p53 protein expression and prognosis in gallbladder carcinoma and premalignant lesions

BACKGROUND/AIMS

p53 protein expression in gallbladder carcinoma has recently been detected by immunohistochemical techniques, but the relationship between p53 expression and prognosis or clinico-pathological factors is still obscure.

MATERIALS AND METHODS

We investigated 48 gallbladder carcinoma, 7 adenoma and 11 dysplasia cases for p53 expression by immunohistochemical techniques.

RESULTS

p53 expression was positive in 39.6% of gallbladder cancer cases, but in no adenoma or dysplasia cases. No significant correlation was found between p53 overexpression and prognosis or recurrence in 20 patients with carcinoma involvement up to the subserosal layer. p53 overexpression was correlated with DNA aneuploidy pattern and the absence of stones, but was not correlated with clinical staging or lymph node metastasis.

CONCLUSION

These results suggest that p53 gene mutation is related to the transition from premalignancy to malignancy in gallbladder carcinogenesis, as well as DNA ploidy alterations and carcinogenesis unassociated with gallstones, but has no bearing on the prognosis.

Changing trends in the management of extrahepatic cholangiocarcinoma

A series of 107 patients with cholangiocarcinoma diagnosed between January 1980 and December 1991 is reported. Changing patterns of investigation and treatment in the periods 1980-1985 and 1986-1991 are analysed. There was a decrease in the use of percutaneous transhepatic cholangiography in the second period (86 versus 51 per cent of patients) but increased use of endoscopic retrograde cholangiography (19 versus 71 per cent) and computed tomography (8 versus 59 per cent). The overall resectability rate (17 per cent) was similar to those of other reported series but greater in the second period (8 versus 21 per cent). Palliation by endoscopic and percutaneous stenting was associated with a high incidence of recurrent cholangitis (55 per cent) and jaundice (35 per cent). During the second 6-year period, more effective palliation was achieved by segment III cholangiojejunostomy with a lower incidence of recurrent cholangitis (19 per cent) and jaundice (19 per cent). Overall prognosis for patients with this condition is grim and efforts must usually be aimed at providing the most appropriate palliation.

Outcomes after curative resections of cholangiocarcinoma

OBJECTIVES

To elucidate the clinical and pathologic features of extrahepatic cholangiocarcinomas and to identify prognostic variables in patients treated surgically.

DESIGN

Retrospective review of clinical records of patients undergoing surgical exploration for cholangiocarcinoma, with univariate and multivariate analyses of the clinical and pathologic factors that influenced patient survival.

SETTING

Mayo Clinic, Rochester, Minn.

STUDY PARTICIPANTS

One hundred seventy-one patients undergoing operative intervention for diagnostic, palliative, or curative reasons between 1976 and 1985. Follow-up was complete until death or for a minimum of 5 years for surviving patients.

INTERVENTION

A curative surgical resection was performed in 29% of patients, while the remainder underwent tumor biopsy or a palliative procedure.

MAIN OUTCOME MEASURE

Patient survival following operative treatment.

RESULTS

The operative mortality in this patient cohort was 5% and median survival was 13 months. Overall 5-year survival was 16%, with 44% of patients having a curative resection still alive at 5 years. Using univariate analysis, curative resection, tumor stage, Eastern Cooperative Oncology Group performance status, total bilirubin concentration, lymph node status, liver invasion, tumor morphology, tumor grade, and site of tumor origin were significant determinants of prognosis. Using the Cox proportional hazards model for multivariate analysis, curative resection, Eastern Cooperative Oncology Group performance status, total bilirubin concentration, and tumor grade were the only variables predictive of patient outcome. A curative resection of a proximal cholangiocarcinoma had a similar chance of providing long-term survival as a curative distal ductal resection.

CONCLUSIONS

Although the tumor extent and the patient's overall health will affect outcome, curative resection for cholangiocarcinoma at all sites should be undertaken since this treatment offers the best chance for long-term survival.

[Palliative therapy of primary liver tumors]

In Europe and North America, primary liver tumors are rare. Resection is the only means of cure, but is possible in only 20-30% of the patients affected, so that in all other patients, i.e. the vast majority, only palliative treatment is possible. In a retrospective analysis we investigated the 68 patients we had treated for hepatocellular or cholangiocellular carcinoma of the liver. In 14 patients resection was possible, while 28 patients were treated by chemoembolization and 26 by intraarterial regional chemotherapy to the liver. There was no difference in tumor stage between the two groups receiving different palliative treatments. The patients in whom resection was performed, in contrast, mostly had less advanced tumors. For chemoembolization we used a mixture of Ethibloc, mitomycin, Adriamycin and cisplatin. Up to 1986, the intraarterial chemotherapy was performed with mitomycin and 5-FU. Since 1986 we have used Adriamycin and cisplatin. The overall median survival time was 8 months: after resection 17 months, after chemoembolization 6.5 months, and after intraarterial chemotherapy 6.5 months. There was a significant difference in survival between patients with tumor stage II and those with tumor stages III and IV. On comparing the survival time achieved with our treatments and that ensuing in the natural course of patients with liver tumor we found no improvement.

Possibility of hepatic resection in patients on maintenance hemodialysis

A review of seven hepatic resections in six patients undergoing maintenance hemodialysis is presented. These cases consisted of hepatocellular carcinoma in four, and cholangiocellular carcinoma, myelolipoma and focal nodular hyperplasia in one each. The last preoperative hemodialysis was undertaken within 24 h prior to the operation with heparin. Intraoperatively, infused solutions containing no potassium, along with strict attention to preventing overhydration, allowed us to manage the patients without hemodialysis on the day of the operation. No specific intra-operative complications related to hemodialysis were noted. Postoperative hemodialysis was performed on the first or second day after operation, using nafamstat mesilate, a synthetic protease-inhibiting agent. The morbidity rate in the hemodialyzed patients was 85.7% (6/7), which was significantly higher than that in the non-hemodialyzed patients who underwent hepatic resections in our hospital. Fluid collection in the pleural and/or peritoneal cavities was frequent and difficult to control, but transient. Our experience suggests that hepatic resection is an acceptable procedure for hemodialyzed patients, when used in conjunction with careful perioperative management.

