Bile Duct Tumor Thrombus Research Articles

Surgical resection for hepatocellular carcinoma with bile duct tumor thrombus

Hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) is relatively rare, with an incidence of about 1.2% to 12.9%.1 Surgical resection is the preferred treatment for HCC with BDTT; however, whether the extrahepatic bile duct should be preserved or resected remains controversial.2–4 BDTT rarely invades the walls of the extrahepatic bile duct due to its expansive growth characteristics. Thus, most BDTT can be treated with tumor thrombectomy, avoiding resection of the extrahepatic bile duct.

Indocyanine green fluorescence navigation for hepatocellular carcinoma with bile duct tumor thrombus: a case report

BackgroundBile duct tumor thrombus (BDTT) is one of the features of advanced hepatocellular carcinoma (HCC). In the resection of HCC with BDTT, it is important to detect the BDTT tip to decide the appropriate point of bile duct division. In this regard, the efficacy of indocyanine green (ICG) fluorescence navigation has been confirmed for the detection of HCC, whereas its utility for BDTT has not yet been reported. Herein, we describe our experience with right hepatectomy for HCC with BDTT using ICG fluorescence navigation.Case presentationA 72-year-old woman had experienced local recurrences of HCC after radiofrequency ablation, with BDTT reaching the confluence of the right anterior branch and posterior branch. Right hepatectomy was planned, and 2.5 mg of ICG was injected one day before surgery. After transection of the liver parenchyma, the right liver was connected with only the right hepatic duct. ICG fluorescence imaging visualized the tip of BDTT in the bile duct with clear contrast; the proximal side (hepatic side) of the right hepatic duct showed stronger fluorescence than the distal side (duodenal side). The bile duct was divided at the distal side of the BDTT border, and the tip of BDTT was recognized into the resected right hepatic duct without laceration. The patient had an uneventful postoperative course and currently lives without recurrences for 6 months.ConclusionsICG fluorescence navigation assisted in the precise resection of the bile duct in HCC with BDTT.

A case of bile duct tumor thrombus of hepatocellular carcinoma diagnosed by peroral cholangioscopy

A case of bile duct tumor thrombus of hepatocellular carcinoma diagnosed by peroral cholangioscopy

Focal intrahepatic strictures: A proposal classification based on diagnosis-treatment experience and systemic review.

BACKGROUNDFocal intrahepatic strictures (FIHS) refer to local strictures of the small and medium intrahepatic bile ducts. FIHS are easily misdiagnosed due to their rare incidence, and few studies have focused on the diagnosis and treatment approaches.AIMTo propose a new classification for FIHS in order to guide its diagnosis and treatment.METHODSThe symptoms, biochemistry results, imaging results, endoscopic examination results and initial and final diagnoses of 6 patients with FIHS admitted between January 2010 and December 2019 were retrospectively analyzed.RESULTSThe 6 patients were diagnosed with intratubular growth-type intrahepatic cholangiocarcinoma (IG-ICC), recurrent multiple hepatocellular carcinoma (rmHCC) with bile duct tumor thrombus (BDTT), adenosquamous carcinoma (ASC), hepatolithiasis, small duct primary sclerosing cholangitis (SD-PSC) and autoimmune hepatitis (AIH). The initial and final diagnoses were not consistent in 4 patients. Hepatectomy was performed in patients with IG-ICC, ASC and hepatolithiasis according to the locations of their FIHS. Patients with rmHCC with BDTT received lenvatinib/sintilimab, while patients with SD-PSC and AIH received UDCA. We proposed the following classification system for FIHS: type I: FIHS located within one segment of the liver; type II: FIHS located at the confluence of the bile ducts of one segment or two adjacent segments; type III: FIHS connected to the left or right hepatic duct; and type IV: Multiple FIHS located in both lobes of the liver.CONCLUSIONOur proposed classification system might help to guide the diagnosis and treatment of FIHS. Hepatectomy should be performed not only for malignant FIHS but also for benign strictures with severe secondary damage that cannot be improved by nonsurgical methods.

