting ISGLS grade B/C PHLF in HBV-related HCC patients and determining appropriate candidates for hepatectomy.

Outcomes of resection for hepatocellular carcinoma with macroscopic bile duct tumour thrombus: A propensity score matched study

The incidence of hepatocellular carcinoma (HCC) with bile duct tumour thrombus (BDTT) is low, and related studies, especially studies on long-term survival, are uncommon. The present study aimed to evaluate the clinicopathological characteristics, prognostic factors and postoperative long-term outcomes of BDTT in patients with HCC. The clinicopathological characteristics and postoperative long-term outcomes of patients with HCC both with and without BDTT were compared before and after propensity score matching (PSM). Prognostic risk factors were assessed by Cox proportional hazards regression analyses after PSM. Tumour stages in the BDTT group were significantly higher than those in the group without BDTT (P=0.001). Overall survival (OS) and recurrence-free survival (RFS) rates were significantly higher in the group without BDTT than in the BDTT group before PSM (P<0.001 and P=0.003, respectively). However, no significant difference in OS or RFS was found between the two groups after PSM (P=0.249 and P=0.121, respectively). Moreover, the median OS and RFS times of the BDTT patients who underwent tumour thrombectomy and bile duct resection were not significantly different (P=0.891 and P=0.787, respectively). In the multivariate analysis, macrovascular invasion (HR, 3.701; 95% CI, 1.313-9.10.437; P=0.013) was the only independent predictor of OS. Although the clinicopathological characteristics of the BDTT group suggested more advanced stage disease and poorer oncological outcomes than the group without BDTT, BDTT was not a poor prognostic factor for patients with HCC who underwent liver resection. Curative resection is recommended for patients with HCC and BDTT, even for those with poor liver function, after proper perioperative management in order to achieve good long-term survival.

Surgical Outcomes of Hepatocellular Carcinoma With Bile Duct Tumor Thrombus: A Korea-Japan Multicenter Study

OBJECTIVE

To identify optimal surgical methods and the risk factors for long-term survival in patients with hepatocellular carcinoma accompanied by macroscopic bile duct tumor thrombus (BDTT).

SUMMARY BACKGROUND DATA

Prognoses of patients with hepatocellular carcinoma accompanied by BDTT have been known to be poor. There have been significant controversies regarding optimal surgical approaches and risk factors because of the low incidence and small number of cases in previous reports.

METHODS

Records of 257 patients from 32 centers in Korea and Japan (1992-2014) were analyzed for overall survival and recurrence rate using the Cox proportional hazard model.

RESULTS

Curative surgery was performed in 244 (94.9%) patients with an operative mortality of 5.1%. Overall survival and recurrence rate at 5 years was 43.6% and 74.2%, respectively. TNM Stage (P < 0.001) and the presence of fibrosis/cirrhosis (P = 0.002) were independent predictors of long-term survival in the Cox proportional hazards regression model. Both performing liver resection equal to or greater than hemihepatectomy and combined bile duct resection significantly increased overall survival [hazard ratio, HR = 0.61 (0.38-0.99); P = 0.044 and HR = 0.51 (0.31-0.84); P = 0.008, respectively] and decreased recurrence rate [HR = 0.59 (0.38-0.91); P = 0.018 and HR = 0.61 (0.42-0.89); P = 0.009, respectively].

CONCLUSIONS

Clinical outcomes were mostly influenced by tumor stage and underlying liver function, and the impact of BDTT to survival seemed less prominent than vascular invasion. Therefore, an aggressive surgical approach, including major liver resection combined with bile duct resection, to increase the chance of R0 resection is strongly recommended.

A proposed modification for the Barcelona Clinic Liver Cancer staging system: Adding bile duct tumor thrombus status in patients with hepatocellular carcinoma

BACKGROUND

The Barcelona Clinic Liver Cancer (BCLC) staging system is widely applied to stage hepatocellular carcinoma (HCC). However, it may be inaccurate when applied to East Asian HCC patients. In this study, a large Chinese HCC cohort was analyzed to evaluate possible modifications for the BCLC staging system.

METHODS

Between January 1995 and December 2009, 622 HCC patients who underwent hepatectomy were enrolled. Prognostic risk factors were analyzed using univariate and multivariate analyses. The ability of the modified system to predict survival was evaluated by determining the area under the receiver operating characteristic curve.

RESULTS

Patients without bile duct tumor thrombus (BDTT; 1-, 3- and 5-year overall survival, 80%, 60% and 48%, respectively) showed a substantial survival advantage over those with BDTT (1-, 3- and 5-year overall survival, 77%, 42% and 23%, respectively; χ² = 6.280, P = 0.012). In BCLC stage 0-A patients, significant differences were identified between the BDTT group and the non-BDTT group, while no such differences were found in BCLC stage B patients. Based on this finding, BCLC stage 0-A BDTT patients were recategorized into stage B. The modified BCLC classification featured better performance in the prediction of overall survival than the original system (modified BCLC χ² = 53.596, P < 0.001; original BCLC χ² = 46.335, P < 0.001). The ability to predict mortality was also slightly higher using the modified BCLC system.

CONCLUSIONS

Modification of the BCLC system to include BDTT status might further enhance its prognostic ability.

Ablative therapies for hepatic and biliary tumors: endohepatology coming of age

Ablative therapies refer to minimally invasive procedures performed to destroy abnormal tissue that may arise with many conditions, and can be achieved clinically using chemical, thermal, and other techniques. In this review article, we explore the different ablative therapies used in the management of hepatic and biliary malignancies, namely hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), with a particular focus on radiofrequency ablation (RFA) and photodynamic therapy (PDT) techniques.

Successful Resection in a Case of Hepatocellular Carcinoma Masquerading as Hilar Cholangiocarcinoma: A Case Report

Obstructive jaundice in the setting of a hilar mass raises strong suspicion of a cholangiocarcinoma, with diagnosis usually made on imaging. Jaundice, when present in patients with hepatocellular carcinoma, is mostly related to underlying liver disease (i.e. cirrhosis) and only rarely to diffuse tumor infiltration of liver parenchyma or hilar invasion. We report here the good outcome of a 67 year-old patient who presented with obstructive jaundice, underwent surgery and was given a diagnosis of hepatocellular carcinoma, which was made only at histopathological examination of resected specimen.