Increased arterial ketone body ratio as a prerequisite for recovery after hepatectomy

It is reported that a prompt increase in the arterial ketone body ratio (acetoacetate/beta-hydroxybutyrate), which reflects the mitochondrial redox state of the liver graft, is a decisive prerequisite for graft survival in clinical liver transplantation. To contrast the rôle of hepatic mitochondrial redox state in partial hepatectomy with that in hepatic replacement, the changes in the ketone body ratio were investigated in 107 cases of hepatectomy. The ketone body ratio in uneventful cases (n = 70) in the first three days after hepatectomy was significantly higher than that in eventful cases. In the uneventful cases, the ketone body ratios were all increased to above 1.0 within two days after hepatectomy, except in diabetics, whose preoperative values did not reach 1.0 under oral glucose load. However, 20 (22.7%) out of 88 cases whose ketone body ratios promptly increased after hepatectomy had mild to moderate complications thereafter. It is suggested that the recovery of hepatic mitochondrial redox state is also a prerequisite in partial hepatectomy, where a reduced and often damaged liver confronts systemic metabolic load.

Aggressive surgical therapy for Klatskin tumors

Thirty-one patients underwent limited hepatic resection with Roux-en-Y biliary-enteric anastomosis and placement of biliary stents for cholangiocarcinoma of the hepatic duct bifurcation (Klatskin tumor). Resection included wide tumor excision and bile duct resection at the liver hilum without major hepatic resection and was undertaken in all patients unless precluded by intraoperative evidence of vascular invasion. All patients were operated on by a single surgeon during the 10 years between 1981 and 1991. Similar procedures were performed for both curative (n = 17) and palliative (n = 14) treatment of this disease entity. In this series, the overall mean postoperative survival of these patients was 17 months. The mean postoperative survival of patients undergoing surgery with curative intent was 21 months in contrast to 12 months for those undergoing planned palliation. One patient in this series has been alive for more than 6 years with no evidence of disease. Five patients experienced major postoperative complications (16%), and there were two perioperative deaths (6%). This retrospective review supports an aggressive surgical approach in patients with Klatskin tumor.

[Long-term results of chemoembolization of primary liver cancer with epirubicin-lipiodol]

This pilot study deals with the long-term results from lipiodol-epirubicin chemo-embolisation in 25 patients with hepatocellular or cholangiocellular carcinomas. In a three-and-a-half year follow-up period 16 of these 25 patients died, maximum survival time being 28.4 months. Survival varied from 9.2 to 28.4 months compared with a survival time of 2-8 months in untreated patients. In this case hypervascular tumours have a better prognosis than the rarer hypovascular tumours due to the improved deposition and activity of the chemotherapeutic agent inside the tumour itself.

Optimal timing for stent replacement in malignant biliary tract obstruction

Endoscopic stent placement has become accepted palliative therapy for malignant biliary tract obstruction. Because stent occlusion remains a significant late complication, prophylactic replacement has been suggested, although the appropriate time interval remains unclear. Patients with malignant biliary strictures who received 10F or 11.5F stents were analyzed with respect to clinical response, occlusion rates at 3 and 6 months, and survival rates. Seventy stents were placed in 50 patients. Pancreatic carcinoma was the most common underlying malignancy. Overall, obstructive symptoms resolved in 94% of cases. Occlusion rates at 3 months (4.2%) and 6 months (10.8%) were not significantly different. Median overall survival averaged 22 weeks. Results were also stratified by underlying diagnosis, with the worst clinical response and survival being seen in the group of patients with metastatic cancer. Findings suggest that the time interval for stent replacement can be extended safely from 3 to 6 months, resulting in decreased patient discomfort and cost and obviating any replacement in that significant percentage of patients who expire before 6 months.

Cholangiocarcinoma: ultrasound features and correlation of tumor position with survival

Cholangiography is the definitive imaging modality for assessing cholangiocarcinoma. This study was designed to evaluate the ultrasound (US) features of cholangiocarcinomas and assess the accuracy of US in mapping tumor site when compared to cholangiography. Findings were correlated with patient survival. Thirty-one patients with an US diagnosis of cholangiocarcinoma underwent cholangiography. The US diagnosis was correct in 29 of 31 cases. Complete agreement with cholangiography occurred in 23 (78%) cases. In six patients, there was discrepancy over the precise tumor location. US diagnosis of cholangiocarcinoma had a high predictive value (0.94) and proved an accurate method of mapping tumor site. Lesions arising in the hilar region carried a worse prognosis (50% were dead within 80 days).

Improvements in survival by aggressive resections of hilar cholangiocarcinoma

The operative management of hilar cholangiocarcinoma has evolved because of advances in diagnostic imaging that have permitted improved patient selection, and refinements in operative techniques that have lowered operative mortality rates. Over a 4-year period, 48 patients with hilar cholangiocarcinoma were managed. Twenty-seven patients were treated by palliative measures. Preoperative investigation identified 29 patients who were judged fit for operation without proven irresectability by radiologic studies, and 21 of the 29 patients had tumor removal (72%). Twenty-three operative procedures were performed: local excision (n = 12) (two had subsequent hepatic resection), and hepatic resection primarily (n = 9). Eight patients had complications (35%), and one patient died (4.3%). The mean actuarial survival after local excision in 36 months, and after hepatic resection, 32 months. Palliation as assessed by personal interview was excellent for more than 75% of the months of survival. A combination of careful patient selection and complete radiologic assessment will allow an increased proportion of patients to be resected by complex operative procedures with low mortality rate, acceptable morbidity rate, and an increase in survival with an improved quality of life.

Survival after hepatic resection for malignant tumours

A retrospective analysis of 194 patients who underwent hepatic resection for primary or metastatic malignant disease from January 1962 to December 1988 was undertaken to determine variables that might aid the selection of patients for hepatic resection. Hepatic metastases were the indication for resection in 126 patients. The 5-year survival rate was 17 per cent. For patients with resected metastases from colorectal cancer (n = 104), the survival rate at 5 years was 18 per cent. The 5-year survival rate was 27 per cent when the resection margin was > 5 mm compared with 9 per cent when the margin was < or = 5 mm (P < 0.01). No patient with extrahepatic invasion, lymphatic spread, involvement of the resection margin or gross residual disease survived to 5 years, compared with a 23 per cent 5-year survival rate for patients undergoing curative resection (P < 0.02). The survival rate of patients with poorly differentiated primary tumours was nil at 3 years compared with a 20 per cent 5-year survival rate for patients with well or moderately differentiated tumours (P not significant). The site and Dukes' classification of the primary tumour, the sex and preoperative carcinoembryonic antigen level of the patient, and the number and size of hepatic metastases did not affect the prognosis. The 5-year survival rate for patients with hepatocellular carcinoma (n = 42) was 25 per cent. An improved survival rate was found for patients whose alpha-fetoprotein level was normal (37 per cent at 5 years) compared with those having a raised level (nil at 3 years) (P < 0.01). Involvement of the resection margin, extrahepatic spread and spread to regional lymph nodes were associated with an 8 per cent 5-year survival rate versus 44 per cent for curative resection (P < 0.005). The presence of cirrhosis, the presence of symptoms, and the multiplicity and size of the tumour did not affect the prognosis. The 5-year survival rate of 11 patients with hepatic sarcoma was 25 per cent. No patient with peripheral cholangiocarcinoma survived to 1 year in contrast to patients with hilar cholangiocarcinoma, all four of whom survived for more than 14 months.

