• bile duct invasion
• hepatocellular carcinoma
• safety
• transarterial chemoembolization
• treatment outcome

• Humans
• Carcinoma, Hepatocellular/therapy
• Carcinoma, Hepatocellular/pathology
• Carcinoma, Hepatocellular/mortality
• Male
• Chemoembolization, Therapeutic/methods
• Liver Neoplasms/therapy
• Liver Neoplasms/pathology
• Liver Neoplasms/mortality
• Female
• Propensity Score
• Drainage/methods
• Retrospective Studies
• Middle Aged
• Aged
• Neoplasm Invasiveness
• Treatment Outcome

• 82102161 National Natural Science Foundation of China
• 202201011719 Guangzhou Science and Technology Plan Project
• 2021A1515010548 Natural Science Foundation of Guangdong Province
• 2023A1515010481 Natural Science Foundation of Guangdong Province
• 202103000021 the Major Program for Tackling Key Problems of Guangzhou City
• National Natural Science Foundation of China
• Natural Science Foundation of Guangdong Province

• bile duct invasion
• bile duct wall
• hepatocellular carcinoma

Hepatocellular carcinoma with biliary ductal invasion is rare and associated with a significantly lower survival rate.

We present an unusual case of a patient with hepatocellular carcinoma and biliary invasion, who had his diagnosis confirmed by histological analysis from tissue extracted by endoscopic retrograde cholangiopancreatography. An 87-year-old male presented with a 1-day history of right upper quadrant pain and jaundice. His past medical history included recurrent gallstone cholangitis and a previous cholecystectomy. An abdominal CT demonstrated a dilated intrahepatic biliary tree with left proximal intrahepatic hyperdensities, as well as a 3 cm hepatocellular carcinoma. He was initially suspected to have concurrent gallstone cholangitis and a newly diagnosed hepatocellular carcinoma. Endoscopic retrograde cholangiopancreatography and balloon trawling of the intraductal lesions extracted necrotic tumour-like tissue which was histologically consistent with hepatocellular carcinoma. The extraction of the intra-biliary portion of HCC resulted in complete resolution of his jaundice, enabling further treatment with nivolumab, which would not have been possible if the obstruction was not cleared. The patient is currently well and has completed his 6th cycle of nivolumab.

Obstructive jaundice is an uncommon presentation for patients with HCC. it is key for clinicians to be aware of the possibility of intrabiliary invasion in order obtain an early diagnosis and to reduce any delay in treatment.

• Case report
• Endoscopic retrograde cholangiopancreatography
• Hepatocellular carcinoma
• Intrabiliary
• Intraductal

Hepatocellular 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.

To propose a new classification for HCC with BDTT in order to guide its diagnosis and treatment.

A retrospective review of the diagnosis and treatment experience regarding seven typical HCC patients with BDTT between January 2010 and December 2019 was conducted.

BDTT 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).

We 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.

• Hepatocellular carcinoma
• Tumor thrombus
• Bile duct
• Diagnosis
• Treatment

• Bile Duct Neoplasms/complications
• Bile Duct Neoplasms/diagnostic imaging
• Bile Duct Neoplasms/surgery
• Bile Ducts/diagnostic imaging
• Bile Ducts/surgery
• Carcinoma, Hepatocellular/complications
• Carcinoma, Hepatocellular/diagnostic imaging
• Carcinoma, Hepatocellular/surgery
• Humans
• Liver Neoplasms/complications
• Liver Neoplasms/diagnostic imaging
• Liver Neoplasms/surgery
• Retrospective Studies
• Thrombosis

Antibiotic resistance is a leading cause of treatment failure in Helicobacter pylori infection. In Africa, there are very little data concerning the susceptibility of Helicobacter pylori isolates to antibiotics. The purpose of this study was to evaluate the resistance prevalence of Helicobacter pylori strains circulating in Cameroon, and to assess overexpression of efflux pump as a possible multi-drug resistance mechanisms.

A total of 140 H. pylori isolates were recovered from gastric biopsies of dyspeptic patients in two reference hospitals in Cameroon and analyzed for their antimicrobial susceptibility to amoxicillin, co-amoxiclav, ampicillin, penicillin, imipenem, metronidazole, rifabutin, erythromycin, clarithromycin, azithromycin, levofloxacin, ciprofloxacin, norfloxacin, tetracycline, doxycycline and minocycline. Antibiotic sensitivity was tested by disk diffusion method. Phe-Arg-naphthylamide (PAßN) was used as efflux pump inhibitor. INT broth microdilution method in supplemented Brain Heart Infusion broth was used to determine the MIC of ampicillin, amoxicillin, metronidazole, erythromycin, clarithromycin and doxycycline in the absence and the presence of PAßN against 32 selected MDR isolates.

