1
|
Gkika E, Hawkins MA, Grosu AL, Brunner TB. The Evolving Role of Radiation Therapy in the Treatment of Biliary Tract Cancer. Front Oncol 2021; 10:604387. [PMID: 33381458 PMCID: PMC7768034 DOI: 10.3389/fonc.2020.604387] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/04/2020] [Indexed: 12/13/2022] Open
Abstract
Biliary tract cancers (BTC) are a disease entity comprising diverse epithelial tumors, which are categorized according to their anatomical location as intrahepatic (iCCA), perihilar (pCCA), distal (dCCA) cholangiocarcinomas, and gallbladder carcinomas (GBC), with distinct epidemiology, biology, and prognosis. Complete surgical resection is the mainstay in operable BTC as it is the only potentially curative treatment option. Nevertheless, even after curative (R0) resection, the 5-year survival rate ranges between 20 and 40% and the disease free survival rates (DFS) is approximately 48–65% after one year and 23–35% after three years without adjuvant treatment. Improvements in adjuvant chemotherapy have improved the DFS, but the role of adjuvant radiotherapy is unclear. On the other hand, more than 50% of the patients present with unresectable disease at the time of diagnosis, which limits the prognosis to a few months without treatment. Herein, we review the role of radiotherapy in the treatment of cholangiocarcinoma in the curative and palliative setting.
Collapse
Affiliation(s)
- Eleni Gkika
- Department of Radiation Oncology, University Medical Centre Freiburg, Freiburg, Germany
| | - Maria A Hawkins
- Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Medical Centre Freiburg, Freiburg, Germany
| | - Thomas B Brunner
- Department of Radiation Oncology, University of Magdeburg, Magdeburg, Germany
| |
Collapse
|
2
|
Ren B, Guo Q, Yang Y, Liu L, Wei S, Chen W, Tian Y. A meta-analysis of the efficacy of postoperative adjuvant radiotherapy versus no radiotherapy for extrahepatic cholangiocarcinoma and gallbladder carcinoma. Radiat Oncol 2020; 15:15. [PMID: 31941520 PMCID: PMC6964081 DOI: 10.1186/s13014-020-1459-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 01/05/2020] [Indexed: 12/13/2022] Open
Abstract
Objective The benefit of adjuvant radiotherapy (ART) for extrahepatic cholangiocarcinoma (EHCC) and gallbladder carcinoma (GBC) is unclear, with conflicting results from nonrandomized studies. We reported a meta-analysis to determine the impact of adjuvant radiotherapy on survival. Methods PubMed, EMBASE, Cochrane Library and CNKI databases were searched to identify clinical trials of postoperative ART versus no radiotherapy for EHCC and GBC. The obtained data were analyzed using RevMan 5.3 and Stata 14.0 statistical software. Differences between two groups were estimated by calculating the odds ratio (OR) and 95% confidence interval (CI). Results A total of 21 clinical trials involving 1465 EHCC and GBC patients were selected according to the inclusion and exclusion criteria and included in this meta-analysis. The meta-analysis showed the following: The 5-year overall survival (OS) rate was higher in the ART group than in the no radiotherapy group (OR = 0.63; 95% CI = 0.50–0.81, p = 0.0002). The 5-year OS rate was significantly higher for those with lymph node-positive disease (OR = 0.15; 95% CI 0.07–0.35; p < 0.00001) and margin-positive disease (OR = 0.40; 95% CI 0.19–0.85; p = 0.02) in the ART group than in the no radiotherapy group. ART had a tendency to bring benefit to the 5-year OS of patients with margin-negative disease but the difference was not statistically significant (OR = 0.57, 95% CI 0.30–1,07, p = 0.08). The local recurrence rate was significantly lower in the ART group than in the no radiotherapy group (OR = 0.54; 95% CI = 0.38–0.76, p = 0.0004), and there was no significant difference in the distant metastasis rate between the two groups (OR = 1.33; 95% CI = 0.95–1.87, p = 0.10). Conclusions A meta-analysis of the existing study results showed that compared with no radiotherapy, ART is an effective postoperative treatment for EHCC and GBC.
