A logical approach to hepatocellular carcinoma presenting with jaundice

This prospective cohort study on patients with hepatocellular carcinoma (HCC) presenting with jaundice emphasized the importance of differentiating patients with hepatic insufficiency from patients with obstructive jaundice caused by tumor.

There are little data in the medical literature on the management of patients with HCC presenting with jaundice. Experience has accumulated mainly from case reports and retrospective studies.

Data were collected prospectively on 2095 patients with HCC seen over a 12-year period. All patients were investigated with blood tests, abdominal ultrasound, and chest radiography. Endoscopic retrograde cholangiopancreatography-percutaneous transhepatic cholangiography, computed tomography and hepatic angiography were carried out in selected patients.

Of the 530 patients who had clinically detectable jaundice, 481 had jaundice due to hepatic insufficiency and 49 patients had obstructive jaundice. Patients with hepatic insufficiency had extremely poor prognosis, and 90% of them died within 10 weeks of first presentation. "Curative" resection, however, was possible in 9 of 49 patients with obstructive jaundice, and histologic analysis showed resectional margin involvement by tumor in 1 patient. In addition, 35 patients were treated with biliary stents to relieve the obstructive jaundice. Supportive treatment only was given to five patients who were considered too terminally ill. The overall survival of patients with HCC with obstructive jaundice was similar to those patients who presented with no clinical detectable jaundice and was much better than those with jaundice due to hepatic insufficiency (log-rank test, p < 0.001).

The prognosis of patients with HCC who presented with jaundice due to hepatic insufficiency was dismal. It is important to identify the patients who had obstructive jaundice because with proper treatment, good palliation and occasional cure are possible.