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 BDTr 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, 6cases 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.

SpyGlass in Diagnosis of Hepatocellular Carcinoma with Right Hepatic Duct Tumor Thrombus Hemorrhage: A Case Report

Hepatocelluar carcinoma presenting as a biliary duct tumor thrombus is a relatively rare entity, with poor prognosis. The primary clinical manifestation of this disease is obstructive jaundice, which can often be misdiagnosed. A 59-year-old female patient was admitted with sudden onset of abdominal pain. Laboratory tests suggested obstructive jaundice, and enhanced magnetic resonance imaging of the upper abdomen did not show obvious biliary dilatation. Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography suggested an occupying lesion in the upper bile duct. SpyGlass and biopsy finally confirmed hepatocellular carcinoma with right hepatic duct tumor thrombus hemorrhage. The SpyGlass Direct Visualization System, as an advanced biliary cholangioscopy device, showed the advantages of single-person operation as well as easy access to and visualization of the lesion.

Prognosis of hepatocellular carcinoma with bile duct tumor thrombus after R0 resection:a matched study

BACKGROUND： Hepatocellular carcinoma （HCC） with bile duct tumor thrombus （BDTT） is rare. The present study aimed to determine post-surgical prognoses in HCC patients with BDTT, as outcomes are currently unclear. METHODS： We compared the prognoses of 110 HCC patients without BDTT （group A） to 22 cases with BDTT （group B）. The two groups were matched in age, gender, tumor etiology, size, number, portal vascular invasion, and TNM stage. Additionally, 28 HCC patients with BDTT were analyzed to identify prognostic risk factors. RESULTS： The 1-, 3-, and 5-year overall survival rates were 90.9%, 66.9%, and 55.9% for group A and 81.8%, 50.0%, and 37.5% for group B, respectively. The median survival time in groups A and B was 68.8 and 31.4 months, respectively （P=0.043）. The patients for group B showed higher levels of serum total bilirubin, alanine aminotransferase and gammaglutamyl transferase, a larger hepatectomy range, and a higher rate of anatomical resection. In subgroup analyses of patients with BDTT who underwent R0 resection, TNM stage Ⅲ-Ⅳ was an independent risk factor for overall survival; these patients had worse prognoses than those with TNM stage Ⅰ-Ⅱ after R0 resection （hazard ratio=6.056, P=0.014）. Besides, univariate and multivariate analyses revealed that non-R0 resection and TNM stage Ⅲ-Ⅳ were independent risk factors for both disease-free survival and overall survival of 28 HCC patients with BDTT. The median overall survival time of patients with BDTT who underwent R0 resection was longer than that of patients who did not undergo R0 resection （31.0 vs 4.0 months, P=0.007）.CONCLUSIONS： R0 resection prolonged survival time in HCC patients with BDTT, although prognosis remains poor. For such patients, R0 resection is an important treatment that determines long-term survival.

Hepatocellular carcinoma with tumor thrombus in bile duct:A proposal of new classification according to resectability of primary lesion

BACKGROUND Hepatocellular carcinoma(HCC)with tumor thrombus in the bile duct(BDTT)is easily misdiagnosed or mistreated due to the clinicopathological diversity of the thrombus and its relationship with primary lesions.AIM To propose a new classification for HCC with BDTT in order to guide its diagnosis and treatment.METHODS A retrospective review of the diagnosis and treatment experience regarding seven typical HCC patients with BDTT between January 2010 and December 2019 was conducted.RESULTS BDTT was preoperatively confirmed by computed tomography/magnetic resonance imaging in only four patients.Three patients with recurrent HCC and one patient with first-occurring HCC had no visible intrahepatic tumors;of these,misdiagnosis occurred in two patients,and three patients died.One patient was mistreated as having common bile duct stones,and another patient with a history of multiple recurrent HCC was misdiagnosed until obvious biliary dilation could be detected.Only one patient who received hepatectomy accompanied by BDTT extraction exhibited disease-free survival during the follow-up period.A new classification was proposed for HCC with BDTT as follows:HCC with microscopic BDTT(Type Ⅰ);resectable primary or recurrent HCC mass in the liver with BDTT(Type Ⅱ);BDTT without an obvious HCC mass in the liver(Type Ⅲ)and BDTT accompanied with unresectable intra-or extrahepatic HCC lesions(Type Ⅳ).CONCLUSION We herein propose a new classification system for HCC with BDTT to reflect its pathological characteristics and emphasize the significance of primary tumor resectability in its treatment.