Four year experience with cholangiocarcinoma: a survey of patients, clinical presentation, management and prognosis in two hospitals

Seventeen patients with cholangiocarcinoma diagnosed in Toa Payoh and Tan Tock Seng Hospitals from 1986-90 were studied retrospectively. There was a male preponderance (male:female = 12:5) with a mean age of 58 years (range 28-82 years). All presented with obstructive jaundice. Three had cholangitis. Biliary stones were associated in 3 (18%). Two patients (12%) had choledochal cysts. The level of obstruction was identified at the hilum in 12 (70.5%), lower third in 4 (23.5%) and at a choledochojejunostomy anastomosis in 1 (6%). Ultrasound and percutaneous cholangiography (PTC) were the commonest investigations used. Endoscopic retrograde cholangio-pancreatography (ERCP) was performed in 7 (41%) and computer tomography (CT) of abdomen in 6 (35%). Biochemically, a raised alkaline phosphatase (1.5-9 x normal) was typical. Biliary bypass surgery was performed in 7 (41%); Whipple's procedure in 2 (12%) and drainage only in 6 (35%). Nine operated upon survived an average of 6 months (range 2-11 months) and six by drainage survived an average of 62 days (range 13-155 days). Three (of which two declined treatment) were lost to follow up. Cholangiocarcinoma is an uncommon cancer occurring in the older age group. In younger patients, choledochal cyst seems to be an association. Survival is dismal with palliative treatment.

Surgical treatment of intrahepatic cholangiocarcinoma: four patients surviving more than five years

BACKGROUND

To find the rational surgical strategy for the treatment of intrahepatic cholangiocarcinoma (ICC), clinical features of ICC were studied in 20 patients who underwent hepatic resection in the National Cancer Center Hospital from 1980 to 1990.

METHODS

According to the morphologic pattern, we classified the ICCs into two subcategories, mass-forming and infiltrating, which correlated with their biologic behavior.

RESULTS

Of 10 patients who underwent hepatectomy for mass-forming ICC, three survived more than 5 years without recurrence. The 1-, 3-, and 5-year survival rates were 59.3%, 44.4%, and 44.4%, respectively. Of 10 patients who underwent hepatectomy for infiltrating ICC, one survived more than 5 years without recurrence. The 1-, 3-, and 5-year survival rates were 72.0%, 27.0%, and 27.0%, respectively. The pathologic findings and recurrences indicated that the salient feature of the mass-forming type was its tendency for intrahepatic metastasis especially near a main lesion, and of the infiltrating type was the infiltrative spread via Glisson's capsule and hilar lymph nodal metastasis.

CONCLUSIONS

An anatomic and extensive liver resection should be performed for mass-forming ICC, whereas a hepatectomy with excision of the extrahepatic bile duct and hilar lymph nodal dissection is recommended for infiltrating ICC.

The association between cholangiocarcinoma and hereditary nonpolyposis colorectal carcinoma

Eighteen patients with a biliopancreatic carcinoma in 15 different cancer family syndrome (CFS) families were studied. Only families with three or more first-degree relatives with colorectal carcinoma were included, and other characteristics of CFS were required in at least two cases. In 14 patients, the histologic specimen was available for reevaluation. In 11 (79%), the tumor was confirmed as a carcinoma of the biliary tract or papilla of Vater. In three (21%), carcinoma of the pancreas was the most probably alternative. In all four patients without histologic reevaluation, the diagnosis had been carcinoma of the biliary tract. This study suggests that carcinoma of the biliary tract or papilla of Vater is associated more commonly with CFS than with carcinoma of the pancreas. In this respect, CFS resembles familial adenomatosis coli, in which this association previously has been established.

[The surgical treatment of malignant liver tumors]

From study of the data concerning 133 patients who underwent operation for tumor of the liver the authors found that 43 (32.2%) patients were treated by a radical operation and 34 (25.5%) were subjected to palliative interventions. Among the radical interventions hemihepatectomy was performed on 21 (48.8%) patients. The total number of complications after radical operations was 46.3%, the mortality rate 11.6%. The authors discuss problems of the prevention of some complications, intraoperative hemorrhages in the first place. Different variants of bile diversion accounted for most of the palliative interventions. Survival in radical operations was 38.56 months, in palliative operations 8.34 months, and in exploratory operations 5.9 months.

Liver transplantation for primary hepatic cancer

Although early survival following transplantation for primary hepatic cancer is excellent, previously reported high recurrence rates have generally discouraged liver replacement for this indication. Since the inception of the Boston Center for Liver Transplantation (BCLT) in 1983, 33 of 383 (8.6%) liver allograft recipients have undergone orthotopic transplantation as definitive treatment for otherwise unresectable cancer. Diagnoses included hepatocellular carcinoma (HCCA) in 24 patients (73%), and cholangiocarcinoma (CHCA) in 9 patients (27%). Actuarial survival rates for patients with hepatocellular carcinoma were 71%, 56%, and 42% at 1, 2, and 3 years, respectively. The actuarial survival rates for patients with cholangiocarcinoma were 89% at 6 months, and 56% at 1, 2, and 3 years. Of the nine patients with cholangiocarcinoma, 56% (5/9) developed recurrent disease. Although this recurrence rate is disheartening, because of the lack of other morbidity, long-term survival in these patients is comparable to patients with HCCA. In contrast, recurrent hepatocellular carcinoma developed in 25% of recipients (5/20) who survived longer than 3 months posttransplantation. Other causes of death in patients with hepatocellular carcinoma included perioperative complications, 16.6% (4/24); sepsis, 8.3% (2/24); coronary artery disease, 4.2% (1/24); and lymphoma, 4.2% (1/24). Favorable prognostic factors included: primary tumor less than 3 cm in size and absence of associated cirrhosis. These results emphasize that orthotopic liver transplantation can provide a long-term cure for approximately 50% of patients whose primary hepatic malignancy is unresectable by conventional procedures.

