Predictive factors for prognosis of hilar cholangiocarcinoma: Postresection radiotherapy improves survival

Cholangiocarcinoma: principles and current trends

BACKGROUND

Cholangiocarcinoma (CCA) is a lethal cancer of the biliary epithelium, originating from the liver (intrahepatic), at the confluence of the right and left hepatic ducts (hilar) or in the extrahepatic bile ducts. It is a rare malignancy associated with poor prognosis.

DATA SOURCES

We searched the PubMed/MEDLINE database for relevant articles published from 1989 to 2008. The search terms used were related to "cholangiocarcinoma" and its "treatment". Although no language restrictions were imposed initially, for the full-text review and final analysis, our resources only permitted the review of articles published in English. This review deals with the treatment of cholangiocarcinoma, the principles and the current trends.

RESULTS

The risks and prognostic factors, symptoms and differential diagnosis are thoroughly discussed. In addition, the tools of preoperative diagnosis such as endoscopic retrograde cholangiopancreatography, digital image analysis, fluorescence in situ hybridization and magnetic resonance cholangiopancreatography are reviewed. Moreover, the treatment of CCA is discussed.

CONCLUSIONS

The only curative treatment available is surgical management. Unfortunately, many patients present with unresectable tumors, the majority of whom die within a year of diagnosis. Surgical treatment involves major resections of the liver, pancreas and bile duct, with considerable mortality and morbidity. However, in selected cases and where indicated, appropriate management with aggressive surgery may achieve a good outcome with a prolonged survival expectancy.

Cholangiocarcinoma: A position paper by the Italian Society of Gastroenterology (SIGE), the Italian Association of Hospital Gastroenterology (AIGO), the Italian Association of Medical Oncology (AIOM) and the Italian Association of Oncological Radiotherapy (AIRO)

The incidence of Cholangiocellular carcinoma (CCA) is increasing, due to a sharp increase of the intra-hepatic form. Evidence-ascertained risk factors for CCA are primary sclerosing cholangitis, Opistorchis viverrini infection, Caroli disease, congenital choledocal cist, Vater ampulla adenoma, bile duct adenoma and intra-hepatic lithiasis. Obesity, diabetes, smoking, abnormal biliary-pancreatic junction, bilio-enteric surgery, and viral cirrhosis are emerging risk factors, but their role still needs to be validated. Patients with primary sclerosing cholangitis should undergo surveillance, even though a survival benefit has not been clearly demonstrated. CCA is most often diagnosed in an advanced stage, when therapeutic options are limited to palliation. Diagnosis of the tumor is often difficult and multiple imaging techniques should be used, particularly for staging. Surgery is the standard of care for resectable CCA, whilst liver transplantation should be considered only in experimental settings. Metal stenting is the standard of care in inoperable patients with an expected survival >4 months. Gemcitabine or platinum analogues are recommended in advanced CCA whilst there are no validated neo-adjuvant treatments or second-line chemotherapies. Even though promising results have been obtained in CCA with radiotherapy, further randomized controlled trials are needed.

Prognostic factors after surgical resection for intrahepatic, hilar, and distal cholangiocarcinoma

BACKGROUND

The prognosis of patients with cholangiocarcinoma is unsatisfactory. Therefore, evaluation of prognostic factors and establishment of new therapeutic strategies are needed to improve their long-term survival. The aim of this study was to identify useful prognostic factors for patients with intrahepatic, hilar, and distal cholangiocarcinoma.

MATERIALS AND METHODS

Records of 127 patients with cholangiocarcinoma (21 with intrahepatic cholangiocarcinoma, 50 with hilar cholangiocarcinoma, and 56 with distal cholangiocarcinoma) who underwent surgical resection were reviewed retrospectively. Relationships between survival and clinicopathological factors including patient demographics and tumor characteristics were evaluated using univariate and multivariate analysis.

RESULTS

For all 127 patients, overall 1-, 3-, 5-year survival rates were 80, 51, and 40%, respectively. Univariate analysis revealed that adjuvant chemotherapy (P = .049), tumor differentiation (P = .014), lymph node metastasis (P < .001), surgical margin status (P < .001), UICC pT factor (P < .001), and UICC stage (P < .001) were associated significantly with survival. UICC pT factor (P = .007), adjuvant chemotherapy (P = .009), surgical margin status (P = .012), and lymph node metastasis (P = .014) remained independently associated with long-term survival by multivariate analysis. The 5-year survival rates of patients with or without positive surgical margins were 13 and 49%, respectively. The 5-year survival rates of patients treated with or without adjuvant chemotherapy were 47 and 36%, respectively.