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.

A special recurrent pattern in small hepatocellular carcinoma after treatment:Bile duct tumor thrombus formation

AIM:To investigate the clinicopathologic features of bile duct tumor thrombus(BDTT) occurrence after treatment of primary small hepatocellular carcinoma(sHCC) .METHODS:A total of 423 patients with primary sHCC admitted to our hospital underwent surgical resection or local ablation.During follow-up,only six patients were hospitalized due to obstructive jaundice,which occurred 5-76 mo after initial treatment.The clinicopathologic features of these six patients were reviewed.RESULTS:Six patients underwent hepatic resection(n=5) or radio-frequency ablation(n=1) due to primary sHCC.Five cases had an R1 resection margin,and one case had an ablative margin less than 5.0 mm.No vascular infiltration,microsatellites or bile duct/canaliculus affection was noted in the initial resected specimens.During the follow-up,imaging studies revealed a macroscopic BDTT extending to the common bile duct in all six patients.Four patients had a concomitant intrahepatic recurrent tumor.Surgical re-resection of intrahepatic recurrent tumors and removal of BDTTs(n=4) ,BDTT removal through choledochotomy(n= 1) ,and conservative treatment(n=1) was performed.Microscopic portal vein invasion was noted in three of the four resected specimens.All six patients died,with a mean survival of 11 mo after BDTT removal or conservative treatment.CONCLUSION:BDTT occurrence is a rare,special recurrent pattern of primary sHCC.Patients with BDTTs extending to the common bile duct usually have an unfavorable prognosis even following aggressive surgery.Insufficient resection or ablative margins against primary sHCC may be a risk factor for BDTT development.

Intraductal papillary neoplasm of the bile duct in liver cirrhosis with hepatocellular carcinoma

A case of intraductal papillary neoplasm of the bile duct (IPNB) arising in a patient with hepatitis B-related liver cirrhosis with hepatocellular carcinoma (HCC) is reported. A 76-year-old man was admitted to our hospital with recurrent HCC. Laboratory data showed that levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were elevated. He died of progressive hepatic failure. At autopsy,in addition to HCCs,an intraductal papillary proliferation of malignant cholangiocytes with fibrovascular cores was found in the dilated large bile ducts in the left lobe,and this papillary carcinoma was associated with an invasive mucinous carcinoma (invasive IPNB). Interestingly,extensive intraductal spread of the cholangiocarcinoma was found from the reactive bile ductular level to the interlobular bile ducts and septal bile ducts and to the large bile ducts in the left lobe. Neural cell adhesion molecule,a hepatic progenitor cell marker,was detected in IPNB cells. It seems possible in this case that hepatic progenitor cells located in reactive bile ductules in liver cirrhosis may have been responsible for the development of the cholangiocarcinoma and HCC,and that the former could have spread in the intrahepatic bile ducts and eventually formed grossly visible IPNB.

Extrahepatic intraductal ectopic hepatocellular carcinoma:bile duct filling defect

BACKGROUND:Obstructive jaundice caused by an intraductal hepatocellular carcinoma is a rare initial symptom.We report a rare case of an extrahepatic icteric type hepatocellular carcinoma.METHODS:A 75-year-old patient was admitted to our hospital because of obstructive jaundice 3 months after resection of multilocular hepatocellular carcinoma.A postoperative bile leakage was treated by placement of a decompressing stent in the common bile duct.Endoscopic retrograde choledochoscopy showed extended blood clots filling the bile duct system and computed tomography revealed a local swelling in the common extrahepatic bile duct.The level of alpha-fetoprotein(AFP)was only slightly elevated but that of CA19-9 was dramatically increased.Cholangiography showed an intraductal filling defect typical of a cholangiocellular carcinoma.RESULTS:Bile duct brushing cytology showed no cholangiocellular carcinoma but hepatocellular carcinoma cells in the extrahepatic bile duct.An extrahepatic bile duct resection was performed.Histological examination confirmed the diagnosis of extrahepatic intraductal growth of hepatocellular carcinoma.CONCLUSION:Ectopic hepatocellular carcinoma is a rare but important differentially diagnosed of extrahepatic bile duct filling defect.

