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Surgical treatment of hepatocellular carcinoma with biliary tumor thrombi
1Department of Surgery, Veterans General Hospital-Kaohsiung, National Yang-Ming University, Taiwan.
Insights
Hepatocellular carcinoma with jaundice caused by bile duct invasion and tumor thrombi (BTT) is rare but aggressive. Aggressive hepatic resection offers the best outcomes, while choledochotomy is contraindicated.
Area of Science:
- Hepatobiliary Surgery
- Surgical Oncology
- Gastroenterology
Background:
- Hepatocellular carcinoma (HCC) with jaundice is often deemed untreatable due to underlying cirrhosis and tumor burden.
- Bile duct invasion and tumor thrombi (BTT) represent a rare but distinct cause of jaundice in HCC patients.
- Charcot's triad (jaundice, fever, right upper quadrant pain) was observed in over half of BTT cases.
Purpose of the Study:
- To investigate the characteristics and outcomes of HCC with jaundice specifically caused by BTT.
- To evaluate treatment strategies and determine the optimal management for this subgroup of HCC patients.
Main Methods:
- Retrospective analysis of 7 cases of HCC with jaundice attributed to BTT.
- Comparison of clinicopathological features (tumor size, growth pattern, AFP levels, DNA ploidy) with general HCC cases.
- Review of treatment modalities including palliative drainage, hepatic resection, and choledochotomy.
Main Results:
- BTT constituted 0.8% of HCC with jaundice cases, frequently presenting as small HCC with a spreading growth pattern.
- Aneuploid DNA, elevated AFP levels (>400 IU/ml), and Charcot's triad were common in BTT.
- Palliative drainage yielded poor prognosis; aggressive hepatic resection was safe and effective, while choledochotomy led to tumor seeding.
Conclusions:
- HCC with BTT is an aggressive subtype requiring specific diagnostic and therapeutic considerations.
- Hepatic resection is the preferred treatment for resectable BTT, offering the best survival outcomes.
- Choledochotomy for thrombus removal should be avoided due to the high risk of tumor dissemination.
Abstract:
Treatment is always abandoned in those HCC with jaundice, because it is usually attributed to the underlying liver cirrhosis and extensive tumor. In this series, 7 cases (0.8%) of HCC with jaundice were caused by bile duct invasion and tumor thrombi (BTT). 57% of cases showed Charcot's triad. 57% of BTT were small HCC, significantly higher than the 1.7% of total cases (p<0.05). The growth pattern of BTT was all spreading type, significantly higher than the 42% of total operation cases (p<0.05). The DNA ploidy of BTT was all aneuploid. 57% of BTT had AFP level higher than 400 IU/ml, but it was 27% in total cases. The prognosis is poor in those treated with palliative tube drainage. Aggressive hepatic resection was proved to be safe and achieved the best results in our limited experience. Choledochotomy to remove tumor thrombi is contraindicated because it easily causes tumor seeding. It is advocated to search BTT for resection from the group of HCC with jaundice.