Hepatic resection and transplantation for peripheral cholangiocarcinoma

Prognosis after resection for hepatitis B virus-associated intrahepatic cholangiocarcinoma

AIM: To investigate the prognostic factors after resection for hepatitis B virus (HBV)-associated intrahepatic cholangiocarcinoma (ICC) and to assess the impact of different extents of lymphadenectomy on patient survival.

METHODS: A total of 85 patients with HBV-associated ICC who underwent curative resection from January 2005 to December 2006 were analyzed. The patients were classified into groups according to the extent of lymphadenectomy (no lymph node dissection, sampling lymph node dissection and regional lymph node dissection). Clinicopathological characteristics and survival were reviewed retrospectively.

RESULTS: The cumulative 1-, 3-, and 5-year survival rates were found to be 60%, 18%, and 13%, respectively. Multivariate analysis revealed that liver cirrhosis (HR = 1.875, 95%CI: 1.197-3.278, P = 0.008) and multiple tumors (HR = 2.653, 95%CI: 1.562-4.508, P < 0.001) were independent prognostic factors for survival. Recurrence occurred in 70 patients. The 1-, 3-, and 5-year disease-free survival rates were 36%, 3% and 0%, respectively. Liver cirrhosis (HR = 1.919, P = 0.012), advanced TNM stage (stage III/IV) (HR = 2.027, P < 0.001), and vascular invasion (HR = 3.779, P = 0.02) were independent prognostic factors for disease-free survival. Patients with regional lymph node dissection demonstrated a similar survival rate to patients with sampling lymph node dissection. Lymphadenectomy did not significantly improve the survival rate of patients with negative lymph node status.

CONCLUSION: The extent of lymphadenectomy does not seem to have influence on the survival of patients with HBV-associated ICC, and routine lymph node dissection is not recommended, particularly for those without lymph node metastasis.

Intrahepatic cholangiocarcinoma. Surg Oncol Clin N Am. 2014;23:231-246. [PMID: 24560108 DOI: 10.1016/j.soc.2013.10.004]

Intrahepatic cholangiocarcinoma (ICC) is a rare tumor, with an increasing incidence worldwide and an overall poor prognosis. Symptoms are usually nonspecific, contributing to an advanced tumor stage at diagnosis. The staging system for ICC has recently been updated and is based on number of lesions, vascular invasion, and lymph node involvement. Complete surgical resection to negative margins remains the only potentially curable treatment for ICC. Gemcitabine-based adjuvant therapy can be offered based on limited data from patients with unresectable ICC. Overall 5-year survivals after resection range from 17% to 44%, with median survivals of 19 to 43 months.

Liver transplantation for intrahepatic cholangiocarcinoma

The indication of liver transplantation for intrahepatic cholangiocarcinoma (ICC) is highly controversial. Initially, liver transplantation was embraced as a promising treatment for ICC, providing both a wider surgical margin and a potential cure for the underlying liver disease. However, the majority of transplant centers have abandoned liver transplantation for ICC due to poor long-term survival and high recurrence rates. Interestingly, these decisions were based on studies with highly inconsistent outcomes due to a limited number of patients, various patient selection criteria, and the use of nonstandardized adjunctive therapy protocols. Indeed, recent studies have revealed that ICC patients with small solitary tumors have excellent long-term survival after liver transplantation. Moreover, as seen in early-stage hilar cholangiocarcinoma, neoadjuvant and adjuvant therapy hold promise for improved long-term survival in patients with locally advanced ICC. As we work to expand treatment options for ICC, further evidence of success in this area is needed in order to justify the use of limited organ resources to treat ICC. Continued efforts to improve diagnosis of ICC, hone patient selection criteria, and implement standardized treatment protocols could provide certain patients with ICC access to potentially life-saving liver transplantation.

Positioning high-dose radiation in multidisciplinary management of unresectable cholangiocarcinomas: review of current evidence

Cholangiocarcinoma is a rare malignancy of the bile ducts. The current standard of care for unresectable nonmetastatic disease is doublet systemic chemotherapy, which provides a median survival of 11.7 months. Although chemoradiation is a therapeutic option that provides almost equivalent or superior survival, the lack of level I evidence presents a major hurdle in routinely recommending it within multidisciplinary clinics. This mini review presents the current evidence on the use of chemoradiation for unresectable nonmetastatic cholangiocarcinoma and rationale for positioning it within multidisciplinary management of unresectable cholangiocarcinomas.

