Peritoneal seeding of cholangiocarcinoma in patients with percutaneous biliary drainage

Pre-operative biliary drainage is associated with shortened survival time in patients with cholangiocarcinoma

Background and objective

Although pre-operative biliary drainage (PBD) is frequently performed in patients with cholangiocarcinoma (CCA), its impact on patient survival is unclear. Our aim was to evaluate the impact of PBD on overall survival of patients with extra-hepatic CCA.

Methods

This was a retrospective study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Patients who underwent biliary drainage within 3 months prior to and/or after diagnosis of CCA were included in the PBD cohort. Patients who did not receive biliary drainage were included in the non-PBD cohort. Cox proportional hazard regression was used to determine independent predictors of survival.

Results

Of 3862 patients with extra-hepatic CCA, 433 (11.2%) underwent curative surgical resection, with a median survival of 14 months (95% confidence interval [95% CI], 10–21 months) in the PBD cohort (n = 126) vs 31 months (95% CI, 26–39 months) in the non-PBD cohort (n = 307) (P < 0.001), during the median follow-up duration for the surgical cohort of 26 months (range, 1–60 months). Among the 433 patients, 126 (29.1%) underwent PBD and had significantly higher Charlson comorbidity index and advanced SEER stage than those without PBD before surgery. On multivariable analysis in patients who underwent curative surgical resection, after adjusting patient demographics, tumor characteristics, Charlson comorbidity index, radiotherapy and chemotherapy, PBD was significantly associated with shortened survival time (hazard ratio, 2.35; 95% CI, 1.34–4.10; P = 0.003).

Conclusions

PBD appears negative impact on long-term survival in patients with potentially resectable CCA and should be avoided if possible.

Scalp recurrence of cholangiocarcinoma after curative hepatectomy: A report of two cases

Cholangiocarcinomas are the second most common primary liver malignancies. The lymphatics are the common route of metastatic spread for cholangiocarcinomas. The most frequent sites of metastasis are the liver, abdominal lymph nodes, peritoneum and lungs. Cutaneous metastasis of cholangiocarcinoma is rare, and most commonly occurs following percutaneous biliary drainage. Brain or skull metastases from this tumor are uncommon. However, these rare metastatic lesions may occasionally be the first disease manifestation, although scalp recurrence following curative treatment is uncommon. We herein present the cases of two patients with cholangiocarcinoma, who were evaluated as resectable based on the criteria for cholangiocarcinoma resectability, and developed scalp recurrence following curative hepatectomy. Therefore, although scalp recurrence is a rare occurrence following curative treatment for cholangiocarcinoma, metastases should be included in the differential diagnosis.

Verification of the oncologic inferiority of percutaneous biliary drainage to endoscopic drainage: A propensity score matching analysis of resectable perihilar cholangiocarcinoma

BACKGROUND

Percutaneous transhepatic biliary drainage is an established biliary drainage method but is associated with a potential risk of seeding metastasis. The aim of this retrospective study was to evaluate whether percutaneous transhepatic biliary drainage really increases seeding metastasis and worsens the postoperative survival in patients with resectable perihilar cholangiocarcinoma.

METHODS

Patients who underwent resection for perihilar cholangiocarcinoma after percutaneous transhepatic biliary drainage or endoscopic biliary drainage were retrospectively reviewed. Seeding metastasis was defined as peritoneal/pleural dissemination and percutaneous transhepatic biliary drainage sinus tract recurrence. Univariate and multivariate analyses followed by propensity score matching were performed to adjust the data for the baseline characteristics of the percutaneous transhepatic biliary drainage and endoscopic biliary drainage patients.

RESULTS

Of 320 resected patients, 168 underwent percutaneous transhepatic biliary drainage and the remaining 152 received endoscopic biliary drainage before operation. The survival of the percutaneous transhepatic biliary drainage patients was significantly lower than that of the endoscopic biliary drainage patients (37.0% vs 44.3% at 5 years, P = .019). Multivariate analyses showed that percutaneous transhepatic biliary drainage was an independent predictor of poor survival (P = .011) and a risk factor for seeding metastasis (P = .005). After propensity score matching (71 patients in each group), the survival of the percutaneous transhepatic biliary drainage patients was significantly worse than that of the endoscopic biliary drainage patients (P = .018). The estimated cumulative recurrence rate of seeding metastasis was significantly higher in the percutaneous transhepatic biliary drainage patients than in the endoscopic biliary drainage patients (P = .005), while the recurrence rates at other sites were similar between the 2 groups (P = .413).

CONCLUSION

Percutaneous transhepatic biliary drainage increases the incidence of seeding metastasis and shortens the postoperative survival in patients with perihilar cholangiocarcinoma. Endoscopic biliary drainage is recommended as the optimal method for preoperative biliary drainage.

Does preoperative biliary drainage compromise the long-term survival of patients with pancreatic head carcinoma?