The effect of bile duct tumor thrombus on the long-term prognosis of hepatocellular carcinoma patients after liver resection: a systematic review and meta-analysis.

BackgroundThe effect of bile duct tumor thrombus (BDTT) on the postoperative long-term prognosis of hepatocellular carcinoma (HCC) patients is still under debate.MethodsThe PubMed, Embase, Cochrane Library, Web of Science databases were systematically searched to collect the clinicopathologic characteristics, perioperative indices, and postoperative survival outcomes in the BDTT and non-BDTT groups of HCC patients from inception to February 1, 2020. The study outcomes were extracted by two independent investigators.ResultsA total of 15 studies involving 6,484 patients were included. The meta-analysis revealed that the levels of serum total bilirubin and alkaline phosphatase were notably higher in patients with HCC and BDTT than those without BDTT. Meanwhile, HCC patients with BDTT had more aggressive biological characteristics, such as poor tumor differentiation, macrovascular invasion, and lymph node metastasis, as compared to patients without BDTT. The 1-year [odds ratio (OR) 0.39, 95% confidence interval (CI): 0.31–0.48, P<0.01], 3-year (OR 0.33, 95% CI: 0.22–0.51, P<0.01) and 5-year overall survival (OS) rates (OR 0.31, 95% CI: 0.20–0.49, P<0.01) of the BDTT group were significantly worse than those of the non-BDTT group. The hazard ratio of HCC with BDTT was 4.27 (95% CI: 3.47–5.26, P<0.01) within 5 years after hepatectomy.ConclusionsHCC patients with BDTT had worse OS compared to patients free of BDTT after surgery. BDTT may be a potential prognostic factor for HCC patients.

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

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. 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. 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. 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.

Comparison of different surgical interventions for hepatocellular carcinoma with bile duct tumor thrombus: a systematic review and meta-analysis.

BackgroundThe optimal surgical modality for hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) remains controversial, especially regarding deciding whether to perform concurrent bile duct resection (BDR).MethodsPubMed, EMBASE, Cochrane Library, Web of Science and Scopus databases were systematically searched from inception to February 2020, in order to compare overall survival (OS) and recurrence-free survival (RFS) rates of HCC patients with BDTT who had either received hepatectomy with extrahepatic bile duct resection (BDR group) or hepatectomy without bile duct resection (NBDR group). Relevant outcomes were extracted by two investigators.ResultsA total of 12 studies involving 355 patients was included. The 1-, 3- and 5-year OS rates were similar in the BDR and NBDR groups (OR =0.58, 95% CI: 0.31–1.09, P=0.09; OR =0.74, 95% CI: 0.43–1.28, P=0.28; OR =0.63, 95% CI: 0.36–1.11, P=0.11, respectively). However, the BDR group had better 1-, 3- and 5-year RFS rates than the NBDR group (OR =0.38, 95% CI: 0.22–0.65, P<0.01; OR =0.40, 95% CI: 0.22–0.72, P<0.01; OR =0.37, 95% CI: 0.19–0.71, P<0.01, respectively).ConclusionsConcomitant bile duct resection results in decreased postoperative recurrence in HCC patients with BDTT. However, the OS rates were similar whether or not patients underwent bile duct resection.

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

BACKGROUNDHepatocellular 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.AIMTo propose a new classification for HCC with BDTT in order to guide its diagnosis and treatment.METHODSA retrospective review of the diagnosis and treatment experience regarding seven typical HCC patients with BDTT between January 2010 and December 2019 was conducted.RESULTSBDTT 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).CONCLUSIONWe 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.

