Hepatocellular carcinoma with obstructive jaundice: Biliary drainage and multimodal therapy

Table 1 Selected classification systems for bile duct tumor thrombus in hepatocellular carcinoma

Classification	Type	Definition	Interpretive use
Satoh	1	BDTT in a first-order hepatic duct branch without reaching the right-left duct confluence	Anatomically limited intraductal extension
Satoh	2	BDTT extending across the right-left hepatic duct confluence	Hilar involvement
Satoh	3	BDTT separated from the primary HCC and growing in the common bile duct	Detached/distal intraductal disease
Zhou et al[11]	I	Microscopic BDTT	Detected pathologically
Zhou et al[11]	II	Resectable primary or recurrent HCC with BDTT	Resectability-oriented category
Zhou et al[11]	III	BDTT without an obvious intrahepatic HCC mass	High diagnostic-mimic risk
Zhou et al[11]	IV	BDTT with unresectable intrahepatic or extrahepatic HCC	Systemic/non-surgical disease context
Zhou et al[11]	a/b	Subclassified by presence/absence of extrahepatic bile duct wall invasion	Proposed surgical-pathology modifier

Zhou et al’s proposal[11] has not been prospectively validated. BDTT: Bile duct tumor thrombus; HCC: Hepatocellular carcinoma.

Table 2 Source-verified clinical outcomes in selected hepatocellular carcinoma-specific biliary drainage studies

Ref.	Cohort and drainage	Clinical response definition	Verified drainage results	Key findings
Lee et al[4], 2002	Retrospective; 22 patients; PTBD	> 50% reduction in total bilirubin within 4 weeks	Good response: 13/22 (59.1%)	Lower baseline bilirubin favored response; survival was not reported in the verified abstract
Hong et al[23], 2008	Retrospective; 15 patients, 19 sessions; percutaneous SEMS	≥ 30% decrease in total bilirubin or total bilirubin < 2 mg/dL	Technical: 15/15 (100.0%); clinical: 11/15 (73.3%)	Major complications: 2/19 sessions (10.5%); mean stent patency: 149.8 days (range: 12-790 days)
Cho et al[19], 2011	Retrospective; 68 patients; ERBD or PTBD	> 30% decrease in total bilirubin within 4 weeks	Effective drainage: 51.5% (numerator not stated in the verified abstract)	Additional HCC treatment was more frequent after effective drainage; mean survival: 247 days vs 44 days
Choi et al[24], 2012	Retrospective; 60 patients; ERBD 29, PTBD 31	Study-defined successful drainage	ERBD: 22/29 (75.9%); PTBD: 15/31 (48.4%)	Median patency: 82 days vs 37 days; median survival after successful vs unsuccessful drainage: 143 days vs 38 days
Choi et al[7], 2013	Retrospective; 60 patients; ERBD or PTBD	Study-defined successful drainage	Successful drainage: 39/60 (65.0%)	TACE was given to 17/39 responders; median survival: 410 days vs 77 days for TACE vs conservative care, with major selection bias
Lu et al[22], 2013	Retrospective; 16 patients; PTBD with external/internal drainage or covered stent	Improvement in clinical symptoms and quality of life	Technical: 16/16 (100.0%); symptom/quality-of-life improvement: 12/16 (75.0%)	Immediate biliary hemorrhage: 5/16; hemorrhage with infection: 3/16; median survival: 199.5 days (mean: 203.7 days)
Choi et al[25], 2013	Retrospective ITT; 111 patients; attempted endoscopic drainage	Study-defined favorable response	Favorable response: 46/111 (41.4%); cannulation failed in 5/111	Further HCC treatment: 40/46 responders (87.0%); median survival: 8.7 months vs 1.3 months for responders vs nonresponders
Sugiyama et al[20], 2014	Retrospective; 36 patients; endoscopic stenting	≥ 50% reduction in total bilirubin	Technical: 36/36 (100.0%); clinical: 27/36 (75.0%)	No early complications; late complications: 13/36 (36.1%); median patency: 43 days; median survival: 150 days vs 22 days
Chung et al[17], 2015	Retrospective; 96 patients; SEMS 36, plastic stent 60	Study-defined successful drainage	SEMS: 25/36 (69.4%); plastic: 39/60 (65.0%)	Adverse events: 6/36 (16.7%) vs 13/60 (21.7%); median patency: 60 days vs 68 days; median survival: 48 days vs 123 days
Woo et al[18], 2017	Retrospective; 74 patients, 76 attempted procedures; endoscopic drainage	Total bilirubin < 3 mg/dL	Technical: 70/76 (92.1%); clinical: 25/70 (35.7%)	Post-drainage HCC treatment was associated with survival; median survival: 28 days overall. An internally inconsistent re-aggravation percentage was not reproduced
Matsumi et al[16], 2021	Multicenter retrospective; 107 patients; endoscopic drainage	≥ 30% reduction in jaundice after technical success; cholangitis resolution when applicable	Technical: 105/107 (98.1%); clinical: 85/105 (81.0%)	ERC-related complications: 3/107 (2.8%); 41/107 received HCC treatment after EBD; median survival: 5.0 months vs 0.93 months
Wang et al[21], 2022	Multicenter retrospective; 138 patients; PTBD	At 4 weeks: Any total bilirubin decrease or nadir < 5, < 3, or < 2 mg/dL as separate endpoints	No single pooled clinical-success rate was reported	Internal prediction-model study restricted to HBV-related cirrhosis; external validation is required
Tachi et al[26], 2025	Retrospective; 10 patients, 14 attempts, 11 evaluable procedures; EUS-HGS	Improved cholangitis or ≥ 50% reduction in total bilirubin within 4 weeks	Technical: 13/14 (92.9%); clinical: 10/11 (90.9%); ≥ 50% reduction by 2 weeks: 8/11 (72.7%)	Mild adverse events: 3/11 (27.3%); no bleeding; survival was not reported