Collapse
Affiliation(s)
- Bixin Ren
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China.,Suzhou Key Laboratory for Radiation Oncology, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Qi Guo
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China.,Suzhou Key Laboratory for Radiation Oncology, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Yongqiang Yang
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China.,Suzhou Key Laboratory for Radiation Oncology, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Lei Liu
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China.,Suzhou Key Laboratory for Radiation Oncology, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Shaohua Wei
- Department of General Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Wei Chen
- Department of General Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Ye Tian
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China. .,Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China. .,Suzhou Key Laboratory for Radiation Oncology, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China.
| |
Collapse
|
3
|
Kang MJ, Jang JY, Chang J, Shin YC, Lee D, Kim HB, Kim SW. Actual Long-Term Survival Outcome of 403 Consecutive Patients with Hilar Cholangiocarcinoma. World J Surg 2017; 40:2451-9. [PMID: 27206402 DOI: 10.1007/s00268-016-3551-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite aggressive surgical resection, prognosis of patients with hilar cholangiocarcinoma is still unsatisfactory. There were limited data about actual long-term survival outcome. This study was designed to explore actual long-term survival outcome of hilar cholangiocarcinoma after surgical treatment, and to investigate the characteristics of patients with actual long-term survival. METHODS The study cohort consisted of 403 consecutive patients with at least 5-year follow-up after surgical treatment for hilar cholangiocarcinoma at Seoul National University Hospital between 1991 and 2010. Prognostic factors were analyzed with Cox proportional hazard models, and the effect of adjuvant treatment was evaluated by propensity score analysis. RESULTS Of all patients, R0 resection rate was 41.2 and 63.8 % among intended curative resection. Adjuvant therapy was performed in 48.8 % after curative surgery. Actual 5-year overall survival (OS) rate was 18.9, and 30.1 % after R0 resection. Actual 5-year disease-free survival rate was 25.8 % after resection. Adjuvant treatment improved prognosis in patients with positive metastatic lymph nodes (median OS 21.9 vs. 11.5 months, p = 0.003). Overall recurrence rate was 55.0 %, and distant metastasis (39.7 %) was more frequent than loco-regional recurrence (20.8 %). Lymph node metastasis (p = 0.021) and poor histologic grade (p < 0.001) were independent prognostic factors after curative resection. Patients who survived more than 5 years had less lymph node metastasis (p = 0.025), poor histologic differentiation (p = 0.010), R2 resection (p = 0.040), and recurrence (p < 0.001). CONCLUSION Actual 5-year OS rate after R0 resection of hilar cholangiocarcinoma is 30.1 %. Adjuvant treatment could be beneficial in patients with lymph node metastasis.
Collapse
Affiliation(s)
- Mee Joo Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Jihoon Chang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Yong Chan Shin
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Dooho Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Hong Beom Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Sun-Whe Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea.
| |
Collapse
|
4
|
Leng KM, Liu YP, Wang ZD, Zhong XY, Liao GQ, Kang PC, Cui YF, Jiang XM. Results of adjuvant radiation therapy for locoregional perihilar cholangiocarcinoma after curative intent resection. Onco Targets Ther 2017; 10:2257-2266. [PMID: 28461760 PMCID: PMC5408944 DOI: 10.2147/ott.s131873] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Purpose This study sought to define the role of adjuvant radiation therapy (RT) for patients with curative intent resection of perihilar cholangiocarcinoma (pCCA). Patients and methods By using the Surveillance, Epidemiology and End Results (SEER) registry, 1,917 patients with non-metastatic pCCA who underwent surgical resection from 1988 to 2009 were included in this study. Propensity score methods were used to compare the survival outcomes of patients treated with and without adjuvant RT after controlling for selection bias. Results Of the 1,917 patients, 762 (39.7%) received adjuvant RT. In the unmatched population, median overall survival (OS) for patients receiving adjuvant RT compared with those undergoing surgery alone was 23 versus 22 months (P=0.651). Patients who received adjuvant RT were younger (65 vs 68 years, P<0.001), had more regional diseases (86.0% vs 76.7%, P<0.001), and had more positive lymph nodes (43.8% vs 32.2%, P<0.001). In the matched population, adjuvant RT did not show better OS (22 vs 23 months, P=0.978) or cancer-specific survival (CSS) (17 vs 18 months, P=0.554). Conclusion Adjuvant RT is not associated with improved survival of patients with resected pCCA. These data suggest that adjuvant RT should not be routinely used to treat patients with pCCA outside research trials. Ideally, prospective randomized trials should be performed to verify the conclusion of this study.
