Surgical resection of hilar cholangiocarcinoma: analysis of survival and postoperative complications

Parenchyma-Preserving Hepatectomy in Perihilar Cholangiocarcinoma: A Chance for Critical Patients?

Introduction

Surgery for perihilar cholangiocarcinoma (pCCA) is associated with high rates of postoperative morbidity and mortality. Extended liver resection (EXT) increases R0 resection rate and survival; however, patients with high perioperative risk are not suitable for extended resection. This study aimed to compare overall survival and surgical morbidity in patients with extended liver resection and parenchyma-preserving hepatectomy (PPH).

Methods

Between January 2010 and November 2020, 113 consecutive patients with pCCA underwent surgery at our institution. Eighty-two patients were resected in curative intent. Sixty-four patients received extended liver resection, and 18 patients PPH. Outcomes of resections were evaluated.

Results

There was no significant difference in overall survival in patients with PPH compared to extended liver resection (log-rank p = 0.286). Patients with PPH experienced lower rates of postoperative morbidity and mortality. There was no case of in-house mortality in PPH-resected patients compared to 10 cases (16%) in patients that received EXT (p = 0.073).

Conclusion

PPH shows similar overall survival with lower rates of postoperative morbidity and mortality. Our findings support the role of a PPH, in selected patients with pCCA, that are not suitable for extended resection due to increased perioperative risk.

Prognostic Significance of Sarcopenia and Systemic Inflammatory Markers in Biliary Tract Cancer: A Retrospective Cohort Study

PURPOSE

To evaluate the prognostic significance of sarcopenia and systemic inflammatory markers in patients with surgically resected biliary tract cancer (BTC).

METHODS

Between July 2010 and December 2022, 146 patients were recruited. Sarcopenia was assessed using the psoas muscle index. Preoperative inflammatory markers were used to calculate the prognostic nutritional index (PNI), neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio. Cox regression analysis was performed to determine prognostic factors for overall survival (OS) and recurrence-free survival (RFS). P < 0.05 was considered statistically significant.

RESULTS

Sixty-four patients had sarcopenia. Sarcopenia was associated with body mass index (< 22 kg/m2), lymph node metastasis, and low PNI (< 42). R1/R2 resection (P = 0.02), sarcopenia (P < 0.001), lymph node metastasis (P = 0.007), intrahepatic cholangiocarcinoma (P < 0.001), and low PNI (P = 0.01) were independent predictors of OS, while male sex (P = 0.04), R1/R2 resection (P < 0.001), lymph node metastasis (P = 0.005), intrahepatic cholangiocarcinoma (P < 0.001), tumor differentiation (other than well; P = 0.003), and low PNI (P = 0.03) were independent predictors of RFS. Patients were stratified into no sarcopenia and high PNI (≥ 42; A), sarcopenia or low PNI (B), and sarcopenia and low PNI (C) groups. Group C had worse OS than the other two groups (P < 0.001 and P = 0.02, respectively).

CONCLUSION

Sarcopenia is associated with the PNI. Sarcopenia and the PNI are independent prognostic factors among patients with resected BTC. Sarcopenia may have better prognostic value when combined with the PNI.

Cholangiocarcinoma: Recent Advances in Molecular Pathobiology and Therapeutic Approaches

Cholangiocarcinomas (CCA) pose a complex challenge in oncology due to diverse etiologies, necessitating tailored therapeutic approaches. This review discusses the risk factors, molecular pathology, and current therapeutic options for CCA and explores the emerging strategies encompassing targeted therapies, immunotherapy, novel compounds from natural sources, and modulation of gut microbiota. CCA are driven by an intricate landscape of genetic mutations, epigenetic dysregulation, and post-transcriptional modification, which differs based on geography (e.g., for liver fluke versus non-liver fluke-driven CCA) and exposure to environmental carcinogens (e.g., exposure to aristolochic acid). Liquid biopsy, including circulating cell-free DNA, is a potential diagnostic tool for CCA, which warrants further investigations. Currently, surgical resection is the primary curative treatment for CCA despite the technical challenges. Adjuvant chemotherapy, including cisplatin and gemcitabine, is standard for advanced, unresectable, or recurrent CCA. Second-line therapy options, such as FOLFOX (oxaliplatin and 5-FU), and the significance of radiation therapy in adjuvant, neoadjuvant, and palliative settings are also discussed. This review underscores the need for personalized therapies and demonstrates the shift towards precision medicine in CCA treatment. The development of targeted therapies, including FDA-approved drugs inhibiting FGFR2 gene fusions and IDH1 mutations, is of major research focus. Investigations into immune checkpoint inhibitors have also revealed potential clinical benefits, although improvements in survival remain elusive, especially across patient demographics. Novel compounds from natural sources exhibit anti-CCA activity, while microbiota dysbiosis emerges as a potential contributor to CCA progression, necessitating further exploration of their direct impact and mechanisms through in-depth research and clinical studies. In the future, extensive translational research efforts are imperative to bridge existing gaps and optimize therapeutic strategies to improve therapeutic outcomes for this complex malignancy.

Combined Serum ALBUMIN with Neutrophil-to-Lymphocyte Ratio Predicts the Prognosis of Biliary Tract Cancer after Curative Resection

BACKGROUND

The mainstay treatment of biliary tract cancer is complete tumor resection. Prior to surgery, risk stratification may help to predict and plan treatment approaches. In this study, we investigated the possibility of combining serum albumin concentrations and neutrophil-to-lymphocyte ratios (NLR) to create a score as ANS to predict the prognoses of biliary tract cancer before surgery.

METHODS

This study retrospectively collected serum albumin concentration, neutrophil, and lymphocyte data measured in biliary tract cancer patients slated to receive complete tumor resections within two weeks before surgery. From January 2013 to December 2019, 268 biliary tract cancer patients who had received tumor resections at our hospital were categorized into 3 ANS groups: ANS = 0 (high albumin and low NLR), ANS = 1 (low albumin or high NLR), and ANS = 2 (low albumin and high NLR).

RESULTS

Five-year survival rates were 70.1%, 47.6%, and 30.8% in the ANS = 0, 1, and 2 groups, respectively. The median overall survival time for the ANS = 0 group could not be determined by the end of the study, while those for ANS = 1 and ANS = 2 groups were 54.90 months and 16.62 months, respectively. The results of our multivariate analysis revealed that ANS could be used as an independent predictor of overall and recurrent-free survival. A high ANS was also correlated with other poor prognostic factors.

CONCLUSIONS

The ANS devised for this study can be used to predict postoperative survival in patients with BTC and to guide treatment strategies.

A meta-analysis of prognostic factors for early recurrence in perihilar cholangiocarcinoma after curative-intent resection

BACKGROUND

Perihilar cholangiocarcinoma (pCCA) is a type of cancer that has a high rate of recurrence after curative-intent surgery, with about half of all recurrences occurring within the first year. The primary aim of this study was to identify prognostic factors (PFs) for early recurrence (ER, within 12 months) after surgery.

METHODS

Systematic searching was conducted from database inception to September 28th, 2022, with duplicate independent review and data extraction. Data on eight predefined PFs were collected, and meta-analysis was performed on PFs for ER, summarized using forest plots.

RESULTS

The study enrolled 11 studies comprising 2877 patients. In the risk-of-bias assessment, seven studies were rated as low risk and four as moderate risk. More than 34.3% (95% confidence interval [CI], 26.1-42.5%) of the patients experienced ER after curative-intent pCCA resection. Of the PFs, vascular invasion (HR, 2.41; 95% CI, 1.47-3.95; OR, 1.60; 95% CI, 1.17-2.18), lymph node metastases (HR, 2.54; 95% CI, 1.92-3.37; OR, 4.26; 95% CI, 2.40-7.57), and R1 resection (HR, 3.27; 95% CI, 1.81-5.92; OR, 2.40; 95% CI, 1.36-4.22) were associated with an increased hazard for ER. The combined OR values also showed that tumor size, poor tumor differentiation, and perineural invasion were linked to an elevated risk of ER, but all of them had apparent heterogeneity.

CONCLUSION

These findings from the review could be used to plan surveillance of ER and guide post-operative individualized management in pCCA. Furthermore, prospective studies are needed to explore more prognostic factors for ER of pCCA.

Benchmarks and Geographic Differences in Gallbladder Cancer Surgery: An International Multicenter Study

BACKGROUND

High-quality surgery plays a central role in the delivery of excellent oncologic care. Benchmark values indicate the best achievable results. We aimed to define benchmark values for gallbladder cancer (GBC) surgery across an international population.

PATIENTS AND METHODS

This study included consecutive patients with GBC who underwent curative-intent surgery during 2000-2021 at 13 centers, across seven countries and four continents. Patients operated on at high-volume centers without the need for vascular and/or bile duct reconstruction and without significant comorbidities were chosen as the benchmark group.

