Hepatocellular carcinoma with obstructive jaundice: diagnosis, treatment and prognosis

Computed tomography features of an intraductal polypoid mass: differentiation between hepatocellular carcinoma with bile duct tumor invasion and intraductal papillary cholangiocarcinoma

OBJECTIVE

To determine the computed tomography (CT) features capable of differentiating hepatocellular carcinoma (HCC) with bile duct tumor invasion (BDTI) from intraductal cholangiocarcinoma (IDCC).

METHODS

Multiphasic CT images of 14 patients with HCC with BDTI and 18 patients with IDCC were retrospectively reviewed. Analysis of the CT findings included the size, location, and margin of the intraductal mass; enhancement pattern of intraductal lesions; degree of ductal dilatation; presence of downstream ductal dilatation and ductal wall thickening; presence of a parenchymal mass and its size; continuity of the parenchymal mass with the intraductal mass; and liver cirrhosis. Objective evaluation of the enhancement patterns of intraductal tumors was done by measuring the CT attenuation coefficients of the tumors and the uninvolved hepatic parenchyma in each phase. Among these findings, statistically significant variables were then determined using the Fisher's exact test or Mann-Whitney U test.

RESULTS

Significant variables that helped to differentiate HCC with BDTI from IDCC included the presence of a parenchymal mass, liver cirrhosis, and a hyperattenuating intraductal tumor on the hepatic arterial phase (HAP). On unenhanced images, the tumor-to-liver contrast of IDCC (16.7+/-8.1) was greater than that of HCC with BDTI (6.4+/-10.4), but on the HAP, that of HCC with BDTI (26.5+/-28.2) was greater than that of IDCC (5.9+/-18.7) (P<0.05). In addition, there was a significant difference in the enhancement ratio of the intraductal tumors on the portal venous phase between the 2 conditions (P=0.003).

CONCLUSIONS

Several objective and subjective multiphasic CT findings may help to differentiate HCC with BDTI from IDCC.

Treatment of malignant biliary obstruction by combined percutaneous transhepatic biliary drainage with local tumor treatment

AIM

To evaluate the utility of local tumor therapy combined with percutaneous transhepatic biliary drainage (PTBD) for malignant obstructive biliary disease.

METHODS

A total of 233 patients with malignant biliary obstruction were treated in our hospital with PTBD by placement of metallic stents and/or plastic tubes. After PTBD, 49 patients accepted brachytherapy or extra-radiation therapy or arterial infusion chemotherapy. The patients were followed up with clinical and radiographic evaluation. The survival and stent patency rate were calculated by Kaplan-Meier survival analysis.

RESULTS

Twenty-two patients underwent chemotherapy (11 cases of hepatic carcinoma, 7 cases of pancreatic carcinoma, 4 cases of metastatic lymphadenopathy), and 14 patients received radiotherapy (10 cases of cholangiocarcinoma, 4 cases of pancreatic carcinoma), and 13 patients accepted brachytherapy (7 cases of cholangiocarcinoma, 3 cases of pancreatic carcinoma, 4 cases of metastatic lymphadenopathy). The survival rate of the local tumor treatment group at 1, 3, 6, and 12 months was 97.96%, 95.92%, 89.80%, and 32.59% respectively, longer than that of the non treatment group. The patency rate at 1, 3, 6, and 12 months was 97.96%, 93.86%, 80.93%, and 56.52% respectively. The difference of patency rate was not significant between treatment group and non treatment group.

CONCLUSION

Our results suggest that local tumor therapy could prolong the survival time of patients with malignant biliary obstruction, and may improve stent patency.