Management strategies in resection for hilar cholangiocarcinoma

Between 1960 and 1990, resection was performed in 23 of 122 patients who underwent surgical treatment for hilar cholangiocarcinoma. Local excision of the lesion alone was performed in 10 cases (43%). Hepatic resection for tumor extending to the secondary bile ducts or hepatic parenchyma was performed in 13 cases (57%): extended right hepatectomy (3), right hepatectomy (1), extended left hepatectomy (6), left hepatectomy (2), and left lobectectomy (1). In three other cases, resection by total hepatectomy and liver transplantation was performed, but these were not included in the analysis of results for resection. Significant operative complications occurred in only two cases (8.7%), and the operative mortality rate was zero. In four cases, complete excision of the tumor could not be achieved macroscopically (macroscopic curative resection rate 19/122; 15.6%). In nine cases, the margins of the resected specimens were free from tumor on histologic examination (microscopic curative resection rate, 9/122; 7.4%). In 10 cases, the resection margins were found to contain tumor on histologic examination. The overall survival rate was 87% at 1 year, 63% at 2 years, and 25% at 3 years (median survival, 24 months). The survival and freedom from recurrence rates for patients with free resection margins was superior to that for patients with involved resection margins or residual macroscopic disease. A potentially curative resection, with histologically negative margins and no recurrence to date, was achieved in seven patients using the following procedures: local excision for two type I lesions; left hepatectomy plus excision of segment 1 for two type IIIb lesions and one type IV lesion; right hepatectomy and right hepatectomy plus excision of segment 1 for two type IIIa lesions. These results indicate that improved survival in hilar cholangiocarcinoma can be achieved by resection, with minimal morbidity and zero mortality rates, if histologically free resection margins are obtained. To achieve this, we recommend the following procedures for each type of lesion, based on our experience and on anatomic considerations: local excision for type I; local excision plus resection of segment 1 for type II; local excision, resection of segment 1, and right or left hepatectomy for types IIIa and b; hepatectomy plus liver transplantation for type IV.

Radiotherapy of cholangiocarcinoma: the roles for primary and adjuvant therapies

A total of 22 patients with cholangiocarcinoma who had been treated with external radiotherapy between 1978 and 1989 were analyzed. Of the 22 patients, 18 had cancer of the hepatic hilus (Klatskin) and 4 had intrahepatic biliary cancer; all but 2 of the subjects had advanced disease. In all, 16 patients underwent primary irradiation for unresectable tumors, 4 were subjected to adjuvant irradiation after gross tumor resection, and 2 received preoperative irradiation followed by gross tumor resection. The mean initial irradiation dose was 52.0 Gy (range, 26-78 Gy). The TDF (time-dose-fractionation) for the entire course of radiotherapy ranged from 49 to 154 (mean, 100). The median survival of all patients was 10 months, and the cumulative 1-year survival value was 37.7%. The external radiotherapy proved to be effective in the treatment of cholangiocarcinoma in terms of palliation and survival.

Intrahepatic cholangiocarcinoma: clinical aspects, pathology and treatment

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary tumor of the liver. To further define its clinicopathology and surgical management, we reviewed our experience. Clinical presentations of 32 patients with ICC was similar to that with hepatocellular carcinoma. Jaundice occurred in only 27 percent. ICC was unresectable due to advanced disease stage in 81 percent. Six patients had curative resections with two 5 year disease free survivors. Underlying liver disease was associated with ICC in 34 percent of patients.

[Combined moving strip whole liver irradiation and traditional Chinese medicine for large liver cancer]

This paper reports the result of large liver cancer treated by moving strip whole liver irradiation from 1980 to 1988. The 5-year survival rate was 30.83% +/- 7.77% and the median survival time was 25.8 months. Analysis of factors affecting prognosis showed: 1. The higher the midplane tissue irradiation dose, the longer the survival (P less than 0.001) and 2. Patients with greater than or equal to 8 less than 13 cm tumor diameter and/or greater than or equal to 50% less than 75% tumor/liver volume ratio had longer survival than those with greater than or equal to 13 cm diameter and/or greater than or equal to 75% tumor/liver volume ratio (P less than 0.001). Traditional Chinese medicine was indispensable as a supplement to this treatment. Both clinical and experimental study suggested that this technique could improve the patient's final outcome.

Variable low dose rate irradiation (131I-anti-CEA) and integrated low dose chemotherapy in the treatment of nonresectable primary intrahepatic cholangiocarcinoma

Previous experience using 131I anti-CEA antibody, which irradiates at a variable low dose rate in combination with a multimodality treatment program, has demonstrated acceptable toxicity and response in primary intrahepatic cholangiocarcinoma. In attempting to improve therapy, Cis-platin was added to the prior regimen. Induction therapy was unchanged. One month later, chemotherapy was given (doxorubicin, 15 mg, 5-fluorouracil, 500 mg, plus Cis-platin, 20 mg/M2) followed the next day by outpatient administration of 20 mCi 131I anti-CEA by i.v. bolus. Five days later, 10 mCi was administered. The latter regimen (chemotherapy plus 20 + 10 mCi 131I anti-CEA) was repeated every 2 months using polyclonal antibodies derived from different species (rabbit, pig, baboon, and horse). Twenty-four patients (29% with prior chemotherapy and/or metastases) were prospectively treated according to this regimen. Toxicity was limited to hematologic toxicity and was manifested by thrombocytopenia and leukopenia (17% and 4% grade 4, respectively, according to RTOG toxicity criteria). Tumor remission was evaluated by CT volumetric analysis and demonstrated a 14% response rate for the induction portion of therapy, 24% for the radioimmunoglobulin portion of treatment, and 50% remission rate when all subsequent tumor volumes were compared to the pre-treatment volume (entire program). The median survival for the entire group of patients was 10.1 months. This result is superior to previously reported trials and, in comparison to our previous study (10.1 vs 6.5 months median survival), further advancement in protocol design appears to have been made. In view of the rarity of this disorder, a randomized trial is not possible and strict statistical analyses cannot be made. The mechanism of 131I-anti-CEA variable low dose irradiation and chemotherapy interaction is discussed as well as further potential modifications for treatment improvement.

