Protocol for the examination of specimens from patients with carcinomas of the extrahepatic bile ducts, exclusive of sarcomas and carcinoid tumors: a basis for checklists. Cancer Committee of the College of American Pathologists

Clinicopathological characteristics of biliary neuroendocrine neoplasms: a multicenter study

OBJECTIVES

This study assessed the clinicopathological features, therapeutic approaches, and prognosis of patients with biliary neuroendocrine neoplasm (NENs).

MATERIALS AND METHODS

Multicenter retrospective study of patients with biliary tract NENs in the gallbladder, the extrahepatic bile duct, or the ampulla of Vater between 2005 and 2014.

RESULTS

Total of 43 patients were included in the study. The median age was 62 years (range: 29-84 years) and 58.1% of the patients were male. The tumors occurred in the gallbladder (n = 11), the extrahepatic bile duct (n = 5) or the ampulla of Vater (n = 27). The liver was the most common metastatic site. Based on the 2010 World Health Organization classification, more patients with gallbladder NENs (11/11 (100%)) had neuroendocrine carcinoma G3 than those with NENs in the ampulla of Vater (10/27 (37.1%)). The median progression free survival time (39.3 vs 5.1 months, p = 0.001) and median overall survival time (46.9 vs 7.9 months, p < 0.001) were significantly longer in patients with ampulla of Vater NENs than gallbladder NENs. A 2010 World Health Organization classification of neuroendocrine carcinoma G3 was independently related to poor overall survival (hazard ratio (HR), 27.1; 95% confidence intervals (CI), 2.81-260.68; p = 0.004).

CONCLUSION

The 2010 World Health Organization classification of neuroendocrine carcinoma G3 was the only factor related to poor prognosis in patients with biliary neuroendocrine neoplasms.

Hepatopancreatoduodenectomy for cholangiocarcinoma: a single-center review of 85 consecutive patients

OBJECTIVE

To outline our experience with hepatopancreatoduodenectomy (HPD) as a treatment for cholangiocarcinoma and to appraise the clinical significance of this challenging procedure.

BACKGROUND

Cholangiocarcinomas often exhibit an extensive ductal spread invading from the hepatic hilus to the lower bile duct, and such tumors can be completely resected only by HPD. Early experiences with HPD were associated with high mortality and morbidity, leading to an underestimation of the survival benefit of HPD.

METHODS

We retrospectively reviewed the medical records of 85 patients with cholangiocarcinoma who underwent HPD from 1992 to 2011. Major hepatectomy was performed in 79 patients (92.9%), and combined vascular resection was performed in 26 patients (30.6%).

RESULTS

The operating time was 762 ± 141 minutes, and blood loss was 2696 ± 1970 mL. Liver failure was the most common abdominal complication (n = 64), followed by pancreatic fistula (n = 60), wound sepsis (n = 33), intra-abdominal abscess (n = 22), refractory ascites (n = 17), bacteremia (n = 16), bile leakage (n = 13), and delayed gastric emptying (n = 12). Re-laparotomy was necessary in 9 cases (11.1%). Overall, 19 patients (22.4%) exhibited Clavien grade 0 to II complications, 58 (68.2%) exhibited grade III, 6 (7.1%) exhibited grade IV, and 2 (2.4%) exhibited grade V (mortality). The overall survival rate for the 85 patients was 79.7% after 1 year, 48.5% after 3 years, 37.4% after 5 years, and 32.1% after 10 years; 9 (10.5%) patients survived for more than 5 years. The rate of survival for the 53 patients with pM0 disease who underwent R0 resection was the most favorable, with 5- and 10-year survival rates of 54.3% and 46.6%, respectively.

CONCLUSIONS

HPD is technically demanding and is associated with high morbidity. However, this surgery can be performed with low mortality and offers a better probability of long-term survival in selected patients. As hepatobiliary surgeons, we should consider HPD to be a standard procedure for laterally advanced cholangiocarcinomas that are otherwise unresectable.

Carcinoid tumors of the extrahepatic biliary tract: report of four cases

Carcinoid tumors located in the biliary tree are exceedingly rare, accounting for 0.2%-2% of all gastrointestinal carcinoids. This study describes four cases of carcinoid tumors of the extrahepatic biliary tract. Four carcinoid tumors arising in the common bile duct (Case 1, 59-year-old man), gallbladder (Case 2, 49-year-old man; Case 3, 65-year-old man), and ampulla of Vater (Case 4, 52-year-old woman) were studied. All of the cases were misdiagnosed before surgery as proximal bile duct cancer, stomach cancer with liver metastasis, gallbladder cancer, and adenocarcinoma of ampulla of Vater, respectively. The clinicopathological characteristics and clinical course were reviewed. Treatment depends on the location of the tumor and the extent of the disease. Aggressive surgical therapy with a curative intention therefore offers the only chance for cure and has to be considered whenever possible.