Current treatment for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. In the United States, the incidence of HCC has increased by nearly 75% since the 1980s. The rise in HCC diagnoses in the United States has been attributed to an increased number of patients infected with viral hepatitis and better diagnostic techniques. The management of HCC begins with diagnostic confirmation, followed by accurate staging. Historically, the prognosis for patients with HCC has been poor; however, improved surveillance and radiologic imaging techniques have led to earlier detection of HCC and an increased opportunity to treat patients. Treatment options for HCC include surgical and nonsurgical modalities. Surgical therapy, by way of partial hepatectomy or orthotopic liver transplantation, is the only potentially curative treatment for HCC, but most patients are not eligible for these procedures by the time of diagnosis. Palliative options include ablative techniques, radiation, and systemic therapies. As the incidence of this malignancy continues to rise, oncology nurses, who are an integral part of the multidisciplinary team caring for these patients, must be aware of current management for HCC. This article will provide an overview of the complex management of patients with HCC in the United States.

Diagnosis and surgical treatments of hepatocellular carcinoma with tumor thrombosis in bile duct: Experience of 34 patients

AIM: Hepatocellular carcinoma (HCC) with bile duct tumor thrombosis (BDT) is a rare event. The prognosis of this type of patients is very dismal. The aim of this study was to share the experience in the diagnosis and treatment of HCC with BDT, to further improve the prognosis of these patients.

METHODS: Thirty-four patients of HCC with BDT received surgical treatment in authors’institute from July 1987 to January 2003 were reviewed retrospectively. The experience in the diagnosis and treatment, and the outcome of this type of HCC patients were summarized.

RESULTS: Thirty of the 34 patients (88.2%) were positive for alpha-fetoprotein (AFP) (> 20 μg/L), and 12 patients (35.3%) were found having obstructive jaundice before operation, 18 cases were suspected of “obstruction of bile duct” preoperatively. The primary tumors were frequently located at the left medial (13 cases) or right anterior lobe (14 cases). Thirty-one patients received liver resections and removal of BDT, while the other 3 patients received removal of BDT combined with hepatic artery ligation and cannulation (HAL + HAI), or only removal of BDT because their liver function reservation and general condition could not tolerate the primary tumor resection. The 1-year survival rate was 71.4% (20/28). The longest disease-free survival was over 15 years. The intrahepatic tumor recurrence within 1 year after operation was found in 14 patients (14/28, 50.0%).

CONCLUSION: Surgical removal of primary tumors and BDT is safe and beneficial to the HCC patients with BDT. Early detection, diagnosis, and surgical treatment are the key points to prolong the survival time of patients.

Eliciting specific antitumor immunity against hepatocellular carcinoma in vitro by fusions of HCC patient-derived dendritic cells with HCC cells

AIM: To investigate the ability of fusions of HCC patient-derived dendritic cells (DC) with HCC cells to induce autologous T lymphocytes to elicit specific immunity against HCC in vitro.

METHODS: Dendritic cells isolated from HCC patient peripheral blood were cultured and proliferated in vitro for one wk by using recombinant human granulocyte/macrophage-colony stimulating factor (rhGM-CSF) and interleukin-4 (rhIL-4). Expression of DC surface markers was assessed by flow cytometry. Fusions of DC with HepG2 cells (HepG2/DC) were achieved by polythyleneglycol (PEG). The ability of HepG2/DC to stimulate proliferation and differentiation of autologous T lymphocytes was assessed by MTT method, and the specific killing efficacy of HepG2/DC-induced cytotoxic T lymphocytes (CTL) to HepG2 was evaluated.

RESULTS: Following one wk culture, DC presented a high-level expression of CD1a, HLA-DR, CD54, CD80 and CD86. Fusions had remarkably greater ability to stimulate proliferation of autologous T lymphocytes in comparison with HepG2, HepG2+DC, DC and PBS, with an A value of 0.816±0.019 vs 0.541±0.020, 0.632±0.018, 0.564±0.018, 0.345±0.013, respectively (P<0.05). The HepG2/DC-activated CTLs showed a potent specific killing efficacy to HepG2.

CONCLUSION: Fusions of HCC patient-derived DC with HCC cells can effectively stimulate autologous T lymphocytes to elicit specific antitumor immunity against HCC, and may represent as a promising approach of immunotherapy for HCC.