Thrombus-First Surgery for Hepatocellular Carcinoma with Bile Duct Tumor Thrombus

ObjectiveThe optimal surgical method of patients with hepatocellular carcinoma (HCC) and bile duct tumor thrombus (BDTT) is still controversial. This study aims to investigate the impact of different surgical methods on BDTT patients. MethodsA multicenter retrospective study was carried out on HCC patients with BDTT who underwent surgery. The survival outcomes of different operation methods were studied. ResultsA total of 120 HCC patients with BDTT from 5 different clinical centers were included. The median disease-free survival (DFS) of the bile duct resection (BDR) group was significantly better than that of the non-BDR group (24.6 months vs. 18.9 months, p = 0.034), but the overall survival (OS) was similar between the two groups (33.6 months vs. 32.3 months, p = 0.193). When we divided the non-BDR group into two groups according to the operation sequence of the hepatic tumor and BDTT, we found that the OS of the thrombus-first group was significantly longer than that of the tumor-first group (42.7 months vs. 23.6 months, p = 0.016). When compared with the BDR group, the thrombus-first group showed similar OS (42.7 months vs. 33.6 months, p = 0.653) and DFS (24.7 months vs. 24.6 months, p = 0.150), which may be the reason the OS rate of the BDR group was similar to that of the non-BDR group. ConclusionsA thrombus-first technique could be considered for HCC patients with extrahepatic BDTT, especially for those patients in which the tumor thrombus did not invade the bile duct.

Postoperative Adjuvant Transarterial Chemoembolization Improves Short-Term Prognosis of Hepatocellular Carcinoma with Bile Duct Tumor Thrombus: A Propensity-Score Matching Study.

PurposeTo evaluate the effect of postoperative adjuvant transarterial chemoembolization (PA-TACE) on the prognosis of hepatocellular carcinoma (HCC) with macroscopic bile duct tumor thrombus (BDTT).Patients and MethodsThis study included 109 patients who underwent R0 resection for HCC with BDTT between January 2008 and December 2017: non-TACE (48) and PA-TACE (61). Propensity-score matching (PSM) was conducted in a 1:1 ratio. Recurrence and overall survival (OS) rates were analyzed using the Kaplan–Meier method. Independent risk factors were identified by univariate and multivariate Cox regression analyses. Subgroup analysis was performed by risk-factor stratification.ResultsThe recurrence rates in the non-TACE and PA-TACE groups were different at 6 months (50.9% vs 26.9%, P=0.03) before PSM and at 6 months (59.3% vs 26.5%, P=0.02) and 12 months (81.4% vs 37.5%, P=0.022) after PSM. OS rates of the non-TACE and PA-TACE groups were different at 6 months (74.0% vs 91.6%, P<0.001) and 12 months (61.1% vs 77.6%, P=0.01) before PSM and at 6 months (73.0% vs 96.8%, P=0.01), 12 months (52.1% vs 89.6%, P=0.001), and 18 months (33.8% vs 64.4%, P=0.034) after PSM. PA-TACE was an independent prognostic factor for both recurrence and OS before and after PSM. Subgroup analysis showed that patients with no HBV infection, tumors >5 cm, macrovascular invasion, alpha-fetoprotein (AFP) >400 ng/mL, or gamma-glutamyl transferase (GGT) >150 U/L benefited significantly from PA-TACE in terms of recurrence rates (all P<0.05). Patients with no HBV infection, multiple tumors, tumors >5 cm, macrovascular invasion, or AFP >400 ng/mL benefited significantly from PA-TACE in terms of OS (all P<0.05).ConclusionPA-TACE could prolong the short-term prognosis of HCC with macroscopic BDTT and should be recommended for patients with no HBV infection, multiple tumors, tumors >5 cm, poor differentiation, macrovascular invasion, AFP >400 ng/mL, or GGT >150 U/L.

Percutaneous endobiliary radiofrequency ablation and stents in management of hepatocellular carcinoma with bile duct tumor thrombus: Initial single-institution experience.

Hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) is a rare condition, but it can lead to hepatic failure and is associated with poor prognosis. Treatment for HCC with BDTT remains a challenge. This study aimed to retrospectively evaluate the safety and feasibility of percutaneous endobiliary radiofrequency ablation (EB-RFA) and biliary metal stent placement as an alternative treatment for patients with HCC with BDTT. From October 2014 to December 2016, nine patients (all men, mean age 53.2±12.0; range 40-70) who underwent percutaneous EB-RFA and biliary metal stent placement for HCC with BDTT were included. Stent patency, overall survival, technical and clinical success rate and complications were investigated. Median stent patency from the time of the first EB-RFA was 6.0 months (95% CI, 5.4-6.6 months) and survival from the time of diagnosis was 6.0 months (95% CI, 2.2-9.8 months). Two of 9 patients underwent bilateral EB-RFA and stent placement, one underwent unilateral EB-RFA and stent-in-stent procedure, and one EB-RFA as treatment for biliary metal stent occlusion. One patient who presented with stent occlusion underwent repeat ablations 182 days after the first ablation procedure and 53 days after the re-ablation procedure. Combination therapy was administered to five patients. The technical and clinical success rate were 100% and 89% per patient. After treatment, serum direct bilirubin levels were notably decreased in eight patients. No major complications were observed. Minor complications included one bile duct bleeding, three postoperative abdominal pain and two cholangitis. Percutaneous EB-RFA and biliary metal stent placement might be technically safe and feasible therapeutic options for patients with HCC with BDTT.

Surgical Outcomes of Hepatocellular Carcinoma With Bile Duct Tumor Thrombus

To identify optimal surgical methods and the risk factors for long-term survival in patients with hepatocellular carcinoma accompanied by macroscopic bile duct tumor thrombus (BDTT). Prognoses of patients with hepatocellular carcinoma accompanied by BDTT have been known to be poor. There have been significant controversies regarding optimal surgical approaches and risk factors because of the low incidence and small number of cases in previous reports. Records of 257 patients from 32 centers in Korea and Japan (1992-2014) were analyzed for overall survival and recurrence rate using the Cox proportional hazard model. Curative surgery was performed in 244 (94.9%) patients with an operative mortality of 5.1%. Overall survival and recurrence rate at 5 years was 43.6% and 74.2%, respectively. TNM Stage (P < 0.001) and the presence of fibrosis/cirrhosis (P = 0.002) were independent predictors of long-term survival in the Cox proportional hazards regression model. Both performing liver resection equal to or greater than hemihepatectomy and combined bile duct resection significantly increased overall survival [hazard ratio, HR = 0.61 (0.38-0.99); P = 0.044 and HR = 0.51 (0.31-0.84); P = 0.008, respectively] and decreased recurrence rate [HR = 0.59 (0.38-0.91); P = 0.018 and HR = 0.61 (0.42-0.89); P = 0.009, respectively]. Clinical outcomes were mostly influenced by tumor stage and underlying liver function, and the impact of BDTT to survival seemed less prominent than vascular invasion. Therefore, an aggressive surgical approach, including major liver resection combined with bile duct resection, to increase the chance of R0 resection is strongly recommended.

A proposed modification for the Barcelona Clinic Liver Cancer staging system: Adding bile duct tumor thrombus status in patients with hepatocellular carcinoma

BackgroundThe Barcelona Clinic Liver Cancer (BCLC) staging system is widely applied to stage hepatocellular carcinoma (HCC). However, it may be inaccurate when applied to East Asian HCC patients. In this study, a large Chinese HCC cohort was analyzed to evaluate possible modifications for the BCLC staging system. MethodsBetween January 1995 and December 2009, 622 HCC patients who underwent hepatectomy were enrolled. Prognostic risk factors were analyzed using univariate and multivariate analyses. The ability of the modified system to predict survival was evaluated by determining the area under the receiver operating characteristic curve. ResultsPatients without bile duct tumor thrombus (BDTT; 1-, 3- and 5-year overall survival, 80%, 60% and 48%, respectively) showed a substantial survival advantage over those with BDTT (1-, 3- and 5-year overall survival, 77%, 42% and 23%, respectively; χ2 = 6.280, P = 0.012). In BCLC stage 0-A patients, significant differences were identified between the BDTT group and the non-BDTT group, while no such differences were found in BCLC stage B patients. Based on this finding, BCLC stage 0-A BDTT patients were recategorized into stage B. The modified BCLC classification featured better performance in the prediction of overall survival than the original system (modified BCLC χ2 = 53.596, P < 0.001; original BCLC χ2 = 46.335, P < 0.001). The ability to predict mortality was also slightly higher using the modified BCLC system. ConclusionsModification of the BCLC system to include BDTT status might further enhance its prognostic ability.

