Hepatocellular Carcinoma With Bile Duct Tumor Thrombus: Extrahepatic Bile Duct Preserving or Not?

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To the Editor:
We read with special interest the recently published article in the May 2015 issue of Annals of Surgery by Yamamoto et al1 from the Graduate School of Medicine, University of Tokyo, Japan. The authors describe a unique peeling-off technique for preserving the common bile duct during surgery for hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT), and they concluded that this less invasive surgical technique may contribute to the improved prognosis by preserving the extrahepatic bile duct. However, we have several concerns about the surgical outcome of this technique and whether or not to preserve the extrahepatic bile duct.
First, the overall relapse rate after bile duct preserving surgery was too high (67%). We have recently published an article in Medicine2 concerning the surgical procedures for the treatment of HCC with BDTT, with similar postoperative recurrent rate in patients who underwent hepatectomy and thrombectomy (78%). However, the relapse rate was significantly lower for patients who received concurrent extrahepatic bile duct resection (37%). We also found that the 1-year, 2-year, and 3-year recurrence-free survival (RFS) rates were significantly higher in patients with hepatectomy plus extrahepatic bile duct resection than in patients with hepatectomy plus thrombectomy.
Second, in the current study, the authors showed that none of the patients had histopathologic evidence of direct tumor invasion into the bile duct wall. However, in our patient cohort, tumor cells were detected in the excised large bile duct wall in more than 70% (10/14) of patients.2 Peng et al3 and Esaki et al4 also reported that direct invasion of the bile duct wall was recognized in more than 10% of patients (12.5% and 15.8%, respectively) with tumor thrombi located in the common bile duct.
Third, we also question the authors’ assertion that the patients with BDTT relapse cannot be considered as local recurrence. Many studies including ours have shown that many patients without venous invasion also developed intrahepatic or BDTT recurrence.2,5,6 In a retrospective case series of 8 patients, Peng et al3 reported that BDTT recurred in 2 patients (25%) who underwent isolated thrombectomy with an unidentified primary tumor, and suggest that the unresected primary tumor might well be the source of the BDTT recurrence. They also found that 1 patient who underwent liver transplantation developed tumor recurrence at the lower end of the common bile duct. We found 1 patient suffered BDTT recurrence once again after reoperation. Based on these, we speculate that tumor invading (or migration through) the biliary tract may be one of the causes of HCC metastasis and recurrence.2,5
Last, the authors suggested that bile duct preserving surgery was beneficial for the maintenance of effective therapeutic choices for future recurrence, and transcatheter arterial chemoembolization (TACE) or radiofrequency ablation (RFA) treatment against recurrence was preferred. However, our results showed that the recurred patients with repeated resection had significantly better overall survival than those who did not. Similar results were obtained by Peng et al3 who showed that repeated resection could achieve a good outcome for local tumor recurrence.
Based on the above analysis, we suggest that hepatectomy combined with concurrent bile duct resection represents an improvement over the peeling-off technique when tumor thrombus extending into extrahepatic bile duct, and repeated resection was recommended for patients with local tumor recurrence or BDTT recurrence if possible. Nevertheless, the peeling-off technique can be a rational technique when curative resection cannot be achieved, although it has some limitations and restrictions.

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