Neuroendocrine carcinoma of the extrahepatic bile duct: A case report

Neuroendocrine carcinoma(NEC) originating from the gastrointestinal hepatobiliary-pancreas is a rare, invasive, and progressive disease, for which the prognosis is extremely poor. The patient was a 72-year-old man referred with complaints of jaundice. He was diagnosed with middle extrahepatic cholangiocarcinoma(cT 4N1M0, c Stage Ⅳ). He underwent a right hepatectomy combined with extrahepatic bile duct and portal vein resection after percutaneous transhepatic portal vein embolization. Microscopic examination showed a large-cell neuroendocrine carcinoma according to the WHO criteria for the clinicopathologic classification of gastroenteropancreatic neuroendocrine tumors. Currently, the patient is receiving combination chemotherapy with cisplatin and etoposide for postoperative multiple liver metastases. Although NEC is difficult to diagnose preoperatively, it should be considered an uncommon alternative diagnosis.

Carcinosarcoma of common bile duct:A case report

BACKGROUND Carcinosarcomas of the common bile duct(CBD)are an extremely rare finding in the clinical setting.Based on a review of 12 literatures,3 cases had the imaging features of ossification.Carcinosarcomas are prone to distant metastasis,as they possess clinical features of both carcinoma and sarcoma,and generally have with a poor prognosis.Due to the small number of cases reported,clinical experience in the diagnosis and treatment of the disease is lacking.CASE SUMMARY The patient was a 75-year-old woman who had experienced recurrent chills with nausea and vomiting for 3 mo.Computed tomography,magnetic resonance imaging,endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography led to the diagnosis of malignant tumor of the CBD.The patient ultimately underwent cholecystectomy,CBD resection,and choledochojejunostomy.Postoperative pathological examination revealed carcinosarcoma of the CBD,and the latest follow-up showed that the patient is recovering well.Based on previous case reports,some carcinosarcoma has ossification characteristics in imaging.If it is misdiagnosed as biliary calculi,the use of laser lithotripsy in surgery may lead to tumor diffusion.Choledochoscopy and narrow band staining of mucosa are very important for diagnosis.CONCLUSION We herein present a rare case of carcinosarcomas of the CBD,we found the tumours may have imaging features of polypoid growth and ossification only when the sarcomal components are bone differentiation,while show soft tissue shadow when non bone differentiation.Confirmation of diagnosis depends greatly upon postoperative pathological examination and the adjuvant treatment has not been established,which leads to the poor prognosis.

Tubulopapillary adenoma of the gallbladder accompanied by bile duct tumor thrombus

Intraductal papillary mucinous neoplasm of the bile duct(IPNB)is recognized as a precancerous lesion;however,both its pathogenesis and progression remain unclear.We present here a case of IPNB arising from the gallbladder accompanied by bile duct tumor thrombus in a 79-year-old female.The resected specimen revealed a tubulopapillary adenoma with no malignant cells.This case suggests that even in the absence of malignant cells,these tumors can behave as malignant tumors requiring aggressive treatment.Even if no malignant cells are present,intraepithelial neoplasms occurring in the ampullopancreatobiliary tract can behave as malignant tumors.

Primary large cell neuroendocrine carcinoma in the common bile duct:First Asian case report

Large cell neuroendocrine carcinoma(LCNEC)in the biliary system is a poorly differentiated,high-grade neuroendocrine tumor.These tumors exhibit aggressive behavior and an increased tendency for early nodal and distant metastases.Herein,we report an unusual case of a pure primary LCNEC of the common bile duct(CBD).A 75-year-old female presented with nausea and jaundice.The patient underwent a CBD excision with lymph node dissection.Upon histological and immunohistochemical examination,the tumor exhibited pure large cell-type neuroendocrine features.Metastases were noted in two of the eight lymph nodes.The patient was administered adjuvant chemotherapy.The patient’s cancer recurred 7 mo after surgery,and the patient died from liver failure 5 mo after recurrence.The prognosis of LCNEC of CBD remains poor despitecurative resection and adjuvant chemotherapy.The role of additional therapies,such as multimodal treatment including radiation therapy,must be further studied to improve the prognoses of patients.

