A proposed staging system for intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma: prognostic factors after liver resection

Liver resection may represent the only hope of cure for patients with intrahepatic cholangiocarcinoma (IHC) but long-term results are still far from satisfactory and the impact of prognostic factors is still controversial. Fifty-five patients underwent hepatectomy for IHC between 1997 and 2008 in our unit. Features of the patients and the tumors, operations, postoperative and long-term results were retrospectively assessed. Twenty-one patients had HBV/HCV infection, four had congenital biliary dilatation. Thirty-two patients had increased CA 19-9; 12 had multiple (≥ 4) tumors. Operations included 43 major resections, with 9 resections of biliary confluence, 40 regional lymphadenectomies. Operative mortality and morbidity were 0 and 27.3%, respectively. There were 44 R0-resections (80.0%). Lymphadenectomy yielded lymph node metastases in 14 cases (14/40; 35.0%). Five-year overall and disease-free survival rates were 30.2 and 27.5%, respectively. At multivariate analysis the strongest poor prognostic factor for overall survival was tumor stage. This factor, with multiplicity of lesions (≥ 4) and tumor grading > 2, was significant predictor of recurrence. CA19-9 > 100 IU/mL and tumor grading > 2 were found to be significantly related with early multinodular hepatic recurrence. Patients with lymph node metastases had significantly lower overall and disease-free survival but patients who underwent lymph node dissection with negative lymph nodes at final pathology showed significantly higher 5-year disease-free survival than patients who did not underwent lymphadenectomy. In conclusion, these results support the role of hepatectomy with regional lymphadenectomy as the best available treatment for IHC. Prognosis after liver resection correlates with clinical stage and multiplicity of lesions.

Inhibition of active autophagy induces apoptosis and increases chemosensitivity in cholangiocarcinoma

Intrahepatic cholangiocellular carcinomas (ICCs) are usually fatal neoplasms originating from bile duct epithelia. However, many cholangiocarcinoma cells are shown to be resistant to chemotherapeutic drugs, which induce cell apoptosis. The role of autophagy and the therapeutic value of autophagy-associated genes are largely unknown in ICC. Here, we showed that autophagy was activated in nutrient starvation and xenograft cholangiocarcinoma cells. Furthermore, expression of autophagic genes and their autophagic activity were higher in clinical ICC specimens than that in normal cholangiocytes separated by laser capture microdissection. Inhibition of autophagy by autophagy inhibitors or siRNA, cholangiocarcinoma cells showed detention of proliferation and increase of apoptosis during nutrient starvation. In addition, autophagy inhibitor treatment or knockdown of beclin 1 suppressed tumor growth and sensitized ICC cells to chemotherapeutic agent-induced cell death. In conclusion, our data showed that autophagy is activated in ICC, and inactivation of autophagy may lead to cell apoptosis and enhance chemotherapy sensitivity.

Surgical outcomes of intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is considered to be a fatal disease because of frequent recurrence despite curative surgery. The macroscopic classification of ICC in the General Rules for the Clinical and Pathological Study of Primary Liver Cancer of the Liver Cancer Study Group of Japan reflects tumor-spreading patterns; therefore, the clinicopathological findings and surgical outcomes can be predicted using this classification. Lymph node and intrahepatic metastases, and a curative resection are important prognostic factors in ICC; however, lymph node dissection is still controversial. In particular, the intraductal growth type and periductal infiltrating type of ICC without hilar invasion have favorable surgical outcomes, whereas the mass-forming type and periductal infiltrating type of ICC with hilar invasion have high hepatic recurrence and local recurrence, respectively. Multimodal treatments are therefore needed to improve the surgical outcomes of ICC.

Intrahepatic cholangiocarcinoma: an international multi-institutional analysis of prognostic factors and lymph node assessment

PURPOSE

To identify factors associated with outcome after surgical management of intrahepatic cholangiocarcinoma (ICC) and examine the impact of lymph node (LN) assessment on survival.

PATIENTS AND METHODS

From an international multi-institutional database, 449 patients who underwent surgery for ICC between 1973 and 2010 were identified. Clinical and pathologic data were evaluated using uni- and multivariate analyses.