RESULTS

Of 906 patients who underwent curative-intent GBC surgery during the study period, 245 (27%) were included in the benchmark group. These were predominantly women (n = 174, 71%) and had a median age of 64 years (interquartile range 57-70 years). In the benchmark group, 50 patients (20%) experienced complications within 90 days after surgery, with 20 patients (8%) developing major complications (Clavien-Dindo grade ≥ IIIa). Median length of postoperative hospital stay was 6 days (interquartile range 4-8 days). Benchmark values included ≥ 4 lymph nodes retrieved, estimated intraoperative blood loss ≤ 350 mL, perioperative blood transfusion rate ≤ 13%, operative time ≤ 332 min, length of hospital stay ≤ 8 days, R1 margin rate ≤ 7%, complication rate ≤ 22%, and rate of grade ≥ IIIa complications ≤ 11%.

CONCLUSIONS

Surgery for GBC remains associated with significant morbidity. The availability of benchmark values may facilitate comparisons in future analyses among GBC patients, GBC surgical approaches, and centers performing GBC surgery.

Percutaneous transhepatic biliary drainage for biliary obstruction in perihilar cholangiocarcinoma: a 10-year analysis of safety and outcomes using the CCI index

PURPOSE

To evaluate percutaneous transhepatic biliary drainage (PTBD) safety and efficacy in patients with perihilar cholangiocarcinoma (PCCA).

METHODS

This retrospective observational study included patients with PCCA and obstructive cholestasis referred for a PTBD in our institution between 2010 and 2020. Technical and clinical success rates and major complication and mortality rates one month after PTBD were used as main variables. Patients were divided and analyzed into two groups: > 30 and < 30 Comprehensive Complication Index (CCI). We also evaluated post-surgical outcomes in patients undergoing surgery.

RESULTS

Out of 223 patients, 57 were included. Technical success rate was 87.7%. Clinical success at 1 week was 83.6%, before surgery 68.2%, 80.0% at 2 weeks and 86.7% at 4 weeks. Mean total bilirubin (TBIL) values were 15.1 mg/dL (baseline), 8.1 mg/dL one week after PTBD), 6.1 mg/dL (2 weeks) and 2.1 mg/dL (4 weeks). Major complication rate was 21.1%. Three patients died (5.3%). Risk factors for major complications after the statistical analysis were: Bismuth classification (p = 0.01), tumor resectability (p = 0.04), PTBD clinical success (p = 0.04), TBIL 2 weeks after PTBD (p = 0.04), a second PTBD (p = 0.01), total PTBDs (p = 0.01) and duration of drainage (p = 0.03). Major postoperative complication rate in patients who underwent surgery was 59.3%, with a median CCI of 26.2.

CONCLUSION

PTBD is safe and effective in the management of biliary obstruction caused by PCCA. Bismuth classification, locally advanced tumors, and failure to achieve clinical success in the first PTBD are factors related to major complications. Our sample reported a high major postoperative complication rate, although with an acceptable median CCI.

Abdominal aortic calcification volume (AACV) is a predictive factor for postoperative complications associated with biliary tract cancer

PURPOSE

Curative surgical treatment of biliary tract cancer is highly invasive and involves postoperative complications. Abdominal aortic calcification is a parameter that is reportedly linked to systemic arteriosclerosis. We measured the abdominal aortic calcification volume (AACV), assessed the correlation between AACV and postoperative complications, and evaluated the clinical utility of AACV.

METHODS

We retrospectively evaluated 97 patients (ampullary carcinoma, n = 21; distal bile duct cancer, n = 43; hilar bile duct cancer, n = 33). We assessed the calcification volume of the abdominal aorta from the renal artery ramification to the common iliac artery bifurcation. The correlation between AACV, clinical factors, and postoperative complications was evaluated.

RESULTS

The average AACV was 5.02 cm³, and the median AACV was 3.74 (range 0-27.4) cm³. The AACV was significantly related to age (P = 0.009), Brinkman index (P = 0.007), and history of cardiovascular disease (P = 0.015). The AACV was strongly correlated with postoperative complications (P < 0.001) and Clavien-Dindo grade > III postoperative complications (P < 0.001). The AACV was also correlated with pancreatic fistula in pancreatectomy cases (P < 0.001). A multivariate analysis revealed that the AACV was an independent predictor of postoperative complications.

CONCLUSION

The AACV was significantly associated with postoperative complications. The AACV could be used for the preoperative assessment of surgical risk.

Prevalence and Risk Factors of Opisthorchis viverrini Infection in Sakon Nakhon Province, Thailand

Opisthorchiasis is a parasitic infection caused by the liver fluke Opisthorchis viverrini. This parasite is widely distributed and well documented in Thailand, Lao PDR, Southern Vietnam, Cambodia, and Myanmar. However, its prevalence is a major problem in these countries. Thus, the aim of this study was to determine the prevalence and risk factors of O. viverrini infection from 2017 to 2020 in Sakon Nakhon province, Thailand. Questionnaires were used to interview 320 participants (160 cases and 160 controls) in a random selection of 18 districts across Sakon Nakhon province. Univariate logistic regression was used to identify the factors associated with O. viverrini infection. The overall prevalence levels of O. viverrini infection in Sakon Nakhon province for 2018, 2019, and 2020 were 3.60%, 5.21%, and 7.01%, respectively. Raw fish consumption was a positive risk factor for its infection in endemic areas. Factors associated with O. viverrini infection were the habit of consuming unsafely prepared fish (OR = 6.33, 95%CI = 0.32–0.59), the medical history of O. viverrini examination (OR = 8.93, 95%CI = 5.15–15.47), a history of O. viverrini infection (OR = 3.64, 95%CI = 1.17–1.44), and a history of taking praziquantel (OR = 3.64, 95%CI = 1.17–1.44). These results identified gaps in the epidemiological knowledge of O. viverrini in this region that need addressing to identify and develop innovative methods for prevention, control, and support efforts to permanently overcome O. viverrini infection in endemic regions.

Clinical Outcomes of Inside Stents and Conventional Plastic Stents as Bridge-to-Surgery Options for Malignant Hilar Biliary Obstruction

BACKGROUND

The appropriate method of preoperative endoscopic biliary drainage (EBD) for cholangiocarcinoma with hilar biliary obstruction remains controversial. The inside-stent technique is a method of placing plastic stents entirely inside the bile duct. Several studies of patients with unresectable stage have reported longer stent patency compared with conventional endoscopic biliary stenting (EBS). Inside-stent techniques have been introduced as a bridge-to-surgery option and as an alternative to conventional EBS.

AIMS

We aimed to evaluate the clinical outcomes of inside stent use and conventional EBS.

METHODS

During this retrospective multicenter study, we reviewed consecutive patients with cholangiocarcinoma who underwent radical surgery after conventional EBS or inside-stent insertion. Adverse event (AE) rates after EBD and post-surgical AEs were compared. A multivariable analysis was performed to identify factors affecting cholangitis after EBD.

RESULTS

Conventional EBS and inside-stent procedures were performed for 56 and 73 patients, respectively. Patient backgrounds were similar between groups, except for percutaneous transhepatic portal vein embolization. The waiting time before surgery was similar between groups (28.5 days vs. 30 days). There were no significant differences in the cholangitis rate (21.4% vs. 26.0%; P = 0.68) and all AEs (25.0% vs. 30.1%; P = 0.56) between groups. The post-surgical AE rate was similar between the groups. The multivariable analysis found that preprocedural cholangitis was a risk factor for cholangitis after EBD (odds ratio: 5.67; 95% confidence interval: 1.61-19.9).

CONCLUSIONS

The outcomes of inside-stent techniques and conventional EBS for the management of preoperative EBD are comparable for patients with cholangiocarcinoma.

Does Caudate Resection Improve Outcomes of Patients Undergoing Curative Resection for Perihilar Cholangiocarcinoma? A Systematic Review and Meta-Analysis

BACKGROUND

Margin-negative (R0) resection is the strongest positive prognostic factor in perihilar cholangiocarcinoma (PHC). Due to its anatomic location, the caudate lobe is frequently involved in PHC. This review aimed to examine the impact of caudate lobe resection (CLR) in addition to hepatectomy and bile duct resection for patients with PHC.

METHODS

The MEDLINE, EMBASE, and Cochrane databases were systematically reviewed from inception to October 2021 to identify studies comparing patients undergoing surgical resection with hepatectomy and bile duct resection with or without CLR for treatment of PHC. Outcomes included the proportion of patients achieving R0 resection, overall survival (OS), and perioperative morbidity.

RESULTS

Altogether, 949 studies were screened. The review included eight observational studies reporting on 1137 patients. The patients who underwent CLR had a higher likelihood of R0 resection (odds ratio [OR], 5.85; 95% confidence interval [CI], 2.64-12.95) and a better OS (hazard ratio [HR], 0.65; 95% CI, 0.54-0.79) than those who did not. The use of CLR did not increase the risk of perioperative morbidity (OR, 1.03; 95% CI, 0.65-1.63).

CONCLUSIONS

Given the higher likelihood of R0 resection, improved OS, and no apparent increase in perioperative morbidity, this review supports routine caudate lobectomy in the surgical management of PHC. These results should be interpreted with caution given the lack of high-quality prospective data and the high probability of selection bias.

Homologous Recombination Repair in Biliary Tract Cancers: A Prime Target for PARP Inhibition?

