The benefits of curative R0 surgical resection with a selective bile duct preserving approach for hepatocellular carcinoma with macroscopic bile duct tumor thrombus: A single center retrospective comparative study

Abstract

Introduction: Hepatocullular carcinoma (HCC) presenting with macroscopic bile duct tumor thrombus (BDTT) is an uncommon event. The role of 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 without BDTT. Method: At our institute, a total of 22 HCC with macroscopic BDTT patients who had undergone curative hepatic resection with a selective bile duct preservation approach. Bile duct resection would be performed when failed tumor thrombectomy or suspected intrahepatic cholangiocarcinoma type III. These were compared to a group of 145 HCC without BDTT patients. The impact of R0 surgical resection and BDTT on clinical outcomes and survival after surgical resection were evaluated. Result: All HCC with BDTT cases underwent major hepatectomy vs 32.4% in the other group. Bile duct preservation rate was 60.8%. The 1, 3 and 5-year survival rates of HCC with BDTT patients compared to the other group were 78.2, 38.1, 26.1% vs 73.6, 55.6, 25.0%, respectively. Regarding multivariate analysis, a tumor size more than five centimeters and venous invasion were independent factors which impacted survival (p-value = 0.001, 0.032). BDTT did not show the impact on recurrence-free survival and overall survival (p-value = 0.073, 0.105). Patients who recieved an R0 resection showed a significantly superior long term outcome regardless of bile duct resection or BDTT status (p-value = 0.001). There was no intraductal recurrence in our series. Conclusion: Bile duct obstruction from tumor thrombus did not necessarily indicate an advanced form of the disease. A selective bile duct preservation approach showed comparable outcomes. In selected patients a proper hepatic resection with a negative margin can improve survival regardless of BDTT status.