Choledochoscopic heat-probe therapy: an adjunctive palliative treatment for intrahepatic cholangiocarcinoma with hepatolithiasis

From 1983 to 1988, 20 out of 440 patients undergoing surgery for hepatolithiasis were discovered to have proximal bile duct adenocarcinomas, an incidence of 4.54%. Pre- and intra-operative diagnosis in all patients was hepatolithiasis. Four patients had left lateral segmentectomies and were found to have intrahepatic cholangiocarcinoma on subsequent histopathologic studies. In 16 patients, choledocholithotomy and biliary drainage were performed requiring post-operative choledochoscopy for removal of residual intrahepatic stones. Follow-up choledochoscopies revealed bile duct cancers in the biopsy specimens obtained. All patients refused any form of reoperation, eight patients accepted heat-probe therapy as an alternative, and were classified under group A. Group B patients (n = 8) refused any form of treatment whatsoever and agreed to periodic follow-ups and maintenance of external biliary drainage. At the half year follow-up, group A had a survival rate of 100%, whereas group B had a survival rate of 62.5%. At the end of one year, there was one survivor in group B, while group A has 2, 3 and 4 year survival rates of 50%, 37.5% and 12.5% respectively. This study has shown that gross and histological documentation of unsuspected proximal biliary cancers in hepatolithiasis patients are possible with the use of the flexible choledochoscope. Furthermore, we believe that choledochoscopic cauterization of tumors with the heat-probe is a reasonable palliative that can lead to appreciably longer survival rates.

Natural history and prognostic variables in primary sclerosing cholangitis

The clinical features at the time of presentation and the outcome in 126 patients with primary sclerosing cholangitis were studied to clarify the natural history and prognosis in symptomatic and asymptomatic individuals. The median age of the patients at the time of presentation was 36 years, 62% were male, and 16% were asymptomatic. The median follow-up from time of presentation was 5.8 years. There were more patients who had liver transplants (21%) than patients who died of liver-related disease (16%); the estimated median survival to these end points was 12 years. Cholangiocarcinoma was found in 8 patients and in 23% of those undergoing liver transplantation. Asymptomatic patients had milder disease than symptomatic patients, but in a univariate analysis the presence of symptoms was not prognostically significant. On multivariate analysis, the following independent prognostic factors were found: hepatomegaly, splenomegaly, serum alkaline phosphatase, histological stage, and age. These features were combined to produce a prognostic model that should be valuable in the stratification of patients in clinical trials and in the timing of liver transplantation, particularly in those patients seen soon after presentation.

Hepatopancreatoduodenectomy for advanced carcinoma of the biliary tract

Twenty-four patients with advanced carcinoma of the gallbladder and/or the bile duct underwent hepatopancreatoduodenectomy, that is, en bloc hepatic resection with pancreatoduodenectomy. They included 14 cases of gallbladder carcinoma, nine cases of bile duct carcinoma, and one case of double cancer of the gallbladder and the bile duct. Eleven kinds of hepatic lobectomy or segmentectomy with pancreatoduodenectomy were carried out, and the caudate lobe was also removed en bloc from 17 patients with carcinoma involving the hepatic hilus. Combined resection of the portal vein was performed in 11 patients, of the inferior vena cava in 2, and of the colon in 5, patients. Forty-four postoperative complications occurred in 22 patients (91.7%). The operative mortality rate was 12.5% (3/24). The median survival and the 2-year survival rate were 7.0 months and 17.9% for all 24 patients, including 3 operative deaths, or 11.0 months and 20.4% for 21 patients surviving hepatopancreatoduodenectomy, and 12.4 months and 20.8% for all 14 patients with gallbladder carcinoma, and 5.2 months and 14.8% for all 9 patients with bile duct carcinoma. The longest survivor died of recurrent tumors at 5 years and 7 months. Hepatopancreatoduodenectomy offered not only an unexpectedly long survival period, but also unexpected morbidity in some cases.

Radiotherapy of bile duct carcinoma using intracatheter 198Au grains

Eight patients with bile duct carcinoma were treated with radiotherapy using intracatheter 198Au grains. The intracatheter 198Au grains in an inner tube were inserted into a percutaneous transhepatic catheter. A plastic tip was placed between these grains to improve spatial and temporal dose allocation. This method and 192Ir wire irradiation resemble each other closely in dose distribution, but the former has the following advantages over the latter. 1) The number of 198Au grains used can be changed quite easily in accordance with the length of the stenosis. 2) The half-life of 198Au is about 2.7 days, and a dose of 25-40 Gy at 1.0 cm from the source is delivered over this period. The medical staff can protect themselves from radioactivity when the sources are withdrawn after brachytherapy. 3) 192Ir wire is not used very frequently in spite of its long half-life (74 days) because bile duct carcinoma is uncommon. 4) In Japan, 198Au grains can be purchased on a weekly basis, so treatment plans can be easily made. The eight patients also received external irradiation and the median survival after onset of radiotherapy was 7.9 months. There have been few systemic or local complications.

Surgical management of 552 carcinomas of the extrahepatic bile ducts (gallbladder and periampullary tumors excluded). Results of the French Surgical Association Survey

Five hundred fifty-two cases of primary carcinoma of the extrahepatic bile ducts (gallbladder and periampullary tumors excluded) collected from 55 surgical centers were reviewed retrospectively. Three hundred seven patients (56%) had upper-third lesions (proximal carcinoma), whereas 71 (13%) and 101 (18%), respectively, had middle-third and lower-third bile duct carcinomas. The remaining patients had diffuse lesions. Resectability rates were 32% for upper-third localization compared to 47% and 51% for middle-third and lower-third localization, respectively. The operative mortality rate for proximal carcinomas was significantly lower with resection (16%) compared with palliative surgery (31%) (p less than 0.05). Overall 1-year survival (operative deaths excluded) was 68% after tumor resection compared to 31% after palliative surgery (p less than 0.001). Long-term results after surgical resection correlated with local and regional extension of the disease. The results of this study show that resection of extrahepatic bile duct carcinomas, particularly in an upper-third localization, often is associated with worthwhile long-term survival.