CONCLUSIONS

R0 resection and adjuvant chemotherapy may be mandatory to achieve long-term survival for patients with cholangiocarcinoma.

Value of indocyanine green clearance of the future liver remnant in predicting outcome after resection for biliary cancer

BACKGROUND

It is difficult to predict hepatic functional reserve accurately before major hepatectomy. The aim of this study was to analyse the usefulness of the future liver remnant plasma clearance rate of indocyanine green (ICGK-F, calculated as plasma clearance rate of indocyanine green (ICGK) x proportion of the future liver remnant) in predicting death after major hepatectomy.

METHODS

Data on ICGK and ICGK-F were collected prospectively and analysed retrospectively for 274 patients who underwent right hepatectomy, right trisectionectomy or left trisectionectomy for biliary cancer between 1991 and 2008. The mortality rate and incidence of postoperative complications were analysed. Patients were separated into two groups according to year of operation (85 patients operated on between 1991 and 2000; 189 from 2001 to 2008).

RESULTS

In multiple logistic regression analyses, an ICGK-F less than 0.05 had the strongest impact on the incidence of postoperative mortality (odds ratio 8.06; P < 0.001). The postoperative mortality rate was significantly lower in the later period (P < 0.001). In patients with an ICGK-F value between 0.040 and 0.049, the mortality rate in the early period was 30 per cent, whereas it was only 8 per cent in the later period.

CONCLUSION

An ICGK-F of 0.05 is a useful cut-off value for predicting mortality and morbidity. With careful perioperative patient management in an experienced institution, this cut-off value can be lowered further.

Postoperative chemoradiotherapy for extrahepatic bile duct cancer

PURPOSE

To evaluate the effect of postoperative concurrent chemoradiotherapy using three-dimensional conformal radiotherapy and to identify the prognostic factors that influence survival in patients with extrahepatic bile duct cancer.

METHODS AND MATERIALS

We retrospectively analyzed the data from 101 patients with extrahepatic bile duct cancer who had undergone postoperative concurrent chemoradiotherapy using three-dimensional conformal radiotherapy. Of the 101 patients, 52 (51%) had undergone complete resection (R0 resection) and 49 (49%) had microscopic or macroscopic residual tumors (R1 or R2 resection). The median radiation dose was 50 Gy. Also, 85 patients (84%) underwent concurrent chemotherapy with 5-fluorouracil.

RESULTS

The median follow-up period was 47 months for the surviving patients. The 5-year overall survival rate was 34% for all patients. A comparison between patients with R0 and R1 resection indicated no significant difference in the 5-year overall survival (44% vs. 33%, p=.2779), progression-free survival (35% vs. 22%, p=.3107), or locoregional progression-free survival (75% vs. 63%, p=.2784) rates. An analysis of the first failure site in the 89 patients with R0 or R1 resection indicated isolated locoregional recurrence in 7 patients. Elevated postoperative carbohydrate antigen 19-9 level was an independent prognostic factor for overall survival (p=.001) and progression-free survival (p=.033). A total of 3 patients developed Grade 3 or greater late toxicity.

CONCLUSION

Adjuvant concurrent chemoradiotherapy using three-dimensional conformal radiotherapy appears to improve locoregional control and survival in extrahepatic bile duct cancer patients with R1 resection. The postoperative carbohydrate antigen 19-9 level might be a useful prognostic marker to select patients for more intensified adjuvant therapy.

Surgical treatment and prognostic analysis of 93 cases of hilar cholangiocarcinoma

OBJECTIVE

To explore the surgical treatment and prognosis of hilar cholangiocarcinoma.

METHODS

This was a retrospective study of 93 cases of hilar cholangiocarcinoma that were treated surgically at our hospital from June 1999 to June 2005. Prognostic factors were also analyzed.

RESULTS

Fifty-two cases were treated with curative resection, 21 with palliative resection, and 9 with nonoperative drainage. Eleven cases underwent palliative drainage operations. The median survive time was 31 months in the curative resection group, 13.7 months in the palliative resection group, and 11 months in the nonoperative drainage group. Patient age, serum total bilirubin, clinical type of Bismuth-Corlette, tumor differentiation, and lymph node metastases were important factors for predicting the prognosis of hilar cholangiocarcinoma.

