Prognostic influence of multiple hepatic lesions in resectable intrahepatic cholangiocarcinoma: A systematic review and meta-analysis

Oncologic impact of statin use on patients treated with hepatectomy for intrahepatic cholangiocarcinoma

AIM

Currently, the only recognized curative treatment for intrahepatic cholangiocarcinoma (ICC) is surgical resection. However, the impact of various clinical factors, including patient history and pharmacological interventions, on survival outcomes is still not fully understood. We aimed to bridge this knowledge gap by identifying clinical determinants that may influence the prognosis of ICC after surgical resection.

METHODS

We conducted a study on 172 patients who underwent hepatectomy for ICC between 2010 and 2019. We evaluated patient demographics, tumor characteristics, and whether patients were on statin therapy. Kaplan-Meier methods were used to analyze overall survival (OS) and recurrence-free survival (RFS), whereas multivariate analysis was utilized to identify prognostic factors.

RESULTS

Statin use was associated with significantly improved OS and RFS. The mean OS was 90.5 months in the statin group compared to 59.9 months in the statin-naive group (p = 0.001). Similarly, RFS was longer in the statin group (77.3 vs. 48.1 months; p = 0.006). Subgroup analyses demonstrated consistent benefits of statin use across different age groups and genders. Multivariate analysis identified statin use as an independent prognostic factor for OS (HR: 0.49, 95% CI: 0.29-0.82, p = 0.007) and RFS (HR: 0.60, 95% CI: 0.36-0.98, p = 0.043).

CONCLUSIONS

Statin therapy may be a potentially favorable medication for patients undergoing hepatectomy for ICC. However, further evaluation of its clinical benefits is required, and additional studies are recommended.

Tumour burden predicts outcomes after curative resection of multifocal intrahepatic cholangiocarcinoma

BACKGROUND

Liver resection for multifocal intrahepatic cholangiocarcinoma (ICC) remains controversial due to a poor prognosis, driven by aggressive tumour biology. The aim of this study was to stratify multifocal ICC patients to identify those who are likely to benefit from resection.

METHODS

Patients who underwent upfront curative-intent hepatectomy for ICC were identified from an international multi-institutional database. Among patients with multifocal tumours, overall survival (OS) was analysed using multivariable Cox regression to identify prognostic factors. Tumour burden score (TBS) was used for stratification of multifocal ICC, with the optimal cut-off determined via restricted cubic spline (RCS) analysis.

RESULTS

Of 1502 patients, 208 (13.8%) had multifocal ICC. Among them, independent predictors of prognosis included TBS (HR 1.09), ASA grade >II (HR 1.48), cirrhosis (HR 2.05), periductal infiltrating/mass forming plus periductal infiltrating morphological subtype (HR 1.58), and receipt of adjuvant chemotherapy (HR 0.59). RCS analysis identified a TBS of 7.0 as the optimal cut-off. Notably, multifocal ICC patients with a low TBS (<7.0) demonstrated comparable 3-year OS to solitary ICC patients with AJCC stage II/III. In contrast, patients with a high TBS (≥7.0) and multifocal ICC exhibited the worst prognosis (3-year OS: stage I and solitary 67.1%, stage II/III and solitary 43.2%, low TBS and multifocal 43.4%, and high TBS and multifocal 17.8% (P < 0.001)).

CONCLUSION

Whereas patients with high-TBS multifocal ICC had a poor prognosis, individuals with low-TBS multifocal ICC demonstrated survival outcomes comparable to solitary ICC patients. These findings emphasize the importance of stratifying patients by tumour burden to guide surgical decision-making and optimize treatment strategies for multifocal ICC.