Collapse
Affiliation(s)
- Kai-Ming Leng
- Department of Hepatopan-creatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Yue-Ping Liu
- Department of Hepatopan-creatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Zhi-Dong Wang
- Department of Hepatopan-creatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Xiang-Yu Zhong
- Department of Hepatopan-creatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Guan-Qun Liao
- Department of General Surgery, Foshan Hospital Affiliated to Southern Medical University, Foshan, People's Republic of China
| | - Peng-Cheng Kang
- Department of Hepatopan-creatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Yun-Fu Cui
- Department of Hepatopan-creatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Xing-Ming Jiang
- Department of Hepatopan-creatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin
| |
Collapse
|
5
|
Burkhart RA, Laheru DA, Herman JM, Pawlik TM. Multidisciplinary management and the future of treatment in cholangiocarcinoma. Expert Opin Orphan Drugs 2016. [DOI: 10.1517/21678707.2016.1130618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
6
|
Esnaola NF, Meyer JE, Karachristos A, Maranki JL, Camp ER, Denlinger CS. Evaluation and management of intrahepatic and extrahepatic cholangiocarcinoma. Cancer 2016; 122:1349-69. [PMID: 26799932 DOI: 10.1002/cncr.29692] [Citation(s) in RCA: 175] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/18/2015] [Accepted: 08/19/2015] [Indexed: 12/13/2022]
Abstract
Cholangiocarcinomas are rare biliary tract tumors that are often challenging to diagnose and treat. Cholangiocarcinomas are generally categorized as intrahepatic or extrahepatic depending on their anatomic location. The majority of patients with cholangiocarcinoma do not have any of the known or suspected risk factors and present with advanced disease. The optimal evaluation and management of patients with cholangiocarcinoma requires thoughtful integration of clinical information, imaging studies, cytology and/or histology, as well as prompt multidisciplinary evaluation. The current review focuses on recent advances in the diagnosis and treatment of patients with cholangiocarcinoma and, in particular, on the role of endoscopy, surgery, transplantation, radiotherapy, systemic therapy, and liver-directed therapies in the curative or palliative treatment of these individuals. Cancer 2016;122:1349-1369. © 2016 American Cancer Society.
Collapse
Affiliation(s)
- Nestor F Esnaola
- Department of Surgery, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
| | - Joshua E Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
| | - Andreas Karachristos
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Jennifer L Maranki
- Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - E Ramsay Camp
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Crystal S Denlinger
- Department of Hematology/Oncology, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
| |
Collapse
|
7
|
Mattiucci GC, Autorino R, D’Agostino GR, Deodato F, Macchia G, Perri V, Tringali A, Morganti AG, Mutignani M, Valentini V. Chemoradiation and brachytherapy in extrahepatic bile duct carcinoma. Crit Rev Oncol Hematol 2014; 90:58-67. [DOI: 10.1016/j.critrevonc.2013.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 09/25/2013] [Accepted: 10/28/2013] [Indexed: 12/19/2022] Open
|
8
|
Valero V, Cosgrove D, Herman JM, Pawlik TM. Management of perihilar cholangiocarcinoma in the era of multimodal therapy. Expert Rev Gastroenterol Hepatol 2012; 6:481-95. [PMID: 22928900 PMCID: PMC3538366 DOI: 10.1586/egh.12.20] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Perihilar cholangiocarcinoma (CCA) is the second most common primary malignant tumor of the liver. In the USA, there are approximately 3000 cases of CCA diagnosed annually, with approximately 50-70% of these tumors arising at the hilar plate of the biliary tree. Risk factors include advanced age, male gender, primary sclerosing cholangitis, choledochal cysts, cholelithiasis, parasitic infection, inflammatory bowel disease, cirrhosis and chronic pancreatitis. Patients typically present with jaundice, abdominal pain, pruritus and weight loss. The mainstays of treatment include surgery, chemotherapy, radiation therapy and photodynamic therapy. Specific preoperative interventions for patients with perihilar CCA include endoscopic retrograde cholangiopancreatography, percutanteous transhepatic cholangiography and portal vein embolization. Surgical resection offers the only chance for curative therapy in perihilar CCA. R0 resection is of utmost importance and has been linked to improved survival. Major hepatic resection is needed to achieve both longitudinal and radial margins negative for tumor. Fractionated stereotactic body radiotherapy has shown promising results in CCA. Perihilar CCA typically presents with advanced disease, and many patients receive systemic therapy; however, the response to current regimens is limited. Orthotopic liver transplantation offers complete resection of locally advanced tumors in select patient groups.