Overall H. pylori resistance rate was 100% to ampicillin, penicillin and co-amoxiclav; 97.14% to amoxicillin, 97.85% to metronidazole, 47.85% to erythromycin, 13.57% to clarithromycin; 5, 2.86 and 0.71% to doxycycline, tetracycline and minocycline respectively. No resistance to azithromycin, rifabutin, imipenem, ciprofloxacin, norfloxacin and levofloxacin was detected among H. pylori isolates. Seventy percent (70%) of the tested isolates elicited a multiple drugs resistance pattern; 42.57% double, 15.71% triple and 5.71% quadruple drugs resistance. Metronidazole and amoxicillin were more concerned with double resistance pattern (86.76%). The spectrum of activity recorded with metronidazole, doxycycline, clarithromycin and erythromycin ranged from 0 to 100% in the absence to the presence of PAßN against the tested MDR isolates. An 8 to 128-fold increase in potency was also noticed with these antibiotics in the presence of PAßN.

With regard to the high resistance rate to both amoxicillin and metronidazole, these drugs should be avoided as components of triple therapy in our milieu. In contrast, ciprofloxacin, norfloxacin, levofloxacin and tetracyclines could be used to achieve a better eradication rate and to reduce the risk of selection of H. pylori resistant strains.

• Antibiotics
• Cameroon
• Efflux pump
• Helicobacter pylori
• Resistance prevalence

Little is known about the treatment or outcomes of hepatocellular carcinoma (HCC) complicated with bile duct invasion.

A total of 247 consecutive HCC patients with bile duct invasion at initial diagnosis were retrospectively included.

The majority of patients had Barcelona Clinic Liver Cancer (BCLC) stage C HCC (66.8%). Portal vein tumor thrombosis was present in 166 (67.2%) patients. Median survival was 4.1 months. Various modalities of treatment were initially employed including surgical resection (10.9%), repeated transarterial chemoembolization (TACE) (42.5%), and conservative management (42.9%). Among the patients with obstructive jaundice (n=88), successful biliary drainage was associated with better overall survival rate. Among the patients with BCLC stage C, overall survival differed depending on the initial treatment for HCC; surgical resection, TACE, systemic chemotherapy, and conservative management showed overall survival rates of 11.5, 6.0 ,2.4, and 1.6 months, respectively. After adjusting for confounders, surgical resection and repeated TACE were significant prognostic factors for HCC patients with bile duct invasion (hazard ratios 0.47 and 0.39, Ps <0.001, respectively).

The survival of HCC patients with bile duct invasion at initial diagnosis is generally poor. However, aggressive treatments for HCC such as resection or biliary drainage may be beneficial therapeutic options for patients with preserved liver function.

• Bile duct invasion
• Hepatocellular carcinoma
• Obstructive jaundice
• Prognosis
• Treatment

We investigated the treatment outcomes and prognostic factors of hepatocellular carcinoma (HCC) with obstructive jaundice.

Among 2,861 patients newly diagnosed with HCC between 2002 and 2011, a total of 63 patients who initially presented with obstructive jaundice were analyzed. Only four patients presented with resectable tumors and underwent curative resection. In the other patients who presented with unresectable tumors, 5, 8, 9, and 18 patients received transarterial chemoembolization (TACE), chemotherapy, radiotherapy, and combined treatment, respectively. Both the clinical and the treatment factors that affect overall survival (OS) were analyzed.

The median OS was 4 months, and the 1-year OS rate was 23%. Patients who received treatment for HCC had a significantly improved OS rate compared with the patients who received supportive care only (1-year OS, 32% vs 0%; p<0.01). Responders to treatment showed a better OS than nonresponders (1-year OS, 52% vs 0%; p<0.01). TACE and radiotherapy resulted in relatively good treatment responses of 64% and 67%, respectively. In multivariate analyses, treatment of HCC (p=0.02) and the normalization of serum bilirubin by biliary drainage (p=0.02) were significantly favorable prognostic factors that affected the OS.

Unresectable HCC with obstructive jaundice has a poor prognosis. However, effective biliary drainage and treatment of HCC such as with TACE or radiotherapy improves survival.

