Hepatocellular carcinoma constitutes over 90% of the primary liver tumors, the rest being cholangiocarcinoma. It has an insidious presentation, which is responsible for the delayed presentation. Hence, the management strategy relies on screening to diagnose it an early stage for curative resection and/or treatment with local ablative techniques or chemotherapy. However, even with different screening programs, more than 60% of tumors are still detected at an advanced stage, leading to an unchanged mortality rate, thereby implying a room for improvement in the screening and diagnostic process. In the last few years, there has been evolution of utility of endoscopy, specifically endoscopic ultrasonography along with Fine needle aspiration, for this purpose, which we comprehensively review in this article.

• Hepatocellular carcinoma
• Liver
• Cancer
• Fine needle aspiration
• Endoscopy
• Endoscopic ultrasound
• Endoscopic ultrasonography
• Staging
• Management
• Treatment

AIM: To review the usefulness of endoscopic biliary stenting for obstructive jaundice caused by hepatocellular carcinoma and identify problems that may need to be addressed.

METHODS: The study population consisted of 36 patients with obstructive jaundice caused by hepatocellular carcinoma (HCC) who underwent endoscopic biliary stenting (EBS) as the initial drainage procedure at our hospital. The EBS technical success rate and drainage success rate were assessed. Drainage was considered effective when the serum total bilirubin level decreased by 50% or more following the procedure compared to the pre-drainage value. Survival time after the procedure and patient background characteristics were assessed comparatively between the successful drainage group (group A) and the non-successful drainage group (group B). The EBS stent patency duration in the successful drainage group (group A) was also assessed.

RESULTS: The technical success rate was 100% for both the initial endoscopic nasobiliary drainage and EBS in all patients. Single stenting was placed in 21 patients and multiple stenting in the remaining 15 patients. The drainage successful rate was 75% and the median interval to successful drainage was 40 d (2-295 d). The median survival time was 150 d in group A and 22 d in group B, with the difference between the two groups being statistically significant (P < 0.0001). There were no statistically significant differences between the two groups with respect to patient background characteristics, background liver condition, or tumor factors; on the other hand, the two groups showed statistically significant differences in patients without a history of hepatectomy (P = 0.009) and those that received multiple stenting (P = 0.036). The median duration of stent patency was 43 d in group A (2-757 d). No early complications related to the EBS technique were encountered. Late complications occurred in 13 patients (36.1%), including stent occlusion in 7, infection in 3, and distal migration in 3.

CONCLUSION: EBS is recommended as the initial drainage procedure for obstructive jaundice caused by HCC, as it appears to contribute to prolongation of survival time.

• Hepatocellular carcinoma
• Obstructive jaundice
• Biliary drainage
• Percutaneous transhepatic biliary drainage
• Endoscopic biliary stenting

• Adult
• Aged
• Bilirubin/blood
• Biomarkers/blood
• Carcinoma, Hepatocellular/complications
• Carcinoma, Hepatocellular/mortality
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/instrumentation
• Cholangiopancreatography, Endoscopic Retrograde/mortality
• Drainage/adverse effects
• Drainage/instrumentation
• Drainage/mortality
• Female
• Humans
• Jaundice, Obstructive/blood
• Jaundice, Obstructive/diagnosis
• Jaundice, Obstructive/etiology
• Jaundice, Obstructive/mortality
• Jaundice, Obstructive/therapy
• Kaplan-Meier Estimate
• Liver Neoplasms/complications
• Liver Neoplasms/mortality
• Male
• Middle Aged
• Palliative Care
• Retrospective Studies
• Risk Factors
• Stents
• Time Factors
• Treatment Outcome

This study aimed to evaluate the effect of percutaneous interventional treatment on obstructive jaundice caused by hepatocellular carcinoma with bile duct tumor thrombus.

A total of 16 patients with bile duct tumor thrombus were included in the current retrospective study. All the patients were subjected to percutaneous transhepatic biliary drainage (PTBD). Treatment included permanent external drainage, internal drainage and routine tube adjustment, and covered stents according to the patients’ clinical manifestations.