Resection of the primary liver cancer of the hepatic hilus

Primary liver cancer (PLC) of the hepatic hilus was designated as a tumor situated at the main branch of the portal vein or pedicle of the hepatic veins in contact with the intrahepatic vena cava. That is, the main tumor located at segment I, IV, V, or VIII and concentrating on the central part of the liver was called "the central type of PLC," which differed from a tumor located at segment II, III, VI, or VII; the latter was called "the peripheral type of PLC." Surgical treatment of the PLC has been significantly improved in the past two decades, but the resection of the central type of PLC is difficult and hazardous. This institution admitted 903 PLC from January 1970 to April 1988, of which 118 cases were the central type; 65 cases were resected successfully, a resectability of 55.1%. One patient died from sepsis within 1 month of operation (mortality 1.53%). The modes of operation for the different segments are described, and suggestions for improvements are presented. The survival rates were compared with a similar number of patients with the peripheral type of tumor in the same period and treated by the same surgeons. The results show noticeable differences. The one-year, three-year, and five-year survival rates after resection were 70.9%, 43.2%, and 39.2% in the central type of PLC; they were 98.3%, 85.0%, and 76.4% in the peripheral type of PLC (P less than 0.001). Further discussion of improvements in surgical techniques and mental awareness are suggested.

Cholangiocarcinoma complicating primary sclerosing cholangitis

Clinical experience and pathologic evidence strongly support an association between PSC and cholangiocarcinoma. Cholangiocarcinoma arises in 5 to 10% of patients with preexisting PSC and can also present in a synchronous fashion with PSC. Cholangiocarcinoma complicating PSC is heralded by rapid clinical deterioration with progressive jaundice, weight loss, and abdominal discomfort. These tumors have been most frequently detected at an advanced stage, which precludes potentially curative resection. Liver transplantation for locally advanced and incidentally discovered tumors has been fraught with frequent tumor recurrence. Regardless of therapy, the prognosis for patients with cholangiocarcinoma complicating PSC has been uniformly poor. There is a clear need for heightened clinical awareness, methods for earlier detection, and effective therapy for patients with cholangiocarcinoma complicating PSC.

Cholangiocarcinoma complicating primary sclerosing cholangitis

Cholangiocarcinoma is more likely to develop in patients with primary sclerosing cholangitis. Our aims were to describe the clinical presentation, course, and management of patients afflicted with both cholangiocarcinoma and primary sclerosing cholangitis and to estimate the prevalence of cholangiocarcinoma in patients with primary sclerosing cholangitis. A retrospective analysis was conducted of 30 patients with both primary sclerosing cholangitis and cholangiocarcinoma managed at our institution during an 8-year period. Development of cholangiocarcinoma was heralded by rapid clinical deterioration with jaundice, weight loss, and abdominal discomfort. Cholangiocarcinoma complicating primary sclerosing cholangitis often was detected at an advanced tumor stage, which precluded effective therapy, and overall median survival was 5 months. Earlier recognition and treatment of cholangiocarcinoma in such patients will be necessary to increase survival rates. Seventy patients with primary sclerosing cholangitis were followed prospectively in a clinical trial of medical therapy for an average of 30 months. Twelve patients died and five were found at autopsy to have cholangiocarcinoma. The potential for cholangiocarcinoma to develop in patients with primary sclerosing cholangitis may indicate that liver transplantation should be considered earlier in the course of the disease.

Resective operations for biliary carcinoma

Records of 25 consecutive patients who underwent resection for proximal bile duct tumor (3 extended right hepatic lobectomies, 6 left hepatic lobectomies, 16 skeletonization resections) and records of 21 patients who underwent pancreatoduodenectomy for distal bile duct carcinoma were reviewed to assess the value of resective therapy. The operative mortality rate for patients with resected proximal bile duct tumor was 4 per cent (0 per cent for liver resection) and that of distal bile duct tumor, 4.6 per cent. The 3- and 5-year actuarial survival rates for patients with proximal bile duct tumor were 44 per cent and 35 per cent, respectively; all except one patient eventually died of disease. Survival was better for patients who had curative resection (margins microscopically free of tumor). The 5-year actuarial survival rate for patients with distal bile duct carcinoma was 58 +/- 12 (SE) per cent, with patients who had negative nodes surviving longer than patients with positive nodes. When major hepatic resection and pancreatoduodenectomy can be performed in selected patients with low operative mortality, patients with bile duct carcinoma should be assessed by an experienced hepatobiliary multidisciplinary group before a decision is made in favor of palliative, endoscopic, or percutaneous techniques because surgical resection appears to offer the best possible long-term survival and probably the best quality of palliation.

A high incidence of liver cancer in Khon Kaen Province, Thailand

Based on a population-based cancer registry in Khon Kaen Province, Thailand, data were collected actively and passively from all hospitals, health centers and the office of the Chief Medical Officer of Khon Kaen. The data were collected prospectively for the year 1988 and retrospectively for the years 1985-1987. Liver cancer, especially cholangiocarcinoma, was the leading cancer in both sexes. The age-standardized incidence rates for the year 1988 were 89.2/10(5) in males and 35.5/10(5) in females respectively, which are among the highest rates recorded in the world. The number of reported liver cancer cases increased each year. The observed geographical clusters of liver cancer appear to be associated with the prevalence and intensity of Opisthorchis viverrini infection, as reported in previous studies in this area.

Primary hepatic malignancies: resection or liver transplantation?

Liver transplantation in malignancies must be confined to patients with potentially curable disease. The indication is widely accepted, however, in non-resectable tumors or in patients with cirrhosis that excludes major resection. Without treatment prognosis is extremely poor in these patients. In our own experience 12 out of 13 non-cirrhotic patients with hepatocellular carcinoma (HCC) died within 9 months, and 17 out of 19 cirrhotic patients died within the first year of non-curative or explorative surgery. None of our patients with HCC in non-cirrhotic livers has lived longer than 38 months, and those with cirrhotic livers more than 61 months even after curative resection. After liver transplantation 1-year survival rate was 54% in 14 patients with primary hepatic carcinomas (12 HCC, 2 CCC). In cirrhotic patients with large or infiltrating HCC the results of resection are worse than after grafting, at least in the Western World, so liver transplantation must be taken into consideration. The lack of grafts limits treatment by transplantation in these patients. Transplantation is only exceptionally indicated for patients with metastatic liver disease.