The concept of perihilar cholangiocarcinoma is valid

BACKGROUND

The term perihilar cholangiocarcinoma has been used for all tumours involving or requiring resection of the hepatic confluence. However, it does not distinguish between intrahepatic and extrahepatic hilar tumours, and has no clinicopathological basis. This retrospective study examined whether the concept of perihilar cholangiocarcinoma is valid clinically.

METHODS

Some 250 patients with perihilar cholangiocarcinoma were divided into extrahepatic (EHC, 167 patients) and intrahepatic (IHC, 83) groups based on tumour location. Clinicopathological data were compared between these groups.

RESULTS

Liver, portal vein, venous and lymphatic invasion, and nodal metastasis were more common in IHCs than EHCs, whereas histological grade and incidence of perineural invasion were similar. IHCs were more advanced at the time of surgery; stage III or IV disease was found in 37.7 per cent of EHCs and 59 per cent of IHCs. Survival was marginally better for patients with EHCs than for those with IHCs (29.3 versus 20 per cent at 5 years; P = 0.057), but survival rates were similar for each tumour stage in the American Joint Committee on Cancer classification.

CONCLUSION

Combining EHC and IHC under the term perihilar cholangiocarcinoma is valid, as these tumours have comparable biological behaviour, with similar clinical management depending on stage and invasion.

Well-differentiated endocrine tumor of the distal common bile duct: a case study and literature review

Primary carcinoid tumors of the extrahepatic biliary tree are exceedingly rare, accounting for 0.2-2% of all digestive carcinoids. The authors in this study describe a case of biliary duct primary well-differentiated endocrine tumor in a 30-year-old man with symptoms of biliary obstruction and watery diarrhoea. Abdominal ultrasound showed a 2-cm solid lesion in the head of the pancreas, compressing the distal common bile duct. A computed tomography scan confirmed these findings, revealing the hypervascular pattern of the tumor. Gastrointestinal hormonal screening demonstrated an increase in plasma serotonin. The patient underwent standard pylorus-preserving pancreatoduodenectomy. Pathological examination showed a neuroendocrine tumor of the distal common bile duct measuring 1.8 cm in greatest dimension. The tumor cells were immunopositive for neuron-specific enolase (NSE), chromogranin A, synaptophysin, serotonin, and cytokeratin. Stains for gastrin and somatostatin were negative. Seven years later, the patient is well, with no evidence of disease. Given the site of these tumors and the difficulty in differentiating them from periampullary lesions, decisions as to the appropriate surgical approach may be problematic. After an exhaustive review of the literature, the authors conclude that pancreatoduodenectomy is the treatment of choice.

[Basic anatomopathological features of tumors and their extensions. Prognostic and therapeutic implications]

Surgical pathology analysis of biopsies or surgical specimens directly determines the diagnosis of the disease. It gives also the different characteristics that are useful for the establishment of the prognosis and for the treatment of each tumor. We report here a synthesis of the different characteristics of neoplastic lesions, necessary or useful for the establishment of the care program of the patients. These macroscopic and microscopic analyses should result in the most precise possible diagnosis and should take into account a list of other factors that allow the development of an optimal strategy for therapy, and the establishment of prognosis of the tumor. These characteristics include properties of the tumor like the size, shape, exact location, and the grade of the lesion, etc. They also concern the relationship of the tumor with certain structures like the basal membranes, the extracapsular extensions, the stroma reaction, the lymphatic vessels, the nerves, etc. The description of local and loco-regional spreading, as well as the analysis of the surgical margins gives also essential information. Sometimes, the description of modifications induced by neoadjuvant therapy, as chemo or radiotherapy, allows the evaluation of the efficiency of these treatments.

[Gross tumor volume and clinical target volume in radiotherapy: generalities. Definitions and generalities in anatomic pathology]

In the field of oncology, surgical pathology analysis of biopsies or surgical specimens directly determines the care program of each patient. Without going into too much detail, we report here the description of different characteristics of neoplastic lesions, necessary or useful for the establishment of the care program of the patients. These macroscopic and microscopic analyses should result in the most precise possible diagnosis and should take into account a list of other factors which allow the development of an optimal strategy for therapy, and the establishment of prognosis of the tumor. These characteristics include properties of the tumor such as the size, shape, exact location, and the grade of the lesion, etc. They also concern the relationship of the tumor to certain structures like the basal membranes, the stroma reaction, the lymphatic vessels, the nerves, and so forth. The description of local and locoregional spreading, as well as the analysis of the surgical margins gives essential information as well. Finally, in certain cases, the description of modifications induced by neoadjuvant therapy allows the evaluation of the treatment's efficacy.