The success rate of PTBD was 100%. Among all the patients, two were treated with permanent external drainage, seven were treated with internal drainage and routine tube adjustment, and seven were treated with detaining covered stents. All the drainage tubes were successfully pulled out from the patients receiving covered stents. Among all the 16 patients, the clinical symptoms and life quality of 12 patients (12/16, 75%) were improved. The average survival time of all the patients was 203.7 days (ranging from 30 days to 391 days) with the median survival time of 199.5 days.

Percutaneous interventional therapy for obstructive jaundice caused by hepatocellular carcinoma with bile duct tumor thrombus is a good choice. It improves patients’ life quality. Permanent external drainage, internal drainage, and covered stents are alternative methods which should be chosen according to the patient's condition.

• bile duct tumor thrombus
• biliary drainage
• covered stent
• hepatocellular carcinoma

• Carcinoma, Hepatocellular/complications
• Carcinoma, Hepatocellular/pathology
• Cholangiopancreatography, Endoscopic Retrograde
• Diagnosis, Differential
• Humans
• Jaundice, Obstructive/diagnosis
• Jaundice, Obstructive/etiology
• Jaundice, Obstructive/surgery
• Liver Neoplasms/complications
• Liver Neoplasms/pathology
• Prognosis

AIM: To study the surgical treatment effect and outcome of hepatocellular carcinoma (HCC) with bile duct tumor thrombi (BDTT).

METHODS: Fifty-three consecutive HCC patients with BDTT admitted in our department from July 1984 to December 2002 were reviewed retrospectively. The clinical data, diagnostic methods, surgical procedures and outcome of these patients were collected and analyzed.

RESULTS: One patient rejected surgical treatment, 6 cases underwent percutaneous transhepatic cholangial drainage (PTCD) for unresectable primary disease, and the other 46 cases underwent surgical operation. The postoperative mortality was 17.6%, and the morbidity was 32.6%. Serum total bilirubin levels of these patients with obstructive jaundice decreased gradually after surgery. The survival time of six cases who underwent PTCD ranged from 2 to 7 mo (median survival of 3.7 mo). The survival time of the patients who received surgery was as follows: 2 mo for one patient who underwent laparotomy, 5-46 mo (median survival of 23.5 mo, which was the longest survival in comparison with patients who underwent other procedures, P = 0.0024) for 17 cases who underwent hepatectomy, 5-17 mo (median survival of 10.0 mo) for 5 cases who underwent HACE, 3-9 mo (median survival of 6.1 mo) for 11 cases who underwent simple thrombectomy and biliary drainage, and 3-8 mo (median survival of 4.3 mo) for four cases who underwent simple biliary drainage.

CONCLUSION: Jaundice caused by BDTT in HCC patients is not a contraindication for surgery. Only curative resection can result in long-term survival. Early diagnosis and surgical treatment are the key points to prolong the survival of patients.

• Hepatocellular carcinoma
• Bile duct tumor thrombi

• Adult
• Aged
• Bile Duct Diseases/complications
• Bile Duct Diseases/etiology
• Carcinoma, Hepatocellular/complications
• Carcinoma, Hepatocellular/surgery
• Female
• Humans
• Jaundice, Obstructive/etiology
• Liver Neoplasms/complications
• Liver Neoplasms/surgery
• Male
• Middle Aged
• Retrospective Studies
• Survival Analysis
• Thrombosis/complications
• Thrombosis/etiology

To study the etiology and the manifestation of ERCP in patients of obstructive jaundice with HCC.

Routine ERCP examinations were performed in 164 cases of hepatocellular carcinoma complicated with obstructive jaundice. Intrahepatic bile duct system was filled as much as possible. Biliary drainage and antibiotics were given routinely after the procedures.

Overall, 97.5% presented as malignant bile duct obstruction and 2.4% was benign biliary tract lesion. Among malignant obstruction, malignant hepatic hilar and perihilar bile duct stricture were found in 67.7%, intraductal tumor thrombus in 20.1%, intraductal thrombus with malignant perihilar stricture in 7.3%, metastasis of hilar lymph nodes in 1.8%, retroperitoneal lymph node metastasis in 1.2%. While in benign lesions, choledolithiasis and distal common bile duct stenosis were found in 1.2%, respectively. In 110 cases presented as malignant perihilar stricture, 95.4% were diagnosed as type III and IV. In 33 cases of ductal thrombi, 90.9% were classified as type III and IV. In 6 cases who were performed papillatomy to remove tumour thrombi, histopathologically, one was diagnosed possibly tumour, one of debris stone and necrotic tissues respectively, two of necrotic tumor tissues and 1 of HCC respectively. Two cases of bile duct cytology were shown exfoliated epithelial cells.