Biliary tract cancers (BTCs) are a heterogeneous group of malignancies that make up ~7% of all gastrointestinal tumors. It is notably aggressive and difficult to treat; in fact, >70% of patients with BTC are diagnosed at an advanced, unresectable stage and are not amenable to curative therapy. For these patients, chemotherapy has been the mainstay treatment, providing an inadequate overall survival of less than one year. Despite the boom in targeted therapies over the past decade, only a few targeted agents have been approved in BTCs (i.e., IDH1 and FGFR inhibitors), perhaps in part due to its relatively low incidence. This review will explore current data on PARP inhibitors (PARPi) used in homologous recombination deficiency (HRD), particularly with respect to BTCs. Greater than 28% of BTC cases harbor mutations in genes involved in homologous recombination repair (HRR). We will summarize the mechanisms for PARPi and its role in synthetic lethality and describe select genes in the HRR pathway contributing to HRD. We will provide our rationale for expanding patient eligibility for PARPi use based on literature and anecdotal evidence pertaining to mutations in HRR genes, such as RAD51C, and the potential use of reliable surrogate markers of HRD.

Current Perspectives on the Surgical Management of Perihilar Cholangiocarcinoma

Cholangiocarcinoma (CCA) represents nearly 15% of all primary liver cancers and 2% of all cancer-related deaths worldwide. Perihilar cholangiocarcinoma (pCCA) accounts for 50-60% of all CCA. First described in 1965, pCCAs arise between the second-order bile ducts and the insertion of the cystic duct into the common bile duct. CCA typically has an insidious onset and commonly presents with advanced, unresectable disease. Complete surgical resection is technically challenging, as tumor proximity to the structures of the central liver often necessitates an extended hepatectomy to achieve negative margins. Intraoperative frozen section can aid in assuring negative margins and complete resection. Portal lymphadenectomy provides important prognostic and staging information. In specialized centers, vascular resection and reconstruction can be performed to achieve negative margins in appropriately selected patients. In addition, minimally invasive surgical techniques (e.g., robotic surgery) are safe, feasible, and provide equivalent short-term oncologic outcomes. Neoadjuvant chemoradiation therapy followed by liver transplantation provides a potentially curative option for patients with unresectable disease. New trials are needed to investigate novel chemotherapies, immunotherapies, and targeted therapies to better control systemic disease in the adjuvant setting and, potentially, downstage disease in the neoadjuvant setting.

Postoperative morbidity adversely impacts oncological prognosis after curative resection for hilar cholangiocarcinoma

BACKGROUND

Postoperative morbidity after curative resection for hilar cholangiocarcinoma (HCCA) is common; however, whether it has an impact on oncological prognosis is unknown.

AIM

To evaluate the influence of postoperative morbidity on tumor recurrence and mortality after curative resection for HCCA.

METHODS

Patients with recently diagnosed HCCA who had undergone curative resection between January 2010 and December 2017 at The First Affiliated Hospital of Army Medical University in China were enrolled. The independent risk factors for morbidity in the 30 d after surgery were investigated, and links between postoperative morbidity and patient characteristics and outcomes were assessed. Postoperative morbidities were divided into five grades based on the Clavien-Dindo classification, and major morbidities were defined as Clavien-Dindo ≥ 3. Univariate and multivariate Cox regression analyses were used to evaluate the risk factors for recurrence-free survival (RFS) and overall survival (OS).

RESULTS

Postoperative morbidity occurred in 146 out of 239 patients (61.1%). Multivariate logistic regression revealed that cirrhosis, intraoperative blood loss > 500 mL, diabetes mellitus, and obesity were independent risk factors. Postoperative morbidity was associated with decreased OS and RFS (OS: 18.0 mo vs 31.0 mo, respectively, P = 0.003; RFS: 16.0 mo vs 26.0 mo, respectively, P = 0.002). Multivariate Cox regression analysis indicated that postoperative morbidity was independently associated with decreased OS [hazard ratios (HR): 1.557, 95% confidence interval (CI): 1.119-2.167, P = 0.009] and RFS (HR: 1.535, 95%CI: 1.117-2.108, P = 0.008). Moreover, major morbidity was independently associated with decreased OS (HR: 2.175; 95%CI: 1.470-3.216, P < 0.001) and RFS (HR: 2.054; 95%CI: 1.400-3.014, P < 0.001) after curative resection for HCCA.

CONCLUSION

Postoperative morbidity (especially major morbidity) may be an independent risk factor for unfavorable prognosis in HCCA patients following curative resection.

Adjuvant chemotherapy for perihilar cholangiocarcinoma: A population-based comparative cohort study

BACKGROUND

Data supporting routine use of adjuvant chemotherapy (AC) compared to no AC (noAC) for perihilar cholangiocarcinoma (hCCA) is unclear. This study aimed to determine whether AC improves long-term survival following resection for hCCA.

METHODS

Patients receiving resection for hCCA followed by AC or no AC from 2010 to 2016 were identified from the National Cancer Database (NCDB). Propensity score matching (PSM) and Cox regression was performed to account for selection bias and analyze impact of AC on overall survival.

RESULTS

Of 924 (56%) noAC and 719 (44%) AC, 320 noAC and 320 AC patients remained after PSM. After matching, AC was associated with improved survival (median: 28.2 vs 19.9 months, p < 0.001), which remained after multivariable adjustment (HR: 0.61, CI_95%: 0.50-0.75, p < 0.001). On multivariable interaction analyses, the benefit of AC over no AC persisted irrespective of nodal status: N0 (HR: 0.62, CI_95%: 0.41-0.92, p = 0.019), N1 (HR: 0.52, CI_95%: 0.36-0.75, p = 0.001), N2 (HR: 0.31, CI_95%: 0.11-0.90, p = 0.032), Nx (HR: 0.22, CI_95%: 0.09-0.55, p = 0.001) and margin status: R0 (HR: 0.74, CI_95%: 0.57-0.97, p = 0.026), R1 (HR: 0.31, CI_95%: 0.21-0.47, p < 0.001). Stratified analysis by nodal, margin and AC status demonstrated consistent results.

CONCLUSION

AC following resection for hCCA was associated with improved survival in this study, even in margin-negative and node-negative disease. These findings suggest incorporation of AC into multimodality therapy for hCCA in all cases, where appropriate.

A combined prediction model for biliary tract cancer using the prognostic nutritional index and pathological findings: a single-center retrospective study

Background

The prognostic nutritional index, a marker of nutritional status and systemic inflammation, is a known biomarker for various cancers. However, few studies have evaluated the predictive value of the prognostic nutritional index in patients with biliary tract cancer. Therefore, we investigated the prognostic significance of the prognostic nutritional index, and developed a risk-stratification system to identify prognostic factors in patients with biliary tract cancer.

Methods

Between July 2010 and March 2021, 117 patients with biliary tract cancer were recruited to this single-center, retrospective study. The relationship between clinicopathological variables, including the prognostic nutritional index, and overall survival was analyzed using univariate and multivariate analyses. A P < 0.05 was considered statistically significant.

Results

The median age was 75 (range 38–92) years. Thirty patients had intrahepatic cholangiocarcinoma; 29, gallbladder carcinoma; 27, distal cholangiocarcinoma; 17, ampullary carcinoma; and 13, perihilar cholangiocarcinoma. Curative (R0) resection was achieved in 99 patients. In univariate analysis, the prognostic nutritional index (< 42), lymph node metastasis, carbohydrate antigen 19-9 level (> 20 U/mL), preoperative cholangitis, tumor differentiation, operation time (≥ 360 min), and R1–2 resection were significant risk factors for overall survival. The prognostic nutritional index (P = 0.027), lymph node metastasis (P = 0.040), and tumor differentiation (P = 0.006) were independent prognostic factors in multivariate analysis. A combined score of the prognostic nutritional index and pathological findings outperformed each marker alone, in terms of discriminatory power.

Conclusions

The prognostic nutritional index, lymph node metastasis, and tumor differentiation were independent prognostic factors after surgical resection in patients with biliary tract cancer. A combined prediction model using the prognostic nutritional index and pathological findings accurately predicted prognosis, and can be used as a novel prognostic factor in patients with biliary tract cancer.

Radiation therapy for recurrent extrahepatic bile duct cancer

PURPOSE

More than half of patients with bile duct cancer (BDC) develop recurrence even after curative resection. Recurrent BDC has a poor prognosis, and no optimal treatment modality has been established. We therefore analyzed our experience on the survival outcomes of radiation therapy (RT) for recurrent extrahepatic bile duct cancer (EHBDC).

PATIENTS AND METHODS

We retrospectively analyzed the records of patients with recurrent EHBDC who underwent concurrent chemoradiation therapy (CCRT) or RT alone at our institution between January 2001 and June 2015. Freedom from locoregional progression (FFLP), progression-free survival (PFS), and overall survival (OS) were assessed, and univariate and multivariate analyses were performed to identify the prognostic factors.