CCL20 is overexpressed in hepatocellular carcinoma with bile duct tumor thrombus and correlates negatively with surgical outcome

There is not yet a consensus regarding prognosis of hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) versus without bile duct tumor thrombus. Chemokine (C-C motif) ligand 20 (CCL20) plays critical roles in the progress of many types of tumor. But the clinicopathological and prognostic value of this marker in HCC with BDTT is unceratin. In this study, we reported that the overall survival (OS) and disease-free survival (DFS) in HCC with BDTT were significantly shorter than in those without BDTT (P<0.05). CCL20 was expressed at a significantly higher level in bile duct tumor thrombus by real-time PCR, western blot, and immunohistochemistry. Patients with high CCL20 expression levels had a poor prognosis. Multivariate survival analysis indicated that CCL20 was an independent prognostic factor for OS. The presence of bile duct tumor thrombus indicateda poor prognosis in HCC patients, but was not a surgical contraindication. CCL20 was associated with tumor progression and high CCL20 expression was correlated with worse surgical outcomes in HCC with BDTT. Inhibition of CCL20 expression might offer novel promising molecular targets for treatment.

Prognostic importance of bile duct invasion in surgical resection with curative intent for hepatocellular carcinoma using PSM analysis

There is not yet a consensus regarding a difference in prognosis for patients with hepatocellular carcinoma (HCC) with and without bile duct invasion (BDI). The present study aimed to clarify the prognostic importance of BDI on the short and long-term outcome of patients with HCC who underwent surgical resection. The present study evaluated HCC with BDI, including peripheral microscopic biliary invasion and revealed that the prognosis of patients with BDI was poorer compared with those without BDI. It should be noted that peripheral BDI also had a negative impact on the prognosis of patients with HCC. The clinical prognosis assessment revealed that BDI should be considered when assigning a disease stage. BDI, either macroscopic or microscopic, indicated a poor prognosis in patients with HCC who underwent curative resection, however it was not a surgical contraindication. Macroscopic BDI and hyperbilirubinemia were significantly associated with a dismal prognosis, which should alert surgeons.

Efficacy of 125I Versus Non-125I Combined with Transcatheter Arterial Chemoembolization for the Treatment of Unresectable Hepatocellular Carcinoma with Obstructive Jaundice

PURPOSE

To compare the therapeutic effects of ¹²⁵I versus non-¹²⁵I combined with transcatheter arterial chemoembolization (TACE) for the treatment of unresectable hepatocellular carcinoma (HCC) with obstructive jaundice.

METHODS

A retrospective analysis was conducted using the records of 54 consecutive patients who were initially diagnosed with HCC with obstructive jaundice between May 2009 and July 2016. Twenty-one cases (group A) were treated with percutaneous transhepatic biliary drainage (PTBD) followed by ¹²⁵I radioactive seed strip implantation through the PTBD tube. After the total serum bilirubin level was reduced to normal and the liver function recovered to Child-Pugh class A or early B, TACE was conducted. In 33 cases (group B) PTBD was performed in combination with TACE without applying the ¹²⁵I radioactive seeds. The duration of biliary patency and survival were analyzed.

RESULTS

The technical success rate in both groups was 100%. The median biliary patency time was 6.000 ± 0.315 months (95% CI 5.382-6.618 months) in group A and 4.000 ± 0.572 months (95% CI 2.879-5.121 months) in group B; the two groups were significantly different (P = 0.001). The median survival was 11.000 ± 0.864 months (95% CI 9.306-12.694 months) in group A and 9.000 ± 0.528 months (95% CI 7.965-10.035 months) in group B; the two groups were significantly different (P = 0.022).

CONCLUSIONS

The combination of 125I with TACE was more effective than TACE without the radioactive seeds for treating patients with unresectable HCC with obstructive jaundice. Future prospective trials with larger samples will be required to validate these results.

A single institution report of 19 hepatocellular carcinoma patients with bile duct tumor thrombus

Background

Obstructive jaundice caused due to bile duct tumor thrombus (BDTT) in a hepatocellular carcinoma (HCC) patient is an uncommon event. This study reports our clinical experiences and evaluates the outcomes of HCC patients with BDTT in a single institution.

Methods

A retrospective review of 19 HCC patients with secondary obstructive jaundice caused due to BDTT during a 15-year period was conducted.

Results

At the time of diagnosis, 14 (73.7%) patients had obstructive jaundice. Eighteen (94.7%) patients were preoperatively suspected of “obstruction of the bile duct”. Sixteen patients (84.2%) underwent a hepatectomy with curative intent, while two patients underwent removal of BDTT combined with biliary decompression and another patient received only palliative care as his liver reserve and general condition could not tolerate the primary tumor resection. The overall early recurrence (within 1 year) after hepatectomy occurred in more than half (9/16, 56.3%) of our patients. The 1-year survival rate of patients was 75% (12/16). The longest disease-free survival time was >11 years.

Conclusion

Identification of HCC patients with obstructive jaundice is clinically important because proper treatment can offer an opportunity for a cure and favorable long-term survival.

NEOADJUVANT TRANSCATHETER ARTERIAL CHEMOEMBOLIZATION FOR BILIARY TUMOR THROMBOSIS: A RETROSPECTIVE STUDY

OBJECTIVES

Curative hepatectomy and tumor thrombectomy for hepatocellular carcinoma with complicating biliary tumor thrombosis (HCC/BTT) is associated with high surgical morbidity and mortality. This retrospective study evaluated the effectiveness and safety of neoadjuvant transcatheter arterial chemoembolization (TACE) in HCC/BTT patients scheduled for curative resection.

METHODS

Thirty consecutive patients with diagnosed HCC/BTT were hospitalized for neoadjuvant TACE and elective curative liver resection (group A; n=20) or curative liver resection alone (group B; n=10). The primary outcome measure was median survival.

