Risk stratification and prognostic nomogram for post-recurrence overall survival in patients with recurrent extrahepatic cholangiocarcinoma

Radiographic features predictive of recurrence and survival after surgical resection of perihilar cholangiocarcinoma

Objective

To study which radiographic features were associated with recurrence and adverse outcome in patients undergoing surgical resection of perihilar cholangiocarcinoma (PCCA), as well as to evaluate the imaging patterns that signify recurrence after the resection of PCCA.

Materials and methods

This study was conducted in a solitary tertiary center and utilized a retrospective, analytical, case-control design. The study population consisted of patients with pathologically confirmed PCCA who underwent surgical resection and were subsequently followed up from January 2009 to December 2017. A total of 77 patients were enrolled in the study and were categorized into two distinct groups, namely recurrent and non-recurrent. The analysis encompassed the examination of demographic data and recurrence patterns. Additionally, survival and multivariate analyses were employed to assess radiographic imaging data and surgical information.

Results

Seventy-seven patients diagnosed with PCCA based on pathological evidence were included in the study. Among the participants, there were 28 females and 49 males, with ages ranging from 41 to 81 years (mean age of 60.65 ± 7.66). A noteworthy finding was the recurrence rate of 65 % observed following surgical resection. The presence of regional lymph node (LN) metastasis, adjacent organ invasion, and surgical margin emerged as the three independent factors that exhibited a significant association with recurrence after post-operative resection (p = 0.023, p = 0.028, and p = 0.010, respectively). The patients with PCCA who experienced regional LN metastasis had a median overall survival (OS) of 22 months, which was significantly lower than the 46 months observed in those without regional LN metastasis (p < 0.018). Furthermore, the individuals with regional LN metastasis had a death rate that was 2.08 times higher than those without (p = 0.040). In addition, those with adjacent organ invasion had an OS duration of 21 months compared with 52 months in those without (p = 0.008), and the rate of death was 2.39 times higher (p = 0.018). Patients with an R1 resection margin had an OS duration of 36 months compared with 51.56 months in those with an R0 resection margin (p = 0.006), as well as a 2.13 times higher rate of recurrence (p = 0.010) and a 2.43 times higher mortality rate (p = 0.013).

Conclusion

The presence of regional LN metastasis, invasion of adjacent organs, and R1 resection margin were identified as distinct factors that are linked to both disease recurrence and reduced OS. Local recurrence, as well as the spread of cancer to distant organs such as the lungs and liver, were frequently observed patterns of recurrence. To enhance the precision of staging, prognosis, and treatment, the inclusion of periductal fat or invasion of adjacent organs should be considered in the staging system for PCCA.

Nomogram based on preoperative clinical and MRI features to estimate the microvascular invasion status and the prognosis of solitary intrahepatic mass-forming cholangiocarcinoma

PURPOSE

To develop a nomogram based on preoperative clinical and magnetic resonance imaging (MRI) features for the microvascular invasion (MVI) status in solitary intrahepatic mass-forming cholangiocarcinoma (sIMCC) and to evaluate whether it could predict recurrence-free survival (RFS).

METHODS

We included 115 cases who experienced MRI examinations for sIMCC with R0 resection. The preoperative clinical and MRI features were extracted. Independent predictors related to MVI+ were evaluated by stepwise multivariate logistic regression, and a nomogram was constructed. A receiver operating characteristic (ROC) curve was used to assess the predictive ability. All patients were classified into high- and low-risk groups of MVI. Then, the correlations of the nomogram with RFS in patents with sIMCC were analyzed by Kaplan-Meier method.

RESULTS

The occurrence rate of MVI+ was 38.3% (44/115). The preoperative independent predictors of MVI+ were carbohydrate antigen 19-9 > 37 U/ml, tumor size > 5 cm, and an ill-defined tumor boundary. Integrating these predictors, the nomogram exerted a favorable diagnostic performance with areas under the ROC curve of 0.767 (95% confidence interval [CI] 0.654-0.881) in the development cohort, and 0.760 (95% CI 0.591-0.929) in the validation cohort. In the RFS analysis, significant differences were observed between the high- and low-risk MVI groups (6-month RFS rates: 64.5% vs. 78.8% and 46.7% vs. 82.4% in the development and validation cohorts, respectively) (P < 0.05).

CONCLUSIONS

A nomogram based on clinical and MRI features is a potential biomarker of MVI and may be a potent method to classify the risk of recurrence in patients with sIMCC.

