Systemic Treatment Versus No Systemic Treatment After Biliary Drainage in Patients with Icteric Hepatocellular Carcinoma: A Retrospective Cohort Study

Background/Objectives: Icteric hepatocellular carcinoma (HCC) is characterized by obstructive jaundice, impaired liver function, and limited treatment options. Biliary drainage may relieve jaundice and permit subsequent anticancer therapy, but the clinical benefit of systemic treatment remains uncertain in this setting. Methods: This retrospective, single-center cohort study included 78 patients with icteric HCC who underwent biliary drainage via endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangial drainage (PTCD). Thirty patients received systemic treatment during the treatment course surrounding biliary drainage (five initiated treatment before drainage and 25 on or after drainage), whereas 48 did not receive systemic treatment. Overall survival (OS) and progression-free survival (PFS) were evaluated using Kaplan–Meier analysis and Cox regression. Propensity score matching (PSM), time-dependent Cox regression, and a 42-day landmark analysis were performed as sensitivity analyses. Results: Median OS was longer with systemic treatment than without systemic treatment (14.6 vs. 6.7 months; p = 0.025), as was PFS (7.5 vs. 3.5 months; p = 0.005). After 1:1 PSM, systemic therapy remained associated with longer PFS (7.6 vs. 4.6 months; p = 0.044), whereas the OS difference was not statistically significant. In time-dependent analyses, systemic treatment was not significantly associated with OS (HR, 0.70; 95% CI, 0.40–1.22; p = 0.207) or PFS (HR, 0.65; 95% CI, 0.38–1.13; p = 0.128). Conclusions: Systemic treatment was associated with favorable outcomes in selected patients in the primary analyses, but these associations were attenuated after accounting for treatment timing. The findings are exploratory and do not establish a causal treatment effect.