Hepatocellular carcinoma with hilar bile duct tumor thrombus versus hilar Cholangiocarcinoma on enhanced computed tomography: a diagnostic challenge

BackgroundHepatocellular carcinoma (HCC) with hilar bile duct tumor thrombus (HBDTT) often mimic hilar cholangiocarcinoma (hilar CC). The purpose of this study is to analyze the Computed Tomography (CT) characteristics of HCC with HBDTT and to identify imaging features to aid its differentiation from hilar CC on enhanced CT.MethodsWe retrospectively identified 58 cases with pathologically proved HCC with HBDTT between 2011 and 2018. Seventy-seven cases of pathologically proven hilar CCs were selected during the same period. The clinical features and CT findings of the two groups were reviewed and compared.ResultsHCC with HBDTTs are more commonly found in men (87.9% vs 63.6%, p = 0.001) with lower age of onset (49.84 vs 58.61 years; p < 0.001) in comparison to hilar CCs. Positive correlation were identified between HCC with HBDTTs and chronic HBV infection (72.4% vs 11.7%; p < 0.001), increased serum AFP (67.2% vs 1.3%; p < 0.001), CA19–9 level (58.6% vs 85.7%; p < 0.001) and CEA level (3.4% vs 29.9%; p = 0.001), parenchymal lesion with intraductal lesion (100% vs 18.2%; p < 0.001), washout during the portal venous phase (84.5% vs 6.5%; p < 0.001), thickened bile duct wall (8.6% vs 93.5%; p < 0.001), intrahepatic vascular embolus (44.8% vs 7.8%; p < 0.001), splenomegaly (34.5% vs 2.6%, p < 0.001). A scoring system consisting of the five parameters obtained from characteristics mentioned above was trialed. The sensitivity and specificity for diagnosing HCC with HBDTT were 96.39, 100 and 92.5% respectively when the total score was 2 or more.ConclusionsHCC with HBDTTs are often distinguishable from hilar CCs based on washout during portal venous phase without thickened bile duct wall. HBV infection and serum AFP level facilitate the differentiation.

Clinical Results of Radiotherapy That Targeted for Tumor Thrombi from Hepatocellular Carcinoma: A Multicenter Retrospective Study

Background: The aim of this multicenter study was to evaluate the outcome of radiotherapy (RT) that targeted for tumor thrombi (TT) from hepatocellular carcinoma (HCC), including the portal vein, hepatic vein, inferior vena cava, and bile duct TT. Methods: Patients who received RT for the treatment of TT between 2005 and 2020 were retrospectively reviewed. We compared patient characteristics, overall survival (OS), the combined chemotherapy regimen, and objective response rates (ORRs) between the treatment modalities and analyzed cumulative incidence formula (CIF) for the deterioration in the Child-Pugh class and the progression of intrahepatic tumors. Results: We evaluated 64 patients, 39 of whom received combined chemotherapy with RT. Multivariate analysis showed that the Child-Pugh class, primary tumor size and the response of TT were significant prognostic factors for OS and the total equivalent dose in 2 Gy fractions (EQD2) of more than 48.75 Gy significantly contributed to ORRs (p=0.04). In the multivariate analysis of CIF, only acute liver damage was the significant factor for the deterioration in the Child-Pugh class (p=0.01) and the length of TT was significant for the progression of intrahepatic tumors (p=0.03). Conclusion: High doses should be delivered to TT, but long tumor thrombi are difficult to control. Tumor thrombus length is more important in predicting intrahepatic progression than the location of the tumor thrombus.