Cancer-specific survival in patients with cholangiocarcinoma after radical surgery: a Novel, dynamic nomogram based on clinicopathological features and serum markers

BACKGROUND

This study aims to (1) identify preoperative testing-based characteristics associated with enhanced prognosis and survival for cholangiocarcinoma patients, and (2)create a distinctive nomogram to anticipate each patient's cancer-specific survival (CSS).

METHODS

Retrospective analysis was performed on 197 CCA patients who underwent radical surgery at Sun Yat-sen Memorial Hospital; they were divided into a 131-person "training cohort" and a 66-person "internal validation cohort." The prognostic nomogram was created following a preliminary Cox proportional hazard regression search for independent factors influencing the patients' CSS. Its applicable domain was examined via an external validation cohort, which included 235 patients from the Sun Yat-sen University Cancer Center.

RESULTS

The median follow-up period for the 131 patients in the training group was 49.3 months (range, 9.3 to 133.9 months). One-, three-, and five-year CSS rates were 68.7%, 24.5%, and 9.2%, respectively, with the median CSS length being 27.4 months (range: 1.4 to 125.2 months). PLT, CEA, AFP, tumor location, differentiation, lymph node metastasis, chemotherapy, and TNM stage were determined to be independent risk factors for CCA patients by univariate and multivariate Cox proportional hazard regression analysis. We were able to accurately predict postoperative CSS after incorporating all of these characteristics into a nomogram. The AJCC's 8th edition staging method's C-indices were statistically substantially (P < 0.001) lower than the nomogram's C-indices (0.84, 0.77, and 0.74 in the training, internal and external validation cohorts respectively).

CONCLUSIONS

A realistic and useful model for clinical decision-making and the optimization of therapy is presented as a nomogram that includes serum markers and clinicopathologic features for predicting postoperative survival in cholangiocarcinoma.

Development and validation of an online calculator to predict early recurrence and long-term survival in patients with distal cholangiocarcinoma after pancreaticoduodenectomy

BACKGROUND

Distal cholangiocarcinoma (DCC) is a malignancy associated with a short survival time. In this study, we aimed to create an online nomogram calculator to predict early recurrence and long-term survival in patients with DCC after pancreaticoduodenectomy.

METHODS

A total of 486 patients with DCC were included. An online nomogram calculator was developed and validated in training, internal validation and external validation cohorts, respectively.

RESULTS

Of the 486 patients who met the inclusion criteria, we allocated 240, 120, and 126 patients to the training, internal validation, and external validation cohorts, respectively. Multivariable analysis showed that preoperative CA19-9, maximum tumor diameter, perineural invasion, and tumor differentiation were significant risk factors for early recurrence in patients with DCC. Incorporating these four factors, the nomogram achieved good AUC values of 0.788, 0.771, and 0.723 for predicting early recurrence in the training, internal validation, and external validation cohorts, respectively. Notably, this nomogram also had good power to predict overall survival. The discrimination ability of the nomogram was evaluated by dividing the predicted probabilities of early recurrence and survival into two risk groups in the training cohort (low risk ≤ 132; high risk > 132; P < .001). Time-dependent ROC and decision curve analysis further revealed that the nomogram provided higher diagnostic capacity and superior net benefit compared to other staging systems.

CONCLUSION

This study developed and validated a web-based nomogram calculator that was capable of predicting early recurrence and long-term prognosis in patients with DCC after pancreaticoduodenectomy with high degrees of stability and accuracy.

A novel online calculator to predict recurrence risk in patients with distal cholangiocarcinoma after radical pancreaticoduodenectomy

BACKGROUND

Patients with distal cholangiocarcinoma (DCC) are prone to relapse even after radical pancreaticoduodenectomy. In this study, we sought to create an online nomogram calculator to accurately predict the recurrence risk of DCC.

METHODS

A total of 184 patients were included. Multivariate Cox regression analysis was used to identify independent prognosis factors for recurrence-free survival and overall survival. A nomogram was constructed according to the prognostic factors in the training cohort and then tested in the validation cohort.

RESULTS

Multivariate Cox analysis showed preoperative carbohydrate antigen 19-9 (p < 0.001), maximum tumor size (p = 0.076), perineural invasion (p = 0.044), and N stage (p = 0.076) were independent prognostic factors for DCC relapse. We then constructed a nomogram with these four factors. The consistency index (C-index) of the nomogram in the training and validation cohorts were 0.703 and 0.665, respectively. Time-dependent receiver operating characteristic and decision curve analyses revealed that the nomogram provided higher diagnostic power and net benefit compared with other staging systems.

CONCLUSION

In this study, we developed an online nomogram calculator that can accurately predict the recurrence risk of DCC and identify patients with a high risk of recurrence in a simple and convenient manner.