BACKGROUND AND OBJECTIVES

The aim of this study was to determine the impact of preoperative biliary drainage (PBD) on long-term survival in patients with pancreatic head carcinoma after surgical resection.

METHODS

Medical records of 160 patients with pancreatic head carcinoma who underwent surgical resection were reviewed retrospectively. Clinicopathological parameters including long-term survival were compared between patients who did and did not undergo PBD.

RESULTS

Overall survival of patients who underwent PBD (n = 93) was significantly worse than that of patients who did not (n = 67) by univariate analysis (P = 0.030). However, multivariate analysis revealed that PBD was not an independent prognostic factor for overall survival (P = 0.227). Patients who underwent percutaneous transhepatic biliary drainage (PTBD) had significantly worse survival than patients who underwent endoscopic retrograde biliary drainage (ERBD, P = 0.038) and patients who did not undergo PBD (P = 0.001). The rate of peritoneal recurrence in patients who underwent PTBD was significantly higher than that of patients who underwent ERBD (P = 0.033) or patients who did not undergo PBD (P = 0.034).

CONCLUSIONS

PBD may not affect the long-term survival of patients with pancreatic head carcinoma if ERBD is used.

Oncological benefit of preoperative endoscopic biliary drainage in patients with hilar cholangiocarcinoma

Due to advances in endoscopic equipment and techniques, preoperative endoscopic biliary drainage (EBD) has been developed to serve as an alternative to percutaneous transhepatic biliary drainage (PTBD). This study sought to clarify the benefit of EBD in comparison to PTBD in patients who underwent radical resections of hilar cholangiocarcinoma. One hundred and forty-one patients underwent radical surgery for hilar cholangiocarcinoma between 2000 and 2008 were retrospectively divided into two groups based on the type of preoperative biliary drainage, PTBD (n = 67) or EBD (n = 74). We investigated if the different biliary drainage methods affected postoperative survival and mode of recurrence after median observation period of 82 months. The survival rate for patients who underwent EBD was significantly higher than those who had PTBD (P = 0.004). Multivariate analysis revealed that PTBD was one of the independent factors predictive of poor survival (hazard ratio: 2.075, P = 0.003). Patients with PTBD more frequently developed peritoneal seeding in comparison to those who underwent EBD (P = 0.0003). PTBD was the only independent factor predictive of peritoneal seeding. In conclusion, EBD might confer an improved prognosis over PTBD due to prevention of peritoneal seeding, and is recommended as the initial procedure for preoperative biliary drainage in patients with hilar cholangiocarcinoma.

Endoscopic ultrasound with biopsy of omental mass for cholangiocarcinoma diagnosis in cirrhosis

In this report, a patient had a previous diagnosis of cholangiocarcinoma with an extended cholecystectomy. Three years later, he was evaluated for recurrent ascites. The patient had several large volume paracentesis, without evidence of malignant cells. Subsequently, endoscopic ultrasound (EUS) with fine needle aspiration (FNA) of both lymph and omental nodules was utilized. While the lymph nodes were negative for malignancy, the omental nodule was interrogated with multiple antibodies and was found to be positive for neoplasia. EUS with FNA can safely be used in patients with cirrhosis to spare the patient invasive evaluation such as exploratory laparotomy (ex-lap) for diagnosis and staging of cholangiocarcinoma.

Quality initiatives: strategies for anticipating and reducing complications and treatment failures in hepatic radiofrequency ablation

Radiofrequency (RF) ablation is one of several local treatment strategies that can be used for the destruction of a variety of primary and secondary liver tumors. As experience with RF ablation grows, it becomes increasingly evident that successful ablation requires meticulous technique. In addition, knowledge of potential complications is critical for both the interventionalist and the radiologist, whose postablation interpretation can facilitate identification of complications and treatment failures. Hepatic RF ablation offers significant advantages in that it is less invasive than surgery and carries a low risk of major complications. Successful prevention of complications and treatment failures begins at initial consultation and continues with preablation evaluation of specific patient factors such as coagulation profiles, use of medications, and risk factors for infection. Other predisposing factors include background liver cirrhosis, prior hepatectomy, and portal hypertension. During ablation, careful attention must be given to tumor size, number, and location. For large or multiple ablations, separate ablation sessions can help reduce the prevalence of postablation syndrome, and clustered electrodes and multiple overlapping treatment zones may be used to reduce the risk of treatment failure. It is critical to reevaluate tumors during ablation to determine the best approach and to compensate for changes in size and relative location due to patient positioning. With use of these strategies, hepatic RF ablation can be performed with greater safety, better patient tolerance, and a reduced risk of complications and treatment failures.

Cutaneous metastases from cholangiocarcinoma following percutaneous transhepatic biliary drainage: Case report and literature review

Percutaneous transhepatic biliary drainage (PTBD) is commonly used in the management of cholangiocarcioma. Major and minor complications of PTBD such as cholangitis, haemorrhage and catheter dislocation are well documented. A lesser reported complication are cutaneous metastases following PTBD for cholangiocarcinoma.