RESULTS

Group A had a significantly shorter overall operative time (160±25 versus 190±35 min; p < .01) and duration of inflow control (14.3±3.6 versus 25.1±5.1 min; p < .01) and significantly less intraoperative blood loss (150±35 versus 520±75 ml; p < .01) and transfusion (100±40 versus 375±55 ml; p < .01) as compared to group B. Among patients undergoing both thrombectomy and curative resection, the median survival of group A was significantly longer than that of group B (28.5 [9-54] versus 21.5 [6-39] months; p < .01); among those who received thrombectomy alone, the median survival of group A was also significantly longer than that of group B (12.8 [6-25] versus 4.5 [2-7] months; p < .01).

CONCLUSIONS

Neoadjuvant TACE significantly reduced the surgical risk of curative liver resection and significantly prolonged median survival in HCC patients with complicating BTT.

Albumin–bilirubin versus Child–Pugh score as a predictor of outcome after liver resection for hepatocellular carcinoma

Background

The Child–Pugh (CP) score is used widely to assess liver function and predict postoperative outcomes in patients with hepatocellular carcinoma (HCC). Recently, the albumin–bilirubin (ALBI) score has been validated as a predictor of overall survival in these patients. This study aimed to compare the ability of the ALBI and CP scores to predict outcomes in patients with HCC after liver resection with curative intent.

Methods

Consecutive patients who underwent liver resection with curative intent for HCC between January 2007 and July 2013 were included in this retrospective study. The performance of the ALBI score in predicting postoperative liver failure (PHLF) and long-term survival was compared with that of the CP score.

Results

A total of 1242 patients were enrolled. Of these, 166 (13·4 per cent) experienced PHLF. The area under the receiver operating characteristic (ROC) curve of the ALBI score for predicting PHLF was greater than that of the CP score (0·723 versus 0·607; P &lt; 0·001). Similar to findings for CP grade, the incidence and severity of PHLF increased with increasing ALBI grade. The ALBI grade stratified patients into at least two distinct overall survival cohorts (P &lt; 0·001), whereas the CP grade did not. The ALBI grade also classified patients with CP grade A disease into two distinct overall survival cohorts (P &lt; 0·001), and overall survival rates in the group with poorer survival were similar to those in the majority of patients with CP grade B disease. Both CP and ALBI scores had low power in predicting disease-free survival.

Conclusion

The ALBI grade predicted PHLF and overall survival in patients with HCC undergoing liver resection with curative intent more accurately than the CP grade.

Bile duct invasion can be an independent prognostic factor in early stage hepatocellular carcinoma

Backgrounds/Aims

In hepatocellular carcinoma (HCC), bile duct invasion occurs far more rarely than vascular invasion and is not well characterized. In addition, the pathologic finding of bile duct invasion is not considered an independent prognostic factor for HCC following surgery. In this study, we determined the characteristics of HCC with bile duct invasion, and assessed the clinical significance of bile duct invasion.

Methods

We retrospectively reviewed the medical records of 363 patients who underwent hepatic resection for HCC at Seoul National University Hospital (SNUH) from January 2009 to December 2011. Preoperative, operative, and pathological data were collected. The risk factors for recurrence and survival were analyzed. Subsequently, the patients were divided into 2 groups according to disease stage (American Joint Committee on Cancer/International Union Against Cancer 7^th edition): early stage (T1 and 2) and advanced stage (T3 and 4) group; and risk factors in the sub-groups were analyzed.

Results

Among 363 patients, 13 showed bile duct invasion on pathology. Patients with bile duct invasion had higher preoperative total bilirubin levels, greater microvascular invasion, and a higher death rate than those without bile duct invasion. In multivariate analysis, bile duct invasion was not an independent prognostic factor for survival for the entire cohort, but, was an independent prognostic factor for early stage.

Conclusions

Bile duct invasion accompanied microvascular invasion in most cases, and could be used as an independent prognostic factor for survival especially in early stage HCC (T1 and T2).

Bile duct thrombi in hepatocellular carcinoma: is aggressive surgery worthwhile?

INTRODUCTION

Obstructive jaundice as a result of bile duct tumour thrombus (BDTT) is an unusual clinical entity and an uncommon presenting feature of hepatocellular carcinoma (HCC). This study evaluates the outcome of hepatectomy for HCC with obstructive jaundice as a result of BDTT in non-cirrhotic livers.

METHODS

Between 1997 and 2012, out of 426 patients with HCC in non-cirrhotic livers, 39 patients with BDTT (Group I n = 39), who underwent a hepatectomy, were analysed and compared with the non-BDTT group (Group II n = 387).

RESULTS

The demographic profile and biochemical parameters between Group I and Group II were compared; apart from the presence of jaundice at presentation and an elevated serum bilirubin, there were no significant differences. Post-operative morbidity and mortality were 11 (28.2%) and 2 (5.1%), respectively, in Group I. There were no differences between the groups with regards to the operative variables and short-term outcomes. The 1-, 3- and 5-year survival rates in Group I were 82%, 48% and 10%, respectively, with a median survival of 28.6 months and were significantly poorer than Group II (90%, 55% and 38%, respectively, with a median survival of 39.2 months).

CONCLUSION

The mere presence of BDTT in HCC does not indicate an advanced or inoperable lesion. When technically feasible, a formal hepatic resection is the preferred first-line treatment option in these patients.

Hepatocellular Carcinoma Presenting with Obstructive Jaundice during Pregnancy

Introduction. Both hepatocellular carcinoma (HCC) presenting during pregnancy and HCC presenting with obstructive jaundice due to a tumor cast in the biliary tract are very rare. The management of these patients remains challenging. Presentation of Case. A 23-year-old lady presented with obstructive jaundice at 38 weeks of gestation. Investigations showed HCC with a biliary tumor thrombus. She received percutaneous transhepatic biliary drainage (PTBD) and caesarean section. Right hepatectomy, extrahepatic bile duct resection, and left hepaticojejunostomy were carried out when the jaundice improved. The postoperative course was uneventful. She was discharged home on postoperative day 10. Histopathology showed HCC with a tumor thrombus in the bile duct. The surgical margins were clear. One year after surgery, the mother was disease-free and the baby was well. Conclusion. With proper management, curative treatment is possible in a pregnant patient who presented with obstructive jaundice due to a biliary tumor thrombus from HCC.