Concomitant adenosquamous carcinoma and cystadenocarcinoma of the extrahepatic bile duct: A case report

BACKGROUND Infiltrative adenosquamous carcinoma(ASC) of the extrahepatic bile duct is reported infrequently, which is an unusual variant of the ordinary adenocarcinoma. The simultaneous development of ASC and cystadenocarcinoma in the extrahepatic biliary tree is rare. In addition, the accurate preoperative diagnosis of concomitant carcinoma in the multiple biliary trees at an early stage is often difficult. Thus, awareness of the risk of the multiplicity of biliary tumors is perhaps the most important factor in identifying these cases.CASE SUMMARY Here, we report a case of a 63-year-old female with jaundice, who was referred to Shuguang Hospital because of abdominal pain for 1 mo. An abdominal contrastenhanced computed tomography revealed a type I choledochal cyst and intraluminal masses suggestive of adenoma of the common bile duct. In addition,a preoperative diagnosis of a concomitant Klatskin tumor and type I choledochal cyst was made. The patient underwent anti-inflammatory therapy, followed by radical surgery due to hilar cholangiocarcinoma and resection of the choledochal cyst. Examination of the surgical specimen revealed a papillary tumor of the common bile duct, which arose from the malignant transformation of a preexisting cystadenoma. Histologic examination confirmed a special type of cholangiocarcinoma; the tumor in the hilar bile duct was an ASC, whereas the tumor in the common bile duct was a moderately differentiated cystadenocarcinoma. The patient showed rapid deterioration 8 mo after surgery.CONCLUSION Although concomitant ASC and cystadenocarcinoma of the extrahepatic bile duct is difficult to diagnose before surgery, and the prognosis is poor after surgery,surgical resection is still the preferred treatment.

Rational therapeutic strategy for T2 gallbladder carcinoma based on tumor spread

AIM:To evaluate the adequacy of surgical treatment of T2 gallbladder carcinoma(GBCa)according to tumor spread in the subserosal layer. METHODS:A series of 84 patients with GBCa were treated at Saga University Hospital,Japan between April 1989 and October 2008.The tumor stage was graded according to the TNM staging for GBCa from the American Joint Committee on Cancer Manual 6th edition. Tumor staging revealed 30 patients with T2 tumors.T2 GBCa was divided into three groups histologically by the extent of tumor spread in the subserosal layer,using a score of ss minimum(ss min),ss medium(ss med)or ss massive(ss mas). RESULTS:For ss min GBCa,there was no positive pathological factor and patient survival was satisfactory with simple cholecystectomy,with or without extra-he- patic bile duct resection.For ss med GBCa,some pathological factors,h-inf(hepatic infiltration),ly(lymphatic invasion)and n(lymph node metastasis),were positive. For ss mas GBCa,there was a high incidence of positive pathological factors.The patient group with extra-hepatic bile duct resection with D2 lymph node dissection (BDR with D2)and those with S4a5 hepatectomy had significantly better survival rates.CONCLUSION:We suggest that radical surgery is not necessary for ss min GBCa,and partial hepatectomy and BDR are necessary for both ss med and ss mas GBCa.

Recent advances in the surgical treatment of hepatocellular carcinoma

Hepatocellular carcinoma(HCC) is the most common primary liver malignancy. The treatment of HCC is complex and complicated by the severity of associated chronic liver disease, the stage of HCC, and the clinical condition of the patient. Liver resection(LR) is one of the most efficient treatments for patients with HCC, with an expected 5-year survival of 38%-61% depending on the stage of the disease. Improved liver function assessment, increased understanding of segmental liver anatomy from advanced imaging studies, and surgical technical progress are important factors that have led to reduced mortality in patients with HCC. The indication for LR may be expanded due to emerging evidences from laparoscopic hepatectomies and combined treatments with newly developed chemotherapies. Liver transplantation(LT) is considered as an ideal treatment for removal of existing tumors and the injured/preneoplastic underlying liver tissue with impaired liver function and the risk of multicentric carcinogenesis that results from chronically injured liver. However, LT is restricted to patients with minimal risk of tumor recurrence under immunosuppression. The expansion of criteria for LT in HCC patients is still under trial and discussion. Limited availability of grafts, as well as the risk and the cost of transplantation have led to considerable interest in expansion of the donor pool, living donor-related transplantation, and combined treatment involving LR and LT. This highlight presents evidence concerning recent studies evaluating LR and LT in HCC patients. In addition, alternative therapies for the treatment of early stage tumors and the management of patients on transplant waiting lists are discussed.

Small cell carcinoma of the liver and biliary tract without jaundice

An 80-year-old woman presenting with chest pain was found to have a large,lobulated soft tissue mass in the liver and nearby tissues on abdominal computed tomography(CT).The tumor had invaded the common hepatic artery and main portal vein.Jaundice developed 4 wk later,at which point,a pancreas and biliary CT scan revealed a large mass in the right lobe of the liver and a hilar duct obstruction,which was found to be a small cell carcinoma.Despite its rarity,liver and bile duct small cell carcinoma should be considered in the differential diagnosis of atypical chest pain without jaundice.