Collapse
Affiliation(s)
- Vicente Valero
- Department of Surgery, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, Harvey 611, 600 N Wolfe Street, Baltimore, MD 21287, USA
| | - David Cosgrove
- Division of Surgical Oncology, Department of Medical Oncology, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph M Herman
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, Harvey 611, 600 N Wolfe Street, Baltimore, MD 21287, USA
| |
Collapse
|
9
|
Horgan AM, Amir E, Walter T, Knox JJ. Adjuvant therapy in the treatment of biliary tract cancer: a systematic review and meta-analysis. J Clin Oncol 2012; 30:1934-40. [PMID: 22529261 DOI: 10.1200/jco.2011.40.5381] [Citation(s) in RCA: 468] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE The benefit of adjuvant therapy (AT) for biliary tract cancer (BTC) is unclear, with conflicting results from nonrandomized studies. We report a systematic review and meta-analysis to determine the impact of AT on survival. METHODS Studies published between 1960 and November 2010, which evaluated adjuvant chemotherapy (CT), radiotherapy (RT), or both (CRT) compared with curative-intent surgery alone for resected BTC were included. Only tumors of the gallbladder and bile ducts were assessed. Published data were extracted and computed into odds ratios (ORs) for death at 5 years. Subgroup analyses of benefit based on lymph node (LN) or resection margin positivity (R1) were prespecified. Data were weighted by generic inverse variance and pooled using random-effect modeling. RESULTS Twenty studies involving 6,712 patients were analyzed. There was a nonsignificant improvement in overall survival with any AT compared with surgery alone (pooled OR, 0.74; P = .06). There was no difference between gallbladder and bile duct tumors (P = .68). The association was significant when the two registry analyses were excluded. Those receiving CT or CRT derived statistically greater benefit than RT alone (OR, 0.39, 0.61, and 0.98, respectively; P = .02). The greatest benefit for AT was in those with LN-positive disease (OR, 0.49; P = .004) and R1 disease (OR, 0.36; P = .002). CONCLUSION This analysis supports AT for BTC. Prospective randomized trials are needed to provide better rationale for this commonly used strategy. On the basis of our data, such trials could involve two active comparators rather than a no-treatment arm among patients with LN-positive or R1 disease.
Collapse
Affiliation(s)
- Anne M Horgan
- Princess Margaret Hospital, Toronto, Ontario, Canada
| | | | | | | |
Collapse
|
10
|
Akamatsu N, Sugawara Y, Hashimoto D. Surgical strategy for bile duct cancer: Advances and current limitations. World J Clin Oncol 2011; 2:94-107. [PMID: 21603318 PMCID: PMC3095469 DOI: 10.5306/wjco.v2.i2.94] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Revised: 10/12/2010] [Accepted: 10/19/2010] [Indexed: 02/06/2023] Open
Abstract
The aim of this review is to describe recent advances and topics in the surgical management of bile duct cancer. Radical resection with a microscopically negative margin (R0) is the only way to cure cholangiocarcinoma and is associated with marked survival advantages compared to margin-positive resections. Complete resection of the tumor is the surgeon’s ultimate aim, and several advances in the surgical treatment for bile duct cancer have been made within the last two decades. Multidetector row computed tomography has emerged as an indispensable diagnostic modality for the precise preoperative evaluation of bile duct cancer, in terms of both longitudinal and vertical tumor invasion. Many meticulous operative procedures have been established, especially extended hepatectomy for hilar cholangiocarcinoma, to achieve a negative resection margin, which is the only prognostic factor under the control of the surgeon. A complete caudate lobectomy and resection of the inferior part of Couinaud’s segment IV coupled with right or left hemihepatectomy has become the standard surgical procedure for hilar cholangiocarcinoma, and pylorus-preserving pancreaticoduodenectomy is the first choice for distal bile duct cancer. Limited resection for middle bile duct cancer is indicated for only strictly selected cases. Preoperative treatments including biliary drainage and portal vein embolization are also indicated for only selected patients, especially jaundiced patients anticipating major hepatectomy. Liver transplantation seems ideal for complete resection of bile duct cancer, but the high recurrence rate and decreased patient survival after liver transplant preclude it from being considered standard treatment. Adjuvant chemotherapy and radiotherapy have a potentially crucial role in prolonging survival and controlling local recurrence, but no definite regimen has been established to date. Further evidence is needed to fully define the role of liver transplantation and adjuvant chemo-radiotherapy.