Hepatocellular apoptosis after hepatectomy in obstructive jaundice in rats

AIM: To investigate the hepatocellular apoptosis after hepatectomy in obstructive jaundice and biliary decompression rats.

METHODS: After bile duct ligation for 7 days, rats were randomly divided into OB group in which the rats underwent 70% hepatectomy, OB-CD group in which the rats underwent hepatectomy accompanied by choledochoduodenostomy, CD-Hx group in which the rats underwent choledochoduodenostomy and then received 70% hepatectomy on the fifth day after biliary decompression. The control group (Hx group) only underwent hepatectomy.

RESULTS: The level of total serum bilirubin and serum enzymes was significantly lower in CD-Hx group than in OB-CD and OB groups on day 1, 3 and 5 after hepatectomy. The apoptotic index was significantly lower in CD-Hx group than in OB-CD and OB groups on day 3 and 5. The oligonucleosomal DNA fragments and Caspase-3 activity were also lower in CD-Hx group than in OB-CD and OB groups 3 days after hepatectomy, without differences between CD-Hx and Hx groups.

CONCLUSION: Hepatocellular apoptosis plays vital roles in jaundice rats, and biliary decompression is more effective in treatment of patients with severe jaundice before operation.

Imaging diagnosis of pancreato-biliary diseases: A control study

AIM: To evaluate the clinical value of various imageological methods in diagnosing the pancreato-biliary diseases and to seek the optimal procedure.

METHODS: Eighty-two cases of pancreato-biliary diseases confirmed by surgery and pathology were analyzed. There were 38 cases of cholelithiasis, 34 cases of pancreato-biliary tumors and 10 other cases. The imageological methods included B-US, CT, ERCP, PTC, cross-sectional MRI and MR cholangiopancreatography (MRCP).

RESULTS: The accuracy rate of MRCP in detecting the location of pancreato-biliary obstruction was 100%. In differentiating malignant from benign obstruction, the sensitivity of the combination of MRCP and cross-sectional MRI was 82.3%, the specificity was 93.8%, and the accuracy rate was 89.0%. The accuracy rate for determining the nature of obstruction was 87.8%, which was superior to that of B-US (P = 0.0000) and CT (P = 0.0330), but there was no significant difference between direct cholangiopancreatography and the combination of MRCP and conventional MRI (P = 0.6666).

CONCLUSION: In most cases, MRCP can substitute direct cholangiopancreatography for diagnosis. The combination of MRCP and cross-sectional MRI should be considered as an important means in diagnosing the pancreato-biliary diseases, pre-operative assessment and post-operative follow-ups.

Role of serum total sialic acid in differentiating cholangiocarcinoma from hepatocellular carcinoma

AIM: This study was designed to evaluate the clinical application of serum total sialic acid (TSA) in the diagnosis of cholangiocarcinoma (CCA).

METHODS: Serum TSA was determined by periodate-resorcinol microassay in 69 patients with CCA, 59 patients with hepatocellular carcinoma (HCC), 37 patients with cirrhosis, 61 patients with chronic hepatitis and 50 healthy blood donors.

RESULTS: The mean serum TSA concentration in CCA (2.41 ± 0.70 mmol/L) was significantly higher than those of HCC, cirrhosis, chronic hepatitis and healthy blood donors (1.41 ± 0.37 mmol/L, 1.13 ± 0.31 mmol/L, 1.16 ± 0.26 mmol/L, and 1.10 ± 0.14 mmol/L, respectively; P < 0.001). Based on ROC curve analysis, a cut-off point of 1.75 mmol/L discriminated between CCA and HCC with a sensitivity, specificity and accuracy of 82.6%, 83.1%, and 82.8%, respectively.

CONCLUSION: Based on our results, serum TSA would be a useful marker for the differential diagnosis of CCA from HCC.

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