RESULTS

A total of 76 patients were included in the analysis. The median OS was 16 months and the rates of 2-year FFLP, PFS, and OS were 61%, 25%, and 33%, respectively. Among the evaluable patients, the first site of failure was the locoregional area in 16 patients, distant metastasis in 27, and both sites in 8. On univariate analysis, disease-free interval (p = 0.012) and concurrent chemotherapy (p = 0.040) were found as significant prognostic factors for OS. One patient with CCRT developed a grade 3 hematologic toxicity, and two patients experienced late grade 3 toxicities including duodenal ulcer bleeding and obstruction.

CONCLUSIONS

RT for recurrent EHBDC showed favorable survival and local control with limited treatment-related toxicities. Considering that the most common pattern of failure was distant metastasis, further studies on the optimal scheme of chemotherapy and RT are warranted.

Personalized Preoperative Nomograms Predicting Postoperative Risks after Resection of Perihilar Cholangiocarcinoma

INTRODUCTION

Curative treatment of perihilar tumors requires major hepatectomy responsible for high morbidity and mortality. Current nomograms are based on definitive pathological analysis, not usable for patient selection. Our aim was to propose preoperative predictors for severe morbidity (Dindo-Clavien ≥3) and mortality at sixth month after resection of perihilar tumors.

PATIENTS AND METHODS

We reviewed perioperative data of 186 patients operated with major hepatectomy for perihilar tumors between 2012 and 2018 in two high-volume centers. Univariate and multivariate analysis were performed to determine the preoperative predictors of morbidity and mortality. A stepwise regression in forward direction was developed to select variables for definitive models. Hosmer-Lemeshow test, Akaike information criteria and area under the ROC curves were calculated to validate both nomograms.

RESULTS

Resections were indicated for perihilar and intrahepatic cholangiocarcinoma in 125 and 61 cases, respectively. Severe complications occurred in 76 patients (40.8%). Nineteen patients (10.2%) deceased before the sixth postoperative month. The predictors of severe morbidity were: male gender, portal vein embolization, planned biliary resection, low psoas muscle area/height² and low hemoglobinemia. The predictors of early mortality were: age, high bilirubinemia, hypoalbuminemia, biliary drainage and long drainage-to-surgery interval. For both models, the p values of Hosmer-Lemeshow tests were of 0.9 and 0.99, respectively, the Akaike information criteria were of 35.5 and 37.7, respectively, and area under the curves was of 0.73 and 0.86, respectively.

CONCLUSION

We developed two accurate and practical nomograms based on exclusively preoperative data to predict early outcomes following the resection of perihilar tumors. If validated in larger series, these tools could be integrated in the decision-making process for patient selection.

Systematic review of perioperative and oncologic outcomes of minimally-invasive surgery for hilar cholangiocarcinoma

Most surgeons have traditionally been reluctant toward minimally-invasive surgery for bile duct tumors. This study aimed to perform a systematic literature review on perioperative and oncologic results of pure laparoscopic and robotic curative-intent surgery for hilar cholangiocarcinoma. According to the PRISMA statement, a systematic review was conducted into Pubmed, EMBASE and Cochrane. A critical appraisal of study was performed according to the Joanna Briggs Institute tools. Nineteen studies (12 on pure laparoscopy and 7 on robotics) were included: 7 case reports, 9 case series, 3 case-control (193 patients). The pooled conversion, morbidity, biliary leak and mortality rates were 5.5%, 43%, 16.4% and 4%. The weighted mean of operative time, blood loss and postoperative stay were 388 min, 446 mL and 14 days. For pure laparoscopy, the pooled R0 rate was 86%; overall survival and disease-free survival rates ranged from 85 to 100% and from 80 to 100% (median observation time 6-18 months). For robotic surgeries, the pooled R0 rate was 69% and overall survival rates ranged from 90 to 100% (median observation time 5-15 months). Case reports were overall of high quality, case series of moderate / high-quality, case-control studies ranged from low to high quality. In selected patients, minimally-invasive surgery for Klatskin tumors appears feasible, safe, satisfactory for perioperative outcomes and adequate for oncologic results. However, the results are based on few studies, limited in patient numbers and with allocation criteria more restrictive than open, reporting short follow-up and mainly with non-comparative design: evidence of higher quality is recommended.

Inhibition of T-cell-mediated immune response via the PD-1/ PD-L1 axis in cholangiocarcinoma cells

Cholangiocarcinoma (CCA) is a malignant biliary tract epithelium tumor. The programmed death-1 (PD-1)/programmed receptor-ligand 1 (PD-L1) signaling pathway has been implicated as an immune escape mechanism in several cancers. The present study aimed to assess the expression of PD-L1 on human CCA cell lines and its potential role in suppressing CD8⁺ T- cell function. A panel of intrahepatic CCA cell lines was evaluated for immune regulatory checkpoint ligands and inflammation markers. Effects of pro-inflammatory cytokine, interferon gamma (IFN-γ), on the expression of immune regulatory checkpoint ligands and inflammation markers were determined. The PD-L1 function was measured by co-culturing CCA cells with lymphocytes. Most of the selected Thai CCA cell lines, including HuCCA-1, RMCCA-1, KKU-100, and KKU-213, expressed higher PD-L1 than normal cholangiocyte MMNK-1 and ANK-1 cells. Both PD-L1 and cyclooxygenase-2 (COX-2) expressions were highest in HuCCA-1 cells. A 48 h treatment with IFN-γ increased the expression of PD-L1 and COX-2 in CCA cells. The expression of CTLA-4 ligands, including H7-1 and H7-2, did not change after IFN-γ treatment. Rofecoxib, a specific COX-2 inhibitor, mitigated IFN-γ-induced PD-L1 expression. After 48 h co-incubation, CD8⁺ T-cell apoptosis was increased as compared to the control group. Pretreatment of CCA cells with IFN-γ further increased CD8⁺ T-cell apoptosis. Pembrolizumab, an anti-PD-1 antibody, mitigated CCA cell escape phenomenon. The inhibition of T-cell-mediated immune response via the PD-L1/PD-1 axis are evidenced in intrahepatic CCA. Immunotherapy with checkpoint inhibitor offers a potentially therapeutic strategy for CCA patients; however, further in vivo and clinical studies are required.

The value of caudate lobectomy in hilar cholangiocarcinoma treatment: A meta-analysis

PURPOSE

To discuss the value of caudate lobectomy in hilar cholangiocarcinoma (HCCA) treatment.

METHODS

A systematic review was performed in PubMed, MEDLINE database, EMBASE, and Cochrane Library for trials comparing combined caudate lobectomy with controls from January 1, 1990 to December 2, 2020. The outcomes were postoperative radical cure information, survival condition, morbidity, and mortality.

RESULT

Ten studies were included. No difference was observed in the morbidity (odd ratio (OR) 0.93, 95% confidence interval (CI) 0.65-1.33) and mortality (OR 1.16, 95% CI 0.55-2.42) between the combined caudate lobectomy and control groups. Hepatectomy combined with caudate lobectomy was associated with higher incidence of radical resection (OR 3.88, 95% CI 2.18-6.90) and longer survival (hazard ratio 0.45, 95% CI 0.38-0.55).

CONCLUSION

Combining caudate lobectomy can significantly increase the incidence of radical resection of HCCA and the postoperative survival time. The morbidity and mortality were not increased after the operation. Thus, caudate lobectomy should be included when performing partial hepatectomy for HCCA.

Prognostic factors of resectable perihilar cholangiocarcinoma: a systematic review and meta-analysis of high-quality studies

Data on prognostic factors associated with outcome following resection of perihilar cholangiocarcinoma vary. We sought to define and characterize current available evidence on prognostic factors associated with perihilar cholangiocarcinoma after resection. The PubMed, Embase, and Cochrane library were systematically searched for relevant studies published before December 2019. Prognostic factors were identified from multivariate regression analyses in studies. Only high-quality studies were included (Newcastle-Ottawa Scale > 6 stars). A total of 45 studies involving 7338 patients were analyzed. The meta-analysis demonstrated that serum bilirubin levels (hazard ratio: 1.76, 95% confidence interval: 1.27-2.44), serum CA19-9 levels (hazard ratio: 1.32, 95% confidence interval: 1.05-1.65), tumor size (hazard ratio: 1.27, 95% confidence interval: 1.04-1.55), major vascular involvement (hazard ratio: 1.61, 95% confidence interval: 1.09-2.38), distance metastasis (hazard ratio: 17.60, 95% confidence interval: 2.01-154.09), perioperative blood transfusion (hazard ratio: 1.36, 95% confidence interval: 1.15-1.62), T-stage (hazard ratio: 1.96, 95% confidence interval: 1.47-2.61), lymph node metastasis (hazard ratio: 2.06, 1.83-2.31), resection margin status (hazard ratio: 2.34, 95% confidence interval: 1.89-2.89), not-well histology differentiation (hazard ratio: 2.03, 95% confidence interval: 1.69-2.44), perineural invasion (hazard ratio: 2.37, 95% confidence interval: 1.59-3.55), and lymphovascular invasion (hazard ratio: 1.41, 95% confidence interval: 1.15-1.73) were prognostic factors for poorer overall survival. Adjuvant chemotherapy (hazard ratio: 0.37, 95% confidence interval: 0.25-0.55) had a positive effect on prolonged overall survival. In addition, positive resection margin status (hazard ratio: 1.96, 95% confidence interval: 1.47-2.61) and lymph node metastasis (hazard ratio: 2.06, 95% confidence interval: 1.83-2.31) were associated with poorer disease-free survival. The prognostic factors identified in the present meta-analysis can be used to characterize patients in clinical practice and enrich prognostic tools, which could be included in future trial designs and generate hypotheses to be tested in future research to promote personalized treatment.