Effective biliary drainage and proper treatment improve outcomes of hepatocellular carcinoma with obstructive jaundice

Background/Aims

We investigated the treatment outcomes and prognostic factors of hepatocellular carcinoma (HCC) with obstructive jaundice.

Methods

Among 2,861 patients newly diagnosed with HCC between 2002 and 2011, a total of 63 patients who initially presented with obstructive jaundice were analyzed. Only four patients presented with resectable tumors and underwent curative resection. In the other patients who presented with unresectable tumors, 5, 8, 9, and 18 patients received transarterial chemoembolization (TACE), chemotherapy, radiotherapy, and combined treatment, respectively. Both the clinical and the treatment factors that affect overall survival (OS) were analyzed.

Results

The median OS was 4 months, and the 1-year OS rate was 23%. Patients who received treatment for HCC had a significantly improved OS rate compared with the patients who received supportive care only (1-year OS, 32% vs 0%; p<0.01). Responders to treatment showed a better OS than nonresponders (1-year OS, 52% vs 0%; p<0.01). TACE and radiotherapy resulted in relatively good treatment responses of 64% and 67%, respectively. In multivariate analyses, treatment of HCC (p=0.02) and the normalization of serum bilirubin by biliary drainage (p=0.02) were significantly favorable prognostic factors that affected the OS.

Conclusions

Unresectable HCC with obstructive jaundice has a poor prognosis. However, effective biliary drainage and treatment of HCC such as with TACE or radiotherapy improves survival.

Targeted inhibition of the FGF19-FGFR4 pathway in hepatocellular carcinoma; translational safety considerations

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death and new therapies are urgently required to treat this disease. Recent data suggest that the FGF19-FGFR4 axis may be a key driver in certain forms of HCC, making the pathway an interesting, emerging molecular target for potential therapeutic intervention. A complication is that, outside of malignant disease, FGFR4 plays an important physiological role in the regulation of hepatic bile acid (BA) synthesis. FGF19 signalling via FGFR4 suppresses de novo BA production in the liver, tightly maintaining hepatic and systemic levels of these detergent-like molecules at a physiological threshold and preventing pathological complications of raised BA levels, such as cholestatic liver injury and bile acid diarrhoea. In some cases of HCC, the malignant disease causes bile duct obstruction, preventing BA secretion from the liver and resulting in cholestasis. Here, the role of FGFR4 signalling in both HCC and BA homoeostasis is discussed. The potential effects of therapeutic FGF19-FGFR4 inhibition on human hepatobiliary/gastrointestinal physiology are considered along with the potential safety implications of FGF19-FGFR4 blockade in patients with HCC.

Clinical usefulness of endoscopic palliation in patients with biliary obstruction caused by hepatocellular carcinoma

BACKGROUND/AIMS

To evaluate the clinical usefulness of endoscopic biliary drainage (EBD) in patients with hepatocellular carcinoma (HCC).

METHODS

A total of 111 jaundiced patients underwent attempted EBD for relief of HCC-related biliary stricture at our hospital over a 5-year period and all were included in the intention-to-treat (ITT) analysis.

RESULTS

After an endoscopic attempt at drainage, 46 (41.4%) of the 111 patients achieved a favorable response. Biliary cannulation failed in 5 patients. Child-Pugh class C, portal vein thrombosis and severe hyperbilirubinemia were negatively correlated with a favorable EBD response. In the ITT population, 40 (87.0%) of the favorable responders received further treatment for HCC, >2 (3.1%) of the unfavorable responders (p < 0.001). The median survival time for ITT patients with and without a favorable response to EBD was 8.7 and 1.3 months, respectively (p < 0.001). Cox's model showed that a favorable EBD response was an independent predictor of longer survival (hazard ratio 0.20, p < 0.001).

CONCLUSIONS

For HCC patients with tumor-related biliary obstruction, predictors of effective endoscopic palliation of cholestasis were relatively mild hyperbilirubinemia and preserved liver function and intact portal vein flow. A favorable EBD response was associated with longer survival outcomes.

Clinical characteristics and surgical prognosis of hepatocellular carcinoma with bile duct invasion

Objectives. Bile duct invasion (BDI) is a rare event in hepatocellular carcinoma (HCC). The present study aimed at investigating clinical characteristics and surgical outcome of HCC patients with bile duct invasion. Methods. 413 patients with HCC undergoing curative surgery were divided into two groups with (B(+)) and without BDI (B(-)). BDI was further classified as central type (B1) and peripheral type (B2). Survival was compared, and risk factors affecting prognosis were identified. Results. 35 (8.5%) patients were diagnosed BDI. Total bilirubin was significantly higher in B(+) group than in B(-) group (P < 0.001). Multiple lesions and large nodules (>5 cm) were predominantly identified in B(+) group (P < 0.01, resp.). Portal vein invasion was more frequently observed in B(+) than in B(-) group (P = 0.003). Univariate and multivariate analyses identified central BDI as a significant factor affecting prognosis of HCC patients (risk 1.3, 95% CI 1.1-2.2, P = 0.015). The gross overall survival of patients in B(+) was significantly worse than in B(-) (P = 0.001), which, however, was not different between B2 and B(-) (P > 0.05). Conclusions. Central but not peripheral BDI was associated with poorer prognosis of HCC patients. Curative surgical resection of tumors and invaded bile duct supplies the only hope for long-term survival of patients.

Clinical application of percutaneous drainage in treating hepatocellular carcinoma with bile duct tumor thrombus

Aim of the study

This study aimed to evaluate the effect of percutaneous interventional treatment on obstructive jaundice caused by hepatocellular carcinoma with bile duct tumor thrombus.

Material and methods

A total of 16 patients with bile duct tumor thrombus were included in the current retrospective study. All the patients were subjected to percutaneous transhepatic biliary drainage (PTBD). Treatment included permanent external drainage, internal drainage and routine tube adjustment, and covered stents according to the patients’ clinical manifestations.

Results

The success rate of PTBD was 100%. Among all the patients, two were treated with permanent external drainage, seven were treated with internal drainage and routine tube adjustment, and seven were treated with detaining covered stents. All the drainage tubes were successfully pulled out from the patients receiving covered stents. Among all the 16 patients, the clinical symptoms and life quality of 12 patients (12/16, 75%) were improved. The average survival time of all the patients was 203.7 days (ranging from 30 days to 391 days) with the median survival time of 199.5 days.

