Primary hepatocellular carcinoma (PHC) with biliary tract thrombosis (CEBT) was previously considered to be an advanced tumor, losing the opportunity for surgery and having a very poor prognosis. With the improvement of the understanding of tumor biology and the rapid development of imaging, the detection rate of primary hepatocellular carcinoma with biliary tract cancer thrombosis (PHC-CEBT) is increasing day by day; with the development of aggressive surgical treatment and comprehensive treatment for middle and late stage tumors, the treatment of this disease has achieved better results. The total of 16 cases of PHC-CEBT admitted between December 1998 and June 2003 are summarized as follows. 1. Materials and methods 1.1 Sixteen cases of PHC-CEBT were admitted, 9 males and 7 females, aged 35-67 years (mean 49.0 years). They were seen 1~4 months after the disease (mean 2.5 months). The main manifestations were distension and discomfort in the liver or epigastric region, poor appetite, jaundice, emaciation, hepatosplenomegaly, fever, increased ALT, positive HBsAg, increased serum bilirubin, positive AFP, ultrasound showing hepatic occupying lesions, dilated intra- and extrahepatic bile ducts, strong echogenicity, substantial echogenicity and flocculent echogenicity in the bile ducts, and hepatic occupying lesions, dilated bile ducts and occupying lesions in the bile ducts on CT and MRI. 1.2 Surgical method: PHC was resected first, and then CEBT was removed. 14 cases of hepatic resection and 2 cases of diffuse hepatocellular carcinoma were cured by microwave knife and liver biopsy. After the removal of CEBT, the bile ducts were repeatedly flushed with saline, and the bile ducts were checked to be free of cancerous emboli. The T-tube was left in place for postoperative chemotherapy, regular follow-up and follow-up treatment. 2. Results: There was no surgical death in this group. The follow-up period was 2.3~36 months. The two cases with T-tube drainage only survived for 2.5 months and 4.5 months respectively, mainly due to hepatorenal syndrome. 14 cases with PHC resection survived for 1 year, 1~2 years, 2.5~3 years in 12 cases, 9 cases, 6 cases and 2 cases respectively, including 1 case survived for 4.5 years, mainly due to tumor recurrence and metastasis, infection, jaundice and hepatorenal syndrome. 3.Discussion Because of the jaundice or CEBT in PHC in the past, it was mostly considered as advanced tumor manifestation, and the total incidence was 2.3~4.8%, which was often regarded as a contraindication to surgery, and because the preoperative correct diagnosis rate was not high, once diagnosed, it was mostly advanced, even if surgery was performed, the resection rate was very low, and the prognosis was very poor, and the postoperative survival was only 1~3 months. In recent years, with the improved understanding of biological characteristics of hepatocellular carcinoma, the establishment of the concept of comprehensive treatment of middle and late stage tumors and the continuous improvement of imaging means, PHC-CEBT can be diagnosed early and treated actively and effectively at an early stage, especially with active surgical treatment, which can greatly improve the prognosis, and the understanding of CEBT has been greatly improved. In addition to the clinical manifestations of PHC, CEBT is asymptomatic in early stage or intrahepatic grade 2 bile duct cancer embolus, and mainly manifests obstructive jaundice when the cancer embolus reaches grade 1 or extrahepatic bile duct. Progressive painless jaundice is usually seen when the cancer embolus invades or extends to the intra- and extrahepatic bile ducts, and is often confused with primary bile duct cancer or hepatitis. Diagnosis and differential diagnosis can be helped if hepatic occupying lesions or positive AFP are found. Fluctuating jaundice is seen in biliary tract obstruction caused by necrotic detachment of tumor, suspension of extrahepatic bile duct thrombus or biliary bleeding due to cancer invasion of adjacent vessels. It is similar to the fluctuating jaundice of cholelithiasis and may also occur as biliary colic and black stool when bleeding. Acute cholangitis type of CEBT is most commonly seen when PHC invades the larger bile ducts in the liver, and can be the first symptom, mainly manifesting as abdominal pain, fever and jaundice, and even shock. Preoperative CEBT is difficult to diagnose, and the diagnostic rate of imaging examination is low. Some patients have not found liver-occupying lesions preoperatively (or even intraoperatively), and intraoperative pathological examination of frozen sections of cancer emboli is also missed, which makes the diagnosis more difficult. For patients without preoperative liver-occupying lesions, this disease should be considered first when there is a history of hepatitis B or hepatic sclerosis, positive HbsAg, positive AFP, and intra-biliary occupying lesions detected by imaging. If no intraoperative hepatic occupying lesion is found, intraoperative ultrasound and cholangioscopy can be used to discover the site, scope