[Intra and extra hepatic cholangiocarcinomas radiation therapy]

Cholangiocarcinomas are digestive tumors whose incidence remains low and have poor prognosis. The benefits of adjuvant radiochemotherapy and radiotherapy have never been demonstrated in any phase III randomized controlled trial. Chemotherapy with capecitabine 6 months is the standard of care in adjuvant setting. Radiochemotherapy is validated in R1 patients. It is not recommended in neoadjuvant situations given the lack of evidence. Chemotherapy and radiochemotherapy are validated in adjuvant or locally advanced diseases. Stereotactic radiation therapy offers an interesting perspective, at the cost of significant digestive toxicities, requiring evaluation in randomized trials.

Inhibitory effect of isomorellin on cholangiocarcinoma cells via suppression of NF-κB translocation, the phosphorylated p38 MAPK pathway and MMP-2 and uPA expression

Evidence indicates that most cancer deaths are caused by tumor invasion and metastasis. Cholangiocarcinoma (CCA) is a tumor of the bile duct epithelium characterized by slow growth, rapid metastasis and poor prognosis. Caged xanthones are extracted from gamboge, a dry resin exuded by Garcinia hanbury. These compounds have been reported to be cytotoxic to several types of cancer cells, without affecting normal cells. The aim of the present study was to determine the effect of isomorellin on the inhibition of CCA cell (KKU-100) viability, migration, invasion and the expression of invasion-regulated proteins. Cytotoxicity of isomorellin was evaluated using a sulforhodamine B assay. The anti-migratory and anti-invasive effects of isomorellin on KKU-100 cells were assessed using wound healing and chamber invasion assays, respectively. Furthermore, the activities of matrix metalloproteinases (MMPs)-2 and -9, and urokinase-type plasminogen activator (uPA) were also investigated. The expression levels of proteins regulating invasion were determined via western blot analysis. The cell viability of KKU-100 cells was decreased following treatment with isomorellin in a dose-dependent manner, with IC50 values at 24, 48 and 72 h of 3.46±0.19, 3.78±0.02 and 4.01±0.01 µM, respectively. Wound healing and chamber invasion assays indicated that isomorellin significantly inhibited KKU-100 cell migration and invasion in a dose-dependent manner. In addition, isomorellin significantly inhibited cancer cell migration and invasion abilities via focal adhesion kinase (FAK), protein kinase C (PKC), the phosphorylated (p)-p38 mitogen-activated protein kinase (MAPK) pathway, and nuclear factor (NF)-κB expression and translocation to the nucleus, thus resulting in downregulation of MMP-2, uPA and cyclooxygenase-2 (COX-2) expression. Therefore, inhibition of MMP-2, uPA and COX-2 expression may result in decreased CCA cell invasion ability. These data demonstrated for the first time that the suppression of KKU-100 cell viability, invasion and migration, and downregulation of NF-κB, MMP-2, uPA and the p-p38 MAPK pathway, may result in isomorellin-mediated anti-invasiveness.

Lipoproteins-Nanocarriers as a Promising Approach for Targeting Liver Cancer: Present Status and Application Prospects

The prevalence of liver cancer is increasing over the years and it is the fifth leading cause of mortality worldwide. The intrusive features and burden of low survival rate make it a global health issue in both developing and developed countries. The recommended chemotherapy drugs for patients in the intermediate and advanced stages of various liver cancers yield a low response rate due to the nonspecific nature of drug delivery, thus warranting the search for new therapeutic strategies and potential drug delivery carriers. There are several new drug delivery methods available to ferry the targeted molecules to the specific biological environment. In recent years, the nano assembly of lipoprotein moieties (lipidic nanoparticles) has emerged as a promising and efficiently tailored drug delivery system in liver cancer treatment. This increased precision of nano lipoproteins conjugates in chemotherapeutic targeting offers new avenues for the treatment of liver cancer with high specificity and efficiency. This present review is focused on concisely outlining the knowledge of liver cancer diagnosis, existing treatment strategies, lipoproteins, their preparation, mechanism and their potential application in the treatment of liver cancer.

Reassessing the role of surgery in the elderly or chronically sick with proximal extrahepatic cholangiocarcinoma

BACKGROUND

Most data on postoperative outcomes among patients with proximal extrahepatic cholangiocarcinoma are reported by single institutions. The purpose of this study was to analyze postoperative outcomes stratified by age and comorbidities.

METHODS

Patients with proximal extrahepatic cholangiocarcinoma who underwent a resection were identified in the National Cancer Database. Pathologic, postoperative, and survival outcomes were compared based on age and Charlson-Deyo comorbidity index.

RESULTS

Among the 1,579 patients, the average age was 66 years, and 9.4% of patients were older than 80 years. Most patients had a Charlson-Deyo score of 0 (72.4%), with the minority having scores of 1 (20.5%) or ≥2 (7.1%). Patients ≥80 years had a higher 90-day mortality rate compared with patients 65 to 79 and <65 years (21.3% vs 12.0% vs 7.4%, P < .001). Patients with a Charlson-Deyo score ≥2 had longer duration of stay, greater likelihood of requiring an unplanned readmission, and a higher 90-day mortality rate compared with patients with a lower comorbidity index. Median survival of patients <65, 65 to 79, and ≥80 years was 31, 24, and 17 months, respectively. A similar trend was seen with increasing Charlson-Deyo score (0: 27 months, 1: 25 months, ≥2: 20 months). On multivariable analysis, age ≥80 years (hazard ratio = 1.52, P = .01) and Charlson-Deyo score ≥2 (hazard ratio = 1.45, P = .01) were associated with poor survival.

CONCLUSION

In patients with proximal extrahepatic cholangiocarcinoma, age ≥80 years and greater comorbidity index are associated with increased risk of 90-day mortality and poor overall survival. This suggests that resections in high-risk patient populations should be approached with caution.

Impact of body mass index on postoperative outcomes in patients undergoing radical resection for hilar cholangiocarcinoma

BACKGROUND

Body mass index (BMI) has been widely used as a prognostic indicator. The association between preoperative BMI and postoperative morbidity in patients with hilar cholangiocarcinoma (HCCA) has not been proved. This study aimed to identify the association between preoperative BMI and postoperative morbidity following radical resection of HCCA.

METHODS

Patients were divided into three groups according to preoperative BMI: low BMI (≤18.4 kg/m² ), normal BMI (18.4-24.9 kg/m² ), and high BMI (≥24.9 kg/m² ). Baseline characteristics, operative variables, postoperative 30-day mortality, and morbidity were compared. Risk factors associated with postoperative morbidity were assessed using univariable and multivariable logistic analyses.

RESULTS

Among 260 patients, 183 (70.4%) had normal BMI, 32 (12.3%) had low BMI, and 45 (17.3%) had high BMI. Compared to the patients with normal-BMI, both low and high BMI patients exhibited a significantly higher postoperative morbidity (87.5% and 82.2% vs 63.9%, P = .019 and P = .025, respectively). Additionally, the multivariable analysis revealed that both low and high BMI patients remained independently associated with an increased risk of postoperative morbidity. (OR: 3.707, 95% CI: 1.080-12.725, P = .037; and OR: 2.858, 95% CI: 1.167-7.002, P = .022, respectively).

CONCLUSION

BMI is an independent risk factor for higher postoperative morbidity in patients who undergo surgical treatment of hilar cholangiocarcinoma.

Stereotactic body radiotherapy in the management of oligometastatic and recurrent biliary tract cancer: single-institution analysis of outcome and toxicity

INTRODUCTION

Biliary tract cancers (BTC) are rare malignancies arising from biliary system. Systemic therapy is the cornerstone for stage IV disease, with poor overall survival (OS). Evidence is lacking about safety and efficacy of local ablative treatments, such as surgery and stereotactic body radiotherapy (SBRT) in the context of metastatic BTC (mBTC).

MATERIALS AND METHODS

We retrospectively analyzed clinical outcomes for a cohort of mBTC patients treated with SBRT for oligometastatic disease. Inclusion criteria were 1-5 distant metastases; SBRT with a dose/fraction of a least 5 Gy to a biological effective dose (BED) of at least 40 Gy considering an α/β of 10 Gy. Analyzed outcomes included local control (LC), distant progression-free survival (DPFS), PFS, and OS.

