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Review
. 2024 Feb 8;9(1):1-12.
doi: 10.22575/interventionalradiology.2023-0019. eCollection 2024 Mar 1.

Transarterial Therapy for Hepatocellular Carcinoma Invading the Bile Duct

Shiro Miyayama  1
Affiliations
Review

Transarterial Therapy for Hepatocellular Carcinoma Invading the Bile Duct

Shiro Miyayama. Interv Radiol (Higashimatsuyama). .

Abstract

Hepatocellular carcinoma invading the bile duct (bile duct tumor thrombus) is an unfavorable condition. Although overall survival following surgical resection among patients with hepatocellular carcinoma with bile duct tumor thrombus is significantly better than that among those treated with transarterial chemoembolization or chemotherapy, surgical resection can be indicated for selected patients. Additionally, systemic therapy is indicated only for patients with Child-Pugh class A. Therefore, transarterial therapy plays an essential role in the treatment of bile duct tumor thrombus. Transarterial chemoembolization with iodized oil and gelatin sponge particles is an established first-line transarterial treatment that can necrotize most bile duct tumor thrombi. However, we should pay attention to symptoms caused by intraductal hemorrhage during transarterial chemoembolization and the sloughing of necrotized bile duct tumor thrombi.

Keywords: bile duct tumor thrombus; hepatocellular carcinoma; transarterial therapy.

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Conflict of interest statement

The author has received lecture fees from Guerbet.