Conclusions

Percutaneous interventional therapy for obstructive jaundice caused by hepatocellular carcinoma with bile duct tumor thrombus is a good choice. It improves patients’ life quality. Permanent external drainage, internal drainage, and covered stents are alternative methods which should be chosen according to the patient's condition.

Intrahepatic bile duct recurrence of hepatocellular carcinoma without a detectable liver tumor

INTRODUCTION

Invasion of the portal and hepatic veins by hepatocellular carcinoma (HCC) is common, but macroscopic bile duct invasion is rare. Once a tumor thrombus completely obstructs the main bile duct, it causes obstructive jaundice. This type of HCC, known as icteric-type HCC (IHCC), has a poor prognosis.

PRESENTATION OF CASE

A 72-year-old woman had been treated for chronic hepatitis C since 1997. In 2002, percutaneous ethanol injection therapy was performed for HCC in segment 8. HCC recurrence occurred in 2004, and she underwent transarterial embolization (TAE) and radiofrequency ablation (RFA). In 2006, an S8 segmentectomy was performed for re-recurrence of HCC. Three years after surgery, computed tomography (CT) revealed a tumor occupying the right anterior intrahepatic bile duct and extending into its right main branch. With a preoperative diagnosis of HCC recurrence in the bile duct, we performed a right hepatectomy and thrombectomy. Histological examination showed moderately to poorly differentiated HCC. No tumor tissue other than the intrahepatic bile duct tumor was detected in the resected liver specimen.

DISCUSSION

HCC with biliary tumor thrombus is associated with a poor prognosis. In general, IHCC is difficult to diagnose and treat in the early stages. A characteristic radiological finding for this type of IHCC is the hypervascularity of the tumor thrombus.

CONCLUSION

To the best of our knowledge, this is a rare case of IHCC recurrence as a tumor thrombus without recurrence in the resected liver specimen.

Successful treatment of stereotactic body radiation therapy combined with transarterial chemolipiodolization for hepatocellular carcinoma with biliary obstruction

Conventional radiation therapy (RT) is a widely recognized treatment for hepatocellular carcinoma (HCC). However, conventional RT plays only a limited role in HCC treatment because of its low efficacy and the low tolerance of the liver for this modality. Stereotactic body radiation therapy (SBRT) was recently developed and represents the most advanced radiation therapy technique currently available. It can deliver a high dose in a short time to well-defined hepatic tumors, with rapid dose fall-off gradients. We believe that SBRT with transarterial chemolipiodolization (TACL) may prove promising as a combined treatment modality for HCC due to its precision and relative safety. Here we present a case of successful treatment of advanced HCC with obstructive jaundice using this combined modality.

Diagnosis of bile duct hepatocellular carcinoma thrombus without obvious intrahepatic mass

AIM

To study the diagnosis of hepatocellular carcinoma (HCC) presenting as bile duct tumor thrombus with no detectable intrahepatic mass.

METHODS

Six patients with pathologically proven bile duct HCC thrombi but no intrahepatic mass demonstrated on the preoperative imaging or palpated intrahepatic mass during operative exploration, were collected. Their clinical and imaging data were retrospectively analyzed. The major findings or signs on comprehensive imaging were correlated with the surgical and pathologic findings.

RESULTS

Jaundice was the major clinical symptom of the patients. The elevated serum total bilirubin, direct bilirubin and alanine aminotransferase levels were in concordance with obstructive jaundice and the underlying liver disease. Of the 6 patients showing evidence of viral hepatitis, 5 were positive for serum alpha fetoprotein and carbohydrate antigen 19-9, and 1 was positive for serum carcinoembryonic antigen. No patient was correctly diagnosed by ultrasound. The main features of patients on comprehensive imaging were filling defects with cup-shaped ends of the bile duct, with large filling defects presenting as casting moulds in the expanded bile duct, hypervascular intraluminal nodules, debris or blood clots in the bile duct. No obvious circular thickening of the bile duct walls was observed.

CONCLUSION

Even with no detectable intrahepatic tumor, bile duct HCC thrombus should be considered in patients predisposed to HCC, and some imaging signs are indicative of its diagnosis.

Surgery of hepatocellular carcinoma complicated with cancer thrombi in bile duct: efficacy for criteria for different therapy modalities

PURPOSE

This study retrospectively compared different therapy modalities in patients with hepatocellular carcinoma (HCC) complicated by bile duct thrombi (BDT).

METHODS

A total of 184 patients with BDT were selected from a pool of 12,114 patients with HCC, and their cases were reviewed in this study.

RESULTS

The occurrence rate of BDT was 1.84% (223/12,114) in our study. The radical resection rate in types I, II, III, and IV was 70% (7/10), 38.46% (10/26), 20.4% (29/142), 33.3% (2/6), respectively. The mean survival time in patients who underwent radical hepatic resection and BDT removal (group A), palliative hepatectomy and BDT removal (group B), palliative hepatectomy and BDT removal plus unilateral liver artery ligation or postoperative transcatheter arterial chemoembolization (TACE; group C), TACE (group D), drainage to relieve the jaundice by ERCP or PTCD (group E), and conservative treatment (group F) was 37, 6, 16, 11, 3.0, 3.0 months, respectively. The survival rate of patients in group A was significantly greater than in other group (P < 0.0001); the rate in groups C and D was significantly higher than that in groups B, E, and F (P < 0.001). In group A, 1-year recurrence rate was 20.8% (10/48). One patient with severe jaundice suffered chronic liver failure after right lobe resection and died 2 months after operation. In groups B, C, D, E, and F, in ten cases, cholangitis occurred, in eight cases, hemobilia occurred, and 72 of 136 patients suffered liver failure and died within 6 months. Five patients underwent orthotopic liver transplantation; at the time of writing, three patients are still alive, and the longest survivor has now survived for 37 months since undergoing transplantation.

CONCLUSIONS

Radical hepatic resection and removal of BDT, combined with TACE, are the best approach for treating HCC patients with BDT. Biliary drainage to relieve the jaundice is critical.