Successful treatment of hepatocellular carcinoma with bile duct tumor thrombus using surgical resection with pre- and postoperative transcatheter arterial chemoembolization: a case report

Successful treatment of hepatocellular carcinoma with bile duct tumor thrombus using surgical resection with pre- and postoperative transcatheter arterial chemoembolization: a case report

The new classifications of biliary tract diseases based on actual anatomy

In order to facilitate the treatment strategies for biliary tract injury, hilar cholangiocarcinoma, bile duct tumor thrombus, cholangiocellular carcinoma and bile duct cystic dilatation, many classifications have been made, even more than 10 types for one disease. Each type is represented by numbers or English alphabet, which are not only confusing but also difficult to remember. The Academician Mengchao Wu divided the liver into five sections and four segments base on its anatomy, this classification is very direct and visual, thus had been using till now. In order to overcome those complicated problems, it is considered to develop a new classification based on actual anatomic location similar to that for liver cancer, which is easy to remember and to directly determine the treatment strategy. All kinds of classifications have their own characteristics and advantages and disadvantages. This practical classifications avoid the complexity and may be useful for clinicians.

Clinical efficacy and prognostic factors analysis of hepatectomy for hepatocellular carcinoma

Objective To investigate the clinical efficacy and prognostic factors of hepatectomy for hepatocellular carcinoma (HCC). Methods The retrospective case-control study was conducted. The clinico-pathological data of 789 HCC patients who were admitted to the Sichuan Cancer Hospital Affiliated to School of Medicine of University of Electronic Science and Technology of China from January 2009 to January 2016 were collected. There were 669 males and 120 females, aged from 42 to 60 years, with a median age of 52 years. Surgical procedures were determined according to the preoperative and intraoperative comprehensive evaluations of patients. Observation indicators: (1) situations of surgical treatment; (2) postoperative pathological examinations of patients; (3) follow-up and survival situations; (4) prognostic factors analysis. Follow-up using outpatient examination and telephone interview was performed to detect patients′ survival up to May 2017. Normality of measurement data was done using the K-S test. Measurement data with skewed distribution were represented as M (range). Count data were described as absolute number or percentage. The survival rate and survival curve were respectively calculated and drawn by the Kaplan-Meier method. The univariate analysis and multivariate analysis were done using the Log-rank test and COX regression model, respectively. Results (1) Situations of surgical treatment: all the 789 patients underwent successful hepatectomy, liver volume dissected accounting for 32.5% (range, 17.0%-52.0%) of the total liver volume. Of the 789 patients, 413 underwent anatomical hepatectomy including 116 of hepatic segmentectomy, 136 of right hemihepatectomy, 77 of left hemihepatectomy, 57 of left lateral lobe hepatectomy, 27 of central hepatectomy, 376 underwent nonanatomical hepatectomy including 344 of partial hepatectomy, 17 of extended right hemihepatectomy, 15 of extended left hemihepatectomy. Volume of intraoperative blood loss was 400 mL (range, 200-500 mL) in the 789 patients and 173 had intraoperative blood transfusion. Of the 789 patients, 240 had postoperative complications(68 with postoperative severe complications), including 65 of liver insufficiency, 37 of ascites and pleural effusion, 37 of pulmonary complications, 19 of infectious complications, 17 of cardiovascular complications, 17 of abdominal hemorrhage, 11 of gastrointestinal complications, 9 of neruologic complications, 8 of postoperative bile leakage, 10 of other complications, 11 of death; the same patient can merge multiple complications. The 229 survival patients with complications were cured by symptomatic supportive treatment. Duration of postoperative hospital stay was 9 days (range, 7-11 days). (2) Postoperative pathological examinations. Results of postoperative pathological examinations showed 17 patients with bile duct tumor thrombus, 92 with naked eye tumor thrombus at portal vein branches and 167 with microvascular invasion. Of the 789 patients, High-, moderate-, low-differentiated carcinoma were detected in 19, 678, 92 patients, respectively. (3) Follow-up and survival situations: 690 of the 789 patients were followed up for 1-96 months, with a median time of 21 months. The 1, 3, 5-year overall survival rates were 82.1%, 66.1%, 59.2% in the 789 patients. (4) Prognostic factors analysis: results of univariate analysis showed that level of preoperative alphafetoprotein (AFP), Child grade of preoperative liver function, Barcelona clinic liver cancer staging, tumor diameter, surgical procedure of hepatectomy, volume of intraoperative blood loss, intraoperative blood transfusion, postoperative complications, postoperative severe complications, bile duct tumor thrombus, portal vein tumor thrombus, vascular invasion were related factors affecting prognosis of HCC patients after hepatectomy (χ2=8.603, 8.864, 39.970, 28.978, 6.376, 26.144, 8.955, 6.596, 9.910, 7.288, 37.566, 19.183, P<0.05). Results of multivariate analysis showed that tumor diameter, volume of intraoperative blood loss, portal vein tumor thrombus were independent factors affecting prognosis of HCC patients after hepatectomy (hazard ratio=1.085, 1.000, 2.259, 95% confidence interval: 1.053-1.118, 1.000-1.001, 1.621-3.146, P<0.05). Conclusion Hepatectomy for HCC has a good safety, with satisfactory clinical efficacy. Tumor diameter, volume of intraoperative blood loss, portal vein tumor thrombus are independent factors affecting prognosis of HCC patients after hepatectomy. Key words: Liver neoplasms; Liver cancer; Hepatectomy; Prognosis; Vascular tumor thrombus; Portal vein tumor thrombus