Standardizing the reporting of cholangiocarcinoma: the society of abdominal radiology disease focused panel on cholangiocarinoma lexicon

In March 2023, the Society of Abdominal Radiology (SAR) Disease Focused Panel (DFP) on Cholangiocarcinoma (CCA) was formed. One of its initial tasks was for creation of a lexicon specific for CCA to complement the terms related to the Liver Imaging Reporting and Data System (LI-RADS) category M. A committee was formed and vetted 15 unique terms for CCA. The multidisciplinary members of the DFP passed each term by over 90% approval. The purpose of this paper is to describe the process for developing the lexicon, introduce the lexicon terms, and provide a pictorial atlas of the 15 vetted terms relating to the imaging findings of CCA.

[Prognostic factors and preoperative therapy in resectable intrahepatic cholangiocarcinoma]

OBJECTIVE

To identify prognostic factors and role of preoperative therapy for resectable intrahepatic cholangiocarcinoma (IHCC).

MATERIAL AND METHODS

We analyzed the results of surgical and combined treatment of IHCC between 1999 and 2023. Immediate and long-term outcomes were evaluated depending on negative prognostic factors and additional therapy.

RESULTS

The study included 195 patients. Postoperative complications grade ≥III were observed in 35 (17.9%) case. Mortality rate was 3.1% (n=6). Thirty-eight patients (19.5%) underwent treatment before surgery, 109 (55.9%) ones - after surgery. The median overall survival was 31 months, 5-year overall survival - 32.0%. The following factors worsened overall survival: node size ≥8 cm (HR 1.45; 95% CI 0.97-2.17), invasion (HR 1.63; 95% CI 1.07-2.47), multiple lesion (HR 1.51; 95% CI 1.00-2.28). R1 resection worsened disease-free survival (HR 1.88; 95% CI 1.14-3.10). Lymph node metastases decreased overall (HR 1.96; 95% CI 1.27- 3.04) and disease-free survival (HR 2.37; 95% CI 1.63-3.44). Two and more negative factors worsened overall (p=0.0013) and disease-free survival (p=0.0005). Absence of adjuvant therapy worsened overall (HR 2.12; 95% CI 1.41-3.20) and disease-free survival (HR 1.42; 95% CI 0.99-2.04). There was a trend towards higher overall (p=0.088) and progression-free survival (p=0.029) in case of preoperative therapy (n=195). In unfavorable prognosis group, preoperative therapy (n=33) was superior to standard treatment (resection+capecitabine after surgery, n=26). There was a trend towards higher overall survival (p=0.066) and significantly better progression-free survival (17 vs 13 months, p=0.018).

CONCLUSION

Negative prognostic factors for resectable IHCC are lesion size ≥8 cm, intrahepatic and regional metastases, invasion into neighboring structures, R1 resection. Combination of negative factors worsened prognosis. Adjuvant therapy improved postoperative outcomes. Preoperative therapy may be advisable in case of negative factors and high risk of R1 resection.

Introducing and Validating the Multiphasic Evidential Decision-Making Matrix (MedMax) for Clinical Management in Patients with Intrahepatic Cholangiocarcinoma

Background: Despite the significant advancements of liver surgery in the last few decades, the survival rate of patients with liver and pancreatic cancers has improved by only 10% in 30 years. Precision medicine offers a patient-centered approach, which, when combined with machine learning, could enhance decision making and treatment outcomes in surgical management of ihCC. This study aims to develop a decision support model to optimize treatment strategies for patients with ihCC, a prevalent primary liver cancer. Methods: The decision support model, named MedMax, was developed using three data sources: studies retrieved through a systematic literature review, expert opinions from HPB surgeons, and data from ihCC patients treated at Heidelberg University Hospital. Expert opinions were collected via surveys, with factors rated on a Likert scale, while patient data were used to validate the model's accuracy. Results: The model is structured into four decision-making phases, assessing diagnosis, treatment modality, surgical approach, and prognosis. Prospectively, 44 patients with ihCC were included for internal primary validation of the model. MedMax could predict the appropriate treatment considering the resectability of the lesions in 100% of patients. Also, MedMax could predict a decent surgical approach in 77% of the patients. The model proved effective in making decisions regarding surgery and patient management, demonstrating its potential as a clinical decision support tool. Conclusions: MedMax offers a transparent, personalized approach to decision making in HPB surgery, particularly for ihCC patients. Initial results show high accuracy in treatment selection, and the model's flexibility allows for future expansion to other liver tumors and HPB surgeries. Further validation with larger patient cohorts is required to enhance its clinical utility.