RESULTS

Median tumor size was 6.5 cm. Most patients had a solitary tumor (73%) and no vascular invasion (69%). Median survival was 27 months, and 5-year survival was 31%. Factors associated with adverse prognosis included positive margin status (hazard ratio [HR], 2.20; P < .001), multiple lesions (HR, 1.80; P = .001), and vascular invasion (HR, 1.59; P = .015). Tumor size was not a prognostic factor (HR, 1.03; P = .23). Patients were stratified using the American Joint Committee on Cancer/International Union Against Cancer T1, T2a, and T2b categories (seventh edition) in a discrete step-wise fashion (P < .001). Lymphadenectomy was performed in 248 patients (55%); 74 of these (30%) had LN metastasis. LN metastasis was associated with worse outcome (median survival: N0, 30 months v N1, 24 months; P = .03). Although patients with no LN metastasis were able to be stratified by tumor number and vascular invasion (N0; P < .001), among patients with N1 disease, multiple tumors and vascular invasion, either alone or together, failed to discriminate patients into discrete prognostic groups (P = .34).

CONCLUSION

Although tumor size provides no prognostic information, tumor number, vascular invasion, and LN metastasis were associated with survival. N1 status adversely affected overall survival and also influenced the relative effect of tumor number and vascular invasion on prognosis. Lymphadenectomy should be strongly considered for ICC, because up to 30% of patients will have LN metastasis.

New staging system and a registry for perihilar cholangiocarcinoma

Perihilar cholangiocarcinoma is one of the most challenging diseases with poor overall survival. The major problem for anyone trying to convincingly compare studies among centers or over time is the lack of a reliable staging system. The most commonly used system is the Bismuth-Corlette classification of bile duct involvement, which, however, does not include crucial information such as vascular encasement and distant metastases. Other systems are rarely used because they do not provide several key pieces of information guiding therapy. Therefore, we have designed a new system reporting the size of the tumor, the extent of the disease in the biliary system, the involvement of the hepatic artery and portal vein, the involvement of lymph nodes, distant metastases, and the volume of the putative remnant liver after resection. The aim of this system is the standardization of the reporting of perihilar cholangiocarcinoma so that relevant information regarding resectability, indications for liver transplantation, and prognosis can be provided. With this tool, we have created a new registry enabling every center to prospectively enter data on their patients with hilar cholangiocarcinoma (www.cholangioca.org). The availability of such standardized and multicenter data will enable us to identify the critical criteria guiding therapy.

Cholangiocarcinoma--controversies and challenges

Cholangiocarcinomas are a diverse group of tumors that are presumed to originate from the biliary tract epithelium either within the liver or the biliary tract. These cancers are often difficult to diagnose, their pathogenesis is poorly understood, and their dismal prognosis has resulted in a nihilistic approach to their management. The two major clinical phenotypes are intrahepatic, mass-forming tumors and large ductal tumors. Among the ductal cancers, lesions at the liver hilum are most prevalent. The risk factors, clinical presentation, natural history and management of these two types of cholangiocarcinoma are distinct. Efforts to improve outcomes for patients with these diseases are affected by several challenges to effective management. For example, designations based on anatomical characteristics have been inconsistently applied, which has confounded analysis of epidemiological trends and assessment of risk factors. The evaluation of therapeutic options, particularly systemic therapies, has been limited by a lack of appreciation of the different phenotypes. Controversies exist regarding the appropriate workup and choice of management approach. However, new and emerging tools for improved diagnosis, expanded indications for surgical approaches, an emerging role for locoregional and intrabiliary therapies and improved systemic therapies provide optimism and hope for improved outcomes in the future.

Comparison of the prognostic accuracy of the sixth and seventh editions of the TNM classification for intrahepatic cholangiocarcinoma

BACKGROUND

The seventh TNM edition introduced a new, specific staging structure for intrahepatic cholangiocarcinoma (IHC).

OBJECTIVE

To compare the accuracy of the sixth and the new seventh edition to predict survival after hepatectomy for IHC.

METHODS

In all, 434 consecutive patients who underwent hepatectomy at 16 tertiary-care centres (1990-2008) were identified. End points were overall (OS) and recurrence-free survival (RFS) for both T cohorts and stage strata.

RESULTS

After a median follow-up of 32.4 months, 3- and 5-year OS and RFS estimates were 47.1% and 32.9%, and 26.5% and 19.1%, respectively. Overall, both the editions were statistically significant discriminators of OS and RFS (P < 0.05). However, the survival curves of the new T2a and T2b cohorts appear superimposed. Conversely, the old T2 and T3 cohorts accurately stratify patients into distinct prognostic groups (P < 0.01). The seventh edition does not show monotonicity of gradients (the T4 category demonstrates significantly better OS and RFS compared with T2 patients). The seventh edition stage I and II are significantly different whereas the old stage I and II were not.

CONCLUSIONS

The new seventh edition of the AJCC/UICC Staging System proved to be adequate although further studies are need to confirm its superiority compared with the previous edition.