Collapse
Affiliation(s)
- Nobuhisa Akamatsu
- Nobuhisa Akamatsu, Daijo Hashimoto, Department of Hepato-Biliary-Pancreatic Surgery, Saitama Medical Center, Saitama Medical University, 1981 Tsujido-cho, Kamoda, Kawagoe, Saitama 350-8550, Japan
| | | | | |
Collapse
|
11
|
Fuller CD, Wang SJ, Choi M, Czito BG, Cornell J, Welzel TM, McGlynn KA, Luh JY, Thomas CR. Multimodality therapy for locoregional extrahepatic cholangiocarcinoma: a population-based analysis. Cancer 2009; 115:5175-83. [PMID: 19637356 DOI: 10.1002/cncr.24572] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although surgical resection is the mainstay of treatment for extrahepatic cholangiocarcinoma, the majority of patients present with advanced disease. Due in part to numeric rarity, the optimum role of radiotherapy (RT) for extrahepatic cholangiocarcinoma, as well as its relative benefit, is an area of debate. The specific aim of this series was to estimate survival for extrahepatic cholangiocarcinoma patients receiving surgery and adjuvant RT using a robust population-based data set. METHODS Data were extracted from the Surveillance, Epidemiology, and End Results (SEER) limited-use data set for selected extrahepatic cholangiocarcinoma cases. Lognormal multivariate survival analysis was implemented to estimate survival for patients for treatment cohorts based on extent of surgical intervention and RT. RESULTS Parametric estimated median survival for patients receiving total/radical resection + RT was 26 months; it was 25 months for total/radical resection alone, 25 months for subtotal/debulking resection + RT, 21 months for subtotal/debulking resection, 12 months for RT alone, and 9 months for those not receiving surgery or RT. Parametric multivariate analysis revealed age, American Joint Committee on Cancer Stage, grade, and surgical/radiation regimen as statistically significant covariates with survival. Surgery alone and adjuvant RT cohorts demonstrated evidence of improved survival compared with no treatment; comparatively, RT alone was associated with survival decrement. Early improvement in survival in adjuvant cohorts was not observed at later time points. CONCLUSIONS Survival estimates using SEER data suggest an early survival advantage for adjuvant RT for patients with locoregional extrahepatic cholangiocarcinoma. Although future prospective series are needed to confirm these observations, SEER data represent the largest domestic population-based extrahepatic cholangiocarcinoma cohort, and may provide useful baseline survival estimates for future studies.
Collapse
Affiliation(s)
- Clifton D Fuller
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Gwak HK, Kim WC, Kim HJ, Park JH. Extrahepatic bile duct cancers: surgery alone versus surgery plus postoperative radiation therapy. Int J Radiat Oncol Biol Phys 2009; 78:194-8. [PMID: 19910130 DOI: 10.1016/j.ijrobp.2009.07.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 06/30/2009] [Accepted: 07/07/2009] [Indexed: 12/20/2022]
Abstract
PURPOSE The goal of this study was to determine the role of radiotherapy after curative-intent surgery in the management of extrahepatic bile duct (EHBD) cancers. METHODS AND MATERIALS From 1997 through 2005, 78 patients with EHBD cancer were surgically staged. These patients were stratified by the absence of adjuvant radiation (n = 47, group I) versus radiation (n = 31, group II) after resection. Pathology examination showed 27 cases in group I and 20 cases in group II had microscopically positive resection margins. The patients in group II received 45 to 54 Gy of external beam radiotherapy. The primary endpoints of this study were overall survival, disease-free survival, and prognostic factors. RESULTS There were no differences between the 5-year overall survival rates for the two groups (11.6% in group I vs. 21% in group II). However, the patients with microscopically positive resection margins who received adjuvant radiation therapy had higher median disease-free survival rates than those who underwent surgery alone (21 months vs. 10 months, respectively, p = 0.042). Decreasing local failure was found in patients who received postoperative radiotherapy (61.7% in group I and 35.6% in group II, p = 0.02). Outcomes of the patients with a positive resection margin and lymph node metastasis who received postoperative radiation therapy were doubled compared to those of patients without adjuvant radiotherapy. Resection margin status, lymph node metastasis, and pathology differentiation were significant prognostic factors in disease-free survival. CONCLUSIONS Adjuvant radiotherapy might be useful in patients with EHBD cancer, especially for those patients with microscopic residual tumors and positive lymph nodes after resection for increasing local control.