Clinicopathologic characteristics of hepatocellular carcinoma with bile duct invasion

To clarify the characteristics of hepatocellular carcinoma (HCC) with bile duct invasion, we retrospectively analyzed clinical features and surgical outcome of HCC with bile duct invasion (b(+) group, n = 15) compared to those without bile duct invasion (b(-) group, n = 256). In the b(+) group, four patients (27%) showed obstructive jaundice, and a diagnosis of bile duct invasion was obtained preoperatively in seven patients (47%). The levels of serum bilirubin and carbohydrate antigen 19-9 were significantly higher in the b(+) group. Macroscopically, confluent multinodular type and infiltrative type were predominant in the b(+) group (P = 0.002). Microscopically, capsule infiltration (P = 0.040) and intrahepatic metastasis (P = 0.013) were predominant in the b(+) group. Portal vein invasion was associated significantly with the b(+) group (P = 0.004); however, the frequency of hepatic vein invasion was similar (P = 0.096). The median survival after resection was significantly shorter in the b(+) group than in the b(-) group (11.4 vs. 56.1 months, P = 0.002), and eight of 11 intrahepatic recurrences in the b(+) group occurred within 3 months after surgery. HCC with bile duct invasion has an infiltrative nature and a high risk of intrahepatic recurrence, resulting in poor prognosis.

Liver failure after partial hepatic resection: definition, pathophysiology, risk factors and treatment

Liver failure is a dreaded and often fatal complication that sometimes follows a partial hepatic resection. This article reviews the definition, incidence, pathogenesis, risk factors, risk assessment, prevention, clinical features and treatment of post-resectional liver failure (PLF). A systematic, computerized search was performed using key words related to 'partial hepatic resection' and 'liver failure' to review most relevant literature about PLF published in the last 20 years. The reported incidence of PLF ranges between 0.7 and 9.1%. An inadequate quantity or quality of residual liver mass are key events in its pathogenesis. Major risk factors are the presence of comorbid conditions, pre-existent liver disease and small remnant liver volume (RLV). It is essential to identify these risk factors during the pre-operative assessment that includes evaluation of liver volume, anatomy and function. Preventive measures should be applied whenever possible as curative treatment options for PLF are limited. These preventive measures intend to increase RLV and protect remnant liver function. Management principles focus on support of end-organ and liver function. Further research is needed to elucidate the exact pathogenesis of PLF and to develop and validate adequate treatment options.

An icteric type hepatocellular carcinoma with no detectable tumor in the liver: report of a case

A 70-year-old man was admitted to our hospital with obstructive jaundice. Computed tomography revealed a tumor in the left intrahepatic bile duct extending to the common bile duct without any significant lesions in the liver. Cholangiography showed a filling defect due to an intraductal tumor. Cytology of the bile juice was negative and tumor markers were carcinoembryonic antigen 5.7 ng/ml, carbohydrate antigen 19-9 49 U/ml, alpha-fetoprotein 9 ng/dl, and PIVKA-II 19 200 AU/ml. With a preoperative diagnosis of hilar bile duct carcinoma, a laparotomy was performed. The common bile duct was filled with a tumor and it extended into the bilateral intrahepatic bile ducts. The intraductal tumor was removed together with the extrahepatic bile ducts. An intraoperative histological examination of the tumor showed a well-differentiated hepatocellular carcinoma. No lesions were detected in the liver by ultrasonography, palpation during the operation, or a computed tomography scan after the operation. At 1 year postoperatively, no recurrence has been seen in this patient.

Hepatocellular carcinoma presenting with obstructive jaundice

BACKGROUND

Jaundice occurs in 5-44% of patients with hepatocellular carcinoma (HCC). It is an important clinical presentation as the different aetiological causes of jaundice in HCC determine the therapeutic approach and the prognosis. This article aims to review the classification, management and prognosis of patients with jaundice associated with HCC.

METHODS

A Medline search was undertaken to identify articles using the key words 'hepatocellular carcinoma', 'jaundice' and 'tumour thrombus'. Additional articles were identified by a manual search of the references from the key articles.

RESULTS

Patients with jaundice due to hepatic parenchymal insufficiency (hepatocellular type) have a very dismal prognosis. For patients with biliary obstruction due to HCC (icteric type), the reported 1-, 3- and 5-year survival rates after curative resection were 57.1-100%, 20-47% and 6.7-45%, respectively. The mean survival after palliative biliary drainage alone was less than 6 months but when biliary drainage was combined with other palliative treatment, the mean survival could be up to 1 year.

CONCLUSIONS

It is important to differentiate the hepatocellular type from the icteric type of HCC. For patients with the icteric type of HCC, curative liver resection can achieve a survival comparable to that in patients without jaundice. For patients with unresectable icteric type of HCC, treatment can provide improvement in patient's quality of life and survival.

Treatment of malignant biliary obstruction by combined percutaneous transhepatic biliary drainage with local tumor treatment

AIM

To evaluate the utility of local tumor therapy combined with percutaneous transhepatic biliary drainage (PTBD) for malignant obstructive biliary disease.

METHODS

A total of 233 patients with malignant biliary obstruction were treated in our hospital with PTBD by placement of metallic stents and/or plastic tubes. After PTBD, 49 patients accepted brachytherapy or extra-radiation therapy or arterial infusion chemotherapy. The patients were followed up with clinical and radiographic evaluation. The survival and stent patency rate were calculated by Kaplan-Meier survival analysis.

RESULTS

Twenty-two patients underwent chemotherapy (11 cases of hepatic carcinoma, 7 cases of pancreatic carcinoma, 4 cases of metastatic lymphadenopathy), and 14 patients received radiotherapy (10 cases of cholangiocarcinoma, 4 cases of pancreatic carcinoma), and 13 patients accepted brachytherapy (7 cases of cholangiocarcinoma, 3 cases of pancreatic carcinoma, 4 cases of metastatic lymphadenopathy). The survival rate of the local tumor treatment group at 1, 3, 6, and 12 months was 97.96%, 95.92%, 89.80%, and 32.59% respectively, longer than that of the non treatment group. The patency rate at 1, 3, 6, and 12 months was 97.96%, 93.86%, 80.93%, and 56.52% respectively. The difference of patency rate was not significant between treatment group and non treatment group.