RESULTS

51 patients meeting the inclusion criteria. Primary tumor sites were intrahepatic cholangiocarcinoma (35%), extrahepatic cholangiocarcinoma (31%), ampullary adenocarcinoma (20%), gallbladder adenocarcinoma (14%). 21 patients were treated on liver lesions, 17 on nodal metastasis, 5 patients on lung lesions, 4 patients on recurrence along the extrahepatic bile duct. After a median follow-up of 14 months median OS was 13.7 months, 1- and 2-year OS were 58% and 41%, respectively. Node and lung as metastatic sites were associated with a longer OS (p < 0.001). Median LC was 26.8 months, and intrahepatic cholangiocarcinoma was associated with longer LC (p = 0.036). Median DPFS was 11 months, with 1- and 2-year DPFS of 48% and 27.8%, respectively. Ten patients reported grade 1-2 toxicity and 2 cases of acute G3 biliary obstruction.

CONCLUSIONS

Stereotactic body radiotherapy (SBRT) is feasible in the context of mBTC. OS and PFS results are promising, considering that our patients were heavily pre-treated with systemic therapy. Patients with nodal or lung relapse have better prognosis. Distant relapses remain the main pattern of failure, but treatment of all metastatic sites seems to improve DMFS.

Is radical resection of hilar cholangiocarcinoma plus partial resection of pancreatic head justified for advanced hilar cholangiocarcinoma?

BACKGROUND

To outline our experience with the radical resection of hilar cholangiocarcinoma (HCCA) combined with the partial resection of the pancreatic head (RRHCCAPRPH) as a treatment for HCCA with distal bile duct involvement and to appraise the feasibility of this challenging procedure.

METHODS

Between 2007 and 2017, 205 patients with HCCA who underwent curative surgery at our hospital were included. Among the patients, extrahepatic bile duct resection combined with hepatectomy (EBDRH), RRHCCAPRPH and hepatopancreaticoduodenectomy (HPD) was performed in 168, 21 and 16 patients, respectively. Clinical pathological factors, post-operative complications and survival were compared between the three groups.

RESULTS

There was a significant difference in operative blood loss, operative time, post-operative hospital stay and tumour size between EBDRH group, RRHCCAPRPH group and HPD group (P < 0.05). In terms of post-operative complications, there was no statistical difference between the three groups (P = 0.177). Further analysis showed that the incidence of pancreatic fistula (43.8%) and delayed gastric emptying (25%) after HPD were significantly higher than the other two groups. The median survival time and overall survival rate for 172 patients with R0 resection were 33 months and 85.5% at 1 year, 47.7% at 3 years, 28.4% at 5 years. Furthermore, the 1-, 3- and 5-year survival rates of patients with EBDRH, RRHCCAPRPH and HPD after R0 resection were 86.2%, 48.7%, 29.2%; 85.0%, 44.0%, 24.7% and 78.6%, 42.9%, 22.9%, respectively (P = 0.948).

CONCLUSION

The RRHCCAPRPH in some selected patients can actually replace HPD as a surgical treatment for HCCA with distal bile duct involvement.

Liver Transplantation for Cholangiocarcinoma: Insights into the Prognosis and the Evolving Indications

PURPOSE OF REVIEW

Cholangiocarcinoma (CCA) is a rare malignancy of the biliary ducts that can be classified as intrahepatic, perihilar, or distal based on anatomic location. Although surgical resection can be curative, complete excision with negative margins is often difficult to achieve. In patients with unresectable disease, long-term survival is rarely seen with medical therapy alone. A multimodal treatment approach, including liver transplantation (LT) for select patients with unresectable CCA, should be considered.

RECENT FINDINGS

While currently only an approved indication for early, liver-limited, perihilar cholangiocarcinoma, promising results have been achieved for LT in localized intrahepatic disease. The absolute indication for transplant for intrahepatic tumors is currently the subject of multiple investigations. Continued advances in neoadjuvant/adjuvant therapy and better understanding of tumor biology may further augment the number of candidates for surgical therapies, with liver transplant acting as a promising tool to improve patient outcomes. Thorough consideration for any expansion in the indication for liver transplant in malignancy is necessary in order to balance patient outcomes with utilization of the scarce donor organ resources.

Multigene mutational profiling of biliary tract cancer is related to the pattern of recurrence in surgically resected patients

The aim of the present study was to investigate the relationship between the mutational gene profile and recurrence in biliary tract cancers (BTC). A total of 103 specimens of patients with BTC, who underwent curative surgery in a single tertiary HPB surgery referral center from 1990 to 2012, were assessed for mutational status in 52 cancer-related genes. Considering the different types of BTC, the 5-year recurrence-free survival (RFS) rate was 16.7% (median RFS 7 months) in gallbladder cancer, 42.9% (median RFS 26.4 months) in intrahepatic cholangiocarcinoma, and 19.7% (median RFS 16.5 months) in perihilar cholangiocarcinoma, p = 0.166. At the multivariate analysis including clinical, pathological, and molecular features, the factors independently related to RFS were radicality of surgery (OR 2.050, CI 1.104-3.807, p = 0.023), LN status (OR 1.835, CI 1.006-3.348, p = 0.048), mutational status of ARID1A (OR 2.566, CI 1.174-5.608, p = 0.018), and TP53 (OR 2.805, CI 4.432-5.496, p = 0.003). ARID1A mutation was associated with a local and systemic recurrence in the 43% and 29% of cases, respectively; and TP53 mutation was associated with a local and systemic recurrence in the 29% and 41% of cases. Moreover, TP53 was most commonly mutated in tumor of patients with early recurrence, p = 0.044. ARID1A and TP53 mutations seem to be related to poor outcome after surgery and may be considered molecular predictors of the biological aggressiveness in BTC.

A systematic review and meta-analysis of caudate lobectomy for treatment of hilar cholangiocarcinoma

BACKGROUND

Surgical resection remains the only potentially curative therapy for hilar cholangiocarcinoma (CCC) patients. This meta-analysis aimed to review the current evidence on perioperative and long-term outcomes of routine caudate lobe resection (CLR) for surgical treatment of hilar CCC.

METHODS

A systematic literature search using MEDLINE, EMBASE and Cochrane databases was performed for studies providing comparative data on perioperative and long-term outcomes of patients undergoing resection for hilar CCC with and without CLR. The MINORS score was used for quality assessment. For time-to-event outcomes hazard ratios (HRs) and associated 95% CI were extracted from identified studies, whereas risk ratios (RRs) were calculated for overall morbidity, mortality, and resection margin status. Meta-analyses were carried out using random-effects models.

RESULTS

Eight studies involving 1350 patients met the inclusion criteria. The quality of the included studies was low to moderate. CLR resulted in significantly improved overall survival (HR 0.49; 95%CI 0.32-0.75, P < 0.01). Postoperative morbidity (RR 0.93; 95% CI 0.77-1.13; P = 0.48) and mortality (RR 1.01; 95% CI 0.42-2.41; P = 0.99) rates were comparable between both groups. Patients without concomitant CLR were at higher risk for residual tumor at the resection margin (RR 1.40; 95% CI 1.09-1.80; P = 0.01).

CONCLUSION

CLR is associated with improved long-term survival and negative tumor margins after resection of hilar CCC with no adverse impact on perioperative outcomes. CLR might provide the potential to become a standard-of-care procedure in the surgical management of hilar CCC.

Retrospective analysis of intensity-modulated radiotherapy and three-dimensional conformal radiotherapy of postoperative treatment for biliary tract cancer

Purpose

This study was conducted to compare the outcome of three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) for the postoperative treatment of biliary tract cancer.

Materials and Methods

From February 2008 to June 2016, 57 patients of biliary tract cancer treated with curative surgery followed by postoperative 3D-CRT (n = 27) or IMRT (n = 30) were retrospectively enrolled.

Results

Median follow-up time was 23.6 months (range, 5.2 to 97.6 months) for all patients and 38.4 months (range, 27.0 to 89.2 months) for survivors. Two-year recurrence-free survival is higher in IMRT arm than 3D-CRT arm with a marginal significance (25.9% vs. 47.4%; p = 0.088). Locoregional recurrence-free survival (64.3% vs. 81.7%; p = 0.122) and distant metastasis-free survival (40.3% vs. 55.8%; p = 0.234) at two years did not show any statistical difference between two radiation modalities. In the multivariate analysis, extrahepatic cholangiocarcinoma, poorly-differentiated histologic grade, and higher stage were significant poor prognostic factors for survival. Severe treatment-related toxicity was not significantly different between two arms.

conclusions

IMRT showed comparable results with 3D-CRT in terms of recurrence, and survival, and radiotherapy toxicity for the postoperative treatment of biliary tract cancer.

Survival outcomes of hepatic resections in Bismuth-Corlette type IV cholangiocarcinoma

BACKGROUND

Surgical resection for Bismuth-Corlette type IV (BC-IV) hilar cholangiocarcinomas, also termed Klatskin tumours are technically challenging and were once considered unresectable tumours. Following advances in hepatobiliary imaging and surgical techniques, emerging evidence suggests that surgical resection is a viable avenue for long-term survival. We aimed to identify factors affecting survival outcomes of hepatic resections for BC-IV cholangiocarcinomas.

METHOD

A systematic review was performed across multiple databases and several clinical trial registries. Two reviewers independently screened and selected papers that contained survival data on BC-IV cholangiocarcinoma after hepatic resections.