Prognosis for patients with hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) after surgical treatment.

Hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) is rarely seen in clinical practice, and its treatment strategies and prognosis are still a subject of debate. To ascertain the characteristics of and prognosis for HCC with BDTT, 49 patients with HCC with BDTT were studied out of 763 consecutive patients with HCC who underwent surgical treatment from July 2004 to May 2018. The clinical characteristics of and prognosis for those 49 patients were reviewed and analyzed retrospectively. Of the 49 patients, 25 underwent radical resection, 7 underwent thrombectomy through a choledochotomy, and 17 underwent palliative internal and external bile duct drainage. Results indicated that patients who underwent a radical resection had a better prognosis than patients in the other two groups, with a median survival of 19 months vs. 8 months and 3 months (p < 0.001). Moreover, the preoperative bilirubin level (p = 0.025), intraoperative blood loss (p = 0.006), tumor size (p = 0.005), and the presence of portal and hepatic vein tumor thrombi (p = 0.021) were significant prognostic factors associated with long-term survival for patients who underwent radical resection in this study. Radical resection should be performed with adequate preoperative preparation for patients with HCC with BDTT in whom surgery is not contraindicated.

Current status of imaging biomarkers predicting the biological nature of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is heterogeneous in terms of its biological nature. Various factors related to its biological nature, including size, multifocality, macroscopic morphology, grade of differentiation, macro/microvascular invasion, bile duct invasion, intra-tumoral fat and molecular factors, and their value as prognostic imaging biomarkers have been reported. And recently, genome-based molecular HCC classification correlated with clinical outcome has been elucidated. The imaging biomarkers suggesting a less aggressive nature of HCC are smaller size, solitary tumor, smooth margin suggesting small nodular type with indistinct margin and simple nodular type with distinct margin, capsule, imaging biomarkers predicting early or well-differentiated grade, intra-tumoral fat detection, and low fluorodeoxyglucose (FDG) accumulation. The imaging biomarkers suggesting an aggressive HCC nature are larger size, multifocality, non-smooth margin suggesting simple nodular type with extranodular growth, confluent multinodular, and infiltrative type, imaging biomarkers predicting poor differentiation, macrovascular tumor thrombus, predicting microvascular invasion imaging biomarkers, bile duct dilatation or tumor thrombus, and high FDG accumulation. In the genome-based molecular classification, CTNNB-1 mutated HCC shows a less aggressive nature, while CK19/EpCAM positive HCC and macrotrabecular massive HCC show an aggressive one. Better understanding of these imaging biomarkers can contribute to devising more appropriate treatment plans for HCC.