CONCLUSION

Our results suggest that local tumor therapy could prolong the survival time of patients with malignant biliary obstruction, and may improve stent patency.

Surgical treatment of hepatocellular carcinoma with bile duct tumor thrombi

AIM: To study the surgical treatment effect and outcome of hepatocellular carcinoma (HCC) with bile duct tumor thrombi (BDTT).

METHODS: Fifty-three consecutive HCC patients with BDTT admitted in our department from July 1984 to December 2002 were reviewed retrospectively. The clinical data, diagnostic methods, surgical procedures and outcome of these patients were collected and analyzed.

RESULTS: One patient rejected surgical treatment, 6 cases underwent percutaneous transhepatic cholangial drainage (PTCD) for unresectable primary disease, and the other 46 cases underwent surgical operation. The postoperative mortality was 17.6%, and the morbidity was 32.6%. Serum total bilirubin levels of these patients with obstructive jaundice decreased gradually after surgery. The survival time of six cases who underwent PTCD ranged from 2 to 7 mo (median survival of 3.7 mo). The survival time of the patients who received surgery was as follows: 2 mo for one patient who underwent laparotomy, 5-46 mo (median survival of 23.5 mo, which was the longest survival in comparison with patients who underwent other procedures, P = 0.0024) for 17 cases who underwent hepatectomy, 5-17 mo (median survival of 10.0 mo) for 5 cases who underwent HACE, 3-9 mo (median survival of 6.1 mo) for 11 cases who underwent simple thrombectomy and biliary drainage, and 3-8 mo (median survival of 4.3 mo) for four cases who underwent simple biliary drainage.

CONCLUSION: Jaundice caused by BDTT in HCC patients is not a contraindication for surgery. Only curative resection can result in long-term survival. Early diagnosis and surgical treatment are the key points to prolong the survival of patients.

Surgical results for hepatocellular carcinoma with bile duct invasion: a clinicopathologic comparison between macroscopic and microscopic tumor thrombus

BACKGROUND

The aim of this study was to evaluate the prognostic factors and long-term results after surgery in patients with hepatocellular carcinoma (HCC) with bile duct invasion.

METHODS

The records of 38 HCC patients with microscopic (tumor thrombus was found in more than the second order branch of the biliary tree; n = 19) and macroscopic (tumor thrombus was found in no more than the second order branch of the biliary tree; n = 19) bile duct invasion were reviewed in this study. Survival rates were calculated with regard to 18 clinicopathological factors. A log-rank analysis was performed to identify which factors predict the prognosis. The relationships between the degree of bile duct invasion and 17 clinicopathologic factors were also compared.

RESULTS

The overall 1-, 3-, and 5-year survival rates were 79%, 45%, and 33%, respectively. The indicators of a favorable prognosis included no intrahepatic metastases, curative surgical resection, and macroscopic bile duct invasion.

CONCLUSION

We found a favorable long-term postoperative result for HCC patients with macroscopic bile duct invasion. Even if HCC tumor thrombus is recognized in the major branches of bile duct, extensive and curative surgical treatment should be recommended when hepatic functional reserve is satisfactory without intrahepatic metastases.

Extrahepatic biliary obstruction after percutaneous tumour ablation for hepatocellular carcinoma: aetiology and successful treatment with endoscopic papillary balloon dilatation

BACKGROUND AND AIMS

Percutaneous tumour ablation (PTA), such as ethanol injection and radiofrequency ablation, is now recognised as a primary treatment for hepatocellular carcinoma (HCC). Although PTA is a relatively safe procedure, it can cause biliary obstruction as a rare complication. As patients with cirrhosis undergoing surgery or endoscopic retrograde cholangiopancreatography/sphincterotomy have a high mortality rate from bleeding, we adopted the use of endoscopic papillary balloon dilatation (EPBD) in these patients and now report the results. We retrospectively analysed the incidence of biliary obstruction after PTA and the efficacy of treatment with EPBD.

PATIENTS AND METHODS

A total of 1043 patients with HCC were treated by PTA, of whom 538 were treated with transarterial embolisation with up to eight years of follow up.

RESULTS

There were 17 (1.6%) cases of hilar obstruction due to tumour progression and 35 (3.4%) cases of extrahepatic obstruction. Apart from the expected causes of biliary obstruction (haemobilia n = 11, gallstones n = 11, and three miscellaneous causes), we found that 10 patients had obstruction due to biliary casts. This is the first description of biliary casts after percutaneous tumour ablation therapy. Extrahepatic biliary obstruction by procedure related haemobilia occurred within three days of PTA while other causes occurred between 0 and 17 (average 4.9) months. Biliary casts occurred more frequently after ethanol injection than after radiofrequency ablation. EPBD successfully dissipated biliary obstruction in 33 of 35 cases, while two died due to hepatic failure despite successful drainage.

CONCLUSIONS

Extrahepatic biliary obstruction is an uncommon complication after PTA for HCC, and can be safely and effectively treated with EPBD, despite impaired liver function.

Diagnosis and surgical treatments of hepatocellular carcinoma with tumor thrombosis in bile duct: Experience of 34 patients

AIM: Hepatocellular carcinoma (HCC) with bile duct tumor thrombosis (BDT) is a rare event. The prognosis of this type of patients is very dismal. The aim of this study was to share the experience in the diagnosis and treatment of HCC with BDT, to further improve the prognosis of these patients.

METHODS: Thirty-four patients of HCC with BDT received surgical treatment in authors’institute from July 1987 to January 2003 were reviewed retrospectively. The experience in the diagnosis and treatment, and the outcome of this type of HCC patients were summarized.

RESULTS: Thirty of the 34 patients (88.2%) were positive for alpha-fetoprotein (AFP) (> 20 μg/L), and 12 patients (35.3%) were found having obstructive jaundice before operation, 18 cases were suspected of “obstruction of bile duct” preoperatively. The primary tumors were frequently located at the left medial (13 cases) or right anterior lobe (14 cases). Thirty-one patients received liver resections and removal of BDT, while the other 3 patients received removal of BDT combined with hepatic artery ligation and cannulation (HAL + HAI), or only removal of BDT because their liver function reservation and general condition could not tolerate the primary tumor resection. The 1-year survival rate was 71.4% (20/28). The longest disease-free survival was over 15 years. The intrahepatic tumor recurrence within 1 year after operation was found in 14 patients (14/28, 50.0%).