A snapshot on current approaches to lymphadenectomy in liver resection for intrahepatic cholangiocarcinoma: results from an international survey

The use of lymphadenectomy (LND) during resection of intrahepatic cholangiocarcinoma (ICC) is still debated, leading to differing practices in different centers and countries. The aim of this study was to assess such differences. A survey on LND for ICC was distributed to the members of the International Hepato-PancreatoBiliary Association (IHPBA) and the Italian Chapter of IHPBA (AICEP). Two-hundred thirty-four surgeons completed the survey (88% males; median age 46 years). Preoperative nodal staging was deemed mandatory/very important by 65%. Adequate LND was defined as hepatoduodenal ligament LND by 33%, LND at specific nodal stations by 28% and retrieval of > 5 nodes by 28%. The decision to perform LND was influenced by comorbidities (48%), chronic liver disease (38%) and satellitosis (32%). Most participants modify perioperative management in case of clinically positive nodes, 50% stating they would give neoadjuvant therapy. The role of LND in clinically node negative disease was adequate staging for 88%, survival benefit for 50.5% and clinical trials eligibility for 18.5%. Our survey confirms heterogeneity in the evaluation of role and extent of LND for ICC, how this relates to subjective perception of importance of LND, and need of a systematic approach in this area.

Biliary tract cancer

BACKGROUND

Biliary tract cancers comprise a heterogeneous collection of malignancies usually described as cholangiocarcinoma of the intra- or extrahepatic bile duct, including perihilar cholangiocarcinoma and gallbladder cancer.

METHODS

A review of pertinent parts of the ESSO core curriculum for the UEMS diploma targets (Fellowships exam, EBSQ), based on updated and available guidelines for diagnosis, surgical treatment and oncological management of cholangiocarcinoma.

RESULTS

Following the outline from the ESSO core curriculum we present the epidemiology and risk factors for cholangiocarcinoma, as well as the rationale for the current diagnosis, staging, (neo-)adjuvant treatment, surgical management, and short- and long-term outcomes. The available guidelines and consensus reports (i.e. NCCN, BGS and ESMO guidelines) are referred to. Recognition of biliary tract cancers as separate entities of the intrahepatic biliary ducts, the perihilar and distal bile duct as well as the gallbladder is important for proper management, as they each provide distinct clinical, molecular and treatment profiles to consider.

CONCLUSION

Core competencies in knowledge to the diagnosis, management and outcomes of biliary tract cancers are presented.

Clonal analysis of metachronous double biliary tract cancers

The molecular mechanisms underpinning the development of metachronous tumors in the remnant bile duct following surgical resection of primary biliary tract carcinomas (BTCs) are unknown. This study aimed to elucidate these mechanisms by evaluating the clinicopathologic features of BTCs, the alterations to 31 BTC-related genes on targeted sequencing, and the aberrant expression of p53, p16, SMAD4, ARID1A and β-catenin on immunohistochemistry. Twelve consecutive patients who underwent resection of metachronous BTCs following primary BTC resection with negative bile duct margins were enrolled. Among the 12 metachronous tumors, six exhibited anterograde growth in the lower portion and six exhibited retrograde growth in the upper portion of the biliary tree. Surgical resection of metachronous BTCs resulted in recurrence-free survival in seven, local recurrence in five, and death in two patients. Nine achieved 5-year overall survival after primary surgery. Molecular analyses revealed that recurrently altered genes were: TP53, SMAD4, CDKN2A, ELF3, ARID1A, GNAS, NF1, STK11, RNF43, KMT2D and ERBB3. Each of these was altered in at least three cases. A comparison of the molecular features between 12 paired primary and metachronous BTCs indicated that 10 (83%) metachronous tumors developed in clonal association with corresponding primary tumors either successionally or phylogenically. The remaining two (17%) developed distinctly. The successional tumors consisted of direct or evolved primary tumor clones that spread along the bile duct. The phylogenic tumors consisted of genetically unstable clones and conferred a poor prognosis. Metachronous tumors distinct from their primaries harbored fewer mutations than successional and phylogenic tumors. In conclusion, over 80% of metachronous BTCs that develop following primary BTC resection are probably molecularly associated with their primaries in either a successional or a phylogenetic manner. Comparison between the molecular features of a metachronous tumor and those of a preceding tumor may provide effective therapeutic clues for the treatment of metachronous BTC. © 2024 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