The benefit of curative liver resection with a selective bile duct preserving approach for hepatocellular carcinoma with macroscopic bile duct tumor thrombus

Background:Hepatocellular carcinoma(HCC)presenting with macroscopic bile duct tumor thrombus(BDTT)is an uncommon event.The role of a curative hepatic resection and associated long-term outcomes remain controversial.In addition the necessity for bile duct resection is still unclear.The aim of this study was to evaluate outcomes of hepatectomy with a selective bile duct preservation approach for HCC with BDTT in comparison to outcomes without BDTT.Methods:A total of 22 HCC with BDTT patients who had undergone curative hepatic resection with a selective bile duct preservation approach at our institute were retrospectively reviewed.These were compared to group of 145 HCC without BDTT patients.The impact of curative surgical resection and BDTT on clinical outcomes and survival after surgical resection were analyzed.Results:All HCC with BDTT cases underwent major hepatectomy vs.32.4%in the comparative group.Bile duct preservation rate was 56.5%.The 1-,3-and 5-year survival rates of HCC with BDTT patients in comparison to the HCC without BDTT group were 81.8%,52.8%and 52.8%vs.73.6%,55.6%and 40.7%(P=0.804)respectively.Positive resection margin,tumor size≥5 cm and AFP≥200 IU/mL were significant risk factors regarding overall survival.However,it is unclear whether presence of a bile duct tumor thrombus has an adverse impact on either recurrence free survival or overall survival.Conclusions:Bile duct obstruction from tumor thrombus did not necessarily indicate an advanced form of disease.Tumor size and AFP had greater impact on long-term outcomes than bile duct tumor thrombus.Major liver resection with a selective bile duct preserving approach in HCC with BDTT can achieve favorable outcomes comparable to those of HCC without BDTT in selected patients.

Role of serum total sialic acid in differentiating cholangiocarcinoma from hepatocellular carcinoma

AIM:This study was designed to evaluate the clinical application of serum total sialic acid (TSA) in the diagnosis of cholangiocarcinoma (CCA).METHODS: Serum TSA was determined by periodateresorcinol microassay in 69 patients with CCA, 59 patients with hepatocellular carcinoma (HCC), 37 patients with cirrhosis, 61 patients with chronic hepatitis and 50 healthy blood donors.RESULTS: The mean serum TSA concentration in CCA (2.41±0.70 mmol/L) was significantly higher than those of HCC, cirrhosis, chronic hepatitis and healthy blood donors (1.41±0.37 mmol/L, 1.13±0.31 mmol/L, 1.16±0.26 mmol/L, and 1.10±0.14 mmol/L, respectively; P＜0.001). Based on ROC curve analysis, a cut-off point of 1.75 mmol/L discriminated between CCA and HCC with a sensitivity,specificity and accuracy of 82.6%, 83.1%, and 82.8%,respectively.CONCLUSION: Based on our results, serum TSA would be a useful marker for the differential diagnosis of CCA from HCC.

Surgical operation and re-operation for hepatocellular carcinoma with bile duct thrombosis

Background Few reports have evaluated the efficacy of re-operation for relapse after initial surgery for hepatocellular carcinoma （HCC） with bile duct thrombosis （BDT）.The aim of this study was to investigate the efficacy of initial surgery and subsequent re-operation for HCC with BDT, and their effects on prognosis.Methods The clinical data of 880 patients with HCC, including 28 patients with BDT, who underwent radical hepatectomy between 1998 and 2008 in our hospital, were reviewed.The effects of BDT and re-operation on prognosis were retrospectively analyzed.Results The 1-, 3- and 5-year survival rates were 89.3%, 46.4% and 21.4%, respectively, in 28 patients with BDT versus 91.4%, 52.9% and 20.9% in 852 patients without BDT （P 〉0.05）.Six patients with BDT underwent re-operation after disease relapse, and their survival time was significantly longer than those who did not undergo re-operation （P 〈0.05）.Multivariate analysis indicated that portal vein invasion and tumor size were independently associated with tumor relapse and prognosis （P〈0.05）.Univariate analysis and multivariate analyses showed that obstructive jaundice was not significantly correlated with tumor relapse or prognosis （P 〉0.05）.Conclusions Hepatectomy plus BDT removal is an effective treatment option for HCC with BDT.Obstructive jaundice is not a contraindication for surgery.Re-operation after relapse can provide good outcomes if the cases are appropriately selected.