Surgical treatment of intrahepatic cholangiocarcinoma: outcomes and predictive factors

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) remains a rare tumour, although its incidence is increasing. Surgical resection is the mainstay of treatment. Published data regarding prognostic factors and optimal patient selection for resection are scant. We sought to determine the clinicopathologic characteristics of resectable ICC and outcomes following surgical treatment.

METHODS

We reviewed prospectively collected clinical data including patient, pathologic and operative details. Survival and recurrence outcomes were analysed using Cox hazard models and the Kaplan-Meier method.

RESULTS

We identified 31 surgically treated patients. Their 3-year overall survival rate (OS) was 40.1%; median follow-up was 16.2 months (range: 0.2-86.9 months). R0 resection was associated with significantly improved OS compared with R1/R2 resection (3-year OS was 68.6% in R0 vs. 24.0% in R1/R2; P= 0.042). The postoperative complication rate was 58.1%. Two patients died of postoperative liver failure within 30 days. Preoperative hypoalbuminaemia was significantly associated with worse survival.

CONCLUSIONS

Surgical therapy for ICC is associated with longterm survival in the subset of nutritionally replete patients in whom an R0 resection can be achieved. Surgical mortality is significant in patients undergoing extended resection. The margin involvement rate is high and surgeons should consider the infiltrative nature of the disease in operative planning.

Cholangiocarcinoma: new insights into disease pathogenesis and biology

Cholangiocarcinomas are rare malignant tumors whose incidence is increasing worldwide. Risk factors for this malignancy include both infectious and non-infectious diseases characterized by chronic inflammation of the bile duct epithelia. Diagnosis of these cancers remains difficult because of the lack of sensitive diagnostic tests. The prognosis is poor probably because of the lack of effective treatments for unresectable cancer.

AJCC 7th edition of TNM staging accurately discriminates outcomes of patients with resectable intrahepatic cholangiocarcinoma: By the AFC-IHCC-2009 study group

BACKGROUND

This year, the 7th edition of the AJCC staging manual has for the first time attributed a unique pTNM staging to intrahepatic cholangiocarcinoma (IHCC) that is intended to replace the 2 Western and ideally also the 2 Eastern systems currently in use. This proposal, which has not yet been validated, was tested in the current study.

METHODS

Among 522 patients operated on with curative intent for an IHCC between 1994 and 2008 in tertiary hepatobiliary centers, those with mass-forming-type IHCCs, an R0 resection, and accurate pathological node staging were retained for evaluation. The distribution of these patients and their actuarial survival in the new TNM stages (as well as in the 4 previous ones) were compared.

RESULTS

Only 163 patients fulfilled the inclusion criteria, mainly because of the lack of routine lymphadenectomy, but patients and tumors characteristics of this population were representative. These patients were evenly distributed between AJCC 7th edition stages (stage I, 28%; stage II, 32%; stage III, 35%), which was not the case for the other systems. With an average follow-up of 34 months in survivors, the AJCC 7th edition was more discriminating than the others in predicting survival (median for stage I not reached; for stage II, 53 months, P = .01; for stage III, 16 months, P < .0001). Survival of these patients according to the 2 Japanese classifications was identical to that anticipated.

CONCLUSIONS

The 7th edition is clinically relevant and may be applicable worldwide, provided routine lymphadenectomy at the time of surgery for IHCC becomes the standard of care.

Intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is a primary cancer of the bile ducts, arising from malignant transformation of the epithelial cells that line the biliary apparatus. ICC is relatively uncommon, but its incidence is on the increase. ICC is frequently discovered as an incidental, indeterminate liver mass. Surgical resection of ICC represents the only potentially curative therapeutic option. The role of routine hilar lymphadenectomy is controversial, but should be considered to optimize staging. Although adjuvant chemotherapy and radiotherapy is probably not supported by current data, each should strongly be considered in patients with lymph node metastasis or an R1 resection. For those patients with inoperable disease, locoregional therapy with transarterial chemoembolization can be considered.

Staging of intrahepatic cholangiocarcinoma

PURPOSE OF REVIEW

Staging of intrahepatic cholangiocarcinoma (ICC) has historically mirrored that for hepatocellular carcinoma, largely due to the fact that ICC has been an uncommon disease. This review summarizes recent developments related to prognostication in ICC that have allowed the development of a distinct Western staging system for this disease.