Outcome of radical surgery in hilar cholangiocarcinoma

In a prospective study performed between 1977 and 1985, 27 patients with cholangiocarcinoma at the confluence of the hepatic ducts underwent resection aiming at cure. Eleven patients underwent local excision and 16 underwent partial liver resection (extended right hepatic lobectomy in 12, left hepatic lobectomy in 3, and extended left hepatic lobectomy in 1). The 60-day hospital mortality rate was 7.4% (2 patients). None of 11 patients who underwent local excision and only 1 (5.5%) of 18 patients who had not undergone previous surgery, or preoperative biliary drainage, died in the hospital. The overall median and mean survival times for the 24 patients who left the hospital were 25 and 29 months, respectively (range, 5 to 80 months). Twenty patients died after a median survival of 22 months (mean, 25 months; range, 5 to 80 months). Four patients are alive and well at 45, 48, 51, and 54 months. Estimated (Kaplan-Meier) survival rates for all 27 patients at 1, 3, and 5 years were 70%, 26%, and 22%, respectively, with almost all patients dying of persistent or recurrent local disease. Survival time after hepatic resection was not statistically different from that after local excision of the lesion (p greater than 0.1). The difference in survival times between patients with histologic clearance and those with microscopically positive or close (less than 1 mm) resection margins was marginally significant statistically (p = 0.037). The quality of life was good. These results are in agreement with those of other studies employing treatment by excision and emphasize the need to assess all patients with hilar cholangiocarcinoma with a view to resection before the adoption of surgical bypass or palliative intubational procedures. However, further progress is unlikely to be made without significant advances in adjuvant therapy.

Ultrasound-guided percutaneous transhepatic cholangiography and drainage in patients with hilar cholangiocarcinoma

The use of ultrasound-guided PTCD in 49 patients with hilar cholangiocarcinoma was evaluated. In 11 patients PTCD was performed as a preoperative measure either to outline tumor extension or to treat cholangitis. Postoperatively, the catheters were used to stent bilioenteric anastomoses and served to guide iridium wires for radiotherapy in nine patients with nonresectable tumor or tumor residue after resection. In 20 inoperable patients with tumor diameter smaller than 3 cm and in whom at least one catheter could be manipulated through the tumor, PTCD was combined with internal and external radiotherapy. The remaining 18 patients were palliated with PTCD only. In 29 patients (59%) complete drainage of the biliary system was achieved. Twenty-seven of these had complete internal drainage using endoprostheses. Two had a combination of an endoprosthesis and external catheter drainage. Of the 20 patients (41%) with incomplete drainage, 12 had endoprostheses, four had a catheter and an endoprosthesis, and in the remaining four external catheter drainage was the optimum result. PTCD was successful in treating eight of ten patients with cholangitis and 12 of 16 patients with pruritus. Procedure-related complication occurred in 11 patients (22%). With the exception of one, all complications could be classified as minor, requiring only conservative measures. A major complication was seen in a patient with ascitic fluid and severe cholangitis. PTCD caused a bacterial peritonitis, of which the patient died. The median survival of patients treated with PTCD alone only was 4 months. A significant increase in survival was noted in patients treated with PTCD and radiotherapy (median survival 8 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis and treatment of cholangiocellular carcinoma of the liver

Of the 239 patients with primary liver cancer treated in our department over the last 13 years, 27 had cholangiocellular carcinoma, and 4 cystic adenocarcinoma of the liver. In this paper, the diagnosis and treatment of cholangiocellular carcinoma was reviewed and discussed. Twenty-four (88.9%) of the 27 patients with cholangiocellular carcinoma underwent surgery and 16 (66.7%) had hepatic resection. There were no operative deaths. None with hilar type cancer survived more than 2 years but in the case of the peripheral type the one-year cumulative survival rate after hepatectomy was 63.6%, the 3- and 5-year rates were both 33.9%. Two cases survived more than 5 years. One was a 69-year-old female who died of tumor recurrence 5 years and 6 months after hepatectomy; the other a 61-year-old female who is still alive and well, without recurrence, 10 years and 5 months after right trisegmentectomy. Although the cholangiocellular carcinoma in our series were in the advanced stages, good results were obtained by hepatic resection with multimodal treatment.

The role of radiotherapy in the treatment of bile duct carcinoma

Forty-two patients with irresectable bile duct carcinoma (n = 31) or with microscopic evidence of tumor rest after aggressive surgery for bile duct carcinoma (n = 11) were given radiotherapy consisting intentionally of external-beam therapy and intraluminal 192Iridium (192Ir) wire application(s) following bile drainage procedures. The treatment was well tolerated; complications were mainly infectious and related to the success of the drainage. A median survival of 10 months was achieved for the group as a whole. Patients treated following microscopically incomplete resection survived longer than patients with an irresectable tumor (15 vs 8 months median survival, p = 0.06). Gross lymph node involvement also proved to be a prognostic factor.

Management of proximal cholangiocarcinomas by surgical resection and radiotherapy

Ninety-six patients with proximal cholangiocarcinomas were managed surgically. Fifty-three patients (55 percent) were resected, 39 curatively (41 percent), and 43 (45 percent) underwent palliative stenting. The preoperative placement of Ring catheters and the operative use of silastic transhepatic biliary stents greatly facilitated the surgical management of these lesions. Sixty-three patients (66 percent) also received postoperative radiotherapy. Hospital mortality was 4 percent (four deaths). Hospital mortality was 2 percent after resection (1 of 53 patients) and 7 percent after palliative stenting (3 of 43 patients). All deaths resulted from sepsis. One, 3, 5, and 10-year survivals for the entire group were 49 percent, 12 percent, 5 percent, and 2 percent, respectively. One, 3, 5, and 10-year survivals in the resected group (66 percent, 21 percent, 8 percent, and 4 percent, respectively) were superior to those in the stented group (27 percent, 6 percent, 0 percent, and 0 percent, respectively). Radiotherapy appeared to significantly extend survival in those patients undergoing palliative stenting, but not in those undergoing resection. We conclude that surgical resection of proximal cholangiocarcinomas can be performed safely and that it significantly prolongs survival. Further improvement in long-term survival will depend on advances in adjuvant therapy.

Clinical experience in 20 hepatic resections for peripheral cholangiocarcinoma

During the 10-year period from 1978 to 1987, hepatic resections were performed on 20 patients with peripheral cholangiocarcinoma (PCC). Nine of these patients were men and 11 were women (mean age, 48.5 years). Among them, 80% had intrahepatic stones with recurrent cholangitis. The 20 patients were subdivided into the following three groups: Group I (12 patients with surgery for PCC); Group II (4 patients with surgery for chronic cholangitis [but the final pathologic diagnosis confirmed PCC]); and Group III (4 patients with surgery for space-occupying liver lesions). No early postoperative mortality was noticed. The few complications that occurred were related to surgery for hepatolithiasis. Postoperative wound infection was the most common complication. The overall mean survival time was 20.5 months. Four patients survived for more than 3 years; one was even alive for more than 5 years after surgery.

