中华放射医志chin

1、中華放射醫誌 Chin J Radiol 2006; 31: 121-125 121Intraductal Forceps Biopsy of Icteric Hepatocellular Carcinoma after Percutaneous Transhepatic Biliary DrainageJeng-Hwei Tseng Kuang-Tse Pan sung-Yu CHu i-Hao su CHiH-Hui Lee CHien-Fu HungDepartment of Diagnostic Radiology, Chang-Gung Memorial Hospital at Linkou College of Medicine and School of Medical Technology, Chang-Gung UniversityTo determine the usefulness and effectiveness of percutaneous transhepatic intradutcal biopsy for icteric type hepatocel

2、lular carcinoma (HCC). Thirteen patients with chronic hepatitis and obstructive jaundice received percutaneous transhe- patic biliary drainage (PTBD). Intraductal forceps biopsy was performed through the established per- cutaneous transhepatic tract 1 to 2 weeks later. Adequate specimen for pathological diagnosis was obtained in all patients. Transient hemobilia occurred in all patients and minor complications such as low grade fever and pain were occasionally seen. No major complication was enc

3、ountered. Intraductal forceps biopsy after percutaneous transhepatic drainage is a safe and effective method for tissue confirmation of icteric HCC even in cases of bleeding tendency and presence of small amount of ascites.Key words: Bile ducts obstruction; Biopsy; Hepatocellular carcinomaJaundice is a common late manifestation in patients with HCC because of advanced liver cirrhosis or substantial tumor infiltration of the liver paren- chyma 1, 2. Obstructive jaundice is a rare initial manifest

4、ation of HCC with reported incidence of 1.2-9% 2-5. In 1975, Lin et al. reported 8 cases of HCC invading biliary tree at their early stage and named this specific HCC as an “ icteric type hepatoma” 2. Subsequently, sporadic cases of HCC with bile duct invasion have been reported. Kojiro et al. stated that intraductal growth of the neoplasm seems to be attributed in most case 3. However, tissue proof of such neoplasm may be difficult because the primary tumor may be small and rupture into bile du

5、ct early in the disease process. Furthermore, a core needle biopsy is not always possible due to the presence of ascites and bleeding diathesis in the patients with liver cirrhosis. Relief of obstructive jaundice is mandatory for both preservation of normal liver function and control of cholangitis that can be achieved by PTBD. It will be ideal if PTBD can be used for relief of obstructive jaundice and existing percutaneous transhepatic tract provides a route for tissue confirmation. Intraductal

6、 biopsy of HCC has been rarely reported 6, 7 and no large scale study has been conducted. Thus, we reported our experience of intraductal forceps biopsy using the existing tract after PTBD for tissue proof in 13 patients.PATIeNTs AND MeTHoDsFrom March 2000 to September 2004, 13 chronic hepatitis carriers complicated with liver tumor and elevated bilirubin level (9.5 to 18.7 mg/ dL, mean 13.6 mg/dL) as well as imaging diag- nosis of obstructive jaundice were enrolled in this study. There are 12 m

7、ale and 1 female patients with the ages ranging from 32 to 83 years and a mean of 56 years. The level of Alfa-fetoprotein (AFP) ranged from 8 to 256 (ng/ml). None of these patients had received any treatment before PTBD. Reprint requests to: Dr. Chien-Fu Hung Department of Diagnostic Radiology, Chang-Gung Memorial Hospital. No. 5, Fu Hsing Street, Kwei-Shan, Taoyuan 333, Taiwan, R.O.C.Intraductal biopsy of hepatocellular carcinoma122Bleeding diathesis resulting from thrombocyto- penia (platelet

8、50, 000/ mm3) was found in 3 patient and prolonged prothrombin time in another 5 patients. Computer tomography (CT), magnetic resonance imaging (MRI) and Magnetic Resonance Cholangiopancreatography (MRCP) performed prior to PTBD revealed small amount of ascites at right subphrenic and/or subhepatic space in 6 patients. Ultrasound-guided left-sided biliary drainage was successfully performed in all patients after blood product transfusion to correct the bleeding tendency. Puncture was done with 2

9、1-gauge needle (US Guided Puncture Needle, Cliny, Yokohama, Japan) and 0.018-inch guide wire (Radifocus Guide Wire, RF*GA18153M, Terumo, Tokyo, Japan) was inserted into the dilated ductal branch through the needle cannula. Advancement of the guide wire was monitored under fluoroscopy after opacification of the bile ducts with injection of contrast medium. Initially, an 8.5-French pigtail catheter (Nephrostomy Catheter, Cook, Bloomington, Indiana, USA) was placed proximal to the obstruction site for relief of the obstructive jaundice and cholangitis. After matura- tion of the PTBD tract and subsidence of the chol- angitis within 1-2 weeks, a 0.035-inch guide wire (Radifocus, RF*GA35153M, Terumo, Tokyo, Japan) was used to cannulate through the obstruction and passed down into duodenum. A 6-French angio- graphic introducing sheath (Radifocus introducer II, Terumo, Tokyo, Japan) was used as a work

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