Biliary embolism is rare in primary liver cancer, accounting for about 2%-9% of autopsy and surgical specimens [1, 2]; in the past, such patients were considered to be in advanced stages and were treated negatively. In recent years, it has been concluded that aggressive surgical treatment of these patients can significantly relieve symptoms and prolong survival [3,4]. From June 2006 to December 2008, 16 patients with primary hepatocellular carcinoma combined with bile duct embolism were admitted to our hospital, and all of them underwent surgical treatment, which achieved better therapeutic effects. The results are reported as follows. 1 Clinical data 1.1 General data The group consisted of 11 male cases and 5 female cases, aged from 31 to 72 (average 53) years old, with disease duration from 15d to 11 months. Clinical manifestations were abdominal pain, abdominal distension, poor appetite, emaciation, itchy skin, fatigue, clay-colored stools, etc., combined with obstructive jaundice in 11 cases. There was a history of hepatitis B in 14 cases and hepatitis C in 1 case; preoperative imaging suggested that 15 cases were accompanied by different degrees of cirrhosis. Total serum bilirubin ranged from 12 to 531 (mean 347.3) μmol/L, AFP was positive in 13 cases (81.3%), of which >500 ng/mL was found in 9 cases (56.3%), HBsAg was positive in 8 cases (50%), and HCVAb was positive in 1 case. 1.2 Imaging examination: preoperative ultrasound, CT, MRI or cholangiography, etc. The imaging characteristics of HCC combined with cholangiocarcinoma embolus were as follows: bile ducts were mildly dilated, dilated bile ducts were pushed and pushed down, wall thickening or enhancement was rare, the dilated bile ducts were often located next to the primary tumor of liver, and there was an echogenic mass in the bile ducts; primary tumors of liver were mainly characterized by the “fast in and out” enhancement mode of contrast [1.2.1]. Primary tumors of the liver mainly show a “fast in and fast out” pattern of contrast enhancement [5]. 1.3 Location of primary tumor and cancer embolus The primary tumor diameter ranged from 1.8 to 325 px, with multinodular cancer foci in 2 cases and single foci in 14 cases; the cancer embolus was located in the right hepatic duct in 4 cases, in the common bile duct in 3 cases, in the left hepatic duct extending to the common hepatic duct in 5 cases, in the right hepatic duct extending to the common hepatic duct in 4 cases, and combined with the cancer embolus of the right branch of the portal vein in 1 case. According to Satoh’s classification[2], there were 4 cases of type I, 9 cases of type II and 3 cases of type III. One case developed jaundice 10 months after left hemihepatectomy for hepatocellular carcinoma, and ultrasound and CT revealed an intraductal mass in the common bile duct, with no lesion in the liver (Figures 1 and 2); one case developed obstructive jaundice due to biliary embolus in an outside hospital and underwent a choledochotomy with embolus extraction, with no hepatic occupancy, and then jaundice reappeared a year later, and CT revealed dilatation of the intra- and extra-hepatic bile ducts and hepatic prehepatic lobe (Figures 3 and 4), and then right hemihepatectomy with choledochotomy was performed (Figure 3), and right hemihepatectomy with choledochotomy was performed. In one case, no intrahepatic tumor was found before surgery, and only a low-density mass in the lumen of the common bile duct caused obstructive jaundice, and a 3 cm common bile duct cancer embolus was removed during surgery (Table 1). 1.4 Surgical treatments Sixteen patients underwent surgical treatments, including left hemihepatectomy + choledochotomy for thrombus extraction in 2 cases, right hemihepatectomy + choledochotomy for thrombus extraction in 3 cases, segmental hepatectomy + choledochotomy for thrombus extraction in 4 cases, left hemihepatectomy + choledochotomy + bile-intestinal anastomosis in 1 case, middle lobe hepatectomy + bile duct removal + portal vein thrombus removal in 1 case, enlargement of the left hemihepatectomy + left hepatic duct removal in 1 case, right hemihepatectomy + right hepatic duct removal in 1 case. Right hepatic duct resection and embolization in 1 case, resection of liver V and VI + cross-section embolization in 1 case, and embolization of the common bile duct in 2 cases (in 1 case, no liver primary foci were found, and the embolization was confirmed to be hepatocellular carcinoma; in the other case, a mass in the common bile duct was found 10 months after resection of the left hemi-hepatic portion of the liver cancer, and the embolization was carried out to take out the hepatocellular carcinoma). The embolus was in the shape of brown fish or mixed with old thrombus, soft and friable, and most of them did not have close adhesion with the bile duct wall, so it was easy to be removed and the wall of the bile duct was smooth; there were 2 cases in which the embolus was found to be seriously adherent with the wall of the bile duct during the operation, so the embolus could not be removed cleanly, and was resected along with the wall of the bile duct that had been infringed (Table 1). 2.Results The liver function of this group gradually returned to normal or close to normal after surgical treatment; one case of bile leakage occurred, and the drainage tube was pulled out after 34d of continuous negative pressure drainage; there were no other serious complications, and no perioperative deaths. The postoperative pathology was hepatocellular hepatocellular carcinoma in 15 cases combined with different degrees of cirrhosis. All 16 patients in this group were followed up, with an average survival time of 23.6 (4~63) months, 6 cases are now alive, and the longest survival time is more than 5 years. 