Recurrence and survival time
Patients were followed up with US or CT abdomen at least every 3–6 months at our Outpatient Department, especially during the first 2 years. The follow-up study was conducted until February 2015 with a duration that ranged from 2 to 132 months. No patient was lost to follow-up, and all 19 patients were followed up regularly until death. In our series, there was no postoperative 3-month mortality from hepatic resection, and the 6-month disease-free survival was observed in eleven of 18 (61.1%) patients.
Twelve patients were followed up over 1 year with the 1-year survival rate of 75% (12/16). The patients who were followed up over 3 and 5 years were analyzed separately as a subgroup for survival. Their 3- and 5-year survival rates were 62.5% and 60%, respectively (Figure 3). Interestingly, there were five long-term survivors (≥5-year survival) whose longest disease-free survival time was >11 years. All of them were still alive up to the last follow-up visit without recurrence of cancer in our series.
The survival times for the three patients who did not undergo liver resection or received only biliary decompression were only 2, 2, and 7 months, respectively.
Jaundice was present in 19–40% of HCC patients at the time of diagnosis and was usually associated with advanced liver cirrhosis or extensive tumor infiltration.7,14–17 Obstructive jaundice caused due to BDTT in HCC patients is an uncommon feature, being identified in only 1–5% of patients treated operatively.4,18–21 The incidence in our series was 4.7%. HCC may involve the biliary tract in several different ways: tumor thrombosis, hemobilia, tumor compression, and diffuse tumor infiltration.16 As the incidence of HCC has increased, more details have been reported.22 This might be due to the improvement of diagnostic imaging strategies and more awareness toward the recognition of this condition.
Patients with HCC who manifested with obstructive jaundice from BDTT present difficult and challenging problems in differential diagnosis. A correct diagnosis of this group of patients is important, because surgical treatment may be beneficial with favorable long-term results.4,8,9,16,23–25On the contrary, there was no chance of palliation or possible cure in patients with advanced tumor infiltration or progressive terminal liver failure. In our series, corrected preoperative diagnosis as having HCC obstructing the bile duct was high (in almost all patients, 17 of 19 patients), and only one patient was misdiagnosed as hilar CCA, and in another patient, the BDTT diagnosis was determined from the pathological result because there was no suspicious bile duct dilatation from the preoperative CT of the abdomen.
Curative resection of the tumor improved the outcomes of this type of disease in some previous reports.8,26–31 Either preoperative PTBD or endoscopic biliary drainage can be chosen to relieve jaundice with similar procedure-related risk.32–34 Preoperative PTBD was performed in five patients without any PTBD-related complications, in our series. Chen et al4 previously reported their experience with 20 HCC patients with BDTT that caused jaundice, in which only two (10%) patients underwent liver resection. Similarly, Lau et al27 reported a low resectability rate of 18% (2/11). This might be attributed to poor hepatic reserve caused by underlying cirrhosis and obstructive jaundice. In our study, however, 15 of 19 (78.9%) patients underwent a hepatectomy with curative aim and one of 19 patients for palliative aim after appropriate preoperative management, regardless of whether jaundice was present. So, carefully evaluating patient’s liver function and future liver remnant were important keys of successful management in HCC with BDTT patients, which could achieve a high rate of R0 resection in 11/16 (68.7%) patients. These results would emphasize that biliary tumor thrombi from HCC were not necessarily a contraindication for hepatectomy and do not imply advanced disease.
Intrahepatic metastasis by spreading via the portal vein route was an important mechanism of recurrence. Overall recurrence after hepatectomy occurred in more than half (9/16, 56.3%) of our patients and all with early recurrence within 1 year. Recurrence in one patient was bile duct-related and manifested another episode of obstructive jaundice. Cancer recurring at the choledochotomy site or intraoperative implantation appeared to be the likely cause of this condition. Interestingly, there was one patient without portal vein or microscopic venous invasion who also developed both intrahepatic recurrence and pulmonary metastasis. Therefore, this finding implied that HCC invading through the bile duct may have another route of intrahepatic and distant metastasis. A similar result was previously reported by Ikenaga et al.11 TACE, direct ethanol injection (DEI), sorafinib, or metastectomy in selective patients are well-established treatments for recurrent intrahepatic HCC and distant metastasis. The pattern of recurrence and modality of treatment after recurrence are shown in Table 3.
In our series, the postoperative 1-year survival rate of patients was 75.0% with a 1-year disease-free survival rate of 43.8%. These are better than that of a previous report from Qin et al.3 All the five long-term survivors (≥5-year survival) received a major liver resection (hemihepatectomy and/or bile duct resection) with the longest disease-free survival of >11 years in one patient. This might be attributed to appropriate treatment. In HCC patients with BDTT, shorter survival may be associated with venous or lymphatic invasion, positive margin, poorly differentiated tumor, as well as underlying liver cirrhosis and advanced tumor stage.
Obstructive jaundice due to biliary thrombus in HCC patients is an uncommon feature but must be kept in mind as one of several differential diagnoses. Bile duct obstruction from tumor thrombus is not necessarily a contraindication for surgery and does not imply advanced disease. Identification of this group of patients is clinically important, because if the appropriate operation is selected, it can offer an opportunity for cure and favorable long-term survival.
The authors report no conflicts of interest in this work.
Anon Chotirosniramit, Akkaphod Liwattanakun, Worakitti Lapisatepun, Wasana Ko-iam, Trichak Sandhu, Sunhawit Junrungsee
Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Source: Journal of Hepatocellular Carcinoma.
Originally published March 7, 2017.