Percentages were recalculated to one decimal place when numerators and denominators were available. Between-study response rates are not directly comparable because definitions, anatomy, hepatic reserve, and denominators differed. PTBD: Percutaneous transhepatic biliary drainage; SEMS: Self-expandable metal stent; ERBD: Endoscopic retrograde biliary drainage; HCC: Hepatocellular carcinoma; TACE: Transarterial chemoembolization; ITT: Intention-to-treat; ERC: Endoscopic retrograde cholangiography; EBD: Endoscopic biliary drainage; HBV: Hepatitis B virus; EUS-HGS: Endoscopic ultrasound-guided hepaticogastrostomy.

Table 3 Potential treatment approaches after biliary drainage in hepatocellular carcinoma with obstructive jaundice

Disease setting	Potential approach after successful drainage	Evidence basis and limitation
Resectable disease with adequate hepatic reserve	Hepatectomy with thrombectomy and selective bile duct resection when required for complete resection	Retrospective surgical cohorts; strong selection by anatomy, hepatic reserve, and tumor stage
Unresectable, intrahepatic-predominant disease	TACE in selected patients; HAIC or focal radiotherapy only after case-specific multidisciplinary review or in trials	TACE: Retrospective HCC-OJ cohorts; HAIC/radiotherapy: Small series, case reports, or extrapolation
Advanced disease with PVTT or extrahepatic spread	Systemic therapy only after adequate hepatic recovery and infection control; clinical trial preferred	No direct prospective OJ evidence; recommendations extrapolated from broader HCC trials
Transplant consideration	Exceptionally selected, center-specific assessment; not a standard indication	Small single-center retrospective series; no validated general selection criteria
Inadequate drainage response or progressive hepatic failure	Drainage optimization, infection control, symptom palliation, best supportive care, and reassessment	Clinical-practice framework; no comparative prospective evidence

TACE: Transarterial chemoembolization; HAIC: Hepatic arterial infusion chemotherapy; HCC: Hepatocellular carcinoma; OJ: Obstructive jaundice; PVTT: Portal vein tumor thrombus.