Efficacy of hepatic arterial infusion chemotherapy using 5-fluorouracil and systemic pegylated interferon α-2b for advanced intrahepatic cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma is categorized into intrahepatic cholangiocarcinoma (ICC) and extrahepatic cholangiocarcinoma (ECC). The prognosis of ICC is far worse than that of ECC. In this pilot trial, the efficacy of hepatic arterial infusion chemotherapy (HAIC) using 5-fluorouracil (5-FU) combined with subcutaneous administration of pegylated interferon (PEG-IFN) α-2b in patients with advanced ICC was evaluated.

METHODS

The subjects were 20 advanced ICC patients treated using subcutaneous PEG-IFNα-2b (50-100 μg on day 1 of every week, for 4 weeks) and intra-arterial infusion of 5-FU (250 mg/day for 5 h on days 1-5 of every week, for 4 weeks). One treatment cycle lasted 4 weeks. Therapy was discontinued in patients with progressive disease (PD). For responses other than PD, treatment was repeated for ≥1 cycle.

RESULTS

The objective early response rate was 60.0 %. Cumulative survival rates were 71.6 % at 6 months, 53.7 % at 12 months, 28.6 % at 18 months, and 14.3 % at 24 months. Median survival time was 14.6 months. All adverse reactions were controllable by temporary suspension of treatment. Serious complications and treatment-related deaths were not observed.

CONCLUSIONS

The combination therapy of PEG-IFNα-2b and 5-FU for advanced ICC seems not to be worse than the results of the previous studies. Furthermore, most adverse effects are transient and well tolerated. Based on the present findings, this combination therapy may be useful for patients with advanced ICC as one of the therapeutic option.

[Hepatocellular carcinoma and cholangiocarcinoma]

Hepatocellular carcinoma and cholangiocarcinoma are relatively rare tumors of the gastrointestinal tract in western Europe but their incidence has been increased in recent years. Newly diagnosed intrahepatic lesions or intrahepatic cholestasis require extensive laboratory tests and imaging studies in order to confirm the diagnosis of hepatocellular carcinoma, intrahepatic or extrahepatic cholangiocarcinoma. The treatment options range from liver resection or liver transplantation to conservative measures (in cases of non-resectable lesions). This review article aims to provide an overview on the diagnostic options and the subsequent treatment.

The diagnostic conundrum and liver transplantation outcome for combined hepatocellular-cholangiocarcinoma

Combined hepatocellular-cholangiocarcinoma (cHCC-CC) is a rare primary liver malignancy with mixed hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC) histological features. It is almost impossible to obtain an accurate, preoperative noninvasive diagnosis of cHCC-CC with tumor markers or cross-sectional abdominal imaging due to the mixed histological features. Despite these difficulties, accurate cHCC-CC diagnosis remains an important goal with prognostic significance. In our study, we retrospectively reviewed the tumor markers: AFP and CA 19-9, and cross-sectional liver imaging, in light of liver explant findings, to identify and characterize cHCC-CC features followed by liver transplantation (LT) outcome analysis. The results from this 12 patient cohort failed to identify characteristic features for cHCC-CC. None of the imaging features helped to identify the cHCC-CC tumor and they mimicked either HCC or CC, depending on the degree of glandular differentiation expressed histologically. In our cHCC-CC LT recipients, the 1-, 3- and 5-year cumulative survival probabilities were 79%, 66% and 16%, respectively with a 5-year survival comparable to or better than LT for intrahepatic CC but poorer than LT for HCC following the Milan criteria. Conceivably explained by its cholangiocarcinoma component the LT outcome for this rare and hard to diagnose tumor appears poor.

Survival analysis of intrahepatic cholangiocarcinoma after resection

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy, but the studies for the outcome after resection of ICC are rare. The aim of this study was to elucidate outcomes and prognostic factors of ICC in patients undergoing hepatic resection.

METHODS

A retrospective study was conducted with a total of 63 patients who underwent surgical resection with curative intent for ICC. We performed the survival analysis with preoperative and postoperative clinicopathologic factors according to the clinical outcome.

RESULTS

The cumulative 1-, 3-, and 5-year survival rates were 68.2, 50.5, and 31.8%, respectively. Univariate analysis revealed that patient's old age, high preoperative carbohydrate antigen 19-9 (CA19-9) level, major vessel invasion, T classification, lymph node metastasis, lymphatic invasion, perineural invasion, intrahepatic metastasis, and narrow resection margin were statistically significant. By multivariate analysis, patient's old age, high preoperative CA19-9 level, lymphatic invasion, and narrow resection margin were independent dismal prognostic factors. The preoperative CA19-9 level shows a significant correlation with some histopathologic factors including major vessel invasion, bile duct invasion, and perineural invasion.