RESULTS

Of 13 499 papers from our search result, 21 papers satisfied the inclusion criteria. The median post-operative survival was 30.8 months. The average 1- and 5-year post-operative survivals were 61.6 and 33.3%, respectively. Predictors of long-term survival included achievement of R0 margins, minimisation of operative time and reduction intra-operative blood loss.

CONCLUSION

Our analysis demonstrates improving post-operative outcomes and survival in surgical resection of BC-IV cholangiocarcinoma and suggests that radical surgical resection is a valid treatment option for the disease.

Expanding the Surgical Pool for Hepatic Resection to Treat Biliary and Primary Liver Tumors

Surgical management of primary liver and biliary tract tumors has evolved over the past several decades, resulting in improved outcomes in these malignancies with historically poor prognoses. Expansion of patient selection criteria, progress in neoadjuvant and adjuvant therapies, development of techniques to increase future liver remnant, and the select utilization of liver transplantation have all contributed to increasing the patient pool for surgical intervention. Ongoing and future studies need to focus on improving multimodality treatment regimens and further refining the selection criteria for transplantation in order to optimize utilization of limited organ resources.

The synergistic antitumor effect of Huaier combined with 5-Florouracil in human cholangiocarcinoma cells

BACKGROUND

5-Florouracil (5-FU) is a commonly used chemotherapeutic drug for cholangiocarcinoma, whereas it has unsatisfactory effect, and patients often have chemo-resistance to it. The combination of chemotherapeutic agents and traditional Chinese medicine has already exhibited a promising application in oncotherapy. Huaier extract (Huaier) has been used in clinical practice widely, exhibiting good anti-tumor effect. This paper aims to investigate the possibility of combination 5-FU and Huaier as a treatment for cholangiocarcinoma.

METHODS

A series of experiments were performed on the Huh28 cells in vitro, which involved cell proliferation, colony formation, apoptosis, cell cycle, migratory and invasive tests. Besides, western blots were also performed to examine the potential mechanism of 5-FU.

RESULTS

The combination effect (antagonism, synergy or additive) was assessed using Chou-Talalay method. Using the CCK-8 and Colony formation assay, the anti-proliferation effect of 5-FU combined with Huaier was observed. Apoptosis inducing and cell cycle arrest effect of the combination of two drugs were assessed by flow cytometry. To determine the combined treatment on cell immigration and invasion ability, wound healing and Transwell assay were performed. The above experiment results suggest that the combined 5-FU and Huaier, compared with treatment using either drug alone, exhibited stronger effects in anti-proliferation, cycle arrest, apoptosis-induced and anti-metastasis. Further, western blot results reveal that the inhibition of STAT3 and its target genes (e.g. Ki67, Cyclin D1, Bcl-2 and MMP-2) might be set as the potential therapeutic targets. Besides, the inhibition of combination treatment in proteins expression associated with proliferation, apoptosis, cell cycle and metastasis was consistent with that of previous phenotypic experiments.

CONCLUSIONS

Huaier combined with 5-FU exhibited a synergistic anti-tumor effect in Huh28 cell. Furthermore, the mechanisms might be associated with the activation and translocation of STAT3, as well as its downstream genes.

Neoadjuvant therapy in the treatment of hilar cholangiocarcinoma: Review of the literature

Cholangiocarcinoma (CCA) is a malignant tumor of the biliary system and includes, according to the anatomical classification, intra hepatic CCA (iCCA), hilar CCA (hCCA) and distal CCA (dCCA). Hilar CCA is the most challenging type in terms of diagnosis, treatment and prognosis. Surgery is the only treatment possibly providing long-term survival, but only few patients are considered resectable at the time of diagnosis. In fact, tumor’s extension to segmentary or subsegmentary biliary ducts, along with large lymph node involvement or intrahepatic metastases, precludes the surgical approach. To achieve R0 margins is mandatory for the disease-free survival and overall survival. In case of unresectable locally advanced hCCA, radiochemotherapy (RCT) as neoadjuvant treatment demonstrated to be a therapeutic option before either hepatic resection or liver transplantation. Before liver surgery, RCT is believed to enhance the R0 margins rate. For patients meeting the Mayo Clinic criteria, RCT prior to orthotopic liver transplant (OLT) has proved to produce acceptable 5-years survivals. In this review, we analyze the current role of neoadjuvant RCT before resection as well as before OLT.

[Predictors of outcomes in surgery for hilar cholangiocarcinoma]

AIM

To determine significant predictors of long-term outcomes of surgery for portal cholangiocarcinoma.

MATERIAL AND METHODS

Analysis included 49 out of 84 patients who were operated at the Vishnevsky Institute of Surgery in 2003-2016. Morphological examination (2011-2016) revealed great percentage of following positive variables: micro- (42.9%) and lymphovascular invasion (11.8%), positive resection margin (59.2%), perineural invasion (83.3%), depth of invasion - (83.3%), cells in surrounding fatty tissue (92.3%), invasion of entire thickness of bile ducts' walls (57.1%). Hemihepatectomy was carried out in 50 (59.5%) cases, advanced hemihepatectomy - in 16 (19%) patients. Left-sided hemihepatectomy (34.6%) was more common compared with right-sided hemihepatectomy (8.6%) for biliary confluence lesion (Bismuth-Corlette type IV).

RESULTS

TNM stage (p=0.29), tumor localization Bismuth-Corlette type (p=0.10), regional lymph nodes metastases (p=0.77) do not significantly affect survival in univariate analysis. At the same time, TNM stage was significant factor if patients dividing into groups was considered (p=0.05). In regression analysis tumor cells differentiation (p=0.00028), positive resection margin (p=0.0034), perineural invasion and depth of invasion (p=0,00086) were significant predictors of survival. Multivariate analysis confirmed prognostic role of lymphovascular invasion alone (p=0.05). There was no correlation between survival and TNM stage (η=0.057), depth of invasion (η= -0.229) and lymphovascular invasion (η= -0.143645). There was significant reverse moderate correlation between survival and perineural invasion (η= - 0.468750), resection margin (η= -0.558) and tumor differentiation grade (η= -0.481).

CONCLUSION

Significant predictors of long-term outcomes of surgery for portal cholangiocarcinoma are TNM stage, lymphovascular invasion, tumor cells differentiation, perineural invasion.

The Chemosensory Function of Primary Cilia Regulates Cholangiocyte Migration, Invasion, and Tumor Growth

Cholangiocytes, the epithelial cells lining the biliary tree in the liver, express primary cilia that can detect several kinds of environmental signals and then transmit this information into the cell. We have reported that cilia are significantly reduced in cholangiocarcinoma (CCA) and that the experimental deciliation of normal cells induces a malignant-like phenotype with increased proliferation, anchorage-independent growth, invasion, and migration. Here, we tested the hypothesis that the chemosensory function of cholangiocyte primary cilia acts as a mechanism for tumor suppression. We found that in the presence of extracellular nucleotides cilia-dependent chemosensation of the nucleotides inhibited migration and invasion in normal ciliated cholangiocytes through a P2Y11 receptor and liver kinase B1 (LKB1)-phosphatase and tensin homolog-AKT-dependent mechanism. In contrast, in normal deciliated cholangiocytes and CCA cells, the nucleotides induced the opposite effects, i.e., increased migration and invasion. As activation of LKB1 through a cilia-dependent mechanism was required for the nucleotide-mediated inhibitory effects on migration and invasion, we attempted to activate LKB1 directly, independent of ciliary expression, using the compound hesperidin methyl chalcone (HMC). We found that HMC induced activation of LKB1 in both ciliated and deciliated cells in vitro, resulting in the inhibition of migration and proliferation. Furthermore, using a rat syngeneic orthotopic CCA model, we found that HMC inhibited tumor growth in vivo. Conclusion: These findings highlight the importance of the chemosensory function of primary cilia for the control of migration and invasion and suggest that, by directly activating LKB1 and bypassing the need for primary cilia, it is possible to emulate this chemosensory function in CCA cells; these data warrant further studies evaluating the possibility of using HMC as therapy for CCA.

Morbidity and mortality after major liver resection in patients with perihilar cholangiocarcinoma: A systematic review and meta-analysis

BACKGROUND

Morbidity and mortality after hepatectomy for perihilar cholangiocarcinoma are known to be high. However, reported postoperative outcomes vary, with notable differences between Western and Asian series. We aimed to determine morbidity and mortality rates after major hepatectomy in patients with perihilar cholangiocarcinoma and assess differences in outcome regarding geographic location and hospital volume.

METHODS

A systematic review was performed by searching the MEDLINE and EMBASE databases through November 20, 2017. Risk of bias was assessed and meta-analysis and metaregression were performed using a random effects model.

RESULTS

A total of 51 studies were included, representing 4,634 patients. Pooled 30-day and 90-day mortality were 5% (95% CI 3%-6%) and 9% (95% CI 6%-12%), respectively. Pooled overall morbidity and severe morbidity were 57% (95% CI 50%-64%) and 40% (95% CI 34%-47%), respectively. Western studies compared with Asian studies had a significantly higher 30-day mortality, 90-day mortality, and overall morbidity: 8% versus 2% (P < .001), 12% versus 3% (P < .001), and 63% versus 54% (P = .048), respectively. This effect on mortality remained significant after correcting for hospital volume. Univariate metaregression analysis showed no influence of hospital volume on mortality or morbidity, but when corrected for geographic location, higher hospital volume was associated with higher severe morbidity (P = .039).