CONCLUSIONS

Resection was the main treatment for hilar cholangiocarcinoma, and curative resection was the best way to obtain better prognosis. Age, preoperative serum total bilirubin, bismuth clinical type, tumor histopathological grading, and lymph node metastases were considered to have a significant effect on prognosis.

Adjuvant gemcitabine plus S-1 chemotherapy improves survival after aggressive surgical resection for advanced biliary carcinoma

OBJECTIVE

The aim of this study was to evaluate the efficacy of adjuvant gemcitabine plus S-1 chemotherapy after aggressive surgical resection for advanced biliary carcinoma.

SUMMARY BACKGROUND DATA

No effective adjuvant therapy for advanced biliary carcinoma has been reported although its prognosis is extremely poor.

METHODS

Medical records were reviewed for 103 patients with International Union Against Cancer (UICC) stage II biliary carcinoma who underwent aggressive surgical resection. About 50 patients received 10 cycles of adjuvant gemcitabine plus S-1 chemotherapy and 53 patients did not. Clinicopathological factors and patient survival were compared between the 2 groups using univariate and multivariate analysis. A cycle of chemotherapy consisted of intravenous gemcitabine 700 mg/m(2) on day 1 and oral S-1 50 mg/m(2) for 7 consecutive days, followed by a 1-week break from chemotherapy.

RESULTS

Patient demographics, tumor characteristics, and surgical procedures did not differ between the 2 groups. Aggressive surgical procedures including major hepatectomy or pancreatoduodenectomy were performed for 94 of 103 patients. In the chemotherapy group, 37 patients (74%) were given the full number of 10 cycles. The use of postoperative adjuvant chemotherapy (P < 0.001) and surgical margin status (P = 0.003) were independently associated with long-term survival by multivariate analysis. Five-year survival rates of patients who did or did not receive postoperative adjuvant chemotherapy were 57% and 24%, respectively (P < 0.001). Toxicity during chemotherapy was mild.

CONCLUSIONS

Adjuvant gemcitabine plus S-1 chemotherapy may be one of several factors contributing to improved outcomes after aggressive surgical resection of advanced biliary carcinoma in recent years.

Major hepatectomy for perihilar cholangiocarcinoma

BACKGROUND/PURPOSE

Hilar cholangiocarcinoma and intrahepatic cholangiocarcinoma involving the hepatic hilus are defined as "perihilar cholangiocarcinoma". The principle of surgical treatment is hemi-hepatectomy or trisectionectomy of the liver, caudate lobectomy, and resection of the extrahepatic bile duct for complete resection of the tumor. The aim of this study was to review the outcomes of major hepatectomy for perihilar cholangiocarcinoma.

METHODS

Using the Kaplan-Meier method and the Cox proportional hazards model, we analyzed the results in 125 patients with perihilar cholangiocarcinoma who had undergone major hepatectomy.

RESULTS

Right hepatectomy, right trisectionectomy, left hepatectomy, and left trisectionectomy were performed in 66, 8, 49, and 2 patients, respectively. Curative resection was achieved in 79 patients (63.2%). Mortality and morbidity rates were 8.0 and 48.7%, respectively. The overall 1-, 3-, and 5-year survival rates of all patients were 73.2, 36.7, and 34.7%, respectively. The median survival was 26.8 months. Multivariate analysis showed that the independent prognostic factors for overall survival were gender, histopathological grading, curative resection, and American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) pT.

CONCLUSIONS

Major hepatectomy for perihilar cholangiocarcinoma was acceptable and showed satisfactory outcomes. For long-term survival in these patients, the surgeon should aim for complete resection of the tumor with negative margins.

Gemcitabine-based adjuvant chemotherapy improves survival after aggressive surgery for hilar cholangiocarcinoma

BACKGROUND

The prognosis of hilar cholangiocarcinoma is dismal although aggressive surgery including major hepatectomy has been performed. The aim of this study was to clarify useful prognostic factors and the usefulness of gemcitabine-based adjuvant chemotherapy for patients with hilar cholangiocarcinoma who had undergone aggressive surgical resection.

METHODS

Medical records of 42 patients with hilar cholangiocarcinoma who underwent surgical resection were reviewed retrospectively. Univariate and multivariate models were used to analyze the effect of various clinicopathological factors on long-term survival.