CONCLUSIONS

Preoperative CA19-9 level was a valuable clinical factor for predicting histopathologic invasiveness as well as clinical outcome. An adequate resection margin was the only modifiable factor by a surgeon during hepatic resection for ICC.

Yttrium-90 radiotherapy for unresectable intrahepatic cholangiocarcinoma: a preliminary assessment of this novel treatment option

BACKGROUND

There are no treatment options for unresectable intrahepatic cholangiocarcinoma (ICC) with proven efficacy. The objective of this study was to present data on the safety and efficacy of a novel treatment option, yttrium-90 ((90)Y) radioembolization for unresectable ICC.

METHODS

Twenty-five patients underwent resin-based (90)Y radioembolization for unresectable ICC between January 2004 and May 2009. Patients were assessed at 1 month and then at 3-month intervals after treatment. Radiologic response was evaluated with the Response Criteria in Solid Tumors (RECIST) criteria. Clinical and biochemical toxicities were prospectively recorded. Survival was calculated by the Kaplan-Meier method and potential prognostic variables were identified.

RESULTS

No patient was lost to follow-up. The median follow-up was 8.1 (range, 0.4-56) months and the median survival after (90)Y radioembolization was 9.3 months. Two patients died within 1 month of treatment; the median follow-up for the remaining 23 was 8.9 (range, 1.5-56) months. Two factors were associated with an improved survival: peripheral tumor type (vs. infiltrative, P = .004) and Eastern Cooperative Oncology Group performance status of 0 (vs. 1 and 2, P < .001). On imaging follow-up of 23 patients, a partial response to treatment was observed in 6 patients (24%), stable disease in 11 patients (48%), and progressive disease in 5 patients (20%). The most common clinical toxicities were fatigue (64%) and self-limiting abdominal pain (40%). Two patients (8%) each developed grade III bilirubin and albumin toxicity. One patient (4%) developed grade III alkaline phosphatase toxicity.

CONCLUSIONS

(90)Y radioembolization may be a relatively safe and efficacious treatment for unresectable ICC. In the absence of other effective therapeutic options, this treatment warrants further investigation.

Surgical treatment of mass-forming intrahepatic cholangiocarcinoma: an 11-year Western single-center experience in 107 patients

Hepatic resection is the only cure for intrahepatic cholangiocellular carcinoma (ICC). The purpose of this study was to clarify the clinicopathologic characteristics and surgical outcome of patients with ICC. We retrospectively studied the records of 67 patients who underwent laparotomy for ICC from January 1995 through December 2005. Univariate and multivariate analyses were conducted for several variables to evaluate their influence on the outcome. Forty-five patients underwent hepatic resection. In 19 patients, the tumors were found to be unresectable at the time of laparotomy. Median 2- and 5-year survival rates in the 45 resected patients were 62% and 35%, respectively. For 36 patients who underwent curative resection, the 2- and 5-year survival were 67% and 41%, respectively; with a median survival of 43 months. The overall 5-year recurrence-free survival was 30%. The 90-day postoperative mortality rate was 4% and morbidity 28%. Multivariate analyses confirmed resection margin, lymph node involvement, blood loss, and blood transfusion to be independent significant variables for overall survival. Predictors of longer recurrence-free survival were lymph node involvement, vascular infiltration, blood loss, and transfusion. Surgical treatment of ICC by curative hepatic resection in patients without nodal invasion provides good long-term results. In contrast, incomplete tumor removal does not provide a survival benefit. An improved quality of preoperative staging was able to increase the resectability rate to acceptable 70%.

Impact of systemic inflammation on outcome following resection for intrahepatic cholangiocarcinoma

AIMS

To analyse the results and prognostic factors affecting disease-free and overall survival following potentially curative resection for intrahepatic cholangiocarcinoma (IHCC).

METHODS

Patients undergoing resection for IHCC from January 1996 to December 2006 were included. Data analysed included demographics, clinical and histopathology data.

