Extrahepatic bile duct resection in patients with hepatocellular carcinoma with bile duct tumor thrombi / 中华肝胆外科杂志

Objective To review the role of extrahepatic bile duct resection in patients with hepatocellular carcinoma with bile duct tumor thrombi.Methods The Pubmed,Wan Fang and China Science and Technology Journal Database were reviewed systematically.Any case reports or studies involving treatment of hepatocellular carcinoma with bile duct tumor thrombi were included in this literature search.Two authors independently assessed the studies for inclusion and extracted the data.Univariate analysis was used to compare the baseline characteristics and the Kaplan-Meier method was used for analyzing survival and diseasefree survival outcomes.Results Using predetermined inclusion criteria,16 studies which included 170 patients entered into this study.All these patients underwent surgical resection of hepatocellular carcinoma and bile duct tumor thrombi.Based on the Satoh classification,45 patients were type Ⅰ,107 patients type Ⅱ and 18 patients type Ⅲ.Twenty-four patients underwent liver resection combined with extrahepatic bile duct resection.The remaining 146 patients underwent liver resection combined with thrombectomy.The 1-,3-,and 5-year survival rates of all the patients were 73.4％,41.5％ and 21.8％,and the corresponding recurrences free survival rates were 62.5％,29.2％ and 13.1％,respectively.On Kaplan-Meier analysis,there were no significant differences in the survival outcomes between the 2 groups of patients,(P ＞ 0.05).The 1-,3-,and 5-year survival rates of the extrahepatic bile duct resection group were 66.7％,41.7％ and 12.5％,and those of the thrombectomy group were 74.6％,41.3％ and 23.8％,respectively.On subgroup analysis (Satoh type Ⅱ and Ⅲ),no significant differences were observed between the two groups (P ＞0.05).The 1-,3-,and 5-year survival rates of the extrahepatic bile duct resection group were 65.2％,38.0％ and 13.0％,and those of the thrombectomy group were 72.8％,39.5％ and 20.9％,respectively.Conclusion Extrahepatic bile duct resection did not improve the overall survival of patients with hepatocellular carcinoma with bile duct tumor thrombi.

A clinicopathological characteristics of 35 patients with hepatocellular carcinoma associated with bile duct tumor thrombi / 中华肝胆外科杂志

Objective To analyze the clinical and pathological characteristics of 35 hepatocellular carcinoma (HCC) patients with bile duct tumor thrombi (BDTT),and to investigate the expressions of CD133,CD90,EpCAM,CK19,VEGF,and C-kit in the tumor tissues.Methods 35 HCC patients with BDTT out of 943 HCC patients who underwent surgical treatment were studied.The expressions of biomarkers in tissue specimens were determined by immunohistochemistry.35 HCC patients without BDTT were selected using the method of stratified sampling as a control group.Results In 19 of 35 patients,the diameters of the primary tumor were less than 5 cm (range 0 ～ 17 cm,average 6.9 ± 0.7 cm).When compared to the control group,most of the primary tumors were moderately to lowly differentiated (33/35,94％ vs 18/ 35,51％),had incomplete capsules (18/35,51％ vs 3/35,8％) and micro vascular invasion (29/35,83％ vs 7/35,20％).The positive expression rates of CD90,EpCAM,CK19,VEGF,CD133,and C-kit in the group of patients with HCC with BDTT and in the control group were 82.9％,77.1％,71.4％,85.7％,80.0％,80.0％ and 57.1％,54.3％,34.3％,65.7％,54.3％,51.4％,respectively.The 1-,2-,3-year postoperative survival rates of the HCC patients with BDTT were 69％,37％,20％ respectively which were worse than the HCC patients without BDTT (1-,2-,3-year postoperative survival rates were 88％,72％,62％ respectively,P ＜ 0.05).Conclusions The prognosis of HCC patients with BDTT was worse than HCC patients without BDTT.The expressions of liver stem cell biomarkers in the tumor specimens of the group of HCC patients with BDTT were higher than the control group.These findings prompt that this kind of HCC originate from liver stem ceils.