The causal relationship between gut microbiota and biliary tract cancer: comprehensive bidirectional Mendelian randomization analysis

Background

Growing evidence has shown that gut microbiome composition is associated with Biliary tract cancer (BTC), but the causality remains unknown. This study aimed to explore the causal relationship between gut microbiota and BTC, conduct an appraisal of the gut microbiome's utility in facilitating the early diagnosis of BTC.

Methods

We acquired the summary data for Genome-wide Association Studies (GWAS) pertaining to BTC (418 cases and 159,201 controls) from the Biobank Japan (BBJ) database. Additionally, the GWAS summary data relevant to gut microbiota (N = 18,340) were sourced from the MiBioGen consortium. The primary methodology employed for the analysis consisted of Inverse Variance Weighting (IVW). Evaluations for sensitivity were carried out through the utilization of multiple statistical techniques, encompassing Cochrane's Q test, the MR-Egger intercept evaluation, the global test of MR-PRESSO, and a leave-one-out methodological analysis. Ultimately, a reverse Mendelian Randomization analysis was conducted to assess the potential for reciprocal causality.

Results

The outcomes derived from IVW substantiated that the presence of Family Streptococcaceae (OR = 0.44, P = 0.034), Family Veillonellaceae (OR = 0.46, P = 0.018), and Genus Dorea (OR = 0.29, P = 0.041) exerted a protective influence against BTC. Conversely, Class Lentisphaeria (OR = 2.21, P = 0.017), Genus Lachnospiraceae FCS020 Group (OR = 2.30, P = 0.013), and Order Victivallales (OR = 2.21, P = 0.017) were associated with an adverse impact. To assess any reverse causal effect, we used BTC as the exposure and the gut microbiota as the outcome, and this analysis revealed associations between BTC and five different types of gut microbiota. The sensitivity analysis disclosed an absence of empirical indicators for either heterogeneity or pleiotropy.

Conclusion

This investigation represents the inaugural identification of indicative data supporting either beneficial or detrimental causal relationships between gut microbiota and the risk of BTC, as determined through the utilization of MR methodologies. These outcomes could hold significance for the formulation of individualized therapeutic strategies aimed at BTC prevention and survival enhancement.

[The Russian consensus on the treatment of intrahepatic cholangiocarcinoma]

The Russian consensus on the treatment of intrahepatic cholangiocarcinoma was prepared by the group of experts consisting of surgeons, interventional radiologists, radiation therapists and oncologists. The purposes of this consensus are clarification and consolidation of opinions of multidisciplinary team on the following issues of management of patients with intrahepatic cholangiocarcinoma: indications for surgical treatment, features of therapeutic tactics for mechanical jaundice, technical aspects of liver resection, prevention of post-resection liver failure, indications for liver resection using transplantation technologies, laparoscopic and robot-assisted liver resection, perioperative systemic chemotherapy, local non-resection/non-radiotherapy methods of treatment, radiotherapy, follow-up and choice of treatment for recurrence.