CONCLUSION

Morbidity and mortality rates after major hepatectomy for perihilar cholangiocarcinoma are high. The Western series showed a higher mortality compared with the Asian series, even when corrected for hospital volume. Standardized reporting of outcomes is necessary. Underlying causes for differences in outcomes between Asian and Western centers, such as differences in treatment strategies, should be further analyzed.

Improved Survival in Surgically Resected Distal Cholangiocarcinoma Treated with Adjuvant Therapy: a Propensity Score Matched Analysis

BACKGROUND

Data on the efficacy of adjuvant therapy (AT) in distal cholangiocarcinoma (dCCA) is limited. This study aimed to determine the role of AT in resected dCCA and identify subgroups that benefit from AT.

METHODS

We conducted a retrospective review of surgically resected dCCA in the NCDB from 2004 to 2013. Patients who received AT or observation (OB) were matched by propensity score. Log-rank test was used to compare OS.

RESULTS

Of 1782 patients with resected dCCA, 840 (47%) were in the OB group and 942 (53%) in the AT group. AT was younger (64.0 vs. 68.7 years, p < 0.001), had less comorbidities (Charlson Deyo score 0) (74.6 vs. 68.0%, p < 0.001), and more likely to have private insurance (p < 0.001). AT was more likely to present with T3/T4 stage (72 vs. 57%, p < 0.001), N1/N2 disease (58 vs. 37%, p < 0.001), and positive surgical margins (26 vs. 16%, p < 0.001). After 1:1 propensity score matching, 500 OB and 500 AT patients were compared. AT was associated with better OS (HR 0.79; 95% CI 0.67-0.93). Median OS was 31 and 25 months for the AT and OB (p = 0.006). The 1-, 3-, and 5-year survival rates were 87, 46, and 31% for AT; 79, 39, and 24% for OB. Subgroup analysis revealed an associated survival advantage for AT in T3/T4 tumors (HR = 0.72; 95% CI 0.59-0.89), node positive disease (HR 0.70; 95% CI 0.56-0.87), and positive margins (HR 0.58; 95% CI 0.42-0.81).

CONCLUSION

AT is associated with improved OS in resected dCCA, especially in T3/T4 tumors, node positive disease, and positive margins.

Assessment of treatment outcomes in patients with advanced hilar cholangiocarcinoma (stages III-IV): Clinical significance of interventional therapy

The clinical significance of palliative interventional therapy in the management of patients with advanced hilar cholangiocarcinoma (HCCA; stages III-IV) has yet to be studied. The present work was aimed to compare the clinical outcomes of the patients treated with surgery or interventional therapy.A total of 90 patients with advanced HCCA, who admitted Fuyang First People's Hospital from May 2015 to February 2016, were enrolled. Forty-five of them were assigned to the experimental group receiving biliary drainage as the interventional therapy, and the remaining 45 patients were designated as the conventional group receiving radical/palliative surgery. Before and after the treatment total bilirubin from blood was measured. The length of treatment and medical cost were also examined. All patients were followed up for at least 1 year after the treatment.For both the experimental and conventional groups, the serum bilirubin levels after treatment were significantly lower than those before treatment (P < .05); however, no significant differences between groups were seen. There were no significant differences between experimental and conventional groups in the incidence of postoperative complications and survival outcomes. Of note, the length of treatment of the experimental group was substantially shorter than that of the conventional group (P < .05). The medical expense of the experimental group was only about one-third of that of the conventional group (P < .05).Although the interventional therapy does not improve patients' survivals and reduce the incidence of complications, it significantly shortens the treatment length, reducing substantially the medical expense. This finding provides new insights into the treatment strategy for patients with advanced HCCA.

The clinicopathological factors associated with prognosis of patients with resectable perihilar cholangiocarcinoma: A systematic review and meta-analysis

The refinement in surgical techniques combined with the preoperative management has improved the resectability rate of perihilar cholangiocarcinoma (pCCA). However, the prognosis of pCCA with curative resection is still dismal. This meta-analysis was performed to investigate the prognostic clinicopathological factors in resectable pCCA.PubMed, the Cochran Library, ScienceDirect, and Web of Science were searched systematically to identify reports focusing on studying the prognostic clinicopathological factors in resectable pCCA. The hazard ratios (HRs) and its 95% confidence interval (95%CI) from the identified studies using Cox proportional hazard regression model were extracted for overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) analysis.Three prospective and 35 retrospective cohort studies including 5681 resectable pCCA were included in the pooled analysis. Among more than 20 clinicopathological factors associated with negative survival of pCCA, only 6 were included in quantitative analysis which showed that lymph node involvement was associated with a reduced OS (HR = 2.04; 95%CI: 2.10-2.62), DSS (HR = 1.80; 95%CI: 1.39-2.34), DFS (HR = 4.38; 95%CI: 1.89-10.14), negative resection margin (HR = 2.04; 95%CI:1.73-2.41), operative transfusion (HR = 1.82; 95%CI: 1.06-3.11), and T3 or T4-stage (HR = 2.04; 95%CI: 2.04-2.53) were poor prognostic factors of OS, and poor or moderate differentiation was also an adverse prognostic factor of OS (HR = 2.71; 95%CI: 1.80-4.07) and DSS (HR = 1.74; 95%CI: 1.25-2.44). The overall median resectability rate (95CI%), R0 resection (95CI%), and 5-year OS (95CI%) in Eastern and Western countries were 74.9 (66.4-78.4) % and 41.3 (32.6-80.8) %, 70.7 (65.6-80.8) % and 75.9 (64.0-80.4) %, and 33.0 (29.7-39.7) % and 25.5 (20.0-31.6) %, respectively.Negative resection margin, lymph node involvement, poor or moderate differentiation grade was identified as the negative predictor factors of resectable pCCA. Operative transfusion and T3/T4 stage were also associated with a reduced survival of resectable pCCA.

Precision medicine in cholangiocarcinoma

Cholangiocarcinoma is one of the epithelial cancers with the poorest prognosis and the narrowest therapeutic choice in humans. Compared with other cancer types, cholangiocarcinoma has been often neglected by oncology and liver research studies, thereby leaving many issues unsolved. Apart from the early and marked aggressiveness, one of the main reasons of the still unsatisfying clinical management of cholangiocarcinoma is its wide tumor heterogeneity needing more than other diseases a 'precision medicine' approach. In this regard, in the last few years there has been an awakening of interest aimed at dissecting the complex molecular and genomic profile of cholangiocarcinoma. Thus, a range of molecular players have been recently identified as putative mechanistic determinants of cholangiocarcinoma invasiveness, encompassing tyrosine kinase receptors, metabolic enzymes, transcription factors, small GTPases, ubiquitin ligases, and chromatin-remodelling proteins, whose aberrant expression may derive from stochastic mutations as well as from pro-oncogenic paracrine signals released by the stromal microenvironment, which is particularly exuberant in cholangiocarcinoma. Herein, we sought to overview the most relevant observations unravelling the genomic landscape of cholangiocarcinoma, and the prognostic and predictive biomarkers that consequently have been emerging. Then, we will discuss innovative treatment approaches derived from conventional chemotherapy, targeted therapies, antiangiogenic therapies and immunotherapy, and how they are opening new avenues towards a precision medicine in cholangiocarcinoma.

Outcomes of adjuvant treatments for resectable intrahepatic cholangiocarcinoma: Chemotherapy alone, sequential chemoradiotherapy, or concurrent chemoradiotherapy

BACKGROUND

Prospective randomized trials have not been used to evaluate the efficacy of adjuvant therapies after intrahepatic cholangiocarcinoma (ICC) resection.

METHODS

We analyzed data from the Taiwan Cancer Registry database of ICC patients receiving resection. To compare outcomes, patients with ICC were enrolled and categorized into the following adjuvant treatment modality groups: group 1, concurrent chemoradiotherapy (CCRT); group 2, sequential chemotherapy (CT) and radiotherapy (RT); and group 3, CT alone.

RESULTS

We enrolled 599 patients with resectable ICC who received surgery without distant metastasis. Of these patients, 174 received adjuvant CCRT (group 1), 146 received adjuvant sequential CT and RT (group 2), and 279 received adjuvant CT alone (group 3). Multivariate Cox regression analysis indicated that pathologic stage and positive margin were significantly poor independent predictors. After adjustment for confounders, adjusted hazard ratios (95% confidence intervals) for overall mortality at advanced pathologic stages III and IV were 0.55 (0.41-0.74) and 0.92 (0.70-1.33) in groups 1 and 2, respectively, compared with group 3.

CONCLUSIONS

Adjuvant CCRT improved survival in resected ICC with advanced pathologic stages or a positive margin in early pathologic stages compared with adjuvant CT alone or adjuvant sequential CT and RT.