Collapse
Affiliation(s)
- Hee Keun Gwak
- Department of Radiation Oncology, Inha University College of Medicine, Incheon, South Korea
| | | | | | | |
Collapse
|
13
|
Kohn GP, Martinie JB. Laparoscopic robot-assisted completion cholecystectomy: a report of three cases. Int J Med Robot 2009; 5:406-9. [DOI: 10.1002/rcs.270] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
14
|
Anderson C, Kim R. Adjuvant therapy for resected extrahepatic cholangiocarcinoma: a review of the literature and future directions. Cancer Treat Rev 2009; 35:322-7. [PMID: 19147294 DOI: 10.1016/j.ctrv.2008.11.009] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Revised: 10/01/2008] [Accepted: 11/27/2008] [Indexed: 12/15/2022]
Abstract
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.
Collapse
Affiliation(s)
- Carryn Anderson
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA.
| | | |
Collapse
|
15
|
Cleary SP, Dawson LA, Knox JJ, Gallinger S. Cancer of the gallbladder and extrahepatic bile ducts. Curr Probl Surg 2007; 44:396-482. [PMID: 17693325 DOI: 10.1067/j.cpsurg.2007.04.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Sean P Cleary
- Department of Surgery, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | | | | | | |
Collapse
|
16
|
Heron DE, Stein DE, Eschelman DJ, Topham AK, Waterman FM, Rosato EL, Alden M, Anne PR. Cholangiocarcinoma: the impact of tumor location and treatment strategy on outcome. Am J Clin Oncol 2003; 26:422-8. [PMID: 12902899 DOI: 10.1097/01.coc.0000026833.73428.1f] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The purpose of this study was to evaluate how the outcome of patients with extrahepatic cholangiocarcinoma (EHBC) may have been influenced by tumor location and treatment selection. The primary endpoint of this study is overall survival (OS). Between January 1983 and December 1997, 221 patients with biliary tumors were evaluated at Thomas Jefferson University Hospital. Of these, 118 fit the inclusion criteria for this study. The extent of disease was assessed by computed tomography, percutaneous transhepatic cholangiography or endoscopic retrograde cholangiopancreatography, magnetic resonance imaging, and ultrasonography. All patients had histologic confirmation of malignancy. Roux-en Y, hepaticojejunostomy, or choledochojejunostomy followed surgical resection of the primary tumor. Palliative measure (PS) included biliary catheter placement without brachytherapy or external beam irradiation (RT). RT was delivered via high-energy photons. Intraluminal brachytherapy was performed via percutaneous biliary catheterization with iridium-192 ribbon sources. Chemotherapy consisted of either intravenous 5-fluorouracil alone or in combination with doxorubicin, mitomycin C, or paclitaxel. PS consisted of metal bile duct stent placement. Median follow-up time for the entire group was 102 months and 43 months for patients who were still alive at the conclusion of the study period. Patients with proximal tumors underwent resection (n = 5), surgery and RT (n = 23), RT only (n = 31), chemotherapy only (n = 6), or PS (n = 12). Patients with distal tumors were treated with surgical resection (n = 17) or a combination of surgery and RT (n = 13), RT only (n = 6), or PS (n = 4). Median survival time (MST) for all 118 patients was 22 months. The MST for patients with distal tumors was 47 months versus 17 months for those with proximal tumors. The MST has not been reached for patients with distal EHBC treated with surgical resection and postoperative RT, whereas the median survival for those treated with surgery alone is 62.5 months. However, 4 of 17 of these patients had in situ carcinoma. Six patients had distal tumors treated with RT only with a MST of 6 months. Patients with proximal tumors treated with surgery and RT had a superior OS at 5 years compared to patients treated with RT alone (24 vs. 13 months; p = 0.007). There was an improved OS in patients with proximal tumors treated with surgical resection and RT compared to surgery alone (p = 0.023). There is no discernable influence of chemotherapy on outcome in patients with proximal EHBC. The MST for patients treated with PS was 3.5 months. Surgery and postoperative RT appear to be better than either surgery or RT alone in patients with proximal EHBC. In patients with distal EHBC, the addition of resection and RT appears to offer an advantage, which is increasingly apparent with longer follow-up time. The prognosis remains dismal for patients treated with palliative intent.