Figures

Figure 1.
Figure 1.
Classification of the degrees of bile duct tumor thrombus (BDTT) proposed by the Liver Cancer Study Group of Japan. Abbreviations: CBD, common bile duct; CHD, common hepatic duct; GB, gallbladder; LHD, left hepatic duct; RHD, right hepatic duct
Figure 2.
Figure 2.
Hemobilia caused by a bile duct tumor thrombus (BDTT). A. Unenhanced CT showed the tumor (black arrow) invading the bile duct (arrowhead) and hemobilia in the right hepatic duct (white arrow). B. Arterial-phase CT showed the tumor (arrow), BDTT (arrowhead), and increased inhomogeneous enhancement of the liver parenchyma suggesting acute cholangitis. The bile ducts in the anterior segment of the right hepatic lobe were also dilated. C. The serum total bilirubin concentration was 7.4 mg/dL, and endoscopic retrograde cholangiography showed the BDTT extending to the common bile duct (arrow) and coagula (arrowheads). Thereafter, endoscopic nasobiliary drainage (ENBD) was performed (not shown). The serum total bilirubin concentration decreased to 2.9 mg/dL 4 days after ENBD, and two conventional transarterial chemoembolization (cTACE) sessions were performed at 1-month interval (not shown). D. Unenhanced CT performed 1 week after the second cTACE showed a dense iodized oil accumulation in the tumor (arrow) and BDTT (arrowhead), and the serum total bilirubin concentration was normalized 1 month after the second cTACE. However, HCCs and BDTT recurred 6 months after the first cTACE, and cTACE was repeated (ENBD was also performed before cTACE when the serum total bilirubin concentration was ≥3 mg/dL) (not shown). E. Arterial-phase CT performed 3 months after the sixth cTACE (1 year and 6 months after the first cTACE) showed the disappearance of the BDTT, although the bile duct in the lateral segment of the left hepatic lobe was slightly dilated because of the stricture caused by cTACE. The patient died of tumor progression 2 years and 4 months after the first cTACE, despite four additional cTACE sessions.
Figure 3.
Figure 3.
HCC invading the portal vein and bile duct. A. Arterial-phase CT showed recurrent HCCs 6 years and 10 months after the first conventional transarterial chemoembolization (cTACE) invading the portal vein and bile duct. The arrows indicate a recurrent tumor near the iodized oil accumulated tumor (arrowheads). Endoscopic retrograde cholangiography showed a bile duct tumor thrombus (BDTT) in the right hepatic duct and coagula in the common bile duct. The serum total bilirubin concentration was 8.2 mg/dL, and a plastic stent was placed, bridging between the left hepatic duct and duodenum (not shown). The second cTACE was performed when the serum total bilirubin concentration decreased to 3.6 mg/dL (not shown). B. Unenhanced CT performed 1 week after cTACE showed a dense iodized oil accumulation in the portal vein tumor thrombus (PVTT) and BDTT, as well as in the recurrent tumor (arrows). The arrowheads indicate the plastic stent in the bile duct. C. Arterial-phase CT performed 2 months after the second cTACE showed that some necrotized BDTT tissues dropped in the common bile duct (arrow); however, PVTT and BDTT were still viable. The arrowheads indicate the plastic stent in the bile duct. Therefore, the third cTACE was performed (not shown). D. Unenhanced CT performed 1 week after the third cTACE showed a dense iodized oil accumulation in the PVTT and BDTT. Additionally, some PVTT tissues were detached and migrated into the branch of the left portal vein. However, the patient died of progression of PVTT 6 months after the second cTACE (7 years and 4 months after the first cTACE).
Figure 4.
Figure 4.
Bland embolization for active hemobilia from a bile duct tumor thrombus (BDTT). A. The patient had undergone five conventional transarterial chemoembolization (cTACE) sessions for multiple HCCs, and arterial-phase CT performed 4 years and 5 months after the first cTACE showed recurrent tumors (arrows) around the iodized oil accumulated tumor and BDTT in the right hepatic duct (arrowhead). The left hepatic duct was dilated, and increased inhomogeneous enhancement of the liver parenchyma was seen. B. The serum total bilirubin concentration was 4.2 mg/dL, and endoscopic retrograde cholangiography showed BDTT (arrow) and coagula (arrowhead). Then, a plastic stent was endoscopically placed in the bile duct (not shown). C. A self-expandable metallic stent was placed, bridging the BDTT 6 days after plastic stent placement, but the serum total bilirubin concentration was elevated to 7.0 mg/dL due to active hemobilia from BDTT. D. Therefore, bland embolization was planned to stop active hemobilia. A common hepatic arteriogram showed multiple tumors (arrows). Four hepatic arterial branches were embolized with a gelatin sponge slurry approximately 0.5 mm in diameter (not shown). The next day, an endoscopic nasobiliary drainage (ENBD) catheter was placed to monitor the nature of the bile (not shown), and active hemobilia stopped after bland embolization. E. A cholangiogram obtained 1 week after bland embolization through the ENBD catheter showed the disappearance of coagula in the bile duct. The arrow indicates BDTT. The serum total bilirubin concentration decreased to 2.0 mg/dL, and it decreased to 0.9 mg/dL 3 months after bland embolization. Thereafter, the best supportive care was administered, and the patient died of tumor progression 1 year and 5 months after bland embolization (5 years and 11 months after the first cTACE) without clinically problematic cholangitis and active hemobilia.
Figure 5.
Figure 5.
Sloughing of a necrotized bile duct tumor thrombus (BDTT). A. The patient had undergone two conventional transarterial chemoembolization (cTACE) sessions for HCC, and arterial-phase CT performed 2 years and 4 months after the first cTACE showed a recurrent tumor in segment 4 invading the common bile duct (arrow). The serum total bilirubin concentration was 7.4 mg/dL, but it spontaneously decreased to 3.1 mg/dL 1 month later. B. Therefore, the third cTACE was performed. A common hepatic arteriogram showed no tumor staining. C. An arteriogram of the middle hepatic artery showed the tumor (arrow) and BDTT (arrowhead), and cTACE was performed. D. An arteriogram of the medial subsegmental artery of the left hepatic artery also showed a part of the tumor (arrow), and cTACE was performed. E. A coronal view of cone-beam CT performed immediately after cTACE showed a dense iodized oil accumulation in the tumor (arrow) and BDTT (arrowhead). F. The patient presented with epigastric pain, fever, and jaundice 1 week after the third cTACE, and unenhanced CT showed the dropped BDTT in the common bile duct (arrow). G. Endoscopic retrograde cholangiography showed the dropped BDTT in the common bile duct (arrow), and it was removed endoscopically. However, the tumor in segment 4 recurred, and the patient died of tumor progression 1 year and 4 months after the third cTACE, despite additional cTACE.
Figure 6.
Figure 6.
Hemobilia during conventional transarterial chemoembolization (cTACE). A. This patient had undergone 2 cTACE sessions for HCC. Arterial-phase CT performed 1 year and 3 months after the first cTACE showed a bile duct tumor thrombus (BDTT; arrow) near the previously embolized tumor (arrowhead). B. A selective arteriogram of the anterior segmental artery of the right hepatic artery demonstrated BDTT (arrow). The feeder of BDTT arose from the anterior–inferior subsegmental artery of the right hepatic artery and turned left along the direction of tumor invasion into the bile duct (arrowhead). cTACE was performed through this branch. C. During cTACE, iodized oil flowed into the common bile duct (arrowheads) suggesting active hemobilia. Iodized oil was densely accumulated in the BDTT (asterisk), and a vascular lake in the BDTT was noted (arrow). The next day of cTACE, the serum total bilirubin concentration was elevated to 4.1 mg/dL from 2.8 mg/dL. D. Unenhanced CT performed 1 week after cTACE showed a dense iodized oil accumulation in the BDTT (arrow). The serum total bilirubin concentration was decreased to 1.4 mg/dL. Thereafter, four additional cTACE sessions were performed for recurrent HCCs, and the patient was lost to follow-up 4 years and 1 month after the first cTACE due to dementia.
Figure 7.
Figure 7.
Hepatic arterial infusion chemotherapy (HAIC) for HCC with a portal vein tumor thrombus (PVTT) and a bile duct tumor thrombus (BDTT). A. Arterial-phase CT showed HCC invading the portal vein (arrow) and bile duct (arrowhead). B. A celiac arteriogram showed the tumors (arrows). C. An indwelling catheter for HAIC was implanted, and two cycles of low-dose cisplatin combined with 5-fluorouracil plus interferon were performed. D. Arterial–phase CT performed 6 months after HAIC showed that all tumors disappeared, although the left portal vein was occluded (arrow) and the left hepatic lobe was decreased in size. However, new tumors developed 1 year and 4 months after HAIC, and seven additional conventional transarterial chemoembolization (cTACE) sessions were performed (not shown). E. Arterial-phase CT performed 7 years after HAIC showed no viable tumors in the liver. However, ascites developed. The arrowhead indicates HCC treated with cTACE. The patient died of liver failure 7 years and 4 months after HAIC.
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