1 case was found to have multiple metastases in the liver 8 months after surgery, and then underwent hepatic arterial embolization and chemotherapy; the other case was found to have multiple metastases in both lungs 1 year after surgery, and then both cases were confirmed to have died after follow-up. 3.Discussion This disease has the clinical manifestations of both hepatocellular carcinoma and biliary obstruction [6], and often the first jaundice or biliary tract infection symptoms, which masks the symptoms of hepatocellular carcinoma, such as nausea, fatigue, and emaciation [7]. In our cases, there were 11 cases with preoperative combined jaundice, 15 cases with different degrees of liver cirrhosis, 13 cases (81.3%) with positive AFP, of which 9 cases (56.3%) were >500 ng/mL, and 8 cases (50%) with positive HBsAg. This disease is easily misdiagnosed and should be differentiated from cholangiocarcinoma, jaundiced hepatitis, hepatocellular jaundice due to hepatocellular carcinoma, and choledocholithiasis. Ultrasound, CT, MRI and biliary imaging are useful in the diagnosis of this disease, especially in guiding the treatment [8,9.10]. The imaging features of HCC invading the bile ducts include: mild bile duct dilatation, dilated bile ducts pushed down, wall thickening or enhancement is rare, the dilated bile ducts are often located next to the liver primary tumor, and there is an echogenic mass in the bile ducts; the primary tumor in the liver is mainly characterized by the presence of contrast medium, and the biliary ducts are not well ventilated. Primary tumors of the liver mainly showed the “fast-in-fast-out” enhancement mode of the contrast medium. However, cholangiocellular hepatocellular carcinoma (ICC) invades the bile ducts, and the imaging manifestations of ICC are: obvious bile duct dilatation, uneven thickness of dilated bile ducts, wall thickening with obvious enhancement, and the dilated bile ducts are often located in the mass; the mass manifests mild enhancement of the margins or lack of enhancement[5] . The primary foci of hepatocellular carcinoma are usually located in the lobes adjacent to the bile duct thrombus, such as the right anterior lobe and the left inner lobe, and the size of the primary foci varies, and the bile duct thrombus can be simple thrombus or cancerous thrombus, which is the same pathology as the primary foci in the liver[11.12] . The principle of surgical treatment for this disease is to resect the primary liver tumor and remove the bile duct cancerous thrombus as much as possible[13] . If the disease permits, lobectomy should be pursued, preferably with resection of the tumor first, to increase exposure and possibly reduce transmural metastasis of the cancer cells. At the same time, the bile duct can be “met” with the common bile duct incision through the hepatic section to ensure that the embolus is removed [6]. The bile duct embolus can be easily removed, but if the embolus is tightly adherent to the bile duct wall or if the primary cancer invades the confluence of the bile ducts, the bile ducts should be resected [12].There is no significant difference in the survival rate between those who have undergone choledochotomy and those who have not undergone choledochotomy for HCC combined with bile duct embolus [2,11]. If HCC combined with cholangiocarcinoma embolus recurs after surgery, reoperation can be performed, and still can achieve better long-term results. One patient in our group had undergone choledochotomy for obstructive jaundice due to bile duct embolism one year ago in an outside hospital, and no liver occupation was found. When jaundice appeared again, CT revealed dilatation of the intra- and extrahepatic bile ducts, and anterior hepatic lobe occupancy (Fig. 2), and the patient was operated for right hemihepatectomy with choledochotomy and had been survived for 2 years. Some studies have reported that bile duct embolization is not an independent predictor of poor prognosis in primary liver cancer, and the 3-year survival rate of HCC combined with bile duct embolization can be up to 47%, and the 5-year survival rate is up to 28%[11] . The median survival of our cases was 23.6 months, and the longest has survived for more than 5 years. Peng Shuxia[12] reported that in 15 patients with HCC combined with bile duct cancer embolization, the 1-year survival rate was 73.3%, the 3-year survival rate was 40%, and the survival rate of 2 cases was more than 5 years. Therefore, it can be concluded that the positive surgical treatment after definite diagnosis of primary liver cancer combined with cholangiocarcinoma embolus can achieve better therapeutic effect. Figure 1 Hepatosclerosis, mild dilatation of the intrahepatic bile ducts, and solid lesions in the upper extrahepatic bile ducts Figure 2 Dilatation of the intrahepatic bile ducts, and soft-tissue density in the common bile duct (cancerous embolus) in the upper segment of the bile ducts (below the arrowheads) Figure 3 , Figure 4 Dilatation of the intrahepatic bile ducts, with stenosis of the bile ducts and the hilar region interrupted, and soft-tissue shadows in the right anterior lobe of about 22mm in size, close to the side of dilatation of the bile ducts, with enhancement in the arterial phase (Figure 3), and hypodensity in the portal phase (Figure 4)