Collapse
Affiliation(s)
- Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh, School of Medicine, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Kim S, Kim SW, Bang YJ, Heo DS, Ha SW. Role of postoperative radiotherapy in the management of extrahepatic bile duct cancer. Int J Radiat Oncol Biol Phys 2002; 54:414-9. [PMID: 12243816 DOI: 10.1016/s0360-3016(02)02952-8] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To analyze the outcome of postoperative radiotherapy (RT) or chemoradiation for patients with extrahepatic bile duct cancer who had undergone either curative or palliative surgery, and to identify the prognostic factors for these patients. METHODS AND MATERIALS Between March 1982 and December 1994, 91 patients with extrahepatic bile duct cancer underwent RT at the Department of Therapeutic Radiology, Seoul National University Hospital. Of these patients, 84 were included in this retrospective study. The male/female ratio was 3.7:1 (66 men and 18 women). The median age of the patients was 58 years (range 33-76). Gross total surgical resection was performed in 72 patients, with pathologically negative margins in 47 and microscopically positive margins in 25. Twelve patients underwent surgical exploration and biopsy or subtotal resection with palliative bypass procedures. All the patients received >40 Gy of external beam RT after surgery. Concurrent 5-fluorouracil was administered during external beam RT in 71 patients, and maintenance chemotherapy was performed in 61 patients after RT completion. The minimal follow-up of the survivors was 14 months, and the median follow-up period for all the patients was 23 months (range 2-75). RESULTS The overall 2- and 5-year survival rate was 52% and 31%, respectively. The 2- and 5-year disease-free survival rate was 48% and 26%, respectively. On univariate analysis using the Kaplan-Meier product limit method, the use of chemotherapy, performance status, N stage, size of residual tumor, stage, and tumor location were significant prognostic factors. However, on multivariate analysis using Cox's proportional hazard model, N stage (N0 vs. N1 and N2, p = 0.02) was the only significant prognostic factor. CONCLUSION Long-term survival can be expected in patients with extrahepatic bile duct cancer who undergo radical surgery and postoperative chemoradiation. Regional lymph node metastasis is a poor prognostic factor for these patients.
Collapse
Affiliation(s)
- Suzy Kim
- Department of Therapeutic Radiology, Seoul National University College of Medicine, Chongno-gu, Seoul, South Korea
| | | | | | | | | |
Collapse
|
18
|
Abstract
Investigation into the molecular and cellular biology of carcinogenesis continues to elucidate potential mechanisms for the initiation and progression of biliary tract cancer. The potential role of cell cycle regulators, such as Fas ligand, has been examined in the etiology of bile duct carcinoma. In addition, there is evidence for a possible link between chronic inflammation and malignant transformation through the relation between nitric oxide and DNA repair enzymes. Noninvasive imaging modalities, including helical computed tomography scanning, magnetic resonance cholangiopancreatography (MRCP) and positron emission tomography (PET) scanning, are gaining acceptance and may eventually supplant standard methods of evaluation. In addition, innovative tissue-sampling modalities including choledochoscopy are being developed. Several large series, Japanese and Western, continue to report improved 5-year survival rates after aggressive surgical resections of hilar cholangiocarcinoma. Although chemotherapeutic options remain limited in biliary tract carcinoma, radiation therapy may provide a benefit in local control in patients with microscopically positive margins. Photodynamic and multimodality therapy also may become important components of improving palliation for patients with advanced disease.
Collapse
Affiliation(s)
- J N Cormier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | | |
Collapse
|