and nature of the lesion, and intraoperative frozen rapid pathological examination of cancer emboli can help qualitative diagnosis. If there is preoperative hepatic occupying lesion with infarction or cholangitis, this disease should be highly suspected, and intraoperative bile duct incision and careful exploration can confirm the diagnosis. Among the preoperative imaging examinations, ultrasound, CT, MRI or transoral choledochoscopy are the most valuable. Ultrasound mainly shows flocculent echogenicity, substantial echogenicity or strong echogenicity in the bile duct, but no posterior acoustic shadow (which is different from gallstones); MRI has higher sensitivity and diagnostic rate than CT and ultrasound, and has localization, scope and qualitative value, especially it can show the relationship between the cancer thrombus and the primary focus and bile duct wall, dilatation of bile duct inside and outside the liver, multiple filling defects in the bile duct, and multiple filling defects in the bile duct. It shows multiple filling defects in the intra- and extra-hepatic bile ducts, distended strips, smooth and intact bile duct walls, stone-like cup-like filling defects and bile duct cancer-like linear stenosis, and complete or incomplete obstruction. The main treatment method for PHC-CEBT is surgery. Removing the primary foci of hepatocellular carcinoma, removing the cancerous emboli and relieving biliary obstruction are the best treatment methods, which can significantly improve the efficacy and prognosis if combined with comprehensive treatment. Since CEBT causes severe obstructive jaundice, which often leads to rapid deterioration of the disease and aggravation of liver function damage, and often combined with biliary bleeding, hypoproteinemia, biliary tract infection, ascites and hepatorenal syndrome, which further aggravate the development of the disease, therefore, medical treatment is ineffective, and only surgery is the only hope to improve symptoms, enhance life quality and prolong life. Only surgery is the only hope to improve the symptoms, improve the quality of life and prolong the life. The specific surgical method should depend on the site and scope of the primary focus and bile duct cancer embolus, liver cirrhosis or liver reserve function damage, etc. All PHC in this group are combined with hepatic sclerosis, and the reserve function and hepatic compensatory capacity after resection must be fully considered when hepatic resection is performed. For those with diffuse tumor lesions or large tumors, tumors invading important anatomical structures that cannot be resected, severe hepatic steatosis or hepatic dysfunction that cannot tolerate liver resection or liver tumors not found intraoperatively, only bile duct exploration to remove cancer emboli and hepatic artery ligation can be performed, and partial microwave curing of diffuse liver tumors is feasible when available. When possible, the primary foci should be removed as much as possible, and it is better to remove the primary foci before removing the cancer embolus. In patients with hepatocellular carcinoma or hepatectomy, intraoperative ultrasound monitoring and routine careful exploration of the bile duct are important ways to detect and completely eradicate cancer emboli early. T-tube chemotherapy drug infusion or drip after PHC resection and CEBT removal is an important effective adjuvant treatment, which can significantly improve the efficacy and prolong the survival, and is important to prevent cancer recurrence and metastasis. In our group, 9 cases of PHC-CEBT survived for more than 1.5 years by T-tube chemotherapy drug infusion or drip, and one of them survived for 54 months. Only 2.5 to 4.5 months were survived after T-tube drainage alone. From our clinical practice and treatment results: 1. AFP, ultrasound, CT, MRI and other examinations are beneficial to the diagnosis and differential diagnosis of this disease. There is a difference between this kind of obstruction and the infarct yellow caused by liver tumor compression. 2. The understanding of the characteristics of this disease should be strengthened, and striving for radical resection is the key to obtain a good prognosis. Confined intrahepatic tumor with CEBT is different from general advanced hepatocellular carcinoma, which can still be surgically resected, and the opportunity of surgical exploration should not be abandoned. Surgical treatment is more effective, and surgery is the only effective treatment to improve symptoms, quality of life and prognosis. 3.Removal of primary foci is the source of eliminating cancer thrombus generation. 4.Removing the net cancer embolus and releasing biliary obstruction can only correct the liver function damage and other complications, otherwise the condition deteriorates rapidly after surgery. 5.After resection of primary foci and removal of CEBT, infusion or drip of chemotherapy drug via T-tube is an effective therapy to consolidate and improve the therapeutic effect, prevent recurrence of cancer embolism and improve the prognosis.