Evaluation of partial hepatectomy for primary liver carcinoma

From 1964 to 1985, 120 cases of primary liver carcinoma had undergone hepatectomy in our hospital. Seven of these cases underwent hepatic lobectomy, 28 cases had palliative hepatic resection, and 85 cases had partial hepatectomy. We introduced different surgical modes and compared the mortality, survival rates, and complications between the hepatic lobectomy and partial hepatectomy groups. The mortality rates of these two groups were 14.3 and 3.5%, respectively, and the 1, 3, and 5 year survival rates were 83.3, 33.3, and 16.7 and 68.8, 48.1, and 20%, respectively. In the palliative hepatectomy group (28 cases), ten cases received combined radiotherapy postoperation. Most of these cases died during the first year postoperation. Primary liver cancer in Asia is commonly associated with hepatic cirrhosis. We suggest that partial hepatectomy is suitable for such patients. The results of the present series showed that the outcomes of the hepatic lobectomy and partial hepatectomy groups did not differ, but in partial hepatectomy, the operative mortality and complications were reduced, bleeding minimized, and operation time also shortened.

Liver resection for bile duct cancer

Hilar cholangiocarcinoma is now diagnosed more frequently, and modern diagnostic methods allow a much more precise definition of the extent of disease, which assists in planning the therapeutic approach. Resection of tumors at the confluence of the bile ducts is possible in 20 per cent of patients. When the tumor extends along the hepatic ducts into the right or the left side of the liver, excision may be combined with partial hepatectomy. Involvement of the portal vein and hepatic artery do not necessarily preclude resection. The operative mortality rate of partial hepatectomy for hilar cholangiocarcinoma is about 10 per cent, and median survival after operation is approximately 22 months, with a few long-term cures reported. The quality of survival after the excision of tumor and biliary-enteric reconstruction is very good and indeed appears to be better than that after palliation by biliary decompression alone.

The role of liver transplantation in hepatobiliary malignancy. A retrospective analysis of 95 patients with particular regard to tumor stage and recurrence

The role of hepatic transplantation in patients with nonresectable liver or bile duct cancer remains a controversial issue. An analysis of 95 consecutive cases was undertaken to evaluate retrospectively the pathological tumor stage--in accordance with the TNM system--and outcome after transplantation. Included were patients with the following diagnoses: hepatocellular carcinoma (n = 52), cholangiocellular carcinoma (n = 10), hepatoblastoma (n = 2), hemangiosarcoma (n = 2), bile duct carcinoma (n = 20), and liver metastases from different primary tumors (n = 9). The overall actuarial survival rate at 5 years was 20.4%. Median survival improved significantly within the last 4 years as compared to the preceding era (18.06 vs. 4.0 months). Currently 27 patients are alive, with the longest follow-up more than 12 years. The incidences of residual or recurrent tumor were 27 and 28, respectively. Particularly in patients who underwent transplantation for hepatocellular or bile duct carcinoma without extra-hepatic tumor spread, the results were significantly better; median survival time achieved for these two groups were 120 (p less than 0.01) and 35 months (p less than 0.05). Prolonged survival without tumor recurrence was not seen in patients with cholangiocellular carcinoma or liver metastases. These results demonstrate clearly that liver transplantation for hepatobiliary malignancy is still justified on the premises of careful patient selection by adequate tumor staging.

Klatskin tumours: a 20 year experience

The management of 27 patients who presented with cholangiocarcinoma of the hepatic confluence over the past 20 years is reviewed, and the dramatic changes, both in accuracy of diagnosis and modes of treatment, are documented. All 27 presented with jaundice, three underwent laparotomy only, four had a T-tube inserted, one had a straight transhepatic tube inserted, seven U-tubes were placed and four patients underwent surgical resection. More recently, seven patients were drained percutaneously and a further patient was treated by an endoscopic stent. There were six postoperative deaths. Of the 24 who received active treatment, the mean survival was 8 months with a range of 0-40 months. The advantages and disadvantages of the various methods of diagnosis and treatment are discussed. The possible role of radiotherapy and chemotherapy are reviewed briefly.

Percutaneous transhepatic endoprostheses for hilar cholangiocarcinoma

In patients with unresectable hilar cholangiocarcinoma, percutaneous transhepatic endoprosthesis insertion is one of the available methods of palliation. We reviewed our experience with it in 35 consecutive patients with hilar cholangiocarcinoma who were judged on clinical or radiologic evidence to be unsuitable for resective or palliative surgery. The 30-day mortality rate was 14 percent (5 of 35 patients). Of the remaining 30 patients, endoprosthesis placement was successful in 28, with 2 patients discharged with a permanent external drainage catheter. Twenty-four patients survived a median of 3 months (range 1 to 17 months), and 2 were lost to follow-up. Good or fair palliation of symptoms was achieved in 50 percent of the discharged patients and in 66 percent of those living longer than 3 months. We believe that percutaneous transhepatic endoprostheses can provide useful palliation in patients with hilar cholangiocarcinoma, even in the presence of advanced disease.

Definitive radiation therapy in bile duct carcinoma

Between 1980 and 1985, 24 patients with primary adenocarcinoma of the bile duct were treated with various combinations of surgery, biliary intubation, external irradiation, and transcatheter brachytherapy. Seventy-five percent of tumors were in the proximal bile ducts. Ten patients received no or only palliative radiation, Group 1, whereas 14 patients received definitive courses of radiation (4 by external beam irradiation, 2 by transcatheter irradiation, and 8 by both modalities), Group 2. Survival in Group 1 and Group 2 was significantly different (p less than 0.005) with median survivals of 2.0 and 12.8 months, respectively. This result may be in part due to differences in treatment and in part due to selection bias because the series is small, uncontrolled, and retrospective. Median survival of the 8 patients treated with combined modalities was 13.2 months (range 7.4-30.3) with 4 patients alive 8.7 to 16.2 months, 3 without cholangiographic evidence of disease. Complications of therapy were common, including bacterial sepsis (58%), cholangitis (38%), gastrointestinal bleeding (46%), intra or extrahepatic abscesses (33%), and recurrent biliary obstruction (25%). Cholangitis, hemorrhage, abscesses, and ulcers appeared more frequently in definitively treated patients, whereas recurrent biliary obstruction was absent in this group and frequent in Group 1. Differences in complication rates between groups were not statistically significant. Early diagnosis and management usually reversed a downhill clinical course in patients with abscess and hemorrhage. Both surgical and percutaneous techniques of biliary decompression, the usual initial form of therapy in bile duct cancer, are associated with frequent and serious complications. Although many of our complications may have derived from biliary decompression, it is possible that definitive treatment may have increased the frequency of serious complications.