We report a case of a 79 year old man who presented with right upper quadrant pain, jaundice and weight loss, with dilated intra-hepatic bile ducts on imaging. The cytology results from a sample taken during endoscopic retrograde cholangiopancreatography were highly suspicious of cholangiocarcioma. A PTBD was subsequently performed and bilateral metal biliary stents were placed without external drainage. Five months after the PTBD he was found to have a hard nodule under the PTBD puncture site. The nodule was excised and the histology confirmed a cholangiocarcinoma metastasis.

A review of the literature identified twelve cases of cutaneous metastases from cholangiocarcinoma, following PTBD. In addition, tumour seeding along the catheter tract following PTBD, with metastatic deposits on the abdominal wall, peritoneoum, chest wall, pleural space, and liver parenchyma have also been reported.

Health care professionals should be aware of this rare complication and offer appropriate management options to patients.

Does bile spillage during an operation present a risk for peritoneal metastasis in bile duct carcinoma?

Whether bile spillage during operation presents a risk for peritoneal metastasis in the treatment of bile duct carcinoma was studied in 15 patients (12 with bile duct cancer, 3 with cancer of the papilla of Vater) who had all undergone a pancreatoduodenectomy. Preoperative bile was sampled through a percutaneous transhepatic biliary drainage catheter. Nine patients with bile duct cancer and one with cancer of the papilla of Vater showed positive bile cytology. The operative bile was obtained at the hepatic duct stump after a resection of the tumor-bearing bile duct. The operative bile in 10 patients with positive preoperative bile was found to be positive, while that in the five patients with negative preoperative bile was negative. Thus, the specificity of operative bile was identified as 100%. Moreover, in five patients with preoperative positive bile, saline irrigation of intrahepatic bile duct after a full recovery of hepatic bile revealed cancer cells to remain in the intrahepatic biliary trees. The viability of preoperative bile was 61%-97% with 1 x 10(4)-2.4 x 10(5) tumor cells, whereas there was a 41%-97% viability with 7.6 x 10(4)-10.4 x 10(5) tumor cells in the operative or irrigated bile. Accordingly, the patients with preoperative positive bile are thus suggested to be at high risk of inducing peritoneal metastasis due to the inadvertent spillage of hepatic bile at the time of resection of a bile duct tumor.

Tumor seeding from percutaneous biliary catheters

Percutaneous transhepatic biliary decompression has been used since 1973 as a preoperative surgical adjunct in patients with obstructive jaundice. Tumor seeding along the catheter tract is an unusual complication but it occurred recently in one of our patients who had preoperative biliary drainage for four days. Four months after his pancreaticoduodenectomy, a 2-cm nodule developed at the catheter exit site. This nodule was a metastatic focus of adenocarcinoma similar to his pancreatic tumor. He died 1 month later and at autopsy was found to have numerous metastases along the catheter tract. A review of the world literature found 17 other patients with this complication. Thirteen of the 18 total patients had catheters placed for palliation, while 5 patients underwent preoperative drainage before definitive procedures, and 4 of these patients had undergone "curative" resections. Nine of the 18 patients had biliary obstruction from cholangiocarcinoma, while seven patients had primary pancreatic carcinoma. Positioning of the catheter tip above the obstructing tumor and maintaining the catheter for only a short duration before operation (mean 8 days for resected patients, range 2 to 16 days) did not protect against catheter-related tumor seeding. Patients with suspected malignant obstruction of the biliary tract who may have resectable tumors should not undergo routine preoperative biliary decompression. If, on exploration, the tumor is found to be unresectable, then a palliative bypass may be performed.

Fine needle aspiration biopsy in malignant obstructive jaundice

Percutaneous cytodiagnosis of malignancy in patients with biliary tract obstruction is often useful in planning subsequent therapy. Of 121 patients presenting for percutaneous transhepatic cholangiography and biliary drainage, 45 had fine needle aspiration biopsies. Forty-one patients had malignant obstruction of the biliary tree, while benign disease was present in 4 patients. Neoplasia was diagnosed in 12 of 13 patients with bile duct carcinoma, 16 of 22 patients with pancreatic cancer, and 3 of 6 patients with other malignancies. Radiologic biopsy sensitivity was only slightly inferior to surgical biopsy sensitivity in the same patient population. A scheme for biliary cytodiagnosis is presented, which uses a percutaneous approach for patients with suspected pancreatic carcinoma and a transcatheter approach for patients with suspected bile duct carcinoma. The utility of this procedure and the low complication rate are stressed.

Cutaneous seeding of malignant tumours after insertion of percutaneous prosthesis for obstructive jaundice

Three cases of cutaneous malignant deposits at the site of skin puncture for insertion of percutaneous biliary prosthesis are described. Tumour dissemination casts doubts on the value of percutaneous intubation of the biliary tree when preparing patients for curative resection of pancreatic or biliary tumours.