A prognostic model in patients with advanced biliary tract cancer receiving first-line chemotherapy

BACKGROUND

Standard treatment of advanced biliary tract cancer (aBTC) is represented by first-line chemotherapy (CT1). However, some patients do not gain any benefit from CT1, contributing to the overall dismal prognosis of aBTC. The present study aimed to devise a prognostic model in aBTC patients receiving CT1.

METHODS

A large panel of clinical, laboratory, and pathology variables, available before the start of CT1, were retrospectively assessed in a multi-centric cohort to determine their prognostic value on univariate and multivariate regression analysis. The variables that showed a significant correlation with overall survival (OS) were computed in a three-tier prognostic score. External validation of the prognostication performance was carried out.

RESULTS

Clinical histories of 935 patients (median OS 10.3 months), with diagnosis dates ranging from 2001 to 2017, were retrieved from 14 institutions. According to multivariate analysis, Eastern Cooperative Oncology Group performance status, carbohydrate antigen 19.9, albumin levels, and neutrophil/lymphocyte ratio were strongly associated with OS (p <0.01). The prognostic score could generate a highly significant stratification (all between-group p values ≤0.001) into groups of favorable (comprising 51.5% of the sample), intermediate (39.2%), and poor prognosis (9.3%): median OS was 12.7 (CI_95% 11.0-14.4), 7.1 (CI_95% 5.8-8.4), and 3.2 months (CI_95% 1.7-4.7), respectively. This OS gradient was replicated in the validation set (129 patients), with median OS of 12.7 (CI_95% 11.0-14.3), 7.5 (CI_95% 6.1-8.9), and 1.4 months (CI_95% 0.1-2.7), respectively (all between-group p values ≤0.05).

CONCLUSION

A prognostic score, derived from a limited set of easily-retrievable variables, efficiently stratified a large population of unselected aBTC patients undergoing CT1. This tool could be useful to clinicians, to ascertain the potential benefit from CT1 at the start of treatment.

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.

Next-generation sequencing-guided molecular-targeted therapy and immunotherapy for biliary tract cancers

BACKGROUND

Chemotherapy is a standard regimen for advanced or relapsed biliary tract cancer (BTC) with a 5-year overall survival (OS) rate of approximately 5% and a median OS of less than a year. Targeted therapies and immunotherapy aimed at providing more personalized treatments for BTCs have been tested. The objective of this study was to evaluate the effects of targeted therapy and immunotherapy on advanced BTC patients.

METHODS

Twenty-four advanced/relapsed BTC patients were enrolled and examined with next-generation sequencing (NGS). Eight of them received NGS-guided targeted or immunotherapy, and the other 16 patients underwent routine chemotherapy. Comparison analysis of OS and objective response rate (ORR) was performed.

RESULTS

IDH1, BRCA2, MAP2K1, and BRAF (V600E) were the major actionable genes mutated in this cohort. Patients who received NGS-guided therapy exhibited higher OS (not achieved vs. 6.5 months, p < 0.001) and ORR (87.5% vs. 25%, p < 0.001) than those without targetable mutations and who received first-line chemotherapy. BTCs harboring mutations in IDH1, ATM/BRCA2, or MAP2K1/BRAF (V600E) received treatment with dasatinib, olaparib, or trametinib, respectively. Three of the patients had high tumor mutation burden (TMB-H) and were treated with immune-checkpoint inhibitors and chemotherapy. All these patients achieved complete response or partial response.

CONCLUSIONS

NGS-guided targeted therapy and immunotherapy are promising personalized therapies for advanced or relapsed BTCs. TMB is a useful biomarker for predicting immunotherapy efficacy.

A Novel Prognostic Nomogram for Patients With Recurrence of Intrahepatic Cholangiocarcinoma After Initial Surgery

Background: The prognosis of patients with post-operative recurrent intrahepatic cholangiocarcinoma (ICC) is at great variance. We aimed to propose a novel efficient prognostic nomogram in facilitating the risk stratification for post-operative recurrent ICC patients. Methods: From 2000 to 2016, a total of 237 post-operative recurrent ICC patients were enrolled in this study, and randomly divided into training (n = 178) and validation cohorts (n = 59) at a ratio of 3:1. The performance of this nomogram was assessed by discrimination, calibration, and clinical usefulness, and the results were compared with four other currently used ICC staging systems. Results: On multivariate analysis of the training cohort, serum CA 19-9, albumin-bilirubin grade at recurrence, time from primary resection to recurrence, tumor number at recurrence, and treatment for recurrence were selected for the model. The concordance index (C-index) of our model was 0.791 [95% confidence interval (CI), 0.736-0.846], which was statistically higher than the values of the following systems: American Joint Committee on Cancer (AJCC) 8th edition (0.610), Liver Cancer Study Group of Japan (0.613), Nathan (0.582), and Okabayashi (0.600; P < 0.001 for all). The nomogram performed well in terms of calibration when compared with actual observation. The findings were supported by the validation cohort. Conclusions: Compared with four currently used staging systems for ICC, our nomogram showed more promising clinical utility in improving individualized predictions of survival for post-operative recurrent ICC patients.