HCCs with obstructive jaundice are mostly caused by malignant stricture, particularly perihilar and hilar strictures. Next are tumour thrombi in biliary tract. Malignant perihilar stricture and tumour thrombi could be both existed in some patients. Jaundice caused by hilar and retroperitoneal lymph node metastasis is rare. Not all obstructive jaundice in HCC patients is malignant, a very small part could be caused by common bile duct stone and distal duct stenosis.

• N/A

Obstructive jaundice as the main clinical feature is uncommon in patients with hepatocellular carcinoma (HCC). Only 1%-12% of HCC patients manifest obstructive jaundice as the initial complaint. Such cases are clinically classified as “icteric type hepatoma”, or “cholestatic type of HCC”. Identification of this group of patients is important, because surgical treatment may be beneficial. HCC may involve the biliary tract in several different ways: tumor thrombosis, hemobilia, tumor compression, and diffuse tumor infiltration. Bile duct thrombosis (BDT) is one of the main causes for obstructive jaundice, and the previously reported incidence is 1.2%-9%. BDT might be benign, malignant, or a combination of both. Benign thrombi could be blood clots, pus, or sludge. Malignant thrombi could be primary intrabiliary malignant tumors, HCC with invasion to bile ducts, or metastatic cancer with bile duct invasion. The common clinical features of this type of HCC include: high level of serum AFP; history of cholangitis with dilation of intrahepatic bile duct; aggravating jaundice and rapidly developing into liver dysfunction. It is usually difficult to make diagnosis before operation, because of the low incidence rate, ignorant of this disease, and the difficulty for the imaging diagnosis to find the BDT preoperatively. Despite recent remarkable improvements in the imaging tools for diagnosis of HCC, such cases are still incorrectly diagnosed as cholangiocarcinoma or choledocholithiases. Ultrasonography (US) and CT are helpful in showing hepatic tumors and dilated intrahepatic and /or extrahepatic ducts containing dense material corresponding to tumor debris. Direct cholangiography including percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP) remains the standard procedure to delineate the presence and level of biliary obstruction. Magnetic resonance cholangiopancreatography (MRCP) is superior to ERCP in interpreting the cause and depicting the anatomical extent of the perihilar obstructive jaundice, and is particularly distinctive in cases associated with tight biliary stenosis and along segmental biliary stricture. Choledochoscopy and bile duct brushing cytology could be alternative useful techniques in the differentiating obstructions due to intraluminal mass, infiltrating ductal lesions or extrinsic mass compression applicable before and after duct exploration. Jaundice is not necessarily a contraindication for surgery. Most patients will have satisfactory palliation and occasional cure if appropriate procedures are selected and carried out safely, which can result in long-term resolution of symptoms and occasional long-term survival. However, the prognosis of icteric type HCC is generally dismal, but is better than those HCC patients who have jaundice caused by hepatic insufficiency.

• Carcinoma, Hepatocellular/complications
• Carcinoma, Hepatocellular/diagnosis
• Carcinoma, Hepatocellular/therapy
• Cholestasis/etiology
• Humans
• Liver Neoplasms/complications
• Liver Neoplasms/diagnosis
• Liver Neoplasms/therapy
• Prognosis

• Aged
• Bile Duct Neoplasms/diagnostic imaging
• Bile Duct Neoplasms/pathology
• Bile Ducts/pathology
• Bile Ducts, Intrahepatic
• Carcinoma, Hepatocellular/diagnostic imaging
• Carcinoma, Hepatocellular/pathology
• Cholangiocarcinoma/diagnostic imaging
• Female
• Humans
• Liver Neoplasms/diagnostic imaging
• Liver Neoplasms/pathology
• Male
• Middle Aged
• Neoplastic Cells, Circulating/pathology
• Polyps/diagnostic imaging
• Prospective Studies
• Ultrasonography, Interventional