CONCLUSION: Surgical removal of primary tumors and BDT is safe and beneficial to the HCC patients with BDT. Early detection, diagnosis, and surgical treatment are the key points to prolong the survival time of patients.

Three cases of small hepatocellular carcinoma presenting as obstructive jaundice

BACKGROUND

Despite improved diagnostic tools, it is often difficult to make a correct diagnosis of small hepatocellular carcinoma (HCC) in patients with obstructive jaundice.

CASE OUTLINES

Three cases of small HCC (<2 cm diameter) presenting as obstructive jaundice are reported. All tumours were initially diagnosed as hilar cholangiocarcinoma based on ultrasonography, computed tomography, cholangiography and angiography. Because of insufficient hepatic function, none of the patients underwent hepatic resection. One patient died 8 months after first admission to our hospital, another died of disseminated intravascular coagulation I month after admission, and the third was treated with hepatic arterial infusion chemotherapy and survived >36 months.

CONCLUSION

It is important to consider HCC in the diagnosis of obstructive jaundice in patients who are predisposed to HCC because of liver cirrhosis and/or chronic viral hepatitis, and have elevated serum alpha-fetoprotein.

Hepatocellular carcinoma: surgical indications and results

Hepatocellular carcinoma (HCC) is a tumour of increasing incidence that usually arises in cirrhotic liver. Untreated, the prognosis is grim and the only curative treatment is surgical resection. The practical application of segmental surgery to the liver together with the use of ultrasound and other imaging techniques, patient selection criteria and improvements in perioperative technique and postoperative care have contributed to better results in hepatic surgery. Today, less than 10% mortality for resection of cirrhotic livers, with up to 50% 5-year survival rates are to be expected. However, the limits of resection for cure: intrahepatic recurrence makes stringent follow-up necessary. In this way the available modalities of treatment can be applied so as to improve survival. Herein, a current 'state-of-the-art' of surgical indications and results for HCC is given.

Hepatocellular carcinoma with obstructive jaundice: diagnosis, treatment and prognosis

Obstructive jaundice as the main clinical feature is uncommon in patients with hepatocellular carcinoma (HCC). Only 1%-12% of HCC patients manifest obstructive jaundice as the initial complaint. Such cases are clinically classified as “icteric type hepatoma”, or “cholestatic type of HCC”. Identification of this group of patients is important, because surgical treatment may be beneficial. HCC may involve the biliary tract in several different ways: tumor thrombosis, hemobilia, tumor compression, and diffuse tumor infiltration. Bile duct thrombosis (BDT) is one of the main causes for obstructive jaundice, and the previously reported incidence is 1.2%-9%. BDT might be benign, malignant, or a combination of both. Benign thrombi could be blood clots, pus, or sludge. Malignant thrombi could be primary intrabiliary malignant tumors, HCC with invasion to bile ducts, or metastatic cancer with bile duct invasion. The common clinical features of this type of HCC include: high level of serum AFP; history of cholangitis with dilation of intrahepatic bile duct; aggravating jaundice and rapidly developing into liver dysfunction. It is usually difficult to make diagnosis before operation, because of the low incidence rate, ignorant of this disease, and the difficulty for the imaging diagnosis to find the BDT preoperatively. Despite recent remarkable improvements in the imaging tools for diagnosis of HCC, such cases are still incorrectly diagnosed as cholangiocarcinoma or choledocholithiases. Ultrasonography (US) and CT are helpful in showing hepatic tumors and dilated intrahepatic and /or extrahepatic ducts containing dense material corresponding to tumor debris. Direct cholangiography including percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP) remains the standard procedure to delineate the presence and level of biliary obstruction. Magnetic resonance cholangiopancreatography (MRCP) is superior to ERCP in interpreting the cause and depicting the anatomical extent of the perihilar obstructive jaundice, and is particularly distinctive in cases associated with tight biliary stenosis and along segmental biliary stricture. Choledochoscopy and bile duct brushing cytology could be alternative useful techniques in the differentiating obstructions due to intraluminal mass, infiltrating ductal lesions or extrinsic mass compression applicable before and after duct exploration. Jaundice is not necessarily a contraindication for surgery. Most patients will have satisfactory palliation and occasional cure if appropriate procedures are selected and carried out safely, which can result in long-term resolution of symptoms and occasional long-term survival. However, the prognosis of icteric type HCC is generally dismal, but is better than those HCC patients who have jaundice caused by hepatic insufficiency.

Hepatocellular carcinoma with biliary tumor thrombi: aggressive operative approach after appropriate preoperative management

BACKGROUND

The aim of this study was to clarify clinicopathologic characteristics of, and to evaluate an aggressive treatment strategy for, hepatocellular carcinoma with biliary tumor thrombi.

METHODS

From 1980 to 1999, a total of 132 patients underwent hepatectomy for hepatocellular carcinoma. Of these, 17 patients had macroscopic biliary tumor thrombi and were retrospectively analyzed.

RESULTS

The operative procedures included right hepatic trisegmentectomy (n = 1), right or left hepatic lobectomy (n = 11), and segmentectomy or subsegmentectomy (n = 5). In 13 patients, tumor thrombi extended beyond the hepatic confluence and was treated by thrombectomy through a choledochotomy in 8 patients and extrahepatic bile duct resection and reconstruction in 5 patients. The 3- and 5-year survival rates were 47% and 28%, respectively, with a median survival time of 2.3 years. These survival rates were similar to those achieved in 115 patients without biliary tumor thrombi. In a multivariate analysis, expansive growth type and solitary tumors were independent prognostic variables for favorable outcome after operation, whereas biliary tumor thrombi was not a significant prognostic factor.

CONCLUSIONS

Surgery after appropriate preoperative management of hepatocellular carcinoma with biliary tumor thrombi yields results similar to those of patients without biliary involvement. Hepatectomy with thrombectomy through a choledochotomy appears to be as effective as a resection procedure.