Development and validation of a preoperative nomogram for predicting survival of patients with locally advanced prostate cancer after radical prostatectomy

Background

For selected locally advanced prostate cancer (PCa) patients, radical prostatectomy (RP) is one of the first-line treatments. We aimed to develop a preoperative nomogram to identify what kinds of patients can get the most survival benefits after RP.

Methods

We conducted analyses with data from the Surveillance, Epidemiology, and End Results (SEER) database. Covariates used for analyses included age at diagnosis, marital status, race, American Joint Committee on Cancer (AJCC) 7th TNM stage, Prostate specific antigen, Gleason biopsy score (GS), percent of positive cores. We estimated the cumulative incidence function for cause-specific death. The Fine and Gray’s proportional subdistribution hazard approach was used to perform multivariable competing risk analyses and reveal prognostic factors. A nomogram was built by these factors (including GS, percent of positive cores and N stage) and validated by concordance index and calibration curves. Risk stratification was established based on the nomogram.

Results

We studied 14,185 patients. N stage, GS, and percent of positive cores were the independent prognostic factors used to construct the nomogram. For validating, in the training cohort, the C-index was 0.779 (95% CI 0.736–0.822), and in the validation cohort, the C-index was 0.773 (95% CI 0.710–0.836). Calibration curves showed that the predicted survival and actual survival were very close. The nomogram performed better over the AJCC staging system (C-index 0.779 versus 0.764 for training cohort, and 0.773 versus 0.744 for validation cohort). The new stratification of risk groups based on the nomogram also showed better discrimination than the AJCC staging system.

Conclusions

The preoperative nomogram can provide favorable prognosis stratification ability to help clinicians identify patients who are suitable for surgery.

Nomogram incorporating clinicopathological parameters to predict the survival of patients with mantle cell lymphoma

This study intended to present a practicable prognostic nomogram for patients with mantle cell lymphoma (MCL). The clinical data of 281 patients were reviewed. A nomogram that could predict overall survival (OS) was constructed based on the Cox proportional hazard model. To compare the capacity of the nomogram with the International Prognostic Index (IPI) and MCL International Prognostic Index (MIPI) scoring systems, we used the concordance index (C-index) to validate the veracity and the calibration curve. Age, Eastern Cooperation Oncology Group, lactate dehydrogenase, white cell count and Ki-67 were independent prognostic factors in the multivariate analysis and were subsequently included in the nomogram construction. The C-index was 0.81 and 0.79 in the primary and validation cohorts, respectively, which were superior to the predictive capacity of the IPI and MIPI systems in both cohorts. The nomogram makes it possible for physicians to predict patient OS individually and correctly, but certain limitations are noted.

Pattern of the First Recurrence Has No Impact on Long-Term Survival after Curative Intent Surgery for Perihilar Cholangiocarcinomas

AIM

To explore the pattern of the first recurrence and impact on long-term survival after curative intent surgery for perihilar cholangiocarcinomas (PHC).

MATERIALS AND METHODS

Patients with curative intent surgery for PHC between 1996 and 2017 were analyzed. Survival times were estimated using the Kaplan-Meier method. Comparisons were made with the log-rank test.

RESULTS

A number of 139 patients were included. The median overall survival was 26 months. A recurrence was observed in 86 patients (61.9%), during a median follow-up time of 89 months. The median disease-free survival was 21 months with 1-, 3-, 5-, and 10-year estimated recurrence rates of 38%, 60%, 69%, and 77%, respectively. A number of 57 patients (41%) developed distant only recurrence, while 26 patients (18.7%) presented local and distant recurrences. An isolated local recurrence was observed in 3 patients (2.2%). The median overall survival was 15 months for patients with local recurrence, 15 months for patients with liver metastases, and 17 months for patients with peritoneal carcinomatosis (p = 0.903) as the first recurrence.

CONCLUSION

Curative intent surgery for PHC is associated with high recurrence rates. Most patients will develop distant metastases, while an isolated local recurrence is uncommon. The pattern of recurrence does not appear to have a significant impact on survivals.