RESULTS

Twenty-seven patients were identified with a median age of 57 (32-84) years. The 1-, 3- and 5-year overall and disease-free survival rates were 74%, 16% and 16%, and 44%, 15% and 15%, respectively. On univariate analysis, age <65 years, female gender, neutrophil to lymphocyte ratio (NLR) >or= 5, micro-vascular invasion and lymph node involvement were predictors of poorer overall survival. Multivariate analysis did not identify any independent predictors of overall survival. A NLR >or= 5 was the only adverse predictor of disease-free survival. The median disease-free survival of patients with NLR >or= 5 was 6 months compared to 18 months for those with NLR < 5. There was a significant association between patients with a NLR >or= 5 and larger tumour size, satellite lesions, micro-vascular invasion and lymph node involvement.

CONCLUSION

Long-term outcome following resection of IHCC is poor. A pre-operative NLR >or= 5 was an adverse predictor of disease-free survival and was associated with an aggressive tumour biology profile.

Treatment of unresectable cholangiocarcinoma with gemcitabine-based transcatheter arterial chemoembolization (TACE): a single-institution experience

BACKGROUND

Survival for patients with unresectable cholangiocarcinoma is reported to range from only 5-8 months without treatment. Systemic chemotherapy has not been shown to significantly improve survival, but newer regimens involving gemcitabine have shown increased response rates. Transcatheter arterial chemoembolization (TACE) has been shown to prolong survival in hepatocellular carcinoma patients, but experience using TACE in the treatment of cholangiocarcinoma is limited. We report our experience treating cholangiocarcinoma with TACE using chemotherapeutic regimens based on the well-tolerated drug gemcitabine.

METHODS

Forty-two patients with unresectable cholangiocarcinoma were treated with one or more cycles of gemcitabine-based TACE at our institution. Chemotherapy regimens used for TACE included: gemcitabine only (n=18), gemcitabine followed by cisplatin (n=2), gemcitabine followed by oxaliplatin (n=4), gemcitabine and cisplatin in combination (n=14), and gemcitabine and cisplatin followed by oxaliplatin (n=4).

RESULTS

Patients were 59 years of age (range 36-86) and received a median of 3.5 TACE treatments (range 1-16). Thirty-seven patients (88%) had central cholangiocarcinoma, and five (12%) had peripheral tumors. Nineteen patients (45%) had extrahepatic disease. Grade 3 adverse events (AEs) after TACE treatments were seen in five patients, whereas grade 4 AEs occurred in two patients. No patients died within 30 days of TACE. Median survival from time of first treatment was 9.1 months overall. Results did not vary by patient age, sex, size of largest initial tumor, or by the presence of extra-hepatic disease. Treatment with gemcitabine-cisplatin combination TACE resulted in significantly longer survival (13.8 months) compared to TACE with gemcitabine alone (6.3 months).

CONCLUSIONS

Our report represents the largest series to date regarding hepatic-artery-directed therapy for unresectable cholangiocarcinoma and provides evidence in favor of TACE as a promising treatment modality in unresectable cholangiocarcinoma. Our results suggest that gemcitabine-based TACE is well tolerated and confers better survival when given in combination therapy (with cisplatin or oxaliplatin) for patients with unresectable cholangiocarcinoma.

Trends in survival after surgery for cholangiocarcinoma: a 30-year population-based SEER database analysis

The prognosis of patients with cholangiocarcinoma historically has been poor, even after surgical resection. Although data from some single-institution series indicate improvement over historical results, survival after surgical therapy for cholangiocarcinoma has not been investigated in a population-based study. We used the Surveillance, Epidemiology, and End Results database to identify patients who underwent surgery for cholangiocarcinoma from 1973 through 2002. Multivariate modeling of survival after surgery for intrahepatic cholangiocarcinoma showed an improvement in survival only within the last decade studied, resulting in a cumulative 34.4% improvement in survival from 1992 through 2002. In contrast, multivariate modeling of survival after surgery for extrahepatic cholangiocarcinoma revealed a 23.3% increase in adjusted survival per each decade studied, resulting in a cumulative 53.7% improvement from 1973 through 2002. We conclude that survival after surgery for extrahepatic cholangiocarcinoma has dramatically improved since 1973. Patients with intrahepatic cholangiocarcinoma, however, have achieved an improvement in survival largely confined to more recent years. We suggest that these trends are largely caused by developments in imaging technology, improvements in patient selection, and advances in surgical techniques.