Misdiagnosis analysis of hepatocellular carcinoma combined with bile duct tumor thrombi / 第二军医大学学报

Objective To summarize the key points for diagnosis and differential diagnosis of hepatocellular carcinoma combined with bile duct tumor thrombi(HCCBDT), and analyze the common reasons for misdiagnosis. Methods A total of 392 patients with HCCBDT over a 18-year period were included in this study. The liable disease types of misdiagnoses were summarized and the main causes of preoperative misdiagnosis were analyzed. The patients were divided into two groups according to the time periods: Group A(from 1993 to 2001, 128 patients) and Group B(from 2002 to 2011, 264 patients). The misdiagnosis rates and types of misdiagnosed diseases were compared between the two groups. The key points of diagnosis and differential diagnosis of HCCBDT were summarized. Results The overall preoperative misdiagnosis rate was 16. 6% (65/392) in our patients. The misdiagnosis rate of Group B (9. 8%, 26/264) was significantly lower than that of Group A (30. 5%, 39/ 128) (P<0. 001). And 91. 7% (242/264) patients received ERCP/MRCP examination in Group B, which was significantly higher than that in the Group A(67. 9%, 87/128) (P<0. 001). The misdiagnosis rate of ERCP/MRCP(5. 5%, 18/329) was significantly lower than those of B-type ultrasound examination (26. 8%, 105/392) (P<0. 001) and CT/MRI scan(25. 0%, 98/392) (P<0. 001). The misdiagnosed diseases included hepatocellular carcinoma with hilar bile duct compression (4. 1%, 16/392), hilar bile duct adenoma/carcinoma (4. 3%, 17/392), distal bile duct adenoma/carcinoma (including ampullary adenoma/carcinoma) (2. 3%, 9/392), mucus-like bile duct adenoma/carcinoma (1. 0%, 4/392), metastatic liver cancer with bile duct tumor thrombi (1. 0%, 4/392), and bile duct stones (3. 8%, 15/392). The proportions of misdiagnosis as liver cancer with hilar bile duct compression in the Group A and Group B were 9. 4% (12/128) and 1. 5%(4/264), respectively, and those as bile duct stone were 7. 8% (10/128) and 1. 9% (5/264), respectively (P<0. 01). Conclusion More knowledge on the HCCBDT clinical features, effective imaging examination methods, and more efforts on differential diagnosis with the similar diseases can reduce misdiagnosis of HCCBDT.

Two-Stage Hepatectomy for Bilateral Hepatocellular Carcinoma with Bile Duct Tumor Thrombi

Curative hepatectomy is the most important prognostic factor for hepatic cancer, but also has a high rate of morbidity and mortality. Liver failure due to insufficient liver volume is the main cause of postoperative mortality. Preoperative portal vein embolization can induce hypertrophy of the remnant liver, and a two-stage hepatectomy, with or without portal vein embolization, could be used to treat patients with unresectable liver tumors. We report the case of a successful two-staged hepatectomy for bilateral hepatocellular carcinoma with tumor thrombi.

Hepatocellular Carcinoma with Biliary Tumor Thrombi

Hepatocellular carcinoma (HCC) with obstructive jaundice that is caused by bile duct tumor thrombi (BDT) is a rare finding and the appropriate treatment has not yet been detrmined. Some authors have reported that hepatic resection and the removal of the BDT without extrahepatic bile duct resection were sufficient procedures. On the other hand, other authors have reported that it was reasonable to resect the extrahepatic bile duct with the primary lesion. The 55-year-old man was admitted with obstructive jaundice and he was without any other symptoms. Preoperative ERCP (Endoscopic retrograde cholangiopancreatography) and CT (Computed tomography) showed the BDT extending from the main mass in the left lobe to the common hepatic duct. An ENBD (endoscopic naso-biliary drainage catheter) was placed to decrease the serum total bilirubin concentration (17.5 mg/dl on admission). The serum total bilirubin concentration was 4.7 mg/dl one day before the operation. The ICG-R15 was 36% one week before the operation. The serum AFP (alpha-fetoprotein) concentration was 4872 ng/ml. The serum ALP (alkaline phosphatase) and GGT (gamma-glutamyl transferase) concentrations were elevated. The serum albumin concentration and prothrombin time were normal. Left lobectomy, extrahepatic bile duct resection and Roux-en-Y hepaticojejunostomy were performed with stenting each bile duct orifice. Histologically, the BDT had partially invaded the confluence of the bile duct. At present, the patient is doing well without any recurrence of tumor. Many reports have insisted the BDT rarely invades the confluence portion of bile duct. Therefore BDT extraction without extrahepatic bile duct resection is a sufficient procedure for HCC with the BDT. However, this strategy was inadequate for our case.