RECENT FINDINGS

A large cancer registry study focused on identification of prognostic factors after resection of ICC with the aim of developing a distinct staging system for ICC. On the basis of this analysis and corroborative data from smaller institutional series, the American Joint Committee on Cancer (AJCC) 7th edition staging manual includes a distinct staging system for ICC that focuses on multiple tumors, vascular invasion, and lymph node metastasis. This system is simpler than the AJCC 6th edition staging yet preserves prognostic discrimination; the new system is also significantly superior to the Japanese staging system. Some evidence suggests that the number of lymph nodes involved by tumor may influence prognosis. Margin-negative resection is a major therapeutic determinant of outcome in ICC and should be pursued unless distant metastasis is present.

SUMMARY

For the first time, a distinct staging system for ICC has been adopted by the AJCC. Understanding of prognostic factors in ICC remains incomplete but is improving. This field is in evolution, and further refinements to the staging of ICC are likely as more data emerge on this increasingly common malignancy.

Cholangiocarcinoma: update and future perspectives

Cholangiocarcinoma is commonly considered a rare cancer. However, if we consider the hepato-biliary system a single entity, cancers of the gallbladder, intra-hepatic and extra-hepatic biliary tree altogether represent approximately 30% of the total with incidence rates close to that of hepatocellular carcinoma, which is the third most common cause of cancer-related death worldwide. In addition, cholangiocarcinoma is characterized by a very poor prognosis and virtually no response to chemotherapeutics; radical surgery, the only effective treatment, is not frequently applicable because late diagnosis. Biomarkers for screening programs and for follow-up of categories at risk are under investigation, however, currently none of the proposed markers has reached clinical application. For all these considerations, cancers of the biliary tree system should merit much more scientific attention also because a progressive increase in incidence and mortality for these cancers has been reported worldwide. This manuscript deals with the most recent advances in the epidemiology, biology and clinical presentation of cholangiocarcinoma.

Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990-2009

Several advances in diagnosis, treatment and palliation of cholangiocarcinoma (CC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. CC is a relatively rare tumor and the main risk factors are: chronic inflammation, genetic predisposition and congenital abnormalities of the biliary tree. While the incidence of intra-hepatic CC is increasing, the incidence of extra-hepatic CC is trending down. The only curative treatment for CC is surgical resection with negative margins. Liver transplantation has been proposed only for selected patients with hilar CC that cannot be resected who have no metastatic disease after a period of neoadjuvant chemo-radiation therapy. Magnetic resonance imaging/magnetic resonance cholangiopancreatography, positron emission tomography scan, endoscopic ultrasound and computed tomography scans are the most frequently used modalities for diagnosis and tumor staging. Adjuvant therapy, palliative chemotherapy and radiotherapy have been relatively ineffective for inoperable CC. For most of these patients biliary stenting provides effective palliation. Photodynamic therapy is an emerging palliative treatment that seems to provide pain relief, improve biliary patency and increase survival. The clinical utility of other emerging therapies such as transarterial chemoembolization, hepatic arterial chemoinfusion and high intensity intraductal ultrasound needs further study.

The prognosis and survival outcome of intrahepatic cholangiocarcinoma following surgical resection: association of lymph node metastasis and lymph node dissection with survival

BACKGROUND

Surgical resection has been shown to improve long-term survival for patients with intrahepatic cholangiocarcinoma (ICC). The benefit of lymph node dissection is still controversial. The aims of this study were to investigate the prognostic factors of ICC and to examine the impact of lymph node metastasis and extent of lymph node dissection on survival.

MATERIALS AND METHODS

A total of 64 patients with ICC were operated on with curative intent and resultant macroscopic curative resection (R0 and R1). The patients were classified according to the extent of the lymph node dissection. Clinicopathological characteristics and survival were reviewed retrospectively.

RESULTS

All patients underwent anatomical resection. The 5-year survival rates were 39.5%. Multivariate analysis revealed that lymph node metastasis (hazard ratio: 3.317) was an independent prognostic factors on survival. Recurrence occurred in 41 patients. Median disease-free survival time was 12.3 months. Tumor differentiation was an independent prognostic factor for disease-free survival (hazard ratio: 3.158). The extent of lymph node dissection did not affect the occurrence of complication. Regional+alpha lymph node dissection group demonstrated similar survival to those of lymph node sampling group, although significant high incidence of lymph node metastases was observed in the regional+alpha lymph node dissection group. The extent of lymph node dissection did not affect the survival in the patients without lymph node involvement.

CONCLUSIONS

The regional+alpha lymph node dissection enhanced the survival in the ICC patients with lymph node metastasis, and the exact nodal status could be confirmed by lymph node dissection in the pericholedochal lymph nodes.