Serum cytokeratin 19 fragment (CYFRA21-1) as a prognostic factor in intrahepatic cholangiocarcinoma

BACKGROUND

A high serum cytokeratin 19 fragment (CYFRA21-1) concentration in patients with various cancers is associated with poor prognosis. This study aimed to establish the clinical significance of preoperative serum CYFRA21-1 in patients with intrahepatic cholangiocarcinoma.

METHODS

CYFRA21-1, carcinoembryonic antigen (CEA), and carbohydrate antigen (CA) 19-9 concentrations were measured in sera from 71 patients with intrahepatic cholangiocarcinoma. The prognostic significance of serum CYFRA21-1 levels was assessed by univariate and multivariate analyses.

RESULTS

Analysis of the areas under the receiver operator characteristic (ROC) curves clearly showed better discrimination between intrahepatic cholangiocarcinoma and benign liver diseases for CYFRA 21-1 than for CEA or CA 19-9. Based on the maximization of the Youden's index, the optimal cut-off value was 2.7 ng ml(-1) for CYFRA 21-1 (sensitivity, 74.7%; specificity, 92.2%). The serum CYFRA21-1 concentration was related to tumor stage, since the CYFRA21-1 concentrations varied according to tumor size, vascular invasion, and number of tumors. The 3-year recurrence-free survival rates for patients with high and low concentrations of CYFRA21-1 were 25.0% and 76.2%, respectively (log-rank test, p < 0.01). The 3-year overall survival rates for patients with high and low concentrations of CYFRA21-1 were 39.4% and 63.6%, respectively (p = 0.01). On multivariate analysis, a high concentration of CYFRA21-1, nodal metastases, and a microscopic resection margin involvement were independent prognostic factors associated with both tumor recurrence and postoperative death.

CONCLUSIONS

A high serum CYFRA21-1 concentration is associated with tumor progression and poor postoperative outcomes in patients with intrahepatic cholangiocarcinoma.

Multi-disciplinary treatment for cholangiocellular carcinoma

Cholangiocarcinoma (CC) is rare malignant tumors composed of cells that resemble those of the biliary tract. It is notoriously difficult to diagnose, and is associated with a high mortality. Traditionally, CC is divided into intrahepatic and extraheaptic disease according to its location within the biliary tree. Intrahepatic cholangiocellular carcinoma (IH-CCC) or peripheral cholangiocellular carcinoma (CCC) appears within the second bifurcation of hepatic bile duct, and is the second most common primary liver cancer following hepatocellular carcinoma (HCC), IH-CCC or peripheral CCC often presents with advanced clinical features, and the cause for this cancer rise is still unclear. MRI, CT and PET provide useful diagnostic information in those patients. Surgical resection is the only chance for cure, with results depending on selected patients and careful surgical technique. Liver transplantation could offer long-term survival in selected patients when combined with chemotherapy. Chemotherapy, radiation therapy or combination therapies remain as the only treatment for inoperable patients. However, these are uniformly ineffective in patients’ survival.

Advances in the surgical management of liver malignancies

Primary malignancies of the liver include tumors arising from the hepatocytes (hepatocellular carcinoma and the fibrolamellar variant) and the intrahepatic bile ducts (intrahepatic cholangiocarcinoma). Hepatocellular carcinoma is the most common primary cancer of the liver and is a leading cause of death from cancer worldwide. Although it is uncommon in the United States, the incidence of hepatocellular carcinoma is rising. Hepatitis, ethanol use, and cirrhosis often dominate the clinical picture and may dictate prognosis. New clinical and pathological staging systems have allowed for the more accurate stratification of patients to more appropriately identify patients for resection, transplantation, and percutaneous ablation therapies. A correlation between liver volume and surgical outcome has recently been demonstrated, with small liver remnant size being associated with increased morbidity. Portal vein embolization has therefore been proposed as one way to induce hypertrophy of the anticipated liver remnant before resection. Initial reports have shown that portal vein embolization decreases the incidence of postoperative complications. More recently, systemic chemotherapy and chemoembolization have been investigated as both primary and neoadjuvant therapy. Chemoimmunotherapy with 5-fluorouracil and interferon may be associated with a superior response rate in the fibrolamellar variant of hepatocellular carcinoma. Two recent randomized studies have also indicated improved survival after hepatic artery embolization in selected patients.

Clinical outcomes and apomucin expression of intrahepatic cholangiocarcinoma according to gross morphology

BACKGROUND

The clinicopathologic characteristics and the expression of apomucin (MUC) in intrahepatic cholangiocarcinoma (ICC) with respect to gross morphology have not been comprehensively examined.