RESULTS

Overall 1-, 3-, and 5-year survival rates of the 42 patients with hilar cholangiocarcinoma were 81%, 42%, and 30%, respectively (median survival time, 21.5 months). Univariate analysis revealed that adjuvant gemcitabine-based chemotherapy, tumor differentiation, lymph node metastasis, and surgical margin status were associated significantly with long-term survival (P < 0.05). Furthermore, use of a Cox proportional hazards regression model indicated that only adjuvant gemcitabine-based chemotherapy was a significant independent predictor of a favorable prognosis (P = 0.035). The toxicity of adjuvant gemcitabine-based chemotherapy was mild. Five-year actuarial survival rates of patients who did or did not receive adjuvant gemcitabine-based chemotherapy were 57% and 23%, respectively (P = 0.026).

CONCLUSIONS

Postoperative adjuvant gemcitabine-based chemotherapy may be a promising strategy to improve survival after surgical resection for hilar cholangiocarcinoma. A prospective randomized study should be done to confirm the results of this study.

Management of bile duct tumors

Cholangiocarcinomas are a rare but highly fatal disease. The only curative treatment is radical surgical resection of the tumor and the regional lymph nodes. More than half of patients have irresectable disease, which implicates a median survival of < 1 year. The mainstay of palliative treatment is endoscopic or percutaneous drainage of the biliary system. In patients with good performance status, palliative chemotherapy seems to provide some survival benefit together with an improved quality of life. No standard chemotherapy has been defined but gemcitabine monotherapy or the combination of gemcitabine with platin derivates or capecitabine seems to be more effective than other protocols. Additionally, photodynamic therapy has shown promising results and radiation might be helpful for localized disease. In a very selected population liver transplantation can also be an option.

Adjuvant therapy for resected extrahepatic cholangiocarcinoma: a review of the literature and future directions

Cholangiocarcinoma is a rare neoplasm originating from the intra- or extrahepatic bile duct epithelium. Incidence has been increasing worldwide in the last three decades. Complete surgical resection provides the only possibility of cure, but even with resection 5-yr survival can be as low as 11%. Adjuvant therapy has the potential to play a crucial role in prolonging survival and local control. Retrospective series have suggested benefit to adjuvant radiation, chemotherapy or concurrent chemo-radiation. The scarce prospective data has not shown a survival benefit to adjuvant therapy. In this article we review and summarize the published data regarding adjuvant therapy for resected extrahepatic cholangiocarcinoma. Prospective, multi-institutional randomized trials are needed to clarify the role of adjuvant therapy in this disease.

Prognostic factors in patients with advanced cholangiocarcinoma: role of surgery, chemotherapy and body mass index

AIM

To study the factors that may affect survival of cholangiocarcinoma in Lebanon.

METHODS

A retrospective review of the medical records of 55 patients diagnosed with cholangio-carcinoma at the American University of Beirut between 1990 and 2005 was conducted. Univariate and multivariate analyses were performed to determine the impact of surgery, chemotherapy, body mass index, bilirubin level and other factors on survival.

RESULTS

The median survival of all patients was 8.57 mo (0.03-105.2). Univariate analysis showed that low bilirubin level (< 10 mg/dL), radical surgery and chemotherapy administration were significantly associated with better survival (P = 0.012, 0.038 and 0.038, respectively). In subgroup analysis on patients who had no surgery, chemotherapy administration prolonged median survival significantly (17.0 mo vs 3.5 mo, P = 0.001). Multivariate analysis identified only low bilirubin level < 10 mg/dL and chemotherapy administration as independent predictors associated with better survival (P < 0.05).

CONCLUSION

Our data show that palliative and postoperative chemotherapy as well as a bilirubin level < 10 mg/dL are independent predictors of a significant increase in survival in patients with cholangiocarcinoma.

[The effect of R1 resection in the hepatobiliary pancreatic system]

Macroscopic and microscopic complete resection, i.e. R0 resection, is a basic principle of oncologic hepatopancreatobiliary (HPB) surgery. The reported R1 rates for different HPB tumor entities vary considerably, most likely because of ambiguities in the exact definition of R1 resection and the lack of standardized histopathologic examination and reporting. R1 resections can be interpreted as technical/surgical failure (e.g. for small, peripherally located liver tumors). In most cases, however, R1 resections are determined by the anatomic location of the tumor and the growth pattern (e.g. pancreatic cancer with perineural invasion). R0 resections have been identified as positive predictive markers for several HPB tumors (in comparison to R1 resection). Therefore HPB surgeons should always aim at macroscopic and microscopic complete resections. Nonetheless, R1 resections often provide an advantage over no resection with respect to survival and quality of life in patients with these tumors.