• Drug therapy
• Radiotherapy
• Transarterial chemoembolization

Patients with cirrhosis-associated hepatocellular carcinoma (HCC) rarely present with acute pancreatitis (AP) and obstructive jaundice as the main clinical features. AP with obstructive jaundice caused by common bile duct embolism (CBDE) is very rare.

A 54-year-old man with CBDE was misdiagnosed with common bile duct stones three times over a 7-month period. Investigations during this time did not identify CBDE. Surgical exploration was performed because of AP, obstructive jaundice, and a tumor in the left lobe of the liver. CBDE from the hepatic tumor was diagnosed by intraoperative biopsy and frozen section examination. The patient underwent left hemihepatectomy, cholecystectomy, and bile duct exploration.

Preoperative diagnosis of CBDE is difficult because of the rarity of the condition, lack of physician awareness, and easy misdiagnosis on imaging examinations. Early and accurate diagnosis of this condition is important.

• hepatocellular carcinoma
• obstructive jaundice
• bile duct tumor thrombus
• diagnosis
• diagnostic imaging

• Alanine Transaminase/blood
• Bile Ducts/diagnostic imaging
• Bile Ducts/pathology
• Bilirubin/blood
• CA-19-9 Antigen/blood
• Carcinoembryonic Antigen/blood
• Carcinoma, Hepatocellular/blood
• Carcinoma, Hepatocellular/complications
• Carcinoma, Hepatocellular/diagnosis
• Carcinoma, Hepatocellular/pathology
• Cholangiopancreatography, Endoscopic Retrograde
• Cholangiopancreatography, Magnetic Resonance
• Cholestasis/blood
• Cholestasis/etiology
• Cholestasis/pathology
• Female
• Humans
• Jaundice, Obstructive/blood
• Jaundice, Obstructive/etiology
• Jaundice, Obstructive/pathology
• Liver Neoplasms/blood
• Liver Neoplasms/complications
• Liver Neoplasms/diagnosis
• Liver Neoplasms/pathology
• Male
• Middle Aged
• Neoplasm Invasiveness
• Retrospective Studies
• Tomography, X-Ray Computed
• Ultrasonography
• alpha-Fetoproteins/analysis

• Aged
• Bile Duct Neoplasms/complications
• Bile Duct Neoplasms/pathology
• Bile Duct Neoplasms/surgery
• Bile Ducts, Intrahepatic
• Carcinoma, Hepatocellular/complications
• Carcinoma, Hepatocellular/pathology
• Carcinoma, Hepatocellular/surgery
• Common Bile Duct Neoplasms/complications
• Common Bile Duct Neoplasms/pathology
• Common Bile Duct Neoplasms/surgery
• Humans
• Jaundice, Obstructive/etiology
• Male

• Aged
• Carcinoma, Hepatocellular/diagnosis
• Cholestasis, Extrahepatic/etiology
• Humans
• Jaundice, Obstructive/etiology
• Liver Neoplasms/diagnosis
• Male
• Neoplasm Recurrence, Local/diagnosis

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

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.

• Bile Duct Neoplasms/diagnosis
• Bile Duct Neoplasms/diagnostic imaging
• Bile Duct Neoplasms/pathology
• Bile Duct Neoplasms/surgery
• Carcinoma, Hepatocellular/diagnosis
• Carcinoma, Hepatocellular/diagnostic imaging
• Carcinoma, Hepatocellular/pathology
• Carcinoma, Hepatocellular/surgery
• Disease-Free Survival
• Female
• Follow-Up Studies
• Humans
• Jaundice, Obstructive/diagnosis
• Jaundice, Obstructive/diagnostic imaging
• Jaundice, Obstructive/pathology
• Jaundice, Obstructive/surgery
• Liver Neoplasms/diagnosis
• Liver Neoplasms/diagnostic imaging
• Liver Neoplasms/pathology
• Liver Neoplasms/surgery
• Male
• Prognosis
• Radiography
• Retrospective Studies
• Survival Rate
• Thrombosis/diagnosis
• Thrombosis/diagnostic imaging
• Thrombosis/pathology
• Thrombosis/surgery

• obstructive jaundice
• hepatocellular carcinoma

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

• Bile Duct Neoplasms/diagnostic imaging
• Carcinoma, Hepatocellular/diagnostic imaging
• Female
• Humans
• Liver Neoplasms/pathology
• Male
• Middle Aged
• Neoplastic Cells, Circulating
• Ultrasonography, Doppler, Color