STUDY DESIGN

We reviewed the clinical data of 98 patients with ICC who underwent resection at Seoul National University Hospital from 1980 to 1998. We also examined the expression profiles of MUC1 and MUC2 in 30 ICC tissues by immunohistochemistry using mouse monoclonal antibodies.

RESULTS

Of 98 cases, 42 were of the mass-forming type of ICC, 22 were of the periductal-infiltrating type, 21 were of the intraductal-growth (IG) type, and 13 were of the mixed type, and the overall 5-year cumulative survival rate was 23.3% in the mass-forming type, 0% in the periductal-infiltrating type, and 76.2% in the IG type. MUC1 was expressed in all types (mass-forming type 75.0%, periductal-infiltrating type 100%, and IG type 73.3%), but significantly, MUC2 was expressed only in the IG type (80.0%), which had better prognosis than the other types.

CONCLUSIONS

It is apparent that the IG type of ICC should be distinguished from the other types of ICC because a favorable prognosis can be expected after complete surgical resection.

Peripheral cholangiocarcinoma (cholangiocellular carcinoma): clinical features, diagnosis and treatment

Peripheral cholangiocarcinoma is a relatively rare cancer. However, it is known to have an unfavourable prognosis compared with that of hepatocellular carcinoma. Little is known about its aetiology, clinical or pathological features. Recently, with the development of imaging modalities, early staged cholangiocarcinoma has been diagnosed with relative ease. Surgery is the optimal therapy. Total hepatectomy does not provide survival benefit. Conventional surgery remains the only effective treatment, even for patients with advanced-stage tumours. Factors influencing survival after hepatectomy were tumour-free margin, lymphnodes metastasis and histopathology of tumour. Palliative intrahepatic tubing or percutaneous transhepatic biliary drainage and brachytherapy can alleviate jaundice and cholangitis, thereby prolonging survival in some cases.

Biliary tract surgery

The use of the laparoscope in biliary tract surgery continues to play a major role in improving the operative management of patients with biliary diseases. Laparascopic cholecystectomy has been safely performed as a day-case procedure and has lowered the morbidity of cholecystectomy in the setting of acute cholecystitis. Laparoscopic common bile duct exploration allows cholecystectomy and the removal of common bile duct stones to be performed during the same procedure, thereby decreasing hospital stay. Several new noninvasive modalities have been recently developed to image the biliary tract. In addition, laparoscopic ultrasound has led to rapid intraoperative imaging of the extrahepatic biliary tree. The long-term results of laparoscopic bile duct injuries have been better defined during the past several years. Finally, the role of surgical resection for gallbladder cancer detected during or after laparoscopic cholecystectomy has recently been evaluated.

Aggressive surgical treatment of intrahepatic cholangiocarcinoma: predictors of outcomes

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver cancer and constitutes 10% of primary liver malignancies. Surgery is the optimal therapy; the majority of the patients will require extensive resections that are associated with significant morbidity.

METHODS

We retrospectively studied the records of 26 patients who underwent exploratory laparotomy for intrahepatic cholangiocarcinoma between June 1991 and December 1997 at the Mount Sinai Hospital. Patients with perihilar (Klatskin) tumors were excluded. All patients were considered resectable based on CT or MRI findings. Patients with positive margins or nodal invasion received adjuvant chemotherapy and radiation.

RESULTS

Sixteen patients underwent 18 resections; in 10 patients the tumors were unresectable at laparotomy and only biopsy was performed. The mean age (62 versus 53 years) was significantly higher, and the mean total bilirubin level (0.71 versus 6.17 mg/dL) was significantly lower in the resected group (p=0.031 and 0.017, respectively). No patient with a total bilirubin over 1.2 mg/dL was found to be resectable. Median actuarial survivals were 42.9+/-8.9 months for resectable and 6.7+/-3.6 months for unresectable patients (p=0.005). Positive margins were associated with significantly shorter disease-free survival. But resected patients with positive margins survived significantly longer than those who were unresectable. Tumor size, presence of satellite nodules, and degree of tumor necrosis on histologic examination were significant predictors of outcomes. Survival among patients receiving adjuvant therapy was not significantly altered.

CONCLUSIONS

We conclude that an aggressive surgical approach is warranted in patients with ICC because resection offers the only hope for longterm survival. Our findings emphasize the importance of achieving tumor-free margins. Noncurative resection offers a survival advantage over no resection. Histologic examination of resected specimens can help select patients with poor prognoses.